Tommy Acker Comprehensive Case Study

Tommy Acker’s Comprehensive Case Study

Patient Initials: Tommy AckerDate of Encounter:
Sex: MaleAge/DOB/Place of Birth: 26 months old

History by the Mother:

Chief Complaint: Abdominal Pain

Child Profile: Tommy Acker, a 26-month-old male with a history of Down syndrome and atrial-septal defect repair for ASD. Mother describes him as usually healthy, active, and playful, though developmentally delayed due to Down syndrome. He has limited speech, tends to be clumsy, and frequently experiences falls, but none requiring medical attention. Generally well-behaved with a good appetite, normal fluid intake, and regular sleep. He resides at home with his mother, two siblings, and is cared for by neighbors or the mother’s boyfriend in her absence.

History of Present Illness (HPI):

  • Onset: 2 days ago
  • Location/Radiation: Abdominal pain
  • Duration: Constant; worsening over 2 days
  • Character: Aching
  • Aggravating Factors: Being touched
  • Relieving Factors: None
  • Timing: Constant
  • Severity: Severe

Presenting Symptoms:

Tommy was brought to the ED by his mother with complaints of abdominal pain for the past 2 days, associated with emesis, lethargy, rapid breathing, and decreased urine output. These symptoms followed a fall from his bed during a nap. No head trauma reported, but he has refused food and drinks since the incident. His medical history includes atrial-septal defect repair with transient congestive heart failure (CHF) as an infant. Tommy appears listless and pale, with hypotension, tachycardia, tachypnea, signs of dehydration, a grossly distended abdomen with epigastric bruising, and diffuse tenderness. A 2.0-cm reducible umbilical hernia is also noted.

Medications: None currently.

Past Medical History (PMH): Normal pregnancy and birth without complications. A history of atrial-septal defect and transient CHF as an infant.

Allergies: None

Medication Intolerances: None

Chronic Illnesses/Major Traumas: Atrioventricular septal defect, transient CHF, heart murmur. Denies any recent trauma.

Hospitalizations/Surgeries: Atrioventricular septal defect repair.

Immunizations: Up-to-date with DTaP x 5, Hep-A x2, Hep-B x3, HIB x4, MMR x2, PCV7 x4, IPV x4, VZV x2, FLU x2.

Family History:

  • Mother: Anemia, 3 healthy pregnancies
  • Father: Unknown; not involved
  • 5-year-old Sibling: Asthma
  • 6-month-old Sibling: Healthy

Social History

The mother is a single parent but currently dating the father of the 6-month-old sibling. She graduated from high school and works as a cashier at a local retail shop. Despite limited income, she cannot afford daycare and relies on her neighbor for childcare assistance. If the neighbor is unavailable, her boyfriend occasionally helps, although he prefers not to due to the children becoming whiny simultaneously. Both the mother and the boyfriend smoke, but they claim to keep it away from the kids. T.A. is exposed to second-hand smoke. The mother denies the use of illicit drugs, alcohol, and marijuana. She feels safe in her community and the surrounding neighborhood, stating they have adequate transportation and access to healthcare when necessary.

Tommy Acker Comprehensive Case Study ROS

Review of Systems (ROS)Findings
General– Complains of listlessness, fatigue, lethargy, decreased energy. – Denies fever, chills, weight change, and night sweats.
Cardiovascular– Known history of ASD with repair. – Denies dizziness, chest pain, palpitations, PND, orthopnea, edema, peripheral cyanosis.
Skin– Complains of cool/clammy skin. – Bruising noted on the abdomen. – Denies rashes, bleeding, or any changes in lesions or moles.
Respiratory– Breathing rate appears more rapid than baseline. – Denies cough, shortness of breath, wheezing, hemoptysis, dyspnea, pneumonia history, TB, or sputum production.
Eyes– Denies the use of corrective lenses, redness, blurring, or visual changes of any kind.
Gastrointestinal– Complains of abdominal pain, vomiting x1 episode. – Denies diarrhea, constipation, hepatitis, bloating, hemorrhoids, eating disorders, ulcers, red or black tarry stools.
Ears– Denies ear pain, hearing loss, ringing in ears, discharge.
Genitourinary/Gynecological– Patient wears diapers; urine is notably dark, strong-smelling, and less frequent. – Denies urgency, frequency, or burning. – No complaints of dysuria or hematuria.
Nose/Mouth/Throat– Denies throat pain, hoarse voice, and foul-smelling breath. – Denies sinus problems, dysphagia, nosebleeds, nasal discharge, or dental disease.
Musculoskeletal– Denies back pain, joint swelling, stiffness or pain, fracture history, osteoporosis.
Breast– Deferred.
Neurological– Developmentally delayed related to Down Syndrome, poor verbal communication. – Denies syncope, seizures, transient paralysis, weakness, paresthesias, black-out spells, gait abnormality, or tremors.
Heme/Lymph/Endo– Complains of bruising but denies blood disorders, night sweats, increased thirst, swollen lymph nodes, palpable masses, increased hunger, cold or heat intolerance.
Psychiatric– Complains of fussiness x2 days. – Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts.
    
OBJECTIVEFindings
Weight22 lbs. (<5th Percentile)
BMI19.7 (97th Percentile)
Temperature97.9
Blood Pressure68/40
Height2’ 4”
Pulse140
Respiration50

OBJECTIVE (Physical Examination)

Area ExaminedFindings
General Appearance and parent-child interaction– Lying still on the exam table, sucking thumb. – Appears to be an ill, listless, and lethargic 26-month-old male with poor eye contact, tachycardia, and rapid breathing. – Pale, cool, clammy skin. – Appropriate weight and afebrile.
Skin– Pale, cool, clammy, and slightly mottled skin. – Thoracotomy scar consistent with heart surgery. – Diffused diaper rash. – Faint circumferential macular discoloration on bilateral wrists consistent with aging ligature marks. – Bruises in various stages of healing.
HEENT (Head, Eyes, Ears, Nose, Throat)– Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. – Eyes: fundi & red reflex present, non-injected conjunctivae, no nystagmus, no green/yellow discharge noted in conjunctiva, negative hordeolum. – Ears: Low set, Canals patent. Bilateral Tympanic Membranes pearly grey with positive light reflex; landmarks easily visualized. – Nose: Nasal mucosa pink. No septal deviation. – Neck: Supple. Full Range of motion; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. – Oral mucosa pink and moist. Pharynx is not erythematous and without exudate. Dental caries noted.
Cardiovascular– Early systolic murmur present. – Capillary refill delayed at 4 seconds. – Pulses weak throughout. – No edema.
Respiratory– Tachypnea noted with symmetric chest wall movement during inspiration and expiration. – Respirations non-labored; lungs clear to auscultation bilaterally.
Gastrointestinal– Abdomen is grossly distended with significant epigastric bruising, in a distribution atypical for a fall. – Firm to palpation with diffuse tenderness, guarding, and rebound tenderness. – Reducible 2.0-cm umbilical hernia present.
Breast– No masses, tenderness, asymmetry, nipple discharge, or axillary lymphadenopathy.
Genitourinary– Circumcised male, testes undescended and non-tender. – No evidence of trauma, urethral discharge, or inguinal herniation. – Visual inspection of rectum reveals no fissures, bleeding, or masses. – Soft, brown stool, guaiac-negative.
Musculoskeletal– Full ROM seen in all 4 extremities, spontaneous movements. – No trauma or focal deficits.

Neurological:

  • Cranial nerves II-XII intact.
  • Alert to verbal stimulation.
  • No nuchal rigidity or meningeal irritation noted (Wald, 2016).

Psychiatric:

  • Alert to verbal stimuli.
  • Poor eye contact, lethargy, listless; delayed responses.

In-house Lab Tests:

  • CBC: WBC 19,000
  • CMP
  • PT/INR
  • Venous blood gas
  • Lipase
  • Serum Amylase
  • Serum Lactic acid
  • Urinalysis

Diagnostic Imaging:

  • Head CT
  • Skeletal Survey
  • CT abd/pelvis with IV contrast

Pediatric/Adolescent Assessment Tools:

  • Age-Appropriate: Vital signs assessment tool. Faces Pain Scale (1-5)

HEADSSSVG Assessment for Adolescents:

  • Home: Lives at home with mother and two other siblings.
  • Education: Unable to afford daycare/childcare. Neighbor and boyfriend care for the child while mother works.
  • Eating: Eats a balanced diet with fruits and vegetables, good appetite.

Activities:

  • On average, active and energetic.
  • Enjoys playing with age-appropriate toys and siblings.

Substance Use:

  • The mother admits to smoking in the home.
  • Denies drug/alcohol use of any kind.

Safety:

  • Denies guns or weapons in the home.
  • Sits in a car seat, forward-facing when riding in automobiles.
  • Wears a helmet when riding a bicycle.

Assessment

  1. Traumatic Intra-Abdominal Organ Injury (S36.899A): Pediatric trauma, a significant contributor to morbidity and mortality, often involves abdominal injuries. Abdominal trauma, frequently resulting from blunt mechanisms like motor vehicle accidents, can lead to substantial morbidity and mortality, with an 8.5% mortality rate (CDC, 2019; Christian & Greenbaum, 2015). In T.A.’s case, the duodenal hematoma likely resulted from a punch to the abdomen by his mother’s boyfriend.
  2. Systemic Inflammatory Response Syndrome (SIRS [R65.10]): SIRS, triggered by various insults such as trauma, infection, or ischemia, manifests as a clinical response. Meeting two or more criteria, including abnormal white blood cell count, elevated heart rate, increased respiratory rate, or abnormal temperature, confirms SIRS (Kaplan, 2018). T.A. exhibited a WBC count of 19000, heart rate of 160, SBP of 68, and a respiratory rate of 50, meeting the criteria for SIRS.
  3. Child Abuse: Act of Commission (T74.12XA): Child abuse encompasses physical, sexual, neglect, and emotional abuse. Neglect involves failing to meet a child’s basic needs, while physical abuse results from intentional physical force leading to injury. Emotional abuse harms a child’s emotional well-being (CDC, 2019). In T.A.’s case, neglect, physical abuse by the mother’s boyfriend, and discrepancies in the reported injury stories raise concerns about child abuse.
  4. Volvulus (K56.2): Volvulus, often non-traumatic, presents with gastrointestinal discomfort or acute abdomen symptoms. It is associated with congenital malrotation of the midgut (Saxena, 2017). T.A.’s symptoms, however, do not align with volvulus characteristics, suggesting a less probable diagnosis.

Plan including Education

Initial Resuscitation and Stabilization Protocol:

  1. Assess airway, circulation, and breathing. Administer oxygen for hypoxia.
  2. Implement continuous cardiac monitoring, continuous pulse oximetry, and vital signs monitoring.
  3. Establish two large-bore intravenous lines for isotonic fluid boluses as required.
  4. Perform a thorough Primary (airway, breathing, circulation, disability, and exposure) and Secondary (head-to-toe exam) survey (Kaplan, 2018).

Further Management: Given T.A.’s critical condition, additional steps are crucial:

  • Conduct a CT scan of the abdomen and pelvis with contrast.
  • Seek an emergent surgical consult for immediate intervention.

Admission to Intensive Care Unit (ICU): Transfer T.A. to the ICU for continuous monitoring and specialized care, ensuring optimal management of his critical state.

Legal and Protective Measures: Initiate contact with child protective services, involve law enforcement, and engage social-work personnel as necessary to address potential child abuse concerns (Tommy Acker’s Comprehensive Case Study).

Education: Provide education to the mother regarding the critical nature of T.A.’s condition, the importance of cooperation with medical professionals, and the involvement of child protective services for a comprehensive assessment of the child’s well-being. Emphasize the necessity of a safe and supportive environment for optimal recovery and development.

Evaluation of Tommy Acker’s Case Study

Tommy Acker’s case presents a distressing scenario involving a non-verbal toddler with Down Syndrome and a cardiac history. The single mother, facing financial constraints, relies on her neighbor and boyfriend for childcare. Unfortunately, signs of abuse and neglect become apparent, demanding a comprehensive assessment.

Children with disabilities, per the CDC, face a higher risk of abuse due to perceived additional demands on families (CDC, 2019). Tommy’s assessment reveals alarming findings, such as a firm, distended abdomen, diffuse diaper rash, and bruises. His mother’s delayed response to his deteriorating condition raises concerns about neglect (Christian & Greenbaum, 2015). Dental caries, exposure to secondhand smoke, and broken ribs in various stages of healing intensify the gravity of the situation (Tommy Acker’s Comprehensive Case Study).

Child abuse encompasses physical, sexual, neglect, and emotional abuse. Neglect involves failing to meet a child’s basic needs, including medical care. Tommy’s situation indicates neglect as his mother prioritizes basic needs over education, exposing him to potential physical abuse from her boyfriend (CDC, 2019).

Abdominal trauma is a leading cause of mortality in pediatrics. Children’s unique anatomy and larger organs make them vulnerable. Traumatic injuries, like Tommy’s duodenal hematoma, can result from blunt force trauma, as seen in this case (Christian & Greenbaum, 2015).

Tommy’s diagnosis extends to Systemic Inflammatory Response Syndrome (SIRS), triggered by trauma, infection, or other insults. Meeting criteria like elevated heart rate, abnormal WBC count, and low blood pressure, Tommy requires stabilization through intravenous lines and fluid boluses (Kaplan, 2018).

Considering volvulus in the differential diagnosis is crucial due to its potential severity. Tommy’s symptoms align, and recognizing this non-traumatic cause is vital for appropriate intervention (Saxena, 2017).

Preventing abuse and neglect involves a multidisciplinary approach, including social workers, nurses, psychologists, communities, police, and pediatricians. Reporting abuse promptly and following appropriate procedures is essential (Schilling & Christian, 2014). Early interventions and aggressive therapy can mitigate trauma in cases of neglect and abuse (Hagan, Shaw, & Duncan, 2017).

Tommy’s critical condition necessitates an emergent surgical consult, admission to the intensive care unit, and comprehensive monitoring. Addressing abuse concerns is imperative for his well-being, emphasizing the need for a collaborative and proactive approach in safeguarding children at risk (Tommy Acker’s Comprehensive Case Study).

References

Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C., & Garzon, D. (2017). Pediatric Primary Care (6th ed.). St. Louis: Elsevier.

Centers for Disease Control. (2019). Child maltreatment: facts at a glance. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html

CDC. (2000). The National Center for Health Statistics in collaboration with the national center for chronic disease prevention and health promotion http://www.cdc.gov/growthcharts

Christian C, Greenbaum VJ. (2015). Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children. UpToDate. Retrieved from https://www.uptodate.com/contents/child-abuse-epidemiology-mechanisms-and-types-of-abusive-head-trauma-in-infants-and-children

Davis, C., & Rajasegaran, K. (2018). Headss up! An evaluation of an adolescent simulated patient program to teach headss assessment to medical students in a diverse se asian context. Journal of Adolescent Health, 62(2), S107.

Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2017). Bright Futures Guidelines for health supervision of infants, children, and adolescents (4th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

IHuman (2017). Tommy Acker V3 PC (basic DDX) review mode. Retrieved from: https://app.i-

human.com

Kaplan, L. J. (2018). Systemic Inflammatory Response Syndrome. Retrieved from https://emedicine.medscape.com/article/168943-overview

Saxena, A. (2017). Pediatric Abdominal Trauma. Medscape. Retrieved from https://emedicine.medscape.com/article/1984811-overview Tommy Acker’s Comprehensive Case Study Tommy Acker’s Comprehensive Case Study

Schilling S, Christian C. (2014). Child physical abuse and neglect. Child and Adolescent Psychiatric Clinics of North America. 2014; 23(2):309-319.

Tommy Acker Comprehensive iHuman Case Study

Children with disabilities face an increased vulnerability to abuse or neglect compared to their non-disabled counterparts. Signs of potential abuse include abrupt behavioral changes, unexplained injuries like cuts or bruises, and indications of neglect such as dirty hair or constant hunger (Burns et al., 2017). In Tommy Acker’s case, the presence of a diffuse diaper rash and alterations in behavior, as reported by his mother, raise concerns about potential abuse.

Data from the Department of Health and Human Services highlights a troubling statistic, indicating that 13.3 percent of abused children have some form of disability. Further literature review estimates that approximately 26.7 percent of disabled children may become victims of violence, with 20.4 percent experiencing physical violence and 13.7 percent falling victim to sexual violence (Child Maltreatment, 2012). This heightened risk is attributed to the perceived additional demands a disabled child places on a family.

Recognizing clinical presentations indicative of abusive injuries is paramount. In Tommy’s case, his critical condition is exacerbated by his mother’s delay in seeking medical attention. Ligature marks on his wrists and unmentioned rib fractures discovered in the skeletal survey emphasize the severity of the situation. Abdominal trauma ranks as the second most common cause of death in abused children, and T.A.’s developmental delays and special needs increase his susceptibility to abuse (Yu, Ngo, & Goldstein, 2016).

A primary diagnosis in this case is abuse, supported by chest and abdominal x-rays revealing multiple fractures in various healing stages. Inconsistencies between the reported cause of abdominal injury and the observed trauma, along with the delayed medical attention and ligature marks, serve as clear evidence of abuse. Another diagnosis is blunt abdominal trauma due to child abuse, supported by a CT scan revealing a duodenal hematoma. Tommy will require ICU admission, a surgical consult, IV fluids for shock, and continuous monitoring. Additionally, Systemic Inflammatory Response Syndrome (SIRS) is considered due to signs of fluid deficit and hypoperfusion, accompanied by an abnormal WBC count (Kaplan, 2018).

Considering the possibility of an incarcerated hernia is crucial, given the reducible 2.0 cm umbilical hernia found during the physical examination. This condition can cause severe acute abdominal pain, distension, and signs of shock. Early diagnosis is imperative to prevent life-threatening complications. Hirschsprung disease is also considered in the differential diagnosis, although ruled out due to the absence of chronic vomiting, constipation, and abdominal obstruction (Burn et al., 2017). Tommy Acker’s Comprehensive Case Study underscores the importance of a thorough and multidisciplinary approach to address the complex medical and social aspects of the case.

Consideration of Volvulus in Differential Diagnosis

Volvulus emerges as a potential differential diagnosis due to its capacity to induce acute bowel obstruction, typically characterized by cramping abdominal pain. However, it is essential to note distinctions from TA’s persistent pain, including cramping nature, associated vomiting, signs of dehydration, and abdominal distension with tympanic sounds upon percussion. Acute volvulus presents as an acute abdomen, accompanied by abdominal distension, nausea, vomiting, the absence of stools, and expulsion of gases via the anal route. In this context, volvulus refers to an abnormal rolling of a structure over its meso, leading to symptoms arising from intestinal lumen occlusion and compromised blood supply, resulting in ischemia and gangrene (Millet et al., 2014).

Approach to Battered Child Syndrome

Addressing the battered child syndrome requires a multifaceted approach, necessitating the development of protective laws for children and the establishment of multidisciplinary teams comprising pediatricians, psychologists, nurses, and social workers. The mandatory reporting of suspected abuse is the initial step in combating this societal scourge, as illustrated in Tommy Acker’s Comprehensive Case Study. The case underscores the importance of maintaining a high degree of suspicion when presented with an unconvincing family explanation that contradicts the severity of trauma or the presence of associated lesions at various stages of evolution.

Fractures in the skull, long bones, ribs, and retinal hemorrhages are frequently associated with child maltreatment, although their absence does not exclude the diagnosis, as demonstrated in this case. Early therapeutic aggressiveness and intervention play a pivotal role in reducing morbidity and mortality, akin to other causes of multiple trauma. The aggressive management employed for the critically ill patient, encompassing admission to the ICU, continuous cardiac monitoring, oxygen supplementation, and aggressive IV fluid hydration, undoubtedly contributed to his survival (Child Maltreatment, 2012). Tommy Acker’s Comprehensive Case Study highlights the significance of timely and comprehensive intervention in cases of suspected child abuse.

References

Bowling, K., Hart, N., Cox, P., & Srinivas, G. (2017). Management of paediatric hernia. BMJ : British Medical Journal (Online), 359doi:http://dx.doi.org.southuniversity.libproxy.edmc.edu/10.1136/bmj.j4484

Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C., & Garzon, D. (2017). Pediatric Primary Care (6th ed.). St. Louis: Elsevier. Tommy Acker’s Comprehensive Case Study.

Chen, Y. Y, Su, W. W., Soon, M. S., & Yen, H. H. (2016). Gastrointestinal: Intramural

hematoma of the duodenum. J Gastroenterol Hepatol, 21(6),1071

Child Maltreatment 2012, (U.S. Department of Health and Human Services, Administration for

Children and Families, Administration on Children, Youth and Families, Children’s

Bureau), Table 3–9, accessed July 28, 2018, http://www.acf.

hhs.gov/programs/cb/resource/child-maltreatment-2012.

Kaplan, L. J. (2018). Systemic Inflammatory Response Syndrome. Retrieved from

https://emedicine.medscape.com/article/168943-overview Tommy Acker’s Comprehensive Case Study

Millet, I., Orliac, C., Alili, C., Guillon, F., & Taourel, P. (2014). Computed tomography findings of acute gastric volvulus. European Radiology, 24(12), 3115-22. doi:http://dx.doi.org.southuniversity.libproxy.edmc.edu/10.1007/s00330-014-3319-2

Yu, D., Ngo, T., Goldstein, M. (2016). Child abuse-a review of inflicted intraoral, esophageal, and abdominal visceral injuries. Clinical Pediatric Emergency Medicine. Volume 17, issue 4. PP. 284-295. Tommy Acker’s Comprehensive Case Study Tommy Acker’s Comprehensive Case Study.