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Morning Report
5/17/2013
Amy Rapp, MD
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11 year old female presents to ED for 1 year of chronicabdominal pain.
Pain is located in RUQ, but child is unable tocharacterize it further, frequent I dont knows
Pain is intermittent and comes every 2-3 months andlasts 2-3 days.
For the last 3 months pain seems to be more frequent.
Recently she has begun to have back pain as well.
No associations with food, though markedly decreasedappetite.
Family has tried Tylenol and heat packs, neither ofwhich has helped.
Family comes to the ED as this is worst pain episodeand the child began to have emesis today.
She denies prior episodes of emesis.
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Marked, reportedly unintentional weight loss thatis concerning to mother, though she doesnt
know how much. Soft, daily normal stools, no diarrhea, no blood or
mucous.
LMP was roughly 1 month prior, 3 lifetimeperiods, still somewhat irregular
Mother has also begun to notice right sidedswelling in her cheek.
Has seen multiple providers (poor continuity) forthese complaints, including PCP, GI, and recentlyENT (for swelling in cheek).
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Work up thus far:
CBC, CMP normal
AXR showed stool on right side of colon
Treated with miralax for constipation Abdominal ultrasound revealed physiologic
right ovarian cyst
ENT biopsied cheek 2 days prior but resultsare not yet available.
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PMH: Term, previously healthy
PSH: None SH: Lives with mom, step-dad, 2 younger
brothers. 6th grade, straight As. Has not missedsignificant amounts of school. Family is Spanish
speaking but child speaks English. FH: No IBD, liver disease, childhood cancers,
eating disorders, mental health disease. MGGMhad lung cancer after smoking for years.
Imm: UTD
Development: Normal
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T 37.5 HR 130s 80 RR 20 BP 125/76 Sat 97% RA
General Appearance: cachectic, alert, does not appear to feel well, apathetic, NAD
Head: NC/ATHEENT: Right sided facial swelling over parotid glandwithout overlying
erythema. Rubbery mass palpable over right parotid gland, not tender to palpation.
There is no induration or fluctuance. The margins of the mandible feel smooth and
continuous without interruption or mass. Dry lips, conjunctivae clear, sclera
anicteric, TMs/OP clear, no nasal discharge, PERRL. Right buccal mucosashows a well healing 1.5cm incision.
Neck: supple, scant anterior cervical LAD
Resp: CTAB, no wheezing or stridor, no increased WOB or retractions
CV: mildly tachycardic, normal rhythm, normal S1 and S2; no murmurs, gallops
Abd: soft, nondistended, +BS, no HSM, no rebound tenderness, no CV tenderness.TTP over RU/RLQ.
Ext: WWP, CR
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11 yr female with acute on chronic
abdominal pain, vomiting, right sided
facial swelling and weight loss.
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GI
- Hepatitis
- Cholecystitis
- Cholelithiasis
- Celiac
- Pancreatitis
- IBD
- Gastritis
- GERD- PUD/H. pylori
- SMA syndrome
- Lymphadenitis
- Constipation
Neuro- Abdominal migraine
Psych
- Anorexia
- Bulemia
GU
- Ruptured ovarian cyst
- Ectopic pregnancy
ENT
- Parotitis
ID
- UTI/Pyelonephritis
- HIV
ONC- Lymphoma/leukemia
- Sarcoma
- Neuroblastoma
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Work Up
CMP/Mg/Ph/CBC/TSH/free T4/uric acid normal
LDH 926 (
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Abdominal CT
Impression: Right paraspinal soft tissue masswith epidural extension is most consistentwith neuroblastoma. Associated multiple
sclerotic lesions within the bone arecharacteristic of osseous metastases.
Dx: Stage IV Neuroblastoma with multiplebony mets
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Neuroblastoma
~10% of childhood cancer, most commonmalignancy in infants
Generally dx at ~2yrs, 97% before age 10
Derived from neuroblasts of postganglionicsympathetic nervous system.
Prognosis determined by age and stage, bestprognosis if dx
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MC presentation is non-tender abdominal
mass
Most are metastatic at diagnosis
Paraneoplastic syndromes are common on
boards but less so in real life- VIP syndrome: intractable secratory diarrhea
and abdominal distention
- Opsomyoclonus: jerking and random eyemovements, can be associated with ataxia
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Dx: histologic evidence of neuronal origin orevidence ofincreased secretion of catecholamine
metabolites in urine HVA/VMA can be followed for off-therapy
screening
4S: infants
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