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Thursday, October 18, 2007

A Toddler With Fever and Abdominal Tenderness

Who's work is much harder? Is it of the nurse or of the physician? Well, some say that the work of a nurse is much more difficult compared to a physician's, that is since physicians only tend to diagnose diseases while nurses take on the front line, which is where real labor takes place. Some might even go as far as saying that physicians always leave their work to nurses, nurses do the rounds while they go home to rest. Some others say that nurses have also studied medicine as part of their course curriculum and thus are also capable of diagnosing a patient.

Well, if the latter statement is correct... as a nurse, can you really diagnose a patient using your skills in critical thinking? Well, let's find out... Let's play guess my disease... Here we go...

Situation

A 14-month-old boy is brought to the emergency department (ED) by his parents for an evaluation of persistent fever, vomiting, and diarrhea that has lasted for 3 days. The mother states that the child was examined by his pediatrician 2 days before this presentation for a “viral illness“; however, the child has appeared increasingly ill since then. He has become irritable, and he has been minimally active and feeding poorly. He has had a normal stool output and appearance, as well as normal urination frequency. The parents deny observing a runny nose or any coughing, wheezing, or stridor in the patient. The child lives at home with his parents, he is not in day care, and he has had no contact with people who are sick.

On physical examination, the boy is crying, fussy, and poorly consoled. His vital signs include a rectal temperature of 101°F (38.33°C), a respiratory rate of 32 breaths/min, a blood pressure of 98/56 mm Hg, and a heart rate of 168 bpm. His oxygen saturation is 100% while he is breathing room air. The patient’s weight is 22 lb (10 kg). Palpation reveals diffuse abdominal tenderness without rigidity or guarding. The patient has diffusely hypoactive bowel sounds. His stool is negative for occult blood. The rest of the physical findings are otherwise unremarkable.

Conventional abdominal radiography and computed tomography (CT) scanning are performed (see image). The laboratory investigation reveals the following results: white blood cell (WBC) count, 19.4 × 109/L, with a predominance of neutrophils; hemoglobin, 8.4 g/dL; hematocrit, 26.6%; platelets, 310 × 109/L; sodium, 136 mmol/L; potassium, 3.8 mmol/L; chlorine, 105 mmol/L; CO2, 20 mmol/L; blood urea nitrogen (BUN), 6 mmol/L; creatinine, 17.7 ┬Ámol/L (0.2 mg/dL); and glucose, 4.1 mmol/L (73 mg/dL). The urinalysis shows trace ketones, but the results are otherwise normal.


Hint

The patient’s symptoms developed approximately 2 days after the mother dropped a box of pins on the carpet at home.

Okay doc nurse... go figure... If you can figure what the diagnosis is, then that means you're not only an excellent nurse but a good doctor as well, if not... then just leave the work to a physician. lol.

See if your diagnosis is correct. See the answer.

5 comments:

Anonymous said...

I am a 14 year old... Either the pins where eaten, but that would not cause a fever unless it carried a pathogen... the pins would cause abdominal tenderness... On the other hand, the pins might not have anything to do with it.

Anonymous said...

Yeah, the pins were eaten. I can see one on the X-ray. And it is very likely that the pin could have carried a pathogen, but I'm stopped there. There should have been blood traces in the stool, and a tenderness would confirm that, but there aren't any blood traces, leading me to believe something simultaneous is going on here.

LCM said...

Persistent fever, vomiting, diarrhea, diffusely hypoactive bowel sounds, and the fact that the urinalysis shows trace ketones all indicate dehydration. The fact that the patient is feeding poorly is also evidence of this.

The patient has not experienced a runny nose, coughing, wheezing, etc which would suggest that the 'viral infection' was a misdiagnosis.

Urination frequency is normal but the color of the urine has not been mentioned. Darker urine would suggest nutrients have not been diluted by water as would occur normally.

The pin from the CT is obviously located close to the kidney, where exactly I am not sure of due to the fact I am neither a nurse or doctor. My opinion is the pin has punctured an pathway or organ and has caused the infant to be unable to absorb and use water efficiently resulting in dehydration which explains the symptoms.

The pin will have to be removed and the hole caused by it will most likely heal within a short period of time. The hole is not large, and since the patient is an infant, recovery will be swift.

LCM said...

Am I right?
- liam_cm@hotmail.com

Anthony said...

The child had swallowed the pins, and this caused an acute gastroenteritis. Know that the pins cannot be digested normally by the digestive system and this irritated the GI tract. Dehydration is one of the complications of a Gastroenteritis, meaning, if the child doesn't get an operation and the pins (root of the problem) removed, death would more likely follow.

You're right about the misdiagnosis and the dehydration. You have the talent in diagnosing, if you ask me. Keep it up..