CASE 3
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Transcript of CASE 3
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Meckel’s Diverticulum
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General DataI.S.6 mos oldFemaleFilipinoRoman CatholicPandacan, Manila
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Bloody stools
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History of Present Illness4days PTC fever (T38.8C),Paracetamol drops
no fever, cough, colds, vomitinggood appetite and activityno consult
2 days PTC persistence prompted consult with AMD, Dx: acute viral illness
1 day PTC lysis of fever 2 episode of dark stools, irrritable,
decrease in appetiteER : SFA ileus; no recurrence of
stoolsDx : AVI, resolving; t/c Milk Allergy
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History of Present IllnessFew hrs PTC 2 episode of voluminous
maroon colored stoolsAdmitted
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Review of SystemGeneral: (-) weight loss, anorexia, easy
fatigabilityHEENT: no trauma, no ear infection, Neck: (-) limitation of motion, mass,
adenopathy Respiratory: (-) shortness of breath, easy
fatigability, wheezing Cardiology: (-) palpitation or cyanosisMusculoskeletal: (-) swelling, deformities
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Past Medical HistoryNo bronchial asthma no Primary Tuberculosis infectionno known allergiesThis is the patient’s first admission
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Family History(+) Diabetes: maternal grandparents(+) Hypothyroid : motherNo history of cancer
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Birth and Nutritional HistoryBorn to a 34 year old G3P2, non-smoker,
non-alcoholic beverage drinker, with regular prenatal check up
Denied illness during pregnancyBorn Full term via Repeat Ceasarian section
at Cardinal Santos Medical CenterNo fetomaternal complicationsNo history of BreastfeedingEnfapro 6oz/bottle x 12 bottles/dayComplimentary feeding (Cerelac): 6 mos old
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ImmunizationBCG 1 DOSE
HEPA B 2 DOSES
DPT 2 DOSES
OPV 2 DOSES
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Developmental HistoryPresently, sits with support
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Upon arrival ERS>(+) maroon
colored stoolO>pale looking,
irritableHR 106 RR28 clear breath soundssoft abdomen, non tendergood pulses
A>Lower GI bleed t/c Meckel’s Diverticulum
P>lab work up PRBC 10cc/kgpost transfusion Hgb 10.6
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Laboratory ExaminationCBC 7.7/23.4/9090/N16 L79 M5/170,000Retic count 0.35Stool Exam RBC 30-40Fecal occult Blood PositivePT 10.4 INR 0.83 181% PTT 41.8Urinalysis <1.005 ph7.5PBS: microcytic hypochromicNa 139 K 4.6 Cl 102 Ca 9.3
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Laboratory ExamSFA non specific, non obstructive gas patternMeckel's Diverticulum Scintigraphy which
showed radioactive activity on the right lower quadrant which may represent ectopic gastric mucosa.
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Upon arrival at PICUs/p Explore
Laparotomy, Resection of Meckel’s diverticulum with end to end anastomosis
OR findings: 1.5cm Meckel’s Diverticulum approx 25cm from appendix
Estimated Blood Loss <20cc
s/p 160 PRBC (20cc/kg)
P> NPOD5NR x 40cc/hrCefazolin 250mg/IV
(125mkd)Ranitidine 10mg/IV q8Nubain 2mg q6Ketorolac 10mg q6
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Second PICU DayS> no bleedingO>BP 90/60,
afebrile Stable VSCBC
13.7/39/11680/N50 L40 M8 B1/268K
P> transfer to regular room
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Meckel’s Diverticulumremnant of the embryonic yolk sacEmbyonal stage: omphalomesenteric duct
connects the yolk sac to the gut, nutrition5th and 7th wk AOG: duct separates from the
intestineYolk sac + lining epith similar to stomachPartial or complete failure of involution of the
omphalomesenteric duct results in various residual structures.
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FrequencyOccurs in 2–3% of all infantsa 3–6 cm outpouching of the ileum along the
antimesenteric border 50–75 cm from the ileocecal valve
1st 2 years of life, 2.5yo
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ManifestationsIntermittent painless rectal bleeding Stool: brick colored or currant jelly colored. Bleeding: self-limited, contraction of the
splanchnic vesselsr/o acute appendicitisDiverticulitis can lead to perforation and
peritonitis
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DiagnosisMeckel radionuclide scan: IV infusion of
technetium-99m pertechnetate: mucus secreting ectopic gastric mucosa : visualization of the Meckel diverticulum
sensitivity enhanced scan : 85%specificity : 95%. Other methods of detection: abdominal
ultrasound, superior mesenteric angiography, abdominal CT scan, and exploratory laparoscopy.