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C A S E P R E S E N T A T I O N Paeds3


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Published in: Health & Medicine

C A S E P R E S E N T A T I O N Paeds3

  1. 1. Dr Raymond Arhin
  2. 2. <ul><li>HB </li></ul><ul><li>4 weeks old baby girl </li></ul><ul><li>PC-Cough and colds-2weeks Vomiting, apnoea </li></ul><ul><li>HPC- Gradual onset of symptoms, bouts of cough and coryzal symptoms seen GP 2X-Viral infection, Chest infection given Amoxicillin. On day of presentation became blue after coughing bout. Episode lasted about 30 secs. </li></ul><ul><li>Coughs worse with feeds. </li></ul><ul><li>No fever, feeding okay, wetting nappies </li></ul>
  3. 3. Pregnancy and developmental history <ul><li>Conception- Twin Pregnancy </li></ul><ul><li>Pregnancy was uneventful </li></ul><ul><li>NVD at 37+2weeks </li></ul><ul><li>Birth weight 2.81kg </li></ul><ul><li>Bottle fed SMA </li></ul><ul><li>Immunisations- awaited </li></ul>
  4. 4. <ul><li>4/52 4/52 8yrs 11yrs </li></ul><ul><li>No family history of Asthma, Eczema, Fits or contact with Cough or cold in recent past </li></ul>
  5. 5. Examination <ul><li>T 36 C, Pulse 170/min, RR32/min, Sats 92% </li></ul><ul><li>CVS: HS I & II + Murmur, Liver not palpable, regular good volume pulses peripherally, CRT<2 secs both centrally and peripherally </li></ul><ul><li>CHEST: No signs of resp. distress, good air entry with mild wheeze </li></ul><ul><li>ABDOMEN: Soft , No organs palpable, No masses palpable </li></ul><ul><li>CNS: Alert, Good tone, No neurological deficits </li></ul><ul><li>ENT: Ears clear, Throat normal </li></ul>
  6. 6. DIFFERENTIALS <ul><li>Bronchiolitis </li></ul><ul><li>GORD </li></ul><ul><li>Whooping Cough </li></ul><ul><li>Croup </li></ul><ul><li>Pneumonia </li></ul><ul><li>Cyanotic heart disease </li></ul>
  7. 7. PLAN <ul><li>Admit for observation </li></ul>
  8. 8. Day of Admission <ul><li>Cyanotic episode lasting about 30 secs following feeds. </li></ul><ul><li>Started regular monitoring of saturations. </li></ul><ul><li>Nurses observed several episodes of desaturations with and without cough. </li></ul>
  9. 9. Day1 <ul><li>Observed to be choking on feeds. </li></ul><ul><li>Greenish vomit 1X ,copious amounts </li></ul><ul><li>Assessment: GORD started on GAVISCON </li></ul><ul><li>5 more episodes of desaturations dropping to 50%-65% lasting between 10-20 secs. </li></ul><ul><li>observed to have a loud cough, no resp.distress, no audible wheeze ,2/6 sysytolic murmur </li></ul><ul><li>Impression- Bronchiolitis </li></ul><ul><li>Investigations for FBC, U&E, LFT, CRP, NPA, Blood c/s,CXR, Blood gas </li></ul><ul><li>Started on nasal CPAP in view of recurrent apnoeas </li></ul>
  10. 10. RESULTS
  11. 11. DAY2 <ul><li>Continued to have desaturations </li></ul><ul><li>Cough persisted </li></ul><ul><li>Feeding reduced </li></ul><ul><li>Started on IV Fluids </li></ul><ul><li>Continued on CPAP </li></ul>
  12. 12. Day3 <ul><li>Coughing decreased </li></ul><ul><li>Restarted oral feeds </li></ul><ul><li>Maintaining saturations </li></ul><ul><li>Extended NPA </li></ul>
  13. 13. Day4 <ul><li>Feeding improved </li></ul><ul><li>Desaturations persisted </li></ul><ul><li>Apnoeic episodes worse with Gaviscon so it was stopped </li></ul>
  14. 14. Day5 <ul><li>Twin brother also has a cold and cough </li></ul><ul><li>Further history revealed mum did not have immunisations because she reacted to DPT. </li></ul><ul><li>Chest- some coarse crepitations </li></ul><ul><li>Consider Whooping cough </li></ul><ul><li>Pernasal swab </li></ul><ul><li>ECG </li></ul>
  15. 15. Day6 <ul><li>Cough with desaturations getting worse. </li></ul><ul><li>Saturations drop 60-70% </li></ul><ul><li>Quick recovery </li></ul><ul><li>Started on Erythromycin in view of persistent desaturarations </li></ul>
  16. 16. Day7 <ul><li>Much more stable </li></ul><ul><li>Desraturations persist but quick recovery </li></ul><ul><li>No oxygen required </li></ul>
  17. 17. Day8 <ul><li>Continued to have coughs </li></ul><ul><li>Not Requiring any oxygen </li></ul><ul><li>Chest Good Air occasional crackles </li></ul><ul><li>Fit for discharge </li></ul><ul><li>Further assessment of hart murmur via Telemedicine </li></ul><ul><li>DISCHARGED HOME </li></ul>
  18. 19. Cases of whooping cough 'treble' Monday, 10 March 2008 Cases of whooping cough have nearly trebled since 2003, according to figures from the Department of Health. The figures were obtained in response to a parliamentary question from the Liberal Democrats health spokesman Norman Lamb . The figures show that there were 386 cases of whooping cough five years ago compared to 1,071 in 2007.
  19. 20. <ul><li>Whooping cough cases soar </li></ul><ul><li>Last Updated: 1:00am GMT 11/03/2008 </li></ul><ul><li>'Give teenagers jab for whooping cough' </li></ul>Whooping cough cases soar Doctors said this suggested that teenagers as well as babies should be vaccinated against whooping cough, as in , as in France, Germany and the US
  20. 21. Cases of whooping cough has doubled in last year
  21. 22. <ul><li>In 2003, there were just 386 cases in England but provisional figures suggest there were as many as 1,071 in 2007. </li></ul><ul><li>During this period, uptake of the jab remained steady over the last few years - around 93% or 94% coverage between 2003 and 2007. </li></ul><ul><li>A vaccine is given to babies. It forms part of the DTaP/IPV/ Hib jab, which protects against diphtheria, tetanus, pertussis, polio and haemophilus influenzae type b </li></ul><ul><li>Recent research from the University of Oxford said that while immunisation is effective, doctors needed to be aware that protection did not last indefinitely. </li></ul>
  22. 23. <ul><li>Whooping cough cases fluctuate on about a four year cycle, so there will always be highs and lows that are comparable with fluctuations in other countries </li></ul><ul><li>Department of Health </li></ul>
  23. 24. Whooping Cough <ul><li>What is whooping cough? Whooping cough (pertussis) is still a very serious disease when it occurs in children under the age of one year old. But thanks to an effective vaccine and prevention against infection, it is now quite rare. Whooping cough is a very serious disease when it occurs in children aged under one year. Before the vaccination against whooping cough was introduced, three out of four children caught the disease and some died every year. Today only a few get whooping cough. </li></ul>
  24. 25. <ul><li>What causes whooping cough? Whooping cough is caused by a bacteria (Bordetella pertussis) and is one of the most contagious bacterial infections. If one child in a group of siblings gets it, the other children are extremely likely to become infected if they have not already had the disease or been vaccinated. This also includes babies. Although infants who are breastfed are usually protected against most common childhood infections, they receive no protection against whooping cough. This is why early vaccination is recommended. </li></ul>
  25. 26. Pathophysiology <ul><li>Bordetella pertussis is an aerobic, nonmotile, gram-negative coccobacillus that attaches to and multiplies on the respiratory epithelium, starting in the nasopharynx and ending primarily in the bronchi and bronchioles. Transmission is only human to human by means of exposure to aerosol droplets. The disease is highly contagious. Approximately 80-90% of susceptible individuals who are exposed develop the disease. </li></ul>
  26. 27. Pathophysiology cont’d <ul><li>A mucopurulous or sanguineous exudate forms in the respiratory tract. This exudate compromises the small airways (especially those of infants) and predisposes the affected individual to atelectasis, cough, cyanosis, and pneumonia. The lung parenchyma and bloodstream are not invaded; therefore, blood culture results are negative. </li></ul>
  27. 28. Age <ul><li>Pertussis occurs predominantly in those aged 3 months to 5 years, with more than 70% of cases reported in children younger than 5 years. </li></ul><ul><li>Because of the lack of maternal immunity transfer, 10-15 % of all cases occur in infants younger than 6 months, yet more than 90% of all deaths occur in this same age group </li></ul>
  28. 29. History <ul><li>Pertussis typically consists of 3 stages: </li></ul><ul><li>incubation, </li></ul><ul><li>catarrhal, </li></ul><ul><li>paroxysmal. </li></ul>
  29. 30. INCUBATION PERIOD <ul><li>The asymptomatic incubation period lasts 7-10 days. </li></ul>
  30. 31. CATARRHAL STGE <ul><li>The catarrhal stage follows and lasts about 2-7 days. Findings include the following: </li></ul><ul><ul><li>Minimal or no fever </li></ul></ul><ul><ul><li>Rhinorrhea </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Mild but increasing cough </li></ul></ul>
  31. 32. Paroxysmal stage <ul><li>The paroxysmal stage follows, lasting about 1-8 weeks. </li></ul><ul><ul><li>It is characterized by paroxysms of coughing, which are provoked by feeding (in infants) and exertion. </li></ul></ul><ul><ul><li>These paroxysms are less spontaneous than those observed in typical respiratory infections. </li></ul></ul><ul><ul><li>The inspiratory gasp or whoop eventually develops, especially in those aged 6 months to 5 years. </li></ul></ul>
  32. 33. <ul><li>Infants younger than 6 months often have vomiting in association with the cough, which leads to dehydration. </li></ul><ul><ul><li>Hypoxia tends to be more severe than what the child's clinical appearance suggests. </li></ul></ul><ul><ul><li>A substantial number of patients present with cyanosis and apnoeic spells. </li></ul></ul>
  33. 34. Physical <ul><li>The classic inspiratory gasp or whoop primarily develops in those aged 6 months to 5 years. It is usually absent in those younger than 6 months and in most older vaccinated children and adults;. </li></ul><ul><li>Hypoxia should be considered and assessed. </li></ul><ul><li>Dehydration is common on presentation. </li></ul><ul><li>Mild fever is common. Fever with a temperature of over 39°C is rare. </li></ul>
  34. 35. Causes <ul><li>The main causative organism is B pertussis. </li></ul><ul><li>Bordetella parapertussis and Bordetella bronchiseptica are less common than B pertussis and produce a clinical illness that is similar but milder to pertussis due to B pertussis. </li></ul><ul><li>Risk factors include the following: </li></ul><ul><ul><li>Nonvaccination in children </li></ul></ul><ul><ul><li>Contact with an infected person </li></ul></ul><ul><ul><li>Epidemic exposure </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul>
  35. 36. Vaccination <ul><li>The vaccination takes place at the age of two, three and four months as part of the 'five-valent' diphtheria, tetanus, pertussis, Hib, polio vaccination (Pediacel). After the first two vaccinations protection is almost 100 per cent. </li></ul><ul><li>However protection wear off after about 10 years </li></ul>
  36. 37. Lab Studies <ul><li>Blood work </li></ul><ul><ul><li>Lymphocytosis is often profound (>70% of the total WBC count), especially in children. </li></ul></ul><ul><ul><li>In adults, especially those that had been vaccinated, lymphocytosis is rare. </li></ul></ul><ul><li>Cultures </li></ul><ul><ul><li>A definitive culture diagnosis is not always possible. </li></ul></ul><ul><ul><li>Results of blood culture are uniformly negative because B pertussis grows solely in the respiratory epithelium. </li></ul></ul><ul><ul><li>An immediately plated, deep, culture of a nasopharyngeal swab sample grown in Regan-Lowe charcoal agar or fresh Bordet-Gengou is considered the criterion standard for those who present within the first 3 weeks of their cough. The results are positive in <50% (perhaps 15-40%) of cases, and results become available too late (about 1 week) to be clinically useful. </li></ul></ul>
  37. 38. Lab <ul><li>Direct fluorescent antibody (DFA) studies </li></ul><ul><ul><li>DFA studies are performed by using a nasopharyngeal sample. </li></ul></ul><ul><ul><li>Although the results can be available within minutes, its use is not recommended because of both low sensitivity and low specificity. Specimens should be obtained within the first 3 weeks of the disease (ie, in incubation, catarrhal, or early paroxysmal stages) or the sensitivity and specificity decrease. </li></ul></ul><ul><li>Polymerase chain reaction (PCR) testing to detect DNA </li></ul><ul><ul><li>PCR testing may reveal <10 organisms per swab sample. </li></ul></ul><ul><ul><li>Its sensitivity may be greater than that of culturing. </li></ul></ul><ul><ul><li>False-positive results have been a problem, with some reports of more than 50%. Although this or a positive culture is the case definition for reporting pertussis to the WHO, some are now recommending ELISA confirmation before declaring an epidemic.    </li></ul></ul><ul><li>Enzyme-linked immunosorbent assay (ELISA) is also useful. Many now consider serologic testing with ELISA to be the criterion standard. </li></ul>
  38. 39. <ul><li>Imaging Studies </li></ul><ul><li>Chest radiography may show focal atelectasis and/or peribronchial shadowing </li></ul>
  39. 40. <ul><li>Emergency Department Care </li></ul><ul><li>General supportive measures (eg, oxygenation, breathing treatments, mechanical ventilation) should be administered as needed. </li></ul><ul><li>Infants should be carefully observed for apnoea, cyanosis, or hypoxia. </li></ul><ul><li>Patients should be isolated from susceptible individuals (especially infants) for 4 weeks, especially until 5-7 days of antibiotic therapy is completed. When patients present with paroxysmal cough, the clinical course is not shortened, but transmission is considerably decreased after 5 days of therapy. </li></ul>
  40. 41. <ul><li>Factors that should prompt a consideration of admitting the patient are the following: </li></ul><ul><ul><li>Age younger than 1 year </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Apneic or cyanotic spells or hypoxia </li></ul></ul><ul><ul><li>Moderate-to-severe dehydration </li></ul></ul><ul><li>The effectiveness of prophylaxis for exposed susceptible persons has not been determined; however, it is recommended for household and close contacts of the patient. Regimens include the following: </li></ul><ul><ul><li>Erythromycin 50 mg/kg/d divided 4 times a day (qid) for 14 days </li></ul></ul><ul><ul><li>Alternative: Clarithromycin 7.5 mg/kg 2 times a day (bid) for 14 days (The effectiveness of clarithromycin has not been proven but is inferred.) </li></ul></ul>
  41. 42. Summary <ul><li>The disease begins with a cold and a mild cough. After this, the typical coughing bouts set in. The coughing continues until no air is left in the lungs. After this comes a deep intake of breath that produces a heaving, 'whooping' sound when the air passes the larynx (windpipe) that gives rise to the name of the disease. </li></ul><ul><li>The patient will eventually cough up some phlegm and these attacks may well be followed by vomiting. The child's temperature is likely to remain normal. </li></ul><ul><li>A bout of whooping cough can be very distressing for both the child and the parents who feel unable to help. </li></ul><ul><li>Coughing attacks may occur up to 40 times a day and the disease can last for up to eight weeks </li></ul>