chiaroscuro27 Posted August 26, 2012 Share Posted August 26, 2012 Just wrapped up another 12 hour shift in the ED... I remember how beneficial the student cases here were to me as a PA-S, so here's to paying it forward. 11 yo white female presents to your ED with a chief complaint of abdominal pain. What do you want to know??? Link to comment Share on other sites More sharing options...
flyingsquirrel Posted August 26, 2012 Share Posted August 26, 2012 Vitals? Temp? Does she look sick? (or is she texting while you do your exam), does she appear well nourished/hydrated? How long has this been going on? Constant or intermittent pain? How does she describe the pain? Where exactly is the pain? Anything provoke or relieve the pain? NVD? pre-menarche? Any school/family stress? (is this psychosomatic?) Recent travel? Recent dietary changes? UTD on vaccinations? Any medical Hx? Any meds/vitamins/supplements? Any chance of ingestion or exposure (if acute)? I'm sure there's more...I'll see how far that gets us. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted August 26, 2012 Administrator Share Posted August 26, 2012 Thanks for posting this. I'm just sad that I'm no longer eligible to participate. I'll have to start doing these myself in a month or two... Link to comment Share on other sites More sharing options...
PA4me2010! Posted August 26, 2012 Share Posted August 26, 2012 Is this the first time having this pain? Fevers? Link to comment Share on other sites More sharing options...
Just Steve Posted August 26, 2012 Share Posted August 26, 2012 Pmhx: childhood illnesses, immunizations, surgeries, any hospitalizations, accidents/injuries Medications: any current rx to include time, dose, route, reason, any BCP? (it's the ER, crazier things happen), any supplements/vitamins, any alternative therapies Allergies to include type of reaction. List all allergies to include food, environmental, seasonal, as well as meds Fmhx: Any familial diseases Social hx: tobacco, alcohol, recreational drugs (again, it's the ER, take nothing at face value), diet, exercise, living situation, personal relationships, safety, stress to include sexuality struggles, trauma to include emotional/mental/physical Review of symptoms: General: fever, fatigue, chills, appetite, weakness, nausea, weight changes, vomiting Skin: bruising or changes of hair/nails HEENT: changes in vision, tearing, headaches, hx of caries, lesions, hoarseness (chasing the bulimia dx with that), sore throat, changes in tastes Cardiac: hx of murmur or structural defect, palpitations Respiratory: cough, dyspnea, hemoptysis GI: hematochezia, jaundice, diarrhea, melena, constipation, bowel changes GU: dysuria, UTI, flank pain, frequency, burning, kidney infection, renal stones Genital: rash, itching, STD, lesions, menarche, cycle frequency, pelvic pain, LMP Musculskeletal: pain, weakness, stiffness, swelling psychiatric: anxiety, mania, emotional trauma, depression, changes in sleep pattern, eating disorder and of course, a physical exam would be helpful as well :-) guarding, rebound, radiation, skin temp/moisture, vitals, overall impression to include body posture, gait, eye contact. percussion of quads, organmegly, liver borders, auscultation of large vessels (aorta, renal, iliac), palpation, obturator test, psoas test, murphy's sign (highly doubtful it's a gallbladder in this age group but just covering bases and it's a free exam. Will hold off on labs/imaging studies until we have a good patient impression. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted August 26, 2012 Author Share Posted August 26, 2012 OK...great start to the case. You're asking all the right questions! You walk in and find a rather tall, thin 11 yo lying down on the bed with a cool rag on her face and head. She's accompanied by her mother. Vitals: Temp: 97.0 HR: 87 RR: 16 BP: 100/60 Ht and Wt: 5'4, 45 kg Pain: 2/10 No texting during the exam; she looks like she's not well but doesn't look toxic. Mom says this is not the norm for her as she is the vibrant, strong kid in the family. Pain began a few hours ago and has increased slightly since then. It is constant and achy. The girl had an uneventful evening the night before. No recent illnesses, no sick contacts although everyone in the family has suffered from some sort of "food poisoning" within the past few weeks according to mom. Some viral gastro stuff going on at school as well. Pain is mostly epigastric in nature but she says it kind of hurts all over and she's never had this kind of pain before. She can't think of anything that makes the pain better or worse. No treatments tried before her presentation to the ED. No nausea, vomiting, diarrhea or constipation. When I ask if she feels sick to her stomach, she says yes but I'm not convinced she knows what I mean. NKDA and no current meds. PMH is remarkable for what mom calls "kidney problems." After some probing, she tells me the girl has had several kidney infections and problems with her bladder, but these things have resolved. No surgical history. She is pre-menarche. UTD on immunizations, no recent travel. Pt. was able to eat spaghetti this morning with no problem. ROS: Essentially negative. PE: ( I only give you what you ask for!) Abdomen is hard to palpate because the patient has a hard time relaxing the musculature. No guarding, rebound. Skin feels a bit clammy to touch. Vitals are listed above. No OGM. Diffuse tenderness of the abdomen but more so in the epigastric area and LUQ. Pt doesn't grimace on exam, but shakes her head yes or no when asked if certain areas hurt more than others. No palpable masses and no distention. Negative on all signs pertaining to appy and gallbladder disease. No bruits heard on auscultation. What next? Dispo home, work her up, or ask more probing questions? Off to work for my fourth and final shift of the week. I'll check in periodically. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted August 26, 2012 Author Share Posted August 26, 2012 Thanks for posting this. I'm just sad that I'm no longer eligible to participate. I'll have to start doing these myself in a month or two... Hey rev! Congrats on passing the PANCE. Yes you CAN participate in these student cases! The only difference is that you're on the other side of the fence now! Feel free to chime in here. Link to comment Share on other sites More sharing options...
PA4me2010! Posted August 26, 2012 Share Posted August 26, 2012 Any CVA tenderness. what about cardio exam? Any murmur,gallops, extra heart sounds? How about some lab values, CBC, CMP, UA Link to comment Share on other sites More sharing options...
Just Steve Posted August 26, 2012 Share Posted August 26, 2012 "no sick contacts although everyone in the family has suffered from some sort of "food poisoning" within the past few weeks according to mom. Some viral gastro stuff going on at school as well" Food poisoning Is not a quasi random non specific event. I think the historian is trying to categorize events into somehing that can be explained easily. I would dig for details and specifics. I would like to dig a bit more into the hx of kidney issues as well. Can't dispo home especially with clammy skin. In my opinion clammy skin is a HUGE indicator that something isn't right. Gotta find out what it is. Physical exam of oral mucosa...dry? Vitals are decent but kids compensate well. Eyes sunken/dull or shiny/bright? UA looking for casts, blood, sediment and the usual protein, glucose etc... CBC with diff...no fever yet but curious of white count O&P of stool...parasite/helmith may help explain other family and school gi issues Complete chem panel...curious of BUN/creatine, glucose...also like to know triglycerides to get a hint of pancreatic issues. LFTs as well. I doubt serious findings because of mild findings on exam but not ready to pay for US quite yet nor radiate. Ddx: Gastritis Parasite Tumor Link to comment Share on other sites More sharing options...
fyrelight74 Posted August 26, 2012 Share Posted August 26, 2012 I'd also want to check for type 1 diabetes due to the clamminess and "urinary problems". Get a random glucose. Throw in a TSH since she's tall and thin and active. On exam, is there an imperforate hymen? Perhaps this is onset of menses? Also want a UA bc of prior urinary problems. Maybe get an abdominal xray. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted August 26, 2012 Administrator Share Posted August 26, 2012 Hey rev! Congrats on passing the PANCE. Heh, don't jinx me by congratulating me prematurely... I'm waiting for Thursday, stuck in the no-longer-student-but-not-yet-C realm. :-S Link to comment Share on other sites More sharing options...
Just Steve Posted August 26, 2012 Share Posted August 26, 2012 I'd also want to check for type 1 diabetes due to the clamminess and "urinary problems". Get a random glucose. Throw in a TSH since she's tall and thin and active. On exam, is there an imperforate hymen? Perhaps this is onset of menses? Also want a UA bc of prior urinary problems. Maybe get an abdominal xray. Please don't take this as critical...it's really difficult to carry the tone of friendly banter/conversation/brainstorming via typed text. I just would like to engage a bit of conversation surrounding some thought processes on tests. I don't want to appear that I am attacking or belittling.. just trying to get some dialogue going.... A quick google search shows the price of a TSH at about 80 bucks. If the patient's hair/nails are of appropriate presentation (supple, shiny hair with firm nails) and a palpation of the neck does not reveal any nodules, could we forgo that exam for now? There is a lack of tachycardia and the thinness could be explained by activity level/normal exercise pattern. Another google search shows the national average cost for an abdominal x ray runs about $240 bucks. What are you hoping to see on the x ray? So far, with the exam findings, I am not sure there are air/fluid levels in the abdomen, pain is a bit high for constipation, she doesn't sound sick enough for a twisted bowel yet...I am sure I am missing something but not sure what. I am a big fan of performing studies to back up what I am diagnosing through my H&P. I would love to throw all the patients through the lab and x ray on their way to the exam table but that is hoping for the studies to give me the diagnoses. The glucose will be covered by the CMP. I am on the fence of doing a pelvic on an 11 year old without some really compelling lower abdominal pain. Thoughts on my thoughts? Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted August 27, 2012 Author Share Posted August 27, 2012 OK guys. Sorry for the delayed response. I just got in from work. Cardiac exam is normal: no MRG, nice regular rate, and rhythm is fine. No CVA tenderness, but that is a great thought. Just Steve: good call on the history from mom. It's so easy to be swayed one way or the other by family members. You must follow your gut and do right by patient. Regarding the kidney history, mom says the pt had two bouts of kidney infections as a child. She also suffered from urinary incontinence and was worked up with an IVP. There were no concrete findings according to mom, and the child has been symptom free for some years now. Oral mucosa are moist, good capillary refill, pulses are 2+, and no tachycardia, so very little to clue you in on fluid depletion. Eyes are not sunken in and patient is not pale in color. Firelyght: I did not perform a pelvic exam on this girl as I didn't feel it was warranted in this case. I don't even think that crossed my mind, but I'd like to hear your thoughts on it. Looks like a few of you are ready to move to labs and diagnostics. What are we leaning towards dispo wise? Will she likely stay or will she go home? Let's also create a Ddx. So far we have: 1. Gastritis 2. Parasite 3.Tumor This list is way too short. Think of your patient population and what is commonly seen. Put your findings together so far. Do they warrant further investigation? Link to comment Share on other sites More sharing options...
flyingsquirrel Posted August 27, 2012 Share Posted August 27, 2012 I'll add... 4. new onset diabetes 5. pancreatitis 6. bowel perforation/peritonitis 7. splenomegaly You said her skin is "not pale". What color is it? Why does she have a damp cloth on her face? Link to comment Share on other sites More sharing options...
Just Steve Posted August 27, 2012 Share Posted August 27, 2012 She stays for work up...not ready to admit her yet but can't send home with some acetaminophen and tell her to f/u prn. other ddx: peptic disease - not a crazy dx, worth looking into, consider helico IBS - not high on my list due to lack of diarrhea lactose intolerance - I'd expect a bigger history of this sort of discomfort, but it may be a new presentation. Again, I'd expect changes in bowel habits pancreatic insufficiency - I would expect pain to be greater with perhaps a fever starting to brew, but won't dismiss it at this point celiac sprue- same thoughts as lactose intolerance viral syndrome - will keep it high on my list gastroenteritis - lack of emesis or diarrhea knocks this down the list a bit constipation - pt denies abdominal migraine - starting to wander from the ranch to the savannah... instead of chasing horses this is starting to look at zebras. Can dig into personal and family hx of migraines a bit GABHS - very doubtful due to the lack of concurrent pharyngeal findings UTI - keep it high on the list toxins - definitely in the Land Rover speeding across the savannah... but lead poisoning may explain other family members/school chums.. Wash. DC schools got shut down a few years ago due to high lead levels in the water. Munchausen with or without proxy- still in the Land Rover, still speeding... Stress - keep it high on the list The patient lacks the toxic presentation to be your life threatening issues like DKA, peritonitis, myocarditis, hirschbrung She has aged out of things like malrotation, intussusception... Perhaps a better respiratory/chest assessment to rule out a visceral referral but starting to stretch Perhaps a deeper interview concerning diet habits and the correlation of this sort of pain with foods consumed may point in a direction of dietary basis. Also dig in a bit deeper to stressors such as school and such. The school year is about to fire up, maybe the child is pretty freaked out about it. I know I am... Barring any further enlightening history, I think some labs would be nice Link to comment Share on other sites More sharing options...
tigerlily Posted August 27, 2012 Share Posted August 27, 2012 Awe, I'm a pre-PA. This is interesting though, thank you for the thread! I can't wait to play when/if I become a student :D Link to comment Share on other sites More sharing options...
flyingsquirrel Posted August 27, 2012 Share Posted August 27, 2012 The patient lacks the toxic presentation to be your life threatening issues like DKA, peritonitis, myocarditis, hirschbrung She has aged out of things like malrotation, intussusception... While from her vitals I don't think that she has DKA, kids don't always have a toxic presentation. They will look sick, but DKA can mimic a viral illness and pediatric patients can compensate extremely well. I have seen kids in DKA with a pH of 6.9 who looked no more ill than my partner who was fighting a bad cold. I don't mean to jump on you, but pedi DKA is one of the things I used to see at least weekly (if not daily). I've seen very experienced people miss both DKA and new onset diabetes because they don't think to check the glucose in kids "because they didn't look that sick". Once you get the high glucose level back, then you need to get a blood gas (venous works just fine) and urine ketones to parse out whether it is DKA, HHNKC, or just hyperglycemia... Speaking of which...I'd like to see the labs (CBC, chem, LFT, UA) too, please. Link to comment Share on other sites More sharing options...
rcdavis Posted August 27, 2012 Share Posted August 27, 2012 Common diagnoses are common. May I respectfully suggest considering appendicitis before lead poisoning? Not slamming pb poisoning nor abdominal migraines ( cannot dx what u don't think of), but in any young kid with belly appy should ge high on your ddx.. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted August 27, 2012 Author Share Posted August 27, 2012 Common diagnoses are common. May I respectfully suggest considering appendicitis before lead poisoning? Not slamming pb poisoning nor abdominal migraines ( cannot dx what u don't think of), but in any young kid with belly appy should ge high on your ddx.. You may suggest anything you like, rcdavis. *bows down in awe of your knowledge and wisdom* Indeed, common things are common. I like that you all are thinking about the zebras, but in the midst of all that, don't forget about the horses. You have just left the pts room after getting a thorough history. You're sitting at the nurses station formulating your Ddx when mom approaches you and tells you the pt has just thrown up. You follow her back to the room and find a basin full of the spaghetti the child ate some hours ago. After reassessing her you find the following: Abdomen: Rigid on palpation with the pain mostly periumbilical and epigastric in nature, but still diffuse. Skin: Still clammy, pt has the towel on her head and face to "cool her down." You check another temperature. Still WNL at 98.6. Blood pressure is now up to 126/87. The girl is sick but stable. You ask the nurses to supply her with another emesis basin, and as you return to the nurses station you hear the pt vomiting for the second time. If you ever considered dispo-ing her home, you are now thinking otherwise. What interventions do you want to make right now? Do you want to rearrange your Ddx? Here's what we have so far: 1. Gastritis 2. Appendicitis (thanks rcdavis) 3. PUD 4.DKA 5.Pancreatitis 6. Lead poisoning 7. Bowel perf 8. Splenomegaly 9.UTI 10. Viral syndrome The length of this list is much better, but there are a few things that I would for sure put on this list, especially given the patient's age. Labs: Most of you want CBC, CMP, UA, the typical stuff. Great! Hematology WBC 17.2, with neutrophils 86% and bands 11% H/H, RBC's and platelets WNL Chemistries All electrolytes are WNL, glucose is 123 AST/ALT WNL, ALP is 129 BUN/Cr are WNL Urinalysis is negative across the board. No signs of infection there. Thoughts? Link to comment Share on other sites More sharing options...
Just Steve Posted August 27, 2012 Share Posted August 27, 2012 I purposefully stayed away from the appendix for a few reasons... 1. It's more fun to wander around the savannah sometimes than ride the same trails on the ranch. aka: sometimes case studies are good for making me get out of the box and sniff around for other ideas. 2. the location of her discomfort WAS atypical for an appy but now with the "southern migration" towards her periumbilical region and the emesis, the appy is climbing quickly to a very high spot on the ddx. 3. Originally she was lacking some traditional signs of exam. I didn't see mention of results from a psoas or obturator test...it may have swayed me sooner. The reassessment of a more rigid belly and the back to back episodes of emesis it definitely nudges us towards a peritoneal issue. That nudge is supported by the increase in neutrophils and bands. So a revisited ddx: 1. peritonitis with an infected appendix highly suspected Gastritis - it's my personal experience that a case of "Deli Belly" (or Dehli, for you international travelers) typically doesn't give you a rigid abdomen and I am not sure if it'll kick your neutrophils up so high...I won't strike it off the list yet, but it's gonna move way towards the bottom 3. PUD - won't dismiss it as it may have led to a perf but at her young age and otherwise benign past history surrounding her gastric region, I have my doubts that this is a concern 4.DKA - no mention of an altered LOC and a benign chem panel I am willing to let this one slip off the list 5.Pancreatitis - just not feeling it...historically it's not a young person's disease..and it's time to park the Land Rover and stop chasing zebras right now 6. Lead poisoning - I wouldn't be me if I didn't toss out some obscure nonsense once in awhile.. it's off the list. Pt presentation has changed far to dramatically to waste time considering this 7. Bowel perf - not a classic presentation, but will keep it on the list 8. Splenomegaly - it's my understanding that an enlarged spleen is a sequela of a disease process, not a cause of disease. While her spleen may or may not be enlarged I personally would feel better chasing down the infection rather than focusing on the spleen itself. While I don't think a smear was done with the blood count I believe some abnormalities would have shown up in the RBC results if her spleen was really under attack. With a normal H&H and lack of previous hx indicating various cancers, I would recommend bumping this off the ddx. UTI - clean urine, time to look elsewhere. I'd remove this from the list. 10. Viral syndrome - like gastritis, I don't believe this gives you a rigid abdomen...I also don't believe this will make your neutrophils climb. I won't dismiss this but I think her condition is now more serious than a viral syndrome and she deserves a more aggressive treatment than NPO x24 followed by BRAT diet for 72 hr. lnterventions... I believe that most cases of peritonitis calls for antibiotics. 1. IV, prefer no smaller than 18g due to probable trip to the OR. Hang .9% NS, 5 cc/kg/hr 2. Cefoxitin 30mg/kg IV, infuse over 15 minutes 3. NPO except for ice chips Now the decision of radiation vs US...Not really sure. Probably depends if we have someone who is skilled with US or not.. or if we have a CT available. Either way I'm going to go ahead and give surgery a heads up. While this patient may resolve with antibiotics, or I may be way off base but either way, I'd like to know how the OR is looking for room availability or if it's after hours, how long to get a room up and ready. If I turf to surgery, do I have to write the admit orders, or is it now their ball game? Link to comment Share on other sites More sharing options...
flyingsquirrel Posted August 27, 2012 Share Posted August 27, 2012 That ALP is WNL for an 11yo. I am concerned about the bandemia and elevated WBC and would therefore draw blood cultures before starting ABX. Try to confirm appendicitis with US, if still unsure, then go to CT. IV NS at maintenance (85 mL/hr). Some 11yo have adult sized veins and you can get an 18ga IV in them no problem, others you would be lucky to find a site for a 20ga. Pedi surg is much less picky about the size of the IVs than adult surgery...just make sure they are good solid lines. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted August 27, 2012 Author Share Posted August 27, 2012 Done! The nurses at your hospital don't like sticking kids and they give you hell for it if they don't think its warranted. Oh well, she's your patient and your clinical suspicion and the fact that she's vomiting yet again has bought her a line in the right AC some fluids. NPO...done. The rural ED has its own unique set of challenges. No specialists, very little ancillary staff on the weekends, no emergency dialysis, no MRI, and no US unless it is emergent. You have the nurses call to see if US can come in. They tell you it will be more than an hour before anyone can show up. Let's hold off on consultations until I get more feedback from other players. Comb through the Ddx. Have you done all the simple, easy things to rule them in or out? Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted August 27, 2012 Author Share Posted August 27, 2012 That ALP is WNL for an 11yo. I am concerned about the bandemia and elevated WBC and would therefore draw blood cultures before starting ABX. Try to confirm appendicitis with US, if still unsure, then go to CT. IV NS at maintenance (85 mL/hr). Some 11yo have adult sized veins and you can get an 18ga IV in them no problem, others you would be lucky to find a site for a 20ga. Pedi surg is much less picky about the size of the IVs than adult surgery...just make sure they are good solid lines. At our institution that ALP was flagged as an abnormal level. I wasn't too impressed with it in light of the other LFT's, but there is something to consider here. Think about the presentation so far. This girl was fine the night before. No recent illnesses, ate breakfast and was out with the family when all of a sudden this stomach pain began. It has gotten worse since she presented to the ED and continues to get worse and worse. And now she's vomiting. So yes, the ALP may be slightly elevated now, but as she is showing us, things can change in the blink of an eye. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted August 27, 2012 Administrator Share Posted August 27, 2012 When looking at rads for an 11 YOF abdomen, I will opt for u/s over CT if there's any reasonable chance I can avoid irradiating her ovaries... Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted August 27, 2012 Moderator Share Posted August 27, 2012 At our institution that ALP was flagged as an abnormal level. I wasn't too impressed with it in light of the other LFT's, but there is something to consider here. Think about the presentation so far. This girl was fine the night before. No recent illnesses, ate breakfast and was out with the family when all of a sudden this stomach pain began. It has gotten worse since she presented to the ED and continues to get worse and worse. And now she's vomiting. So yes, the ALP may be slightly elevated now, but as she is showing us, things can change in the blink of an eye. I'm not going to divert the teaching points at all, or try to interject in the middle of a student case...but I had pretty much the exact same scenario last week in one of my ER's. So I'm quite curious to see if the outcome is the same :) Link to comment Share on other sites More sharing options...
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