Respiratory System

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

Chief Complaints
Cough and cold - 4 months.
Breathlessness- 2 months.

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 in colour, purulent, foul smelling sputum Exacerbated on lying on the left lateral position No diurnal or seasonal variations Relieved by mediations temporarily

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

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.

Past history
H/o exanthematous fever probably measles 6

months 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

Antenatal history
Spontaneously conceived Booked and immunised Trimesters - uneventful

Birth history
Delivered at term by emergency cesarean section

(Indication meconium 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

Developmental history
Gross motor, fine motor, language, social and

adaptive milestones attained corresponding to the age

The child is studying in 3rd standard. Fairly good scholastic performance.

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

Immunisation
BCG scar present

Immunised till 6 months

Pulse polio immunisation given until 5 years

Dietary history
Exclusively breast fed for 6 months. 24hr dietary recall
Expected Calories Proteins 1700 21 Observed 1121 32.7 Gap 579 -

Socio-economic status
Mother Education 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 properly Water for the children is not boiled before consumption

History Summary
8 year old male child presented with complaints

of 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 6months back 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.

Examination

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, pedel

edema
No dysmorphic features No external markers of allergy and Tuberculosis BCG scar present

Vitals
Pulse rate 98 beats/ min. Normal in rate, rhythm

and volume Respiratory rate 31 breaths/ min. Thoracoabdominal. Intercostal retraction present. Blood pressure 100/70mm of Hg Febrile 98.4 F

Anthropometry
observed Weight Height BMI 11 15.1kgs 115cms expected 25kgs 135cms 61% 85% Grade 2 malnutrition Grade 2 stunting

Head to foot examination

Head circumference 48cms Chest circumference 53cms Abdominal circumference 58 cms

Halitosis present Normal facies Chest appears normal Polydactly medial extra digit in left hand External genitalia appears normal

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

Inspection
Chest wall is symmetrical Trachea appears to be in midline. Apex beat seen in the left fifth intercostal space

1cm 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.

Palpation
Tracheal position and Apex beat confirmed.
Chest expansion 4 cm (during inspiration,

circumference: 57 cm, during expiration circumference: 53 cm) Chest wall moves equally with respiration. No Tactile fremitus, no tenderness No chest wall deformities No kyphosis or scoliosis

VOCAL FREMITUS
RIGHT
SUPRACLAVICULAR INFRACLAVICULAR MAMMARY AXILLARY INFRAXILLARY SUPRASCAPULAR INTERSCAPULAR INFRASCAPULAR NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

LEFT

PERCUSSION
RIGHT SUPRACLAVICULA R INFRACLAVICULAR MAMMARY AXILLARY INFRAXILLARY RESONANT RESONANT DULL RESONANT DULL LEFT RESONANT RESONANT RESONANT RESONANT RESONANT

SUPRASCAPULAR
INTERSCAPULAR INFRASCAPULAR NO PERCSSION

RESONANT
DULL DULL

RESONANT
RESONANT RESONANT

AUSCULTATION
RIGHT SUPRACLAVICULAR INFRACLAVICULAR MAMMARY AXILLARY INFRAXILLARY SUPRASCAPULAR INFRASCAPULAR INTERSCAPULAR NVBS NVBS BRONCHIAL VR NVBS BRONCHIAL VR NVBS NVBS BRONCHIAL VR LEFT NVBS NVBS NVBS NVBS NVBS NVBS NVBS NVBS

 Persistent coarse leathery crepitations is heard

well in both lung bases both during inspiration and expiration. No Bronchophony, Aegophony, and Whispering pectoriloquy. No wheeze, pleural rub, pericardial rub.

Examination of other systems

Abdomen: Soft, no mass felt, No organomegaly

Cardiovascular system: S1 S2 heard. No

murmur. CNS: No focal neurological deficits

Summary
8 year old male child presented with complaints if

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 exathematous fever 6months back which resolved following treatment. Examination revealed pan digital clubbing and halitosis. On auscultation, bronchial breath sounds and coarse leathery basal crepitations were heard in the right lung.

Diagnosis
Bronchiectasis of the right lung involving the

middle and lower lobe with the probably etiology being post-measles infection with grade 2 malnutrition and grade 2 stunting.

Investigations
Blood Hb%, total count, differential count,

platelet ESR Mantoux test Sputum culture & AFB X-ray chest HR-CT Fibreoptic bronchoscopy Broncho-alveolar lavage Bronchography Sweat chloride test

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

Thank you