CASE PRESENTATION pediatrics detail.pptx

#peds

1. CASE PRESENTATION SUBHIKSHA D 85

2. NAME - Pranav AGE - 2years SEX – Male INFORMANT – Mother - Reliable ADDRESS – KK Nagar CHIEF COMPLAINTS: Fever and cough x 4 days Shortness of breath x 3 days

3. HISTORY OF PRESENTING ILLNESS : Child was apparently normal till 4 months of age He presented now at the OPD with complaints of : 1. FEVER and COUGH for past 4 days Insidious in onset gradually progressive present throughout the day No diurnal or postural variation of the cough Fever was insidious in onset and low grade and intermittent in nature , no chills or rigor The child is also tired most of the time

4. 2. SHORTNESS OF BREATH x 3days Insidious in onset , gradually progressive It was of NYHA Class 4 3. Yesterday the mother also noticed mild bluish discoloration of the finger tips and tongue. There was H/O suck rest suck cycle present while he was breastfed There was H/O profuse forehead sweating while breastfeeding H/O poor weight gain and poor feeding present

5. H/O similar episodes since 4 months of age requiring hospitalization It used to occur every 4 months – (4 th month,8 th month,12 th month, 16 th month , 20 th month) – requiring hospitalization for one week Last episode – 4 months ago No history of swelling of the limbs/sacrum , decreased urine frequency/quantity , painful swelling of the joints, abdominal pain, altered sensorium or seizures

6. PAST HISTORY : H/O similar episodes since 4 months of age requiring hospitalization It used to occur every 4 months – (4 th month,8 th month,12 th month, 16 th month , 20 th month) – requiring hospitalization for one week Last episode – 4 months ago On the 8 th week of life baby was admitted in the hospital for poor feeding, irritability , breathlessness and facial puffiness and managed for heart failure and was advised surgery but parents weren’t willing for the surgery No H/O any surgeries ANTENATAL HISTORY Mother conceived spontaneously at 25years of age Pregnancy confirmed by urine pregnancy test after 1month of amenorrhea She is registered and attended all Antenatal visits

7. 1 st TRIMESTER : Dating scan was done No H/O fever with rash/ lymphadenopathy No H/O drug intake/radiation exposure 2 ND TRIMESTER : Took Iron and folic acid tablets ; anomaly scan – N Quickening felt at 5 months Immunized with TT 2 doses Diagnosed with Gestational Diabetes mellitus during her antenatal visit with Glucose tolerance test (at 22 weeks) and was on insulin No H/O PIH 3 RD TRIMESTER : Fetal movements perceived No H/O bleeding PV

8. NATAL HISTORY : Full term male baby weighing 2.8 kg delivered via normal vaginal delivery. Baby cried immediately after birth and was shifted to the mother’s side POST NATAL HISTORY : Breastfeeding initiated immediately after birth No H/O NICU admission NEONATAL HISTORY : Birth order -1 Passed meconium and urine within 24hours No H/O bluish discoloration of skin

9. DEVELOPMENTAL HISTORY : IMMUNIZATION HISTORY : Immunized regularly for age GROSS MOTOR FINE MOTOR SOCIAL MILESTONES LANGUAGE Runs, explores drawers Scribbles , towers of 3 blocks Asks for food, drink, toilet, shows toys to people 2-3 word sentences Uses pronouns(I, me , you)

10. NUTRITIONAL HISTORY : Baby was breastfed till 6months of age , complementary feeds started after 6months. Child took long time to feed CALORIE DEFICIT = 42.3% PROTEIN DEFICIT- Adequate (24g) TIME OF THE DAY FOOD CONSUMED CALORIES PROTEINS MORNING MILK – 100ml IDLI – 1 BANANA – 1/2 65 50 55 1.1 2 0.75 AFTERNOON RICE- 1/2CUP BOILED EGG 1 SAMBAR-1/2 CUP 90 80 150 2 6 10 EVENING MILK-100ML 65 1.1 NIGHT IDLI -1 50 2

11. PERSONAL HISTORY: Mixed diet Bowel bladder habits - normal Sleep- Normal FAMILY HISTORY : Non consanguineous marriage No h/o similar complaints in the family No h/o congenital heart disease in the family No h/o sudden cardiac death in the family SOCIO ECONOMIC HISTORY : Upper middle class according to BG Prasad scale.

12. SUMMARY 2 year old boy fully immunized with mild motor developmentally delay born to a gestational diabetic mother presents to the OPD with complaints of fever and cough for past 4 days and breathlessness of Grade 4 NYHA for the last 3 days and cyanosis for 1 day and significant past h/o of recurrent respiratory tract infections requiring hospitalization and H/O suck rest suck cycle, poor feeding and failure to thrive.

13. GENERAL EXAMINATION : Consent was obtained from the mother and the child was examined Baby was dyspneic on sitting Awake, conscious, lethargic , not playful Cyanosis – in tongue and finger tips Clubbing – grade -2 No pallor , lymphadenopathy , icterus , pedal edema

14. VITALS : PULSE- 110beats/min Normal in rate, rhythm, volume ,character ,NO radio-radial or radio-femoral delay , B/L Peripheral pulses felt equally. RR- 60 breaths per minute , abdominothoracic Temperature- Febrile 100F BP- 90/60mm Hg right upper limb

15. ANTHROPOMETRY Height- 78cm Weight- 9kg Head circumference - 47cm

16. INTERPRETATION: PARAMETER Z SCORE INTERPRETATION WEIGHT FOR AGE BELOW -3SD SEVERELY UNDERWEIGHT HEIGHT FOR AGE BELOW -3SD SEVERELY STUNTED WEIGHT FOR HEIGHT BETWEEN -2SD TO -3SD MODERATE WASTING HEAD CIRCUMFERENCE BETWEEN 0- -1SD NORMAL

17. HEAD TO FOOT EXAMINATION Head size and shape – N No facial dysmorphism Eyes, ears – N Skin – Bluish discoloration of finger tips, tongue SYSTEMIC EXAMINATION : CARDIOVASCULAR SYSTEM EXAMINATION: INSPECTION : Chest wall- symmetric Trachea – midline Chest in drawing –present Apex beat – not visible JVP couldn’t be made out

18. No scars, sinuses , engorged sinuses No chest wall deformities PALPATION: All inspectory findings are confirmed Trachea in midline Apex beat – felt at left 5 th intercostal space at mid clavicular line Palpable P2 Minimal Left parasternal heave No thrills

19. PERCUSSION : Left heart correspond to apex Right heart border corresponds to right sternal border Liver dullness- Right 5 th intercostal space AUSCULTATION : MITRAL AREA: S1 S2 heard S3 AORTIC AREA: S1 S2 heard No other added sounds/murmurs PULMONARY AREA: S1 single S2 heard P2 loud End diastolic murmur

20. No other added sounds or murmurs ABDOMEN: Soft , tender hepatomegaly , no organomegaly RESPIRATORY SYSTEM: Trachea in midline , B/L air entry present, normal vesicular breath sounds heard CNS: No focal neurological deficit

21. SUMMARY: 2 year old boy fully immunized severely malnourished with mild motor developmental delay born to a gestational diabetic mother presents to the OPD with complaints of fever and cough for past 4 days and breathlessness of Grade 4 NYHA for the last 3 days and cyanosis for 1 day and significant past h/o of recurrent respiratory tract infections requiring hospitalization and H/O suck rest suck cycle and failure to thrive O/E - Chest indrawing , Palpable P2 , left mild parasternal heave , loud P2 and end diastolic murmur at the pulmonary area

22. PROVISIONAL DIAGNOSIS: Congenital heart disease with left to right shunt probably due to ventricular septal defect with features of pulmonary artery hypertension now complicated with Eisenmenger syndrome and the child is in sinus rhythm

23. INVESTIGATIONS CBC , RFT , LFT ECG – RVH X RAY- NO/Minimal cardiomegaly Prominent pulmonary artery Central Plethora ECHO , Doppler, Cardiac catheterization

24. TREATMENT Poor prognosis Management of pulmonary hypertension- CCB, nitrates, endothelin antagonists, prostanoids ,PDE inhibitors Inhaled O2 , anticoagulants , management of anemia Heart lung transplantation

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