This week we highlighted a case of persistent emesis without diarrhea. The differential for persistent emesis is broad and can be difficult to parse out. The crux of the decision is to determine how much emesis is too much and what portion of the work-up should be completed in the emergency department

In this specific case, the patient was admitted to the hospitalist service for failure to tolerate adequate PO. He was admitted for 14 days and had an extensive work-up. His hospital course by system was as follows:

GI: Upper GI was obtained and was normal. No concern for SMA syndrome. Abdominal US showed no gallstones or appendicitis. No further imaging obtained. Concern highest for rumination vs cyclic vomiting. Due to low caloric intake, an NG was placed and he received NG feeds for several days before he was able to tolerate improved PO intake. He was discharged home without an NG tube.

Cardiac: Persistent bradycardia with prolonged QTc and inverted T waves on EKG remained persistent on multiple EKGs. QTc improved prior to discharge. He now follows with cardiology. Suspected congenital long QT syndrome given that he had such a profound effect from one dose of ondansetron and mild electrolyte derangement (K 2.9).

Neuro: Initially had bradycardia and hypertension, concerning for possible increased ICP. Head CT within normal limits. MRI brain obtained on day 10 due to persistent symptoms, which was unremarkable.

Nephro: During his admission, he developed intermittent dizziness and headaches. He was noted to have BP > 95^th percentile with these symptoms. He was started on treatment for hypertension and his headache and dizziness resolved.