clinicopathological conference pediatrics durante, esperon, espino, fernando, figuracion, flores,...
DESCRIPTION
SUBJECTIVE projectile vomiting non-villous, non-bloody amounting to half a cup occurs 2-3 times a day did not experience tinnitus, gait disturbance, gastrointestinal, and urinary problemsTRANSCRIPT
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CLINICOPATHOLOGICAL CONFERENCE PEDIATRICSDurante, Esperon, Espino, Fernando, Figuracion, Flores, Fong, Francisco, Francisco, Garcia, Garcia, Garcia, Garcia, Garcia, Garimbao
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SUBJECTIVE 10-year-old intermittent headache of 1 year duration
vague frontal headaches occur twice a week, usually in the late
afternoons diagnosed to have Iron Deficiency
Anemia prescribed with oral Iron preparation
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SUBJECTIVE projectile vomiting
non-villous, non-bloody amounting to half a cup occurs 2-3 times a day
did not experience tinnitus, gait disturbance, gastrointestinal, and urinary problems
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SUBJECTIVE allergic to shrimp diagnosed with asthma last 2007 family history of diabetes mellitus and
hypertension
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OBJECTIVE slightly pale conjunctivae + horizontal nystagmus GCS 15 (E4V5M6) positive for Romberg’s sign no motor or sensory deficit negative for Babinski sign, ankle clonus,
nuchal rigidity, Kernig’s sign, and Brudzinski sign
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COURSE IN THE WARDS Admission given Omeprazole 40 mg IV OD
to prevent irritation of the esophageal mucosa due to multiple bouts of vomiting
Ist HOSPITAL DAY given Dexamethasone 2.5mg q6h
for the treatment of vasogenic edema associated with brain tumors
given Mannitol at 100 cc q6h to decrease intracranial volume
Imaging studies were also done
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COURSE IN THE WARDS CSF analysis from ventricular drainage
5 cc of clear, colorless fluid pH of 7.5 specific gravity of 1.010 RBC 514 x 106
WBC 1 x 106, 100% lymphocytes glucose of 4.7 mmol/L protein 0.11 g/L (-) Pandy’s
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COURSE IN THE WARDS 4TH HOSPITAL DAY
the patient underwent an operation Ceftriaxone 750 mg IV was started and
other medications were continued
6th HOSPITAL DAY Limited lateral eye movements on the left
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COURSE IN THE WARDS 7TH HOSPITAL DAY Omeprazole IV and Dexamethasone IV
were shifted to oral preparation no episodes of vomiting were noted
MRI of the whole spine and liver function test to evaluate for possible metastasis
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LABORATORIESResult Interpretation
Calcium 2.62 Normal Magnesium 1.0 Normal Creatinine 61 Normal Uric Acid 281 Normal Sodium 143 Normal Potassium 3.7 Normal Chloride 105 Normal
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LABORATORIES4/4/09 4/9/09 Interpretati
onHGB 141 128 NormalHCT 0.42 0.38 NormalPC 260 NormalWBC 10.9 NormalNeutrophils 0.66 NormalLymphocytes
0.24 Normal
Eosinophils 0.05 NormalBasophilsStabs 0.01 NormalESR 21 IncreasedBlood Type: B+
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LABORATORIESResult Interpretation
Color colorless NormalTransparency clear NormalpH 7.5 NormalSpecific Gravity 1.010 NormalRBC 514 IncreasedWBC 1(100% lymphocytes) NormalTotal Protein 0.11 Slightly
decreasedGlucose 4.7 NormalPandy’s Test negative Normal
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POST OP EVALUATION MRI of the spine
Normal cervical, lumbar and thoracic spine Audiometry
Normal hearing acuity CT scan
Heterogenous hyperdense lesion in the cerebellar vermis with perilesional edema and mass effect
Moderate extraventricular obstructive hydrocephalus
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PRIMARY IMPRESSION:MEDULLOBLASTOMA Primarily considered due to:
Results of the patient’s CT scan (hyperdense lesion in the cerebellar vermis) most common malignant hyperdense brain
tumor arising in the cerebellar vermis The patient’s age (10 y/o)
usually seen in 0-14 years of age
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PRIMARY IMPRESSION:MEDULLOBLASTOMA Presenting signs and symptoms
vague headache vomiting (+) Romberg sign cranial nerve deficits
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PRIMARY IMPRESSION:MEDULLOBLASTOMA Incidence
accounts for 90% of embryonal tumors 2% of all primary brain tumors 18% of all pediatric brain tumors predominately in males majority occur in the midline cerebellar
vermis
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PRIMARY IMPRESSION:MEDULLOBLASTOMA Signs and Symptoms
signs and symptoms of increased intracranial pressure and; headache, nausea, vomiting, mental status
changes, and hypertension cerebellar dysfunction
ataxia, poor balance, dysmetria
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PRIMARY IMPRESSION:MEDULLOBLASTOMA Etiology and Pathogenesis
occur in the posterior fossa 30–40% = chromosome 17p deletions 10–20% = genetic loses on chromosomes
1q and 10p 10% = abnormalities of chromosome 9p arises from cerebellar stem cells
perivascular pseudorosette and Homer-Wright rosette formation
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DIFFERENTIAL DIAGNOSIS:EPENDYMOMASRULED IN due to: RULED OUT due to:-Age and the gender of the patient-Headache -Projectile vomiting-Presence of some cerebellar signs
-Absence of lower CN affectations-Timing of the headache in this illness gradually decrease during the day and relieved by vomiting -In CT scan this will show heterogenous hyperdense lesion
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DIFFERENTIAL DIAGNOSIS:HEMANGIOBLASTOMA
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DIFFERENTIAL DIAGNOSIS:CRYPTOCOCCOMA
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PLAN:Diagnostic Procedures Laboratory studies
CBC, lectrolytes and liver and renal function tests
Imaging studies CT scan, MRI, and bone scan
Other procedures audiography or brainstem auditory-evoked
response, lumbar Puncture bone marrow aspirate biopsy and histologic study of the specimen
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PLAN:Treatment Surgery
to relieve cerebrospinal fluid buildup to confirm the diagnosis by obtaining a
tissue sample to remove as much tumor as possible
Glucocorticoid treatment to decrease the volume of edema
surrounding brain tumors
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PLAN:Treatment ventriculostomy
to divert excess cerebrospinal fluid from the brain
radiation therapy to reduce the number of left-over cells