Post on 04-Jun-2018
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Demographic information
Name: Master. Arun
Age: 8 years
Sex: Male
Date of birth: 18 April 2005 Religion: Hindu
Born of non-consanguineous marriage
Tharamani, Chennai
Socio economic status class 3
Informant : Mother reliable
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Chief Complaints
Cough and cold- 4 months.
Breathlessness- 2 months.
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History of presenting illness The patient was apparently asymptomatic 4 months
back, then he developed
Cough and cold
Insidious in onset
Duration 4 months
Progressive
Productive cough with copious, yellowish-green incolour, purulent, foul smelling sputum
Exacerbated on lying on the left lateral position
No diurnal or seasonal variations Relieved by mediations temporarily
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Breathlessness
Breathlessness for 2 months
Insidious in onset,
Progressive,no postural variations
Class 2 according to NYHA classification
No relieving factors.
No H/o Paroxysmal nocturnal dyspnea
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Negative history
No h/o fever, chest pain, wheeze.
No h/o hemoptysis, ear discharge
No h/o Jaundice, chronic diarrhoea
No h/o syncope, cyanosis, chest pain,palpitations.
No h/o oliguria, abdominal distension, pedal
edema.
No h/o loss of appetite, loss of weight
No h/o hoarseness of voice
No h/o foreign body aspiration/known choking
spells.
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Past history
H/o exanthematous fever probably measles 6months back. Was admitted in Govt. general
hospital and treated.
No h/o similar illness in the past.
No H/o contact with tuberculosis
No H/o oil instillation in the ear
No h/o previous hospitalizations.
No h/o known allergies, Asthma
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Birth history
Delivered at term by emergency cesarean section(Indicationmeconium stained liquor)
Birth weight 2.8kgs
Cried after birth
No H/o jaundice, seizures, feeding difficulties. No H/o discharge or redness of umbilical stump
No H/o Ventilatory/Incubatory care, Phototherapy
Breast feeding started immediately
Meconium and urine passed within 24hrs
Antenatal history Spontaneously conceived
Booked and immunised Trimesters - uneventful
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Developmental history
Gross motor, fine motor, language, social and
adaptive milestones attained corresponding to the
age
The child is studying in 3rdstandard. Fairly good
scholastic performance.
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Family history
Pedigree chart
During birth,
Maternal age 26
Paternal age 30
Born of a non-consanguineous marriage 1 elder brother -15 years healthy
No h/o of asthma, cystic fibrosis in the family
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Immunisation
BCG scar present
Immunised till 6 months
Pulse polio immunisation given until 5 years
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Dietary history
Expected Observed Gap
Calories 1700 1121 579
Proteins 21 32.7 -
Exclusively breast fed for 6 months.
24hr dietary recall
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Socio-economic status
MotherEducation 10th
Occupation household maid
Income Rs.5000/month
Class 3 Lower middle
Housing condition pacca house, 1 room, 1 kitchen,
adequately ventilated
Sewage and garbage disposal done properlyWater for the children is not boiled before
consumption
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History Summary
8 year old male child presented with complaintsof chronic cough and breathlessness for the past
4 months. Cough was associated with copious,
purulent sputum production. There is past history
of an episode of exanthematous fever 6monthsback which resolved following treatment. This
child is most probably suffering from a
suppurative lung disease. I would like to proceed
with the examination of respiratory system.
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Examination
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General Examination
The child was Conscious
Oriented to time place and person
Lethargic
Co-operative
Clubbing present grade 1, pan digital
No pallor, icterus, cyanosis, lymphadenopathy, pedeledema
No dysmorphic features
No external markers of allergy and Tuberculosis
BCG scar present
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Vitals
Pulse rate
98 beats/ min. Normal in rate, rhythmand volume
Respiratory rate 31 breaths/ min. Thoraco-
abdominal. Intercostal retraction present.
Blood pressure 100/70mm of Hg
Febrile 98.4 F
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Anthropometryobserved expected
Weight 15.1kgs 25kgs 61% Grade 2
malnutrition
Height 115cms 135cms 85% Grade 2
stunting
BMI
11Head circumference48cms
Chest circumference 53cms
Abdominal circumference 58 cmsHead to footexamination
Halitosis present
Normal facies
Chest appears normal
Polydactly medial extra digit in left hand
External genitalia appears normal
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Local examination - Respiratory
UPPER RESPIRATORY TRACT-
Nose is normal - no DNS, Polyp, congestion,
rhinorrhoea, foreign body
No sinus tenderness
Oral cavity appears normal. No dental caries,
bleeding gums.
Tonsils not enlarged
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Inspection Chest wall is symmetrical Trachea appears to be in midline.
Apex beat seen in the left fifth intercostal space1cm medial to MCL.
Chest wall moves equally with respiration. Intercostals retractions present
No grunt/stridor
No drooping of shoulders, bony abnormalities,chest wall deformity seen.
No scars, sinuses, engorged veins.
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Palpation
Tracheal position and Apex beat confirmed.
Chest expansion 4 cm (during inspiration,
circumference: 57 cm, during expirationcircumference: 53 cm)
Chest wall moves equally with respiration.
No Tactile fremitus, no tenderness
No chest wall deformities
No kyphosis or scoliosis
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RIGHT LEFT
SUPRACLAVICULAR NORMAL NORMAL
INFRACLAVICULAR NORMAL NORMAL
MAMMARY NORMAL
AXILLARY NORMAL NORMAL
INFRAXILLARY NORMAL
SUPRASCAPULAR NORMAL NORMAL
INTERSCAPULAR NORMALINFRASCAPULAR NORMAL
VOCAL FREMITUS
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RIGHT LEFT
SUPRACLAVICULA
R
RESONANT RESONANT
INFRACLAVICULAR RESONANT RESONANT
MAMMARY DULL RESONANT
AXILLARY RESONANT RESONANT
INFRAXILLARY DULL RESONANT
SUPRASCAPULAR RESONANT RESONANT
INTERSCAPULAR DULL RESONANT
INFRASCAPULAR DULL RESONANT
NO PERCSSION
PERCUSSION
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RIGHT LEFT
SUPRACLAVICULAR NVBS NVBS
INFRACLAVICULAR NVBS NVBS
MAMMARY BRONCHIAL VR NVBSAXILLARY NVBS NVBS
INFRAXILLARY BRONCHIAL VR NVBS
SUPRASCAPULAR NVBS NVBS
INFRASCAPULAR NVBS NVBS
INTERSCAPULAR BRONCHIAL VR NVBS
AUSCULTATION
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Persistent coarse leathery crepitations is heardwell in both lung bases both during inspiration
and expiration.
No Bronchophony, Aegophony, and Whispering
pectoriloquy.
No wheeze, pleural rub, pericardial rub.
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Examination of other systems
Abdomen:Soft, no mass felt, No organomegaly
Cardiovascular system:S1 S2 heard. No
murmur.
CNS:No focal neurological deficits
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Summary
8 year old male child presented with complaints ifchronic cough and breathlessness for the past 4
months. Cough was associated with copious,
purulent sputum production. There is past history
of an episode of exathematous fever 6monthsback which resolved following treatment.
Examination revealed pan digital clubbing and
halitosis. On auscultation, bronchial breath
sounds and coarse leathery basal crepitationswere heard in the right lung.
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Diagnosis
Bronchiectasis of the right lung involving themiddle and lower lobe with the probably etiology
being post-measles infection with grade 2
malnutrition and grade 2 stunting.
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Investigations
Blood
Hb%, total count, differential count,platelet
ESR
Mantoux test
Sputum culture & AFB
X-ray chest
HR-CT
Fibreoptic bronchoscopy
Broncho-alveolarlavage
Bronchography
Sweat chloride test
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Management
Medical management Chest physiotherapy and postural drainage
Antibiotics and Vaccination support
Nutritional support Symptomatic therapy bronchodilators,
corticosteroids
Long term oxygen therapy
Surgical management
Segmental or lobar pneumonectomy
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Thank you