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ADMISSION CONFERENCE

ADMISSION CONFERENCE

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ADMISSION CONFERENCE

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  1. ADMISSION CONFERENCE Conti, Mary Angeli

  2. General Data K.A.R 1 year, 7month old Male Filipino Sta. Cruz, Manila Informant: Mother Reliability: 80% Date admitted: November 3, 2009

  3. Chief Complaint Fever

  4. History of Present Illness Cough & Colds

  5. History of Present Illness Difficulty of Breathing ADMISSION

  6. Review of Systems • (+) Weight loss, decreased appetite • No pruritus, jaundice, pallor • No abdominal pain, diarrhea • No constipation • No easy bruisability, epistaxis • No loss of consciousness, seizures, alteration in mental status

  7. Personal History FEEDING HISTORY Picky eater, prefers food with soup Breakfast: Rice and hotdog Lunch: Rice, Soup, Dish Dinner: Rice, Soup, Dish Snacks: Milk 8 oz every four hours Multivitamins, ascorbic acid

  8. Personal History DEVELOPMENTAL AND BEHAVIORAL HISTORY Can already run well, and can jump Cannot use pronoun and produce 3-word sentences Can feed self using spoon Not yet toilet trained by day Can remove clothes by himself Can point to body parts

  9. Personal History PAST ILLNESSES December 2008 - Acute Gastroenteritis, Dehydration No previous trauma, surgeries No previous blood transfusions

  10. Immunization History Health Center, dates were unrecalled

  11. Family Profile

  12. Family History (+) Asthma - Mother, Father, Maternal aunt (+) DM - Grandfather (-) Heart disease, kidney disease (-) Thyroid disease

  13. Socioeconomic and Environmental History Wooden house shared by 10 individuals Grandmother - primary caregiver when mother is at work Drinking water from refilling station Garbage collected daily, no segregation No pets (+) Smoking exposure No nearby factories

  14. Physical Examination Awake, alert, in cardiorespiratory distress, well nourished, well hydrated HR: 140 bpm, reg RR: 55 cpm, reg Temp 37.2°C Wt: 12.5 kg (z=0) Ht: 90 cm (z=0) BMI: 15.43 (z=0, N) Warm moist skin, no active dermatoses, no jaundice, no cyanosis, no rashes Pink palpebral conjunctivae, anictericsclerae

  15. Physical Examination No tragal tenderness, non-hyperemic EAC, intact tympanic membrane in both ears, retained cerumen AD, (-) aural discharge (-) Alar flaring, midline nasal septum, no nasal discharge, turbinates not congested Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged, (-) circumoral cyanosis

  16. Physical Examination Supple neck, no palpable cervical lymphadenopathies Symmetrical chest expansion, (+) subcostal retractions, (+) coarse crackles in bilateral lung fields, (+) wheezes on both lung fields Adynamicprecordium, AB 4th LICS MCL, no murmurs Flat abdomen, no visible peristalsis or mass, normoactive bowel sounds, tympanitic, soft, non-tender Pulses full and equal, no edema, no cyanosis

  17. Neurologic Examination Alert, awake Cranial nerves are intact No gross hearing deficits Can move head from side to side Motor 5/5 on all extremities Reflexes: DTRs ++ on all extremities No Babinski No meningeal signs

  18. Salient Features Subjective findings Objective findings • 2 y/o Male • Persistent cough and colds • Tachypnea • Nocturnal awakening • History of pneumonia • (+) family history of asthma • (+) cigarette smoke exposure • RR 55 cpm • Afebrile • No nasoaural discharge tonsils not enlarged • (+) Subcostal retractions • (+) Crackles, wheezes both lung fields • No cyanosis

  19. Approach to Diagnosis Look foer a symptom, sign or laboratory finding pathognomonic of a disease Look for a symptom, sign or laboratory finding pointing to an organ system Look for a symptom, sign or laboratory finding pointing to a group of diseases Look for a symptom, sign or laboratory finding whose mechanism is well-understood Look for a symptom, sign or laboratory finding found in the least number of diseases

  20. Approach to Diagnosis

  21. Pulmonary System Approach to Diagnosis

  22. Differential Diagnosis

  23. Clinical Assessment

  24. Course at the E.R. and at the Ward

  25. Course at the E.R.

  26. Course in the Ward

  27. Course in the Ward

  28. Course in the Ward

  29. Asthma

  30. GINA, 2008

  31. Host Factors: Genetics • Search for genes focus on the ff areas: • Production of allergen-specific IgE antibodies (atopy) • Expression of airway hyperresponsiveness • Generation of inflammatory mediators • Determination of the ratio between Th1 and Th2 immune responses GINA, 2008

  32. Host Factors: Obesity • Leptins • May affect airway function and increase the likelihood of asthma development GINA, 2008

  33. Host Factors: Obesity Am J Respir Crit Care Med Vol 174. pp 112–119, 2006 Originally Published in Press as DOI: 10.1164/rccm.200602-231PP on April 20, 2006

  34. Host Factors: Sex • Prior to 14 years of age • Male > Female • Adulthood • Female > Male • Unclear • Lung size is smaller in males than in females at birth but larger in adulthood GINA, 2008

  35. GINA, 2008

  36. Allergens

  37. Tobacco Smoke

  38. Pathogenesis • Airway inflammation • Airway hyperresonsiveness • Airway narrowing (bronchoconstriction)

  39. Asthmatic Inflammation Subacute/Chronic Inflammation Early Asthmatic Response Late Asthmatic Response Normal Airway Inhaled trigger chemotactic factors cytokines Recruitment and activation of inflammatory cells Neural & vascular effects Mast Cells Alveolar macrophages

  40. Pathogenesis • Airway inflammation • Airway hyperresonsiveness • Airway narrowing (bronchoconstriction)

  41. Nelson’s 18th edition

  42. Clinical Manifestations • Intermittent dry coughing and/or expiratory wheezing • Most common chronic symptom of asthma • Shortness of breath, chest tightness, intermittent nonfocal chest “pain” GINA, 2008

  43. GINA pocket, 2007

  44. Categories of asthma • Transient early wheezing • Often outgrown in the first 3 years of life • Associated with prematurity and parental smoking • Persistent early-onset wheezing (before age 3) • Recurrent episodes of wheezing with acute viral RTI, no evidence or FHx of atopy • symptoms persists through school age to 12 y/o • Cause: RSV in children <2 y/o • Late onset/wheezing asthma • Persists throughout childhood and into adulthood • Atopic background with eczema GINA, 2008

  45. Highly suggestive of asthma • Frequent episodes of wheeze (once a month) • Activity induced cough or wheeze • Nocturnal cough in periods without viral infections • Absence of seasonal variation in wheeze • Symptoms that persist after age 3 GINA, 2008

  46. Presence of wheeze before age 3 + 1 major Or 2 of the 3 minor criteria GINA, 2008