Pediatrics

9 year old boy with fever, emesis and hematuria

Shilpa Gulati on May 26, 2013

A 9 year old boy with mild intermittent asthma presents to you in the ER with fever and emesis (x2) since this morning. He had strep pharyngitis diagnosed by throat swab a few weeks ago that was treated with azithromycin (full course completed). Since that time he has had low energy and ongoing nasal congestion, and his mother noticed that his voice changed to sound “muffled.”

 

Last Thursday, after returning from track practice, the patient began experiencing headache, malaise and cough. On Saturday he woke up with puffy eyelids and "chipmunk cheeks" that resolved partially over the next couple days. On Monday they reported to the patient’s PCP, where UA was positive for blood, rapid strep test was negative, and monospot was negative. Labs were drawn at Beaumont. He was advised to follow up in a couple days.

 

On Wednesday, he had worsening cough (continued since last week) and fever. They returned to the PCP where UA was again positive for blood; CXR at Beaumont showed focal RLL infiltrate. He was subsequently sent to your ED.

Meds: none

Allergies: penicillin, cephalosporins

Past Medical History: Mild intermittent asthma

Past Surgical History: Revision circumcision at 3yo

Past Hospitalizations: none.

Neonatal/pediatric History: Full term without complications.

Imms: UTD per mother. Did not receive flu shot this year.

Social History: Lives with parents, 3 siblings, cat, and dog. No smokers in the home. In 4th grade, runs track and does Karate.

ROS: Denies any recent weight loss or gain, anorexia, purpura, joint pain, dysuria, urinary urgency or change in frequency, or change in bowel movements.

  • Temp  39 C
  • HR  101
  • BP  134/81
  • RR  20
  • O2  98% on Room Air

Physical Exam

Weight: 36.2kg (83%ile)

General: Young healthy-appearing boy watching a movie in bed.

Eyes: No conjunctival injection, anicteric. Pupils equally round and reactive to light, extraocular movements intact. Moderate periorbital edema.

HENT: Moist mucous membranes with no oral lesions. No lymphadenopathy.

CV: Slightly tachycardic with regular rhythm. No murmurs, rubs or gallops. Cap refill <2 sec, pulses 2+ throughout.

Resp: Shallow breaths with good air movement. No evidence of increased WOB. Mild rales at bilateral lung bases with no rhonchi, wheezes or crackles.

GI/ABD: Soft, nondistended, no organomegaly. Tender to palpation diffusely, worse at RUQ, no flank pain. No rebound, guarding, or rigidity.

MS: Extremities nonedematous, warm and well perfused. No joint swelling or pain to palpation.

Skin: No skin lesions, bruises or purpura found.

Neuro: Alert, oriented, interactive and comfortable.

BMP
138
4.7
110
19
0.6
21
98
Ca8.4
Mg2
Phos4.5
CBC
9.2
10.1
153
Coag
PT 13
PTT 28
INR 1.2
Liver Enzymes
AST 29
Alk 180
Bilirubin (total) 0.5

ASO titer +

A 9 year old boy with mild intermittent asthma presents to you in the ER with fever and emesis (x2) since this morning. He had strep pharyngitis diagnosed by throat swab a few weeks ago that was treated with azithromycin (full course completed). Since that time he has had low energy and ongoing nasal congestion, and his mother noticed that his voice changed to sound “muffled.”

 

Last Thursday, after returning from track practice, the patient began experiencing headache, malaise and cough. On Saturday he woke up with puffy eyelids and "chipmunk cheeks" that resolved partially over the next couple days. On Monday they reported to the patient’s PCP, where UA was positive for blood, rapid strep test was negative, and monospot was negative. Labs were drawn at Beaumont. He was advised to follow up in a couple days.

 

On Wednesday, he had worsening cough (continued since last week) and fever. They returned to the PCP where UA was again positive for blood; CXR at Beaumont showed focal RLL infiltrate. He was subsequently sent to your ED.

Meds: none

Allergies: penicillin, cephalosporins

Past Medical History: Mild intermittent asthma

Past Surgical History: Revision circumcision at 3yo

Past Hospitalizations: none.

Neonatal/pediatric History: Full term without complications.

Imms: UTD per mother. Did not receive flu shot this year.

Social History: Lives with parents, 3 siblings, cat, and dog. No smokers in the home. In 4th grade, runs track and does Karate.

ROS: Denies any recent weight loss or gain, anorexia, purpura, joint pain, dysuria, urinary urgency or change in frequency, or change in bowel movements.

  • Temp  39 C
  • HR  101
  • BP  134/81
  • RR  20
  • O2  98% on Room Air

Physical Exam

Weight: 36.2kg (83%ile)

General: Young healthy-appearing boy watching a movie in bed.

Eyes: No conjunctival injection, anicteric. Pupils equally round and reactive to light, extraocular movements intact. Moderate periorbital edema.

HENT: Moist mucous membranes with no oral lesions. No lymphadenopathy.

CV: Slightly tachycardic with regular rhythm. No murmurs, rubs or gallops. Cap refill <2 sec, pulses 2+ throughout.

Resp: Shallow breaths with good air movement. No evidence of increased WOB. Mild rales at bilateral lung bases with no rhonchi, wheezes or crackles.

GI/ABD: Soft, nondistended, no organomegaly. Tender to palpation diffusely, worse at RUQ, no flank pain. No rebound, guarding, or rigidity.

MS: Extremities nonedematous, warm and well perfused. No joint swelling or pain to palpation.

Skin: No skin lesions, bruises or purpura found.

Neuro: Alert, oriented, interactive and comfortable.

BMP
138
4.7
110
19
0.6
21
98
Ca8.4
Mg2
Phos4.5
CBC
9.2
10.1
153
Coag
PT 13
PTT 28
INR 1.2
Liver Enzymes
AST 29
Alk 180
Bilirubin (total) 0.5

ASO titer +

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