Medical College of Georgia

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Clinical Cases

1. A mother brings her 18-month-old boy for a scheduled well baby visit. She is concerned because her neighbor's 18-month-old can do more than her own child. By history he sat alone at nine months, started pulling up at 14 months, but does not yet walk. He says "Dada", "Mama", and "dog", but no other words. 

   • Outline your initial differential diagnoses, your approach and your response to this mother's concerns including any additional history, physical examination and laboratory information you would like to obtain. 

   • How would your approach and response to the mother change if the child walked well at this age, but said no words.

2. It is 3:00 AM Saturday morning and you are on call in the hospital. The mother of a 1-month-old infant calls you from home and tells you that her baby has a temperature of 39.3ºC. Describe your management of this child in detail, and how it would vary depending on the results of information you would seek including history, physical examination, if done, and laboratory data, if any. One year later (assuming you managed the patient properly!) the same mother calls with the same complaint that her 13-month-old child has a temperature of 39.3ºC. 

   • Describe your management of this child, specifically contrasting the differences in management and reasons for these differences between a 1 month-old and a 13-month old febrile infant.

3. A full-term infant is noted to be jaundiced at 48 hours of age. The total bilirubin is 13.0 mg/dl with a direct bilirubin of 1.0 mg/dl.

   • What are the most common causes of jaundice in this setting? 

   • Discuss your approach to this infant's hyperbilirubinemia and any additional information you would require including history, physical examination and laboratory data. 

   • How would you explain this infant's jaundice to the parents?

4. A pregnant woman presents in your office for a pre-delivery visit – she wants you to be her child's physician! This is her first pregnancy, and she expresses concern about her ability to care for a newborn infant. She has read about breast feeding her infant, and wants to know about the advantages and disadvantages of both breast feeding and formula feeding. She also asks about vitamin and fluoride supplementation for her infant, and how and when to proceed with solid foods. 

   • Outline what you would tell her during this session, including answers to her specific questions.

5. A mother has brought her 2-year-old son for evaluation. She says he has had a fever, has been irritable, and has been pulling on the right ear. With a similar history for two previous ear infections, the mother suggests that the child probably has another ear infection. 

   • Describe the specific information you would seek to make a diagnosis of otitis media in this patient. 

   • Describe the sequence of pathophysiological and clinical events which lead to this problem. 

   • Assuming the diagnosis of otitis media is made, outline an appropriate treatment plan (including follow-up), the expected clinical course and possible complications which you should anticipate.

6. You see an 8-year-old girl in the office with complaint of sore throat, abdominal pain and fever (102.4ºF) for two days. 

   • List the diagnostic entities which you consider most likely. 

   • What additional historical information, physical examination findings, and laboratory data (if any) would you obtain to support or refute each of the entities you consider likely in this patient? 

   • For each entity under consideration, also give the general treatment approach.

7. A 4-week-old infant is brought to the clinic with a history of having forcefully vomited several feedings. 

   • Construct a differential diagnosis of the most important and most likely possible etiologies for this problem. 

   • Outline your approach to this problem by listing the historical questions you would ask, the physical examination findings you would be alert for, and any laboratory or other studies you would obtain which would confirm each diagnosis. 

   • How would this differential diagnosis and approach differ if these same symptoms occurred in a newborn infant?

8. A 5-year-old female presents to the office with the acute onset of dysuria, frequency and hematuria. 

   • Construct a differential diagnosis for this patient and outline the important historical questions, physical findings and laboratory tests you would do at this visit. 

   • How would you explain your diagnostic concerns to the mother? 

   • How would you treat this girl and what would be your plans for further follow-up? 

   • How would your approach differ if the patient were male?

9. An inquisitive first-time mother has just given birth to a healthy term infant. She asks you to be her baby's doctor. She wants to know the schedule of well child visits for the next two years, the immunizations her child will need to receive, and the "real truth" about the problems and risks involved with the immunizations. 

   • Outline an appropriate response to her questions.

10. A 36-month-old male is seen in the office for routine health assessment. His mother has no specific complaints. There is a history of several ear infections, but no ongoing problems. There were no neonatal problems. Developmentally, he walked at 12 months, handled a spoon well at 18 months, and spoke in two word sentences at 24 months. He currently has a 250 word vocabulary, can balance on each foot for one second, and can put on a shirt, but not dress himself completely. At birth his weight was 3400 gms, length 51 cm, and head circumference 35.0 cm. Past growth points include:

On physical examination his weight is 12.0 kg, length 90 cm, and head circumference is 49.5 cm.

• Discuss the problem(s) suggested by this data, describing the most common and /or important diagnoses which should be considered. 

• Outline your initial approach to investigate the problem(s) including pertinent history, physical findings which you would seek, and any key laboratory investigations.

• Head Circumference Growth Chart–Boys

• Growth Curve–Boys

11. A 4-year old child presents to you with the acute onset of limp and inability to bear weight on his right leg. 

    • Construct a differential diagnosis of disorders which you consider most important (common and/or serious). 

    • For each diagnostic possibility, what would be your approach to reach a diagnosis including any additional history, physical examination, laboratory or other studies?

12. A two-year-old child is brought to the Emergency Room by his anxious parents. His mother says he has had a "barky" cough for six hours with increasing difficulty breathing for the past hour, and has felt "hot" to the touch. You observe an anxious child who is drooling slightly. His temperature is 38.7ºC. 

    • What diagnostic possibilities are most important to consider? 

    • What additional history, physical examination and laboratory data do you require to evaluate this patient? 

    • What is your plan for the immediate evaluation and management of this patient?

13. A 6 month-old child is brought to the Emergency Room by her parents because she "rolled off the couch" two days ago. On examination, you find multiple eccymoses over the body, and a radiograph reveals a spiral fracture of the right femur. 

    • Given this presentation, what are the principal diagnostic considerations? 

    • What additional questions would you ask of the parents to further define the problem? 

    • Give the significance of each question. How would you explain your concerns to the parents? 

    • How would you proceed with the evaluation and management of this child?

14. A three-year-old is brought to the clinic with a skin rash of one week's duration. The rash is mildly pruritic and involves the skin above the upper lip, the nares, chin, hands, and arms. The lesions consist of 0.5-2.0 cm patches of yellow crusting with surrounding erythema. The rash began around the nose and has spread rapidly to the other areas. 

    • What is the most likely diagnosis? 

    • What history, physical exam and laboratory data (if any) would you obtain in further evaluating this child? 

    • How will you treat the patient, and what possible complications could result from this problem?

15. A 3000 gm baby is born to a 26-year-old mother who has one previous child. At 2 hours of age, the baby's respiratory rate is noted to be 80 breaths per minute. 

    • Construct a differential diagnosis for this problem. 

    • Discuss your approach to this baby's problem including any additional history, physical examination or laboratory data you would require. 

    • What would be your initial management? 

    • How would your differential diagnosis and management vary if the infant were cyanotic?

16. A two-year-old child presents to the clinic with a fever of 39.7ºC and a red rash. She has had coryza for three days and some cough. Today she developed the fever and rash, and is also complaining of a headache. Her mother says she is irritable and sleepy. 

    • What are the most important diagnostic entities to consider? 

    • What history, physical examination and laboratory data (if any) would be most important and helpful in distinguishing between these entities and why?

17. While examining a 5-year-old-girl on a pre-school health assessment visit, you note that she has a III/VI systolic heart murmur. 

    • What additional history, physical exam and laboratory data are required to evaluate this child's murmur? 

    • What are the basic criteria which one may use to differentiate an "innocent" or functional heart murmur from a pathologic heart murmur? 

    • What are the most common causes of an innocent and pathologic heart murmur in this age group? 

    • How would you explain this problem to the parent?

18. A fifteen year old girl is brought to your clinic by her parents after she threatened to "take a bunch of pills". She seems depressed in affect, and on initial evaluation is clinically stable. 

    • Explain your approach to this young woman, including important history, physical exam findings, diagnostic studies, management principles and advice to her parents.

19. A 14 year-old male presents for a football sports physical.

    •  What are the important points to consider in the history and physical examination of this patient? 

    • Describe any findings which would disqualify him from participation in football, and provide an explanation for each.

20. A 1-year-old boy is brought to the clinic with his second episode of acute wheezing and moderate respiratory distress. 

    • List a differential diagnosis for these symptoms. Specifically state the information which would be most useful in making a diagnosis from the history and physical, and any appropriate tests. 

    • Also outline an appropriate treatment plan should the diagnosis of asthma be made.

School of Medicine | Medical College of Georgia

Please email comments, suggestions or questions to:
Kenda Rindt, krindt@mail.mcg.edu.
May 28, 2003