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Case Presentation in Pediatrics

R. Francisco – J. Garimbao Dr. Balderas. Case Presentation in Pediatrics. Identifying data EMA, an 8-year old, Filipino, Roman Catholic female, from Parang , Marikina. Patient History. Chief Complaint Fever of 13 days Abdominal pain of 2 days. History of Present Illness

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Case Presentation in Pediatrics

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  1. R. Francisco – J. Garimbao Dr. Balderas Case Presentationin Pediatrics

  2. Identifying data EMA, an 8-year old, Filipino, Roman Catholic female, from Parang, Marikina Patient History

  3. Chief Complaint • Fever of 13 days • Abdominal pain of 2 days

  4. History of Present Illness • 13 days prior to admission • Intermittent low grade fever (undocumented) • temporarily relieved by Paracetamol • No other symptoms were noted • 10 days prior to admission • still with fever • productive cough • swelling of the face • no decrease in activity

  5. 6 days prior to admission • Red discoloration of urine 2 days prior to admission • Facial edema disappeared • Still with fever, cough, and reddish urine • Intermittent peri-umbilical pain Few hours prior to admission • Peri-umbilical pain worsened as well as her fever

  6. Past Health Prenatal • Mother is eclamptic Birth • Born full-term • Via normal spontaneous delivery, phyician assisted at Amang Rodriguez Hospital • BW= 4lbs • BL and APGAR=unknown

  7. Neonatal History • Had pneumonia during 2nd week of life

  8. Immunization History • Complete vaccination obtained from the health center

  9. Feeding History solely breastfed for 1 month introduced to formula at 2 months ( Bona with 1:1 dilution ratio, Bonakid from six months to 1 year and was then shifted to bear brand) introduced to solid food at 6 months no allergies to food

  10. Developmental History • Unremarkable

  11. Past Illnesses/Hospitlizations • No major illness/hospitalization/surgery/ history of allergic reactions prior to the current admission apart from pneumonia during 1st week of life as stated above.

  12. Family History • Her grandmother in the paternal side had aplastic anemia

  13. Social and Environmental History • The patient lives in a 1-story house with 1 toilet along with 5 other occupants • Water for both drinking and household purposes are from the faucet.

  14. General Survey Patient is awake, alert, and ambulatory but uncooperative and is not in any cardio-respiratory distress Vital Signs PR: BP: RR: Temperature: Physical Examination

  15. Anthropometrics: Length: 64in (162.56cm) Weight: 49kg (108.03lbs) BMI: 18.5

  16. Skin pink-pinkish red maculopapular rash distributed on all his extremities red scar-like lesions on the back warm to touch with normal turgor, nails pink with no signs of infection, pallor, cyanosis or clubbing

  17. HEENT Head • The skull was symmetric, atraumatic with well distributed black hair • no hair loss/infestations. Scalp without any masses, lesions, signs of trauma and pigmentations. • No facial asymmetry was noted. • Face have scars on the nasolabial line with red non pruritic patches on the cheeks (~0.5-3cm in diameter)

  18. Eyes Eyes are symmetrical, with no exopthalmos/enophthalmos or edema anictericsclera and pink conjunctivae both pupils constricting on direct and indirect pupillary reflex test. VA: OS= J2, OD=J1. Fundoscopy: (+) ROR

  19. Ears Auricles are aligned no gross deformities, lesions, swelling or masses or discharge

  20. Nose No gross deformities, swelling, bleeding, lesions, erosions, masses, infections. Nasal septum at the midline

  21. Mouth Pink, moist lips with no deformities with pustules (~1-2mm) on the buccalmucosa uvula and tongue at the midline with no tonsillar redness/enlargement

  22. Neck Trachea midline thyroid is non palpable as well as lymph nodes

  23. Thorax and Lungs: Chest symmetrical with equal expansion and excursion and without gross abnormalities or respiratory lag. No intercostal retractions, no use of accessory respiratory muscles. No lesions, masses on anterior chest but with scars on the back no tenderness noted equal tactile fremitus. Vesicular breath sounds with no adventitious sounds on auscultation

  24. Cardiovascular: Adynamicprecordium with no deformities/palpable thrills or bruits. Distinct S1 and S2 heard loudest at the 4th-5th ICS left parasternal border with regular rate and rhythm. No murmurs or adventitious heart sounds noted

  25. Abdomen It was flat and symmetrical with no lesions/deformities/discolorations. Normoactivebowel sounds with no bruits over all quadrants. Quadrants were non-tender and tympanitic.

  26. Musculoskeletal: There were no gross deformities of joints and extremities Normal tone and a muscle grade of 5/5 on all muscle groups with full range of motion and no crepitations. No tenderness on joints and extremities.

  27. MSE the patient is awake, alert, and cooperative Cranial Nerves Unremarkable

  28. Reflexes Deep tendon reflexes on biceps, triceps, knee and ankle have a grade of +2, (-) Babinski reflex Sensory: pain perception is intact for all extremities Cerebellar: no babinski; intact

  29. Differentials Henoch-SchonleinPurpura Urinary Tract Infection (UTI) Systemic Lupus Erythematosus (SLE) MembranoproliferativeGlomerulonephritis (MPGN) Primary Impression: Acute PoststreptococcalGlomerulonephritis

  30. Henoch-SchonleinPurpura • Rule in • -Renal involvement • -Gross Hematuria • -Asian prevalence • -Occurs mainly in young children. • Rule out • -Typical anaphylactoidpurpura ex: Henoch-SchonleinPurpura. • -Arthritis and/or arthralgia • -No fever • -Boys

  31. Urinary Tract Infection (UTI) • Rule in • -Hematuria • -Fever • -Female gender • Rule out • -No edema • -No increased blood pressure.

  32. Systemic Lupus Erythematosus (SLE) • Rule in • -Increased blood pressure • -Edema • -Dark urine • -Fever • -Female gender • -Asian • Rule out • -Butterfly skin rash • -Arthritis • -Most commonly 20-45 years of age (onset.)

  33. MembranoproliferativeGlomerulonephritis (MPGN) • Rule in • -Blood pressure and GFR affected. • -(Some) Acute nephritis and hematuria. • -Edema • Rule out • -Young adults. • -Urinary abnormalities persist past time of expected resolution for acute poststrep. Glomerulonephritis.

  34. Acute poststreptococcalglomerulonephritis was considered as the primary diagnosis due to: • patient develops an acute nephritic syndrome 1–2 wks after a possible streptococcal pharyngitis ( fever and cough) • Hematuria • facial edema Acute PoststreptococcalGlomerulonephritis

  35. Diagnostics CBC ASO titer Renal Function Tests • BUN • Creatinine • Urinalysis Plan

  36. Treatment • Treatment is supportive and focuses on control of hypertension and edema if present. • A loop diuretic (furosemide) should be given in order to remove excess fluid which reduced edema and also helps to correct hypertension. • Antibiotics for streptococcal infection such as penicillin should be given within the first 36 hours from the onset of symptoms

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