აი ცხელ-ცხელი ქეისი თქვენ. ეს ბავშვი 1 თვის წინ ვნახე და ქეის რეპორტი დავწერე. ინგლისურადაა, ქართულად გადათარგმნა მეზარება, პარდონ
P.S. 9 mo female
C.C. “weakness”
HPI: This patient is a 9-month-old female who presented to ER for 3-week history of weakness, lethargy and decreased PO intake as per her mother. She initially visited her PMD a day earlier who sent her to ER for “abnormal lab value.” Mom claims that the child has been less playful and cheerful lately. She is usually a really happy baby, but last few weeks she has been sleeping more and has not been moving around as much. She also has decreased PO intake. Normally the baby would drink 5oz of Similac Q3 hours, but lately she has been drinking 2oz Q3-4 hours. Urine output has not changed significantly. She urinates more than 5 times a day. Patient sometimes gags and spits up but does not vomit. She has no recent history of fevers, chills, coughs, rhinorrhea, nasal congestion, diarrhea, or rashes. No sick contacts at home, no recent travel history.
Mother also mentioned that the patient’s clothes have become looser. She felt that that baby has lost some weight. The patient was weighed at PMD’s office and turned out to have had lost 4 lbs since last visit which was 1 month prior. The PMD ordered basic labs, and a day later called the mother and told her to take the child to ER due to an “abnormal lab value”.
PMH: No significant PMH, no hospitalizations, no surgeries.
Allergies: NKDA
Medications: none
Birth Hx: Born at 39 weeks gestation via C/S for non-reassuring FHRT. Birth weight – 5lbs: Small for Gestational Age. Spent 4 days in NICU for hypoglycemia and presumed sepsis. She was also noted to have torticollis, which resolved and echocardiogram showed small anterior restrictive VSD.
Developmental Hx:
Pt is lagging developmentally at all levels.
Gross Motor (3-4 mo level): She is unable to sit unsupported, does not roll front to back. Can hold up his head.
Fine motor (4-5 mo): grasps with both hands together. Does not transfer hand to hand.
Language (6 mo level): She babbles but does not say any words. Does not understand commands.
Social (4-5 mo level): Does not have stranger anxiety. Extremely social and happy around strangers.
Family Hx: Grandfather has HTN, DM, and heart disease. Mother had unknown electrolyte disturbance and was hospitalized 4 times. Uncle was hospitalized as a child for 2 years for paralysis (details can’t be recalled).
Only child. Mother is 32, healthy. Father is 34, healthy.
Social Hx: lives with parents. Parents have no marital problems. Financially stable. No one smokes or drinks alcohol at home. No drugs. No medications are kept at home. 1 healthy family dog.
Review of systems:
- General: weakness, fatigue, weight loss, and change in appetite. No chills, fever, sweats.
- Neuromuscular: no tremors, no seizures, no syncope.
- Cadiovascular: no CP, no SOB, no cyanosis, no murmur, no HTN.
- Respiratory: no URI, no cough, no wheezing, no asthma, no pneumonia, no otitis media.
- GI: no nausea, no vomiting, no diarrhea, no constipation, no rectal bleeding, no abdominal pain, no jaundice.
- GU: no polyuria, no change in urine color, no recent UTI.
Vitals: BP: 101/64 HR: 136 RR 37 T 97.8 Wt: 5.8kg (<5%) Ht: 25.5 in (<5%)
Head circumference 43cm (25%)
Physical Exam:
General: NAD, awake, alert, smiling, very friendly. Looks smaller than stated age. Has tendency to arch his back.
Skin: no jaundice, no rash, no cyanosis, no pallor.
Head: NCAT, low nasal bridge, upturning nose, elfin facies.
Eyes: EOMI, bilateral red reflex present, no icterus, bright blue color
Ears, Nose, Throat: clear TM b/l, throat clear, ears normal set but somewhat enlarged.
Neck: supple, lymph nodes not palpable.
Thorax: symmetric expansion, good air entry, LCAB
CVS: +S1S2, RRR, Grade 2/6 holosystolic SEM best heard at lower sternal border.
Abdomen: Soft, NTND, bowel sounds present, no palpable masses, no organomegaly.
Extr: FROMx4, 2+ pulses, cap refill <2sec,
Neuro: grossly intact CN 2-12, hypotonic extremities, does not hold her head up, no focal deficits.
Pertinent labs:
CBC: 11.9> 11.1/32.7<370
Na 143 K 3.9 Cl 112 Bicarb 25 BUN 15 Cr 0.3 Glu 92
Ca2+ >16mg/dL Phos 4.2 Mg 1.8 Intact PTH <3 TSH 4.55 Free T4 1.08
Total Protein 7.2 Albumin 4.8 Tbili 0.2 Dbili 0.0 SGPT/OT 15/29 Alk Phos 192
Albumin 4.8
Venous Blood Gas: 7.40/42/41/26
VitD 25-OH wnl Vit A - wnl
U/A – negative UCx – negative
Random urine Cr = 23.4 Random urine Ca = 17.0 Ca/Creatinine= 0.7 (nl 0.2)
Pertinent Studies:
- EKG: Normal rate and rhythm, no PR, QRS, or QT abnormalities, nonspecific T wave abnormalities present. Possible RVH or biventricular hypertrophy.
- CXR: Lungs clear, no masses. Visualized osseus structures intact.
- Abd XR – normal, no abnormal calcifications
- Hand & Wrist XR – normal osseous structures, no subperiosteal bone resorption, no evidence of osteitis fibrosa cystica. Normal.
- Renal U/S – bilateral medullary neprhocalcinosis.
- Echocardiogram: small PFO with L→R shunting, small mid-muscular VSD with restrictive L→R shunting, mild supravalvular aortic stenosis.
რა არის ეს?, კლინიკური შემთხვევა, N 3
