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Missed Diagnoses 2: Why didn’t I think of that either? Eileen Klein, MD, MPH

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

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Missed Diagnoses 2: Why didn’t I think of that either? Eileen Klein, MD, MPH

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  1. Missed Diagnoses 2:Why didn’t I think of that either?Eileen Klein, MD, MPH

  2. Agenda • Illustrative Cases • Tip offs and Tips for Success • Diagnosis specific pearls

  3. 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

  4. 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

  5. Management • Ondansetron • Oral Rehydration • Plan – discharge when tolerating PO fluids

  6. Why didn’t I think of that? Notes:

  7. Case 2 – Knee pain 2 year old girl with 3 day history of right knee pain • No fever • Now refusing to walk

  8. 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

  9. Evaluation and Plan • Knee X-ray • normal • Discharge • Diagnosis of contusion • Return for fever or increase pain

  10. Why didn’t I think of that? Notes:

  11. 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

  12. 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

  13. 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

  14. Why didn’t I think of that? Notes:

  15. 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

  16. 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

  17. 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

  18. Why didn’t I think of that? Notes:

  19. 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

  20. 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

  21. http://www.ehow.com/way_5406085_swollen-eyelids-cure.html

  22. Why didn’t I think of that? Notes:

  23. 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

  24. 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

  25. X-Ray http://www.wheelessonline.com/ortho/dorsal_fracture_dislocations_of_the_pip_joint

  26. Why didn’t I think of that? Notes:

  27. Case 7 – Abdominal pain 5 year old girl with abdominal pain • 3 hour history of pain • Mild urinary frequency • Mild constipation by history

  28. Exam • Alert, cooperative • T 37 HR 120 RR 22 BP 90/60 • Diffuse tenderness • Difficult exam but no obvious peritoneal signs • Normal GU exam

  29. Work up • WBC • 7.0 • Urinalysis • Normal • Treatment with IVF • Exam unchanged • Plan discharge with diagnosis of Abdominal Pain and possible Constipation

  30. Why didn’t I think of that? Notes:

  31. 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

  32. 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?

  33. 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

  34. Why didn’t I think of that? Notes:

  35. 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!

  36. Thank you!!

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