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Pulmonary Case Conference

Pulmonary Case Conference. General Data. DC 1 year 6 months Male Phase 1 Lot 29 Block 2 St. Michael St. Camacho Nangka , Marikina City Roman Catholic. Chief Complaint. Fever. HPI. 4DaysPTC fever (max temp 38.9 0 C, axillary ) (+)clear watery nasal discharge

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Pulmonary Case Conference

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  1. Pulmonary Case Conference

  2. General Data • DC • 1 year 6 months • Male • Phase 1 Lot 29 Block 2 St. Michael St. Camacho Nangka, Marikina City • Roman Catholic

  3. Chief Complaint • Fever

  4. HPI • 4DaysPTC • fever (max temp 38.90C, axillary) • (+)clear watery nasal discharge • (+)decrease in appetite, • Paracetamol 25mg/kg/dose • 3DaysPTC • (+) persistence of symptoms • PhenylpropanolamineHCl drops (Disudrin) 1.6mg/kg/dose

  5. HPI • 2DaysPTC • Persistence of symptoms • (+) productive cough • 3 episode of post tussive vomiting of previously ingested fluids with sputum amt 5-15ml/ episode • Prefer drinking than eating

  6. HPI • 1Day PTC • one episode of vomiting, with fever, colds, cough, decreased level of activity and decreased fluid and food intake • consult at a local hospital • CBC (Hb 103g/L, Hct 0.32, WBC 4.8 x 109/L, platelet 270 x 109/L, Neutrophil 0.49, Lymphocytes 0.51 • Diagnosis: Lower Respiratory Tract infection • Med: Cefixime 6mg/kg/day ; Salbutamolnebulization q8

  7. HPI • Few hours PTC • bloody nasal discharge • blood-tinged sputum • Persistence of fever, decreased level of activity, and poor oral intake • sought consult at USTH Pedia-SBC,

  8. Review of Systems General: (-) weight loss Skin: (-) rashes, (-) jaundice, (-) cyanosis Head: (-) injuries/lacerations, (-) eye redness, (-) eye discharge/exudates, (-) tearing, (-) aural discharge, (-) cleft lip or palate Pulmonary: HPI Cardiac: (-) edema, (-) cyanosis Gastrointestinal: (-) diarrhea, (-) constipation, (-) melena, (-) hematochezia Genitourinary: (-) hematuria, (-) anuria/oliguria Neurologic/Psychiatric: (-) convulsions Hematopoietic: (-) easy bruisability, (-) bleeding manifestations Extremities: (-) joint deformities, (-) joint swelling

  9. Gestational History • Born to a 28 year old, G3P2 (2002). • Frequent prenatal check-up at a local clinic • No hepatitis B screening and gestational diabetes screening done • Denied: • use of illicit drugs, smoking, and drinking alcohol during pregnancy. She also denied exposure to radiation or other chemicals.. • Medications: • multivitamins. • anti-Koch’s medication for a month

  10. Birth History • Term at 39-40 weeks AOG delivered via NSD. • Lying-in clinic. • Attended by a midwife • labor for 2 hours • Birth weight was 6.5kg. Neonatal History • spontaneous cry; no resuscitation was needed. • poor suck at birth • No congenital abnormalities were noted.

  11. Feeding History • Patient was not breastfed due to inability of mother to excrete milk. • Milk (0-6months) - Bona (2:1 dilution) 2oz – 10-12x/day • (6 months – 1year) – Bonamil (2:1 dilution) 4oz – 10-12x/day • Current: Bear Brand Jr (1:1 dilution) 6oz – 4-6x/day • Complementary Feeding started at 9 months (gruel, chicken, bread)

  12. Feeding History

  13. Past Medical History • Pneumonia (2009) Immunization History • Completed EPI at a local health center • BCG 1 dose • Hepatitis B 3 doses • OPV 3 doses • DPT 3 doses • Measles 1 dose Developmental/ Behavioral history • Patient’s development is at par with age. • Motor: walks and runs well, ascends stairs one foot at a time, • Language: knows more than 10 words including mama and papa, • Fine: drinks from a cup and uses spoon. • Social: Understands simple directions, Shows affection by kissing parents

  14. Socioeconomic and Environmental History • Lives with his parents and 2 older brothers • 2-storey house • made of wood and concrete • well lit and well ventilated. • Main water: NAWASA and water used for drinking is boiled for 30 minutes. • Garbage is collected 3x/week and segregates and recycles. • Father often smokes inside the house. • They have no pets and no nearby factories.

  15. Family History • (+) Hypertension – maternal grandmother • (+) PTB – mother – took medications for only a month, stopped since pregnant with child • (-) DM, cancer, asthma, allergies, kidney and thyroid disorders

  16. Family Profile

  17. Physical Examination Awake, irritable, ill looking, not in cardiorespiratory distress, well nourished, moderately dehydrated Vital signs: CR: 145bpm,regular RR: 33cpm, regular Temp: 37.00C Anthropometric measurement: Weight: 10kg (z score 0 normal) Length: 80cm (z score 0 normal) Weight for length (z score 0 normal) BMI: 15.63 (z score 0 normal)

  18. Physical Examination Warm, moist skin, no active dermatoses, good skin turgor, CRT <2sec No scalp lesions, tauma, deformities, sutres and fontanels closed Pink palpebral conjunctiva, anicteric sclera, pupils 2-3mm ERTL, (+) sunken eyes Midline nasal septum, (+) turbinates congested, (+) clear nasal discharge Nonhyperemic external auditory canal, intact tympanic membrane, (+) retained cerumen, AU

  19. Physical Examination Moist buccal mucosa, hyperemic posterior pharyngeal wall, tonsils grade II, bilateral Supple neck, no palpable cervical lymph nodes Symmetrical chest expansion, (-) retractions, clear breath sounds Adynamicprecordium, apex beat at 4th LICS MCL, no murmurs Globular abdomen, normoactive bowel sounds, soft, no palpable masses Redundant prepuce, bilateral descended testes Pulses full and equal, no edema, no cyanosis

  20. Neurologic Examination • Awake, irritable, with spontaneous eye movement, pupils isocoric 2-3mm ERTL, no facial asymmetry, uvula midline, gross movements on all extremities, no muscle atrophy

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