St.

Georges University, School of Medicine Department of Pathology Clinico-pathological Conference (CPC) 5 November 21st, 2013

General Guidelines for doing a CPC (This is an individual exercise geared towards demonstrating independent and lifelong learning) Please do not consult or discuss With anyone else including fellow students or faculty

Dr.Ajay Kumar and Dr.Hussam Hussain

1. Analyze the symptoms and signs. Is it an acute or chronic process? Which organ systems are involved? Analyze the course of the illness. a. Make a list of points in favor and against each of your possibilities. b. What investigations would you like to do? Explain the reason for each investigation and what results you expect. c. Make a list of points you cannot explain based on your present list of diagnoses. Is there anything else you would have liked to know as far as symptoms and signs are concerned? Why?

2. Interpret the results of investigations provided. a. Explain how they support or move you away from each of your initial diagnoses. Revise your diagnostic possibilities. b. Is there any other investigation you would have liked to perform? Why?

3. Comment on the therapeutic approaches. a. Were they justified? b. Was anything lacking in the management?

4. Summarize your final diagnostic possibility (ies).

5. What diagnostic procedures were indicated in the end? What results do you expect to get from it?

6. Write up the detailed analysis submission at the start of the CPC and be prepared to make a 15 - 20 minutes presentation to your group if you are chosen? If your name is not chosen for the presentation, you should be prepared to participate intelligently in the discussion that follows the presentation

The Case A 7-month-old male child is brought to the emergency department because of an involuntary jerking movements of all the extremities 2 hours ago. The episode was self-limiting and lasted for 2-3 minutes; the child was unresponsive during the episode. The mother also states that the child had fever, irritability, lethargy and refusal of feeding for last 2 days. There is no history of similar symptoms in the past or any medical problems. He was born at 32 weeks of gestation and was admitted to neonatal ICU due to prematurity. He was exclusively breast fed for the first 6 months of life and formula feeding was started 4 weeks ago. His developmental milestones are normal but his weight and height are less for his age. His vaccinations are up-to-date. He is not known to have any history of allergy. He has no family history of seizures. His mother is a business executive and just started working again while his father lost his job recently and stays at home and takes care of the children.

http://www.uwhealth.org/health/topic/special/vital-signs-in-children/abo2987.html

Vitals: temp: 100.40F (!"#$%, BP: 85/50 mmHg, HR: 120/min, RR: 40/min. Physical examination: Reveals a conscious, irritable child, with bulging anterior fontanelle, increased head circumference and pallor. CVS: S1 and S2 are heard Chest: bilateral vesicular breath sounds Abdomen: normoactive bowel sounds with no organomegaly Laboratory Investigations: CBC: Hb-9 g/dL, WBC-17,500 /mm3, Platelets-300,000/mm3 He was treated in the ER and admitted to the ward for further work up and reassessment. Questions: 1. Enumerate the likely etiologies and differential diagnosis at this stage? 2. Delineate the pathophysiologic basis of his clinical presentation. 3. List additional investigations that would be helpful in this patient with the reasons and the expected results. 4. List the possible complications of his pathology.

&6 weeks later, he was brought to the emergency room unresponsive with apnea after a

generalized seizure. The parents state that they only brought him to the emergency room because he started coughing with difficulty in breathing while he was playing with toys. He requires 10 min of cardiopulmonary resuscitation, after which he is noticed to have a bulging fontanel and bilateral retinal hemorrhages. Examination

CVS: Normal heart sounds are auscultated with non-displaced point of maximal impulse Chest: Vesicular breath sounds with decreased air entry to the right lung Abdomen: Normal contour, no organomegaly Laboratory Investigations: CBC: Hb: 9.1 g/dL, WBC: 12,000/mm3, Platelet count: 280,000 /mm3 Chest X-ray: A chest film reveals two posterior rib fractures on the right hemithorax Questions: 1. Enumerate the possible differential diagnosis for this presentation. 2. Delineate the pathophysiology of his condition. 3. List additional investigations that would support your diagnosis 4. Outline the preventive measures that should be implemented