CASE PRESENTATION

BREASTFEEDING CASES
1) Baby Cruz is a 7-week-old baby brought in to your clinic by parents for evaluation. He
was born at 38 weeks AS 9, 9 via CS with birthweight of 2. 8kg.
At present, his weight is 4kg and mother claimed baby was well until the last 2 weeks when the
mother noticed less wet diapers and a decrease in the volume she was able to pump. Prior to
this visit with you, she had been evaluated by a lactation consultant. At a visit 1 week ago, pre-
and post-feeding weights showed low transfer of milk, but no nipple trauma. Her son now has a
coordinated suck and swallow, asymmetric latch with a wide angle of the jaw. The mother
holds the infant in a neutral position with the head slightly extended. The mother had been
healthy prior to the pregnancy, had no pregnancy complications and had an unremarkable
labor and delivery. Her breast exam was normal.
Mother’s concerns: • The baby never seems satisfied unless he is breastfeeding, otherwise, he
is crying • Her in-laws, who recently arrived to help with the baby, have encouraged her to stop
breastfeeding because he seems so unhappy • She doesn’t think the baby likes her • She isn’t
sleeping well • She feels as if she has already failed as a mother Probing questions: • What
factors might contribute to the change in milk supply? • How might you counsel this mother?
Her family? • What are some ways to help this mother increase her milk supply?

2. You are seeing a 7 day old infant for a routine post-nursery follow-up visit. The 18 year old first time
mother is concerned that the baby is not eating enough. The infant is a normal full term male with no
significant perinatal history. The baby drinks Enfamil 1-2 oz every 2-3 hours in addition to breastfeeding.
She offers the baby the breast before each feed, but he either refuses to latch on or falls asleep after 5
minutes. When offered the bottle, he drinks about 1-2 ounces at a time. The mother complains that her
breasts are full and tender, and that it hurts when the baby breastfeeds.
On review of systems, the baby is voiding 6-8 times a day, and stooling 4-6 times a day. There is no
emesis, diarrhea, or excessive fussiness. FH is positive for allergies. The mother denies medical
problems, denies prior surgeries, and is on no medications. SH is positive for a teen mother who lives
with her parents. The father is not involved.

OPD Case 1 Constipation

2 year old male from Laguna
CC: difficulty defecating
History of Present Illness
Born FT to a 29 year old G3P2(2002) mother via SVD at a hospital, no FMC Noted to have difficulty
defecating for 6 weeks, often seen standing against the wall and straining. This morning, noted to have
blood streaked stools.
(+) passage of stool within 24 hours of life
(-) current medications , no pica
PHYSICAL EXAMINATION
General Survey
Awake, not in cardiorespiratory distress
Anthropometrics
Weight =12 kg, length =79 cm
Vital signs
BP 80/50 HR 102 bpm RR 32 bpm T 36.5C O2 sats (room air) = 100%
Skin: No rash
Head and Neck:Pink conjunctivae, anicteric sclerae, (-) nasal congestion, (-) cervical lymphadenopathies
Chest and Lungs: Equal chest expansion, (-) retractions, (-)rales, (-) wheezes
Cardiac: Adynamic precordium, normal rate and regular rhythm, no murmur
Abdomen: Normoactive bowel sounds, (-) masses/tenderness, (-) hepatomegaly, intact Traube’s space,
no abnormal abdominal musculature, no
sacral dimple/tuft of hair, no fissures, good sphincteric tone
Extremities: Full and equal pulses, (-) edema/cyanosis/clubbing, wide, CRT less than 2 sec

OPD Case 2 ARI

N.B is a 2/M from Paco, Manila brought to your office because of a chief complaint of fussiness and
tugging at his right ear for the past two days.
He has had coughing and a runny nose for about 5 days that has been treated with saline nose sprays
and a humidifier. He has a low-grade fever with Tmax of 38.3 C past two days. No vomiting, diarrhea,
abdominal pain.
Past medical history: unremarkable
Birth and maternal history: unremarkable
Immunization history: +BCG, +DPT4/IPV4, +Hep B3, +RV2, +PCV3, +MMR, +measles
Physical Examination
VS T 38.4, P 100, RR 28, BP 100/65.
He is active, alert to his surroundings and otherwise in no distress.
HEENT: Right tympanic membrane is erythematous and bulging, with poor mobility on pneumatic
otoscopy. Left TM is clear with good mobility. Throat is non-erythematous. There are small cervical
lymph nodes.
Chest: Lungs are clear to auscultation.
The rest of the examination is normal.

OPD case 3: Sorethroat

An 11 year old male presents with fever up to 39 degrees (102 degrees F), joint pain and swelling, along
with occasional shortness of breath. The fever comes and goes at random times of the day. The
symptoms have been present now for 4 days. Two days ago, his right knee was painful and swollen, but
today it has improved. The joints involved today include the right ankle and left knee. They are quite
tender, painful and also swollen. He was also noted to have frequent sorethroat and no treatment was
given and no consult done.Few hours prior to consult persistence of above signs and symptoms promted
consult.
Exam: VS T 38.2, P 160, RR 32, BP 100/60, awake, coherent, in slight respiratory distress
HEENT: Enlarged, erythematosus tonsils with exudates. Lungs are clear but with tachypnea. Heart
sounds are tachycardic with a holosystolic murmur 3/6 heard at apex with radiation to axilla. No gallops
are heard. His PMI is prominent (size of silver dollar) at the 7th intercostal space in the mid-axillary line.
His abdomen is soft with normoactive bowel sounds. His liver edge is 6 to 7 cm below the RCM. His left
knee is swollen and extremely tender with warmth. He has difficulty with range of motion but can flex
his knee 30 degrees passively. His right ankle is very swollen and warm. He has limited subtalar motion.
Both his knee and ankle are very tender even to touch. Neuro: No abnormal movements of arms, hands,
or tongue are noted. He is unable to walk due to pain.
OPD case 4 FEVER and Rash
General Data:
Our patient is J.K., a 3/F from Pandacan, Manila who was brought in by his mother at your clinic with a
chief complaint of fever and rashes.
History of Present Illness
The patient was apparently well until… Seven days prior to consult – the patient was noted to have non-
productive cough associated with runny nose. The patient was given cough syrup with no apparent relief
of symptoms. She also described the patient’s eyes to be somewhat reddish and watery but with no
discharge. The patient was afebrile and had good appetite and activity, hence no consult was done.
Three days prior to consult – the patient was noted to have persistence of symptoms this time
associated with high grade, non-remitting fever (Tmax 40C) associated with a diffuse reddish rash that
was noted by the mother to begin at the forehead and face. The patient was brought to a local health
center where she was given Paracetamol and advised increased oral fluid intake. There was noted
temporary relief of fever.
Two days prior to consult – there was persistence of high-grade fever; however, the rash became
blotchy and progressed to the trunk and extremities. She had good appetite and activity and the mother
opted to observe the patient at home and continue Paracetamol. However, on the day of consult, due to
persistence of the rash and fever, the mother opted to bring the patient to you for opinion, hence this
consult.

Immunization History
The patient was given BCG x 1 dose, OPV x 3 doses, Hepatitis B x 2 doses, DPT x 3 doses and oral
rotavirus vaccine c/o the local health center. No other immunizations were given.

PHYSICAL EXAMINATION
General Survey
Awake, comfortable, not in cardiorespiratory distress
Anthropometrics
Weight = 17 kgs (z-score=2), height = 95 cms (z-score=1), head circumference = 50 cm (z-score=1)
Vital signs
BP 90/60 HR 100 bpm RR 30 bpm T 38.0C O2 sats (room air) = 99%
Skin (+) diffuse erythematous, generalized maculopapular rash
Head and Neck Pink conjunctivae, anicteric sclerae, (-) nasal congestion, (-) eye redness/discharge, (+)
bluish red spots on buccal mucosa, (-) cervical lymphadenopathies
Otoscopy: intact tympanic membrane, (-) TM bulging
Chest and Lungs Equal chest expansion, clear breath sounds, (-) retractions
Cardiac Adynamic precordium, distinct heart sounds, normal rate and rhythm, no murmurs
Abdomen Flat, normoactive bowel sounds, (-) masses/tenderness/organomegaly
Extremities Full and equal pulses, (-) edema/cyanosis/clubbing

OPD case 5 Chronic cough /Tuberculosis

You are presented with a 3 year old male with cough. Three weeks prior to consultation, the patient
developed cough after staying for a year with his grandparents. The parents consulted their family
doctor and was prescribed with ambroxol. However, there was persistence of cough until 2 weeks prior
to consultation, he developed nocturnal fever. His mother got worried hence, prompted consultation
with the same doctor and was prescribed with amoxicillin. But despite giving the medications, there was
persistence of cough and fever.
 1. What pertinent information will you ask in the history?
2. What physical examination findings will you look for?
3. Give 5 differential diagnosis of chronic cough. Give reasons to rule in
and rule out.
You requested for complete blood count, chest radiograph, and mantoux skin test. Complete blood
count showed slightly elevated white blood cell count. Chest radiograph showed enlarged perihilar
lymphadenopathies. Mantoux skin test revealed 5mm induration.
4. Explain the presence of perihilar lymphadenopathies on chest radiograph.
5. How do you administer the mantoux skin testing?
6. How do you interpret the results of mantoux skin testing? Interpret the result of this patient.
7. What is the significance of mantoux skin testing?
8. What other diagnostic tests can be done to diagnose this patient? Justify your answers
9. What is your final diagnosis? Defend your answer.
10. How do you manage this patient pharmacologically and non- pharmacologically?
11. How long will you manage this patient?
12. What advise will you give the parents of this child?
13. How often will you follow-up patients with this condition?
14. What will you ask and monitor on follow-up of this patient?
15. What is the prognosis of this patient?

OPD case 7 Ear Pain

MD a two year old Male who came in due to fussiness and tugging at his right ear for the past two days.
HPI: 5 days PTC He has had cough and a runny nose and self medicated with saline nose sprays and a
humidifier. He has a low-grade fever of about 38.3 degrees Celsius axillary for the past two days.
Few hours PTC persistence of ear pain prompted consult.
Both parents smoke cigarettes. He attends daycare. His immunizations are up to date, including 13-
valent pneumococcal conjugate vaccine.
Exam: VS T 38.4, P 100, RR 28, BP 100/65.
He is active, alert to his surroundings and otherwise in no distress.
HEENT: Right tympanic membrane is erythematous and bulging, with poor mobility on pneumatic
otoscopy. Left TM is clear with good mobility. Throat is non-erythematous. There are small cervical
lymph nodes.
Lungs are clear to auscultation.
The rest of the examination is normal.

Ward Case 1:Diarrhea/ fluid and electrolytes

An 18 month old female is directly admitted to the hospital from her primary care physician's office. She
has had 15 episodes of diarrhea and 5 episodes of vomiting. She has a fever with a maximum
temperature of 102.4 degree measured on a tympanic thermometer. She is weak, pale and her eyes are
sunken. Her weight in the office is 11.0 kg which is decreased from her weight in the office of 11.6 kg
just three days ago during a well child check. Urine output is difficult to assess because of the diarrhea.
Exam: VS T 37.8, P 110, RR 40, BP 100/60, oxygen saturation 100% in room air. Weight 11.0 kg. She is
alert, but subdued and quite. She is not toxic and not irritable. Her eyes might be slightly sunken. Her
oral mucosa is sticky (tacky). Her neck is supple. Heart regular, no murmurs. Lungs are clear. Abdomen is
scaphoid, soft and non-tender with hyperactive bowel sounds. No inguinal hernias are present. Her skin
turgor is diminished, but no tenting is present. Capillary refill time is 3 seconds over her thighs. Her
extremities are cool in her feet, but warm elsewhere.
WARD Case 2: Failure to Thrive
This is a 12 month old female who presents for a well child check. Within the past 4 months, her weight
has fallen from the 25th percentile to significantly less than the 5th percentile. Her height has dropped
from the 10th percentile to slightly less than the 5th percentile, while her head circumference has
remained at about the 25th percentile. Her language, motor, cognitive, and social development are
normal. She seems to eat appropriate foods for her age, but the her mother notes that she tends to be
restless and fidgety while eating, and that she does not like the texture of certain foods, often leading to
parental frustration at mealtimes. Her stools tend to be frequent, with particles of food seen. Urine is
normal. There are no symptoms of respiratory or neurological disease, and her review of systems is
otherwise negative.
Her past medical history is entirely unremarkable. She was born at term, weighing 3.0 kg (6 pounds, 10
ounces), without any perinatal complications. Her family history is negative for any endocrinopathies or
chronic illnesses. Mother is 155 cm (5 feet, 1 inch) 61 inches tall, and father is 168 cm (5 feet, 6 inches).
Mother experienced menarche at age 12.5 years and recalls that there were other children in the family
who were deemed small as young children but who caught up later in childhood. Mother describes a
history of increased sadness and worry since her child was born. Parents are married, and there is no
history of abuse or violence in the household.
Exam: Vital signs, including blood pressure, are normal. Weight 7 kg (< 5th percentile), height 70 cm (5th
percentile), head circumference 45.5 cm (50th percentile). She is alert and interactive, and appears to
relate well with her mother. Her anterior fontanelle is still open, roughly 2 cm. Two teeth (one just
emerging) are present. Thyroid, lymph nodes, heart, lungs, abdomen, genitalia, nervous system, and
skin are all normal.
WARD CASE 3: Vomiting
X. Y. is a 3 day old newborn, roomed in baby, who was observed to have
vomiting. He was born Full term to a 25 year old primigravid mother, via spontaneous
vaginal delivery with no known fetomaternal complications. Mother has no
known maternal comorbidities, with regular prenatal check-up at a private
OBGYN.
Upon delivery, patient was noted to have good activity, good cry, and was able to
latch with the mother. He was roomed-in with the mother, feeding adequately
until present. Patient is also noted to cough with associated cyanosis, which is associated with
each feeding.

Physical Exam
Patient is awake and irritable, not in respiratory distress
Weight 3.7kg Length: 48 cm HC: 35
HR 166, RR 58, T 36.8 C, BP 80/50, sats 100%
Slightly icteric sclera, no facial dysmorphisms
Equal chest expansion, no gross deformities, no retraction, coarse crackles
Bilateral Globular with hyperactive bowel sounds, no masses palpable
Pink nailbeds, has simian crease, complete digits

Ward Case 4. UTI

This is a 4 month old female who presents to the office with a chief complaint of fever, vomiting, and
loose stools. She has had tactile fever for 3 days, and had 5-6 episodes of emesis on the first day of
illness. Stools were liquid on the first and second days of illness. She was seen at an emergency room 2
days ago, where the impression was gastroenteritis. No labs or x-rays were done in the emergency
department. She returns to the office now because of persistent fever. Vomiting and diarrhea have
resolved, but she is breast-feeding less well than usual. Her mother notes that her urine seems "strong"
and that she is not as playful as usual. She has had no known ill contacts. She has no cough, URI
symptoms, or rash. Past history is unremarkable and she is on no medications.
Exam: VS T 38.9, P164, R40, Wt. 5.3kg (15%ile, and 150gm below her pre-illness weight). She is alert,
smiling, active, not toxic, and in no distress. Her anterior fontanelle is soft and flat. Her eyes and ENT
exams are normal. Her oral mucosa is moist. Her neck is supple. Heart rate is regular without murmurs.
Lungs are clear and her respirations are non-labored. Her abdomen is flat, soft, non-tender, without
hepatosplenomegaly or masses. Her external genitalia are normal. Her skin is warm and well perfused,
with no rash. Her back exam reveals no deformities or cutaneous defects. Her neurologic exam shows
normal tone, strength, and activity.
Ward Case 5. Tea colored urine
A 7 year old male presents to his primary care physician with the chief complaint of dark "cola colored"
urine, facial puffiness and abdominal pain for the past 2 days. He had been in his usual state of good
health until 14 days ago when he had a sore throat and fever. His sore throat and fever resolved. He was
not seen by a physician at that time. Over the past 2 days facial puffiness has been noted, but no
swelling of his hands or feet. He has had some nonspecific abdominal pain that comes and goes which
does not seem to be related to eating or bowel movements. There is no nausea or vomiting. His urine is
dark brown and he has not been voiding as much as usual, only 2 times in the past 24 hrs. There is no
urinary frequency, urgency, dysuria or foul smell to the urine. His appetite has been poor although he is
still drinking fluids well. He is also complaining of some back pain in the flank area that he describes as a
dull pain that comes and goes and does not seem to be related to activity. His energy level is down and
he has not felt up to going to school for the past 2 days. He is also complaining of a dull generalized
headache that has not been relieved with acetaminophen.
Review of systems is negative for recent skin infection, skin rash, cough, rhinorrhea, seizure activity,
fever, arthralgia or weight loss. His past medical history, family history and social history are
unremarkable.
Exam: VS T 37, P 100, RR 20, BP 120/75, oxygen saturation 100% in RA. Height and weight at 50th %tile.
He is tired appearing but in no acute distress. Pupils are equal and reactive. Optic disc margins are sharp.
Sclera are white and conjunctiva are clear. Mild periorbital is edema noted. TMs are normal. Throat, oral
mucosa and nose are normal. His neck is supple without lymphadenopathy. Heart is regular without
murmurs. Lungs are clear. Abdomen is diffusely tender (mild), without guarding or rebound. Bowel
sounds are normal. No organomegaly is noted. Mild CVA tenderness is present. His extremities are
warm, with strong pulses. Capillary refill is less than 2 seconds. No edema is noted in his legs, feet or
hands. No skin rashes or impetigo scars are noted. His genitalia are normal. No scrotal edema is present.
Neurologic exam is normal.
Ward case 6. Prolonged Fever
his is a 2 year old Japanese-Korean male presenting with 5 days of fever up to 39 degrees C (102.2
degrees F). On the second day of illness, he developed red lips and an erythematous maculopapular rash
over his torso. By the third day of illness, his conjunctivae were injected without exudates, his rash
involved his extremities, and he developed a strawberry tongue. On the fourth day of illness, he had
edema to his hands and feet with a diffuse red-purple discoloration over the palms and soles. His lips
were now cracked and bleeding. He was noted to be irritable and fussy, with decreased oral intake.
Exam: VS T 39.5, P 130, RR 40, BP 100/60, oxygen saturation 100% in room air. Weight and height are at
the 25th percentile. He is alert and slightly fussy, but he consoles easily and he is not lethargic. His
bulbar conjunctivae are injected with limbal sparing (less injected around the limbus where the cornea
fuses with the conjunctiva), but no exudates. His lips are red and cracked. His tongue is bright red. His
neck is supple with bilateral small lymph nodes. Heart is slightly tachycardic, with no murmurs or gallop.
Lungs are clear. Abdominal exam finds no abnormalities. He has some mild edema of his hands and feet
with some red-purple discoloration of the palms and soles wrapping partially around the dorsum with a
sharp demarcation at the wrists and ankles. He has a generalized deeply erythematous rash which is flat
with irregularly shaped pink-red lesions ranging from 1 to 7 cm in diameter, with some areas coalescing.
The lesions blanch. No joint swelling is noted. He moves all extremities well

ERCASE 1:Wheezing
A three year old comes in with a complaint of coughing for 2 weeks. Coughing is present every night. He
has also had a mild fever, but his temperature has not been measured at home. His parents have been
using a decongestant/antihistamine syrup and albuterol syrup which were left over from a sibling.
Initially the cough improved but it worsened over the next 2 days. He is noted to have morning sneezing
and nasal congestion. There are colds going around the pre-school. He has had similar episodes in the
past, but this episode is worse. He has no known allergies to foods or medications.
His past history is notable for eczema and dry skin since infancy. He is otherwise healthy and he is fully
immunized. His family history is notable for a brother who has asthma. In his home environment, there
are no smokers or pets.
Exam: VS T 38.1, P 100, RR 24, BP 85/65, oxygen saturation 99% in room air. He is alert and cooperative
in minimal distress if any. His eyes are clear, nasal mucosa is boggy with clear discharge, and his pharynx
has moderate lymphoid hypertrophy. He has multiple small lymph nodes palpable in his upper neck. His
chest has an increased AP diameter and it is tympanitic (hyperresonant) to percussion. Rhonchi and
occasional wheezes are heard on auscultation, but there are no retractions. Heart is in a regular rhythm
and no murmurs are heard. His skin is dry, but not flaky, inflamed or thickened.

ERCASE2: Abdominal pain

General Data:
Our patient is J.C., a 18yr /F from Makati who was brought to the OPD due to abdominal pain.
History of Present Illness
The patient presented with a 6-hour history of moderate pain in the right upper abdomen that began
after eating dinner and radiates through to her back. This pain gradually increased before becoming
constant over the last few hours. She has had previous episodes of similar pain since 1 month ago for
which she has not sought medical advice. She was only self-medicated with omeprazole 20mg/cap OD
and Buscopan which afforded temporary relief.
Ancillary History
Past Medical History: No previous hospitalizations or surgery, (-)no history of asthma ,
Family Medical History: (-) Family history of bronchial asthma or malignancy, (+) family history of sickle
cell disease, (+) family history of DM and hypertension
PHYSICAL EXAMINATION
General Survey
Awake, not in cardiorespiratory distress
Anthropometrics
Weight =79 kgs, height =160 cm, BMI = 30
Vital signs BP 120/90 HR 92 bpm RR 32 bpm T 36.5C O2 sats (room air) = 100%
Skin No rash, no jaundice
Head and Neck Pink conjunctivae, anicteric sclerae, (-) nasal congestion, (-) cervical lymphadenopathies
Chest and Lungs Equal chest expansion, (-) retractions, (-)rales, (-) wheezes
Cardiac Adynamic precordium, distinct heart sounds, normal rate and regular rhythm, no murmurs
Abdomen Normoactive bowel sounds, (+) tenderness to palpation in the right upper quadrant , (-)
guarding or rebound tenderness, (-) hepatomegaly, intact Traube’s space
Extremities Full and equal pulses, (-) edema/cyanosis/clubbing, CRT less than 2 sec

ERCase 3: Difficulty of Breathing

JC, 3 year old boy from Las Piñas came to the PEdia Er because of difficulty of breathing.
The condition started 7 days prior to admission as dry-non productive cough occurring
at nighttime. There was watery nasal discharge. No fever no vomiting noted. He was self medicated with
Salbutamol syrup and Phenylpropanolamine.
Two days prior to admission he had fever 38.2˚c, cough became productive with whitish
phlegm, consulted at Jonelta Clinic and was advised Salbutamol nebule 3x day and Paracetamol as
needed for fever.
One night before admission he was not able to sleep because of continuous cough and
there was loss of appetite. Few hours prior he experienced difficulty of breathing thus consulted at ER
and was subsequently admitted.
Physical Examination:
General survey: conscious, irritable, febrile in mild respiratory distress.
Vital Signs: weight 10kg, (50th percentile), height 80 cm, RR: 60 cpm Temp 38.2˚C
Skin: no cyanosis, no rashes
HEENT- Normocephalic, with alar flaring, palpable matted cervical lymphadenopathies
>0.5 cm in diameter, no tonsillopharyngeal congestion
Chest and Lung: Symmetrical chest, suprasternal intercostal retractions, no dullness, coarse crepitant
crackles and occasional inspiratory wheeze
Heart: Tachycardic, no murmur
Abdomen: flat, soft, no organomegaly
Extremities: no clubbing of fingers

ERCase 4: Anemia
A 20 month old boy presents to out patient department with a chief complaint of pallor. A neighbor
who has not seen the child for 3 months told his mother that the boy appears pale. The mother brings
him for a check-up and brought along a complete blood count with the following results:

Hemoglobin 7.5g/dL (12.0 – 16.0)

Hematocrit 23% (37.0 – 45.0)
6
RBC 3.3 x 10 /uL (4.3 – 5.5)
MCV 72 fL (83-97 fL)
MCH 20.2 pg (26-34 pg)
MCHC 26 g/dL (32 – 36 g/dL)
RDW 19%
WBC 5.5 10∧3/uL (4.4 – 11.0)
Segmenters 36%
Lymphocytes 56%
 Monocytes 8%
∧
Platelet count 213 10 3/uL (150- 450)

PHYSICAL EXAMINATION:
Conversant, playful, comfortable, not in respiratory distress
HR= 130/min RR= 30/min BP= 90/60 Wt= 12kgs
Anicterie sclerae, pale palpebral conjunctivae, no tonsillopharyngeal congestion
No chest wall deformity, equal chest expansion, clear breath sounds, No wheezes/rales/ rhonchi, no
masses
Adynamic precordium, no heaves/thrill, distinct heart sounds, regular rhythm, grade 1-2/6 soft systolic
murmur heart at the apex
Soft, flat abdomen, normoactive bowel sounds, no tenderness
Equal and bounding pulses, pale nailbeds, no edema, no cyanosis

ERcase5: Poisoning
A 16 year old male was brought to the PER because of loss of consciousness. Few hours prior to consult,
patient intentionally ingest a glass of silver jewelry cleaner because he was scolded by his father. He was
noted to have shortness of breath and vomiting. He was then brought to the Pedia Er. While on the
transport he was noted to have seizures and eventually noted unconscious. He was received in the ER
GCS9, hypotensive with BP 60/40, Hr 150, deep shallow breathing, poor pulses and CRT >5secs.

ERcase 6 Seizures
A 15 month old boy brought to the emergency department because of seizure
Few hours PTA: Patient was noted to have fever Tmax of 40 degrees Celsius. His mother gave him
paracetamol. About 20 minutes ago when the mother was checking up on her child, she noticed shaking
of the arms and legs and his eyes had a blank stare. This went on for what seemed like 5 minutes.
Patient was also noted to have cough and colds. There is no vomiting, diarrhea, rash, or
fussiness. Persistence of above signs and symptoms prompted consult.
Past medical history is unremarkable.
Family history is significant for an uncle who has epilepsy and Mother have history of febrile seizure
when she was a child.
Exam: VS T 39.8 degrees C HR 165, RR 30, BP 90/60, O2 sat 100% on RA. He is clingy, alert to his
surroundings, and otherwise is in no distress. Skin is without bruising or neurocutaneous stigmata.
Anterior fontanelle is closed. Pupils are equal and reactive. EOMs are conjugate. The red reflex is
present bilaterally. There is no sunsetting of the eyes. TMs are normal. His mouth exam shows moist
mucosa without erythema. The Brudzinski and Kernig signs are difficult to assess. Respirations are
regular. Neurologically, he moves both arms and legs equally. His tone appears normal. The rest of the
examination is normal.
ERcase 8 Upper Airway obstruction
A 20 month old male who presents to the emergency department with a chief complaint of cough. Two
days ago he developed rhinorrhea, fever, a hoarse cry and a progressively worsening, harsh, "barky,"
cough. Few hours PTA he developed a "whistling" sound when he breathes, so his parents brought him
to the emergency department. His past medical history is unremarkable. His 6 year old brother also has
cold symptoms.
Exam: VS T 37.5, P 140, R 36, BP 90/64, oxygen saturation 96% in room air. He is alert, with good eye
contact, in mild respiratory distress. He has a dry barking cough and a hoarse cry. He has some clear
mucus rhinorrhea but no nasal flaring. His pharynx is slightly injected, but there is no enlargement or
asymmetry. His heart is regular without murmurs. His lung exam shows good aeration and slight
inspiratory stridor at rest. He has very slight subcostal retractions. No wheeze or rhonchi are noted. His
abdomen is flat, soft, and non-tender. His extremities are warm and pink with good perfusion.
Developmental case
Tina is a three-year-old girl. She had an unremarkable neonatal history, Tina is able to make many
vocalizations and is able to say one recognizable word. Tina will say “juice”, which she pronounces as
“oos.” Throughout the day, Tina cries and falls to the floor to gain access to food, obtain a favorite toy,
or when she wants to be picked up. Her parents, Mr. and Mrs. Williams, would like to know what is the
problem with their only child? They do not know how to help her.