Pediatric history taking | Infant with Jaundice

This is a format for case presentation and clinical examination in a child presenting with features of jaundice. The article is written in the same way as if the case is presented to the examiner.

Introduction / Opening the consultation

XYZ, an 8 months old girl baby, 1st born to non-consanguineously married parents, xxx by religion, resident of xxx, presented to the outpatient department accompanied by mother for her follow-up today. Informant is mother xxx, who seems a reliable source for history.

Chief complaints

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

History of presenting illness

This was the first pregnancy of a 25-year-old mother, Lata. She was registered case and received iron, folic acid, calcium, and antenatal immunization. She has had no history of complications like diabetes, hypothyroidism, or hypertension during ANC. No H/O fever, rash, lymphadenopathy. The ultrasound scans were done, both normal.

XYZ (use name often than 'patient') was delivered by a normal vaginal route at term vigorously and required only routine newborn care after delivery. The birth weight was 2.4 kg. There was no history of PROM or difficult/instrumental delivery.

As a baby xyz was started on breastfeeding within an hour after birth and passed meconium and urine on day 1. She was discharged the very next day. She was been provided usual neonatal care and the mother reports no concerns until 6 weeks of age. She continued to receive usual immunization but no concerns were reported wither by the health care worker/vaccinator confirming her history.

Around 2 months of age, mother noticed dark yellow staining of diaper though stool was pale colored. Upon consulting a local doctor and some tests were done. Mum was informed about a liver problem and she was referred to another center for further investigation and management. They were further advised for a surgical procedure but it was refused. They opted for alternative medicines. We do not have details of those medications or therapy.

At 6 months of age, XYZ got admitted with episodes of vomiting blood along with bluish swellings/spots on the skin. She was then treated with IV antibiotics, blood transfusion, and other IV medications. We do not have a record of these at present. She remained hospitalized for 12 days and was then discharged with oral medications, again no records are available or according to the record/summary the medications were......

Since her last admission, xyz is under regular follow-up. She is on regular oral medications (mention names). Her stool is still pale colored and her urine is dark-colored.

She is relatively well and keeping with her peer's in development. Parents have been counseled that her condition is irreversible and are slowly adapting to the difficult situation.

History to ascertain etiology

1. Maternal history of drug ingestion,
2. Jaundice/ infection in pregnancy, for viral illness CMV, Rubella, Hep B.
3. Neonatal umbilical catheterization
4. Progressive abdominal distension - Storage disorder
5. Cardiac disease symptoms for chronic congestive liver failure
6. Dysmorphic features - Congenital syndromes
7. Family history of hemolytic anemia

History of complications

1. Bleeding from any site eg hematurea - coaguloapthy
2. Altered sensorium - encephaopathy
3. Abdominal distention - Ascites
4. Hisotry of pruritis - Cholestasis
5. Fever - Secondary infections
6. Respiratory distress - secondary to large ascites, secondary resp infection
7. Paleness - for anemia

Developmental history

1. Head Control @ 6m
2. Rolling over now

1. Grasp object
2. Transfers from hand to hand.

1. Babbles

1. Prefers mother
2. Appreciate mirror image.

Conclude your findings. Gross motor delay is present. Developmental age is ----.

Immunization history

Give a detailed account of immunization if asked. Keep it ready by enquiring during history taking, Go through immunization record if available.

Nutrition history

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

Detail account of food content can be asked. Be ready with calorie requirements for the age and calorie as well as protein gap.

Family history

1. Draw 3 generation pedigree.
2. Mention if there is any significant family history that can give clues toward the current illness.

Socio-economic history

Socio-economic status of the family, Monthly expenses for the child, attitude of caregiver, whether they are getting any help from Govt or NGOs.

Treatment history

Summarised details of drugs, side effects, progress of symptoms, invasive procedures etc.

Sign-posting/ summarizing history

8 month old girl with pale stool and dark-colored urine, likely to be a case of conjugated hyperbilirubinemia admitted as a part of regular follow-up.

1. Biliary atresia, choledocal cyst, congenital infections, metabolic cause.
2. (most likely BA as they were offered surgery at 2 months)

Viva Questions could be

1. Storage disorders presenting with Jaundice in Infant
2. Bilirubin pathway
3. How to differentiate between conjugated vs unconjugated hyperbilirubinemia etc
4. Add more in comment box below

Physical Examination

Opening remarks

what is the first impression after you examined xyz. For eg, does she looks well, is she anxious, or sitting comfortably. Are their obvious striking feature like deeply jaundiced malnourished etc.

1. Vitals - PICCLE
2. Antropometry - Height, weight, Chart on percentile graph. Grade of malnutrition if any.
3. Head to toe examination.

Mention -

All dysmorphic features like that of Down’s Syndrome, hypothyroidism or Alagille syndrome.

Signs of vitamin deficiency are important in case of liver cell failure. eg muddy sclera, rachitic features, dry skin, subcutaneous bleeding spots.

Summarise finding

XYZ has stable vitals along with findings of Jaundice, bruises, and Grade 1 malnutrition.

Abdomen

1. Inspection: Localized bulge, distension (which quadrant is more affected)
2. Palpation: Superficial palpation: Guarding, tenderness, rigidity
3. Deep Palpation: Hepatomegaly-
   1. Tender/Nontender
   2. Surface: Smooth/Nodular
   3. Span and Size
   4. Border: well felt/ sharp/diffuse
   5. Consistency: Soft/firm/hard
4. Deep Palpation: Splenomegaly
   1. Size (Grades of splenomegaly)
   2. Consistency: Soft/firm
   3. Splenic notch
5. Deep Palpation: Kidneys/Divarication of recti/ Hernial sites
6. Percussion: Shifting dullness/horseshoe dullness/fluid thrill. Puddle’s sign
7. Auscultation: Renal Bruit, Venous hum
8. Other systems: Cardiac murmur, hydrocephalus, Meningitis

Here is a detailed proforma of abdominal examination in case of hepatosplenomegaly.

1. Cardiovascular - Signs of congestive heart failure, hemic murmur due to anemia
2. Respiratory - Secondary resp infection, effusion secondary to hypoproteinemia
3. CNS - Encephalopathy

Diagnosis

Summarise positive findings from the history and physical examination and put your differentials.

A case of conjugated type jaundice with umbilical hernia along with signs of vitamin deficiency, Grade 1 malnutrition, mild - gross motor delay without signs of dysmorphism. There are no signs of portal hypertension or liver cell failure.

The most likely diagnosis could be to be chronic cholestasis of infancy and the most likely etiology could be biliary atresia. Other likely differentials could be neonatal hepatitis, inborn errors of metabolism or chromosomal disorders.

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Author

Mandira Roy | DNB(Pediatrics), fellowship in Developmental Pediatrics

Mandira has completed her pediatric residency at the Institute of Child health Kolkata and currently working as a Pediatrician with a special focus on developmental medicine