Dr. KANTA HALDERResident (MD;Phase A)

BICH

Particulars of the patient

Name: Shifa

Age: 6 years

Sex: Female

Informant: Mother

Address: Shariyatpur

Date of Admission: 25.05.2015

Date of Examination: 02.06.2015

Chief Complaints

Fever for 5 days

Cough for 5 days

Respiratory distress for same duration

History of present illness:

According to the statement of mother, Shifa

was reasonably well 5 days back. Then she developed fever which was high grade, intermittent in nature, not associated with chills and rigor and relieved by taking antipyretics, highest recorded temperature was 103°F. She also had history of cough which was productive in nature and respiratory distress for same duration. She had no history of contact with TB patient.

Cont..

With these complaints, she was treated in alocal hospital and referred to Dhaka Shishu Hospital for further evaluation and better management.

History of Past illness:

She had history of same type of attack 2 times since her 3 years of age and got hospitalized and treated with nebulization along with antibiotic. She was then diagnosed as a case of bronchial asthma and was taking inhaler sulbutamol, tab montelucast and tab theophylline irregularly for last 1.5 years. Shifa was not entirely symptom free in between the attacks and had h/o mild cough.

Birth History: She was delivered normally at term at home

without any perinatal complication.

Feeding History:

She is on family diet.

Immunization History:

She is immunized as per EPI schedule.

Familly History :

She is the 2rd issue of her non-consanguinous

parents.Her other family members are healthy.

Socio-economic History :

She came from a low socio-economic

background.She lived in a tin-shed house,drinks tube-well water and use sanitary latrine.

Treatment History

After admission, Shifa was getting nebulization

and other injectable and oral medication.

Developmental History

She is developmentaly age appropriate.

General Examination :

Appearance: Ill looking

Anaemia:

Jaundice:

Cyanosis:

Clubbing: Absent

Oedema:

Dehydration:

Cont..

Skin: BCG mark present

Bony tenderness: Absent

Lymphnode: Not palpable

Signs of meningeal irritation: Absent

Neck Vein: Not engorged

Ear:

Nose: Normal

Throat:

Cont..

Vital Signs:

Heart Rate: 100/min

Respiratory Rate: 26/min

Temperature: 100°FBlood Pressure: 90/50 mmHg

Anthropometry:

Cont..

Weight: 11 kg

Height: 104cm

HAZ: -2.4 (moderately stunted)

WHZ: -5.6 (severely wasted)

Systemic Examination

Respiratory system :

Inspection :

Respiratory rate: 26/min

Shape of the chest : Normal

Movement of the chest : Bilaterally symmetrical

Cont..

Palpation :

Trachea is centrally placed

Vocal fremitus is increased in mid-clavicular, mid-axillary and post-scapular line of right lung.

Apex beat lies in left 5th intercostal space, just lateral to the midclavicular line

Percussion :

Percussion note is dull in mid-clavicular, mid-axillary and post-scapular line of right lung.

Cont..Auscultation :

Breath sound is diminished on mid-clavicular, mid-axillary and post-scapular line of rightside but vescicular on left side.

Vocal resonance is increased in mid-clavicular, mid-axillary and post-scapular line of right lung.

Crepitation presents in right lung field.

Cont..

Cardiovascular system :

1st & 2nd heart sounds are audible in all 4 areas.

There is no added sound.

Alimentary system :

No organomegaly

No ascitis

Other Systemic examination: No abnormality

Salient feature

Shifa,a 6 years old girl,2nd issue of her non-

consanguinous parents was admitted with the complaints of high grade, intermittent fever, productive cough and respiratory distress for 5 days. She had no history of contact with TB patient. She had h/o repeated attack of same type of illness and got admitted in the hospital for 2 times since 3 years of age.In between the attacks, she had mild cough not responding to

Cont..

medication. Shifa was ill looking, febrile. Percussion note was dull, vocal fremitus and vocal resonance was increased and breath sound was diminished in right lung with crepitation. Other systemic examination reveals no abnormality.

Provisional Diagnosis:

Right sided recurrent pneumonia

Differential Diagnosis:

• Pulmonary tuberculosis

• Cystic fibrosis

• Immunedeficiency

Investigations:

Complete Blood Count :

• Hb: 13.1 gm/dl

• WBC: Total count: 8,800/cumm

Differential count:

o Neutrophil: 55%o Lymphocyte: 40%o Monocyte: 03%

o Eosinophil: 02%o Basophil : 00%

Cont..

o RBC:Normocytic normochromic

o WBC:Mature with above distribution

o Platelet: Adequate

• Platelet : 196,000/cumm

• PBF:

Cont..

Analysis of sputum : AFB not found

Smear shows numerous Gram positive cocci and leukocytes.

Gastric lavage for AFB : Not found

Mantoux test : 00 mm

Echocardiogram : Normal

Chest X-ray:

Cont..

HRCT of chest: Consolidation in medial basal segment of right lower lobe with segmental volume loss (collapse).

Sweat chloride test: 92.4 mmol/L (07.06.15)

17.9 mmol/L (09.06.15)

Final Diagnosis:

Right sided collapse-consolidation

(due to cystic fibrosis)

Management :

A. Counseling

B. Supportive:

• Maintainance of hydration and nutrition

• Antipyretics

Cont..

C. Specific treatement:

• Inj. Ceftriaxone

• Inj. Vancomycin

D. Chest Physiotherapy

E. Follow up

Thank You