SOCIOCLINICAL CASE PRESENTATION OF A CHILD WITH ACUTE UPPER RESPIRATORY TRACT INFECTION
Submitted to Dept. of Community Medicine on 26th May 2011
Name:- ***** PANDEY
Age:-4 yrs
Sex:-Female
Locality:-Urban
District:-Chitwan
Name of head of the family: - Mr ***** Pandey
Religion:-Hindu
Type of the family:-Joint
Caste:-Brahmin
Informant:- Mother
Reliability of informant:-good
DOA: 21-05-2011
DOE: 25-05-2011
GENERAL INFORMATION ABOUT FAMILY MEMBERS
table no 1.
ECONOMIC ASPECT OF THE FAMILY
1}Total income of the family:-7000(p)+25000(T)+7000(s)+15000®=54000
2}Per capita income of the family:-6000
3}Expenditure:-
a)Food:-20000
b)Clothing:-3000
c)Education:-5000
d)Housing:-3000
e)Medical care:-4000
f)Others:-15000
Dietary habits of the family:-Non vegetarian
ENVIRONMENTAL SANITATION
Housing:-Pucca three storeyed house
Water supply:-Municipal supply+sanitary well
Excreta disposal:-Water seal latrine
Refuse disposal:-Municipality collection
Drainage:-Septic tank
Livestock & poultry:-Nil
PRESENTING COMPLAINTS
Fever on/off for 6 days
Cough with running nose for 4 days
HISTORY OF PRESENTING ILLNESS :-
According to the mother, Narbada was apparently well 6 days back
Fever:
Insidious onset.
on and off in nature.
mostly occuring during evenings and nights.
Progressive, associated with chills but no rigors.
Maximum recorded temperature 103o.
subsided after taking paracetamol syrup.
No h/o headache, rashes, burning micturition, diarrhoea and abdominal pain.
No h/o of loss of consciousness, convulsions, and antecedant illness.
Cough
Onset after 2 days of fever.
Non productive.
10-15 bouts in a day, mostly during evening time.
Progressive in nature.
Associated with spontaneous vomiting after each bout. The vomitus was little in amount, contained mucus like substances.
No any diurnal and postural variations.
No history of FB inhalation or water brash.
No ear problems
No difficulty in breathing, no child turning blue or excessive crying.
HISTORY OF PAST ILLNESSES
Illnesses in the past :- Episode of allergic rashes before 2 year, treated well with 1 week hospital stay.
Other illnesses :- Neonatal physiological jaundice
Chronic illnesses:- None
Treatment availed:- None
FAMILY HISTORY
No similar history in the family member.
No familial diseases, genetic disorders.
No h/o DM, HTN, Bronchial Asthma, allergies in siblings and parents.
MATERNAL HISTORY
Maternal age: 22 years,
Parity : 1
No history of abortion and still birth
No history 0f maternal illness,HTN,DM,STDs, and blood dyscrasias.
PERINATAL HISTORY
Antenatal
Booked, immunised and supervised case
Hospital visits for 10 times
TT 2 doses,iron,calcium,folate taken
No radiation/teratogenic drugs exposure
No substance abuse
No history of ecclampsia,GDM and any other maternal illness
Intranatal
Normal vertex presentation
Full term, spontaneous labour onset
No undue prolongation of labour
Fetal monitoring normal
Mode NVD
Initial delivery assessment normal
Post natal
Birth wt: 2 kg SGA
Physiological jaundice appeared after 1 week and subsided spontaneously
APGAR score 10
Immediate cry after birth
DEVELOPMENTAL HISTORY
Normal growth and development according to age,race and sex
Normal gross motor,fine motor,social and language development.
Normal development compared to children of the same age
FEEDING HISTORY
Exclusively breast fed for 5 months
Weaning with massed dal bhat and honey
Breast feeding was supplemented with jaulo and sarbottam pitho
Breat feeding continued upto 15months
Now she eats family foods along with occasional fruits and other nutritional supplements
IMMUNIZATION HISTORY
BCG given at 1 month age
All vaccinations given at proper age and doses
TRAVEL AND CONTACT HISTORY
No recent travel history
Contact with cases of fever and cough (her brother and other friends)
DRUG AND ALLERGY HISTORY
No recent intake of drugs
Allergy was documented against certain cloths and house dust 2 years back
GENERAL EXAMINATION
Appearance: well looking, comfortable
Built and nutrition:- thin
Conscious GCS 15/15, cooperative
Decubitus:- sitting
i/v Canula in situ in left hand
No skin eruptions, no puffiness in face.
No pallor, icterus, lymphadenopathy, oedema, clubbing, cyanosis.
Hydration status normal
Extremities normal
No neck veins engorged.
VITALS
Respitary rate: 26/min,regular
Pulse: 110/min, regular, no pulse deficit,no RR and RF delay.
BP: 80/40 mmHg, on right arm in sitting posture.
Temperature: 100oF taken on EAC.
ANTHROPOMETRY
• Weight :14kg
• Height : 99cm
• Head circumference : 47.5cm
• Chest circumference : 51cm
• Mid upper arm circumference : 16.5cm
SYSTEMIC EXAMINATION
Respiratory system
Upper respiratory tract
Running nose, salute sign present, mild congestion of throat, no tonsils enlarged
Inspection
Normal size and shape of chest with symmetrical movements with respiration.
No use of accessary muscles and nasal flaring.
No scar marks, and abnormalities.
Respiratory rate : 30/min.
No chest indrawing present.
Palpation
Trachea central.
Apex beat on 5th ICS left 1.5cm inwards to MCL.
Symmetrical chest movement.
No tenderness, but tempeature febrile.
Percussion
Liver dullness starts from right 5th intercostal space
Normal resonant note on percussion on both sides of the chest
Auscultation
Normal vesicular breath sound on both sides of the chest.
No wheezing or stridor present now.
Vocal resonance normal.
Other systems
CVS : normal s1, s2, no murmurs
CNS : intact and normal
Abdomen : no abnormality seen, no organomegaly
LABORATORY FINDINGS:-
Rapid malaria test : negative
Leishmann stain of blood : negative
Hemogram : Normal TLC and DLC
Hb 11.8gm%
ESR normal
Chest x-ray normal.
Throat swab culture and sensitivity:yet to come
Gram stain of throat swab : Gm positive cocci seen
Blood culture and sensitivity : yet to come
Urine report : normal
CASE SUMMARY
Narmada pandey, 4 years girl, inhabitant of Lila Chowk Narayangarh, was brought to hospital with chief complaints of fever and cough with running nose for 6 days.
She was in contact with similar case(her brother and other friends) (source of infection) for about 1month.
She had a low birth weight(2kg), and is thinly built. She was reared in urban area and was boardsed in a day care school.
Fever was Insidious onset, progressive, on and off , associated with chills but no rigors.
After 2 days of fever, she developed Non productive cough,10-15 bouts in a day, mostly during evening time but Associated with spontaneous vomiting after each bout.
On examination she was found to be having increased respiratory rate(30/min), pulse rate(120/min), and fever(101oF). She had congestion of throat with salute sign and running nose.
Investigation showed marginal neutrophilia, throat swab stain positive for cocci bacteria.
COMPREHENSIVE DIAGNOSIS
Identification data:
4year old girl with h/o LBW, reared in urban area and boarderesd in a day care school.
Has history suggesting an allergic condition too.
Climatic changes, overcrowded urban dwellings nearby.
Clinical diagnosis:
Respiratory rate: 30/min
Fever: 103o F recorded maximum temp.
Stridor not present now.
Thin built (?malnutrition- child is difficult to feed)
No chest indrawing and cyanosis.
Other problems in family:- ?
Provisional diagnosis: Acute Upper Respiratory Tract Infection, AURI (viral? Bacterial?)
COMPREHENSIVE MANAGEMENT
Management of the case:
Using the guidelines prescribed by WHO,
Child with fever, cough
No chest indrawing and wheezes, sig. tachypnea = no pneumonia.
Assessment and treatment of sore throat, fever ?hospital stay needed?.
Advices to the mother.
Medications given:
Inj. Ceftriaxone 375mg i/v
Inj Amikacin 100mg i/v BD
Syp. Paracetamol 7.5 mg PO SOS
Syp. Expectorant (Terbutaline+Bromohexine) 1spoon PO TDS.
High risk strategy:-
Identifying risk factors:-
Day care centre leaving in overcrowded conditions
Low birth weight
Indoor smoking
Allergic conditions
Nutritional status
Health promotion
Specific protection
Population strategy
Climatic conditions
Urban and industrializing dwellings
Socioeconomic status
Pollution
Behavior of high risk:- smoking, crowding,
Specific protection
Health promotion
PREVENTIVE AND PROMOTIVE MEASURES
Specific advice for the mother:-
Proper medication as prescribed by the physician
Restrict the child from playing with other child for few days till recovered
Mouth covering during cough
Proper disposal of vomitus and sputum
Do not share clothes with other children till recovered
Make good ventilation in the room
Monitor fluid and food intake.
Secondary prevention:-
Continuation of primary prevention
Aim is to prevent recurrence and progression of same illness and its complications
Use of prescribed antibiotic for exact period.
Mass strategy: early detection of cases by early s/s and triage of cases according to age and severity and early referral and treatment
Thank you and have a GREAT day!!!
Prakash
