Tommy Acker’s Case Study Assignment Paper
Tommy Acker’s Case Study Assignment Paper
|STUDENT NAME:||DATE OF ASSIGNMENT:|
|Patient Initials: Tommy Acker||Date of Encounter:|
|Sex: Male||Age/DOB/Place of Birth: 26 months old2/5/2017|
|Historian: MotherPresent Concerns/CC: “Stomach ache” (abdominal pain)|
|Child Profile: Listless and ill appearing 26-month-old, male with a history of Downs’s syndrome and ASD repair. The mother states that “normally he is a healthy, very active and playful toddler.” She mentions that he is delayed developmentally due to his Downs syndrome. She states that he does not speak much, says basic words and does not pick things up as quickly as other children. She states that he is clumsy. He is always tripping, falling, or bumping into things as if he does not see that it is there. None of his falls/incidents have resulted in him requiring medical attention. She states that he is normally well-behaved, has a good appetite, drinks an adequate amount of fluids, sleeps well during the night, and does not require much else. He does not go to day care and lives at home with his two siblings and mother. His mother works and their neighbors or mother’s boyfriend babysit the children.|
|HPI:Onset: 2 days ago
Location/Radiation: abdominal pain
Duration: constant; worsening over 2 days
Aggravating factors: being touched
Relieving Factors: none
Tommy, a 26-month-old male with Down syndrome, was brought into the ED by his mother who reports he has been “complaining” of abdominal pain x 2 days, had emesis x 1, is lethargic, sweating, breathing rapidly and has diminished urine output. All symptoms started soon after his “falling out of the bed during his nap.” She denies associated head trauma but claims he is not eating or drinking. She denies prior injuries that required medical attention. PMH is notable for post atrial-septal defect repair with transient CHF as an infant. The child appears listless and pale. Exam reveals hypotension, tachycardia, tachypnea, and signs of dehydration. The abdomen is grossly distended with significant epigastric bruising, in a distribution that is atypical for a fall. It is firm to palpation with diffuse tenderness, guarding and rebound tenderness. A reducible 2.0-cm umbilical hernia is present.
|Medications: None currently.|
|PMH: Normal pregnancy and no complications noted at birth.
Medication Intolerances: None
Chronic Illnesses/Major traumas: Atrioventricular septal defect, transient CHF, heart murmur Denies any trauma
Hospitalizations/Surgeries: Atrioventricular septal defect repair
Immunizations: Immunizations up-to-date; 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
Single-Mother but currently dating 6-month-old sibling’s father. Mother graduated from high school and is employed as a cashier at a local retail shop. She states that she does not make a lot of money and is unable to afford daycare. Her neighbor helps her with childcare and if her neighbor is unavailable, her boyfriend will help her. Her boyfriend does not like to babysit because he claims the children become whiny at the same time and he cannot tolerate it. The mother and the boyfriend both smokes, but “try to keep it away from the kids.” T.A. is exposed to second-hand smoke. She denies the use of any illicit drugs, ETOH, and marijuana. Mother feels safe in community and surrounding neighborhood and feels they have adequate transportation and access to care when necessary.
|Review of Systems (ROS)|
|General:Complains of listlessness, fatigue, lethargy, decreased energy. Denies fever and chills, weight change, and night sweats. Tommy Acker’s Comprehensive Case Study.||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 abdomen. Denies rashes, bleeding or any changes in lesions or moles.||Respiratory:Breathing rate appears more rapid then baseline. Denies cough, shortness of breath, wheezing, hemoptysis, dyspnea, pneumonia history, TB, or sputum production.|
|Eyes:Denies 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, nose bleeds, nasal discharge, or dental disease.||Musculoskeletal:Denies back pain, joint swelling, stiffness or pain, fracture history, osteoporosis|
|Breast:Deferred.||Neurological:Developmentally delayed related to Downs Syndrome, poor verbal communication. Denies syncope, seizures, transient paralysis, weakness, paresthesia’s, black out spells, gait abnormality or tremors.|
|Heme/Lymph/Endo:Complains of bruising but denies blood disorders, night sweats, increase thirst, swollen lymph-nodes, palpable masses, increase hunger, cold or heat intolerance.||Psychiatric:Complains of fussiness x2 days. Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts.|
|OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart|
|Weight 22lbs. (<5th Percentile)BMI: 19.7 (97th percentile)||Temp 97.9||BP 68/40|
|Height 2’ 4”||Pulse 140||Resp 50|
|OBJECTIVE (Physical Examination)|
|General Appearance and parent-child interaction: Lying still on exam table sucking thumb. Appears to be an ill, listless, and lethargic 26-month-old male with poor eye contact, tachycardia and rapid breathing. He is lying on exam table, his skin is pale, cool, and clammy. He is of an appropriate weight and is afebrile at this time.|
|Skin: Skin is pale, cool, clammy, and slightly mottled. A thoracotomy scar is consistent with heart surgery. Diffused diaper rash, faint circumferential macular discoloration on bilateral wrist consistent with aging ligature marks. Bruises is various stages of healing noted|
|HEENT: 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. PERRLA (pupils equal, round, reactive to light and accommodation) 4mm, upward slanting with small skin folds on inner corners. Extraocular Movements intact.
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 is present. Capillary refill delayed at 4 seconds. Pulses weak throughout. No edema.|
|Respiratory: tachypnea noted with symmetric chest wall with inspiration and expiration. Respirations non-labored; lungs clear to auscultation bilaterally.|
|Gastrointestinal: Tommy Acker’s Comprehensive Case Study. The abdomen is grossly distended with significant epigastric bruising, in a distribution that is atypical for a fall. It is firm to palpation with diffuse tenderness, guarding and rebound tenderness. A reducible 2.0-cm umbilical hernia is 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 19000 Head CT
CMP Skeletal Survey
PT/INR CT abd/pelvis with IV contrast
Venous blood gas
Serum Lactic acid
|Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)
Age Appropriate: Vital signs assessment tool. Faces Pain Scale (1-5)
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 Tommy Acker’s Comprehensive Case Study.
Activities: on average: active and energetic, enjoys playing with age-appropriate toys and siblings.
Drugs: 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 and wears helmet when riding bicycle.
|1. Traumatic intra-abdominal organ injury (S36.899A): Trauma is the leading cause of morbidity and mortality in the pediatric population. The abdomen is the third most commonly injured anatomic region in children, after the head and the extremities (Christian & Greenbaum, 2015). Abdominal trauma can be associated with significant morbidity and may have a mortality as high as 8.5% (CDC, 2019). More than 80% of traumatic abdominal injuries in children result from blunt mechanisms; most commonly, they are related to motor vehicle accidents. However, in T.A. his mother’s boyfriend punching him in his abdomen most likely caused his duodenal hematoma.2. Systemic Inflammatory Response Syndrome (SIRS [R65.10]): SIRS can be caused by ischemia, inflammation, trauma, infection, or several insults combined. The diagnosis of SIRS depicts a clinical response to a nonspecific insult of either infectious or noninfectious origin. SIRS is defined as 2 or more of the following criteria: Fever of more than 100.4°F or less than 96.8°F, heart rate of more than 140 beats per minute, respiratory rate of more than 30 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32 mm Hg, or abnormal white blood cell count, systolic blood pressure ,75mmHG (Kaplan, 2018). T.A. had a WBC count of 19000, his heart rate was 160, SBP 68, and he was tachypneic at fifty breaths per minute, thus, meeting more than two criteria for SIRS.
3. Child Abuse: Act of Commission (T74.12XA): According to the Centers for Disease Control (CDC), physical, sexual, neglect, and emotional abuse are the four common types of abuse and neglect (CDC, 2019). Neglect is defined as the failure to meet a child’s basic physical and emotional needs, including food, shelter, clothing, education, and access to medical care (CDC, 2019). Physical abuse is intentionally using physical force that may result in injury, such as, hitting, kicking, burning, or shaking of a child (CDC, 2019). Emotional abuse refers to the behaviors that harm a child’s self-worth or emotional well-being, such as shaming, rejection, or withholding love or affection (CDC, 2019). Abuse can come from several individual, family, societal, and environmental factors. In the situation with T.A., the mother was neglecting her children to be able to provide basic needs for them, while depriving them of education and exposing them to physical abuse from her boyfriend. Tommy’s injuries also do not match up to the stories his mother is reporting, and she seemed to take some time to bring him in to be evaluated and became defensive when possible questions that may point toward abuse were asked Tommy Acker’s Comprehensive Case Study.
4. Volvulus (K56.2): Volvulus can vary in presentation from vague, recurrent gastrointestinal discomfort to sudden onset of an acute abdomen with associated shock symptoms (Saxena, 2017). It may present in any age group and is not associated with traumatic injury. More often it occurs as a result of a congenital malrotation of the midgut (Saxena, 2017).
|PLAN including education|
|Initial resuscitation and stabilization protocol:
1. Assess airway, circulation and breathing. Provide oxygen for hypoxia.
2. Place on continuous cardiac monitor, continuous pulse oximetry, and monitor vital signs Tommy.
3. Place two large-bore intravenous lines to administer isotonic fluid boluses as they are needed.
4. Complete Primary (airway, breathing, circulation, disability, and exposure) and secondary (head-toe exam) surveys (Kaplan, 2018).
T.A. is a child that is critically-ill. He will require further testing such as a CT scan of his abdomen and pelvis with contrast and an emergent surgical consult. He will also be admitted to the intensive care unit for further management. It is important to contact child protective services, police, and social-work personnel as needed.
*ALL references must be Evidence Based (EB)
Evaluation of Case – Tommy Acker’s Case Study Assignment Paper
Tommy Acker’s case study was an especially depressing situation. Tommy is a non-verbal toddler with Downs Syndrome and a cardiac history. His mother is a single mother with three young children. She is a high school graduate and currently works as a cashier at a retail store. She does not make enough money to send her children to daycare, so she depends on the assistance of her neighbor and her boyfriend for child care. According to the Centers of Disease Control (CDC), children with disabilities are at higher risk for abuse or neglect compared to children without disabilities due to the perceived, extra demands a special-needs child places on a family (CDC, 2019). Signs of abuse include behavioral changes, cuts, bruises, or broken bones in various stages of healing, dirty hair, clothing, or diaper rash (Burns, Dunn, Brady, Starr, Blosser, Garzon, 2017).
Tommy’s assessment revealed a diffuse diaper rash, bruises, a firm, distended abdomen, and his mother reported his behavior had changed within the last two days after falling from his bed during a nap. He is found to be critically ill requiring an emergent surgical consult, from bleeding or injury caused by blunt force trauma to his abdomen (iHuman, 2017). Tommy’s father is not involved in his life and his mother is frequently absent due to working to support her children. He is exposed to second hand smoke, he has dental caries, and his scans show various broken ribs in different stages of healing Tommy Acker’s Comprehensive Case Study. His mother waited two days to bring him in for an evaluation, thus, delaying him care and allowing his condition to deteriorate (Christian & Greenbaum, 2015). Therefore, child abuse and neglect belong in Tommy’s diagnosis list.
According to the Centers for Disease Control (CDC), physical, sexual, neglect, and emotional abuse are the four common types of abuse and neglect (CDC, 2019). Neglect is defined as the failure to meet a child’s basic physical and emotional needs, including food, shelter, clothing, education, and access to medical care (CDC, 2019). Physical abuse is intentionally using physical force that may result in injury, such as, hitting, kicking, burning, or shaking of a child (CDC, 2019). Emotional abuse refers to the behaviors that harm a child’s self-worth or emotional well-being, such as shaming, rejection, or withholding love or affection (CDC, 2019). Abuse can come from several individual, family, societal, and environmental factors. In the situation with T.A., the mother was neglecting her children to be able to provide basic needs for them, while depriving them of education and exposing them to physical abuse from her boyfriend.
Trauma is the leading cause of mortality in the pediatric population. The abdomen is the third most commonly injured anatomic region in children, after the head and the extremities (Christian & Greenbaum, 2015). This is because a child’s anatomy is different of that of an adult. Children’s major organs are larger in size so more surface area is exposed in a child versus an adult (Saxena, 2017). Abdominal trauma can be associated with significant morbidity and may have a mortality as high as 8.5% (CDC, 2019). More than 80% of traumatic abdominal injuries in children result from blunt mechanisms; most commonly, they are related to motor vehicle accidents. However, in Tommy’s situation, his mother’s boyfriend punching him in his abdomen most likely caused his duodenal hematoma.
Tommy also is diagnosed with Systemic Inflammatory Response Syndrome (SIRS). SIRS can be caused by ischemia, inflammation, trauma, infection, or several insults combined (Kaplan, 2018). The diagnosis of SIRS depicts a clinical response to a nonspecific insult of either an infectious or a noninfectious origin. Tommy’s mental status, clammy skin, and deteriorating condition direct the provider to consider this as a diagnosis. SIRS is defined as 2 or more of the following criteria: Fever of more than 100.4°F or less than 96.8°F, heart rate of more than 140 beats per minute, respiratory rate of more than 30 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32 mm Hg, or abnormal white blood cell count, systolic blood pressure ,75mmHG (Kaplan, 2018). Tommy had a WBC count of 19000, his heart rate was 160, SBP was 68, and he was tachypneic at fifty breaths per minute, thus, meeting more than two criteria for SIRS. This indicates the need to stabilize this child by inserting two large bore intravenous lines so isotonic fluid boluses may be administered if necessary (Kaplan, 2018) .
A differential diagnosis to consider is a volvulus, because it is a must-not miss-diagnosis, and Tommy’s symptoms and age align with this as a possibility. Volvulus can vary in presentation from vague, recurrent gastrointestinal discomfort to sudden onset of an acute abdomen with associated shock symptoms (Saxena, 2017). It may present in any age group and is not associated with traumatic injury. More often it occurs as a result of a congenital malrotation of the midgut (Saxena, 2017).
Tommy is predisposed to abuse, and neglect based on his age as well as, the fact that he has a disability. Schilling and Christian (2014) mention that a multidisciplinary approach including social workers, nurses, psychologists, communities, police, and pediatricians can help to prevent abuse. First, a report of abuse must be made, and it must be investigated following the state and facility’s appropriate steps (Schilling & Christian, 2014) Tommy Acker’s Comprehensive Case Study. Hagan, Shaw, and Duncan (2017) state that aggressive therapy and early interventions can help reduce trauma when a child experiences neglect and abuse at a young age. Tommy was stabilized, emergent surgery was consulted, and he will be admitted to the intensive care unit for continuous monitoring of his hemodynamic status, provided oxygen, and an aggressive fluid replacement protocol will be initiated all in an effort to save his life (iHuman, 2017).
References for Tommy Acker’s Case Study Assignment Paper
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
Schilling S, Christian C. (2014). Child physical abuse and neglect. Child and Adolescent Psychiatric Clinics of North America. 2014; 23(2):309-319.
Children with disabilities may be at higher risk for abuse or neglect than children without disabilities. Signs of abuse are sudden changes in behavior or unusual behavior, cuts, and bruises or broken bones (not due to a medical condition). Possible signs of neglect are dirty hair or skin, constant hunger or thirst without a known cause, and diaper rash not caused by a medical condition (Burns, Dunn, Brady, Starr, Blosser, Garzon, 2017).Tommy had a diffuse diaper rash, and his behavior had changed according to his mother Tommy Acker’s Comprehensive Case Study.
Data collected by the Department of Health and Human Services (2012), reported that 13.3 percent of abused children had some disability. In a review of the literature, it was estimated at approximately 1 in 4 or 26.7 percent of disabled children will be a victim of violence. Of those, 20.4 percent will be victims of physical violence and 13.7 percent victims of sexual violence (Child Maltreatment, 2012). It is alarming at how disabled children are abused more, but it is believed that this is due to the extra demands a disabled child places on the family Tommy Acker’s Comprehensive Case Study.
Recognizing the clinical presentation of a child with abusive injuries is crucial. It is evident that the patient is extremely ill; however, the mother waited 2 days to bring him in for medical attention. He has ligature marks to both wrists as well as a large bruise to his abdomen Tommy Acker’s Comprehensive Case Study. Upon evaluation of his skeletal survey, the patient has had multiple rib fractures that his mother never mentioned. Abdominal trauma is the second most common cause of death in children who have been abused. The diagnosis and management of these injuries require careful consideration (Yu, Ngo, and Goldstein, 2016). By T.A. having developmental delays, chronic illnesses, and having special needs, these all predispose him to abuse.
One of the primary diagnoses in this particular case is abuse. The chest and abdominal x-ray showed evidence of multiple fractures in different stages of healing which definitively supports this diagnosis. There is an inconsistency between the reported cause of the abdominal injury “fell out of the bed” and the proven presentation of the trauma. In addition, the delay in seeking health attention and the ligature marks on patient wrists are clear evidences of abuse.
Another final diagnosis must be blunt abdominal trauma due to child abuse. According to the CT scan of the abdomen, Tommy has a large central area of edema inclusive of a collection of blood, marked bowel distension, findings consistent with a duodenal hematoma. Tommy Acker’s Comprehensive Case Study He will be admitted to the ICU, and a call will be placed to Child Protective Services to report the abuse. He will need IV fluids for his shock, a surgical consult and continuous monitoring.
I also consider Systemic Inflammatory Response Syndrome (SIRS) as a primary diagnose due to the signs of fluid volume deficit and hypoperfusion such as hypotension; tachycardia; increased respiratory rate; dark and strong-smelling urine; decreased urinary output; lethargy; decreased energy; cool, clammy, and pale skin are present in this patient along with abnormal WBC count (Kaplan, 2018).
The differential diagnosis of incarcerated hernia should not be missed since a 2.0 cm umbilical hernia is found on PE, but this is reducible. This condition causes a severe acute abdominal pain, generalized abdominal distension, overlying skin changes and signs of shock. The most important thing is to rule out a vascular involvement of a hernia. In the cases of strangulation, the skin appears hard and painful, may appear ecchymosis, phlegmon or even fistulation in advanced stages. The hernia strangulation is usually accompanied by an important systemic manifestation, with vomiting, in part by the vagal component and partly by the occlusion, abdominal pain that usually accompanies of distension, an important affectation of the general state being able to arrive at the shock. Early diagnosis is very important since incarcerated hernias can be life threatening if left untreated. (Millet et al., 2014).
Hirschsprung disease should also be considered as a differential diagnosis because he did vomit, and this happens in children with Down syndrome but with the absence of chronic vomiting, constipation and abdominal obstruction it was ruled out (Burn et al. 2017) .
Volvulus is a condition that should also be considered as a differential diagnosis since it causes an acute bowel obstruction which is presented with abdominal pain, but this cramping in character, not constant like TA’s pain, also it is associated with vomiting, signs of dehydration, abdominal distension with tympanic sounds at percussion. The acute form present as an acute abdomen associated with abdominal distension, nausea and vomiting, absence of stools and expulsion of gases via anal. In the digestive tract, a volvulus refers to a structure that rolls abnormally over its meso and its symptoms result from the occlusion of the intestinal lumen (obstruction in closed loop) and blood supply (ischemia-gangrene)(Millet, Orliac, Alili, Guillon, & Taourel, 2014).
The approach to the battered child syndrome is complex. The development of protective laws for children and multidisciplinary teams with pediatricians, psychologists, nurses, and social workers among others, is necessary to fight against this social scourge. The first step is the mandatory report. Tommy Acker’s Comprehensive Case Study. This case illustrates the need to maintain a high degree of suspicion regarding an unconvincing explanation of the family, which does not correspond to the severity of the trauma or the presence of associated lesions at different stages of evolution Fractures of the skull, long bones, ribs, and retinal hemorrhages in the examination of the fundus are frequently associated with child maltreatment; however, its absence does not exclude the diagnosis, as happened in our case. As with the multiple trauma of other etiologies, therapeutic aggressiveness, and early intervention, if any, contribute to reducing morbidity and mortality (Child Maltreatment, 2012). The aggressive management of our critically ill patient, with admission to ICU, continuous cardiac monitoring, oxygen supplementation, aggressive hydration with IV fluids, was undoubtedly a determining factor in his survival.
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.
Kaplan, L. J. (2018). Systemic Inflammatory Response Syndrome. Retrieved from
Millet, I., Orliac, C., Alili, C., Guillon, F., & Taourel, P. (2014). Computed tomography findings of acute gastric volvulus. European Radiology, 24(12), 3115-22.
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.
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