Professional Documents
Culture Documents
HPI:
-5 YO boy who has been vomiting his
entire life
-Vomited frequently as an infant
-Vomiting got worse, not better, with age
-Continues to have episodic vomiting
-Usually throws up a few times per week
-Sometimes goes a full month without
vomiting but then it starts again
HPI, continued:
-Most recent episode has been going on for
about 2 months:
-Vomiting twice daily
-Often vomits early in the day, but not always
-Sometimes throws up food he ate 4 days
ago
-5 lb weight loss
-Stools 2x daily
-Rare dark stools but no frank blood
Prior Work-up:
-At age 3, had extensive work-up (EGD,
colonoscopy, biopsies) at a Childrens
Hospital in Texas
- Extensive allergy testing: no allergies
- Recently tried cyproheptadine for 2
weeks
- Have tried benadryl and erythromycin
in the past without improvement
Past Medical
History:
Past Medical
History Cont.
Home Medications:
-None
Allergies:
-Possible lactose intolerance
Family History: No known family
history of GI illnesses (IBS,
cancers, Celiac). Siblings and
parents are healthy. Strong family
history of migraine HAs.
Social History: Moved from TX to
Utah this year. Attends
kindergarten. Likes horses, playing
with legos and video games.
Review of Systems:
Positive:
Negative:
Persistent vomiting
Frequent headaches
Sometimes feels
dizzy
Weight loss
Occasional
constipation
Fevers
Mouth sores
Rashes
Diarrhea
Changes in vision
Physical Exam:
Vitals: Temp 36.7 HR 74 RR 15 BP 94/59 SpO2 99% on RA
GEN: Awake and alert school-aged boy examined sitting up in bed, drinking a
slushie and playing with an i-pad. Appears pale.
HEENT: NCAT. Pupils dilated but equal and reactive. EOMI. Gaze is conjugate.
Ears with normal position and rotation. No nasal discharge. MMM. Mouth
without oral ulcers or exudate.
Neck: Full ROM, no obvious LAD.
CV: RRR. No murmur. Pulses appropriate. Cap refill <3 sec.
RESP: Normal RR. Clear lung fields bilaterally with equal and complete air entry.
No signs of increased WOB.
ABD: Soft, non-tender and non-distended. +Hyperactive BS. Spleen and liver
are not enlarged. No masses.
Extremities: No clubbing, cyanosis, or edema.
GU: Did not examine
Neuro/Psych: Talks with a lisp but otherwise interacts appropriately. CN intact
without deficits. Strength within normal limits in bilateral upper and lower
extremities. Sensation intact to light touch in bilateral face and upper/lower
extremities. No dysmetria while playing angry birds. Seems wobbly on
Rhomberg and during gait test.
SKIN: No rashes, scars, jaundice, or unusual birthmarks. Appears pale.
Differential Diagnosis,
GI:Vomiting
ID:
PSYCH:
GERD
Physiologic reflux
Dietary allergy/intolerance
Pyloric stenosis
NEC
Malrotation/volvulus
Congenital
atresia/stenosis/web
Hirschsprung disease
Bowel obstruction
Rumination
Peptic ulcer
Eosinophilic esophagitis
Hepatobiliary disease
Pancreatitis
Gastroparesis/ileus
Cyclic vomiting
Gastroenteritis
UTI
Strep pharyngitis
Post-tussive
Appendicitis
ENDO:
Inborn error of
metabolism
DKA
Adrenal
insufficiency
Munchausen by
proxy
Psychogenic
Bulimia
NEURO:
Hydrocephalus
Intracranial
hemorrhage
Brain tumor
OTHER:
Toxic ingestion
Pregnancy
Drug/alcohol
abuse
Work-up:
CMP: Na 140 K 4.2 Cl 108 HCO3 23 AG 9 Gluc 78
BUN 10 Cr 0.43 Ca 10.1 Pro 7.1 Alb 4.4 Bili 0.4 Alk
phos 249 ALT 15 AST 26
CBC with diff: WBC 8.7 HGB 14.3 HCT 39.5 PLAT 187
Neut 79% Lymph 16% Mono 2% Eos 3% ANC 6900
CRP <0.1
ESR 3
Lipase: 14
Imaging
Imaging
Headache
Abnormal gait
Abnormal
coordination
Papilledema
Seizures
Squinting
Change in behavior
Macrocephaly
CN palsies
Lethargy
Abnormal eye
movements
Hemiplegia
Weight loss
Vision changes
Alerted LOC
Work-up
-IMAGING (MRI OF BRAIN AND SPINE)
-HISTOLOGIC EVALUATION
Our Patient:
Medulloblastoma