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Case Write up 1
Pediatric Clerkship

Case Write-up: Lower Limb

Weakness
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Case Write up 1
Pediatric Clerkship
Patient’s Demographics:

Patient’s initials: S. A

Age: 6 years and 5 months Gender: Female

DOB: 27/08/2016 Nationality: Emirati

Admission Details:

Date of clerking by student: 17/1/2023. Date of admission: 15/1/2023

Admission source: ER

Chief complaint:
lower limb weakness and pain for 3 days.

History of presenting illness:

S.A, is a 6-year-old girl, previously known to have G6PD deficiency and alpha thalassemia trait,
was referred from Ain Al Khaleej hospital to the ER with a 3 day history of lower limb pain and
a 1 day history of lower limb weakness, the pain was bilateral and she would complain of lower
limb pain. The pain was a needle piercing like sensation that occurs when she stands on both of
her feet, it was not specific to a certain area. She mentioned that the pain increases with standing
up and it would be relieved when she would lie down. She also rates the pain a 7 out of 10, 10
being the worst pain she could feel. 3 days ago, she was able to walk normally however she was
feeling pain. 1 day prior to admission she could not walk unsupported, she was not able to walk
in a straight line and was afraid of falling. On the day of admission, she was able to bear weight
on her legs but she would stand unsteadily and required support. She did not have any back pain
or urinary incontinence. She had a history of nasopharyngitis infection 2 weeks prior to recent
presentation it was managed with antibiotics. She has not received any recent vaccinations.

S.A had lower limb pain and weakness for 3 days. She was brought to the ER after referral from
a private hospital. In the ER, she was not given any medication and was referred to neurology
ER.
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Review of system:

Constitutional: no fever, fatigue, no chills, no seizures, no headache, no weight loss.

Neurologic: Unable to move both legs Weakness in both legs. No numbness, No seizures, No
abnormal movements. Oriented and active. Normal Upper limbs activity, normal range of
movement of upper arms, normal speech and facial expressions.

Musculoskeletal: generalized pain in both legs, No swelling, No stiffness

Genital/urinary: no urinary incontinence, no dysuria, No urgency, No change in frequency,

normal urine output.

Skin: Pale. No skin lesions, No rash, No change in nails or hair.

Nose and mouth: No oral ulcers, No mucosal dryness No nasal congestion or runny nose, No
dental cries or cyanosis, No earache or discharge.

Lymphatics: No swollen lymph glands.

Eyes: No changes in vision No abnormal eye movement, No discharge

Respiratory: No cough No SOB, No distress

Cardiovascular: No chest pains. No palpitation (heart racing feeling).

Gastrointestinal: Good oral intake, no nausea or vomiting or pain or bowel movement changes
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Past medical and surgical history:

Recent nasopharyngeal infection that occurred 2 weeks before presenting to the ED.
Known case of G6PD.
Alpha thalassemia trait
No previous surgeries
Medication & Allergies:

She has allergies from Augmentin – Reaction type: Rash

She can’t eat beans and fava beans due to her G6PD deficiency.
Perinatal History:
Antenatal: Mother was following her regular follow-ups in Tawam Hospital
and was taking all supplements regularly. The mother denied any complications
like diabetes, eclampsia, or infections.
Birth: Born to term, normal vaginal delivery, non-eventful. Weight at birth 3.2 kg, she did not
need any hospitalization, no jaundice or need for oxygenation. No NICU admission.

Post-natal: S. A was normal, no feeding difficulties, no jaundice, no infection

or abnormal findings. She was breastfed.
Developmental history:
S.A. has met her developmental milestones.
Gross motor: As a 6-year-old S. A was able to skip alternating feet and jumps over low
obstacles, however due to her current presentation she is not able to do so.
Fine motor: She can copy triangles, write, and ties shoes.
Social: During the examination she responded and reacted with me, she was a very cheerful child
and was a very good communicator. She showed me her coloring books and asked to write my
name.
Language: She can speak in full sentences, understands what is being said, responds with full
sentences, and asks the meaning of some words.

Immunization History:
Received her Hepatitis B and BCG vaccines at birth. All other immunizations are
up to date. She is also vaccinated against covid. There were no reactions to any
previous vaccine.
Nutrition History:
At 6 months the mother was breast-feeding all night and during day 3 x per day, bottle-feeding
Aptmil, 120ml, 4 times per day.
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At 12 months, bottle-feeding 150 mL 4 times a day. and solids (fruits, vegetables, meats)

At 18 months, feeding solids (3 meals per day, eating at regular family mealtimes), appetite
good, balanced and drinking from cup.

At 2- 6-year-old, balanced food and fluid intake.

Family history:
Father and mother are not related. S. A has 11 sisters and brothers including him, he is the 10th
child. All siblings are healthy. However, his eldest brother has G6PD alongside with his maternal
aunt. Moreover, his cousin has sickle cell anemia. The mother has a thalassemia trait. Moreover,
there is a strong family history of asthma.

Social history:
S.A lives in Al Ain with his parents and 10 siblings. Mother is a housewife, and the
father works. There are no smokers in the household. S.A currently goes to school
and he’s in grade 1. In the household, there are no pets. No member of household
had similar symptoms during the same time.

General Physical examination: (17/1/2023)

On general inspection, S.A looked well, comfortably breathing and not in
any distress. She was awake, active, oriented, and social. No signs of
respiratory distress, shortness of breath, breathing sounds and retractions. No
cyanosis, redness or jaundice was noticed. On finger inspection, nails are
normal. S.A was attached to an IV line however, no nasal cannula or a
facemask was attached.

Vital signs: according to her age, her vitals were normal:

Tympanic temperature 37.1 degrees Celsius
Peripheral pulse rate 88 bpm
Respiratory rate 24 br/min
Oxygen Saturation 98% on room air
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Growth parameter:
According to the WHO growth charts S.A is at a normal centile for his age.
Weight: 23kg (75th centile)
Height: 119 cm (75th centile)
Interpretation: normal growth
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Head to toe exam:

Head: Head was symmetrical and uniformly spherical and normal in size.
No dysmorphic features noted. No nose deformity. No central cyanosis,
normal palate.
Eyes: Normal sized eyes, no protrusion or ptosis. No signs of scleral icterus and
conjunctival pallor. Pupils were reactive to light. Extraocular movements are intact.
Ears: Examination of the ears is normal, normal tympanic membrane.

Oropharynx: no pharyngeal erythema, oral mucosa is moist and pink. There are
no spots or ulcerations on inspection. The lips are pink and no signs of
dehydration.
Neck: Supple, on palpation there is no tenderness and no masses or enlarged lymph
nodes and thyroid examination was normal.

Extremities: The hands and feet were warm. In the hands there was no clubbing or
peripheral cyanosis. The capillary refill time was less than 2 seconds. Skin turgor
was normal. Full range of movement in both upper and lower limbs.

Dermatological: the skin is warm and pale. There are no signs of jaundice. There
are no rashes, ulcerations, or other skin lesions.

Respiratory examination:
On inspection, the chest moves symmetrically with respiration, no scars, or
deformities. There is no signs of labored breathing and no subcostal, intercostal
and suprasternal retractions.

On palpation, the trachea was centrally located, normal chest expansion.

On auscultation, there are normal breathing sound was heard and are equal.

Abdominal examination:
On inspection, the abdomen is symmetrical, not distended and there are no obvious
hernias and no scars.
On superficial palpation the abdomen was soft, and no tenderness felt over
the abdomen. On deep palpation, there were no palpable masses or
hepatosplenomegaly.
On auscultation, normal bowel sounds were heard.
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Cardiovascular examination:

On inspection there are no chest deformities, scars, or asymmetry. There is no

peripheral or central cyanosis and no edema observed.
On palpation, the apex beat is felt at the 4th intercostal space mid-clavicular line,
with no heave or thrills.

On auscultation, normal first and second heart sounds are present and there are no
murmurs or added sounds.

The brachial and femoral pulses are palpable, the rate and rhythm are regular.

CNS examination:
Mental status: alert and oriented.

Cranial nerves: cranial nerves II-XII were all normal upon examination.

Gait: cannot assess gait as she cannot walk at all, and cannot maintain balance.

Muscle tone: tone in UL is normal. Tone in LL 3/5.

Muscle power: UL power is 5/5. LL power is 3/5. Was not able to dorsiflex or
plantar flex at all.

Reflexes: absent ankle reflex and absent knee reflex.

Sensory examination: preserved sensation of the lower limb.

Negative Brudzinski and Kernig sign.

Problem List:
1. Fever for 1 day
2. Vomiting for 1 day
3. Change in urine color for 1 day
4. Jaundice
5. History of eating mixed nuts
6. Family history of thalassemia
7. Family history of G6PD
8. Family history of sickle cell disease

Differential diagnosis:
1- G6PD deficiency:
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S.A presented with Jaundice, fatigue, pallor, shortness of breath, dark-colored urine and
palpitations which are all symptoms that can be attributed to G6PD deficiency. In addition, S.A
has a family history of G6PD where his brother and aunt are diagnosed with G6PD deficiency.
Moreover, he had a history of eating mixed nuts that included fava beans the day before his
symptoms began that is possibly the reason for his presentation. Thus, it is possible that G6PD
deficiency is the most likely diagnosis considering the positive family history and intake of fava
beans.
2- Hepatitis A infection:

The presence jaundice, abdominal pain, fever, vomiting, dark urine, feeling tired, and decreased
appetite can indicate hepatitis A infection. However, there were no sick contacts and none of the
household members have similar symptoms.
3- Hereditary spherocytosis:

The presence of a mild pallor and jaundice can indicate hereditary spherocytosis
however, on physical examination, the absence of splenomegaly makes the
diagnosis less likely. In addition to the absence of the complications that is acute
cholecystitis.

Thalassemia:

The presentation that includes pallor from anemia, fatigue, and jaundice can be
attributed to thalassemia. Moreover, S.A’s mother has a thalassemia trait which
makes it more likely that he develops thalassemia.

4- Viral gastroenteritis:

The abdominal pain, fever and vomiting may indicate that there is a viral
infection.

5- Sickle cell disease:

The presence of family history, and pallor which can indicate anemia. However, this is less likely
as S. A is previously healthy and no previous attacks.

Investigations:
S.A’s symptoms are mild and therefore beginning with a more conservative
approach to the necessary investigations to further identify and confirm the
appropriate diagnosis, based on the Uptodate recommendation:

1- CBC with differential (to assess leukocyte, hemoglobin, reticulocyte)

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2- Hemoglobin electrophoresis (look for abnormal hemoglobin

3- Blood smear (to assess the shape of the red blood cells)
4- CRP (Inflammatory marker)
5- Serum electrolytes (checking for signs of dehydration, and for imbalances)
6- Liver function test: AST, ALT, GGT, Total and direct bilirubin, albumin (to check
the liver function status)
7- Hepatitis A IgM
8- G6PD levels (to investigate whether there is a decrease in the G6PD enzyme)
9- Urinalysis
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Lab results:(26/12/2022)
CBC and differential:
WBC 24.0 x10^9/L (high)
RBC 2.14 x10^12/L (low)
Hgb 61 g/L (low)
Hct 0.19 L/L (low)
MCV 87.9 fL (high)
MCH 28.5 pg
MCHC 324 g/L
Platelet 231 x10^9/L
RDW-CV 17.0% (high)
MPV 8.90 fL (low)
Retic Cnt 138.00 x10^9/L (high)
MetHb ven POC 6.8% CRIT

Neutro # 19.73 x10^9/L (high)

Lymph # 2.68 x10^9/L
Mono # 1.50 x10^9/L (high)
Eos # 0.02 x10^9/L
Baso # 0.11 x10^9/L

General chemistry: (26/10/2022)

Sodium Lvl 134 mmol/L (low)

Potassium Lvl 4.3 mmol/L
Chloride Lvl 100 mmol/L
CO2 22 mmol/L
Creatinine 49 micromol/L
Urea Lvl 7.90 mmol/L
Albumin Lvl 37 g/L
AST 105 IU/L (high)
ALT 19 IU/L
Bilirubin Total 100.3 micromol/L (high)
Bilirubin Direct 6.9 micromol/L (high)
Haptoglobin 0.21 g/l (low)
LDH 1,483 IU/L (high)
G6PD Qnt 2.16 units/g (low)
CRP 42.6 mg/L (high)
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Blood film review: (26/10/2022)

anisocytosis +1
Poikilocytosis +1
Burr cells +1
Spherocytes +1
Polychrome +2
schistocytes +1
Blisters +2
Bite cells +1

Urinalysis: (26/10/2022)

Color red
U spec grav 1.035
U pH 5.0
Leuk est negative
Protein urine +1
U WBC <5 x10^6/L
U RBC 19 x10^6/L (high)

The microbiological result for Hepatitis A was not performed. Covid-19 was not detected.

Updated problem list:

1. Fever, vomiting, change in urine color, jaundice for 1 day
2. History of eating mixed nuts
3. Family history of G6PD
4. Normocytic anemia with high reticulocyte, LDH and bilirubin
5. Methemoglobinemia
6. Leukocytosis with neutrophilia
7. Family history of sickle cell disease

Discussion/interpretation of lab data:

S.A presented with fever, vomiting, jaundice, pallor, abdominal pain, change in
urine color for 1 day. On investigation, it appeared that S.A has had elevated WBC
count, CRP, monocyte elevation and neutrophilia. These results may indicate that
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there is an infection which may be viral gastroenteritis in this case due to his
presentation.
Moreover, on investigations, it was confirmed that S.A was found to have
normocytic anemia, high reticulocyte count, elevated LDH, low RBC count, low
Hgb, methemoglobinemia, and low G6PD quantity. The evidence of
methemoglobinemia is mostly explained by the possible underlying G6PD
deficiency and indicates acute hemolysis. Considering these test results, feeding
history and family history of G6PD, it makes it more likely that S.A is suffering
from hemolytic anemia secondary to G6PD deficiency.
Hospital course:

The patient was started on IV ondansetron (0.15mg/kg), IV sodium chloride 0.9%

bolus (10mL/kg) and received 1 pack of RBC in the emergency department and
was to receive another pack if needed. Moreover, IV paracetamol (200mg) and
ibuprofen (200mg) was administered to control the fever and abdominal pain. He
was kept under a restricted diet for patients with G6PD deficiency.
On 28/12/22, S.A recoieved another blood transfusion where he remained
hemodynamically stable with no further dark urine. Furthermore, his hemoglobin
levels, reticulocyte count were still monitored to check for any changes.

The fever and vomiting he presented with was resolved and has not spike any
further episodes. These were most likely secondary to the acute hemolysis.

Management plan:

1. In patient management (admit the patient):

Patient presented with bilateral lower limb pain for 3 days and
weakness for 1 day. Hence, she should be admitted to be kept under
supervision and further management to prevent further consequences.
2. Administer steroid therapy:
S.A presented with bilateral lower limb pain and weakness, hence; administering
corticosteroids belong to the first line treatment in inflammatory neuropathy. For
example: methylprednisolone and prednisolone.

3. Administer an intravenous immunoglobulin:

After the lumbar puncture, administer IVIG, which is a product made of antibodies
that can be given to help the body in fighting infections. And in S.A’s case, it is given
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as a treatment for Guillain-Barre syndrome or transverse myelitis.

Progress during hospitalization:

The patient was admitted with acute bilateral lower limb weakness and pain. After her
hospitalization and after taking the required medications, S.A is able to stand and walk
independently, however; her reflexes of the lower limb is still absent.

FOLLOW-UP
By the time of discharge, she is able to stand and walk independently. However, a follow up
appointment with the general pediatric clinic and neurology clinic is required to avoid any
further complications..

Discharge plan: (27/1/2023)

- Continue prescribed medications and explain to the parents the importance of
compliance.
- Follow up appointment after 1 week at the general pediatric clinic, and neurology clinic.
- Family was informed that in case of any weakness or deterioration or in case of any
emergency, get in touch with ED or Urgent Care.

Follow up: (SOAP format) 27/1/2023

Subjective: 6-year-old female, previously healthy girl who presented with acute
bilateral lower limb pain and weakness for 3 days following nasopharyngitis
infection 2-3 weeks. She is vitally stable, not in respiratory distress. Standing
and walking independently however reflexes of lower limb are still absent.
Objective: Investigations showed that S.A has transverse myelitis. Her CSF
results shows pleocytosis, her IgG index is >0.7 which means that there is an
inflammatory reaction. The MRI showed swelling of the conus medullaris with
cauda equina enhancement.
Assessment: Most likely transverse myelitis. As there is motor dysfunction
that is bilateral and progressing at the time of her presentation. The
inflammation identifies in the CSF and the elevated IgG index confirms
this.
Plan: Continue with the required G6PD diet. Continue and comply taking the
required medications. Follow up appointment after 1 week with a general
pediatrician at the outpatient clinic. Monitor the blood levels and check for any
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changes.