Transcript Exam
Missed Diagnoses 2: Why didn’t I think of that either? Eileen Klein, MD, MPH Agenda • Illustrative Cases • Tip offs and Tips for Success • Diagnosis specific pearls Case 1 - Dehydration 3 year old boy with vomiting for one day • • • • • • Tired for past week No fever No dysuria Decreased PO Emesis X 2 URI 10 days ago Exam • Quiet 3 year old, awake • Temp=37.2 • • • • HR=180 RR=40 Clear Lungs No murmur, quiet heart sounds Abdomen soft, no rebound Capillary refill 3 seconds and cool to midcalf BP=100/55 Management • Ondansetron • Oral Rehydration • Plan – discharge when tolerating PO fluids Why didn’t I think of that? Notes: Case 2 – Knee pain 2 year old girl with 3 day history of right knee pain • No fever • Now refusing to walk Exam • Alert, calm, well hydrated • Temp=37.8 HR=110 RR=20 BP=100/60 • Cooperative but fussy with leg exam • Points to right knee where the band-aid is and screams with exam • No focality to exam Evaluation and Plan • Knee X-ray • normal • Discharge • Diagnosis of contusion • Return for fever or increase pain Why didn’t I think of that? Notes: Case 3 – Abdominal pain 10 year old boy with abdominal pain and vomiting • • • • • • Woke this morning with vomiting After vomiting had abdominal pain No history of trauma Pain is diffuse No fever Emesis X 10 Exam • Alert, Cooperative, uncomfortable, sweating • Temp=37.2 HR=135 RR=18 BP=100/60 • Abdomen seems soft, but difficult exam • Seems to have pain with hip shake Work up and Management • CBC • WBC = 8.1 (normal differential) • Urinalysis and electrolytes • Normal • Pain seems unchanged after IV fluids • Low concern for appendicitis • Consider discharge with instructions to return if pain worsens Why didn’t I think of that? Notes: Case 4 – Groin swelling 3 week old girl with fussiness and left inguinal swelling • • • • Otherwise healthy Swelling noticed today during diaper change Increasing fussiness over the past few hours No fever Exam • Alert, active, fussy but consolable when held • Temp=36.9 HR=180 RR=24 BP=85/60 • 2X2 cm left inguinal bulge: • Firm • No fluctuance or erythema • Unable to hear bowel sounds within swelling • Exam otherwise normal Work up and Management • Inguinal hernia • Attempts at reduction of inguinal hernia unsuccessful • Surgery consulted • Additional attempts at reduction unsuccessful at IV sedation • Concern for incarcerated hernia Why didn’t I think of that? Notes: Case 5 – Puffy eye 5 year old with puffy eye • • • • • One day history of eyelid swelling No Fever No vomiting or diarrhea Not eating well Decreased energy Exam • Alert and non- toxic; well appearing • T 36.5 • • • • • • • HR 110 RR 22 Swelling of right upper and lower eyelid No erythema Extra ocular muscles intact Pupils equal and reactive to light No conjunctivitis Benadryl for possible allergic reaction Told to return if symptoms do not improve http://www.ehow.com/way_5406085_swollen-eyelids-cure.html Why didn’t I think of that? Notes: Case 6 – Finger injury 12 year old boy finger injury playing basketball • Had collision with another boy while playing basketball • Digit now at unusual angle Exam • Alert, cooperative • T 37.0 HR 70 RR 20 BP 105/65 • Mild-moderate tenderness to palpation • No erythema, fluctuance or bruising • At an abnormal angle • X-ray show fracture/dislocation • Dislocation reduced • Plan splint and follow up X-Ray http://www.wheelessonline.com/ortho/dorsal_fracture_dislocations_of_the_pip_joint Why didn’t I think of that? Notes: Case 7 – Abdominal pain 5 year old girl with abdominal pain • 3 hour history of pain • Mild urinary frequency • Mild constipation by history Exam • Alert, cooperative • T 37 HR 120 RR 22 BP 90/60 • Diffuse tenderness • Difficult exam but no obvious peritoneal signs • Normal GU exam Work up • WBC • 7.0 • Urinalysis • Normal • Treatment with IVF • Exam unchanged • Plan discharge with diagnosis of Abdominal Pain and possible Constipation Why didn’t I think of that? Notes: Case 8 2 year old girl not using left arm • Mom was swinging child around when the child began to cry and stop moving left arm Exam • Happy, Playful, holding left arm at side • T 37 HR 100 • No Bony tenderness • Neurovasularly intact • Will not use left arm • What should be done? RR 20 BP 100/60 Management • • • • Hyperpronation of forearm at elbow “Pop” felt Patient cried briefly On re-examination using arm normally Diagnosed with • Radial head subluxation - aka Nursemaids Elbow • Discharged Why didn’t I think of that? Notes: Summary Making timely and correct diagnosis requires: • Taking a thorough history • Getting appropriate exposure • Not losing the forest for the trees • Giving reasons to return Final tip: • Use your colleagues – they are a great resource! Thank you!!