Miah Zavarro – Pediatrics

Missed PE, Missed Hx, Missed tests (lot)

CC – Swollen hands and feet – 21months old

 Tachypnea

 Adopted – unknown FH

 Swollen hand/feet painful for 2days – suspect hand-foot-mouth disease, improves w/rest and

ibuprofen

 Abdominal pain

 Cold 1 week ago – suspect minimal change disease

Diagnosis –

- Sickle cell anemia, septic-arthritis, reactive-arthritis, psoriatic-arthritis, rheumatoid arthritis

-juvenile.

Tests- blood culture/sensitivity, peripheral blood smear, cbc, crp, hgb-electrophoresis, esr

Problem Statement:

( Demographic description – chief complaint – Hx and PE key findings – risk factors )

Miah Zavarro is a 21month old female brought in by her adoptive mother with complaint of swollen and

painful hands and feet. Swelling started 2 days ago and is painful. Her mother reports she also has

abdominal pain that’s made her fussy at night when sleeping and decreased her appetite. PE shows

scleral icterus and splenomegaly. Her mother reports she had a cold 1 week ago, and claims similar -less

severe- episodes of swelling have happened in the past that have resolved spontaneously

CC: Miah Zavarro is a 21month old female brought in by her adoptive mother with complaint of swollen

and painful hands and feet.

HPI: Swelling started 2 days ago and is painful. Her mother reports she also has abdominal pain that’s

made her fussy at night when sleeping and decreased her appetite.

Meds: Ibuprofen for symptoms

PMH: Her mother reports she had a cold 1 week ago, and claims similar -less severe- episodes of

swelling have happened in the past that have resolved spontaneously

FH: Adopted from Haiti

ROS: Only positive findings are seen in HPI

Physical Exam:

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VS: Pulse – 134; BP – 90/58 RR – 28; T – 98.6F; SpO2 – 98%

Eyes: Scleral icterus noted

Abdomen: abdomen is distended, splenomegaly noted with tenderness to palpation, liver WNL, normal

bowel sounds heard.

Extremities: Right foot swelling with warmth, left hand and fingers swelling with dactylitis, patient

refuses to bear weight on feet.

ASSESSMENT/PLAN

Test Results:

 Blood culture and sensitivity: Negative

 Peripheral blood smear: Normocytic, normochromic anemia with abnormal sickle-shaped cells

 CBC: leukocytosis w/ normal differential, thrombocytosis, normocytic anemia (MCV in range)

 CRP: Elevated

 Hgb electrophoresis: Diagnostic for homozygous (SS) Sickle cell disease, w/o evidence of

concurrent thalassemia

 ESR: Elevated

 Left Hand X-ray: Dactylitis in hands – thinning of bony cortex

 Right Hand X-ray: Dactylitis in hands – thinning of bony cortex

 Left Foot X-ray: Dactylitis in feet – thinning of bony cortex

 Right Foot X-ray: Dactylitis in feet – thinning of bony cortex

 Reticulocyte count: elevated – showing signs of worsening anemia

 Liver function tests (LFT): Increased unconjugated bilirubin- suggesting extravascular hemolysis

 Lactate dehydrogenase (LDH): Increased

 Antinuclear antibody (ANA): negative

 Tuberculin skin test (PPD): negative

 Rapid Plasma Reagin (RPR): Negative.

Management Plan

 Hydration, pain management, nasal oxygen, and bed rest

 Avoid triggers of crises

 Penicillin prophylaxis

 Hydroxyurea

 Erythropoetin

 ALLOGENIC BONE MARROW TRANSPLANT for curative therapy

Exercises:

1. Diagram

2. 25%

3. No change

1. decrease