Hot Seat #165. 7 yo with vomitingPosted on: January 29, 2021, by : Mary Beth Howard
Harrison Hayward, MD
HPI: 7-year-old male with an elevated BMI and otherwise healthy presents to an outside ED with 1 week of fever. He had COVID-19 one month ago, from which he fully recovered. Last week, he developed a fever and headache/abdominal pain. His PMD diagnosed him with a UTI and started cefdinir, which the patient has been taking without issue. Since then, the fever has persisted with Tmax 102F, refractory to antipyretics. Today, he has had PO intolerance, 4-5 episodes of NBNB emesis and 2-3 episodes of NB, watery diarrhea. He went to an outside ED, where initial exam was notable for:
Vital Signs T 39C, HR 160s, BP 70s/30s, RR 20s, 92% on RA, Wt 60kg
General Fatigued, but no acute distress
HEENT Normocephalic, atraumatic. +Conjunctival injection bilaterally without discharge. EOMI. Throat pink. +Stiffness of the neck. No LAD
CV Tachycardic. Extremities warm. No peripheral edema
Pulm Non-labored respirations with symmetric, fine crackles throughout; good aeration
Skin: No rash
Initial work-up notable for:
-CBC: WBC 12.7, H/H 11.3/36.5, plt 121
-CMP: Na 131, K 5.3, Cl 103, CO2 21, BUN 18, Cr 0.76, AlkP 213, AST/ALT 61/47, Albumin 2.9
-Trop <0.01, CK 109
-COVID PCR negative, RVP negative
Imaging done at outside ED:
-CXR: wnl. No acute lung or heart pathology
-CT ab/pelv impression: Prominent appendix with periappendiceal inflammation and mesenteric lymphadenopathy. Diffuse wall thickening of the ascending to transverse colon. No evidence of bowel ischemia or perforation.
LP was also done, notable for: Protein 78, RBC 42, WBC 124 63% neutrophils. Culture pending.
He is given ceftriaxone, vancomycin, Zosyn, and Decadron . Over the course of 8 hours, he received 2L NSB with improvement in the BP to 80s/40s. At this point, the OSH calls for transfer for “management of meningitis.”
BPs remain 80/40 when CNH transport team arrives. A third NS bolus is given en route. On arrival, exam is notable for:
Vital Signs T 38C, HR 147, BP 74/36, RR 22, 100% on 2L NC
General Sleepy, but arousable. Slow to respond.
Neuro A&Ox3. No focal neuro deficits
CV Tachycardic. Cap refill time 4-5s. Extremities warm. No peripheral edema
Pulm +Mild retractions. Fine crackles and end expiratory wheeze throughout
Abdomen soft, nontender. +Mildly distended/tympanitic. No hepatomegaly
CXR shows no cardiomegaly or opacities. Norepinephrine is initiated. Remainder of Tier 1 & Tier 2 MIS-C labs are sent.
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