Transcript CASE PRESENTATION

CASE PRESENTATION
INTERN FLORIDA TALADTAD
UPCM CLASS 2011
IDENTIFYING DATA
 SJ
 7 years old
 Female
 Right-handed
 Roman Catholic
 Muntinlupa City
CHIEF COMPLAINT
 Vulvar itchiness
SOURCE AND RELIABILITY
 Patient and the patient’s father
 With good reliability
HISTORY OF PRESENT
ILLNESS
 3 days prior to consult, patient started to complain of
terminal dysuria. (-) tea-colored urine, (-) hematuria
(-) urinary changes (-) oliguria (-) vaginal pain (-)
fever (-) abdominal pain (-) groin pain. No consults
were done and no medications were taken.
 2 days prior to consult, dysuria was then associated
with whitish-grayish vaginal discharge. Patient’s
father applied ‘gawgaw’ on the patient’s labia which
offered no relief of symptoms. (-) prior systemic
antibiotic use, (-)bleeding, (-) fever, (-) vaginal pain
(-) history of vaginal manipulation ; Still no consults
done and no medications taken.
 1 day prior to consult, patient then complained of
vulvar itchiness , still with dysuria, and (+) cheesy,
whitish-grayish vaginal discharge, non foul smelling.
(-) vaginal pain, (-) bleeding, (-) fever, (-) abdominal
pain
 Persistence of vaginal discharge and vulvar itchiness
prompted consult.
REVIEW OF SYSTEMS
General: (-) wt. loss, (-) fatigue, malaise, fever, chills
Skin: (-) changes in skin color, excessive dryness, lesions,
lumps, sores
Head: (-) No headaches, head injuries, dizziness,lightheadedness and syncope
Eye: (-) blurring of vision, eye pain, diplopia, redness,
itchiness, discharges
Ear: (-) vertigo, ear pain, infection and discharge
Nose and Sinuses: (-) sinus pain, epistaxis, nasal
obstruction, discharge, itching and sneezing; (+) coryza
Oral Cavity: (-) bleeding of lips, gums, mouth, tongue, or
throat
 Neck: (-) pain, stiffness, and limitation of motion
 Throat: (-) soreness, hoarseness
 Respiratory: (-) cough, hemoptysis, shortness of
breath
 Cardiac: (-) chest pain, palpitations, dyspnea related
to exertion, orthopnea, paroxysmal nocturnal
dyspnea
 Genitourinary: (-) polyuria, oliguria, nocturia,
hematuria, flank pain
BIRTH AND MATERNAL HISTORY
 Patient was born full-term to a then 28 year-old
mother G3P3(3003), at a lying-in clinic, via SVD
assisted by a midwife, with no known fetomaternal
complications. Patient had good cry and good suck.
PAST MEDICAL HISTORY
 Patient has no known comorbidities
 (-) history of allergy
 (-) previous hospitalizations or surgeries
NUTRITIONAL HISTORY
 Patient was breastfed for 2 months, then shifted to
formula feeding, also with intake of water at 3
months of life
 Is fond of eating fruits and junk food
PERSONAL AND SOCIAL HISTORY
 Patient is an incoming Grade 2 student
 With good activity, loves to play with her playmates
outside the house
 with no note of behavioral changes since the onset of
symptoms
 Presently living with her 2 siblings and parents in
Muntinlupa
FAMILY GENOGRAM
Serrano-Johnson Family May 23,2010
I
II
III
Sophia, 7
FAMILY HISTORY
 (+) Heart disease, maternal grandmother
 (+) CVD, paternal grandfather
 No other diseases in the family
PHYSICAL EXAMINATION
General Survey
 Conscious, coherent, oriented to time, person, and
place, not in cardiorespiratory distress
Vital Signs
 BP = 100/60 HR = 88 RR = 20 Temp = 37.7 Wt:
24.3 kgs
Skin
 Warm, smooth, no jaundice or cyanosis.
Nails
 Pink nail beds, no lesions, good capillary refill
HEENT
 Head: without signs of trauma or deformities.
 Eyes: Pink conjunctivae, pupils 2-3 mm EBRTL,
anicteric sclerae, eyelids are symmetrical, no ptosis,
cornea without opacity.
 Ears: no lesions, tragus nontender, no discharge. Intact
gross hearing.
 Nose: No deformity, inflammation, and tenderness.
Nasal mucosa is pink and no bleeding, swelling, and
lesion. Nasal septum has no deviation, (+) coryza
 Oral cavity: oral mucosa pink, soft, moist
 (-) CLAD, (-) tonsillopharyngeal congestion
Lungs
 Chest is symmetrical. No tenderness, no delay in chest expansion,
equal tactile and vocal fremitus on all lung fields. Resonant on all
lung fields. No crackles, wheeze, rales and stridor.
Heart
 Adynamic precordium. PMI at 5th ICS LMCL. No thrills and heaves.
Normal rate with regular rhythm. No murmur was heard.
Abdomen
 Slightly globular abdomen. No obvious mass noted, no visible veins,
no scars, no striae, no pulsations. Normoactive bowel sounds. No
tenderness.
Extremities
 There were no edema, lesions, and masses observed in all four
extremities. (-) inguinal lymphadenopathy
Genital examination
 Normal external genitalia, (-) lesions, (+) minimal
swelling and erythema of the vulva, (+) whitishgrayish discharge, with cheesy white vaginal
discharge
ASSESSMENT
 t/c Vaginitis probably secondary to Vulvovaginal
Candidiasis
 t/c Urinary Tract Infection
 r/o Sexual Abuse
PLAN
 Diagnostics:
 urinalysis
 Vaginal discharge GS/CS
 Therapeutics:
 Diphenhydramine 12.5/5ml , 5 ml BID
 Non-pharmacologic:
 Increase oral fluid intake
 Maintain proper perineal hygiene
CLINICAL DILEMMA
 In pediatric patients, what is the effectiveness of
single-dose oral treatment of Fluconazole for
Vulvovaginal candidiasis compared to standard daily
therapy in the resolution of symptoms using a
randomized controlled trial?
 In pediatric patients presenting with vaginal
discharge, what is the specificity and sensitivity of
vaginal d/c Gram stain compared to vaginal fluid
DNA analysis using a cross-sectional study?