A Convoluted Picture

Jennifer L. Tiller, MSN, RN, CPNP


J Pediatr Health Care. 2007;21(5):325-326, 354-35. 

In This Article

Case Study

K. is here with her parents after a visit to the local emergency department for nausea and vomiting the previous night. It has been 6 hours since K. was discharged from the emergency department.

K. is a 14-month-old girl who was treated in the emergency department the previous night for vomiting. She was in her usual state of good health when she began to vomit 3 days ago. K.'s mother states that her daughter has vomited three to four times per day in the past 3 days but that she has been eating some crackers here and there and drinking clear fluids well. The mother says K. does not have hematemesis and that the episodes typically come 1 to 2 hours after eating or drinking. K. was seen in an after-hours clinic 2 days ago and diagnosed with acute viral gastroenteritis. She was febrile at that visit with a temperature of 100.2° F, but she has remained afebrile since then. She has had five to six wet diapers a day during this illness and no diarrhea. Last night, the mother was bathing K. when she suddenly "went limp" in her arms and became unresponsive. Emergency medical services was called to the home, and by the time they had arrived, K. was conscious but groggy. The mother denies any apparent seizure activity. The child was taken to the local children's emergency department, where she was diagnosed with dehydration and received intravenous fluids (unknown amount). Prior to initiation of fluids, laboratory tests were performed, and K.'s electrolytes and glucose levels were within normal limits. She was discharged in good condition. K.'s mother states that no resuscitation was needed at the emergency department. K. is in your office this morning (approximately 6 hours after discharge from the emergency department) for evaluation.

K. is the product of a term birth to a gravida 1, para 1 mother. Pregnancy, delivery, and neonatal course were uneventful. K. began saying words at 9 months and walking at 12 months. Her growth parameters are within normal limits.

K. has never been hospitalized, nor has she had any surgeries. She is up to date on all of her immunizations, including hepatitis A No. 1, given at her 12-month well-child examination. The pentavalent rotavirus vaccine was not yet approved by the Food and Drug Administration when K. was due for those immunizations. She has had two or three upper respiratory viral illnesses but otherwise has been healthy. She has no history of recent illness except for this complaint.

No one else in the home has been ill, nor has the child traveled recently. There are no new pets in the home.

K. is an only child who lives at home with both parents, who are with her today. She is in day care 3 days a week. K.'s mother is a neonatal nurse at a local hospital and is very upset about K.'s illness. She is tearful in the room and during your examination.

Gastrointestinal review was as previously stated. K.'s last episode of emesis was yesterday around 6:00 pm. Notably, she has had no diarrhea, but the mother reports one or two "less firm than normal" stools. She has had no cough, rhinorrhea, mood or mental status changes (except for the episode the previous night), or rashes. Her parents deny a recent history of head trauma and state that K. had not been excessively somnolent until last night's episode. K.'s mother says K.'s urine does not have a strong odor. K. has had no other recent illness, takes no medications on a regular basis, and is not currently taking anything for this illness.

K. is a nontoxic toddler who appears to be ill but is in no acute distress. K protests only slightly to examination. She appears well-hydrated and has tears during the examination. Her vital signs are as follows: respiratory rate, 32; pulse, 100; temperature, 99.0° F (37.2° C); and weight, 18.75 lb (8.5 kg), which is up 1 lb (2.2 kg) from her well-child examination 1 month ago. Her head is normocephalic/atraumatic, her anterior fontanelle is closed, and her ears are clear with appropriate light reflexes and landmarks noted. She has moist conjunctivae, tears with crying, and red reflex bilaterally. Pupils are equal, round, and reactive to light. Her nasal examination is negative. Her neck is supple without lymphadenopathy, tenderness, or rigidity, and her Kernig's and Brudzinski's signs are negative. K.'s oropharynx shows moist mucous membranes, thin saliva, tonsils 2+ with no exudate, and her pharynx is pink. Her lungs are clear to auscultation bilaterally with good air movement to all fields. Her heart rate is regular without evidence of murmur. Her abdomen is soft and nontender without distension; she has slightly hyperactive bowel sounds in all four quadrants. There is no rebound or guarding. No masses are appreciated, and her liver edge is 1 cm below the right costal margin. There is no splenomegaly. A genitourinary examination is deferred. Capillary refill is less than 2 seconds, and her skin is warm and moist with good turgor. There are no rashes or lesions.

A moderately soft stool specimen from K.'s diaper is examined. The stool is brown in color, and there is no foul odor. The availability of a stool specimen led the examiner to order a Hemoccult test in hopes that would shed light on K.'s nebulous presentation. Hemoccult for this specimen is strongly heme-positive, and further stool testing is ordered. K.'s parents wait in your office for observation and to obtain a fresh stool specimen for culture. Surprisingly, a second specimen checked approximately 1 hour later is heme-negative, and K. appears much more appropriate, laughing and playing with her mother. She is drinking Gatorade from a sippy cup without difficulty and has had no emesis.

  1. What differentials should be considered in this case?

  2. What diagnostic studies should be ordered for K.?

  3. What could have explained K.'s neurologic changes the previous evening, in light of her seemingly normal hydration level?

  4. hat could explain the presence, then the absence within an hour, of blood in K.'s stool?


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