Life Span Development Case Study: Pediatric and Adolescent EMS Assessment

Dispatch Information:
- Unit assigned: Ambulance $5281$
- Response location: $1425$ Washington Avenue
- Patient demographic: $16$ \text{-year-old} female
- Chief complaint: Abdominal pain
Arrival and Initial Scene Dynamics:
- Emergency responders are greeted outside by an anxious father holding his screaming and terrified $2$ \text{-year-old} son.
- Father's distress and initial statement: "My daughter’s upstairs in her bedroom with her mom. I think her appendix burst!"
Initial Patient Presentation:
- Patient position: Found curled in a fetal position on her bedroom floor in obvious physical distress.
- Subjective symptoms: Intense lower abdominal pain accompanied by severe nausea.
- Verbal statement: "My stomach hurts, please help me!"
- Environmental factors: Both parents watching the initial clinical evaluation intently over the responder's shoulder.

Primary Assessment Findings (Recording Time: $0\,\text{minutes}$ ):
- Appearance: Curled in a fetal position, presenting with obvious severe distress.
- Level of Consciousness: Alert to person, place, and day ( $\text{A}$ status on the AVPU scale).
- Airway Status: Open and clear.
- Breathing: Respiratory rate of $24\,\text{breaths/min}$ , showing adequate depth and effort.
- Circulation: Strong radial pulses present at $118\,\text{beats/min}$ ; no external hemorrhaging observed.
Initial Clinical Evaluation Questions:
- Differential Diagnosis Considerations:
- Acute appendicitis.
- Ectopic pregnancy or pregnancy-related complications.
- Ovarian cyst rupture or pelvic inflammatory disease (PID).
- Severe gastroenteritis or urinary tract involvement.
- Patient Interview Strategy:
- Establish rapid rapport using an empathetic and calm tone.
- Maintain sensitivity regarding personal and sexual medical history, recognizing that an adolescent may withhold crucial information in the presence of guardians.
- Vital Sign Interpretation:
- Heart rate of $118\,\text{beats/min}$ represents tachycardia for a $16$ \text{-year-old} female.
- Respiratory rate of $24\,\text{breaths/min}$ represents mild tachypnea for an adolescent.

Focused Physical Assessment Findings:
- Patient repositioned into a position of comfort to facilitate thorough physical examination.
- Pain location: Pain centered in the right-sided lower abdomen.
- Pain severity: Rated as a $9$ on a $0\text{--}10$ visual analog scale.
- Pain radiation: Pain radiates to both the back and the groin.
Medical and Surgical History:
- Past Surgical History: Previous knee surgery performed a few years prior (reported by father).
- Current Medications (reported by father):
- Fexofenadine (prescribed for allergies).
- Albuterol (prescribed for asthma).
Gynecological and Sexual History Interview:
- Menstrual history: Takes extended-cycle birth control pills specifically for menstrual cycle regulation.
- Last Menstrual Period (LMP): Occurred a little less than $2\,\text{months}$ prior to evaluation.
- Pregnancy inquiry: When asked in front of her father if there is any possibility of pregnancy, the patient adamantly denies it.
- Parental reaction: Father expresses offense at the question regarding potential pregnancy.

Secondary Vital Signs (Recording Time: $10\,\text{minutes}$ ):
- Skin: Pale, warm, and moist.
- Pulse: $118\,\text{beats/min}$ .
- Blood Pressure: $130/88\,\text{mm Hg}$ .
- Respirations: $24\,\text{breaths/min}$ .
- $SaO_2$ : $98\%$ on room air.
Secondary Assessment Clinical Questions:
- Refined Differential Diagnosis:
- High suspicion for ruptured ectopic pregnancy given RLQ pain, radiation to groin/back, altered cycle, and tachycardia.
- Acute appendicitis.
- Ovarian torsion or ruptured ovarian cyst.
- Next Steps in Prehospital Treatment:
- Rapid, gentle transport to an appropriate emergency facility.
- Intravenous ( $\text{IV}$ ) line establishment for fluid management and access.
- Continuous monitoring of hemodynamics for potential hemorrhagic shock.
- Transport Management of Guardians:
- Parent should be requested to ride in the front cab of the ambulance rather than the patient compartment. This provides necessary patient confidentiality to reassess sensitive sexual history privately.

Transport Operations:
- Patient loaded into the patient compartment of the ambulance for a $20\text{-minute}$ transport to the local hospital.
- Father requested to ride in the cab (front passenger seat) of the vehicle.
Confidential Re-Interview in Transit:
- Environment: Private assessment conducted in the rear of the ambulance away from family members.
- Re-evaluation: EMS re-addresses sexual history and pregnancy possibility, explaining that accurate truthfulness is vital to her physical health and medical treatment.
- Patient Disclosure: Patient confides that she is sexually active and missed taking a couple of her birth control pills over the preceding few months.
- Patient Statement: "I’m freaking out. I think I’m pregnant and my dad’s going to kill me!"
Treatment and Transfer of Care:
- Psychological Support: Caregivers reassure and calm the patient while providing continuous care.
- Clinical Interventions: Successful initiation of an intravenous ( $\text{IV}$ ) line during transport.
- Emergency Department Arrival: Detailed clinical report handed off to the emergency department nurse.
- Parent Guidance: Partner escorts the patient's father from the cab directly to the emergency department waiting area.

Final Primary Differential Diagnosis:
- Ectopic pregnancy (potentially ruptured or unstable), given the confirmed sexual activity, missed oral contraceptive doses, $2\,\text{month}$ amenorrhea, right lower quadrant abdominal pain radiating to back/groin, pale/moist skin, and tachycardia ( $118\,\text{beats/min}$ ).
Impact of Diagnosis on Emergency Management:
- Prompted private patient re-interviewing, which yielded critical missing history (active sexual history and non-adherence to contraceptives).
- Directs focus toward fluid resuscitation capabilities ( $\text{IV}$ line initiation), rapid transport, and alert monitoring for hypovolemic/hemorrhagic shock secondary to potential intra-abdominal bleeding.