Grady Harris
Questions (to mother) - Yields 100%
1. How can I help him today?
a. He isn’t himself. He’s been whining and refusing to eat. I think
... [Show More] he’s saying that his tummy hurts.
When I took a look at his tummy, it had a big bruise.
2. Does he have any other symptoms or concerns we should discuss?
a. Yeah, he vomited once last night, and he just keeps rubbing his entire stomach. He’s not his usual,
cheerful self. He’s really low in energy and withdrawn. He pees less - you know, I’m not changing so
many wet diapers, and his pee is dark and strong smelling. Um, oh, and you can see, he’s still kind
of sweaty and clammy. He seemed to be breathing fast – maybe he’s nervous.
3. When did his abdominal pain start?
a. About 2 days ago.
4. What are the events surrounding the start of his abdominal pain?
a. My boyfriend says my baby fell from the bed during a nap and the problems started after that. I
don’t really know what he hit when that happened, but all his problems started: whining, being
really low energy or withdrawn, not eating, and peeing less. He even vomited once last night.
5. Does anything make the pain in his abdomen better or worse?
a. He seems to be worse when I touch him, or pick him up.
6. How many wet diapers does your child make per day?
a. Usually? I’m not always there to change them, but now there seems to be fewer. Also, his pee smells
strong and it looks dark.
7. How many stool diapers does your child have per day?
a. Normally? He usually poops once a day. I haven’t changed one in at least a day now. I’m a bit
worried about that.
8. What childhood illnesses has he had?
a. Other than all the fuss with his heart defect, he’s been a pretty healthy little guy. I mean, he’s slow -
but that's what you get with Down Syndrome. Everything’s affected…his growth, he doesn’t really
say many words yet, and he doesn’t pick new things up very quickly. That can be kind of
frustrating, you know.
9. Are his immunizations up to date?
a. Yeah, they are, except for the last ones.
10. Is he taking any prescription medications?
a. Uh…no. Not anymore. He used to take medication for his heart problems, but since they fixed that
he doesn’t need them anymore.
11. Is he taking any over the counter or herbal medications?
a. No, I don’t give him any of those things.
12. Has he had pain in his abdomen before?
a. No, not like this. He has always eaten well and he’s never acted like this before. I can tell you that
for sure.
13. Has he had any trauma to his abdomen?
a. Maybe. He fell out of bed - maybe that’s the cause.
14. Does he have any allergies?
a. No, he doesn’t have allergies.
15. Has he had any significant traumatic injuries or accidents?
a. He’s a real clumsy little guy. Always falling down, tripping over things, bumping into things and
stuff. Doesn’t look where he’s going. I wouldn’t call that a huge, big accident though. He’s never had
any broken bones.
16. How is his family and family life?
a. It’s just me and my three kids: my 6-month-old, my 5-year-old and my two year old. The father of
my two-year-old is out of the equation, and never has been with us. Sometimes my boyfriend, who’s
the father of my 6-month-old, stays over. I'm a cashier at a retail shop - I mean I only graduated
from high school - and so I don't make that much money and I can't afford daycare, so my
neighbors really help me out. Sometimes my boyfriend looks after them, but he doesn't really like to
because you know kids - they whine or cry at the same time it seems and he gets really on edge
about it.
17. What and when did he last drink?
a. I tried to give him some water two hours ago. He won’t take anything.
18. Can you tell me about any current or past medical problems he has had?
a. He was born with Down Syndrome and when he was a baby he had a problem with his heart. Part
of that was he also used to have CHF and took medications, but that got better after his operation.
He is a bit slower to learn things than some other children. But he has the biggest heart, and he just
loves everybody. And he's otherwise healthy. Please help my baby!
19. Does he have diarrhea?
a. No, I haven’t seen any.
20. Is there any blood in his stools or with his bowel movements?
a. He hasn’t pooped in a while. So actually, I’m not totally sure about that, but I don’t think so.
21. How long does the pain in his abdomen last?
a. It’s been going on since it started. I mean, I wouldn’t bring him here if I thought it was going away.
22. Tell me about the health of his grandparents, parents, and children.
a. I’ve got anemia. My oldest has asthma. His birth father? I know nothing about his health. Don’t care
to be honest.
23. Any previous medical, surgical, or dental procedures?
a. My son had surgery to close a hold in his heart. I think they call the surgery “ASD”. I haven’t taken
him to the dentist, though. I really should do that.
24. Does he bruise or bleed easily?
a. Yes, he seems to get bruises really easily. He’s also a clumsy little guy, tripping over stuff all the
time.
25. Does he have any skin problems?
a. No, uh, that is, he’s a baby you know so he can get some diaper rash, but I think he’s fine.
26. Has he recently had an upper respiratory infection?
a. Not recently…but he always seems to be congested.
27. Has he had any seizures?
a. No, nothing like that. I think my boyfriend and neighbors would have told me that for sure.
28. Were there any complications with his birth?
a. You mean besides his Down Syndrome? No, the birth itself was okay, I guess.
29. Has he had any trauma to his head?
a. No. Well, I mean, I don’t truly know. He could have hit his head when he fell. I’m really worried, do
you think he hit his head hard or something?
30. Is he exposed to secondhand smoke?
a. Well…uh…I guess so. I do smoke – and so does my boyfriend – but we try to keep it away from the
kids and we don’t smoke in the same room as them.
31. Have you noticed a sudden change of behavior or personality in him?
Physical Assessment - Yields 94%
Respiratory Rate 50, normal, unlabored
Blood Pressure on one arm 68/40, normal, hypotensive
Brachial pulse on both arms 160, normal rhythm, weak
Cognitive Verbal
Inspect skin overall Skin cool, sweaty, and slightly mottled. Thoracotomy scar consistent with
history of AV-septal repair. Diffuse diaper rash. Faint circumferential
macular discolorations at wrists consistent with aging ligature marks.
Capillary refill (fingers) Less than 3 seconds
Capillary refill (toes) 4 seconds
Quinke’s Test Blanching observed
Inspect/palpate scalp No visible scaliness, edema, masses, lumps, deformities, scars, rashes,
nevi, or other lesions, non-tender.
Inspect/palpate head No signs of head trauma. Down syndrome facies: flat face, up slanting eyes.
Inspect eyes No conjunctival pallor. No scleral icterus.
Fundoscopic exam with
ophthalmoscope
No signs of papilledema.
Look at pupils (do it twice) Left and right: normal reactive.
Inspect ears Normal appearing external structures. No deformities or edema. No
discharge noted.
Inspect nose No discharge or polyps. No edema or tenderness over the frontal or
maxillary sinuses.
Inspect nostrils No polyps or discharge.
Inspect mouth/pharynx No hoarseness: oropharynx not injected, clear mucosa, tonsils without
exudate. Tongue normal color, symmetrical, no swelling or ulcerations.
Normal gag reflex. Dental caries noted.
Inspect neck No visible scars, deformities, or other lesions. Trachea is midline and
freely mobile. No asymmetry or accessory respiratory muscle use with
quiet breathing.
a. He’s become very withdrawn, and that’s really unlike him. He’s usually so happy and just loves
everybody. I’m really worried. He’s usually such a good boy, we hardly ever have to send him to bed
without dinner for misbehaving.
Palpate Neck Thyroid firm, an acceptable size for patient gender and age. No nodules
palpated.
Palpate all lymph nodes No pathologically enlarged lymph nodes in the cervical, supraclavicular,
axillary, or inguinal chains.
Chest wall and lungs (visual
inspection)
Unlabored movement of chest wall. Thoracotomy scar consistent with
history of AV septal repair. Thorax atraumatic per gross inspection.
Auscultate abdominal sounds Hypoactive bowel sounds in all four quadrants.
Percuss abdomen No tympany or shifting dullness.
Visually inspect abdomen Ecchymosis overlying the epigastric measuring 10 cm in longest diameter
and oval in shape, abdomen distended, 2 cm umbilical hernia.
Auscultate lungs Normal in all fields bilaterally
Auscultate heart Murmur, early systolic.
Palpate for PMI PMI nondisplaced.
Palpate abdomen Abdomen distended, firm. Diffuse tenderness to palpation with associated
guarding and rebound. Reducible umbilical hernia.
Visually inspect extremities No overt limb deformities or bony crepitus. Moves all extremities
spontaneously but weakly; no evident focal deficits. Faint circumferential
macular discolorations at wrists consistent with aging ligature marks.
GU male exam Atraumatic, diffuse diaper rash, normal circumcised male, testes
descended; nontender, no evidence of inguinal herniation.
Inspect for muscle/bulk tone normal bulk, no rigidity, no signs of trauma.
Inspect/palpate back/spine Nontender to vertebral palpation, no overt back deformities.
Palpate extremities No localized musculoskeletal pain to palpation of extremities.
Look in ears with otoscope Tympanic membranes intact, no hemotympanum, no signs of otitis media.
Look for involuntary
movements
None of the following involuntary movements:
fibrillations, fasciculations, asterixis, tics, myoclonus, dystonia’s, chorea,
athetosis, hemiballismus, nor seizures.
MSAP - Not graded
Abdominal pain following a minor fall MSAP
Poor appetite Related
One episode of vomiting Related
Lethargy Related
Sweating Related
Tachypneic Related
Decreased urination, dark, strong-smelling urine Related
Listless, ill appearing Related
Decreased responsiveness Related
Tachycardia Related
Hypotension Related
Abdominal distention; epigastric bruising Related
Diffuse abdominal tenderness, guarding, rebound tenderness Related
Atrial-Septal-Defect s/p surgical repair Unknown
Dental Caries Related
Down Syndrome, global developmental delay Unknown
Low income, single parent w/multiple young children Unknown
Small for age, Down Syndrome features Unknown
3/6 systolic murmur Unknown
Reducible 2.0 cm umbilical hernia Unknown
Fading (old) ligature marks Unknown
Diaper Rash Unknown
History of CHF Resolved
Problem Statement
Grady is a 26-month-old male w/Down Syndrome brought in by mother who reports that he has been “whining”
about abdominal pain x2 days, one episode of vomiting, he is lethargic, sweating, breathing rapidly, and has decreased
urine output that is dark in color. Mother reports symptoms began after Grady “fell out of bed during his nap” while
under the care of her boyfriend. She denies any knowledge of head trauma but reports that he is not eating or
drinking. Denies prior injuries requiring medical attention. PMH significant for s/p ASD repair w/transient CHF in
infancy. Child appears listless and pale.
Differential Diagnosis - Yields 100%
Diagnosis Lead Alt MNM
Blunt Abdominal Trauma X X
Child Abuse (Acts of
Commission)
X X
Systemicinflammatory
response syndrome
X X
Traumatic brain injury X X
Hirschprung’s disease X X
Hernia,
incarcerated/strangulated
X X
Henoch-Schonlein
purpura
X X
Volvulus X X
Orders - Yields 100%
Amylase, serum Abnormal
CBC Abnormal
CMP Abnormal
CT Abdomen/Pelvis Abnormal
Head CT Normal
Lactic Acid Abnormal
Lipase Abnormal
PT/INR Abnormal; critical
Skeletal Survey Acute rib fracture, left 8th
Healing rib fractures, right 4th and 5th
Old rib fractures, right 9th and 10th
CXR otherwise without evidence of active disease
NG tube and foley catheter in place
No free abdominal air
Diffuse bowel distention
No evidence of pneumonia as a source of infection
No other evident fractures per limited survey of extremities
Urinalysis Abnormal
Venous Blood Gas Abnormal
Diagnosis (He has THREE) - Yields 100%
1. Blunt force trauma
2. Child abuse - act of commission
Electronic Health Record
Reason for encounter Grady is here today brought in by his mother with reports of "not being himself", he is
whining and refusing to eat, and she thinks that he is trying to say that his tummy
hurts.
History of present illness Two-day history of decreased appetite and thirst with abdominal pain, one episode of
vomiting, decreased urinary output with dark, strong-smelling urine noted in diapers.
Mother reports that he has been low in energy and withdrawn, sweaty/clammy
following a "fall from bed while napping" while under the care of her boyfriend.
General Complaints of listlessness, fatigue, lethargy, decreased energy, denies fever.
HEENT/Neck Mother denies throat pain, hoarse voice, and foul-smelling breath. Denies sinus
problems, dysphagia, nose bleeds, nasal discharge, or dental disease. Denies ear pain,
hearing loss, ringing in ears, discharge. Denies use of corrective lenses, redness,
blurring, or visual changes of any kind.
Cardiovascular Mother reports history of ASD with repair, transient CHF in infancy. Denies chest pain,
palpitations, orthopnea, edema, peripheral cyanosis.
Respiratory Mother is reporting more rapid breathing. Denies other respiratory complaints.
Gastrointestinal Mother reports complaints of abdominal pain, one episode of vomiting. Mother denies
diarrhea, constipations, red or tarry black stools. She reports that she has not changed
a stool diaper recently.
Genitourinary Mother reports decreased urinary output and dark, strong-smelling urine in diapers.
Musculoskeletal/Osteopat
hic Structural
Examination
Mother denies back pain, joint swelling, stiffness, or pain, fracture history.
Neurologic Mother reports developmentally delayed due to Down Syndrome. Poor verbal
communication. Denies syncope, seizures, black out spells. Mother reports that the
patient is "clumsy" and "does not look where he's going", so he bumps into things a lot
- implying unsteady gait.
Integumentary/Breast Mother reports bruising to the patient's stomach, cool, clammy skin. Denies rashes,
bleeding, or any lesions/moles. Reports occasional diaper rash.
3. Systemic inflammatory response syndrome (SIRS)
Psychiatric
Mother reports increased fussiness over the last 2 days. Denies sleeping difficulties.
Endocrine Mother denies night sweats, increased thirst, swollen lymph nodes, palpable masses,
increased hunger, cold or heat intolerance.
Hematologic/Lymphatic
Mother reports that the patient bruises easily but denies blood disorders or abnormal
bleeding.
Allergic/Immunologic
Mother denies known environmental or medication allergies.
PMH
Normal pregnancy, uncomplicated birth. Atrial Septal Defect, Transient CHF, Heart
Murmur
Hospitalizations & Surgeries Atrial septal defect repair.
Preventative health Mother reports patient is up to date on all vaccinations except for his "most recent
ones".
Medications
No current prescription or over the counter medications.
Allergies
No known diagnosed allergies
Social History Lives with mother and two other siblings, one of 6-months, the other 5-years old.
Mother has boyfriend who occasionally watches the children while she works. She is a
single mother - but dating the father of her 6-month-old child. Patients father is not in
the picture. Mother is a cashier at a local retailer, only graduated high school, cannot
afford daycare. She relies heavily on her boyfriend and her neighbors to help watch her
children so she can work. She denies use of alcohol and other illicit drugs.
Family History Mother: anemia Father: unknown
5-year-old sibling: asthma
6-month-old sibling: healthy
Physical Exam
General Lying on exam table, listless, sucking thumb, noted increased respiratory rate,
responsive to verbal stimuli, delayed responses.
HEENT/Neck Head: no signs of head trauma, Down Syndrome facies: flat face, upslanting eyes.
Scalp: no visible scaliness, edema, masses, lumps, deformities, scars rashes, nevi, or
other lesions noted, non-tender to palpation. Eyes: no conjunctival pallor, sclerae
anicteric. PERRLA bilaterally. Ears: normal appearing external structures, no
deformities or edema, no discharge noted. Tympanic membranes intact, no
hemotympanum, no signs of otitis media. Nose: no discharge or polyps, no edema or
tenderness over the frontal or maxillary sinuses. Mouth: no hoarseness, oropharynx
not injected, clear mucosa, tonsils without exudate, tongue is normal color,
symmetrical, no swelling or ulcerations, normal gag reflex. *Dental caries noted*.
Neck: no visible scars, deformities, or other lesions. Trachea is midline and freely
mobile. No asymmetry or accessory muscles used with quiet breathing. Thyroid is firm
and appropriate size for patient gender and age. No nodules to palpation.
Cardiovascular Early systolic murmur. Capillary refill of toes delayed at 4 seconds. Bilateral pulses
weak throughout. No edema noted. Hypotensive at 68/40. Tachycardic at 160 BPM.
Nondisplaced PMI.
Chest/Respiratory Tachypneic at 50 BPM, bilateral lung sounds clear to auscultation throughout. No
retractions or noted use of accessory muscles for breathing. Unlabored movement of
chest wall. Thoracotomy scar consistent with history of AV septal repair. Thorax
atraumatic per gross inspection.
Abdomen *Hypoactive bowel sounds all four quadrants, no tympany or shifting dullness,
Ecchymosis overlying the epigastric measuring 10 cm in longest diameter and oval in
shape, abdomen distended, 2 cm umbilical hernia. Abdomen distended, firm. Diffuse
tenderness to palpation with associated guarding and rebound. Reducible umbilical
hernia.
GU/Rectal Rectal - deferred.
GU - Atraumatic, diffuse diaper rash, normal circumcised male, testes descended;
nontender, no evidence of inguinal herniation.
Musculoskeletal/Osteopat
hic Structural
Examination
Full ROM noted to upper and lower bilateral extremities. No overt limb deformities or
bony crepitus. Moves all extremities spontaneously but weakly, no evident focal
deficits. Faint circumferential macular discolorations at wrists consistent with aging
ligature marks. No localized musculoskeletal pain to palpation of extremities. Normal
bulk, no rigidity, no signs of trauma. Nontender to vertebral palpation, no overt back
deformities.
Neurologic None of the following involuntary movements: fibrillations, fasciculations, asterixis,
tics, myoclonus, dystonia's, chorea, athetosis, hemiballismus, nor seizures.
Skin Pale, cool, clammy, slightly mottled. Thoracotomy scar is consistent with surgical
history. Diffuse diaper rash. Faint circumferential macular discoloration to bilateral
wrists consistent with aging ligature marks. Bruises in various stages of healing noted.
Lymphatic No noted lymphadenopathy in the cervical, supraclavicular, axillary or inguinal chains.
Psychiatric Alert to verbal stimuli. Poor eye contact, lethargic, listless, delayed responses.
Exercises
Using the CDC BMI chart for boys provided following
his growth chart, what percentile is the patient’s BMI?
97%, greater than 95%
This patient meets several SIRS criteria for his age
group - T/F?
True
What historical or physical findings would lead you to
suspect a nonaccidental, or intentional, injury in a child?
Poor dentition, injury/injuries inconsistent with
reported injury, rib fractures on chest x-ray in multiple
Choose all that apply. stages of healing.
Select the option that best describes Munchausen’s
syndrome
The syndrome is related to Munchausen by proxy, a
form of child abuse.
Which of the following are the first and second most
lethal injuries seen in physical child abuse?
C. Head injuries
B. Abdominal injuries
Management Plan
● Initial resuscitation and stabilization:
● Assess airway, breathing and circulation.
● Place on continuous cardiac monitor and continuous pulse oximeter to monitor VS
● Provide oxygen supplementation for hypoxia.
● Establish two large bore intravenous line: Administer IV isotonic-fluid boluses as needed.
● Complete primary (airway, breathing, circulation, disability, exposure) and secondary
● (head to toe exam) surveys.
► After the primary survey, the student should recognize that this is a critically ill child.
Evaluation:
● Obtain a SAMPLE history: Signs and symptoms, Allergies, Medications, Past medical history, Last oral intake,
Events leading up to the injury or illness.
● Order additional diagnostic testing, including labs and imaging, as needed.
● Obtain an emergent surgical consult.
● Admit the patient to the ICU for further management.
● Mobilize security personnel, if indicated.
● Contact child protective services: contact police and social-work personnel, as needed.
● Tommy will be admitted to the pediatric intensive care unit. The hospital as local police and child protective
services were notified. The patient’s currently being interviewed by the police and the social worker will
provide reliable contact information for her boyfriend.
Updates
The mother’s boyfriend (Drew B.) was interviewed by the police. He admitted he could
not take the whining,” and “punched Tommy in the stomach and threw him on the bed the
boyfriend was arrested and is awaiting trial. Tommy had a prolonged ICU stay, but progressively improved to the
point of readiness. Social services and child protective services assisted the obtaining additional financial support for
day care, counseling, and mandated classes. Tommy and his two siblings are in the custody of child protective
receiving counseling. Jackie J. currently has supervised visitation. [Show Less]