Pediatrics: A Case-Based Review [1st ed.] 9783132053717

Table of contents :
Case 1 Six-year-old boy with high fever, vomiting, and headache
Case 2 Child with barking cough and dyspnea
Case 3 Child with high fever and seizure
Case 4 Apathetic infant with persistent skin folds
Case 5 Two-year old girl with colic-like stomach pains and vomiting
Case 6 Twelve-month old boy comes for a health screening
Case 7 Ten-year-old boy with painfully swollen knee
Case 8 Girl with petechial dermatorrhagie
Case 9 Infant with projectile vomiting
Case 10 Young girl with recurrent shortness of breath
Case 11 Fourteen-month-old toddler with "runny ear"
Case 12 Three-year-old boy who has had contact with chicken pox
Case 13 Five-year-old girl with a swollen jaw angle
Case 14 Severely ill infant with cough and shortness of breath
Case 15 Young girl with difficulty swallowing and fatigue
Case 16 Two-year-old boy with coughing fit and cyanosis
Case 17 Twelve-month old boy with screaming fit and swollen testicles
Case 18 Eight-year-old boy with macrohematuria
Case 19 Boy almost 1-year-old with failure to thrive
Case 20 Macrosomal newborn after obstructed labor with shoulder dystocia
Case 21 Ten-year-old girl with fever and headache
Case 22 Eight-year-old boy with high fever and rash
Case 23 Five-year-old girl after fall from jungle gym
Case 24 Infant with high fever, sucking weakness, and vomiting
Case 25 Toddler burned by boiling water
Case 26 Five-year-old girl with abdominal pain and anal itching
Case 27 Fourteen-year-old girl with weight loss and social withdrawal
Case 28 Newborn whose mother has poorly controlled diabetes mellitus
Case 29 Five-year-old girl with hematuria
Case 30 Three-year-old boy with numerous pigment spots
Case 31 Feverish 2-year-old girl with pustulent crusty rash
Case 32 Hypotrophic newborn with abnormal phenotype
Case 33 Five-year-old boy with knee pain and protective limping
Case 34 Ten-year-old boy with scleral icterus
Case 35 Fifteen-month-old child with an abrasion and no tetanus vaccination
Case 36 Fifteen-year-old girl found unconscious with hypothermia
Case 37 Two-year-old child who has ingested an unknown fluid
Case 38 Five-day-old newborn with icterus and sucking weakness
Case 39 Three-year-old girl refusing to eat
Case 40 Newborn with morphological abnormalities
Case 41 Two siblings with itching eczematous changes on the skin of the neck and head
Case 42 Consultation regarding "sudden infant death syndrome" (SIDS)
Case 43 Five-year-old boy with high fever and abdominal pain
Case 44 Four-year-old boy with recurrent urinary tract infections
Case 45 Seven-year-old boy with pneumonia and bone pain
Case 46 Four-year-old boy with fever and exanthema
Case 47 Four-year-old girl with facial swelling
Case 48 Five-year-old girl with pale skin and splenomegaly
Case 49 Seven-year-old girl with headaches and abnormal behavior
Case 50 Four-year-old boy with pain in right lower abdomen
Case 51 Three-year-old girl with protective posture of right arm
Case 52 Ten-year-old boy with tingling paresthesia, speech disorder, and headache
Case 53 Sixteen-month old boy with undescended testis
Case 54 Eight-year-old boy with abdominal pain and weight loss
Case 55 Premature birth in 28th week of pregnancy with shortness of breath and abdominal pain on pressure
Case 56 Five-year-old boy with intense abdominal pain
Case 57 Two-year-old boy with high fever, rash, and swollen joints
Case 58 Four-month-old screaming infant with inguinal swelling
Case 59 Nineteen-month-old girl with bloody diarrhea, hematomas, and anuria
Case 60 Newborn with persistent cyanosis
Case 61 Four-year-old boy with rattling breath and hypersalivation
Case 62 Six-year-old boy with failure to thrive and recurrent pulmonary infections
Case 63 Fourteen-year-old girl who collapsed on a school trip
Case 64 Three-year-old boy with deteriorating general condition and gastroenteritis
Case 65 Healthy newborn delivered by cesarean section
Case 66 Eleven-year-old boy with high fever and joint pain
Case 67 Newborn boy with conspicuous genitals
Case 68 Six-year-old girl with abnormal appearance
Case 69 Premature baby with acute deterioration of general condition
Case 70 Four-year-old girl with fatigue and difficulty concentrating
Case 71 Exasperated parents with an 8-week-old screaming baby in the emergency department
Case 72 Five-month-old infant with severe cough for the past few weeks
Case 73 Fourteen-year-old girl with recurrent abdominal pain
Case 74 Fifteen-year-old boy with no signs of progressing puberty
Case 75 Two separate cases of infants following a fall from the changing table
Case 76 Attention in the delivery room for newborns with congenital deformities
Case 77 Newborn born in the 41st week of pregnancy after pathological CTG
Case 78 Young boy with palpitations, reduced performance, and shortness of breath
Case 79 Almost two-year-old boy, with neurodermatitis
Case 80 A young colleague during the pediatric admission examination
Case 81 Five-month old boy with therapy-resistant diarrhea
Case 82 Thirteen-year-old school girl with petechiae in poor general condition
Case 83 Fourteen-month old boy with persistent nosebleed and hematomas
Case 84 Uncontrollable six-year-old boy with aggressive behavior
Case 85 Twelve-year-old boy with painful swelling of the right foot
Appendix
Sources of Images
Forms of juvenile idiopathic arthritis (JIA)
Childhood diseases
Body mass index
Important reference values
Index

Citation preview

I

Thieme

Pediatrics A Case-Based Review Michaela Kreckmann, MD Private Practice Saarbriicken,Gerrnany 141 illustrations

Thieme Stuttgart · New York · Delhi · Rio de Janeiro

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Unry of cm1ng1~1n-Pablladan nm is avallab~ from the publisher.

This book is an authorized trmslatioo of the 2nd German editioo published and copyrighted 2008 by Georg Thieme Verlag. Stuttgart. Title of the Gerrrulo edition: Pallbuch Paedi.atrle Transktor: Gertrude Champe. Surry, MB, USA

Names: Kreckmann. Michaela, author.

IV

Title: Pedlatrlcs : a case-based review/ Mlchula Kreckmann ; trauslator, Gertrude Clwnpc. Other titles: Fallbuch Phadiatrie. Eoglisb Desaiption: Stut!iart ; New Yort : Thieme, (2019) I 'This book is an authorized translation ofthe 2nd GemYn edition published and copyrjgbted 2008 by Georg Thieme Ved~ Stuttg;lrt. Titfe of the Gennan edition: F.JUbuchPaediatrie"- Galley. I lnd.udes llmx. I Identifiers: I.a:N 2019020002 (print) I LCCN 2019021658 (ebook) I ISBN 9783132053717 () I ISBN 9783132053618 (alk. paper) I ISBN 9783132053717 (e-ISBN)

Subjects: I MESH: Pediatrics I Diagnosis, Dltrerentlal I DiaJMstlc Techniques and Procedures I case Reports OUs.iflcadon: LCC RJSO (ebook) I I.CC RJ50 (print) I NIM

ws 100 I DOC 618.92f007S-dc23 LC rea>rd available at hn:ps:/Jlccn.loc.gxw/2019020002

C 2019 Georg Thieme Verlag KG

Thieme Publishers Stuttgart ROdigerstrasse 14, 70469 Stuttgart, Germany +49 [0(711 8931 421, customl!nervi.ceOthieme.de

Impartmt Date: Medicine is an ~Di science

umiergoing motinual dewlopmeot. ~ and dioial ~ are c:ontinually expanding our lcoowledge. in particular our knawledge of proper tremnent and drug tberapy. Insolilr as this book mentions any dosage or application. readers may rest assured that the authors. editors, and pubJlshers have made every effort to ensure that such referentectfve Umping A S·year-old boy has been complalnlng of pain In his right knee since the day before. The pain has gotten so intense that he can hardly walk. There is no fever. Anam· nestically, he had a respiratory infection a week earlier and also has a distinct protective limping on the right side. Examination shows painful limitation of m~ ment in the right hip joint The joint is neitfter warm and swollen, nor red. All other joints, including the right knee joint. are freely movable. Ultrasound examination of the hip joint shows thilt compared to the other side. the lntra·artlcular space Is widened (see Fig.).

34

SOtiographic longitudinal S«tiolt of tilt pro;Omal femur in tilt orta

of tilt femur nedc

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What 1s your d1agnos1s1 Justify your dec1s1on.

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Explain the cllnlul pkture of Perthes disease.

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What do you know about slipped capital femoral epiphysis7

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Answers and Comments Page 143

IEm Ten-year-old boy with scleral icterus During vacation, a 10-year-old boy went camping with his family at a popular camp site that is no longer maintained daily by park rangers. The family has been home for 3 weeks. For the past few days, he has been complaining of upper abdominal pain, nausea, and lack of

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Case appetite. He feels listless and tired and has a slight fever (38.4°C). Since the day before, the mother has noticed yellowing of the sclera and so the boy is brought to the emergency department.

34

What diseases can be considered? What is the most likely diagnosis?

What diagnostic procedures do you order to confirm your suspected diagnosis? What findings would you expect?

Name additional clinical signs you would find if your suspected diagnosis is confirmed.

What do you know about the infectious pathway and incubation time of the disease? When may the boy relllrn to school?

0o cases ot this disease have to be reportec11

~ Answers and Comments Page 146

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Case

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IEm Fifteen-month-old mild with an abrasion and no tetanus vaccination A15-month-old child gets a scrape wound while playing on the playground. The wound is very soiled with earth. The child is brought to the emergency department. The

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parents, who up to now have refused all vaccinations for the child, are worTied now and request an anti-tetanus vaccination.

What are your first steps?

The medical history reveals that the child has a cold at the moment. • ... and actually, when someone has a cough and a cold, it's not right to give a vaccination; the parents inform.

36

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Are the parents right? Name the general contraindications for vaccination.

The parents continue to be concerned that their child could suffer adverse effects from the vaccination. They have heard that there can be brain damage.

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What is meant by the adverse effects of vaccination? What is your reaction to the parents' assertion? What reactions to vaccination can the parents expect?

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You have answered the parents' questions and informed them. The parents give their permission.

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Must the parents' permission be recorded in writing? How do you proceed in vaccinating the child?

According to the recommendations of the United States Centers for Disease Control and Prevention (CDC). a 15-month-old child has normally already received various immunizations. What are they? List the ages at which these immunizations are normally given.

-+ Answers and Comments Page 148

IIm Fifteen-year-old girl found unconscious with hypothermia EMTs bring in a 15-year-old girl in the early morning hours to the emergency department of a pediatric clinic. She was found unconscious in the city park by passers-by. She was lying in vomit and her clothes were completely wet. Using the personal data on a student ID that the girl was carrying, it was possible to inform the parents. The girl was invited on the evening before to a going away party for a classmate. Examination reveals the following: unconscious patient,

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defense response to painful stimulus, no external signs of injury, distinct smell of alcohol, symmetrical proprioceptive reflexes, no pathological reflexes, pupils moderately large, prompt light reaction, auscultation of heart and lungs as well as abdominal palpation normal, blood pressure 100/70 mmHg, heart rate 60/min, body temperature (rectal) 35. l 0C, and blood sugar 63 mg/dl (3.5 mmol/L).

Case

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What is your suspected diagnosis?

37

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What acute measures do you initiate?

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What do you do next?

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Answers and Comments Page 152

Case

37

IEm Two·year-old chlld who has Ingested an unknown ftutd In your pedfatrlc emergency department, you receive a phone call from an agitilted father. His 2-year-old daughter was unattended for only a short time and

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durtng that time she swallowed almost all of a bottle of •some kind of medicine. he wasn't quite sure what it was."

The father asks you what he should do now. What additional information do you ask fur on the telephone and what advice do you give the father?

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About 45 minutes after the call, the t.rtfler comes tx> the dinic's emergency depart· ment with his daughter. He has brought the almost-empty bottle along (see Fig.). The father informs that the battle hadn't been quite full (5 ml syrup containing 200 mg paracetamol and 2.275 g sorbitol). The child weighs 11 kg. The little girl does not seem Impaired; she Is playlng cheerfully with tfte teddy bear she brought along. The chlld's face and hands are strII completely sticky with tfte syrup and

there are also traces of the medicine on her T-shirt. Physical examination shows no abnormalities.

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Approxtmately how much of the active agent has the little girl consumed? How do you esttmate tfte toxicity of the active agent consumed1

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Whit symptzims must you expect with paraceblmol poisoning?

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Whit measures do you tnltiate?

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Give your re tfie emergency department bec.ause for tfie past 2 hours she no longer wanted to move her right arm. On furtfier investigation, you leam that earfier. while she was walking down tfie stairs holding her motfier"s hand, she slipped. The mother pulled her up by the hand, in order tD prevent her from falling. On examination, the arm seems to be painful and you cannot get her to raise the arm even with the incentive of a piece of candy (see Ag. b).

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Justify your suspected diagnosis on the basis ot the mec11ca1 history and the c11n1ca1 pkture.

What other possible injuries should you be considering? How can you distinguish between these and your suspected diagnosis?

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Explain the mechanism of Injury for your suspected diagnosis.

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What do you do next?

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Answers and Comments Page 181

11Em Ten-year-old boy with tingling paresthesia. speech disorder. and headache A10-year-old boy is brought to the emergency department with the information that 1 hour ago he suddenly complained about flickering vision problems and a feeling of numbness first in the right arm and then in the right leg. The parents also observed blurred, •babbling• speech. After a few minutes, these symptoms disappeared, and instead, the boy was now complaining of strictly left-sided, intense headache and nausea. Bright

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light was unpleasant for him. This was the first occurrence of such an event. Anamnestically, the parents report that the little boy had febrile convulsions. His development has been normal. You examine the boy, who is still complaining of leftsided headache and nausea. There are no other symptoms. The neurological examination and the remaining physical examination are normal.

Case

52

Which differential diagnoses are you considering? What Is the most likely diagnosis? What Is your rationale?

53

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What further tests would you consider useful?

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What treatment do you initiate?

~ Answers and Comments Page 182

Case

53

IEm Sixteen-month-old boy with undescended testis During the night shift, a 16-month-old boy is brought in because of a febrile respiratory infection. In the physical examination, in addition to bronchitis, you make the secondary observation that only the left testicle has descended into the scrotum. Upon questioning,

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you learn that the right testicle has never been in the scrotum and that even while bathing it never migrates into the scrotum. Up to now, there has never been a diagnosis or a treatment.

What do you think about the fact that up to now there has never been a diagnosis or a treatment? What advice do you give the parents?

What did you want to find out when you asked the parents whether the testicle is in the scrotum during bathing?

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Name and explain the different fonms of undescended testis.

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What could cause undescended testis?

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What therapeutic possibilities are available for the treatment of undescended testis?

-+ Answers and Comments Page 184

IB:m Eight-year-old boy with abdominal pain and weight loss An 8-year-old boy is brought to the emergency department because he has been complaining of abdominal pain and nausea for 2 days. On the previous night, though he vomited several times. diarrhea and fever were absent. Now he is increasingly sleepy. The parents informed that for the past 2 weeks the boy was tired,

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fatigued, and in a bad mood. In this time, he had lost a good 3 kg, although he was eating with good appetite and drinking a great deal. In addition, the parents observed that their son constantly needed the toilet. In fact, in the past week, the boy had even wet his bed on two nights.

Case

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What is your suspected diagnosis on the basis of this medical history? What pathological findings might you gather In the cllnlcal examination If your suspected diagnosis Is correct?

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What examinations do you perform to confinn the diagnosis?

55

You examine the boy, who is sleepy but reacts when addressed. His breathing is markedly deep and his breath smells of acetone. Clear signs of dehydration are found: persistent skin folds, dry skin and mucosa, dry coated tongue, and sunken eyes. The abdomen is shrunken. It is soft on palpation and there is no defensive tension. You feel neither enlarged organs nor pathological resistances. Peristalsis sounds normal. Normal heart and lung sounds. In the neurological examination, reflexes are normal, and the pupillary light reflex is prompt. No signs of meningismus are found. The outpatient nurse measures pulse and blood pressure: Heart rate 11 O/min, blood pressure 90/50 mm Hg.

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What acute treabnent do you initiate? How do you proceed?

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Explain the etiology of the disease.

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What kind of diet shou Id the child have with this disease? Explain and calculate the energy needs of the 8-year-old boy.

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~ Answers and Comments Page 186

Case

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ID Premature btrth tn the 28th 'W'eek of pregnancy wtth shortness of breath and abdoml· nal pain on pressure In the premature ward, you are caring for an extremely small premature baby. The boy was born by cesarean section after 27 weeks and 5 days of pregnancy because oftfte motller's HELLP syndrome (spedal form of pre-edampsla). The birth weight was 840 g. body length 30 cm, and head drcumference 26 cm. Postnatally, the boy adapted well at first. breathed spontineously, and quickly became rosy with oxygen (2-4 L/mln with mask). Six hours postpartum he showed symptoms of clyspne.i. so much that he had to be intubated and ventilated (see Fig.).

56

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What are the symptoms of respiratory distress syndrome? Explain the etiopathogenesis of respiratDry distress syndrome.

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How Is respiratory dlstres.s syndrome treated?

I The parents have heard tftat ventilation can lead to •problems with the eyes.•

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What disease are the parents th1nktng on 0esa1be the d1n1ca1 picture.

I Two days later the dtild's general condition is dramatically worse. The child becomes septic gray mottled skin, recapillarization time is extended to 5 seconds, the need for ventilation and oxygen has increased (Fi02 =0.7), the abdomen Is swollen. The chlld vomits blle repeatedly and excretes bloody, mucous stools. Palpation of the abdomen clearty causes pain.

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Which disease is it most likely? How can you confirm your swpected diagnosis?

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Answers and Comments Page 189

IEm Five-year-old boy with intense abdominal pain A 5-year-old boy with intense abdominal and rectal pain is presented to the emergency department. The parents explain that the boy has not had a bowel movement for a week and can no longer go to the toilet because of the pain and hasn't vomitted. Occasionally, especially during the day, the boy would soil his pants; his underpants were often soiled. Often, the boy would have no bowel movement for days, but then have diarrhea. The mother already knows the symptoms; in the past 2 years, she has taken the child to the pediatrician more than once because of absence of bowel movements. It

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Case

has not yet been possible to detennine the cause of the complaints. The boy, who is writhing with abdominal pain, is examined. The following clinical findings are observed: abdomen distended, diffuse pain on pressure, no defensive tension, resistances in lower abdomen bilaterally, active intestinal sounds, anus reddened perianally with traces of scratching. Rectal examination: painful, ampulla wide and filled with hardened stool, barely possible to insert finger, good sphincter tonus; remaining physical examination is normal.

56

How do you explain the alternation between stool retention and diarrhea? What is the cause of the boy's soiled underpants?

57

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What is your suspected diagnosis? What are the general underlying causes of these symptoms?

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What is your next diagnostic step?

The detailed diagnostic workup did not find a cause for the constipation.

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What is your next treatment step?

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Answers and Comments Page 192

Case

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IEm Two·year-old boy with a high fever. rash, and swollen Jotnts A pediatrician refers a 2·year-old boy to the children's hospital. For 10 days he has had a high fever (about

CRP 27 mg/dl (270 mg/L), and sed rate 120 mm In the first hour.

39•q, lack of appetite, and a slightly transient skin rash with coarse spots (see Fig.). Since the day before, the little boy has not wanted to walk; the parents observed swelling in the left ankle. Similar symptoms, except for the joint swelling, occurred 3 months ago as well, which disappeared within a week on treatment with an anti· pyretic {ibuprofen). At that time, a suspected diagnosis of fifdl disease was established. The physical examination of the boy, who seemed to be very sick, reveals not only the maculopapulous rash already described and a hot, palnful swelling In the left ankle, but also a generalized lymphadenop· athy and hepatomegaly. A blood study results In the following findings: Hb 9.6 g/dl, leukocytes 15,300/ pl {differential: neutrophils 68%, banded neutrophils 11 %, segmented neutrophils 13%, lymphocytes 8%), thrombocytes 635,000/µL, MCV 62 fl. MCH 20 pg,

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What is your diagnosis? What differential diagnoses are you considering?

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What further tests would you consider usetu11

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How Is the disease that you are suspecUng generally treated'l

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Answers and Comments Page 194

IEm Four-month-old screaming infant with inguinal swelling A 4-month-old boy is brought into the emergency department by his parents at night because for the past 3 hours, he has been crying almost without interruption and cannot be soothed.

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The screaming child has a right inguinal swelling and the rest of the physical examination reveals no pathological findings.

Case

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Name and justify your suspected diagnosis. What differential diagnoses must you take into account in case of an inguinal swelling?

59

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There are two forms of this disease. List differences. What form is the infant most likely to have?

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What do you do next?

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List complications of this disease.

~ Answers and Comments Page 196

Case

59

IB Nineteen-month-old girl with bloody diarrhea, hematomas. and anuria An emergency doctor br1ngs a seve11!ly Ill, apathetic, 19-month-old llttle girt to tile pedlatrfc emergency department. The pa11!nt:s lnfonn that the llttle glrl has been suffering for 1 week from diarrhea and vomiting and has been passing bloody stools since tile previous day. During the weekthat she has been ill, the girt increasingly refused all food and fluid and is no longer excreting urine. Examination reveals the following findings: apathetic

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llttle glrl with sallow, pale, lcter1c skin, lndlvldual hematomas and petechlal skin bleeding on the trunk, perslstl!nt skin folds, circles around the eyes, protruding abdomen, lively peristalsis, liver and spleen not enlarged, no palpable resistances, heart 2/6 systolic murmur with maximum aver Erb's point, lung sounds normal, no meningismus, temperature 36.S"C, blood pressure 90/50 mmHg, and pulse 120/min.

What diagnostic measures do you consider useful to Initiate nextl What are the grounds for this?

I The laboratory test had the following results, among others: leukocytes 12,300/µL, Hb 8.5 g/dL. MCV 86 fl, MCH 30 pg, thrombocytes 78,000/µL, retlculocytes 16%.., Quick 79%, PTT 20s, LOH 480 U/L, potassium 5.9 mmol/L. total blllrubln 5.3 mg/di.., c11!atlnlne 2.5 mg/di.., urea 22 mg/dl; blood smear (see Fig.).

Blood.smear

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Interpret the laboratory values, What is your diagnosis?

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Explain the pathogenesis of the disease.

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How do you treat the girt?

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!IB Newborn with persistent c:yanosls A gynecologist calls a pe/ the changes?

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What other studies do you order to mnfinn this dl;:ignosls?

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The boy's mother is experting her second child. How great is the possibility that this child is also sick?

I _. Answers and Comments Page 205

Case

62

63

Case

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IEm Fourteen-year-old gir1 who collapsed on a school trip An emergency doctor was called to a fruit juice-pressing house where a 14-year-old schoolgirl had collapsed on a class trip. When he arrived, the girl was sleeping deeply and reacted inadequately when she was addressed or touched (pinching, cheek slap, tweaking). There was a great deal of excitement and no one could give any information as to what, precisely, had happened. The doctor started an infusion of Ringer solution and

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brought the patient by ambulance to the emergency department at a hospital for children and adolescents. During the transport, the girl woke up. Later on, she could not remember anything about this event. She reacts appropriately, and the vital signs, such as pulse, respiration, saturation, and blood pressure, are normal, and at 120 mg/dl, the blood sugar value is nonnal.

The emergency physician says: "That was certainly a seizure." What possible causes do you consider?

64

In the meantime, the classroom teacher and the patient's best friend arrive. The friend tells you that the girl cried out and then tel Idown. Then she got completely stiff and for a short time, twitched with her arms and legs. Her face was completely blue. Everything was terTible. She kept calling her friend by name and throwing cold water in her face, but the girl didn't wake up.

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What is the most likely seizure type here? What do you look for in the physical examination?

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What further measures do you suggest?

-+ Answers and Comments Page 208

ID Three·yeal"'old boy with deteriorating general condition and gastroenteritis A 3·year-old boy was admitted 2 days ago with a sud· den high fever (up to 40"C). colic-like abdominal pain, and bloody diarrhea. Up to now, he had been treated symptomatically, ttiat is, ttie fever was lowered with paracetamol syrup; he was given a low fat diet and oral electrolyte solution as well as an accompanying infusion ttierapy. in order to cc mp ens ate for the ongoing loss of fluid through diarrhea. His condition has become mark· edly worse than it was a few hours earlier. The boy is very restless. There Is marked cyanosls of the llps. and the skin Is blotchy over the whole body; the caplllary fill· Ing time ls extended (4 seconds}. The breathing Is rapid. A glance atthe child's fever curve will give a better pie· ture (see Fig.).

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What information do you obtain from the fever auve? Wilti what suspedl?d diagnosis was the boy probably admitted?

Blood ls drawn for analysis. In the meantime, the emergency laboratory provides the patholog!cal findfngs (see Fig.).

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Ref.J 1nerapeutic Unit R