MHAM-CM

Group 5A
 General Objective

❖ To elaborate the case of patient S.L.H.A, 2 years old and

7 months, female, presenting with rashes, irritable and
complains of loss of appetite and loose bowel
movement.
 Specific Objectives
❖ To present a clinical formulation based on the patients history
and physical examination findings in relation to the
diagnosis.

❖ To discuss its risk factors factors, pathophysiology, clinical

presentation, course and prognosis.

❖ To discuss the course of treatment and prognosis of the

patient.
 General Data
GENERAL DATA

Patient: S.L.H.A
Age: 2 years old and 7 months
Religion: Roman catholic
Gender : female
Date of birth: April 4, 2016
Address: Ambauan, Catigbain, Bohol 6343

Admiited for the 2nd time in Chong Hua Hospital

Informant: Mother
Reliability: 90%
Date and time of interview: December 5, 2018 Time: 3:00 pm
 Prenatal history
Mother was 33 years old, G1P0 at the time of pregnancy, first
prenatal check up was at 8 weeks AOG.

Regular prenatal check ups at the clinic thereafter with her

private OB, with regular intake of vitamins: iron, folic acid, and
calcium.

No history of maternal illness during pregnancy, laboratories

were all unremarkable.
 Natal history

Patient was delivered term, cephalic via normal spontaneous delivery at a hospital
attended by an obstetrician.

Unrecalled APGAR, but had good cry, pink all over and with active, spontaneous
movements. Birthweight unrecalled but mother said the patient was appropriate
for gestational age, as what her OB said.

No perinatal complications, as claimed.

Patient was given Vitamin K, Hep B Vaccine and eye prophylaxis.

 Post natal history
Patient was exclusively breastfeed until 6 months, introduced with semi-solid food at 6
months and solid food at 1 year.
Developmental milestones:
❖ 2 months - social smile, coos
❖ 4 months - laughs, reaches for toys, rolls over
❖ 6 months - rolls both ways, babbles, sits with support
❖ 9 months - sits without support, pulls to stand, “peek-a-boo”, says “mama”
❖ 1 year - walks with support, points at wants
❖ 1 year and 3 months - walks without support, combines words
❖ 1 year and 6 months - runs, imitates houeswork
❖ 2 years 6 months - toilet trained
 Immunization History
1st dose 2nd dose 3rd dose
BCG +
DPT + + +
OPV + + +
Hib
❖ Patient’s mother
+ claimed to +have complete +primary
immunization
HepB + + +

Flu +
Varicella +
AMV +
MMR + +
 Past medical history
Patient was admitted at Chong Hua Hospital in 2017 for Dengue
fever with warning signs. No known comorbidities, no history of
other medical illness, surgeries or past hospitalizations.

Family history
✓ Patient’s mother is a 34 year-old housewife and father is a 36 year-
old businessman who is the family’s source of income. Both parents
are healthy with no known heredofamilial diseases. Birth rank: 1/1.
 Socioeconomic history
✓ Patient’s nuclear family live in a concrete home with a
water-sealed type of toilet. They use mineral water for
drinking and pipeline water for daily use like bathing,
cleaning and washing clothes.

Environmental history
✓ Patient has never been ecposed to any dangerous
chemicals, second-hand smoking, and other environmental
hazards. Their garbage is collected by the barangay weekly.
 Chief complaint

Rashes Loose stools

 History of present Illness

Fever LAD, loose Rashes

watery stools
3 days prior to admission
4 days prior to admission, Onset of red macular rashes
5 days prior to consulted private beginning to appear at her
genital area, generalized type
admission, onset of fever physician, noted (+) LAD on
of rash, itchy, loose stool
with highest recorded left cervical chain, was
subsided, consulted a diff.
temperature of 39.3℃, prescribed with Co- Privated physician and
amoxiclav 450mg/5ml, medications was changed
given Calpol 125mg/5ml
unrecalled dose 2x a day; from Co-amoxiclav to
5mL every 4 hours x 6 doses compliant but now with Amoxicillin due to suspected
to no relief. onset of watery yellow allergy.
stools with particles x 5
Prescribed wth Loratidine 5ml.
episodes.
Noted: red eyes,
bleeding and cracked
painful lips
 History of present Illness

Irritability
2 days prior to A day prior to
admission admisison, still symptoms
persisted thus sought
Onset of another Loose consult and was advised
watery yellow stools with admission.
particles 7X episodes was
noted, amounting approx
½ glass, irritable and
eager to drink.
 Salient features
ASSOCIATED SIGNS AND SYMTPOMS

Desquamating
rashes on both
inguinal areas.
PHYSICAL EXAMINATION
General Survey Vital signs:

BP: 90/50 mmHg

Patient is awake, Temp: 38 C
RR: 28 cpm
irritable, febrile, not in HR: 131 bpm
respiratory distress O2 sat: 99%
Wt.: 15kg
Ht.: 94
PHYSICAL EXAMINATION
Skin: flushed, hot to touch, with good turgor and mobility, no lesions
noted
HEENT:
– Head: Head has normal contour, face is symmetrical with no lesions
– Eyes: anicteric sclerae, (+) bulbar conjunctival injection, no discharges,
+PERRLA, no limitations to extraocular muscle movement
– Ears: No discharges, symmetrical with no lesions and signs of inflammation
– Nose: no nasal discharges, septum midline, non-tender
– Mouth/ Throat: (+) oral mucocutaneous ulcers, cracked lips, no
tonsillopharyngeal edema
– Neck: no vein engorgement, supple, (+) cervical lymphadenopathy, no
nuchal rigidity
PHYSICAL EXAMINATION
Cardiovascular:
Inspection: adynamic precordium, PMI at 4th ICS
Palpation: no thrills felt over the precordium; bounding pulses
Percussion: dull
Auscultation: Distinct heart sounds, (-) murmurs
Respiratory:
Inspection: No retractions
Palpation: No tenderness, symmetrical chest expansion, normal tactile
fremitus
Percussion: Resonant
Auscultation: Clear breath sounds
PHYSICAL EXAMINATION
Abdomen:
Inspection: protuberant
Auscultation: normoactive bowel sounds
Percussion: tympanitic
Palpation: non-tender
Genitourinary: (+) desquamating rashes on bilateral inguinal areas, grossly
female
Rectal: not assessed
Extremities: (+) swollen wrists and ankles, strong peripheral pulses, CRT <2s
Spine: no deformities and tenderness noted
lymph nodes: no palpable nodes noted
 PHYSICAL EXAMINATION
Neurologic: GCS 15
CN I- able to smell
CN II- 3 mm isocoric, no diplopia
CN III, IV, VI- no ptosis, (+) PERRLA, full EOM, no nystagmus
CN V- good sensory function, (+) corneal reflex
CN VII- no facial asymmetry, able to puff out cheeks and clench teeth, (+) blink
reflex
CN VIII- good acuity to rubbed fingers, good balance
CN IX, X- (-) hoarseness of voice, uvula midline, symmetrical soft palate, (+) gag
reflex, able to swallow
CN XI - able to rotate head and shrug shoulders against resistance
CN XII- tongue midline, no fasciculations

Motor system - no abnormal movements, 5/5 muscle strength on all extremities

Cerebellar function - no ataxia or tremors, reaches and manipulates toys
Reflexes - 2+ on all DTRs, (-) Babinski reflex, (-)ankle clonus
 At the ER:
Subjective Objective Assessment Plan
Patient seen with no Vital Sign: T/C Kawasaki Disease 1. Labs: CBC, SGPT,
current complaint. BP- 90/60 Serum Na, ESR, CRP;
No episode of vomiting. HR- 110 2D Echo
2 episodes of bowel RR- 30 2. Human
movement – brownish, Temp- 37.1c Immunoglobulin
non mucoid, non Spo2- 98% (Gamma IVIg)
bloody. 5000mg/100mL vial.
No febrile episode for GS: awake, irritable, Give 30,000mg (30g)
the last 24 hours. febrile, NIRD or 600mL over 12
No abdominal pain. Skin: flushed, hot when hours as IV infusion
No cough. touched as follows:
Good appetite. HEENT: (+) conjuctival 1st hour 9mL/hr
injection bilateral, (+) oral
Normal frequency of mucocutaneous ulcers, 2nd hour 18mL/hr
urination cracked lips, strawberry >Give remaining 573mL
tongue over 10 hours at
Abd: protuberant 57mL/hr via infusion
GUT: (+) desquamating pump
rashes on both inguinal
areas
PVS: (+) swollen wrist and
ankles
Day 1:
Subjective Objective Assessment Plan
Patient seen with Vital Signs: Kawasaki 7:30AM
no current BP- 90/60 Disease > Aspirin 300mg tab
complaint. HR- 100 Sig.: ½ tab, TID
No episode of RR- 27 >To secure 6 vials Gamma IV 5G 100
vomiting. Temp- 36.5c mL
2 episodes of Spo2- 98% >For Gamma IVIG infusion
bowel movement tomorrow
– brownish, non GS: awake, calm, afebrile, >IVF TF: D5 0.3% NaCl 500mK at 55-
mucoid, non NIRD 60mL/kg
bloody. Skin: warm, good turgor and
No febrile episode mobility 10:00AM
for the last 24 HEENT: (+) conjuctival >Hydrocortisone (Cortizan) cream,
hours. injection bilateral, (+) oral Day 2 apply lightly to inguinal area twice a
No abdominal mucocutaneous ulcers, day for 3 days
pain. cracked lips, strawberry >Physiogel AI lotion, apply to
No cough. tongue affected areas twice daily
Good appetite. Abd: protuberant, NABS
Normal frequency GUT: (+) desquamation 12:40PM
of urination rashes on both inguinal areas > IVF TF: D5 IMB 500mL at 55-
- minimal 60mL/hr
PVS: (+) swollen wrist and
ankles, CRT <2sec, SPP
BLOOD COUNT RESULTS REFERENCE UNIT
WBC 9.10 5 – 15.5 1000/uL
RBC 3.96 3.9 – 4..6 10^6/Ul
Hemoglobin 10.2 11.5 – 12.5 g/dl
Hematocrit 29.9 34 – 37 %
Platelet 343 150 – 350 10^3/uL

BLOOD INDICES
MCV 75.5 75 – 85 fL
MCH 25.8 24 – 27 Pg
MCHC 34.1 31.0 – 34.0 g/dL
RDW 15.2 NRA %
PDW 8.7 NRA %
MPV 9.0 NRA fL
 RELATIVE
DIFFERENTIAL COUNT RESULTS REFERENCE UNIT

Neutrophil 66.6 33 %
Lymphocyte 26.0 59 %
Monocyte 4.9 5 %
Eosinophils 2.3 3 %
Basophils 0.2 NRA %
ABSOLUTE DIFFERENTIAL COUNT
Neutrophil 6.05 1.5 – 8.5 10^3/uL
Lymphocyte 2.37 3 – 9.5 10^3/uL
Monocyte 0.45 0.5 10^3/uL
Eosinophil 0.21 0.3 10^3/uL
Basophils 0.02 NRA 10^3/uL
 TEST RESULTS REFERENCE UNIT
SGPT-ALT 14 5 – 45 U/L
SODIUM (SERUM) 134.0 135 – 147 MMOL/L
CRP HS 69.35 0–5 Mg/dl
(QUANTITATIVE)
Erythrocyte 82 0 – 20 mm/hr
Sedimentation Rate
 Day 2
Subjective Objective
Patient seen with no Vital Sign: Kawasaki Disease
current complaint. BP- 90/60
No episode of vomiting. HR- 97
1 episodes of bowel RR- 28
movement – brownish, Temp- 36.6c
Spo2- 98%
non mucoid, non
bloody. GS: awake, calm, afebrile
No febrile episode for Skin: warm, good turgor
the last 24 hours.
No abdominal pain.
and mobility
Day 3
HEENT: clear sclera, (+)
No cough. oral mucocutaneous
Good appetite. ulcers – minimal
Normal frequency of Abd: distended
urination GUT: (+) desquamating
rashes on both inguinal
areas — resolving
PVS: CRT < 2sec, strong
peripheral pulses
Assessment Plan
>Labs:
- 2D echo: unremarkable
Meds:
>IVIG infusion started at
9mL/hr for the first hour,
18mL/hr for the 2nd hour
>Give remaining 573mL
over 10 hours at 57mL/hr
via infusion pump
>Aspirin 300 mg tablet
Sig.: give ½ tab TID PO
>Hydrocortisone
(Cortizan) cream 1%,
apply lightly to inguinal
area twice a day for 3
days
>Physiogel AI lotion, apply
to affected areas twice
daily
 ECHOCARDIOGRAPHIC REPORT
INTERPRETATION

1. LEVOCARDIA
2. Intact interatrial and interventricular septum
3. Atrioventricular and ventriculoarterial concordance
4. Normal chamber sizes
5. Tricuspid regurgitation, mild with tricuspid regurgitant jet
of 22mmhg
6. Good left ventricular systolic fuction
7. Normal pulmonary artery pressure by TR jet
 ECHOCARDIOGRAPHIC REPORT
INTERPRETATION

8. LCA:
proximal = 0.15 (z-score -1 SD)
distal = 0.15 (z-score -1 SD) RCA:
proximal = 0.14 (z-score -0 SD)
distal = 0.14 (z-score -0 SD)
9. No pericardail effusion

CONCLUSION: NORMAL 2D ECHO

 Radiologic report

❖ Chest radiograpgh APL view reveals inhomogenous

densities on the right middle lung.
❖ The tracheal air column is situated at the midline.
❖ The bronchopulmonary vessels are well demonstrated
and are not accentuated.
 Radiologic report

❖ The aorta is neither tortuous nor ecstatic. The cardiac

silhoutte is not enlarged.
❖ The hemidiaphgram are well outlined and the
costophrenic angles are sharp and distinct.
❖ The osseothoracic cage vessels are significant bony and
abnormalities

INTERPRETATION: Pneumonia Right Middle Lung

 Day 3
Subjective Objective Assessment Plan
Patient seen with no Vital Sign: Kawasaki Disease >May go home
current complaint. BP- 90/60 tomorrow
No episode of vomiting. HR- 97 >Meds:
1 episodes of bowel RR- 28 Aspirin 300 mg tablet
movement – brownish, Temp- 36.6c Sig.: give ½ tab OD PO
Spo2- 98%
non mucoid, non for 3 months
bloody. GS: awake, calm, afebrile >Repeat 2D Echo after 2
No febrile episode for Skin: warm, good turgor weeks
the last 24 hours. and mobility >Cardio follow-up in
No abdominal pain.
No cough.
Day 3
HEENT: clear sclera, moist
lips
Bohol after 2 weeks

Good appetite. Abd: distended

Normal frequency of GUT: (+) desquamating
urination rashes on both inguinal
areas — resolving
PVS: CRT < 2sec, strong
peripheral pulses
 Epidemiology
❖ Occurs primarily in children, peak
incidence is between 1 to 2 years of age
80% are younger than 4 years of age
50% are younger than 2 years of age
❖ Recent reports have emphasized the

occurrence of Kawasaki disease in older

children, who may have higher
prevalence of cardiovascular
complications related to late diagnosis.
 Diagnosis

The diagnosis of KD is based on the presence of characteristic

clinical signs.

❖ For classic KD, the diagnostic criteria require the presence of

fever for at least 4 days and at least four of five of the other
principal characteristics of the illness

❖ In atypical or incomplete KD, patients have persistent fever but

fewer than four of the five characteristics. In these patients,
laboratory and echocardiographic data can assist in the
diagnosis
 FEVER PERSISTING AT LEAST 5 DAYS †
PRESENCE OF AT LEAST 4 PRINCIPAL FEATURES:
1. CHANGES IN EXTREMITIES:
ACUTE: ERYTHEMA OF PALMS, SOLES; EDEMA OF HANDS, FEET
SUBACUTE: PERIUNGUAL PEELING OF FINGERS, TOES IN WEEKS 2
AND 3 POLYMORPHOUS EXANTHEM
 2. bilateral bulbar conjunctival injection without exudate
3. changes in lips and oral cavity: erythema, lip cracking,
strawberry tongue,

4. diffuse injection of oral and pharyngeal mucosa

5. cervical lymphadenopathy ( > 1.5 cm diameter), usually unilateral
 Diagnosis
There is no diagnostic test for KD, but patients usually
have characteristic laboratory findings:
1. The leukocyte count is normal to elevated, with a predominance of
neutrophils and immature forms.
2. Normocytic, normochromic anemia is common.
3. The platelet count is generally normal in the first week of illness
and rapidly increases by the second to third week of illness.
4. An elevated sedimentation rate and/or C-reactive protein value is
universally present in the acute phase of illness. The ESR may
remain elevated for weeks.
5. Sterile pyuria, mild elevations of the hepatic transaminases,
hyperbilirubinemia, and cerebrospinal fl uid pleocytosis may also
be present