Pulmonary Case Conference

General Data

• DC • 1 year 6 months• Male • Phase 1 Lot 29 Block 2 St. Michael St.

Camacho Nangka, Marikina City• Roman Catholic

Chief Complaint

• Fever

HPI

4DaysPTC•fever (max temp 38.90C, axillary) •(+)clear watery nasal discharge•(+)decrease in appetite, • Paracetamol 25mg/kg/dose

3DaysPTC(+) persistence of symptoms

Phenylpropanolamine HCl drops (Disudrin) 1.6mg/kg/dose

HPI

2DaysPTC•Persistence of symptoms •(+) productive cough•3 episode of post tussive vomiting of previously ingested fluids with sputum amt 5-15ml/ episode•Prefer drinking than eating

HPI

1Day PTC•one episode of vomiting, with fever, colds, cough, decreased level of activity and decreased fluid and food intake• consult at a local hospital • CBC (Hb 103g/L, Hct 0.32, WBC 4.8 x

109/L, platelet 270 x 109/L, Neutrophil 0.49, Lymphocytes 0.51• Diagnosis: Lower Respiratory Tract

infection• Med: Cefixime 6mg/kg/day ;

Salbutamol nebulization q8

HPIFew hours PTC

•bloody nasal discharge •blood-tinged sputum•Persistence of fever, decreased level of activity, and poor oral intake•sought consult at USTH Pedia-SBC,

Review of SystemsGeneral: (-) weight loss Skin: (-) rashes, (-) jaundice, (-) cyanosisHead: (-) injuries/lacerations, (-) eye redness, (-) eye discharge/exudates,

(-) tearing, (-) aural discharge, (-) cleft lip or palatePulmonary: HPICardiac: (-) edema, (-) cyanosisGastrointestinal: (-) diarrhea, (-) constipation, (-) melena, (-)

hematocheziaGenitourinary: (-) hematuria, (-) anuria/oliguriaNeurologic/Psychiatric: (-) convulsionsHematopoietic: (-) easy bruisability, (-) bleeding manifestationsExtremities: (-) joint deformities, (-) joint swelling

Gestational History

• Born to a 28 year old, G3P2 (2002).• Frequent prenatal check-up at a local clinic • No hepatitis B screening and gestational diabetes

screening done• Denied:• use of illicit drugs, smoking, and drinking alcohol during

pregnancy. She also denied exposure to radiation or other chemicals..

• Medications:– multivitamins.– anti-Koch’s medication for a month

Birth History • Term at 39-40 weeks AOG delivered via NSD. • Lying-in clinic.• Attended by a midwife • labor for 2 hours • Birth weight was 6.5kg.

Neonatal History• spontaneous cry; no resuscitation was needed.• poor suck at birth• No congenital abnormalities were noted.

Feeding History

• Patient was not breastfed due to inability of mother to excrete milk.

• Milk (0-6months) - Bona (2:1 dilution) 2oz – 10-12x/day

• (6 months – 1year) – Bonamil (2:1 dilution) 4oz – 10-12x/day

• Current: Bear Brand Jr (1:1 dilution) 6oz – 4-6x/day• Complementary Feeding started at 9 months

(gruel, chicken, bread)

Feeding History

Past Medical History• Pneumonia (2009) Immunization History• Completed EPI at a local

health center• BCG 1 dose• Hepatitis B 3 doses• OPV 3 doses• DPT 3 doses• Measles 1 dose

Developmental/ Behavioral history

• Patient’s development is at par with age. – Motor: walks and runs

well, ascends stairs one foot at a time,

– Language: knows more than 10 words including mama and papa,

– Fine: drinks from a cup and uses spoon.

– Social: Understands simple directions, Shows affection by kissing parents

Socioeconomic and Environmental History• Lives with his parents and 2 older brothers – 2-storey house• made of wood and concrete• well lit and well ventilated.

• Main water: NAWASA and water used for drinking is boiled for 30 minutes.

• Garbage is collected 3x/week and segregates and recycles.

• Father often smokes inside the house. • They have no pets and no nearby factories.

Family History

• (+) Hypertension – maternal grandmother• (+) PTB – mother – took medications for only a

month, stopped since pregnant with child • (-) DM, cancer, asthma, allergies, kidney and

thyroid disorders

Family Profile

Physical Examination

Awake, irritable, ill looking, not in cardiorespiratory distress, well nourished, moderately dehydrated

Vital signs: CR: 145bpm,regular RR: 33cpm, regular Temp:

37.00C Anthropometric measurement: Weight: 10kg (z score 0 normal) Length: 80cm (z score

0 normal) Weight for length (z score 0 normal) BMI: 15.63 (z

score 0 normal)

Physical Examination

Warm, moist skin, no active dermatoses, good skin turgor, CRT <2sec

No scalp lesions, tauma, deformities, sutres and fontanels closed

Pink palpebral conjunctiva, anicteric sclera, pupils 2-3mm ERTL, (+) sunken eyes

Midline nasal septum, (+) turbinates congested, (+) clear nasal discharge

Nonhyperemic external auditory canal, intact tympanic membrane, (+) retained cerumen, AU

Physical Examination

Moist buccal mucosa, hyperemic posterior pharyngeal wall, tonsils grade II, bilateral

Supple neck, no palpable cervical lymph nodesSymmetrical chest expansion, (-) retractions, clear breath

soundsAdynamic precordium, apex beat at 4th LICS MCL, no murmursGlobular abdomen, normoactive bowel sounds, soft, no

palpable massesRedundant prepuce, bilateral descended testesPulses full and equal, no edema, no cyanosis

Neurologic Examination

• Awake, irritable, with spontaneous eye movement, pupils isocoric 2-3mm ERTL, no facial asymmetry, uvula midline, gross movements on all extremities, no muscle atrophy