CBL Practice Case – Summer 2010

Kaitlyn Brown

Case Presentation

A young single mom brings her seven-year-old son, Joey Davies, to a clinic in Northern Ontario.

She notes that he has been pale, extremely lethargic, frequently constipated, and has had a poor appetite the past few weeks. In the past two days, he has vomited four times.

Joey also complains of abdominal pain and headaches.

Medical History

Joey has frequently been absent from school due to general malaise. His mom notes that he does not like school.

Joey has had notable learning difficulties – he did not begin speaking in sentences until the age of 3 and soon after beginning school, he was diagnosed with ADHD. Although he is in grade 2, he still reads at a kindergarten level and struggles with basic math. Teachers say he tends to be “forgetful.”

Is not medicated for ADHD (“I don’t want to shoot my kid up with that garbage”); is given gripe water for upset stomach and children’s advil for pain on occasion.

Other notable medical complaints in the past:- anxiety attacks- frequent headaches

Social/Personal History

Joey lives in a rural community of Northern Ontario. The majority of the community has high school level education. There are high rates of suicide, alcoholism, teen pregnancy, and low birth weights.

Ms. Davies is a single mom who became pregnant with Joey when she was 19. She has worked at a local plastics factory since she graduated high school at the age of 18.

Joey has no siblings and does not know his father. He lives with his mother in a small, rundown house.

Physical Examination: Vital Signs

BP = 97/57Temperature = 98.7°FHR = 95 bpmBreaths = 22 breaths/minutePain: stomach “ouches lots”, head “bangs”

sometimes

Physical Examination

The following abnormalities were noted:- Skin is pale and dry.- Faint blue-black tinge along gum margins. Several teeth have fillings due to tooth decay.- Palpation of abdomen is painful but normal otherwise.

All other aspects of the physical examination are within normal range.

Differential Diagnosis

Based on the physical examination and patient history, what are the possible diagnoses?

What tests should be ordered?

Complete Blood Count

Normal Range Joey’s ResultsRBC (10^12/L) 4.0-5.3 3.6Hgb (g/dL) 11.15-14.5 10Hct (%) 33-43 32MCV (Fl) 76-90 75MCH (pg) 25-31 25MCHC (g/Dl) 32-36 32RDW (%) 11.5-15 11.5PLTS (10^9/L) 150-450 267MPV (fL) 6-9.5 7.9

* Values pertaining to WBCs are all within normal ranges.* Normal ranges taken from those established at a children’s hospital in Buffalo, New York, for males aged 2 to 9 years.

Is this the whole story?

Based on the CBC, it is clear that Joey suffers from a specific problem. Does this problem explain all symptoms?

What next?

Stool Test and Analysis

The findings of two stool samples, taken a week apart, were analyzed. Both had similar findings:- Dark in colour, hard in consistency, heavier-than-average density, rock-like shape. No substantial amounts of mucus or blood present.- Fecal Proteins:Lactoferrin: -ve

X-Ray Results

FINDINGS:-Bands of increased density at metaphyses of tubular bones-- Bone-in-Bone appearance-Distal femur has an erleneyer flask-like appearance

Joey: Frontal X-ray of both knees

Note: abdominal X-ray shows small pieces of foreign matter in GI tract.

The last pieces of the puzzle?

Serum Lead Level: 40 micrograms/LPeripheral smear: stippled erythrocytesFree erythorcyte protoporyphyrin = 0.9

micromol/LUrine lead level is elevated

Diagnosis!

What factors might have contributed to Joey’s development of this health problem?

What can be done to treat him and to reduce exposure?

Treatment

Complete a home inspection and remove sources of lead exposure in Joey’s environment.

Treat anemia with iron supplementation

Ensure family follows good hygiene practices

Chelation therapy