Morning Report 8/28

Hannah Duffey, MD
PGY3

Case
HPI: This 7M 29D Female previously healthy child presenting with vomiting
and decreased energy.
Nine days prior to admission EN began vomiting. She would only vomit a few
times per day.
Her vomiting has been mucousy and occasionally has appeared yellow but
non-bloody.
She also developed watery, diarrhea around the same time her vomiting
started.
Six days prior to admission her vomiting became more frequent.
She also seemed tired and had decreased po intake.
Her stool output decreased and stools have intermittently been more
formed.
She had intermittent tactile fevers over the last week.
She has been having a least 3 wet diapers per day.
The day of admission she was vomiting more frequently and appeared very
pale so caregivers decided to take her to the ED.

History
PAST MEDICAL HISTORY:
Birth hx: term, NSVD, no complications
No major or chronic illnesses

PAST SURGICAL HISTORY:

No surgeries

IMMUNIZATIONS:
Up to date

MEDICATIONS:
None regularly

ALLERGIES:
No known drug allergies

Physical Exam
T 37.7. HR 145. RR 60. BP 95/50. SaO2 100% on Nasal Cannula at 1 LPM.
WEIGHT - 6.9Kg, (7 %ile) HEIGHT - 67cm, (31 %ile)
GENERAL: alert, pale infant, appropriately distressed with exam
HEAD: normocephalic, atraumatic.
EYES: normal red reflex and pupillary reflexes bilaterally, extraocular
movements intact, conjugate gaze, no conjunctival injection.
EARS: normal external ears.
NOSE: no discharge or obstruction.
OROPHARYNX: dry, pale oral mucosa, no lesions or tonsillar exudate.
NECK: supple without lymphadenopathy or tenderness to palpation.
CARDIOVASCULAR: tachycardic, regular rhythm, 2/6 systolic ejection
murmur at the left sternal boarder, 2+ pedal pulses bilaterally.
LUNGS: tachypneic, subcostal and intercostal retractions, good air
movement throughout, no crackles or wheezes.
ABDOMEN: soft, nontender, nondistended, liver edge palpabe at the costal
margin, spleen 1-2cm below the left costal margin, no masses.
EXTREMITIES: all extremities warm and well perfused. No cyanosis, clubbing,
or edema; nail beds are pale
NEUROLOGIC: awake and alert, cranial nerves II-XII grossly intact, grossly
normal strength and tone, patellar tendon reflexes normal.

Differential diagnosis
8 month old with vomiting, diarrhea, decreased
energy and pallor

Differential diagnosis
Heme/Onc:
ALL, AML,
lymphoma
Anemia- HUS,
folate, iron or B12
def, pernicious
anemia,
autoimmune
hemolytic disease,
hereditary
spherocytosis,
Neuroblastoma

CV:
CHD, CMP

Resp:
Congenital
diaphragmatic
hernia, CPAM

Endocrine:
Hypothydroidism

Differential diagnosis
ID:
Bacterial (strep,
staph) sepsis,
bacterial pneumonia
Parvovirus
Bronchiolitis
Viremia, adenovirus,
enterovirus
UTI, pyelonephritis
Giardia,
cryptosporidium
EHEC

GI:
Celiac disease
Severe food allergies
Intussusception
IBD
Sucrase isomaltase
deficiency
Pancreatic insufficiency
Neuro:
Increased ICP (mass,
hydrocephalus, chiari
malformation)

Initial work-up in ED
Complete Metabolic Panel: Na = 137, K = 6, Cl = 111, CO2 = 7, BUN = 25,
Cr = 0.32, Glucose = 107, Ca = 8.5, Protein = 5.7, Albumin = 3.7, Bilirubin =
2.9, Alk. Phos. = 153, ALT = 15, AST = 42
K 4.9
LDH 1953
Direct bili 0.5
Indirect bili 2.4
CBC: WBC 9.7, Hgb 2.4, Hct 7.3, Plt 33; MCV 101, RDW 80.6
Imaging
CXR
Findings most suggestive of pulmonary edema with small pleural effusions.
Imaging findings are not typical for viral
or bacterial infection. Correlation with known clinical information would be
helpful.

Peripheral blood smear:

macrocytosis,
thrombocytopenia,
schistocytes, 3% blasts
B12- 284, Homocysteine levels
5, methylmalonic acid 0.13
Folate 5
Coombs testing: negative per
blood bank
Stool culture: normal stool
flora; EHEC and parvo negative
Retic % 1.42folate and B12
16.9

UpToDate
Algorithm
In article: Approach to the child with anemia
Diagnostic approach to isolated anemia in
children: Morphologic classification

Folate Deficiency
Anemia

11

Folate
Deficiency
Anemia
Symptoms
Anemia
Decreased
energy
Pallor

GI symptoms:
Nausea
Vomiting
Abdominal pain
Diarrhea,
especially after
meals
Anorexia, weight
loss

Stomatitis
Tongue may appear
Swollen
Beefy
Red or shiny,
usually around the
edges and tips
initially

12

Folate
Deficiency
Anemia
Diagnosis

Cannot be made
based on folate
level alone
Should obtain B12,
MMA, and
Homocysteine to
rule out B12
deficiency
Confounding
factors: renal
failure,
intravascular
volume depletion
History of dietary
deficiency

13

Treatment
Folate supplementation

14