CM Case Presentation.pptx ./

health studies

1. PEADIATRIC SEMINAR

2. DEMOGRAPHICS Name: C M Sex: Female Age: 8 months Address: Garden House Informant: Mother (A B) DOA: 23/01/25

3. Chief Complaint Breathing Fast Fever C  

4. History of Complaint Patient was in her usual state of health until days ago when she head the child persistently coughing. Mother reports the cough being dry and was not accompanied by vomiting afterwards. Patient would cry and become irritable after coughing not wanting to be touched especially on the chest however there was no history of convulsions Mother states this did not prompt her worry as the child has had a cough that comes and goes ever since she was born

5. History of Complaint The following Day, Mother reports having noticed the patient’s body was hot, that prompted her to use a wet cloth to cool the patient. However that very night the Child was sweating vey much soaking the clothes she was wearing. Mother says the patient was less active and noticed the child breathing fast, having difficulties when crying, refusing to eat and Body was hotter compared to the day before. Mother then brought the child to Kanyama General Hospital.

6. Review of systems GIT Poor feeding nor diarrhea MSS No joint swelling

7. Past medical history First admission Child is non exposed No Epilepsy No Tuberculosis No S ickle cell Disease

8. Drug history Amoxicillin Syrup given at home for her cough No herbal medication given Allergic to penicillin – usually becomes irritable, has an upset stomach and Diarrhea

9. Birth history Born at via Caesarean section after failed induction, indication of Induction was Severe Pre-Eclampsia Cried immediately after birth Birth weight 3kg  

10. Immunization History Upto Date according to Underfive Card. Awaiting the Measles Vaccine at 9 months

11. Developmental history Exclusively breastfed to date Solid food at 6 months Started grabbing Toys at 4 months Sitting at 6 months Standing at 7 months Sounds at 7 months (dada)

12. Family History No Family History of Asthma, Tuberculosis or Sickle cells disease Mother is RVD-NR

13. Social history 1 st Born Stays in garden house 5 roomed house, well ventilated with 7 occupants, 5 adults and 2 children Water source is the compound Borehole Mother is a stay at home wife who occasionally takes alcohol Father works and neither smokes nor take alcohol

14. Summary CM Female who stays in garden house presented with a positive history of shortness of breath Fever C as well as poor feeding, single incident of drenching night sweat and irritability, however no restlessness, diarrhea or vomiting. Said to be allergic to penicillin and no history of having come into contact with a Tb patient.  

15. Impression Community Acquired Pneumonia

16. Differential Diagnosis Bronchiolitis Tuberculosis Influenza Aspiration Pneumonia

17. PHYSICA

18. General Inspection Close to patient who was in mothers arms, with a nasal cannula connected to an active Oxygen cylinder. Alert and active Irritable Non lethargic rapid shallow breaths and Nasal flaring No sign of Malnutrition or Obesity No cannula in situ

19. V itals RR 38 breaths per minute Pulse 125 beats per minute Temperature 36.2 Oxygen saturation 98

20. Head and Neck Hair – Brown in color with Good distribution Eye – had neither Conjunctiva pallor nor sclera Jaundice or periorbital swelling Nose – Nasal flaring, discharge. Neck – No lymphadenopathy Mouth – no central cyanosis

21. extremities Capillary refill time <2s No finger clubbing No pedal edema

22. Chest Inspection No scar Symmetrical in expansion Increased work during inspiration – use of accessory muscles No “see-saw” breathing

23. Chest palpation No tenderness Crepitations felt Increased Tactile Fremitus when patient cries No Abnormal masses

24. Percussion Not done due to irritability of the patient Alert and active, Irritable

25. Auscultation Decreased breath sounds on the left lower lung area Coarse crackles No Wheezing

26. abdomen No distension No hepatosplenomegaly

27. neurological No bulging frontanels Able to flex the neck in all directions

28. summary Examination of CM F alert and active in mothers arms, with a nasal cannula and quite irritable on general inspection. on chest examination Increased, work during inspiration, however had no “sea-saw ” breathing, chest was non tender, Crepitations and Increased Tactile Fremitus f elt when crying, though percussion was not done, auscultation revealed Decreased breath sounds on the left lower lung area, Coarse crackles but there was No Wheezing.  

29. Impression Community Acquired Pneumonia DDX Pulmonary Tuberculosis

30. investigations Chest X-ray

31. FBC

32. management Kept in Vital monitored especially SPO2 2 hourly interval

33. management Pharmacological management