usmle step 2 cs neonatal jaundice

onset,progression,parts of body involved,rhesus factor of baby,mom dad.

（ROS)review of system for pediatric -

FEVER CUD SAD+ABD SYMPTOMS+PAM IF BIG DEALS

F ever

E ye discharge & redness/ear pulling

V omit

E ar discharge/pain

R ash , R hinorhea (runny nose)

Cry ,Chest symptoms

C old (cough,Recent URI?, sore throat,difficulty swallowing,dysphagia,sob)

U rinary changes (frequency,urgency,burning,dysuria,hematuria, color,odor ,content,consistency,how mny wet diapers? )

D iarrhea (amount,blood,color,consistency,content,mucus, frequency)

Sleep

Seizure

Activty (awake,playful, how does he looks?)

Dehydrated (dry mouth, shrunken eyes?

Pediatric (PMH) past medical history

PAM IF BIG DEALS

PMH -childhood illness and infection? has ur child had any serious illness or infection?does the child have dm,asthma,seizure?

PSH- have ur child had any surgey before

Hospitalize? -
Allergy- does ur child have any allergies?
Medication- is ur child taking any medication

Ill contact- have u heard of any sick contact?anybody else sick at home?

Family history- does anyone in ur family have a similar problem/other medical problem?

Birth history

-was ur pregnancy full term(40weeks or 9months?)

- did u have routine checkup during pregnancy?how often?

-did u have any complications during ur pregnancy/during ur delivery/after delivery?

-was an ultrasound performed during your pregnancy?

- did u smoke,drink or use drugs during pregnancy?

- was it a vaginal delivery or C-section?

-did ur child have any medical problems after birth?

-when did ur child have her/his first bowel movement? 
-how long did u stay at hospital after delivery?any complication? 

Imunization - are ur child immunization utd?

Growth development - is ur child develepment on track for their given age?

- when did ur child first smile?first sit up? first crawling?start talking?start walking? learn to dress himself?start using short sentense? 

Day care- accommodation / main carer / who lives with child?/any sick contact?

Eating habits - did u notice any changes of ur child's eating habits?

did u breast feed ur child?hw long? hw mnt times per day? is he feeding/sucking  well?

Appetite- how is ur child appetite?

Last check up - when was the date of your child's last routine checkup?was it normal?

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Differential Diagnosis of Neonatal Hyperbilirubinemia

Hyperbilirubinemia type	Hemolysis present	Hemolysis absent
Unconjugated	Common Blood group incompatibility: ABO, Rh factor, minor antigens Infection Rare Hemoglobinopathies: thalassemia Red blood cell enzyme defects: G6PD, pyruvate kinase Red blood cell membrane disorders: spherocytosis, ovalocytosis	Common Breast milk jaundice Infant of mother with diabetes Internal hemorrhage Physiologic jaundice Polycythemia Rare Hypothyroidism Immune thrombocytopenia Mutations of glucuronyl transferase (i.e., Crigler-Najjar syndrome, Gilbert syndrome) Pyloric stenosis
Conjugated	Common Cytomegalovirus infection, hyperalimentation cholestasis, neonatal hepatitis, sepsis, TORCH infection, urinary tract infection Rare Biliary atresia, cystic fibrosis, hepatic infarction, inborn errors of metabolism (e.g., galactosemia, tyrosinosis)

 

Red flags for pathologic jaundice

• Jaundice in first 24 hours
• Rapidly rising total bilirubin concentration (>86umol/L/day)
• Younger gestational age
• Previous sibling with jaundice
• Significant bruising
• Jaundice persisting for more than 2-3 weeks
• East Asian ethnicity

An additional workup for hyperbilirubinemia may include:

• Blood group and direct Coombs testing in babies who are at risk of Rh or ABO isoimmunization.
• Evaluations for sepsis, congenital infection
• Screening for metabolic disorders
• Thyroid studies
• Blood smear for cell morphology if the history suggests a red blood cell defect
• Hemoglobin electrophoresis can be considered to investigate for hemoglobinopathy
• G6PD assay can be considered if ethnicity or family history confers increase risk of G6PD deficiency (though an X-linked recessive disorder, females heterozygotes can have ~50% of their red blood cells deficient due to random X chromosome inactivation

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History

HPI: the source of information is the patient’s mother. The mother of a 5 day old M c/o her child having yellow discoloration of the eye and skin for 2 days. It has not worsened . the child is awake ,responsive,playful and active. He si breastfed. His stomach is soft and he has 2-3 daily bowel movements. The color of his stools is brown. She denies any h/o recent fever,vomiting,seizure,URI,or breathlessness. There is no noticeable dryness of the mouth. He is wetting 7-8 diapers per day evry 3-4 hours. He was deliverd vaginally at full term. The mother did receive antibiotics for a positive culture before delivert. The blodd group of both mother and the neonate is B positive,while that of the father is A positive.

 ROS:negative

Allergies:NKDA

Medication:none

PMH:none

PSH:none

FH:his elder sister was hospitalized after the first week of birth for jaundice

Physical examination: none

Differential diagnosis

Diagnosis 1 : physiological jaundice

-          Infants first weeks of life

-          No changes in feeding ,urination or bowel movements

Diagnosis 2 : ABO or Rh incompatibility

Infant in first week of life

Mother and father with different ABO type

Diagnosis 3 neonatal sepsis

History of maternal infection

Diagnostic workup:

Total and indirect bilirubin

Blood typing

Direct coombs test

CRP