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)
Diet history•Child is on artificial feeds since 1.5 months of age 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 -
Family history• Total family members- 4• Non consanguineous marriage• Parents healthy.• No history of TB/ congenital defects/ allergy in the family
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
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
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.
ON EXAMINATIONVitals• Pulse Rate- Tachycardia Cardiovascular System• Respiratory-Tachypnea • Apical impulse diffuse & ill sustainedAnthropometry • Systolic thrill -apex & LLSB VSD • Epigastric pulsations• Weight for age below the 3rd percentile • pansystolic murmur (LLSB)Per abdomen Respiratory System• Hepatomegaly • Suprasternal and Subcostal indrawing PNEUMONIA
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, CONGENITALDEFECT most probably VSD with associated PNEUMONIA. With signssuggestive 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 deafnessVATER Syndrome V -vertebrae disorders, A -anus issues, C - cardiac related problems, T -trachea disorder, E - esophageal, R - renal Defects and L -limb oriented disordersFAVSPHACE 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
VIRAL PNEUMONIA BACTERIAL PNEUMONIACLINICALLY -Not very high grade fever -High grade fever -Non purulent expectoration -Associated with purulent expectoration. -Signs of lobar consolidn. or assoc pleural effusionTOTAL COUNTS Normal or elevated Always elevated Usu. not greater than 20,000/cc Usu in the range of 15,000/cc-40.000/ccDIFFERENTIAL COUNTS Lymphocyte predominance Neutrophil predominanceRADIOLOGY Hyperinflation with bilateral Lobar consolidation interstitial infiltratesDEFINITIVE DIAGNOSIS Isolation of virus. Isolation of bacteria Detection of viral genome in respiratory secretions
BIOCHEMICAL INVESTIGATIONS ELECTROLYTES Na+,K+,Cl-,HCO3- ‘LIVER FUNCTION’ TESTS Total and Direct Bilirubin ; ALT ARTERIAL BLOOD GAS ANALYSIS
Hospitalisation - ABCInvestigation When do you take and how? action?Pulse oximetry Administer supplementary oxygen by hood (OR)Signs of acute hypoxemia (OR)•dyspnoea, tachypnoea, Positive Pressure Ventilationbradypnoea, apnoea•pallor, cyanosis•lethargy or restlessness Caution: ventilation/perfussion mismatch•use of accessory muscles: nasal may occur in pneumoniaflaring, intercostal or sternal NOTE: asthalin (SALBUTAMOL) may be givenrecession, tracheal tug by nebuliser if wheezing presentHb <13g/dL Packed cell transfusionHydration status Child is vomitting / IV fluids Appears toxic, dehydrated.Chest X-Ray Effusion / Drainage of effusion Empyema Antibiotics
Pneumonia Management: ARI ProgrammeClassification Treatment PlacePneumonia Cotrimoxazole Home / PHC Age : 3-12 months – 2 tablets twice daily Reassess after 2 days. (Trimethoprim 20 mg + sulfamethoxazole 100 mg)Severe Pneumonia Ampicillin + gentamycin Hospital (OR) Benzyl penicilin 50,000 units/kg/dose – every Treat for 2 6 hours weeks. (OR) Cefotaxime + gentamycinVery severe pneumonia Cefotaxime or Ceftriaxone + Gentamycin Hospital (IV) Treat for 2 weeks
Antibiotics-Augmentin= amoxicillinclavunateAmikacin =aminoglycosideAntiviral-Tamiflu = oseltamavirPCT-For feverIV FLUIDS-Isolyte P in 5% dextrose
Type of VSD Treatment Small VSD Spontaneous closure- follow up.Indications for Watch out for complications!surgery : Eg.Infective Endocarditis1. Infective Moderate VSD Spontaneous closure – follow up endocarditis2. Pulmonary Plan surgery before age 2-5 yrs, before HTN is Eisenmengerisation reversible when PVR fall Watch out for complications! is 6 units , Eg. Pulmonary Hypertension operate ASAP!3. Large VSD Large VSD SURGERY is the only TREATMENT4. CHF not Ideal age= below 2 years/ 2-5 years before responding to eisenmengerisation. medical treatment Surgical closure of defect by Dacron - used to5. Associated cover the defect and sides sewn . cardiac defects Types : open heart surgery or cardiac catheterisation VSD with Heart Lung transplantation PULMONARY HTN