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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.
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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
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Morning Report
Morning Report
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Morning Report
Patient presents to PCP then admitted to KCH ward team
Our Case
KCH ward team
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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
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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
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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
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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
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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
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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
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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
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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
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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…
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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
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Barium Swallow was
Workup
Swallow was normal
Barium Swallow
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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
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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
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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
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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