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 
this point?

     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 
diaphragms.

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 
pleural effusions.
     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 
avoided.