Personal details
Name kalid mohammed Age: 1 year and 4months
Sex: male Address: diredawa
Religion: muslim Historian: father
Date of admission: 11/12/04 E.C
Parent’s name: mother hayat age 18 occupation house wife.
Father mohammed abdo age 29 occupation mechanic.
Date of interview: 22/12/04.
Chief Complaint: worseningof cough and fast breathing of 10 days duration.
Previous Admissions: mentioned on HPI.
HPI
This is a 1 year and 4 months child who was relatively well about one month back, at
which time he developed cough and fast breathing. The cough is non- productive and there was
grunting associated with the fast breathing.
during this time the parents have taken him to dire dawa hospital where he was given
unspecified syrup ,injectable medicine and glucose.After two weeks he is discharged and
referred to this hospital with out improvement.
He has high grade intermittent fever ,runny nose, unquantified amount lose of
weight,losf appetite fatigability and interruption of breast feeding this followed by vomitting of
non projectile and non food particle of ingested milk. Before ten days on admission ,the cough
and shortnessof breath is become worsening and he was put on nasal oxygen and his rapid
breathing was slightly improved.
other wise he has no history of contact withTB petients or chronicaly couher.
no HX of night sweat or haemoptsis . Nohx of bowel and urinary colour or habit change .
n o hx of cardiac disease.
past medical history
She started her antinatal care follow up at 6 months, had been vaccinated, tested for HIV
and found to be non-reactive; she delivered in the tena tabia with the labor which started
spontaneously lasted for about 6 hours. He cried immediately after birth and was breastfed
within the first hour after delivery.
Family History
Social: The mother and father are alive and they live together in a small single room
house with 1 window. The father is a mechanic and the mother doesn’t have an occupation, she
is a housewife. They drink tap water. He is the first child for the parents.No history of measels
mumps other child hood ilness.
Medical: no known history of Diabetes, asthma,cardiac disease and Hypertension in the
family.
Immunization History
He was vaccinated according to EPI.
Nutritional History
He was exclusively breastfed for 6 months and his mother started giving him water upto
6 months, whenafter he was started on supplemental foods like cerifam, fafa, pastini until the
age of 1 year and . He currently is still breastfed but he has loss of apetite and doesn’t eat other
foods as well.
Developmental History
He was able to sit by himself at 6 months,
Gross motor: walks
Fine motor: pincer grasp
Language: uses 3-4 words
Social and Behavior: turns when called
Review of systems
General:
Head: no headache, no head injury
Ears: no earache, no discharge, no ringing in ears
Eyes: no discharge, eye redness in the 2 weeks which resolved
Nose: no epistaxis, no sneezing, see rest on HPI
Mouth: no dental carries, no bleeding gums, no ulceration
Throat: no hoarsness of voice, no difficulty in swallowing
Respiratory: no wheezing, see rest on HPI
Cardiovascular: no fainting, no history of easy fatigability on breast feeding, no
orthopnea, no edema
Gastrointestinal: no constipation, no diarrhea, no jaundice see rest on HPI
Genitourinary: no dysuria, no frequency, no urgency, no change in urine color
Integumentary: no rashes, no hair or nail changes, no lumps
Locomotor: no swelling of joints, no deformity of joint
Central Nervous System: no paralysis, no speech defect
Physical Examination
General Appearance: he is sick looking, he looks malnourished, he is in respiratory distress with
flaring of the ala nasi and subcostal and intercostal retractions, he is alert, has no dysmorphic
features
Vital Signs: RR 59 per minute, normal pattern, tachypnea
Temperature 37.3 degree Celsius axillary, normal
BP
Pulse rate 135 per minute radial, full, regular, is tachycardic
Antrhopometry: Weight 8kg is between 70%-80% using the Harvard curve,
Height 76cm is on the 3rd centile using NCHS, the lower border of normal
Weight for Height
MUAC
Head circumference 47.5cm is between mean and -2SD
HENT
Head: round head, no tenderness on palpation
Neck: no mass, no shorteness of neck, no webbing of neck, no distended neck vein
Eyes: pink conjunctiva, white sclera
Ears: ears positioned normally, no discharge, no tenderness
Nose: both nostrils are patent, no discharge, the septum is located medially
Mouth: no cracked lips, pink tongue, no atrophy, no thrush, no gum hypertrophy, no carries, no
hyperemia, no exudates
Glands: no enlarged lymph nodes, no thyroid enlargement
Respiratory System:
Inspection: symmetrical chest movement, no scars, no exudates, SC and IC retractions,
no cyanosis, no clubbing
Palpation: central trachea, no tenderness, symmetrical chest wall expansion
Percussion: resonant percussion note on left lung, dull on entire right lung
Auscultation: vesicular breath sounds on both lungs but with decreased air entry in the
entire right lung, no abnormal or added sounds
Cardiovascular System:
Peripheral: radial, femoral, carotid pulses are present, no palmar pallor, JVP is not raised
Inspection: no bulging, quite precordium
Palpation: no heave, no thrill
Auscultation: S1 and S2 well heard, no murmur or gallop
Gastrointestinal System:
Inspection: abdomen is distended, flanks are full, umbilicus is inverted, horizontal slit,
symmetrical abdomen and moves with respiration, no scars, no visible pulsations, no distended
veins, hernia sites are free
Palpation: superficial tenderness on right upper quadrant and suprapubic area, no
superficial mass, no rigidity or guarding, no splenomegaly, liver is slightly tipped, no kidney
enlargement
Percussion: tympanic note, fluid thrill and shifting dullness positive
Auscultation: bowel sounds are heard, no bruit over renal and aorta arteries
Genitourinary:
Inspection: distended suprapubic area, skin of shaft of penis is ulcerated, shaft of penis is
swollen, scrotum is enlarged, normal uretheral opening
Palpation: tenderness on slight touch of scrotum, 22 cm sized scortum
Locomotor system:
Inspection: no deformities of limbs, joints or vertebral columns, no wasting of muscles,
edematous
Palpation: no warmth, no tenderness over joint swellings, Grade 3 edema, no restriction
of movement in any joint
Integumentary System:
Skin: no jaundice, no pallor, no cyanosis, no hypo/hyper pigmentation of skin, skin is wet
Hair: normal distribution of hair, hair not plackable easily, balck color, smooth texture
Nail: no spooning or clubbing, no cyanosis
Central Nervous System:
Cranial Nerves:
I) Smells alcohol
II) Good acuity, field of vision
III/IV/VI) eye ball moves in all directions
V) Sensation on face is intact, muscles of mastication are present, there is no ptosis and
corneal reflex is positive
VII) Face is symmetrical, can close eyes against resistance, no deviation upon smiling, can
frown
VIII) Hears slight rustling sound
IX/X) central uvula, palate arches upward when saying ‘ah’,
XI) Shrugs shoulder against resistance, turns face to side against resistance
XII) Can protrude tongue, no deviation on protrusion of tongue, no atrophy
Motor
Upper Lower
right left right left
Bulk symmetrical 33cm 36cm
Fasciculation No induced or spontaneous No induced or spontaneous
Tone Normotonic normotonic
Power Grade 4 Grade 3
Reflexes
Superficial Deep
Corneal blinks Biceps ++
Abdominal Contraction towards Triceps ++
umbilicus
Cremasteric Retraction on same Brachioradialis ++
side
Plantar downgoing Patellar ++
Ankle ++
Co-ordination
Can not be assesed.
Sensoy
Can feel superficial and deep pain sensation.
Assessment
Subjective: This is a 1 year and 4 months old child. He has had cough and fast breathing
of 10 duration with an episode of vomiting, loss of apetite, grunting weight loss, he was
also thirsty.
Objective: Tachypnea, Tachycardia, decreased air entry on right lung, dullness on
percussion, underweight, assymetrical chest wall expansion, intercostal and subcostal
retractions
Differential Diagnosis
1) Pneumonia
2) TB
3) Malignancy
Discussion of Differential Diagnosis
Malignancy
Primary tumors of the lung are rare in children and adolescents. Bronchial adenoma and
carcinoi are the most common primary tumors. Metastatic lesions are the most common forms
of pulmonary malignancy in children; primary processes include Wilms tumor, osteogenic
sarcoma, and hepatoblastoma. Adenocarcinoma and undifferentiated histology are the most
common pathologic findings in primary lung cancer; pulmonary blastoma is rarer and frequently
occurs in the setting of cystic lung disease. Mediastinal involvement with lymphoma is more
common than primary pulmonary malignancies. Pulmonary tumors may present with fever,
hemoptysis, wheezing, cough, pleural effusion, chest pain, dyspnea, or recurrent or persistent
pneumonia or atelectasis. Tumors may be suspected on plain chest x-ray; CT scanning of the
chest is necessary for precise anatomic definition. Bronchial tumors are occasionally diagnosed
during fiberoptic bronchoscopy performed for persistent or recurrent pulmonary infiltrates or
for hemoptysis.
In this particular patient the fever, loss of weight, dullness on percussion of one lung,
assymetrical chest wall expansion, decreased air entry, retractions go for this diagnosis.
Tuberculosis
Pediatric tuberculosis (TB) is the disease state caused by Mycobacterium tuberculosis, an
acid-fast bacillus (AFB). Pediatric TB should be regarded as a spectrum of exposure, from
infection to disease, because progression from an infected individual (exposure) to infection and
subsequently disease can occur much faster in children under 2 years of age. Progression
through this spectrum is age-dependent, being 40% to 50% for zero up to 2-year-olds,
approximately 20% for 2- to 4-year-olds, and 10% to 15% for those 5 years old and over, the 5-
to 10-year-olds being the most protected age group. Adolescence is another vulnerable age
group. The majority of children with tuberculosis infection develop no signs or symptoms at any
time. Occasionally, infection is marked by low-grade fever and mild cough, and rarely by high
fever, cough, malaise, and flulike symptoms that resolve within 1 wk.
In this particular patient the fever, cough, dullness on percussion, decreased air entry,
retractions, assymetrical chest wall expansion favors for this diagnosis.
Pneumonia
Pneumonia is an inflammation of the parenchyma of the lungs. Although most cases of
Pneumonia are caused by microorganisms, noninfectious causes include aspiration of food or
gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions, and
drug- or radiation-induced pneumonitis. Viral and bacterial pneumonias are often preceded by
several days of symptoms of an upper respiratory tract infection, typically rhinitis and cough. In
viral pneu monia, fever is usually present; temperatures are generally lower than in bacterial
Pneumonia. Tachypnea is the most consistent clinical manifestation of Pneumonia. Increased
work of breathing accompanied by intercostal, subcostal, and suprasternal retractions, nasal
flaring, and use of accessory muscles is common. Bacterial Pneumonia in adults and older
children typically begins suddenly with a shaking chill followed by a high fever, cough, and chest
pain. Physical findings depend on the stage of Pneumonia. Early in the course of illness,
diminished breath sounds, scattered crackles, and rhonchi are commonly heard over the
affected lung field. With the development of increasing consolidation or complications of
Pneumonia such as effusion, empyema, or pyopneumothorax, dullness on percussion is noted
and breath sounds may be diminished. A lag in respiratory excursion often occurs on the
affected side. Abdominal distention may be prominent because of gastric dilation from
swallowed air or ileus. Abdominal pain is common in lower lobe Pneumonia. The liver may seem
enlarged because of downward displacement of the diaphragm secondary to hyperinflation of
the lungs or superimposed congestive heart failure. Nuchal rigidity, in the absence of
meningitis, may also be prominent, especially with involvement of the right upper lobe.
In this particular patient the tachypnea, fever, dullness on percussion, assymetrical chest
wall expansion, decreased air entry abdominal distention, intercostals and subcostal retractions,
cough, running nose support this diagnosis.
Investigation
Chest X-Ray CBC
Early morning gastric washings Mantoux test
The final suggested differential diagnosis is:
community acquired pneumonia.
