Intern Case Report 2.1

intern-report

Presented by Sarah Albers, MD

CC: FeverHPI: A 23-month-old female presents to the ED with fever for the last 2-3 days.  Recently finished antibiotics for an ear infection.  Mom said she was doing well until 2-3 days ago, when she developed some nausea, non bloody, nonbilious vomiting, loose stools, and a fever as high as 104 at home.  She was seen at another hospital last night, diagnosed with a virus and told her to take Motrin and Tylenol, 10 cc of each alternating.

Apparently, there was some miscommunication between mom and the previous hospital.  She has been giving 10 cc of Tylenol and Motrin Infant Drops instead of the child formula and so there is a concern for overdose.  She has had 2 doses of each, last dose of Motrin was about an hour and a half ago, Tylenol was about three and half hours ago.  The patient is eating and drinking, awake, interactive, slightly decreased urine output.  Mom said the urine is very foul smelling and darker than normal.

PAST MEDICAL HISTORY: Reflux.

HOSPITALIZATIONS: None.

PAST SURGICAL HISTORY: None.

MEDICATIONS: Zantac.

ALLERGIES: None

IMMUNIZATIONS: Up to date.

FAMILY HISTORY: None

SOCIAL HISTORY: Positive for sick contacts.

BIRTH HISTORY: Full term, no complications.

Physical Exam and Vitals

BP 97/52, P 148, RR 32, Temp 39.0 (temporal), repeat 40.2 axillary.

HEENT:

Head:  Normocephalic, atraumatic.

Eyes:  Extraocular movements intact.  Pupils are equal, round, and reactive.  No conjunctival pallor or scleral icterus.

Mouth:  Mucous membranes pink, moist.  No intraoral lesions.

NECK:  Supple.

CARDIOVASCULAR:  S1, S2 regular.  No murmurs, rubs, or gallops.

RESPIRATORY:  Clear bilaterally.  No wheezing, rales, or rhonchi.

ABDOMEN:  Soft, nontender, nondistended.

MUSCULOSKELETAL:  No gross deformity.

EXTREMITIES:  No cyanosis, clubbing, or edema.

SKIN:  Warm, dry, and intact.

NEUROLOGIC:  The patient is awake, alert, interactive, and has a normal gait

Labs:

WBC: 18

Hgb: 12.2

Hct: 36.5

Plts: 243

Fecal leukocytes: negative

Ova and parasites: negative

Stool culture: negative

C diff: negative

Blood culture: negative

UA:

pH 7.5

sp gr 1.009,

blood 1+

LE 3+

Nitrites neg

WBC’s 50-100

Bacteria 1+

UCx: >100,000 E Coli

Abd U/S Final Read:

1.  Unremarkable ultrasound examination of the kidneys.

2.  Two splenules in the left upper quadrant.

Side note:

This is a 23-month-old who had fever for 2 days.  She was seen previously at another hospital, and no urine was obtained.   Also, she had approximately 2 g of Tylenol over 2 hours.  Her 24 hour dose calculates to be approximately 80 mL/kg per dose which is below the toxic level.  The patient has also had approximately 400 mg of Motrin which calculates about 30 mg/kg which is below the toxic level as well.  Toxicology should be (and was) consulted (with no acute intervention).

Questions:

1)    What is the most common source of UTI in Pediatrics?

  1. E coli
  2. b. Fungi (Candida species)
  3. Staphylococcus saprophyticus
  4. Streptococcus group B
  5. Adenovirus

2)    How should the urine analysis be obtained in this non toilet trained child?

  1. Sterile bag collection
  2. Bladder catheterization
  3. Suprapubic catheterization
  4. Wring out the diaper
  5. Wait for the child to urinate

3)    What is the concentration/dosage of Children’s Tylenol?

  1. 80 mg / 0.8mL
  2. 160 mg  /5 mL
  3. 100 mg / 5mL
  4. 50 mg / 1.25 mL
  5. 150 mg / L

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.

7 Responses

  1. 1. 1
    2. 2
    3. 2

  2. 1.(1) 2. (2), 3. (1)

  3. 1. E. Coli
    2. Bladder catheterization
    3. 160 mg / 5 mL

  4. 1. 1
    2. 2
    3. 2

  5. 1) 1. e coli
    2) 2. bladder cath
    3) 3. 100/5

  6. 1. e. coli
    2. bladder cath / straight cath
    3. 160mg/5mL

  7. 1.1
    2.2
    3.2

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