DATE: 16/01/2020

INFORMANT: L.A, mother, Class 6, witnessed current illness so I deem it reliable

PATIENT’S INITIALS: E.A.O

AGE: 2 years 4/12

SEX: female

RESIDENCE: Defi

RELIGION: Christian

NHIS: Active

PRESENTING COMPLAINT(S): Referral from Defi G hospital o/a cough-3 days

Hoarseness of voice-3 days

Fast breathing-1 day

HISTORY OF PRESENTING COMPLAINTS: Patient was apparently well until 3 days ago when she
suddenly started coughing in the morning and was persistent throughout the day.it had no aggravating nor
relieving factors. During the day, her voice gradually became hoarse which progressively worsened
making it unable to hear whatever she says. Prior to presentation mother recalls child drooling saliva but
was for a short time. A day ago, she suddenly started breathing fast and was rushed to Defi G hospital.
She was put on intranasal oxygen and given IV hydrocortisone and referred here for further management
on the same day. At PEU, blood samples were taken for FBC, and electrolytes. A posteroanterior lateral
chest x-rays have been taken. Nebulization with salbutamol was done and IV cefuroxime and IV
gentamycin have been administered.

ODQ: Fever+, nasal discharge 0, noisy breathing +, dyspnea +, poor feeding +, night sweat0, weight loss0,
lethargy0,

REVIEW OF SYSTEMS

CENTRAL NERVOUS SYSTEM: seizure0, visual disturbance0, hearing disturbance0

MUSCULOSKLETAL: joint swelling0

GASTROINTESTINAL: vomiting 0, abdominal pain0, diarrhea0, constipation0, melena0

RESPIRATORY: orthopnea 0,

CARDIOVASCULAR: pedal swelling0, decreased physical activity0

GENITOURINARY: passes urine+, frequency0, hematuria0, polyuria0

PAST MEDICAL AND SURGICAL HISTORY: She has no chronic illness such as epilepsy, sickle
cell disease, tuberculosis, diabetes, and hypertension. She had no previous admissions. No past surgeries
or haemotransfusion. No past episodes of presenting complaint.

DRUG HISTORY: She is currently on IV cefuroxime 750mg, IV Gentamycin 50mg, Dextrose normal
saline, adrenaline inj., ringer’s lactate 500mls, IV hypertonic saline, paracetamol syrup, IV
dexamethasone. She is on no long term medications syrup. No use of herbal preparation. She has no food
or drug allergy.

PREGNANCY: mother booked at 11 weeks and was a regular ANC attendant. She had no disease during
the pregnancy such as diabetes, fever, hypertension, and rash.

BIRTH: Mother carried to term, delivered via SVD... Baby cried at birth and no resuscitation was done.
Mother cannot recall birth weight. They were discharged on the same day.

NEONATAL: She had no neonatal febrile illness or jaundice.

IMMUNIZATION: Has completed the EPI schedule according to maternal and child health record book.
BCG scar is present

DEVELOPMENTAL HISTORY

GROSS MOTOR: started walking at 1 year but can kick things.

FINE MOTOR: can draw a line

HEARING AND SPEECH-can say 2 to 3 word sentences

SOCIAL AND PERSONAL- she has begun toilet training, plays with friends

DIETARY: Exclusive breastfeeding was done for 6 months and complementary feed such as porridge
was introduced afterwards. She was weaned at 1 year. Currently feeds 3 times a day. Morning takes tom
brown with milk and bread, afternoon takes rice with stew and fish, and evening takes banku with stew.
Takes fruits and snacks in between
FAMILY: no known chronic illness such as diabetes, hypertension, sickle cell, epilepsy, tuberculosis

SOCIAL: She lives with both parent and older brother in compound house which is well ventilated...
Father is a 30year old driver. Mother is a 27 year old hair dresser and SHS 1 graduate. Her older brother
is 5 years in class 1 and is doing well. They drink from a well and they use a public toilet. They sleep
under a treated net.

SUMMARY

I have presented a 2years 4/12 female with 4days history of drooling saliva, 3 days history of cough and
hoarseness of voice and a day’s history of fast breathing associated with fever, dyspnea, noisy breathing
and poor feeding.

Anthropometry

Wt-for-age (0SD normal

Ht-for age (-2SD normal

Wt-for-ht (0SD normal

MUAC: 12cm (normal)

Head circumference: 46cm (15th percentile-normal)

General examination: Patient looks ill, not pale, anicteric, afebrile (37.2), no palpable lymph nodes, no
pedal swelling, well hydrated, on intranasal oxygen with spo2 of 100%

RS: Respiratory Rate is 86cpm, FAN, ICR, LCI, no clubbing, no cyanosis, trachea is central, chest is
symmetrical, moves with respiration, and percussion is resonant,

Air entry is adequate bilaterally, breath sounds are vesicular, wheeze present on both anterior and
posterior chest.

CNS: Patient is alert and conscious, GCS 15/15, normal posture, no abnormal movement, no dysmorphic
features, no neurocutaneous manifestation, spine is normal

Tone, power (5/5) and reflexes are normal in upper limbs and lower limbs, Cranial nerves are normal.
GI: good oral hygiene and dentition, mouth is moist, abdomen is flat, moves with respiration, use of
abdominal muscles to breathe, umbilicus is inverted, hernia orifices intact. Abdomen is non tender. Liver
and spleen not palpable. Both kidneys are not bimanually palpable. No shifting dullness, bowel sounds
present

CVS: Pulse is 108 bpm, regular, good volume, no collapsing pulse, peripheral pulses palpable, no radio
radial or radio femoral delay. Apex beat is in left 4 th intercostal space midclavicular line, no heaves, and
no thrills

S1+s2+0 present in all auscultatory areas, no additional sounds, no murmurs, and lung bases are clear

SUMMARY

I examined a young female infant who looks ill, in respiratory distress shown by FAN, LCI, ICR, use of
abdominal muscles, not pale, anicteric. On auscultation, there’s rhonchi.

DIAGNOSIS: Foreign body aspiration

Differentials 1. Laryngitis

2. Bronchiolitis

Diagnostic investigation

1. Full blood count

2. Chest x-ray (Lateral and PA view)

3. Laryngoscopy