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Approach to Chronic Cough in Children

Approach to Chronic Cough in Children. Pramono, MD 2nd year PCMC Resident. General data. D.A. 14 year s old, female Upper Bicutan Taguig City Consulted last Aug ust 2 2 nd 2013. Chief Complaint. Cough x 2 months duration. History of present illness. History of present illness.

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Approach to Chronic Cough in Children

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  1. Approach to Chronic Cough in Children Pramono, MD 2nd year PCMC Resident

  2. General data • D.A. • 14years old, female • Upper BicutanTaguig City • Consulted last August 22nd2013

  3. Chief Complaint Cough x 2 months duration

  4. History of present illness

  5. History of present illness

  6. History of present illness

  7. Review of systems • (+) weight loss (+) body malaise • (-) headache (-) sore throat • (-) palpitation (-) dyspnea • (-) hemoptysis (-) abdominal pain • (-) diarrhea (-) constipation • (-) dysuria (-) edema • (-) swelling of joints (-) numbness • (-) bleeding (-) pallor • (-)rashes

  8. Past Medical History • January 2013- cough x 1week • no consult done; no medications taken. • 2011- Bronchitis, • consultation was done at private doctor, diagnosis said but no explained, given unrecalled medications for 7 days. Which resolved after intake of medications for 5 days. • 2009- Pneumonia, • consultation was done, at local health center, given unrecalled antibiotic for 1 week with improved condition after. • No history of allergy to food nor medication • No history of operation or admission at hospital before

  9. Family History 41, janitor 34, HW (+) PTB 11 (-)diabetes (-)asthma (-)hypertension (-)cancer, blood dyscrasias (-)seizure disorder (-)neuromuscular, skeletal disorders

  10. Family History • Father was a diagnosed case of Pulmonary TB, January 1999, • Presented with 1 year recurrent cough, hemoptysis, and weight loss • Chest Xray : pulmonary tuberculosis • Three-regimen Isoniazid, Rifampicin, Pirazinamide for two months, continued with INH and rifampicin for four months • Good compliance and improving condition during medication • Currently, father is having recurrent dry cough for one year, starting January 2013, with weight loss. • No check up was done, no medication was taken.

  11. Family History • Patient’s Uncle , paternal side, was having infection on the lungs, with pleural effusion, it was said by father that his brother was admitted January 2013, due to “may tubig sa baga”. • Patient’s father visited his brother last January 2013, when his brother was sick, and was with him for 2 days. • Patient’s father does not fully understand what was his brother’s illness. • Patient had no direct contact to her uncle. • Patient’s grandmother passed away about 15 years ago, it was said by father that she had pulmonary tuberculosis.

  12. Patient’s father

  13. Birth and Maternal History • Born to a 19 year old G1P1 (1001) mother • Non-smoker, non-alcoholic beverage drinker • Regularcheck-up at local health center • Normal Ultrasound at 7 months • Regular intake of multivitamins, ferrous sulfate • No exposure to radiation,no intake of toxic substances nor viral exanthems. • Deliveredfulltermvia NSD at hospital assisted by obgyne • Withgood cry and activity, no fetomaternal complications • Birthweight of 2.5 kg • No history of neonatal convulsion, cyanosis

  14. Nutritional History • Patient was purely breastfed up to 1 year of age. • Complimentary feeding started at 6 months old. • She is a non- picky eater. • Consumes ½ cup of rice per meal with viand, with 2 snacks in between

  15. Immunization History: C/O Local Health Center • BCG • DPT 3 • Hepa B3 • OPV3 • Measles • MR 1 • No boosters given

  16. Socioeconomic • Lives in a 1-storey house, well lit, fairly ventilated with 2 windows, 1 bedroom • 4household members • Tapwater not boiled as drinking source • Garbagecollected daily • No nearby industries, crowded area • NoExposure to smoke

  17. Gynecologic History • Menarche at 12 years old • Regular menstruation lasting 7 days, mild-moderate flow, no dysmenorrhea • Last Menstrual Period: August 5, 2013 • Breast budding at 11 years old • Pubic hair appearance at 12 years old

  18. HEADSSS • H- eldest of two children; lives with parents and younger brother, closest to mother, no sibling rivalry • E- currently a 4th year high school student at a public school in Taguig; her favorite subject is English, wants to be ateacher, average grade 80%, has a goodrelationship withteachers and classmates, no bullying, no truancy , no failing grades

  19. HEADSSS • E-no food preference; favorite dish is adobo, has decreased appetite since the illness; no eating disorders no body image issues • A-likes to listen to music, watches TV 4 hrs/day, no involvement in sports

  20. HEADSSS • D- has never tried smoking cigarettes, alcohol drinking or prohibited drugs • S- heterogenous sexual orientation; has never had a boyfriend but has a crush on a male classmate; had 1 suitor when she was 13 years old but refused to be courted;(-) sexual contact

  21. HEADSSS • S- no depression or suicidal ideation. She knows and understands her illness, she is optimistic that she will get well from her illness. • S- believes in One supreme being, prays often, goes to church every Sunday with family

  22. Physical Examination • Gen. Survey: awake, ambulatory, not in respiratory distress • Weight: 44.2 kg (Percentiles 25-50) • Height: 152cm (percentiles 5-10) • BMI: 19(Z score 0) • SMR : Breast 3; Genitalia 3 Vital Signs : • Temp: 36.7 oC CR: 88 bpm • RR: 19 BP: 90/60mmHg

  23. Physical Examination • Skin: brown, warm, moist, no active dermatoses • HEENT: pink palpebral conjunctiva, anicteric sclerae, symmetrical auricles, no tenderness, patent ear canals, pinktympanic membrane, visible cone of light, no nasal deformity, septum midline, (+) greennasal discharge, no tonsillopharyngeal congestion, (+) CLADS, size 0.8-1.1 cm , bilateral, multiple • Chest and Lungs: symmetrical chest expansion, good air entry, no retractions, equal stem fremiti at both lung fields, (+) rhonchi on bilateral lower lung fields, no rales, no wheezing

  24. Physical Examination • Cardiovascular: adynamic precordium, apex beat at 4th ICS left mid clavicular line, normal rate, regular rhythm, no murmur • Abdomen: flat, no visible veins, no bruit, normoactive bowel sounds, tympanitic , soft, no tenderness, no organomegaly, no masses • Genitals: grossly female; SMR 3 • Extremities: full pulses, no edema, no cyanosis

  25. Neurologic Examination • Conscious, coherent • Oriented to time, place and person • Cranial nerves: • CN I: can smell • CN II: pupils 2-3mm EBRTL • CN III,IV,VI: fullextraocular muscles • CN V: good masseter tone • CN VII: no facial asymmetry • CN VIII: gross hearing intact • CN IX,X: good gag • CN XI: can shrug shoulders • CN XII: tongue midline • Good muscle tone, no fasciculation or atrophy, no involuntary movements • Motor: 5/5 all extremities • Sensory: 100% all extremities • DTR: ++ • No Brudzinski, Kernigs, Babinski, Clonus

  26. Working Impression Pneumonia t/c Pulmonary TB Middle Adolescent with Psychosocial issue (Chronic Illness) No stunting, no wasting

  27. Approach To Chronic Cough in Children Acute vs Chronic cough in children • Definition of chronic cough : daily cough more than 4 weeks • Chronic Cough : • Specific cough • Associated with other signs and symptoms (suggestive of an associated or underlying problem) • Non Specific cough • Dry cough in the absence of an identifiable respiratory disease of known etiology Guidelines for evaluating Chronic Cough in Pediatric :ACCP Evidence-Based Clinical Practice Guidelines, Anne B. Chang et al, Chest 2006;129

  28. Approach To Chronic Cough in Children F I G U R E 1 Guidelines for evaluating Chronic Cough in Pediatric :ACCP Evidence-Based Clinical Practice Guidelines, Anne B. Chang et al, Chest 2006;129

  29. Approach To Chronic Cough in Children F I G U R E 1 Guidelines for evaluating Chronic Cough in Pediatric :ACCP Evidence-Based Clinical Practice Guidelines, Anne B. Chang et al, Chest 2006;129

  30. Approach To Chronic Cough in Children F I G U R E 3 Guidelines for evaluating Chronic Cough in Pediatric :ACCP Evidence-Based Clinical Practice Guidelines, Anne B. Chang et al, Chest 2006;129

  31. Management • Diagnostic : • CBC : Hgb 136, hct 40, wbc 14.1, seg 77, lym 14, apc 297 • Chest Xray • Sputum AFB • Started Cefuroxime 500 mg/tab 3x a day for 7 days • Follow up after 1 week

  32. On Follow Up, OPDAugust 30, 2013 S = No fever, + cough, (-) cold, improving chest pain, fair appetite. Father (+) cough, (-)hemoptysis, noted with weight loss. O = awake ambulatory, not in distress T= 36.7oC , CR = 90, RR = 20, BP = 90/60 No rashes, no scrofuloderma Pink palpebral conjunctivae, anicteric sclerae, - CLADs, non congested tonsil, no ear discharge. Adynamic precordium, no murmur Symmetrical chest expansion, no chest retraction , clear breath sound. Soft abdomen, flat, no organomegallywarm equal full pulse, CRT < 2 seconds.

  33. On Follow Up, OPDAugust 30, 2013 Sputum AFB negative day 1, day 2, day 3 Chest xray official result : compared with study done outside (date could not be discerned, from the available Chest xray film) there are now increased reticular infiltrates in both lower lobes with interspersed peribronchial cuffings and cystic lucencies with honeycomb appearance. There are few fibroids in the left lung apex. The rest of the lung are clear, the heart is normal in size, diaphragm and sulci are intact. Thoracic dextroscoliosis is evident. No other remarkable findings. Impression : Pneumonia with bronchiectatic and or bronchitis changes. Minimal left lung apical fibroids.

  34. Radiologic Findings for TB in Children • A presumptive diagnosis of Pulmonary TB is acceptable in symptomatic patients with suggestive findings on Chest Xray • This maybe sufficient to initiate treatment after due consideration of benefits and risk to the individual • Radiographic terms will be used to describe structural or anatomic extent of the disease, and not to imply activity status of the disease • The term “minimal” or “extensive” should be used to describe the advance of disease • The use of mobile CXR facilities with miniature film should not be used for interpretation and commitment to a diagnosis of PTB Clinical practice guidelines for Tuberculosis 2006 Update

  35. Radiologic findings for TB in Children Some commonly used terms in radiographic findings • Cavity : a focus of increased density whose central portion has been replaced by air, may or may not contain air fluid level. Surrounded by a wall usually of variable thickness • Ciccatricial changes/atelectasis : refers to volume loss found in patients with local or general pulmonary fibrosis, secondary to fibrotic contraction, compliance is decreased • Fibrosis : scarring of lung parenchyma Clinical practice guidelines for Tuberculosis 2006 Update

  36. Radiologic findings in TB in Children Some commonly used terms in radiographic findings • Cavity : a focus of increased density whose central portion has been replaced by air, may or may not contain air fluid level. Surrounded by a wall usually of variable thickness • Ciccatricial changes/atelectasis : refers to volume loss found in patients with local or general pulmonary fibrosis, secondary to fibrotic contraction, compliance is decreased • Fibrosis : scarring of lung parenchyma Clinical practice guidelines for Tuberculosis 2006 Update

  37. Radiologic findings in TB in Children Some commonly used terms in radiographic findings • Infiltrates : single or multiple irregular shadows ; shadows of parenchymal abnormalities characterized histologically by cellular infiltration, wheter interstitial, alveolar • Nodules : well defines regions of dense confluent cellularity which is < 3 cm • Masses : well defines regions of dense confluent cellularity which is < 3 cm Clinical practice guidelines for Tuberculosis 2006 Update

  38. Approach to Diagnosis of Tuberculosis in Children • History , including history of TB contact and symptoms consistent with TB (Epidemiologic) • Clinical examination, including growth assesment • Tuberculin Skin testing (Immunologic) • Chest Xray (Radiologic) • Bacteriological confirmation if possible (DSSM, PCR, Culture) • Investigation of suspected source of infection • HIV testing WHO 2006 Guidance for NTP on Management of TB in children

  39. CLINICAL MANIFESTATION “TB symptomatic” is defined as a child with any 3 or moreof the following signs and symptoms: • Cough/ wheezing of two weeks or more • Unexplained fever of two weeks or more • Either loss of appetite , loss of weight, failure to gain weight, or weight faltering • Failure to respond to two weeks of appropriate antibiotic therapy for lower respiratory tract infection • Failure to regain previous state of health after two weeks of a viral infection or exanthem • Fatigue, reduced playfulness, or lethargy Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013

  40. CLINICAL MANIFESTATION “TB symptomatic” is defined as a child with any 3 or more of the following signs and symptoms: • Cough/ wheezing of two weeks or more • Unexplained fever of two weeks or more • Either loss of appetite , loss of weight, failure to gain weight, or weight faltering • Failure to respond to two weeks of appropriate antibiotic therapy for lower respiratory tract infection • Failure to regain previous state of health after two weeks of a viral infection or exanthem • Fatigue, reduced playfulness, or lethargy Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013

  41. Algorythm WHO - DOH

  42. 1 Summary of Casefinding : PTB 2 Walk in Referrals All Children 0-14 yo with ANY symptom presumptive of TB Contact screening All children 0-14 yo close contacts of registered TB TB symptomatic 10-14 yo All 0-4 yo TB symptomatic 10-14 yo TB symptomatic 0-9 yo TB symptomatic 5-9 yo TST Flow Chart 1 to 3 DSSM DSSM TB infection TB exposure 0-4 yo TB Disease TB Treatment IPT Register treatment card & ID card Quarterly Reports Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013

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