Transcript Senior Case Presentation - RCRMC Family Medicine Residency

Senior Case Presentation
Armi Azad, M.D.
Introduction
• S.R. is a 4 y/o HF transferred from MVCH
for higher level of care
• Chief Complaint:
Intermittent fever x 1 month (ranging from
100.4 to 103º) and R hip pain for the past
couple of weeks; no hx. of trauma
Review of Systems
• On further questioning:
+occasional abdominal pain
generalized weakness and fatigue
?decreased appetite
• ROS otherwise negative
PMHx
Strep Throat x 1 month ago, tx’d w/ PO
Abx. x10 dys.
PSHx
No Surgical History
Birth Hx
Full Term
C/S 2/2 failure to progress
Birth Wt= 8 lbs.
Family History
Mother Denies
Social History
Lives with both parents
2 older siblings
No sick contacts
No pets
No tobacco exposure
Pre-school waiting List
History Cont’d.
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Development- Appropriate
Diet- Regular
Meds- Motrin
Allergies- Amoxicillin  rash
Immunizations- Up to date
Physical Exam
Vital Signs:
T=101.5
P=115
R=24
BP=84/59
Wt= 17 kg
Height= 103 cm
Physical Exam
• Gen- pale, scared/anxious
• HEENT- normocephalic, PERRLA
neck supple
no lymphadenopathy
throat clear
TM’s clear B/L
Physical Exam
• CV- RRR, 2/6 systolic murmur
• Resp- CTA B/L
• Abd- Soft, ND, +BS
+tenderness to deep palpation RLQ
no CVA tenderness
Physical Exam
• MS- Decreased abduction R hip 2/2 pain,
+TTP R lower back (no bony TTP),
5/5 motor strength x 4 extremities
+sensation intact B/L
DTR’s intact B/L
• Neuro- AAOx3, CN’s II-XII grossly intact,
gait WNL
What tests do you want to order?
Diagnostic Testing
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CBC w/ peripheral smear
CMP
UA, UCx/Blood Cx.
Pelvis and R hip x-rays
ESR, CRP, ASO titer
Laboratory Results
7.8
6.8
423
23.1
MCV= 76.3
ESR= >140
CRP= 13.7
ASO= 15 (<150)
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Segs= 19 (37-80%)
Lymphs= 57 (25-35%)
Mono= 5 (0-12%)
Eos= 1 (0-7%)
Bands= 17 (0-6%)
Laboratory Results
137 103 12
86
5.0 28
Albumin= 3.3
Total Protein= 7.0
AST= 54
ALT= 14
0.4
Ca= 9.6
BiliT= 0.2
AlkPhos= 150
Retic= 2.4%
Urine Analysis
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Color
Glucose
Bili
Blood
Nitrite
LE
WBC
RBC
yellow
negative
negative
negative
moderate
2+
5-10
0-2
Laboratory Results
• Urine Cx- negative
• Blood Cx’s- negative x2
X-ray
• Pelvis and R hip x-rays: unremarkable
Any Thoughts?
Differential Diagnoses
of Hip Pain
1
Now What?
Radiology
• CT Pelvis:
– Large fecal collection in rectum
– Thickening of urinary bladder
– No evidence of acute osteo or a pelvic abscess
Update
• Continued fevers despite IV Abx
• Migratory bone pain (i.e. L shoulder, mid
back)
• Intermittent RLQ abdominal tenderness to
deep palpation
6.7
8.0
372
19.9
3- Phase Bone Scan
• Vascular Flow StudyNo abn. Increased vascular flow in lower abdomen,
pelvis, and thighs
• Blood Pool PhaseSlight hyperemia in the right medial ilium
3- Phase Bone Scan
• 3-hr Delayed Static ImagesAbn. accumulation in R mastoid and clivus
Abn. accumulation in body of C2/C3
Mild generalized accumulation in bodies of L3/L4
and multiple levels of the thoracic vertebrae
Non-functional R kidney
Bone Scan Images
Impression
Metastases
vs.
Extensive Diffuse Osteomyelitis
More Radiology
• CT Chest w/ contrastMultiple osteolytic and osteoblastic lesions in the thoracic
spine
• CT Abd/Pelvis w/ contrast3.6 cm L adrenal mass
No ascites or adenopathy
Osteolytic lesion in R posteromedial ilium w/ sclerotic rim
Neuroblastoma
• What is it?
– 4th most common malignancy of childhood
– Cancerous tumor that begins in nerve tissue of
infants and very young children
– Usually begins in tissues of adrenal gland
(sometimes in neck, chest, and/or pelvis)
Neuroblastoma
• Metastasizes quickly (i.e. LN’s, liver, lungs,
bones, CNS, bone marrow)
• 70% of all children diagnosed have some
metastatic disease
Frequency
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Approx. 650 new cases dx’d in U.S./year
More common in whites
Male-to-Female ratio 1.3:1
79% of children diagnosed by age 4
97% of cases diagnosed before age 10
Etiology
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• Chromosome #1
• Deletion/rearrangement on
short arm of C’some 1
• Amplification of n-myc
oncogene
• Inherited mutation + 2nd
mutation after birth
vs.
2 acquired mutations after
birth
Symptoms
• Abdominal mass/distention
• Uncontrolled eye movement if facial
involvement
• Changes in urination, diarrhea
• Pain, limping, paralysis, weakness if bone
marrow involvement
• Fever
• High BP and increased HR
Staging
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Treatment
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Surgery
Chemotherapy
Radiation
Bone marrow transplant
Antibiotics
Supportive care
Continuous follow-up
Prognosis
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• Depends on a variety of factors including
age of pt. and stage of disease
• Survival significantly better for children
less than 1 year of age
• N-myc amplification confers worse
prognosis
• Increased ploidy has better prognosis
Survival
6
• Patients risk stratified into 3 groups
• 5-year survival by risk group:
1) Low Risk- 95%
2) Intermediate Risk- 85-90%
3) High Risk- 30-50%
Back to S.R.
• Chemotherapy: completing 4 of 6 cycles
today
• Surgery to remove tumor
• Bone marrow transplant
References
1.
2.
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4.
5.
An Evidence-Based Approach to the Evaluation and Management of Hip
Pain in Children. Pediatric Case Reviews, Volume 2:1; January 2002
http://www.emedicine.com/med/topic2836.htm
http://www.okstate.edu/artsci/zoology/ravdb/3024.htm
Staging of Neuroblastoma at Imaging. Report of the Radiology Oncology
Diagnostic Group 2002; Volume 223:1 (p. 168-175)
http://www.cancer.org/docroot/cri/content/cri_2_4_3x_how_is_neuroblasto
ma_staged_31.asp