Case for hanson

[FLK]

Hanson, since you are keen to learn perhaps I'll give you a peds case.

A five day old infant comes to your office because of irritability

PMH : full term male
Uncomplicated pregnancy
Birthweight : 8 lb 8 oz
Exclusively breast fed
Discharged at 30 hours of age

PE: weight 7 lb 14 oz Resp 46 HR 159 BP 56/35
irritable.......cannot be consoled by mother
jaundiced to knees


Now please take my history ( maternal and infant) and tell me what you want to look for on your exam.

provide differential diagnosis
proposed work up

I will provide any information that you need.

[Hanson]

Originally Posted by FLK

Hanson, since you are keen to learn perhaps I'll give you a peds case.

A five day old infant comes to your office because of irritability

PMH : full term male
Uncomplicated pregnancy
Birthweight : 8 lb 8 oz
Exclusively breast fed
Discharged at 30 hours of age

PE: weight 7 lb 14 oz Resp 46 HR 159 BP 56/35
irritable.......cannot be consoled by mother
jaundiced to knees


Now please take my history ( maternal and infant) and tell me what you want to look for on your exam.

provide differential diagnosis
proposed work up

I will provide any information that you need.

Wow, this is a ped case. Let the future intern try this out.

From the information given I come up with 4 broad differential diagnosis:

1. Physiological Jaundice (within the first week)
2. Breastfeeding jaundice/dehydration
3. Other weird heredity/congental jaundice diseases
4. Septicemia

Questions:
Q1. Is the baby full term? Any complications during pregnancy?
Q2. When did you first notice the jaundice?
Q3. Location of the jaundice?
Q4. Anything make the jaundice worse/better?

Nutritional Questions: (the baby lost some weights)
Q5. How do you feed your baby?
- if she is exclusively breast feeding then breastfeeding jaunidce is more likely.
- if she supplements breast feeding with formula then the next question is
Q6. How did you prepare the formula?

Infectious Process Questions:
Q7. When did you first notice the irritability?
Q8. Any fever, chills? How did you take the temp?
Q9. Any sick contacts?
Q10. Pulling of the ears?

Dehydration Questions:
Q11. Does the baby cry at all? Do you see tear come out of those beautiful eyes?
Q12. How many wet diapers?

Stool Analysis:
Q13. What color is the stool? Ash like?
Q14. How many bowel movements a day?

Developmental/Immunization Questions:
Q15. Is the baby up to date on his shots?
Q16. Does the baby coos, cry, move?

PAM HUG FOSS:
P: Any significant Past medical History?
A: Allergy/Asthma?
M: Any medications?

H: Hospitalization?
U: What color is the urine? Are they stinky?
G: Constipation, diarrhea, nausea, vomitting, black stool, bloody stool.

F: Any family history of jaundice, sickle cell diseases, G6PD?
O: OB/Gyn: Full term, abortion
S: Social history: Can you afford food for your baby?
S: Sexual history: STD/HIV


Physical Exam:

VS: weight 7 lb 14 oz Resp 46 HR 159 BP 56/35
Okay, not quite sure these vital signs are normal for babies, but they are not in adults.

1. Look into the eyes, tongue, and skin to see the degree of jaundice.
2. Examine for bulging tympanic membrane and pharyngeal exudates.
3. Examine for bulging fontanelle for meningitis.
4. Examine for sunking fontanelle for dehydation.
5. Emamine for capillary refill (less than 3 seconds = no dehydration?)
6. Palpate the abdominal for organomegaly.
7. Auscultate the lungs/heart.
8. Look for patent anus.
9. Is the baby floppy?

Well, jaundice in the first week isn't bad. This patient is most likely to have breastfeeding jaundice because mom breastfeeds the baby exclusively. Also mom told me that she doesn't do it very often because it hurts. That is one of the reason why the baby is not gaining weight.

The baby does not have enough bowel movements. Also, the baby is very dehydrated with a sunken fontanelle and a long capillary refill. The baby urine does not smell good at all. The smell almost knocked me out!

Work up:

1. CBC with peripheral smear.
2. Bilirubin levels

This is the CSA so I have to come up with 2 more tests.
3. Stool analysis
4. Urine analysis.

Okay, let me know if I pass or fail and what I should do to improve this.

Thanks,
Hanson

[FLK]

Sorry for the delay....site was down and I stopped checking

Questions:
Q1. Is the baby full term? yes
Any complications during pregnancy? like what? please ask specific questions did you want to ask the mother if she had diabetes or PIH or is a heavy smoker? No to all
Q2. When did you first notice the jaundice? a few days ago
Q3. Location of the jaundice? she says ????? her baby looks orange all over
Q4. Anything make the jaundice worse/better? when she takes him outside he looks less orange. when she turns out the lights he looks less orange

Nutritional Questions: (the baby lost some weights)
Q5. How do you feed your baby? she breast feeds him every hour or two. he is very hungry he eats for 20 minutes on each breasts and still cries after eating
- if she is exclusively breast feeding then breastfeeding jaunidce is more likely. [/b] why? differentiate breast milk from breast feeding jaundice
- if she supplements breast feeding with formula then the next question is
Q6. How did you prepare the formula? she does not supplement, but good question

Infectious Process Questions:
Q7. When did you first notice the irritability? he has been fussy since she took him home
Q8. Any fever [b]his temperature is 99.4 degrees[b], chills can babies get chills....no this is a symptom. ? How did you take the temp? under his arm
Q9. Any sick contacts? babies 3 yr old cousin has chickenpox
Q10. Pulling of the ears? can a newborn pull on his ears?

Dehydration Questions:
Q11. Does the baby cry at all?he cries a lot Do you see tear come out of those beautiful eyes? not really
Q12. How many wet diapers? last night was the alst one it smelled bad

Stool Analysis:
Q13. What color is the stool? greenish. none for 18 hours Ash like?no, but would you expect this at this age?
Q14. How many bowel movements a day?

Developmental/Immunization Questions:
Q15. Is the baby up to date on his shots? what shots would he be expected to have and does it matter?
Q16. Does the baby coos, cry, move? do newborns coo? yes he moves and cries

PAM HUG FOSS:
P: Any significant Past medical History? Full term newborn. breastfed.
A: Allergy/Asthma? do newborns have allergies? what kinds? Do newborns have asthma? If a newborn wheezes what do they likely have and what evaluation(s) are warrented?
M: Any medications? none

H: Hospitalization? none sice discharge
U: What color is the urine? dark. yellowwhy do you ask? Are they stinky? smells strong
G: Constipation, what questions are more appropriate to ask for a newborn with possible constipation? Does constipation even occur in a newborn? diarrhea, thick green stool--slightly lighter in color the last day nausea, another symptom vomitting, no emesis. just spit up mucous in newborn nursery black stool yes. becoming less black/green color, bloody stool. no

F: Any family history of jaundice no, sickle cell diseases[b]nope. he's white [b], G6PD? nope. and nobody in the family has ever had their spleen out...why do I care?
O: OB/Gyn: Full term, abortion
S: Social history: Can you afford food for your baby? no. but I am getting $ from Uncle Sam so I can have a few more kids.... just kidding. she has good insurance and appears well dressed and well educated...she is an engineer and husband is a attorney
S: Sexual history: STD/HIV she is a virgin...almost


Physical Exam:

VS: weight 7 lb 14 oz Resp 46 HR 159 BP 56/35
Okay, not quite sure these vital signs are normal for babies, but they are not in adults. look them up...they're normal

1. Look into the eyes,[b] positive red reflex OU. no cataracts/[b] tongue, and skin to see the degree of jaundice. baby is a pumpkin
2. Examine for bulging tympanic membrane and pharyngeal exudates. normal
3. Examine for bulging fontanelle for meningitis. fontanelle is flat...even slightly depressed when holding the infant upright at 30 degrees) small cephalohematoma
4. Examine for sunking fontanelle for dehydation.
5. Emamine for capillary refill (less than 3 seconds = no dehydration?) capillary refill is 2 seconds. skin is warm. feet and hands are cool
6. Palpate the abdominal for organomegaly. liver edge palpable
7. Auscultate the lungs/heart. baby is screaming. PMI is normal. femoral pulses aer normal
8. Look for patent anus. done. it's there
9. Is the baby floppy? no. why do you care?

Well, jaundice in the first week isn't bad. unless you get kernicterus
Work up:

1. CBC with peripheral smear. looking for what?
2. Bilirubin levels total 23. direct 0.4

This is the CSA so I have to come up with 2 more tests.
3. Stool analysis
4. Urine analysis.
no, you want a retic count and type and coombs. you should also get electrolytes

Okay, let me know if I pass or fail and what I should do to improve this.

pretty good job. since I am playing the role of the examiner, please address my questions that I would have asked you......
lab values : Hematocrit: 58
Platelet count 350,000
WBC 15.4 normal differential
retic Count: 2.5
lytes: sodium 154 Potassium 5.4 Chloride 125 Bicarb 23

you need to ask the mother some more specific questions about feeding and her mental state>

breast engorgement?
breasts smaller after a feeding does she hear the infant swallow?
does she hearinfant swallowing ?
you have already been given several clues
Differential diagnosis:
Proposed management

you passed, now go for the A+. remember: newborns do not have symptoms..

after you fine tune your answers, I will explain this case in detail

[Hanson]

Originally Posted by FLK

Sorry for the delay....site was down and I stopped checking

Questions:
Q1. Is the baby full term? yes
Any complications during pregnancy? like what? please ask specific questions did you want to ask the mother if she had diabetes or PIH or is a heavy smoker? No to all
Q2. When did you first notice the jaundice? a few days ago
Q3. Location of the jaundice? she says ????? her baby looks orange all over
Q4. Anything make the jaundice worse/better? when she takes him outside he looks less orange. when she turns out the lights he looks less orange Wow, mom is a very good observer.

Nutritional Questions: (the baby lost some weights)
Q5. How do you feed your baby? she breast feeds him every hour or two. he is very hungry he eats for 20 minutes on each breasts and still cries after eating Oh, he has potentials to beat the Japanese in hot dog eating contest (50 hot dogs in 12 minutes).
- if she is exclusively breast feeding then breastfeeding jaunidce is more likely. [/b] why? differentiate breast milk from breast feeding jaundiceI guess to help pinpoint the problem and find a solution. With breast milk jaundice you can't do much because the problem is in the milk. However, with breast feeding jaudice the problem is in the art of breast feeding. We can correct this by teaching the mom to breast feed correctly.- if she supplements breast feeding with formula then the next question is
Q6. How did you prepare the formula? she does not supplement, but good question

Infectious Process Questions:
Q7. When did you first notice the irritability? he has been fussy since she took him home
Q8. Any fever [b]his temperature is 99.4 degrees[b], chills can babies get chills....no this is a symptom. ? How did you take the temp? under his arm
Q9. Any sick contacts? babies 3 yr old cousin has chickenpox
Q10. Pulling of the ears? can a newborn pull on his ears?Oh, that is right. He can't. Poor baby.
Dehydration Questions:
Q11. Does the baby cry at all?he cries a lot Do you see tear come out of those beautiful eyes? not really
Q12. How many wet diapers? last night was the alst one it smelled bad

Stool Analysis:
Q13. What color is the stool? greenish. none for 18 hours Ash like?no, but would you expect this at this age?
Q14. How many bowel movements a day?

Developmental/Immunization Questions:
Q15. Is the baby up to date on his shots? what shots would he be expected to have and does it matter?The only one is HBV shot.
Q16. Does the baby coos, cry, move? do newborns coo? yes he moves and criesOh, that's right babies don't coos until 2 months.
PAM HUG FOSS:
P: Any significant Past medical History? Full term newborn. breastfed.
A: Allergy/Asthma? do newborns have allergies? what kinds? Do newborns have asthma? If a newborn wheezes what do they likely have and what evaluation(s) are warrented?I guess babies do not produce IgG until they are 6 months so they are susceptible to bacterial infections. So he may have pneumonia. Evaluate for fever, chills, spinal tap, pan culture mom's history of Group B Strep infection.M: Any medications? none

H: Hospitalization? none sice discharge
U: What color is the urine? dark. yellowwhy do you ask? Are they stinky? smells strong
G: Constipation, what questions are more appropriate to ask for a newborn with possible constipation? Does constipation even occur in a newborn? diarrhea, thick green stool--slightly lighter in color the last day nausea, another symptom vomitting, no emesis. just spit up mucous in newborn nursery black stool yes. becoming less black/green color, bloody stool. no

F: Any family history of jaundice no, sickle cell diseases[b]nope. he's white [b], G6PD? nope. and nobody in the family has ever had their spleen out...why do I care?I was trying to ask for blood dyscracia stuffs. I guess if I asked these questions then I should include a Coomb test for evalutation.O: OB/Gyn: Full term, abortion
S: Social history: Can you afford food for your baby? no. but I am getting $ from Uncle Sam so I can have a few more kids.... just kidding. she has good insurance and appears well dressed and well educated...she is an engineer and husband is a attorney
S: Sexual history: STD/HIV she is a virgin...almost


Physical Exam:

VS: weight 7 lb 14 oz Resp 46 HR 159 BP 56/35
Okay, not quite sure these vital signs are normal for babies, but they are not in adults. look them up...they're normal

1. Look into the eyes,[b] positive red reflex OU. no cataracts/[b] tongue, and skin to see the degree of jaundice. baby is a pumpkin
2. Examine for bulging tympanic membrane and pharyngeal exudates. normal
3. Examine for bulging fontanelle for meningitis. fontanelle is flat...even slightly depressed when holding the infant upright at 30 degrees) small cephalohematoma
4. Examine for sunking fontanelle for dehydation.
5. Emamine for capillary refill (less than 3 seconds = no dehydration?) capillary refill is 2 seconds. skin is warm. feet and hands are cool
6. Palpate the abdominal for organomegaly. liver edge palpable
7. Auscultate the lungs/heart. baby is screaming. PMI is normal. femoral pulses aer normal
8. Look for patent anus. done. it's there
9. Is the baby floppy? no. why do you care?

Well, jaundice in the first week isn't bad. unless you get kernicterus
Work up:

1. CBC with peripheral smear. looking for what?Looking for spherocytosis and schistocytes and left shift.2. Bilirubin levels total 23. direct 0.4 This is abnormal. This is out of the physiological jaundice ranges. Must be pathological jaundice.
This is the CSA so I have to come up with 2 more tests.
3. Stool analysis
4. Urine analysis.
no, you want a retic count and type and coombs. you should also get electrolytes

Okay, let me know if I pass or fail and what I should do to improve this.

pretty good job. since I am playing the role of the examiner, please address my questions that I would have asked you......
lab values : Hematocrit: 58 this is normal for age
Platelet count 350,000
WBC 15.4 normal differential
retic Count: 2.5 this is normal for age
lytes: sodium 154 Potassium 5.4 Chloride 125 Bicarb 23 No anion gap, normal lab values

you need to ask the mother some more specific questions about feeding and her mental state>

breast engorgement?
breasts smaller after a feeding does she hear the infant swallow?
does she hearinfant swallowing ?
you have already been given several clues
Differential diagnosis: Infection, hemolytic anemia, cystic fibrosis, biliary atresia
Proposed management: Pan Cultures and Tzank smear for chicken pox. Sweat test for cystic fibrosis, bile acid test. Exchange transfusion since the total bilirubin in this sick baby is too high. Consult Dr. FLK is the safest answer.

you passed, now go for the A+. remember: newborns do not have symptoms..

after you fine tune your answers, I will explain this case in detail

This is a very good case. It would be very nice to hear this case in detail. Thanks.

Hanson

[FLK]

Originally Posted by Hanson

This is a very good case. It would be very nice to hear this case in detail. Thanks.

Hanson

well for a totally made up case, I guess I have to make up a diagnosis.
this is likely a case of multifactorial hyperbilirubinemia.

Intant is below birthweight, is feeding poorly, is hypernatremic, has decreased urine output ans has a fairly high bilirubin.

Hyperbilirubinemia always think:
Increased PRODUCTION...or decreased elimination.

Increased production> Immune vs non-immune
Immune-Rh incompatability, ABO, minor blood group.
Non Immune....Intrinsic vs extrinsic RBC desctuction vs polycythemia
Intrinsic RBC defect...structural vs enzyme
Structural----heredetary spherocytosis, etc
enzyme-- G6PD, PK defeciency

Extrinsic:
Sepsis, hepatitis, hematoma ( hepatic, CEPHALOHEMATOMA...in this case)

DECREASED Elimination
reduced PO intake, bowel obstruction, sepsis , hepatitis, hypothyroidism

This patient has a cephalohematoma, borderline polycythemia...which is probably due to hemoconcentration secondary to dehydration, has fed poorly, and is dehydrated.

Normal reticulocyte count and negative coombs test does not suggest hemolysis.


Basically this infant requires hospitalization for intravenous fluid and phototherapy.
the decision to look for invasice bacrerial disease is a judgement call and if it was me would probably depend on the hostory and phisical and the appearance of the infant after some rehydration.
Breat feeding need not be interrupted, however, supplementation with commercial infant formula would be indicated ( IMO ) if maternal milk supply is inadequate.

You can obtain a pre and post feed weight to determine oral intake.

I have treated hundreds of patients with a similar story, and often times I have noticed that once the infant and the mother calm down, and the infant gets a little rehydration and the bilirubin levels come down ( that is a whole other lecture on the subtleties of bilirubin encephalopathy, if this phenomenon even exists as some suggest )the breast feeding usually goes well......
Hanson, I give you an A-
Congrats. Hope this was somewhat helpful.

PS:
This patient likely does not meet exchange transfusion criteria.
remember that the published

mortality rate for an exchange transfusion is 5-10%!!!....they are rarely done anymore, and clinicians have little experience. I myself have only done about 15. Also, remember you are exposing your patient to blood products.

This patient does not exhibit signs of overt encephalopathy, and since this is non-hemolytic there is no rush to do an exchange.
rehydration and agressive phototherapy should be more than adequate fo this patient.

regarding the tzanck smear...of what? there are no lesions.
Congenital varicella occurs when mothers get primary varicella 3-5 days BEFORE delivery. These infants require IV acyclovir, and get very sick.

As pointed out preciously, further questioning should be done of the mother to see if she ever had chicken pox, and then it is VERY unlikely this patient would get the infection, adn the incubation period is about 10-20 days anyway

[Hanson]

Very interesting case. Thanks for all the real world info.

hanson