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Case Presentation: a 14-year-old girl with no known medical problems
A 14-year-old girl with no known medical problems presents to the ED with worsening epigastric pain for 3 days. The girl says the pain worsens after eating. The patient denies associated symptoms including vomiting, diarrhea, constipation, dysuria, and fever. The patient also denies alcohol consumption, drug use, and sexual activity.
Her vital signs are: heart rate, 55 beats/min; blood pressure, 90/50 mm Hg; respiratory rate, 18 breaths/min; and oxygen saturation, 100% on room air. On physical examination, you notice the patient has dry mucous membranes, discolored teeth, and a few scarred callouses on the dorsum of her right hand; the examination is otherwise normal. You are concerned about the patient?s vital signs, perplexed as to why she is not tachycardic despite her low blood pressure, and somewhat surprised that she is denying emesis or diarrhea, given her low blood pressure.
You tell the patient?s parents that you will order fluids and some basic laboratory tests and then reassess.
About 30 minutes later, the nurse calls you into the room because the patient’s oxygen saturation has decreased to 85%, and she is in respiratory distress after completion of the fluid bolus. On auscultation, you hear diffuse crackles bilaterally. You place the patient on bilevel positive airway pressure and perform a bedside ultrasound that shows B-lines in bilateral lungs suggestive of pulmonary edema. A portable chest x-ray also shows evidence of pulmonary edema.
Why did this patient rapidly develop pulmonary edema? Did the bolus worsen her condition? What diagnoses should be considered? Are there questions that you should ask the patient privately?
You asked the 14-year-old girl’s parents to step out of the room so that you could ask her some questions in private. Once her parents had left, you asked her the SCOFF questions, and she answered ?yes? to 3 of the 5 questions (lost > 14 lbs in a 3-month period, felt fat even though she was thin, had thoughts and fears about food and weight dominating her life). The patient also reported self-induced vomiting. You ordered a CBC, BMP, magnesium and phosphorus levels, chest x-ray, and echocardiogram and restricted food and visitors. Further fluid boluses were held. Psychiatry and neuropsychiatry were consulted. The patient was admitted to the PICU on bilevel positive airway pressure
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Last Updated on January 26, 2023