GENERAL CLINICS-11st August, 2012

Personal Data

• Patient name- Disha• Age- 8.5 months• Date of birth- 5/11/2011• Address- Rae, Bantwala• Informant- Mother (reliable)• Date of admission- 27/7/2012• Mother’s name and education- Pushpa (4th)• Father’s name and education- Jaya (6th)

Presenting complaints

• Feeding difficulty - 7.5 months

• On and off fever - 2 months

• Cough with expectoration - 1 month

History of present illnessFeeding difficulty

• Onset- At 1.5 months

• Difficulty to breast feed, can not feed continuously

• Feeding associated with sweating and subcostal retractions

• No history of orthopnoea, cyanosis, syncope or edema.

• For above complaints patient was taken to near-by hospital and was told to start artificial feeds for the child (lactogen was started).

Fever• Onset- 2 months back• Insidious in onset. On and off fever.• Not associated with rigor• No aggravating factors, relieved by

medications• Not associated with vomiting, urinary

complaints, ear discharge, skin rashes, yellowish discoloration of skin, neck pain

Cough with expectoration• Onset- 1 month• Insidious in onset. • Associated with expectoration- 1 tablespoon,

whitish, non foul smelling, non blood stained.• No postural or diurnal variation.• There was worsening of cough with

expectoration 3 days back• Child developed wheeze, was inactive, and

was pale to look at.

• For above complaints patient came to RAPCC• Was admitted to the ICU for 3 day and was

given blood.• The cough and fever have now subsided.• Mother also gives history of weight loss in the

last 1 month (1kg)

Past history

• No similar complaints in the past.• No history of seizures/ tuberculosis

Antenatal history

• 1st pregnancy• Age at pregnancy- 30 years• 1st trimester- No history of fever with rash,

irradiation, drug intake, alcohol intake.• 2nd trimester- No history suggestive of PIH/

GDM. T.T injections taken• 3rd trimester- No history suggestive of GDM

Natal and Post Natal history

• Full term normal delivery• Child cried at birth• Passed urine and meconium

Developmental history

• Social smile- 2 months• Roll over- 7 months• Currently • Gross motor- Sit with support (6 months)• Fine motor- Immature pincer grasp (9months)• Language- monosyllable sounds (6 months)• Social- shows displeasure when toy pulled off(6months)

Immunization status

• Immunized upto date• BCG, OPV• DPT, OPV (1,2 & 3)

Diet history

Item Calories(kcal) Proteins (g)

Artificial feed – 65g/day 306 9

Milk- 200 ml 130 6

Rice- 1 cup 175 4

Total 611 19

Expected 640 13

Deficit 29 -

•Child is on artificial feeds since 1.5 months of age

Family history

• Total family members- 4• Non consanguineous marriage• Parents healthy.• No history of TB/ congenital defects/ allergy in

the family

4 4

Summary

• 8.5 month old baby came to RAPCC with worsening fever associated with cough and expectoration 3 before admission. Patient has history of feeding difficulty since 7.5 months and on and off fever since 2 months, cough with expectoration since 1 month. Patient was admitted to ICU for 3 days and was given I unit blood. She has slower development. She is immunized up to date and 29 calorie deficit

Examination

Vitals• Pulse Rate- 124 beats per minute. (Tachycardia)• Respiratory Rate- 64 per minute. (Tachypnea)• Afebrile during examination.

Anthropometry• Weight for age below the 3rd percentile.• Length , Head circumference, chest circumference

within normal limits.

Head to toe examination• No abnormalities

Systemic Examination

Respiratory System• Suprasternal and Subcostal indrawing seen during

respiration.• On palpation, trachea was central and other

inspection findings confirmed.• On percussion, resonant note was heard in all

regions.• On Auscultation, Breath sounds were of equal

intensity bilaterally, vesicular in nature with no added souds.

Cardiovascular System• Apical impulse was seen in the 5th intercostal

space 1cm lateral to the left midclavicular line.• No precordial bulge, parasternal heave or other

visible pulsations.• On palpation, Apical impulse confirmed. It was

diffuse and ill sustained.• Systolic thrill was palpable over the apex and the

left lower sternal border. • Epigastric pulsations were palpable.

Auscultation• Mitral area- S1 not heard, S2 is soft and

pansystolic murmur heard.• Tricuspid area- S1 and S2 muffled by pansystolic

murmur.• Pulmonic and Aortic area – S1 not heard, S2 is

soft and pansystolic murmur heard.

Highest intensity of the murmur is over the tricuspid area and along the left lower sternal border.

Per Abdomen Examination• No abnormalities on inspection.• On palpation, Liver is palpable upto 4cm below the right costal

margin in the midclavicular line. Liver is nontender, soft, has rounded margins and a

smooth surface.• No other organomegaly, no fluid in the abdomen.

CNS Examination• No abnormalities.

DIFFERENTIALS

HISTORY :POSITIVE FINDINGS

HOPI• Feeding difficulty - 7.5 months• Fever - 2 months• Cough with expectoration - 1

month

DEVELEPOMENTAL HISTORY • Gross motor- 6 months• Language- 6 months• Social-6months• Calorie deficit -29 Kcal

DIFFICULTY IN FEEDING

GOOD INTAKE

Decreased ORAL intake

Sucking-swallowing problems

Feeds well but

regurgitates

POOR INTAKE

Feeding prob.

INFECTION

HYPOTHYROIDISM

RESPIRATORY INSUFFICIENCY

CHD

FATIGUE

CONSIDER THE FOLLOWING:FEVER(2 mo) + COUGH(1 mo)

RESPIRATORY • Bronchiolitis• Pneumonia• Croup• URTI- Tonsillitis

CARDIAC• Congestive heart failure• Acyanotic congenital

heart disease

ON EXAMINATION Vitals• Pulse Rate- Tachycardia• Respiratory-Tachypnea

Anthropometry• Weight for age below

the 3rd percentile

Per abdomen• Hepatomegaly

Cardiovascular System• Apical impulse diffuse & ill

sustained• Systolic thrill -apex & LLSB • Epigastric pulsations• pansystolic murmur (LLSB)

Respiratory System• Suprasternal and Subcostal

indrawingPNEUMONIA

VSD

Diagnosis8.5 month old with History of

• FEEDING DIFFICULTY since 7.5 months and

• on and off FEVER since 2 months,

• COUGH WITH EXPECTORATION since 1 month; exacerbated in the past 3

days.

Symptoms and signs are suggestive of cardiac pathology, CONGENITAL

DEFECT most probably VSD with associated PNEUMONIA. With signs

suggestive of CARDIAC FAILURE (diaphoresis, tachycardia, hepatomegaly)

What to look out for:

CHARGE Syndrome Coloboma of the eye, Heart defects, Atresia of the nasal choanae, Retardation of growth and/or development, Genital and/or urinary abnormalities, and Ear abnormalities and deafness

VATER Syndrome V -vertebrae disorders, A -anus issues, C - cardiac related problems, T -trachea disorder, E - esophageal, R - renal Defects and L -limb oriented disorders

FAVS

PHACE Syndromes P - Posterior fossa abnormalities and other structural brain abnormalities H - Hemangioma of the cervical facial region A - Arterial cerebrovascular anomalies C - Cardiac defects, aortic coarctation and other aortic abnormalities E - Eye anomalies

INVESTIGATIONS

ALOK SHETTY K(080201370)

LABS WITH GAMUT OF INVESTIGATIONS..!!

• BIOCHEMISTRY—LFT;RFT;Electrolytes;ABG analysis

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

• RADIOLOGY—ChestX ray;USG;ECHO

• HISTOPATHOLOGY AND CYTOLOGY

• MICROBIOLOGY—Blood culture;Stool & Urine examination

KEEPING IN MIND THE PROVISIONAL CLINICAL DIAGNOSIS & POSSIBLE DIFFERENTIALS, ORDER RELEVANT INVESTIGATIONS…

HEMATOLOGICAL INVESTIGATIONS

HEMOGLOBIN— COUNTS — Total count Differential count PERIPHERAL SMEAR— ESR— PLATELETS —? BLOOD GROUPING—

HEMATOLOGICAL INVESTIGATIONS

HEMOGLOBIN 27TH July-5.6g/dL 30th July-7.8g/dL(after blood transfusion) COUNTS Total count- 8,700/cc Differential count- N-51% L-42% E-4% M-3% PERIPHERAL SMEAR Microcytic Hypochromic anemia with anisopoikilocytosis with target cells ESR PLATELETS 5,40,000/cc

VIRAL PNEUMONIA BACTERIAL PNEUMONIA

CLINICALLY -Not very high grade fever-Non purulent expectoration

-High grade fever-Associated with purulent expectoration.-Signs of lobar consolidn. or assoc pleural effusion

TOTAL COUNTS Normal or elevated Always elevated

Usu. not greater than 20,000/cc

Usu in the range of 15,000/cc-40.000/cc

DIFFERENTIAL COUNTS

Lymphocyte predominance

Neutrophil predominance

RADIOLOGY Hyperinflation with bilateral interstitial infiltrates

Lobar consolidation

DEFINITIVE DIAGNOSIS

Isolation of virus.Detection of viral genome in respiratory secretions

Isolation of bacteria

BIOCHEMICAL INVESTIGATIONS ELECTROLYTES Na+,K+,Cl-,HCO3

-

‘LIVER FUNCTION’ TESTS Total and Direct Bilirubin ; ALT ARTERIAL BLOOD GAS ANALYSIS

BIOCHEMICAL INVESTIGATIONS ELECTROLYTES Na+--137meq/L (136-149meq/L) K+--5.2meq/L (3.5-5.3meq/L) Cl---99.0meq/L (98-111meq/L) HCO3

---20.3meq/L (23-27meq/L) DECREASED

‘LIVER FUNCTION’ TESTS Total Bilirubin- 0.2mg/dL (0.2-1.2mg/dL) Direct Bilirubin- 0.06mg/dL (upto 0.3mg/dL) ALT- 18U/L ( 5-40 U/L)

ARTERIAL BLOOD GAS

PARAMETER REFERENCE RANGE

pH 7.428 7.35-7.45

pCO2 30.1mmHg 35.0-45.0mmHg

Saturation of O2 99.8% 94.0-100.0%

HCO3- 20.9mmol/L 22-26mmol/L

RADIOLOGICAL INVESTIGATIONS CHEST X RAY

ECHOCARDIOGRAPHY

RADIOLOGICAL INVESTIGATIONS CHEST X RAY

ECHOCARDIOGRAPHY 4.5mm Perimembranous Ventricular

Septal Defect with left to right shunt

MICROBIOLOGICAL INVESTIGATIONS

Stool Examination Blood culture

MICROBIOLOGICAL INVESTIGATIONS

Stool Examination Normal Blood culture No growth

THANK YOU

Treatment

Pneumonia

Hospitalisation - ABCInvestigation When do you take

action? and how?

Pulse oximetry (OR)Signs of acute hypoxemia

•dyspnoea, tachypnoea, bradypnoea, apnoea•pallor, cyanosis•lethargy or restlessness•use of accessory muscles: nasal flaring, intercostal or sternal recession, tracheal tug

Administer supplementary oxygen by hood

(OR)

Positive Pressure Ventilation

Caution: ventilation/perfussion mismatch may occur in pneumoniaNOTE: asthalin (SALBUTAMOL) may be given by nebuliser if wheezing present

Hb <13g/dL Packed cell transfusion

Hydration status Child is vomitting / Appears toxic, dehydrated.

IV fluids

Chest X-Ray Effusion / Empyema

Drainage of effusion Antibiotics

Pneumonia Management:ARI Programme

Classification Treatment Place

Pneumonia CotrimoxazoleAge : 3-12 months – 2 tablets twice daily

(Trimethoprim 20 mg + sulfamethoxazole 100 mg)

Home / PHC

Reassess after 2 days.

Severe Pneumonia Ampicillin + gentamycin(OR)Benzyl penicilin 50,000 units/kg/dose – every 6 hours(OR)Cefotaxime + gentamycin

Hospital

Treat for 2 weeks.

Very severe pneumonia Cefotaxime or Ceftriaxone + Gentamycin

(IV)

Hospital

Treat for 2 weeks

Antibiotics-

Augmentin= amoxicillin clavunate

Amikacin = aminoglycoside

Antiviral-

Tamiflu = oseltamavir

PCT- For fever

IV FLUIDS-Isolyte P in 5% dextrose

Treatment

VSD

Type of VSD Treatment

Small VSD Spontaneous closure- follow up.

Watch out for complications! Eg.Infective Endocarditis

Moderate VSD Spontaneous closure – follow up

Plan surgery before age 2-5 yrs, before Eisenmengerisation

Watch out for complications!Eg. Pulmonary Hypertension

Large VSD SURGERY is the only TREATMENTIdeal age= below 2 years/ 2-5 years before eisenmengerisation.

Surgical closure of defect by Dacron - used to cover the defect and sides sewn .Types : open heart surgery or cardiac catheterisation

VSD with PULMONARY HTN

Heart Lung transplantation

Indications for surgery :1. Infective

endocarditis2. Pulmonary

HTN is reversible when PVR fall is 6 units , operate ASAP!

3. Large VSD4. CHF not

responding to medical treatment

5. Associated cardiac defects