4/12/2010

1

Morning Report:g pAn Interactive Case Presentation

Lindsa B rns MDLindsay Burns, MDPediatric Chief Resident and Clinical

Instructor in PediatricsKentucky Children’s Hospital

I have no conflicting financial interests or relationships to disclose

Disclaimer

relationships to disclose.

4/12/2010

2

Review a case presentation with emphasis on workup differential building and management

Objectives

workup, differential building and management Introduce new techniques in medical learning

with audience response systems Reinforce the importance of a strong, broad

differential t a

Resident Physician presents a case from recent admission

Morning Report Format

admission Audience asks pertinent questions to understand

chief complaint Build a differential based on history Review the patient’s exam

R i i h diff i l f h l Revisit the differential after exam to help narrow Plan a workup Establish a diagnosis combining all data

4/12/2010

3

Morning Report

Morning Report

4/12/2010

4

Morning Report

Patient presents to PCP then admitted to KCH ward team

Our Case

KCH ward team

4/12/2010

5

11 year old male with “difficulty swallowing a biscuit four days ago”

Chief Complaint

biscuit four days ago “Since then has not been able to eat or drink

anything”

Four days of not tolerating liquids or solids, only 8oz of fluid intake in 4days

History of Present Illness

8oz of fluid intake in 4days Occasionally has trouble swallowing saliva,

spitting saliva in a cup Feels a sensation of something stuck in his throat No problems sleeping, no drooling during sleep Decreased urine output past 2 days Lost 6lbs since these symptoms started

4/12/2010

6

History of Present Illness

No feverN i i d f d h i No prior episodes of dysphagia

Nothing improves dysphagia Attempting any PO intake makes dysphagia

worse N i di h No emesis, nausea or diarrhea No shortness of breath

6 lbs weight loss No rashes

Review of Systems

No rashes No respiratory distress No cardiac abnormalities Hard stools in past month Decreased UOPc as UO Treated for ADHD when younger

4/12/2010

7

Full TermA 6 h f lif i f 1

Past Medical History

Apnea at 6month of life, monitor for 1 year ADHD – no meds for 3years, had anger

outburst on stimulants and was managed for this a few days at an inpatient facility

Surgical – S/P Tonsillectomy/Adenoidectomy Surgical – S/P Tonsillectomy/Adenoidectomy

Medications: noneAll i NKDA

Further History

Allergies: NKDA Diet: regular, except past 4 days Immunizations: UTD Growth and Development: normal growth,

d l d h i d ith h delayed speech – improved with speech therapy

Water Source: city

4/12/2010

8

Dad with severe GERD on high dose PPI, back injury in MVA 3yo ago

Family History

injury in MVA 3yo ago Paternal Grandmother esophageal surgery,

stroke Mom with anxiety Cousin ODD Cousin ODD

Lives with mom, dad and 6yo sister in eastern KY

Social History

KY One dog

4/12/2010

9

What is the most concerning portion in his history?1. Not handling his own

salivasaliva2. Decreased UOP3. Decreased weight4. Not intubated yet5 N t i l i5. Not on a surgical service

What is the number one diagnosis on your differential?1. GERD2 E h l li2. Esophageal malignancy3. Esophagitis +/- stricture4. Foreign Body in esophagus5. Vascular Ring6 Neuromuscular disorder6. Neuromuscular disorder7. Malignancy in mediastinum8. Ingestion9. Pharyngitis

4/12/2010

10

Foreign Body in Esophagus GERD

Differential of acute onset Dysphagia

GERD Esophagitis, +/- stricture Pharyngitis Ingestion, caustic Vascular ring Esophageal tumor Mediastinal tumor Neuromuscular junction

impairment

Weight: 49kg (92%)H i h 65i h (105%)

Physical Exam

Height: 65inch (105%) BMI 18 Temp: 98.9F HR 82 RR 24 BP 113/68

4/12/2010

11

General: Alert, non-toxic, appears anxiousSki G d f i N h

Physical Exam

Skin: Good perfusion, No rashes HEEN: NC/AT, EOMI, PERRL, nares clear, TM’s

normal Throat: Moist mucous membranes, secretions

pooling in mouth No erythema No vesicles pooling in mouth, No erythema, No vesicles, palate equal non-edematous

Neck: No adenopathy, supple, nl ROM

Chest: CTA b/l, no wheezing, good air entryCV l l RRR N M/R/G

Physical Exam

CV: nl pulses, RRR No M/R/G Abdomen: soft, full to palpation but no

discrete masses, no rebound, non-tender, normoactive bowels sounds

Neuro: normal strength DTR’s 2+ Neuro: normal strength, DTR s 2+ Psych: anxious, very active in exam, moving

constantly

4/12/2010

12

Now that you have a physical exam, what is your top diagnosis?1. GERD2. Esophageal malignancyp g g y3. Esophagitis +/- stricture4. Foreign Body in esophagus5. Vascular Ring6. Neuromuscular disorder7. Malignancy in mediastinum8. Ingestion9. Pharyngitis

What is the first test you would order?1. PFT’s

B i 2. Barium swallow

3. GI consult4. Chest Xray5 EKG5. EKG6. Psych consult7. CBC

4/12/2010

13

Barium Swallow was orderedGI l d

Our Patient

GI was consulted

Parents stepped out the roomA R id h i i lk d i h i

In the meantime…

Astute Resident physician talked with patient alone

New History emerged…

4/12/2010

14

Patient asked about what he thinks is causing dysphagia

New History

dysphagia He says…..he has been bullied at school over the

past couple of weeks. Other boys have been calling him “a girl” and

“weakling” and questioning his sexual orientation He does not want to return to school He does not want to return to school He has not slept in his own room in years, he sleeps

on couch and has father sleep in chair beside him Dad had MVA 3 years ago, since then pt is worried

about parents dying

After parents returned and new history discussed they admit he had been bullied since

New History

discussed, they admit he had been bullied since middle school but unaware of connection with dysphagia

Patient started eating ice-cream, fruit loops and drinking fluids soon after conversation

Child Psychiatry was consulted for recommendations on outpatient treatment plan

4/12/2010

15

Barium Swallow was

Workup

Swallow was normal

Barium Swallow

4/12/2010

16

Prevalence of Bullying in US: 10% f hild t “ t i ti i ti ” b

Bullying

10% of children report “extreme victimization” by bullying

80-90% adolescents will experience some form of bullying in school life

Bullying:Children hurting children. Gwen Glew, Fred Rivara and Chris Feudtner Pediatr. Rev. 2000;21;183

Bullying

FIGURE 1. Incidence of bullying by grade. Each bar corresponds to the percentage of Norwegian students in each grade who reported being bullied in the previous year. Data from Olweus. Bullying; Children hurting children. Gwen Glew, Fred Rivara and Chris Feudtner Pediatr. Rev. 2000;21;183

4/12/2010

17

1. Identify the problemC l hild h h l

Role of the Pediatrician

2. Counsel parents, children, perhaps school about interventions

3. Refer to psychiatrists/psychologist for mental health management

4 Advocate for prevention of bullying and 4. Advocate for prevention of bullying and violence against children at school

Trouble sleepingU h i S d

Other health symptoms associated with bullying

Unhappiness, Sadness Abdominal Pain Headaches Nocturnal enuresis

4/12/2010

18

What would you advise our patient to do about bullying?

20% 20% 20%20%20%1. Fight Back

I2. Ignore3. Be Assertive4. Walk away5. Tell an adult

 Fight Back

 Ignore

 Be Assertive

 Walk away

 Tell an adult

Walk away from the scene, do not run, project air of confidence

Walk, Talk, Squawk

air of confidence Talk to the bullies, say something confident not

provocative to their face “you don’t scare me” Squawk to a teacher or parent. Inform the

adults that can help the situation and the a u ts t at ca p t s tuat o a t victims

Bullying:Children hurting children. Gwen Glew, Fred Rivara and Chris Feudtner Pediatr. Rev. 2000;21;183

4/12/2010

19

Bullying Movie

Prevention Initiatives

Keep strong, broad differential especially if workup is negative

Learning Points

workup is negative Patient that has been bullied can present with

somatic complaints Identify, Counsel, Refer, and Advocate Medical learning has changed in it modality Medical learning has changed in it modality,

more technological devices