Stage 1 – Initial assessment

Your next patient is Charlie, a 6 month old girl whose parents 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:

A&E_form.pdf

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, Charlie looks stressed and frightened bu the bright lights and the teenager shouting in the other bay.

The parents ask what you are going to d?

Her mother tells you that she has been looking like this from time to time, 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. This was put down to reflux and she was written up for something that goes in her milk. She had this for a few weeks when she 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 short period 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 husband are well.

During the history taking, Charlie has changed quite a bit – she looks less pale now rather than pale and is now interested in his environment. Her mother has put a dummy (soother) in her mouth. Her dad has gone to pick up the other children from school.

You decide to examine her:

Pale 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       92        g/L
Wcc    12.3 x 10⁹/L
Plats    435 x 10⁹/L
Urea    9.1 mmol/L
Na       143 mmol/L
K         3.5 mmol/L
Creat   35 micromol/L
CRP    21 mg/L
Ca        2.3 mmol/L
PO₄     0.85 mmol/L

What would you like to do now?