That's a pretty impressive history. I would have ordered a chest CT to evaluate for a source of diaphragm irritation. However, I'm not an ER physician - I'm on oncologist, so all my patients get chest CTs (er, half joking there...).
The NY Times had a great column last year on a case of refractory hiccups that turned out to be from a PE:
I have certainly seen bad spontaneous DVT's in teenagers. One of the most remarkable was a massive IVC clot that came extremely close to occluding the renal veins in a 16 year old girl. Her only risk factors for DVT were mild obesity, occasional cigarettes and oral contraceptives.
On Feb 13, 2012, at 11:02 AM, Lakshmi Vemuru wrote:
> Hello Everyone,This is an other interesting case for discussion
> A 15 year old healthy female presented to our Pediatric Emergency Department with a chief complaint of persistent hiccups for 16 days. They have been constant throughout the day and even when she falls asleep. History of six pounds of weight loss due to difficulty to eat. She was initially seen in a different PER and eventually transferred to Nationwide Children's Hospital where she had an extensive evaluation including brain MRI, MR angiogram. She was seen by gastroenterologist, neurologist,and psychiatrist. All the studies were normal except for mild Chiari I malformation. She was discharged home on Neurontin, took for one week and stopped since there was no change. Patient was brought to our Pediatric Emergency Department for second opinion. Patient had a head concussion when she was elbowed in the face at the gym. This happened in mid January. Subsequently she had mild headaches for about a week which resolved by itself. No other clinical history. Apart from continuous hiccups, her physical including neurological exam was normal. I consulted our neurologist who recommended to give IV haldol. After 2mg of IV haldol her hiccups were resolved. Patient was observed overnight and discharged. At a follow up visit next day the patient remained symptom free.
> Questions to the group:1)Have anyone seen a case like this?2)If so, what was your management?3)In this case patient responded to haldol.If not, would you do anything different like ordering labs, imaging studies or any different consultations?Hope to hear from the groupThanks in advanceLakshmi Vemuru
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