Case Write Up

By Saleh Abdullah Al-Shehri 0704020 Group M6 Fifth year Medical Student

History was taken from the Mother, she was reliable and cooperative. Atheer is a 7 year old Yemeni girl who presented to the ER on the 7th of November Sunday morning. Is a known case of Asthma, diagnosed one year ago at KAAUH. She presented with:-Shortness of Breath -Fever -Cough All of these symptoms 1 day before admission.

She was in her usual state of health until Saturday morning where she started to get slightly Dyspneic at which point her mother gave her two puffs of Ventolin .She later went to school when she came back from school she was starting to show symptoms of an URTI watery runny nose, coughing, was more severely dyspneic with a Fever the mother did not measure it. At 1:00 pm the mother gave her an anti pyretic suppository and her fever went down slightly at around 6:00 pm she gave her an other suppository. Later that evening the dyspnea was so sever that's when the mother decided to seek medical attention around midnight that evening. The Dyspnea was gradual, continuous, interfering with her normal daily activity, not relieved by bronchodilators and associated with an expiratory wheeze. She has a positive history for a allergic rhinitis .The dyspnea was associated with a non-productive cough. There was no history of contact with TB patients, nor any smokers. The dyspnea was not associated with any chest pains, but was associated with a generalized non specific faint abdominal pain.

The Fever was sudden, continuous and was associated with a non specific generalized abdominal pain. The fever was not associated with any headaches, photo-phobia, neck-stiffness, night sweats, neither vomiting nor any convulsions. There was also no history of ear pain, dysuria nor any diarrhea. There was neither history of recent travel nor any history of animal contact. There was also no recent history of contact with ill patients. There was a dry non-productive Cough that was continuous, gradual and increasing in nature with no special character associated with shortness of breath with no history of dust, fumes nor any smoke contact. There was also no history of gastro-esophageal reflux disease. The cough was not associated with any post-tussive vomiting although the mother stated that in previous exacerbations this was a common occurrence. There was a negative history for blood stained coughs hemoptysis. There was a history of decreased oral intake due to the illness which was concerning the mother. The mother added that her dyspnea was slightly relieved by percussing the back.

There were three previous hospital admissions:-27/10/2009 acute exacerbation of bronchial asthma -10/06/2010 acute exacerbation of bronchial asthma -09/09/2010 acute exacerbation of bronchial asthma

Hospital Course:Since admission the patient has been markedly improving with the fever subsiding on the evening of the 8th of November. Investigations done were a CBC which showed a slight Neutrophilia and Eosinophilia .CXR showed right upper lobe consolidation. Urinalysis and U/E was unremarkable. ESR was slightly elevated 24 Diagnosed as lobar Pneumonia with exacerbations of asthma. Since admission she has received Oxygen, Magnesium sulfate, Atrovent, Ventolin, Hydrocortisone, Augmantien and Paracetamol. Systemic Review:Beside what was mentioned on the history of presenting illness was grossly unremarkable. Allergies: The patient is a know case of a Mild persistent Asthma diagnosed 1 year ago and has morning allergic rhinitis and watery eyes with negative history of eczema. Peri-natal History: The child is a product of a full term pregnancy with spontaneous vaginal delivery with no complications and a birth weight of 3 kg was discharged from hospital one day after pregnancy. Past Medical:Three hospital admissions for exacerbation of asthma. Diagnosed 1 year ago as a case of Mild Persistent Asthma by spirometry. Not known to have any other chronic illness. At home she is on Ventolin PRN.

Past Surgical:No previous History of surgery, with no history of any blood transfusions. Developmentally: Up to age and is doing well in elementary school. Vaccinations: Received all the primary vaccines with no adverse reactions, last vaccines taken at 6 years old. Nutritionally: The patient usually eats with her family on the table although with the recent illness her oral intake decreased. Social History: The father has an office job and the mother is a house wife. Financially the family is middle class. The patient is a first grade student who lives in Jeddah Al-Naseem district .She lives with her parents and three other sisters in an apartment. She sleeps with her three other sisters in one big room no overcrowding with ceramic flooring. They dont have any pets at home. Family History: There is a positive family history for bronchial asthma as her eldest sister is also an asthmatic. She has three sisters aged 13, 11, and 6 respectively. Her parents are all non smokers and nonconsanguineous. Family Tree:

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Summery: Atheer is a 7 year old Yemeni girl who presented to the ER on the 7th of November Sunday morning with Fever, Shortness of breath and Cough for one day. Known case of Asthma, diagnosed as a case of lobar pneumonia with exacerbation of asthma.

Physical Examination was done on the 10th of November. General Examination: The patient looked well not showing signs of respiratory distress oriented with person place and time. With no cyanosis no pallor no plethora nor any jaundice. The patient was lying comfortably in her bed. She was connected to a right sided I.V cannula. Growth Parameters: Weight: 19.5 kg 30th percent on the percentile chart. Height: 120 cm 60th percent on the percentile chart. Head circumference: 50 cm 35th percent on the percentile chart. Vital Signs: Heart Rate:95 Bpm Blood pressure: 105/68 O2 Sat : 99 %

Respiratory Rate:20 Temperature :37.5 C

Hand Examination: There was no clubbing, no peripheral cyanosis, no muscle wasting, no flapping tremors and no leukonychia nor any no splinter hemorrhage. Pulse was regular with good volume although there was a slight Water hammer pulse. Head and neck Examination:There was neither central cyanosis nor any cervical lymphadenopathy with a central trachea. Otoscopy of the ear showed non erythmatous tympanic membrane with a good cone of light. Throat exam showed no enlarged tonsils and a non impressive throat.

Lower Limbs Examination: No lower limb edema, no muscle wasting and normal palpable pulse.

Chest Examination:
-On Inspections respiration was mainly thracoabdominal with no use of accessory muscles. There was a slight pectus crinatum pigeon chest. There was neither scoliosis nor any kyphosis. -On palpation trachea was central with no deviations. Tactile Fremitus was increased on the right upper lung zone of the back. Chest expansion was bilaterally symmetrical. -On percussion there was dullness at the upper right lung zone of the back. -on Auscultation there was decreased air entry on the right side associated with expiratory wheeze.

Cardio Vascular Exam: Normal first and second heart sounds with no added sounds. Good palpable peripheral pulses. Central Nervous System Examination: Grossly intact as the patient was conscious oriented and alert with Person Place and Time. Normal deep tendon reflexes. Bilaterally reactive pupils . Abdominal Examination: Soft lax non-tender abdomen with no Organomegally .

Deferential Diagnosis: 1-Lobar Pneumonia with Exacerbation of Asthma 2- TB 3-Upper respiratory tract infection 4-UTI Problem list: 1-The mother was concerned about the lack of appetite her girl has. I- Although to be expected as her daughter is ill reassurance and proper nutrition intake is vital meeting with a nutritionist is recommended. 2-Also the mother was worried that her medications were not relieving her in her attacks. II- Booking an appointment with a pulmonologist to re-assess her asthma type. 3-The mother worried why her daughter O2 saturations was low at admission. III: Explained to the mother due to her daughters pneumonia and asthma it becomes increasingly harder for her to saturate her blood.

Thank you for your time.