Intern Report Case 1.8

intern-report

Presented by Rob Klever, MD

HPI
15 year-old female with a past medical history for asthma, who presents to the ED for a headache, myalagias and anorexia of two days duration.  She states that her headache is constant, located bilaterally frontal and of aching quality, relieved by laying down, worsened with movement and has intermittent photophobia. She reports last week that she a had a ‘stuffy nose’ and had one episode of diarrhea and vomiting.

Her grandmother states that took her to the pediatrician five days ago who diagnosed her with viral illness and gave her a prescription for amoxicillin that she took for two days then stopped because she had felt better before developing the headache.

ROS
Patient states that she as a mildly sore neck, but no stiffness.  Pt reports feeling malaised.

Patient denies any fevers, chills, nausea, vomiting, cough, congestion, wheezing, shortness of breath, chest pain, weakness, numbness or tingling in any of her extremities, constipation, diarrhea then the aforementioned week before, changes in bowel or bladder habits.

PMHx
Asthma, currently well controlled on no medications.
Medications: Albuterol prn
Allergies: NKDA

Social Hx
Patient states that several people in her church youth group have been sick lately, but denies any recent travel.
She lives at home with her grandmother and does well at school as a sophomore.
She denies any alcohol, tobacco and drug use.
She reports no sexual history and states last menstrual period was two weeks ago lasting normal duration and volume.

Family Hx
Positive for migraine headaches, negative for sickle cell and diabetes.

Physical Exam:
VS: Temp: 36.6C; HR 84; RR 24; BP 109/71; Wt 69.4 kilo
General: 15 year female who appears stated age.
Eyes: PERRLA, EOMI, sclera icteric, conjuctiva pale, fundoscopic exam shows sharp disc margins, no evidence of papillaedema.
Ears: TM clear
Tonsils: tonsils bilaterally 1+; no evidence of erythema, edema or exudates
Neck: soft, supple, no evidence of meningsmus.  No Kernig’s or Brudzinki’s sign present. Trachea midline.
Cardiac: RRR s1,s2; no m/r/g
Lungs: CTA B
Abdomen: soft, NTND, no evidence of HSM, no rebound, no guarding
Extremities: Patient moves all extremities spontaneously, normal muscle strength and tone.
Neuro exam: Patient has normal gait and station; patient has normal strength and reflexes in all 4 extremities.  CN II thru XII intact.
Skin: Warm, dry and well perfused.  Good skin turgor. No evidence of rashes, petechiae or bruises.  There is palmar pallor present.

Initial Lab Values:
CBC: WBC: 13.0; H/H 4.1/13.4; Plt 8
Na/K/Cl/CO2/BUN/Cr/Glu: 139/4.3/102/23/17/1.5/123
UA: Cloudy, Amber, SG 1.014, pH 5.5, 3+ Blood, 1+ protein, negative nitrite, trace leukocyte esterase, > 100 RBCs, 5-10 WBC, 2-5 RBC casts, 2+ bacteria
Urine β-HcG: Negative

Questions:

1)    Given the history and initial lab values, what is the most likely diagnosis?
a.    Urosepsis with associated DIC
b.    Idiopathic Thrombocytopenic Purpura
c.    Viral Meningitis caused by Parvovirus B19
d.    Catastrophic anti-phospholipid syndrome
e.    Thrombotic Thrombocytopenic Purpura

2)    What lab test do you want to order to confirm the diagnosis?
a.    Aerobic and Anaerobic Blood Cultures
b.    Hemoglobin Electrophoresis
c.    Lumbar Puncture
d.    Peripheral Smear
e.    PT/PTT/INR; D-dimer; Fibrinogen, Fibrinogen Split Products

3)    What is your initial ED management?
a.    Transfusion of pRBCs and Platelets
b.    High dose prednisone, pRBCs, FFP while awaiting Plasma Exchange Transfusion
c.    Early Goal Directed Therapy (Fluids, Antibiotics, pRBCs)
d.    Early intubation, Dialysis, Fluid Bolus, Platelets, Steroids, Broad-spectrum antibiotics
e.    Give methylprednisolone and IVIG

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

One Response

  1. 1. TTP (e)
    2. Peripheral smear (d)
    3. (b) methylprednisolone 1mg/kg/d IV and FFP infusion, pRBC’s

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