Pediatrics 2 rotation

Case write-up 4 (Respiratory disorder)

Reem Sadeq Alsuraihi- U18100852

2022-2023
History

Demographics
 Initials: M.A
 MRN: U91537-1
 Age: 3-year-old
 Gender: Male
 Nationality: UAE
 Date of admission: 21/12/2022
 History given by: Mother
 Reliable: Yes

Chief complaint
3 years old Male patient presents with fever since 3 days.

History of presenting illness

M.A., a 3-year-old boy, arrived at the emergency room complaining of a fever that had
lasted three days and peaked at 39 C on the second day of the complaint. However, after
being admitted, the child has been afebrile. The fever has persisted and is unchanged by
paracetamol. It is accompanied by chills, night sweating, a sore throat, a runny nose, and a
nasal congestion, but there is no ear discharge or convulsions. The patient also has a
productive cough, producing a spoonful of white, bloodless sputum. The patient now
breathes louder and experiences breathing difficulties, which causes him to wake up from
sleep at night. His mom noticed decreased in appetite with reduced oral intake. Patient's
mother denies any nausea, vomiting, or abdominal pain. There is no recent travel or sick
contact.

Review of systems
 Constitutional: fever, no weight loss, no insomnia, poor appetite.
 Neurological: no headache,no hearing difficulty, no dizziness, no visual problems, no
muscle weakness , no numbness.
 Cardiovascular: No palpitations, no chest pain or chest tightness, no cyanosis.
 Respiratory: shortness of breath, no Hemoptysis, no Chest pain, cough, wheezing.
 Gastrointestinal: No nausea and vomiting, no diarrhea, no constipation, no jaundice.
 Genitourinary: no urinary frequency, no urgency, no dysuria.
 Musculoskeletal: No Muscle wasting, no Morning stiffness, normal gait, no joint
swelling, no skin rash.
 Endocrinological: no polyuria, no polydipsia, no dry mouth.
Past medical and surgical history
 The patient diagnosed with tonsilitis last week and the ENT doctor refer the patient
to surgery because of enlarged tonsils that obstruct the airway while sleeping.

Family history
 Mother is 26 years old
 Father is 29 years old
 The parents’ marriage is non-consanguineous.

Allergy history
 no known allergies.

Social history
The child lives with her parents and 1 sibling in a villa. The child has her own nanny. There
are no pets, and no smokers in the house.

Prenatal & Birth History

Prenatal: Mother is G2P2 and used to visit her doctor for routine check-ups. During her
pregnancy, she took folic acid and iron supplements. Throughout her pregnancy, she didn't
experience any complications (with HTN, diabetes, or infections).

Natal: M.A. was born at the 37th week; the birth weight was 2.800 kg, delivery was normal
vaginal delivery and not complicated. After delivery, M.A. did cry. Breastfeeding and
mother-to-child interaction started right away. Neither the mother nor the child
experienced any complications.

Postnatal: The baby passed urine and meconium in the first 24 hours. She did not develop
jaundice. The baby and the mother were sent home the next day without experiencing any
problems.
Feeding History:
At 10 months old, the child was weaned. She began eating solid food at 6 months, and she
currently eats prepared meals. The child usually eats 3 meals and two snacks:
-Breakfast: cereals with milk
-morning snack: orange juice
-Lunch: rice with chicken or fish
-afternoon snack: apple
-Dinner: pasta or nugget

Immunization:
The child has received all recommended vaccinations in accordance with the UAE
immunization schedule.

Gross Motor:
he only recently started using a tricycle, alternately placing hir foot on each step as she
ascends and descends the steps. he has good kicking and catching skills.

Fine Motor:
he is adept at drawing circles, and he can stack 10 Lego pieces.

Language:
he answers straightforward inquiries. he almost finishes her sentences.

Social:
he demonstrates love feelings toward his parents, and friends. he interacts and has fun with
her friends.

Therefore, she has reached every milestone that is proper for her age.
Physical examination

Vitals signs
 Temperature: 37.4 ̊C
 Pulse: 105bpm
 BP: 98/70
 RR: 26 breaths/min
 spO2: 96% in room air.

Measurements
 Weight: 13 kg
 Height: 91 cm

General examination
• The patient was not in distress and was laying in bed with mild tachypnea. There are no
scleral yellowish discoloration or pallor, cyanosis, muscular wasting, speech problems, nail
clubbing, or indicators of dehydration. He was aware, alert, and oriented, and had an IV line
attached.

Focused examination

On examination:

Respiratory:
- Equal air entry bilaterally
- Bilateral crepitations.
- Normal abdominothoracic respiration pattern.
- Subcostal retraction.
Abdominal:
- The abdomen was soft and nontender.
- No masses felt on light and deep palpation. 
- no hepatomegaly or splenomegaly.
- negative rebound test and negative Murphey’s punch test.
- no abdominal bruit detected.

Cardio:
- chest looks symmetrical no scars and no deformities or abnormal shape.
- Normal location of apex beat with normal character.
- Normal heart sounds (S1 and S2) no murmurs or add sounds.
- Upper and lower limb peripheral and central pulses are both present and have a
normal volume and pattern.

Neuro:
- Normal gait and there are no neurological deficits.
- Normal tone, power, and reflexes.
- No loss of sensation in periphery and normal cranial nerves examination.
- He is alert and oriented to person, place, and time.

Musculoskeletal:
- Normal range of motion. No rigidity.

Skin:
- The skin felt cool to the touch. Normal capillary refill and skin turgor (both taking
about two seconds). No rashes or other skin anomalies.

Head & ENT:

- Typical head size and shape in relation to body size. There are no visible dysmorphic
traits.
- Tear production is normal. No scleral icterus or conjunctival pallor.
- No mouth breathing. There is some nasal congestion.
- Good oral hygiene, dry lips, moist mucous membranes, and no halitosis. No
aphthous ulcers or central cyanosis were present.
- The tympanic membranes are clean, although the tonsils are slightly enlarged.

Neck:
- The neck had no swollen or painful lymph nodes and was symmetrical and flexible.
- The trachea was midline.

Growth charts
Weight: 16 kg and falls on the 75th percentile for age
Height: 97 cm and falls on the 60th percentile for age
Differential diagnosis
 Pneumonia
 Acute bronchiolitis
 Tonsilitis

Investigations

Lab investigations

Respiratory Syncytial Virus - RSV:

Result Value
RSV Not detected
(negative)

Strep A antigen:
Result Value
Strep A antigen Not detected
(negative)

Corona virus (covid-19) PCR test:

Result Value
Corona virus, Not detected
covid-19 RNA (negative)
PCR

Influenza A&B:
Result Value
Influenza A Not detected
(negative)
Influenza B Not detected
(negative)
CBC:
Result Value
WBC  9.4 10^9/L
RBC  4.0 10^12/L
Hgb  113 g/L
Hct  0.38L/L
MCV 80.8 Fl
MCH 28.4pg
MCHC 351 g/L
RDW-CV 14.1%
Platelet  358 10^9/L
MPV 7.8 fL
Neutrophils 6.5 10^9/L (high)
Neutrophils%  69.1%
Lymphocytes 2.1 10^9/L (low)
Lymphocytes%  22.4%

Monocytes 0.4 10^9/L

Monocytes%  4.7%
Eosinphils 0.3 10^9/L
Eosinphil % 3.5%
Basophils 0.0 10^9/L
Basophil% 0.3%

Culture and sensitivity – blood :

Result Value
Gram stain Gram positive cocci in
result clusters seen.
X-ray :

Prominent hilar vasculature

Provisional diagnosis
- Pneumonia

Management plan
My plan
- Admit the patient to paediatric ward.
- Start IV maintenance fluids.
- Start Atrovent neb Q8 h and Ventolin Q8 h
- Paracetamol every 6 hours
- IV fluid D5+0.45% NS at 40ml/ hour.
- Saline nasal spray
- Nasal suction care
- IV Augmentin
Follow up
Subjective: Patient feels better, and the fever subsided after one day of admission .
Objective: Vitals are stable and afebrile. The patient looks well and not in pain. he is
maintaining saturation on room air. there are no symptoms of dehydration or respiratory
distress.
Assessment: The patient had recovered successfully from pneumonia.
Plan: The patient will be discharged. Mother is advised to return if the child experiences the
same symptoms. OPD follow up next week.
Learning points

- A respiratory illness called pneumonia is characterized by inflammation of the lungs'

interstitial tissue and/or alveolar space.
- It is the biggest infectious cause of death in industrialized countries. Aspiration of
airborne infections (mainly bacteria, but sometimes viruses and fungi) is the most
common way that pneumonia is spread, however stomach contents can also cause
aspiration pneumonia.
- Based on the patient's age, immunological condition, and the location of the
infection's origin, the most likely causative bacteria can be narrowed down
(community-acquired or hospital-acquired).
- Clinical characteristics are used to categorize pneumonia as either typical or atypical,
and each type has its own range of frequently occurring infections. The typical
symptoms of pneumonia include an abrupt onset of fever, lethargy, and a strong
cough.
- Crackles and bronchial breath sounds can be heard on auscultation. Dyspnea, an
ineffective cough, and extrapulmonary symptoms are the first signs of atypical
pneumonia. Usually, auscultation is not noteworthy. Some patients could exhibit
traits from both categories.
- Pathogen identification in blood, urine, or sputum samples, as well as blood testing
for inflammatory parameters, are examples of diagnostics.
- The chest x-ray in typical pneumonia patients only reveals opacity in one lobe,
whereas the x-ray in atypical pneumonia cases may reveal diffuse, frequently
undetectable infiltrates.
- The freshly acquired pulmonary infiltrate on the chest x-ray, along with the
distinctive clinical characteristics, corroborate the diagnosis. Empiric antibiotic
therapy and supportive measures make up management (e.g., oxygen
administration, antipyretics).

Literature review

Although there is growing evidence linking vitamin D deficiency to community-acquired

pneumonia (CAP), the outcomes of the individual published research were mixed. The
objective of this study was to quantify the relationship between vitamin D and CAP.

Using the keywords "vitamin D" or "cholecalciferol" or "25-hydroxyvitamin D" in

combination with "community-acquired pneumonia" or "CAP" or "pneumonia" and no
restrictions, we ran this meta-analysis in PubMed, Medline, and EMBASE up to 31
September 2018. Following the recommendations of Meta-analysis of Observational Studies
in Epidemiology, this meta-analysis was carried out. Odds ratios (OR) and weighted mean
differences were used to quantify the relationship between vitamin D levels and CAP
(WMD). A random-effect or fix-effect meta-analysis was used to integrate the results, and
sensitivity analyses were carried out to investigate potential contributing factors.

There were eight observational studies with 20,966 participants total. In this meta-analysis,
CAP patients with vitamin D deficiency (serum 25(OH)D levels 20 ng/mL) had a significantly
higher risk of developing CAP (odds ratio (OR) = 1.64, 95% confidence intervals (CI): 1.00,
2.67), and CAP patients' serum vitamin D levels clearly decreased by 5.63 ng/mL (95% CI:
9.11, 2.14). A sensitivity analysis revealed that the aggregate effect as a whole was not
significantly changed by the absence of any one study.

The evidence reported here suggests a link between VDD and a higher risk of CAP, with a
person having a serum vitamin D level below 20 ng/mL having a higher chance of developing
CAP (OR = 1.64, 95%CI: 1.00, 2.67). To evaluate the specific impact of vitamin D
supplementation, well-designed trials and more data are needed to understand how vitamin
D affects the CAP. As a result, in the future, it may be possible to think about those who are
at risk for VDD and how to supplement with vitamin D.

Zhou, Y.-F., Luo, B.-A., & Qin, L.-L. (2019). The association between vitamin D deficiency
and community-acquired pneumonia. Medicine, 98(38).
https://doi.org/10.1097/md.0000000000017252