RN HEALS

CASE PRESENTATION

General Data
A case of Meting. 7 y.o., male, Filipino, Roman Catholic, residing at Benolho, Albuera,Leyte was check for the several times at this center last January 17,2011.

Chief Complaint
Nag-sige siya hilanat, balik-balik as verbalized by the mother.

History of Present Illness

1 day prior to check-up
     

febrile (Temp 38.5C) (+) headache (+) productive cough (+) decreased appetite & activity (-) colds, vomiting, diarrhea Paracetamol at 250mg every 4 hours

Few hours prior to check-up  fever persisted  (+) dizziness  (+) loss of appetite  consulted private physician CBC = WBC 31.30/hpf

Review of Systems
y y y y y y y y y y y y y y

General : no weight loss Skin : no rashes Head : no lightheadedness Eyes : no pain, no blurring of vision Ears : no pain, no vertigo Nose :no colds, no epistaxis Throat : (+) pain, no hoarseness Neck : no pain, no stiffness Respiratory : no dyspnea Cardiovascular : no chestpain GIT : (+) abdominal pain, no dysphagia GUT : no dysuria, no hematuria, no oliguria, no urgency/frequency Musculoskeletal : (+) body malaise, no muscle/joint pain Neurological : no seizure

Past Medical History

y Past hospitalization : Pneumonia (2007) Dengue

Fever( 2006), admitted at OSPA-FMC x 5days, tx unrecalled meds y Past illness :Fever y Past surgery : none y Accidents & Injuries : Fall y Allergies : none

Maternal/Birth History
 born to 29y.o G1P0, non smoker and

non alcoholic

mother  prenatal check up started 2mos. AOG, monthly thereafter  regular intake Multivitamins & Ferrous sulfate  no illness, bleeding, exposure to radiation, teratogen  delivered full term via spontaneous vaginal delivery, no complications observed

Feeding History
 exclusively breastfed x 6 months  shifted to formula milk consuming 6-8 bottles (4oz)/

day  supplementary feeding at 6 mos. with no particular food preference

Growth and Development

6 mos.- rolls over, can chew 9 mos.- stands with support, says Ma,Da 18 mos.- walks well, drinks from cup 2 y.o- runs well, able to remove clothes 3 y.o- can tell little stories, play with peers, toilet trained by day y 4 y.o- able to count nos. up to 10, toilet trained by day y 5 y.o- daycare student, able to draw y 6 y.o- kinder student, can write fairly well y 7 y.o- grade one student, able to add & subtract nos., participate in class activity Patient is at par with age.
y y y y y

Immunization
(all vaccines given at a local health center in Benolho,Albuera)

(+) BCG- 1 dose (+) DPT- 3 doses (+) OPV- 3 doses (+) Hep B- 3 doses (+) Measles- 1 dose

Family History
Mother- 29y.o, apparently well Father- 36 y.o, apparently well Siblings: None Heredofamilial diseases: (-) HTN, (-) DM, (-) CA Others: (-) exposure to person with PTB

Psychosocial History
 lived with parents and siblings in well-lit and

ventilated house  use purified water for drinking  grade one student, achiever in class

Physical Examination
y General Survey: awake, conscious, ambulatory, weak-

looking, fairly nourished, fairly groomed, not in distress: BP: 100/60 mmHg Wt: 20.7 Kg (p10) HR: 124 bpm (60-100) Ht: 115 cm (p10) RR: 32 cpm (14-22) Temp: 38.6C ( 37.8)

y Skin: warm, moist, good turgor, no active lesions y HEENMT: atraumatic, normocephalic, pink palpebral

conjunctivae, anicteric sclerae, no tragal tenderness, patent auditory canal, intact tympanic membrane, no alar flaring, moist lips and buccal mucosa, hyperemic enlarged grade 2 tonsils, no exudates, nonhyperemic posterior pharyngeal wall y Neck: supple, no palpable cervical lymph nodes, no nuchal rigidity

y Chest and Lungs: symmetrical chest expansion, no

retraction, equal tactile fremitus, resonant all lung fields, clear breath sounds y Heart: adynamic precordium, PMI palpable at 5th ICS L MCL, tachycardic at 124bpm regular rhythm, no murmur y Abdomen: flat, soft, no tenderness, no organomegaly, normoactive bowel sounds

y Genital: grossly male, uncircumcised y Back & Spine: no deformity, no costovertebral

tenderness y Extremities: no edema, no cyanosis, good capillary refill, full and equal pulses

Neurological Examination
y GCS: 15 y Mental / Speech status: awake, conversant, follows commands y Cranial Nerves:

I- able to smell coffee candy II- pupils 2-3mm, equally reactive to light III ,IV, VI- EOM intact V- able to chew VII- no facial asymmetry VIII- hearing intact IX, X- (+) gag reflex XI- able to raise shoulder, can turn head side to side XII- tongue at midline y Motor: 5/5 on all extremities y Sensory: no sensory deficits y Reflexes: ++ in all reflexes

Impression
Tonsilitis and UTI

Urinalysis
y color- yellow y transparency- hazy y pH 5.0 y sp gr 1.030 y sugar trace y protein trace y ketones +1 y nitrites (-)

leuc. est. (-) blood (-) RBC 5.50/uL WBC 33/hpf(0-1) Bact. 88.80/uL crystals (-) casts (-)

y ESR = 72mm/H (0-15)

y Na = 132meq/L (136-145) y K = 3.90meq/L (3.5-5.1)

Final Diagnosis

Urinary Tract Infection

Salient Features
Acute Tonsillopharyngitis
y 7y.o y throat pain y enlaged hyperemic tonsils y CBC: WBC 31.30/hpf

Urinary Tract Infection

y febrile episodes y vomiting y abdominal pain y uncircumcised y UA:

segmenters 95%

WBC 33/hpf

Acute Tonsillopharyngitis
y Streptococcal pharyngitis: AKA strep throat or strep
tonsillitis y throat infection caused by Streptococcus bacteria.

y Complications: rheumatic fever, acute

glumerolonephritis

y Causative agents:
y Viruses: adenoviruses, coronaviruses, enteroviruses,

rhinoviruses, RSV, EBV, HSV , metapneumovirus y group A -hemolytic streptococcus (GABHS)

Pathogenesis
y Viral URTI transmission y Streptococcal pharyngitis

peaks early in shool years

y Colonization of pharynx by GABHS- result either

asymptomatic carriage or acute infection

y M protein

major virulence factor of GABHS

Manifestations
y sore throat, fever, absence of cough y headache, abdominal pain & vomiting y pharynx is red, tonsils enlarged with yellow,

blood-tinged exudate y petechiae or doughnut lesions on soft palate & posterior pharynx y uvula red, stippled & swollen y anterior cervical lymph nodes enlarged & tender

Diagnosis
y Goal: to identify GABHS infection

y Diagnostics: throat culture & rapid strep test

TREATMENT
y Penicillin- narrow spectrum & few adverse effects y Oral amoxicillin y single IM dose Benzathine penicillin or

Benzathine-Procaine penicillin G combination

y Erythromycin- for patients allergic to -lactam

antibiotics y Cephalosporins- more effective in eradicating streptococcal carriage y Paracetamol- for aches, pains or fever

Urinary Tract Infection

y State in which organisms actively multiply and

persist in the GUT y occur in 3 5% of girls and 1% of boys y In girls: first UTI usually occurs by the age of 5 years, with peaks during infancy and toilet training y In boys: 1st yr of life, much more common in uncircumcised boys, male : female ratio 2.8 5.4 : 1 y Beyond 1 2 years striking female preponderance, male : female ratio of 1 : 10

Etiology
y UTIs caused mainly by colonic bacteria y In females: 75 90% of all infections caused by E. coli, followed by Klebsiella spp. and Proteus spp. y In males ( 1 yo): Proteus as common as E. coli y Staphylococcus saprophyticus and enterococcus are pathogens in both sexes. y UTIs are ascending infections: arise from the fecal flora, colonize the perineum, and enter the bladder via the urethra. y In uncircumcised boys: bacterial pathogens arise from the flora beneath the prepuce.

Pathogenesis
y Is based on the presence of bacterial pili or

fimbriae on the bacterial surface y Type I fimbriae: found on most strains of E. coli., referred as mannose-sensitive y Type II fimbriae: known as mannose-resistant, can agglutinate by P blood group erythrocytes, known as P fimbriae y Bacteria with P fimbriae are more likely to cause pyelonephritis.

Manifestations
y In neonates: lethargy, fever or temperature

instability, irritability & jaundice y In older infants: fever, vomiting and irritability y In young children: nocturnal enuresis or daytime wetting y In older children: low-grade or no fever, dysuria, urinary frequency, or urgency

Risk Factors
female gender uncircumcised male vesicoureteral reflux toilet training voiding dysfunction obstructive uropathy urethral instrumentation y wiping from back to front in females
y y y y y y y y tight clotting y y y y y y

(underwear) pinworm infestation constipation anatomic abnormality ( labial adhesion) nerupathic bladder sexual activity pregnancy

Diagnosis
y UA & Urine culture are necessary for confirmation and appropriate therapy. y A midstream urine sample usually is satisfactory. y If the culture shows >100,000 colonies of a single pathogen, or if there are 10,000 colonies and the child is symptomatic, the child is considered to have a UTI. y In uncircumcised males - prepuce must be retracted prior to urine collection. y In infants - adhesive, sealed, sterile collection bag after disinfection of the skin of the genitals can be useful, particularly if the culture is negative.

Treatment
y Empiric antibiotic- started in symptomatic

patients with a suspicious UA while culture result are pending y Toxic-appearing children- admitted to the hospital for initial IV antibiotics and hydration. y Oral antibiotics - are started once the child has shown initial improvement.