GENERAL CLINICS case 4

HISTORY

SHILPA.G.KAMATH080201360

Personal Data

• Patient name- Shreya

• Age- 1 year 4 months

• Date of birth- 29/03/2011

• Address- Bantwala

• Informant- Mother – 7th std (reliable)

• Date of admission- 2/8/2012

Presenting complaints

• Cough with expectoration – 6 days

• Breathlessness – 6 days

History of presenting illness

• Cough – associated with expectoration

Onset- insiduous

Gradually progressive

Present throughout the day

No aggravating factors

Relieved on medication

• Expectoration

Scanty, white, mucoid, non foul smelling, not blood stained

• Breathlessness

Associated with cough and expectoration

Associated with occasional wheeze

Worsens on lying down, at night

Relieved when mother holds baby upright

• Came to GWH on 30th July with above complaints

• Nebulization done

• Symptoms subsided

• Patient discharged the same day

• Symptoms recurred 3 days later, admitted.

Past history

• Has had similar episodes in the past since the age of 1.5months

• 3 admissions

• Nebulization done each time

Antenatal history

• Age at first pregnancy: 26 years

• Birth order-5

• h/o 3 abortions – 4th, 5th and 6th month of gestation

• Age at 4th pregnancy: 29 years (baby healthy)

• Age at 5th pregnancy : 31 years

• Spontaneous conception• 1st trimester- No history of fever with rash,

exposure to drugs or radiation, increased frequency or burning micturition. IFA tablets taken.

• 2nd trimester- No history suggestive of PIH/ GDM. T.T injections taken

• 3rd trimester- No history suggestive of PIH/GDM

• 4 USG done. Anomaly detected at 8th month POG (Down’s syndrome)

Natal and postnatal history

LSCS at 9th month

Cried immediately after birth

Birth weight – 2.8kg

Breast feeding initiated after 2 hrs

NICU admission- 4days – phototherapy

Passed urine and meconium

At 1.5 months age:• Diagnosed to have Down’s syndrome• Child being taken for physiotherapy twice

a week since the age of 1.5 months• h/o recurrent respiratory infections• No h/o constipation / vomiting/ bleeding

gums or from other sites• No h/o impaired vision or hearing• No h/o nasal regurgitation of food/choking

• h/o feeding difficulty since 1.5 months of age

• Inability to feed continuously

• h/o inadequate weight gain

• No history of orthopnoea, cyanosis, syncope or edema

Developmental history

• Social smile - 8 months

• Recognized mother- 9 months

• Stranger anxiety – 1 year

• Head control – 1 year

• Rolling over – 1 year

• Unidextrous grasp – 1 year

• Monosyllables- 14 months

• Bisyllables- 16 months

Immunization history

• Appropriate for age

Diet history

• Exclusively breast fed till 6 months of age

Calories(kcal) Proteins(g)

Breakfast 226 6.4

Lunch 302 7.7

Snacks 290 4.1

Dinner 88 1. 7

Total 791+ 402= 1190 18.5+6.6=25

Expected 1030 22

Family history

• Total family members- 4

• Non consanguineous marriage

• Parents healthy.

• No history of TB/ congenital defects/ allergy in the family

Summary

• 16 months old baby , a known case of Down’s syndrome, came to RAPCC with cough and expectoration and breathlessness 6 days prior to admission. Patient has history of recurrent respiratory tract infections, feeding difficulty since 1.5 months , was diagnosed to have a cardiac anomaly at 1.5months of age.She has global developmental delay. She is immunized up to date and no calorie deficit

EXAMINATIONTamanna ahemad

080201372

VITALS

• Pulse rate-104 beats per min (normal)

• Respiratory rate-36 per min (tachypnea)

• Afebrile during examination

ANTHROPOMETRY

• Weight for age

• Less than 3rd percentile

• Grade 1 PEM (IAP)

• undernutrition (wellcome trust)

• Length

• Less than 3rd percentile

• Grade III stunting (waterlow classification)

• Weight for height

• No wasting (waterlow classification)

• Head circumference• Microcephaly (less than 3rd percentile)• Brachycephaly is present

• Mid arm circumference-14 cm(normal)

• Chest circumference is greater than head circumference

Head to toe examination

• Sparse thin shiny hair

• Flat occiput

• Ant fontanelle-1*1cm

• Depressed nasal bridge

• Hypertelorism

• Epicanthic fold present

• Up-slanting of eyes

• Low set ears

• Mouth kept open with protruding tongue

• Short neck

• Short broad hands

• Hypotonia,hyperflexible limbs

• Kennedy crease

Developmental assesment

• Gross motor-sits without support (8 months)

• DQ-50• Fine motor-radial grasp present (8 months)• DQ-50• Social-stranger anxiety (6 months) DQ-38 • Language-bisyllables (9 months) DQ-56

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM

• Respiratory rate-36/min• On Inspection,abdominothoracic

respiration,movements bilaterally symmetrical• On Palpation,trachea is central,inspectory

findings confirmed• On percussion,resonant note heard in all

areas• On auscultation,breath sounds of equal

intensity bilaterally,vesicular,crepitations heard bilaterally

• Cardiovascular system• S1 S2 heard,no murmurs

• CNS• Hypotonia,power cannot be

assessed,reflexes are normal

• P/A• Soft nontender,no organomegaly

Summary

• Tachypnea

• Grade 1 PEM

• Grade III Stunting

• Microcephaly,brachycephaly

• Mongoloid facies

• Developmental delay

• Bilateral crepitations

DIFFERENTIAL DIAGNOSIS

- Naseeba(080201378)

ON HISTORY

• COUGH WITH EXPECTORATION

• BREATHLESNESS• WHEEZING• FEEDING DIFFICULTY• DEVELOPMENTAL

DELAY

ON EXAMINATION

• MONGOLOID FACIES • HYPOTONIA• B/L CREPITITIONS• DEVELOPMENTAL

DELAY

CHARACTERISTIC FACIAL FEATURES

SUGGESTIVE OF

DOWN SYNDROME

RESPIRATORY

COUGH WITH EXPECTORATION• PNEUMONIA• TB• FB

WHEEZE• WALRI• BRONCHIOLITIS• FB

BREATHLESSNESS

• PNEUMONIA

• BRONCHIOLITIS

• BA

• FB

CARDIAC

• CHD

• PULMONARY EDEMA

HYPOTONIA

• DOWN SYN

• HYPOTHYROIDISM

• MYOPATHIES

INVESTIGATIONS

- Aiswarya . S (080201390)

INVESTIGATIONS FOR DOWN S SYNDROME

• Karyotyping.• To diagnose complications-• Complete blood count.• Peripheral smear• Radiological findings• X ray spine• X ray chest.• X ray bones.• X ray pelvis.

• AUDIOLOGY

• OPHTHALMOLOGICAL.

• THYOID FUNCTION TESTS.

• ECHO-PDA with Left to Right shunt.

• BLOOD SUGAR.

INVESTIGATIONS

• BIOCHEMISTRY—LFT,RFT,Electrolytes;ABG analysis

• HEMATOLOGY—Hb,Counts,ESR,Plateletes,PeripheralSmear

• RADIOLOGY—ChestX ray.

• MICROBIOLOGY—Blood culture;Stool & Urine examination

• KARYOTYPING

INVESTIGATIONS FOR PNEUMONIA

• Chest radiography

• Total and differential count.

• Haemoglobin count.

• Culture studies

HAEMATOLOGICAL INVESTIGATIONS

HEMOGLOBIN—9gm% COUNTS —

Total count-6500/cc. ESR—27.9 PLATELETS —3,40,000/cc

BIOCHEMICAL INVESTIGATIONS

• ELECTROLYTES

Na+,K+,Cl-,HCO3

‘LIVER FUNCTION’ TESTS

Total and Direct Bilirubin ; ALT

• ARTERIAL BLOOD GAS ANALYSIS

• THYOID FUNCTION TESTS.

Electrolytes.

• Na+=139meq/l((136-149meq/L)• K+=5.2meq/l (3.5-5.3meq/L)• Cl-=99meq/l (98-111meq/L)• Hco3-=27.4meg/l. (22-26mmol/L)

• BLOOD GAS ANALYSIS• PH-7.55 (7.35-7.45) PCO2-17.2mmHg. (35.0-45.0mmHg) PO2-159mm Hg• LIVER FUNCTION TESTS• Total bilurubin-.2 mg/dl (0.2-1.2mg/dL)• Direct bilirubin-.1mg/dl. (upto 0.3mg/dL)• SGOT-33U/L. (15-55U/L)• SGPT-22U/L. ( 5-40 U/L)• ALP-107U/L.

THYROID FUNCTION TESTS

• T3-1o7ng/dl.(70-190ng/dl)

• T4-8.05ng/dl(.8-2.2ng/dL)

• TSH-1.60mIU/L(.7-6.4mIU/L)

• KARYOTYPING• T(21,22)

MICROBIOLOGICAL EXAMINATION

• STOOL EXAMINATION

• Stool pus cells-2-3hpf.• Stool RBC-nil.• Stool fat globules-present.• Stool mucous-nil.• Occult blood-nil.• Ova,cyst-nil.

INVESTIGATIONS

• BIOCHEMISTRY—LFT,RFT,Electrolytes;ABG analysis

• HEMATOLOGY—Hb,Counts,ESR,Plateletes,PeripheralSmear

• RADIOLOGY—ChestX ray.

• MICROBIOLOGY—Blood culture;Stool & Urine examination

• KARYOTYPING

TREATMENT - Prithvishree Ravindra (080201366)

IMNCI guidelines

PNEUMONIA

• Indications for hospitalisation :

• AT time of diagnosis:

Features of hypoxia ( restlessness, anxiety, cyanosis. Inability to sleep, talk, walk, unconsciousness, seizures) ; Reduced urine output/ dehydrated ; Vomiting/ poor oral intake

High risk factors

• DURING TREATMENT

No improvement/ progressive deterioration when on treatment as outpatient

OUTPATIENT MANAGEMENT

• 1 – 5 years age :

• Paediatric Tablet Cotrimoxazole (Sulphamethoxazole 100 mg and trimethoprim 20 mg ) - 3 tablets twice a day

• Reassess after 48 hours

• If improves – continue for 3 more days. No improvement – continue for 48 hours and reassess.

• Explain parents WARNING SIGNS – return immediately

INPATIENT MANAGEMENT

Specific Supportive

Antibiotics Hydration

Nutrition

Oxygen

Antipyretics

Physiotherapy

Asthalin nebulisation if wheeze is present

Antibiotics

• Benzyl penicillin/ ampicillin / 3rd generation cephalosporin +/- aminoglycosides

• Inj. Benzyl penicillin – 5000IU per kg/dose 6th hourly IM• Inj. Ampicillin – 50mg/kg/dose 6th hourly IM• Inj. Gentamicin – 2.5 mg/kg/dose 8th hourly IV

• Continue for 10-14 days

• Assess twice a day – if deterioration :

CXR to look for staphylococcal infection

(pneumatoceles ) – change to cloxacillin

• Atypical pneumonia - macrolides

SUPPORTIVE CARE

• Fever – Paracetamol (10-15 kg/dose ) every 4 to 6 hourly

• Tachypnea, cyanosis, chest indrawing – oxygen by oxygen hood, oxygen mask, nasal catheter, nasopharyngeal catheter

• Not drinking/dehydrated – IV fluids

• Asthalin nebulisation : if wheeze present

Treatment of the index case

• Nebulisation with asthalin

• IV fluids Iso – P

• Inj. Ampicillin IV

• Injection Gentamycin IV

• Syp PCT

DOWN SYNDROME – Health supervision

DOWN SYNDROME – Health supervision

Condition Time to screen Comment

Congenital heart disease

Birth Young adult for acquired valve disease

50% risk for congenital heart disease. Increased risk for pulmonary hypertension

Strabismus, cataracts, nystagmus

Birth or by 6 monthsCheck vision annually

15% - cataracts50% - refractory errors

Hearing impairment or loss

Birth or by 3 months – ABERIf tympanic membrane not visualised- 6 monthly for 3 yearsAnnually therafter

Congenital hearing loss70% risk – serious otitis media

Constipation Birth Hirschsprung disease

DOWN SYNDROME – Health supervision

Condition Time to screen Comment

Celiac disease 2 years/ symptomatic Screen – IgA and tissue transglutamase antibodies

Hematologic disease At birth , adoloscence and when symptoms develop

Neonatal polycythemiaLeukemoid reactionLeukemia

Hypothyroidism Birth, repeat at 6 – 12 months and then annually

1% - congenital5% acquired

Growth and development

At each visitUse Down syndrome growth curves

Discuss school placement optionsProper diet to avoid obesity

For index case

For index case

DOWN SYNDROME – Health supervisionCondition Time to screen Comment

Obstructive sleep apnea Start at 1 year. Then at each visit

Monitor for snoring, restless sleep

Atlantoaxial subluxation/ instability

Each visit – history and physical examRadiographs at 3 -5 years or when planning to participate in contact sports / Transient neurological symptoms

Maybe asymptomatic

Gynaecological care Adoloscent girls Menstruation/ contraception use

Recurrent infections When present Check IgG subclass and IgA levels

Psychiatric, behavioral disorders

Each visit Depression,anxiety, OCD, schizoprenia.Autism , Early onset alzheimers

PDA - left to right shunt

• Catheter based treatment – occlusive devices or coils

• Surgery if :• Large PDA ( larger than size of available devices)