GARCIA MJ, GARZON MMP, GASPAR IV, GATCHALIAN C, GAW MG, GERALDOY YR

Pediatrics Cardiology Conference

Patient

JMS8 years old/FJune 19, 2002456 Lambakin, Marilao, BulacanRoman CatholicFilipinoInformant : MotherReliability : Good

Chief Complaint

unsteady gait

History of Present Illness

4 wks PTA (+)decreased appetite (+) decreased activity level (+)episodes of joint mild pains

relieved by rest

3 wks PTA (+) undocumented fever with cough, colds and difficulty of

breathing paracetamol 250 mg tab ½ tab every 4 hours, salbutamol + carbocisteine (Solmux) 2mg/500mg/5ml 5mL twice a day, Vitamin C 5 mL once daily nebulized with 1 salbutamol nebule symptoms have resolved

History of Present Illness

2 wks PTA (+)decreased appetite, decreased activity (+)decreased interaction with family relatives At school:

patient does not maintain good eye contact kept on moving a lot and cannot stay still during recitation

1 wk PTA (+)frequently drops and loses her pen in class (+)hard time gripping her utensils while eating

3 days PTA wobbly gait, with weak voice and slurred speech

History of Present Illness

1 day PTA increased movement while sleeping persistence of symptoms

St. Michael Hospital Referred to a private neurology physician, they were

referred to Neurology Pediatrics patient was brought to Jose Reyes Hospital

A>>Rheumatic Heart Disease Lack of bed, hence patient was brought to our institution.

Review of Systems

General: (+) weight loss (-) delay in growthCutaneous: (-) rashes, (-) active dermatoses,

(-) hair lossRespiratory: (-) chest pain, (-) cough, (-)

difficulty of breathingCardiovascular: (-) orthopnea, (-) cyanosis, (-)

easy fatigabilityGastrointestinal: (-)vomiting, (-) jaundice, (-)

diarrea (-) constipation

Review of Systems

Genito-urinary: (-) hematuria, (-) change in urine frequency (-) dysuria

Endocrine: (-) heat/cold intoleranceMusculoskeletal: (-) gross deformities, (-)

edemaHematopoietic: (+) pallor, (+) easy

bruisability, (-) epistaxisNervous/Behaviour: (-) seizures (-) sleep

problems, (-) convulsions (-) paralysis

24 hour food recallMeal Food CHO CHON FATS KCAL

Breakfast

1 pc Hotdog - 8 10 122

1 cup Rice 46 4 - 200

Lunch

½ cup Rice 23 2 - 100

½ pc Hotdog - 4 5 61

1 pack Pancit canton 23 2 - 100

Dinner

1 cup Rice 46 4 - 200

1 pc Chicken fillet - 16 4 100

ACI 883

RENI 1600

% 55.19%

Ideal Body Weight: Age in year x 2 + 8 = 24 kg

Past Medical History Asthma – 7 years old – given salbutamol nebulization when needed UTI – 4 years old – was given unrecalled antibiotics for 1 week- consult

done at OPD Immunization History Mother claims that patient has completed immunizations until 9 months

in a local health center. Developmental History *at par with age Can do complex pattern movements Can tell time Reads for pleasure Can do concrete operations Accepts rules

Family History

Member Age Relation Educational Attainment

Occupation Health

Jose 39 Father Engineering Cell site caretaker Healthy

Rosalinda 38 Mother High school graduate

Textile factory worker Healthy

Jasmine 1 Sister - - healthy

(+) goiter – grandmother, 1 uncle, 2 aunts(+) cancer – grandmother: brain cancer “lymphoma”(-) HPN, stroke, DM, asthma, allergy, kidney disease, blood dyscrasia, TB, Seizures Family Profile

Personal, Socioeconomic and Environmental History

The patient lives with her parents in a well lit well ventilated house made of concrete.

Purified water is used for drinking and is not boiled.

Garbage is segregated and collected everyday by municipal trucks.

There are no pets, no factories nearby. Average monthly income of P15,000.

Physical Examination on Admission

Alert, awake, not in cardiorespiratory distress, well hydrated, well nourished

VS: BP: 110/70 HR 99 bpm RR 16/min T 36.5C

Wt : 31.5 kg (z = above 1) Ht : 137 cm (z = above 1)

BMI : 16.78 (z = above 0) Warm, moist skin, no active dermatosesEENT: Pink palpebral conjunctivae and anicteric

sclera, no tragal tenderness, no aural discharge, non-hyperemic external auditory canal, midline nasal septum, turbinates not congested, no nasal discharge, moist buccal mucosa, (+) hyperemic posterior pharyngeal wall, tonsils not enlarged

Physical Examination on Admission

Supple neck, (+) palpable cervical lymph nodes

Symmetrical chest expansion, no retractions, clear breath sounds

Adynamic precordium, apex beat at 5th LICS MCL, no murmurs

Flat abdomen, soft, non-tender, normoactive bowel sounds, no masses palpated

No cyanosis, no edema, pulses full and equal on all extremities

Neurological Examination

Conscious, coherent, oriented to time, place and person

can smell, pupils 2-3 mm isocoric ERTL, (+) direct and consensual light reflex, no visual field cuts, (+) ROR, EOMs full and equal, sensory deficit on R side of face, can clench teeth, can raise eyebrows, can close eyes tightly, can smile, no hearing deficit, no lateralization on Weber’s, AC > BC, uvula midline, can shrug shoulders equally, can turn head from side to side against resistance, tongue midline on protrusion,

Neurologic Examination

Good muscle bulk, no fasciculation, no atrophy

No spasticity, no rigidityMMT 5/5 on all extremitiesSensory deficit on L upper & lower

extremitiesCan do FTNT, APST, with involuntary

movements of extremitiesDTRs ++ on all extremities (+) Babinski, (-) nuchal rigidity, (-) ankle

clonus

Subjective Objective

9yr old/female Unsteady gait (+)decreased appetite, (+) decreased activity level (+)episodes of joint mild pains (+) undocumented fever with

cough, colds and difficulty of breathing

(+) poor eye contact, interaction Frequently drops her pen and

hard time gripping her utensils wobbly gait, with weak voice and

slurred speech increased movement while

sleeping

(+) hyperemic posterior pharyngeal wall

(+) palpable cervical lymph nodes

sensory deficit on R side of face

Sensory deficit on L upper & lower extremities

Can do FTNT, APST, with involuntary movements of extremities

(+) Babinski

Salient Features

Course in the Wards

1st Hospital Day

Patient was hydrated with Plain NSS 1L at 18-19 drops/min

Normal Range Result

Hgb 115-155 113

RBC 4.33

Hct 0.35-0.45 0.35

Platelet 150-450 346

WBC 4.5-13.5 8.30

Neutrophils 0.54-0.62 0.47

Segmenters

0.54-0.62 0.47

Lymphocytes

0.25-0.33 0.42

Eosinophils 0.01-0.03 0.11

Blood chemistry:

Cranial MRI with contrast : normal contrast-enhanced cranial MRI

Normal Range Result

Creatinine 0.47 0.4-0.6

Sodium 138 138-146

Potassium 3.90 3.5-5

Total Calcium 9.32 8.8-10.8

Salbutamol nebulization given 15 minutes prior to scheduled MRI.

Patient was also referred to the service of Pediatric Cardiology and Pediatric Neurology. (video)

2nd Hospital Day

On repeat physical exam, grade 2-3/6 holosystolic murmur at the left parasternal area was appreciated by Pediatric Cardiology

Chest x-ray was done

cardiomegaly, pulmonary congestion

2nd Hospital Day

ASO titer high at 598.01 (N.V. 0-240 IU/mL).

12-lead ECG sinus tachycardia, normal axis within normal limits

3rd Hospital Day

Patient complained of oral sores in the inner lower lip Solcoseryl paste was given

Pedia Neuro started Valproic acid 250mg/5ml 5mL q12h

4th Hospital Day

Patient was re-examined by Pediatric Cardiology

2D-Echocardiography: Minimal posterior pericardial effusion 1-2 aortic regurgitation 2-3 mitral regurgitation Normal coronary arteries Dilated Left ventricle Good contractility indices No structural defects Apparent prolapse of the anterior leaflet which appear to

be slightly thickened and deformed

Benzathine Penicillin G 1,200,000 IU/IM injection every 4 weeks

Digoxin 0.25 mg/tab ½ tab BID

8th Hospital Day

Valproic Acid was discontinued

Prednisone 20mg/tab was started at 1 tablet by mouth TID after meals

Last Hospital Day

Final diagnosis: Rheumatic Heart Disease Take home medications:

Prednisone 20mg/tab at 1 tab three times a day after meals

Ranitidine 150mg/tab 1 tab twice a day Digoxin 0.25mg/tab at ½ tab twice a day Benzathine penicillin G 1.2 M IU/IM every 4 weeks