Professor

1
Professors Rounds

• April 19, 2007

2
Guidelines forProfessors Rounds

• For the Participants
• Give succinct answers as to your reasoning
• You may not ask questions of the resident
  presenter
• You may add to answers given by another colleague
  if it adds to the teaching point being made
• You must commit to ONE diagnosis at commit time
• For the Moderator
• Try to ask questions that draw on the
  participants experience strengths
• Know when to curtail discussion and move forward
  to next points

3

• CC Her stomach hurts

4

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.

5

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.

6

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.

7

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.

8

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.

9

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.

10

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.

11

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.

12

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.

13

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress,
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.
• PMH Seizure disorder since infancy - GTC
  seizures approximately 2-3x per month. Last
  seizure approximately 2 weeks ago.

14

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress,
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.
• PMH Seizure disorder since infancy - GTC
  seizures approximately 2-3x per month. Last
  seizure approximately 2 weeks ago.
• Septo-optic dysplasia. Diagnosed with
  panhypopituitarism at age 3.

15

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress,
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.
• PMH Seizure disorder since infancy - GTC
  seizures approximately 2-3x per month. Last
  seizure approximately 2 weeks ago.
• Septo-optic dysplasia. Diagnosed with
  panhypopituitarism at age 3.
• PSH Strabismus repair at age 2.

16

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress,
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.
• PMH Seizure disorder since infancy - GTC
  seizures approximately 2-3x per month. Last
  seizure approximately 2 weeks ago.
• Septo-optic dysplasia. Diagnosed with
  panhypopituitarism at age 3.
• PSH Strabismus repair at age 2.
• Immunizations UTD no influenza vaccine this
  season.

17

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress,
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.
• PMH Seizure disorder since infancy - GTC
  seizures approximately 2-3x per month. Last
  seizure approximately 2 weeks ago.
• Septo-optic dysplasia. Diagnosed with
  panhypopituitarism at age 3.
• PSH Strabismus repair at age 2.
• Immunizations UTD no influenza vaccine this
  season.
• Meds Keppra, Depakote, Cortef, Synthroid,
  Growth hormone.

18

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress,
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.
• PMH Seizure disorder since infancy - GTC
  seizures approximately 2-3x per month. Last
  seizure approximately 2 weeks ago.
• Septo-optic dysplasia. Diagnosed with
  panhypopituitarism at age 3.
• PSH Strabismus repair at age 2.
• Immunizations UTD no influenza vaccine this
  season.
• Meds Keppra, Depakote, Cortef, Synthroid,
  Growth hormone.
• Allergies None

19

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress,
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.
• PMH Seizure disorder since infancy - GTC
  seizures approximately 2-3x per month. Last
  seizure approximately 2 weeks ago.
• Septo-optic dysplasia. Diagnosed with
  panhypopituitarism at age 3.
• PSH Strabismus repair at age 2.
• Immunizations UTD no influenza vaccine this
  season.
• Meds Keppra, Depakote, Cortef, Synthroid,
  Growth hormone.
• Allergies None
• FH No significant family history.

20

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress,
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.
• PMH Seizure disorder since infancy - GTC
  seizures approximately 2-3x per month. Last
  seizure approximately 2 weeks ago.
• Septo-optic dysplasia. Diagnosed with
  panhypopituitarism at age 3.
• PSH Strabismus repair at age 2.
• Immunizations UTD no influenza vaccine this
  season.
• Meds Keppra, Depakote, Cortef, Synthroid,
  Growth hormone.
• Allergies None
• FH No significant family history.
•   SH AW lives at home with her mother who
  attends community college and father who is a
  transit conductor.

21

• CC Her stomach hurts
• HPI AW is a 7 year old female who has had
  abdominal pain for two days.
• Her mother reports that on the morning prior
  to admission, AW began complaining of stomach
  pain around her belly button.
• She has had a decreased appetite to both solids
  and liquids since the onset of her pain.
• On the night prior to admission, her pain
  became worse. Her mother did not feel that it
  was changing in location. AWs mother gave her
  warm milk. One hour after drinking the milk, AW
  began to vomit.
• The emesis was NB/NB. AW vomited approximately
  5 times overnight. Her last episode was early
  the morning of admission. She has tolerated
  nothing PO since the onset of vomiting.
• On the morning of admission AWs mother was
  concerned about the worsening pain and persistent
  vomiting and therefore brought her to the ED for
  evaluation.
• ROS no diarrhea, last BM was the day prior to
  admission, mild distension, decreased UOP x1 day,
  malaise x1 day, nasal congestion, no fever, no
  sick contacts, no recent travel.
• AW had Strep pharyngitis 2 weeks prior to
  admission. She completed a 10 day course of
  Amoxicillin. Fever, throat pain and decreased PO
  resolved in 2 to 3 days on antibiotics.
• Birth Hx term C/S for FTP fetal distress,
  multiple perinatal complications requiring a 2
  month NICU stay including meconium aspiration,
  ETT x1 month, seizures beginning DOL 1.
• PMH Seizure disorder since infancy - GTC
  seizures approximately 2-3x per month. Last
  seizure approximately 2 weeks ago.
• Septo-optic dysplasia. Diagnosed with
  panhypopituitarism at age 3.
• PSH Strabismus repair at age 2.
• Immunizations UTD no influenza vaccine this
  season.
• Meds Keppra, Depakote, Cortef, Synthroid,
  Growth hormone.
• Allergies None
• FH No significant family history.
•   SH AW lives at home with her mother who
  attends community college and father who is a
  transit conductor.
• Dev Hx Significant language, social and
  cognitive delays. In 1st grade special education
  class. Receives PT/OT/speech therapy.

22

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA

23

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands

24

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands
• HEENT microcephalic, PERRLA, EOMI, mild left
  strabismus, TMs translucent, scant nasal
  congestion, dry lips, moist mucous membranes,
  clear oropharynx

25

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands
• HEENT microcephalic, PERRLA, EOMI, mild left
  strabismus, TMs translucent, scant nasal
  congestion, dry lips, moist mucous membranes,
  clear oropharynx
• Neck supple, no lymphadenopathy

26

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands
• HEENT microcephalic, PERRLA, EOMI, mild left
  strabismus, TMs translucent, scant nasal
  congestion, dry lips, moist mucous membranes,
  clear oropharynx
• Neck supple, no lymphadenopathy
• Respiratory CTA b/l symmetric BS no wheeze,
  ronchi, or rales

27

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands
• HEENT microcephalic, PERRLA, EOMI, mild left
  strabismus, TMs translucent, scant nasal
  congestion, dry lips, moist mucous membranes,
  clear oropharynx
• Neck supple, no lymphadenopathy
• Respiratory CTA b/l symmetric BS no wheeze,
  ronchi, or rales
• Cardiac tachycardic, RR, normal S1S2, no
  murmur, 2 distal pulses

28

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands
• HEENT microcephalic, PERRLA, EOMI, mild left
  strabismus, TMs translucent, scant nasal
  congestion, dry lips, moist mucous membranes,
  clear oropharynx
• Neck supple, no lymphadenopathy
• Respiratory CTA b/l symmetric BS no wheeze,
  ronchi, or rales
• Cardiac tachycardic, RR, normal S1S2, no
  murmur, 2 distal pulses
• Abdomen soft, mild to moderate generalized
  tenderness, mild distension, BS, no HSM, no
  guarding, no rebound

29

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands
• HEENT microcephalic, PERRLA, EOMI, mild left
  strabismus, TMs translucent, scant nasal
  congestion, dry lips, moist mucous membranes,
  clear oropharynx
• Neck supple, no lymphadenopathy
• Respiratory CTA b/l symmetric BS no wheeze,
  ronchi, or rales
• Cardiac tachycardic, RR, normal S1S2, no
  murmur, 2 distal pulses
• Abdomen soft, mild to moderate generalized
  tenderness, mild distension, BS, no HSM, no
  guarding, no rebound
• GYN Tanner 1 female

30

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands
• HEENT microcephalic, PERRLA, EOMI, mild left
  strabismus, TMs translucent, scant nasal
  congestion, dry lips, moist mucous membranes,
  clear oropharynx
• Neck supple, no lymphadenopathy
• Respiratory CTA b/l symmetric BS no wheeze,
  ronchi, or rales
• Cardiac tachycardic, RR, normal S1S2, no
  murmur, 2 distal pulses
• Abdomen soft, mild to moderate generalized
  tenderness, mild distension, BS, no HSM, no
  guarding, no rebound
• GYN Tanner 1 female
• Extremities WWP, no clubbing/cyanosis/edema,
  FROM of joints, lt2 sec cap refill

31

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands
• HEENT microcephalic, PERRLA, EOMI, mild left
  strabismus, TMs translucent, scant nasal
  congestion, dry lips, moist mucous membranes,
  clear oropharynx
• Neck supple, no lymphadenopathy
• Respiratory CTA b/l symmetric BS no wheeze,
  ronchi, or rales
• Cardiac tachycardic, RR, normal S1S2, no
  murmur, 2 distal pulses
• Abdomen soft, mild to moderate generalized
  tenderness, mild distension, BS, no HSM, no
  guarding, no rebound
• GYN Tanner 1 female
• Extremities WWP, no clubbing/cyanosis/edema,
  FROM of joints, lt2 sec cap refill
• Skin no lesions

32

• Physical Exam
• Wt 22.7 kg ( 50) Ht 112 cm (3)
• T 36.3 HR 118 RR 29 BP 111/59
  O2 sat 100 RA
• General sleepy but arousable, no acute
  distress, able to follow commands
• HEENT microcephalic, PERRLA, EOMI, mild left
  strabismus, TMs translucent, scant nasal
  congestion, dry lips, moist mucous membranes,
  clear oropharynx
• Neck supple, no lymphadenopathy
• Respiratory CTA b/l symmetric BS no wheeze,
  ronchi, or rales
• Cardiac tachycardic, RR, normal S1S2, no
  murmur, 2 distal pulses
• Abdomen soft, mild to moderate generalized
  tenderness, mild distension, BS, no HSM, no
  guarding, no rebound
• GYN Tanner 1 female
• Extremities WWP, no clubbing/cyanosis/edema,
  FROM of joints, lt2 sec cap refill
• Skin no lesions
• Neuro Alert and responsive, CN II-XII intact,
  no nystagmus, strength 5/5, sensation grossly
  intact, symmetric 2 reflexes throughout, wide
  based but steady gait

33

• Labs
• 17
• 49.1
• S38 B1 L40 M21
• UA SG 1.010, pH 6.0, urobilinogen 0.2
• TSH 0.006 (0.4-4.6), FT4 0.9 (0.8-2.0)
• Rapid Strep pos, Throat Culture neg

135
26
101
94 10.3
256
11.5
0.8
5.4
22
206
47
6.8
0.5
14
3.7
0.1
34
Patient Course

• AW was evaluated in the ED and initially given a
  NS bolus and a stress dose of Hydrocortisone. On
  admission, IV fluids were continued and surgery
  was consulted. It was not felt that she had a
  surgical abdomen.
• Overnight, AW continued to have emesis without
  diarrhea and worsening abdominal distension. A
  KUB was performed which showed an abnormal but
  nonspecific bowel gas pattern with mild
  dilatation of the small bowel, stool in the
  descending colon, and possible ascites. In the
  morning, an US was obtained to better evaluate
  the ascites. The sono showed a moderate amount of
  ascites with cellular debris and a normal
  appendix. The pancreas could not be visualized.
  Amylase and lipase were sent to evaluate for
  pancreatitis and were elevated at amylase 953 and
  lipase 3123.
• The neurology service recommended a trial off
  Depakote, which can cause pancreatitis. Her
  anti-epileptic medications were adjusted to
  account for the discontinuation of the Depakote.
  Her amylase and lipase trended down quickly, and
  her abdominal pain resolved. Her diet was
  gradually advanced. The stress dose
  hydrocortisone was tapered to her maintenance
  dose. AW had no seizure activity during her
  hospitalization. She was discharged home on
  HD10.