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2015(c)SGU
FEVER
A 5 week old male is seen in the ED with a 2 day history of decreased PO intake and
increased fussiness. The baby was born at term via NVSD without complications and
had been well until onset of present symptoms. There is a two year old sibling at home
with a URI. Physical exam reveals a rectal temperature of 103* F without obvious
localization and irritability.
2. Define sepsis.
4. What other elements of the physical exam are important to assess in this infant?
Why?
The CBC reveals WBC 26,000 with 72% polys, 14% bands and 14% lymphs.
6. Is this a normal CBC and differential for this infant? _____Yes _____No
If no, what would be a normal WBC/ diff for this infant?
JMN ! 2015(c)SGU
8. What antimicrobial regimen would you initiate empirically? Explain your choice.
9. For each set of CSF results, indicate the most likely diagnosis using the choices
below.
4 0-100 2 65 60 negative
Bacterial Meningitis
Early Viral Meningitis! ! ! Normal CSF
HSV Meningoencephalitis! ! ! Tuberculous Meningitis
HEMATURIA / PROTEINURIA
A 7 year old male presents with a 2 day history of headache and a 10 minute
generalized tonic clonic seizure. Mom reports his urine has looked darker today - like
coca-cola. The nurse informs you his blood pressure is 150/90. You note a crusted
lesion on his chin and mild pitting edema of his lower extremities.
2. What would your initial diagnostic evaluation include? Justify each test.
A 5 year old girl with a 4 day history of URI symptoms presents with diffuse abdominal
pain, bilateral ankle swelling and a palpable purpuric rash on her buttocks and lower
extremities. Urinalysis reveals numerous RBCs; on exam of the sediment you note
RBC casts.
A 15 year old previously healthy African-American male presents with sudden onset of
bright red urine with mild flank pain. There is no history of trauma, but he was at
basketball practice for several hours earlier today.
A 2 year old male is referred to your practice. The child has a history of eyelid swelling
for a week, especially prominent on awakening in the morning. The patient was
diagnosed with allergic conjunctivitis at an Urgi-Center last week and prescribed eye
drops but Mom reports she now notices the patient"s hands and feet are also puffy and
his pants are tight around the waist. On dipstick his urine has 4+ protein. The sediment
has many RBCs but no RBC casts.
11. What additional diagnostic studies would you request to confirm your diagnosis?
Justify each.
12. If your clinical suspicion is confirmed, what would your management plan include?
JMN ! 2015(c)SGU
ANEMIA
You are seeing a 15 month old male for a health maintenance visit. The baby has been
feeding well, taking about 40 ounces of whole cow"s milk daily since 8 months of age.
The development is appropriate for age. Physical examination reveals conjunctival
pallor and a grade II/VI short systolic murmur at the left midsternal border.
CBC reveals Hgb 8.2, Hct 25, MCV 60, retic 1%. RDW 18
Hemoglobin
MCV
Reticulocyte count
RDW
4. What other diagnostic tests, if any, would you request to confirm your diagnosis?
Explain your reasoning.
! a)
! b)
! ! !
! ! ! for a 16 year old male? ________g/dl
You are evaluating a 5 month old infant in the ED with a 2 day history of profuse watery
diarrhea and occasional vomiting. On physical exam the weight is 6kg, HR 160, BP
100/65. You note poor skin turgor and capillary refill of 3 seconds. He is behind in his
immunizations.
The initial BMP reveals Na 133, K 3.6, Cl 110, HCO3 9, BUN 29, Creatinine 0.5
5. Check the appropriate box for each of this infant's lab values. Explain the
pathophysiologic basis of abnormal values.
Na+
K+
Cl-
HCO3-
BUN
Creatinine
BUN/Creatinine
Anion Gap
6. What is this infant's daily maintenance fluid requirement? How would you administer
this?
7. What additional component of fluid management needs attention in this infant? How
would you accomplish this?
8. Would your management change if the initial serum sodium was 165mEq/L? If yes,
how?
9. Would your management change if the initial serum sodium was 119mEq/L? If yes,
how?
MURMURS
A mom brings her 3 week old daughter to your office with the complaint that the baby
has not been feeding well for the last week. The baby was born at term without
complications and was discharged after 48 hours in the nursery. Birth weight was 7 lbs
and physical exam was reportedly normal. For the first two weeks the baby had been
taking 3 ounces of formula every three hours; each feeding lasted 10-15 minutes. This
past week, the baby is only able to take one ounce of formula over 10 minutes and then
becomes fussy and short of breath with beads of sweat on her forehead. She settles
down and resumes feeding after resting for 10-15 minutes but develops respiratory
distress and diaphoresis each time she feeds.
Physical exam reveals temp 98.6*F, HR180, RR 60, BP 90/60 room air O2 sat 98%,
weight 3.2 kg. A grade IV/VI harsh holosystolic murmur is audible at the lower left
sternal border and the liver edge is blunted and palpable 4cm below the right costal
margin.
1. List 3 diagnoses this infant is presenting with. Enter the positive/ negative findings
from the history and physical exam that support each diagnosis.
DIAGNOSIS #1:
HISTORY FINDINGS PHYSICAL EXAM FINDINGS
DIAGNOSIS #2:
HISTORY FINDINGS PHYSICAL EXAM FINDINGS
DIAGNOSIS #3:
HISTORY FINDINGS PHYSICAL EXAM FINDINGS
JMN ! 2015(c)SGU
2. Provide a pathophysiologic explanation for why the murmur was not audible on
physical exam in the nursery.
4. How much weight should this infant have gained since birth?
You are evaluating an asymptomatic 6 year old girl who wants to play soccer. On
physical exam you note a II/VI systolic ejection murmur at the upper left sternal border
with physiologic splitting of S2.
WHEEZING
You are evaluating a 3 month old infant who presents to the ED on New Year's Day with
a history of rhinorrhea and cough for 3 days with rapid, labored breathing for one day.
PMH is significant for eczema. The patient's 4 year old sib has asthma and had URI
symptoms a week ago. Vital signs: temp 103, RR 70, HR 160, room air Sat 92%. On
exam you note nasal flaring, subcostal and intercostal retractions, decreased aeration
and bilateral wheezing.
1. What is the most likely diagnosis for this infant's respiratory distress/
5. What is the pathophysiologic explanation for the nasal flaring and retractions seen on
physical exam?
A blood gas reveals pH 7.32, pCO2 38, pO2 90, HCO3 15.
7. Interpret this blood gas.
pH
pCO2
pO2
HCO3
9. List 5 pathophysiologic causes of hypoxemia. Which likely explains this infant's pO2?
11. What would your management plan for this infant include?
Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
JMN ! 2015(c)SGU
LIMP
An 18 month old male is admitted with a one day history of fever and limp. He has had
URI symptoms for 3 days. Mom reports she has had to carry him around today as he
refuses to stand or walk. The nurse tells you the patient's temperature is 103.6*F
axillary. On exam he appears acutely ill, lying in the crib with his right leg flexed,
abducted and externally rotated at the hip. There is no obvious erythema of the skin but
you note warmth and tenderness on palpation of the right inguinal area. Passive range
of motion of the hip is very limited and the patient refuses to bear weight on the right leg
when you attempt to stand him up.
1. What is the most like;y diagnosis for this patient? Explain your choice.
The CBC reveals WBX 34.6 with 85% polys, 10% bands and 5% lymphs. Hemoglobin is
10.2 g/dl, MCV 75, Platelets 650,000.
Your senior resident consults Orthopedics. 10cc of purulent material is aspirated from
the patient's right hip joint.
4. Describe the anatomic factors which make septic arthritis of the hip a medical/
surgical emergency in this age group.
7. What else would be included in your diagnostic and therapeutic plan for this patient?
A 4 year old female presents with a complaint of right knee pain for 3 weeks. She had
fallen off her new bike just prior to onset of symptoms. There is no associated URI but
mom reports tactile fever for the last week. On physical exam you note an ill-appearing
child with temperature 101.4*F, tenderness over the right proximal femur and full range
of motion at the hip and knee. Patient ambulates with a mild antalgic gait.
The CBC reveals WBC 34.6 (20%polys, 2%bands, 66%lymphs and 12% atypical
lymphs), hemoglobin 8.8g/dl, MCV 78, Platelets 50,000.
10. What should be the next step in evaluation and management of this patient?
A 6 year old boy complains of left knee pain for 3 months. He was a 32 week premie
but has since been thriving with normal development. He is afebrile with limited range
of motion of the left hip, a normal knee exam and an obvious limp. CBC and Xrays are
normal.
A 16 year old obese male complains of acute right hip pain after playing baseball. He is
afebrile with limited range of motion of the right hip and inability to ambulate. CBC is
normal.