Transcript Clerk*s Grandrounds

Clerk’s Grandrounds
Go, K, Go, MR, Go, MF, Go, MH, Go,
RM
General Data
HB
3 years old/female
Sta. Cruz, Manila
Birthdate: Feb. 8, 2007
Admitted: January 1, 2011
Informant: Parents
Reliability: Good
CC: Fever
Chief Complaint
• Difficulty of breathing
History of Present Illness
• Patient is a known asthmatic since 6 months of age
• Maintained on Salbutamol (dosage form and dosage)
2 days PTA
Few hours
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
• (+) 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
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
History of Present Illness
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Cardiovascular: no cyanosis
Respiratory: see HPI
Gastrointestinal: see HPI
Genitourinary: see HPI
• 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
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
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
O2 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
Physical Examination
• HEENT: Normocephalic, No scalp lesions, (-) alopecia,
pale palpebral conjunctivae, anicteric sclera, nonhyperemic, 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
Physical Examination
• Lungs/ Chest:
– Symmetrical labored chest expansion
– (+) suprasternal retractions, (+) intercostal
retractions
– (+) 14x10 cm swelling non-erythematous warmth
at posterior thorax 5th – 10th intercostals space, (+)
crepitations over anterior and posterior thoraces,
(+) hyperresonance
– (+) wheezes with fair to tight air entry, (+) rhonchi,
(+) fine crackles on both bases
Physical Examination
• Cardiovascular: Adynamic precordium, AB 5th 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
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
Salient Features
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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 5th –
10th intercostals space
(+) crepitus subcutaneous emphysema at both arms 14x16 cm of nonhyperemic
Assessment
• Bronchial Asthma, in Moderate Acute
Exacerbation
• Secondary Spontaneous Pneumothorax,
probably due to Bronchial Asthma
• Pneumonia
• Subcutaneous Emphysema
Day 1
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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
COMPLETE BLOOD COUNT
HGB
RBC
HCT
MCV
MCH
MCHC
RDW
MPV
PLATELET
WBC
DIFFERENTIAL COUNT
NEUTROPHILS
METAMYELOCYTES
BANDS
SEGMENTED
LYMPHOCYTES
MONOCYTES
EOSINOPHILS
BASOPHILS
1/1/11
146
4.95
.43
87.30
29.40
33.70
13.30
8.20
437
22.40
.86
.05
.31
.14
-
UNIT
g/L
X10^12/L
U^3
Pg
g/dL
fL
X10^9/L
X10^9/L
REFERENCE RANGE
120-170
4.0-6.0
.37-.54
87 +-5
29+-2
34+-2
11.6-14.6
7.4-10.4
150-450
4.5-10.0
.50-.70
.00-.05
.50-.70
.20-.40
.00-.07
.00-.05
.00-.01
ABG
pH
PCO2
PO2
Temp
FIO2
BP
HCO3
O2 sat
BE
TCO2
O2CT
BB
SBE
AaDO2
a/A
RI
1/1/11
7.343
14.7
76
37
21
758.2
8
94.3
-14.2
8.4
19.9
33.8
-15.7
55.8
.58
.7
UNIT
mmHg
mmHg
%
mmHg
mmol/L
%
mmol/L
mmol/L
VOL%
mmol/L
mmol/L
mmHg
Day 2
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(+) dry lips
Increased IVF to 16-17gtts/min
Initiated liquid, then soft diet
Ranitidine 10mg/SIVP
ABG
pH
PCO2
PO2
Temp
FIO2
BP
HCO3
O2 sat
BE
TCO2
O2CT
BB
SBE
AaDO2
a/A
RI
1/1/11
7.343
14.7
76
37
21
758.2
8
94.3
-14.2
8.4
19.9
33.8
-15.7
55.8
.58
.7
1/2/11
7.390
17.9
176
36.9
80
760.3
10.8
99.2
-10.9
11.4
19.9
36.7
-12.3
375.9
.32
2.1
UNIT
mmHg
mmHg
%
mmHg
mmol/L
%
mmol/L
mmol/L
VOL%
mmol/L
mmol/L
mmHg
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 + 97.8 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
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
Day 5
• Oral methylprednisolone discontinued
Day 7
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(+) congested turbinates
(+) vomiting
(+) abdominal pain
Ranitidine discontinued
Lansoprazole (Prevacid) 15mg/tab ½ tab OD
Day 8
• Discharged stable and improved
Final Diagnosis
• Bronchial asthma, in moderate acute
exacerbation
• Secondary spontaneous pneumothorax
secondary to bronchial asthma
• Pneumonia
• Subcutaneous emphysema, resolved
Case Discussion
Journal