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Clerk’s Grandrounds Go, K, Go, MR, Go, MF, Go, MH, Go, RM.

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Presentation on theme: "Clerk’s Grandrounds Go, K, Go, MR, Go, MF, Go, MH, Go, RM."— Presentation transcript:

1 Clerk’s Grandrounds Go, K, Go, MR, Go, MF, Go, MH, Go, RM

2 General Data HB 3 years old/female Sta. Cruz, Manila Birthdate: Feb. 8, 2007 Admitted: January 1, 2011 Informant: Parents Reliability: Good CC: Fever

3 Chief Complaint Difficulty of breathing

4 History of Present Illness Patient is a known asthmatic since 6 months of age Maintained on Salbutamol (dosage form and dosage) 2 days PTA (+) cough productive of yellowish sputum, with anorexia andprogressive dyspnea, no other accompanying symptoms Salbutamol nebulization  partial relief No consult done, no other medicatiions taken Few hours PTA (+) bilateral swelling over the submandibular area, with progression of cough and dyspnea Consult at Mary Child Hospital CXR- requested (result?) Referred to Jose Reyes and eventually transferred to our institution du to room inavailability

5 Review of Systems General: no weight loss/gain (+) anorexia, (+) weakness Cutaneous: no rashes, no abnormal pigmentation, no pruritus HEENT: no lacrimation, (+) naso-aural discharge, no epistaxis, no salivation

6 History of Present Illness Cardiovascular: no cyanosis Respiratory: see HPI Gastrointestinal: see HPI Genitourinary: see HPI

7 Growth and development: – At par with age Feeding injury – Solid food introduced: 6 months – First food introduced: Cerelac – Number of feeding per day: 3x of small feedings/ day Past medical history: – No allergic rhinitis, no atopic dermatitis, previous hospitalizations and surgeries Family history: (+) asthma - father (-) allergic rhinitis, food allergy, atopic dermatitis, congenital anomalies Immunization history: – Completed

8 Social/Environmental history Patient’s aunt is the primary caregiver patient together with her parents and aunt live in a bungalow type house with an average monthly income of P20,000 House has adequate space and ventilation Patient’s drinking water is from NAWASA Garbage is segregated and collected daily No smokers in the household and no factories nearby

9 Physical Examination General: Lethargic, in cardiorespiratory distress, carried, ill-looking, poorly nourished and hydrated Vital Signs: BP: 80/50 PR=140 bpm RR=56 T=36.9 O 2 sat 75% Anthropometric data: weight: 11kg (weight for age: below 0: normal), Height: 94 cm (length for age: 0: normal), (weight for height: below -2: wasted), BMI: 12 (below -3: severely wasted) Warm moist skin, (-) active dermatoses, (-) hematoma

10 Physical Examination HEENT: Normocephalic, No scalp lesions, (-) alopecia, pale palpebral conjunctivae, anicteric sclera, non- hyperemic, pupils 1-2 mm ERTL, no tragal tenderness, non-hyperemic EAC, (+) impacted cerumen on the left, midline nasal septum, (+) nasal discharge, (+) alar flaring, dry buccal mucosa, dry lips, (-) oral ulcers, tonsils not enlarged, NHPPW, supple neck, thyroid not enlarged, no cervical lymphadenopathies,(+) bilaterally symmetrical submandibular swelling

11 Physical Examination Lungs/ Chest: – Symmetrical labored chest expansion – (+) suprasternal retractions, (+) intercostal retractions – (+) 14x10 cm swelling non-erythematous warmth at posterior thorax 5 th – 10 th intercostals space, (+) crepitations over anterior and posterior thoraces, (+) hyperresonance – (+) wheezes with fair to tight air entry, (+) rhonchi, (+) fine crackles on both bases

12 Physical Examination Cardiovascular: Adynamic precordium, AB 5 th LICS MCL, (-) heaves, thrills and lift, S1>S2 at the apex, S2>S1 at the base, (-) murmurs Abdomen: Flat abdomen, normoactive bowel sounds, (-) direct tenderness in epigastric area, no masses, no rebound tenderness GUT: no CVA tenderness, grossly female, Majora covers minora Extremities: Pulses full and equal on all extremities, no cyanosis, (+) crepitus subcutaneous emphysema over both arms 14x16 cm of non-hyperemic, non-tender, (-) rubor swelling mass

13 Neurological Exam Conscious, coherent oriented to person, time and place, GCS 15 No anosmia, Pupils Left 2-3 mm isocoric ERTL, (+) corneal reflex, (+) ROR, clear disc margins, no visual field cuts, EOM full and equal, V1V2V3 intact, (-) ptosis, (-) shallow right nasolabial fold, can smile, can raise eye brows, can puff cheeks, (-) lateralization on Weber, AC>BC on Rinne’s AU, (+) gag reflex, can shrug shoulders, turns head side to side against resistance, tongue midline on protrusion, uvula midline on phonation Motor: MMT 5/5 on all extremities, no fasciculation, spasticity, flaccidity Sensory: (-) sensory deficiency DTR’s: +2 on all extremities (-) Babinski, right, (-) nuchal rigidity, (-) kernig’s

14 Salient Features 3 year old/female Difficulty of breathing Known case of asthma maintained on salbutamol Hypotensive, tachycardic, tachypneic, hypoxemic, afebrile Lethargic, in cardiorespiratory distress, poorly nourished and hydrated - (+) suprasternal retraction, (+) intercostal retractions, (+) wheezes, (+) ronchi -(+) 14x10 cm swelling non-erythematous warmth at posterior thorax 5 th – 10 th intercostals space -(+) crepitus subcutaneous emphysema at both arms 14x16 cm of non- hyperemic

15 Assessment Bronchial Asthma, in Moderate Acute Exacerbation Secondary Spontaneous Pneumothorax, probably due to Bronchial Asthma Pneumonia Subcutaneous Emphysema

16 Day 1 Hooked to O2 per mask IVF D5 0.3 NaCl 500cc to run at 11-12gtts/min CBC: Increased WBC count ABG Portable CXR: Extensive subcutaneous emphysema of the chest and neck area and probable pneumothorax, left Medications – Methylprednisolone 11mg/SIVP Q6 – Ampisulbactam 300mg/SIVP Q6 – Salbutamol 2.5mg/nebule 1 nebule every hour Referred to Pedia Pulmo and Pedia Allergo

17 COMPLETE BLOOD COUNT1/1/11UNITREFERENCE RANGE HGB146g/L RBC4.95X10^12/L HCT MCV87.30U^ MCH29.40Pg29+-2 MCHC33.70g/dL34+-2 RDW MPV8.20fL PLATELET437X10^9/L WBC22.40X10^9/L DIFFERENTIAL COUNT NEUTROPHILS METAMYELOCYTES- BANDS SEGMENTED LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS

18 ABG1/1/11UNIT pH7.343 PCO214.7mmHg PO276mmHg Temp37 FIO221% BP758.2mmHg HCO38mmol/L O2 sat94.3% BE-14.2mmol/L TCO28.4mmol/L O2CT19.9VOL% BB33.8mmol/L SBE-15.7mmol/L AaDO255.8mmHg a/A.58 RI.7

19 Day 2 (+) dry lips Increased IVF to 16-17gtts/min Initiated liquid, then soft diet Ranitidine 10mg/SIVP

20 ABG1/1/111/2/11UNIT pH PCO mmHg PO276176mmHg Temp FIO22180% BP mmHg HCO3810.8mmol/L O2 sat % BE mmol/L TCO mmol/L O2CT19.9 VOL% BB mmol/L SBE mmol/L AaDO mmHg a/A RI.72.1

21 Day 3 (+) epigastric pain relieved by ranitidine (+) 4 episodes post-tussive bilious vomiting Aminophylline 2.2ml in 20ml IVF to run for 30 mins then maintained at 2.2ml IVF to run at 20ml/hr – (-) tachycardia, headache, seizure, GI upset Mucosolvan 10 drops added to 20 drops ambroxol and salbutamol nebule – Further increase bronchodilation

22 Day 4 Follow up CXR – Remarkable improvement of subcutaneous emphysema – Adequate expansion of the left lung Aminophylline drip and IV methylprednisolone discontinued Doxophylline 100mg/5ml (10mg/kg/day) 2.5ml BID Methylprednisolone 8mg/tab 1 tab Q8

23 Day 5 Oral methylprednisolone discontinued

24 Day 7 (+) congested turbinates (+) vomiting (+) abdominal pain Ranitidine discontinued Lansoprazole (Prevacid) 15mg/tab ½ tab OD

25 Day 8 Discharged stable and improved

26 Final Diagnosis Bronchial asthma, in moderate acute exacerbation Secondary spontaneous pneumothorax secondary to bronchial asthma Pneumonia Subcutaneous emphysema, resolved

27 Take Home Medications Co-amoxiclav 457ml/5ml 3 ml every 12 hours until January 8, 2011 Muconase nasal spray 2-3 sprays per nostril every 6 hours, suction after Doxophylline 10mg/5ml 2.5ml BID Salbutamol puff 2 puffs every hours Prednisone 10mg/5ml 3 ml BID Lansoprazole (Prevacid) 15mg/tab ½ tab once a day

28 Case Discussion

29 Journal


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