Jessica, a seven-month old, is being seen for evaluation of acute abdominal pain.

Why did you bring your child here today? What are the problems?
"She's been having fits of crying all afternoon for no apparent reason. I think her stomach hurts because
she pulls her knees up and won't let us touch her tummy. It seems to be getting worse. She's just getting
over an ear infection, and now this."

When did you first notice the problem? When did it start?
"It started pretty suddenly, around noon or so. She just started crying really loudly."

Have you noticed anything that makes the problem better or worse?
"No. Usually when she cries, my wife or I will hold her and talk to her, and that will make her feel
better...but not this time!"

Does anything happen before the symptoms occur?

"No, she just seems to cry out of the blue."

How often does your child experience these symptoms?

"It seems to happen a couple of times an hour."

Have the symptoms recurred repeatedly or only once? How often?

"I think it happens a couple of times an hour, but I can't be sure. It happened once in the car on the way
over here."

Can you describe the symptoms?

"I wish I could! All I can tell you is that she cries."

How severe are the symptoms? Minor? Debilitating?

"Well, I think it's pretty severe, because she usually doesn't cry so much. She had an ear infection about
4 or 5 days ago, and she didn't cry this much."

Do the symptoms improve or get worse at different times/days/seasons?

"Well, it just seems to be getting a little worse with time."

Why do you think it started when it did?

"I don't know. And from her actions, it appears the stomach pain comes on all of a sudden.

What are the most troublesome symptoms this problem has caused?
"The way she screams, I think the pain must be pretty bad."

What do you fear most about this problem? Are you concerned about anything in particular?
"We're not worried about anything in particular. We just want her to feel better and not be in so much
pain."

Has your child ever experienced anything like this before?

"Not before today, no. She was crying a little bit earlier in the week when she had an ear infection, but
nothing like this."
Does anything else happen when your child feels these symptoms?
"Yeah, my wife and I get worried!"

Have you taken your child to other health care professionals about these problems?
"No. This just started this afternoon and by the time we decided to bring her in it was too late to get an
appointment, so we just brought her to the emergency room."

Has anyone in your family or any friends had any similar problems?
"No, never."

Has the problem had any negative effect on your child's daily routine?
"Yeah, because she seems to be getting tired, with all that crying."

Have you noticed any changes in your child's daily routine?

"No, not until today. And today it's been just like I said...crying, crying, crying."

Has your child been ill recently? When? What kind of illness?
"Yeah, she had an ear infection about 4 or 5 days ago. We saw the nurse practitioner at our HMO, and
she gave us an antibiotic prescription. The name of it was Ambesyl, or something like that."

Has your child recently been injured? What kind of injury?

"No, she hasn't."

Have any major life changes occurred to cause emotional stress?

"Well, I lost my job last month, but I'm sure Jessica's happy now that I'm home all day."

Explore the meaning of the parent and/or child's behaviors during the interview (crying, laughing, anger)
Not applicable.

Lifestyles———-

Animal contact/insect bites

"No...we don't have any pets in the house."

Diet of child
"She eats pretty much what we eat, with some exceptions. She eats a lot of cereal and bananas. We just
started giving her real milk a few weeks ago."

Hazards, environmental and occupational, of child

"None."

Over-the-counter drug use by child (laxatives, aspirin, cold medicines)

"No, we didn't give her anything, because we weren't sure what we should give."

Medical history————
Allergies [Medical History]
"None that we know of."

Birth history - prenatal, perinatal, and postnatal (mother and child)

"She was born in this hospital by C-section. My wife had a C-section for Matthew because her labor went
on too long, so they decided to just repeat the C-section for Jessica. But everything went fine, and they
both went home a few days after the delivery. I think she was 20 inches and 8 pounds."

Blood transfusions (child)

"None."

Development history
"She's developing pretty much like her brother did. She hasn't said her first word yet, although
sometimes it sounds like she's saying 'mama.' She's been crawling for a month or so now and can stand
up if she's holding onto something."

Drugs, present medication, past medication, non-medical uses

"We're just giving her the antibiotic for the ear infection she had a few days ago...what was it
called?...Ambesyl, or something like that. It's a pink syrup. The nurse said to give it to her until the bottle
was empty.

Family/sibling medical history

"We're all relatively healthy. Matthew had the stomach flu last week, but other than that he's been fine.
My wife and I don't have any major problems. I think she has some relatives with diabetes or something,
but her blood sugar has returned to normal since her pregnancy."

Growth history
"She's been growing up a storm, just like her brother did. She was 20 inches and 8 pounds at birth, and
now I think she weighs almost 20 pounds."

Health care professionals currently involved with the child

"We belong to an HMO and we usually see one of the doctors or nurse practitioners there. It was too
late this evening to get an appointment, so I brought her to the emergency room instead."

Immunizations
"She's current on everything...here's her record."
He hands you an immunization record which shows that Jessica has received:
DtaP at two months
DtaP at four months
DtaP at six months

Injuries
"None."

Other past medical history including psychiatric, surgical, previous lab

"Well, she's never been seriously ill; no surgeries or hospitalizations or anything. She had a cold a few
months ago, and last week she had an ear infection, but she's taking antibiotics for that.

Pyschosocial———-

Average day, activities of child

"My wife and I are both home during most of the day. If we have errands to do we'll take her with us for
some fresh air. Otherwise she naps, plays with toys, you know, the usual seven-month-old stuff."

Early development, including place of birth of child

"She was born here, and we've lived in this city since then. I think she's developed normally. I mean,
she's about the same as her brother Matthew was, and he's a pretty normal kid!"

Family unit, characteristics and history

"Myself, my wife, our three year old son Matthew, and Jessica live in a house about ten minutes from
here. My wife and I have been married for five years. We bought the house before Matthew was born,
so the kids have always lived there. I guess we're you're typical family, with Daddy working and Mommy
taking care of the kids...except I recently lost my job. Hopefully things will get back to normal soon."

Finances especially for health care

"My HMO coverage is going to run out soon, because I recently lost my job. That's just one of the
reasons I'm trying so hard to find another one!"

Home situations location, suitability, help availability, transportation

"We live about ten minutes from here. Transportation isn't a problem; my wife and I each have a car."

Social setting (friends, family) of child

"We have some friends in the area that we get together with every so often, and sometimes they'll bring
their children over. Other than that, Jessica really isn't in contact with too many other children."

Family occupational history

"My wife did some temporary secretarial work before we were married...she was temping in my
company, and that's how we met. I'm trained in aerospace engineering, and right now I'm looking for a
job.

Skiiin—————

Burning and/or itching [Skin]

"None."

Hair distribution, changes, alopecia, hair loss [Skin]

"Normal."

Nail changes
"None."

Night sweats [Skin]

"None."
Pain - Skin
"None."

Photosensitivity
"None."

Rash
"None."

Raynaud's Syndrome [Skin]

"None."

Redness, cyanosis, jaundice, or flushing [Skin]

"None."

Skin changes (color, moles, birthmarks, spots)

"None."

Sweat disorders [Skin]

"None."

Lyyyyyyyymphhh———

Lymph gland enlargement

"None."

Pain - Lymph Glands

"None."

Redness - Lymph Glands

"None."

Heeead——

Aura or warning [Head]

"None."

Pain - Head
"None."

Eyes——

Blindness, visual loss

"She's always watching us when we walk around...as far as we can tell, her vision's fine."
Double vision [Eyes]
"None."

Eye dryness
"None."

Lid droop, ptosis

"None."

Pain - Eyes
"None."

Redness - Eyes
"None."

Ears—-

Drainage, otorrhea
"None."

Hearing loss
"None."

Pain - Ears
"Well, she had an ear infection last week, and she was pulling at her ears a lot, like they hurt. But she's
stopped doing that since we put her on the antibiotics."

Redness - Ears
"None."

Ringing in ears, tinnitus

"None."

Vertigo [Ears]
"None."

Nose——

Bloody nose, epistaxis

"None."

Nasal congestion
"None."

Pain - Nose
"None."
Redness - Nose
"None."

Rhinorrhea or sinus congestion

"None."

Throaaat ——-

Chewing difficulty, mastication

"None."

Dentition, caries, teeth problems

"None."

Dysphagia swallowing difficulties [Throat]

"None."

Hoarseness, laryngitis
"None."

Mouth dryness
"None."

Oral ulcers
"None."

Polydipsia, thirst [Throat]

"None."

Sore throat
"None."

Breast—-

Redness - Breasts
"None."

Ciculatory—-

Ankle swelling, edema

"None."

Arrhythmia; heartbeat: fast, irregular, or palpitations

"None."

Chest pain [Circulatory]

"None."

Claudication
"None."

Cold hands, feet [Circulatory]

"None."

Nocturnal dyspnea [Circulatory]

"None."

Appetite [Gastrointestinal]
"She doesn't seem as hungry this evening, and she didn't take much dinner."

Diarrhea
"Oh yeah! My wife changed Jessica's diaper right before we brought her in, and there was some bloody
junk in it. Kind of like diarrhea, but more like mucous. I can't believe I forgot to tell you that because my
wife was really worried! Jessica had blood in her diaper before, when she was about three months, and
the doctor said it was just a fissure. But this looked a little different...darker."

Nausea and/or vomiting

"She spit up a little bit of green stuff tonight before we came in."

View|Face-Right
The face is symmetrical. There are no obvious deformities. The patient's smile and cry are both
symmetrical.

View|Scalp
Hair distribution is normal. The scalp is smooth and supple; no lumps, interruptions, or other lesions are
noted. There are no areas of tenderness.

View|Ear-Right
Auricles are symmetric, normally placed, and without deformities; no area of tenderness is noted. No
ear lobe creases are present.

Eyes are symmetric in size, shape, color and position. No scars, erythema, or growths are noted on lid or
conjunctiva. Cornea is clear; pupil is round, equal and black. Conjunctiva is moist and without discharge.

View|Nose
The patient's nose is symmetric. Nasal mucosa is pink and moist, with a small amount of clear discharge;
the septum is midline and without polyps; the turbinates are pink and moist with a clear passage
between them. Maxillary and frontal sinuses transilluminate.
View|Mouth
No teeth are present. Gums are pale red. There are no mucosal lesions. Hard palate is intact, uvula is
midline and moves symmetrically. Tongue appears normal without coating. Pharynx is diffusely pink; no
exudate; tonsils are easily seen and are without exudate.

View|Neck
The patient's neck is symmetric, without masses or scars.
The hyoid bone, thyroid, cricoid cartilages and trachea are symmetric, in the midline and mobile.
Internal jugular pulses are noted to 2 cm above the sternal angle with the patient’s head, neck and trunk
elevated at 30 to 45° with the head of the patient in the midline position or slightly turned to the
opposing side. On swallowing water the trachea rises well.

Feel|Scalp
The patient's scalp is smooth and supple; no lesions are noted; size and contour are normal, without
apparent deformities. There are no areas of tenderness. The anterior fontanel is about 0.5 x 0.5 cm in
measure.

Flashlight|Eye-Right
The infant follows flashlight motion. The pupils respond equally to both direct and consensual light
stimulation

Ophthalmoscope|Eye-Right
The red reflex is present. Disc margins are sharp.

Otoscope|Ear-Right

The drum appears minimally dull, and there is fluid visible behind the tympanic membrane. There is no
evidence of acute infection or inflammation. This exam is compatible with resolving otitis media.

The patient's left ear canal is clear; the drum is intact, with a bright cone of light in the pars tensa. The
malleus is visible through the drum. There are no concretions nor apparent thickenings in the drum.

There are no pre or post auricular nodes, nor any posterior cervical, anterior cervical or supraclavicular
nodes. No tenderness is noted.
Both lobes and the isthmus of the thyroid are small, palpable, smooth, non-tender, without nodules,
and rise with the trachea upon swallowing. Sternocleidomastoid and upper trapezius muscles are
symmetric, non-tender and relaxed.

The chest is symmetric. Respiratory movements are quick and symmetric. Mild retractions are present.
Respiratory rate is regular at 46 breaths per minute, without use of accessory muscles.

On inspection, the abdomen is symmetric, skin is smooth, soft without scars; venous pattern is minimal
and there are no rashes. The abdomen is mildly distended, and there is a relatively firm sausage-shaped
mass that is oriented transversely. Peristalsis is not visible. The umbilicus is small, inverted, midline, and
without signs of inflammation or herniation.

On auscultation, clicks and gurgles are heard 10 to 15 times per minute and there are occasional
borborygmi; no hums, bruits or friction rubs are heard.
Palpation of the abdomen causes obvious discomfort in the infant. There is some guarding, but no
rigidity nor rebound tenderness. The abdomen is mildly distended, and there is a relatively firm sausage-
shaped mass that is oriented transversely. The liver edge is 1-2 cm below the right costal margin.

Feel|Abdomen-upperLeft
Palpation of the abdomen causes obvious discomfort to the infant. There is some guarding, but no
rigidity nor rebound tenderness. The abdomen is mildly distended. No masses are palpable; the spleen
cannot be palpated.

I Examination of the abdomen causes obvious discomfort in the infant. There is some guarding, but no
rigidity nor apparent rebound tenderness. The abdomen is mildly distended. No masses are palpable.

Feel|Abdomen-lowerRight
Palpation of the abdomen causes obvious discomfort to the infant. There is some guarding, but no
rigidity nor apparent rebound tenderness. The abdomen is mildly distended. There is a relative paucity
of bowel in the right lower quadrant.

Respirations are quick but unlabored. No use of accessory muscles is noted. There is a small sacral
dimple.

Blood Pressure 85/60 mm Hg

Heart Rate 140
Temperature 36.8 ° C
Respiration 46
Pulse 140
O2 sat 97%
RhythmRegular
Length 27.5" (70 cm)
Weight 18 lbs (8.2 kg)