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?

Re-evaluation

• Increased work of breathing when lying flat

• What test would you do next?

Chest X-ray

Diagnosis: Myocarditis

http://www.bmj.com/content/320/7230/297.full

Tips and Tip offs

• History• Not much vomiting• Recent URI

• Exam• Quiet heart sounds• Tachycardia (out of proportion) and tachypnea• Cool to mid calf – significant without big fluid losses

Myocarditis

• Characterized by• Apparent dehydration out of proportion to history• Decreased pulses• Gallop and distant heart sounds• Evidence of failure

• Hepatomegaly• Crackles on lung exam

• History often includes:• Fatigue• Respiratory distress

• Initial management• Avoid fluids• Start pressors

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?

Return visit 1 day later

• Fever• Now refusing to move leg• Exam – holding hip in abduction with knee

flexed• Elevated WBC and CRP• Normal hip x-ray but fluid in hip on ultrasound

Diagnosis:

Septic Hip

Tips and Tip offs

• History• Hip pain refers to the knee

• Exam• Inadequate assessment of hip irritability

• Evaluation• Need to evaluate for hip infection if there is any

concern with CBC, Blood culture, CRP and x-ray (AP and frog leg)

Septic Hip

• Most common organism• Staphylococcus aureus• Streptococcus• Gram negative organisms also possible

• E.g., Kingella kingae, Neisseria Gonorrhea

• Associated with• Almost uniformly no warmth or redness at hip• Pain• Limitation of motion

• Treatment• Expeditious drainage and intravenous antibiotics• Delayed drainage increases risk for avascular necrosis and future

disability (arthritis)

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?

Re-evaluation

Dad arrives and patient tells dad he had a bike accident on friends bike but was afraid he would get into trouble

• Exam unchanged

• Abdominal CT

Diagnosis:

Duodenal hematoma

Tips and Tip offs

• History• History didn’t fit exam findings

• Exam• Peritoneal signs unusual with short duration of

symptoms

Duodenal hematoma

• Main causes – Discrete injury• Rapid acceleration/deceleration• Seat Belt• Direct Blow• Handle bar injury

• Symptoms usually 24-48 hours after injury• Vomiting• Abdominal pain

• Diagnosis• Abdominal CT

• Treatment• Supportive versus Operative

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?

Additional workup

• Ultrasound done• Inguinal hernia present• Ovary within hernia sac

Diagnosis:

Inguinal hernia with entrapped ovary

Tips and Tip offs

• Firm bulge

• Female patient

• No bowel sounds heard

• Inability to easily reduce

Inguinal hernia

• Hernia more common on the right• Hernia more common in boys• Incarceration – occurs in 15-30 of hernia patients• Incarcerated in girls typically includes ovary in hernia

sac compared to intestine• Include Lymphadenitis in the differential diagnosis

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?

What happened next

• Child returned the next day with swelling of both eyelids and hands

• Blood pressure elevated• Protein in urine• Low serum albumin• Nephrology consulted – patient admitted

• Diagnosis:

Nephrotic Syndrome

Tips and Tip offs

• Didn’t think of alternative diagnoses• Periorbital cellulitis• Edema due to non-allergic process

• Exam• Didn’t take blood pressure

• Lab• If took blood pressure and high then

would need urinalysis

Nephrotic Syndrome

• Periorbital edema common initial finding• Often mistaken for allergic reaction• Primary idiopathic nephrotic syndrome most

common in younger children (<6 years)• Diagnosis:

• Proteinuria• Hypoalbuminemia

• Additional labs: • Electrolytes, BUN, Creatinine, Complement 3

• Primary Treatment – Steroids• Most are steroid sensitive

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?

What happened next

• Immediately re-dislocated

• What should be done?

• Call orthopedic surgery

Diagnosis:

Volar Plate Injury/Entrapment

Tips and Tip offs

• Exam• Location of injury• Immediate “re-dislocation”

Volar Plate injury/entrapment

• Can occur at DIP, PIP, and MCP joints• Consider when reduction not stable with active motion• Requires orthopedic consult• Often requires operative repair

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?

What happened next

• Mom concerned because she seems to be in severe pain

• Re-exam patient writhing with severe abdominal pain

• Abdominal X-Ray done

Abdominal X-Ray

http://plasticstudent.com/case/step/535

What should be done next?

Abdominal ultrasound done

Surgery consulted

Diagnosis:

Ovarian Torsion

Tips and Tip offs

• History• Pain severe• Acute onset

• Don’t let age rule out this diagnosis in your mind

Ovarian Torsion

• 15% of cases in pre-menarchal girls• Acute onset of severe pain without fever• Hard for younger children to localize pain

• In girls think about ovarian torsion when you are considering appendicitis

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?

Follow up

• Child returned 5 minutes later not using right arm

• Parents left the ED swinging the child between them

• Diagnosis:

Recurrent nursemaids elbow

Tips and Tip offs

• Didn’t instruct parents to swing under armpit and not by hands

Radial Head Subluxation

• Ages 6 months – 5 years• Annular ligament trapped in joint due to traction on pronated hand• Suspect even if history not classic• Patient generally calm holding arm flexed at elbow• Treatment

• Supination/flexion method• Hyperpronation method

http://pediatrics.aappublications.org/content/110/1/171/F3.small.gif

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!!