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TMC Case Presentation

TMC Case Presentation

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TMC Case Presentation

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  1. TMCCase Presentation • GROUP 4

  2. General Information • CP, 7 years-old, male • Born on May 05, 2006 • Filipino, Roman Catholic

  3. Chief Complaint • Difficulty of Breathing

  4. 1 Week PTA HPI • Noted occasional dry cough and colds without any other associated symptoms. • No nausea and vomiting, no headache, no diarrhea, no dysuria, no body weakness. • No consult was done nor meds taken

  5. 1 DAY PTA HPI • Persistence of cough with nasal discharge and increase difficulty of breathing. • Patient was nebulized with Salbutamol every 4-6 hours with mild relief. • No cyanosis, no cyanosis, no vomiting, no abdominal. • No consult was done.

  6. Morning PTA HPI • Symptoms persisted associated with Tmax 380C • Patient was observed of persisten wheezing wheezing • Prompting consult hence subsequent admission

  7. Past Medical Hx • 4 yo – Diagnosed of Bronchial Asthma, previously maintained on Montelukas 5 mg/ta • last attack was 2 months ago = given Prednisone • 5 yo – Primary Koch’s infections – treated for 6 months

  8. Immunization Hx • BCG (1x) • DPT (3x) • OPV (3x) • HepB (3x) • Measles (1x)

  9. FM Hx • (+) Allergic Rhinitis, (+) Asthma, (+) Eczema

  10. ROS • (-) weight changes, rashes, lumps, easy bruising, headaches, hemoptysis, edema, cyanosis, jaundice, no limitation of movement, no stiffness

  11. PE • General: Patient is alert, coherent and not in cardiorespiratory distress • VS: HR 125, RR 40, Temp 37.80C, BP: 110/70

  12. PE • HEENT: Normocephalic head, no masses, pale conjunctivae, anicteric sclerae, intact TM, midline nose septum, masses, no CLAD, no engorgement of neck veins, supple neck • Cardiac: adynamic precordium, fast rate, regular rhythm, no murmurs heard, PMI at 5th ICS MCL • Pulmonary: (+) Suprasternal and Subcostal Retractions, (+) alar flaring, (+) Wheezes symmetric chest expansion

  13. PE • Abdomen: Soft, Flabby, normoactive bowel sounds, no tenderness, no masses, liver edge not palpable, no organomegaly • Genitalia: not assessed • DRE: not done • Skin/Extremities: Smooth texture, good turgidity, no rashes, no cyanosis, no clubbing

  14. Primary Impression • Bronchial Asthma in Acute Exacerbation