Hot Seat #143: 12 year-old girl with nausea
Posted on: January 9, 2020, by : Dennis Ren
HPI: 12 year old female presents with weight loss and nausea. Associated symptoms include dizziness and “feeling cold.” Her parents report that her food intake has decreased starting around 6 months ago. She has lost 8-12 kg since the symptoms started. She reports nausea and abdominal pain whenever she eats or drinks, which causes her to vomit. Over the last few days, she has severely restricted her food and water intake . In the last year she has only had one menstrual period.
She denies excessive exercising, binging, purging, laxative or diuretic use, excessive water intake.
ROS:
Constitutional: Denies fevers. Endorses weight loss
HEENT: Denies headache, changes in vision, sore throat
RESP: Denies SOB, cough
Cardiovascular: Denies chest pain or palpitations. Denies syncope
GI: Endorses vomiting, abdominal pain, bloating, heart burn
GU: Denies dysuria, vaginal bleeding/discharge
Neuro: Dizziness. Denies headache, numbness, tingling, weakness
Psych: Anxious, denies SI/HI
Endocrine: Denies changes to hair, polyuria, polydipsia, cold intolerance
PMHx/PSHx: No past medical or surgical history. Does not take any medications.
FamHx: None
Social: Lives with parents and siblings. Feels safe at home. Endorses stress at school. Denies drug use, sexual activity.
Physical Exam
T: 36.2 C HR: 88 RR: 19 BP: 95/58 O2: 100%
General: Alert, appropriate for age.
Skin: Warm centrally with cool extremities
Neck: Supple, no LAD
Eyes: PERRL, EOMI, normal conjunctiva
Ears, Nose, Mouth, and Throat: Moist oral mucosa. No pharyngeal erythema or exudates
Cardiovascular: Regular rate and rhythm. No murmurs. No rubs. No gallops. <2 second capillary refill
Respiratory: CTAB. Non-labored respirations
GI: Soft, nontender, non-distended. No organomegaly
MSK: No swelling. No tenderness
Neurological: Alert. No focal neurological deficits
Bloodwork and EKG are obtained:
- CBC: WBC 8, Hb 13.4, HCt 37.5, Platelets 212
- CMP: Na 124, K 4.3, Cl 91, CO2 24, Glucose 71, BUN 29, Cr 0.8, Ca 9.9, Total protein 7, Albumin 3.7, ALK 102, AST 25, ALT 22, Bilirubin 0.6, Phosphorous 5.6, Magnesium 1.8
- TSH 4.5 (normal)
- Prealbumin 17.5 (normal 24-47)
- UA: glucose negative, protein negative, blood negative, ketones trace, spec grav 1.016
- Upreg: negative
- EKG: NSR, Prolonged QT 500
The patient remains clinically well-appearing with stable vital signs.
Question 1:
| LESS THAN 3 YEARS PEM Experience | MORE THAN 3 YEARS PEM Experience |
You are concerned about your diagnosis given her level of hyponatremia with a normal urine specific gravity in the absence of a history of excessive losses or laxative abuse.
Question 2
Question 3
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Though anorexia nervosa would be the most common cause of the patients restricting eating behaviors, those electrolyte abnormalities are concerning. Another diagnosis I was considering is Addison’s disease, which can have hyponatremia and present with very vague symptoms. Overall, I am concerned that this patient did not get this hyponatremic quickly, and deserves a slower correction that might be best suited in the PICU.
To restate the case: We have a previously healthy 12 year old female with nausea, vomiting, 8-12 kg weight loss over 6 months, anorexia (?reported restriction of intake – intentional versus secondary to nausea/vomiting), amenorrhea who presents with ‘dizziness on standing’ though is well appearing with stable vital signs. She also has hyponatremia with an elevated BUN/Cr ratio, low pre-albumin however with a normal potassium. It would help to have her BMI (is she normal weight for her age?).
Broad DDx includes malignancies, vasculitis, endocrinopathies, infections, cardiac disease and psychiatric disorders.
Grouping these into three categories, we have:
Organic (Malignancy, Malabsorption Syndrome/other GI, Endocrine – hypothyroid, DM, pheochromocytoma, panhypopit, adrenal insufficiency, hyperparathyroidism, HIV, vasculitis
Psychiatric (endogenous – depression, anorexia vs exogenous); abuse of medications – ADHD meds?
Functional/Idiopathic -increased exercise)
An important distinction with weight loss is a) preserved appetite vs b) loss of appetite. Endocrine causes usually present with increased or preserved appetite. However Addison’s disease can present with anorexia
DDx using SPIT (good way to teach residents/students):
S (Serious) – It is always important to start with this category to ensure consideration of important ‘not to miss’ diagnoses. From those mentioned above, malignancy (reassuring that she does not have HSM or LAD and has a normal CBC – however abdominal pain and nausea may make you want to pursue GI causes with scope or imaging – Crohns, malignancy), underlying cardiac disease (reassuring to have normal exam however the prolonged QT does give you pause– though this could be from rapid weight loss). SIADH (however she has an normal specific gravity); malabsorption (though would expect diarrhea with normal intake)
P (probable) – Then we move to what is more common and what we think is most likely the cause of the symptoms. Anorexia nervosa is common.
I (interesting) – This is a good category to encourage learners to think of less common causes (Addison’s as Katie suggested) Symptoms that fit with Addison’s – dizziness, weight loss, hyponatremia (can present without hypokalemia), amenorrhea, nausea/vomiting, however there is no report of the classic bronzing/darkening of the skin.
T (treatable) – what can you do today (with minimal risk) to potentially treat a cause. We should treat the hyponatremia (slowly as Katie mentioned). Additionally, think about those items on the Serious list that are easily treatable in this category.