1. Morning Report- Monday, August 1 st 2011

2. That was for Simone, who gave me the great idea for trivia at the beginning of AM report!!

4.  Step 1: ABCs!! Assess hemodynamic status of the patient  Orthostatic changes- best indicator of significant blood loss  Step 2: Establish severity of bleeding  Coffee ground emesis, melena: lower rate of bleeding  Bright red blood: ?higher rate of bleeding

5.  Step 3: Determine the location of the bleeding  UGI: bleeding above the ligament of Treitz  Hematemesis  LGI: bleeding distal to the ligament of Treitz  Bloody diarrhea  Bright red blood mixed with or coating stool  Hematochezia, melena, or occult blood loss can be due to both UGI or LGI bleeds  Passing NGT can determine if the blood is originating from the UGI tract ot LGI tract

6.  Food coloring  Colored gelatin or children’s drinks  Red candy  Beets  Tomato skins  Antibiotic syrups  Bismuth or iron preparations  Spinach  Blueberries  Grapes  Licorice

7.  Break into 3 groups:  Infant  2-5 years old  Older child  Come up with a differential diagnosis for lower GI tract bleeding in your age group  The “Older child group” has an additional task…since our case is an older child, which diagnosis do you think is most likely and why?

9.  Necrotizing enterocolitis  Hirschprung enterocolitis  Volvulus/ Intussusception  Infectious colitis  Anal fissure  Eosinophilic proctocolitis  Nodular lymphoid hyperplasia  Swallowed maternal blood  Coagulopathy  Allergic colitis

11.  Intussusception  Volvulus  Henoch-Schonlein purpura  Hemolytic-uremic syndrome  Meckel diverticulum  Juvenile polyp  Ulcerative colitis/ Crohn’s disease  Infectious colitis  Nodular lymphoid hyperplasia  Perianal streptococcal cellulitis  Rectal prolapse/ rectal ulcer

13.  Infectious colitis  Ulcerative colitis/ Crohn disease  HSP  Intestinal ischemia  Meckel diverticulum  Juvenile polyp  Hemorrhoid

14. Transmission SymptomsLabsTreatment Salmonella Chicken, milk, eggs; exotic pets (reptiles) Fever, diarrhea with blood/ mucous High WBC with left shift, +stool WBC, RBC (?+ BCx) None with uncomplicated GE; at risk* Amoxil, Bactrim Shigella Person-to person ; daycare ! Fresh fruits and veges Fever, abd. pain, watery diarrhea that becomes bloody, szs High WBC and band ct, +stool WBC, RBC Azithromycin, 3 rd gen. cephalosporins, quinolones Campylobacter jejuni Undercooked poultry or meat Fever, abd pain, diarrhea with blood, vomiting +stool WBC, RBC; Cx with chocolate agar Erythromycin E.Coli O157:H7 Undercooked beef, unpasturized milk Fever, diarrhea with blood/ mucous +stool WBC, RBC; look for signs of HUS Abx not indicated! (increases risk for HUS) Yersinia enterocolitica Pork (chitterlings) Dysenteric syndrome, can mimic appy / Crohns +stool WBC, RBCBactrim, aminoglycosides, cephalosporins (3 rd ), quinolones Clostridium difficile ABx exposure Mild diarrhea  dysentric syndrome Dx with toxin assay PO Flagyl (Vanc)

18. Noon Conference: Radiology