TMCCase Presentation

GROUP 4

General Information

•CP, 7 years-old, male

•Born on May 05, 2006

•Filipino, Roman Catholic

Chief Complaint

•Difficulty of Breathing

HPI

•Noted occasional dry cough and colds without any other associated symptoms.

•No nausea and vomiting, no headache, no diarrhea, no dysuria, no body weakness.

•No consult was done nor meds taken

1 Week PTA

HPI

•Persistence of cough with nasal discharge and increase difficulty of breathing.

•Patient was nebulized with Salbutamol every 4-6 hours with mild relief.

•No cyanosis, no cyanosis, no vomiting, no abdominal.

•No consult was done.

1 DAY PTA

HPI

•Symptoms persisted associated with Tmax 380C

•Patient was observed of persisten wheezing wheezing

•Prompting consult hence subsequent admission

Morning PTA

Past Medical Hx

•4 yo – Diagnosed of Bronchial Asthma, previously maintained on Montelukas 5 mg/ta

• last attack was 2 months ago = given Prednisone

•5 yo – Primary Koch’s infections – treated for 6 months

Immunization Hx

•BCG (1x)

•DPT (3x)

•OPV (3x)

•HepB (3x)

•Measles (1x)

FM Hx

•(+) Allergic Rhinitis, (+) Asthma, (+) Eczema

ROS

• (-) weight changes, rashes, lumps, easy bruising, headaches, hemoptysis, edema, cyanosis, jaundice, no limitation of movement, no stiffness

PE

•General: Patient is alert, coherent and not in cardiorespiratory distress

•VS: HR 125, RR 40, Temp 37.80C, BP: 110/70

PE • HEENT: Normocephalic head, no masses, pale conjunctivae, anicteric sclerae, intact TM, midline nose septum, masses, no CLAD, no engorgement of neck veins, supple neck

• Cardiac: adynamic precordium, fast rate, regular rhythm, no murmurs heard, PMI at 5th ICS MCL

• Pulmonary: (+) Suprasternal and Subcostal Retractions, (+) alar flaring, (+) Wheezes symmetric chest expansion

PE • Abdomen: Soft, Flabby, normoactive bowel sounds, no tenderness, no masses, liver edge not palpable, no organomegaly

• Genitalia: not assessed

• DRE: not done

• Skin/Extremities: Smooth texture, good turgidity, no rashes, no cyanosis, no clubbing

Primary Impression

•Bronchial Asthma in Acute Exacerbation