Underfive

Patient Data
Name: patient S
Date of Birth: November 5 2010
Age: 5months
Gender: Female
Address: Curug incomplete
Occupation: none
education: none
family: lives with her parents
Mothers occupation: works as a housewife
Fathers occupation: works as a driver.


DATA

Main Complaints: high body temperature since 4 days ago

Additional complaints: cough, running nose, cries, weak, not being able to
sleep well.

Present Disease History:
The patient came with her mom complaining increase in body temperature
since 4 days ago. It is getting worse since the first day. It gets worse at night
and she sometimes has night sweat. She also has wet cough since 3 days
ago. Sometimes produce sputum. The mucus color is transparent and a bit
yellowish. Her mother stated that her child became less active and looking
sick. It gets worse as her body temperature increases. She started to get
running nose since 3 days ago. She gets irritated by it, causing her unable to
sleep well at night. She also cried often, probably when she is irritated by
increased body temperature, cough and running nose. Now, shes not even
crying out loud, looking weak and pale. Since 4 days ago along with the fever
her appetite was decreased, she refused to drink milk as much as before. In a
day she drank at most 3 bottles of 100cc milk.

In the past history of disease:
The mom denied any previous diseases

Family Disease History:
She denied any family disease

Environmental Illness History:
A history of illness in the home environment was not asked

Drug Use History:
She denied using medication

Allergy History:
She denied any allergy


Certain habits:
She got no habits in specific

Others:
Completed immunization so far.

Operating history:
She never had operation.


Physical Examination

General Condition: looks sick and weak
Weight: 4.5kg
Height : 55cm
Consciousness : compos mentis
Vital Sign:
Temperature = 38.5 degree Celsius
Heart Rate = 110x/min
Respiratory Rate = 20x/min
Blood Pressure = -

Head :
Inspection :
Hair :
Normal
No sign of malnourished
Eyes:
Sclera : a bit reddish sclera
Pupil : responsive to light
Conjunctiva : normal
Nose :
Symmetrical
Running nose with whitish and transparent and yellowish
discharge
No flaring nose
Mouth :
No sign of further abnormality and lesion or scar from surgery
Pharynx : hyperemic
Tonsils : Enlarged (T2-T2)
Neck: swollen around the neck.
Skin : looks normal, no lesion is seen

Chest :
Inspection :
Normochest
No lesion or surgery scar is visible
Symmetrical respiratory movement
Palpation :
Normal and symmetrical focal fremitus
Normal and symmetrical chest expansion
No tenderness
Percussion :
1. Lung : Sonor, normal
2. Heart : Normal, no enlargement
Auscultation :
1. Lung : Normal, vesicular
2. Heart : Normal, presence of S1 and S2 without additional heart
sound
Abdomen :
Inspection :
No lesion or surgery scar is visible
Palpation :
No mass
No tenderness
Percussion :
Timpani, normal
Auscultation :
Bowel movement heard 6x/min

Supporting examination:
1. Nasopharyngeal samples for bacteria : (was not done)
Culturing of throat swabs, nasal swabs or washes, or nasal
aspirates remains the standard for confirming bacterial URI
pathogens (see Procedures). Samples should be taken from the
posterior pharynx or tonsils, not the oral cavity. Nasopharyngeal
aspirates are recommended for pertussis.

Cultures may be
falsely negative for group A streptococci because of inadequate
specimen collection, covert use of antibiotics, or suboptimal
laboratory practices. Prolonged illness may reduce the
sensitivity of culture. Specimens are optimally obtained in the
first 4 days of illness. Some patients may be chronically
colonized with group A streptococcus.
2. Nasopharyngeal samples for viruses: (was not done)
Viral cultures remain the standard for confirming infection.
Throat swabs, nasal swabs or washes, or sputum may be
cultured on special viral media to detect influenza virus, PIV,
adenovirus, RSV, and other viruses. Culturing may require days
to weeks.
3. Rapid tests for bacteria: (was not done)
Rapid antigen tests for group A streptococci have excellent
specificity and yield results in 10-20 minutes; individual practices
wherein excellent correlation has been verified between rapid
tests and culture results may choose not to routinely culture in
every instance. Rapid direct fluorescent antibody testing is
available to test for pertussis. PCR testing for pertussis is
emerging as a sensitive detection tool. However, recent
respiratory illness outbreaks mistakenly attributed to pertussis
highlight the limitations of relying solely on PCR tests to confirm
pertussis. The positive predictive value is lower when PCR
testing is used as a screening tool without culture confirmation
during a suspected pertussis outbreak.
4. Rapid tests for viruses: (was not done)
Various antigen, immunofluorescence, and PCR assays are
available to detect viruses in secretions. Rapid tests for
influenza can be conducted on specimens from nasopharyngeal
swabs, washes, or aspirates, yielding results within 30 minutes.
Most rapid tests to detect influenza that are performed in a
physician's office are approximately greater than 70% sensitive
and approximately greater than 90% specific. Therefore, viral
culture may yield a positive result in up to 30% of the cases with
negative rapid influenza test results.
5. Enzyme immunoassays : (was not done)
Are done to detect PIV. Reverse transcriptase PCR may detect
various viruses in nasopharyngeal samples. PCR detection of
various viruses from blood samples is emerging as a way to
track certain viral infections.
6. Titer comparison: (was not done)
Antibody titers compared between paired specimens obtained
weeks apart may help in retrospectively identifying a particular
pathogen in immunocompetent patients. The first sample should
be obtained during the first week of illness, and the second
should be obtained 2-4 weeks later.
7. Monospot: (was not done)
In a patient with symptoms of infectious mononucleosis due to
EBV, a positive result on a monospot heterophile antibody test is
diagnostic. levels are moderate to high in the first month of
illness and decrease rapidly thereafter. Monospot results are
positive in more than 85% of cases. False-positive results are
seen in a few patients; false-negative results are seen in 10-
15% of patients, primarily in children younger than 10 years.

Summary:
The patient came with her mom complaining fever since 4 days ago. It is
getting worse since the first day. It gets worse at night and she sometimes
has night sweat. She also has wet cough since 3 days ago. Its productive.
The mucus color is transparent and a bit yellowish. Her mother stated that her
child became fatigue and looking sick since 4 days ago. It gets worse as her
fever gets worse. She started to get running nose since 3 days ago. Her nasal
discharge was transparent and yellowish, but not thick. She gets irritated by it,
causing her unable to sleep well at night. She also cried often, probably when
she is irritated by the symptoms such as running nose and cough. Now, shes
not even crying out loud, fatigue and pale. Since 4 days ago along with the
fever her appetite was decreased, she refused to drink milk as much as
before. In a day she drank at most 3 bottles of 100cc milk. On physical
examination, weight 4.5kg, height 55cm. vital sign: body temperature 38.5
degree Celsius, HR 110x/min, RR 20x/min. The mucus was transparent and a
bit yellowish. The sclera was a bit reddish. The tonsil was enlarged (T2/T2)
and hyperemic. There was swollen lymph in neck. Otherwise normal.


ANALYSIS

Differential Diagnosis
1. Tuberculosis
Pulmonary tuberculosis (TB) is caused by the bacteria Mycobacterium
tuberculosis (M. tuberculosis). You can get TB by breathing in air
droplets from a cough or sneeze of an infected person. Most people
who develop symptoms of a TB infection first became infected in the
past. However, in some cases, the disease may become active within
weeks after the primary infection.

The primary stage of TB usually doesn't cause symptoms. When
symptoms of pulmonary TB occur, they may include:
Cough (usually cough up mucus)
Coughing up blood
Excessive sweating, especially at night
Fatigue
Fever
Unintentional weight loss


2. Pneumonia

Pneumonia is a respiratory condition in which there is infection of the
lung.
Community-acquired pneumonia refers to pneumonia in people who
have not recently been in the hospital or another health care facility
(nursing home, rehabilitation facility).
The most common symptoms of pneumonia are:
Cough (with some pneumonias you may cough up greenish or yellow
mucus, or even bloody mucus)
Fever, which may be mild or high
Shaking chills
Shortness of breath (may only occur when you climb stairs)

Working Diagnosis :
Influenza:
Influenza virus infection, one of the most common infectious diseases, is a
highly contagious airborne disease that causes an acute febrile illness and
results in variable degrees of systemic symptoms, ranging from mild fatigue to
respiratory failure and death. These symptoms contribute to significant loss of
workdays, human suffering, mortality, and significant morbidity.


Treatment Plan
The main treatment in malnourished patient is basically proper diet,
consuming sufficient nutrition.
1. Paracetamol
Paracetamol works as a weak prostaglandin inhibitor. It achieves this
by blocking the production of prostaglandins, which are chemicals
involved in the transmission of the pain message to the brain. In this
regard, paracetamol is different from Aspirin and NSAIDs (non-
steroidal anti-inflammatory drugs) in that it blocks the pain message at
the brain and not at the source of the pain, as the others do.
Paracetamol is an antipyretic that can reduce fever by affecting the part
of the brain known as the hypothalamus that regulates the temperature
of the body. This is why paracetamol is included in many cough, cold
and flu medications. Specifically, paracetamol has been given to
children after they have been given vaccinations in order to prevent
them developing post-immunisation pyrexia, or fever.

2. B6
To relieve pain and to assist the breakdown of protein

3. Antibiotic (ciprofloxacin)
To prevent further bacterial infection

4. Mucolytic agents or expectorant (ambroxol or Ipecacuanha)

To loosen and clear mucus and phlegm from the respiratory tract.


Drugs given in the clinic :
1. Ciprofloxacin (tablet 500mg orally 2x/day)
` This drug is an antibacterial drug that kills bacteria by interfering
with the enzymes that cause DNA to rewind after being copied,
which stops synthesis of DNA and of protein

2. OBH (1spoon syrup orally 3x/day)
OBH is one type of expectorant that helps bring up mucus and
other material from the lungs, bronchi, and trachea.

3. B6 (10mg orally 3x/day)

4. Paracetamol (60mg tablet orally 3x/day)


Patient Reaction

Feeling : fatigue
Insights : the patient appeared thin and look uneasy
Fear : the patients mom is worried
Expectation : mom is willing for the child to get better

Recommendation

Rest for a few days, take the medicine well and finish off the antibiotic to
prevent antibiotic resistance. Drink enough water and eat non-oily food and
clean food.











































Disease Review

Influenza virus infection, one of the most common infectious diseases, is a
highly contagious airborne disease that causes an acute febrile illness and
results in variable degrees of systemic symptoms, ranging from mild fatigue to
respiratory failure and death. These symptoms contribute to significant loss of
workdays, human suffering, mortality, and significant morbidity.
Influenza viruses are encapsulated, negative-sense, single-stranded RNA
viruses of the family Orthomyxoviridae. The core nucleoproteins are used to
distinguish the 3 types of influenza viruses: A, B, and C. Influenza A viruses
cause most human and all avian influenza infections.
The primary risk factor for human infection with avian H5N1 influenza virus is
direct contact with diseased or deceased birds infected with it. Contact with
excrement from infected birds or contaminated surfaces or water are also
considered mechanisms of infection. Close and prolonged contact of a
caregiver with an infected person is believed to have resulted in at least 1
case. Other specific risk factors are not apparent given the few cases to date.
Abrupt onset of illness is common. Many patients with influenza are able to
report the time when the illness began.
The general appearance varies among patients who present with influenza.
Some patients appear acutely ill, with some weakness and respiratory
findings, while others appear only mildly ill. Upon examination, patients may
have some or all of the following findings:
Fever of 100-104F; fever is generally lower in elderly patients than in young
adults
Tachycardia, which most likely results from hypoxia, fever, or both
Pharyngitis - Even in patients who report a severely sore throat, findings
vary from minimal infection to more severe inflammation
Eyes may be red and watery
Skin may be warm-to-hot, as reflected by the temperature status. Patients
who have been febrile with poor fluid intake may show signs of mild volume
depletion with dry skin
Pulmonary findings during the physical examination may include dry cough
with clear lungs or rhonchi
Nasal discharge is absent in most patients

The goals of pharmacotherapy are to reduce morbidity and to prevent
complications. Agents include vaccines and antiviral drugs (ie, amantadine,
rimantadine, oseltamivir, zanamivir). The uricosuric agent probenecid may be
used as an adjunct to antiviral treatment.





Source :
http://emedicine.medscape.com/article/219557-overview
http://medical-dictionary.thefreedictionary.com/Mucolytic+agent