Initial assessment

Your next patient is Charlie, a 6 month old girl whose carers have brought her to the children’s emergency department. You are a junior paediatric trainee and have been working all day on this particular shift.

This is the information in the triage nurse’s clerking:

6 month girl. Known GORD. Gaviscon.

Now presents with worse vomiting/not interested in feeds

Active and interested.

AVPU

HR 145/min; RR 35/min; SaO2 95% air; T 37.1 C

Prioritisation:

Waiting area / Cubicles / Resuscitation

You take Charlie from the waiting area into an assessment cubicle and note that she seems quite different from the triage nurse’s report. She is irritable and in pain. She looks pale in addition. Her parents are distraught and ask what you are going to do. Her mother tells you that she has been looking like this every now and then, before recovering. Because of this you take her into one of the cubicles for better monitoring:

RR 38/min; SaO2 96% air; HR 150/min

You decide to find out some more of what has been happening. The mother tells you some more:

She has always been a sicky baby, pretty much since birth. His was put down to reflux and he was written up for something that goes in his milk. He had this for a few weeks when he was younger, but it didn’t make any difference. Now she is careful to keep her daughter upright, and the sickiness has pretty much stopped.

Two few days ago she developed something a bit different. Still vomiting, but more than normal for the reflux, and not really related to posture – she was sick even when sitting up.

There has been little else wrong with her – the vomit is just watery yellow with bits of congealed milk. There has been no diarrhea, or any bowel action at all, and no fever.

The only other different thing is that Charlie from time to time has an spell lasting 5-10 mins where she is in what appears to be much more pain and seems to go pale.

No one else in the family is unwell – she is her mother’s first baby, but both she and her partner are well.

During the history taking, Charlie has changed quite a bit – she looks pink now rather than pale and is now interested in his environment. Her mother has put a

dummy (soother) in her mouth. The man with her has gone to pick up his own children from school.

You decide to examine her:

Pink and active.

RR 35/min, no recession, breath sounds equal.

HR 135/min, CRT 2-3 sec, BP 90/35 mmHg, HS 1 and 2, nil added

Abdomen – tender, mildly distended, active bowel sounds. No obvious masses or obvious organomegally

Neuro – moving all limbs, no obvious deficit.

You are a little surprised to see that the triage nurse has already

taken some blood tests, which are now available. The nurse explains that she has done the training to be able to do this.

Hb 112 g/L

Wcc 12.3 x 109/L

Plats 435 x 109/L