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ADMISSION CONFERENCE. Conti, Mary Angeli. General Data. K.A.R. 1 year, 7 month old Male Filipino Sta. Cruz, Manila Informant: Mother Reliability : 80 % Date admitted: November 3, 2009. Chief Complaint. Fever. History of Present Illness. Cough & Colds. History of Present Illness.
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ADMISSION CONFERENCE Conti, Mary Angeli
General Data K.A.R 1 year, 7month old Male Filipino Sta. Cruz, Manila Informant: Mother Reliability: 80% Date admitted: November 3, 2009
Chief Complaint Fever
History of Present Illness Cough & Colds
History of Present Illness Difficulty of Breathing ADMISSION
Review of Systems • (+) Weight loss, decreased appetite • No pruritus, jaundice, pallor • No abdominal pain, diarrhea • No constipation • No easy bruisability, epistaxis • No loss of consciousness, seizures, alteration in mental status
Personal History FEEDING HISTORY Picky eater, prefers food with soup Breakfast: Rice and hotdog Lunch: Rice, Soup, Dish Dinner: Rice, Soup, Dish Snacks: Milk 8 oz every four hours Multivitamins, ascorbic acid
Personal History DEVELOPMENTAL AND BEHAVIORAL HISTORY Can already run well, and can jump Cannot use pronoun and produce 3-word sentences Can feed self using spoon Not yet toilet trained by day Can remove clothes by himself Can point to body parts
Personal History PAST ILLNESSES December 2008 - Acute Gastroenteritis, Dehydration No previous trauma, surgeries No previous blood transfusions
Immunization History Health Center, dates were unrecalled
Family History (+) Asthma - Mother, Father, Maternal aunt (+) DM - Grandfather (-) Heart disease, kidney disease (-) Thyroid disease
Socioeconomic and Environmental History Wooden house shared by 10 individuals Grandmother - primary caregiver when mother is at work Drinking water from refilling station Garbage collected daily, no segregation No pets (+) Smoking exposure No nearby factories
Physical Examination Awake, alert, in cardiorespiratory distress, well nourished, well hydrated HR: 140 bpm, reg RR: 55 cpm, reg Temp 37.2°C Wt: 12.5 kg (z=0) Ht: 90 cm (z=0) BMI: 15.43 (z=0, N) Warm moist skin, no active dermatoses, no jaundice, no cyanosis, no rashes Pink palpebral conjunctivae, anictericsclerae
Physical Examination No tragal tenderness, non-hyperemic EAC, intact tympanic membrane in both ears, retained cerumen AD, (-) aural discharge (-) Alar flaring, midline nasal septum, no nasal discharge, turbinates not congested Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged, (-) circumoral cyanosis
Physical Examination Supple neck, no palpable cervical lymphadenopathies Symmetrical chest expansion, (+) subcostal retractions, (+) coarse crackles in bilateral lung fields, (+) wheezes on both lung fields Adynamicprecordium, AB 4th LICS MCL, no murmurs Flat abdomen, no visible peristalsis or mass, normoactive bowel sounds, tympanitic, soft, non-tender Pulses full and equal, no edema, no cyanosis
Neurologic Examination Alert, awake Cranial nerves are intact No gross hearing deficits Can move head from side to side Motor 5/5 on all extremities Reflexes: DTRs ++ on all extremities No Babinski No meningeal signs
Salient Features Subjective findings Objective findings • 2 y/o Male • Persistent cough and colds • Tachypnea • Nocturnal awakening • History of pneumonia • (+) family history of asthma • (+) cigarette smoke exposure • RR 55 cpm • Afebrile • No nasoaural discharge tonsils not enlarged • (+) Subcostal retractions • (+) Crackles, wheezes both lung fields • No cyanosis
Approach to Diagnosis Look foer a symptom, sign or laboratory finding pathognomonic of a disease Look for a symptom, sign or laboratory finding pointing to an organ system Look for a symptom, sign or laboratory finding pointing to a group of diseases Look for a symptom, sign or laboratory finding whose mechanism is well-understood Look for a symptom, sign or laboratory finding found in the least number of diseases
Pulmonary System Approach to Diagnosis
Host Factors: Genetics • Search for genes focus on the ff areas: • Production of allergen-specific IgE antibodies (atopy) • Expression of airway hyperresponsiveness • Generation of inflammatory mediators • Determination of the ratio between Th1 and Th2 immune responses GINA, 2008
Host Factors: Obesity • Leptins • May affect airway function and increase the likelihood of asthma development GINA, 2008
Host Factors: Obesity Am J Respir Crit Care Med Vol 174. pp 112–119, 2006 Originally Published in Press as DOI: 10.1164/rccm.200602-231PP on April 20, 2006
Host Factors: Sex • Prior to 14 years of age • Male > Female • Adulthood • Female > Male • Unclear • Lung size is smaller in males than in females at birth but larger in adulthood GINA, 2008
Pathogenesis • Airway inflammation • Airway hyperresonsiveness • Airway narrowing (bronchoconstriction)
Asthmatic Inflammation Subacute/Chronic Inflammation Early Asthmatic Response Late Asthmatic Response Normal Airway Inhaled trigger chemotactic factors cytokines Recruitment and activation of inflammatory cells Neural & vascular effects Mast Cells Alveolar macrophages
Pathogenesis • Airway inflammation • Airway hyperresonsiveness • Airway narrowing (bronchoconstriction)
Clinical Manifestations • Intermittent dry coughing and/or expiratory wheezing • Most common chronic symptom of asthma • Shortness of breath, chest tightness, intermittent nonfocal chest “pain” GINA, 2008
Categories of asthma • Transient early wheezing • Often outgrown in the first 3 years of life • Associated with prematurity and parental smoking • Persistent early-onset wheezing (before age 3) • Recurrent episodes of wheezing with acute viral RTI, no evidence or FHx of atopy • symptoms persists through school age to 12 y/o • Cause: RSV in children <2 y/o • Late onset/wheezing asthma • Persists throughout childhood and into adulthood • Atopic background with eczema GINA, 2008
Highly suggestive of asthma • Frequent episodes of wheeze (once a month) • Activity induced cough or wheeze • Nocturnal cough in periods without viral infections • Absence of seasonal variation in wheeze • Symptoms that persist after age 3 GINA, 2008
Presence of wheeze before age 3 + 1 major Or 2 of the 3 minor criteria GINA, 2008