Presented by Debia Kim, MD
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.
Medications: Lantus 8 units subq qhs, zofran prn
SH: lives with mom, dad, siblings, no smokers in the home. He is in 3rd grade, doing well at school.
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.
cbg 7.33/35/74.3/18/97%, lactate 1.8
serum acetone neg
serum Osm 295
stool cx neg
U/A: LE neg, nitrite neg, glucose neg, ketones neg, bili neg, protein neg, RBC
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.
A. What is the most likely diagnosis?
- Early appendicitis
- Diabetic Ketoacidosis
- Cyclical Vomiting Syndrome
- Inflammatory Bowel Disease
B. True or false: this patient may benefit from an anti-motility agent and early attempts at solid food intake
C. Which of the following anti-emetic drugs works both centrally in the vomiting center and peripherally in the afferent visceral nervous fibers?
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