Confirming diagnosis Severely diminished or absent T-cell number and function, as well as lymph node biopsy showing absence of lymphocytes, can confirm diagnosis of SCID.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Common variable immunodeficiency:
Diagnosis
(Handbook of Diseases)
Characteristic diagnostic markers in this disorder include decreased serum immunoglobulin (Ig) M, IgA, and IgG detected by immunoelectrophoresis, along with a normal circulating B-cell count. Antigenic stimulation confirms an inability to produce specific antibodies; cell-mediated immunity may be intact or delayed. X-rays usually show signs of chronic lung disease or sinusitis.
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Source: Handbook of Diseases, 2003
Severe combined immunodeficiency disease:
Diagnosis
(Handbook of Diseases)
Clinical indications point to the diagnosis. Most infants with SCID suffer recurrent overwhelming infections within 1 year of birth. Some are diagnosed after a severe reaction to vaccination.
Defective humoral immunity is difficult to detect before an infant is 5 months old. Before age 5 months, even normal infants have very small amounts of the serum immunoglobulins (Ig) IgM and IgA, and normal IgG levels merely reflect maternal IgG. However, severely diminished or absent T-cell number and function and lymph node biopsy showing absence of lymphocytes can confirm the diagnosis of SCID.
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Source: Handbook of Diseases, 2003
Cough - Case 4-2: 7-Week-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 7-week-old boy presented to his pediatrician with a 3-week history of
rhinorrhea, congestion, and cough; previously he was in good health. He had no
history of fever. A chest roentgenogram demonstrated a left lower lobe
infiltrate, and a 10-day course of erythromycin for treatment of pneumonia was
started. At the completion of this antibiotic course, the boy
's mother felt that his respiratory status had improved to some extent, but his
work of breathing was still increased from baseline. Furthermore, his cough was
persistent in nature. One week later, a repeat chest roentgenogram revealed
persistence of the left lower lobe infiltrate, and he was referred for further
evaluation. The review of symptoms revealed good oral intake and normal urine
output.
II. Past Medical History
He was born at 41 weeks' gestation with a birth weight of 3,000 g. There were no pregnancy- or
birth-related complications. He had no history of cyanosis or feeding
difficulties. He was feeding on formula, taking 2 ounces every 2 hours. He had
two older siblings who were both healthy.
III. Physical Examination
T, 37.3°C; RR, 54/min; HR, 153 bpm; BP in right upper extremity, 93/59 mm Hg; BP in left
upper extremity, 87/62 mm Hg; BP in right lower extremity, 94/63 mm Hg; SpO
2, 95% in room air
Weight, 4.5 kg
Initial examination revealed a well-developed infant in moderate respiratory
distress. The physical examination was remarkable for nasal flaring,
intercostal retractions, and intermittent grunting. He had good aeration and
scattered rales at both lung bases. Cardiac examination revealed a normal first
heart sound (S
1) and a prominent second pulmonary sound (P2). A II-III/VI systolic murmur was appreciated at the left sternal border. The
liver edge was palpated 4 cm below the right costal margin. The remainder of
the physical examination was normal.
IV. Diagnostic Studies
Laboratory analysis revealed a peripheral blood count of 8,400 WBCs/mm3, with 35% segmented neutrophils, 60% lymphocytes, and 5% eosinophils. The
hemoglobin was 11.4 g/dL, and there were 203,000 platelets/mm
3. Electrolytes, blood urea nitrogen, and creatinine were all within normal
limits. Antigens of respiratory viruses were not detected by immunofluorescence
of nasopharyngeal washings.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Cough - Case 4-6: 4-Month-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 4-month-old boy, who was born prematurely at 28 weeks' gestation, presented with a 1-week history of a cough. Over the next 4 days,
his mother reported an increasing cough with no history of fever or rhinorrhea.
He had decreased oral intake and decreased urine output. He had some
posttussive emesis and no diarrhea. His uncle had been sick for the previous 3
weeks with rhinorrhea and a cough.
II. Past Medical History
He was born at 28 weeks' gestation and required endotracheal intubation for a short period after birth.
While in the newborn intensive care unit, he had course of necrotizing
enterocolitis that did not require surgery. He was ultimately discharged home
with an apnea monitor and oral caffeine. However, his mother had recently run
out of this medication, and he was no longer receiving it. He had two siblings
who were healthy.
III. Physical Examination
T, 37.2°C; RR, 27 to 40/min; HR, 138 bpm; BP, not obtained; SpO2, 96% in room air and decreasing to 93% with feeds
Weight, 25th percentile
On examination, he was alert with moderate respiratory distress and frequent
episodes of coughing. His chest examination was significant for grunting with
substernal, intercostal, and supraclavicular retractions. Rales were
appreciated on the right with good aeration throughout. No wheezes were heard.
The remainder of his physical examination was within normal limits.
IV. Diagnostic Studies
The complete blood count revealed 25,400 WBCs/mm3, with 51% lymphocytes, 17% atypical lymphocytes, 25% segmented neutrophils, and
6% monocytes. The hemoglobin was 12.3 gm/dL, and the platelet count was
494,000/mm
3.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Diarrhea - Case 17-1: 2-Month-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 2-month-old male child presented with vomiting and diarrhea. He had been
discharged from the hospital 3 days earlier, with a diagnosis of
gastroesophageal reflux based on a pH probe and an upper gastrointestinal
radiographic series. He was discharged to home on ranitidine and metoclopramide
and had been doing well until the evening before presentation, when he
developed vomiting and diarrhea. He had 12 episodes of nonbloody, nonbilious
vomiting and 8 episodes of loose stools. There was no fever or associated upper
respiratory tract symptoms. He had normal urine output. His mother reported
that he was more fussy than usual, and she noted a lump in his groin on the day
of presentation to the hospital.
II. Past Medical History
The patient was a full-term baby with an uncomplicated pregnancy, labor, and
delivery history. He had been hospitalized only once, diagnosed with
gastroesophageal reflux, and prescribed ranitidine and metoclopramide.
III. Physical Examination
T, 36.9C; RR, 32/min; HR, 136 bpm; BP, 100/54 mm Hg
Weight, 5th percentile
On examination, the infant was alert and in no acute distress. His head, neck,
cardiac, and respiratory examinations were unremarkable. He was well hydrated
with a nontender and nondistended, soft abdomen. There was no
hepatosplenomegaly. There were no abdominal masses. He had normal male
genitalia, with bilaterally descended testicles. A tender, firm, and
erythematous mass measuring 5
× 3 cm was palpable in the right inguinal region.
IV. Diagnostic Studies
The complete blood count revealed 10,100 white blood cells (WBCs)/mm3, with 11% segmented neutrophils and 76% lymphocytes). The hemoglobin was 10.8
g/dL with a mean corpuscular volume of 87 fL, and the platelet count was
387,000 mm
3. Serum electrolytes, blood urea nitrogen (BUN), and creatinine values were
normal.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Diarrhea - Case 17-4: 15-Month-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 15-month-old boy presented with a 3-month history of watery diarrhea
associated with weight loss. At 12 months of age, he developed diarrhea
characterized by six to eight watery brown stools per day accompanied by
significant flatulence. There was no associated emesis or blood in the stool.
He had continued to have a good appetite despite the frequent stooling. Dietary
changes, including a BRAT (bananas, rice, apples, toast) diet and a
lactose-free diet, had been introduced but did not improve the diarrhea.
Occasional low-grade fevers had been noted. There was no history of foreign
travel or ill contacts. There were two cats and one dog in the home. He had
lost 3 pounds in the last 3 months.
II. Past Medical History
He was a full-term infant with a birth weight of 6 lb, 11 oz who was fed Similac
without any problems. He had normal weight gain and developmental milestones.
He had been introduced to rice cereal, baby foods, and adult table foods
without any problems. He was taking no medications.
III. Physical Examination
T, 36.8°C; RR, 26/min; HR, 100 bpm; BP, 102/53 mm Hg
Weight, less than 5th percentile (50th percentile for a 6-month-old child);
height, 10th percentile
The initial examination revealed a quiet, gaunt-appearing child. His eyes were
sunken, but the rest of the head, eyes, ears, nose, mouth, and throat
examination was unremarkable. His cardiac and respiratory examinations were
normal. His abdominal examination revealed no masses. His liver edge was
palpable at the right costal margin. There was no clubbing of the fingers. He
had dry skin around his nose and lips. He had very little subcutaneous fat. His
neurologic examination was nonfocal.
IV. Diagnostic Studies
Laboratory analysis revealed 11,100 WBCs/mm3 with 29% segmented neutrophils, 66% lymphocytes, and 5% monocytes. The
hemoglobin was 12.2 g/dL, and there were 492,000 platelets/mm
3. Electrolytes were significant for a potassium concentration of 2.8 mmol/L and
a bicarbonate concentration 16 mmol/L. His ESR was 4 mm/hour. Urinalysis was
negative, with a urine specific gravity of 1.005. The serum alkaline
phosphatase level was low at 115 U/L, whereas ALT was elevated at 59 U/L, AST
at 64 U/L, and lactate dehydrogenase at 845 U/L.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Jaundice - Case 15-3: 2-Month-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 2-month-old male infant was admitted for further evaluation of his jaundice
and poor growth.
II. Past Medical History
The baby was born via spontaneous vaginal delivery after an uncomplicated,
full-term pregnancy and weighed 3.0 kg at birth. On the second day of life, he
was transferred to the special care nursery because of hypoglycemia requiring
intravenous dextrose. A sepsis evaluation was performed, and the baby received
7 days of ampicillin and gentamicin. On the third day of life, his total
bilirubin level was noted to be 18.6 mg/dL (with a direct bilirubin
concentration of 2.8 mg/dL), and he received phototherapy for 4 days. His
complete blood count, blood type and antibody screen, abdominal ultrasound, and
state newborn screen were all normal. The birth hospital reported that the baby
was taken home on the ninth day of life against medical advice; his prefeed
blood sugar measurement that day was 33 mg/dL.
The baby had been seen by his pediatrician three times for weight and bilirubin
checks; blood sugar measurements at those visits were described as
“borderline.” His feeding regimen was about 2.5 ounces every 3 hours of cow's milk formula. Because of poor growth and persistent hyperbilirubinemia, he was
referred to the hospital
's gastroenterology clinic and subsequently admitted for additional evaluation.
III. Physical Examination
T, 37.3°C; RR, 24/min; HR, 140 bpm; BP, 96/60 mm Hg
Weight, 3.6 kg (less than 3rd percentile); length, 52 cm (less than 3rd
percentile); head circumference, 38 cm (10th percentile)
Physical examination revealed a cachectic, somewhat icteric 2-month-old boy in
no apparent distress. There was scleral icterus and a 5
× 5 cm anterior fontanel; the oropharynx was clear, with moist mucous membranes.
His neck was supple without lymphadenopathy or masses. Breath sounds were clear
and unlabored. His pulse was regular, and there was no murmur. The abdomen was
soft, nontender, and nondistended; the liver edge was palpable just below the
right costal margin, and a small umbilical hernia was present. The testes were
palpable (but not fully descended) bilaterally; the penis appeared small, with
a stretched penile length of 2.0 cm. The baby appeared alert with grossly
normal tone and reflexes. The remainder of the examination was unremarkable.
IV. Diagnostic Studies
Serum electrolyte measurement revealed the following: sodium, 131 mEq/L;
potassium, 4.1 mEq/L; chloride, 100 mEq/L; bicarbonate, 22 mEq/L; BUN, 14
mg/dL; creatinine; 0.2 mg/dL; and glucose, 50 mg/dL. The complete blood count
revealed 8,000 WBCs/mm
3 with 5% band forms, 30% segmented neutrophils, and 52% lymphocytes. The
hemoglobin was 9.2 g/dL, and the reticulocyte count was 1.7%. The total
bilirubin measured 10.5 mg/dL; the direct and unconjugated bilirubin levels
were 1.5 and 9.0 mg/dL, respectively. Serum albumin was normal. ALT was 46 U/L,
AST was 87 U/L, and GGT was 125 U/L.
Abdominal ultrasound examination of the liver revealed normal size, slightly
increased echogenicity, and a small, nondistended gall bladder without biliary
dilatation. The spleen and kidneys were normal. A sweat test was attempted, but
an insufficient amount of sweat was obtained to properly interpret the test.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Pallor - Case 10-1: 3-Week-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 3-week-old twin B Caucasian male infant presented to an outpatient clinic for
evaluation of anemia. He was noted in the nursery to be pale and had a
hemoglobin of 12.3 g/dL and a mean corpuscular volume (MCV) of 120 fL. The
hemoglobin measurement repeated at 2 weeks of age was 8.1 g/dL with a
reticulocyte count of 1.2%. He had initial problems with weight gain that
improved after the mother started to pump breast milk and to feed the baby with
a bottle. He was described as usually sleepy, including falling asleep during
feeds. He had no vomiting, diarrhea, fever, or cough. He had normal
gold-colored bowel movements. There had been no change in urine color. There
was no rash.
II. Past Medical History
The infant was born at 38 weeks' gestational age after in vitro fertilization. The pregnancy was complicated by maternal anemia. The mother's blood type was O-positive. The mother did not receive any medications during
pregnancy except for prenatal vitamins. The infant was delivered vaginally. He
had a transverse lie and was delivered vertex after external manipulation. The
birth weight was 2,470 grams. His twin (twin A) weighed 2,900 g. On the first
day of life, the infant was noted to have a swollen right upper leg with
significant bruising. The initial radiograph was normal, but a subsequent film
showed evidence of a healing fracture that was presumably related to birth
trauma. There was no history of jaundice in the newborn nursery.
The family history was remarkable for the mother's anemia which did not require specific treatment. The maternal grandmother also
had a history of anemia. Both the maternal grandmother and an aunt had required
cholecystectomy for gallstones. The infant received a multivitamin with iron.
He did not have any known allergies. He received a diet of breast milk with
occasional cow
's milk supplementation.
III. Physical Examination
T, 36.7°C; RR, 46 to 66/min; HR, 166 to 230 bpm; BP, 70/37 mm Hg
Weight, 3.1 kg (25th percentile); height, 50 cm (50th percentile); head
circumference, 36 cm (approximately 75th percentile)
On examination, the infant awakened easily and cried. He was remarkably
pale-appearing. The anterior fontanel was open and flat. The conjunctivae were
pale. The sclerae were anicteric. Mucous membranes were moist. The clavicles
were intact. The infant was tachypneic, but the lungs were clear to
auscultation. On cardiac examination, normal first and second heart sounds (S1
and S2, respectively) were heard. A III/VI systolic murmur was best appreciated
at the left upper sternal border. There were no gallops or rubs. No murmurs
were heard along the back. The liver edge was just palpable, but the spleen was
not palpable. The area of known extremity fracture had minimal edema but no
tenderness. There was some widening of the right distal femur compared with the
left. The remainder of the examination was normal.
IV. Diagnostic Studies
Complete blood count revealed the following: 11,300 white blood cells (WBCs)/mm3 (1% metamyelocytes, 43% segmented neutrophils, 34% lymphocytes, and 19%
monocytes); hemoglobin, 3.9 g/dL; 430,000 platelets/mm
3; MCV, 117 fL; RBC distribution width (RDW), 17; and reticulocyte count, 0.3%.
The peripheral blood smear revealed a few small spherocytes but no
schistocytes, burr cells, or target cells.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Pallor - Case 10-3: 5-Month-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 5-month-old African-American boy presented with pallor, difficulty breathing,
and lethargy. He had been in his usual state of good health until 4 days before
admission, when he developed a fever to 39 to 39.5
°C with rhinorrhea. There was no coughing, vomiting, or diarrhea. The patient
otherwise seemed well at the time. Over the next few days, he developed
increased work of breathing with decreased appetite. One day before admission,
the mother noted that he seemed lethargic and irritable. Oral intake was
significantly decreased; the infant was taking in only 8 ounces rather than his
typical 48 ounces over the day. The patient was brought to the emergency
department. In retrospect, the father noted that the child
's abdomen seemed to be increasing in size and firmness over the last month, with
some tenderness.
II. Past Medical History
The infant was born at term after an uncomplicated pregnancy. He was taken home
on the second day of life. He had no known allergies. He did not take any
medications. He had received the appropriate immunizations for age, including
two doses of the heptavalent pneumococcal conjugate vaccine. The family history
was notable for sickle cell disease in a paternal cousin and reactive airways
disease, cervical cancer, and ovarian cancer in several maternal relatives. A
great uncle died of
“jaundice” at 3 years of age and a cousin at 10 years of age.
III. Physical Examination
T, 38.4°C; RR, 58/min; HR, 160 bpm; BP, 83/38 mm Hg
Weight, 5.7 kg
In general, the child was lethargic and responsive only to painful stimuli. He
also had severe respiratory distress. The anterior fontanel was sunken. The
pupils were equal, round, and reactive to light. The conjunctivae and oral
mucosae were pale. The lips were dry and cracked. There were white patches on
the buccal mucosa that were easily removed with scraping. There was shotty
anterior and posterior cervical adenopathy. The lungs were clear to
auscultation, but the child had mild grunting and flaring. There was a II/VI
systolic ejection murmur at the left lower sternal border. The abdomen was
firm, with a liver edge palpable 5 cm below the right costal margin. The spleen
was palpable at the level of the umbilicus. Bowel sounds were present. The
extremities were cool with delayed capillary refill (5 seconds). On neurologic
examination, the child localized pain but had decreased tone and diminished
spontaneous activity.
In the emergency department, the patient had an oxygen saturation of 94% in room
air. He received several normal saline boluses as well as sodium bicarbonate
and intravenous dextrose. Blood and urine cultures were obtained. Intravenous
cefotaxime was given for presumed sepsis.
IV. Diagnostic Studies
The complete blood count revealed the following: 14,100 WBCs/mm3 (2% band forms; 52% segmented neutrophils, 42% lymphocytes, 2% eosinophils, and
2% atypical lymphocytes); hemoglobin, 2.6 g/dL; 184,000 platelets/mm
3; MCV, 88 fL; RDW, 17.4. The total bilirubin was 4.6 mg/dL with an unconjugated
level of 3.8 mg/dL. Hepatic transaminases, were normal but the lactate
dehydrogenase level was 2,984 IU/L (normal range, 934 to 2,150 IU/L). The chest
radiograph was normal. There was no cardiomegaly, infiltrates, or mediastinal
masses.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Seizures - Case 19-3: 8-Month-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
An 8-month-old boy was well until 1 week before admission, when he was found by
his mother having a
“seizure.” He had shaking and jerking of all extremities that did not stop when his
extremities were held. He did not respond to touch or stimulation. There was no
cyanosis. The episode lasted approximately 15 minutes. By the time Emergency
Medical Services personnel arrived, the patient was alert and feeding on a
bottle. He was not taken to the hospital. His last feeding had been
approximately 3 hours before the event. Two days later, he was evaluated by his
primary physician, who performed the following laboratory evaluations: glucose
(during feeding), 121 mg/dL; alanine aminotransferase (ALT), 73 U/L; aspartate
aminotransferase (AST), 93 U/L;
γ-glutamyl transferase (GGT), 28 U/L; and cholesterol, 423 mg/dL. These
laboratory studies were repeated 2 days later, with similar results except the
glucose was 16 mg/dL. Head CT and EEG were normal. He was hospitalized for
additional evaluation.
II. Past Medical History
The patient was born at 38 weeks' gestation with a birth weight of 3,400 g. His delivery was complicated by
meconium aspiration. He was treated with supplemental oxygen and empiric
antibiotics for 3 days. He also had hypoglycemia requiring intravenous dextrose
and bottle feedings every 1.5 hours. This resolved, and he was discharged home
on the fourth day of life. At 3 months of life, he had been diagnosed with
otitis media and received oral antibiotics. There was no family history of
seizures or mental retardation.
III. Physical Examination
T, 36.2°C; RR, 20/min; HR, 90 to 110 bpm; BP, 120/55 mm Hg; SpO2, 100% in room air
Height, 25th percentile; weight, 10th percentile; head circumference, 25th
percentile
On examination, he was thin but playful and interactive. The anterior fontanel
was open and flat. His pupils were symmetrically reactive to light. The heart
sounds were normal, and the lungs were clear to auscultation. His abdomen was
slightly protuberant, with a liver edge that was firm and palpable 6 cm below
the right costal margin. The spleen tip was just palpable below the left costal
margin. There was no ascites or palpable abdominal mass. The infant was
circumcised and had normal male genitalia. The neurological examination was
normal. He was able to sit without support and maintained good head control.
Deep tendon reflexes were 2+ and symmetric. The gag reflex was intact. There
were no hyperpigmented or hypopigmented skin lesions.
IV. Diagnostic Studies
Serum chemistry values included sodium, 137 mmol/L; potassium, 5.5 mmol/L;
chloride, 100 mmol/L; bicarbonate, 13 mmol/L; calcium, 10.5 mg/dL; phosphorous,
6.5 mg/dL; and serum glucose 20 mg/dL. The cholesterol and triglyceride
concentrations were 465 and 4,070 mg/dL, respectively. Hepatic function tests
included AST, 125 U/L; ALT, 155 U/L; GGT, 564 U/L; total bilirubin, 0.6 mg/dL;
and albumin, 4.0 g/dL. Serum and urinary ketones were present. The WBC count,
hemoglobin, and platelet count, as well as prothrombin and partial
thromboplastin times, were normal. Blood, urine, and stool cultures were
obtained.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Vomiting - Case 3-1: 7-Week-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 7-week-old African-American male infant presented with a 2-day history of
frequent vomiting. The vomiting was nonprojectile, nonbilious, and, on one
occasion, streaked with blood. Oral intake was poor. He had urinated once over
an 18-hour period. On the day of admission, he had profuse, watery diarrhea. No
one in the family had had vomiting or diarrhea.
II. Past Medical History
The patient was born at term and weighed 3,300 g. He was delivered via cesarean
section due to arrested descent. Because of feeding difficulties in the
nursery, he was discharged home on a lactose-free formula. Since then, his oral
intake had been appropriate. He had not previously been hospitalized. He had
received his first hepatitis B immunization.
III. Physical Examination
T, 38.1°C; RR, 50/min; HR, 170 bpm; BP, 86/38 mm Hg; SpO2, 88% in room air
Weight, 4.0 kg (10th percentile); length, 25th percentile; head circumference,
10th percentile
Examination revealed a well-nourished infant who was crying but consolable (Fig.
3-1).
The anterior fontanelle was open and slightly sunken. The mucous membranes were
moist, and the sclerae were nonicteric. The lungs were clear to auscultation,
and the cardiac examination was normal without any murmurs. The abdomen was
soft and mildly distended, without hepatomegaly or splenomegaly. The
extremities were cool. He had no rashes, good tone, and a symmetric neurologic
examination.
IV. Diagnostic Studies
Laboratory evaluation revealed 24,500 white blood cells(WBCs)/mm3, with 9% band forms, 24% segmented neutrophils, 40% lymphocytes, 20% monocytes,
and 5% atypical lymphocytes. The hemoglobin was 15.2 g/dL, and the platelet
count was 577,000 cells/mm
3. On red blood cell morphologic analysis, mild anisocytosis, poikilocytosis, and
burr cells were noted. Serum chemistries and cerebral spinal fluid analysis
were normal. His urine was dark yellow and turbid, with a specific gravity of
1.038, a pH of 5.5, 3+ protein, and 5 to 10 granular casts without bacteria,
nitrites, or WBCs. On chest radiography, the cardiac silhouette and lung fields
were normal.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Wheezing - Case 1-3: 5-Week-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 5-week-old boy presented to the emergency department with a 1-day history of
fever and
“wheezing.” His visit to the hospital was prompted by a rectal temperature of 38.6°C. His respiratory difficulty seemed worse with feeding. There had been no
emesis, diarrhea, rhinorrhea, cough, or cyanosis. He had been drinking
approximately 4 ounces of a cow
's milk-based formula every 3 hours. His only ill contact was his mother, who had
had cough and rhinorrhea for 1 week.
II. Past Medical History
He was born by spontaneous vaginal delivery at 39 weeks gestation. His birth
weight was 3,900 g. The pregnancy, labor, and delivery were uncomplicated.
Prenatal ultrasound revealed polyhydramnios but was otherwise normal. The
mother
's prenatal laboratory studies included a negative group B Streptococcus screen. Testing for antibodies to human immunodeficiency virus (HIV) had not
been performed. The infant had not previously been hospitalized.
III. Physical Examination
T, 38.5°C; HR, 180 bpm; RR, 70/min.; BP, 62/40 mm Hg; SpO2, 96% in room air
Length, 25th percentile; weight, 50th percentile
The infant was ill-appearing and in moderate respiratory distress. His anterior
fontanelle was open and flat. There was no conjunctival injection or discharge.
There was intermittent grunting and nasal flaring. Moderate intercostal and
subcostal retractions were present. Breath sounds were diminished throughout
the left chest. The right lung was clear to auscultation. There was no
wheezing. The heart sounds were normal. The liver was palpable 1 cm below the
right costal margin. The spleen was not palpable. The Moro reflex, grasp, tone,
and reflexes were normal. There were no rashes or petechiae.
IV. Diagnostic Studies
Arterial blood gas revealed the following: pH, 7.40; carbon dioxide tension
(PaCO
2), 40 mm Hg; oxygen tension (PaO2), 214 mm Hg; and bicarbonate, 26 mEq/L. The complete blood count demonstrated
37,900 WBCs/mm
3, including 3% band forms, 67% segmented neutrophils, and 30% lymphocytes. The
platelet count was 520,000/mm
3, and hemoglobin was 9.4 g/dL. Serum electrolytes, blood urea nitrogen, and
creatinine were normal. There were no WBCs, protein, or nitrites on
urinanalysis. A blood culture was obtained. Lumbar puncture was not performed
due to the patient
's respiratory distress. Chest radiography demonstrated left lower lobe
consolidation with an associated pleural effusion causing rightward shift of
the mediastinal structures (Fig. 1-4).
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Wheezing - Case 1-5: 5-Week-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 5-week-old Caucasian boy presented to the emergency department with worsening
cough and respiratory difficulty. Two weeks before admission, he was evaluated
by his primary physician for poor weight gain and periodic emesis. His weight
of 3,050 g was the same as his birth weight. He had Hemoccult-positive stool
and was diagnosed with cow
's milk protein allergy. His formula was changed to a protein hydrolysate
formula. One week before admission, his weight had increased to 3,100 g.
However, he began having more frequent episodes of emesis. Three days before
admission he developed a cough, tachypnea, and audible wheezing. He was
evaluated at a nearby hospital, diagnosed with bronchiolitis, and treated with
nebulized albuterol. His tachypnea had not improved despite receiving nebulized
albuterol every 4 hours. His cough had increased in frequency. He was evaluated
in the emergency department for worsening cough and continued tachypnea. The
parents mentioned that the infant had always appeared dusky with crying, but
this color change has occurred more frequently over the past few days. He had
also had numerous episodes of posttussive emesis. Over the past 3 days, he had
taken only 2 ounces of formula every 4 hours. The parents denied ill contacts,
diarrhea, and lethargy. Both parents smoked, but only outside the home. There
were no pets.
II. Past Medical History
He was born at 37 weeks' gestation after an uncomplicated pregnancy. The mother's group B Streptococcus colonization status was not known, so she received two doses of ampicillin
before delivery. The infant
's Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. He had not
previously required hospitalization.
III. Physical Examination
T, 37.7°C; RR, 60/min; BP, 78/37 mm Hg; HR 160 bpm; SpO2, 88% in room air
Weight, 3.0 kg (less than 5th percentile); length, 49 cm (less than 5th
percentile)
Physical examination revealed a cyanotic infant in moderate respiratory
distress. The anterior fontanelle was open and flat. There was no conjunctival
injection. There were no oral mucosal ulcerations. Capillary refill was brisk.
The heart sounds were normal. Femoral pulses were palpable. There were
intercostal retractions. Rales and wheezes were present diffusely. The liver
edge was palpable 3 cm below the right costal margin. The remainder of the
examination was normal.
IV. Diagnostic Studies
Laboratory analysis revealed 10,200 WBCs/mm3, with 76% segmented neutrophils, 19% lymphocytes, and 3% monocytes. The
hemoglobin was 13.0 g/dL, and there were 350,000 platelets/mm
3. Hepatic function panel was as follows: total bilirubin, 0.3 mg/dL; alanine
aminotransferase, 32 U/L; aspartate aminotransferase, 66 U/L. The prothrombin
and partial thromboplastin times and fibrinogen split products were normal.
Blood cultures were obtained. Chest radiography revealed diffuse interstitial
pulmonary edema but a normal cardiothymic silhouette.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Wheezing - Case 1-6: 4-Month-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 4-month-old African-American boy was well until 9 days before admission, when
he developed fever to 38.9
°C and a cough. Seven days before admission, he was evaluated by his primary
physician and treated with ranitidine for suspected GER. Four days before
admission, he developed tachypnea and grunting and received nebulized
albuterol. On the day of admission he had continued fevers and worsening cough.
His oral intake was poor. He had taken only 2 to 3 ounces of breast milk every
4 hours over the past day. His urine output was also decreased. Several family
members had upper respiratory tract infections.
II. Past Medical History
He was born at 40 weeks' gestation after an uncomplicated pregnancy. He had received all of the
appropriate immunizations for age, including the second dose of
diphtheria-tetanus-alellular pertussis vaccine (DTaP). There was no family
history of asthma or sickle cell disease.
III. Physical Examination
T, 37.0°C; RR, 76/min; HR, 120 bpm; BP, 102/72 mm Hg; SpO2, 93% with 3 L O2/min by nasal cannula
Weight, 10th to 25th percentile; length, 10th percentile; head circumference,
10th percentile
He was awake and alert. The anterior fontanelle was open and flat. He had
flaring of the alae nasi. There were moderate intercostal, subcostal, and
supraclavicular retractions. Scattered rhonchi were present, with diminished
breath sounds at the bases bilaterally. There was no focal wheezing. The heart
sounds were normal. The spleen was palpable just below the left costal margin.
The remainder of the examination was normal.
IV. Diagnostic Studies
The WBC count was 10,200/mm3, with 15% band forms, 68% segmented neutrophils, and 12% lymphocytes. The
hemoglobin was 10.3 g/dL, and the platelet count was 277,000/mm
3. Arterial blood gas analysis revealed the following: pH, 7.42; PaCO2, 30 mm Hg; and PaO2, 90 mm Hg. Hepatic function panel revealed a total bilirubin of 0.3 mg/dL;
alanine aminotransferase, 55 U/L; aspartate aminotransferase, 82 U/L, and
lactate dehydrogenase, 3,280 U/L. No antigens to respiratory syncytial virus;
parainfluenza types 1, 2, and 3; influenza A and B; or adenovirus were detected
by immunofluorescence of nasopharyngeal aspirate. Serum immunoglobulin (Ig)
results were as follows: IgA, 24 mg/dL (normal range, 27 to 73 mg/dL); IgM, 528
mg/dL (normal range, 37 to 124); and IgG, 650 mg/dL (normal range, 292 to 816
mg/dL).
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
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