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Cagayan State University

Carig Campus, Tuguegarao City
COLLEGE OF MEDICINE

PEDIATRICS WARD
MD3 ALPHA 1 MIDTERM GROUP

CASE PRESENTATION 1

SUBMITTED BY:
AGAS, EZRA LEY
MUHAMMED, RAFI CK
SIMANGAN, CARLSON

SUBMITTED TO:
DR. GRANDELEE TAQUIQUI
General data:
Name: JS
Age: 15
Gender: Female
Civil status: Single
Address: Namabbalan, Tuguegarao City
Birthday: November 27, 2002
Religion: Catholic
Nationality: Filipino
Occupation: Student
Date of Admission: September 30, 2018
Time of Admission: 10 am
Date of interview: October 1, 2018
Informant: Mother and Patient
Reliability: 80%

Chief Complaint: Ingestion of kerosene; mild abdominal pain

History of Present Illness:
On September 30, 2018, few hours prior to admission the patient overheard her mother talking
over the phone with her father that she is a big problem of theirs.
One(1) hour prior to admission, the patient ingested two tablespoon of kerosene intentionally.
After ingestion, the patient experienced mild abdominal pain. There were no signs of distress, no
nausea and vomiting, and no difficulty of breathing. The patient went to her mother and hugged her
which made the mother noticed the smell of kerosene coming out from her mouth.
Few minutes prior to admission the mother immediately rushed her daughter at Cagayan Valley
Medical Center and the patient was admitted for further evaluation and management.

Maternal History
Her mother, G6P6 (6006), was 38 years old when she delivered the patient. She delivered the
patient at term in the nearby RHU where she had her complete prenatal check up.

Past Medical History
This is the first medical hospitalization of the patient. She does not have any allergies and is not
on any maintenance medication.

Nutritional History
According to her mother, most of the time, she skips her meals, and consumes only half of the
meals served. Her meals composed mainly of rice, vegetables, fish, and meat. She sees her skinny body
as normal and trendy like her Korean pop idols.

Growth and Development

TANNER SCALE
Breast: Tanner III: The breast begins to become more elevated, and extends beyond the
borders of areola, which continues to widen but remains in contour with the surrounding breast.
Pubic hair: Tanner III: There is small amount of long downy hair with slight pigmentation at the
labia majora.
WHO Child growth standards

According to WHO, the patient has an average stature in relation to her age but her weight is
lower than normal. The patient weighs heavier than the 0.7% of the population and weighs less than
the other 99.3%.

Immunization History
The mother claimed that the patient had completed her vaccination at the nearest RHU in their
place.

Personal and Social History
The patient is the youngest among the brood of six. Her father is a 46 year old security guard in
manila. Her mother is a 53 year old housewife. She is currently living with her mother and her two
siblings in a bungalow with 3 rooms.

Family History

Both of her parents are alive and well. Her mother had asthma but the last attack was 5 years
ago. Her grandmother on father side died from diabetes. There were no family histories of any
psychiatric condition or depression

HEADSS Screening Interview for Rapid Psychosocial History
Home: Patient lives with her mother and her two siblings (eldest and fifth) since last year. Her 2 nd elder
sister moved into another house with her live–in partner 10 months ago. Her only brother and another
sister who had been initially staying with them went to manila last year and also worked as a security
guard like their father. She is more close to her father.
Education: She is a grade 10 student at Gosi High School. She is a consistent honor student since her
elementary grade.
Activites: Spends time browsing facebook, instagram, and twitter; Loves watching korean drama series
which compromises her sleep; she also plays badminton with friends.
Drugs: Denies use of alcohol, cigarette, and prohibited drugs
Suicidality: Denies previous attempt of suicide. Denies suicidal ideation.
Sex: Denies having any sexual contact. She identifies herself as being female although at times would
love to wear loose t-shirts or jersey owned by her brother. She admitted having a relationship with a
lesbian.

Review of Systems
 Constitutional: (-) fatigue, (-) fever
 Integumentary : (-) pruritus
 Head: (-) headache, (-) dizziness
 Eyes: (-) blurring of vision, (-)pain, (-)tearing
 Ears: (-) pain, (-)tinnitus
 Nose: (-) itchiness; (-) stuffiness
 Mouth and Throat: (-) difficulty swallowing; (-) toothache
 Neck: (-)pain; (-)stiffness
 Cardio respiratory: (-) DOB, (-) palpitation, (-) chest pain
 Gastrointestinal: (+) mild abdominal pain, (-) nausea and vomiting, (-) diarrhea
 Genitourinary: (-) oliguria, (-) dysuria
 Musculoskeletal: (-) muscle weakness, (numbness), (-)tingling sensations

Physical Examination
 General: patient lying in bed, conscious and coherent, not in distress.
 Vital signs:
o Temperature: 36.5 °C
o Pulse rate: 75 bpm
o Respiratory rate: 19 cpm
o Blood pressure: 110/70 mmHg
o 02 sat: 98%
 Anthropometric measurement:
o Height: 5’2’’
o Weight: 39 kg
o BMI: 15.7

 Skin: (-rashes),(-) bruises, (-)jaundice, (-) cyanosis
 Head: normocephalic head; with long healthy hair; no mass
 Eyes: pupils equal, round and reactive to light and accommodation; anicteric sclera, pink palpebral
conjunctiva;
 Ears: (-) ear discharges; (-)periauricular tag, (-) swelling and tenderness,
 Nose: (-) nasal discharges;
 Mouth and Throat: (-) cleft lip; small lips
 Neck: (-) lumps palpated at the neck; (-) engorgement of veins, (-)rigidity
 Chest and Lungs: symmetrical chest expansion; normal breath sounds on both lung fields, (-)
retractions, (-)rales, (-)wheezes, (-) cough
 Heart: adynamic precordium; PMI at 5th ICS midaxillary line; (-) murmurs
 Abdomen: flat and soft; normoactive bowel sounds
 Extremities: (-) edema; (-) deformities
 Genitalia: grossly female
 Neurologic: GCS 15/15
Mental Status Examination
 Well groomed and with good hygiene
 She was cooperative. She only spoke when asked to answer questions. No aberrations in the speed and
tone of speech nor trembling of voice noted. However, she could not maintain eye-to-eye contact
during the interview
 Oriented to time, place, and person
 Intact memory
Salient Features
The patient is a 15 year old female grade 10 student. She is considered underweight with a BMI of 15.7
because of poor appetite. Most of time she is having lack of sleep because of spending her time on social
media. She now lives with her mother and two siblings since last year . She identifies herself as being female
although at times would love to wear loose t-shirts or jersey owned by her brother. She admitted having a
relationship with a lesbian. She presented at the emergency room with mild abdominal pain after intentional
ingestion of 2 tablespoon of kerosene.

Differential Diagnosis

1. Persistent depressive disorder (dysthymia) is characterized by depressed or irritable mood for more days than
not, for at least 1 yr (in children/adolescents). Those who suffer from depression experience persistent feelings
of sadness and hopelessness and lose interest in activities they once enjoyed. Aside from the emotional
problems caused by depression, individuals can also present with a physical symptom such as chronic pain or
digestive issues.
The DSM-5 outlines the following criterion to make a diagnosis of dysthymia.

RULE IN RULE OUT
A. Depressed mood for most of the day, for more days than not,
1. Intentional kerosene ingestion as indicated either by subjective account or observation by
2. Mild abdominal pain others, for at least 2 yr.
Note: In children and adolescents, mood can be irritable and
3. Poor appetite duration must be at least 1 yr.
4. Poor sleep B. Presence, while depressed, of 2 (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
C. During the 2 yr period (1 yr for children or adolescents) of the
disturbance, the individual has never been without the
symptoms in Criteria A and B for more than 2 mo at a time.
D. Criteria for a major depressive disorder may be continuously
present for 2 yr.
E. There has never been a manic episode or a hypomanic
episode, and criteria have never been met for cyclothymic
disorder.
F. The disturbance is not better explained by a persistent
schizoaffective disorder, schizophrenia, delusional disorder, or
other specified or unspecified schizophrenia spectrum and other
psychotic disorder.
G. The symptoms are not attributable to the physiologic effects
of a substance (e.g., a drug of abuse, a medication) or another
medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.

2. Adjustment Disorder- The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
defines as “the presence of emotional or behavioral symptoms in response to an identifiable
stressor/s, which occurred within three months of the beginning of the stressor/s. Adjustment disorder
is associated with suicidal ideation and suicide attempt. Children and adolescents typically show the
following symptoms in Adjustment Disorder:

RULE IN RULE OUT
 Poor sleep  Stressors occurred 3 months ago
 Decreased appetite  Irritable
 Separation from family members  Depressed
 Intentional kerosene ingestion  Poor grades and performance in school

3. Gender Identity disorder/ Gender Dysphoria-The Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) in adolescents and adults diagnosis involves a difference between one’s
experienced/expressed gender and assigned gender, and significant distress or problems functioning.

RULE IN RULE OUT
 Cross dress at times It lasts at least six months and is shown by
 In a relationship with same sex at least two of the following:

1. A marked incongruence between one’s
experienced/expressed gender and
primary and/or secondary sex
characteristics
2. A strong desire to be rid of one’s
primary and/or secondary sex
characteristics
3. A strong desire for the primary and/or
secondary sex characteristics of the
other gender
4. A strong desire to be of the other
gender
5. A strong desire to be treated as the
other gender
6. A strong conviction that one has the
typical feelings and reactions of the
other gender

7. Paranoid type- schizophrenia-Patients with the paranoid subtype of schizophrenia are also more likely
to commit suicide Suicide is a major cause of death among patients with schizophrenia. Research
indicates that at least 5–13% of schizophrenic patients die by suicide, and it is likely that the higher end
of range is the most accurate estimate.

RULE IN RULE OUT
1.Intentional kerosene ingestion Two (or more) of the following, each present
for a significant portion of time during a 1-
month period (or less if successfully treated).
At least one of these must be (1), (2), or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent
derailment or incoherence).
4. Grossly disorganized or catatonic
behavior.

Negative symptoms (i.e., diminished
emotional expression or avolition).

Final diagnosis:

Hydrocarbon poisoning

Pathophysiology of hydrocarbon poisoning

Poisoning is the number 1 cause of injury death in the United States. In adolescents, poisoning is the
3rdleading cause of injury related death. Exposures in the adolescent age group are primarily intentional and
thus often result in more severe toxicity. Adolescents ages 13- 19 accounted for 45 of the 73 poison related
paediatrics death in 2012 reported to the National Poison Data System. Kerosene is oil used as a fuel for
lamps, as well as heating and cooking. The poisonous ingredient is hydrocarbon.

The toxic potential of hydrocarbons is directly related to both the dose and the compound’s physical
properties: volatility, solubility, viscosity, and surface tension.
Viscosity refers to the compound’s resistance to flow (eg, gasoline and mineral oil have low viscosity). As the
viscosity increases, the aspiration potential decreases.
Volatility refers to the compound’s ability to vaporize. The higher the volatility, the easier the compound is to
inhale. Thus, highly volatile compounds with low viscosity are more likely to be inhaled or aspirated. Simple
petroleum distillates such as kerosene, mineral oil, gasoline, and furniture polish are examples of such
substances that are easily aspirated.
Compounds that are lipophilic are able to cross the blood-brain barrier, leading to CNS effects. Halogenated
hydrocarbons (eg, methylene chloride, chloroform, carbon tetrachloride) and aromatic hydrocarbons (eg,
benzene, toluene, xylene) are easily absorbed through respiratory and gastrointestinal mucosa, often leading
to CNS toxicity.
Pulmonary effects

Pulmonary toxicity is the result of hydrocarbon aspiration causing direct effects on lung parenchyma.
Low-viscosity, highly volatile hydrocarbons, such as kerosene and mineral oils, are easiest to aspirate. The
hydrophobic nature of hydrocarbons allows them to penetrate deep into the tracheobronchial tree, producing
inflammation and bronchospasm. These volatile chemicals can displace alveolar oxygen, leading to hypoxia.
Direct contact with alveolar membranes can lead to hemorrhage, hyperemia, edema, surfactant inactivation,
leukocyte infiltration, and vascular thrombosis, resulting in poor oxygen exchange, atelectasis, and
pneumonitis. Hypoxia ensues secondary to ventilation/perfusion mismatch, shunt formation, and
bronchospasm. Respiratory symptoms generally begin in the first few hours after exposure and usually resolve
in 2–8 days.
Complications include hypoxia, barotrauma due to mechanical ventilation, and acute respiratory distress
syndrome (ARDS). Prolonged hypoxia may result in encephalopathy, seizures, and death.
GI effects

Local irritation is the usual GI manifestation of hydrocarbon ingestion. Abdominal pain and nausea are
common complaints. Vomiting increases the likelihood of pulmonary aspiration. Hepatotoxicity occurs more
frequently with occupational exposure and is less likely to result from inhalant use.
CNS effects

Hydrocarbon toxicity produces various CNS effects. After inhalation, hydrocarbons are absorbed
through the lungs into the bloodstream. Most of these chemicals are CNS depressants, with Initial effects
similar to the disinhibition observed in patients with alcohol intoxication. Effects occur in a dose-dependent
manner. Narcotic-like depression may also be observed. Euphoria may develop, as in alcohol or narcotic
toxicity. Eventually, lethargy, headache, obtundation, and coma may follow. Seizures are uncommon and are
believed to be due to hypoxia.
Acute exposure leads to an increase in gamma-aminobutyric acid (GABA) and glycine function. With
more chronic exposure, these effects become blunted as tolerance develops. Activation of the mesolimbic
dopaminergic system is also thought to be responsible for the addictive properties of these agents.
Hydrocarbon inhalation induces oxygen radicals that persist for up to 24 hours, exerting the greatest effect on
the hippocampus. The most pronounced effects are seen in the developing brain; this would account for the
learning and memory deficits experienced by adolescents who abuse hydrocarbons.

Etiologic factors
 Inappropriate storage
 Lack of parental guidance and awareness
 Attractive color and pleasant odor
 Suicidal tendencies

Hydrocarbon poisoning

Hydrocarbon poisoning
GIT Pulmonary

Hydrocarbon poisoning
Ingestion
aspiration of
Vomiting hydrocarbon
GIT irritation Hydrocarbon poisoning

inhibit suractant
Edematous/hyperemic
gastric mucosa
alveolar instability

Superficial Obstruction
early dista airway closurel

Gastric juice Secretion
Ventilation perfusion
Acid Mucus mismatch
Ulceration
hypoxia

Nasea/vomiting

Abdomial pain CNS
Treated untreated

bleeding
Recovery

Shock

death

Management:
Non Pharmacologic
 Stabilization of airway, oxygen supplementation, and oxygen saturation monitoring
 Remove all contaminated clothing; clean affected hair and skin with water irrigation to reduce risk of
additional irritation and inhalation.
 Put the patient on NPO.
 Laboratory: CBC,CXR to diagnose pneumonitis, ECG
 Avoid gastric lavage to prevent aspiration
 Psychiatric evaluation
 Supportive management: Family support

Pharmacologic
 Medications: prophylactic antibiotics; omeprazole
 Put an IV line and administer IV fluids