PEDIATRICS GRANDROUNDSSeptember 24, 2009

Atazan, Atienza, Atotubo, Austria, Avancena, Balaoing

• J.A.• 15 yo/girl• San Antonio, Zambales

• Informant: Mother and patient• Reliability: good

CHIEF COMLAINT: WEAKNESS

HISTORY OF PRESENT ILLNESS

• erythematous non-pruritic rash over both cheeks, intensifies when exposed to sunlight

• Fever (highest temp: 39oC)• No cough, colds, diarrhea• Paracetamol 500mg/tab

• Recurrence of symptoms• Consulted at local hospital- CBC, urinalysis, CXR• Assessment: UTI• Paracetamol & multivitamins

4 months

PTA

1 month

PTA

HISTORY OF PRESENT ILLNESS

• Persistence of symptoms• Bilateral leg weakness• Non painful swelling of Right 2nd -3rd PIP • Consulted at another local hospital-CBC, urinalysis• Assessment: UTI• Co-amoxyclav 635mg/tab BID 7 days; Vitamin B

complex

2weeks

PTA

HISTORY OF PRESENT ILLNESS

• Persistence of symptoms• Increased bilateral leg weakness with pain on

thighs upon movement graded 5/10 non radiating• Consulted at local hospital• Chloroquine BID 1 day; Chloramphenicol 7 days

• Persistence of symptoms• Patient was referred to our institution and

subsequent admission

1weekPTA

Few hrsPTA

REVIEW OF SYSTEMS

General: (-) weight loss/gain; decreased appetiteSkin: (-) hair lossRespiratory: (-)dyspnea, hemoptysis Cardiovascular: (-)syncope, cyanosis, palpitations, or chest painGastrointestinal: (-) vomiting, diarrhea, abdominal painGenitourinary: (-)dysuria, hamaturia Endocrine: (-) heat nor cold intolerance, polyuria, polyphagia,

polydipsiaHematologic: (-) epistaxis, gum bleeding, easy bruising Nervous/Behavior: (-) dizziness, seizures, tremors, sleep

problems

MENSTRUAL HISTORY

• M: 14 yo• I: irregular (30-60days)• D: 3-4 days• A: 2-3 pads• S: (-) dysmennorrhea • LMP: July PMP: Unrecalled

PERSONAL HISTORY

• Feeding HistoryBreakfast: 1c rice, 1 fried egg, 1/2c green leafy

vegetables, 1pc med bananaLunch: 1c rice, 1 pc chicken(leg), softdrinksSnack: 2 slices of sweet bread/ chips, softdrinksDinner: 1c rice, 1c vegetables, 1pc fish

PERSONAL HISTORYHEEADSSSS

Good interrelationship with family members, lives with parents and 2 siblings; equally close to both parents

4th year HS, co-ed school, average student, denies any difficulties or any problems in school

Mixed diet, eats mostly vegetables, meat, fish; fond of softdrinks

Enjoys hanging out at friends house-chatting; watches tv<2hrs/day; not fond of going to malls or bars

Denies illicit drug use, has not tried smoking nor drinking currently has 1st boyfriend (9mos), denies intimate or

sexual activities No suicidal ideations; bikes without a helmet; Methodist-

goes to service weekly

PERSONAL HISTORY

• Immunizations– BCG 2 doses, date unrecalled– DTP 3 doses, date unrecalled– OPV 3 doses, date unrecalled– Hepa B 3 doses, date unrecalled– Measles – 1 dose, date unrecalled– MMR, Hib, Tetanus, Hep A(-)

PAST MEDICAL HISTORY

• (+)- ASTHMA, last attack 6yrs old• (+)- OTITIS MEDIA• (+)- BRONCHOPNEUMONIA (1996)• (-) –allergies (food, drugs)

FAMILY HISTORY

• (+) HPN, DM- maternal grandmother• (+) Asthma, CA- paternal uncle• (+) TB- paternal grandfather• (-) SLE, kidney disease, thyroid, blood

dyscrasias,

FAMILY PROFILEAge/Sex Educational

AttainmentOccupation Health Status

Orly (father) 42M College graduate DPWH Apparently healthy

Ana lisa (mother) 38F College graduate Teacher Apparently healthy

John Eric (sibling)

14M 3rd year HS student Apparently healthy

Julia( sibling) 4mosF Apparently healthy

SOCIOECONOMIC & ENVIRONMENTAL

• Concrete 3 bedroom bungalow, well-lit, well ventilated.

• Nuclear family• Mother - primary caregiver• Father - primary breadwinner• Water refilling station• Garbage collection daily, does not segregate• 3 cats, 1 dog, 5 guinea pigs• no factories/gas station nearby

Course in the Ward

Day 1 (9/15)

• CBC w/ platelet• Urinalysis• ANA titer• Anti-dsDNA• BUN, Creatinine• Paracetamol 500mg/tab• Referred to Rheumatology

Day 2 (9/16)

• IVF: D5NM 1L to run at 18-19 drops/min (100%)• Aeknil 300 mg/IVP• CXR (PA, lat)• Mantoux test• CK Total• Methylprednisolone pulse therapy (30mg/kg)

– 1 g in D5W 100ml to run for 2 hrs

Day 3 (9/17)

• Methylprednisolone, 1 gram in D5W 100 mL, to run for 2 hours

Day 4 (9/18)

• Referred to Rehabilitation Medicine• Methylprednisolone, 1 gram in D5W 100 mL,

to run for 2 hours

Day 5 (9/19)

• Prednisone 20mg/tab, 3 tabs PO after breakfast

• Plaquenil 200mg/tab, 1 tab after dinner once daily

• Milk, 1 glass BID• Calcium tablet, 1 tab BID if milk is not given

• Rehab Med: SLE/ deconditioned syndrome• PPE: no atophy, 30-degree extension leg/leg,

Right elbow ad limited range of motion of Left shoulder; MMT 5/5 bilateral UE; 4/5 bilateral LE; DTRs ++; (-) sensory deficit, babinski, clonus, Hoffmans

• Will start formal physical therapy on tues, for general muscle reconditioning and tolerance to a more upright position

• Patient complains of pain on R triceps, especially on manipulation, (-) tenderness

• Suggest xray of L elbow joint (AP-lat) prior to manipulating said joint during physical therapy

• Xray of L elbow joint• CK total

Chest Xray (9/16)

• Normal Chest

CBC (9/15)Ref. Range 9/15

Hgb 120-170 96RBC 4.0-6.0 3.52Hct 0.37-0.54 0.28MCV 87±5 79.80MCH 29±2 27.20MCHC 34±2 34.10RDW 11.6-14.6 20.20MPV 7.4-10.4 7.50Plt 150-450 200WBC 4.5-10.0 3.60Neutrophils 0.5-0.70 0.72Bands 0.00-0.05 -Segmented 0.50-0.70 0.72Lymphocytes 0.20-0.40 0.28Monocytes 0.00-0.07 -Eosinophils 0.00-0.05 -Basophils 0.00-0.01 -

Urinalysis (9/15)

• Dark yellow• Slightly turbid• pH 6.0• Spec. Gravity 1.1015• (-) albumin• (-) sugar

• RBC 0-1/hpf• Pus cell 1-3/hpf• Squamous cell +• Bacteria +

9/16

Ref. RangeCK Total 6,450 (high) 26- 192

9/16

Ref. Range

Urea Nitrogen 9.9 5 - 18Creatinine 0.52 0.5 - 1

ECC = 161.8

9/16

ANA Positive up to 1:320 (speckled)Anti-dsDNA Positive up to 1:10