Dr.KAMEL HASSAN PEDIATRIC PROBLEM SOLVING CASES

Pediatric Problem solving - Case 26

2008-11-06T03:56:00.000-08:00

Pediatric Problem Solving – Case 26

A 14 month old infant presents to clinic because of poor weight gain and delayed walking . History revealed exclusive breast feeding with little baby food. On examination he has large head, distended abdomen, and palpable swellings at costochondral junctions.
What is the expected laboratory finding in this infant ?

A. Low calcium.
B. Low alkaline phosphatase .
C. Low phosphorus.
D. None of the above.
Explanation of the case:

 14 month old infant, exclusive breast feeding without vit. D supplementation.  Delayed walking, large head, distended abdomen and palpable swelling at costochondral junctions= rosary beads (skeletal and thoracic manifestations of rickets). This is typical case of infantile vitamin D deficiency rickets.

 Choice A: Points against: serum Ca level is usually normal in case of rickets and decreases only in certain cases as parathyroid exhaustion, severe cases and shock therapy with vit. D as it causes deposition of blood Ca in bone.
 Choice B: Points Against: serum level of alkaline phosphatase increases in case of rickets.
 Choice C: (the right choice) Points with: serum level of phosphorus markedly decrease in case of rickets.

 Choice D: Points against: there is already one correct answer..

Pediatric Problem solving - Case 25

2008-10-27T12:23:00.000-07:00

Pediatric Problem Solving – Case 25

An 8 years old girl present with low grade fever and a diffuse maculopapular rash. On examination her physician notes mild tenderness and marked swelling of her posterior cervical and occipital lymph nodes. Three days after the onset of illness , the rash has vanished.
What is the most likely diagnosis ?
A.Measles.
B.German measles.
C.Roseola infantum.
D.Infectious mononucleosis.

Explanation of the case:

An 8 years old girl with low grade fever (this is infection).  With Swelling of specific lymph nodes ( posterior cervical & occipital ) and not generalized lymaphadenopathy  And rash whish disappeared 3 days after the onset of illness (very typical of German measles) . This case fulfills the criteria of German measles

Choice A : a. Points against: there is no Koplik spots. b. There is no high fever; there is no conjunctivitis, no coryza and no cough.

Choice B : ( the right choice)

Choice C : a. Points against: the age group of Roseola infantum is from 6 months to 2 years, and the girl’s age is 8 years. b. Fever accompanying Roseola infantum is high fever not low grade fever.

Choice D: a. Points against; there is no evidence of sore throat or presence of any exudates on the tonsils. b. There is no evidence of splenomegaly which is characteristic in case of infectious mononucleosis.

Pediatric Problem Solving - Case 24

2008-10-17T14:18:00.000-07:00

Pediatric Problem Solving – Case 24
A 1 day old infant develops jitteriness and convulsions . He was born at 34 weeks gestation to a woman whose pregnancy was complicated by diabetes mellitus and pregnancy induced hypertension.

Which of the following serum values could explain his condition?

A. serum bicarbonate level of 22 mEq/dl

B. serum calcium of 6.2 mg/dl

C. serum glucose of 45 mg/dl

D. Serum sodium of 138 mEq/dl.

Explanation of the case:

convulsions is due to :

1. premature infant (34 weeks)

2. Infant of diabetic mother develops hypocalcaemia in the first 3 days, hypocalcaemia → convulsions.

3. Prematurity induce hypocalcaemia.

Choice (A) : point against : normal level of bicarbonate

Choice (B) : the right choice :serum level below 7 mg, hypocalcaemia

 Choice (C): point against: normal level of glucose.

 Choice (D): point against: normal level of sodium.

Pediatric Problem Solving - Case 23

2008-10-10T15:24:00.001-07:00

Pediatric Problem Solving – Case 23
A 4 month old infant presents with fever and poor feeding. Examination revealed moderate dehydration, poor perfusion, and screaming. The WBCs count is elevated with shift to the left. Urine analysis of a catheterized specimen reveals red blood cells, white blood cells, and scant bacteria.
What is the most appropriate course of treatment?

A. Fluid restriction.

B. Surgical intervention

C. I.V. antibiotics therapy

D. Wait for culture results

Explanation of the case

Poor feeding in children means loss of function and leads to dehydration.

Poor perfusion is dangerous as it may lead to circulatory failure.

Screaming in children indicates pain.

Increased WBCs count with shift to the left = bacterial infection.

A catheterized specimen ( to avoid contamination) reveals red blood cells, white blood cells, and scant bacteria = Urinary tract infection Diagnosis : septic shock on top of UTI

Choice (A): point against: the infant is dehydrated; fluid restriction will worsen the condition.

choice (B) : point against: not indicated

Choice (C): right choice: as this case is a septic shock which may be complicated and cause death, so must be treated immediately.

choice (D) : point against : takes time, it should be done later after the patient start receiving I.V. antibiotics then change the treatment according to culture results.

Pediatric Problem Solving - Case 22

2008-10-10T15:03:00.000-07:00

Pediatric Problem Solving – Case 22
A 1 day infant who was born by a difficult forceps delivery is alert and active. She doesn't move her left arm and keeps it internally rotated by her side with the forearm extended and pronated.

Which of the following is an expected clinical finding?

A. Intact both Moro and grasp reflex.

B. Lost both Moro and grasp reflex.

C. Intact Moro and lost grasp reflex

D. Lost Moro and intact grasp reflex.

Key points: Difficult forceps delivery. She doesn't move her left arm and keeps it internally rotated by her side with the forearm extended and pronated. All this points to Left Erb's palsy. Expected that all reflexes are lost except grasp reflex.

Right choice is: D (Lost Moro and intact grasp reflex.)

Pediatric Problem Solving-Case21

2008-10-05T13:57:00.000-07:00

Pediatric Problem Solving – Case 21
A 10 week old infant develops fever (38.5 C), vomiting, and irritability. His heart rate is 170/m and respiratory rate is 40/m. the infant's anterior fontanel is full, but there is no neck rigidity. The rest of the examination is unremarkable.
What is the most appropriate diagnostic test?
A. CSF examination

B. Complete blood count and ESR.

C. X- ray skull

D. chest x-ray

Explanation of the case:
Tachycardia is proportionate to fever.
Full anterior fontanel indicates increase of intra cranial tension.
Absence of neck rigidity don't exclude meningitides as it's not a dependent sign in children due to
open fontanel, which offer a relief of increased tension
Fever, vomiting, irritability are signs of infection.
choice (A): right choice: From the above cerebrospinal fluid examination is the most appropriate diagnostic test for meningitis as it indicates turbidity of CSF and confirm meningitis

Choice (B): point against. It will be done later as this is not a specific diagnostic test as it will show increase in WBCS count indicating infection but doesn’t detect the type of infection.

Choice (C): point against: it is useless in this case as it will show nothing and the infant will be exposed to X-ray without important reason.

Choice (D): the respiratory rate is normal and there is no symptoms suggesting any chest problems.

Pediatric Problem Solving-Case20

2008-09-17T15:41:00.000-07:00

Pediatric Problem Solving – Case 20
A 2 month old boy with a 3 day history of mild fever and runny nose suddenly develops high fever, cough and respiratory distress. Within 48 hours, the patient deteriorated and has developed a peumatocele and a left sided pneumothorax.
What is the most appropriate first action?
A.I.V. antibiotics

B.Blood gases

C.Chest tube

D.Antipyretics

Explanation of the case:
mild fever and runny nose = common cold
Suddenly develops high fever, cough and respiratory distress indicates that common cold progress to lower respiratory tract infection, then pneumonia.
The patient develops pneumothorax which is very dangerous as it compresses the lung and may lead to cyanosis and shock.
1st action to be done is to treat pneumothorax
 Choice (A) : point against: it takes 48 hs to start action and this case is emergency
 Choice (B): point against: it diagnoses acidosis, but this is not the 1st action.
 Choice (C): point with: chest tube is needed to drain air and must be done immediately.
 Choice (D): point against: part of the ttt but not the 1st action.

Pediatric Problem Solving-Case19

2008-09-13T15:51:00.000-07:00

Pediatric Problem Solving – Case 19
A 2 week old infant has had no immunization, sleeps 18 h a day, weight 3.5 kg, and takes 60 ml of standard infant formula four times a day, but no solid food and no iron or vitamin supplements.
What should be of most concern about this infant?
A.Immunization state

B.Caloric intake

C.Iron levels

D.Circadian rhythm
Explanation of the case:
2 week infant has no immunization history, average weight (3.5 kg)
2 week old infant needs no iron or vitamin supplements at this age
Average feeding of an infant is 8 – 10 times per day.
 Choice (A): point against: infant of 2 weeks has no immunization history yet.
 Choice (B) : the right choice (average feeding is 8-10 times per day, this infant has low caloric intake)

 Choice (C): point against: 2 weeks infant doesn't need iron at this age.
 Choice (D): point against: unrelated.

Pediatric Problem Solving-Case18

2008-09-09T14:50:00.000-07:00

Pediatric Problem Solving – Case 18
A 10 month old female infant is brought to a clinic for routine health evaluation. Her diet consists of ordinary food and a lot of fresh whole milk. On examination, she is pale, hemoglobin is 7.5 gm% otherwise there are no abnormalities.

The most likely diagnosis is:
A.Thalassemia

B.Iron deficiency anemia

C.Sickle cell anemia

D.Anemia of chronic illness

Explanation of the case:
•hemoglobin is 7.5 gm% → anemia
•no abnormalities → not hemolytic anemia
•fresh whole milk : allergy or iron deficiency anemia( which is very common)
 Choice (A) : point against: there's no abnormalities
 Choice (B) : the right choice
 Choice (C) : point against: there's no abnormalities
 Choice (D): point against: no history of chronic illness.

Pediatric Problem Solving-Case17

2008-09-06T14:24:00.000-07:00

Pediatric Problem Solving – Case 17
A 3 years old fully immunized child presents with fever and difficulty in breathing. She has had tonsillitis over the past week, for which she received oral antibiotics for 2 days. On examination, she looks unwell, she has mild recession, and a soft inspiratory sound is audible.

What is the most likely diagnosis:
A. Bronchial asthma

B. Retro-pharyngeal abscess

C. Epiglottitis

D. Pneumonia
Explanation of the case:

A fully immunized child, so most probably she doesn’t have pneumonia due to Hemophilus influenza. she has tonsillitis the week before, for which she received an inadequate dose of antibiotics (2days).now, her general condition is unwell, she has fever, dyspnea and stridor (i.e. soft inspiratory sound)
 Choice (A): Point against: the audible sound is inspiratory, in case of asthma, it is supposed to be expiratory

 Choice (B): the right answer: Points with: inadequate ttt + stridor which means this is an upper respiratory tract infection. in retropharyngeal abscess, the tongue is pushed upwards and backwards, so the main complication is difficulty breathing.
 Choice (D): Points against: stridor means an upper not lower respiratory tract infection.

Pediatric Problem Solving-Case16

2008-09-02T11:51:00.000-07:00

Pediatric Problem Solving – Case 16
A 7 year old boy was limping for 3 days presented to the surgical department with severe acute colicky abdominal pain. The surgery resident asked for medical consultation for a rash on the back of both lower limbs of the child.
The acute abdomen is due to :
A. Rheumatic fever

B. Appendicitis

C. Henoch-schonlein purpura

D. Rheumatoid arthritis

Explanation of the case:

 Choice (A): Points with: age + limping
Points against: rash, no other signs of the criteria of rheumatic fever, rheumatic fever will not cause the other associations as acute abdomen.
 Choice (B):Points against: other findings(other than acute abdomen) are not related
 Choice (C):the right answer :Points with: purpura on back of both lower limbs + acute abdomen + limping [This is a vasculitic syndrome]
 Choice (D): Points against: other findings(other than limping) are not related

Pediatric Problem Solving-Case15

2008-08-31T13:24:00.000-07:00

Pediatric Problem Solving – Case 15
A 15 months old infant presents to the emergency department with a 4-day history of high fever without any localizing sign. She suffers self limiting convulsion and is admitted for observation. The next day the fever subsides, but a red popular rash develops over her trunk and abdomen.
What is the most likely diagnosis:

A. Measles
B. Rubella
C. Roseola
D. Chicken pox

Explanation of the case:

Short self limiting convulsions = due to fever.
The girl had an incubation period of 4 days showing high fever, but without any localizing sign (without 3C of measles: Coryza, cough and conjunctivitis).then she shows red maculo-papular rash starting on her trunk. When the rash appeared, the fever subsided.
 Choice (A): points against ,In measles, there should be localizing sign (3C), and the fever rash relation-ship is different, the fever should rise markedly with appearance of rash on the 4th/5th day of the prodroma, rash starts on the face
 Choice (B): points against: Fever should increase with appearance of rash.
 Choice ( C ): the right answer , Where prodroma is 4 days showing high fever, rash appears after 4 days, first on trunk, fever subsides
 Choice (D): Rash isn’t maculo-papular

Pediatric Problem Solving -Case 14

2008-08-29T10:33:00.000-07:00

Pediatric Problem Solving – Case 14
A 3 day old infant presents with the complaint of yellowish skin. Both the mother and the baby have O +ve blood. The baby's direct serum bilirubin is 0.2 mg/dl. With a total serum bilirubin of 11.8 mg/dl. The hemoglobin is 17 gm/dl. Platelets count is 278,000/ul. Reticulocyte count is 1.5%. the peripheral smear doesn’t show abnormalities.
The most likely diagnosis:

A. Rh or ABO incompatibility

B. Physiologic jaundice

C. Sepsis

D. Congenital spherocytic anemia

E. Biliary atresia
Key points:
3 days old: physiologic jaundice occurs at this age,Both mom and baby have O+ve blood: not incompatibility,Hemoglobin 17, reticulocyte 1.5%: this is normal, so no hemorrhage nor hemolysis occurred [ no anemia]
N.B: if hemoglobin was 11.5 for example, the right answer would be hemolytic anemia.
Platelete count is normal: platelete count decreases in sepsis. So this isn’t sepsis
Peripheral smear shows no abnormality: normal shape of blood cells, so no Spherocytosis.
 Choice (A): points against: no hemolysis evident by hemoglobin and reticulocyte count
 Choice (B): points with: age, indirect hyperbilirubinemia [as the direct bilirubin is not more than 20% of total bilirubin], didn’t cross maximum level of total bilirubin in physiological jaundice which is 12, exclusion of other causes.
 Choice ( C ): points against:no sepsis evident by normal platelete count
 Choice (D): point against: normal peripheral smear, no Hemolysis
 Choice (E): not direct hyperbilirubinemia

Pediatric Problem Solving -Case 13

2008-08-29T10:20:00.000-07:00

Pediatric Problem Solving – Case 13
A 3 week old baby, who was full term, Is brought to the hospital. He has recently been having problems completing his feeds and today appears short of breath. On examination, his HR was 180/min, RR 72/min, rectal temperature 37.4, BP 80/50, and he had a 4 cm hepatomegaly. All blood tests were normal.
What is the most likely diagnosis:
A. Neonatal hepatitis

B. Respiratory distress syndrome

C. Heart failure

D. Congenital infection Explanation of the case:

Explaination of the case.
Infant is recently short of breath + high heart rate not in proportion with age nor temperature + high RR + hepatomegaly = heart failure ,………… Heart failure triad:
Tachypnea Tachycardia Tender hepatomegaly
His temperature is normal (37.4 - 0.5 = 36.9)
 Choice (A): will not cause all these signs
 Choice (B): points against: it is more in premature
 Choice ( C ): points with: Heart failure triad is present
 Choice (D): points against: Normal blood tests, no other symptoms associated (e.g. rubella is associated with many other problems, and many other congenital infections as well)

Pediatric Problem Solving -Case 12

2008-08-26T15:07:00.000-07:00

Pediatric Problem Solving – Case 12
An infant can move his head from side to side while following moving object, can lift his head from prone position 45 degrees off the examination table, and smiles when encouraged. he can sit with support .

The most likely age of this infant is:
A). 1 month

B). 5 months

C). 9 months

D). 12 months

Explaination of the case
The right choice is (B) 5 months
Move from side to side=1month
Smiles=2 months
Lift his head 45 degrees=3rd month
Sit without support= 4th/5th month
N.B: if the case included certain conditions delaying growth i.e. neurological conditions or rickets, the answer would be different.
If baby has rickets: sits supported when 9 months.

Pediatric Problem Solving -Case 11

2008-08-26T04:09:00.000-07:00

Pediatric Problem Solving – Case 11
A 6-month-old boy is brought by his mother because he is floppy when placed in a sitting position. He does not seem to be interested in reaching for toys. At 4 month visit, his head support was weak and had a persistent Moro reflex.

What is the most likely diagnosis?
A ) Duchenne muscular dystrophy

B ) Cerebral palsy

C ) Brain tumor

D ) Meningitis

Eplaination of the case.

 Choice (A): points against: occurs around the age 6 to 7 years old
 Choice (B): is the right choice: atonic CP
Points with: floppy, with delayed developmental milestones, persistent primitive reflexes.
 Choice ( C ): brain tumour usually takes more duration in older ages.
 Choice (D): no signs of inflammation, will not take this long duration as at the 4th month visit there was developmental delay, now the baby is 6 months old and is still floppy with persistent primitive reflexes

Pediatric Problem Solving -Case 10

2008-08-25T14:08:00.000-07:00

Pediatric Problem Solving – Case 10
A 5-month-old girl presented with history of constipation and delayed developmental milestones. She had prolonged physiological jaundice. On exam, she is hypoactive, has an open mouth with large tongue. Other systemic examinations are within normal.
What is the next step in management?

A) Checking T4 and TSH
B ) Checking serum bilirubin
C ) Doing CT scan of head
D ) Follow up after 4 weeks Explanation of the case:

Explaination of the case
key points:
Constipation, delayed developmental milestones, being hypoactive open mouth with large tongue, prolonged physiological jaundice = hypothyroidism
 Choice (A): the right choice
Points with: manifestations of hypothyroidism. In any case, u've to investigate for treatable causes first.
 Choice (B): there's no use of checking bilirubin + it is physiological.
 Choice ( C ): there's no use of CT scan, even if there was brain damage, it's not treatable
 Choice (D): the condition cant be delayed

Pediatric Problem Solving -Case 9

2008-08-20T12:07:00.000-07:00

Pediatric Problem Solving – Case 9
A 7-week old baby is referred with a 2-week history of vomiting. He is being formula fed (160 ml)every 2-3 hrs. On examination he is well. thriving, on the 90"' percentile and has a normal examination. What is the most likely diagnosis:
A -Pyloric stenosis

B -Gastro-oesophageal reflex

C -Over-feeding

D –Acute gastroenteritis
Explanation of the case:
 Choice (A):points against: The baby is thriving, on the 90th percentile = growing well, in the high normal. If it was pyloric stenosis, there should be vomiting and malnutrition
 Choice (B):points against: occurs on the second week, the child would not be on the 90th percentile, would not be able to eat every 2 to 3 hours.
 Choice ( C ): [the right choice] : points with: high dose formula, high amount(every 2-3 hours).
 Choice (D):points against: there is no inflammatory symptoms or signs, no diarrhea.

Pediatric Problem Solving -Case 8

2008-08-19T01:02:00.000-07:00

Pediatric Problem Solving – Case 8
A 4week-old, full term, breast fed girl has worsening yellowish discolouration of the skin, that the parents first noticed 15 days ago. On her examination, she is well appearing with good suckling and reflex activity, and is noted to have a liver edge 4cm below her costal margin. Her total bilirubin is 12 and direct bilirubin is 9.
What is the most likely diagnosis
A. Biliary atresia

B. Cholecystitis

C. Sepsis

D. Breast milk jaundice Explanation of the case:

Explaination of the case.
Key points;
15 days = persistent jaundice
Appears good = not lethargic/septic
Hepatomegaly, direct bilirubin is more than 20% of total bilirubin , therefore cholestatic jaundice not breast milk.
 Choice (A): [the right choice] Points with: it Is not septic, nor breast milk + Direct bilirubin is more than 20% of total bilirubin + hepatomegaly
N.B: it is biliary atresia as it's the most appropriate choice in the choices given in this case, but it could be any other cause of cholestasis.
 Choice (B): not related to the case at all
 Choice (C): points against: she's appearing good with good activity

 Choice (D): if breast milk jaundice, it would have been indirect (unconjugated) bilirubinemia.

Pediatric Problem Solving -Case 7

2008-08-17T22:38:00.000-07:00

18-8-2008

Pediatric Problem Solving – Case 7
An 18 months old boy came to the emergency department with rapid respiration, drowsiness. He had a history of vomiting and diarrhea for 3 days before the onset of his condition. By examination HR was 160, RR was 60, Temp. was 38.5 and Bp was 60/40. He had delayed capillary refill.

What is the most likely action to be done?
A- Chest x-ray.

B- Giving oral ttt and follow up.

C- Administration of IV fluids.

D- Blood gas analysis.
Explanation of the case:
key points:
Vomiting and diarrhea = ongoing losses of fluids and electrolytes, Increased HR (out of proportion with age and fever), RR, and decreased BP, DELAYED capillary refill= shock
 Choice A :points against: it is an emergency + no need for it
 Choice B :points against: it is an emergency
 Choice C: (the right choice):points with: shock is an emergency with dramatic response to IV fluids
 Choice D:points against: what happens clinically is (1) canula (2) take a blood sample (3) IV fluids. But we DO NOT wait for the results of blood gases, we start IV fluids at once, then if results show acidosis, we treat it.

Pediatric Problem Solving -Case 6

2008-08-17T09:25:00.000-07:00

17-08-2008
Pediatric Problem Solving – Case 6
A 3 years old boy came to the outpatient's clinic complaining of mild fever, runny, nose, malaise and vomiting. On throat examination there was hyperemia of the throat.
What is the most likely medicine to be given

A-Oral Amoxicillin

B- Paracetamol

C- Multivitamin

D-Acetylsalicylic acid. Explanation of the case
 Choice (A): points against: A mild infection (only runny nose, some hyperemia, mild fever, malaise), therefore most probably viral not bacterial infection. So exclude oral amoxicillin.
 Choice (B) the right choice: points with: All the child needs in this case is supportive measures like an antipyretic (paracetamol). Viral infections resolve spontaneously in a few days .
 Choice (C): points against: Child is feverish, vitamins may increase load (bacteria can use some vitamins/iron causing more problems)
 Choice (D):points against: Child 3 years old with mild throat infection most probably viral, so don not give acetylsalicylic acid as it may cause Reye's syndrome.
It is acute fatty hepatoencephalopathy with peak incidence in children ranging between 6-12 years old, occurs with viral infection e.g. influenza, measles.

Pediatric Problem Solving -Case 5

2008-08-16T01:37:00.000-07:00

Pediatric Problem Solving – Case 5
A 12 years old female came to hospital with fever, difficulty in breathing, severe effort intolerance and joint pain which started in the rt. wrist and later involved the lt. knee. By examination BP was 90/60, HR was 140, RR was 35 and Temp. was 39 c. Abdominal examination revealed enlarged tender liver.
The first action to be done
A- Starting antifailure treatment

B- NSAID administration

C- IV fluid administration

D- Blood culture
Explanation of the case
Key points
1. 12 years old + fever + Joint pain (large joints) + pain moves from joint to joint = most probably rheumatic fever.
2. HR 30 beats per min more than normal (HR is affected by both temperature and age, in this case age is 12, so HR is supposed to be 90/min, the temperature is 39, so it is supposed to increase HR 20/min. )
3. Tachypnea (normal RR is 20 in this age).
4. blood pressure is within normal, but we do not depend on this sign in children from 2, 3 and 4, patient is having heart failure (an emergency)
so we have to start antifailure ttt = diuretics, digoxin..etc..
 Choice A: (the right choice
 Choice B: points Against: we are not sure of diagnosis + we've to start antifailure ttt before anything else

Pediatric Problem Solving -Case 4

2008-08-15T12:23:00.000-07:00

Problem Solving – Case 4
A mother brings to the clinic her 4 years old son who began complaining of Rt knee pain 2 weeks ago, is limping slightly, is fatigued and has had a fever 38.2C .
What is the important diagnostic Lab test to perform
A. CBC with differential

B. Sedimentation rate

C. EBV titre

D. Rheumatoid factor

Explanation of the case
a- Patient suffers from arthritis and not Arthralgia

b- Difference between them: Arthralgia is subjective pain (patient says he is in pain).But arthritis is detected by swelling / limitation of movement as in limping
c- Rt (unilateral) knee pain = not rheumatic fever i.e. not polyarthritis
d- 2 weeks = not trauma
 Choice A:the right answer
a) Points with: important to be done in the beginning to exclude major problems like Leukemia and to give hints on other diseases as viral infection, rheumatoid, acute infection.
b) Leukemia in CBC: lymphocytic count increased, anaemia and thrombocytopenia.
Choice B: a) Points against: not very useful as it is non-specific
Choice C: a) Points against: better do CBC first for the previous causes above
 Choice D: a) Points against: same as C + rheumatoid is mainly in small joints

Pediatric Problem Solving -Case 3

2008-08-14T02:57:00.000-07:00

Problem Solving – Case 3
A 10 months old infant presents with a day history of blanching confluent rash which started on his face and now covers his entire body. He is miserable with conjunctivitis and fever of 38 C. the illness started with runny nose and cough 5 days previously.

What is the most likely diagnosis?

A. Scarlet fever
B. Sweat rash
C. Chicken pox
D. Measles
Explaination of the case

 Choice A:
a) Points against: Fever is followed in 2 days by rash + less aggressive prodroma (miserable with) + sore throat [it is a streptococcal infection ]
 Choice B:
a) Points against: the disease is obviously of infectious etiology
 Choice C:
a) Points against: presents with fever of low grade followed 1 day later by rash
 Choice D: [the right answer]
a) Age + aggressive prodroma + 4 to 5 days between fever and rash appearance (showing runny nose and cough) + conjunctivitis + 38.5 C.
b) The rash covers the entire body eventually.

N.B. German measles is excluded as the rash in it never appears in the whole body at the same time ,i.e. when the rash reaches certain parts it disappears in other.
N.B. measles must show :Coryza (runny nose)+ Cough+ Conjunctivitis

Pediatric Problem Solving -Case 2

2008-08-13T13:58:00.000-07:00

Pediatric Problem Solving – Case 2
A 2 week old infant develops fever, 38.9 C, vomiting, and irritability. His heart rate is 170/min, and RR is 40/min. The infants anterior fontanelle is full, but there is no nuchal (neck-related) rigidity. The rest of examination is

unremarkable.

What is the appropriate management

A. Oral fluid and follow up in 24 hr

B. Oral amoxicillin and follow up in 1 week

C. Admission to hospital for investigation and ttt

D. IM ceftriaxone and follow up in 1 week Explanation of the case

Explaination of the case
 the bulging fontanelle (full) = increased ICT. Fever, vomiting and irritability = infection
There is no neck rigidity because this sign and others like brudzinski's..etc.. are non-dependable signs in children because of the open fontanelle which offers a relief of the increased tension.
N.B.: Rule: An infant (a)febrile + (b)vomiting+ (c)irritable = admission to the hospital
N.B: if the fontanelle is depressed = dehydrated infant
 Choice A: can never be a choice in anyway

 Choice B: a) Points against: oral = management at home which is unacceptable in this case+amoxicillin is not the drug needed.
 Choice C: [the right answer
a) Points with: the infant needs to be admitted for CT, CBC, culture, IV antibiotics, follow up to avoid complications as convulsions.
 Choice D
a. Points against: patient must be admitted, so any choice other than IV antibiotics suggested by parents who might want go back home is unacceptable.