Identification

This is ---------- a --------- old male patient born from healthy parents, mother called ------- age----- who is
a ---------- and follows her education till 8 th grade who is -------in religion from---sub-city, city and a father
called ----- age ----- who is a ------ with --------- educational level, who is-------- in religion from sub-
city,city, was admitted to ------------Pediatric Ward at bed number ------------ on ----------------.

Chief Complaint: Shortness of breath of 2 months duration

Previous Admissions: none

HPI

This is a 12 year old child who was relatively well until 2 months back where she
developed SOB which was initially during playing, later when she was walking around the house
and later at rest with a total duration about 1 week to develop the SOB at rest. She also
developed bilateral leg swelling which initially started at the foot which later increased upto the
level of the knee in 1 week, there was no pain associated with the swelling and increases in the
afternoon and there was no other swelling in other body parts. In addition there is dry cough
and palpitation. She developed a localized and separate knee swelling 3 days later on her right
leg which grew insidiously, which was painful, and limited joint movement. She was given
unspecified injections of Benzantine Pencilin and following this the knee swelling subsided.

2 years back she had developed facial puffiness when she woke up in the morning, and
15 days later developed skin rash over the face. She had pain during urination and reddish
discoloration of urine. It was red-brown in color, spontanelously bled and was itchy. Its size and
itchiness increased upon exposure to sunlight. She was given a green, rectangular pill which she
took once a week and topically applied medication which was applied at night for a duration of
6 months, afterwhich the rash disappeared.

She has easy fatiguablity, observed but unquantified weight loss, history of bleeding
tendency, She has no orthopnea, no PND, no night sweats, no history of recurrent sore throats,
no fast breathing, no chest pain, no fever, no bluish discoloration, no choking incident, no loss
of consciousness, no audible breath sounds, no drooling, no difficulty in swallowing, no
hoarseness of voice, no bone pain, no blurring of vision, no dizziness, no family history of
asthma, no seasonal variation of the cough, no history of contact with chronic cougher, no
family history of Diabetes Mellitus, no reddish discoloration of urine, no flank pain, no change
in urine volume, no urgency, no yellowish discoloration of the eye or skin, no abdominal pain,
no vision problems no headache no abnormal body movement.

Following the development of the SOB the parents took her to Robe hospital where
after blood was drawn for investigation, she was reffered to TA and got admitted on sene
28/2004.

Past Medical History

Family History

Social: The mother and father are alive and they live together in a two room house with
1 window. The father is a driver and the mother doesn’t have an occupation, she is a
housewife. They drink tap water. He is the third child for the family.

Medical: no known history of Diabetes and Hypertension in the family

Immunization History

He was vaccinated according to EPI. The mother was given a certificate after finishing
the vaccination.

Nutritional History

He was exclusively breastfed for 3 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 after this he started eating potato, gomen, rice twice a day. He currently is
still breastfed but he has loss of apetite and doesn’t eat other foods as well.

The mother exposed him to direct sunlight until the age of 3 months for 1 hour in the
morning time from 1:30-2:30

Developmental History

He was able to sit by himself at 6 months, he was able to say his first word by
approximately 9-10 months.

Gross motor: walks

Fine motor: pincer grasp

 Language: uses 3-4 words

Social and Behavior: turns when called

Review of systems

General: see HPI

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, see rest on

HPI

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

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 100mmhg systolic normal, 60 mmhg diastolic normal

Pulse rate 135 per minute radial, full, regular, is tachycardia

Antrhopometry: Weight 8kg is between 70%-80% using the Harvard curve, underweght

Height 76cm is on the 3rd centile using NCHS, the lower border of normal

Weight for Height

MUAC 13 cm moderate malnutrition

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, running nose, 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: asymmetrical chest movement, no scars, no exudates, SC and IC retractions,

no cyanosis, no clubbing

Palpation: central trachea, no tenderness, asymmetrical 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: no tenderness on superficial palpation, no superficial mass, no rigidity or

guarding, no hepatosplenomegaly, no kidney enlargement

Percussion: tympanic note, no fluid thrill or Shifting dullness

Auscultation: bowel sounds are heard, no bruit over renal and aorta arteries

Genitourinary:

Inspection: no distention of suprapubic area, normal uretheral opening

Palpation: no costovertebral angle tenderness, descended testes

Locomotor system:

Inspection: no deformities of limbs, joints or vertebral columns, no wasting of muscles

Palpation: no restriction of movement in any joint, no tenderness on palpation of joints

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

Central Nervous System:

General: appropriate behavior, conscious

Cranial Nerves:

II) pupil is responsive to light

III/IV/VI) eye ball moves in all directions

V) suckles

VII) Face is symmetrical upon smiling

 VIII) turns toward noise

IX/X) central uvula,

XII) no deviation on protrusion of tongue, no atrophy

Motor

Upper Lower
right left right left
Bulk symmetrical Symmetrical
Fasciculation No induced or spontaneous No induced or spontaneous
Tone Normotonic Normotonic
Power Grade 3 Grade 3
Reflexes

Superficial Deep
Corneal Blinks Biceps ++
Abdominal Contraction towards Triceps ++
umbilicus
Cremasteric Retraction on same Brachioradialis ++
side
Plantar Downgoing Patellar ++
Ankle ++

Sensory

Can feel superficial and deep pain

No meningeal signs

Assessment

Subjective: This is a 1 year and 5 months old child. He has had cough and fast breathing
of 4 weeks duration and coughing of 3 weeks duration with an episode of vomiting, loss
of apetite, weight loss of 2 kg, 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
Discussion of Differential Diagnosis

discuss deply from lower to top each of differential diagnosis------

example; 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 go for this diagnosis.

Investigation
Chest X-Ray CBC

Early morning gastric washings Mantoux test