Clerk’s Grandrounds Go, K, Go, MR, Go, MF, Go, MH, Go, RM
Apr 01, 2015
Clerk’s Grandrounds
Go, K, Go, MR, Go, MF, Go, MH, Go, RM
General Data
HB3 years old/femaleSta. Cruz, ManilaBirthdate: Feb. 8, 2007Admitted: January 1, 2011Informant: ParentsReliability: GoodCC: 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
•(+) 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
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
• 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, 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
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• 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 non-
hyperemic
Assessment
• Bronchial Asthma, in Moderate Acute Exacerbation
• Secondary Spontaneous Pneumothorax, probably due to Bronchial Asthma
• Pneumonia• Subcutaneous Emphysema
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
COMPLETE BLOOD COUNT
1/1/11 UNIT REFERENCE RANGE
HGB 146 g/L 120-170RBC 4.95 X10^12/L 4.0-6.0HCT .43 .37-.54MCV 87.30 U^3 87 +-5MCH 29.40 Pg 29+-2MCHC 33.70 g/dL 34+-2RDW 13.30 11.6-14.6MPV 8.20 fL 7.4-10.4PLATELET 437 X10^9/L 150-450WBC 22.40 X10^9/L 4.5-10.0DIFFERENTIAL COUNT NEUTROPHILS .86 .50-.70 METAMYELOCYTES - BANDS .05 .00-.05 SEGMENTED .31 .50-.70 LYMPHOCYTES .14 .20-.40 MONOCYTES - .00-.07 EOSINOPHILS - .00-.05 BASOPHILS - .00-.01
ABG 1/1/11 UNITpH 7.343
PCO2 14.7 mmHgPO2 76 mmHg
Temp 37FIO2 21 %BP 758.2 mmHg
HCO3 8 mmol/LO2 sat 94.3 %
BE -14.2 mmol/LTCO2 8.4 mmol/LO2CT 19.9 VOL%
BB 33.8 mmol/LSBE -15.7 mmol/L
AaDO2 55.8 mmHga/A .58RI .7
Day 2
• (+) dry lips• Increased IVF to 16-17gtts/min• Initiated liquid, then soft diet• Ranitidine 10mg/SIVP
ABG 1/1/11 1/2/11 UNITpH 7.343 7.390
PCO2 14.7 17.9 mmHgPO2 76 176 mmHg
Temp 37 36.9FIO2 21 80 %BP 758.2 760.3 mmHg
HCO3 8 10.8 mmol/LO2 sat 94.3 99.2 %
BE -14.2 -10.9 mmol/LTCO2 8.4 11.4 mmol/LO2CT 19.9 19.9 VOL%
BB 33.8 36.7 mmol/LSBE -15.7 -12.3 mmol/L
AaDO2 55.8 375.9 mmHga/A .58 .32RI .7 2.1
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
• (+) 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