Pediatrics Clerkship H&P
Identifying Information
Two-month-old male accompanied by her mother. The mother is the primary historian
and is deemed reliable.
Chief Complaint
Increased fussiness, decreased feeding, and fever for one day.
HPI
This is a 2 month old infant who presented to the After Hours Clinic for fever and
fussiness. The mother states that the patient would normally take 2oz of Similac formula
every 2-3 hours. He would also get up in the middle of the night for feedings every 3
hours. However, over the last 24 hours, he has not been taking his feedings as frequently.
He has taken 3 feedings of 2oz over the last 24 hours. He did not wake during the night
for any feeding. The mother also noted that the patient was increasingly fussy during the
day. He would cry when left along for any amount of time, which was a deviation from
his normal routine. He was able to be consoled when held however. He has had 6 wet
diapers in the last 24-hours, and he normally has 6-8 per day. He typically has stool in the
diaper 3 times per day, with 3 normal stools noted in the last 24 hours.
The mother took the patient's tympanic membrane temperature which was found to be
103F. The mother became worried about the infant's high temperature because he has an
underlying heart condition, as well as a history of UTI, so decided to take him into the
clinic. There, the patient was noted to be ferile and somewhat lethargic, so they
recommended him for admission to the hospital.
The mother states that the patient has not had any cough, diarrhea, vomiting, rash, sick
contacts, or wheezing.
Past Medical History
Birth: Patient was born at term to a G4P3 mother via spontaneous vaginal delivery. The
pregnancy was complicated by chronic hypertension and diabetes. The mother was
treated with methyldopa and labetalol during pregnancy. She did not require insulin. The
patient weighed 3.29kg (30th %) at birth and was 50cm long (50th %) with head
circumference of 36cm (50th %).
Hospitalizations:
As stated in the HPI, he was hospitalized at 2 weeks of life for SVT and UTI. He was
treated with adenosine and converted to sinus rhythm. He was treated with Ampicillin for
the UTI which grew Group B Strep. Renal ultrasound and VCUG were performed and
were negative.He was continued on propranolol for the SVT.
At one month of age he went to Mayo Clinic as an outpatient for further work-up of the
heart condition. He was placed on a continuous cardiac monitor. He had preexcitation
which correlated with a diagnosis of Wolff-Parkinson White syndrome. He was admitted
to the hospital for titration of his dose of propranolol. He was discharged in stable
condition with no runs of SVT on a dose of propranolol 4.5mg/kg/day. They were
instructed that they could return to Mayo Clinic when the patient is 4-6 years of age to
have an ablation performed to destroy the accessory pathways found in WPW syndrome.
Surgeries: none
Illnesses: Wolff-Parkinson White syndrome
Meds: Propranolol 4.5mg/kg/day divided into three doses= 8.5mg po TID
Allergies: NKDA
Diet: Patient is solely formula fed. As per HPI he has had decreased feedings for the last
24-hours. He has also shown increasing fussiness over the last 24 hours. He normally
takes 2oz every 2-3 hours.
Habits: He typically wakes up every 3-4 hours during the night for feedings. However,
he slept longer during the last night. No exposure to tobacco smoke in the home.
Development: Gr Motor: He is able to hold his head steady when being held. He turns
his head from side-to-side. Fine Motor: He is able to follow objects past his nose.
Language: He is startled by loud noises. Social: Mom says he recognizes her face. He
smiles when prodded.
Immunizations: He received a Hep B at birth. He has not yet received any other
vaccinations. He is due for the following vaccinations as he is 2 months of age: Hepatitis
B, DTaP, IPV, Rotavirus, Hib, and PCV.
Family History
The mother has hypertension and diabetes mellitus type II. The father is healthy. The
patient's two brothers both have asthma. The oldest brother has an atrial septal defect.
The patients sister is healthy. The maternal grandparents both have hypertension. The
paternal grandparents are both deceased. No family history of any cancer or arrhythmias.
Social History
The patient lives in Bismarck with his mother and three older siblings (2 brothers and a
sister). The mother does not smoke, and there is no smoke exposure in the home. They
have no pets. There are no sick contacts at home. He does not yet go to daycare.
Review of Systems
General: decreased feedings, fussiness, and fever as per HPI; no weight loss
Skin: no rash
Head: no trauma
Eyes: no discharge, conjunctivitis
Ears: no discharge, tugging
Nose: no discharge
Throat: no spitting up after feedings
Endocrine: no growth issues or ambiguous genitalia
CV: as per HPI
Respiratory: no cough, wheezing, difficulty breathing
GI: no vomiting, diarrhea
GU: one prior UTI as per HPI; no changes in diaper wetting
Musculoskeletal: moves all extremities equally
Neuro: no seizures
Heme: no easy bruising, bleeding
Physical Exam
Vitals: T- 103.2F P- 165 R- 30 SaO2- 98% on room air
Growth: Wt- 5.8kg (70th %) Length- 60cm (75th %) HC- 40.cm (50th %)
General: Patient is awake, but appears somewhat sleepy being held by mom.
Head: atraumatic, normocephalic; soft anterior fontanelle; no meningeal signs
Eyes: no icterus, no discharge, no conjunctivitis
Ears: no discharge, tympanic membranes without erythema with good cone of light
bilaterally
Nose: no discharge, moist nasal mucosa
Throat: moist oral mucosa, mild erythema to oropharynx, no exudates, uvula midline
Neck: no lymphadenopathy, no nuchal rigidity noted
CV: RRR, S1/S2, no murmurs, gallops or rubs noted; no thrills or heaves palpated.
Femoral pulses 2+ with capillary refill <2 seconds
Resp: clear to auscultation bilaterally; no wheezes, crackles, or rhonci noted; no
retractions
Abd: soft, nontender, nondistended; bowel sounds present; no hepatosplenomegaly; no
masses. No CVAT or suprapubic tenderness to palpation.
GU: normal appearing external genitalia; Tanner stage 1; As diaper is taken off, patient
has a large, loose stool that is yellow-green-brown in color. There was no blood or mucus
in the stool.
Ext: warm, symmetric tone, muscle development and strength
Neuro: no atrophy; moves all extremities equally; reflexes 2+ at patella, ankle, and
biceps bilaterally; Moro reflex intact and symmetric; rooting reflex intact and symmetric;
tonic neck reflex intact and symmetric
Skin: moist; without rash or erythema
Labs/Imaging
None
Problem List
1. Fever
2. Fussiness by history/lethargy on exam
3. Decreased feedings
4. Wolff-Parkinson-White syndrome
5. Heart-rate at upper limit of normal
6. Tachycardia difficult to determine due to propranolol use (possible blunting HR)
7. History of UTI
8. Mother hypertensive and diabetic during pregnancy
9. Formula fed from birth
10. Two-month immunizations due
11. Family history hypertension
12. Family history diabetes
13. Family history asthma
14. Single parent home
15. Diarrhea
Differential Diagnosis
1. Gastroenteritis- This seems to be the most likely diagnosis at this time. The
patient's only symptom or physical exam sign besides the fever was the
diarrhea during the exam. It is possible that the mother brought the child in so
early in the course of a brewing gastroenteritis that this was in fact the first
episode of diarrhea. The fever would have been the first sign.
2. Enterovirus- This is a pathogen present this time of year that may result in
fever, diarrhea, pharyngitis (potential etiology of decreased feedings) and
aseptic meningitis. One could document this with a positive PCR of CSF
fluid.
3. UTI- This is also a possibility in this infant, especially since he has a history
of a prior UTI. It is possible that the prior UTI was never fully eradicated, or
this could be a new infection.
4. Viral URI- This is a common cause of fever in infants, however this child ve
any signs of URI including cough, coryza, conjunctivitis, or rash.
5. Pneumonia- This is less likely in this patient with a normal respiratory rate
and chest exam. In pediatrics, fever and tachypnea equal pneumonia until
proven otherwise.
6. Bacteremia- Occult bacteremia is always a possible etiology of fever of
unknown source in an infant. Unfortunately, infants less than 3 months of age
often do not appear “toxic” while bacteremic. Therefore, it is good to
consider this possibility in the differential diagnosis of this fussy, lethargic
infant. It is possible that it could be Group B Strep since the patient had a UTI
with that microorganism in the past. It is possible that since he received
antibiotics for his UTI that a Group B Strep sepsis was only partially treated at
the time. One could also suspect other neonatal organisms, such as E Coli,
Listeria, and Staph. As well, Strep pneumo and Haemophilus could be
present in a 2 month old, particularly since he is still unimmunized. A
positive blood culture would prove this diagnosis.
7. Meningitis/Encephalitis- This seems possible due to patient’s age, level of
fever and fussiness with lethargy. One could only prove this diagnosis by
performing a lumbar puncture, which may reveal a CSF pleocytosis and
perhaps a positive bacterial culture or HSV/Enteroviral PCR test. Obtaining
pregnancy history for maternal HSV may be a useful clue for this diagnosis.
Assessment
This is a 2-month-old male with rate controlled Wolff-Parkinson-White syndrome, a
history of UTI, and a fever of new onset.
Plan
1. FEN- Since we are admitting the patient to the hospital for monitoring of his
cardiac activity and to determine the origin of his fever, we will start him on IV
fluids for mild dehydration (even though oral rehydration would be a good trial on
an outpatient basis). At less than 1-year-old, mild dehydration would be
calculated at about a 5% deficit. Replacement fluid volume will be 290mL (5800g
* 5% = 290mL). We will give a 116mL NS fluid bolus over about 1 hour. This
will leave us with 174mL to give as replacement. Since baby is voiding, we will
use D5 ¼ NS with KCl 20meq/L as our replacement fluid. We will give 87mL
over the first 8 hours, and 87mL over the next 16 hours after that. We will add
maintenance fluids during this time as well at a rate of 23mL/hr (4mL/kg/hr *
5.8kg = 23.2mL/hr. That will give us a rate of 34mL/hr for the first 8 hours after
the bolus (23mL/hr + 87mL/8hr = 34mL/hr). For the subsequent 16 hours we will
continue fluids at a rate of 28mL/hr (23mL/hr + 87mL/16hr = 28mL/hr). We will
encourage continued oral feedings with formula every 2oz every 2-3 hours as is
his normal routine. Feedings will be continued even if patient is found to have a
gastroenteritis. We will track Ins and Outs so that we may adjust fluid intake
appropriately to assure the patient stays fluid balanced. We will draw a chemistry
8 panel to check for any electrolyte imbalances that may need correction.
2. CV- We will connect patient to continuous cardiac monitoring for rhythm and rate
checks. We will need to be prepared in the case of the patient going into SVT.
Vagal maneuvers should be performed if patient goes into SVT. We may need to
have IV beta blockers available. Adenosine should not be used in this patient
during an attack of SVT due to his underlying WPW syndrome.
3. Resp- We will place the child on an SaO2 monitor to obtain saturations. We will
observe patient for any signs of respiratory pathology and perform appropriate ID
studies if found.
4. ID- We will perform some laboratory studies looking for the source of the fever,
including a CBC/manual differential and a blood culture, a catheterized urinalysis
and urine culture, and a lumbar puncture to look at a CSF culture, cell count ,
protein and glucose. We will also send CSF for enterovirus PCR. We will obtain
further history from mom regarding her possible history of herpes/STDs. If this
history is suggestive, we will also send the CSF for HSV PCR. The decision
regarding empiric antibiotic use while we await culture results will be based on
the results of the preliminary studies. Should the CBC/manual differential,
urinalysis, and/or CSF cell count and protein/glucose studies look suspicious, we
will empirically begin cefotaxime +/- vancomycin while we await culture results.
If the patient continues to have loose stools, we will send a stool sample for
culture, C. diff toxins, and rotavirus. If the results come back positive for UTI,
we will consider repeating a VCUG to check for reflux back into the upper
urinary tract. We will also consider repeating an abdominal ultrasound to check
for anatomical variants of upper GU tract if UTI is present. While we await
laboratory results, we will continue to monitor the patient for other clues
regarding fever etiology. We will treat fever with Acetaminophen 15mg/kg/dose
every 4-6 hours.
Learning Issue
The treatment of WPW syndrome includes radiofrequency catheter ablation (RFCA) of
the accessory pathways. These accessory pathways may lie in close association to the AV
node within the triangle of Koch.
The AV node resides within the right atrium within the triangle of Koch. The triangle of
Koch is formed by the septal cusp tricuspid valve annulus, the ostium of the coronary
sinus, and the tendon of Todaro.
An adverse outcome of RFCA includes complete AV block due to unwanted ablation of
the AV node during the procedure.
How does the size of the triangle of Koch correlate to age of the patient and their body
size? When should patient be considered for RFCA treatment?
McGuire and colleagues found no association between body surface area and the
dimensions of the triangle of Koch in adults1. However, further studies in the pediatric
population have shown correlations.
In a postmortem study of the triangle of Koch in 14 pediatric patients between the ages of
1 day to 5.5 years old, Golberg et al found that the size of the triangle of Koch was
directly proportional to patient weight, height, BSA, age, and heart weight. They found
the strongest association to be body surface area2.
A study by Kugler et al charted outcomes of 725 RFCA in pediatric patients between the
ages of birth to 20-years-old. They found that the complication rate was 4.8% in these
procedures. Their multivariate analysis showed that body weight of less than 15kg was an
independent risk factor for complications of RFCA. The complication rate in patients
<15kg was 10% in this study3.
Based on these studies, our patient should be managed medically until he weighs at least
15kg. At that point, he could be considered for RFCA treatment to destroy the accessory
pathways.
References
1. McGuire MA, Johnson DC, Robotin M, et al. Dimensions of the triangle of Koch
in humans. Am J Cardiol. 1992 Sep 15;70(7):829-30.
2. Goldberg CS, Caplan MJ, Heidelberger KP, Dick M II. The dimensions of the
triangle of Koch in children. Am J Cardiol 1999 Jan 1;83(1):117-120.
3. Kugler JD, Danford DA, Deal BJ, et al. Radiofrequency catheter ablation for
tachyarrhythmias in children and adolescents. The Pediatric Electrophysiology
Society. N Engl J Med 1994 May 26;330(21):1481-7.