5. PDA

Case PresentationCase Presentation

SYED ARIFF AMIR SYED AWALYMUHAMMAD NIZAR MOHAMMAD YATIMFAIZUL HARIS MOHD HATTA

DEMOGRAPHIC DETAILSDEMOGRAPHIC DETAILSName : KADate of Birth : 31st May 2010Age : 7 months oldGender : MaleEthnic Group : MalayDate of Admission : 18th December 2010Date of Clerking : 20th December 2010 Informant : MotherWard of Admission : 8C, Hospital Sungai

BulohAddress : Sekinchan

CHIEF COMPLAINTCHIEF COMPLAINTKA, a 7 month old malay boy a

known case of PDA & ASD was admitted to HSB on 18th December 2010 due to shortness of breath one day prior to admission associated with vomiting and chesty cough 2 days prior to admission.

HISTORY OF PRESENTING HISTORY OF PRESENTING COMPLAINTCOMPLAINT

KA was previously well until 2 days prior to admission when he started to develop chesty cough, & shortness of breath.

1. CHESTY COUGH Sudden onset, continuous throughout whole day,

no relieving factor, aggravated at night, disturbed his sleep, loss his appetite

2. SHORTNESS OF BREATH Sudden in onset, breath using mouth, rapid

movement of the abdomen

On the same day, the mother brought him to KK Sekinchan due to these symptoms and he was prescribed with anti – tussive drug, and antibiotic.

Mother claimed that the medication doesn’t relieved the symptoms.

One day prior to admission, patient developed vomit in the morning associated with cough and shortness of breath; post – tussive vomiting, 3 episodes, vomitus contained mucous, whitish in colour, no blood stain, no bile and it was about 1/3 of a cup in each episode.

Mother brought patient to HTK and was prescribed with syrup PCM, anti-tussive drug and antibiotic. Symptoms became worsened

On the day of admission, his shortness of breath became worsened at 3 a.m; patient was slept, his breath became noisy, no aggravating and no relieving factor.

Mother brought him to HSB due to his shortness of breath at 7.00 a.m

SYSTEMIC REVIEWSYSTEM COMPLAINTS

General No fever, no irritability

Cardiovascular No pedal edema, no sweating

Respiratory Shortness of breath, cough, no haemoptesis

Gastrointestinal Vomit, loss appetite, no abdominal pain, no haemetemesis and no alter bowel habits

Genitourinary No polyuria, no dysuria and no haematuria

Central Nervous System

No loss of consciousness, no neck stiffness, no weakness

ENT No runny nose, no ears discharge

MSK no gross deformities

PAST MEDICAL AND SURGICAL HISTORYWas admitted to HSB on September due

to shortness of breath. He was then diagnosed to have viral bronchopneumonia.

DRUG ADMISSIONSpironolactoneFrusamide*Both are for ASD & PDA

ALLERGYNo know allergy

BIRTH HISTORYBIRTH HISTORY• No complication to the mother during

pregnancy

• He was delivered at 30 weeks of gestation via spontaneous vaginal delivery with weight of 1.55kg at Hospital Tanjung Karang.

• He was admitted to NICU for 22 days due to respiratory distress syndrome. He was also diagnosed with PDA & ASD

.

FEEDING HISTORYMix (breast milk + formula milk)

since 1st day of life.He started to consume semisolid

food at 6 months old.

IMMUNISATION HISTORY• Up to age

DEVELOPMENTAL HISTORY (corrected age: 5 months old)• Gross motor- Can sit with hands on couch

for support. Can roll from supine to prone• Vision and Fine motor- Can transfer

objects from one hand to the other hand and can feed independently with biscuits

• Speech and language- Can babble in combined syllables.

• Social- Looks for fallen toy and understand NO!

FAMILY HISTORYFAMILY HISTORYPatient is the second child of 2

siblings- His elder sister, 2 years old, healthy

Father-35 years old, healthyMother-32 years old, healthyNo consaguinity

SOCIAL AND SOCIAL AND ENVIRONMENTAL HISTORYENVIRONMENTAL HISTORYFather - TechnicianMother - HousewifeTotal income –RM900Live in a small village house;

utilities are good with no pets and carpet in house.

Father is a smoker, about 1 packs of 20’s per day.

HISTORY OF CONTACTHISTORY OF CONTACTUneventful

EFFECTS OF ILLNESS ON THE PATIENTS AND THE FAMILY

Since their average monthly income was low, the illness affected their economic status as they have to pay the medical costs and transportation cost.

Physical ExaminationPhysical Examination

General ExaminationGeneral Examination

•  KA, a 7 month old boy was lying in supine position supported by one pillow.

• He does not look ill, not pale• He was conscious and alert. • He was in respiratory distress but not in pain and his hydrational status was adequate.

• There was no muscle wasting, no gross deformity and no abnormal movement.

• There was one branula located on the dorsum of his right hand.

Vital signTemperature : 37.5°C Blood Pressure : 107/34 mmHgPulse Rate : 166 beats/ min, Respiratory Rate: 66 breaths/minSp O2 : 97 %AnthropometryWeight : 4.86 kg (below 3rd centile)

Height : 63 cm (at 25th centile)HC : 38 cm (3rd centile)

Examination for hydration status

His hydrational status was adequate. The mucous membrane was moist and there was normal skin turgor. No sunken of anterior fontanelle, no sunken eye, CRT less than 2 sec.

Examination of face, Examination of face, head, neck and limbshead, neck and limbs• Appearance : No face deformity• Head : No frontal bossing• Hair : No hair loss, no bald spot• Face :No cyanosis, no pallor and no puffiness of

face• Oral cavity : Fair oral hygiene, moist mucous

membrane, no ulcers and no central cyanosis• Eyes : No pallor and no jaundice• Ear, nose and throat : Throat not injected and

tonsil was enlarged and red. No ear discharge but had runny nose

• Neck : No thyroid enlargement, no nodes are palpable.

• Skin : No rashes, eczema or any abnormal finding• Extremities : Warm peripheries, no clubbing

fingers and toes, no koilonychias, no pedal edema, no muscle wasting

Developmental assessmentDevelopmental assessment

Gross motor : Can roll from supine to prone

Vision and fine motor : Reaches for objects, plays with toes

Speech and language : Babbling in single syllables

Personal social : Mouthing

Systemic ExaminationSystemic ExaminationRespiratory System

Inspection : - No chest deformity, no dilated veins, moves symmetrically with respiration,

no visible pulsation, mild subcostal and intercostal recession, chest looked hyperinflated 

Palpation : - Trachea is centrally located not deviated, symmetrical and equal chest

expansion. - The apex beat is located at the 6th intercostal space at midclavicular line.

Percussion : Was not done

Auscultation: - Normal bronchovesicular breath sound at both lungs with equal air entry

on both sides there was additional sounds -generalise rhonchi heard louder during expiration at right lung posteriorly -generalise crepitation heard louder duing inspiration at both lung

anteriorly -Crepitation was louder than Rhonchi.

Cardiovascular systemCardiovascular system

• Inspection: The chest was symmetrical and normal in shape. There was no scar, no precordial bulging, no visible apex beat and no prominent dilated veins.

• Palpation: The apex beat was located at the sixth intercostal space at the midclavicular line. There was no thrill and heave. The peripheral pulses were present with normal rhythm and volume. all arterial pulses are present(radial, brachial, carotid, popliteal, dorsalis pedis, posterior tibial artery), there was collapsing pulses. There is no Radio-Femoral delay,or pulsus paradoxus. there is no raised in Jugular Venous Pressure

• Auscultation: systolic murmur best heard, at upper left sternal edge, not radiated, S1S2 heard

Abdominal ExaminationAbdominal Examination•Inspection: The abdomen was not distended, symmetrical in shape and moved with respiration. The umbilicus was centrally located and inverted. There was no scar, prominent dilated vein, skin discolouration, visible peristalsis and visible pulsation.•Palpation: The abdomen was soft and non tender on light palpation. On deep palpation, the liver and spleen were not palpable. Both kidney were not ballotable.•Percussion : No shifting dullnes•Auscultation : Normal bowel sounds were present.

Central Nervous System Central Nervous System ExaminationExamination

• Mental status : he was alert and respond to his surrounding, not active.

• Muscle tone: There was no hypertonia or hypotonia

• Muscle power: not was performed• Reflexes :all present with positive Babinski’s sign

CLINICAL SUMMARYCLINICAL SUMMARY• KA, a 7 month old malay boy a known case of

PDA & ASD was admitted to HSB due to shortness of breath one day prior to admission associated with vomiting and chesty cough 2 days prior to admission.

• On examination, he has signs of mild respiratory distress evidence by tachypnoea (66 breaths/min), subcostal and intercostal recession, on auscultation there was additional sounds

• - generalise rhonchi heard louder during expiration at right lung posteriorly

• -generalise crepitation heard louder duing inspiration at both lung anteriorly

• -Crepitation was louder than Rhonchi

PROVISIONAL DIAGNOSISPROVISIONAL DIAGNOSIS• Pneumonia

–Difficulty in breathing–Chesty cough, running nose lethargy and poor feeding

–Preceded by upper respiratory infection

–Decreased oxygen saturation–Signs of respiratory distress–Widespread crepitation and rhonci. But crepitation more prominent.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Differential diagnosis Support Against

Bronchiolitis BreathlessnessSigns of respiratory distresshyperinflated chest

- No fever- No noisy breathing (wheezing)-Crepitations more prominent than rhonci

Asthma BreathlessnessNo fever

- no history of asthma- no wheezing-No family hx of asthma

Cardiac failure BreathlessnessSigns of respiratory distress

- no signs of peripheral or central cyanosis.

General InvestigationGeneral Investigation

18/12/2010 Normal Range

Impression

WBC 16.93 6.0-16.0 x 109/L

increase

RBC 4.09 4.0-6.0 x 1012/L

normal

RBC Distribution

14.0% normal

Hemaglobin 11.3 11.1-14.1 g/dL normal

Hematocrit 38.6 37.0-45.0 % normal

MCH 24.6 24-33 Pg normal

MCV 77.1 77-95 fL Normal

MCHC 31.6 31-40 pg/cell Normal

Platelet 445 110-450 x 109/L

Normal

Full Blood Count

18/12/2010 Normal Range

Neutrophil (%) 57.8 40-75%

Lymphocyte 50.0 20-45%

Monocyte 5.6 2-10%

Eosinophil 1.8 0-5%

Basophil 0.1 0-0.2%

Automated Differential

25/07/08 Normal Range

Urea 3.3 2.5-8.0 mmol/L

Sodium 139 133-145 mmol/L

Potassium 3.9 3.5-6.0 mmol/L

Creatinine 35.8 20-65 µmol/L

Renal Profile

• Liver profile

Normal range

Value Interpretation

Total protein 64.0-83.0 g/L

74.0 Normal

Albumin 35-50 g/L 35 Normal

Globulin 20-35 g/L 33 Normal

Albumin/Globulin Ratio

0.89 1 Normal

Total bilirubin 3.4- 20.5 umol/L

3.4 Normal

Alkaline phosphatase

40-150 U/L 145 Normal

Alanine Aminotransferase

7-53 U/L 14 Normal

Urine FEME , urine C&S- all normal, no abnormal microorganism growth detected

throat swab -Parainfluenza 2 Virus Antigen detected

nasopharyngeal aspirate for RSV study – No RSV detected

C-Reactive Protein-

1.20mg/dl normal value < 1 mg/ dl

increase

Chest x-rayChest x-ray

Interpretation :hyperinflated lungs, hazziness in both lungs, cardiomegaly  

Final diagnosisFinal diagnosisBronchopneumonia with underlying congenital heart disease (ASD, VSD)

MANAGEMENTSMANAGEMENTS(taken from Malaysian CPG and Paediatrics Protocols)(taken from Malaysian CPG and Paediatrics Protocols)

I. Assessment of severity of pneumonia

II. Assessment of oxygenationIII. Criteria for hospitalizationIV. Antibiotic therapyV. Supportive treatment

ManagementManagement• Admit to ward• Medication- Continues syrup spironolactone 6.25mg BD - Continues syrup frusemide 4mg BD   - iv ampicilin 120mg 6hrly - neb 2hrly salbutamol- neb 4hrly atrovent - cont syrup tamiflu • keep face mask oxygen• Close monitoring vital signs and oxygen saturation

• encourage orally• Refer to dietician

DiscussionDiscussion

Problems…Problems…

1. Preterm2. Congenital Heart Disease3. Bronchopneumonia

Complications of PretermComplications of PretermRespiratory Distress Syndrome (RDS)Persistent Ductus Arteriosus (PDA)

Necrotizing EnterocolitisInfectionsRetinopathy of Prematurity (ROP)Apnea and BradycardiaAnemiaBronchopulmonary DysplasiaHernias and Hydroceles.

ASD & PDAASD & PDA◦Manifested as:

Recurrent chest infection Poor weight gain Tachypnoe Tachycardia Cardiomegaly Collapsing pulse Systolic murmur

Why failure to thrive?Why failure to thrive?

Why recurrent chest Why recurrent chest infection?infection?

Management of heart Management of heart disease in the patientdisease in the patientGiven spirinolactone and

furosemide.Was referred to dietician for high

calories diet.Appointment in June 2011 with

IJN.

PneumoniaPneumonia

DefinitionDefinition◦Infection of the lower respiratory

tract that involves the airways and parenchyma with consolidation of the alveolar spaces.

◦Highest in infancy, remains relatively high in childhood, low in adult and increases again in old age.

EtiologyEtiologyVirus (common in younger

children)◦RSV◦Influenza A and B◦Adenovirus◦Parainfluenza 1,2,3

Bacteria

Age Bacterial pathogens

Newborns Group B streptococcus, E. coli, Klebsiella, Enterobacteriaceae

1-3months Chlamydia trachomatis

Preschool Strp. pneumoniae, HiB, Staph. Aureus

school Mycoplasma pneumoniae, Chlamydia pneumoniae

Microorganisms entryMicroorganisms entry

1. Inhalation of the microbes2. Aspiration of the organism3. Hematogenous spread from a

distant focus4. Direct spread from an adjoining

site of infection

TypesTypesBronchopneumonia

◦Inflammation of the lung that is centered in the bronchioles and leads to the production of an exudates that obstructs smaller airways and causes patchy consolidation of the adjacent lobules.

Lobar pneumonia◦Pneumonia localized to one or more

lobes of the lung in which the affected lobe or lobes are completely consolidated.

Why consolidation occurs?Why consolidation occurs?

SymptomsSymptomsFeverFast breathingCoughLethargyPleuritic chest painPoor feeding

SignsSignsTachypnoeNasal flaringChest indrawingDullness on percussionDecreased breath soundCrackles on auscultation

InvestigationsInvestigationsFull blood countRenal profileChest X-rayBlood culturePleural tap analysisSerology

Viral vs BacterialViral vs BacterialCharacteristics Viral Bacterial

Fever Low grade, acute High grade, gradual onset

Mucosal congestion and inflammation of

upper airway

Suggestive Not suggestive

FBC WBC normal or mildly elevated,

lymphocytes predominance

WBC elevated, neutrophils

elevated

X-ray Usually characteristics of

bronchopneumonia

Usually lobar consolidation

TreatmentTreatmentFactors like the clinical or

investigation findings, age of the child, local epidemiological agents, sensitivity to microbial agents and the severity of the pneumonia should be considered.

1st line Beta-lactam drugs

Ampicillin, amoxycillin, benzylpenicillin

2nd line Cephalosporins Cefotaxime, cefuroxime, ceftazidime

3rd line Carbapenam Imipenam

others aminoglycosides

Gentamicin, amikacin

Macrolide antibiotic is used if Mycoplasma or Chlamydia are the causative agents.

Supportive treatmentSupportive treatmentNebulized bronchodilatorsFluids

◦Must be given in appropriate amountOxygen

◦Concentration determined by pulse oximetry

Anti-pyretic

Others…Others…Had to go to 3 health care centers

before getting proper treatments.Mother had to stay away from

husband and daughter.Working father had to drive every

night to HSB ◦Got tired◦Economy◦Leaves daughter with sister in law.

Take home messageTake home messageTreat every patient seriously.Never treat any case lightly.Job is not gained by us, but

granted by Allah.Be sincere & always istiqamah.

Thank youThank you