Case Presentation

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 1st time in this institution

Difficulty of Chief Complaint Breathing

History of Present Illness

(+) nonproductive cough (+) Colds (+) High Grade Fever (-) DOB Cetirizine 5ml OD

2 days PTA

1 day PTA

Still w/ fever & Cough (+) DOB Medication given: Paracetamol 120mg/5ml, tsp q 4hrs for fever Cetirizine 0.2 mkg

An hour PTA

Increase intensity & occurrence of dyspnea Prompted consultation to AMD & advised for admission

Personal History
Prenatal Hx Birth Hx Neonatal Hx
Patient was born to 20 y.o G1P0 mother Prenatal Check-up was done No complications noted

Via NSVD by PMD in cephalic presentation Umbilical cord sloughed off after 5 days

Pinkish with good cry No complications

Feeding Hx 24 hour Diet Recall

Breastfeed for 1 years supplemental: 6 months

5 bottles of formula milk ( 10 ml: 5 scoop 5-6 tbsp of rice 1 matchbox of fish/meat

Behavior

Playful Sleeps: 9 pm & wakes up: 6 am

Immunization

Complete

Growth & Development

GROSS MOTOR Sits without support @6 months Stands with support @8months Walks well alone @13 months Runs well @1year & 8months old Upstairs 1 foot per step @ 3 years & 6 moths old ADAPTIVE FINE MOTOR Grasps object placed in hand @4months Holds bottle @9 months Thumb finger grasp @10 months Drinks from cup @15 months Imitates a circle @2 yrs old LANGUAGE Call mama Imitates sound @9months Points to 1 body part @2 yrs old Tells stories @3 yrs old Gives full name @3 yrs old PERSONAL SOCIAL Smiles @2months Plays a peek a boo @8 months Waves bye bye @9 months Imitates housework @15 months Uses spoon @18 months Remove garment @2 yrs old Plays interactive games @3 yrs old Dresses with supervision @3 yrs old

Past Medical History

UTI 1 year old Primary Kochs Infection

Medical Illnesses

 April 2012 due to BAIAE Hospitalization at Bethany Hospital

Allergy

Egg

 INH 200mg/5ml Rifampicin 200mg/5ml Medications PZA 500mg/5ml Sig: 4ml OD 30 mins AC breakfast x 6 mos

Family History
Father Mother
Siblings
30 years old, OFW, apparently well 24 years old, Housewife, apparently well
1 year old, female apparently well

Heredofamilial Mother side: (+) asthma Disease

Psychosocial History
Was born March 27, 2010
Live with his parents in a concrete house

Patient (+) electricity With stuffed toys, dog

(+) Water (NAWASA)

(+) toilet inside the house

Review of System
General: (+) fever Nose & Sinuses: Cold with nasal discharges Respiratory: (+) dyspnea, (+) nonproductive cough

Physical Examination

General Survey Vital Signs

Patient was seen & examined awake, irritable, well nourished, well groomed, mesomorph, febrile, with the following vital signs & anthropometric measurements:

HR- 144 bpm RR 35 cpm Temp 37.9 C

General Survey
Patient was seen & examined awake, irritable, well nourished, well groomed, mesomorph, febrile, with the following vital signs & anthropometric measurements:

Vital signs Temperature Heart Rate Respiratory Rate

Actual 37.9 C 144 bpm 35 pm

Normal Value 36.5 to 37.5 C 10932.6 3012.1

Anthropometric Measurement
Actual Weight Height HC CC AC MAC 15.6 kg 83 cm 49 cm 55 cm 57 cm 18 cm Above 95th Percentile Above 50th percentile Ideal 14 kg 95 cm Above 50th percentile Below 3rd percentile

Severe

< 80%

Waterlow Classification: Stunting = Actual Ht 100 Ideal ht. for age = 83cm /95cm x 100 = 87.37 % (mild)

x Wasting = Actual Wt x 100 Ideal wt. for ht = 15.6kg/ 14kg x 100 = 111% Normal)

Normal > 90% Mild Mod Severe

80-90% 70-80% < 70%

Normal Mild Mod Severe

> 95% 90 -95% 80 -90% less than 80%

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

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 all over lung field

ABDOMEN: flabby, soft, no tenderness, normoactive bowel sound, no organomegaly EXTREMITIES: symmetrical, full and equal pulses, no cyanosis, no edema

BACK AND SPINE: (-) kidney punch, no flank tenderness

Diagnostic Exam
Urinalysis Color Dark yellow 5 1-2/hpf few Transparency clear Spec. Gravity 1.025

pH RBC Bacteria

Protein Pus Cells A. Urates

Trace 5-8/hpf few

Sugar Epithelial Cells M. Threads

Negative Moderate Moderate

CBC Hb Hct 146 0.41 WBC Platelet Count 4.25 204 Neutrophils Lymphocytes 0.65 0.35

Diagnostic Exam
CXR-PA view
Primary Kochs Infection

Dengue Rapid Test

NS1Ag: Negative

IgG: Negative

IgM: Negative

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

Differential Diagnosis
Mechanical Vascular Infectious/ Inflammatory
TB Foreign Body Obstruction Congestive Heart failure

Autoimmune / Allergies

Pneumonia

Asthma

COPD

Foreign Body Aspiration

Rule In 3 year old, male with wheezing all over lung field Difficulty of Breathing (+) nonproductive cough (+) Fever Rule Out No history of Foreign Body Intake ALLERGIC SYMPTOMS

Pneumonia
Rule In Difficulty of Breathing (+) nonproductive cough (+) Colds (+) Fever with lymphadenopathy Rule out We connot totally rule out

Pulmonary Tuberculosis
3 year old, male, Filipino with lymphadenopathy Difficulty of Breathing (+) nonproductive cough (+) Colds (+) Fever Primary Kochs Complex MOTTED LYMPHADENOPTHY

Bronchial Asthma in Admitting Acute Diagnosis Exacerbation

EMERGENCY ROOM
S Chief Complaint: Difficulty of Breathing 2 days PTC(+), nonproductive cough and colds assoc with high grade fever 1 day PTC, still with cough, colds & fever now assoc with DOB O With vital signs: HR- 144 bpm RR 35 cpm, Temp 37.9 C with lymphadenopathy With subcostal retraction with wheezing all over lung field A Bronchial Asthma P Please admit patient to ward of choice under the service of Dr. Tizon. Secure consent for admission. TPR q shift. Diet for Age if tolerated. Diagnostics: CBC with platelet count Urinalysis CXR-APL view

EMERGENCY ROOM
S O A P

Start venoclysis D5 0.3 NaCl 500 ml regulated at 60 gtts/min x 8 hrs Medications: Rapid salbutamol nebulization, 1 neb q 15min x 3 doses then alternate with pulmodual nebulization 2.5 ml q 6 hours Hydrocortisone 65mg q 6 hours Ampicillin 800mg IVTT q 6 hours ANST ( ) Paracetamol 250mg/5ml, 5ml q 4 hours PRN for temperature greater than 37.8 C Continue Anti Kochs medication once available (patients stock) Monitor I & O q 4 hours Monitor V/S q 4 hours Refer for any episode of respiratory distress Relay results once In. AMD informed. Refer accordingly.

1ST Day of Hospitalization

S (+) fever (+) cough (+) cold (+) Vomit 1 episode approx 50 cc per bout O A P Follow-up chest X-ray. Decrease IVF rate to 50 cc/hour IVF to follow with D5 IMB 500 cc at 50 cc/hour. Dengue Rapid Test (tomorrow A.M) Ns1Ag, IgM & IgG Decrease ampicillin 500mg q 8 hours IVTT Cetirizine 5ml OD (patients stock) Refer accordingly. Vital Signs: BAIAE HR 114 bpm Pneumonia RR 26 cpm Temp 37.7 C (+) left basal crackles (+) minimal wheeze

2nd Day of Hospitalization

S Afebrile (+) cough (+) cold (-) rashes (+) defecate (1x) O Vital Signs: HR- 128 bpm RR 32 cpm Temp 37.5 C (+) wheeze (+) crackle bibasal A P IVF to follow: D5 IMB 500 cc @ 50 cc/hr. Decrease hydrocortisone to every 8 hours. Continue other medications. Refer accordingly.

3rd Day of Hospitalization

S afebrile (+) Cough (-) Vomiting (-) rashes O Vital Signs: HR- 130 bpm RR 30 cpm Temp 37.3 C (+) minimal wheezing (+) good air entry A P IVF to follow: D5 IMB 500 cc @ 50 cc/hr Azithromycin (Zithromax) 250mg/5ml, 4ml OD, PO. Continue other medication.

4th Day of Hospitalization

S Afebrile (+) Cough (-) vomiting (-) Rashes O Vital Signs: HR- 130 bpm RR 34 cpm Temp 36.8 C (+) minimal wheezing (+) good air entry A P IVF to follow: D5 IMB 500 cc @ 25 cc/hr Increase hydrocortisone same dose q 6 hours Continue other medication. Decrease IVF rate to 20 cc/hr.

5th Day of Hospitalization

S Afebrile (+) Cough (-) vomiting (-) Rashes O Vital Signs: HR- 122 bpm RR 32 cpm Temp 37.2 C (+) minimal wheezing (+) good air entry A P IVF to consume then D/C, then connect IV cannula to heplock Decrease hydrocortisone to q 8 hours IVTT. Decrease salbutamol nebulization to every 8 hours alternate with pulmodual. Continue other meds.

6th Day of Hospitalization

S Afebrile (+) Cough (-) vomiting (-) Rashes O Vital Signs: HR- 120 bpm RR 30 cpm Temp 37 C (-) wheeze (-) crackle A P Disconitue Hydrocortisone. Prednisolone 20mg/5ml at 2.5 ml BID P.O. Nebulization q 8 hours. Continue medications.

6th Day of Hospitalization

S Afebrile (-) dyspnea (-) Cough (-) colds O Vital Signs: HR- 120 bpm RR 30cpm Temp 36.7 C (-) wheeze (-) crackles A P Discontinue IV meds, remove cannula. May go home. Home medication: Seretide 25/125, 2 puffs BID. Cetirizine 5ml OD at H.S Follow-up after 1 week.

Case discussion

Epidemiology
Asthma ranked number 1 among the noninfections admissions in 57 of accredited hospitals
PPS Registry of Diseases, 1994

Prevalence of wheezing among 6-19 years in Metro Manila schools was 27.45%
Del Mundo, textbook of Pediatrics 2002

A large international survey study of childhood asthma prevalence in 56 countries found a wide range in asthma prevalence, from 1.6 to 36.8%
ISAAC Study

DEFINITION
a chronic inflammatory disorder of the airways in which many cells play a role, including mast cells and eosinophils this inflammation causes symptoms that are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment, and causes associated increase in airway hyperresponsiveness to a variety of stimuli.

Anatomy

PATHOPHYSIOLOGY
is complex and involves the following components: 1) Airway inflammation 2) Intermittent airflow obstruction 3) Bronchial hyperresponsiveness

Endogenous Factors Genetic Predisposition Male Environmental Factors Allergens Sensitizers Triggers Allergens URTI Exercise Cold air

Respiratory infxn

Activation of inflammatory & epithelial cells

Mediators (histamine, leukotrienes, cytokines) Bronchospasm Mucus Secretion Airway hyperresponsiv eness

Table 254-1 Risk Factors and Triggers Involved in Asthma Endogenous Factors Genetic predisposition Atopy Airway hyperresponsiveness Gender Ethnicity? 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) Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Passive smoking Respiratory infections

Signs and symptoms to look for include:

Frequent coughing spells, which may occur during play, at night, or while laughing. It is important to know that cough may 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