Вы находитесь на странице: 1из 5

PRIMARY IMPRESSION

Pediatric Community Acquired Pneumonia C (Moderate) secondary Tetralogy of


Fallot with Down Syndrome
PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA C (Moderate)
Based from History
Based from Physical Examination
Chief complaint:
rate of 62 cycles per minute
a pulse rate of 118
Ubo
(+) rhonchi appreciated in all lung fields
History of Present Illness:

The patient is apparently well until 3 years


and 8 months prior to admission when the
patient experienced shortness of breath
described as a whistling-like sound.
2 years prior to admission, the patient
experienced continuous cough and colds
with associated fever of 39 degrees oC.
Ambroxol 5mL every 6 hours was given to
the patient as prescribed for his cough but
provided no relief which prompted the
mother to bring the patient to a private
clinic in Silang.
4 days prior to admission, the patient
suffered from intermittent cough and
difficulty of breathing with associated
sudden weakness.
Few hours prior to admission, the patient
experienced cough with circumoral and
peripheral cyanosis.

TETRALOGY OF FALLOT
Based from History
History of present Illness:
The patient is apparently well until 3 years
and 8 months prior to admission when the
patient experienced shortness of breath
described as a whistling-like sound. This
was associated with circumoral and
peripheral cyanosis with her tongue hanging
outside her mouth as if she was gasping for
air

Based from Physical Examination


Chest and Lungs:
Nail clubbing
Cyanosis of the lips
Cardiovascular:
PMI is at the 6th ICS Left AAL.
Heart rhythm was irregular with a murmur
3/6, systolic in timing, harsh in character
heard over the pulmonic area and left
sternal border.

3 days prior to admission, while the patient


is writing, she suddenly had an episode of
seizure that lasted for 5 seconds.
Few hours prior to admission, the patient
experienced cough with circumoral and
peripheral cyanosis. Muscle weakness was
also noted.
Personal and Social History:
She has easy fatigability.
Even walking small distances or just simply
laughing exhausts her.
She usually assumes a prone position or a
forward facing sitting position with her
anterior thighs close to her chest.
DOWN SYNDROME
Based from History
From Birth and Maternal History:
Her mother was 41 years old when she was
born.
She did not take any vitamins since she
believed that completing the anti-tetanus
vaccines was enough and did not undergone
any imaging studies.
She admitted that during the 1st month of
pregnancy, the mother drank glass of beer
not knowing that she was already pregnant
at that time.
Developmental History:
The patient has delayed fine and gross
motor skills, expressive and receptive
language, personal and social skills and
delayed developmental milestones.
CASE DISCUSSION

DIFFERENTIAL DIAGNOSIS

Based from Physical Examination


-upslanting palpebral fissure
-folded ears (small ears with overfolded helix)
-flat nasal bridge
-open mouth with tendency of protruding
tongue
-transverse palmar crease
-abdominal protuberance
-low set ears
-short stature

Differential
Description
Rule In
Rule Out
Diagnosis
AIRWAY NON-INFECTIOUS CAUSES
Non-infectious causes are typically ruled out because according to Del Mundo et al. (2000),
presence of fever with the cough indicates it is at least related to an infection.
Bronchial
Asthma is a chronic
The patient presents with
However, this was
Asthma
inflammatory condition cough, shortness of breath
ruled out because of
of the lung airways
described as a whistlingthe patient presented
resulting in episodic
like sound, respiratory rate
with fever, suggesting
airflow obstruction.
is 62 cycles per minute. In
an infectious cause.
most children, asthma
develops before age 5 years
(our patient is 4 years old).
The patient also has a
positive family history of
asthma.
Pulmonary
Pulmonary edema is the Cough is a frequent
However, this can be
Edema
excessive accumulation complaint and may provide ruled out because of
of fluid in the
an early clue to worsening
the patient presented
interstitium and air
pulmonary edema. In
with fever, suggesting
spaces of the lung,
addition, this can be ruled
an infectious cause.
leading to oxygen
in because of the presence
desaturation, decreased of tachypnea, and dyspnea.
lung compliance, and
respiratory distress. It
can result from
increased pulmonary
capillary pressure,
increased capillary
permeability, lymphatic
insufficiency, decreased
oncotic pressure, and
increased negative
interstitial pressure.
AIRWAY INFECTIOUS CAUSES
Bronchitis
Bronchitis is a
Cough is the most common Fever is a relatively
nonspecific
observed symptom in
unusual sign and,
inflammation of the
bronchitis. The patient also when accompanied by
bronchial. Acute
presented with clubbing of
cough, suggests either
bronchitis is a
digits and peripheral
influenza or
syndrome, which is
cyanosis.
pneumonia. There

often viral, with


characteristic feature of
cough. It often follows
a viral upper respiratory
infection.
Tuberculosis
Bronchiolitis

Bronchiolitis is an
acute inflammatory
injury of the
bronchioles that is
usually caused by a
viral infection (most
commonly respiratory
syncytial virus and
human
metapneumovirus).

were also absence of


sore throat, headache,
muscle aches and
runny nose.

In the patient, this can be


ruled in because of the
presence of symptoms
including tachypnea, fever,
cough, and dyspnea. In
severe cases of bronchiolitis
may progress over 48 hours
to respiratory distress with
tachypnea, irritability and
possibly cyanosis.

However, this can be


ruled out because of
the absence of
symptoms such as
sneezing and clear
rhinorrhea, and
irritability. Nasal
flaring was also
absent in the patients
PE. In addition, 95%
occur in children
younger than 2 years
old (our patient is
already 4 years old).

PARENCHYMAL DISEASES OF THE LUNG


Non-infectious causes are typically ruled out because according to Del Mundo et al.
(2000), presence of fever with the cough indicates it is at least related to an infection.
Bronchiectasi Bronchiectasis is
This was ruled in because
However, this was
s
characterized by a
of the presence of cough,
ruled out because of
structural abnormality
fever and dyspnea. Physical the absence of
of the bronchial tree
examination findings of
hemoptysis, pleuritic
resulting in chronic
rhonchi.
chest pain and risk
obstructive lung
factors such as sex are
disease.
also against the
diagnosis of
bronchiectasis (more
common in males,
with a 2:1 malefemale ratio).
PLAN OF MANAGEMENT
DIAGNOSTICS
THERAPEUTICS
SUPPORTIVE

References:
Del Mundo, et al. (2000), Textbook of Pediatrics and Child Health. The Respiratory System. 4th
Edition.
Rudolph, C. D. (2003). Rudolph`s pediatrics. New York: McGraw-Hill, Medical Pub. Division.

Вам также может понравиться