PulmoCon

Geronimo, Maria Angelica; Geronimo, Ralph Ernesto; Go, Camille-Marie; Go, Crystal Karen

January 24, 2011Pulmonology ConferenceGeneral DataJ.M.3 months oldMaleSampaloc, ManilaRoman CatholicCC: Difficulty of BreathingCC: Difficulty of BreathingReview of SystemsGeneral: (-) weight changesCutaneous: (-) rashes, (+) jaundice HEENT: (-) eye redness (-) eye discharge (-) ear discharge (-) gum bleedingCardiovascular: (-) cyanosisRespiratory: see HPI Gastrointestinal: (-) acholic stools

Review of SystemsGenitourinary: (-) tea-colored urine (-) oliguria (-) dischargeNervous/Behavior: (-) seizures (-) tremors (-) mood/behavioral changesEndocrine: (-) polyuria (-) polydipsia (-) polyphagia (-) heat/cold intoleranceMusculoskeletal: (-) edema (-) swelling (-) limitation of motion (-) tendernessHematopoietic (-) bleeding tendencies (-) easy bruisability

Gestational HistoryMother: 36 year-old G1P0 housewifeFather:37 year old seamanRegular prenatal checkups USTH OPD for 7 times(-) viral exanthem, radiation and any intake of illicit, prohibited or abortifacient drugs, intake of alcohol and smokingUTI (September 2010) - Cefalexin for 7 days and claimed to be compliant; Repeat UA - normal OGCT and Hepatitis screening were not doneGestational HistoryHPN (HBP 160/100; UBP is 110-10/70mmHg) Magnesium sulfateNicardipine drip BetamethasoneEmergency CS secondary to preeclampsia

Birth HistoryLive, preterm, singleton male, delivered via E CS secondary to preeclampsiaBW 1.66 kgBL 44 cmHC 31 cmCC 25 cmAC 22 cmAS 8,9MT 32-33 weeksAGANeonatal History1st hour if life CXR: air bronchogram with densities on the right lower lobePersistent respiratory distress intubated (NICU)PDA: grade II continuous murmur2nd day of life hyperbilirubinemia (6.8) Phototherapy on the 5th HDNeonatal hepatitis

Neonatal History2D echocardiography: PDA, patent foramen ovale, LVE, LAE and pulmonary arterial hypertensionBlood CS: Klebsiella pneumoniaAssessment: sepsisDischarged at his 52nd day of life

Feeding HistoryMixed Breastfed and Milk formula15 minutes/breast3x a day alternating with Formula S26 lactose free 1 scoop in 2 ounces every 3 hoursMother claims that there is not enough milk being produce thats why she started on powdered milkGood appetite with no feeding difficulties

24 Hour Food RecallCHOCHONFatsKcalBreakfast Milk 2 ounce64585Merienda Milk 2 ounce64585Lunch Milk 4 ounce12810170Merienda Milk 2 ounce64585Dinner Milk 2 ounce64585ACI510RENI560%91%Developmental HistoryGood motor activityVisually tracks objects and looks aroundHas social smileMother do not practice him to sit with support or do prone positionHas head lag when pulled

Past Medical HistoryOctober 10, 2010: sepsis, neonatal hepatitis and PDA No previous surgeries doneNo allergy, eczema, asthma, food or drug sensitivities

Immunization HistoryHepatitis B 11/22/10, 12/22/10BCG - 11/24/10DTP and OPV - 12/22/10

Family ProfileNameAgeRelationEducational AttainmentOccupationHealthSG38FatherCollege graduateSeamanHealthyCG36MotherCollege graduateUnemployedPreeclampsiaFamily History(+) Asthma paternal grandmother(+) HPN maternal grandmother(-) DM, blood dyscrasia, autoimmune disease, congenital disorders, thyroid diseases, cancer, allergy

Socioeconomic and Environmental History Rented studio type made of concreteAdequate space for each household member, well-lit and well ventilatedWater stationMeals are home-cooked prepared by his mother or sometimes they buy cooked-mealsNo pets, no factories or other industrial establishments within the vicinity of the residenceGarbage is not segregated and is being collected everydayNot exposed to second hand smoke

Physical ExaminationAwake, alert, in respiratory distress, ambulatory, well-hydrated, well nourished, ill-lookingHR 135 bpm, regular, RR 48 cpm, regular, T36.7oC, SpO2 (?)Wt: 3.26 kg (z score below -3 severely underweight)Lt: 51 cm (z score below -3 severely stunted)BMI: 12.53 (z score below -2 severely wasted)Warm, moist skin, no jaundice(?) jaundice siya noong pinuntahan namin!!!!!, no visible gross skin lesions, good skin turgorPhysical ExaminationNormocephalic head, no visible scalp lesions, patent anterior fontanelPink palpebral conjunctivae, anicteric sclerae, pupils 2-3 mm ERTLNo tragal tenderness, intact tympanic membraneNo nasoaural discharge, nasal septum midline, turbinates not congestedMoist buccal mucosa, nonhyperemic posterior pharyngeal walls, tonsils not enlarged,

Physical ExaminationSupple neck, no palpable cervical lymphadenopathy, thyroid gland not enlargedSymmetrical chest expansion, (+) subcostal retractions, equal tactile and vocal fremiti, (+) crackles over both lung field with occasional wheezes at left lung fieldAdynamic precordium, apex beat at 4th LICS MCL, no heaves/lifts, no thrills, normal rhythm, S1 louder than S2 at the apex, S2 louder than S1 at the base, (+) Grade II continuous murmur

Physical ExaminationGlobular abdomen, normoactive bowel sounds, soft, no tenderness, no palpable masses, Traubes space not obliterated Genitalia: grossly male with both descended testesPulses are full and equal, no edema, no cyanosis

Neurologic ExaminationAwake, alert Cranial nerves: CNI not assessed, pupils 2-3mm equally reactive to light, (+) direct and consensual light reflex, (+) ROR, EOM full and equal, no gross facial asymmetry, gross hearing intact (able to localize sound), CN IX, X, XI, XII not assessedNo spasticity, rigidy, flaccidity, no limitation in movementNo sensory deficitsDTR +2 No nuchal rigidity, Brudzinskis and Kernigs (+) Moro, grasp, plantar, sucking reflex

Salient Features3 month old maleHistory of colds, non-productive coughPE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung field

3 month old maleHistory of colds, non-productive cough, difficulty of breathingPE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung fieldPulmonary PathologyPneumoniaApproach to the DiagnosisPPS Clinical Practice Guideline for PCAP 2004

Complete Blood CountBacterialViralWBC 15,000 40,000WBC < 20,000GranulocytesLymphocytesChest Xray (PA Lat)Gold standard for the diagnosis of pneumoniaIndicates complications PCAP such as a pleural effusion or empyemaIn our patient...01/12/11Hgb89RBC2.85Hct0.26MCV92.90MCH31.10MCHC33.50RDW15.90MPV9.0Platelet382WBC 9.80Neutrophils0.28Segmenters0.28Bands-Metamyelocyte-Lymphocytes0.64Monocytes-Eosinophils0.08Basophils-Myelocytes-Reticulocyte CountCourse in the wardsPneumonia