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Pediatrics (week 10): Cases

final will be case based and we prob will see at least one of these cases: know leukemia

5yo male presents with 6d fever and URI sx
strep pharyngitis dxd c rapid strep test, concurrent L OM
Rx: amoxicillin
3 days later complaining of leg pain, ankle swelling, rash on buttocks and ankles
Henoch Schoenlein purpura, buttocks and ankles
referred to ER with development of gross hematuria and crampy abd pain with vomiting
ddx: scarlet fever, post strep glomerulonephritis, drug rxn, Stevens Johnson, appdx
dx: henoch schoenlein - immuno mediated vasculitis affecting small vessels of skin, GIk oints, kidneys
sx:abd cramp, intussuception risk-->necrosis, joint pain & swelling, GN of kidneys
Labs: CBC, ESR PT, PTT, C3, ANA, urinalysis, stool guiaiac, abd US
PE: normal vitals, o2 sat 96%, heart and lung normmal, skin rash
LABS: WBC's up, left shift, high plts, electrolytes off dt vomiting, bun/creat Ok, 2+ prot and rbcs in urine
stool guaiac normal
Tx: admitted for dehydration
Risk: intussuception
F/u: weekly labs, 1/3 of kids will have recurrence within 6 wks

next case persistent pharyngitis, hematuria, not getting better
her tx: cod liver oil, kidney stim liquescence, probx, similase, constit homeop, chiro, nephrologist referral

11yo male
presents with fatigue, excessive sleep (20hrs/day, falling asleep at dinner table) fever 1d of 100-101,
decr appetite, rash on ankles x1d no itch, pain, spread
has had fevers & somnolescence with growth spurts before
to mother falling asleep at table wasn't that unusual but rash was what brought her in
ankle rash: petechial
denies other sx: h/a, eent, d/v/c, skin, pain
vitals normal
+ ant cx LAD, abd: splenomeg 5cm below costal margin, nt, hepatomegaly 3cm below costal margin, mildly ttp
Labs: US, CBC, CMP12, monospot?, spoke with on call ped hem onc at OHSU for other workup?
Worry: leukemia
Tx: went home until labs came in, CMP came in first, CBC is usu faster
CMP was normal except AST and ALT 85 and 68 respectively
CBC abn: WBCs 195K wow, 93% blasts, RDW high, RBC count not that bad, modest anemia, plts low but not critical
Dx: is bone marrow bx
Tx: off to providence, docs who saw CBC were setting up bed, wanted him in 2hrs because cell count is going up exponentially right now, wanted to start chemo same or next day, WBC count in a few hours was 395K
Dx: ALL, mc childhood leuk
Tx: was on bactrim weekly during chemo to prevent pneumocystis infx, kid got ARDS anyway but lived
kept out of school to avoid exposures
prog: good, recovery rates high, do tx and get through it

19yo female presenting in feb
swollen tongue
hx of jan strep infx, norwalk virus in late jan., a grandmother died of the norwalk
bit tongue a week ago, started swelling 2d ago, now achy under jaw, skin looking pale, fatigue
working fulltime NS, exercising daily elliptical trainer, social life
pale look hidden by makeup, rosy cheeks were fake
vitals: no fever
PE: edema on lat 1/2 of ctongue, macerated tissue and hiwte exudate, neg cx AD, conjx and nail beds pale
tx: augmentin po
labs: cbc, cmp, ferritin
ast alt fine, ferritin 232, all fine except
cbc: MCV is 112, blasts 81, wbcs 52.6, rbcs 1.75 Low, hgb 6.7 LOW, hct 19.6, plts 46
dx: leukemia again, severe anemia
risk: infx-->sepsis, hypoxia, bleeds
hospital: wanted her there in 1 hr to add iv abx and start chemo
phone call: get to ER in hour dt sig risk of sepsis or bleeding, mom says she's tired, can we go later
DX: AML, tx is different from ALL
Tx: bone marrow transplant from sibling
Warning: no vaccines

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