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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 - PowerPoint PPT Presentation
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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 BP=100/55
• Clear Lungs• No murmur, quiet heart sounds• Abdomen soft, no rebound• Capillary refill 3 seconds and cool to midcalf
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 RR 20 BP 100/60
• No Bony tenderness• Neurovasularly intact• Will not use left arm
• What should be done?
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!!