About this Written Case

[ssstrong]

---

Members do not see this ad.

Hello, I took my pediatrics end course examination, and I wanna ask about this case :

6 month old male infant developed low grade fever with cough and rhinorrhea. 3 days later he developed shortness of breath and became reluctant to feed. on examination he was pale, the respiratory rate was 50, the heart rate was 150, liver palpable 5 cm below the costal margin and the spleen was not palpable. WBC 10.000 , what is the diagnosis ?

 

[J-Rad]

What do you think it is? They've given you a case in which things progress in an unexpected way, but you should be able to unify most of it. I imagine a question structured like this was an MCQ. What options were given to you (presuming you aren't violating any non-disclosure agreements for official tests)? That will help you think it through. But, most people here aren't going just hand you an answer without any willingness, on your part, to start to work through it.

Sent from my MB855 using Tapatalk

 

[ssstrong]

Hello, it was not an MCQ, just like this.

They gave us the answer but really i am not satisfied with it, so i wanted to ask you about it

 

[Slade]

Hello, it was not an MCQ, just like this.

They gave us the answer but really i am not satisfied with it, so i wanted to ask you about it

If the age was switched form 6 months to 6 weeks, it would be a straightforward "congenital heart defect" + viral syndrome => congestive heart failure. I don't think a congenital heart defect would go unrecognized for 6 months though, so I don't know, maybe viral cardiomyopathy. Either way, the respiratory distress, tachypnea, tachycardia and hepatomegaly without splenomegaly is consistent with congestive heart failure. As to what caused it, not sure.

 

[J-Rad]

I think congestive heart failure is the only reasonable diagnosis to put as an answer. IMO it would be out of order for them to look for a cause from the case as presented. Viral myocarditis could be the etiology, but so could undiagnosed L-->R shunt with an exacerbating respiratory illness. Playing the odds, the latter is far less likely as any child getting routine healthcare maintenance is likely to get "caught" if they had a big enough defect to not cause a murmur (typically a very large VSD either isolated or as part of spectrum of other defects). That child will usually be failing to thrive and appear symptomatic to the parents. That said, not every child gets routine healthcare maintenance and not every parent is observant. I've seen young toddlers show up after months-long absences from well baby checks with huge heads from hydrocephalus (oddly, actually brought for some mild, asymptomatic and completely unrelated complaint; not for the huge head) and a truncus show up at around 6mo when the family couldn't understand why they weren't eating (or growing) well.

 

[ssstrong]

Thank for the answer, this is what i wanted to ask, what in this case is going against bronchiolitis ? it causes lung hyperinflation so that the liver will be pushed downward and i know there should palpable spleen also but is it constant finding ?

 

[Slade]

Thank for the answer, this is what i wanted to ask, what in this case is going against bronchiolitis ? it causes lung hyperinflation so that the liver will be pushed downward and i know there should palpable spleen also but is it constant finding ?

Imagine a 6 month old, now take your hand and measure 5cm on your abdomen (about 4-5 fingers). In a 6 month old, that means liver is down to the pelvis. Hyperinflated lungs will only bring it down 1cm if at all. Plus, the typical lung exam for bronchiolitis would show wheezing, crackles, rhonchi, the whole deal. In this case, the tachypnea is from pulmonary edema. However, the key fact in this presentation is definitely the enlarged liver.

 

[ssstrong]

Thank You , it is clear now