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ASTHMA-AdCon.pptx
- 1. ADMITTING CONFERENCE PGI ARANETA –PGI DE GUZMAN – PGI SALIH
- 3. PATIENT PROFILE Name: D.H. Age: 2-year-old(October 11. 2019) Gender: Female Nationality: Filipino Patient data Address: Upper Pinget, Baguio City 1st admission in SLU-HSH Informant: Mother (90% reliability) COUGH Chief Complaint
- 4. 2 months PTA •Patient experienced an acute episode of cough • Non-productive • No associated night time awakening, fever, difficulty of breathing, dyspnea, colds, nor audible wheezing • No consult was done. • No interventions done.
- 5. 1 month PTA •Patient persistence of cough • Non-productive • With associated tachypnea, difficulty of breathing, and colds • No associated fever and audible wheezing • Consult was done with her private Pediatrician • Patient was given Salbutamol + Guaifenesin 1 mg/50 mg syrup, 5 mL TID x 5 days and Cetirizine 3.5 mL OD x 5 days • Persistence of non-productive cough • Relief of other symptoms
- 6. 2 days PTA •Progression of the cough • Occurs more frequently • With associated tachypnea, difficulty of breathing, audible wheezing, shallow subcostal retractions, and colds • No associated fever • Consult was done with her private Pediatrician • Patient was prescribed with Procaterol Hydrochloride 5 mcg/5 mL syrup x 7 days and Montelukast 4 mg/tab ODHS x 2 weeks
- 7. 1 day PTA •Progression of the cough • Productive • Occurs more frequently • With associated tachypnea, difficulty of breathing, audible wheezing, colds, and deep supraclavicular and subcostal retractions • Steam inhalation with PNSS was done • 1 episode of vomiting • Previously ingested milk with whitish sputum • Approximately 30 cc • Consult was done with her private Pediatrician and was advised admission
- 8. Prenatal History • Motherwas 32 y/o (G1P0) (0-0-0-0) • Cognizant of pregnancy at 5 weeks age of gestation • Prenatal checkups, unrecalled number of visits, done regularly • UTZ results were unrecalled • No history of exposure to smoking, alcohol, radiation
- 9. Natal History • Bornterm via LSCS at Pines City Doctors Hospital • BW: 2.65 kg, • Unrecalled Birth Length, Head Circumference, Chest circumference, APGAR score and Ballard score • No congenital malformations and resuscitative measures done
- 10. Neonatal History • Patientwas breastfed with good suck for 18 days and was shifted to formula milk due to low breast milk production. • The umbilical stump fell off after unrecalled days without signs of infection. • Newborn screening results are normal
- 11. FEEDING HISTORY BREAKFAST Rice,egg, cereals, mashed potato, pancakes, banana 100 +70 + 65 + 120 LUNCH Rice, chicken/fish 100 + 180 DINNER Rice, pork, mixed vegetables 100 + 120 + 60 SNACK Cookies, yogurt 150 + 50 TOTAL CALORIC INTAKE PER DAY 1, 115 kcal/day RECOMMENDED DAILY ENERGY AND NUTRIENT INTAKE PER DAY OF A 2 YEAR OLD FEMALE 1, 070 kcal/ day Patient was bottle fed per demand consuming about 2-3, 210 mL bottles in a day. Semisolid foods were introduced at 6 months. The patient was noted to be a picky eater.
- 12. Growth and DevelopmentalHistory BIRTH WEIGHT 2.65 kg PRESENT WEIGHT 12.5 kg BIRTH LENGTH unrecalled PRESENT LENGTH 88 cm BMI 15.1 AT BIRTH HC: unrecalled CC: unrecalled AC: unrecalled
- 13. Growth and DevelopmentalHistory Z score of 0 =
- 14. Growth and DevelopmentalHistory Z score of 0 =
- 15. Growth and DevelopmentalHistory Z score of 0 =
- 16. Developmental Milestones ASPECT MILESTONE GROSSMOTOR Walks well FINE MOTOR Imitates vertical strokes/scribing, builds tower cubes LANGUAGE Names pictures, 10 words, identifies 1 or more body parts PERSONAL/SOCIAL Feeds self, complains when in pain
- 17. Growth and DevelopmentalHistory SOCIAL DEVELOPMENT Sleeps at 10:30 pm and wakes up at 8:30 am Toilet Trained Interact with family and peers without discipline problems
- 18. Immunization History VACCINE 1STDOSE 2ND DOSE 3RD DOSE BOOSTER PLACE ADVERSE REACTIONS BCG (at birth) ✓ 05/20/2018 SLU-HSH none Pentavalent vaccine DPT (6-10-14 weeks) ✓ ✓ ✓ SLU-HSH OPV (6–10-14 weeks) ✓ ✓ ✓ ✓ 02/26/2019 InactivatedPolio Vaccine (14 weeks) ✓ SLU-HSH Hepatitis B (witihn 24 hours) ✓ ✓ ✓ ✓ SLU-HSH Anti-measles (9 months) ✓ SLU-HSH MMR (12 months) ✓ ✓ SLU-HSH Influenza (yearly) ✓ ✓ ✓ ✓ SLU-HSH Pneumococcal (6-10-14 weeks) ✓ ✓ ✓ SLU-HSH Japanese Encephalitis ✓ SLU-HSH
- 20. Past Medical History •No previous hospitalizations and surgeries • No known allergy to any food or medication
- 21. Family History • Historyof Bronchial Asthma and Hypertension on both maternal and paternal side • Maternal side: o Colon cancer, gouty arthritis, and twinning • No family history of Diabetes Mellitus, Cardiovascular and Coronary Disease
- 22. Social and EnvironmentalHistory • Father: o 62-year-old, retired tour guide o Primary care giver • Father: o 34-year-old, OFW nurse • No exposure to tobacco smoke and indoor or outdoor air pollution
- 23. Review of Systems GENERAL SURVEY (-)Weight loss, (-) sweats/diaphoresis, (+) irritable, (+) fair oral intake INTEGUMENTARY (-) cyanosis, (-) pallor, (-) lesions, (-) dryness, (-) rash, (-) sores HEAD AND NECK (-) lesions, (-) trauma, (-) swelling, (-) headache, (-) pain, (-) stiffness EYES (-) tearing, (-) itching, (-) redness, (-) discharge, (-) pain, (-) diplopia, (-) dryness EARS (-) discharge, (-) pain NOSE (-) dryness, (-) congestion, (+) clear nasal discharge, (-) bleeding MOUTH AND THROAT (-) sores, (-) ulcers, (-) dryness, (-) gum bleeding, (-) dental caries RESPIRATORY (+) occasional productive cough, (-) dyspnea, (-) hemoptysis, (-) cyanosis CARDIOVASCULA R (-) edema, (-) cyanosis, (-) murmurs, (-) rheumatic fever GASTROINTESTIN AL Good oral intake, (-) anorexia, (-) abdominal pain, (-) vomiting, (-) nausea, (-) diarrhea, (-) constipation, (-) flatulence, (-) melena, (-) hematochezia URINARY AND RENAL (-) dysuria, (-) hematuria, (-) nocturia, (-) frequency GENITAL (-) pain, (-) swelling, (-) discharges, (-) tenderness, (-) itching MUSCULOSKELET AL (-) deformities, (-) swelling, (-) tenderness, (-) stiffness HEMATOLOGIC (-) anemia, (-) bleeding, (-) bruising, (-) transfusions, (-) malignancies NERVOUS (-) seizures, (-) convulsions, (-) tremors
- 24. Physical examination • Awake,active, irritable with loud cry, not in cardiopulmonary distress with and SpO2 of 98% at room air GENERAL SURVEY • Temp: 36.5˚C • HR: 132 bpm • RR: 32 cpm • SPO2: 98% @ RA VITAL SIGNS • Weight: 12.5 kg • Height: 88 cm • BMI: 16.14 kg/m2 : Z-score = 0 (Normal) ANTHROPOMETRICS
- 25. Physical examination 03 S kin/ HE E NT - Nopallor,nocyanosis,good skinturgor - Pinkishpalpebralconjunctiva, anictericsclerae - Moistlipsandbuccalmucosa - Withsupraclavicular retractions,noneckvein engorgement, nocervicalLA D 04 L u ng s - Symmetrical chest wall expansion - Subcostalretractions - Diffusewheezing 05 - Tachycardic - Regular rhythm - Nomurmurs He a rt - Flat, nondistended, normoactivebowel sounds,tympanitic, soft, - Notenderness - Nomasses - Noorganomegaly 06 A b d o m e n
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- 27. Problem: Productive Cough SUBJECTIVEFINDINGS: OBJECTIVE FINDINGS: • 2-year-old female • Familial history of bronchial asthma • 2 MONTHS PTA: intermittent non-productive cough occurring throughout the day and during the night, with no nighttime awakening, with no associated tachypnea, difficulty breathing, fever, colds, audible wheezing • 1 MONTH PTA: persistence of non-productive cough with associated tachypnea and difficulty breathing and colds. • Salbutamol + Guaifenesin 1 mg/50 mg syrup, 5 mL TID and Cetirizine 3.5 mL syrup ODHS for 5 days > RELIEF • 2 DAYS PTA: Non-productive cough occurring frequently with associated tachypnea, difficulty breathing, audible wheezing, with observed shallow subcostal retractions, and colds. There was no associated fever. • 1 DAY PTA: Productive cough without expectoration of sputum with associated tachypnea, difficulty breathing, audible wheezing, colds, now with observed deep supraclavicular and subcostal retractions. One episode of vomiting of previously ingested milk with whitish sputum approximately 30 mL after steam inhalation. • General survey: Awake, active, irritable, ambulatory with loud cry, in cardiopulmonary distress with an SpO2 of 98% at room air • Vital signs: CR: 132 bpm RR: 32 cpm Temperature: 36.5ºC • Skin: No pallor, no jaundice, no rashes, no petechiae, no pigmentation, warm to touch, good skin turgor • HEENT: non-sunken eyeballs, no periorbital edema, anicteric sclera, pink palpebral conjunctiva. Nasal area has clear, watery discharge, no congestion, and no alar flaring. Mouth and throat have moist lips & buccal mucosa. • Chest and lungs: Symmetrical chest wall expansion, with supraclavicular and subcostal retractions, with diffuse occasional wheezes
- 28. Bronchial Asthma in MildAcute Exacerbation; Pediatric Community Acquired Pneumonia - C CLINICAL IMPRESSION
- 29. Basis of Impression Patient’sManifestations and Salient History Bronchial asthma in mild acute exacerbation SUBJECTIVE FINDINGS: • 2-year-old female • Familial history of bronchial asthma • Productive cough, cannot expectorate sputum, with associated tachypnea, difficulty of breathing, audible wheezing, colds. No fever OBJECTIVE FINDINGS: • General survey: Awake, active, irritable, ambulatory with loud cry, in cardiopulmonary distress with an SpO2 of 98% at room air • Vital signs: CR: 132 bpm RR: 32 cpm Temperature: 36.5ºC • Skin: No pallor, no jaundice, no rashes, no petechiae, no pigmentation, warm to touch, good skin turgor • HEENT: Non-sunken eyeballs, no periorbital edema, anicteric sclera, pink palpebral conjunctiva. The nose has clear, watery discharge, no congestion, and no alar flaring. Mouth and throat have moist lips & buccal mucosa. • Chest and lungs: Symmetrical chest wall expansion, with supraclavicular and subcostal retractions, with diffuse occasional wheezes • Onset early in life (often childhood) • Family History of asthma in first-degree relatives • >1 type of symptom (wheeze, shortness of breath, cough, chest tightness) • Cough: Recurrent or persistent non-productive • Difficulty of breathing occurring with exercise, laughing or crying • Wheezing: Recurrent • Symptoms often worse at night or in the early morning • Symptoms vary over time and in intensity (intermittent) • Acute exacerbation are triggered by viral infections
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- 31. Basis of Impression Patient’sManifestations and Salient History PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA-C SUBJECTIVE FINDINGS: • 2-year-old female • Productive cough, cannot expectorate sputum, with associated tachypnea, difficulty of breathing, audible wheezing, colds. No fever • Pneumonia can occur at any age, although it is more common in younger children. • Pneumonia accounts for 13% of all infectious illnesses in infants younger than 2 years of age. • SYMPTOMS: fever, cough (productive or nonproductive), congestion, chest pain, dehydration, and lethargy
- 32. Basis of Impression Patient’sManifestations and Salient History PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA-C OBJECTIVE FINDINGS: • General survey: Awake, active, irritable, ambulatory with loud cry, in cardiopulmonary distress with an SpO2 of 98% at room air • Vital signs: CR: 132 bpm RR: 32 cpm Temperature: 36.5ºC • Skin: No pallor, no jaundice, no rashes, no petechiae, no pigmentation, warm to touch, good skin turgor • HEENT: Non-sunken eyeballs, no periorbital edema, anicteric sclera, pink palpebral conjunctiva. The nose has clear, watery discharge, no congestion, and no alar flaring. Mouth and throat have moist lips & buccal mucosa. • Chest and lungs: Symmetrical chest wall expansion, with supraclavicular and subcostal retractions, with diffuse occasional wheezes • SIGNS: Tachypnea, C/L: rales, dullness, decreased tactile and vocal fremitus & intercostal retractions • Increased work of breathing accompanied by intercostal, subcostal, and suprasternal retractions, nasal flaring, and use of accessory muscles is common • Prodrome of upper respiratory tract infection leading to the abrupt onset of fever, restlessness, apprehension, and respiratory distress.
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- 34. Differential Diagnoses Patient’s Manifestations Bronchial AsthmaPediatric Community Acquired Pneumonia Covid-19 Pneumonia Bronchiolitis Risk Factors: Family history of bronchial asthma (+) (+/-) (+/-) (-) Subjective/Objective Data: Non productive -> Productive cough (+) Usually non-productive (+) (+/-) Usually dry cough/ non- productive (+) Colds (+) (+) (+) (+) Vomiting (+) (+) (+) (+/-) Tachycardic (157 bpm) (+) (+) (+/-) (+) Tachypneic (32 cpm) (+) (+) (+) (+) Supraclavicular and subcostal retractions (+) (+) (+/-) (+) Wheezing (+) Wheezing is a common (+) Crackles and wheezing are (+) Coarse breath sounds, (+) Wheeze/crackles
- 35. Diagnostic Tests COVID-19 RT-PCR 01 CompleteBlood Count 03 Chest X-ray (APL) 02 Therapeutic Trial 04
- 36. Diagnostic Tests COVID-19 RT-PCR 01 TESTRATIONALE PATIENT’S RESULT COVID-19 RT PCR swab To rule out COVID-19 infection Negative
- 37. Diagnostic Tests Chest X-ray(APL) 02 TEST Bronchial asthma Pediatric Community Acquired Pneumonia COVID - 19 Pneumonia Bronchiolitis Chest X- ray expected findings Plain chest radiographs can be normal in up to 75% of patients with asthma. Reported features with asthma include: • Pulmonary hyperinflation • Bronchial wall thickening: peribronchial cuffing • Hyperinflation • Bilateral interstitial infiltrates • Peribronchial cuffing • Multifocal and bilateral ground glass opacities and consolidations with peripheral and basal predominance • Hyperinflation with patchy atelectasis
- 38. Diagnostic Tests Chest X-ray(APL) 02 Chest X-ray (March 27, 2022) CHEST: Interstitial densities are seen in the inner lung zones Cardiac shadow is normal in size and contour Intact diaphragm with clear costophrenic recesses Bones and soft tissue shadows appear unremarkable IMPRESSION: Pneumonia, both inner lung
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- 40. Diagnostic Tests Complete BloodCount 03 COMPLETE BLOOD COUNT WITH PLATELET (March 27, 2022) Result Reference range Erythrocytes 4.7 3.8-5.4 10^12/L Hemoglobin 128 115-148 g/L Hematocrit 0.36 0.38-0.44 MCV 76.4 80.0-100.0 fL MCH 27.5 27.0-34.0 pg MCHC 360 310-370 g/L RBC morphology Normocytic, Normochromic Platelet 456 150-450 x 10^9/L WBC count 16.1 4.0-11.0 10^9/L Neutrophils 66.3 45.0-55.0 % Lymphocytes 23.4 38.0-45.0 % Eosinophils 3.2 2.0 - 5.0 % Monocytes 6.7 3.0 - 6.0 % Basophils 0.4 0.0 - 1.0 % NRBC # 0.0
- 41. Diagnostic Tests Therapeutic Trial 04 •As-needed short acting beta2-agonist (SABA) + regular low dose Inhaled Corticosteroids (ICS) ⇒ at least 2-3 months • Expected outcome: o Marked improvement during treatment o Deterioration is stopped
- 42. Bronchial Asthma in MildAcute Exacerbation; Pediatric Community Acquired Pneumonia - C WORKING DIAGNOSIS
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- 46. Management Plan • InitialER department management o Oxygen inhalation at 1 lpm o Salbutamol nebule 20 minutes for the 1st hour o IV methylprednisolone 1 mg/kg every 6 hours
- 48. Management Plan • Lowdose ICS o Budesonide 500 mcg/ml • SABA o Salbutamol
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- 51. Management Plan • Non-pharmacologic oCompletion of immunization Influenza PCV o Avoid exposure to airborne allergens and pollutants
- 52. Genetic Factors EnvironmentalFactors Atopy Exposure to triggers of airway hyperresponsiveness ↑ levels of inflammatory and bronchoconstrictive mediators and cells Inflammation of lower airway Mucus production 2° to WBC & epithelial cell debris Airflow past inflamed airways ↑ irritation and cough response Dry cough Mechanical obstruction of airflow in lower airways Smooth muscle constriction in lower airways ↓ ventilation of alveoli Hypoxemi a HR ↑ to improve perfusion to tissues Respiratory centers ↑ RR to compensate Tachycardia Tachypnea Productive cough ↑ RV and ↑ PCO2 causes ↑ RR Retractions ↑↑airway obstruction Narrow airways → turbulent airflow Expiratory wheeze ↑ work of breathing
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