1. Missed Diagnoses 2: Why didn’t I think of that either? Eileen Klein, MD, MPH

2. Agenda Illustrative Cases Tip offs and Tips for Success Diagnosis specific pearls

3. Case 1 - Dehydration 3 year old boy with vomiting for one day Tired for past week No fever No dysuria Decreased PO Emesis X 2 URI 10 days ago

4. Exam Quiet 3 year old, awake Temp=37.2HR=180RR=40BP=100/55 Clear Lungs No murmur, quiet heart sounds Abdomen soft, no rebound Capillary refill 3 seconds and cool to midcalf

5. Management Ondansetron Oral Rehydration Plan – discharge when tolerating PO fluids

6. Why didn’t I think of that? Notes:

7. Case 2 – Knee pain 2 year old girl with 3 day history of right knee pain No fever Now refusing to walk

8. Exam Alert, calm, well hydrated Temp=37.8 HR=110 RR=20 BP=100/60 Cooperative but fussy with leg exam Points to right knee where the band-aid is and screams with exam No focality to exam

9. Evaluation and Plan Knee X-ray normal Discharge Diagnosis of contusion Return for fever or increase pain

10. Why didn’t I think of that? Notes:

11. Case 3 – Abdominal pain 10 year old boy with abdominal pain and vomiting Woke this morning with vomiting After vomiting had abdominal pain No history of trauma Pain is diffuse No fever Emesis X 10

12. Exam Alert, Cooperative, uncomfortable, sweating Temp=37.2 HR=135RR=18 BP=100/60 Abdomen seems soft, but difficult exam Seems to have pain with hip shake

13. Work up and Management CBC WBC = 8.1 (normal differential) Urinalysis and electrolytes Normal Pain seems unchanged after IV fluids Low concern for appendicitis Consider discharge with instructions to return if pain worsens

14. Why didn’t I think of that? Notes:

15. Case 4 – Groin swelling 3 week old girl with fussiness and left inguinal swelling Otherwise healthy Swelling noticed today during diaper change Increasing fussiness over the past few hours No fever

16. Exam Alert, active, fussy but consolable when held Temp=36.9 HR=180 RR=24 BP=85/60 2X2 cm left inguinal bulge: Firm No fluctuance or erythema Unable to hear bowel sounds within swelling Exam otherwise normal

18. Work up and Management Inguinal hernia Attempts at reduction of inguinal hernia unsuccessful Surgery consulted Additional attempts at reduction unsuccessful at IV sedation Concern for incarcerated hernia

19. Why didn’t I think of that? Notes:

20. Case 5 – Puffy eye 5 year old with puffy eye One day history of eyelid swelling No Fever No vomiting or diarrhea Not eating well Decreased energy

21. Exam Alert and non- toxic; well appearing T 36.5 HR 110RR 22 Swelling of right upper and lower eyelid No erythema Extra ocular muscles intact Pupils equal and reactive to light No conjunctivitis Benadryl for possible allergic reaction Told to return if symptoms do not improve

22. http://www.ehow.com/way_5406085_swollen-eyelids-cure.html

23. Why didn’t I think of that? Notes:

24. Case 6 – Finger injury 12 year old boy finger injury playing basketball Had collision with another boy while playing basketball Digit now at unusual angle

25. Exam Alert, cooperative T 37.0HR 70RR 20BP 105/65 Mild-moderate tenderness to palpation No erythema, fluctuance or bruising At an abnormal angle X-ray show fracture/dislocation Dislocation reduced Plan splint and follow up

26. X-Ray http://www.wheelessonline.com/ortho/dorsal_fracture_dislocations_of_the_pip_joint

27. Why didn’t I think of that? Notes:

28. Case 7 – Abdominal pain 5 year old girl with abdominal pain 3 hour history of pain Mild urinary frequency Mild constipation by history

29. Exam Alert, cooperative T 37HR 120RR 22BP 90/60 Diffuse tenderness Difficult exam but no obvious peritoneal signs Normal GU exam

30. Work up WBC 7.0 Urinalysis Normal Treatment with IVF Exam unchanged Plan discharge with diagnosis of Abdominal Pain and possible Constipation

31. Why didn’t I think of that? Notes:

32. Case 8 2 year old girl not using left arm Mom was swinging child around when the child began to cry and stop moving left arm

33. Exam Happy, Playful, holding left arm at side T 37HR 100RR 20BP 100/60 No Bony tenderness Neurovasularly intact Will not use left arm What should be done?

34. Management Hyperpronation of forearm at elbow “Pop” felt Patient cried briefly On re-examination using arm normally Diagnosed with Radial head subluxation - aka Nursemaids Elbow Discharged

35. Why didn’t I think of that? Notes:

36. Summary Making timely and correct diagnosis requires: Taking a thorough history Getting appropriate exposure Not losing the forest for the trees Giving reasons to return Final tip: Use your colleagues – they are a great resource!

37. Thank you!!