INTERN FLORIDA TALADTAD UPCM CLASS 2011 CASE PRESENTATION

IDENTIFYING DATA SJ 7 years old Female Right-handed Roman Catholic Muntinlupa City

CHIEF COMPLAINT Vulvar itchiness

SOURCE AND RELIABILITY Patient and the patient’s father With good reliability

HISTORY OF PRESENT ILLNESS

3 days prior to consult, patient started to complain of terminal dysuria. (-) tea-colored urine, (-) hematuria (-) urinary changes (-) oliguria (-) vaginal pain (-) fever (-) abdominal pain (-) groin pain. No consults were done and no medications were taken.

2 days prior to consult, dysuria was then associated with whitish-grayish vaginal discharge. Patient’s father applied ‘gawgaw’ on the patient’s labia which offered no relief of symptoms. (-) prior systemic antibiotic use, (-)bleeding, (-) fever, (-) vaginal pain (-) history of vaginal manipulation ; Still no consults done and no medications taken.

1 day prior to consult, patient then complained of vulvar itchiness, still with dysuria, and (+) cheesy, whitish-grayish vaginal discharge, non foul smelling. (-) vaginal pain, (-) bleeding, (-) fever, (-) abdominal pain Persistence of vaginal discharge and vulvar itchiness prompted consult.

REVIEW OF SYSTEMS General: (-) wt. loss, (-) fatigue, malaise, fever, chills Skin: (-) changes in skin color, excessive dryness, lesions, lumps, sores Head: (-) No headaches, head injuries, dizziness,light- headedness and syncope Eye: (-) blurring of vision, eye pain, diplopia, redness, itchiness, discharges Ear: (-) vertigo, ear pain, infection and discharge Nose and Sinuses: (-) sinus pain, epistaxis, nasal obstruction, discharge, itching and sneezing; (+) coryza Oral Cavity: (-) bleeding of lips, gums, mouth, tongue, or throat

Neck: (-) pain, stiffness, and limitation of motion Throat: (-) soreness, hoarseness Respiratory: (-) cough, hemoptysis, shortness of breath Cardiac: (-) chest pain, palpitations, dyspnea related to exertion, orthopnea, paroxysmal nocturnal dyspnea Genitourinary: (-) polyuria, oliguria, nocturia, hematuria, flank pain

BIRTH AND MATERNAL HISTORY Patient was born full-term to a then 28 year-old mother G3P3(3003), at a lying-in clinic, via SVD assisted by a midwife, with no known fetomaternal complications. Patient had good cry and good suck.

PAST MEDICAL HISTORY Patient has no known comorbidities (-) history of allergy (-) previous hospitalizations or surgeries

NUTRITIONAL HISTORY Patient was breastfed for 2 months, then shifted to formula feeding, also with intake of water at 3 months of life Is fond of eating fruits and junk food

PERSONAL AND SOCIAL HISTORY Patient is an incoming Grade 2 student With good activity, loves to play with her playmates outside the house with no note of behavioral changes since the onset of symptoms Presently living with her 2 siblings and parents in Muntinlupa

FAMILY GENOGRAM Serrano-Johnson Family May 23,2010 I II III Sophia, 7

FAMILY HISTORY (+) Heart disease, maternal grandmother (+) CVD, paternal grandfather No other diseases in the family

PHYSICAL EXAMINATION General Survey Conscious, coherent, oriented to time, person, and place, not in cardiorespiratory distress Vital Signs BP = 100/60 HR = 88 RR = 20 Temp = 37.7 Wt: 24.3 kgs Skin Warm, smooth, no jaundice or cyanosis. Nails Pink nail beds, no lesions, good capillary refill

HEENT Head: without signs of trauma or deformities. Eyes: Pink conjunctivae, pupils 2-3 mm EBRTL, anicteric sclerae, eyelids are symmetrical, no ptosis, cornea without opacity. Ears: no lesions, tragus nontender, no discharge. Intact gross hearing. Nose: No deformity, inflammation, and tenderness. Nasal mucosa is pink and no bleeding, swelling, and lesion. Nasal septum has no deviation, (+) coryza Oral cavity: oral mucosa pink, soft, moist (-) CLAD, (-) tonsillopharyngeal congestion

Lungs Chest is symmetrical. No tenderness, no delay in chest expansion, equal tactile and vocal fremitus on all lung fields. Resonant on all lung fields. No crackles, wheeze, rales and stridor. Heart Adynamic precordium. PMI at 5th ICS LMCL. No thrills and heaves. Normal rate with regular rhythm. No murmur was heard. Abdomen Slightly globular abdomen. No obvious mass noted, no visible veins, no scars, no striae, no pulsations. Normoactive bowel sounds. No tenderness. Extremities There were no edema, lesions, and masses observed in all four extremities. (-) inguinal lymphadenopathy

Genital examination Normal external genitalia, (-) lesions, (+) minimal swelling and erythema of the vulva, (+) whitish- grayish discharge, with cheesy white vaginal discharge

ASSESSMENT t/c Vaginitis probably secondary to Vulvovaginal Candidiasis t/c Urinary Tract Infection r/o Sexual Abuse

PLAN Diagnostics:  urinalysis  Vaginal discharge GS/CS Therapeutics:  Diphenhydramine 12.5/5ml, 5 ml BID Non-pharmacologic:  Increase oral fluid intake  Maintain proper perineal hygiene

CLINICAL DILEMMA

In pediatric patients, what is the effectiveness of single-dose oral treatment of Fluconazole for Vulvovaginal candidiasis compared to standard daily therapy in the resolution of symptoms using a randomized controlled trial?

In pediatric patients presenting with vaginal discharge, what is the specificity and sensitivity of vaginal d/c Gram stain compared to vaginal fluid DNA analysis using a cross-sectional study?