Downs + pneum
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Here is a summary of the treatment plan for the index case: - Admit the patient and start IV antibiotics like ampicillin and gentamicin to treat pneumonia. Also give nebulization with asthalin. - Provide supportive care including IV fluids, oxygen supplementation if needed, antipyretics and physiotherapy. - Once pneumonia is treated and symptoms improve, discharge the patient with oral antibiotics like cotrimoxazole for a total course of 10-14 days. - Monitor the patient regularly as per guidelines for Down syndrome for any associated health issues and provide appropriate long term care and supervision.
Downs + pneum
- 1. GENERAL CLINICS case 4
- 3. Personal Data • Patient name- Shreya • Age- 1 year 4 months • Date of birth- 29/03/2011 • Address- Bantwala • Informant- Mother – 7th std (reliable) • Date of admission- 2/8/2012
- 4. Presenting complaints • Cough with expectoration – 6 days • Breathlessness – 6 days
- 5. History of presenting illness • Cough – associated with expectoration Onset- insiduous Gradually progressive Present throughout the day No aggravating factors Relieved on medication
- 6. • Expectoration Scanty, white, mucoid, non foul smelling, not blood stained
- 7. • Breathlessness Associated with cough and expectoration Associated with occasional wheeze Worsens on lying down, at night Relieved when mother holds baby upright
- 8. • Came to GWH on 30th July with above complaints • Nebulization done • Symptoms subsided • Patient discharged the same day • Symptoms recurred 3 days later, admitted.
- 9. Past history • Has had similar episodes in the past since the age of 1.5months • 3 admissions • Nebulization done each time
- 10. Antenatal history • Age at first pregnancy: 26 years • Birth order-5 • h/o 3 abortions – 4th, 5th and 6th month of gestation • Age at 4th pregnancy: 29 years (baby healthy) • Age at 5th pregnancy : 31 years
- 11. • Spontaneous conception • 1st trimester- No history of fever with rash, exposure to drugs or radiation, increased frequency or burning micturition. IFA tablets taken. • 2nd trimester- No history suggestive of PIH/ GDM. T.T injections taken • 3rd trimester- No history suggestive of PIH/GDM • 4 USG done. Anomaly detected at 8th month POG (Down’s syndrome)
- 12. Natal and postnatal history LSCS at 9th month Cried immediately after birth Birth weight – 2.8kg Breast feeding initiated after 2 hrs NICU admission- 4days – phototherapy Passed urine and meconium
- 13. At 1.5 months age: • Diagnosed to have Down’s syndrome • Child being taken for physiotherapy twice a week since the age of 1.5 months • h/o recurrent respiratory infections • No h/o constipation / vomiting/ bleeding gums or from other sites • No h/o impaired vision or hearing • No h/o nasal regurgitation of food/choking
- 14. • h/o feeding difficulty since 1.5 months of age • Inability to feed continuously • h/o inadequate weight gain • No history of orthopnoea, cyanosis, syncope or edema
- 15. Developmental history • Social smile - 8 months • Recognized mother- 9 months • Stranger anxiety – 1 year • Head control – 1 year • Rolling over – 1 year • Unidextrous grasp – 1 year • Monosyllables- 14 months • Bisyllables- 16 months
- 16. Immunization history • Appropriate for age
- 17. Diet history • Exclusively breast fed till 6 months of age Calories(kcal) Proteins(g) Breakfast 226 6.4 Lunch 302 7.7 Snacks 290 4.1 Dinner 88 1. 7 Total 791+ 402= 1190 18.5+6.6=25 Expected 1030 22
- 18. Family history • Total family members- 4 • Non consanguineous marriage • Parents healthy. • No history of TB/ congenital defects/ allergy in the family
- 20. Summary • 16 months old baby , a known case of Down’s syndrome, came to RAPCC with cough and expectoration and breathlessness 6 days prior to admission. Patient has history of recurrent respiratory tract infections, feeding difficulty since 1.5 months , was diagnosed to have a cardiac anomaly at 1.5months of age.She has global developmental delay. She is immunized up to date and no calorie deficit
- 22. VITALS • Pulse rate-104 beats per min (normal) • Respiratory rate-36 per min (tachypnea) • Afebrile during examination
- 23. ANTHROPOMETRY • Weight for age • Less than 3rd percentile • Grade 1 PEM (IAP) • undernutrition (wellcome trust)
- 24. • Length • Less than 3rd percentile • Grade III stunting (waterlow classification) • Weight for height • No wasting (waterlow classification)
- 25. • Head circumference • Microcephaly (less than 3rd percentile) • Brachycephaly is present • Mid arm circumference-14 cm(normal) • Chest circumference is greater than head circumference
- 26. Head to toe examination • Sparse thin shiny hair • Flat occiput • Ant fontanelle-1*1cm • Depressed nasal bridge • Hypertelorism • Epicanthic fold present
- 27. • Up-slanting of eyes • Low set ears • Mouth kept open with protruding tongue • Short neck • Short broad hands • Hypotonia,hyperflexible limbs • Kennedy crease
- 28. Developmental assesment • Gross motor-sits without support (8 months) • DQ-50 • Fine motor-radial grasp present (8 months) • DQ-50 • Social-stranger anxiety (6 months) DQ- 38 • Language-bisyllables (9 months) DQ- 56
- 30. RESPIRATORY SYSTEM • Respiratory rate-36/min • On Inspection,abdominothoracic respiration,movements bilaterally symmetrical • On Palpation,trachea is central,inspectory findings confirmed • On percussion,resonant note heard in all areas • On auscultation,breath sounds of equal intensity bilaterally,vesicular,crepitations heard bilaterally
- 31. • Cardiovascular system • S1 S2 heard,no murmurs • CNS • Hypotonia,power cannot be assessed,reflexes are normal • P/A • Soft nontender,no organomegaly
- 32. Summary • Tachypnea • Grade 1 PEM • Grade III Stunting • Microcephaly,brachycephaly • Mongoloid facies • Developmental delay • Bilateral crepitations
- 34. ON HISTORY ON EXAMINATION • COUGH WITH • MONGOLOID FACIES EXPECTORATION • HYPOTONIA • BREATHLESNESS • B/L CREPITITIONS • WHEEZING • DEVELOPMENTAL • FEEDING DIFFICULTY DELAY • DEVELOPMENTAL DELAY
- 35. CHARACTERISTIC FACIAL FEATURES SUGGESTIVE OF DOWN SYNDROME
- 36. RESPIRATORY COUGH WITH EXPECTORATION • PNEUMONIA • TB • FB WHEEZE • WALRI • BRONCHIOLITIS • FB
- 37. BREATHLESSNESS • PNEUMONIA • BRONCHIOLITIS • BA • FB
- 38. CARDIAC • CHD • PULMONARY EDEMA
- 39. HYPOTONIA • DOWN SYN • HYPOTHYROIDISM • MYOPATHIES
- 40. INVESTIGATIONS - Aiswarya . S (080201390)
- 41. INVESTIGATIONS FOR DOWN S SYNDROME • Karyotyping. • To diagnose complications- • Complete blood count. • Peripheral smear • Radiological findings • X ray spine • X ray chest. • X ray bones. • X ray pelvis.
- 42. • AUDIOLOGY • OPHTHALMOLOGICAL. • THYOID FUNCTION TESTS. • ECHO-PDA with Left to Right shunt. • BLOOD SUGAR.
- 43. INVESTIGATIONS • BIOCHEMISTRY— LFT,RFT,Electrolytes;ABG analysis • HEMATOLOGY— Hb,Counts,ESR,Plateletes,PeripheralS mear • RADIOLOGY—ChestX ray. • MICROBIOLOGY—Blood culture;Stool & Urine examination • KARYOTYPING
- 44. INVESTIGATIONS FOR PNEUMONIA • Chest radiography • Total and differential count. • Haemoglobin count. • Culture studies
- 45. HAEMATOLOGICAL INVESTIGATIONS HEMOGLOBIN—9gm% COUNTS — Total count-6500/cc. ESR—27.9 PLATELETS —3,40,000/cc
- 46. BIOCHEMICAL INVESTIGATIONS • ELECTROLYTES Na+,K+,Cl-,HCO3 ‘LIVER FUNCTION’ TESTS Total and Direct Bilirubin ; ALT • ARTERIAL BLOOD GAS ANALYSIS • THYOID FUNCTION TESTS.
- 47. Electrolytes. • Na+=139meq/l((136-149meq/L) • K+=5.2meq/l (3.5-5.3meq/L) • Cl-=99meq/l (98-111meq/L) • Hco3-=27.4meg/l. (22-26mmol/L) • BLOOD GAS ANALYSIS • PH-7.55 (7.35-7.45) PCO2-17.2mmHg. (35.0-45.0mmHg) PO2-159mm Hg • LIVER FUNCTION TESTS • Total bilurubin-.2 mg/dl (0.2-1.2mg/dL) • Direct bilirubin-.1mg/dl. (upto 0.3mg/dL) • SGOT-33U/L. (15-55U/L) • SGPT-22U/L. ( 5-40 U/L) • ALP-107U/L.
- 48. THYROID FUNCTION TESTS • T3-1o7ng/dl.(70-190ng/dl) • T4-8.05ng/dl(.8-2.2ng/dL) • TSH-1.60mIU/L(.7-6.4mIU/L) • KARYOTYPING • T(21,22)
- 49. MICROBIOLOGICAL EXAMINATION • STOOL EXAMINATION • Stool pus cells-2-3hpf. • Stool RBC-nil. • Stool fat globules-present. • Stool mucous-nil. • Occult blood-nil. • Ova,cyst-nil.
- 50. INVESTIGATIONS • BIOCHEMISTRY— LFT,RFT,Electrolytes;ABG analysis • HEMATOLOGY— Hb,Counts,ESR,Plateletes,PeripheralS mear • RADIOLOGY—ChestX ray. • MICROBIOLOGY—Blood culture;Stool & Urine examination • KARYOTYPING
- 51. TREATMENT - Prithvishree Ravindra (080201366)
- 52. IMNCI guIdelINes
- 53. PNeuMONIA • INdICAtIONs fOr hOsPItAlIsAtION : • At tIMe Of dIAgNOsIs: Features of hypoxia ( restlessness, anxiety, cyanosis. Inability to sleep, talk, walk, unconsciousness, seizures) ; Reduced urine output/ dehydrated ; Vomiting/ poor oral intake High risk factors • durINg treAtMeNt No improvement/ progressive deterioration when on treatment as outpatient
- 54. OutPAtIeNt MANAgeMeNt • 1 – 5 years age : • Paediatric Tablet Cotrimoxazole (Sulphamethoxazole 100 mg and trimethoprim 20 mg ) - 3 tablets twice a day • Reassess after 48 hours • If improves – continue for 3 more days. No improvement – continue for 48 hours and reassess. • Explain parents WARNING SIGNS – return immediately
- 55. INPAtIeNt MANAgeMeNt Specific Supportive Antibiotics Hydration Nutrition Oxygen Antipyretics Physiotherapy Asthalin nebulisation if wheeze is present
- 56. ANtIbIOtICs • Benzyl penicillin/ ampicillin / 3rd generation cephalosporin +/- aminoglycosides • Inj. Benzyl penicillin – 5000IU per kg/dose 6th hourly IM • Inj. Ampicillin – 50mg/kg/dose 6th hourly IM • Inj. Gentamicin – 2.5 mg/kg/dose 8th hourly IV • Continue for 10-14 days • Assess twice a day – if deterioration : CXR to look for staphylococcal infection (pneumatoceles ) – change to cloxacillin • Atypical pneumonia - macrolides
- 57. suPPOrtIVe CAre • Fever – Paracetamol (10-15 kg/dose ) every 4 to 6 hourly • Tachypnea, cyanosis, chest indrawing – oxygen by oxygen hood, oxygen mask, nasal catheter, nasopharyngeal catheter • Not drinking/dehydrated – IV fluids • Asthalin nebulisation : if wheeze present
- 58. treAtMeNt Of the INdex CAse • Nebulisation with asthalin • IV fluids Iso – P • Inj. Ampicillin IV • Injection Gentamycin IV • Syp PCT
- 59. dOWN sYNdrOMe – heAlth suPerVIsION
- 60. dOWN sYNdrOMe – heAlth suPerVIsION Condition Time to screen Comment Congenital heart Birth 50% risk for congenital disease Young adult for heart disease. acquired valve disease Increased risk for pulmonary hypertension Strabismus, cataracts, Birth or by 6 months 15% - cataracts nystagmus Check vision annually 50% - refractory errors Hearing impairment or Birth or by 3 months – Congenital hearing loss loss ABER 70% risk – serious If tympanic membrane otitis media not visualised- 6 monthly for 3 years Annually therafter Constipation Birth Hirschsprung disease
- 61. dOWN sYNdrOMe – heAlth suPerVIsION Condition Time to screen Comment Celiac disease 2 years/ symptomatic Screen – IgA and tissue transglutamase antibodies Hematologic disease At birth , adoloscence Neonatal polycythemia and when symptoms Leukemoid reaction develop Leukemia Hypothyroidism Birth, repeat at 6 – 12 1% - congenital months and then 5% acquired annually Growth and At each visit Discuss school development Use Down syndrome placement options growth curves Proper diet to avoid obesity
- 62. For index case
- 63. For index case
- 64. dOWN sYNdrOMe – heAlth suPerVIsION Condition Time to screen Comment Obstructive sleep apnea Start at 1 year. Then at Monitor for snoring, each visit restless sleep Atlantoaxial subluxation/ Each visit – history and Maybe asymptomatic instability physical exam Radiographs at 3 -5 years or when planning to participate in contact sports / Transient neurological symptoms Gynaecological care Adoloscent girls Menstruation/ contraception use Recurrent infections When present Check IgG subclass and IgA levels Psychiatric, behavioral Each visit Depression,anxiety, disorders OCD, schizoprenia. Autism , Early onset alzheimers
- 65. PdA - left tO rIght shuNt • Catheter based treatment – occlusive devices or coils • Surgery if : • Large PDA ( larger than size of available devices)
Editor's Notes
- #61: 57% adults – mitral valve prolapse. Valvular regurgitation