Clinical case study of a 9 yr patient
A patient of 9 year old complaint if anorexia nausea vomiting and abdominal pain.
child awoke in the morning.
In afternoon she noted a sudden onset of abdominal pain particularly at her epigastrium as well as her right lower abdomen and right shoulder..
pain exaggerated by movements.
subjective fever , malaise progressive discomfort are her complains.
no history of chronic abdominal pain or non steroidal anti inflammatory drug use..
no family history if inflammatory bowel disease
She was febrile to 102.9 and tachycardia to135.
BP and respiratory status are normal
chest and heart exams were unremarkable..
right shoulder had a full range of motion and demonstrated no evidence of trauma..
patient manifested a notable leukocytosis to 20 with an associated left shift
ultrasound revealed free fluid in the pelvis
CT scan confirmed pneumoperitoneum but without extravasation of contrast..
thickened dilated loops of bowel were noted in right lower quadrant with the fluid
no clear source of perforation was identified..
on leproscopy purulent ascites were noted....
X ray showing pneumoperitoneum is given..
what is the presumptive diagnosis?????