1. 8 month old male presented with vomiting for 5 days
Case discussion
8 month old male presented with vomiting for 5 days
Intern: 林伯昱

2. Identifying Information
陳O睿, 8-month-8-day-old male
Birth history:
G1P1, term, AGA, C.S (mother spinal cord injury)
Growth and development:
BH: 73cm(75%~85%), 8.3kg(25~50%)
No developmental delay
Past medical history:
Convulsive episode at 1 week old, no diagnosis after survey
Falling from bed two times in the past
Seborrheic dermatitis
History of carbuncle and furuncle
NKDA
Chart Number：

3. History of present illness (2 versions)
8 days prior to admission (5 days)
Fall from bed: 80 cm high, head on floor
Crying, no LOC, no seizure, no limb weakness
6 days prior to admission (3 day)
Decreased oral intake: congee + 150ml QID  120ml QID
Vomiting every day after oral feeding, esp. morning feeding
2 days prior to admission (1 day)
Vomiting persisted
Fever up to 38 degree Celsius, wax and wane
Dry cough, no diarrhea, no sputum production, no skin rash
Grand mother had dry cough also

4. Family history
Dry cough for weeks

5. Physical examination T：38.6oC, P：156/min, R：32/min, BP：111/64mmHg
General: fair spirit, loud crying, easily consoled
HEENT:
Fontanel not bulging, no scalp hematoma
Pink conjunctiva, anicteric sclera, injected throat, no ulcer no pus
Neck: freely movable, no palpable LAP
Chest: clear breath sound, no crackle, no wheezing
Heart: regular heart rhythm, grade II systolic murmur, esp. apex
Abdomen: normoactive bowel sound, normal on palpation
Limbs: warm, active peripheral pulses
Skin: no petechiae, no ecchymosis, no rash

6. Neurologic examination
Light reflex: normal
Extraocular movement: normal
Gag reflex: normal
Normal muscle tone, no limb weakness

7. Lab data on admission

10. Impression Fever Head injury
Dry cough, injected throat, contact history
CBC no left shift, CRP: 16.7mg/L, U/A(-)
Plan: throat swab viral test, supportive care
Head injury
Vomiting after eating every day, no scalp hematoma
Discrepancy in history, previous head trauma
Neurosonography: subdural, subarachnoid effusion
Plan:
Eye fundus, long bone X ray, brain MRI
Consult social worker

11. Ophthalmoscope examination
No retinal hemorrhage (OU)

12. Long bone X ray

13. MRI, GRE 10 days post injury

14. Consult social worker Good family support, enough care takers.
No medical evidence of shaking baby syndrome
Informed the family to reinforce child safety at home

16. CSF data Blood

17. Throat swab
Stool
Blood culture

19. 5th day after admission Fever abruptly subsided
Maculopapular rash appeared on trunk
Roseola infantum
The patient was discharged after 24 hr fever free.

20. Discussion: Evaluation of suspected shaking baby syndrome

21. History Retrospective case series, 163 cases
0-3 y/o, presented with acute traumatic intracranial injury
History
Reference: Pediatrics Mar;111(3):602-7

22. History
Reference: Pediatrics Mar;111(3):602-7

23. History Prospective case series, 87 head injury patient, < 2y/o
Reference: Pediatrics Jul;114(1):165-8

24. PE Retinal hemorrhage: deep, peripheral, multiple
Prospective case series, 104 cases
24 hours of admission to PICU,
Royal Hospital for Sick Children Edinburgh PE
Retinal hemorrhage: deep, peripheral, multiple
Reference: Pediatrics Nov;130(5):e

25. PE: other Cutaneous bruising Rib fracture: esp. posterior
Long bone fracture: esp. metaphyseal
Reference: CMAJ Jan 21;168(2):155-9

26. Lab CBC, coagulation profile
CSF: xanthochromia, RBC, myelin basic protein(?)

27. CT in acute condition Subarachnoid: equal Epidural: not likely
Systemic review, , <11 y/o patient, most < 3 y/o
CT in acute condition
Subarachnoid: equal
Epidural: not likely
Reference: Arch Dis Child Dec;96(12):

28. CT in acute condition Multiple SDH over the convexity, posterior fossa
Systemic review, , <11 y/o patient, most < 3 y/o
CT in acute condition
Multiple SDH over the convexity, posterior fossa
Interhemispheric hemorrhage
Hypoxic-ischaemic injury
Cerebral edema
Reference: Arch Dis Child Dec;96(12):

29. MRI
For evaluation of actual damage amount

30. An additional case in brief

31. A patient with similar history
4 m/o, previously healthy
HPI:
Fall from bed when changing diaper
Presented with vomiting, decrease oral intake
On examination: No scalp hematoma
Neurosonography: subdural and subarachnoid effusion

35. Diagnosis
Shaking baby syndrome

36. Thanks for your listening