Respiratory Cases 

(History Taking)
(Ddx : Asthma/Acute Bronchiolitis/Pneumonia/Croup/Pertussis)
2 year old malay boy
Full Term / SVD
ANC : Uneventful
PNC : Neonatal Jaundice require phototherapy x 2/7
2 nd hospitalization
- 1st at 1 year old : AGE admit 2/7 at HRPZ
Immunization up to age
Presented with
🌸Rapid breathing x 2/7
- Worsening on day admission 12 noon
- Noted chest indrawing
🌸 Cough x 3/7
- Chesty in nature
- No prolong bout cough (tro pertussis)
- No barking cough (tro croup)
- Post-tusive vomiting x 2 ( non billious, no blood, milk content)
🌸 Fever x 3/7
- Continous
- No rigor
- Temporarily relieved by syrup PCM 6 hourly
- Highest documented temperature 38.6 C at home
🌸 Runny Nose x 1/7
- Clear nose discharge
🌸 Associated with
- Lethargy - mother noted pt sleep all day, usually active and playful
- Reduce oral intake 1/7, usually take 6 bottle (4 onz), however today only take 2 onz
🌸 Otherwise
- Unsure about PU (passed urine) - claimed as usual
- No diarrhea
- Sick contact with brother had URTI x 1/52 (fever but already resolved)
- Not from dengue prone area
- No h/o travelling
- No water activity
🌸 Interval Symptom 
(If we thinking of asthma, in patient had strong family history, had multiple admission or
nebulization before)
- No daily symptoms
- No nocturnal symptoms
- No exercise induce sympoms
* Ada tak anak puan batuk- batuk atau bersin pada waktu pagi-pagi ketika dia sihat sebelum ni?
Malam? Atau ketika dia kuat bermain?
- Patient no allergy rhinitis, but had eczema under HRPZ follow up
- Strong family history of asthma, both parent had allergy rhinitis, maternal auntie had asthma,
brother had eczema
- Multiple history of nebulization before, since 6 month old, about once every 2 month. No
admission
- Trigger : URTI/Cold whether, cold drink/dust/cat
*Biasanya, apa yang membuatkan dia mudah nampak lelah atau batuk-batuk sebelum ni? Cth
jawapan : Oh doktor, biasa kalau dia selema atau batuk, dia mudah kelihatan lelah (URTI adalah
trigger factor)
- No cat or carpet at home
- Father smokers
❤️NEPHROTIC SYNDROME❤️
(Nota diambil ketika HO teaching with Dr Ikram, HUSM)
📌Definition
Nephrotic syndrome is a clinical syndrome of massive proteinuria defined by
• Oedema
• Hypoalbuminaemia of < 25g/l
• Proteinuria > 40 mg/m²/hour 
(> 1g/m²/day) or 
an early morning urine protein creatinine index of >200 mg/mmol
(> 3.5 mg/mg)
• Hypercholesterolaemia
📌Cause
- Primary or Idiopathic (unknown cause) - commonest type in children
- Secondary 
✅ Infection : streptococcal
✅ Systemic condition : SLE
✅ Malignancy : Leukaemia
✅ Hematological
📌 Investigation
I. Albumin < 3g/dl
II. Cholesterol > 250mg/dl
b)FBC usually normal, raised ESR
c) CXR to R/O pleural effusion
d)Urinalysis
I. Proteinuria +3 or +4
II. Urinary protein excretion (>40mg/m2/hour)
III. 24 hours urinary protein : creatinine ratio > 3
IV. Microscopic hematuria in 10%
V. Pus cells in underlying UTI
📌Management
1. Advice for ambulate - prevent thrombosis, pulmonary embolism
2. Prophylaxis oral penicillin
- penicillin 150 or 250 mg BD
3. Hypovolaemia
- p/w abdominal pain, cold periphery, poor pulse volume, hypotensive 
- Resucitation with IV human albumin 5% (volume expander)
Bagi albumin just for reduce gross edema and resuscitation, jangan bagi just because blood
albumin level low. If minimal edema or ascitis, can just give lasix.
4. Diuretic
- Not give if patient steroid sensitive, usually can give in ward because can monitor any
hypovolemia, steroid resistant can give.
📌STEROID IN NEPHROTIC SYNDROME
(Belum sempat study lagi pasal management ni. Draf2 dulu ya?)
PREDNISOLONE
Initial diagnosis
60mg/m2/ day (max 80mg/day)
For 4 weeks
✅Not respons?
- Renal Biopsy
✅ Response
-
Treatment relapse
Prednisolone 40mg/m2/ eod for 4 weeks (maxium 60mg)
****
Both came with EDEMATOUS
Must differentie whether patiemt Underfill (hypovolume) vd overfill (overload)
If hypovolumic - give Albumin, not lasix
Patient can develop more hypovolume.
🎊SHOCK + RDS🎊
(Hasil coretan ketika HO Teaching)
#####
SHOCK
Definition
- Inadequate perfusion to meet tissue demand.
1. Compesated
- Tacycardic + cold extrimities (Cold Shock) ~ vasoconstriction
- Bounding pulse + warm periphery (warm shock) - (eg sepsis ~ vessel dilatation)
- Oliguria
- Mild Lactate acidosis
2. Hypotensive Shock (Uncompesated shock
- severe lactate acidosis
- prolong CRT
3. Hypovolumic
4. Distributivee shock
5. Cardiogenic shock
6. Obstructive
***
📌Tacycardic? Non specific sign of shock, patient with fever also can have tacycardia
📌Sign?
✅Skin changes
- prolong CRT
✅Impaired mental status
- to monitor progression
✅Etc
*****
📌Approach
1. ABCD
2. Establish life threatening condition/ IV branulla
3. Give 20ml/kg as fast as possible
- Ringer Lactate
- Normal saline
- Other isotonic fluid
- Unless suspect cardiogenic shock
4. Ephinephrine in anaphylactic shock
5. Check electrolyte - 
eg Calcium, if patient hypocalcemic, pt can resistant to recuscitation - if low, correct first
6. Consider inotropic drug - Adrenaline or Noradrenaline
7. Cardiogenic shock - dobutamine (if dehydrated, still can give fluid, but beware, may need CVP
monitoring)
8. Septic shock - Antibiotic
📌What is different between colloid and crystalloid?
- Albumin which one? 
- Osmolarity?
- Plasma?
📌Fluid resistant resuscitation
- after given 60ml/kg crystalloid, BP still not okey
📌Obstructive Shiock (management? Specific in different condition)
- chest tube - tension pneumothorax
- Removal fluid - tamponade
- Ductal dependent lesion - PGE
******
❤️Respiratory Distress Syndrome💪🏻
✅Definition
Oxygenation and ventilation insufficient to meet metabolic demand of the body
✅Respiratory distress
- sign : tachypnia, nasal flaring, chest recession.
✅Child vs adult
Children can nasal breather, adult can use mouth
✅Child (anatomy difference btw adult) - easier to get RDS
Big tongue - can obstruct airway
Epiglotis - Floppier compare
Cricoid - narrow in child, easily airway block
📌Patophysiology
Classified
1. Hypoxia - oxygenation (lung failure)
- Ventilation perfusion mis-match 
✅Obstruction
✅Parencymal disease
2. Ventilation ( pump)
💚Acute Respiratory infection💚
(Learning point from HO teaching paeds today 26/5/19)
1. Why baby easy to get bordatella pertussis?
- Baby not vaccinated yet
- FBC : Lymphocytosis
2. What is different live vaccine, killed vaccine?
3. Diphteria
- Pseudomembrane
- Bull like neck
4. Bigger child vs smaller
- bigger may less tacypnic
5. Stridor - upper airway obstruction (inspiratory)
- laryngomalacia
- Trachea obstruction
- Croup - barking cough
- Epiglotitis - soft stridor, toxic looking, tripod position
6. Wheeze 
- breath out take longer than normal
- Viral induce wheeze, GORD, asthma, foreign body,
7. Polyphonic vs monophonic wheeze
1. Grunting - force expiration again closed glottis tu open airway, to prevent lung collapse
2. Stetor(upper airway - nose)?
📌Acute Bronchiolitis📌
1. High Risk untuk RSV
- Immunocompromise
- Cynotic Heart Problem
- Chronic Lung Disease
- Vaccine : Palivizumab : Passive Imunity (kita bagi antibodi, dia ada, kemudian dia tak ada dah)
- RSV Immunoglobulin - give every month
2. Clinical
- Fine crepitation
3. CXR
- Hyperinflated lung
4. IX
- VBG or CBG
5. Nutrition
- By Ryles Tube feeding if cannot tolerate orally.
6. Oxygen?
Depend on spo 2
Nasal prong 
✅Optiflow - 2ml per kg
✅CPAP - if not tolerate, because pt struggle - 
✅Ventilated (intubate), 
use SIMV, If cannot juga, 
then HFO (high frequency oxygen)
7. Hypertonic saline? 
- Not really effective (previously told to increase mucus secretion) * Evidence based
- if put to much - risk of bronchospasm
8. Antibiotic
- Xray changes etc
❤️PNEUMONIA❤️
1. Infant : 1-3 month old
Chlamidia trachomatis
Presented with eye dischrge - need teke eye swab
Ask parent history high risk behaviour
2. Blood ix
Bacteria : high neutrophil
Viral : Lymphocytosis
Leukopenia : viral or severe overwhelming infection
FBP : immature neutrophil, toxic granulation
3. Bacterial vs viral
4. Antibiotic (start low)
- Peniclillin, Ampicillin,
- Why we use augmentin - more compliance
- Atypical : Azithromycin
5. Complication
- Parapneumonic effusion
(Pleural effusion arise from pneumonia)
- etc
6. Supportive Mx
- Cough medication - not recommended, distract airway clearence
❤️Viral Croup (laryngotracheal bronchitis)❤️
1. It is clinical sx 
- barking cough
2. Organism - commonly parainfluenza virus
3. Epiglotitis (drooling)
- Refer EnT, Intubation, Antibiotic
4. Management?
❤️Mild/ severe
- Nebulize budesonide
- Oral or parenteral Dexamenthasone
❤️Severe - Nebulized Adrenaline - dont discharge yet if pt well, pt may rebound
🌸NEPHRITIC SYNDROME🌸
✅Abrupt onset of one or more
Hematuria
Oliguria
Edema
Hypertension
✅Cause
📌Post infection
Streptococcus, Malaria, Leptospira, etc
📌Systemic Vasculitis
- HSP
📌Others
- IGA nephropathy
- SLe
✅POST STREP AGN
- commonest cause AGn
- Age 6-10 yo
📌Skin lesion - Usually pt present with AGN about 4 weeks later
📌Strep infection - 2 weeks later.
📌Graph/diagram (as per attached)
Hematuria may persist up to 1 year
Complement should normalize after 6 weeks, if C3 still low, maybe something else, need to
investigate
ASOT will be decrease in 6 weeks time
✅Pathophysiology
- Immune complex form in situ within glomerulus
- Inflammation and proliferation of cell in glomerulus
- Permeable to RBC - HEMATURIA
- Permeable to protein - PROTEINURIA - excessive proliferation cell + reduce blood flow -
REDUCE GFR + AZOTHEMIA + OLIGURIA
- Reduce GFR - AKI/CKD/ESRF
✅Clinical Symptom
- Edema
- Hypetension
- Oliguria
✅Blood Ix
- UFEME : RBC (microscopic hematuria can persist up to 1 year)
- BUSE : urea creat high, hyponatremia, hyperkalemia
- Compliment level : Low C3 but normalize by 6 weeks
- ASOT : initially high. If 1:200 or less (not significant) , titre more than that ( maksudnye kena
dilute dgn banyak to make it disappear)
✅Others
- Renal Biopsy : 
- Indication (picture)
- [ ] Severe AKI need dialysis
- [ ] Feature suggestive non post strep AGN
- [ ] Delay resolution (refer paeds protocol)
✅Management
Diet - Salt restriction
Diuretic - Frusemide 
- Moderate edema : 1-3mg/kg
- Pulmonary Edema : 2-4 mg/kg
📌Medication
1st line
- Lasix : to remove sodium and water
- Sbb patophysiology adalah na and water retention
📌Hypertension 
- Mild : control salt and water intake
- Antihypertensive - Can give niphedipine, if still not controlled, give Frusemide, the Beta Bloker
and ACE Inhibitor (risk hyperkalemia)
🌸Nephritis in Henoch- Scnonlein Purpura
✅Most common vasculitis in children, usually recover without treatment.
✅Clinical Feature
- mild renal involevent - mild proteinuria, microscopic hematuria
- Purpuric Rash
- Athritis
- Abdominal pain
🌹Other cause nephritic
- Immuniglobulin A Nephropathy
- Lupus Nephritis
🌹🌹Leukaemia🌹🌹
(HO teaching Prof Ariffin)
❤️Type :
1. ALL
2. AML
3. JMML - juvenile myelomonocytic leukemia (rare)
❤️What poor prognostic factor leukemia
- Male poorer
- Total White > 50
- Age ; less than 2 year
- Phidalephia chromosome (in JCML)
- Hypodiploid Karyotype (such as in Turner Syndrome) -if hyperploid like Klinefelter/Down
Syndrome good prognosis
- More than 10@12 year old
- CNS involvement 
- Splenomegally
- Hepatosplenomegally
- Bone marrow karyotype (percent blast cell)
- Response to first chemotherapy
-Mediastinum mass
❤️Significant side effect chemo? - but rate of occurance rare
- Tumor Lysis syndrome
(hyperkalemia, hypocalcemia, hyperphosphatemia, hyperuraemia - lead to Arrythmia / Kidney
injury )
- Leukoencephalopathy (white matter disease)
- Night blindness
- Reduce hearing (bleomycin)
- Pulmonary fibrosis
- Cardiac : dilated cardiomyopathy, arrythmia, bradycardia 
- Peripheral Neuropathy 
- GIT : Antropathy
- Renal Toxicity
- Infertility
‼️Urgent Referal
- SVC obstruction
- Mediastinal mass
- SIADH
- Tumor Compression Effect (spinal compression effect need urgent referal)
- Febrile Neutropenia (late give antibiotic can cause death to patient)
🌸Mediastinal widening - leukaemia
SVC obstruction - Lymphoma
🌸Prognostic ALL
- Bone Marrow Karyotype
🌸Tumor Lysis syndrome mx?
- Hyperhydration
- Do not add pottasium, do not tranfuse blood cell except indicated, give hyperhyration
🌸Drug to prevent urate nephropathy
- Rasburicase / previously allopurinol
🌸Vaccine🌸
(HO Teaching with Dr Ikram)
💜Vaccine will enter body, then macrophage will recognize and engulf the antigen, than make
antibody >> B cell
💜Type immunity
- Active : 
- natural - when infected by bacterial
- Artificial : Vaccination - weaken form of the bacterial
- Passive : 
- Natural : maternal antibody : umbilical artery / then breastfeed
- Artificial : Monoclonal antibody : eg Immunoglobulin
✏️Passive : short term only, it not lasted longer period in body. Immediate protection.
💜Antibody
- IgG: Previous infection
- IgM : Acute infection
- IgE : Parasitic infection, hypersensitivity
💜IMMUNOGLOBULIN
- Type of passive immunity
- Eg : in Kawasaki we give
💜Type vaccine
- Live attenuated : Measle, Tuberculosis, Rotavirus, Oral polio, Yellow Fever, Rubella
- Inactivated :inactivated polio virus, whole cell pertussis
- Subunit : Acellular Pertussis, Hib, pneumococcal, Hep B
- Toxoid : inactivated toxin - Tetanus Toxoid and Diphteria Toxoid
*Whole cell pertussis already change to unicellular
*Oral Polio : can cause more complication, alreay change to inactivated
💜Contraindicated
- Fever : serious infection
- Immunodeficiensy : cannot give live attenuated
- Pregnancy : cannot give live attenuated
💜Specific contraindicatoon
- BCG : symptomatic HIV (aids)
💜If patient missed vaccine?
(Give at the first visit eg Hep B and BCG), then
- Live Vaccine btw another live vaccine: need gap 3 month
- DTaP till next DTaP : gap 4 weeks
💜Extra :
Typhoid : Thyphidot M : check IgM antibody
Widal Test : antigent titre : positive acute : 1:160