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Dr. KANTA HALDER Resident (MD;Phase A)

BICH

Particulars of the patient

Name: Shahriar Age: 2 years 6 months Sex: Male Informant: Mother Address: keranigonj Date of Admission: 07.06.2015 Date of Examination: 11.06.2015

Chief Complaints Bending of neck to the left side since 6 months of age Cough for 10 days Respiratory distress for same duration

History of present illness: According to the statement of informant mother,

Shahriar was reasonably well upto his 6 months of age. Then the mother noticed that her child ketp his neck bending to the left side. Now he also developed cough for last 10 days which was dry and non-productive and respiratory distress for same duration. He had h/o contact with TB patient but no h/o foreign body aspiration.

With these complaints, he was admitted to Dhaka Shishu Hospital for further evaluation and better management.

History of Past illness: Shahriar had h/o repeated attack of RTI since his 1

month of age which was usually subsided within 2-3 days with oral medication.

Birth History: He was delivered by LUCS at term due to maternal oligohydramnios without any postnatal complication.

Feeding History:

He is on family diet.

Immunization History: he is immunized as per EPI schedule.

Familly History : He is the 2rd issue of his non-consanguinous

parents. His grandfather was suffering from pulmonary TB and completed anti-TB treatment.

Socio-economic History : He came from a low socio-economic

background.

Treatment History After admission, he was getting nebulization and

other injectable medications.

Developmental History He is developmentaly age appropriate.

General Examination :Appearance: Well, alertAnaemia:Jaundice: Cyanosis:Clubbing: AbsentOedema:Dehydration:

Cont..Skin: BCG mark presentSpine: NormalLymphnode: Not palpableSigns of meningeal irritation: AbsentNeck Vein: Not engorgedEar:Nose: NormalThroat:

Cont..Vital Signs:

Heart Rate: 110/minRespiratory Rate: 28/minTemperature: 98°FBlood Pressure: 90/50 mmHg

Anthropometry:

Cont..

Weight: 10.5 kgHeight: 71.5 cmMUAC: 14.5 cmHAZ: -4.08 (severely stunted)WHZ: 2.0 (normal)

Systemic ExaminationRespiratory system :

Inspection : Respiratory rate: 28/min Shape of the chest : Flat on left side Movement of the chest : Restricted in left side

Cont..Palpation : Trachea is shifted to the left side. Chest expansibility is reduced in left side. Vocal fremitus is reduced in left side in mid-

clavicular, midaxillary and post-scapular line, normal in right side.

Apex beat lies in left 5th intercostal space, lateral to the midclavicular line

Cont..Percussion : Percussion note is dull over left lung field in

midclavicular, midaxillary and post-scapular line, normal in right lung field.

Cont..Auscultation : Breath sound is vesicular, but diminished in

left lung in midclavicular , midaxillary and post-scapular line, vesicular in right lung field.

Vocal resonance is reduced in left lung field, normal in right lung field.

There is no added sound.

Cont..

Cardiovascular system : 1st & 2nd heart sounds are audible in all 4

areas. There is no added sound.Alimentary system : No organomegaly. No ascitis. Other Systemic examination: No abnormality

Salient feature Shahriar, 2 years 6 months old immunized boy,

1st issue of his non- consanguineous parents, was admitted with the complaints of bending of neck to left side since 6 months of age, dry, non-productive cough and respiratory distress for last 10 days. Shahriar had h/o repeated attack of RTI since his 1 month of age which usually subsided within 2-3 days with oral medication. He had h/o contact with TB patient as his grandfather was suffering from

Cont.. pulmonary TB and completed treatment.He

had no h/o foreign body aspiration. Shahriar was well, alert, afebrile. Vitals are within normal limit. Chest movement was restricted in left side. Trachea was shifted to the left side, chest expansibility and vocal fremitus was reduced in left side. Percussion note was dull and breath and vocal resonance was diminished on left side. Other systemic examination revealed no abnormality.

Provisional Diagnosis: Left sided collapse due to tuberculosis

Differential Diagnosis: Left sided collapse due to pneumonia Left sided collapse due to foreign body

aspiration

Investigations Complete Blood Count :

• Hb: 10.5 gm/dl• WBC: Total count: 12,700/cumm Differential count:

o Neutrophil: 48%o Lymphocyte: 47%o Monocyte: 03%o Eosinophil: 02%o Basophil : 00%

Cont..

o RBC:Normocytic normochromico WBC:Mature with above

distributiono Platelet: Adequate

• Platelet : 318,000/cumm• PBF:

Cont..Blood grouping & cross matching : A positiveMantoux test : 00 mm Chest X-ray:

Cont..USG of chest : No free fluid is noted in left

costophrenic angle. Opacity in chest X-ray was due to consolidation.

CT scan of chest :

Final Diagnosis:Left lung agenesis

Management

• Counseling• Supportive treatment : Maintenance of nutrition• Follow up

Thank You