Council on Medical Student Education in Pediatrics

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COMSEP Clinical Cases

COMMON ACUTE PEDIATRIC ILLNESS

Symptoms
Physical Findings


SYMPTOMS

Cough

Fever

  1. A two-week-old presents with a fever of 101° F. She has been feeding a little less than normal and there has been no vomiting or diarrhea. Her physical exam is normal. What makes this patient concerning and why? How would you evaluate and manage this patient?
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  2. A seven-month-old girl presents to your office with a one day history of fever to 103° F, mild irritability, and poor feeding. The physical exam is normal without any localizing findings. What are your concerns? How would you evaluate and manage this patient?
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  3. An eight-year-old presents with a fever of 102° F and headache. He has positive meningeal signs including nuchal rigidity. What other physical findings would you try to elicit? How would you evaluate and manage this patient?
  4. A six-month-old has had a high fever for three days and has been seen in your office for the last two days. He has had a normal exam on both of those visits. On the fourth day he breaks out with an erythematous macular-papular rash all over shortly after his fever breaks and he is very fussy. What is the most likely diagnosis? How would you manage this patient?
  5. A seven-year-old girl presents to your office with a history of two days of cough, coryza, conjunctivitis and a fever to 103° F. Today she developed a red macular-papular rash that started on her face and neck and it is spreading caudally. What are your concerns? How would you evaluate and manage this patient?
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  6. A four-year-old boy presents with a five-day history of fever and rash. He has received acetaminophen and amoxicillin without improvement. He is very irritable with a temperature of 103.6° F, bilateral non-purulent conjunctivitis, enlarged cervical nodes, puffy hands and a maculopapular rash. What is the most likely diagnosis? How would you evaluate and manage this patient?

Sore Throat

  1. A six-year-old presents with a fever, headache, sore throat, and raised, rough, red rash in his trunk and abdomen. There are no symptoms of a URI. What is the most likely diagnosis? How would you evaluate and manage this patient?
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  2. A nine-year-old presents with a sore throat and fever of 101° F. He has a cough and runny nose. There are small minimally tender anterior cervical lymph nodes and a red pharynx without exudate. What is your differential diagnosis? How would you evaluate and manage this patient?
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  3. A fourteen-year-old female present with fever, headache and sore throat. She has exudates on her tonsils, an erythematous posterior pharynx, enlarged posterior cervical lymph nodes and a palpable spleen. What is your most likely diagnosis? How would you manage this patient?
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Otalgia

  1. An eight-month-old male with a four-day history of URI symptoms presents with fever, irritability and pulling at his left ear for the past 24 hours. What physical findings would be consistent with an acute otitis media? How would you treat this patient? How would your management change if the patient were 3 year-old?
  2. A fifteen-month-old was treated for acute otitis media three weeks ago. Today, both tympanic membranes look dull, gray, and have poor mobility. The parents are concerned that his hearing appears abnormal. How would you manage this patient? What if these findings were still present four months later?
  3. An eleven year-old presents in July with left ear pain. He has been afebrile and there has been drainage from the canal. He refuses to let you touch his ear. What is your diagnosis? How would you treat this patient?

Nasal discharge

  1. A three-year-old presents with runny nose, mild irritability, with temperature of 99° F over the past forty-eight hours. Other than clear nasal discharge his examination is unremarkable. How would manage this child? What advice would you give the parents?
  2. An eleven-year-old has springtime nasal congestion and itchy eyes which have become more of a problem over the last three years. How would you manage this child?
  3. A sixteen-month-old presents with a history of nasal discharge for the past week presents with a swollen red eye and fevers to 103° F. What are you most concerned about? What physical findings are important to look for in this patient? How would you proceed if you could not visualize the globe because of the swelling?

Abdominal Pain

  1. A ten-month-old presents with bouts of irritability during which he draws up his legs and appears to be in pain. He had a viral illness the previous week. His stools are hematest negative and he is very lethargic. There is abdominal distention and diffuse tenderness. What is your differential diagnosis? What is the most likely diagnosis? How would you evaluate this patient?
  2. A three-year-old girl has had forty-eight hours of fever, vomiting and diarrhea. How would you evaluate her hydration status? Discuss management principles based on diagnosis and physical exam findings.
  3. A fourteen-year-old male present with six hours of severe abdominal pain that is now more right sided. He has vomited twice and has no appetite. He has had no diarrhea. There is localized pain in the right lower quadrant. What other history and physical findings would be important in this boy? How would you evaluate this patient? How would your approach differ if the patient were a girl?
  4. An eight-year-old female present with abdominal pain, purpuric lesions on the buttocks and lower extremities, and knee and ankle pain. She has also noted her urine to be darker than usual. What is the most likely diagnosis? How would you evaluate this patient? What treatment options are available?
  5. The mother of a fourteen-month-old baby feels an abdominal mass while giving her son a bath. On physical examination you palpate a mass in the left upper abdomen. What is your differential diagnosis? How would you evaluate this child?

Diarrhea

  1. A six-year-old boy presents with pallor and irritability following a week of abdominal pain and blood tinged diarrheal stools. What would you be most concerned about? How would you evaluate and manage this patient?

Constipation

  1. 1. A six-year-old presents with chronic abdominal pain of six week's duration and episodic fecal soiling of his underwear. He has been gaining and growing well. How would you evaluate this patient? What advice and treatment plans would you offer to this family?
  2. The parents of a three week-old male are concerned because their child squirms and grunts while having a bowel movement. The stools are soft and the child is thriving. How would you counsel these parents?

Rashes

  1. A four-year-old girl presents to your clinic with a diffuse pruritic rash. She has numerous evanescent raised erythematous lesions with serpiginous borders and blanched centers. What other information would you like to know about this patient? What other physical findings would concern you? What is the appropriate diagnosis and treatment of this condition?
  2. A four-year-old presents with a dry, erythematous, itchy rash in the antecubital and popliteal fossae. What are the most likely diagnosis and appropriate therapy?
  3. An eighteen-month-old presents with many golden-yellow crusted-weeping lesions around the nose which seem to be spreading according to the child's parents. Discuss the likely diagnosis and management considerations.
  4. A five-year-old boy presents following a dog bite on the back of his hand. What is the initial management for this patient? How would your management change if this were a superficial wound on his leg? What if the bite was from a cat?
  5. A two year-old girl is bitten by a bat while playing in her yard in the early evening. Would you recommend rabies prophylaxis?
  6. A fifteen-year-old boy is concerned that his acne is worsening. He has multiple open and closed comedones scattered over his face. How would you counsel and treat this patient?

Limb/joint pain

  1. A fifteen-year-old girl badly twisted her ankle while playing basketball earlier in the day. What advice would you give her? What are the indications for a radiograph? How would the management change if this were 6 year- old boy?
  2. An athletic twelve-year-old boy complains of pain just below the right knee when running and playing soccer. There is no joint swelling or redness. There is pain on palpating the right tibial tuberosity. Discuss the most likely cause and treatment.
  3. A seven year-old boy complains of pain in his hip and walks with a limp. There is no history of trauma or fever and his past history is non-contributory. What is in your differential diagnosis and how would you evaluate this patient?
  4. A fifteen year old, slightly overweight male, presents with pain in his left hip. There is no history of trauma or fever. What is in your differential diagnosis? How would you evaluate this patient?
  5. .
  6. A fourteen-month-old girl presents with the sudden onset of fever and refusal to walk. Discuss your differential diagnosis and evaluation of this child.
  7. A five-year-old present with a swollen red knee. Discuss your differential diagnosis and evaluation of this child. How would your differential diagnosis change if he later developed swelling of the knee and wrist?
  8. During a routine physical examination, you notice a curvature of the spine in a fourteen year-old female. What other information is important to document on your physical examination? How would you evaluate this patient?

CNS problems

  1. A fourteen-year-old girl presents to the ER with a right-sided headache, which she describes as "the worst headache I've ever had". She reports seeing "flashing lights" prior to the onset of the headache. Discuss your initial assessment and treatment of this patient.
  2. A nine-year-old boy is complaining of headaches for the past two weeks. His mother brings him to the pediatrician for evaluation. Discuss your differential diagnosis and key elements of the history and physical exam.



PHYSICAL FINDINGS


Heart murmur

  1. On routine physical exam a five-year-old girl is found to have a heart murmur. How would you distinguish between and innocent and a pathologic murmur? What information and anticipatory guidance should you give the parents of a child that has an innocent murmur?
  2. You are examining an otherwise healthy one-month-old child and detect a systolic murmur along the left sternal border that radiates to the back. What would you tell these parents and how would you manage the patient?

Lymphadenopathy

  1. A ten-month-old girl present with recurrent pneumonia and failure to thrive. She has thrush and numerous axillary and inguinal nodes. How would you evaluate this patient?
  2. A six-year-old, previously healthy, girl presents with a 3 by 5 cm tender anterior cervical lymph node. What historical and physical examination information is essential to develop an appropriate differential diagnosis?
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Splenomegaly

  1. A four-year-old boy presents with fevers and malaise for a week. He appears pale, has diffuse petechiae, palpable axillary lymph nodes, and his liver and spleen are both enlarged. What is your differential diagnosis? How would you evaluate this patient?
  2. A two-year-old boy with sickle cell disease presents with the sudden onset of pallor and has an enlarged spleen on examination. What would you be most concerned about?

Hepatomegaly

  1. A four-year-old child presents with nausea, vomiting, fever, and fatigue. On physical exam he has scleral icterus and a tender liver edge palpable 3 cm below the costal margin. Discuss your plan for evaluating and treating this patient. What prophylactic measures are necessary?

Possible impaired vision

  1. The parents of a four-month-old are concerned because her eyes cross. What are your concerns? How would you evaluate this patient?
  2. You are unable to see a red reflex when examining the eyes of a newborn. Discuss the causes and your approach to this patient.

Impaired hearing

  1. The parents of a two-year-old boy are concerned that he doesn't appear to hear. How would you evaluate the patient and counsel the parents?

Bleeding

  1. A previously healthy two-year-old present with persistent nosebleeds over the past two days and petechiae on her extremities. What is your differential diagnosis? How would you evaluate this patient?
  2. On a routine health supervision visit a one-year-old boy is found to have an Hgb of 8.8, Hct of 27%, an MCV of 68, and an RDW of 17. What is your differential diagnosis? How would you manage this patient?

Hematuria/Proteinuria

  1. A ten-year-old boy complains of "dark urine" and a headache. Discuss your diagnostic approach to this patient.
  2. A three-year-old boy is brought to the pediatrician because of puffy eyes, swollen legs, an enlarged scrotum, and a sudden weight gain. What is your differential diagnosis and how would you evaluate this patient?

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