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General data. E.C. 6 month old Female Born on March 7, 2013 Taguig City. CHIEF COMPLAINT. Difficulty of breathing. History of Present Illness. Past Medical History. No previous illness No previous hospitalization No previous surgical procedure. Family history. (+) Diabetes mellitus

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general data
General data
  • E.C.
  • 6 month old
  • Female
  • Born on March 7, 2013
  • Taguig City
chief complaint
CHIEF COMPLAINT
  • Difficulty of breathing
past medical history
Past Medical History
  • No previous illness
  • No previous hospitalization
  • No previous surgical procedure
family history
Family history
  • (+) Diabetes mellitus
  • (-) asthma, allergy, heart disease, hypertension, stroke, cancer
birth and maternal history
Birth and Maternal history
  • Born full term delivered via CS (breech delivery) to a 35 year old G1P1
  • Birth weight of 5lbs 6oz
  • Attended by OBGYN, St. Christiana’s hospital
  • With no fetomaternal complications
nutritional history
Nutritional history
  • Not breastfed
  • On formula feeding, started on solid foods
immunization history
Immunization history
  • BCG 1
  • DPT/Polio 2
  • Hib 2
  • Hepatitis B 2
  • Pneumococcal 1
  • Rotavirus 1
  • MMR 0
  • Measles 0
  • Varicella 0
  • Influenza 0
  • Hepatitis A 0
  • Typhoid 0
physical examination
Physical Examination
  • General survey: alert, crying, but consolable
  • Vital signs: BP 90/60mmHg, HR 140bpm, RR 32 cpm, T 36.5deg
  • Anthropometrics:

Hgt 63cm, Wgt 5.4 kg

Head circumference 42cm, Chest circumference 45cm, Abdominal circumference 43 cm

physical examination1
Physical Examination
  • HEENT: anictericsclerae, pink palpebral conjunctivae, no alar flaring, no cervical lymphadenopathy, flat neck veins, no tonsillopharyngeal congestion
  • PULMONARY: equal and symmetric chest expansion, with shallow subcostal retractions, harsh breath sounds, occasional rales, no wheezes
  • CARDIOVASCULAR: adynamicprecordium, PMI at 4th left ICS, midclavicular line, regular cardiac rhythm, no murmur
physical examination2
Physical Examination
  • ABDOMEN: normoactive bowel sounds, soft, no masses, no organomegaly
  • EXTREMITIES: normal skin color, good skin turgor, no cyanosis, no edema, full and equal pulses
physical examination3
Physical Examination
  • NEUROLOGIC:

alert

Cranial nerves: pupils 2-3 mm equally brisk and reactive to light, tracks objects, no nystagmus, no facial asymmetry, responds to sound, (+) gag reflex

Motor: normal tone, no atrophy, 5/5 on all extremities

Reflexes: normal reflex (++) on all extremities

Sensory: responds to touch in all extremities

No Babinski

No meningeal signs

goals of care
Goals of care
  • For the patient to have resolution of respiratory distress by the time of discharge
    • Respiratory rate < 50 cpm
    • No retractions, no alar flaring
    • No vomiting
    • No cyanosis
    • Decreased cough episodes
diagnostics therapeutics
Diagnostics & Therapeutics
  • CBCPC to check for infection
  • Chest Xray to check for pneumonia
  • Nebulizationwith Salbutamol, Salbutamol+Ipratropium, Hydrocortisone
  • IV Ampicillin (100mg/kg/day)
  • IV support: D5IMB at maintenance rate
insert chest xray
Insert Chest Xray
  • Official reading (9/14/13):

hyperaerated lungs, bilateral interstitial infiltrates without consolidation suggestive of viral pneumonia

pedia cardiology notes
Pedia Cardiology notes

PROBLEMS

  • CARDIOPULMONARY:

Cyanosis: not documented but presents with occasional desaturations to mid-80% O2 at room air

      • May be due to Pulmonary arterial hypertension due to pneumonia
      • May be an idiopathic persistent pulmonar y hypertension secondary to large VSD
  • RESPIRATORY:

Pneumonia: patient presents with occasional cough, with rales and occasional wheezing, with shallow subcostal retractions and grunting

Chest xray: bilateral interstitial pneumonia

pedia cardiology notes1
Pedia Cardiology notes
  • CARDIAC:

VSD

Patient has no murmur, with regular cardiac rhythm, no history of cyanotic episodes; noted to have a loud S2

Patient was initially tachypneic, with edema, which may be due to congestion brought about by the large VSD

4-extremity BP: 80/50, all extremities

EKG: RVH

2dECHO: large VSD inlet to muscular, 10-12mm, with severe pulmonary hypertension

pedia cardiology notes2
Pedia Cardiology notes
  • Assessment:

CHF functional class II secondary to CHD, VSD (12mm) inlet to muscular, with severe Pulmonary Hypertension; Pneumonia, community acquired

slide27

Pedia Cardiology notes

  • Plans:
    • Furosemide (1mg/kg) for diuresisand to relieve congestion
    • Captopril 1mg/pptab Q12 as an afterloadunloader
    • Lanoxin 50mcg/ml 0.5ml BID for inotropic support
    • Oral KCL (1meq/kg) BID for 6 doses
    • Sildenafil 3mg/pptab Q6
    • Continue IV antibiotics and nebulizations for pneumonia
    • Continue o2 support and monitoring
    • IVF rate at 5ml/hr
    • Family Conference to discuss options for treatment: PA banding as temporary solution vs definitive surgery
prior to transfer to picu
Prior to transfer to PICU
  • Intubation
  • HR 50s
  • CPR done
  • Bag-tube-ventilation delivered
  • PNSS 10cc/kg given, 2 boluses
  • Epinephrine 0.5mg/ET for 5 doses
  • IJ catheter, right, inserted for IV access
prior to transfer to picu1
Prior to transfer to PICU
  • Intubation
  • HR 50s
  • CPR done
  • Bag-tube-ventilation delivered
  • PNSS 10cc/kg given, 2 boluses
  • Epinephrine 0.5mg/ET for 5 doses
  • Epinephrine drip started 0.1 meq/kg/min
  • Milrinone drip started 0.8mcg/kg/min
  • IJ catheter, right, inserted for IV access
prior to transfer to picu2
Prior to transfer to PICU
  • Laboratory exams requested:
    • ABG
    • CBCPC
    • ICAL, Na, K, Cl
    • Blood typing
    • Hgt
prior to transfer to picu3
Prior to transfer to PICU
  • ABG: mixed respiratory + metabolic acidosis (on PPV)
    • pH 7.176, pCO2 52.6, pO2 24.4, HCO3 19.4, Base 9.3, O2 sat 31.4
ad