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Downs + pneum

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Downs + pneum

  1. 1. GENERAL CLINICS case 4
  2. 2. HISTORYSHILPA.G.KAMATH080201360
  3. 3. 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
  4. 4. Presenting complaints• Cough with expectoration – 6 days• Breathlessness – 6 days
  5. 5. History of presenting illness• Cough – associated with expectorationOnset- insiduousGradually progressivePresent throughout the dayNo aggravating factorsRelieved on medication
  6. 6. • ExpectorationScanty, white, mucoid, non foul smelling, not blood stained
  7. 7. • BreathlessnessAssociated with cough and expectorationAssociated with occasional wheezeWorsens on lying down, at nightRelieved when mother holds baby upright
  8. 8. • Came to GWH on 30th July with above complaints• Nebulization done• Symptoms subsided• Patient discharged the same day• Symptoms recurred 3 days later, admitted.
  9. 9. Past history• Has had similar episodes in the past since the age of 1.5months• 3 admissions• Nebulization done each time
  10. 10. 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
  11. 11. • 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)
  12. 12. Natal and postnatal historyLSCS at 9th monthCried immediately after birthBirth weight – 2.8kgBreast feeding initiated after 2 hrsNICU admission- 4days – phototherapyPassed urine and meconium
  13. 13. 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
  14. 14. • 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
  15. 15. 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
  16. 16. Immunization history• Appropriate for age
  17. 17. 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
  18. 18. Family history• Total family members- 4• Non consanguineous marriage• Parents healthy.• No history of TB/ congenital defects/ allergy in the family
  19. 19. 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
  20. 20. EXAMINATIONTamanna ahemad080201372
  21. 21. VITALS• Pulse rate-104 beats per min (normal)• Respiratory rate-36 per min (tachypnea)• Afebrile during examination
  22. 22. ANTHROPOMETRY• Weight for age• Less than 3rd percentile• Grade 1 PEM (IAP)• undernutrition (wellcome trust)
  23. 23. • Length• Less than 3rd percentile• Grade III stunting (waterlow classification)• Weight for height• No wasting (waterlow classification)
  24. 24. • Head circumference• Microcephaly (less than 3rd percentile)• Brachycephaly is present• Mid arm circumference-14 cm(normal)• Chest circumference is greater than head circumference
  25. 25. Head to toe examination• Sparse thin shiny hair• Flat occiput• Ant fontanelle-1*1cm• Depressed nasal bridge• Hypertelorism• Epicanthic fold present
  26. 26. • Up-slanting of eyes• Low set ears• Mouth kept open with protruding tongue• Short neck• Short broad hands• Hypotonia,hyperflexible limbs• Kennedy crease
  27. 27. 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
  28. 28. SYSTEMIC EXAMINATION
  29. 29. 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
  30. 30. • Cardiovascular system• S1 S2 heard,no murmurs• CNS• Hypotonia,power cannot be assessed,reflexes are normal• P/A• Soft nontender,no organomegaly
  31. 31. Summary• Tachypnea• Grade 1 PEM• Grade III Stunting• Microcephaly,brachycephaly• Mongoloid facies• Developmental delay• Bilateral crepitations
  32. 32. DIFFERENTIALDIAGNOSIS- Naseeba(080201378)
  33. 33. ON HISTORY ON EXAMINATION• COUGH WITH • MONGOLOID FACIES EXPECTORATION • HYPOTONIA• BREATHLESNESS • B/L CREPITITIONS• WHEEZING • DEVELOPMENTAL• FEEDING DIFFICULTY DELAY• DEVELOPMENTAL DELAY
  34. 34. CHARACTERISTIC FACIAL FEATURES SUGGESTIVE OFDOWN SYNDROME
  35. 35. RESPIRATORYCOUGH WITH EXPECTORATION• PNEUMONIA• TB• FBWHEEZE• WALRI• BRONCHIOLITIS• FB
  36. 36. BREATHLESSNESS• PNEUMONIA• BRONCHIOLITIS• BA• FB
  37. 37. CARDIAC• CHD• PULMONARY EDEMA
  38. 38. HYPOTONIA• DOWN SYN• HYPOTHYROIDISM• MYOPATHIES
  39. 39. INVESTIGATIONS- Aiswarya . S (080201390)
  40. 40. INVESTIGATIONS FOR DOWN SSYNDROME• Karyotyping.• To diagnose complications-• Complete blood count.• Peripheral smear• Radiological findings• X ray spine• X ray chest.• X ray bones.• X ray pelvis.
  41. 41. • AUDIOLOGY• OPHTHALMOLOGICAL.• THYOID FUNCTION TESTS.• ECHO-PDA with Left to Right shunt.• BLOOD SUGAR.
  42. 42. INVESTIGATIONS• BIOCHEMISTRY— LFT,RFT,Electrolytes;ABG analysis• HEMATOLOGY— Hb,Counts,ESR,Plateletes,PeripheralS mear• RADIOLOGY—ChestX ray.• MICROBIOLOGY—Blood culture;Stool & Urine examination• KARYOTYPING
  43. 43. INVESTIGATIONS FOR PNEUMONIA• Chest radiography• Total and differential count.• Haemoglobin count.• Culture studies
  44. 44. HAEMATOLOGICALINVESTIGATIONS HEMOGLOBIN—9gm% COUNTS — Total count-6500/cc. ESR—27.9 PLATELETS —3,40,000/cc
  45. 45. BIOCHEMICAL INVESTIGATIONS• ELECTROLYTES Na+,K+,Cl-,HCO3 ‘LIVER FUNCTION’ TESTS Total and Direct Bilirubin ; ALT• ARTERIAL BLOOD GAS ANALYSIS• THYOID FUNCTION TESTS.
  46. 46. 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.
  47. 47. 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)
  48. 48. 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.
  49. 49. INVESTIGATIONS• BIOCHEMISTRY— LFT,RFT,Electrolytes;ABG analysis• HEMATOLOGY— Hb,Counts,ESR,Plateletes,PeripheralS mear• RADIOLOGY—ChestX ray.• MICROBIOLOGY—Blood culture;Stool & Urine examination• KARYOTYPING
  50. 50. TREATMENT- Prithvishree Ravindra (080201366)
  51. 51. IMNCI guIdelINes
  52. 52. 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
  53. 53. 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
  54. 54. INPAtIeNt MANAgeMeNtSpecific SupportiveAntibiotics Hydration Nutrition Oxygen Antipyretics Physiotherapy Asthalin nebulisation if wheeze is present
  55. 55. 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
  56. 56. 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
  57. 57. treAtMeNt Of the INdex CAse• Nebulisation with asthalin• IV fluids Iso – P• Inj. Ampicillin IV• Injection Gentamycin IV• Syp PCT
  58. 58. dOWN sYNdrOMe – heAlthsuPerVIsION
  59. 59. dOWN sYNdrOMe – heAlthsuPerVIsIONCondition Time to screen CommentCongenital heart Birth 50% risk for congenitaldisease Young adult for heart disease. acquired valve disease Increased risk for pulmonary hypertensionStrabismus, cataracts, Birth or by 6 months 15% - cataractsnystagmus Check vision annually 50% - refractory errorsHearing impairment or Birth or by 3 months – Congenital hearing lossloss ABER 70% risk – serious If tympanic membrane otitis media not visualised- 6 monthly for 3 years Annually therafterConstipation Birth Hirschsprung disease
  60. 60. dOWN sYNdrOMe – heAlthsuPerVIsIONCondition Time to screen CommentCeliac disease 2 years/ symptomatic Screen – IgA and tissue transglutamase antibodiesHematologic disease At birth , adoloscence Neonatal polycythemia and when symptoms Leukemoid reaction develop LeukemiaHypothyroidism Birth, repeat at 6 – 12 1% - congenital months and then 5% acquired annuallyGrowth and At each visit Discuss schooldevelopment Use Down syndrome placement options growth curves Proper diet to avoid obesity
  61. 61. For index case
  62. 62. For index case
  63. 63. dOWN sYNdrOMe – heAlthsuPerVIsIONCondition Time to screen CommentObstructive sleep apnea Start at 1 year. Then at Monitor for snoring, each visit restless sleepAtlantoaxial subluxation/ Each visit – history and Maybe asymptomaticinstability physical exam Radiographs at 3 -5 years or when planning to participate in contact sports / Transient neurological symptomsGynaecological care Adoloscent girls Menstruation/ contraception useRecurrent infections When present Check IgG subclass and IgA levelsPsychiatric, behavioral Each visit Depression,anxiety,disorders OCD, schizoprenia. Autism , Early onset alzheimers
  64. 64. PdA - left tO rIght shuNt• Catheter based treatment – occlusive devices or coils• Surgery if :• Large PDA ( larger than size of available devices)

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