Clinical Case 118: Thinking outside the box

OK team – a Paeds case for you today.  It’s one where I am going to give you just a few clues and you have to think up the diagnosis.

Here we go…..

Jemimanisha is an 8  yo. girl who lives in an Aboriginal community about an hour away.

She has been brought to ED by her mother after being up all night complaining of a headache.  She has never had headaches before.  Her Mum is concerned that she ate too much junk food at her friend’s home the night before.

On further questioning – the headache is really quite global – she points at both parietal areas and rubs her head on both sides to show where it hurts.  She has had no recent URTI sxs, no fevers, cough or injury.  She isn’t bothered by lights or the ED noise.  Up until bedtime she was fine.  She woke around 11 PM with the headache &  slept in with her mother after that – her mum says she was restless and crying out all night long [Mum looks tired!].  This morning she vomited after eating toast.  Her belly feels OK and she reports no diarrhoea.

PMHx:

  • Obese with a BMI of 32 [currently seeing dietician]
  • Recurrent ear disease with grommets as a child, multiple presentations with acute OM in last 5 years. None recently.
  • Had a laceration to her ankle last month that required repair under sedation in ED – that went well and she was discharged.  Wound healing OK.

On examination

  • Afebrile, HR 90 SR, well perfused,  SpO2 = 99% RA,  RR = 15/min
  • Neuro exam is NAD – PEARL, no meningism, walking well, coordinated and fundi look ok – no papilloedema.
  • ENT – old scarred TMs bilaterally, no coryza, throat NAD
  • Chest and abdo unremarkable, soft, no signs of lung disease
  • No LN or rash, mucosa looks moist.
  • Leg wound has healed but there is a 3mm dehiscence of the edge of the scar – there is clear, serous fluid oozing out.  It is non-tender, no pus or cellulitis.

OK, that is all I am going to give you at this stage…

Here are the questions:

Q1:  What further information do you want [it is a weekend in Broome – so no labs or X-rays !]

Q2:  What is the diagnosis?

Q3:  What do you need to confirm the diagnosis?

I am sure you super sleuths can work this out!  Who is fastest?

OK – after that whirlwind diagnostic Tweetoff – I have uploaded a BroomeDocs podcast looking at the diagnosis and the our recent experiences with this disease here in the Kimberley – there’s a few pearls in there if you care to listen – 10 minutes!

The summary – its a disease that you will not diagnose if you do not think about it!  Ok Here is the podcast:

DIRECT DOWNLOAD

 

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