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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


(+) 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


(+) 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



(+) 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.



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S O A P


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.



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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.



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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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