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Conference Schedule (Bellevue/Tisch)

In addition to the student specific conferences listed in the schedule below, all students are expected to attend the following departmental conferences:

* Pediatric Grand Rounds: Every Tuesday, 8:00 AM - Farkas Auditorium
* Morbidity and Mortality Conference: Alternate Thursdays, 8:00 AM - Alumni A (Please see monthly Department of Pediatrics Conference Schedule for specific dates)

All student conferences held at Bellevue 8 North Conference Room, unless otherwise noted. Suggested readings can be found in "Rudolph's Fundamentals of Pediatrics."

>> Teaching conference schedule

TEACHING CASE

>> Case A
>> Case B
>> Case C
>> Case D
>> Case E
>> Case F
>> Case G

Case A
You are called to the nursery to examine a 72-hour old male infant because of decreased responsiveness to tactile stimuli.

The infant was the product of a 39 week gestation to a 22 year old primagravida with a history of intermittent alcohol and cocaine exposure during the third trimester. Last known exposure to cocaine was one week prior to delivery. The maternal history is remarkable for recurrent genital herpes controlled with oral acyclovir. A "surveillance" culture of the cervix for herpes virus was reported to be negative one week prior to delivery. The antenatal history is remarkable for rupture of membranes 18 hours prior to an unassisted vaginal delivery unaccompanied by maternal fever or uterine tenderness post-partum. Apgar Scores were 9 and 9 at 1 and 5 minutes of life, respectively. The physical examination on admission to the nursery was unremarkable.

The Ballard Assessment is consistent with a 40 week gestation. Anthropometric analysis indicates an appropriate for gestational age (AGA) infant. The nursing staff informs you that the infant had been breast feeding vigorously every 2-3 hours and had no change in feeding pattern or any temperature instability until now.

Examination reveals a well-proportioned male infant who opens his eyes to vigorous stimulation only. The skin is pale, cool, and the hands and feet appear a "dusky rose" color. The rectal temperature is 36.9 degrees centigrade. The respiratory rate is 70/minute and the pattern appears symmetric and deep without grunting or alar flaring, but subcostal retractions are noted. The heart rate is 195/minute and the blood pressure is 60/48 in the right arm. The anterior fontanelle is flat and the neck is supple. The breath sounds are symmetric bilaterally. No murmur is audible on cardiac examination. The brachial and femoral pulses feel less prominent than on admission. The abdomen is flat, soft and non-tender. The liver edge is 1 cm below the right costal margin and the spleen tip is not palpated. Neurologic assessment reveals decreased active and passive tone with preserved primitive and deep-tendon reflexes.

Questions for Group Discussion:
1. Discuss the abnormalities noted on physical exam and the underlying pathophysiology.
2. Discuss the abnormalities noted on physical exam and the underlying pathophysiology.
3. Given this patient’s history and physical examination, what is your differential diagnosis?
4. Given this patient’s history and physical examination, what is your differential diagnosis?

Case B
You are called to see a 48 hour old infant because of abnormal skin coloration.

The baby is a 3800 gram product of a 39 week gestation to a gravida 2, para 2, 26-year old woman in excellent health. The antenatal history is unremarkable. The peripartum history is remarkable for spontaneous rupture of membranes productive of clear fluid approximately 22 hours prior to delivery, and a maternal core temperature of 38.1 degrees centigrade immediately after delivery. The infant was delivered with the assistance of "low" forceps reportedly without incident. The Apgar scores were 7 at 1-minute and 8 at 5-minutes of life. The infant is receiving formula feedings, approximately 1 oz every 4 hours. The nurse reports occasional spitting of formula after feedings. Meconium has been passed. The stools are reported by the mother to appear Alight colored@ and have a consistency like paste.

Physical examination reveals a male infant with icteric sclerae. The face, trunk and extremities appear yellow. The Ballard examination is consistent with a 39 week gestation. The rectal temperature is 37.6 degrees, respirations 30 per minute and the heart rate 145/minute. There is some firm swelling over the right parietal area which does not extend past the sagittal suture in the midline. The fontanelles are flat. The chest is symmetric and the lungs are clear on auscultation. The heart sounds are normal and no murmur is audible. The abdomen is flat and soft on palpation. The liver is palpated 1.5 cm below the right costal margin. The spleen tip is palpable at the left costal margin. The extremities appear normal. Neurologic examination reveals a sleepy but arousable baby. The primitive reflexes and the deep tendon reflexes are present.

Questions for Group Discussion:
1. Describe the pathophysiology of this baby’s abnormal skin coloration.
2. What is the differential diagnosis for jaundice? What diagnoses would you consider given this specific patient’s history and physical examination?
3. Discuss your initial approach to evaluation and management.

Case C
You are called to see a 2-hour old infant because of abnormal skin coloration.

The baby is a 2400 gram female product of a 35-36 week gestation to a 24 year old gravida 2, para 2, female. The onset of labor was aborted initially with a beta-2 agonist but spontaneous contractions began again 24 hours later despite ongoing therapy. The peripartum history is remarkable for spontaneous rupture of membranes approximately 36 hours prior to an uncomplicated vaginal delivery. The Apgar scores were 8 and 8.

Examination reveals a symmetrical infant without gross evidence of anomalies. The Ballard Assessment is consistent with an infant of 36 weeks gestation. The lips and nail beds, as well as the face, trunk and extremities, appear "dusky rose" in color. The respiratory rate is 70/minute and the heart rate is 180/minute. The fontanelle is soft. The eyes and ears are normal. There is flaring of the alar nasae. The mouth is normal. The chest is symmetric and intercostal retractions are noted. Auscultation reveals diminished inspiratory breath sounds without rales or wheezing. The heart sounds are normal. The abdomen is mildly distended but soft on palpation. Bowel sounds are present. The liver is palpated 1 cm below the right costal margin. The spleen is not palpated. The extremities are normal.

Questions for group discussion:
1. Discuss the abnormalities noted on physical exam and the underlying pathophysiology.
2. Given this patient’s history and physical examination, what is your differential diagnosis? ?
3. Discuss your initial approach to evaluation and management.

Case D
You are called to evaluate a 1-day old infant because of vomiting. The infant was the 3120 gram product of a 39 week unremarkable gestation to a 26 year old primagravida delivered by emergency caesarian section secondary to fetal distress (late heart rate decelerations and acidemia on scalp pH determinations). The Apgar scores were 4 at 1-minute and 7 at 5-minutes. The infant required resuscitation in the delivery room with oxygen and positive pressure ventilation, and was transferred to the Special Care Nursery. During an 8-hour observation in this setting, the infant remained well. Enteral feedings were begun with sterile water at 8 hours of life and advanced to a cow milk-based formula thereafter. Vomiting was not noted with the initial feedings. Subsequently, some post-prandial spitting was noted by the mother and the nursery staff. The infant’s nurse reports that the previous episode of emesis was characterized by an increased volume of regurgitated formula and the current episode by formula mixed with some "green mucus-like" material in large volume.

Physical examination reveals a well-proportioned male infant weighing 3090 grams. The Ballard Assessment is consistent with a 40 week gestation. The core temperature is 37.2 centigrade, respiratory rate 38/minute, and heart rate 132/minute. The skin is clear. The fontanelles are open and soft. The red reflex is present bilaterally, the nares patent, the ears set normally, and the mouth is unremarkable. The chest is symmetric. Auscultation reveals symmetric breath sounds, normal heart sounds, and no murmur. The abdomen appears rounded, and is firm and questionably tender to palpation. The liver and spleen are not palpated. The anus appears patent. The extremities are normal. Neurologic examination is unremarkable.

Questions for group discussion:
1. What is the differential diagnosis for vomiting in infancy? What diagnoses would you consider given this patient’s history and physical examination?
2. Discuss your initial approach to evaluation and management.


Case E
You are called to the nursery to examine a 2-hour old male infant because of low birth weight. The infant was the product of a 37 week gestation to a 34 year old gravida 6, para 4 female whose pregnancy was complicated by hypertension and mild edema in the third trimester, and a self-limiting febrile illness in the first trimester. The infant was delivered vaginally 10 hours after spontaneous rupture of membranes. The Apgar scores were 8 at 1-minute and 9 at 5-minutes.

Physical examination reveals a male infant weighing 1820 grams. The length is 45 cm and the head circumference 33 cm. The temperature is 37.4 centigrade, pulse 122/minute, and respirations 35/minute. The Ballard Assessment is consistent with a 37-38 week gestation. The infant is moving all extremities spontaneously and is crying vigorously. The skin is unremarkable. The fontanelles are open and flat. The sutures are normal. The red reflex is present bilaterally. The nose is patent and the ears are set normally. The oral cavity is normal. The chest is symmetric. Auscultation reveals equal breath sounds, normal heart sounds, and no murmurs. The abdomen is soft and non-tender. The liver is palpated 1.5 cm below the right costal margin. The spleen is not palpated. the genitalia are normal. The musculoskeletal exam is unremarkable. The primitive and deep tendon reflexes are present, and a low-frequency, coarse tremor of the arms and legs is noted when the infant is stimulated or startled (Moro response). The tremor is noted also when the infant is crying.

Questions for group discussion:
1. Plot out this baby’s height, weight and head circumference on an appropriate growth chart and discuss
2. What is your differential diagnosis given this patient’s pattern of growth?
3. Discuss your initial approach to evaluation and management.

  1. Case F

    A 22 kg child is made NPO prior to elective surgery. Calculate maintenance fluids for this patient.

  2. A 3 month old infant has diarrhea and vomiting for 4 days with decreased urine output. Her weight on presentation is 5.3 kg, HR 140, BP 65/40. PE is significant for dry mucous membranes, sunken eyes, and decreased skin turgor. Labs show Na 136, K 4.9, Cl 111, BUN 31, Cr 0.8, HCO3 10, urine SG 1.030. Calculate deficit and maintenance fluids.

  3. Same infant as above except that the child is irritable with doughy skin with the following labs: Na 161, K5.5, Cl 127, HCO3 13, Cr. 1.1. What do you want to do?

  4. An 8 month old with profuse watery diarrhea for four days has had no urine output for 12 hours. On exam the patient is lethargic and limp, BP 45/30, HR 160 with weak pulse. His weight is 7.7 kg and he has the following labs: Na 113, K 4.8, Cl 82, HCO3 7, BUN 56, Cr 2, urine SG 1.031. What is your initial management? Would you change anything if the child were seizing on presentation? Calculate Na deficit and replacement as well as deficit and maintenance IV fluids.


    Case G
    A six-month old is brought in by her mother for her scheduled health supervision visit.
    The baby was born at term without complications. Initial weight gain was appropriate but seemed to slow at the four-month visit. The mother complains that she is difficult to feed and is concerned that she is still not gaining weight appropriately.

    You glance at her growth curve before proceeding further.





    Questions for Group Discussion:

    1. How would you describe this curve?
    2. Would you classify this child as failure to thrive and why?
    3. What is your approach to the differential diagnosis of this patient?