RS CASE.pptx. ............ Mmm.......

Rs case

1. CASE PRESENTATION Dr Chinmayi Y S Moderators- Dr Nagabhushan, Dr Balasubramaniam, Dr Shilpa K L

2. Name- ABC Age- 9years Sex- Female Address- D J Halli, Bangalore Informant- Mother, reliable

3. Presenting complaints H/o chest pain for 15 days H/o fever for 5 days H/o cough for 4 days H/o hurried breathing for 1 day

4. History of presenting illness Apparently well prior to onset of symptoms Chest pain- left lower chest, 15 days duration, occasional, dull aching, mainly felt on deep inspiration, no aggravating or relieving factors, no diurinal or postural variation. It has come down since past 6 days. Associated with easy fatiguability since 15 days Fever- 5 days duration, acute in onset, intermittent type, low grade, relived with medication. No diurinal variation, not associated with chills or rigors

5. History of presenting illness Cough- 4 days duration, acute in onset, productive, no h/o diurinal variation, No postural variation Sputum- whitish,non blood stained non foull smelling, scanty in amount Hurried breathing and chest indrawing for1 day Child was able to speak in sentences No h/o weight loss or loss of appetite No h/o breathlessness, cyanosis .

6. Negative history No h/o running nose sneezing sorethroat ear ache/discharge headache dysphagia/ change in voice

7. Treatment details Received treatment in a hospital for above complaints Received oxygen by mask and IV antibiotics Evaluated and shifted to tertiary centre for further management

8. Course in hospital Child after admission to our hospital received respiratory support for 3 days. A tube was inserted to chest and fluid was drained Distress decreased and fever spikes reduced Child improved over 7 days

9. Past History No h/o previous similar complaints previous hospital admission nebulization Tuberculosis

10. Family history 3rd born non consanginously married couple Other family members-healthy No h/o current similar complaints No h/o Asthma/ TB in family members

11. Antenatal, birth and postnatal history Antenatal history - She had regular ANC visits in government hospital, no comorbidities Birth history - Full term vaginal delivery in a hospital. Birth weight - 3kg Postnatal history - uneventful

12. Diet History Observed Expected Deficit Calories 1100kcal 1800kcal 38% Proteins 23g 36g 36%

13. Immunization history Immunized upto date (as per UIP) BCG scar present

14. Development history Studying in 2nd standard Good scholastic performance Development milestones-appropriate for age

15. Socioeconomic history Family of 5 members Father is an auto driver, not literate Mother is a homemaker, has studied till 5th std Live in a house with1 room, hall , kitchen There is over crowding present Exposure to Indoor smoking present No dust exposure or pets Belong to Class 4 SES ( modified Kuppuswamy Classification )

16. 9yrs girl child no significant past and family history immunized upto date attained age appropriate milestones significant calorie and protein deficit apparently well till 15 days back presented with chest pain, fever, productive cough, hurried breathing, chest indrawing and and easy fatiguability over past 15 days Case Summary

17. S ystem -Respiratory system Lower respiratory tract P robably acute in onset P robably unilateral-(Left side involvement ) P robably parenchymal and pleural involvement D ue to an infective etiology- probably bacterial Case history Analysis

18. Differential Diagnosis Pneumonia Pneumonia with pleural effusion Empyema Case history Analysis

19. Examination Done in supine position on bed Sick looking Respiratory distress

20. Vital parameters Temperature - 100.7 F Pulse- 120 beats per minute, good volume, regular rhythm, no radioradial or radiofemoral delay. Respiratory Rate- 52 cycles per minute Blood pressure - 94/56 mm Hg SPo2- 92% under room air

21. Anthropometry PRESENT EXPECTED INTERPRETATION WEIGHT 20kg HEIGHT 128cm 132cm 0 TO -1SD BMI 12.2 kg/m2 16.1kg/m2 -3SD ( SEVERE THINNESS)

22. Head to toe examination SMR 3 Ears- normal, no ear discharge Nose- Septum mild deviation to right, no nasal discharge, polyp Oral cavity - no tonsillar hypertrophy or pharyngeal congestion No sinus tenderness Dental caries present . No halitosis Mild pallor noted in palms, nail beds No cyanosis/ lymphadenopathy/ clubbing

23. Systemic examination (Respiratory System) INSPECTION - ( child examined in Sitting and supine position) Nose- septum slightly deviated to right, inferior turbinate normal. Throat- No tonsillar hypertrophy or pharyngeal congestion Ears- No ear discharge Trachea appears to be in midline Shape of chest - appears normal Symmetry of chest – b/l symmetrical Apical impulse- could not be visualised Movement of chest- appears to be equal on both sides Mild intercostal retractions noted on bilateral lower chest region No supraclavicular, suprasternal or subcoastal retractions noted No scars or sinuses

24. Systemic examination (Respiratory System) Palpation Trachea is in midline Apex beat felt in 5th ICS, 0.5 cm lateral to midclavicular line Chest movement -decreased on left lower chest No tenderness Measurements: AP diameter - 22cm, Transverse diameter - 13cm Chest circumference, Inspiration - 56 cm, Expiration - 55 cm Hemithorax – Right Inspiration - 27.5cm, Expiration - 27cm Left Inspiration - 28.5cm, Expiration - 28 cm

25. RIGHT LEFT SUPRACLAVICULAR Normal Decreased INFRACLAVI UR Normal Decreased MAMMARY Normal D ecreased INFRAMAMMARY Normal D ecreased AXILLARY Normal D ecreased INFRA AXILLARY Normal Decreased SUPRASCAPULAR Normal D ecreased INTERSCAPULAR Normal D ecreased INFRASCAPULAR Normal Decreased VOCAL FREMITUS

26. Percussion RIGHT LEFT CLAVICLE Resonant Dull SUPRACLAVICULAR Resonant Dull INFRACLAVI UR Resonant Dull MAMMARY Resonant Stony Dull INFRAMAMMARY Resonant Stony Dull AXILLARY Resonant Stony Dull INFRA AXILLARY Resonant Stony Dull SUPRASCAPULAR Resonant Dull INTERSCAPULAR Resonant Stony Dull INFRASCAPULAR Resonant Stony Dull

27. Tidal percussion- Dullness noted ( no change on inspiration) Tympanic percussion- ( Traubes space) - tympanic note Auscultation Normal vesicular breath sounds heard No added sounds

28. BREATH SOUNDS RIGHT LEFT SUPRACLAVICULAR Normal Decreased INFRACLAVI UR Normal Decreased MAMMARY Normal D ecreased INFRAMAMMARY Normal D ecreased AXILLARY Normal D ecreased INFRA AXILLARY Normal Decreased SUPRASCAPULAR Normal D ecreased INTERSCAPULAR Normal D ecreased INFRASCAPULAR Normal Decreased

29. RIGHT LEFT SUPRACLAVICULAR Normal Decreased INFRACLAVI UR Normal Decreased MAMMARY Normal D ecreased INFRAMAMMARY Normal D ecreased AXILLARY Normal D ecreased INFRA AXILLARY Normal Decreased SUPRASCAPULAR Normal D ecreased INTERSCAPULAR Normal D ecreased INFRASCAPULAR Normal Decreased VOCAL RESONANCE

30. CVS - S1 S2 heard, no murmur P/A - Soft, non tender, no organomegaly CNS - Higher mental function - normal No cranial nerve abnormalities Tone, power and reflexes -normal

31. Sick look Severe thinness F ebrile Pallor Tachycardia Respiratory distress (tachypnea, chest indrawing) Hypoxemia (SPO2-92%) Dental caries D ecreased chest wall movement, vocal fremitus, Vocal resonance with dull note all over left lung fields Positive examination findings

32. Respiratory system Lower airway Unilateral Left side- parenchyma/pleural involvement Inference From Clinical Examination

33. Diagnosis Left sided pleural effusion probably secondary to infective etiology most likely bacterial To r/o Tuberculosis Mild anaemia Severe thinness

34. Investigations Hb- 10.8gdl HCT- 31.5 fl TLC- 8070 cells DLC- 47.3%/38.6% Platelet - 2.34 lakhs ESR- 74 mm/hr

35. Pleural fluid analysis Appearance- yellow ( straw) color Cell count - 8000 cells 80% neutrophils, 20% lymphocytes Glucose- 15mg/dl Protein- 2.9g/dl Gram stain- gram positive cocci seen in singles and pairs Culture- sterile

36. Sputum for CBNAAT- NEGATIVE Pleural fluid cbnaat - NEGATIVE USG thorax- left moderate pleural effusion. Final Diagnosis Left sided parapneumonic pleural effusion with mild Anaemia with severe thinness

37. THANK YOU