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Morning Report

Sarah Todd, PGY-3


August 14, 2015

Late one afternoon


while on the GI service, you get call
from the ED:
Hey, Im really sorry but I have a
cyclic vomiter for you. Theres a fiveyear-old down here whos been
vomiting his entire life.

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:

-Born at term, 9lbs 8 oz


-No prior hospitalizations
-Extensive GI work-up and
allergy testing in TX
-Gets carsick easily
Past Surgical History:
-Circumcision
Development:
-Language delay, talks with a
lisp
-Less coordinated than his
older sibling

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.

Otherwise healthy 5 YO boy


with vomiting his entire life
DIFFERENTIAL?

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

CNS Tumors in Children


-Second most common childhood
malignancy (after hematologic
tumors)
-Most common pediatric solid organ
tumor
-Leading cause of death from
childhood cancer

Presentation of CNS Tumors in


School-aged Children

Headache

Vomiting and nausea

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

Medulloblastoma (most common malignant brain tumor in children)


Pilocystic astrocytoma
Ependymoma
ATRT (atypical teratoid/rhabdoid tumors)

POSTERIOR FOSSA TUMORS IN


CHILDREN

Our Patient:
Medulloblastoma

- WHO Grade IV, Large cell


variant with diffuse anaplasia,
no drop mets in the spine
-Tumor resection the day after
diagnosis
-Proton beam irradiation at MD
Anderson(parent
preference)
-Currently in maintenance
chemotherapy
-Admitted last weekwith
fever/neutropenia