Case Presentation

1. Case Presentation Presented by : Dr. Md. Forhad Hossain Assistant Registrar Department of Pediatrics SZMCH, Bogra. Sponsored by : ACI Pharmaceuticals

2. Patient particulars : • Name : SabbirHossain • Age : 3 months 15 days • Father’s Name : Md. AbdurRouf • Mother’s Name : Mrs. Shahana Begum • Address : Vill – Bilchapri, Union – Elangi • P.S – Dhunat, Dist. – Bogra. • Date of admission : 28/08/2008 - 2:55 PM • Cough and running nose for 8 days. • Difficulty in respiration for 4 days. • Vomiting for 1 day. Chief complaints :

3. History of present illness : According to statement of mother the child was alright 8 days back. Then he developed cough and running nose but no fever. The cough was unproductive. This condition continued for 4 days then he developed respiratory distress with audible musical sound (as described by mother shi-shi). The mother also stated that her baby has developed decreased feeding since then along with vomiting occasionally. The vomiting contained food given earlier. The baby does not develop bluish coloration of skin and lips during feeding. There is no history of ear discharge. The baby has normal bowel and bladder habit. The mother also added that this type of illness is first in his life. For this illness the child was taken to local doctors but cann’t mention the name of the drugs and after getting no remedy the child was brought to this hospital for better management.

4. Birth History : The baby was delivered NVD at full term at home by trained Dai. The baby cried immediately after birth. His birth weight was 2.3 kg. No antenatal check up was taken by mother and there is no history of illness during pregnancy and whole perinatal period was uneventful. First 11/2 months of life only breast milk was given. Then along with breast milk suji, moida and cow’s milk HAS BEEN added in the menu of the baby . Feeding history :

5. IMMUNIZATION HISTORY COMPLETE AS PER EPI SCHEDULE

6. Family history :There is no family H/O asthma 31/2 months 10 yrs Socio-economic history : Father : Farmer Mother : Housewife Live in house made of tin. Use tube-well water. Use pacca toilet. Total family member 19. Comment : Low socioeconomic condition. Live in crowded environment.

7. Developmental history : • Social smile present. • Has gained neck control. • Vision and hearing normal • Age : 3 months 15 days • Length : 59 cm • Weight : 6 kg • OFC : 39.5 cm Anthropometric measurement :

8. General physical examination : Appearance : Playful Built : Average Nutrition : Average Anaemia : Absent Jaundice : Absent Cyanosis : Absent Clubbing : Absent Koilonychia : Absent Leukonychia : Absent Oedema : Absent Dehydration : Absent Lymph node : Not enlarged Neck vein : Not engorged Pulse : 135/min Temp. : Normal Respiration rate : 65 / min Skin as whole : N

9. Systemic examination : Respiratory system : Inspection :Size shape and symmetry of chest = N Respiratory rate = 65 / min Chest in drawing = Mild Inter costal retraction = A Movement of aloe nasi = A Others = Normal Palpation :Position of trachea = N Position of apex beat =4th intercostal space medial to mid clavicular line Others = Normal Percussion :Normal Auscultation : Vesicular breathing with prolonged expiration. Rhonchi : Bilatenal huge rhonchi Creps : Mild on both sides

10. Cardiovascular system : Inspection : Normal Palpation : Normal Percussion : Normal Auscultation : 1st + 2nd heart sound audible. No added sound. Alimentary system : Normal Nervous system : Normal Genitourinary system : Normal

11. Salient feature : Sabbir Hossain, aged 3.5 months born at full term at home by NVD by trained Dai is brought up in a poor socioeconomic nonasthmatic family & living in a crowded environment presented with the complaints of cough and running nose for 8 days, difficulty in respiration for 4 days and vomiting for 1 day. The respiratory distress in first of its kind. Along with respiratory distress the child has developed vomiting which is occasional and vomiting contained food particle given earlier. The child has normal bowel and bladder habit. On examination the child alert and playful, afebrile, non cyanotic. There is no oedema, dehydration, neck vein engorgement. Continue …

12. On systemic examination the child is dyspnoeic, has mild chest indrawing first breathing (65/min). On auscultation there is vesicular breathing with prolonged expiration bilateral huge Rhonchi, mild crepitation on both lung fields. Other examination reveals normal. On anthropometric measurement the child normal.

13. Provisional diagnosis : Bronchiolitis

14. Differential diagnosis : Bronchopneumonia

15. Investigations : • CBC Hb : 60% • TC : 7,500 / cu mm • DC : N – 50% E – 05% • Lym – 45% Mono – 02% • Baso – 00% • ESR : 35 mm Hg • X-ray chest : Normal • Other investigation: • 1.Antigen tests of nasal washings provide (usually within 30 min) rapid and accurate (sensitivity 87-91% specifically 96-100%) detection of RSV. • A positive culture or direct fluorescent antibody test result can confirm the diagnosis of RSV infection or other infection (culture sensitivity 60% specifically 100%) • Polymerase chain reaction.

16. FINAL DIAGNOSIS BRONCHIOLITIS

17. MANAGEMENT: • General supportive measures IS one mainstay of treatment for patient with bronchiolitis. • Patient should be head up position. • Humidified O2 inhalation if O2 saturation < 94% on room air. • Dehydration should be corrected - Fever • - Tachypnoea • Diet - Risk of aspiration is significant when resp. rate > 60/min. When there is danger of such aspiration NG TUBE feeding or IV fluid should be given. • Bronchodilator: with salbutamol produce modest short term improvement. Nebulized epinephrine may occasionally be useful.Ipratropium bromide has no role • Steroid : has no beneficial effect. • Mast cell inhibiter cromoglycate had no beneficial effects.8.Counselling

18. Thank You