CONFIRMING DIAGNOSIS Radioimmunoassay confirms hypothyroidism with low triiodothyronine (T3) and thyroxine (T4) levels.
Supportive laboratory findings include:
❑ increased TSH level when hypothyroidism is due to thyroid insufficiency; decreased TSH level when hypothyroidism is due to hypothalamic or pituitary insufficiency
❑ elevated levels of serum cholesterol, alkaline phosphatase, and triglycerides
❑ normocytic normochromic anemia.
In myxedema coma, laboratory tests may also show low serum sodium levels, and decreased pH and increased partial pressure of carbon dioxide, indicating respiratory acidosis.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Hypothyroidism in children:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
A high serum level of thyroid-stimulating hormone (TSH), associated with low triiodothyronine and T4 levels, points to cretinism. Because early detection and treatment can minimize the effects of cretinism, many states require measurement of infant thyroid hormone levels at birth.
Thyroid scan and radioactive iodine uptake tests show decreased uptake levels and confirm the absence of thyroid tissue in athyroid children. Increased gonadotropin levels are compatible with sexual precocity in older children and may coexist with hypothyroidism. Electrocardiogram shows bradycardia and flat or inverted T waves in untreated infants. Hip, knee, and thigh X-rays reveal absence of the femoral or tibial epiphyseal line and delayed skeletal development that’s markedly inappropriate for the child’s chronological age. A low T 4 level associated with a normal TSH level suggests hypothyroidism secondary to hypothalamic or pituitary disease, a rare condition.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Thyroid enlargement:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
The patient’s history commonly reveals the cause of thyroid enlargement. Important data include a family history of thyroid disease, when the thyroid enlargement began, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
Begin the physical examination by inspecting the patient’s trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you’ll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient’s neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.
During palpation, be sure to note the size, shape, and consistency of the gland as well as the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit, which is commonly continuous.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hypothyroidism:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
Symptoms generally correspond directly to the duration and severity of disease.
A. Present illness
1. The probability of thyroid disease is directly related to the number of typical symptoms manifested by the patient (2), including weakness, lethargy, skin changes (dry, coarse, cold, yellow), coarseness or loss of hair, cold intolerance, weight gain, constipation, memory or concentration impairment, depression, hoarseness, goiter, menstrual abnormalities (most commonly menorrhagia), and fluid infiltration of tissues (eyelids, face, peripheral) (3).
2. Loss of axillary or pubic hair, headaches, visual field defects, amenorrhea, galactorrhea, and symptoms of postural hypotension are suggestive of secondary or tertiary hypothyroidism.
B. Past and family history
1. Chronic autoimmune thyroiditis (Hashimoto’s disease), previous radioactive iodine therapy, and prior thyroid surgery are the most common causes of primary hypothyroidism. Other groups with an increased risk for this type include women 4 to 8 weeks postpartum; women aged more than 50 years; patients with immunologically mediated diseases such as diabetes mellitus type 1, pernicious anemia, vitiligo, Addison’s disease, and rheumatoid arthritis; and persons with a family history of thyroid disease. Screening these patients for hypothyroidism using sTSH may be appropriate (1).
2. A pituitary tumor is the most common cause of secondary hypothyroidism. Other historical diagnoses that increase the likelihood of secondary or tertiary disease include pituitary surgery, cranial radiation therapy, postpartum hemorrhage (Sheehan’s syndrome), head trauma, granulomatous diseases, metastatic disease (breast, lung, colon, prostate, others), and infectious diseases (tuberculosis, others) (4).
Physical examination (PE)
The features frequently found in hypothyroidism should be sought.
A. Observation. A welcoming handshake may reveal cold skin and further observations uncover altered affect, hoarseness, facial or eyelid edema, hair loss (scalp, eyebrows), and physical or mental slowing.
B. General examination. Vital sign abnormalities commonly include weight gain, diastolic hypertension, and bradycardia. All major organ systems are affected by thyroid hormone deficiency. The heart may be enlarged, because of both dilation and pericardial effusion, which is indicated by a cardiac rub or distant heart sounds. Adynamic ileus, rarely, can result in megacolon or intestinal obstruction. Tissue glycosaminoglycan accumulation and reduced lymphatic clearance of interstitial proteins can produce carpal tunnel syndrome. The relaxation phase of deep tendon reflexes is prolonged, creating the characteristic “hung-up reflex.” Orthostatic hypotension suggests secondary or tertiary disease, as do visual field defects and galactorrhea.
C. Thyroid examination. Inspect the neck below the thyroid cartilage from the front and side. During palpation, approach the patient from the front or from behind and palpate using the fingers or thumbs. Having the patient swallow during both inspection and palpation causes the thyroid to move and aids in developing a three-dimensional impression of the gland. The size, consistency, and tenderness of the gland should be noted, as should the presence and characteristics of any nodules.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Thyroid Enlargement/Goiter:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
In simple goiter, patients are asymptomatic or, if the gland is sufficiently enlarged, they present with symptoms caused by mechanical pressure. Substernal goiters are frequently responsible for tracheal pressure symptoms, including dyspnea and inspiratory stridor. They can also obstruct the large cervical veins at the thoracic inlet, causing suffusion of the face, giddiness, and syncope (Pemberton’s sign). Esophageal compression can lead to dysphagia (Chapter 9.5). Hoarseness caused by compression of or traction on the recurrent laryngeal nerve is rare in simple goiter and suggests a malignancy (Chapter 6.3). Generalized thyroid pain suggests subacute thyroiditis, whereas sudden localized pain and swelling are consistent with hemorrhage into a nodule. Although simple goiters are usually euthyroid, typical symptoms of hypothyroidism or thyrotoxicosis should be sought. A family history of goiter and a personal history of residing in an endemic goiter area or ingesting goitrogens may be significant (1).
Physical examination
A. General examination. Look for typical vital and physical signs consistent with hypothyroidism or thyrotoxicosis. Pemberton’s sign can be induced by having the patient raise both arms above the head.
B. Thyroid examination. Inspect the neck below the thyroid cartilage from the front, using cross-lighting to accentuate shadows and masses. Full extension of the neck enhances visibility of the gland. Inspection from the side with measurement of any prominence of the normally smooth and straight contour between the cricoid cartilage and the suprasternal notch is useful. Palpitation is done using the technique with which the examiner is most experienced and skilled. Approach the patient from either the front or behind and palpate using the fingers or thumbs. If felt between the cricoid cartilage and the suprasternal notch, the thyroid isthmus can be used to help locate the gland. Palpation of the lobes can be improved by relaxation of the sternocleidomastoid; for example, the left lobe can be defined better by having the patient slightly flex and rotate the neck to the left. Other useful maneuvers include measuring the circumference of the neck or the dimensions of each lobe. Note the location, size, consistency, mobility, and tenderness of any nodules. Having the patient swallow during both inspection and palpation causes the thyroid to move and aids in developing a three-dimensional impression of gland shape and size. This maneuver can also make a low-placed gland accessible. Categorize thyroid size as “normal” or “goiter,” and subcategorize “goiter” as “small” (two or less times normal) or “large” (more than two times normal) (2).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Neck Mass/Thyroid Enlargement:
Differential Overview
(Field Guide to Bedside Diagnosis)
Neck Mass
❑ Inflammatory lymphadenopathy
❑ Parotid swelling/tumor
❑ Laryngeal cancer
❑ Intramuscular hematoma
❑ Lymphoma
❑ Nasopharyngeal carcinoma
❑ Branchial cleft cyst
❑ Thyroglossal duct cyst
❑ Supraclavicular adenopathy
❑ Aortic aneurysm
❑ Carotid aneurysm
❑ Ludwig angina
❑ Pharyngeal pouch
❑ Carotid body tumor
Thyroid Enlargement
❑ Simple goiter
❑ Hashimoto thyroiditis
❑ Grave disease
❑ Drugs
❑ Subacute thyroiditis
❑ Thyroid cancer
❑ Infiltrative disease
Diagnostic Approach
Patients often present for evaluation of a “neck mass” that is a normal structure such as the hyoid, and they will insist that it is new or asymmetric.
With thyroid enlargement, the mass will be low in the neck and extend across the midline. Occasionally, a prominent thyroid nodule will mimic a lymph node but is in an atypical location. The thyroid gland rises and falls with swallowing. The only other structure to do this is a thyroglossal duct cyst.
In a multinodular goiter, a malignancy should be suspected when there is a dominant nodule or cervical adenopathy.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Hypothyroidism in adults:
Diagnosis
(Handbook of Diseases)
Radioimmunoassay confirms hypothyroidism with low triiodothyronine (T3) and thyroxine (T4) levels.
Supportive laboratory findings include:
❑ increased TSH level when hypothyroidism is due to thyroid insufficiency; decreased TSH level when hypothyroidism is due to hypothalamic or pituitary insufficiency
❑ elevated levels of serum cholesterol, alkaline phosphatase, and triglycerides
❑ normocytic, normochromic anemia.
In myxedema coma, laboratory tests may also show low serum sodium levels as well as decreased pH and increased partial pressure of carbon dioxide, indicating respiratory acidosis.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Hypothyroidism in children:
Diagnosis
(Handbook of Diseases)
A high serum level of thyroid-stimulating hormone (TSH) associated with low triiodothyronine and T4 levels points to hypothyroidism. Because early detection and treatment can minimize the effects of cretinism, many states require measurement of infant thyroid hormone levels at birth.
Thyroid scan and 131I uptake tests show decreased uptake levels and confirm the absence of thyroid tissue in athyroid children. Increased gonadotropin levels are compatible with sexual precocity in older children and may coexist with hypothyroidism. An electrocardiogram shows bradycardia and flat or inverted T waves in untreated infants. Hip, knee, and thigh X-rays reveal the absence of the femoral or tibial epiphyseal line and delayed skeletal development that’s markedly inappropriate for the child’s chronological age. A low T 4 level associated with a normal TSH level suggests hypothyroidism secondary to hypothalamic or pituitary disease, a rare condition.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Thyroid enlargement:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
The patient’s history commonly reveals the cause of thyroid enlargement. Important data includes a family history of thyroid disease, when the thyroid enlargement began, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Thyroid enlargement:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
The patient's history commonly reveals the cause of thyroid enlargement. Important data includes a family history of thyroid disease, onset of thyroid enlargement, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
Begin the physical examination by inspecting the patient's trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you'll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient's neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.
During palpation, be sure to note the size, shape, and consistency of the gland, and the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit. The bruit is often continuous.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
DECREASED RESPIRATIONS, APNEA, AND CHEYNE–STOKES BREATHING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Obviously, the association of other signs and symptoms will determine
the workup in most cases. The most important things to do are to order a
blood urea nitrogen (BUN) level, electrolytes, fasting blood sugar (FBS),
arterial blood gases, and a drug screen and to check for increased
intracranial pressure by examining the eye grounds. If the history or
physical findings suggest increased intracranial pressure, and other
metabolic studies (e.g., BUN) are normal, a mannitol or urea drip is begun
while awaiting the results of other investigations such as computed
tomography (CT) scan, electroencephalogram (EEG), and echoencephalogram. A
neurosurgeon should be consulted immediately.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
ACIDOSIS (DECREASED pH):
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The laboratory will be of greatest assistance in determining the cause
of acidosis. An elevated blood sugar and serum acetone level will help
diagnose diabetic acidosis. An elevated blood urea nitrogen (BUN) level
would point to uremia acidosis. Arterial blood gases may show an increased
CO2, isolating pulmonary emphysema as the cause.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Decreased Activity Level - Case 2-1: 15-Year-Old Girl:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 15-year-old girl presented to the emergency department with a 3-month history
of increasing fatigue. She had gradually stopped participating in sports
because of dizziness and palpitations. Her decreased level of activity had
worsened to the point that as soon as she returned home from school in the
afternoon she went to bed and slept the rest of the day. She had had an
18-pound weight loss over the 3-month period. In addition, for the past 5 days
she had had a headache and occasional nonbloody, nonbilious emesis. For the
past 4 days she had also had mild upper abdominal pain. The remainder of her
history and review of systems were noncontributory.
II. Past Medical History
She was the product of a full-term delivery and had had no major medical
illnesses. She had not required any surgeries.
III. Physical Examination
T, 37.2°C; RR, 16/min; HR, 110 bpm; BP, 100/60 mm Hg
Weight and height, 25th percentile
On examination, she appeared pale and tired but was not toxic-appearing. She
answered questions appropriately. The head and neck examination revealed pale
conjunctiva. She did not have any papilledema. Her lungs were clear to
auscultation. Cardiac examination revealed tachycardia but no murmurs or other
abnormal heart sounds. Her abdomen was soft with normal bowel sounds. There was
no hepatosplenomegaly. Capillary refill was delayed at 3 seconds. Her
neurologic examination was normal. Of particular interest, her cranial nerve
examination and motor strength were normal.
IV. Diagnostic Studies
A complete blood count revealed a white blood cell (WBC) count of 2,100 cells/mm3, including 3% bands, 45% segmented neutrophils, and 51% lymphocytes. Hemoglobin
was 5.4 g/dL, and the platelet count was 173,000/mm
3. The mean corpuscular volume (MCV) was elevated at 98.7 fL.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-2: 2-Week-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 16-day-old male infant presented to the emergency department with a 24-hour
history of decreased level of activity. Breast-feeding had not been going well
since birth, but he had been breast-feeding even less than usual for the past
several days. The infant received cow
's milk-based formula supplementation 2 days before presentation because of the
difficulty with breast-feeding. The incident that prompted the emergency
department visit was a 2-second choking episode during a feed. The incident
occurred at the beginning of the feed, and the infant
's eyes appeared to “roll into the back of his head.” The parents denied tonic-clonic or jerking activity and color change, although
the child was less active after this episode. The infant had had decreased
urine output, with only one wet diaper in the preceding 24 hours.
II. Past Medical History
This infant was born after 36 weeks of gestation, the fourth child of a
28-year-old mother. The pregnancy was complicated by preterm labor, and the
mother received magnesium tocolysis. At 36 weeks, the magnesium was stopped and
labor was allowed to progress. Delivery was uncomplicated. Maternal prenatal
laboratory and culture results were reportedly normal. The child was discharged
from the hospital on the second day of life.
III. Physical Examination
T, 37.5°C; RR, 32/min; HR, 142 bpm; BP, 95/65 mm Hg
Weight and height, 5th percentile
On examination, he appeared awake but hypotonic. He was thin-appearing and cried
only with stimulation. His anterior fontanel was sunken, and his lips and
mucous membranes were dry. He had decreased tear production. His lungs were
clear. The cardiac examination revealed a normal rate and rhythm without any
murmur or abnormal heart sounds. His abdomen was soft without any organomegaly.
His extremities were cool, with a 2-second capillary refill time. Both
testicles were descended. His neurologic examination revealed no focal
abnormalities.
IV. Diagnostic Studies
The WBC count was 16,300 cells/mm3, with 38% segmented neutrophils, 54% lymphocytes, and 6% monocytes. The
hemoglobin was 18.2 g/dL. The platelet count was 658,000/mm
3. The results of the basic metabolic panel revealed the following: sodium, 115
mEq/L; potassium, 7.7 mEq/L; chloride, 81 mEq/L; bicarbonate, 16 mEq/L; blood
urea nitrogen, 31 mg/dL; creatinine, 1.0 mg/dL; glucose, 89 mg/dL; and calcium,
10.7 mg/dL. The serum ammonia level was 39
µg/dL. Lumbar puncture revealed 1 WBC/mm3. The cerebrospinal fluid (CSF) glucose and protein concentrations were normal.
Cultures of CSF, blood, and urine were obtained.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-3: 3-Month-Old Girl:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 3-month-old female infant presented to the emergency department with a 1-week
history of increasing fussiness. Three days before admission, the infant
developed poor breast-feeding and weak suck. Although the number of wet diapers
had not changed, they were less saturated after the poor feeding. The parents
related that the child
's cry was not as loud as usual. The child had had no bowel movement during the
previous 4 days. The child was evaluated by her pediatrician and referred to
the emergency department. There was no history of fever, vomiting, or diarrhea,
and there had been no ill contacts.
II. Past Medical History
The child had been healthy until the past week. Pregnancy and delivery were
uncomplicated. There was a family history of pyloric stenosis in the father. A
2-year-old sibling was healthy.
III. Physical Examination
T, 37.4°C; RR, 30/min; HR, 156 bpm; BP, 100/80 mm Hg
Weight and height, 50th percentile
On examination she was alert but had a weak cry. Her head and neck examination
was remarkable for bilateral ptosis and decreased facial expression. Cardiac
and pulmonary examinations were normal. Her abdomen was distended but soft. On
neurologic examination, she had a weak gag and poor tone. Her deep tendon
reflexes were intact.
IV. Diagnostic Studies
Laboratory testing revealed a WBC count of 10,100 cells/mm3, with 33% segmented neutrophils, 56% lymphocytes, and 8% monocytes. Hemoglobin
was 11.7 g/dL; platelets, 490,000/mm
3; sodium, 139 mmol/L; potassium, 4.9 mmol/L; chloride, 106 mmol/L; carbon
dioxide, 18 mmol/L; blood urea nitrogen, 12 mg/dL; creatinine, 0.3 mg/dL; and
glucose, 58 mg/dL. A negative inspiratory force was measured at 20 cm H
2O.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-4: 11-Month-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
An 11-month old boy was brought to the emergency department because of decreased
activity level. He had had a 3-day illness consisting of fever to 39
°C and diarrhea. He had had approximately four episodes of nonbloody diarrhea per
day. He had no history of emesis. On the day of presentation, he had been tired
all day and wanted to lie down constantly. He had consumed four 8-ounce bottles
of Pedialyte. His urine output was decreased. The mother called the paramedics
when she felt that he was worsening.
II. Past Medical History
His prenatal and birth histories were normal. He had a history of wheezing, with
an upper respiratory tract infection at 3 months of age. He had had no
hospitalizations or surgeries. He was taking no medications and had no
allergies. His immunizations were current.
III. Physical Examination
T, 40.3°C; RR, 46/min; HR, 183 bpm; BP, 99/41 mm Hg
Weight and height, 75th percentile
On examination, he was lethargic and minimally responsive to painful stimuli.
The head and neck examination did not reveal any signs of external trauma. His
gaze was dysconjugate, but pupils were reactive from 3 mm to 2 mm bilaterally.
He had sunken eyes and dry mucous membranes. Respiratory examination revealed
shallow, labored respirations with moderately increased work of breathing. He
had intercostal and substernal retractions as well as abdominal breathing.
Breath sounds were coarse to auscultation. Cardiac examination was significant
for the tachycardia; there was no murmur or abnormal cardiac sounds. Abdominal
examination revealed hypoactive bowel sounds but no tenderness or
hepatosplenomegaly. There were no masses. Rectal examination revealed gross
blood. Neurologic examination was significant for overall hyoptonia and
unresponsiveness. Cranial nerves were intact and deep tendon reflexes were 2+
and symmetric. He had an intact gag reflex.
IV. Diagnostic Studies
In the emergency department, blood, urine, and CSF cultures were obtained.
Additional laboratory studies revealed a WBC count of 13,400 cells/mm
3, with 11% bands, 63% segmented neutrophils, 34% lymphocytes, and 2% monocytes.
Hemoglobin was 6.6 g/dL; platelets, 195,000/mm
3; sodium, 131 mmol/L; potassium, 5.8 mmol/L; chloride, 101 mmol/L; carbon
dioxide, 18 mmol/L; blood urea nitrogen, 19 mg/dL; creatinine, 0.7 mg/dL; and
glucose, 57 mg/dL. His prothrombin time (PT) was prolonged at 16.4 seconds, and
his activated partial thromboplastin time (PTT) was 29.1 seconds. Serum and
urine toxicology screens were negative.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-5: 9-Year-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 9-year-old boy developed emesis about 5:00 p.m. one evening and afterward went
to sleep. A few hours later, the parents had a difficult time arousing him, and
subsequently brought him to an emergency department. In the emergency
department, the child was able to relate that he fell at school and hit his
head against the wall. He did not lose consciousness at the time. He complained
of a headache. He denied any potential ingestion.
II. Past Medical History
He was a healthy child with no significant past medical history. He did not take
any medications and was not allergic to any medications. His immunizations were
appropriate for age.
III. Physical Examination
T, 37.5°C; RR, 26/min; HR, 86 bpm; BP, 120/70 mm Hg; SpO2, 97% in room air
On examination he was asleep but was easily arousable. His head was atraumatic,
but he had occipital pain with forward neck flexion. His occiput was diffusely
tender, but no bony defects were palpated. Pupils were 4 mm and reactive to 2
mm. A funduscopic examination was attempted but was unsuccessful. Kernig
's and Bruzinski's tests were negative. The remainder of his head and neck examination was
normal. His lungs, cardiac, and abdominal examination findings were normal as
well. His neurologic examination revealed that the cranial nerves were intact.
He was able to follow commands and to respond appropriately.
IV. Diagnostic Studies
A head computed tomographic (CT) study was obtained and revealed a left-sided
parietal intracranial hemorrhage, mild hydrocephalus, asymmetric ventricles
with the left ventricle being larger than the right, and blood in the fourth
ventricle. A complete blood count and serum electrolytes were normal. Serum and
urine toxicology screens were negative.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-6: 20-Month-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 20-month-old boy was brought to the emergency department with decreased
activity level. He had been vomiting for the previous 3 days and had had two or
three episodes of nonbloody, nonbilious emesis per day. On the day of
presentation, he had been acting listless all day and appeared pale to the
family. There had been no diarrhea. He had just recovered from coxsackievirus
hand-foot-mouth disease 1 week before development of these symptoms. The family
denied any trauma or ingestions. There had been no fever, rhinorrhea, or cough.
II. Past Medical History
One month before this presentation, the patient's serum lead level was found to be 31 µg/dL. His past medical history was otherwise unremarkable. He had not undergone
any surgical procedure. He was not taking any medications and was not allergic
to any medications. His immunization status was up to date.
III. Physical Examination
T, 37.0°C; RR, 27/min; HR, 75 bpm; BP, 100/68 mm Hg
Weight, 10th percentile; height, 50th percentile
On examination, he was somnolent but arousable. He fell asleep as soon as he was
no longer being stimulated. His head was normocephalic and atraumatic. His
tympanic membranes were pearly gray bilaterally, without hemotympanum. His
mucous membranes were moist. His neck was supple, and there was full range of
motion. His lung and cardiac examinations were normal. His abdomen was soft.
There was no abdominal tenderness, masses, or organomegaly. His extremities
were warm and well perfused. His neurologic examination revealed a Glasgow coma
score of 13 but was otherwise normal.
IV. Diagnostic Studies
A complete blood count revealed 12,100 WBCs/mm3 (86% segmented neutrophils, 9% lymphocytes, and 5% monocytes). Hemoglobin was
7.4 g/dL, and the platelet count was 851,000/mm
3. The MCV was low at 55 fL. Basophilic stippling was noted on the peripheral
blood smear. Samples were sent for a serum lead determination and hemoglobin
electrophoresis. Serum electrolytes and transaminases were normal. A lumbar
puncture revealed WBCs, 4/mm
3; RBCs, 4,365/mm3; glucose, 82 mg/dL; and protein, 31 mg/dL. A urine toxicology screen was
negative. Additional laboratory evaluation revealed a PT of 13.0 seconds and a
PTT of 36.6 seconds.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
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