Vomiting is just gastro right? OSCE by Andrew Perry
A 5 year old girl has been brought in to the ED at 1100hrs by her father with recurrent vomitting and a fever since last night. She is now in a cubicle with her father after having completed a nurse assessment.
You are to take a history and then perform an examination.
Once this is complete please advise the parent of your likely diagnosis and proposed plan.
Instructions for the candidate
Please verbalise your examination findings as you proceed. Exam findings are exactly what you encounter with the patient (if a real patient is available) with any variances from actual findings (including if a mannequin is used) verbalised by the examiner after you examine each region.
Domains being examined
- Medical Expertise
For the actor
2 actors: father and child (age in stem can be adapted to child's actual age).
Child: To provide hx as age appropriate i.e. the younger the child the more history is obtained from the parent.
Father: A fairly good historian - only vague on a few small details. To provide majority of history dependent on ability of child to participate as actor.
PROFILE: Pt lives with both parents and younger sibling in nearby suburb. No-one else in family is unwell.
PC: Vomitting and fever since last night
Father starts history by saying he is worried his child has appendicitis or gastroenteritis.
Pt has been off food since last night and overnight woke up parents saying she felt unwell and subsequently started vomitting. Vomitted 5 times in total - last episode 1 hour ago in waiting room. Vomit orange in colour. No blood.
Pt hasn't kept anything down - food or fluid since.
Father unsure when she last urinated - is pretty sure she hasn't been since getting up with patient at 0600hrs this morning.
No associated diarrhoea. Bowels last open yesterday and were normal.
Pt noted to be hot at home and temperature taken - Temp 38.7 degrees. No rigors.
Pt remains hot today and miserable so brought in.
Some mild lower abdominal pain. Pt always points to belly button when asked on location.
Father not sure if patient has dysuria, frequency or malodorous urine.
No cough, sore throat, sore ears or runny nose.
No skin infections.
Has had 3 episodes of fever and vomitting before, last episode a year ago, never associated with diarrhoea. Never this bad and resolved within 24 hours so parents didn't get child reviewed.
ANTENATAL HX: Normal pregnancy. Born at term via NVD.
PMHX: Nil significant
MEDS: Nil regular
IMMUNISATIONS: Up to date
Vitals available on chart provided.
Temp 37.9 degrees. HR 110 BP 90/50 RR 18 SaO2 99% on RA - if possible have this on an observation chart.
Weight - 18 kg. Normal weight and height on growth charts. BGL 5.2
General: Looks well. Alert. Tolerating bright light. No meningism. No obvious rash.
Hydration: Moist mucosa, good skin turgor and cap refill.
CVS: HS dual and nil. Normal pulses (if examined)
RESP: Clear. No cough heard. No increased WOB.
ABDO: Soft. Mildly tender in suprapubic region. No percussion tenderness. Normal BS.
SKIN: No rashes to more complete exam. No cellulitis.
URINALYSIS - father has copy of automated urinalysis strip lying face down on table next to him - says the nurse gave it to him as she couldn't find the notes at the time of doing the test. If candidate says they would like to do the test (extra marks) the father volunteers that it has already been done and provides the result. If candidate doesnt ask for it/mention it the father volunteers it anyway.
LIKELY DIAGNOSIS: UTI.
Possible but unlikely (and give reasons) - appendicitis, gastroenteritis, bowel obstruction
Potential for discharge on oral abx if can get patient to tolerate oral intake.
If can't tolerate oral abx will need admx for IV abx and rehydration.
1. Antibiotics. If tolerates oral intake after therapy.. Best regime as per RCH:
If oral medication is appropriate: Infants and Children
Trimethoprim 4mg/kg (150mg max) BD (only tablets generally available in community, RCH pharmacy make 10mg/mL suspension for RCH patients)
Trimethoprim and sulphamethoxazole (8mg-40mg per mL) 0.5 ml/kg (20ml max) BD
Cephalexin 15mg/kg (500mg max) TDS
10 days total if < 2years, 7 days if older
Check antibiotic sensitivities and adjust therapy in 24 to 48 hours.
2. Address nausea and decreased oral intake
Rehydation - from RCH Clinical Practice Guidelines: http://www.rch.org.au/clinicalguide/guideline_index/Gastroenteritis/
Ondansetron drug dose
Not recommended for children < 6 months old or < 8kg
Should only be administered once in this setting.
Table 1: Ondansetron wafer dose
Weight Ondansetron wafer Dose
8 -15 kg 2mg
15-30 kg 4mg
> 30 kg 8mg
Lemonade, homemade ORS and sports drinks are not appropriate fluids for rehydration
Encourage parents to find methods to help children drink. Eg: cup, icypole or syringe, aiming for small amounts of fluid often.
Suggest oral rehydration solutions (ORS) eg. GastrolyteTM, HYDRAlyteTM, PedialyteTM
Trial of oral fluids in the emergency department:
Note: Most children with mild/no dehydration can be discharged without a trial of fluids, after appropriate advice and follow-up arranged.
In patients requiring rehydration: give frequent small amounts of ORS, aiming for 10-20 ml/kg over 1 hour.
Significant ongoing GI losses (frequent vomiting or profuse diarrhoea) minimise the chance of success at home. Consider early NGT rehydration in these children.
FATHER ASKS ABOUT FOLLOW UP ASSUMING PT TOLERATES ORAL INTAKE INC. ABX:
Pt to stay in ED until tolerates oral intake including first dose of abx.
GP review in next 24 - 48 hours to chase urine. Advise GP may do tests to investigate cause of UTI e.g. US (bonus marks).
Return to ED if patient deteriorates to suggest infection and dehydration is worsening i.e. fevers persist > another 24 hours or patient develops the shakes (rigors), or continues to vomit, or doesn't make urine.
For the examiner
Child - of any age. Or paediatric sized mannequin.
Parent - male or female.
Examination room and bed.
2 chairs - one for patient + parent, 1 for candidate
Vital signs Chart
Urinalysis result on small piece of paper.
Domains Assessment Objectives
- Medical Expertise
- Approach to child with fever
- - Good, age-appropriate interaction with child for both hx and exam
- Appropriate use of parent as collateral hx
Other Assessment Notes
- Good, age-appropriate interaction with child for both hx and exam
- Appropriate use of parent as collateral hx
- identifies that patient unlikely to have either gastroenteritis or appendicitis with UTI being most likely diagnosis
- Understandable explanation of likely diagnosis and plan in layman's terms.
- Reasonable management plan including commencement of appropriate type and dose of antibiotics, and acknowledging that patient may require admx (if dehydrated and fails Trial of Fluids) or may be able to go home depending on response to treatment in the ED.
- Good discharge instructions including when to come back and when and with who to get follow up.