Case # 4–May

Welcome to the ACH PIG Challenge! To answer the questions below please post a comment (which will be sent to us but not published) or email ACHPIGChallenge@gmail.com . We will post answers in June, when the new case is published.  You will be placed in a drawing to win an Atlas of Pediatric Physical Diagnosis by Zitelli and Davis every time you participate!!

It’s your first month intern year in a busy emergency room and your first patient is a 6 week old baby girl.  She is brought to the ER by her parents because she is refusing to eat and crying more than usual.  When she was triaged by the nursing staff, her vital signs are Temp 101 F, HR 170, RR 45, BP unobtainable, O2 Sat 99% on room air.  Her physical exam is remarkable for fussiness but she is consolable by her mother.  Her mucus membranes are moist and her TMs look normal bilaterally.  Other than having some intermittent tachypnea when she cries, her lungs and heart sound normal.  No crackles or wheezing, no murmurs.  Her belly is soft and you hear normal bowel sounds.  She is moving all of her extremities well and while she is warm and has less than 3 seconds capillary refill time, she appears slightly mottled.  Otherwise she has no rashes.  Her Mom and Dad are very worried about her and are anxious to answer all of your questions.  Basically, Mom says that she “just wasn’t herself” yesterday, seemed fussier than usual.  Then, last night she wouldn’t breastfed.  She slept on and off for about 5 hours but continued to refuse to feed until this morning around 8am when she took 2 oz of breastmilk from a bottle.  She continues to be fussy and Mom got really worried because she has never acted this way before.

The nurses tell you about the patient’s temperature and ask you what you would like to do.  Would you give her acetaminophen or ibuprofen?  If so, what dose? 

Yes, it is appropriate to give this patient acetaminophen for her fever.  The correct dose is 15mg/kg of oral or rectal acetaminophen.  Ibuprofen is not appropriate for this patient as she is less than 6 months old.  Remember that there are a few different formulations of acetaminophen, the infant drops are in a more concentrated suspension with 80mg/0.8ml and the children’s formulation comes in a 160mg/5ml suspension. 

In this patient, what, if any, labs or imaging would you order to begin working up her condition?

In a patient this age and with theses symptoms, most pediatricians would agree on a broad approach.  A CBC, blood culture, BMP, CATH (please…no bag!) urinalysis and urine culture, and a CXR would be indicated in this infant with fever, poor feeding, fussiness, and tachypnea.  In addition, most clinicians would also obtain spinal fluid to rule out meningitis.  A lumbar puncture should be done in this infant and sent for gram stain and culture, protein and glucose, cell count and differential, and possible other studies such as enteroviral PCR and/or HSV PCR.  

There are many thoughts on the approach to the febrile infant.  According to Harriet Lane, 17th edition, on page 415, the algorithm gives several options depending on age, how the child looks and other lab results.  Many pediatricians practice differently and have their own unique approach to febrile infants.  In general, if you are concerned about meningitis, you should perform the lumbar puncture! 

You order an IV and a 20ml/kg normal saline fluid bolus because Mom tells you that the baby has only had 1 wet diaper since last night.

1. What is your differential diagnosis? 

Sepsis (bacteremia, urosepsis, etc)!!!  Could be from a UTI, pneumonia, or meningitis.  Or perhaps this is a viral illness.   

2. Does this patient need antibiotics?  If no, why?  If yes, what type and route of antibiotics would you order?

While routine CSF studies can help you in the diagnosis of meningitis, CSF, urine, and blood cultures must incubate in order to isolate bacterial pathogens.  So, in this patient, it would be prudent to give IV antibiotics while awaiting the CSF, urine, and blood culture results for at least 48 hours.  A cephalosporin like ceftriaxone or cefotaxime would be an appropriate antibiotic choice.  Ampicillin may also be added if Listeria is still a concern, although more common in infants less than 1 month of age.   

3. Does this patient need to be admitted to the hospital or can she go home with her parents? 

Admitting to the  hospital for 48hours on parenteral antibiotics, while waiting on blood, urine, and CSF cultures is a good choice.  Again, according to the algorithim in Harriet Lane there are other options as well!  The more conservative choice would be admission. 

4. What type of infections might this patient have? 

UTI, meningitis (bacterial and viral), bacteremia, pneumonia, viral illness. 

CASE #3- March/April

Welcome to the ACH PIG Challenge! To answer the questions below please post a comment (which will be sent to us but not published) or email ACHPIGChallenge@gmail.com . We will post answers in May, when the new case is published.  You will be placed in a drawing to win an Atlas of Pediatric Physical Diagnosis by Zitelli and Davis every time you participate!!

Jimmy is a 5 yo little boy who is brought to the ER by his mother because he “looks puffy” and has been tired and short of breath lately.  About 1 week ago, he had cough, rhinorrhea, sore throat, and fever, which have since resolved. Being an astute medical student, you suggest a renal function panel (electrolytes, BUN, Cr, Albumin, Phos) and a urinalysis as initial work-up.  See the 2 scenarios below:

Scenario A- Physical exam is notable for peri-orbital edema, abdominal distension, lower extremity edema, and scrotal edema, mildly diminished breath sounds at bilateral bases; Vital signs: HR 100, RR 22, T 36.5, BP 104/68, Wt 20 kg; Lab: Na 135, K 4, Cl 105, HCO3 24, BUN 11, Cr 0.5, Glucose 85, Albumin 1.7, Phos 5; UA is unremarkable except for protein of 3+

1. What additional labs would you like?

spot urine protein to creatinine ratio (preferrably first morning void) or 24 hr urine collection to quantitatively measure protein excretion (though it is difficult to obtain accurately timed collections in young children); cholesterol, triglycerides, C3, C4

2. After appropriate diagnostic work-up, Jimmy’s urine protein is found to be 2 grams/day (100mg/kg/day). What is your diagnosis? What is the most common form?

– nephrotic syndrome- Nephrotic syndrome is diagnosed by fulfilling two defining characteristics: urine protein excretion (nephrotic range proteinuria) >50 mg/kg per day, and hypoalbuminemia defined as serum albumin <3 g/dL (30 g/L).

– in children, the most common form is minimal change disease(idiopathic nephrotic syndrome)

 

3. What is your treatment plan? 

glucocorticoid treatment (prednisone)- children with idiopathic nephrotic syndrome will further be classified as glucocorticoid-sensitive (the majority) or glucocorticoid resistant (about 20% will not respond to glucocorticoid and have a worse prognosis)

Scenario B- Physical exam notable for generalized edema and mildly diminished breath sounds at bilateral bases; Vital signs: HR 100, RR 22, T 36.5, BP 136/92, Wt 20kg; Lab: Na 135, K 4, Cl 105, HCO3 24, BUN 28, Cr 1.7, Glucose 85, Albumin 3.5, Phos 5; UA is remarkable for 1+ protein, 3+ blood (urine is coca-cola/tea colored), Small amount of RBC casts, WBC 35

1. What additional lab tests would you like?

streptozyme measures the following 5 antibodies: Anti-streptolysin (ASO), Anti-hyaluronidase (AHase), Anti-streptokinase (ASKase), Anti-nicotinamide-adenine dinucleotidase (anti-NAD),Anti-DNAse B antibodies- or you can get these tests individually.

C2, C3, C4, CH50, throat culture for strep (only + in 25% of cases b/c after antecedent strep pharyngitis infxn), skin culture in pt’s with impetigo, may also get ANA (if >10yo or clinical symptoms suspicious of lupus)

2. What is your diagnosis? What is the most common etiology/form?

– nephritic syndrome- The clinical findings of acute nephritis include hematuria with or without red blood cell casts, variable degrees of proteinuria, edema, and hypertension;

– most common etiology = post-strep glomerulonephritis (C3, CH50 are usually low in Post-strep GN, but in lupus nephritis C3 and C4 are low))

3. What is your treatment plan? Assuming that he does have the most common etiology, what should you tell mom and dad about prognosis?

supportive care; focused on manifestations of disease, particularly complicatioms from volume overload i.e. hypertension and pulmonary edema- diuretics (lasix (furosemide)) for edema (generalized and pulmonary); usually self-limited disease- diuresis begins within 1 week and serum creatinine returns to nml within 3-4 weeks; hematuria can last 3-6 months, increased protein excretion may last years. Most patients, particularly children, have complete clinical recovery/excellent prognosis, and resolution of their disease process begins within the first two weeks. However, there is a small subset of patients who have late renal complications (ie, hypertension, increasing proteinuria, and renal insufficiency).

ACH PIG CHALLENGE Case 2- February

Welcome to the ACH PIG Challenge! To answer the questions below please post a comment (which will be sent to us but not published) or email ACHPIGChallenge@gmail.com . We will post answers in March, when the new case is published.  You will be placed in a drawing to win an Atlas of Pediatric Physical Diagnosis by Zitelli and Davis every time you participate!!

A 12mo female presents to their PCP’s office with a 2 day history of fever (Tmax 101 F), congestion, runny nose, cough and she seems to be tugging at her left ear.  She was a term newborn and has been relatively healthy up until this point.  She has never been hospitalized and has no chronic medical condtions.  She has never been on antibiotics. 

On exam, she is febrile to 39 C, has clear rhinorrhea, her oropharynx is moist and benign in appearance.  She has bilateral small anterior cervical lymphadenopathy that is mobile and nontender.  Her tympanic membranes’s (TM) are not able to be visualized due to cerumen impaction bilaterally.  The rest of her exam is within normal limits.

1.  What is your diagnosis?

Acute Otitis Media

2.  Do you need to investigate her ears further?  If so, what is the next step?

If you didn’t have your attending’s help, you would definitely need to find out a way to see the TMs.  Technically, you could probably trust your attending’s skills…but as an eagar medical student, you should probably take another look.  This time, after an ear wash (my personal favorite is warm water and liquid colace…works like a charm) or with an ear curette gently scoop the ear wax out of the way (you must have a VERY good helper to hold the child still)

3.  Your attending is able to visualize the TMs and reports the following findings.  Erythematous, bulging left sided TM with purulent fluid present.   What are the top 3 causes of this infection? 

S. pneumoniae, H. influenza, Moraxella are the top 3 bacterial causes of otitis media. 

4.  What is your treatment plan, including any dosages of medications you might prescribe?   What other questions might help you decide on your treatment plan for this patient?

If this is the first ear infection for this patient, most pediatricians would prescribe high dose Amoxicillin @ 80-90mg/kg/day divided BID for 10 days.  If the patient has had multiple or resistant ear infections, Augmentin or Omnicef would be great options. Things you might want to ask include if this patient is in daycare, have they had any other ear infections, or if they have any drug allergies.  The answers to these questions might influence your choice of antibiotic therapy.  While there are a large percentage of otitis media that is viral in etiology and might resolve spontaneously, in this patient with fever and symptoms of pain and pulling at the ear, antibiotic therapy is indicated. 

Tylenol (15mg/kg/dose) or Motrin (10mg/kg/dose) are good choices for antipyretics and pain control in this patient. Remember that Infant’s Tylenol and Children’s Tylenol are different suspensions so you might have to help Mom figure out the right amount to give.  Also, Motrin is not indicated in children less than 6 months of age. 

5.  While you are walking out of the exam room, the patient’s Mom stops you to ask another question.  She states that the patient has a horrible cough and wonders if there is anything you can prescribe her.  She states the patient is not able to get any rest and sometimes coughs so hard that she vomits.  What is your response?

If you choose to treat children as part of your medical practice, you will absolutely be confronted with this issue.  Sometimes parents want to try over the counter cough and cold medications but beware that these probably will not work and are indeed not indicated in children less than 2 years of age.  The risks of using these cough and cold medications usually outweigh the benefits.  Reassure Mom that these symptoms will resolve with time and be sympathetic to her situation.  Offer to see the child back if the symptoms do not improve over the next few days and give her a list of reasons when she should worry or bring the child back.  (signs/symptoms of respiratory distress, dehydration, lethargy, inability to take antibiotics, or continued fever after 48-72hrs, etc)

ACH PIG Challenge November-December

Welcome to the ACH PIG Challenge! To answer the questions below please post a comment (which will be sent to us but not published) or email ACHPIGChallenge@gmail.com . We will post answers in mid January when the new case is published.  You will be placed in a drawing to win an Atlas of Pediatric Physical Diagnosis by Zitelli and Davis every time you participate!!

Case #1

A 4 year old caucasian little boy, with no significant past medical history, was brought to the emergency department today crying and refusing to walk.  2 weeks ago he had a cold with cough, runny nose, headache, and a lowgrade fever that has since resolved.  Today his knees and ankles are swollen bilaterally, without erythema or warmth. He is afebrile. Mom says a rash started 1 to 2 days ago to his lower extremities. On exam, he has a raised rash to his buttocks, legs, and feet, similar to the rash seen below.  He weighs 15 kg and his vital signs are within normal limits. 

Questions:

1. How often is the rash present with this clinical diagnosis?

This patient has Henoch Schonlein Purpra (HSP).  The rash is present 100% of the time.  Arthritis is present 75%, GI involvement 50%, renal involvement 25%.

2. The patient’s parents were advised on when to bring the child back, and he was sent home on scheduled ibuprofen for the pain and swelling.  He returns to the emergency department a few days later with refusal to take po secondary to abdominal pain. On exam he is obviously dehydrated; he has sticky mucous membranes, deepset eyes, and tachycardia. You would like to bolus him. How much will you give and what solution?

You should bolus 20ml/kg of an isotonic solution- In this case 300mL Normal Saline or Ringer’s Lactate- over 30 minutes to 1 hr or faster (IV push) if the kid is unstable or looks to be in shock

3. What GI complication is associated with this condition and is characterized by colicky abdominal pain and blood in stool? What diagnostic test(s) could you use for this diagnosis if suspected?

Intususception (submucosal and serosal hematomas may act as  a lead point)- You can diagnose this with an abdominal ultrasound, but air-contrast enema can serve as a diagnostic tool and potential treatment- if you are unable to reduce it with an air-contrast enema surgery will be necessary for reduction- the surgeon’s are usually on stand-by during the air-contrast enema because of risk of perforation.

4. What screening lab test would you do to check for renal involvement? And what abnormalities would you expect to see if this were the case?

Urinalysis- hematuria/proteinuria

5.  GI, Renal, and CNS vasculitis may respond to what treatment?

systemic corticosteroids