DEMOGRAPHIC DATA

Name:Groly Hassan Juma

Age:  3 years

Sex:  FEMALE

Address: Magomen

Religion: Christian

Tribe:  Zaramo

Informant: Biological mother

Date of admission: 07/06/2015

Date of history taking: 11/06/2015

         

 

CHIEF COMPLAINT

Ø Cough 5/7

Ø Difficulty in breathing 5/7

 

HISTORY OF PRESENTING ILLNESS

The patient was apparently well until 5/7 ago, when her mother noted a gradual onset of dry cough which was progressing as time goes and become productive. The productive  cough was whitish in colour not blood stained with amount of about 3ml with no foul smell. No aggravating and relieving factors known by her mother.

    On the same day, her mother noted Difficulty in breathing which was also gradual onset  and the condition was more worse when  feeding with no any sound like wheezing heard  no relieving factor and aggravating factor known by her mother but the difficulty in breathing associate with lower chest in drawing, nasal flaring, refusal to eat, but no bluish discoloration of mucous membrane, the mother reported that there is no history of dizziness, easy fatigability, chest pain, excessive night sweat, weight loss and TB contact  reported.

 

                            

REVIEW OF OTHER SYSTEM

GENITAL URINARY SYSTEM

Ø No crying or pain during urination

Ø No frequency or urgency on urination

Ø No itching of genitalia

Ø No blood in urine

 

MUSCULOR SKELETAL SYSTEM

Ø No muscle pain

Ø No joint pain

Ø No muscle swelling

Ø No any stiffness of muscles

 

NERVOUS SYSTEM

Ø No Headache

Ø No blurred vision

Ø No numbness of the lower limb

Ø No loss of consciousness

 

GASTRO INTESTINAL TRACT

Ø No abdominal pain

Ø No loss of appetite

Ø No vomiting

Ø No constipation

Ø No diarrhea

Ø No difficulty and painful swallowing

 

          EAR,NOSE,THROAT

Ø No ear discharge

Ø No ear pain

Ø No nasal discharge

 

PAST MEDICAL HISTORY

Paediatric History

No history of previous admission(it’s the first admission), No history of blood transfusion, no history of surgery, no history of food or drug allergy known.

 

Antenatal history

Mother conceived when she has 24 years old, she registered booking after the Gestational age of 17week, each visit she receive anti malaria, haematenics, anti worms and Toxoid Tetenus vaccine. And she screened  for Veneral diseases research laboratory (VDRL) , Hb level which both are negative with normal Hb level respectively, also she did not develop any complication during antenatal

 

Natal History

Baby delivered at term with full gestational age of 40 weeks and mode of delivery was Spontaneous vertex vaginal delivery at Sinza hospital and the baby has 3.5kg, the baby cried immediately after delivered and was able to suck. The score was about 8 to 10.

 

Post natal history

 Mother discharged 1day after delivery and umbilical droped after 6days with no pus, no blood, no fever and yellowish discoloration observed by a mother during postnatal.

 

Immunization history

 Child was well immunized and one day after birth was given BCG on right shoulder and oral polio vaccine, after 6weeks he received penta1(Hepatitis b,Haemophilus Influenza type b, toxoid tetanus, Dipthera, Pertusis),Pcv1,Opv1,rota1, On 10th week he received Opv2,pcv2,rota2,penta2.

14th week he received Opv3,pcv3,penta3.

On 9month he received measles and repeated after 1 ½year

After 1year up to know he didn’t receive Vitamin A

 

Dietary history

-Exclusively breast feed for 6month but now mixed with porridge on morning and afternoon he eats ugali then porridge, porridge  mixed with wheat, rice, groundnuts,  and this was given 3times a day and he always eat with family.

 

Developmental milestone

Gross motor- Able to control neck after 7month,sitting without support after  

                       5month,start crowing after 7month.

Fine motor- Prinsa grasping after 9month

                    Palmar grasping after 1year.

 

Language/speech-bubbling dissyllabic (mama, baba) after 1year.

 

Social  -Start recognizing his mother after 1year ,he smile after 9month,

            no fear of strange.

 

 

FAMILY AND SOCIAL HISTORY

Family history of child

They live in the family of 4 people where the patient is 2nd born and the first born is a boy of 7years lives with his grandmother but asthmatic.

There is history of asthma but no any other history of chronic illness like Diabetes,

 Hypertension, sickle cell disease known.

    Both parents are standard seven leaver, her mother Married, Home mother but father is a businessman, they live in poor ventilated house. Also their environment is overcrowded a with other people and also the environment of the house has poor sanitation. No history of alcoholism and cigarette smoking.

 

 

PHYSICAL  EXAMINATION

General examination

The patient is ill looking, Normal hair texture, No angular stomatitis, No lymph node enlarged ,not cyanotic, not jaundiced, No edema, No head nodding.

Vital sign

 Temperature  38.5⁰C febrile

  Pulse rate  110beat/minute elevated

  Respiratory rate  45breath/minute elevated

 

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM 

Inspection

Ø No traditional and surgical mark

Ø Chest wall contour are Normal with no deformities like Kyphosis, Scoliosis, Pectus excavatum, Pectus carinatum.

Ø The patient has Signs of respiratory distress like, nasal flaring ,use accessory muscles of respiration like sternocleidomastoid muscles,

Ø Diaphragmatic paradox  the diaphragm moves opposite of the normal direction on

Inspiration,

Ø lower chest wall in drawing

 

Palpation

Ø No Palpable swelling or tenderness

Ø Trachea is centrally located

Ø unequal chest expansion

Ø Increased  tactile vocal fremitus (TVF)

 

Percussion

Ø Hyper resonant percussion note

 

Auscultation

Ø audible wheezing

Ø Rhonchi was heard.

 

CARDIOVASCULAR SYSTEM

Inspection

Ø No raised JVP

Ø No peripheral cyanosis, no finger clubbing

Ø No surgical scar

Ø No lower limb edema

 

Palpation

Ø Apex beat located on 4th  intercostal space along the left midclavicular line   

Ø No thrill

 

Auscultation

Ø Heart sounds S1 and S2  heard

Ø No mummers


PER ABDOMEN

Inspection

Ø The abdomen is flat, moving with respiration

Ø Inverted umbilicus

Ø No visible surgical, traditional mark.

 

Palpation

Superficial -Not tender on palpation

                  -No palpable mass

 

Deep          -Liver and spleen are not palpable

                  - Both Kidney are not palpable.

 

A tympanic percussion note was heard on percussion,

Normal bowel sound heard on auscultation.

 

CENTRAL NERVOUS SYSTEM

Ø Conscious With Glass gow coma score of 15/15

Ø Patient is alert and Patient is oriented with people and place

Ø Speech of a patient is good

 

 Cranial Nerves

Ø Olfactory - The patient can smell

Ø Optic – The patient can see

Ø Oculomotor, Trochlear, Abducen - The patient can move eyes on both direction like to move eyes upward, downward, medially and laterally.

Ø Trigeminal, Facial – Symmetrical face and the patient can blow cheeks and able to show wrinkles,

Ø Vestibulocochlear – The patient can hear

Ø Glossopharyngeal, Vagus – Normal Gag reflex, Uvula centrally located

Ø Accessory - The patient can moves his shoulder upward against resistance, able to shrug shoulders.

Ø Hypoglossal – The patient can move tongue out and on both direction

 

Motor

   Muscle Bulkness—Normal on both extremities

   Muscle  Involuntary - No involuntary

   Muscle Gait –

   Muscle Tone – Normal tone on both extremities

   Muscle   Power – power of 5/5 on both extremities(normal)

   Muscle  Reflex – Normal reflex on both extremities

   Muscle Sensation – Patient can sense by using both tooth pick and cotton on both               extremities.

 

 

SUMMARY:              

Majuma Rashid female of 3years from Bunju B. who come with dry and productive Cough 5/7  which has no smell ,white in colour aggravated by playing with others. also Difficulty in breathing 5/7 gradual onset  and its worse when breast feeding with no any sound like wheezes associate with lower chest in drawing, nasal flaring ,refusal to eat but no bluish discoloration of mucous membranes .On examination the patient is ill looking with vital signs Body temperature 38.5C,PR 110beats per min, RR 45breaths per min. On respiratory system examination has signs of respiratory distress , unequal chest expansion and increasing g of tactile vocal fremitus. Hyper resonant on percussion and rhonchi sounds heard on auscultation .other systems were found to be normal.


Provisional Diagnosis

 Severe Pneumonia

  -due to the presence of the cough, difficulty in breathing and signs of respiratory distress

Differential diagnosis

-Bronchial Asthma

 -Bronchitis

  -COPD

 

Investigation

- Based on clinical presentation

 -Chest X-ray

         -A full blood count (FBC) not needed, but repeated ESR and Hb show the       

          progress of recovery

         -Blood culture

         -Repeated blood culture when sepsis is

         -Mantoux Test

          Gastric/nasopharyngeal aspirate for Acid-fast bacilli stain (AFB), preferred

            method to diagnose TB.

Treatments.

1. Benzyl penicillin 50000Units per kg IM or IV every 6hours for 5 days.

2. Gentamycin 7.5mg per kg IM or IV once a day for 5 days.

 

If the child does not show improvements from above treatments ,within 48 hours switch to

Ceftriaxone 80mg per kg IM or IV once daily for 5days.

       3.Paracetamol tabs 15mg per kg for 3 days

 

Suppotive care.

ü Remove by gentle sunction any thick secretions.

ü Give maintenance fluids.

ü Encourage the child to eat and oral fluids.

 

COMPLICATION

    -Lung abscess

    -Pleurisy

  

PROGNOSIS.

The prognosis will be good if the child will adhere to above treatment and nurses and mother will monitor the child’s medications administrations on time ,also food and fluid intake.

 

FOLLOW UP.

The child should be reviewed every day until the child improves and recovers completely. Then the child should be discharged .But the mother should bring back the child to hospital if he develops any complication or new complaints.

 

PREVENTION.

 

Ø Make sure the child wears sweaters during cold times.

Ø Do not subject a child beside any smoke or fumes.

Ø Make sure the child is not in contact with any person with respiratory infections.