pediatrics case studies

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    Demographic information

    Name: Master. Arun

    Age: 8 years

    Sex: Male

    Date of birth: 18 April 2005 Religion: Hindu

    Born of non-consanguineous marriage

    Tharamani, Chennai

    Socio economic status class 3

    Informant : Mother reliable

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    Chief Complaints

    Cough and cold- 4 months.

    Breathlessness- 2 months.

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    History of presenting illness The patient was apparently asymptomatic 4 months

    back, then he developed

    Cough and cold

    Insidious in onset

    Duration 4 months

    Progressive

    Productive cough with copious, yellowish-green incolour, purulent, foul smelling sputum

    Exacerbated on lying on the left lateral position

    No diurnal or seasonal variations Relieved by mediations temporarily

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    Breathlessness

    Breathlessness for 2 months

    Insidious in onset,

    Progressive,no postural variations

    Class 2 according to NYHA classification

    No relieving factors.

    No H/o Paroxysmal nocturnal dyspnea

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    Negative history

    No h/o fever, chest pain, wheeze.

    No h/o hemoptysis, ear discharge

    No h/o Jaundice, chronic diarrhoea

    No h/o syncope, cyanosis, chest pain,palpitations.

    No h/o oliguria, abdominal distension, pedal

    edema.

    No h/o loss of appetite, loss of weight

    No h/o hoarseness of voice

    No h/o foreign body aspiration/known choking

    spells.

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    Past history

    H/o exanthematous fever probably measles 6months back. Was admitted in Govt. general

    hospital and treated.

    No h/o similar illness in the past.

    No H/o contact with tuberculosis

    No H/o oil instillation in the ear

    No h/o previous hospitalizations.

    No h/o known allergies, Asthma

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    Birth history

    Delivered at term by emergency cesarean section(Indicationmeconium stained liquor)

    Birth weight 2.8kgs

    Cried after birth

    No H/o jaundice, seizures, feeding difficulties. No H/o discharge or redness of umbilical stump

    No H/o Ventilatory/Incubatory care, Phototherapy

    Breast feeding started immediately

    Meconium and urine passed within 24hrs

    Antenatal history Spontaneously conceived

    Booked and immunised Trimesters - uneventful

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    Developmental history

    Gross motor, fine motor, language, social and

    adaptive milestones attained corresponding to the

    age

    The child is studying in 3rdstandard. Fairly good

    scholastic performance.

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    Family history

    Pedigree chart

    During birth,

    Maternal age 26

    Paternal age 30

    Born of a non-consanguineous marriage 1 elder brother -15 years healthy

    No h/o of asthma, cystic fibrosis in the family

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    Immunisation

    BCG scar present

    Immunised till 6 months

    Pulse polio immunisation given until 5 years

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    Dietary history

    Expected Observed Gap

    Calories 1700 1121 579

    Proteins 21 32.7 -

    Exclusively breast fed for 6 months.

    24hr dietary recall

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    Socio-economic status

    MotherEducation 10th

    Occupation household maid

    Income Rs.5000/month

    Class 3 Lower middle

    Housing condition pacca house, 1 room, 1 kitchen,

    adequately ventilated

    Sewage and garbage disposal done properlyWater for the children is not boiled before

    consumption

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    History Summary

    8 year old male child presented with complaintsof chronic cough and breathlessness for the past

    4 months. Cough was associated with copious,

    purulent sputum production. There is past history

    of an episode of exanthematous fever 6monthsback which resolved following treatment. This

    child is most probably suffering from a

    suppurative lung disease. I would like to proceed

    with the examination of respiratory system.

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    Examination

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    General Examination

    The child was Conscious

    Oriented to time place and person

    Lethargic

    Co-operative

    Clubbing present grade 1, pan digital

    No pallor, icterus, cyanosis, lymphadenopathy, pedeledema

    No dysmorphic features

    No external markers of allergy and Tuberculosis

    BCG scar present

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    Vitals

    Pulse rate

    98 beats/ min. Normal in rate, rhythmand volume

    Respiratory rate 31 breaths/ min. Thoraco-

    abdominal. Intercostal retraction present.

    Blood pressure 100/70mm of Hg

    Febrile 98.4 F

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    Anthropometryobserved expected

    Weight 15.1kgs 25kgs 61% Grade 2

    malnutrition

    Height 115cms 135cms 85% Grade 2

    stunting

    BMI

    11Head circumference48cms

    Chest circumference 53cms

    Abdominal circumference 58 cmsHead to footexamination

    Halitosis present

    Normal facies

    Chest appears normal

    Polydactly medial extra digit in left hand

    External genitalia appears normal

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    Local examination - Respiratory

    UPPER RESPIRATORY TRACT-

    Nose is normal - no DNS, Polyp, congestion,

    rhinorrhoea, foreign body

    No sinus tenderness

    Oral cavity appears normal. No dental caries,

    bleeding gums.

    Tonsils not enlarged

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    Inspection Chest wall is symmetrical Trachea appears to be in midline.

    Apex beat seen in the left fifth intercostal space1cm medial to MCL.

    Chest wall moves equally with respiration. Intercostals retractions present

    No grunt/stridor

    No drooping of shoulders, bony abnormalities,chest wall deformity seen.

    No scars, sinuses, engorged veins.

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    Palpation

    Tracheal position and Apex beat confirmed.

    Chest expansion 4 cm (during inspiration,

    circumference: 57 cm, during expirationcircumference: 53 cm)

    Chest wall moves equally with respiration.

    No Tactile fremitus, no tenderness

    No chest wall deformities

    No kyphosis or scoliosis

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    RIGHT LEFT

    SUPRACLAVICULAR NORMAL NORMAL

    INFRACLAVICULAR NORMAL NORMAL

    MAMMARY NORMAL

    AXILLARY NORMAL NORMAL

    INFRAXILLARY NORMAL

    SUPRASCAPULAR NORMAL NORMAL

    INTERSCAPULAR NORMALINFRASCAPULAR NORMAL

    VOCAL FREMITUS

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    RIGHT LEFT

    SUPRACLAVICULA

    R

    RESONANT RESONANT

    INFRACLAVICULAR RESONANT RESONANT

    MAMMARY DULL RESONANT

    AXILLARY RESONANT RESONANT

    INFRAXILLARY DULL RESONANT

    SUPRASCAPULAR RESONANT RESONANT

    INTERSCAPULAR DULL RESONANT

    INFRASCAPULAR DULL RESONANT

    NO PERCSSION

    PERCUSSION

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    RIGHT LEFT

    SUPRACLAVICULAR NVBS NVBS

    INFRACLAVICULAR NVBS NVBS

    MAMMARY BRONCHIAL VR NVBSAXILLARY NVBS NVBS

    INFRAXILLARY BRONCHIAL VR NVBS

    SUPRASCAPULAR NVBS NVBS

    INFRASCAPULAR NVBS NVBS

    INTERSCAPULAR BRONCHIAL VR NVBS

    AUSCULTATION

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    Persistent coarse leathery crepitations is heardwell in both lung bases both during inspiration

    and expiration.

    No Bronchophony, Aegophony, and Whispering

    pectoriloquy.

    No wheeze, pleural rub, pericardial rub.

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    Examination of other systems

    Abdomen:Soft, no mass felt, No organomegaly

    Cardiovascular system:S1 S2 heard. No

    murmur.

    CNS:No focal neurological deficits

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    Summary

    8 year old male child presented with complaints ifchronic cough and breathlessness for the past 4

    months. Cough was associated with copious,

    purulent sputum production. There is past history

    of an episode of exathematous fever 6monthsback which resolved following treatment.

    Examination revealed pan digital clubbing and

    halitosis. On auscultation, bronchial breath

    sounds and coarse leathery basal crepitationswere heard in the right lung.

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    Diagnosis

    Bronchiectasis of the right lung involving themiddle and lower lobe with the probably etiology

    being post-measles infection with grade 2

    malnutrition and grade 2 stunting.

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    Investigations

    Blood

    Hb%, total count, differential count,platelet

    ESR

    Mantoux test

    Sputum culture & AFB

    X-ray chest

    HR-CT

    Fibreoptic bronchoscopy

    Broncho-alveolarlavage

    Bronchography

    Sweat chloride test

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    Management

    Medical management Chest physiotherapy and postural drainage

    Antibiotics and Vaccination support

    Nutritional support Symptomatic therapy bronchodilators,

    corticosteroids

    Long term oxygen therapy

    Surgical management

    Segmental or lobar pneumonectomy

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    Thank you