garcia mj, garzon mmp, gaspar iv, gatchalian c, gaw mg, geraldoy yr pediatrics cardiology conference
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GARCIA MJ, GARZON MMP, GASPAR IV, GATCHALIAN C, GAW MG, GERALDOY YR
Pediatrics Cardiology Conference
Patient
JMS8 years old/FJune 19, 2002456 Lambakin, Marilao, BulacanRoman CatholicFilipinoInformant : MotherReliability : Good
Chief Complaint
unsteady gait
History of Present Illness
4 wks PTA (+)decreased appetite (+) decreased activity level (+)episodes of joint mild pains
relieved by rest
3 wks PTA (+) undocumented fever with cough, colds and difficulty of
breathing paracetamol 250 mg tab ½ tab every 4 hours, salbutamol + carbocisteine (Solmux) 2mg/500mg/5ml 5mL twice a day, Vitamin C 5 mL once daily nebulized with 1 salbutamol nebule symptoms have resolved
History of Present Illness
2 wks PTA (+)decreased appetite, decreased activity (+)decreased interaction with family relatives At school:
patient does not maintain good eye contact kept on moving a lot and cannot stay still during recitation
1 wk PTA (+)frequently drops and loses her pen in class (+)hard time gripping her utensils while eating
3 days PTA wobbly gait, with weak voice and slurred speech
History of Present Illness
1 day PTA increased movement while sleeping persistence of symptoms
St. Michael Hospital Referred to a private neurology physician, they were
referred to Neurology Pediatrics patient was brought to Jose Reyes Hospital
A>>Rheumatic Heart Disease Lack of bed, hence patient was brought to our institution.
Review of Systems
General: (+) weight loss (-) delay in growthCutaneous: (-) rashes, (-) active dermatoses,
(-) hair lossRespiratory: (-) chest pain, (-) cough, (-)
difficulty of breathingCardiovascular: (-) orthopnea, (-) cyanosis, (-)
easy fatigabilityGastrointestinal: (-)vomiting, (-) jaundice, (-)
diarrea (-) constipation
Review of Systems
Genito-urinary: (-) hematuria, (-) change in urine frequency (-) dysuria
Endocrine: (-) heat/cold intoleranceMusculoskeletal: (-) gross deformities, (-)
edemaHematopoietic: (+) pallor, (+) easy
bruisability, (-) epistaxisNervous/Behaviour: (-) seizures (-) sleep
problems, (-) convulsions (-) paralysis
24 hour food recallMeal Food CHO CHON FATS KCAL
Breakfast
1 pc Hotdog - 8 10 122
1 cup Rice 46 4 - 200
Lunch
½ cup Rice 23 2 - 100
½ pc Hotdog - 4 5 61
1 pack Pancit canton 23 2 - 100
Dinner
1 cup Rice 46 4 - 200
1 pc Chicken fillet - 16 4 100
ACI 883
RENI 1600
% 55.19%
Ideal Body Weight: Age in year x 2 + 8 = 24 kg
Past Medical History Asthma – 7 years old – given salbutamol nebulization when needed UTI – 4 years old – was given unrecalled antibiotics for 1 week- consult
done at OPD Immunization History Mother claims that patient has completed immunizations until 9 months
in a local health center. Developmental History *at par with age Can do complex pattern movements Can tell time Reads for pleasure Can do concrete operations Accepts rules
Family History
Member Age Relation Educational Attainment
Occupation Health
Jose 39 Father Engineering Cell site caretaker Healthy
Rosalinda 38 Mother High school graduate
Textile factory worker Healthy
Jasmine 1 Sister - - healthy
(+) goiter – grandmother, 1 uncle, 2 aunts(+) cancer – grandmother: brain cancer “lymphoma”(-) HPN, stroke, DM, asthma, allergy, kidney disease, blood dyscrasia, TB, Seizures Family Profile
Personal, Socioeconomic and Environmental History
The patient lives with her parents in a well lit well ventilated house made of concrete.
Purified water is used for drinking and is not boiled.
Garbage is segregated and collected everyday by municipal trucks.
There are no pets, no factories nearby. Average monthly income of P15,000.
Physical Examination on Admission
Alert, awake, not in cardiorespiratory distress, well hydrated, well nourished
VS: BP: 110/70 HR 99 bpm RR 16/min T 36.5C
Wt : 31.5 kg (z = above 1) Ht : 137 cm (z = above 1)
BMI : 16.78 (z = above 0) Warm, moist skin, no active dermatosesEENT: Pink palpebral conjunctivae and anicteric
sclera, no tragal tenderness, no aural discharge, non-hyperemic external auditory canal, midline nasal septum, turbinates not congested, no nasal discharge, moist buccal mucosa, (+) hyperemic posterior pharyngeal wall, tonsils not enlarged
Physical Examination on Admission
Supple neck, (+) palpable cervical lymph nodes
Symmetrical chest expansion, no retractions, clear breath sounds
Adynamic precordium, apex beat at 5th LICS MCL, no murmurs
Flat abdomen, soft, non-tender, normoactive bowel sounds, no masses palpated
No cyanosis, no edema, pulses full and equal on all extremities
Neurological Examination
Conscious, coherent, oriented to time, place and person
can smell, pupils 2-3 mm isocoric ERTL, (+) direct and consensual light reflex, no visual field cuts, (+) ROR, EOMs full and equal, sensory deficit on R side of face, can clench teeth, can raise eyebrows, can close eyes tightly, can smile, no hearing deficit, no lateralization on Weber’s, AC > BC, uvula midline, can shrug shoulders equally, can turn head from side to side against resistance, tongue midline on protrusion,
Neurologic Examination
Good muscle bulk, no fasciculation, no atrophy
No spasticity, no rigidityMMT 5/5 on all extremitiesSensory deficit on L upper & lower
extremitiesCan do FTNT, APST, with involuntary
movements of extremitiesDTRs ++ on all extremities (+) Babinski, (-) nuchal rigidity, (-) ankle
clonus
Subjective Objective
9yr old/female Unsteady gait (+)decreased appetite, (+) decreased activity level (+)episodes of joint mild pains (+) undocumented fever with
cough, colds and difficulty of breathing
(+) poor eye contact, interaction Frequently drops her pen and
hard time gripping her utensils wobbly gait, with weak voice and
slurred speech increased movement while
sleeping
(+) hyperemic posterior pharyngeal wall
(+) palpable cervical lymph nodes
sensory deficit on R side of face
Sensory deficit on L upper & lower extremities
Can do FTNT, APST, with involuntary movements of extremities
(+) Babinski
Salient Features
Course in the Wards
1st Hospital Day
Patient was hydrated with Plain NSS 1L at 18-19 drops/min
Normal Range Result
Hgb 115-155 113
RBC 4.33
Hct 0.35-0.45 0.35
Platelet 150-450 346
WBC 4.5-13.5 8.30
Neutrophils 0.54-0.62 0.47
Segmenters
0.54-0.62 0.47
Lymphocytes
0.25-0.33 0.42
Eosinophils 0.01-0.03 0.11
Blood chemistry:
Cranial MRI with contrast : normal contrast-enhanced cranial MRI
Normal Range Result
Creatinine 0.47 0.4-0.6
Sodium 138 138-146
Potassium 3.90 3.5-5
Total Calcium 9.32 8.8-10.8
Salbutamol nebulization given 15 minutes prior to scheduled MRI.
Patient was also referred to the service of Pediatric Cardiology and Pediatric Neurology. (video)
2nd Hospital Day
On repeat physical exam, grade 2-3/6 holosystolic murmur at the left parasternal area was appreciated by Pediatric Cardiology
Chest x-ray was done
cardiomegaly, pulmonary congestion
2nd Hospital Day
ASO titer high at 598.01 (N.V. 0-240 IU/mL).
12-lead ECG sinus tachycardia, normal axis within normal limits
3rd Hospital Day
Patient complained of oral sores in the inner lower lip Solcoseryl paste was given
Pedia Neuro started Valproic acid 250mg/5ml 5mL q12h
4th Hospital Day
Patient was re-examined by Pediatric Cardiology
2D-Echocardiography: Minimal posterior pericardial effusion 1-2 aortic regurgitation 2-3 mitral regurgitation Normal coronary arteries Dilated Left ventricle Good contractility indices No structural defects Apparent prolapse of the anterior leaflet which appear to
be slightly thickened and deformed
Benzathine Penicillin G 1,200,000 IU/IM injection every 4 weeks
Digoxin 0.25 mg/tab ½ tab BID
8th Hospital Day
Valproic Acid was discontinued
Prednisone 20mg/tab was started at 1 tablet by mouth TID after meals
Last Hospital Day
Final diagnosis: Rheumatic Heart Disease Take home medications:
Prednisone 20mg/tab at 1 tab three times a day after meals
Ranitidine 150mg/tab 1 tab twice a day Digoxin 0.25mg/tab at ½ tab twice a day Benzathine penicillin G 1.2 M IU/IM every 4 weeks
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