HELP ON DIAGNOSIS

Nino Caruncho IV nino at mnl.sequel.net
Tue Mar 18 22:34:58 EST 1997


I have a patient who died and I am stumped as to the reason he died. I
wonder if any of you can help me diagnose it.

Please reply to nino at mnl.sequel.net

Or refer me to any area on the internet I can find help.

THANKS!!

CLINICAL ABSTRACT

	B.C.  a 3 y/o male from Paco, Metro-Manila admitted for the
first time.

CHIEF COMPLAINT
Generalized edema of 15 days duration.  Right maxillary and abdominal
masses of 14 days duration.

HISTORY OF PRESENT ILLNESS
The present condition started 17 days PTA as toothache involving the
maxillary incisor and right upper molar with associated low grade
undocumented fever for which a dentist was consulted.  The patient was
then referred to PGH where Ampicillin  5 ml every four hours was given
but there was no relief.
	Fifteen days PTA, right periorbital edema was noted which was
more prominent in the morning and receded in the afternoon.
Fourteen days PTA, slight abdominal enlargement was noted and while
bathing the child, the mother felt a mass in the hypogastric area,
described as smooth, nontender, fluctuant.  A physician was consulted
and abdominal x-rays taken which was read as normal.  Diagnosis given
then was gas pains.  Antispasmodics were prescribed but were not given
to the patient.
	Twelve days PTA, progressive abdominal enlargement and mass
persisted.  They requested transfer to Ospital ng Maynila.
	The patient stayed 11 days at the Ospital ng Maynila,
initially admitted at the Surgical Ward where IVP, UGIS, Ba Enema,
blood exams, and USG were done.  Medications give were Bisacodyl,
furosemide, Agarol, prednisone,  and ampicillin.  During his stay in
the surgical ward, decrease in the frequency of urine was noted so he
was transferred to the Pediatrics Ward where he was noted to be
hypertensive - he was then started on hydralazine and  Serpasil .  He
was then transferred to the present hospital for further management.

PAST HISTORY
Birth:  Born to a 24 year old G3P2 (2002)  mother at Fabella Hospital.
No complications, no cyanosis after birth.
Feeding:  Breastfed up to 7 months alternating with Pelargon 1:2
dilution 2-3 times/day.  Vitamins started at 5 months.  Supplementary
feedings started at 3 months.  No allergy, no vomiting.  At present,
patient has good appetite.
Immunization:  BCG at 3 months.
Developmental:  At present, the patient can dress, bathe  and feed
himself.  He talks in complete relevant sentences.
Past Diseases:  Measles at 2 years old, URI once a month, diagnosed
asthmatic at 2 years old.  Had tonsillitis twice since birth.
Family History:  Father has asthma, mother has breast cyst.  (+)
history of hypertension, heart disease RHD and Koch's, no cancer in
the family.  An aunt (first degree) had some generalized edema at 4
years old, confined at PGH for 2 years old, and diagnosed to have a
kidney disease.

PHYSICAL EXAMINATION:

Weight: 15.5 kg (90th ile)                Height: 91 cm (75th ile)
BP:  130/100 mmHg                        PR: 100/min
RR: 40/min                                      Temp: 36.7 C

General:  F/N, F/D, generally pale, with generalized edema, awake,
conscious, not irritable.
HEENT:  Slightly pale conjunctivae, non-icteric sclerae, bilateral
severe periorbital edema, generalized edema of the face but more on
the right side. Hard mass on the right maxilla with ill-defined
borders; with minimal flaring of the right alae; (+) tender swelling
of the hard palate and gums on the right side, the palate seems to be
pushed down by mass on maxilla.  With posterior cervical
lymphadenopathy measuring 1-2 cm in its widest diameter, smooth,
movable, non-tender.
Chest:  Equal expansion, with slight intercostal retractions
Lungs: Harsh breath sounds
Heart:  Tachycardic, no murmurs
Abdomen:  AC 62 cm, distended, shiny, tense with prominent veins,
hypoactive to absent bowel sounds, tympanitic all over, dull on
flanks, liver area of dullness 10 cm; spleen not palpable, (+) cystic
mass on the hypogastric area, with ill-defined borders, non-tender.
Extremities: Grade 4 non-pitting edema, no edema on upper extremities.
Neurologic:  Awake, conscious, slightly irritable, no gross deficits.

LABORATORY EXAMINATIONS

Hematology	1-28	1-29	2-2	2-4	2-5	2-11	2-12
Hb	8		12.5	5.3	9.2	6.0	9.2
Hct	26		42	16	28	18	30
MCHC	31		30	33	33	33	31
Retic Ct		0.6					
WBC	4500		9150	27250		7350	4800
Seg	38		63	34		43	26
Stab	5			4			1
Lympho	56	          	36	60		56	73
Mono	1		1	1		1	
Baso				1			
Platelet	170,000			Normal		120,000	
RBC		3850					
ESR 		18					
RBCmorph	hypochromic		hypochromic	hypochromic
hypochromic	
NRBC				8/100		5/100	
TIBC		65					

Hema II	2-2    	2-4	2-5	2-6	2-9	2-12
Protime	11.8		18.6	17.1	15.7	14.6
Control	125		24.4	14.4	12.5	12.5
Bleeding time		3'35"				1'00"
Clotting time		4'50"				12'00"

Stool Exam: RBC 0-1/hpf, WBC  0-1/hpf
24 hr Protein (1-30): 0.2 gm; vol 300cc
ECG (2-1): Within Normal Limits
Urine Creatinine Clearance: 1-31:  1.3  (With corr: 3.51 cc/min/1.73
m2)
                             Urine Na: 3-31:  105
	  	       Urine K  : 3-31:  1.1

Urinalysis	1-29	2-2
Color	Light yellow	Yellow
Transparency	Clear	Clear
Reaction	Acidic	Acidic
Specific Gravity	1.018	1.010
Protein	Negative	Negative
Sugar	Negative	(+)
RBC	1-2	0-1
WBC	(-)	2-5
Casts	(-)	(-)

ABG (2-2)	PH                 7.25
	              PCO2            30
	              PO2               110
	              CO2 content  17.5 meq/L
	              HCO3            16.5
	              O2 Satn          96%
C3   79 mg%
CRP (+)
ASO 50 todd units

Chem 	1-28	1-31	2-1	2-2	2-3	2-4	2-5	2-7
2-11	2-13
Na	138			138	140
138
K	4.8		4.3	4.4	5.8
4.4
Cl	88			84	83
88
TP	6

A	2.7

G	2.3

BUN	69			74				80
82	
Crea	6			6.1				4

Chol	231

Ca				10		9.1

AlkPho				1.31

T Bili					0.8

Conj Bili					0.4

SGPT					2

SGOT					20

U. Acid						29.5	29.0	22.5
12.1	
Phosp					5.2

Glc							128
77
X-RAYS:
Small Bowel Series (1-29):  
	Findings in the small intestine in which primary consideration
is lymphoma
Paranasal Sinuses (1-29)
	Soft tissue swelling R maxillary area
	Sinusitis both maxilla
KUB (2-4)
	KUB taken after CT scan shows excretory opacification of both
proximal systems, however, renal outlines are obscured. Morphological
alteration in the proximal collecting system cannot be ascertained in
this study.  No abnormal finding in the bladder.
Plain Abdomen (1-28)
	Slight prominence of the lng markings, may first be due to the
elevated hemidiaphragm, however, this being a nonspecific congestion
cannot be ruled out.
	Ascites.
CT Scan (2-4)
	Marked hepatomegaly
	Bilaterally enlarged, poorly functioning kidneys.  No evidence
of obstructive  hydronephrosis.
	Large intra-abdominal mass, R lower abdomen.

COURSE IN THE WARD
On admission, the patient was anasarcous, hypertensive with a BP of
130/100, afebrile, pale, and azotemic so that blood and renal work-up
were done, e.g., CBC, CXR, abdominal x-ray, RBC, reticulocyte count,
serum iron, C3 were done.  Urinalysis, ESR, CRP, BUN, Creatinine,
cholesterol, ECG.  Daily renal charting and urinalysis were done.
Because of the right maxillary mass, an x-ray of the sinuses were
requested.  Renal consult was done on the 2nd hospital day and an
impression of renal failure secondary to post renal etiology was given
and that  the hypertension was explained to be secondary to the renal
pathology or furosemide abuse.  Fluid limitation was advised and
computed to insensible loss plus ½ of the urine output for the last 8
hours.  Bone marrow aspiration biopsy was attempted but was
unsuccessful.  Small bowel series was requested to delineate the
extent as well as the location of the abdominal mass which was noted
on the plain abdomen.  Patient continued to have good appetite and was
afebrile with good urine output (estimated at 60% of the total intake
every 8 hours).
	On the third HD, referral to ENT service for biopsy of the
maxillary mass was made but because of low hemoglobin (4 mg%) the
service deferred the procedure.
	On the 4th HD, 80 cc of pRBC was transfused.
	On the 6th HD, the gingivo-labial mass biopsy and repeat bone
marrow aspiration biopsy were done.  After the surgery, the patient
had spikes of temperature.  Antibiotics (Ampicillin at 100 mg/kg/day)
and antipyretics were given.  Antibiotics were given at 12 hours
interval because of the deranged renal function.  On the 7th hospital
day, CT scan was done, after which hemoglobin was noted to be 5.3 gm%
but the CT and BT were normal.  At this point, the patient was noted
to have melena and increase in uric acid level.  One hundred fifty cc
of properly cross-matched and typed pRBC was given and patient was
started on allopurinol (10 mg/kg/day)
	On the 8th HD, the patient was noted to have melena twice
amounting to 20-30 cc per BM and protime at the time was prolonged.
Vitamin K 5 mg IV was given.  On the 9th HD, repeat protime done still
revealed prolonged protime and another dose of Vitamin K was given,
At this time, no melena was nted.  Hematological consult  was done and
fresh frozen plasma transfusion was advised because Vitamin K failed
to correct the protime effectively and deficiency in the clotting
factors was entertained.
On the 10th HD, a referral was sent to Surgery for the abdominal mass
and the assessment was a small intestinal mass with no signs of
obstruction.  Chemotherapy was suggested to diminish the size of the
mass, no surgical procedure was advised.
	On the 11th HD, patient had on and off low grade fever with
progression of edema.  The patient was also noticed to have marked
pallor and stat hemoglobin done revealed 6 gm%. One hundred forty cc
pRBC was transfused. Repeat Hb post-BT was 9.3 gm%.
	On the 12th HD, the patient was noted to have coughed out
clotted and fresh blood associated with dyspnea and marked pallor.
Crepitant rales were heard on auscultation.  RBC, CT, BT, protime were
requested. NGT was inserted and lavage done.  Al(OH)3 Mg(OH)2 was also
started.  Digitalization was started to support the patient's heart.
Despite intensive medical treatment, vomiting of fresh and clotted
blood continued, leading to the patient's demise.




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