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:
PEMLit Review: Ultrasound for bronchiolitis?
Case 0003 – Beyond opiates in Chronic pain
Lessons Hard Learned – Episode 6 with Dr Melanie Thompson
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
beingn intracranial htn due to obesity
Test with LP opening pressures
I’ll bite.
1. IIH
2.and 3. USS optic nerve. Then CT. Then LP for pressure
Thanks Prof,
Of course we can do ONSD at any hour! But in this case it was normal. No evidence of raised ICP. There is actually a bit of data for this in Kids from Neuro ICU world.
Sorry – no CT needed here – think simple.
C
What’s the blood glucose and can I at least have a venous blood gas?
OK
Just for you Tori!
BSL is normal = 6.0 mol
VBG shows all normal aside from a very slightly raised K+ of 5.2 mol
We do a lot of VBGs on my shifts! Casey
Is it a Cluster headache..
Nope.. Not unilateral or periorbital, no tearing. Uncommon in kids. Think outside the box. Chaitra – you know this one – you are an ex-Broome Doc!
what’s her BP?
AHah – we have hit the crux of the problem. This 8yo has a BP of 195/110. A quick review of her recent Anaesthetic chart – she had a BP of 90/60 [normal]
Now we are getting somewhere!
Hi Casey,
First time poster:
I am thinking that the leg wound is a worry. Also high burden of strep (aboriginal, recurrent AOM).
??Headache related to leg wound and strep bacteremia.
So swab leg wound.
Good thoughts. You are right about the streptococcal disease part. Thought the leg is not infective. Just a tiny wound leaking clear, watery transudate.
urine dipstick please…
(Lurker with insomnia!)
Ahah – another good question.
So now her BP is super high and her urinalysis reveals:
protein 4++++, blood +++, no leukos, nitrite or glucose…
Erin – I think you know the answer…
C
I will like to know a bit more on the onset n pattern of the headache( constant vs intermittent) + other associated feature of the headache like if there r visual symptoms during headache episodes. What r the relieving n precipitating factor, drug history n family history?Any recent head trauma? What is the child’s blood pressure ?Differential diagnosis will depends on the above Qs ranging from new onset atypical migraine, dehydration, hypertensive headache to worrying underlying bleed n early insidious infection. Tough ones include underlying psychological issues ?bullying or is the patient seeking help for something else. I am going to add rare secondary endocrine cause of headache to the bottom of the list to keep in my mind. Time can be use as a dignostic tool if patient is clinically stable.
post streptococcal glomerulonephritis… (i’m so far outside the box…)
want a urine dip as well: proteins?
BINGO!
Dr PAtrick Buxton got there first on Twitter!
PSGN – it is common in my part of the world.
Headache, peripheral oedema (manifesting as a leaky leg wound), hypertension, proteinuria.
She also has some facial oedema which is subtle and only really something her mother notices once asked directly!
Great work team.
C
Yep – you got it – see above comments!
Post strep GN ?
Blood pressure
Cushings – headache, poor wound healing, obesity, allergic otitis media
24 hour urinaty cortisol
Early onset type ii diabetes- dipstick urine ketones and sugar make sure not dehdrated , consider HONK
Take much to get her BP/headache under control Casey? What were your acute targets?
Good question! 1 dose of nifedipine did the trick. Target for me would be to get rid of the headache or other sign of malignant hypertension (e.g.. if they are in APO etc)
You will need to ask a smarter renal doctor what they think a fair target is!
C
You’re like Agatha Christie. You always leave out one critical piece of the puzzle, without which you can’t figure out that it was actually the butler what did it!
Unsure if that’s a good thing!
That is the way medicine happens – diagnosis requires imagination. Imagine “what if the pt also has hypertension”
C