November 28, 2014

Ateneo School of Medicine and Public Health

Clerkship Year: Pediatrics Rotation (Medical City)
CASE SUMMARY
Date of Consult: November 27, 2014
Time/Place of Consult: TMC
HISTORY

I.

Informant: Parents
Reliability: Very good

IDENTIFYING INFORMATION

Aldrine Joseph Dollente Magpoc (A.M.) is a 2 year old Filipino male, illiterate child, born on 10/ 20/
2012, single, Catholic, currently residing in Pasig City who came in with a chief complain of difficulty of
breathing. Informant is patients mother with a very good reliability.

II. SALIENT FEATURES

SUBJECTIVES

OBJECTIVES

2 year old male

GCS 15, appears to be irritable

Difficulty of breathing: 2 episodes in the

span of <24 hours happening at night,
precipitated by coughs and colds,
characterized
as
followswheezing,
labored breathing, supraclavicular chest
retractions,
mouth
breathing,
and
excessive tearing. Given salbutamol
nebulizer every 4 hours and 2 puffs of
Fixotide
with
temporary
relief
of
symptoms

Vital signs are stable

No noted neurologic deficits, good muscle

tone

No noted chest retraction/ deformities/

scars, equal and symmetric chest
expansion, harsh breath sounds, bilateral
expiratory
wheezing,
no
other
adventitious sound noted

Positive family history for asthma, atopic

dermatitis, and allergic rhinitis

No chest pain,
manifestation

headache,

or

skin

III. IMPRESSION
Bronchial asthma in acute exacerbation
t/c concomitant Upper Respiratory Tract Infection

IV. DIFFERENTIAL DIAGNOSIS

Differentials
Bronchial
asthma
exacerbation

in

Rule In
acute

(+) sudden onset of difficulty of

breathing

Rule Out
None

(+) History of accessory muscle

use
(+) previous episodes of similar
symptoms
(+) family history for asthma,
atopic dermatitis, and allergic
rhinitis
(+)
harsh
breath
sound,
Bilateral expiratory wheezing
Bronchitis

Bronchiolitis

(+) Difficulty of breathing

No fever

(+) History of accessory muscle

use

No other signs of constitutional

symptoms

(+)
harsh
breath
sound,
Bilateral expiratory wheezing

Acute onset

(+) Difficulty of breathing

Non-toxic looking

November 28, 2014

Ateneo School of Medicine and Public Health
Clerkship Year: Pediatrics Rotation (Medical City)
CASE SUMMARY
(+) History of accessory muscle
use
(+) harsh breath sound

No fever
No other signs of constitutional
symptoms
Absence of inspiratory stridor

Pulmonary congenital anomalies

Acute anaphylaxis

URTI

(+) Difficulty of breathing

No cyanosis

(+) History of accessory muscle

use

Non-contributory chest and

abdominal exam findings

(+) harsh breath sound

No digital clubbing

(+) Difficulty of breathing

No mucosal edema

(+) History of accessory muscle

use

No history of prior exposure to

allergen

(+)
harsh
breath
sound,
Bilateral expiratory wheezing

Non-toxic looking

(+) coughs and colds

None

Non-contributory dermatological
exam and vital signs findings

(+) harsh breath sound,

VI. DISCUSSION OF IMPRESSION

Asthma is a chronic inflammation of the pulmonary system manifesting as acute intermittent
episodes usually with identified precipitant factors that could be both physical and psychological. It is
usually presented as wheezing, breathlessness, chest tightness, and cough particularly at night and early
morning.
These episodes are also associated with lower airflow obstruction, reversible either spontaneously
or with therapy. The inflammation can also be causes increased airway hypersensitivity to a variety of
stimuli
Chest radiographs often show peribronchial thickening, hyperinflation, and patchy atelectasis
(Source: Harriet Lane)

VII.

ETIOLOGY
A combination of genetic and environmental factor and genetic/ immunologic factor.

VIII.

PATHOPHYSIOLOGY

Asthma is an inflammatory disorder of the airways, which involves several inflammatory cells and
multiple mediators that result in characteristic pathophysiological changes described as follows:

Airway epithelium shedding

Fibrosis and deposition of collagen III and V

Hypertrophy and hyperplasia of airway smooth muscle

Increased airway mucosal blood flow due to angiogenesis

Mucus hypersecretion
MANAGEMENT

IX. DIAGNOSTIC PLAN

CBC, chest x-ray AP/L, PFT, Na and K

November 28, 2014

Ateneo School of Medicine and Public Health
Clerkship Year: Pediatrics Rotation (Medical City)
CASE SUMMARY
X.

THERAPEUTIC PLAN
Admission to wards
Give the following medication:

Hydrocortisone 60 mg/ IV every 6 hours (43 mg/ kg/ dose)

Salbutamol neb, 1 nebulizer (2ml) every 4 hours and reassess after 8 hours. May be stopped
if no exacerbation is noted.

XI. SUPPORTIVE PLAN

Establish therapeutic alliance with the stakeholders
Monitor VS and O2 sat every 4 hours
WOF: episodes of desaturation, worsening/ progression of symptoms, status asthmaticus, and acute
respiratory failure

XII.

PROGNOSIS

Increased mortality risk is not observed with cases of simple febrile seizure. However, this patient has
a two-fold increase risk of mortality because he suffered from complex seizure that occurred before/ on
the age of 1 and triggered by a temperature of less than 39 C.

XIII.

PATIENT EDUCATION/ PUBLIC HEALTH ISSUES

Given the predominance of febrile seizure caused by influenza A, vaccination against influenza A
during flu season is recommended. Patients parents should be advised and educate regarding the
precipitating factor of the seizure to prevent future episodes
References
Medscape
Medline