Lim, Janine Abigail A.

Med 3B PEDIATRIC CLINICAL CORRELATION Approach to Diagnosis Clinical Cases with Guide

Dr. Carole Sibulo Aug. 4, 2013

CASE 1: AB is a 15 month old male who came in at the emergency room with a chief complaint of rashes. He had fever 3 days prior to consultation with temperatures ranging from 38.5C-39.5C accompanied by slight watery nasal discharge. One day prior to consultation, fever subsided but the mother noted the appearance of rose-colored, non pruritic rash over the trunk and spreading later to the neck, face and extremities. On PE, the patient was awake, alert, active not in cardiorespiratory distress with generalized 2-5 mm erythematous maculopapular rash. The rest of the PE findings were unremarkable. Signs & Symptoms: Fever and rashes Applicable rule: 1D: Presenting manifestation that points to a Group of diseases or disorders To consider congenital rubella, measles or roseola infantum Most Probable Diagnosis: Roseola infantum CASE 2: CD is a 5 year old female who sought consult at the emergency room due to rapid breathing. Five days prior to consultation, the patient developed watery nasal discharge with productive cough. Mother brought the patient to a private physician who prescribed a mucolytic. Three days prior to consultation, she developed high fever with maximum temperature reaching 39C accompanied by poor appetite. A few hours PTC, still with the above signs and symptoms, she was noted to have respiratory distress described as labored and rapid breathing with alar flaring hence the consultation. On PE, the patient was weak-looking, in respiratory distress, febrile (39C), CR: 135 bpm, RR 45 breaths/min, with hyperemic posterior pharyngeal wall, watery nasal discharge, alar flaring, congested nasal turbinates, impacted ear canals, no cervical lymphadenopathy, adynaic precordium, regular rate and rhythm, no murmurs, symmetrical chest expansion, positive supraclavicular, intercostals and subcostal retractions, (+) crackles on both lungs, no cyanosis, no hepatosplenomegaly and no bleeding. Approach: SIGNS AND SYMPTOMS OR LABORATORY FINDINGS POINTING TO AN ORGAN SYSTEM

Signs & Symptoms: Rapid breathing Applicable rule: 1C: Presenting manifestation that points to a definite organ or system History and PE findings reveal involvement of the respiratory system with signs and symptoms pointing to respiratory distress Most Probable Diagnosis: Acute Bronchopneumonia CASE 3: EF is a 7 year old male who was brought to the emergency room due to fever of 7 days duration. This was accompanied by malaise, headache and crampy abdominal pain. Six week prior to consultation, patient complained initially of constipation which was followed by diarrhea after days. Patient had very poor appetite and was weak-looking. On PE, patient was conscious, weaklooking but coherent, not in cardiorespiratory distress, febrile (39C), BP 90/60 mm Hg, CR 120

bpm, RR 20 bpm, no pallor, no cervical lymphadenopathy, no tonsillopharyngeal congestion, symmetrical chest expansion, no retractions, clear breath sounds, normal rate with regular rhythm, no murmur, (+) abdominal distention, with hepatosplenomegaly, normoactive bowel sounds, no edema, full equal peripheral pulses, no bleeding. Initial CBC revealed slight anemia and leucopenia.Urinalysis was normal. Blood culture revealed (+) heavy growth of Salmonella typhi. Signs & Symptoms: Rapid breathing Applicable rule: 1A: Pathognomonic presenting manifestation Blood culture revealed heavy growth of Salmonella typhi Most Probable Diagnosis: Typhoid Fever CASE 4: GH is a 12 year old adolescent female who came to the emergency room due to passage of tea colored urine. Patient was apparently well until 1 week prior to consultation when her mother noted that she puffy eyelids in the morning which later disappeared in the afternoon. No consult was done at that time. Three days prior to consultation, she complained of occasional headache with decreasing urine output. One day prior to consultation, she noted that her urine appeared teacolored. Persistence of above signs and symptoms prompted consultation. On PE she was conscious, conversant, coherent not in cardiorespiratory distress, afebrile, CR 90 bpm, RR 18 breaths/min, BP 140/90 mm Hg, pink palpebral conjunctiva, anicteric sclera, no cervical lymphadenopathy, no tonsillopharyngeal congetion, symmetrical chest expansion, no retractions, normal rate regular rhythm, no murmur, no hepatosplenomagaly, normoactive bowel sounds, no abdominal distention, full and equal pulses, (+) healed lesions on both lower extremities, (++) bipedal edema. Urinalysis showed RBC: 30-35/hpf, WBC: 10-12/hpf, protein (++), sugar (-). Signs & Symptoms: Passage of tea-colored urine Applicable rule: 1D: Presenting manifestation that points to a Group of diseases or disorders Bipedal edema, microscopic hematuria and proteinuria Most Probable Diagnosis: Post-Streptococcal Glomerulonephritis CASE 5: IJ is a 16 year old female adolescent who was brought to your clinic due to cough of two months duration. This was accompanied by weight loss (10%), night sweats and frequent rises in afternoon temperature. Patient lives with a grandfather being treated for pulmonary tuberculosis. On PE, patient was conscious, coherent, not in cardiorespiratory distress, afebrile, BP 110/ 70 mm Hg, CR 90 bpm, RR 18 breaths/ min, no pallor, (+) cervical lymphadenopathy, symmetrical chest expansion, no retractions, clear breath sounds, normal rate with regular rhythm, no murmurs, flat abdomen, with NABS, no hepatosplenomegaly, no edema, no bleeding. Initial CBC was normal, PPD 15 mm, CXR positive for hilar lymphadenopathies. Sputum culture was (+) Mycobacterium tuberculosis. Signs & Symptoms: Cough of two months duration Applicable rule: 1A: Pathognomonic presenting manifestation Sputum Culture positive for MTB; patient presented with (+) weight loss, nights sweats, fever, crackles, and signs of respiratory distress Most Probable Diagnosis: Pulmonary Tuberculosis (Primary Complex)

CASE 6: KL is a 1 day old male infant born to 28 year old G1P0 mother by NSD. Patient was apparently well until on the 22nd hour of life, he was noted to have yellowish discoloration of the skin. Maternal history was unremarkable for any predisposing infection. On PE, patient was awake, active with good cry and good suck, not in cardiorespiratory distress, afebrile, CR 110 bpm, RR 58 breaths/min, (+) yellowish discoloration of the face, no icteresia, symmetrical chest expansion, no retractions, no murmurs, no hepatosplenomegaly, no bleeding. Babys Blood Type: B+, Maternal blood type: O+. Initial CBC platelet count was normal. Bilirubin levels taken on the 24th hour of life revealed: TB: 15, B1: 12, B2: 3. Signs & Symptoms: Jaundice Applicable rule: E: presenting manifestation whose mechanism is well understood In mothers with O+ blood type, there is an increase propensity for the fetus to develop HDN if his/her blood type is different from the maternal blood type. The presence of unconjugated bilirubin, which accounts for the hyperbilirubinemic state of the newborn confirms this diagnosis. Most Probable Diagnosis: Hemolytic Disease of the Newborn/ ABO Incompatibility CASE 7: MN is a 2 year old girl who was brought to the emergency room due to convulsions. Three days prior to admission patient developed moderate to high fever accompanied by malaise and poor appetite. A few hours prior to admission, she developed upward rolling of the eyeballs, cyanosis and body jerking which lasted a couple of minutes. On PE, patient was awake, active, crying, not in cardiorespiratory distress, febrile (39C), CR 120 bpm, RR 25 breaths/min, no pallor, no icteresia, (+) watery nasal discharge, no cervical lymphadenopathy, symmetrical chest expansion, no retractions, clear breath sounds, no murmurs, no hepatosplenomegaly, no edema, nor murmur. On neurologic examination, there was nuchal rigidity, papilledema on fundsocopy and positive Kernigs and Brudzinski signs. Initial CBC revealed leukocytosis. CSF analysis revealed (+) white blood cells, high protein and low CSF glucose levels. Signs & Symptoms: Seizure Applicable rule: 1C: presenting manifestation pointing to a definite organ or system (+) signs of meningeal irritation like nuchal rigidity, Kernigs and Brudzinki sign positive, convulsion and CSF analysis showing (+) WBCs, high CHON and low glucose levels Most Probable Diagnosis: Acute Bacterial Meningitis CASE 8: OP is a 6 year old boy who was brought to the emergency room due to facial swelling. This was accompanied by low to moderate fever and pain on mastication. Immunization is unrecalled. On PE, he was awake, active and not in cardiorespiratory distress, febrile (38C), BP 90/60 mm Hg, CR 105 bpm, RR 20 breaths/min, no pallor, no tonsillopharyngeal congestion, (+) swelling on both sides of the face with both ears displaced upward and outward and the mandibular angle cannot be located, symmetrical chest expansion, no retractions, clear breath sounds, no abdominal distention, no hepatosplenomegaly, no edema, no bleeding. Signs & Symptoms: Facial swelling Applicable rule: 1A: Pathognomonic presenting manifestation Fever and signs of swelling on both sides of the face with ears displaced upward and outward Most Probable Diagnosis: Mumps

CASE 9: QR is 12 year old adolescent male who was brought to the emergency room due to pallor. Two months prior to consultation he was diagnosed to have hepatitis B and was treated supportively. One week prior to consultation he was noted to be pale with several petecchia and purpura all over the body. He also complained of nose bleeding and gum bleeding when brushing his teeth. The mother also noted intermittent moderate to high fever for the past week. On PE, he was conscious, coherent, not in cardiorepiratory distress, febrile (39C), BP 110/70 mm Hg, CR 120 bpm, RR 20 breaths/ min, (+) mucocutaneous pallor, no icteresia, no cervical lymphadenopathy, symmetrical chest expansion, no retractions, clear breath sounds, no murmurs, no hepatosplenomegaly, (+) multiple petecchia, purpura all over the body. Initial CBC revealed anemia, leucopenia and thrombocytopenia. Signs & Symptoms: Pallor Applicable rule: E: presenting manifestation whose mechanism is well understood Anemia, thrombocytopenia and leukopenia Most Probable Diagnosis: Hepatitis B infection CASE 10: ST is a newborn female infant born to 29 year G1P0 mother by NSD. Patient was apparently well when during a routine physical examination in the nursery, she was noted to have a heart murmur. On PE, she was active with good cry, good suck, no cyanosis. There was no pallor, no icteresia with slight prominence of the precordium. A systolic thrill was palpable at the lower left sternal border between the 3rd and 4th intercostals spaces. A grade 3-4 harsh pansystolic murmurm is heard best in the same area. Normal rate and regular rhythm. There was symmetric chest expansion, no retractions, no abdominal distention, no hepatosplenomegaly, no edema, no bleeding. Signs & Symptoms: Pancystolic Murmur Applicable rule: 1C: A presenting manifestation pointing to a definite organ or system Murmur and Systolic thrill points to Cardiovascular System Most Probable Diagnosis: Ventricular Septal Defect