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.