Transcript 10 year old male with fever

10 year old male with fever
General Data
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R.B.
10 /M
Grade 2 student
From Paranaque
Admitted last September 16, 2009
Chief Complaint
• Fever
History of the Present Illness
• Pt is a diagnosed case of
Congenital Heart Disease (CHD, Acyanotic,
VSD, Perimembranous w/ VSA formation 2-3
mm, PDA)
• August 2008, c/o PGH Pedia-Cardio
• Presenting w/ easy fatigability & occ. Dyspnea
• Digoxin 0.25 mg/tab ¼ tab BID, Furosemide
20 mg/tab 1 tab OD – poor compliance
• Last consult May 2009 – lost to follow-up
History of the Present Illness
• 3 weeks PTA – (+) fever,
undocumented, on & off,
(+) non-productive cough,
(+) R knee pain, non-migratory
(-) antecedent history of cough,
(-) sore throat/odynophagia
(-) consults done
self-medicated w/ Mefenamic Acid, provided
temporary relief of symptoms
History of the Present Illness
• 2 weeks PTA – (+) persistence of prev. symptoms
(+) difficulty of breathing
(+) 2-pillow orthopnea
(+) palpitations, (-) PND
prompted consult c/o local hosp.,
A> PDA, Pt given Aspirin 80 mg/tab, then referred
to Phil. Heart Center for further management. Pt
was admitted for 1 day, A> ?, given unrecalled IV
antibiotics, then sent home. Mother advised to
bring the child to PGH for follow-up.
History of the Present Illness
• 1 week PTA – (+) persistence of prev. symptoms
(+) inc. in severity of DOB
(+) pallor
prompted consult c/o another
local hospital, A> ?, Pt given unrecalled
antibiotics, then sent home.
Day of consult - (+) persistence of prev. symptoms,
still w/ fever (high grade, undoc.)
prompted consult @ PGH Pedia-ER
Review of Systems
General: (+) fever, (+) malaise, (+) loss of
appetite, (+) wt. loss (undoc.)
Skin: (+) pallor, (-) cyanosis, (-) skin lesions,
(-) jaundice
HEENT: (-) headache, (-) nasoaural discharge
Resp: (+) DOB, (+) cough (non-prod.),
(-) hemoptysis
CVS: (+) palpitations, (+) 2-pillow orthopnea,
(+) easy fatigability, (-) PND
Review of Systems
GI: (-) nausea/vomiting, (-) abdominal pain, (-)
diarrhea, (-) constipation, (-) melena,
(-) hematochezia
GU: (-) dysuria, (-) hematuria, (-) oliguria
Hematologic: (-) bleeding tendencies,
(-) easy bruisability
Endocrine: (-) polydipsia, (-) polyuria,
(-) polyphagia
Review of Systems
Neuro: (-) loss of consciousness, (-) seizures, (-)
behavioral changes
Past Medical History
• As above
• Admitted last Aug 2008 @ PGH, due to
Community Acquired Pneumonia
• (-) other previous illnesses, (-) bronchial asthma
• (-) previous surgeries, (-) accidents
• (-) allergies to food and medications
Family Medical History
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(+) breast CA (maternal grandmother)
(+) bronchial asthma (maternal grandfather)
(+) PTB (maternal uncle, completed 6 mo tx)
(-) similar symptoms
Birth & Maternal History
• Born FT to a then 20 y/o G2P1 (1001) via SVD
@ home c/o “hilot”. Mother reported that she
had fever @ 4 mos AOG, took Paracetamol. (-)
others meds/other illnesses/exposure to
teratogens/radiation. Reg. PNCU c/o LHC, At
birth, Pt had good cry, good activity, good
suck. (-) Fetomaternal complications noted.
Immunization History
• Done c/o LHC:
(+) BCG
(+) DPT x 3
(+) OPV x 3
(+) Hep B x 3
(-) Measles
Developmental History
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social smile – 2 mos
Rolls over – 4 mos
Sits w/o support, babbles – 6 mos
Stands alone, can say mama, papa – 12 mos
Runs well, obeys simple commands – 2 yrs
Can walk downstairs, knows color – 4 yrs
Complex pattern movt’s (dancing) – 8 yrs
Nutritional History
• Breastfed from birth – 1 yr
• Reg. meals include rice, meat, fish, vegetables
• No particular food preferences
Personal Social History
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Pt is 2nd child among 5 siblings.
Mother is a 31 y/o laundry woman
Separated from Pt’s father
Pt is currently a grade 2 student
Physical Examination
General survey: awake, alert, not in distress
wt = 20.5 kg
VS: BP 100/70, HR 122, RR 28, Temp 38.7
HEENT: slightly pale palpebral conjunctiva,
anicteric sclera, (-) tonsillopharyngeal
congestion, (-) NVE, (-) CLAD
Chest: Equal chest expansion, (+) supraclavicular
retractions, clear breath sounds,
(-) rales/ronchi/wheezes
Physical Examination
CVS: (+) precordial bulge, (+) LV heave, (+) thrill,
apex beat @ 6th ICS Left AAL, distinct heart
sounds, tachycardic, regular rhythm, (+) grade
4/6 holosystolic murmur on the Left PSB, (+)
grade 4/6 high-pitched holosystolic murmur
on the apex.
Abdomen: flat Abd, NABS, soft, (-)
masses/tenderness, (-) hepatosplenomegaly
Extremities: bounding pulses, pale nailbeds
Physical Examination
Extremities: CRT < 2 secs, (-) cyanosis, (-) edema,
(-) clubbing, (-) gross deformity
Neurologic:
oriented to time, place & person
Cranial Nerves: pupils 3 mm EBRTL, full
EOMs, (+) corneal reflex, (-) facial asymmetry,
gross hearing intact, good gag, good shoulder
shrug, tongue in midline
Motor: 5/5 on all extremities
PE at the ER
Sensory: 100% on all extremities
Reflexes: ++
(-) meningeal signs, (-) Babinski, (-) clonus
Pertinent Labs
• 9/17
Blood type: O+
CBC: Hgb 53, Hct 0.146, WBC 11.7, Plt 46,
N 0.753, L 0.104, M 0.132, E 0.004
Chem: Na 126, K 2.3, Cl 82
U/A: yellow, slt hazy, 1.010, 7.5, CHO (-),
CHON (-), RBC 0-1, WBC 0-2, EC (-),
bacteria few, MT (-), cast (-), crystals (-)
Pertinent Labs
• 9/17
ECG: Sinus tachycardia, Right axis deviation,
Left ventricular hypertrophy
ESR: 76 mm/hr
ASO: > 400
2D Echo: RHD w/ moderate to severe MR,
moderate TR, LAE, LVE, no vegetations
seen
Pertinent Labs
• 9/17
Blood CS: (+) Enterococcus sp. After 14.7 hrs
of incubation
S: Ampicillin, Gentamycin,
Streptomycin
R: Penicillin G