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Case Presentation
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Date & Time of Interview: May 11, 2013:; 7:50 PM Source of Information : Parents Referral: None Reliability: 95%
Identifying Data:A case of Manlosa, Thomas Nap, a 3 year
old, male, single, Roman Catholic, presently
residing at Brgy 1 Nazareno, Jaro, Leyte,admitted for the 1 st time in this institution
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Difficultyof
Breathing
Chief Complaint
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History of Present Illness
(+) nonproductive
cough (+) Colds (+) High Grade
Fever (-) DOB Cetirizine 5ml OD
2 days
PTA
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Still w/ fever &Cough
(+) DOB Medication given:
Paracetamol120mg/5ml, tsp q
4hrs for fever Cetirizine 0.2 mkg
1 dayPTA
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Increase intensity& occurrence of dyspnea
Promptedconsultation to
AMD & advisedfor admission
Anhour
PTA
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Personal History
Patient was born to 20 y.o G1P0 mother Prenatal Check-up was done No complications noted
Prenatal Hx
Via NSVD by PMD in cephalic presentation Umbilical cord sloughed off after 5 daysBirth Hx
Pinkish with good cry No complications
NeonatalHx
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Breastfeed for 1 years supplemental: 6 months
Feeding
Hx
5 bottles of formula milk ( 10 ml: 5
scoop 5-6 tbsp of rice 1 matchbox of fish/meat
24 hourDiet Recall
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Playful Sleeps: 9 pm & wakes up: 6
am
Behavior
CompleteImmunization
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Growth & Development GROSS MOTOR ADAPTIVE FINEMOTOR LANGUAGE PERSONALSOCIAL
Sits withoutsupport @6 monthsStands withsupport @8months
Walks well alone@13 monthsRuns well @1year & 8months oldUpstairs 1 foot per step @ 3 years & 6
moths old
Grasps object placed in hand@4monthsHolds bottle @9
monthsThumb finger grasp @10 monthsDrinks from cup@15 monthsImitates a circle
@2 yrs old
Call mamaImitates sound@9monthsPoints to 1 body
part @2 yrs oldTells stories @3yrs oldGives full name@3 yrs old
Smiles @2monthsPlays a peek a boo@8 monthsWaves bye bye @9
monthsImitates housework @15 monthsUses spoon @18monthsRemove garment
@2 yrs oldPlays interactivegames @3 yrs oldDresses withsupervision @3 yrsold
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Past Medical History
UTI 1 yearold
Primary
KochsInfection
Medical
Illnesses
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April 2012 due to BAIAEat Bethany Hospital
Hospitalization
EggAllergy
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INH 200mg/5ml
Rifampicin 200mg/5ml PZA 500mg/5ml
Sig: 4ml OD 30 minsAC breakfast x 6 mos
Medications
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Family History
30 years old, OFW, apparentlywellFather
24 years old, Housewife,apparently wellMother
1 year old, female apparentlywellSiblings
Mother side: (+) asthmaHeredofamilial
Disease
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Psychosocial History
Was born March 27, 2010 Live with his parents in aconcrete house
With stuffed toys, dog(+) electricity
(+) Water (NAWASA)
(+) toilet inside the house
Patient
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Review of System
General: (+) fever Nose & Sinuses: Cold with nasal discharges
Respiratory: (+) dyspnea, (+) nonproductivecough
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Physical Examination
Patient was seen & examined awake,irritable, well nourished, well groomed,mesomorph, febrile, with the following vital
signs & anthropometric measurements:
General
Survey HR- 144 bpm RR 35 cpm Temp 37.9 CVitalSigns
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General Survey
Patient was seen & examined awake, irritable, well nourished,well groomed, mesomorph, febrile, with the following vital signs &anthropometric measurements:
Vital signs Actual Normal Value
Temperature 37.9 C 36.5 to 37.5 C
Heart Rate 144 bpm 109 32.6
Respiratory Rate 35 pm 3012.1
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Anthropometric Measurement
Actual Ideal
Weight 15.6 kg 14 kg Above 50 th percentile
Height 83 cm 95 cm Below 3 rd percentile
HC 49 cm
CC 55 cm Above 50 th percentile
AC 57 cm
MAC 18 cm Above 95 th Percentile
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Waterlow Classification: Stunting = Actual Ht x100
Ideal ht. for age = 83cm /95cm x 100
= 87.37 % (mild)
Wasting = Actual Wt x 100 Ideal wt. for ht
= 15.6kg/ 14kg x 100 = 111% Normal)
Normal > 90%Mild 80-90% Mod 70-80% Severe < 70%
Normal > 95%
Mild 90 -95%Mod 80 -90%Severe less than 80%
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Z-score Result Interpretation
Length for Age Below - 3 Stunted
Weight for Age Above 0 Normal
Weight for length Above 2 Overweight
BMI Above 2 Overweight
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Physical Examination
Skin: moist, warm, no rashes Nose: watery nasal discharge, with nasal
flaring Neck: with lymphadenopathy Chest & Lungs: symmetrical lung expansion,
with subcostal retraction, with wheezing allover lung field
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ABDOMEN: flabby, soft, no tenderness,normoactive bowel sound, no organomegaly
EXTREMITIES: symmetrical, full and equalpulses, no cyanosis, no edema
BACK AND SPINE: (-) kidney punch, no flanktenderness
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Diagnostic Exam
Urinalysis
Color Darkyellow
Transparency clear Spec. Gravity 1.025
pH 5 Protein Trace Sugar Negative
RBC 1-2/hpf Pus Cells 5-8/hpf Epithelial Cells Moderate
Bacteria few A. Urates few M. Threads Moderate
CBC
Hb 146 WBC 4.25 Neutrophils 0.65
Hct 0.41 PlateletCount
204 Lymphocytes 0.35
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Diagnostic Exam
CXR-PA view
Primary
KochsInfection
Dengue Rapid Test
NS1Ag: Negative
IgG: Negative
IgM: Negative
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Salient Features 3 year old, male Difficulty of Breathing (+) nonproductive cough (+) Colds (+) Fever Admitted last April 2012 due to BAIAE at Bethany Hospital Primary Kochs Complex Heredofamilial Disease --Mother side: (+) asthma With stuffed toys, dog
With vital signs: HR- 144 bpm, RR 35 cpm, Temp 37.9 C with lymphadenopathy With subcostal retraction with wheezing all over lung field
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Differential Diagnosis
Mechanical
ForeignBody
Obstruction
Vascular
CongestiveHeartfailure
Infectious/Inflammatory
TB
Pneumonia
COPD
Autoimmune/ Allergies
Asthma
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Foreign Body Aspiration
Rule In Rule Out
3 year old, malewith wheezing all over lung fieldDifficulty of Breathing(+) nonproductive cough
(+) Fever
No history of Foreign Body IntakeALLERGIC SYMPTOMS
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Pneumonia
Rule In Rule out
Difficulty of Breathing(+) nonproductive cough(+) Colds(+) Fever
with lymphadenopathy
We connot totally rule out
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Pulmonary Tuberculosis
3 year old, male, Filipinowith lymphadenopathyDifficulty of Breathing(+) nonproductive cough
(+) Colds(+) FeverPrimary Kochs ComplexMOTTED LYMPHADENOPTHY
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Bronchial
Asthma inAcuteExacerbation
AdmittingDiagnosis
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S O A P
Chief Complaint:Difficulty of Breathing
2 days PTC(+),
nonproductivecough and coldsassoc with highgrade fever
1 day PTC, stillwith cough, colds &
fever now assocwith DOB
With vital signs:HR- 144 bpmRR 35 cpm,Temp 37.9 C
withlymphadenopathyWith subcostalretractionwith wheezing all
over lung field
Bronchial Asthma Please admitpatient to ward of choice under theservice of Dr. Tizon.
Secure consent foradmission.TPR q shift.Diet for Age if tolerated.Diagnostics:
CBC withplatelet countUrinalysisCXR-APL view
EMERGENCY ROOM
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S O A P(+) fever(+) cough(+) cold(+) Vomit 1 episode
approx 50 cc per bout
Vital Signs:HR 114 bpmRR 26 cpmTemp 37.7 C (+) left basal crackles (+) minimal wheeze
BAIAEPneumonia
Follow-up chest X-ray.Decrease IVF rate to50 cc/hourIVF to follow with D5IMB 500 cc at 50cc/hour.Dengue Rapid Test(tomorrow A.M)
Ns1Ag, IgM & IgGDecrease ampicillin500mg q 8 hours IVTTCetirizine 5ml OD(patients stock)Refer accordingly.
1ST Day of Hospitalization
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S O A P
Afebrile(+) cough(+) cold(-) rashes
(+) defecate (1x)
Vital Signs:HR- 128 bpmRR 32 cpmTemp 37.5 C
(+) wheeze(+) crackle bibasal
IVF to follow: D5IMB 500 cc @ 50cc/hr.Decrease
hydrocortisone toevery 8 hours.Continue othermedications.Refer accordingly.
2nd Day of Hospitalization
3rd D f H it li ti
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S O A P
afebrile(+) Cough(-) Vomiting(-) rashes
Vital Signs:HR- 130 bpmRR 30 cpmTemp 37.3 C
(+) minimalwheezing
(+) good air entry
IVF to follow: D5IMB 500 cc @ 50cc/hrAzithromycin
(Zithromax)250mg/5ml, 4mlOD, PO.Continue othermedication.
3rd Day of Hospitalization
4 th D f H it li ti
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S O A P
Afebrile(+) Cough(-) vomiting(-) Rashes
Vital Signs:HR- 130 bpmRR 34 cpmTemp 36.8 C
(+) minimalwheezing
(+) good air entry
IVF to follow: D5IMB 500 cc @ 25cc/hr
Increase
hydrocortisonesame dose q 6hours
Continue othermedication.
Decrease IVF rate
to 20 cc/hr.
4 th Day of Hospitalization
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S O A P
Afebrile(+) Cough(-) vomiting(-) Rashes
Vital Signs:HR- 122 bpmRR 32 cpmTemp 37.2 C
(+) minimalwheezing
(+) good air entry
IVF to consumethen D/C, thenconnect IV cannulato heplock
Decreasehydrocortisone to q8 hours IVTT.Decreasesalbutamolnebulization to
every 8 hoursalternate withpulmodual.Continue othermeds.
5 th Day of Hospitalization
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S O A P
Afebrile(+) Cough(-) vomiting(-) Rashes
Vital Signs:HR- 120 bpmRR 30 cpmTemp 37 C
(-) wheeze(-) crackle
DisconitueHydrocortisone.Prednisolone20mg/5ml at 2.5 ml
BID P.O.Nebulization q 8hours.Continuemedications.
6 th Day of Hospitalization
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S O A P
Afebrile(-) dyspnea(-) Cough(-) colds
Vital Signs:HR- 120 bpmRR 30cpmTemp 36.7 C
(-) wheeze(-) crackles
Discontinue IVmeds, removecannula.May go home.
Home medication:Seretide25/125, 2 puffsBID.Cetirizine 5mlOD at H.S
Follow-up after 1week.
6 th Day of Hospitalization
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Case discussion
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Epidemiology Asthma ranked number 1 among the non-
infections admissions in 57 of accreditedhospitals
PPS Registry of Diseases, 1994
Prevalence of wheezing among 6-19 years inMetro Manila schools was 27.45%
Del Mundo, textbook of Pediatrics 2002
A large international survey study of childhoodasthma prevalence in 56 countries found a widerange in asthma prevalence, from 1.6 to 36.8%
ISAAC Study
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DEFINITION
a chronic inflammatory disorder of the airways inwhich many cells play a role, including mast cellsand eosinophils
this inflammation causes symptoms that areusually associated with widespread but variableairflow obstruction that is often reversible either
spontaneously or with treatment, and causesassociated increase in airwayhyperresponsiveness to a variety of stimuli.
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Anatomy
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PATHOPHYSIOLOGY
is complex and involves the followingcomponents:
1) Airway inflammation2) Intermittent airflow obstruction3) Bronchial hyperresponsiveness
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Environmental Factors
AllergensSensitizers
Respiratory infxn
Endogenous FactorsGenetic Predisposition
Male Triggers
Allergens
URTIExercise
Cold air
Activation of inflammatory
& epithelialcells
Mediators(histamine,
leukotrienes,cytokines)
Bronchospasm MucusSecretion
Airwayhyperresponsiv
eness
Table 254-1 Risk Factors and Triggers Involved in Asthma
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Endogenous Factors Environmental Factors Genetic predisposition Indoor allergens Atopy Outdoor allergens
Airway hyperresponsiveness Occupational sensitizers Gender Passive smoking Ethnicity? Respiratory infections Obesity? Early viral infections? Triggers Allergens Upper respiratory tract viral infections
Exercise and hyperventilation
Cold air Sulfur dioxide and irritant gases Drugs ( -blockers, aspirin) Stress Irritants (household sprays, paint fumes)
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Signs and symptoms to look for
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Signs and symptoms to look forinclude:
Frequent coughing spells, which may occur during play, atnight, or while laughing. It is important to know that coughmay be the only symptom present.
Less energy during play Rapid breathing Complaint of chest tightness or chest "hurting Whistling sound (wheezing) when breathing in or out See-saw motions (retractions) in the chest from labored
breathing Shortness of breath, loss of breath Tightened neck and chest muscles Feelings of weakness or tiredness
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