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Welcome to Case Discussion

Welcome to Case Discussion. linli97@126.com 2011.5.23. Case report. Present History A 14 – month – old male was admitted with cough and wheezing for a week He had no apena and cyanosis, also had no fever, no vomitting and diarrhoea

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Welcome to Case Discussion

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  1. Welcome to Case Discussion linli97@126.com 2011.5.23

  2. Case report • Present History • A 14 – month – old male was admitted with cough and wheezing for a week • He had no apena and cyanosis, also had no fever, no vomitting and diarrhoea • He had lost his appetite, but had not lost his weight apparently

  3. Case report • Previous History • He had a history of airway disease and wheezing before one month ago, and was admitted to our hospital for pneumonia • There was no history of eczema • There was no history of food or drug allergy

  4. Case report • Personal History • Natal: First birth born at 37th week of gestation, normal delivery with birth weight 2.7 Kg. No cyanosis, asphyxia, convulsion or bleeding. • Development: Able to raise head at 2nd m. The first tooth erupted at 6th m, began to walk at 1st y. Normal intelligence. • Nutrition: Breast feed till 6th m, then the additives were added. Weaned from the breast at 12th m. • Immunization: Vaccinated according to the standard schedule, such as B.C.G

  5. Case report • Family History • There was no history of atopy or asthma in the family • There was no history of tuberculosis disease in the family

  6. Case report • Physical examination • T 39℃, HR 110/min, RR 55/min, BP 94/72 mmHg • Well developed and moderate nutrition • Pale and drowsy, passive position • Perioral cyanosis and throat congestion • No pitting edema, no jaundice, no clubbing

  7. Case report • Physical examination • Lungs:Intercostal, subcostal and supra- clavicular retractions • Nasal flaring, mild perioral cyanosis • Using of accessory respiratory muscles • Expiratory wheezing rales and asymmetrical breath sounds on chest auscultation

  8. Case report • Physical examination • Heart:moderate heart sound, regular rhythm without murmur, capillary refill time was normal • Abdomen: abdominal distention. Liver palpated 2cm under costal arch. Shifting dullness negative • Neurological examinations: unremarkable

  9. Case report • Laboratory data • Blood rutine test + CRP WBC 11.0×109/L, N:45%, L:51%, RBC 3.8×1012 /L, Hb 109g/L, PLT 460×109 /L; CRP:7mg /L • Chest X-ray air trapping in the left lung

  10. Question ？ • What is the first impression of this case ? • What further examination should he take ?

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