The parents of a 2-year-old female bring her in to - abrahem

[ArchivalUser]

The parents of a 2-year-old female bring her in to your office for a weeklong history of diarrhea. Initially, her stools were loose and watery, but over the last few days, they have become bloody. The patient has appeared to have abdominal pain on occasion, and her appetite is depressed. Despite bloody diarrhea, her parents attempted to care for her at home until she became more lethargic. They are also worried about some bruising on her extremities.

The nurse takes her vital signs: temperature 37.2° C, pulse 145, blood pressure 88/47, and respiratory rate 40. The patient appears pale, with slight scleral icterus. You note petechiae and purpura on the extremities. Her abdomen is diffusely tender. She responds to commands but appears very lethargic.

While you are arranging her admission to the hospital, some laboratory tests return: Hgb 8 g/dL, Hct 24%, WBC 14,000/mm3, platelets 50,000/ mm3, Na 128 meq/L, K 3.9 meq/L, HCO3 14 meq/L, BUN 38 mg/dL, creatinine 2.1 mg/dL. The peripheral blood smear shows schistocytes, burr cells, and grossly reduced number of platelets.





1
Which of the following is the most appropriate INITIAL management of this patient?
A) Intravenous fluids.
B) Dialysis.
C) Platelet transfusion.
D) Corticosteroids.
E) Antibiotics.


2
Based on the available information, which of the following is the most likely diagnosis?
A) Thrombotic thrombocytopenic purpura.
B) Hemolytic uremic syndrome.
C) Postinfectious glomerulonephritis.
D) Henoch-Schonlein purpura.
E) Autosomal recessive polycystic kidney disease.


3
From the BLOOD culture, you expect to find:
A) Shigella species.
B) Escrichihea coli.
C) Streptococcus pneumoniae.
D) No bacteria.

[ArchivalUser]

A
B
B or D???D

[ArchivalUser]

A
B
B

[ArchivalUser]

The parents of a 2-year-old female bring her in to your office for a weeklong history of diarrhea. Initially, her stools were loose and watery, but over the last few days, they have become bloody. The patient has appeared to have abdominal pain on occasion, and her appetite is depressed. Despite bloody diarrhea, her parents attempted to care for her at home until she became more lethargic. They are also worried about some bruising on her extremities.

The nurse takes her vital signs: temperature 37.2° C, pulse 145, blood pressure 88/47, and respiratory rate 40. The patient appears pale, with slight scleral icterus. You note petechiae and purpura on the extremities. Her abdomen is diffusely tender. She responds to commands but appears very lethargic.

While you are arranging her admission to the hospital, some laboratory tests return: Hgb 8 g/dL, Hct 24%, WBC 14,000/mm3, platelets 50,000/ mm3, Na 128 meq/L, K 3.9 meq/L, HCO3 14 meq/L, BUN 38 mg/dL, creatinine 2.1 mg/dL. The peripheral blood smear shows schistocytes, burr cells, and grossly reduced number of platelets.


1 Which of the following is the most appropriate INITIAL management of this patient?

A) Intravenous fluids.


B) Dialysis.


C) Platelet transfusion.


D) Corticosteroids.


E) Antibiotics.



The correct answer is A. The proper initial management consists of supportive therapy. This patient has signs of dehydration, which is also expected from the history of prolonged diarrhea. She is hyponatremic, and isotonic (0.9%) saline is the IV fluid of choice. Although she has had diarrhea, her potassium is currently in the normal range, probably due to decreased glomerular filtration. Given her renal failure, potassium should not be in her IV fluids.





2 Based on the available information, which of the following is the most likely diagnosis?

A) Thrombotic thrombocytopenic purpura.


B) Hemolytic uremic syndrome.


C) Postinfectious glomerulonephritis.


D) Henoch-Schonlein purpura.


E) Autosomal recessive polycystic kidney disease.



The correct answer is B. Hemolytic uremic syndrome (HUS) is the most likely diagnosis. This patient presents with a classic history of uremia and hemolysis preceded by 5“7 days of diarrhea. Patients tend to become oliguric and sometimes anuric. Answer A, thrombotic thrombocytopenic purpura (TTP), is a related disorder that is rare in infancy. TTP tends to occur in young adults, with women making up about 70% of all cases. In contrast to HUS, patients with TTP present with fever and bleeding. Usually, there is a prodrome of viral illness, but diarrhea occurs only rarely. TTP may present with the classic pentad: thrombocytopenia, fever, mental status changes, renal insufficiency, and hemolytic anemia. See the Chapter 6, Hematology and Oncology, for a further discussion of these entities.

Answer C, postinfectious glomerulonephritis, usually occurs after pharyngitis or skin infection with group A beta-hemolytic streptococci. Common symptoms include edema and hematuria.

Answer D, Henoch-Schonlein purpura, is a transient IgA vasculitis following upper respiratory infections in children and adolescents. There should not be an antecedent history of diarrhea. Autosomal recessive polycystic kidney disease is a rare disorder that presents early in childhood with abdominal masses, hypertension, urinary tract infections, and renal failure.

Helpful Tip: HUS may occur without diarrhea. This subtype of HUS occurs less frequently, is associated with Streptococcus infections, and carries a poorer prognosis.





3 From the BLOOD culture, you expect to find:

A) Shigella species.


B) Escrichihea coli.


C) Streptococcus pneumoniae.


D) No bacteria.



The correct answer is D. Although HUS is the result of bacterial enteritis, the syndrome is not mediated by bacteremia. Instead, the endothelial damage and hemolysis is caused by Shiga toxin, released from E. coli and Shigella dysenteriae. Specifically, E. coli O157:H7 is responsible for hemolytic uremic syndrome.