Case Presentations-Medical or Surgical?

DR SABEENA OBARAY and DR GRAEME FRANCIS HADLEYED Attending Physicians

Sidra Medicine

Declaration

We do not have any relevant financial disclosures to declare.

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At the end of the presentation, the attendee will be able to:

Learning Objectives

Identify the challenges of common presentations such as vomiting, abdominal pain, bloody stool, and headache.

Discuss the role of lab and radiological workup in making sensible decision.

Formulate the appropriate management plan.

Case 1

• 15 week old male• Term delivery. Mild Hypospadias otherwise no medical hx.• Breast and bottle fed 2-3 hourly• Attended ED on Friday with diarrhea and vomiting• Unsettled, seems to be in pain at times• 4-5 vomiting episodes associated with feeds• 1 large offensive watery stool

Examination

• Crying• Alert and Active• Well hydrated• Coryzal• Abdomen soft, normal bowel sounds and no masses• Impression : Viral Gastroenteritis• Admitted to observation ward to await urine

Clinical Course

• Settles on obs ward• Urine NAD• Feeding well• Further episode of diarrhea with flecks of blood• Parents say other family members have gastroenteritis and keen for

discharge• Discharged home with safety net advice

• Is the diagnosis Medical or Surgical• Discharge with safety net advice?• Or Plan admission?

The following day

• Re-attends and seen immediately• Vomiting worse and blood in stool• Vitals : apyrexial,HR 183, RR40, Sats 98 Air• Pale Lethargic and crying• A – patent• B – RR 40, good air entry, Sats 98%• C – Pale, CRT prolonged

• Warm centrally, cool peripherally• Brachial & femoral pulse present, not radial• Dry mouth & sunken eyes

• D – A V P U, BM 13, No rash• E – Full abdomen but not tense

• 45 minutes later – rigid abdomen, distended• Pale & grey• IV access & fluid bolus 10ml/kg• pH 7.4, PCO2 4.1, BE -4.2, Lac 2.2• NG inserted – coffee ground aspirate (60ml)• On call consultant in attendance

• Further 30ml/kg saline• AXR – Dilated bowel loops with fluid levels• Presumptive diagnosis Infective gastroenteritis with ileus

• Bloods: WBC 5.2, CRP 85, Na 136, Urea 7.9• Improved post bolus. • IV paracetamol given • Transferred to ward 15h30• Diagnosis Medical :Infective gastroenteritis with ileus

Progress

• Admitted to ward. Remained unsettled and HR climbed to 160-170• In early evening passed large volume blood PR became tachycardic (200)

with metabolic acidosis and lactate 6

• Surgical unit contacted & bed secured• Further 40ml/kg Saline given

• Anaesthetic review• Further 20ml/kg saline Pre intubation• Intubated with ketamine & atracurium• Difficult to ventilate requiring high pressures• Retrieved to surgical centre• Straight to theatre – ileocolic intussusception• Bradycardic on table – brief Chest compressions• Partial R - hemicolectomy & 5 cm TI• Discharge from PICU 2/2/16

Case 2• 11 month female• Expat brought in by mum and nanny arrived 12:00pm• Known Trisomy 21 , hx cardiac anomalies: TGA, VSD 3 surgeries• PC : Crying from yesterday. • HPC ‘Colicky’ crying on and off (seen at a different institution in Qatar before being

referred to Sidra)• Treated as constipation with given glycerin supp. with little effect• No fever/ lethargy• No issues with feeding/ No vomiting• No diarrhea/ bleeding PR• No cough/cold/ travel abroad• No breathing difficulties/ change of colour

Vitals & Measurements RR: 27 SpO2: 100% WT: 6.6 kgExamination:General: Looks well, no pallor, no jaundice, no cyanosis, not distressedENT: no runny nose, oropharynx not congested ears: normal tympanic membranes, no obvious ear discharge.Respiratory: not distressed, no intercostal, subcostal or suprasternal recessions, air entry is equal no wheeze, no crepitations, no stridorCardiovascular: not dehydrated, normal pulse volume, CRT <2s, heart sounds normal, systolic murmur.Abdomen: Soft, no distension, no tenderness, no guarding, no hepatomegaly, no splenomegaly, percussion note: normal, bowel sounds are normal

Diagnosis: Medical or Surgical?

Discharge with Safety Net Advice ?Admit for observation?

Clinical Course

Discharged at 17:00 with diagnosis of constipationPatient Education given and advised to return if any concernsRe-presented at 20:34

• Mum saying child inconsolable• Warm well perfused, prominent sternum, surgical scar noted,

systolic murmur apical area• RS: Good air entry bilaterally, no respiratory distress• P/A: Soft, non tender, no liver or spleen noted• Left leg held in flexed position, swelling of left leg, no bruises

noted, Right leg normal examination• Genitalia normal examination • XR left leg requested

Presentation changed

• Diagnosis Surgical• XR Left leg shows displaced,

spiral fracture of left Femur• Parents informed about the XR

findings• SCAP Team informed and then

reviewed the following day• Hx of mother massaging leg 2/7

where she heard a click• Skeletal survey and blood work up

requested• Patient had risk factors for NAI

Diagnosis

• 12 day old male brought in by ambulance to ED Resus• Born Term NVD• No Maternal RF for sepsis• Undergone circumcision that morning• Presented with ‘respiratory distress’, ‘lethargy’ and cyanosis at 8pm• No Hx of fever or aspiration• Feeding well• Good urine output

Case 3

• Not dysmorphic but pale and dusky with peripheral cyanosis• Sleeping, not distressed• Afebrile• N anterior fontanelle, moist mucosa• Normal Hear Sounds and good femoral and peripheral pulses• Chest good AE R=L RR 50 Sats 89% on 5L by NC • Abdomen soft not tender no organomegaly• CXR – clear lung fields, no cardiomegaly• 2x IV lines placed • I stat- no acidosis, normal electrolytes, blood work up for sepsis sent to

labs• Charted for Antibiotics

On Examination

• Is the diagnosis Medical or Surgical?• Sepsis?• Cardiac? Would you commence any treatment?• Anything else?

• What other investigations would you like?

What next?

• Cardiology called and requested urgent review• Advised not to start PGE• Echo : Normal cardiac structures and function, small PFO L>R shunt (no cardiology

follow up required)

Cardiology Consult

Blood work up

Methemoglobinemia: Blood disorder where there is an abnormal amount of MetHb formation, thus unable unable to release oxygen effectively to body tissues. MetHb = Ferrous Iron of Hemehas been oxidised to ferric state.

• VBG show Met Hb 46.5%• Normal CBC and electrolytes• No FH of blood diseases• Baby had normal O2 saturations pre-circumcision• Diagnosis Medical : Iatrogenic Methemaglobinemia from Topical

Lidocaine• Treated with Low dose Methylene Blue• Recovered and went home the following day

Diagnosis: Medical (due to surgical procedure)

Case 4• 2y 7m old male• Previously fit and well• Recent travel to Kosovo for 1 month• Arrived PED at 11h45• Problems – Vomiting, diarrhoea, high fever• Triage complete @ 12h25: Vomiting 5 days. 1 day diarrhoea.

• Seen at Urgent Care Clinic yesterday then referred to another local hospital• Discharged home early hours

• Obs at triage: Hr 160, temp 38.4, RR 52, Sats 97%upset, grumpy, quiet. (No PEWS score)

Medical Review

• 5 days vomiting, 1 day diarrhoea.• Vomit mainly non bilious except x1 the night before.• Reduced oral intake• Off legs for > 2 days• No respiratory symptoms• Mother unhappy with local hospital so attended new ED.

Examination

• Pale, lethargic, lying on trolley• HR 162, RR 40, Sats 99% RA• Temp 38.9• No petechia or purpura• Tachypnoeic• Responding to mother but not staff • Distended abdomen, globally tender, guarding• Scanty bowel sounds

Management

• Immediate IV access• 20ml/kg saline bolus given• Gas confirmed compensated metabolic acidosis pH 7.41, PCO2 3.37, BE

-8.5, Bic 18.2, lac 0.9, Na 125• AXR – few dilated small bowel loops, no free air• CXR – Normal• 1st BP post bolus – 105/75

Progress

• IV Cefotaxime• Labs:

• Hb 119, WBC 10.9, Neut 7.8, Plat 374• Na 126, K 4.2, Urea 2.9, Creat 21• Normal Coag• CRP 396

• 15h05 – Repeat gas pH 7.32, PCO2 3.74, BE -9, Bic 17.8, lac 1, Na 132• 2nd 20ml/kg bolus saline• Discussed & planned transfer to surgical centre for further investigations /

rule out surgical abdomen

What would you do?

• Diagnosis Medical or Surgical?• Admit for Observation or Transfer?

Progress

• 2nd bolus continued en route• Required further fluid resuscitation at tertiary centre but not immediately• Surgery that evening, perforated appendix.• Ventilated on PICU post-op but no inotropic support• Full recovery

Case 5

• 18 month old• Brought in by parents• 6 month hx of vomiting. Worse over last week.• Treated as GERD by PHCC with domperidone and ranitidine• Recently switched to omeprazole• Fractious / crying• Pale• Asked to review following triage• During initial assessment vomits and becomes unresponsive

On Examination

A – Required airway support but gagging on GuedelB – Resp rate 10, sats 100% on hi-flow

- Good air entry bilaterallyC – Initial bradycardia down to 60 improved with oxygen and airway support

- Good volume peripheral pulses- BP 100 / 70

D – GCS – 8/15 - E2, V2, M4- Pupils 4mm, sluggishly reactive- hypotonic

E – Apyrexial, no rash, no signs of trauma.

Diagnosis

•Medical or Surgical?•What would you do next?

Progress

• Anesthesia contacted

• RSI

• Morphine & Midazolam sedation

• IV ceftriaxone

• Urgent CT Head requested

• Diagnosis Surgical

• Posterior Fossa Tumour

Further Management

• Emergency Shunt Decompression Performed• Subsequent surgical resection of cerebellar astrocytoma• Underwent protein beam therapy in US• Still recovering but started walking

• Not all vomiting is GI related• Beware vomiting in the absence of

diarrhoea• Constipation is a symptom not a

diagnosis• D+V is not always gastroenteritis• Nitrite +ve urine is not always UTI• Children can look well and smile with

appendicitis• Babies can look well with intussuception

• If you are not certain of the diagnosis and you are concerned do not discharge but observe

• Do not forget safeguarding• VBG is a valuable investigation• Head circumference is a valuable

investigation (not for ED but useful to plot in the community)

• GERD is common in the 1st 6 months but tends to settle once child able to sit and ingest solids

Pearls and Pitfalls