GRAY CASES, CLINICAL CASES AND DATA INTERPETATION

By Dr: ATTALLAH AL MUTAIRYConsultant pediatric intensivistHead PICU19/05/1436

[1] – A 28 weeks gestation 15 day-old baby girl, who develops metabolic acidosis over the past 18 hours has worsening oxygenation and ventilation On examination, the HR; 195 bpm (persistent) bpm and the blood pressure [BP] is 40/25 with a mean arterial blood pressure [MABP] of 30 mm Hg. She is pale with a capillary refill time [CRT] of 6 seconds. Because of bilious gastric aspirate and abdominal distension, a supine abdominal X-ray was done. The ABGs were as the following; pH; 6.9, PaCO2; 15 mm Hg, PaO2; 60 mm, HCO3; 4 mmol/L and Hg. The supine abdominal X-ray is shown below;

(A - ) What is the radiological findingshown?

(B – ) What is the most likely diagnosis.(C) – What is the most immediate action (therapy) you will provide?

[2 – ]A 35 day-day-old baby boy who was delivered un-eventually at term with a birth weight [BW] of 3200 grams starts to have projectile emesis since the age of 12 days. There is history of small infrequent stool but no abdominal distension. On physical examination, he was emaciated with severe failure to thrive [FFT] with a weight of 3100 grams and he was moderately dehydrated with mild jaundice. Despite dehydration, his arterial blood gases [ABGs], reveal the following; pH; 7.52 , PaCO2; 49 mm Hg, PaO2; 102 mm Hg, HCO3; 40 mmol/L, base excess + 14 mmol/L. His renal function tests [RFTs] and serum electrolytes reveal the following; BUN; 6 mmol/L, serum creatinine; 13 micromol/L, Na; 130

mmol/L, K; 3.1 mmol/L and Cl of 82 mmol/L .

(A – ) What do the ABGs and serum electrolytesshow?

(B – ) What is the explanation of low creatinine despite dehydration?

(C – ) What is the most likely diagnosis?(D – ) What is the most useful diagnostic tools to

[ 2 confirm your diagnosis enumerate tools?)E (– List 2 acute and definite therapeutic modality for treatment.

[3] – A 36 month-day-old boy is failing to thrive and has metabolic acidosis. His renal function test [RFTs], serum electrolytes, total protein and albumin were as the following; BUN; 2.3 mmol/L, serum creatinine; 37 micromol/L, Na; 135 mmol/L, Cl; 118 mmol/L, K; 3.2 mmol/L and phosphorus [PO4]; 0.34 mmol/L, total protein 50 g/L and serum albumin of 36 g/L.

(1 – )Calcute anion anion gap [AG].(2 – )What is the type of metabolic acidosis in this patient

and on which bases.?(3 – )What is the most likely diagnosis?

[4] – A 3 month-old Afghani male infant was born at term with average BW. Pregnancy, delivery and post-natal history were unremarkable. He presents with 12 hours of URTI symptoms and signs which were followed in 8 hours by severe irritability, fussiness, excessive inconsolable crying. After few hours, he becomes increasingly lethargic and refuses feeds. He starts to have RD. On examination, he looks acutely ill, in moderately severe RD with flaring of nasal ala, subcostal retractions and grunting. His vital signs were; HR; too fast to count, RR; 85 bpm, T; 37 C and BP of 50/28 (MABP of 35 mm Hg). The CRT was 5 seconds. His SpO2 in 4 L/m oxygen by NC was 88 %. His color was gray/ashen, pale and cyanotic with cold extremities. Chest examination showed wide spread crepitation. CVS reveals S1 + S2 + S3. Liver is 5 cm BCM and tender. The other systemic examination were un-contributory. From the cardiac monitor in lead II shows the following tracing.

(A) - What dose the tracing show?.(B) - What is your most likely diagnosis?(C) - From the other physical examination finding, what is

the other serious diagnosis?(D) - How to treat this infant?

[5] – A 5 month-old Saudi male infant was born at term with lethargy, effortless vomiting, horse voice and enlarging HC. On examination, looks unwell. There is hyper-reflexia and increased tone bilaterally. The CT brain is shown.

(A) - What are the radiological findings.(B) - What is your diagnosis?.(C) What are the posssiple causes.

[6] – A 6 months presented with excessive irritabilty, fever, poor feeding. At the time examination, she had episodes ot hypertonia, up-rolloing of eyes and excessive salivation for 5 minutes. The AF is tense in sitting position. Other systemic examination was unrevealing. CBC showed; WBCs; 35000/mm3 (90 % polymorhs, Hb; 7 g/dl and platelets of 50000/mm3.

(A)- Interpret CBC.(B) - What is the most single important diagnostic test.

[7] – An 18/12 month-old Saudi male infant was admitted with severe chest infection. History revealed that he had recurrent episodes of chest infection and cough, inadequate weight gain despite adequate nutritional intake and excellent appetite. The mother noticed that his stool is sticky and difficult to flush. Chest X-ray showed wide spread honey combing appearance. Laboratory studies revealed; Na; 129 mmol/L, Cl; 85 mmol/L, K; 3 mmol/L, pH; 7.52mmol/L, PaCO2; 48 mm Hg and HCO3; 37 mmol/L.

 (A – )What does the ABGs show?

(B – )What are the abnormalities shown in serum electrolytes .?

(C – )What is the most likely diagnosis?

(D – )What is the confirmatory laboratory test ]enumerate 2 tests[.?

[8] – An 8 year-old female infant presented with inability to walk which progressed to flaccid paralysis of her lower limbs. Within 6 hours, she developed acute respiratory failure [ARF] which mandated endotracheal intubation [ETI] and mechanical ventilation. The CBC and differential count parameters were; WBCs; 8450/mm3, Hb; 11 g/dl and platelets count of 425000/mm3. The serum electrolytes and renal function test [RFTs] were as the following; BUN; 2.3 mmol/L, creatinine; 38 micromol/L, Na; 137 mmol/L, K mmol/L, 3.8 mmol/L, Cl of 99 mmol/L, blood glucose [BG] level of 4.2 mmol/L. The liver enzymes were as the following; AST; 500 U/L and ALT was 750 U/L. She had lumbar puncture which was done aseptically. The CSF findings were as the following; WBCs; 2, RBCs; 5, glucose 3 mmol/L and protein of 85 mg/dl.

(A – )What are the abnormality)s( shown on the laboratory tests.?

(B – )What is the most common single physical finding is expected in the neurological

examination?.

(C – )Mention another investigative tool which

support your diagnosis?.

[8[9 –[Hessa is an 18 month-old Saudi female child who was referred from the out-patient clinic because of pallor and increased curvature of her legs.Hessah was born uneventfully at term and has been healthy. She was on exclusive breast milk for the first 16 months which was replaced by Nido milk since then. Weaning is suboptimal as she has poor appetite. Mother noticed that she is less active than her other brothers. She is pale with large head and bow legs and i8s slightly hypotonic. There are no other historical or physical examination point of not. The CBC revealed the following parameters; WBCs count; 1150/mm3, RBCs count; 2 million/mm, Hb; 5.5 g/dl; MCV; 70 fl, MCHC; 26 %, RDW; 18 and platelets count of 77000/mm. The serum electrolytes were as the following; Na; 140 mmol/L, K; 3.9 Cl; 101 Ca; 2.2 Mg; 1.2,PO4 2 mmol/L, uric acid 250 U/L. Her

X-ray of the right wrist is shown below .

(A – ) Describe the radiological findingsshown.?

(B = ) What problems she has and why?(C – ) 2 Enumerate other blood tests which

support your diagnosis.(D – ) ) 2 How to treat Hessah mention

, pharmacological agents their dose and(duration?

[10 – [Noor is a 3 year-old Saudi female child who has been healthy till 1 and half month back when she started to have fever on daily basis [as high as 39 C and occur 2 – 3 times per day] for 2 months duration, morning pain in both hands, ankle and knees. She had history of skin rash for 4 weeks duration. There was no history of travel or contact with sick patients. On examination, well built child whose has no apparent distress. She has mild pallor of both conjunctiva and lips, but there was no jaundice. Spleen was tipped. There was a maculopaular rash over trunk and swelling over hand fingers and wrest. Other examination was unremarkable. Laboratory tests were as the following; WBCs; 18000/mm3, Hb; 7.8 mg/dl, Platelets; 780,000/mm3, CRP; 12 mg/dl, ESR; 120 ml/h, BUN; 3.2 mmol/L, creatinin; 32 micromol/L, Na; 138 mmol/L, K; 3.9 mmol/L, C108 mmol/L l, Ca; 2.3 mmol/ml

and serum albumin of 32 g/dl .

(A – ) What is your possible diagnosis.(B – ) What is the other diagnostic work up

which may be of help?(C – ) 2 List therapeutic modalities.

[11] – A 7 month-old male infant presented with 3 days history of fever and significant lethargy. No focus of infection was found. Upon physical examination, he developed right sided convulsive tonic clonic seizure which lasted for 10 minute before being aborted by rectal midazolam. The laboratory tests were as the following; WBCs; 9000/mm3, Hb; 10.8 mg/dl, Platelets; 365,000/mm3, CRP; 2 mg/dl, ESR; 15 ml/h, BUN; 3.2 mmol/L, creatinine; 32 micromol/L, Na; 138 mmol/L, K; 3.9 mmol/L, C108 mmol/L l, Ca; 2.3 mmol/ml and serum albumin of 32 g/dl. CT brain revealed hypodense area in the left temporal lobe. The CSF analysis revealed; WBCs; 75, RBCs; 650, protein 48 mg/dl and glucose of 50 mg/dl.

(A – ) What is the most likely diagnosis.(B – ) What is the other diagnostic test you

would perform?(C – ) What is the most urgent single

therapeutic modality you shouldadminister.

[12]- A 3 month-old baby boy who was admitted to PICU as a case of acute viral bronchitis with moderately severe respiratory distress [RD]. There were no apnea. He did not require any method of positive pressure ventilation [PPV]. On day 5 of admission (at 12 noon), he developed a sudden episode of RD, de-saturation, cyanosis, pallor and tachycardia. He was found to be hypotensive. Chest examination showed decreased air a entry over the right lung hemi-thorax. Urgent AP X-ray film of the chest was ordered. The AP chest X-ray film is shown.

(A)- Describe the abnormalities shown on the AP chest X-ray film(B)- What is the diagnosis?(C)- What is the causes of tachycardia and hypotension in such a case?(D)- What are 2 bed-side and immediate diagnostic tools which may be helpful?(E)- What is your immediate therapeutic intervention?.(F)- What is your definite therapeutic intervention after stabIlizing the baby.

[13]- A 7 year-old child is known to have a non invasively repaired atrial septal defect [ASD] in the catheterization lab [non surgical] presented with one week history of lethargy, headache, dizziness, vomiting and inability to stand or walk. On physical examination, he was found to have a very slow heart rate [HR]. The HR was 50 beats per minute [bpm] and the pulses were of good volume. Lead II ECG tracing is shown.

(1) - Describe the findings in the ECG.(2) - What is your diagnosis?(3) - What is the emergency therapeutic modality for this

child?(4) - What is the definite intervention

[14] – A 5 month-old Saudi male infant was born at term with average BW. The pregnancy, delivery and post-natal history were unremarkable. He presented with generalized tonic-clonic seizure with decreased LOC for 15 minutes. 2 weeks back, he had frequent abnormal jerking movements of his right hands with no decrease in the LOC. They occured 6 times per day [duration was less than few second]. There was no fever during both episodes. On physical examination, the only finding was hypo-pigmented skin lesions allover the trunk varying in size from few mm to 1.5 cm in the largest diameter. The CT brain is shown.

(A) - What is the radiological abnormalityshwon.(B) - What they are called?(C) - What is the diagnosis?(D) - What is the complication of such diagnosis?

[15]- The ananterio-posteror [AP] chest X-ray film of a 3 year-old child who developed severe bacterial pneumonia due to Steptococcus Pneumonia is shown.

(A) - What are the 2 obviously shown complications of this disease on this chest X-ray film [one in the right lung and the other in left lung]?

(16) – A 3 year-old child presented with on/off headache for 3 months, early morning vomiting for 6 weeks and weakness of the left side of the body for the last on week. On examination, unwell, conscious, dilated scalp vein over the scalp, hypertonia and increased DTRs in the right side. Babiniski reflex is up-going. CT brain without contrast is shown.

(A) – What is the radiological signs shown?.(B) - What is the radiological diagnosis?(C) - What is the DD?

THANK YOU