_ emesis is non-bloody, non-bilous
_ hx suspicious of abd pain
_ changes in bowel habits
_ assoc fever
_ hx of adequate frequency of bouts of urine output in past 24 hours
_ hx of adequate fluid intake in past 24 hours
_ vaccines UTD
History and Physical Exam.
_PO trial. On re-examination after PO trial, repeat abdominal exam benign, appears improved.
MDM (with A/P):
presentation is most consistent with
nausea/vomiting of benign etiology.
_ Well hydrated based upon history and physical exam findings (normalization of vital signs in ED, normal activity/tone, frequency of urine output on hx).
DDx (I considered that there is a small but finite risk for the following processes. The patient’s presentation does not meet our criteria (reasonable level of consistency with characteristic findings) for being reasonable for additional pursuit of these entities at this time (which are detailed parenthetically below):
-GI (acute intra-abdominal processes)
–pyloric stenosis- consistent with: projectile emesis, hungry appearance, typically <3 mo old
–volvulus- consistent with: TTP on abd exam, abd distention, constipation, palpable mass, toxic appearing, peritonitis, inability to tolerate POs, epimiilogy < 3 mo
–intusseception- consistent with: TTP on abd exam, hx of intermittent severe abd pain w/ interval resolution of sx, hx of bilious emesis, currant stool/bloody stool/changes in stool color, inability to tolerate POs, w/i 3 mo – 3 y/o
–appendicitis- consistent with: RLQ pain, pain on hopping/coughing, progressively worse, non-remittenting abd pain, fever, anorexia, lack of diarrhea, epidemiology 3 y/o – adolescence
–DKA- consistent with not well appearing, lethargic, polyuria/dipsia. Given low pretest probability and not reasonable for further diagnostics, advised to return if symptoms worsen/progress and for prompt f/u with PMD for evaluation and further w/u if sx don’t follow expected natural history with resolution of sx.
-UTI/pyleonephritis- consistent with: hx suggestive of urinary sx (either dysuria or frequency, costo-phrenic angle tenderness, hx of UTIs
–OM- consistent with: TM effusion/erythema
–strept pharyngitis- consistent with: hx suggestive of sore throat, erythema/purulent exudate in throat.
–PNA- consistent with: abnormal pulmonary exam, resp sx
–torsion given no hx of sever intermittent sx suggestive of pain in gonadal region, objective pain on palpation of gonadal region. Given low pretest probability and not reasonable for further diagnostics, advised to return if symptoms worsen/progress and for prompt f/u with PMD for evaluation and further w/u if sx don’t follow expected natural history with resolution of sx.
–head trauma- consistent with trauma on examination, neuro deficits.
–non-accidental trauma- consistent with unexplained injuries noted on exam, inconsistent hx and findngs, abnormal caregiver behavior.
–tox ingestion- consistent with: hx suggestive of possible ingestion, toxidromic syndrome on exam
COUNSELLING: Parents instructed that if symptoms worsen, persist, or new symptoms develop to come back to the ED for re-evaluation. Advised that serious pathologies are unlikely given history/exam and impression of the patient at this time but that when early in a disease process, an evaluation can be falsely reassuring. Advised of monitoring at home for hydration status and return precautions for decrease in urinary frequency, inability to tolerate PO fluids. Patient is at significantly low risk for serious pathology to be appropriate for discharge with outpatient follow up. Patient/family education on working diagnosis, proposed plan, patient/family amenable to plan. Plan discussed with attending physician, in agreement with plan.