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    Toddler with vomiting after head injury

    The Case

    As you finish writing a delivery note for the newborn you just attended, you receive a page. You're almost halfway through your 24-hour shift as a pediatric hospitalist at the local community hospital. The page is from the doctor at the after-hours urgent care clinic across the street. She is referring a nearly 3-year-old boy for evaluation of head trauma and persistent vomiting.

    You meet the toddler and his parents in the emergency department. He was fine until 10 days ago, when he ran down a hill in the afternoon and fell headfirst onto the cement. He had no loss of consciousness, but that evening after dinner he began vomiting, which has continued for the past 9 days. Seven days ago he fell again, off a chair this time, and hit the same spot on his head, causing another minor abrasion. He had no loss of consciousness with this episode either. He has had no fever or diarrhea throughout this time.

    The patient vomited 3 or 4 times a day until 2 days ago, when he was taken to his regular pediatrician who, after noting a normal neurologic exam, was less concerned about the antecedent head trauma and diagnosed otitis media, then administered intramuscular ceftriaxone and hydroxyzine (for emesis). That night the boy ate, walked around, and was "fine," according to his parents. The next day, the vomiting returned, so he was taken back to the pediatrician, who repeated the hydroxyzine injection and wrote a prescription for promethazine suppository.

    This morning, the parents administered the antiemetic suppository and noted that the boy was very sleepy. He hasn't had emesis since yesterday afternoon but has urinated 8 or 10 times today. His emesis had no blood or bile. He has had no headache or abdominal pain. Today, his parents noted swollen hands and feet. The parents state that he may have swallowed a coin 2.5 weeks ago (they noticed him rooting around in a purse and mouthing a coin but aren't really sure whether he ingested anything, and they never saw a coin pass in his stools). Three siblings and the parents have been well. There is no family history of gastrointestinal diseases, asthma, diabetes, or anemia.

    The boy had a brief vomiting illness about 6 months ago that was accompanied by diarrhea. His development is normal. He has had 2 episodes of otitis media. Otherwise, he is healthy without any prior admissions or surgery. The family has a dog, which has been vaccinated and is healthy.

    The parents currently are going through a separation. They state that the child has witnessed many of their arguments and are concerned that he has been more clingy and moody lately. They are worried that the father's recent move out of the house has caused a return of separation anxiety.


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