Professor Rounds 121307

1
Professor Rounds12/13/07

• Previous Cases online
• http//www.pediatrics.ucsd.edu
• Conferences gtgt Professors Rounds

2

• CC Abdominal pain.

3

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.

4

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
• She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.

5

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
• The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.

6

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.

7

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.

8

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.
• BHx Full term, induced vaginal delivery at 6
  pounds. Normal prenatal labs, no complications,
  stayed in the hospital for 2 days.
• PMHx A tonsillectomy at age 5. Past injuries
  include a broken thumb, broken leg, bruised ribs
  and a concussion. She was in a MVA several
  months ago but had no injuries. No other medical
  illnesses.

9

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.
• BHx Full term, induced vaginal delivery at 6
  pounds. Normal prenatal labs, no complications,
  stayed in the hospital for 2 days.
• PMHx A tonsillectomy at age 5. Past injuries
  include a broken thumb, broken leg, bruised ribs
  and a concussion. She was in a MVA several
  months ago,
• but had no injuries. No other medical
  illnesses.
• FHx Diabetes in a maternal grandfather. No
  history of gastrointestinal problems, IBD, IBS,
  heart problems, childhood illnesses,
  rheumatological conditions, migraine or mental
  illness in the family.

10

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.
• BHx Full term, induced vaginal delivery at 6
  pounds. Normal prenatal labs, no complications,
  stayed in the hospital for 2 days.
• PMHx A tonsillectomy at age 5. Past injuries
  include a broken thumb, broken leg, bruised ribs
  and a concussion. She was in a MVA several
  months ago,
• but had no injuries. No other medical
  illnesses.
• FHx Diabetes in a maternal grandfather. No
  history of gastrointestinal problems, IBD, IBS,
  heart problems, childhood illnesses,
  rheumatological conditions, migraine or mental
  illness in the family.
• SHx She finished high school last June with
  grades the B-C range and began vocational
  training in LA, which she enjoys. While
  attending the program, she lives with friends in
  LA, and with her mother, step-father and two dogs
  in San Diego when she is on a break. She states
  that she has a good relationship with her mother
  and stepfather and has not seen her father in
  many months.

11

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.
• BHx Full term, induced vaginal delivery at 6
  pounds. Normal prenatal labs, no complications,
  stayed in the hospital for 2 days.
• PMHx A tonsillectomy at age 5. Past injuries
  include a broken thumb, broken leg, bruised ribs
  and a concussion. She was in a MVA several
  months ago,
• but had no injuries. No other medical
  illnesses.
• FHx Diabetes in a maternal grandfather. No
  history of gastrointestinal problems, IBD, IBS,
  heart problems, childhood illnesses,
  rheumatological conditions, migraine or mental
  illness in the family.
• SHx She finished high school last June with
  grades the B-C range and began vocational
  training in LA, which she enjoys. While
  attending the program, she lives with friends in
  LA, and with her mother, step-father and two dogs
  in San Diego when she is on a break. She states
  that she has a good relationship with her mother
  and stepfather and has not seen her father in
  many months.
• She has a history of binge drinking for about 9
  months she drinks 3 to 4 times a week, 5 to 6
  drinks of beer or hard alcohol. Over the past 3
  months during this program, she has not had
  anything to drink until the week that she came
  home. But during this past week she has been out
  partying with her friends almost every night.
• She smokes one pack of cigarettes every 2 weeks
  and has a history of trying marijuana at 14 years
  of age and has not used it since then. She
  denies any other drug use.

12

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.
• BHx Full term, induced vaginal delivery at 6
  pounds. Normal prenatal labs, no complications,
  stayed in the hospital for 2 days.
• PMHx A tonsillectomy at age 5. Past injuries
  include a broken thumb, broken leg, bruised ribs
  and a concussion. She was in a MVA several
  months ago,
• but had no injuries. No other medical
  illnesses.
• FHx Diabetes in a maternal grandfather. No
  history of gastrointestinal problems, IBD, IBS,
  heart problems, childhood illnesses,
  rheumatological conditions, migraine or mental
  illness in the family.
• SHx She finished high school last June with
  grades the B-C range and began vocational
  training in LA, which she enjoys. While
  attending the program, she lives with friends in
  LA, and with her mother, step-father and two dogs
  in San Diego when she is on a break. She states
  that she has a good relationship with her mother
  and stepfather and has not seen her father in
  many months.
• She has a history of binge drinking for about 9
  months she drinks 3 to 4 times a week, 5 to 6
  drinks of beer or hard alcohol. Over the past 3
  months during this program, she has not had
  anything to drink until the week that she came
  home. But during this past week she has been out
  partying with her friends almost every night.
• She smokes one pack of cigarettes every 2 weeks
  and has a history of trying marijuana at 14 years
  of age and has not used it since then. She
  denies any other drug use.
• She has been sexually active recently, until last
  week, when she and her boyfriend broke up. She
  has not been diagnosed with any STDs in the past
• She endorses recent irritability, sadness and
  insomnia. For the past week she has used tylenol
  PM to fall asleep. She denies anhedonia,
  concentration difficulties, being depressed or
  having suicidal ideation.

13

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.
• BHx Full term, induced vaginal delivery at 6
  pounds. Normal prenatal labs, no complications,
  stayed in the hospital for 2 days.
• PMHx A tonsillectomy at age 5. Past injuries
  include a broken thumb, broken leg, bruised ribs
  and a concussion. She was in a MVA several
  months ago,
• but had no injuries. No other medical
  illnesses.
• FHx Diabetes in a maternal grandfather. No
  history of gastrointestinal problems, IBD, IBS,
  heart problems, childhood illnesses,
  rheumatological conditions, migraine or mental
  illness in the family.
• SHx She finished high school last June with
  grades the B-C range and began vocational
  training in LA, which she enjoys. While
  attending the program, she lives with friends in
  LA, and with her mother, step-father and two dogs
  in San Diego when she is on a break. She states
  that she has a good relationship with her mother
  and stepfather and has not seen her father in
  many months.
• She has a history of binge drinking for about 9
  months she drinks 3 to 4 times a week, 5 to 6
  drinks of beer or hard alcohol. Over the past 3
  months during this program, she has not had
  anything to drink until the week that she came
  home. But during this past week she has been out
  partying with her friends almost every night.
• She smokes one pack of cigarettes every 2 weeks
  and has a history of trying marijuana at 14 years
  of age and has not used it since then. She
  denies any other drug use.
• She has been sexually active recently, until last
  week, when she and her boyfriend broke up. She
  has not been diagnosed with any STDs in the past
• She endorses recent irritability, sadness and
  insomnia. For the past week she has used tylenol
  PM to fall asleep. She denies anhedonia,
  concentration difficulties, being depressed or
  having suicidal ideation.
• MEDS Ortho tri-cyclin, Pepto-Bismol Tylenol
  PM.

14

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.
• BHx Full term, induced vaginal delivery at 6
  pounds. Normal prenatal labs, no complications,
  stayed in the hospital for 2 days.
• PMHx A tonsillectomy at age 5. Past injuries
  include a broken thumb, broken leg, bruised ribs
  and a concussion. She was in a MVA several
  months ago,
• but had no injuries. No other medical
  illnesses.
• FHx Diabetes in a maternal grandfather. No
  history of gastrointestinal problems, IBD, IBS,
  heart problems, childhood illnesses,
  rheumatological conditions, migraine or mental
  illness in the family.
• SHx She finished high school last June with
  grades the B-C range and began vocational
  training in LA, which she enjoys. While
  attending the program, she lives with friends in
  LA, and with her mother, step-father and two dogs
  in San Diego when she is on a break. She states
  that she has a good relationship with her mother
  and stepfather and has not seen her father in
  many months.
• She has a history of binge drinking for about 9
  months she drinks 3 to 4 times a week, 5 to 6
  drinks of beer or hard alcohol. Over the past 3
  months during this program, she has not had
  anything to drink until the week that she came
  home. But during this past week she has been out
  partying with her friends almost every night.
• She smokes one pack of cigarettes every 2 weeks
  and has a history of trying marijuana at 14 years
  of age and has not used it since then. She
  denies any other drug use.
• She has been sexually active recently, until last
  week, when she and her boyfriend broke up. She
  has not been diagnosed with any STDs in the past
• She endorses recent irritability, sadness and
  insomnia. For the past week she has used tylenol
  PM to fall asleep. She denies anhedonia,
  concentration difficulties, being depressed or
  having suicidal ideation.
• MEDS Ortho tri-cyclin, Pepto-Bismol Tylenol
  PM.
• Nutrition She eats a varied diet, does not have
  concerns about her weight and denies any history
  of binging, purging or eating disorders.
• Devo She met all milestones (per mom). Menarche
  at age 12.

15

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.
• BHx Full term, induced vaginal delivery at 6
  pounds. Normal prenatal labs, no complications,
  stayed in the hospital for 2 days.
• PMHx A tonsillectomy at age 5. Past injuries
  include a broken thumb, broken leg, bruised ribs
  and a concussion. She was in a MVA several
  months ago,
• but had no injuries. No other medical
  illnesses.
• FHx Diabetes in a maternal grandfather. No
  history of gastrointestinal problems, IBD, IBS,
  heart problems, childhood illnesses,
  rheumatological conditions, migraine or mental
  illness in the family.
• SHx She finished high school last June with
  grades the B-C range and began vocational
  training in LA, which she enjoys. While
  attending the program, she lives with friends in
  LA, and with her mother, step-father and two dogs
  in San Diego when she is on a break. She states
  that she has a good relationship with her mother
  and stepfather and has not seen her father in
  many months.
• She has a history of binge drinking for about 9
  months she drinks 3 to 4 times a week, 5 to 6
  drinks of beer or hard alcohol. Over the past 3
  months during this program, she has not had
  anything to drink until the week that she came
  home. But during this past week she has been out
  partying with her friends almost every night.
• She smokes one pack of cigarettes every 2 weeks
  and has a history of trying marijuana at 14 years
  of age and has not used it since then. She
  denies any other drug use.
• She has been sexually active recently, until last
  week, when she and her boyfriend broke up. She
  has not been diagnosed with any STDs in the past
• She endorses recent irritability, sadness and
  insomnia. For the past week she has used tylenol
  PM to fall asleep. She denies anhedonia,
  concentration difficulties, being depressed or
  having suicidal ideation.
• MEDS Ortho tri-cyclin, Pepto-Bismol Tylenol
  PM.
• Nutrition She eats a varied diet and does not
  have concerns about her weight and denies any
  history of binging, purging or eating disorders.
• Devo She met all milestones (per mom). Menarche
  at age 12.
• ImmunizationsUp-to-date. Allergies
  Amoxicillin causes diarrhea

16

• CC Abdominal pain.
• HPI A17-year-old female presents with a 12 hour
  history of abdominal pain, nausea and vomiting.
  She was feeling fine until the night before
  presentation when she began to have epigastric
  pain and nausea. Her pain is dull and persistent
  and made it difficult for her to sleep overnight.
  The patient had 8 episodes of non-bloody,
  non-bilious emesis overnight and decided to seek
  medical care. She felt this way last year when
  she had strep throat and is worried she might
  have caught it again.
• ROS She has been more fatigued than usual for
  the past day and also complains of a generalized
  aches everywhere. She has not been able to
  tolerate liquids since the emesis began, but
  thinks her UOP has been normal. 2 nights ago she
  had one episode of emesis after partying with
  her friends, but had no further emesis or nausea
  until today.
• She denies fever, diarrhea, hematochezia, melena,
  cough, cold, runny nose, sore throat, difficulty
  breathing, syncope, rashes or lesions, bruising,
  joint aches, sick contacts or recent travel.
• BHx Full term, induced vaginal delivery at 6
  pounds. Normal prenatal labs, no complications,
  stayed in the hospital for 2 days.
• PMHx A tonsillectomy at age 5. Past injuries
  include a broken thumb, broken leg, bruised ribs
  and a concussion. She was in a MVA several
  months ago,
• but had no injuries. No other medical
  illnesses.
• FHx Diabetes in a maternal grandfather. No
  history of gastrointestinal problems, IBD, IBS,
  heart problems, childhood illnesses,
  rheumatological conditions, migraine or mental
  illness in the family.
• SHx She finished high school last June with
  grades the B-C range and began vocational
  training in LA, which she enjoys. While
  attending the program, she lives with friends in
  LA, and with her mother, step-father and two dogs
  in San Diego when she is on a break. She states
  that she has a good relationship with her mother
  and stepfather and has not seen her father in
  many months.
• She has a history of binge drinking for about 9
  months she drinks 3 to 4 times a week, 5 to 6
  drinks of beer or hard alcohol. Over the past 3
  months during this program, she has not had
  anything to drink until the week that she came
  home. But during this past week she has been out
  partying with her friends almost every night.
• She smokes one pack of cigarettes every 2 weeks
  and has a history of trying marijuana at 14 years
  of age and has not used it since then. She
  denies any other drug use.
• She has been sexually active recently, until last
  week, when she and her boyfriend broke up. She
  has not been diagnosed with any STDs in the past
• She endorses recent irritability, sadness and
  insomnia. For the past week she has used tylenol
  PM to fall asleep. She denies anhedonia,
  concentration difficulties, being depressed or
  having suicidal ideation.
• MEDS Ortho tri-cyclin, Pepto-Bismol Tylenol
  PM.
• Nutrition She eats a varied diet and does not
  have concerns about her weight and denies any
  history of binging, purging or eating disorders.
• Devo She met all milestones (per mom). Menarche
  at age 12.
• ImmunizationsUp-to-date. Allergies
  Amoxicillin causes diarrhea
• End HPI

17

• Physical Exam

18

• Physical Exam
• Vitals Temperature 36.8, heart rate 80,
  respiratory rate 20, blood pressure 121/79.
• Wt 48.3 kg (15) Ht 139 cm (3)

19

• Physical Exam
• Vitals Temperature 36.8, heart rate 80,
  respiratory rate 20, blood pressure 121/79.
• Wt 48.3 kg (15) Ht 139 cm (3)
• General Petite Hispanic girl, lying in bed.
  She is awake and tired appearing, but alert and
  oriented.

20

• Physical Exam
• Vtials Temperature 36.8, heart rate 80,
  respiratory rate 20, blood pressure 121/79.
• Wt 48.3 kg (15) Ht 139 cm (3)
• General Petite Hispanic girl, lying in bed.
  She is awake and tired appearing, but alert and
  oriented.
• HEENT Normocephalic, atraumatic. Conjunctivae
  injected, no icterus, PERRL. NP patent, moist
  mucous membranes. Oropharynx clear, no erythema,
  exudates or lesions.
• Neck Supple. No lymphadenopathy.

21

• Physical Exam
• Vtials Temperature 36.8, heart rate 80,
  respiratory rate 20, blood pressure 121/79.
• Wt 48.3 kg (15) Ht 139 cm (3)
• General Petite Hispanic girl, lying in bed.
  She is awake and tired appearing, but alert and
  oriented.
• HEENT Normocephalic, atraumatic. Conjunctivae
  injected, no icterus, PERRL. NP patent, moist
  mucous membranes. Oropharynx clear, no erythema,
  exudates or lesions.
• Neck Supple. No lymphadenopathy.
• Resp Clear to auscultation bilaterally.
• CV Regular rate and rhythm, normal S1 and S2.
  No murmurs, rubs or gallops.

22

• Physical Exam
• Vtials Temperature 36.8, heart rate 80,
  respiratory rate 20, blood pressure 121/79.
• Wt 48.3 kg (15) Ht 139 cm (3)
• General Petite Hispanic girl, lying in bed.
  She is awake and tired appearing, but alert and
  oriented.
• HEENT Normocephalic, atraumatic. Conjunctivae
  injected, no icterus, PERRL. NP patent, moist
  mucous membranes. Oropharynx clear, no erythema,
  exudates or lesions.
• Neck Supple. No lymphadenopathy.
• Resp Clear to auscultation bilaterally.
• CV Regular rate and rhythm, normal S1 and S2.
  No murmurs, rubs or gallops.
• ABD Positive bowel sounds. Soft, nondistended.
  She has a palpable liver edge 1cm below the
  costal margin, that is tender and some tenderness
  in the epigastrium with deep palpation.

23

• Physical Exam
• Vtials Temperature 36.8, heart rate 80,
  respiratory rate 20, blood pressure 121/79.
• Wt 48.3 kg (15) Ht 139 cm (3)
• General Petite Hispanic girl, lying in bed.
  She is awake and tired appearing, but alert and
  oriented.
• HEENT Normocephalic, atraumatic. Conjunctivae
  injected, no icterus, PERRL. NP patent, moist
  mucous membranes. Oropharynx clear, no erythema,
  exudates or lesions.
• Neck Supple. No lymphadenopathy.
• Resp Clear to auscultation bilaterally.
• CV Regular rate and rhythm, normal S1 and S2.
  No murmurs, rubs or gallops.
• ABD Positive bowel sounds. Soft, nondistended.
  She has a palpable liver edge 1 cm below the
  costal margin, that is tender and some tenderness
  in the epigastrium with deep palpation.
• GU Tanner V, normal rectal exam, hemoccult
  negative.
• EXT Warm and well perfused. No cyanosis,
  clubbing or edema. CR 1 sec.

24

• Physical Exam
• Vtials Temperature 36.8, heart rate 80,
  respiratory rate 20, blood pressure 121/79.
• Wt 48.3 kg (15) Ht 139 cm (3)
• General Petite Hispanic girl, lying in bed.
  She is awake and tired appearing, but alert and
  oriented.
• HEENT Normocephalic, atraumatic. Conjunctivae
  injected, no icterus, PERRL. NP patent, moist
  mucous membranes. Oropharynx clear, no erythema,
  exudates or lesions.
• Neck Supple. No lymphadenopathy.
• Resp Clear to auscultation bilaterally.
• CV Regular rate and rhythm, normal S1 and S2.
  No murmurs, rubs or gallops.
• ABD Positive bowel sounds. Soft, nondistended.
  She has a palpable liver edge that is tender and
  some tenderness in the epigastrium with deep
  palpation.
• GU Tanner V, normal rectal exam, hemoccult
  negative.
• EXT Warm and well perfused. No cyanosis,
  clubbing or edema. CR 1 sec.
• Derm No rashes, jaundice, ecchymosis or
  lesions. She has multiple tattoos on the abdomen.
• Neuro Cranial nerves II through XII are intact.
  DTRs 2 bilaterally at the patella, strenght 5/5
  in all 4 extremities, sensation to light touch
  intact throughout. No pronator drift. Normal
  finger-to-nose.

25

• Physical Exam
• Vtials Temperature 36.8, heart rate 80,
  respiratory rate 20, blood pressure 121/79.
• Wt 48.3 kg (15) Ht 139 cm (3)
• General Petite Hispanic girl, lying in bed.
  She is awake and tired appearing, but alert and
  oriented.
• HEENT Normocephalic, atraumatic. Conjunctivae
  injected, no icterus, PERRL. NP patent, moist
  mucous membranes. Oropharynx clear, no erythema,
  exudates or lesions.
• Neck Supple. No lymphadenopathy.
• Resp Clear to auscultation bilaterally.
• CV Regular rate and rhythm, normal S1 and S2.
  No murmurs, rubs or gallops.
• ABD Positive bowel sounds. Soft, nondistended.
  She has a palpable liver edge that is tender and
  some tenderness in the epigastrium with deep
  palpation.
• GU Tanner V, normal rectal exam, hemoccult
  negative.
• EXT Warm and well perfused. No cyanosis,
  clubbing or edema. CR 1 sec.
• Derm No rashes, jaundice, ecchymosis or
  lesions. She has multiple tattoos on the abdomen.
• Neuro Cranial nerves II through XII are intact.
  DTRs 2 bilaterally at the patella, strenght 5/5
  in all 4 extremities, sensation to light touch
  intact throughout. No pronator drift. Normal
  finger-to-nose.
• End HPI

26
Results
27
Results
12.9 10.2 138
37.6
S 84 B 7 L 5 M 4
MCV 85.9 RBC Morph Normal
28
Results
12.9 10.2 138
37.6

• 94 13 138
• 3.1 24 0.7
• TP 7.8 ALB 4.6 Ca 9.7
• AST 20,921 ALT 11,915
• ALP 84 TBili 2.7 Db 0.8
• Lipase 263

S 84 B 7 L 5 M 4
MCV 85.9 RBC Morph Normal
29
Results
12.9 10.2 138
37.6

• 94 13 138
• 3.1 24 0.7
• TP 7.8 ALB 4.6 Ca 9.7
• AST 20,921 ALT 11,915
• ALP 84 TBili 2.7 Db 0.8
• Lipase 263

S 84 B 7 L 5 M 4
MCV 85.9 RBC Morph Normal
PT 52.5 PTT 53 INR 5.8
30
Results
12.9 10.2 138
37.6

• 94 13 138
• 3.1 24 0.7
• TP 7.8 ALB 4.6 Ca 9.7
• AST 20,921 ALT 11,915
• ALP 84 TBili 2.7 Db 0.8
• Lipase 263

S 84 B 7 L 5 M 4
MCV 85.9 RBC Morph Normal
U-hcg neg UA Sg 1.025, pH 6, 2 prot, 2
bld, Ketones mod, Leuk est neg, Nit
neg Micro 5 WBCs, 8 RBCs No casts or bacteria
PT 52.5 PTT 53 INR 5.8
31
Results

• VBG 7.34/38/47/-4.7

32
Results

• VBG 7.34/38/47/-4.7
• Utox neg
• Tylenol level 14
• ASA undetectable

33
Patient Course

• After further questioning, the patient admitted
  to taking a handful of Tylenol PM pills (30
  pills), 2 days before presentation, to fall
  asleep after she had been out drinking with
  friends.
• She strongly denies any suicidal ideation
• A few hours after taking the medicine, she had an
  episode of emesis (previously mentioned) that
  contained several pill fragments.
• The patient felt better and did not mention the
  ingestion.
• Her mother saw the emesis and believed the
  patient had thrown up all the medication she had
  taken

34
The patient is 48 hours post ingestion at the
time of diagnosis.
35
Hospital Course

• The patient was immediately started on Mucomyst
  and IVF
• She was admitted to IMU but quickly moved to the
  PICU for fulminant liver failure
• Transplant surgery was consulted and a
  preliminary transplant work up was initiated
• Further lab studies
• Hepatitis serologies (HBsag, Hep A IgM, Hep BC Ab
  and Hep C Ab) were all negative
• Alpha-1-Anti-trypsin level and genotyping were
  normal
• Alfa-fetoprotein level was normal

36
Hospital Course

• During her 3 day PICU stay the patient had
  hypotension requiring multiple fluid boluses and
  pressors
• She also developed anuria and acute renal failure
  (ATN on renal biopsy), requiring 5 courses of
  dialysis and 6 weeks of high dose steroids
• The patient stabilized and transferred back to
  IMU where she was followed by pediatrics and
  psychiatry.

37
Hospital Course

• After a 13 day hospital stay, the patient was
  discharged home
• D/C labs BUN 17, Cr 3.6, AST 49, ALT 192, PT 13,
  PTT 27, INR 1.1
• The patient continues to have normal liver
  function and was cleared by Gastroenterology 1
  month after her overdose
• The patient is followed at renal clinic and her
  renal function has now normalized
• She continues to be followed by psychiatry