Pulmonology conference
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Pulmonology Conference. Geronimo, Maria Angelica; Geronimo, Ralph Ernesto; Go, Camille-Marie; Go, Crystal Karen January 24, 2011. General Data. J.M. 3 months old Male Sampaloc , Manila Roman Catholic. CC: Difficulty of Breathing. CC: Difficulty of Breathing. Review of Systems.

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Pulmonology conference

Pulmonology Conference

Geronimo, Maria Angelica; Geronimo, Ralph Ernesto;

Go, Camille-Marie; Go, Crystal Karen

January 24, 2011


General data

General Data

  • J.M.

  • 3 months old

  • Male

  • Sampaloc, Manila

  • Roman Catholic


Cc difficulty of breathing

CC: Difficulty of Breathing


Cc difficulty of breathing1

CC: Difficulty of Breathing


Review of systems

Review of Systems

  • General: (-) weight changes

  • Cutaneous: (-) rashes, (+) jaundice

  • HEENT: (-) eye redness (-) eye discharge (-) ear discharge (-) gum bleeding

  • Cardiovascular: (-) cyanosis

  • Respiratory: see HPI

  • Gastrointestinal: (-) acholic stools


Review of systems1

Review of Systems

  • Genitourinary: (-) tea-colored urine (-) oliguria (-) discharge

  • Nervous/Behavior: (-) seizures (-) tremors (-) mood/behavioral changes

  • Endocrine: (-) polyuria (-) polydipsia (-) polyphagia (-) heat/cold intolerance

  • Musculoskeletal: (-) edema (-) swelling (-) limitation of motion (-) tenderness

  • Hematopoietic (-) bleeding tendencies (-) easy bruisability


Gestational history

Gestational History

  • Mother: 36 year-old G1P0 housewife

  • Father:37 year old seaman

  • Regular prenatal checkups USTH OPD for 7 times

  • (-) viral exanthem, radiation and any intake of illicit, prohibited or abortifacient drugs, intake of alcohol and smoking

  • UTI (September 2010) - Cefalexin for 7 days and claimed to be compliant; Repeat UA - normal

  • OGCT and Hepatitis screening were not done


Gestational history1

Gestational History

  • HPN (HBP 160/100; UBP is 110-10/70mmHg)

    • Magnesium sulfate

    • Nicardipine drip

    • Betamethasone

  • Emergency CS secondary to preeclampsia


Birth history

Birth History

  • Live, preterm, singleton male, delivered via “E” CS secondary to preeclampsia

  • BW 1.66 kg

  • BL 44 cm

  • HC 31 cm

  • CC 25 cm

  • AC 22 cm

  • AS 8,9

  • MT 32-33 weeks

  • AGA


Neonatal history

Neonatal History

  • 1st hour if life – CXR: air bronchogram with densities on the right lower lobe

    • Persistent respiratory distress  intubated (NICU)

    • PDA: grade II continuous murmur

  • 2nd day of life – hyperbilirubinemia (6.8)

    • Phototherapy on the 5th HD

    • Neonatal hepatitis


Neonatal history1

Neonatal History

  • 2D echocardiography: PDA, patent foramen ovale, LVE, LAE and pulmonary arterial hypertension

  • Blood CS: Klebsiella pneumonia

  • Assessment: sepsis

  • Discharged at his 52nd day of life


Feeding history

Feeding History

  • Mixed Breastfed and Milk formula

    • 15 minutes/breast

    • 3x a day alternating with Formula S26 lactose free 1 scoop in 2 ounces every 3 hours 

    • Mother claims that there is not enough milk being produce that’s why she started on powdered milk

  • Good appetite with no feeding difficulties


24 hour food recall

24 Hour Food Recall


Developmental history

Developmental History

  • Good motor activity

  • Visually tracks objects and looks around

  • Has social smile

  • Mother do not practice him to sit with support or do prone position

  • Has head lag when pulled


Past medical history

Past Medical History

  • October 10, 2010: sepsis, neonatal hepatitis and PDA

  • No previous surgeries done

  • No allergy, eczema, asthma, food or drug sensitivities


Immunization history

Immunization History

  • Hepatitis B – 11/22/10, 12/22/10

  • BCG - 11/24/10

  • DTP and OPV - 12/22/10


Family profile

Family Profile


Family history

Family History

  • (+) Asthma – paternal grandmother

  • (+) HPN – maternal grandmother

  • (-) DM, blood dyscrasia, autoimmune disease, congenital disorders, thyroid diseases, cancer, allergy


Socioeconomic and environmental history

Socioeconomic and Environmental History

  • Rented studio type made of concrete

  • Adequate space for each household member, well-lit and well ventilated

  • Water station

  • Meals are home-cooked prepared by his mother or sometimes they buy cooked-meals

  • No pets, no factories or other industrial establishments within the vicinity of the residence

  • Garbage is not segregated and is being collected everyday

  • Not exposed to second hand smoke


Physical examination

Physical Examination

  • Awake, alert, in respiratory distress, ambulatory, well-hydrated, well nourished, ill-looking

  • HR 135 bpm, regular, RR 48 cpm, regular, T36.7oC, SpO2 (?)

  • Wt: 3.26 kg (z score below -3 severely underweight)

  • Lt: 51 cm (z score below -3 severely stunted)

  • BMI: 12.53 (z score below -2 severely wasted)

  • Warm, moist skin, no jaundice(?) jaundice siyanoongpinuntahannamin!!!!!, no visible gross skin lesions, good skin turgor


Physical examination1

Physical Examination

  • Normocephalic head, no visible scalp lesions, patent anterior fontanel

  • Pink palpebral conjunctivae, anictericsclerae, pupils 2-3 mm ERTL

  • No tragal tenderness, intact tympanic membrane

  • No nasoaural discharge, nasal septum midline, turbinates not congested

  • Moist buccal mucosa, nonhyperemic posterior pharyngeal walls, tonsils not enlarged,


Physical examination2

Physical Examination

  • Supple neck, no palpable cervical lymphadenopathy, thyroid gland not enlarged

  • Symmetrical chest expansion, (+) subcostal retractions, equal tactile and vocal fremiti, (+) crackles over both lung field with occasional wheezes at left lung field

  • Adynamicprecordium, apex beat at 4th LICS MCL, no heaves/lifts, no thrills, normal rhythm, S1 louder than S2 at the apex, S2 louder than S1 at the base, (+) Grade II continuous murmur


Physical examination3

Physical Examination

  • Globular abdomen, normoactive bowel sounds, soft, no tenderness, no palpable masses, Traube’s space not obliterated

  • Genitalia: grossly male with both descended testes

  • Pulses are full and equal, no edema, no cyanosis


Neurologic examination

Neurologic Examination

  • Awake, alert

  • Cranial nerves: CNI not assessed, pupils 2-3mm equally reactive to light, (+) direct and consensual light reflex, (+) ROR, EOM full and equal, no gross facial asymmetry, gross hearing intact (able to localize sound), CN IX, X, XI, XII not assessed

  • No spasticity, rigidy, flaccidity, no limitation in movement

  • No sensory deficits

  • DTR +2

  • No nuchal rigidity, Brudzinski’s and Kernig’s

  • (+) Moro, grasp, plantar, sucking reflex


Salient features

Salient Features

  • 3 month old male

  • History of colds, non-productive cough

  • PE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung field


Approach to the diagnosis

Approach to the Diagnosis

3 month old male

History of colds, non-productive cough, difficulty of breathing

PE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung field

Pulmonary Pathology

Pneumonia


Pps clinical practice guideline for pcap 2004

PPS Clinical Practice Guideline for PCAP 2004


Pulmonology conference

Complete Blood Count

Chest Xray (PA Lat)

Gold standard for the diagnosis of pneumonia

Indicates complications PCAP such as a pleural effusion or empyema


In our patient

In our patient...


Course in the wards

Course in the wards


Pneumonia

Pneumonia


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