THIS PATIENT DATA WAS GATHERED BY ROLL NO 14 BATCH 2023 AS PART OF HER COMPETENCE BASED LEARNING EVALUATION PORTFOLIO PREPARATION
THIS CASE IS OF 11YR OLD BOY WHO IS A STUDENT SUFFERING WITH SWELLING ON LEFT SIDE OF NECK AND ON HEAD
*Demographics*
- *Age / Sex:* 11 years / Male
- *Occupation:* Student
- *Informant:* Mother
*Chief Complaints*
- Swelling on left side of neck and on head - 12 days
*History of Present Illness*
- Patient had vomiting and pain in abdomen since one month ago.
- Patient was asymptomatic 18 days ago, then had a seizure-like episode while playing on the road, which lasted for 2 minutes, after which he fainted.
- He was taken to hospital, bandage was applied on head, and he was discharged.
- Next day, he had pain and developed fever, which was high during evening and did not reduce after taking medications.
- Fever is associated with swelling on left side of neck, due to which patient had pain and was unable to move his head.
*History of Medication*
- Levetiracetam
_Note: Some words in the handwritten history were partially illegible due to overlapping pages.
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*Demographics*
- *Age / Sex:* 11 years / Male
- *Occupation:* Student
- *Informant:* Mother
*Chief Complaints*
- Swelling on left side of neck and on head - 12 days
*History of Present Illness*
- Patient had vomiting and pain in abdomen since one month ago.
- Patient was asymptomatic 18 days ago, then had a seizure while playing on the road, which lasted for 2 minutes, after which he fainted.
- He was taken to hospital, bandage was applied on head, and he was discharged.
- Next day, he had pain and developed fever, which was high during evening and did not reduce after taking medications.
- Fever is associated with swelling on left side of neck, due to which patient had pain and was unable to move his head.
*History of Medication*
- Levetiracetam
*History of Present Illness (continued)*
- Swelling on head with pus discharge. It is also associated with swelling of face. He was taken to hospital. He was given:
- Trypsin & Chymotrypsin tablets
- Clobazam tablets
- Paracetamol
- Tobramycin sulphate for drying of eyes
- Phenylephrine nasal spray due to trouble in breathing
- After taking medications, swelling of face decreased, but swelling on neck didn't subside.
- Next day, patient has only had swelling on neck associated with pain.
- Patient is able to move his neck.
- No history of cough.
- History of night sweats, weight loss, wetting the bed.
*Past History*
- He had similar complaints when he was 5 years of age.
- History of seizures since birth.
*General Examination*
- Patient is conscious, coherent, cooperative - alert and well oriented to time, place, person
- Multiple swellings on left side of head
- *PICCLE:*
- *P - Pallor:* Absent
- *I - Icterus:* Absent
- *C - Cyanosis:* Absent
- *C - Clubbing:* Absent
- *L - Lymphadenopathy:* Present
- *E - Edema:* Absent
*Vitals*
- *BP:* 100/60 mmHg
- *PR:* 80 / min
- *RR:* 22 / min
- *Temp:* 96.5 °F
- *SpO2:* 96% on Room Air
*Systemic Examination*
- *CVS:* S1 S2 present (+), No murmur
- *RS:* Bilateral Air Entry present (+), No added sounds / Normal Vesicular Breath Sounds
- *CNS:* Normal
- *Abdomen:* Soft, Non-tender
*Local Examination*
*Inspection:*
- Multiple swellings on left side of head
- Healing scars present
*Palpation:*
- Margins are ill-defined
- Skin surrounding is edematous
- Edema present (+)
- Inspection findings are confirmed
- Swellings of 2 x 2 cm each are palpable
*Local Examination - Continued*
- *Tenderness:* Present (+) over swelling on neck
- *Fluctuant swelling:* Present
- *Mobility:* Mobile
*Investigation Advised*
- CT Scan
*Diagnosis*
- Surgical abscess in neck
*Investigation: USG Small Parts - Left Scalp and Neck*
*Findings:*
- Irregular mixed echogenic collection measuring 25 x 15 mm noted on left side of neck in subcutaneous plane with surrounding inflammation.
- Another similar lesion noted in left occipital region (measuring 22 x 58 mm) and left parietal region (25 x 6 mm).
- On color Doppler, above lesions show no obvious internal vascularity.
- Rest of the visualized structures appear normal.
*Impression:*
- Mixed echogenic collection in left side of neck in subcutaneous plane - S/O Abscess
- Similar lesions in left occipital and parietal region - Likely Suppurative Lymphadenitis
Here is a set of Socratic questions based on this pediatric case report, tailored for medical student learning and clinical reasoning development:
1. Clinical Presentation & Differential Diagnosis
* Question: The patient presented with a painful left-sided neck and head swelling accompanied by high evening-spiking fevers following a minor head trauma and seizure-like episode. How do you differentiate between a superficial soft-tissue injury/hematoma and an infectious abscess or suppurative lymphadenitis clinically?
* Question: What anatomical structures in the posterior triangle or subcutaneous plane of the neck/scalp are most prone to suppurative lymphadenitis in a pediatric patient?
2. History of Present Illness & Red Flags
* Question: The patient has a documented history of seizures since birth and is currently on Levetiracetam, alongside a previous episode of similar complaints at age 5. Could this recurrence point toward an underlying congenital or immunodeficiency syndrome? What further history would you want to gather?
* Question: The history notes systemic symptoms like night sweats and weight loss. How do these "B symptoms" shift your differential diagnosis away from acute localized trauma or simple bacterial adenitis?
3. Investigations & Interpretation
* Question: The USG (ultrasound) showed an irregular mixed echogenic collection with surrounding inflammation and no obvious internal vascularity on color Doppler. Why is color Doppler ultrasound particularly useful when evaluating a fluctuant neck swelling?
* Question: The clinician recommended a CT scan and an ultrasound. In what clinical scenarios would a CT scan with contrast be superior to an ultrasound when managing deep neck space or scalp infections?
4. Management & Complications
* Question: The patient initially received multiple medications including NSAIDs/enzymes (Trypsin & Chymotrypsin), anticonvulsants, and nasal sprays before the abscess was localized. Why can masking symptoms with anti-inflammatories or analgesics potentially delay the diagnosis of a developing surgical abscess?
* Question: Given the proximity of the neck and occipital/parietal lesions to major vascular and neurological structures, what are the potential severe complications if a neck abscess or suppurative lymphadenitis is left untreated?
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