Posted: May 30th, 2015

Paediatric Case Study

Paediatric Case Study

Subjective Information

PC – Shortness of breath and increased work of breathing

HPC – 3-year-old male presents to the Emergency Department with a two-day history of rhinorrhoea, a productive cough and fevers. He woke up overnight gasping for breath and required his ventolin inhaler every three hours until 3am when it became hourly. His mother called an ambulance at 6am. The patient (John) has a twin brother who was admitted to hospital with the similar issue and was discharged only the previous day.

PMH

•    Overall general health: Normally a healthy and sociable 3-year-old little boy. Normal weight for age and height. Good appetite. Sleeps well.
•    Immunisations: Childhood vaccinations up to date
•    Allergies: Shellfish (urticaria)
•    Past hospitalisations: Age 4 months with bronchiolitis, Age 2 x2 admissions with similar symptoms as today and 3 months ago with the same.
•    Past medical illnesses: (as above)
•    Past surgical illnesses: Nil of note.
•    Pregnancy & Birth Hx: First pregnancy with non identical twin boys. Born pre term at 35+4 weeks by emergency caesarean section for pre eclampsia. John was kept in the special care baby unit for 9 days post delivery. Birth weight 5lb and 6 oz.
•    Medications: Fluticasone (Flixotide) inhaler 50mcg via spacer BD & Salbutamol (ventolin) inhaler 100mcg 1-2 puffs as required.
•    Social history: Lives at home with his parents and twin brother. Attends kindergarten twice a week.

Review of Systems

•    Weight: Currently 15kg. No recent changes.
•    Skin: Intact. No rashes, lumps, wounds or bruising.
•    HEENT: No headaches or concussion, no visual or hearing problems, no sore throats or tonsillitis.
•    Respiratory: Bronchiolitis age 4 months. Recent coryzal symptoms. No wheeze or productive cough.
•    Cardiovascular: Nil significant.
•    Gastrointestinal: No abdominal pain, diarrhoea, constipation or vomiting.
•    GU: Nil significant.
•    MSK: Nil significant.

Objective information

•    Vital signs: BP 100/75, HR 165-170, RR 35, T 38.4, SpO2 100% in room air, CRT <2 seconds, weight 15kg.
•    General survey: sitting up on the bed watching a movie, alert, cheerful and interacting with myself and others.
•    Skin: Looks pale. No obvious rashes, birth marks, scars or bruises. Good skin tugour and warm to touch.
•    Head/Face/Eyes: Nil significant.
•    Ears: Tympanic membranes intact and clear.
•    Nose: clear discharge.
•    Mouth & throat: moist pink mucous membranes, throat clear, no erythema or pus evident on tonsils.
•    Neck: No cervical or supraclavicular lymphadenopathy. Trachea midline.
•    Respiratory: RR 35bpm, SpO2 100% in RA, talking in full sentences. Symmetrical chest expansion, mild dyspnoea and work of breathing. Mild inter-costal recession. No cyanosis. Auscultation: Equal air entry, no wheeze or stridor. Productive cough with yellow sputum.
•    Cardiovascular: Dual heart sounds. Nil added.
•    Abdomen: Soft and non-tender. Active bowel sounds.
•    Renal: No urinary symptoms.
•    Neuro: GCS 15. Alert. Moving all 4 limbs. Normal gait.
•    Endocrine: Nil significant.
•    Nutrition: eats a well-balanced healthy diet. 3 meals a day plus snacks.

Assessment

Differential diagnosis:

•    Reactive airways disease (RAD)
•    Upper respiratory tract infection (common cold)
•    Acute bronchitis

Actual diagnosis:

•    Reactive airways disease (RAD)

1.    Management Plan: Non pharmacological oxygen, cardiorespiratory monitoring, pulse oximetry, offer fluid and diet, monitor vitals every 30 mins or more frequently if his symptoms worsen, reassure child and mother and keep them fully informed of the patients care, answereing any questions they may have. Look at guidelines for oxygen etc.