This case presentation describes a 1 year old male patient admitted to the pediatric ward with a 4 day history of fever, cough, runny nose and 2 days of breathlessness. On examination, the patient appeared ill with tachycardia and tachypnea. Chest examination revealed wheezing and crackles. Echocardiogram showed a patent ductus arteriosus. The patient was diagnosed with bronchiolitis and congenital heart disease due to PDA, and was failing to thrive. Treatment included antibiotics, bronchodilators, diuretics and supportive care. The patient's condition was followed up over three days.

1. Welcome to Pediatric case
presentation
By Intern Dr. Nazmus Sakib

2. Particulars of the patient
 Name- Md. Ibrahim.
 Age- 1 year.
 Sex- Male.
 Religion- Islam.
 Address- Dhour, Turag, Dhaka.
 Informant- Mother.
 Date and time of admission- 7th December, 2016 @ 11:30 am.
 Date and time of examination- 7th December, 2016 @ 11:40 am.

3. Chief complaints
 Fever for four days.
 Cough and running nose for four days.
 Breathlessness for two days.

4. History of present illness
 According to the statement of the informant (mother) baby was relatively well four
days back then he has developed fever which is low grade intermittent in nature
with maximum recorded temperature being 101ºF. Fever is not associated with
chills and rigor; subsides after taking antipyretics with little or no sweating. There is
no particular history of evening rise of temperature and night sweats. There is
associated cough and running nose for same duration. Cough is non productive,
present throughout day and night, without any particular aggravating and reliving
factor. Mother also complains of moderate breathlessness for last two days, more
during moderate to severe exertion and relived after taking rest. There is no history
of paroxysmal nocturnal dyspnea and orthopnea. This breathlessness has no
diurnal, seasonal variation and not related to intake of food or exposure to cold,
dust, pollen, fume etc. There is no history of bluish discoloration of skin, finger nail,
toes and lips. His bowel and bladder habit is normal. There is no history of
significant weight loss.

5. History of past illness
 Six months back baby presented with history of repeated lower respiratory tract
infection and occasional breathlessness to a pediatrician. Breathlessness occurred
during exertion and relived after rest. Breathlessness had no diurnal, seasonal
variation and was not related to intake of food or exposure to cold, dust, pollen,
fume etc. There was no history of bluish discoloration of skin, finger nail, toes and
lips. Conservative treatment was given; after which symptoms improved
significantly.

6. Drug History
 Baby has been taking syrup Frusemide and table Spironolactone for last six months
as prescribed by the doctor. He also received Nebulization sometimes due to
occasional breathlessness.

7. Birth history
 Antenatal- Mother was under regular ante natal checkup and her pregnancy was
uneventful.
 Natal- Healthy male baby was delivered by caesarean section.
 Postnatal- Baby cried immediately after birth. Color was pink. Activity was good.

8. Feeding history
 Baby received exclusive breast feeding for first six months then weaning was
started with soft rice, suzi, khichuri. Now the baby is on weaning diet.
Immunization history
 Immunized according to EPI schedule.

9. Developmental history
 Developmental milestones are as per age.
Family history with history of consanguinity
 There are three family members. Baby has no other siblings. All members are well.
History of consanguinity absent.

10. Allergic history
 Nothing significant.
Socioeconomic history
 Belongs to a lower middle class family. Lives in semi paka house, drinks water from
tube well. Father is a service holder.

11. General examination
 Appearance- Ill looking.
 Body build- Below Average.
 Decubitus- On choice.
 Anemia- Absent.
 Jaundice- Absent.
 Cyanosis- Absent.
 Koilonychias- Absent.
 Leuconychia- Absent.
 Clubbing- Absent.
 Edema- Absent.
 Dehydration- Absent.
 Heart rate- 152 beats/min.
 Respiratory rate- 56 breaths/min.
 Temp - 100ºF.
 Thyroid- Not enlarged.
 Lymph node- Not palpable.
 JVP- Not raised.

12. Anthropometric measurements
 Height – 71 cm.
 Weight – 7.1 kg.
Weight for age Z-Score – -3.3 Interpretation – Severe under-weight.
Weight for height Z-Score – -3.0 Interpretation – Severe wasting.
Height for age Z-Score - -1.67 Interpretation – No stunting.
 Occiput frontal circumference (OFC) – 45 cm.
Interpretation – OFC is near to median reference value on NCHC
growth chart. So within normal range.
 Mid upper arm circumference (MUAC) – 12.5 cm.
Interpretation – Borderline.
 Triceps skin fold thickness – 5mm.
Interpretation – Below normal limit.

13. Systemic examination
 Respiratory system- Inspection – Shape and size of the chest is normal.
Fast breathing with respiratory rate 56 breaths/min.
Chest in drawing – Present.
Intercostal recession – Present.
Palpation – Trachea centrally placed.
Apex beat in left fifth intercostal space just medial to
midclavicular line.
Chest Expansibility – normal.
Percussion note – Resonant.
Auscultation – Breath sound – vesicular.
Added sound – Rhonchi and crepitation present in
both lung field in middle and lower zone.

14.  Cardiovascular system – Inspection – Precordium is normal in size and
shape. No scar mark, no visible pulsation, no
venous engorgement.
Palpation – Apex beat in left fifth intercostal
space just medial to mid clavicular line.
Thrill – absent.
Left parasternal heave – absent.
Auscultation – 1st and 2nd heart sound is audible in
all four area. (Mitral, Tricuspid, Pulmonary, Aortic)
of normal intensity and without splitting.
Added sound – Systolic murmur in Tricuspid area.
 Alimentary system - Oral cavity – Normal in appearance. Tongue is
moist, tonsil shows no signs of inflammation.
Abdomen proper – On inspection it is normal in
shape and size. Umbilicus centrally placed and
inverted. No scar mark. No venous engorgement.
On palpation Abdomen is soft, non tender, no
organomegally.
Percussion note is tympanic. No ascites.
Auscultation Bowel sound present.

15.  Nervous system – Higher psychic function – The patient is conscious,
cooperative and alert. Orientation of place, person
intact .
Intelligence and memory – intact.
Motor examination – Upper extremity
Bulk of muscle- wasted.
Tone- normal.
Power- Grade 4.
Reflex- Intact.
Lower extremity
Bulk of muscle- wasted.
Tone- normal.
Power- Grade 4.
Reflex- Intact.
Sensory Examination – Pain and touch sensation of all
dermatomes in both extremities are Intact.
Examination of cranial nerve – Intact.
Signs of meningeal irritation – Absent.

16. Salient feature
 Md. Ibrahim, 1 year old male baby hailing from Dhour, Turag, Dhaka; came with
complaints of Fever, cough, running nose for four days and moderate
breathlessness for last 2 days. On examination baby is ill looking, anemia jaundice
cyanosis absent. There is no edema. Heart rate is 152 beats/min, Respiratory rate is
56 breaths/min. Temperature100ºF. Baby is severely under weight and wasted but
there is no stunting. Triceps skin fold thickness is below normal limit. Chest in
drawing and intercostal recession present. Breath sound is vesicular with rhonchi
and crepitation present in middle and lower zone of both lung field. 1st and 2nd
heart sound is audible in all four area with systolic murmur in tricuspid area. Other
system examination revels normal findings. With these complaints he has been
admitted for further management.

17. Provisional diagnosis
 Bronchiolitis with Congenital acyanotic heart disease most likely ventricular septal
defect with Failure to thrive.

18. Differential diagnosis
 Pneumonia with Congenital acyanotic heart disease likely patent ductus arteriosus.
 Pneumonia with Congenital acyanotic heart disease likely Atrial septal defect.
 Pneumonia with Congenital heart disease with impending heart failure.

19. Investigations
Chest x-ray A/P view (supine)
Trachea: Is in normal position.
Bony Thorax: Normal.
Diaphragm: Both domes are
normal in position, contour and
definition. Costo-phrenic and
Cardio-phrenic angles are normal.
Lung field: No effusion, collapse
or consolidation. Plethoric lung
fields.
Heart: Enlarged in transverse
diameter.
Impression: Cardiomegaly with
plethoric lung fields – suggestive
of shunt anomaly (Left to Right).

20. Complete blood picture
 Hemoglobin 11.0 g/dl
 ESR (Westergren) 35 mm/1st hr
 Total WBC count 12,000/cumm
 Neutrophils 48%
 Lymphocytes 44%
 Eosinophils 05%
 Basophils 03%
 Total Eosinophil count 360/cumm
 Total platelet count 289,000/cumm
 RBC count 4.78 m/ul
 PCV 36.4%
 MCV 80.0 fL
 MCH 27 pg
 MCHC 30.2 g/dl
 Impression – Leucocytosis

21. Echocardiography
Impression:
Situs solitus, Levocardia.
PDA, size 5mm at PA insertion
site, Large.
Dilated LA & LV.
Pressure overload of RV.
Good LV & RV systolic
function.
Left sided aortic arch.
Severe PAH.
PASP = 76 mmHg.

22. Confirmatory diagnosis
This is a case of Bronchiolitis with Congenital acyanotic heart disease due to
patent ductus arteriosus with failure to thrive.

23. Treatment
Receiving note on 7/12/16 @ 11:40 am
Particulars of the patient
 Name- Md. Ibrahim.
 Age- 1 year.
 Sex- Male.
 Religion- Islam.
 Address- Dhour, Turag, Dhaka.
 Informant- Mother.
 Date and time of admission- 7th December, 2016 @ 11:30 am.
Chief Complaints
 Fever for four days.
 Cough and running nose for four days.
 Breathlessness for two days.
On Examination
 Appearance- Ill looking.
 Anemia- Absent.
 Cyanosis – Absent.
 Heart rate- 152 beats/min.
 Respiratory rate- 56 breaths/min.
 Temp - 100ºF.
 Heart – Systolic murmur in tricuspid area.
 Lungs- Rhonchi and crepitation in both lung field.
 Bowel – moved; Bladder – voided.
Advice CBC, Chest x-ray.
Receiving order on 7/12/16 @ 11:50 am
 Diet – Normal (soft)
 Propped up position.
 O2 Inhalation 1.5L/Min ------- SOS.
 Inj. Ceftriaxone (500mg/5ml)
1 vial I/V stat & Once daily.
 Inj. Amikacin (100mg/2ml)
1 ml I/V stat & 12 hourly.
 Syrup. Frusemide
12 drops P/O ----------stat & at morning once daily.
 Nebulization -------------Ipratropium Bromide 0.3cc +
Normal saline 1.5cc
-----------------stat & 6 hourly.
 Syrup. Paracetamol
3/4th TSF 6 hourly if temperature ≥ 100ºF.
 Supp. Paracetamol (125mg)
3/4th stick P/R -----SOS if temperature ≥ 102ºF.
 Nasal Drop Sodium Chloride 0.9%
2 drops in each nostrils 4 times daily.
 Nasal Drop Oxymetazoline Hydrochloride 0.025%
1 drop in each nostril 3 times daily.
 Please monitor vital signs routinely.

24. Treatment
 Follow up on 8/12/16 @ 08:15 am
Particulars of the patient
 Name- Md. Ibrahim.
 Age- 1 year.
 Sex- Male.
 Religion- Islam.
 Address- Dhour, Turag, Dhaka.
 Informant- Mother.
 Date and time of admission- 7th December, 2016 @ 11:30 am.
Subject Complaint
 Cough.
On Examination
 Appearance- Ill looking.
 Anemia- Absent.
 Cyanosis – Absent.
 Heart rate- 150 beats/min.
 Respiratory rate- 50 breaths/min.
 Temp - N
 Heart – Systolic murmur in tricuspid area.
 Lungs- Rhonchi and crepitation in both lung field.
 Bowel – moved; Bladder – voided.
Drug History
 Inj. Ceftriaxone ------ Day 2.
 Inj. Amikacin --------- Day 2.
 Fresh order on 8/12/16 @ 08:45 am
 Diet – Normal (soft)
 Propped up position.
 O2 Inhalation 1.5L/Min ------- SOS.
 Inj. Ceftriaxone (500mg/5ml)
1 vial I/V --------Once daily.
 Inj. Amikacin (100mg/2ml)
1 ml I/V --------12 hourly.
 Syrup. Frusemide
1ml P/O ----------stat & at morning once daily.
 Nebulization -------------Ipratropium Bromide 0.3cc +
Normal saline 1.5cc
----------------------8 hourly.
 Syrup. Paracetamol
3/4th TSF 6 hourly if temperature ≥ 100ºF.
 Supp. Paracetamol (125mg)
3/4th stick P/R -----SOS if temperature ≥ 102ºF.
 Nasal Drop Sodium Chloride 0.9%
2 drops in each nostrils 4 times daily.
 Nasal Drop Oxymetazoline Hydrochloride 0.025%
1 drop in each nostril 3 times daily.
 Please monitor vital signs routinely.

25. Treatment
 Follow up on 9/12/16 @ 08:15 am
Particulars of the patient
 Name- Md. Ibrahim.
 Age- 1 year.
 Sex- Male.
 Religion- Islam.
 Address- Dhour, Turag, Dhaka.
 Informant- Mother.
 Date and time of admission- 7th December, 2016 @ 11:30 am.
Subject Complaint
 Cough.
On Examination
 Appearance- Ill looking.
 Anemia- Absent.
 Cyanosis – Absent.
 Heart rate- 146 beats/min.
 Respiratory rate- 48 breaths/min.
 Temp - N
 Heart – Systolic murmur in tricuspid area.
 Lungs- Rhonchi and crepitation in both lung field.
 Bowel – not moved; Bladder – voided.
Drug History
 Inj. Ceftriaxone ------ Day 3.
 Inj. Amikacin --------- Day 3.
 Fresh order on 9/12/16 @ 08:45 am
 Diet – Normal (soft)
 Propped up position.
 O2 Inhalation 1.5L/Min ------- SOS.
 Inj. Ceftriaxone (500mg/5ml)
1 vial I/V --------Once daily.
 Inj. Amikacin (100mg/2ml)
1 ml I/V --------12 hourly.
 Syrup. Frusemide
1ml P/O ----------stat & at morning once daily.
 Nebulization -------------Ipratropium Bromide 0.3cc +
Normal saline 1.5cc
----------------------8 hourly.
 Syrup. Paracetamol
3/4th TSF 6 hourly if temperature ≥ 100ºF.
 Supp. Paracetamol (125mg)
3/4th stick P/R -----SOS if temperature ≥ 102ºF.
 Nasal Drop Sodium Chloride 0.9%
2 drops in each nostrils 4 times daily.
 Nasal Drop Oxymetazoline Hydrochloride 0.025%
1 drop in each nostril 3 times daily.
 Please monitor vital signs routinely.

26. Treatment
 Follow up on 10/12/16 @ 08:15 am
Particulars of the patient
 Name- Md. Ibrahim.
 Age- 1 year.
 Sex- Male.
 Religion- Islam.
 Address- Dhour, Turag, Dhaka.
 Informant- Mother.
 Date and time of admission- 7th December, 2016 @ 11:30 am.
Subject Complaint
 Cough.
On Examination
 Appearance- Average.
 Cyanosis – Absent.
 Heart rate- 130 beats/min.
 Respiratory rate- 40 breaths/min.
 Temp - N
 Heart – Systolic murmur in tricuspid area.
 Lungs- Rhonchi in both lung field.
 Bowel – not moved; Bladder – voided.
 Assessment – Improving.
Drug History
 Inj. Ceftriaxone ------ Day 4.
 Inj. Amikacin --------- Day 4.
 Fresh order on 10/12/16 @ 08:45 am
 Diet – Normal (soft)
 Propped up position.
 O2 Inhalation 1.5L/Min ------- SOS.
 Inj. Ceftriaxone (500mg/5ml)
1 vial I/V --------Once daily.
 Inj. Amikacin (100mg/2ml)
1 ml I/V --------12 hourly.
 Syrup. Frusemide
1ml P/O ----------stat & at morning once daily.
 Tab. Spironolactone (25mg)
¼ + ¼ + 0
 Syrup. Paracetamol
3/4th TSF 6 hourly if temperature ≥ 100ºF.
 Supp. Paracetamol (125mg)
3/4th stick P/R -----SOS if temperature ≥ 102ºF.
 Nasal Drop Sodium Chloride 0.9%
2 drops in each nostrils 4 times daily.
 Nasal Drop Oxymetazoline Hydrochloride 0.025%
1 drop in each nostril 3 times daily.
 Please monitor vital signs routinely.

27. Treatment
 Follow up on 11/12/16 @ 08:15 am
Particulars of the patient
 Name- Md. Ibrahim.
 Age- 1 year.
 Sex- Male.
 Religion- Islam.
 Address- Dhour, Turag, Dhaka.
 Informant- Mother.
 Date and time of admission- 7th December, 2016 @ 11:30 am.
Subject Complaint
 No new complaints.
On Examination
 Appearance- Good.
 Cyanosis – Absent.
 Heart rate- 126 beats/min.
 Respiratory rate- 38 breaths/min.
 Temp - N
 Heart – Systolic murmur in tricuspid area.
 Lungs- Clear.
 Bowel – moved; Bladder – voided.
 Assessment – Improving.
Drug History
 Inj. Ceftriaxone ------ Day 5.
 Inj. Amikacin --------- Day 5.
 Fresh order on 11/12/16 @ 08:45 am
 Diet – Normal (soft)
 Propped up position.
 O2 Inhalation 1.5L/Min ------- SOS.
 Inj. Ceftriaxone (500mg/5ml)
1 vial I/V --------Once daily.
 Inj. Amikacin (100mg/2ml)
1 ml I/V --------12 hourly.
 Syrup. Frusemide
1ml P/O ----------stat & at morning once daily.
 Tab. Spironolactone (25mg)
¼ + ¼ + 0
 Syrup. Paracetamol
3/4th TSF 6 hourly if temperature ≥ 100ºF.
 Supp. Paracetamol (125mg)
3/4th stick P/R -----SOS if temperature ≥ 102ºF.
 Nasal Drop Sodium Chloride 0.9%
2 drops in each nostrils 4 times daily.
 Nasal Drop Oxymetazoline Hydrochloride 0.025%
1 drop in each nostril 3 times daily.
 Please monitor vital signs routinely.

28. Treatment on discharge
 Drop. Cefixime ------ 1.5 ml 12 hourly for 5 days.
 Syrup. Frusemide --- 1 ml twice daily at morning and noon ---continue.
 Tab. Spironolactone (25mg) ¼ + ¼ + 0 ----continue.
 Syrup. Paracetamol ¾ th TSF 6 hourly if temperature ≥ 100ºF.

29. Advice on discharge
 Take prescribed medicine routinely.
 Consult with pediatric surgeon for further management regarding the heart
disease.

30. Thank You