JAUNDICED INFANT: CLINICAL CASE PRESENTATION

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              History taking and Clinical case presentation INFANT WITH JAUNDICE:
INTRODUCTION:

XYZ, a 8 months old girl baby, 1 st born out to non- consanguineous parents, Hindu by religion, resident of Howrah, came to OPD with her mother for her follow up today. Informant being the mother Lata, who seems to be very reliable.

CHIEF COMPLAINTS:

1. Yellowish discoloration of skin and urine since 2 months of age
2. Pale colored stool for same duration

HOPI:

As the history dates back to 2 months of age and the condition seems to be antenatal in origin we can start from antenatal or natal history in HOPI.

Antenatal

This was the first pregnancy of 25 year old Lata. She was registered case and received iron, folic acid, calcium and TT. She did not have any complication like diabetes, hypothyroid or hypertension. No H/O fever, rash, lyphadenopathy. 2 USG were done, both normal.

Natal

Deliverd by NVD at term, cried immediately after birth, Birth weight- 2.4 kg. No PROM.

Postnatal

Baby started on breast feed within an hour after birth. Passed meconium and urine on day 1. Was discharged next day. She was being checked at home every week till her first vaccination at 6 wks of age. By that time she showed no evidence of jaundice.

Around 2 months of age her mother noticed dark yellow staining of diaper though stool was pale colored. They consulted a local doctor and some tests were done that revealed some liver problem and she was referred to higher centre. There she is was advised some more tests and advised some operative procedure. But they did not go for surgery and tried some alternative medicines.

At 6 months of age she got admitted with one episode of vomiting blood and few bluish swellings on skin. She was treated with IV antibiotics, blood transfusion, some other IV medications nature of which are not known. She remained hospitalized for 12 days and then discharged with some oral medications.

During last episode there was..

No H/O fever, pruritus, altered sensorium, seizure, abdominal distention, paleness of skin, haematuria, any signs of respiratory distress.

Since last admission she is under regular follow up. She is on regular oral medications. Her stool is still pale coloured and urine dark coloured. Parents are counseled about her condition being irreversible and they are accepting it slowly.

She does not have hearing or visual impairment, looks alike her parents, gaining weight slowly and developing almost at par with peers.

DEVELOPMENTAL HISTORY:

GM
Head Control @ 6m
Rolling over now

FM
Grasp object and transfers from hand to hand.

Language
Babbles

Social
Prefers mother, can appreciate mirror image.
Gross motor delay present.

IMMUNIZATION HISTORY: As per Schedule

NUTRITIONAL:

Baby was Exclusively breastfed till 6 months. Then rice based complementary feeding started. She is not taking her feed well since last hospital admission and not gained much weight since then.

FAMILY HISTORY:

3 generation pedigree.
No H/O similar problem in family, any congenital disease

SOCIO ECONOMIC HISTORY:

Socio economic status of father, Monthly expenses for the child, attitude of caregiver, whether they get any help from Govt or NGOs.

TREATMENT HISTORY: summarized

HISTORY IN BRIEF:

8 month old girl with pale stool and dark colored urine likely to be a case of conjugated hyperbilirubinemia presenting with bleeding episode.

D/D 's ARE
Biliary atresia, choledocal cyst, congenital infections, metabolic cause.
(most likely BA as they were offered surgery at 2 months)

EXAMINATION:

OPENING REMARK: First impression of the baby (sitting comfortably on mother’s lap) and some obvious striking feature(like jaundice in this baby)

GENERAL EXAMINATION:

ANTHROPOMETRY: Ht, Wt, HC with charts (enquire if any previous record), MUAC
VITALS:
PICCLE: Icterus +

HEAD TO TOE:
Mention all the congenital anomalies if any like Down’s Syndrome, hypothyroidism or Alagille. Signs of vitamin deficiency in this case. Like muddy sclera, rachitic features, dry skin, subcutaneous bleeding spots.
From general examination we found baby has Grade 1 malnutrion, jaundice, bruise like patches over extremitities. No signs of dysmorphism and liver cell failure.

SYSTEMIC EXAMINATION:

ABDOMEN:

Inspection: Distended upper abdomen with pushed down umbilicus, Umbilical hernia present, No venous prominence. Some bruise like patches present. Flanks are free. Other hernia sites free. External genitalia normal. Back normal.
Palpation: Liver: 5 cm below RCM, mention all the points
Spleen: 4 cm along axis, mention all the points
Purcussion: Liver span 8 cm, no ascites
Auscultation: IPS+ , no bruit.

OTHER SYSTEMS:

CVS- Apex on left 5th ICS on midclavicular line. S1,S2- audible, no murmur.
RS- b/l equal VBS, no added sound
CNS- WNL

SUMMARY:

Prepare own way to summary with important positive and relevant negative history and examination point.(within few lines)

FINAL DIAGNOSIS:

Can be put this way
A case of conjugated jaundice with umbilical hernia with signs of vitamin deficiency, Grade 1 malnutrtion, mild gross motor delay without dysmorphism, any signs of portal hypertension or liver cell failure on regular vitamin supplements, most likely to be a case of chronic cholestasis of infancy most likely etiology being biliary atresia.
AVOID BLAMING PARENTS AS THEY REFUSED SURGERY.

Mandira's Previous posts on case presentations here

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