| Bronchiolitis -
13-12-2006, 01:11 PM
History
Particulars
Name: Y. Paudel
Age: 2 months Sex: Religion: Hindu
Address: Kalanki
Informant: Rama Paudel
Relation: Mother
Informants Education: Intermediate level
Informants Occupation: Housewife
Reliability: Good
Date of admission: 16th Kartik 2063
Male Mode of admission: OPD
Date of examination: 18th Kartik 2063
Chief Complaints
Shortness of breath - 1 month
Noisy breathing - 1 month
Vomiting - 12 days
History of Present Illness (HOPI)
According to the informant, the child was apparently well one month back. Then he started having shortness of breath with noisy breathing. It was acute in onset, progressive in nature, aggravated by crying and relieved by holding the child in upright position. These symptoms had no diurnal variation.
He had vomiting for 12 days with sudden onset, 5 to 6 episodes per day, non projectile type with no known precipitating factor. Vomitus was 30 to 50ml in each episode, containing ingested breast milk, and had curd appearance, non mucoid with no foul smelling, blood & bile stains.
There is no history of cough, fever, nasal discharge, bluish discoloration of skin.
Past History
No history of similar episodes in the past.
There is history of jaundice 3 days after birth and subsided after 1 month without any treatment.
There is no history of TB, pneumonia, asthma, pharyngeal infections and loose motions.
No history of past surgeries and blood transfusion.
Contact History
There is no history of contact or exposure to children or adults suffering from infectious diseases like TB, respiratory infections, diarrhea etc.
Birth History
A. Antenatal History
Pregnancy was diagnosed at hospital.
4 ANC visits
No history of Illness, Irradiation during the trimesters.
Immunized with two doses of Tetanus Toxoid with supplementation of Calcium and Iron from 4 months till 9 months.
No history of maternal infection like fever, rash, lymphadenopathy and urinary problems, anemia, Hypertension, Diabetes Mellitus.
Mothers age at pregnancy was 28 years.
Labor pain for 7 hrs.
Previous child- full term normal vaginal delivery 4 years back at hospital.
History of one spontaneous abortion at 3 months of gestation 15 months back.
No history of alcohol and smoking during the pregnancy.
B. Natal History
Full term normal vaginal delivery at hospital
Vertex presentation.
Baby cried soon after the birth, 3.8 kg with no history of birth injuries, birth asphyxia and neonatal sepsis.
C. Postnatal History
History of jaundice seen after 3 days which lasted up to 1 month and subsided without medication.
Colostrum fed immediately after birth.
Normal feeding and suckling ability.
Meconium passed after 12 hrs. and urine passed after 48 hours.
BCG given within 24 hours.
Child was active.
Developmental History
Gross: momentary neck holding
Fine: eye fixation.
Social: smile, recognition of mother
Language: cooing
Dietary History
Predominant breast feeding.
Lactogen feeding started after 1 month because mothers milk was insufficient. He takes about 5 spoons of lactogen a day.
Immunization History
BCG given at birth.
DPT and OPV not given due to current antibiotic treatment.
Family history
No history of Hypertension, Diabetes, Tuberculosis.
No history of contact with person having communicable diseases like TB, respiratory infections, diarrhea etc.
Socioeconomic History
Father- electrician, mother- housewife, both are literate & economic status is low middle class.
Sewage drainage is well managed. Water source is tap water and boiled water is given to diseased child only.
No pet animals at home.
Drug & Allergy History
He is currently under Antibiotics.
No known allergy till date.
Clinical examination
A. General Examination
1. General characteristics
He is conscious, playful, alert, lying comfortably in mothers lap, no signs of respiratory distress, well nourished, of average built. There are no engorged and dilated veins and obvious skin defects and scars. Skin texture, hair and its body distribution are normal. No abnormal facies.
There is no Pallor, Icterus, Leuconychia, Lymphadenopathy, Clubbing, Cyanosis, Oedema & Hydration status is good.
2. Vitals
1. Pulse is 120/min, regular in rhythm, normal in volume and character, bilaterally symmetrical, the arterial wall is just palpable & there is no radio radial and radio femoral delay. All the peripheral pulses are palpable.
2. Blood Pressure is 80/50 mm of Hg in the Right upper arm in the sitting position, there is no postural drop.
3. Temperature is 98F in the axilla
4. Respiratory rate is 56 per minute in supine position, normal in depth and it is abdomino-thoracic type.
5. Jugular Venous Pressure is not raised.
3. Anthropometry
1. Weight: 6.7 kg (above 97th percentile)
2. length : 66 cm (above 97th percentile)
3. Head circumference : 40 cm (lies at 50th percentile)
4. Mid Arm Circumference : 14 cm
5. Chest circumference: 37 cm (lies at 50th percentile)
B. Systemic Examination
Respiratory System
Inspection
No signs of respiratory distress
Nose and mouth is normal
Chest is bilaterally symmetrical
Trachea is in the midline
Shape of the chest is cylindrical
Apex impulse is not visible
No deformities like Pectus Excavatum, Pectus Carinatum, Kyphosis, Scoliosis
Chest movement is regular and symmetrical
Increased respiratory rate and it is abdominothoracic type.
There is no intercostals and sub-costal recession
No visible lumps, swellings, pulsations, scars
Palpation
Trachea is in the midline
Apex beat is in the 4th left intercostal space, 3 cm from the midline
Expansion of chest wall is bilaterally symmetrical in the both sides
Vocal fremitus is diminished
There is no rise of temperature & tenderness
Percussion
Diminished resonance heard all over the lung field.
Auscultation
Bilateral wheeze and crepitation heard all over the lung field, vesicular breath sound heard.
Alimentary System: Abdomen is soft, non-tender, spleen, liver are not palpable, normal bowel sound heard.
Cardiovascular System: First and second heart sound heard, no murmurs.
Central Nervous System: Intact
Provisional diagnosis
Bronchiolitis
Differential diagnosis
Common Cold
Croup
Asthma
Pneumonia
Lobar Emphysema
Aspiration
Cystic Fibrosis
Allergic Rhinitis
Investigations
Routine blood: TC, DC, Hb%
Blood Culture
Viral Antigen
Arterial Blood Gas Analysis
Chest X-Ray
Final diagnosis
Management
Source: Angel's CONCISE CLINICAL METHODS |
Linear Mode
