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A case of

difficulty of
breathing in a
1 year and 2
month old, male
patient
Prepared by
Gardiola | Gepte | Gonzaga

General Data
JDB is a 1 year and 2 months old, male
Born September 13, 2015 at the OMMC
Filipino, Roman Catholic
Presently lives with both parents in San
Andres Bukid, Manila
First admission at OMMC at Nov 25, 2016
at 10:00AM.

Chief Complaint
Difficulty of breathing

History of Present Illness


4 days PTA, the patient developed fever,
recorded at 38C. This was noted after
the patient slept in the neighbors house.
The patients mother also reported that
the patient started to cough and
described this cough as dry. Coughing
occurred at no particular time of the day.
Halak was also noted to be manifested
by the patient.

History of Present Illness


Patient
was
given
Paracetamol
(Biogesic) 2mL, every 4 hours twice.
Despite his fever and cough, the
patient was still active, can stand and
play around.
Patient was still able to eat and finish
regular breakfast, lunch, and dinner.

History of Present Illness


(continued)
3 days PTA, the fever subsided to 37C. In
the afternoon, the patient took a nap in
their neighbors house again. When the
patient returned home, his mother noted
that his cough was accompanied by
phlegm, the color is white. No difficulty of
breathing was noted or change in the
patients color.
The patient was still active and was
reported to have played with his cousins

History of Present Illness


(continued)
2 days PTA, patient was again febrile at
37.9C. Nasal flaring and supraclavicular
muscle retractions were observed. The
patient was brought to the barangay health
center clinic and was given Amoxicillin
2.5mg/ 5mL suspension, and an anti-asthma
drug Salbutamol (Ventrex) 250 mg/5mL.
The patient was then sent home.

History of Present Illness


(continued)
The patient already appeared ill with
decreased level of activity. His mother
also reported that he slept for several
hours within the day when he was febrile.
He was observed at home until 10PM
when his parents decided to bring him to
OMMC because of the persistence of the
symptoms manifested.

History of Present Illness


(continued)
At the ER, difficulty of breathing was persistent,
coughing was productive, nasal flaring and
supraclavicular retractions were noted. The
patient was crying incessantly.
After 2 hours, the difficulty of breathing
resolved, the nasal flaring and muscle
retractions subsided. The patient looked
apparently well except for the presence of
cough which still persisted.
The patient was sent home hours later.

History of Present Illness


(continued)
On the day of consult, around 5AM,
the patient again manifested difficulty
of breathing seen as nasal flaring and
muscle retractions in the neck. The
patient was irritable and crying.
They returned to the OMMC where he was
admitted at around 10AM.

REVIEW OF SYSTEMS
GENERAL
(-) weight loss/gain, (+) decrease in activity level

CUTANEOUS:
(-) rash, (-) change in skin color,
(-) pigmentation, (-) pruritus
HEENT
HEAD: (-) history of head trauma
EYES: (-) lacrimation (-) redness

REVIEW OF SYSTEMS
(continued)
EARS: (-) discharge
NOSE: (-) epistaxis
MOUTH and THROAT: (-) salivation, (-)
bleeding gums, (-) sore throat
CARDIOVASCULAR:
(-) orthopnea, (-) cyanosis
RESPIRATORY:
(-) hemoptysis, (+) coughing

REVIEW OF SYSTEMS
(continued)
GASTROINTESTINAL:
(-) vomiting, (-) diarrhea, (-)
constipation, (-) passage of worms, (-)
abdominal pain, (-) jaundice, (-)
appetite

GENITOURINARY:
(-) discharge, (-) edema of hands and
feet

REVIEW OF SYSTEMS
(continued)
ENDOCRINE:
(-) polyuria, (-) polydipsia, (-) polyphagia, (-) cold/heat
intolerance

NERVOUS/BEHAVIORAL:
(-) tremors, (-) sleep problems, (-) convulsions

MUSCULOSKELETAL:
(-) limping, (-) stiffness

HEMATOPOIETIC:
(-) pallor, (-) bleeding, (-) easy bruising

PERSONAL HISTORY
GESTATIONAL HISTORY
18 y.o. mother during pregnancy
LMP at Dec 15, 2014
G1P1
Unremarkable health status during pregnancy
Intake of vitamins, ferrous sulfate, and folic acid
AOG at 36 weeks

PERSONAL HISTORY
GESTATIONAL HISTORY
Sought antenatal care at 4th, 6th, 7th
and 8th months
Consulted every other day before
delivery

PERSONAL HISTORY
(continued)
HISTORY OF BIRTH
Premature infant, delivered at 36
weeks
Delivered NSD at OMMC
Birth weight at 3.2 kg
Baby swallowed meconium
APGAR unrecalled

PERSONAL HISTORY
(continued)
NEONATAL HISTORY
Jaundice for 1 day
Underwent phototherapy on the 2nd
day
No cyanosis noted
Newborn screening performed

PERSONAL HISTORY
(continued)
NEONATAL HISTORY
Only 1 month of breastfeeding
Mother stopped breastfeeding the
patient when she caught the flu
Shift to formula feeding

Feeding History
Type of feeding: formula feeding
Breastfeeding was discontinued when
patient was 1 month old because his
mother caught the flu
Formula brand is Bonakid
Consumes about 6 bottles per day

Feeding History
(continued)
Complementary feeding started at 6
months
Macerated meat and vegetables,
Cerelac
Eats breakfast and dinner
Consumes rice, fruits, vegetables
Usual food intake: cereals, rice,
vegetables

Feeding History
(continued)
No food intolerance noted by the
patients parents
Vitamins and iron supplements not
given to child

Development and
Behavioral History
At 1 year and 2 months, the patient can:
Say mama and papa
Drink from a cup
Can hold a Stick-o and feed it to himself
Kisses on request
Releases objects on request
Obeys commands with gestures
Can verbalize and point to an object at a
distance

Past Illnesses
No history of mumps, measles, rubella,
or varicella
No previous hospitalizations
No previous surgeries
No allergies
No noted previous injuries

Family history
Parents are 20 y.o., both graduating
college students
Both are in good physical and mental
health
Caregiver when the patients parents
are away is the maternal grandmother
Patient is an only child

Family history
(continued)
No history of familial illness among
members of the household
No history of Diabetes Mellitus,
cardiovascular diseases, cancers,
hematologic disorders, allergy

Socio-economic history
The family lives in a structure shared with
3 other families.
House is made of wood
2 rooms in the house, total floor area is
about 40 sqm
Maternal grandmother lives with them
Source of household income is the
patients father

Environmental history
Houses in the neighborhood are closely
built
Presence of smokers in house
Garbage collected twice a week
Source of water is from Manila Water
Source of drinking water is the same as
water used for washing and bathing

PHYSICAL EXAMINATION
GENERAL SURVEY
Patient was conscious, calm and quietly
being carried by her mother.
Patient sometimes gets irritated.
He appears to be well-nourished, wellhydrated and looks appropriate to his age.
He is not in respiratory distress and no
signs of discomfort

PHYSICAL EXAMINATION
(continued)
VITAL STATISTICS
Temperature:

36.5 aural

Blood Pressure: Not obtained


Respiratory Rate:
Pulse Rate:

43 bpm

115bpm

PHYSICAL EXAMINATION
(continued)
ANTHROPOMETRIC MEASUREMENTS
Weight:

9.5kg

Length:

77cm

Head circumference:
Chest circumference:
Abdomen:
Arm circumference

45cm
46cm

40cm
14cm

PHYSICAL EXAMINATION
(continued)
ANTHROPOMETRIC MEASUREMENTS
Weight:

9.5kg

Length:

77cm

Head circumference:
Chest circumference:
Abdomen:
Arm circumference

45cm
46cm

40cm
14cm

PHYSICAL EXAMINATION
(continued)
ANTHROPOMETRIC MEASUREMENTS
Weight:

9.5kg

Length: 77cm
Body mass index 16.6
Head circumference: 45cm
Chest circumference: 46cm
Abdomen: 40cm
Arm circumference 14cm

PHYSICAL EXAMINATION
(continued)
GROWTH CHARTS

PHYSICAL EXAMINATION
(continued)
INTEGUMENTARY
Brown in color

No other skin lesions, color changes, or


nailbed pallor noted
Good skin turgor

PHYSICAL EXAMINATION
(continued)
HEAD
Head is normocephalic with no visible lumps
Hair was fine, black, and equally distributed.
There were no noted palpable depressions,
masses. No reported areas of tenderness
upon palpation
Posterior fontanel closed while still anterior
fontanel open

PHYSICAL EXAMINATION
(continued)
EYES: unremarkable
Eyebrows are symmetrically aligned, black, fine,
evenly distributed without scaliness.
Eyelids are symmetrical without any lesions.
No periorbital edema, ptosis or lid lag.
Palpebral conjunctivae pinkish without any
discharge.
Sclerae were anicteric; cornea clear.
Pupils are equally reactive to light.

PHYSICAL EXAMINATION
(continued)
EARS: Unremarkable

Ears are symmetrical with no


preauricular pits or skin tags, redness,
lesion and discharge.
Otoscopy was not done. Patient was
responsive to auditory cues. Responds to
name call at both sides with a distance of 1
foot.

PHYSICAL EXAMINATION
(continued)
NOSE AND SINUSES: Unremarkable
Nose appears symmetric with no
deformities, swelling and lesions.
Pink mucosa
Midline septum
Nasal discharge was noted

PHYSICAL EXAMINATION
(continued)
MOUTH AND THROAT: Unremarkable
Lips are pale, symmetrical with no lesions
Oral mucosa is pinkish, moist without
ulcerations.
Presence of 2 lower incisors.

PHYSICAL EXAMINATION
(continued)
MOUTH AND THROAT: Unremarkable
Lips are pale, symmetrical with no lesions
Oral mucosa is pinkish, moist without
ulcerations.
Presence of 2 lower incisors.

PHYSICAL EXAMINATION
(continued)
MOUTH AND THROAT: Unremarkable
Lips are pale, symmetrical with no lesions
Oral mucosa is pinkish, moist without
ulcerations.
Presence of 2 lower incisors.

PHYSICAL EXAMINATION
(continued)
MOUTH AND THROAT: Unremarkable
Lips are pale, symmetrical with no lesions
Oral mucosa is pinkish, moist without
ulcerations.
Presence of 2 lower incisors.

PHYSICAL EXAMINATION
(continued)
NECK: Unremarkable
Neck was symmetrical no lesions and no
palpable lymph nodes.
No jugular vein distention.
Trachea is at midline.
No bruits heard upon auscultation.
Thyroid gland not palpable.

PHYSICAL EXAMINATION
(continued)
CHEST AND LUNGS:
Chest circumference larger than the head
circumference
AP diameter of the chest is equal to the
transverse diameter
No chest retractions observed during
examination
Chest expansion is symmetrical

PHYSICAL EXAMINATION
(continued)
CHEST AND LUNGS:
Resonant upper lung fields
Bilaterally decreased breath sounds
Bilateral coarse crackles on lower
anterior lung fields

PHYSICAL EXAMINATION
(continued)
CHEST AND HEART:
Adynamic precordium with PMI approximately
1cm noted to be at the 4th LICS midclavicular,
approximately 1 cm in diameter.
No heaves or thrills.
Distinct S1 and S2 heart sounds. S1>S2 at
the apex and S2>S1 at the apex.
No murmurs heard

PHYSICAL EXAMINATION
(continued)
ABDOMEN: Unremarkable
Abdomen is slightly globular.
Skin has no dilated veins, striae, and visible
masses.
Umbilicus inverted.
Bowel sounds normoactive with 11 per
minute (RLQ)
No bruit heard on the abdominal aorta.

PHYSICAL EXAMINATION
(continued)
ABDOMEN: Unremarkable
Abdomen was soft, without muscle
guarding and tenderness upon palpation.
Liver, spleen and kidneys are not
palpable.
Abdomen was tympanitic

GENITALIA was unremarkable

PHYSICAL EXAMINATION
(continued)
EXTREMITIES
Upper and lower extremities appear
proportional.
Nailbeds are pinkish.
No swelling, deformities, redness,
ecchymoses or edema.
Capillary refill time is <2seconds

Neurologic examination
GENERAL EXAMINATION
Patient is alert, awake, cooperative but
sometimes gets irritated and cries.
Not in respiratory distress and does not use
accessory muscles when breathing.
Responds to social overtures.
No unusual facies and gross structural
abnormalities noted.

Neurologic examination
GENERAL EXAMINATION
Patient is alert, awake, cooperative but
sometimes gets irritated and cries.
Not in respiratory distress and does not use
accessory muscles when breathing.
Responds to social overtures.
No unusual facies and gross structural
abnormalities noted.

Neurologic examination
MOTOR EXAMINATION
Symmetrical muscle bulk and spontaneous
muscle movements against gravity are
observed.
Muscle tone is good without spasticity or
flaccidity.
No tremors, tics, involuntary movements and
spasm noted.

SALIENT FEATURES

Difficulty of
Breathing
Pulmonar
y

Extra pulmonary

Cardiac

Cardiac
findings:
(-)
orthopnea
(-) cyanosis
More pa

Musculoskeletal

RULED
OUT

MSK findings:
Muscle
retractions
More pa

Pulmonar
y

Suprastern
al
retractions

Shallow and rapid


breathing
RR=
Coarse late inspiratory
crackles

Upper
Airway
Pathology

Respiratory
distress
Stridor

WHO criteria
for pneumonia

(-) barky cough


(-) Hoarseness

Fever
Tachypnea
Cough

RULED
OUT

Restricti
ve

Pathology in
the lung
parenchyma

Lower
Respiratory
Tract Diseases

Croup

Pneumonia
Bacterial
Viral
Aspiration
Tuberculosis

CANNOT BE
RULED OUT