Clerk’s Grandrounds

Go, K, Go, MR, Go, MF, Go, MH, Go, RM

General Data

HB3 years old/femaleSta. Cruz, ManilaBirthdate: Feb. 8, 2007Admitted: January 1, 2011Informant: ParentsReliability: GoodCC: Fever

Chief Complaint

• Difficulty of breathing

History of Present Illness

•Patient is a known asthmatic since 6 months of age

•Maintained on Salbutamol (dosage form and dosage)

2 days PTA

•(+) cough productive of yellowish sputum, with anorexia andprogressive dyspnea, no other accompanying symptoms

•Salbutamol nebulization partial relief

•No consult done, no other medicatiions taken

Few hours PTA

•(+) bilateral swelling over the submandibular area, with progression of cough and dyspnea

•Consult at Mary Child Hospital

•CXR- requested (result?)

•Referred to Jose Reyes and eventually transferred to our institution du to room inavailability

Review of Systems

• General: no weight loss/gain (+) anorexia, (+) weakness

• Cutaneous: no rashes, no abnormal pigmentation, no pruritus

• HEENT: no lacrimation, (+) naso-aural discharge, no epistaxis, no salivation

History of Present Illness

• Cardiovascular: no cyanosis• Respiratory: see HPI• Gastrointestinal: see HPI• Genitourinary: see HPI

• Growth and development:– At par with age

• Feeding injury– Solid food introduced: 6 months– First food introduced: Cerelac– Number of feeding per day: 3x of small feedings/ day

• Past medical history:– No allergic rhinitis, no atopic dermatitis, previous hospitalizations and

surgeries• Family history:

(+) asthma - father(-) allergic rhinitis, food allergy, atopic dermatitis, congenital anomalies

• Immunization history:– Completed

Social/Environmental history

• Patient’s aunt is the primary caregiver• patient together with her parents and aunt live

in a bungalow type house with an average monthly income of P20,000

• House has adequate space and ventilation• Patient’s drinking water is from NAWASA• Garbage is segregated and collected daily• No smokers in the household and no factories

nearby

Physical Examination

• General: Lethargic, in cardiorespiratory distress, carried, ill-looking, poorly nourished and hydrated

• Vital Signs: BP: 80/50 PR=140 bpm RR=56 T=36.9 O2 sat 75%

• Anthropometric data: weight: 11kg (weight for age: below 0: normal), Height: 94 cm (length for age: 0: normal), (weight for height: below -2: wasted), BMI: 12 (below -3: severely wasted)

• Warm moist skin, (-) active dermatoses, (-) hematoma

Physical Examination

• HEENT: Normocephalic, No scalp lesions, (-) alopecia, pale palpebral conjunctivae, anicteric sclera, non-hyperemic, pupils 1-2 mm ERTL, no tragal tenderness, non-hyperemic EAC, (+) impacted cerumen on the left, midline nasal septum, (+) nasal discharge, (+) alar flaring, dry buccal mucosa, dry lips, (-) oral ulcers, tonsils not enlarged, NHPPW, supple neck, thyroid not enlarged, no cervical lymphadenopathies,(+) bilaterally symmetrical submandibular swelling

Physical Examination

• Lungs/ Chest:– Symmetrical labored chest expansion– (+) suprasternal retractions, (+) intercostal

retractions– (+) 14x10 cm swelling non-erythematous warmth

at posterior thorax 5th – 10th intercostals space, (+) crepitations over anterior and posterior thoraces, (+) hyperresonance

– (+) wheezes with fair to tight air entry, (+) rhonchi, (+) fine crackles on both bases

Physical Examination• Cardiovascular: Adynamic precordium, AB 5th LICS MCL, (-)

heaves, thrills and lift, S1>S2 at the apex, S2>S1 at the base, (-) murmurs

• Abdomen: Flat abdomen, normoactive bowel sounds, (-) direct tenderness in epigastric area, no masses, no rebound tenderness

• GUT: no CVA tenderness, grossly female, Majora covers minora• Extremities: Pulses full and equal on all extremities, no cyanosis,

(+) crepitus subcutaneous emphysema over both arms 14x16 cm of non-hyperemic, non-tender, (-) rubor swelling mass

Neurological Exam

• Conscious, coherent oriented to person, time and place, GCS 15• No anosmia, Pupils Left 2-3 mm isocoric ERTL, (+) corneal reflex, (+) ROR,

clear disc margins, no visual field cuts, EOM full and equal, V1V2V3 intact, (-) ptosis, (-) shallow right nasolabial fold, can smile, can raise eye brows, can puff cheeks, (-) lateralization on Weber, AC>BC on Rinne’s AU, (+) gag reflex, can shrug shoulders, turns head side to side against resistance, tongue midline on protrusion, uvula midline on phonation

• Motor: MMT 5/5 on all extremities, no fasciculation, spasticity, flaccidity• Sensory: (-) sensory deficiency• DTR’s: +2 on all extremities• (-) Babinski, right, (-) nuchal rigidity, (-) kernig’s

Salient Features• 3 year old/female• Difficulty of breathing• Known case of asthma maintained on salbutamol• Hypotensive, tachycardic, tachypneic, hypoxemic, afebrile• Lethargic, in cardiorespiratory distress, poorly nourished and hydrated• - (+) suprasternal retraction, (+) intercostal retractions, (+) wheezes, (+)

ronchi- (+) 14x10 cm swelling non-erythematous warmth at posterior thorax 5th –

10th intercostals space- (+) crepitus subcutaneous emphysema at both arms 14x16 cm of non-

hyperemic

Assessment

• Bronchial Asthma, in Moderate Acute Exacerbation

• Secondary Spontaneous Pneumothorax, probably due to Bronchial Asthma

• Pneumonia• Subcutaneous Emphysema

Day 1

• Hooked to O2 per mask• IVF D5 0.3 NaCl 500cc to run at 11-12gtts/min• CBC: Increased WBC count• ABG• Portable CXR: Extensive subcutaneous emphysema of the

chest and neck area and probable pneumothorax, left• Medications

– Methylprednisolone 11mg/SIVP Q6– Ampisulbactam 300mg/SIVP Q6– Salbutamol 2.5mg/nebule 1 nebule every hour

• Referred to Pedia Pulmo and Pedia Allergo

COMPLETE BLOOD COUNT

1/1/11 UNIT REFERENCE RANGE

HGB 146 g/L 120-170RBC 4.95 X10^12/L 4.0-6.0HCT .43 .37-.54MCV 87.30 U^3 87 +-5MCH 29.40 Pg 29+-2MCHC 33.70 g/dL 34+-2RDW 13.30 11.6-14.6MPV 8.20 fL 7.4-10.4PLATELET 437 X10^9/L 150-450WBC 22.40 X10^9/L 4.5-10.0DIFFERENTIAL COUNT NEUTROPHILS .86 .50-.70 METAMYELOCYTES - BANDS .05 .00-.05 SEGMENTED .31 .50-.70 LYMPHOCYTES .14 .20-.40 MONOCYTES - .00-.07 EOSINOPHILS - .00-.05 BASOPHILS - .00-.01

ABG 1/1/11 UNITpH 7.343

PCO2 14.7 mmHgPO2 76 mmHg

Temp 37FIO2 21 %BP 758.2 mmHg

HCO3 8 mmol/LO2 sat 94.3 %

BE -14.2 mmol/LTCO2 8.4 mmol/LO2CT 19.9 VOL%

BB 33.8 mmol/LSBE -15.7 mmol/L

AaDO2 55.8 mmHga/A .58RI .7

Day 2

• (+) dry lips• Increased IVF to 16-17gtts/min• Initiated liquid, then soft diet• Ranitidine 10mg/SIVP

ABG 1/1/11 1/2/11 UNITpH 7.343 7.390

PCO2 14.7 17.9 mmHgPO2 76 176 mmHg

Temp 37 36.9FIO2 21 80 %BP 758.2 760.3 mmHg

HCO3 8 10.8 mmol/LO2 sat 94.3 99.2 %

BE -14.2 -10.9 mmol/LTCO2 8.4 11.4 mmol/LO2CT 19.9 19.9 VOL%

BB 33.8 36.7 mmol/LSBE -15.7 -12.3 mmol/L

AaDO2 55.8 375.9 mmHga/A .58 .32RI .7 2.1

Day 3

• (+) epigastric pain relieved by ranitidine• (+) 4 episodes post-tussive bilious vomiting• Aminophylline 2.2ml in 20ml IVF to run for 30

mins then maintained at 2.2ml + 97.8 IVF to run at 20ml/hr– (-) tachycardia, headache, seizure, GI upset

• Mucosolvan 10 drops added to 20 drops ambroxol and salbutamol nebule– Further increase bronchodilation

Day 4

• Follow up CXR– Remarkable improvement of subcutaneous

emphysema– Adequate expansion of the left lung

• Aminophylline drip and IV methylprednisolone discontinued

• Doxophylline 100mg/5ml (10mg/kg/day) 2.5ml BID

• Methylprednisolone 8mg/tab 1 tab Q8

Day 5

• Oral methylprednisolone discontinued

Day 7

• (+) congested turbinates• (+) vomiting• (+) abdominal pain• Ranitidine discontinued• Lansoprazole (Prevacid) 15mg/tab ½ tab OD

Day 8

• Discharged stable and improved

Final Diagnosis

• Bronchial asthma, in moderate acute exacerbation

• Secondary spontaneous pneumothorax secondary to bronchial asthma

• Pneumonia• Subcutaneous emphysema, resolved

Case Discussion

Journal