Ignoring an E.D. Nurse's Assessment
Radiology Cases in Pediatric Emergency Medicine
Volume 2, Case 4
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
A 9-year old male was brought to the E.D. after
fainting in school. Upon awakening in the morning, he
vomited twice, but he was sent to school. At school, he
vomited three more times and continued to feel ill and
weak. He fainted briefly, which prompted the school
nurse to call his mother who brought him to the
emergency department. There was no seizure activity
witnessed. He was noted to have a poor appetite and
low grade fever for the past week.
His past history was significant for acute
post-streptococcal glomerulonephritis (5 years ago, now
resolved) and an injury to his left iris.
Examination: VS T36.8 (orally), P110, R24, BP
136/78, oxygen saturation supine in room air 95%. He
was a husky youngster of moderate obesity (weight 72
kg). No acute distress noted. Head without signs of
trauma. Eye exam positive for the irregular left pupil
due to his iris injury. His optic discs were sharp.
EOM's full. TM's normal. Oral mucosa moist. Neck
supple, no adenopathy. Heart regular without murmurs.
Lungs clear. Breath sounds somewhat distant but
consistent with the moderate obesity. Abdomen flat,
soft, non-tender, active bowel sounds. Liver and spleen
edges not palpable. No hernias. Normal testes.
Capillary refill time <2 seconds. Visible perfusion good.
Color slightly pale. Neuro: Speaks well. Facial
function good. Uses extremities well.
A quick glucose check showed a normal value. By
the time of this exam, he was feeling much better and
wanted to go home. He denied any headache,
dizziness, weakness, or nausea at this time. His
mother commented that his color had improved since
the time she picked him up from school. He was not
pale at home.
The diagnostic impression at this time was that of a
viral infection with pallor due to the vomiting. His
mother was told that it is not uncommon for a person to
faint during a flu-like illness. Since he was feeling much
better, he was about to be discharged from the E.D.
An E.D. nurse approached the physician and told
him that she thought the patient's abdomen appeared
distended. She also suggested that an abdominal
series be obtained. A second E.D. nurse agreed. The
physician went back to the patient to re-examine his
abdomen. The abdomen appeared flat. Even after
looking specifically for any distention, none was
appreciated. He continued to have active bowel
sounds. There was no tenderness and no other
abnormalities could be detected. Repeat VS: T98.9
(oral), P118, R24, BP 120/80, oxygen saturation 98% in
room air (supine).
At this point, the patient seemed to be stable and
the physician was confident in his diagnosis. After the
re-evaluation, the nurses made no further comments
about the abdominal distention. What would you do at
Because of the suggestion of the two experienced
E.D. nurses, the physician elected to order the
abdominal series to evaluate the possible abdominal
distention that only these two nurses could see.
View Abdominal Series: Flat (supine) view.
View Abdominal Series: Upright view.
Note that on the upright view, a pair of hands are
holding him by the pelvis suggesting that he had
difficulty sitting up on his own.
The patient was too large to fit his entire abdomen
on the film. The diaphragms were not visible
. Therefore, an AP CXR was done to view his
View AP CXR.
Since the radiographs were obtained to investigate
abdominal distention in a patient with vomiting,
radiographic signs of a bowel obstruction should be the
most important things to look for. These radiographs
show a good distribution of gas throughout the
abdomen. There are no large air fluid levels.
When viewing abdominal radiographs, it is common
to ignore the bony structures and the lungs. Significant
findings in the bony structures of the abdomen that may
be missed include vertebral compression fractures,
dislocated hips (congenital), metastatic lytic lesions,
bone cysts, etc. Pulmonary infiltrates are commonly
missed if the lung portions at the top of the abdominal
film are ignored. Abdominal radiographs are commonly
ordered to investigate abdominal pain. Since lower lobe
pneumonias are commonly the cause of abdominal
pain, always remember to examine the lung portion of
the abdominal films or obtain a CXR to adequately
visualize the lung fields.
In this case, this abdominal series revealed a right
pleural effusion. This can only be seen on the AP chest
view. If our patient were smaller and a separate CXR
was not done, this pleural effusion may only have been
visible at the very top of the film where a blunted
costophrenic angle may have been noted.
Both hemidiaphriagms appear abnormal in contour.
The lateral portions of the hemidiaphragms appear to
be higher than the medial portions (more obvious on the
patient's right than on his left). This indicates the
presence of subpulmonic effusions. On this AP view,
there is a visible effusion on the patient's right only. But
the appearance of the diaphragms suggest bilateral
Bilateral decubitus films were then ordered.
View Decubitus Films.
These images show bilateral pleural effusions, larger
on the patient's right.
After noting the pleural effusions, the possibility of
ascites was raised. Minimal peripheral edema was
noted. Since the patient had a previous episode of
acute glomerulonephritis, the possibility of renal disease
was investigated. His urinalysis and renal function
studies were normal. His blood count failed to show
any abnormalities. Examination of the pleural fluid
revealed malignant cells. Bone marrow studies
confirmed the diagnosis of Burkitt's lymphoma.
This physician was grateful to the two nurses who
had suggested ordering the abdominal series. Even
after the patient was hospitalized, other examiners
failed to appreciate any abdominal distention. Only
these two E.D. nurses could see it. In the orientation
manual for our E.D., students and residents are told,
"Our E.D. nurses are very experienced. If they suggest
anything to you, you should strongly consider carrying
out their suggestion." Additionally, all nursing notes
should be read during a patient's evaluation. Nurses
will often write down observations or historical items
that the patient fails to bring to your attention. Ignoring
an E.D. nurse's assessment is a pitfall that should be
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