Transcript Pediatrics Cardiology Conference

Pediatrics Cardiology
Conference
GARCIA MJ, GARZON MMP, GASPAR IV,
GATCHALIAN C, GAW MG, GERALDOY YR
Patient
 JMS
 8 years old/F
 June 19, 2002
 456 Lambakin, Marilao, Bulacan
 Roman Catholic
 Filipino
 Informant
 Reliability
: Mother
: Good
Chief Complaint
 unsteady gait
History of Present Illness
 4 wks PTA
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(+)decreased appetite
(+) decreased activity level
(+)episodes of joint mild pains
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relieved by rest
 3 wks PTA
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(+) undocumented fever with cough, colds and difficulty of breathing
paracetamol 250 mg tab ½ tab every 4 hours,
 salbutamol + carbocisteine (Solmux) 2mg/500mg/5ml 5mL twice a
day,
 Vitamin C 5 mL once daily
 nebulized with 1 salbutamol nebule
 symptoms have resolved
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History of Present Illness
 2 wks PTA
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(+)decreased appetite, decreased activity
(+)decreased interaction with family relatives
At school:
patient does not maintain good eye contact
 kept on moving a lot and cannot stay still during recitation
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 1 wk PTA
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(+)frequently drops and loses her pen in class
(+)hard time gripping her utensils while eating
 3 days PTA
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wobbly gait, with weak voice and slurred speech
History of Present Illness
 1 day PTA
 increased movement while sleeping
 persistence of symptoms
St. Michael Hospital
 Referred to a private neurology physician, they were referred to
Neurology Pediatrics
 patient was brought to Jose Reyes Hospital A>>Rheumatic Heart
Disease
 Lack of bed, hence patient was brought to our institution.

Review of Systems
 General: (+) weight loss (-) delay in growth
 Cutaneous: (-) rashes, (-) active dermatoses, (-) hair
loss
 Respiratory: (-) chest pain, (-) cough, (-) difficulty of
breathing
 Cardiovascular: (-) orthopnea, (-) cyanosis, (-) easy
fatigability
 Gastrointestinal: (-)vomiting, (-) jaundice, (-) diarrea
(-) constipation
Review of Systems
 Genito-urinary: (-) hematuria, (-) change in urine
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frequency (-) dysuria
Endocrine: (-) heat/cold intolerance
Musculoskeletal: (-) gross deformities, (-) edema
Hematopoietic: (+) pallor, (+) easy bruisability, (-)
epistaxis
Nervous/Behaviour: (-) seizures (-) sleep problems,
(-) convulsions (-) paralysis
24 hour food recall
Meal
Food
CHO
CHON
FATS
KCAL
Breakfast
1 pc
Hotdog
-
8
10
122
1 cup
Rice
46
4
-
200
Lunch
½ cup
Rice
23
2
-
100
½ pc
Hotdog
-
4
5
61
1 pack
Pancit canton
23
2
-
100
Dinner
1 cup
Rice
46
4
-
200
1 pc
Chicken fillet
-
16
4
100
ACI
883
RENI
1600
%
55.19%
Ideal Body Weight:
Age in year x 2 + 8 = 24 kg
Past Medical History
 Asthma – 7 years old – given salbutamol nebulization when needed
 UTI – 4 years old – was given unrecalled antibiotics for 1 week- consult
done at OPD
Immunization History
 Mother claims that patient has completed immunizations until 9 months in
a local health center.
Developmental History
 *at par with age
 Can do complex pattern movements
 Can tell time
 Reads for pleasure
 Can do concrete operations
 Accepts rules
Family History
(+) goiter – grandmother, 1 uncle, 2 aunts
(+) cancer – grandmother: brain cancer “lymphoma”
(-) HPN, stroke, DM, asthma, allergy, kidney disease, blood dyscrasia, TB, Seizures
Family Profile
Member
Age
Relation
Educational
Attainment
Jose
39
Father
Engineering
Rosalinda
38
Mother
Jasmine
1
Sister
High school
graduate
-
Occupation
Cell site
caretaker
Textile factory
worker
-
Health
Healthy
Healthy
healthy
Personal, Socioeconomic and Environmental
History
 The patient lives with her parents in a well lit well
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ventilated house made of concrete.
Purified water is used for drinking and is not boiled.
Garbage is segregated and collected everyday by
municipal trucks.
There are no pets, no factories nearby.
Average monthly income of P15,000.
Physical Examination on Admission
 Alert, awake, not in cardiorespiratory distress, well
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hydrated, well nourished
VS: BP: 110/70 HR 99 bpm RR 16/min T 36.5C
Wt : 31.5 kg (z = above 1) Ht : 137 cm (z = above 1)
BMI : 16.78 (z = above 0)
Warm, moist skin, no active dermatoses
EENT: Pink palpebral conjunctivae and anicteric sclera, no
tragal tenderness, no aural discharge, non-hyperemic
external auditory canal, midline nasal septum, turbinates
not congested, no nasal discharge, moist buccal mucosa,
(+) hyperemic posterior pharyngeal wall, tonsils not
enlarged
Physical Examination on Admission
 Supple neck, (+) palpable cervical lymph nodes
 Symmetrical chest expansion, no retractions, clear
breath sounds
 Adynamic precordium, apex beat at 5th LICS MCL,
no murmurs
 Flat abdomen, soft, non-tender, normoactive
bowel sounds, no masses palpated
 No cyanosis, no edema, pulses full and equal on all
extremities
Neurological Examination
 Conscious, coherent, oriented to time, place and
person
 can smell, pupils 2-3 mm isocoric ERTL, (+) direct
and consensual light reflex, no visual field cuts, (+)
ROR, EOMs full and equal, sensory deficit on R side
of face, can clench teeth, can raise eyebrows, can
close eyes tightly, can smile, no hearing deficit, no
lateralization on Weber’s, AC > BC, uvula midline,
can shrug shoulders equally, can turn head from side
to side against resistance, tongue midline on
protrusion,
Neurologic Examination
 Good muscle bulk, no fasciculation, no atrophy
 No spasticity, no rigidity
 MMT 5/5 on all extremities
 Sensory deficit on L upper & lower extremities
 Can do FTNT, APST, with involuntary movements of
extremities
 DTRs ++ on all extremities
 (+) Babinski, (-) nuchal rigidity, (-) ankle clonus
Salient Features
Subjective
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9yr old/female
Unsteady gait
(+)decreased appetite,
(+) decreased activity level
(+)episodes of joint mild pains
(+) undocumented fever with
cough, colds and difficulty of
breathing
(+) poor eye contact, interaction
Frequently drops her pen and hard
time gripping her utensils
wobbly gait, with weak voice and
slurred speech
increased movement while
sleeping
Objective
 (+) hyperemic posterior
pharyngeal wall
 (+) palpable cervical lymph
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nodes
sensory deficit on R side of
face
Sensory deficit on L upper &
lower extremities
Can do FTNT, APST, with
involuntary movements of
extremities
(+) Babinski
Course in the Wards
1st Hospital Day
 Patient was hydrated with Plain NSS 1L at 18-19
drops/min
Hgb
Normal Range
Result
115-155
113
RBC
Hct
4.33
0.35-0.45
0.35
Platelet
150-450
346
WBC
4.5-13.5
8.30
0.54-0.62
0.47
Segmenters
0.54-0.62
0.47
Lymphocytes
0.25-0.33
0.42
Eosinophils
0.01-0.03
0.11
Neutrophils
 Blood chemistry:
Normal Range
Result
Creatinine
0.47
0.4-0.6
Sodium
138
138-146
Potassium
3.90
3.5-5
Total Calcium
9.32
8.8-10.8
 Cranial MRI with contrast :
 normal contrast-enhanced cranial MRI
 Salbutamol nebulization given 15 minutes prior to
scheduled MRI.
 Patient was also referred to the service of Pediatric
Cardiology and Pediatric Neurology. (video)
2nd Hospital Day
 On repeat physical exam, grade 2-3/6 holosystolic
murmur at the left parasternal area was appreciated
by Pediatric Cardiology
 Chest x-ray was done
cardiomegaly, pulmonary congestion
2nd Hospital Day
 ASO titer high at 598.01 (N.V. 0-240 IU/mL).
 12-lead ECG
 sinus tachycardia, normal axis within normal limits
3rd Hospital Day
 Patient complained of oral sores in the inner lower
lip
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Solcoseryl paste was given
 Pedia Neuro started Valproic acid 250mg/5ml 5mL
q12h
4th Hospital Day
 Patient was re-examined by Pediatric Cardiology
 2D-Echocardiography:
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Minimal posterior pericardial effusion
1-2 aortic regurgitation
2-3 mitral regurgitation
Normal coronary arteries
Dilated Left ventricle
Good contractility indices
No structural defects
Apparent prolapse of the anterior leaflet which appear to be slightly
thickened and deformed
 Benzathine Penicillin G 1,200,000 IU/IM injection
every 4 weeks
 Digoxin 0.25 mg/tab ½ tab BID
8th Hospital Day
 Valproic Acid was discontinued
 Prednisone 20mg/tab was started at 1 tablet by
mouth TID after meals
Last Hospital Day
 Final diagnosis: Rheumatic Heart Disease
 Take home medications:
 Prednisone 20mg/tab at 1 tab three times a day after meals
 Ranitidine 150mg/tab 1 tab twice a day
 Digoxin 0.25mg/tab at ½ tab twice a day
 Benzathine penicillin G 1.2 M IU/IM every 4 weeks