A 10Months Male Child With Bronchiolitis with Grade 3 PEM

THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 

CHEIF COMPLAINTS:-
C/O fever since 1week
C/O Cold since 1week 
C/O cough since 1week 
HISTORY OF PRESENT ILLNESS:-
Baby was apparently asymptomatic 1week back
When he developed 
1) Fever- sudden onset 
              - moderate grade 
              - interfebrile period
              - not associated with chills/ rigors 
              - subsided on taking medication  
              - associated with excessive cry or                             irritability 
 2) cold- associated with rapid breathing 
             - nasal block Positive 
             - running nose Positive 
             - more during night 
3) cough- productive type 
               - gradual onset
               - no diurnal or nocturnal variation 
               - no seasonal variation 
H/O dull activity during fever 
No H/O vomiting/ loose stools/ear discharge 
No H/O seizure activity 
No H/O decreased intake of food 

PAST HISTORY:- 
1st episode- H/O similar complaints @ age of 7 months. Baby was admitted for 3 days kept on oxygen with NP @ 2 litre/ min.
 Inj- Amoxiclav- 3 days and supportive treatment  was given
Inj- pantop
Inj- neomol 
Mucolite drops 
2nd episode- Baby was admitted again after 3 weeks for which kept on oxygen with  NP @ 2 litre /min for 4 days.
Inj- Amoxiclav-7 days and supportive treatment was given                                        IMMUNIZATION HISTORY:-
BCG scar not present 
Last received at age of 2 and half months of age 
NUTRITIONAL HISTORY:-
Alternate top feeding (lactogen) with cerelac

GENERAL EXAMINATION :-
Weight-6.5 kg 
Baby is irritable
All peripheral Pulses felt are normal 
Pallor- Present
No icterus / cyanosis 

VITALS:- 
Temp- 102 C/F
Pr-126bpm
rr-48 cpm
GRBS-80 mg/ dl

HEAD TO TOE EXAMINATION :-
Head- frontal bossing-Positive 
Dry scalp
Eyes,ears, chest, face, abdomen, hands and legs are normal. 

SYSTEMIC EXAMINATION:-
1)Respiratory system 
Inspection- shape normal 
                  - trachea central 
                  - no visible scars/ sinuses/swelling 
Palpitation-chest expansion bilaterally
                     symmetrical 
                   - all inspiratory findings  confirmed 
Auscultation- BAE Positive (B/L air entry +)
                      - B/L fine crepts Positive 
2) GIT 
Inspection- shape of abdomen normal 
                   - umbilicus central  
                   - no scars/ sinuses 
Palpitation- soft
                   - no Tenderness 
                   - no arcromegaly
Auscultation- Bowel sounds 
3) CVS
 Inspection- shape of chest normal 
                    - trachea normal 
                    - no scars/ sinuses 
Palpitation- apex beat felt @ 5th ICS
Auscultation - s1 s2 Positive 
                       - no murmurs
4) CNS- Concious/ irritable 
            - cry/ tone/ activity  normal 

TREATMENT:-
Allowed supervised feeding 
O2 inhalational with NP @ 2 litre/ min 
Inj- neomol (15 mg/kg/dose)
Inj- pantop (1mg/kg/day)
Mucolite drops 1ml/ TID

         



  

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