Description

T.A. is a 26-month-old male with a PMH pertinent for Downs syndrome, ASD (repaired), and CHF who presents with his mother reporting onset of abdominal pain 2 days ago with vomiting x1 yesterday. She also reports poor appetite/fluid intake, decreased diaper count with dark, foul-smelling urine, lack of BM x 2 days, and increased fussiness. Denies fever, dyspnea, and diarrhea. She endorses a recent fall from bed but denies head trauma and other injuries. Child appears lethargic and withdrawn. Exam reveals pale, mottled, cool/ clammy skin, hypotension, tachycardia, tachypnea, hypoactive bowel sounds, and indications of dehydration. Capillary refill is 3-4 seconds. Abdomen is firm, distended, and diffusely tender on palpation with rebound tenderness, involuntary guarding, and rebound tenderness. A 10cm oval epigastric ecchymosis area is appreciated. A reducible 2.0 cm umbilical hernia and diffuse diaper rash were noted. Evidence of faint circumferential macular discoloration at wrists, suspicious of aging ligature marks is of concern.