Download - Respiratory System Final
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Pyrexia of unknown origin-An unusual cause
N.S.VIGNESHWAR
RMMH
Anna!alai "ni#ersi$y
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• 10 months old male infant 2nd born to
nonconsanguineous parents residing atSirkali was brought to casualty by hismother whose reliability was good with
presenting complaints of %e#er x & !on$'
oug' x (wks
)rea$'ing *i+cul$y x (wksRefusal of fee*s x &, *ays
A*o!inal *is$ension x &wk
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• Insidious onset• 1 month
• low grade fe#er, in$er!i$$en$
• No chills or rigor
• No H/o rash• No aggravating factors• elieved by antipyretics
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• oug' present on o/ throughoutthe day *is$uring $'e slee0
• ! wks duration
• Insidious onset
• Associa$e* with *i+cul$y inrea$'ing " !wk
• #ore during lying down posture
• No H/o foreign body intake
•
No H/o eye congestion•
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• H/o refusal of fee*s " 1$ days• H/o weig'$ loss present• A*o!inal *is$ension x &wk
•
No H/o melena• No H/o vomiting, loose stools , %aundice, bleeding per rectum
• No H/o fore head sweating, suckrest suck cycle ,bluishdiscolouration of face
• No H/o sei&ures, loss of
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A*!ission a$ 1!on$'sof age for
12 *ays -3R4I
A*!ission a$ 5!on$'s
of agefor &!on$' 63R4I wi$'a*o!in
al*is$ension
A*!i$$e* a$ 7!on$'sof agefor (
weeks-3R4Iwi$'a*o!inal
*is$ension•
%e#er 8 coug'8 rea$'ing *i+cul$y 9a*o!inal *is$ension
• )loo* $ransfusion - ane!ia• :x wi$' 4) A44 s$ar$e* - 7$' !on 8 no
con$ac$ H;o of 4)
S4 HIS4<R=
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)IR4H HIS4<R=>-• 'ntenatal (No H/o )*+H
IN-+)I*N• No other maternal risk factors• Natal ( )erm normal delivery. 0wt
20$kg• ostnatal ( 3neventful• 3mbilical cord fell on day 4•
assed #econium on day 1
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IMM"NI?A4I<N :- – +5 6Scar present7 – *8 9,1,2,! – :) 1,2,! – Hep; 1,2,! – Hib 1,2,!
• <et to be Immuni&ed with measles
N"4RI4I<N>-
• -;= months then started weaning
Ac$ual Ex0ec$e*
Ga0
+alorie !4$6>cal
7
?996>cal
7
51,@c
alB
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:EVE3<PMEN4A3 age appropriate forchronological age
%AMI3= HIS4<R= no H/o similar illness infamily members
S<I<E<N<MI S4A4"S - 5rade I86'ccording to modiAed >uppusamy scale 7
+attle
present
!92
4
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HEA: 4< %<<4 ECAMINA4I<N>-
• ' open B Cat
• Eyes 6 Pallor 9
• No evidence of 8it0 :eAciency• •
-ars ,*ral cavity normal• • undus normal
• -ars ; no discharge
• Neck ; no lymphadenopathy.• Dimbs 63D/DD7; normal• Pan*igi$al cluing 9
• A*o!en *is$en*e*
• -"ternal genitalia normal
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AN4HR<P<ME4R=A4"A3 ECPE4E:
E-I5H) F0$ >g @0$ >g 5D F(r* cen$ilegra*e IV@IAP7
Dength ==cm 42cm @1GH-':+I+3#--N+-
F!0$cm !rd to 19th centile
Wellcome trust –#arasmus
Waterlow-1° degree stunting
Chronic malnutrition
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VI4A3S
• +onscious , alert• )emp;192 •
H;1$2/min. ;@9/=9 mmhg. +)!secs. ;42/min . Sp92;@!G• No e"ternal markers of )•
No signs of liver cell failure
RESPIRA4<R= S=S4EM
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RESPIRA4<R= S=S4EM
INSPE4I<N>-
• +hest shape Bmovement symmetrical
• 'pical impulse visible
medial to the D) nipple
• No scar, sinuses
• SR98IR98 Ala nasiaring +
• No bony abnormalities
PA3PA4I<N>-
• )rachea midline0
• 'pical impulse; Dt
Fth intercostalspace J inchmedial to #+D 0
• Vocal fremitus- right
axillar !infra
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PER"SSI<N (;• #ullness over $t axillar ! infra
axillar " mammar region
A"S"34A4I<N(;
• reath sounds ; %ronchial %reathsound K R$ axillary 8 infra axillary !a!!ary
• Vocal resonance increased on ta"illary , infra a"illary B mammary
• 'dded sounds ; &'( coarse
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ECAMINA4I<N
INSPE4I<N>-
• :istended• 3mbilicus everted B
pushed down•
'll Muadrants moveseMually withrespiration
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PER"SSI<N>-
• 3i#er s0an-&2.,c! 6normal=7
•
No Shiftingdullness
A"S"34A4I<N>-
• owel sounds 4/
• No bruit
PA3PA4I<N >-
•No rigidity
•3i#er 0al0ale - 5c! elow RM
–rounded edges –Surface ; smooth
–irm in +onsistency
–No ulsations
•S0leen 0al0ale - (c! 3M
•No Cuid thrill
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<4HER S=S4EMSVS >-•
S 1 , S 2 heard• No murmurs• No added sounds
NS>-• Higher mental functions intact•
+ranial nerves intact on t B Dt• No sensory disturbances• #otor system ; intact• No meningeal signs
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S=MP4<MS %IN:INGS
- A S"MMAR=
PA33<R
PAN :IGI4A33"))ING
=MP4<MS>-%EVER<"GH)REA4H3ESSNESS
A):<MINA3 *is$ension
4<SP3EN<MEGA3=
RS• V%8VR• )R<NHIA3
)S• )3 <ARSE
REPI4A4I<NS
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• yre"ia of unknown origin• t side consolidation,
hepatosplenomegaly , with grade I8-# most probably due totuberculosis 6disseminated )7
PR<VIS<NA3 :IAGN<SIS
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:;:
• ronchiectasis• )ropical diseases 6dengue, malaria,
enteric fever, 3)I7• Hemolytic anemia• ImmunodeAciency
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• ++;'nemia with mildthrombocytopenia
•
H;D., g;*l• E+ ; 1!$99
• ;4=G
•
D;1?G• -;=G
• latelet;&.(,Dakhs/mm!
• eripheral smear !icrocy$ic'y0oc'ro!ic ane!iawi$' !il*
$'ro!ocy$o0enia no
)I+; F4$ mcg/dl#+8;D*E
+8;!$Sr0 erritin; normal#+H+ ;normal
Hbelectrophoresis;normal
eticount ;2G;
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• S/)/-D-+)*D<)-S;N*#'D•
*,-1./*-120/ )0ilirubin;
N*#'D
• *r3A(&-435 g/dl . 5D*;!0$. 'D ;!1$
•
+oagulation proAle normal•
3rine /-;normal• lood urine c/s;sterile
• Stool +/S;No enteric growth
• :engue Ig# -lisa negative• 3e0$o Ig#;negative
• 4<RH proAle negative
• #;negative
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• '5;respiratoryalkalosis
• Sr0ammonia;normal
• +S analysis ;normal
•
Man$ouxs$rongly0osi$i#e-
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4 4'orax-R$ !i**le loe consoli*a$ion an* );3no*ular o0aci$ies 9
>*H 5 t i ' i t
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5'#S S)'IN )iddle lobe aspirate
>*H; 5astric 'spirat
D+
G $ i i A%) 6!ti 7
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• Gas$ric uice A%) 6!times7 negative
• )reated with ampicillin Kclo"acillin K gentamicin
• No response fever persisted
•
one marrow aspirate normal
• one marrow c/s;normal
3i i t / I-#
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• +') II ')) started
• Steroids added
•
Reasons fors$ar$ing A44
• 3i#er io0sy to r/o I-#;normal
• An$iio$ics c'ange* tomeropenam and vancomycin
• %ungal ;S +andida5rowth
• Started on amphotericin ;1F days
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-SIS)-N) N-3#*NI'
+ < S ) I +
, I / * S I S
•+ystic Abrosis work up normal•etroviral screening 6parents/child7 -#e•Immunoglobin proAle normal
# tuberculosis ca$alase 0osi$i#e
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•#0tuberculosis;ca$alase 0osi$i#e organism ; *isor*er of 0'agocy$osis •N)4;showed
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HR<NIGRAN"3<MA4<"S
:ISEASE
• low cytometry ; parents notaOordable
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:IS"SSI<N G:HR<NI GRAN"3<MA4<"S:ISEASE@G:B
In'eri$e* disorder of phagocyticactivity common in boyssusceptibility to recurren$ infec$ion
since ir$'#utations in NA:PH oxi*ase
subunits
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3INIA3MANI%ES4A4I<NS
Onset ; infancy to young adulthood• ecurrent pneumonia•
Hepatic or any other abcess• 'nemia of chronic disease• oor growth• Hepatosplenomegaly• GRAN"3<MA formation
-)I*D*5<;catalase
K8-organisms ;
#0tuberculosis.Serratia,
urkholderia
,
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<N%IRMA4I<N• low cytometry
6:H7• N) dye test
4REA4MEN4• HS+)• rophylactic antibiotic Bantifungal
• +orticosteroids
• Interferon P