A 19-month-old boy with a medical history of 1 febrile seizure presented to the emergency department (ED) with 2 days of vomiting and 1 day of diarrhea. He was accompanied by his nonEnglish-speaking mother, who reported several episodes of nonbloody, nonbilious emesis and dark brown, watery stools. The patient had decreased intake of solid foods, but he had been breastfeeding well. Because of his diarrhea, the patients mother was unsure how many voids he had had in the past day. He had not had fevers. The family history was significant for the patients father recently being diagnosed with hepatitis C. The patients mother brought him into the ED because of his symptoms and concern that he looked yellow.

In the ED, the patient was afebrile with normal vital signs for his age (including heart rate of 146 beats per minute), and he was well appearing and active with moist mucous membranes and a capillary refill of <2 seconds. However, the ED provider additionally documented that the patient appeared moderately dehydrated [and] slightly jaundiced, and he ordered a comprehensive metabolic panel (CMP). All values were within normal limits, including total bilirubin, except for a low bicarbonate of 16 mmol/L (normal 2130 mmol/L) and an elevated alkaline phosphatase (ALP) of 926 U/L (normal 129291 U/L). The provider consulted endocrinology for the elevated ALP, who noted a broad differential for elevated ALP and that transient hyperphosphatasemia is a diagnosis of exclusion. They recommended checking 25-hydroxyvitamin D, phosphate, and parathyroid hormone to

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An Explosive Workup for Diarrhea: The Cascade Effect From an Incidental Finding on a Laboratory Panel - AAP News

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