Intern Case Discussion 2.4

intern-report

 

 

Presented by Debia Kim, MD

Case

CC: Abdominal pain, nausea, and diarrhea
HPI: 9 y/o boy who was recently diagnosed with DM1 (2 months ago) presents to the ED with 7 days of waxing and waning vomiting and diarrhea associated with persistent nausea.  Today his abdominal pain is more severe.  Mom says he vomited 5 times yesterday and 4 times this morning before coming to the ED.  The vomitus was clear and not associated with coughing or eating.  He also has brown diarrhea.  He had 3 episodes yesterday and 4 this morning.     A crampy and stabbing generalized abdominal pain varies from a 5 to a 10 out of 10 in severity and is persistently present.  His appetite and activity are decreased.  He denies fever/chills, headache, dysuria, frequency, hematuria, cough and rash.  One week prior to his current presentation the patient was evaluated in Endocrine clinic, where he was told his blood work was “normal.”  Four days prior to his current presentation, he was evaluated at another ED and was dischared home with a prescription for ondansetron and recommended to follow at Children’s Hospital if his pain persisted and concern for possible appendicitis.

PMH: DM diagnosed 2 months ago when he presented in DKA.
PSH: None
Medications: Lantus 8 units subq qhs, zofran prn
Allergies: NKDA
Immunizations UTD
FH: htn
SH: lives with mom, dad, siblings, no smokers in the home.  He is in 3rd grade, doing well at school.

Exam:
VS – BP 125/70, HR 80, RR 30, T 36.6 (temporal), 98% on RA
Constitutional – alert, cooperative male in NAD, well-hydrated
HEENT – NCAT, PERRL bilaterally, EOMI, sclera noninjected, oral mucosa moist without lesions,     no posterior pharyngeal erythema, TMs are clear bilaterally.
Neck – supple, no meningismus, no lymphadenopathy
CV – RRR, +S1, +S2 without murmurs/rubs/gallops.  Cap refill < 2 sec.
Resp – CTAB, no rales, wheezes, rhonchi
Abd – soft, flat, ND, +BS everywhere.  +mild tenderness to palpation in RUQ.  No rebound, no     guarding.  Negative Murphy’s, negative Rovsing, no tenderness at McBurney’s point.  No     palpable masses, no flank/CVA tenderness.
Rectal – No stool present in the rectal vault, hemeoccult negative.
Genitalia – normal external male genitalia with descended testicles bilaterally
Extremities – warm, dry, 2+ pulses x all 4 ext.  FROM, no tenderness, swelling, no rashes.

Lab Results:
cbg 7.33/35/74.3/18/97%, lactate 1.8
10.1>13.7/38.5<340
139/4/108/21/9/0.6<125
serum acetone neg
serum Osm 295
Ca 10.2
Mag 1.8
Phos 4.5
ALT/AST 33/27
stool cx neg
rotavirus neg
U/A: LE neg, nitrite neg, glucose neg, ketones neg, bili neg, protein neg, RBC

Diagnostic Studies
Abd Xray: Nonspecific bowel gas pattern, with a few air-fluid levels seen in nondilated loops of small bowel on the right.
Abd US: Multiple prominent mesenteric lymph nodes with no sonographic evidence of appendicitis.

Questions

A. What is the most likely diagnosis?

  1. Early appendicitis
  2. Gastroenteritis
  3. Diabetic Ketoacidosis
  4. Cyclical Vomiting Syndrome
  5. Inflammatory Bowel Disease

B.  True or false: this patient may benefit from an anti-motility agent and early attempts at solid food intake
True
False

C.  Which of the following anti-emetic drugs works both centrally in the vomiting center and peripherally in the afferent visceral nervous fibers?

  1. Prochlorperazine
  2. Diphenhydramine
  3. Ondansetron
  4. Meclizine
  5. Marinol

Answers

Gastroenteritis
True
Ondansetron

Discussion

Patients who present to the ED with vomiting, diarrhea, and nausea generate a huge differential diagnosis.  Gastrointestinal dysfunction is often the final common pathway for many disease processes.  A complete and thorough history is usually the best tool for narrowing the diagnosis.  Evaluating female patients with these symptoms warrants the clinician to also think about obstetrical and gynecologic etiologies.  After the initial ABCs are addressed in an acutely ill patient, treatment must be focused on the underlying disease causing the symptoms.  In patients who have unclear diagnoses, a safe discharge must involve confidence in a non life-threatening cause of diarrhea/nausea/vomiting and a PO challenge with reliable follow-up in case symptoms return.

Our patient, given his age group and past medical history, necessitates the inclusion of DKA and appendicitis in his differential diagnoses.  However, his history and physical exam suggest abdominal pain secondary to the vomiting and diarrhea (rather than vomiting and diarrhea secondary to pain and appendicitis) and his laboratory studies do not demonstrate ketosis (normal anion gap and urinalysis).  The lack of blood in the stool as well as certain other extra-intestinal manifestations of IBD are absent as well.  Although past medical literature suggests that giving an anti-motility agent in a patient with serious infectious diarrhea (Shigella) increased mortality, current studies on traveler’s diarrhea demonstrate that loperamide and antibiotics often shorten duration of symptoms.  Similarly, early solid food intake also has been shown to expedite the recovery from diarrheal illness as long as the patient is not continually nauseated and is properly counseled on the avoidance of lactose, sorbitol, and caffeine-containing foods/liquids.  The viscera is richly ennervated with vagal afferent nerves, which respond to 5-HT3 (serotonin) agonists.  Ondansetron is the only 5-HT3 receptor agonist listed in the answer choices that works both centrally in the vomiting center and peripherally in the afferent visceral nervous fibers

Clinical Pearls

  • Be sure to ask the patient what they specifically mean by the terms “diarrhea” and “vomiting” — for many patients, “diarrhea” is when they have soft stools or maybe more than one stool per day and “vomiting” may simply mean “coughing up sputum.”
  • Most true diarrheal emergencies in the US ( eg GI bleeds, thyroid storm, mesenteric ischemia, toxicologic exposures, etc, are noninfectious.
  • Don’t let your diarrhea patients rehydrate with juice or milk.

This case discussion presented by Dr Debia Kim

Intern Report Case Presentation 2.4

intern-report

Presented by Debia Kim, MD

Case

CC: Abdominal pain, nausea, and diarrhea
HPI: 9 y/o boy who was recently diagnosed with DM1 (2 months ago) presents to the ED with 7 days of waxing and waning vomiting and diarrhea associated with persistent nausea.  Today his abdominal pain is more severe.  Mom says he vomited 5 times yesterday and 4 times this morning before coming to the ED.  The vomitus was clear and not associated with coughing or eating.  He also has brown diarrhea.  He had 3 episodes yesterday and 4 this morning.     A crampy and stabbing generalized abdominal pain varies from a 5 to a 10 out of 10 in severity and is persistently present.  His appetite and activity are decreased.  He denies fever/chills, headache, dysuria, frequency, hematuria, cough and rash.  One week prior to his current presentation the patient was evaluated in Endocrine clinic, where he was told his blood work was “normal.”  Four days prior to his current presentation, he was evaluated at another ED and was dischared home with a prescription for ondansetron and recommended to follow at Children’s Hospital if his pain persisted and concern for possible appendicitis.

PMH: DM diagnosed 2 months ago when he presented in DKA.
PSH: None
Medications: Lantus 8 units subq qhs, zofran prn
Allergies: NKDA
Immunizations UTD
FH: htn
SH: lives with mom, dad, siblings, no smokers in the home.  He is in 3rd grade, doing well at school.

Exam:
VS – BP 125/70, HR 80, RR 30, T 36.6 (temporal), 98% on RA
Constitutional – alert, cooperative male in NAD, well-hydrated
HEENT – NCAT, PERRL bilaterally, EOMI, sclera noninjected, oral mucosa moist without lesions,     no posterior pharyngeal erythema, TMs are clear bilaterally.
Neck – supple, no meningismus, no lymphadenopathy
CV – RRR, +S1, +S2 without murmurs/rubs/gallops.  Cap refill < 2 sec.
Resp – CTAB, no rales, wheezes, rhonchi
Abd – soft, flat, ND, +BS everywhere.  +mild tenderness to palpation in RUQ.  No rebound, no     guarding.  Negative Murphy’s, negative Rovsing, no tenderness at McBurney’s point.  No     palpable masses, no flank/CVA tenderness.
Rectal – No stool present in the rectal vault, hemeoccult negative.
Genitalia – normal external male genitalia with descended testicles bilaterally
Extremities – warm, dry, 2+ pulses x all 4 ext.  FROM, no tenderness, swelling, no rashes.

Lab Results:
cbg 7.33/35/74.3/18/97%, lactate 1.8
10.1>13.7/38.5<340
139/4/108/21/9/0.6<125
serum acetone neg
serum Osm 295
Ca 10.2
Mag 1.8
Phos 4.5
ALT/AST 33/27
stool cx neg
rotavirus neg
U/A: LE neg, nitrite neg, glucose neg, ketones neg, bili neg, protein neg, RBC

Diagnostic Studies
Abd Xray: Nonspecific bowel gas pattern, with a few air-fluid levels seen in nondilated loops of small bowel on the right.
Abd US: Multiple prominent mesenteric lymph nodes with no sonographic evidence of appendicitis.

Questions

A. What is the most likely diagnosis?

  1. Early appendicitis
  2. Gastroenteritis
  3. Diabetic Ketoacidosis
  4. Cyclical Vomiting Syndrome
  5. Inflammatory Bowel Disease

B.  True or false: this patient may benefit from an anti-motility agent and early attempts at solid food intake
True
False

C.  Which of the following anti-emetic drugs works both centrally in the vomiting center and peripherally in the afferent visceral nervous fibers?

  1. Prochlorperazine
  2. Diphenhydramine
  3. Ondansetron
  4. Meclizine
  5. Marinol

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

Intern Report Case Discussion 2.3

intern-report

Presented by Aimee Nefcy, MD

Case

An 18-month female is brought to the ED by her parents, who state that less than one hour ago they took some coins away from her. They think she may have swallowed one of the coins.  There is no history of gasping, choking, or coughing, and they deny any drooling or crying. No fever, nausea, vomiting, or diarrhea. The child is refusing to drink fluids, but otherwise seems like her normal self

ROS: negative except for as noted in HPI.

PMH: bronchiolitis at age 6mo and hearing impairment

Birth history: full-term, uncomplicated vaginal delivery, birth weight 3.7kg

Meds: none, Allergies: NKDA

FH: asthma in her father

SH: no smoke exposure, does not attend daycare, working smoke detectors

PE: vitals: T 36.8, HR 104, RR 28, Pulse ox 99% RA

General: WN/WD, smiling, playful, active in room

HEENT: PERRL, EOMI, no conjunctival pallor/injection, clear TMs visualized B/L after removal of hearing aids, no nasal discharge, MMM, throat no erythema/exudates, no CLAD, no tenderness to palpation of neck, which is supple. No FB is visualized on examination of the throat.

Respiratory: no tachypnea/retractions/nasal flaring, lungs CTA B/L, no wheezes/stridor/rhonchi/crackles.

Cardiac: RRR, S1 & S2 heard, no M/R/G, pulses 2+ and symmetric

GI: +BS, soft, NT/ND, no masses/organomegaly

GU: normal external genitalia, no lesions/erythema

Musculoskeletal: no cyanosis/clubbing/edema, limbs are atraumatic/nontender

Neurological: cranial nerves grossly intact, no sensory or motor deficits

Skin: warm and dry, no rashes

An x-ray is obtained and is shown below.

_____________________________________________________________________________________________

Questions

1) Based solely on the x-ray, the most likely location is?

a. cannot tell without a lateral view

b. esophagus

c. oropharynx

d. stomach

e. trachea

2) What is the most appropriate course of action?

a. attempt direct visualization by laryngoscopy after appropriate sedation

b. oral fluid challenge and discharge home if tolerated

c. repeat x-ray at 12-24hrs post ingestion to make sure it has passed into the stomach

d. stat surgery consult for emergent endoscopy

e. surgery consult for admission and endoscopy in the morning

3) Which of the following excludes an expectant course of action in foreign body ingestion?

a. an asymptomatic patient

b. an object 5cm long in the stomach

c. an object still in the esophagus after 20hrs

d. a patient suspected of body packing with positive x-ray findings

e. a linear cluster of small, round objects in the small intestinesIntern Report

Answers:

1) b. esophagus

2) d. stat surgery consult for emergent endoscopy

3) e. a linear cluster of small, round objects in the small intestines

Discussion:

Flat, round objects in the esophagus are more likely to be oriented in the coronal plane, and therefore appear circular on AP films and edge-on on lateral films. Those in the trachea are more likely to be oriented sagittally. A history of ingestion, a lack of respiratory symptoms, and symptoms of dysphagia are not sufficient to place the object in the esophagus.

The most appropriate course of action in this case is emergent endoscopy. Although the history points towards ingestion of a coin, the x-ray findings are more consistent with a button battery. Button batteries can be differentiated from coins based on the “halo sign” – a lucent border at the edge of the circle – and a “stacked coins” appearance on lateral views. This child also has a source for the battery; her hearing aids. The National Button Battery Ingestion Hotline and Registry study found that 45% of button batteries ingested were from hearing aids, and 33% of those were removed by a child from their own hearing aid; most patients were 1-2 years old. If the object had been a coin, the correct answer would have been to repeat the x-ray, since blunt objects like coins pass spontaneously into the stomach in one-third of patients within 24hrs, and once in the stomach will likely pass completely without intervention. Only coins that remain in the esophagus after 24hrs require further intervention.

An expectant course of action is excluded by:

  • Objects in the esophagus 24hrs after ingestion or with an unknown time of ingestion, as these are unlikely to advance
  • Objects longer than 6-10cm, even if they are in the stomach, as they are unlikely to pass the duodenum
  • Symptomatic patients, especially those with airway compromise and inability to swallow secretions, but also those with fever, abdominal pain, or vomiting
  • Sharp objects, even those in the esophagus, as they can cause perforation and subsequent mediastinitis and GI bleeding
  • Magnets, which appear as a linear cluster of small, round objects. Magnets attract across intestinal walls and can cause pressure necrosis and perforation, and therefore require surgical retrieval even if the patient is asymptomatic
  • Button batteries, which create current and release corrosive chemicals when casing is degraded by stomach acids, can cause liquefactive necrosis and perforation; retrieval should always be attempted by endoscopy prior to passage into the duodenum
  • Body packers who show signs of intestinal obstruction or toxicity due to rupture of packets; otherwise, asymptomatic patients can be managed expectantly or with WBI

Below is the lateral x-ray, obtained after the battery-like appearance of the “coin” was noted

References:
Della-Giustina D, Kilcline BA, Denny M. Back pain: cost-effective strategies for Distinuishing between benign and life-threatening causes. Emergency medicine Practice February 2000

Reihsaus E, Waldbaur H, Seeling W. Neurosurg Rev. 2000 Dec;23(4):175-204

Leslie SW. Nephrolithiasis: Acute Renal Colic. Emedicine

Sexton DJ. Epidural abscess. upToDate
Lin M. Musculoskeletal Back Pain. Rosen’s Emergency Medicine. Philadelphia: Mosby; 2010: 591-603

This case discussion presented by Dr Aimee Nefcy

Intern Report Case 2.3

intern-report

Presented by Aimee Nefcy, MD

Case

An 18-month female is brought to the ED by her parents, who state that less than one hour ago they took some coins away from her. They think she may have swallowed one of the coins.  There is no history of gasping, choking, or coughing, and they deny any drooling or crying. No fever, nausea, vomiting, or diarrhea. The child is refusing to drink fluids, but otherwise seems like her normal self

ROS: negative except for as noted in HPI.

PMH: bronchiolitis at age 6mo and hearing impairment

Birth history: full-term, uncomplicated vaginal delivery, birth weight 3.7kg

Meds: none, Allergies: NKDA

FH: asthma in her father

SH: no smoke exposure, does not attend daycare, working smoke detectors

PE: vitals: T 36.8, HR 104, RR 28, Pulse ox 99% RA

General: WN/WD, smiling, playful, active in room

HEENT: PERRL, EOMI, no conjunctival pallor/injection, clear TMs visualized B/L after removal of hearing aids, no nasal discharge, MMM, throat no erythema/exudates, no CLAD, no tenderness to palpation of neck, which is supple. No FB is visualized on examination of the throat.

Respiratory: no tachypnea/retractions/nasal flaring, lungs CTA B/L, no wheezes/stridor/rhonchi/crackles.

Cardiac: RRR, S1 & S2 heard, no M/R/G, pulses 2+ and symmetric

GI: +BS, soft, NT/ND, no masses/organomegaly

GU: normal external genitalia, no lesions/erythema

Musculoskeletal: no cyanosis/clubbing/edema, limbs are atraumatic/nontender

Neurological: cranial nerves grossly intact, no sensory or motor deficits

Skin: warm and dry, no rashes

An x-ray is obtained and is shown below.

_____________________________________________________________________________________________

Questions

1) Based solely on the x-ray, the most likely location is?

a. cannot tell without a lateral view

b. esophagus

c. oropharynx

d. stomach

e. trachea

2) What is the most appropriate course of action?

a. attempt direct visualization by laryngoscopy after appropriate sedation

b. oral fluid challenge and discharge home if tolerated

c. repeat x-ray at 12-24hrs post ingestion to make sure it has passed into the stomach

d. stat surgery consult for emergent endoscopy

e. surgery consult for admission and endoscopy in the morning

3) Which of the following excludes an expectant course of action in foreign body ingestion?

a. an asymptomatic patient

b. an object 5cm long in the stomach

c. an object still in the esophagus after 20hrs

d. a patient suspected of body packing with positive x-ray findings

e. a linear cluster of small, round objects in the small intestines

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.