Morning Report 4/3/2013

Morning Report
April 3, 2013

Case Presentation
You are admitting resident when you get a page for a new admit. Receive the following information, a 16 month old term infant who is being admitted for a HGB of 3.4. Patient was life-flighted. No parents. Expected parental arrival is one hour.

Initial Differential?
Hematologic
cancer

Infectious
parvovirus

Immunologic
Cows protein allergy

GI
GI bleed

Trauma
trauma

Parents Arrive
Three days of bloody stool output Stool is dark red, large volume (soaks through the diaper and sheets) New vomiting yesterday No fever Was well-appearing until yesterday evening when was more pale and sleepy

Physical Exam
T 38.1 HR 142 RR 30 BP 96/67 SaO2 100% on Room Air. WEIGHT - 11.5 Kg GENERAL: pale appearing infant lying in mom's arms, fusses with exam, but consoles HEAD: normocephalic. atraumatic. EYES: sunken appearing. NOSE: no discharge or obstruction. OROPHARYNX: moist mucus membranes. NECK: supple without lymphadenopathy or tenderness to palpation. CARDIOVASCULAR: tachycardic. regular S1, S2; distal pulses appropriate, CR 3 seconds centrally LUNGS: clear to auscultation bilaterally, good air flow, no retractions. ABDOMEN: soft, non-tender, non-distended with active bowel sounds and no masses or hepatosplenomegaly. EXTREMITIES: all extremities warm and well perfused. GENITOURINARY: normal Female external genitalia, Tanner stage I.. NEUROLOGIC: awake and alert. SKIN: no rashes, bruising, mottling, jaundice, or unusual birthmarks

Assessment
16 month old term infant who presents with three days of large-volume, melenous stool output, one day of vomiting, and significant anemia.

Second Differential?
Infectious
Salmonella, shigella, campylobacter

Hematologic
ITP, clotting deficiency

GI
Meckels, gastritis, esophagitis, mallory-weiss tear, fissure, intusseception, malrotation/volvulus

Immunologic
Cows milk allergy

Trauma Other: HSP, HUS Oncologic

Cancer

Meckels Diverticulum
Rule of Twos:
2% population 2:1 male:female Within 2 feet of the ileocecal valve Approximately 2 inches long About 2% develop complications in their lifetime 60% of patients who have complications are less than 2 years of age

Presentation
Large volume brick red bloody stool PAINLESS bleeding Patient otherwise well-appearing Large drop in HCT, which can occur very rapidly

Diagnosis/Treatment
Meckel scan: scan consists of the intravenous administration of 99m technetium pertechnetate administration of H2 blockers 24 to 48 hours before the test Only remove those that are symptomatic (although many will remove an asymptomatic one if noted on laparotamy)

Quick Contrast
Intusseception occurs between 6 to 36 months of age (60% younger than 1 year, 80% younger than 2 years) Occurs around the ileocecal valve (if older, needs a lead point) Cyclic, severe abdominal pain Bloody, mucoid stool Sausage-shaped mass in the transverse colon may be palpable