Acute Bronchiolitis Bilateral LungMuhamad Nazarudin Bin Nordin Cohort 6 / semester 6

Patient Detail. NAME : Mr. O MRN : 195xxx

AGE : 7 years old GENDER : Male RACE : Malay

Dr. Diagnosed : Acute Bronchiolitis Bilateral Lung Dr. Consultant : Siti Nor (Prediatrician) D.O.A : 14/10/2011 d.o.a : 15/10/2011

Dr Mx :

1.Investigation : X-Ray done on 14/10/2011 result : secreation retension on lower lobes of both side lung. 2.Conservative : Medicine and rehabilitation.

Subjective Assessment Chief complaint : pt mother c/o cough since 3/7.

pt c/o secreation inside lung. pt c/o short of breathing. pt c/o difficult to removed the secreation. Current Hx : second day pt at ward.pt was

admitted to KSH on 14/10/2011 d/t short of breathing type 2 (when walking). Past Hx : pt admitted to KMC last 2 month d/t

same problem.after 3days admitted there pt was discharged.

Past Medical Hx : NIL Social Hx : student standard 1

second child from 4 stay with family non-active in sport non-smoker and non-alkaholic Family Hx : father smokers

grandfather has asthma

Medicine : Nebulizer

Oxygen Therapy (nasal prongs 2 litre) Antibiotics

Objective Assessment General Observation : young malay boy lying on the

bed with ectomorph size of body.pt wear IV drips at right hand. Local Observation : breathing using apical pt skin was normal no deformities of chest used nasal prongs 2 litre On palpation : 1.Vital sign : Temperature-36.9 degree calcius BP-116/75 mmhg RR-17 b/m Spo2-100% HR-76bpm Interpretation : Temperature,BP,HR and Spo2 was normal.RR pt was increased(hypertension) d/t SOB.

On Examination :

1.AuscultationLobes Upper Medial Lower XXXXXXXXXXXX XXXXXXXXXXXX X X Right Left

crackles sound Interpretation : secreation was present at both lower lobes right and left lung.

2. Percussion notes

Lobes Upper Medial Lower

Right Normal Normal Hyperresonant

Left Normal Hyperresonant

Interpretation : the both lower lobes right and left lungs was hyporesonant because have secreation retention inside it.

3.Breathing patternA:E RatioInhalation 5 Exhalation 4.5

Interpretation : pt using apical and accessory muscle to breath.

4.Chest Expansion AnteriorLevel Apical Right Good Left Good Fair Poor Result Symmetrical Symmetrical Symmetrical

Upper lateral Fair costal Lower lateral Poor costal

PosteriorLevel Apical Right Good Left Good Fair Poor Result Symmetrical Symmetrical Symmetrical

Upper lateral Fair costal Lower lateral Poor costal

Interpretation : reduced of air entry at the upper and lower lateral costal level.

5.Chest MeasurementLevel Axilla Inhaled 1.64 2.63.5 3.63.5 Xyphoid 1.61 2.60.5 3.60.5 10th rib 1.58 2.57.5 3.57.5 Exhaled 61 60.5 60.5 59 58.5 58.5 57 56.5 56.5 Differenc e 3 3 3 2 2 2 1 1 1 1 2 3 Ratio

Interpretation : reduced of air entry on xyphoid and 10th rib level because patient use apical breathing.

6.ADL Functional ActivityActivities Walking Dressing Bating Sleeping Running Eating Good Fair Poor

Interpretation : reduced of ADL functional activity in walking,running and sleeping d/t SOB.

7.Lung Function TestModalities :Triflow Result : One ball up ( 600cc)

Analysis Problem Listing

1.Cough since 3/7 ago. 2. Secreation retention inside the lower lobes both lung. 3.SOB when doing more activity. 4. Reduced of lung expansion on upper and lower lateral costal level. 5.Reduced works of breathing. 6.Reduced of ADL functional activity.

Short Term Goal

1.To reduced secreation retention inside lower lobes of both lung. 2.To increased lung expansion on upper and lower costal level. 3. To increased works of breathing. Long Term Goal

1.To prevent further complication. 2.To restore ADL functional activity.

Plans Of Treatment To reduced secreation

Tx : MPD+vibration Position pt : high sitting + body line forward + support by pillow on anterior of body. To increased lung expansion 1.Tx : TEE Position pt : high sitting Duration : 3repetition. 2.Tx : DBE Position pt : high sitting Duration : 3repetition.

To increased work of breathing

1.Tx : breathing control. Position pt : high sitting. Duration : 3repitition. 2.Tx : pursed lips breathing Position pt : high sitting. Duration : 3repitition.

Intervention To reduced secreation

Tx : MPD+vibration Position pt : high sitting + body line forward + support by pillow on anterior of body. To increased lung expansion 1.Tx : TEE Position pt : high sitting Duration : 3repetition. 2.Tx : DBE Position pt : high sitting Duration : 3repetition.

To increased work of breathing

1.Tx : breathing control. Position pt : high sitting. Duration : 3repitition. 2.Tx : pursed lips breathing Position pt : high sitting. Duration : 3repitition.

Re-Assessment

Subjective pt still have cough. pt still have secreation.

pt still difficult to cough-up the secreation. pt still have SOB grade 2.

OBJECTIVE Cough assessment.

-effective/productive -sputum = slightly yellowish/thick/small amount. Vital sign : Temperature-37.2 degree calcius

BP-114/73 mmhg RR-17 b/m Spo2-100% HR-78bpm Interpretation : Temperature,BP,HR and Spo2 was normal.RR pt was increased(hypertension) d/t SOB.

1.AuscultationLobes Upper Middle Lower XXXXXXXXXXXX XXXXXXXXXXXX X X Right Left

mild crackles sound Interpretation : secreation was present at both lower lobes right and left lung but decreased then before.

2. Percussion notesLobes Upper Middle Lower Right Normal Normal Hyperresonant Hyperresonant Left Normal

Interpretation : the both lower lobes right and left lungs was hyporesonant because have secreation retention inside it.

3.Breathing patternA:E RatioInhalation 5 Exhalation 6

Interpretation : pt still using apical and accessory muscle to breath but have some improvement on exhalation then before.

4.Chest Expansion AnteriorLevel Apical Right Good Left Good Fair Poor Result Symmetrical Symmetrical Symmetrical

Upper lateral Fair costal Lower lateral Poor costal

PosteriorLevel Apical Right Good Left Good Fair Poor Result Symmetrical Symmetrical Symmetrical

Upper lateral Fair costal Lower lateral Poor costal

Interpretation : reduced of air entry at the upper and lower lateral costal level.

5.Chest MeasurementLevel Axilla Inhaled 1.64 2.63.5 3.63.5 Xyphoid 1.61 2.60.5 3.60.5 10th rib 1.59 2.58.5 3.58.5 Exhaled 61 60.5 60.5 59 58.5 58.5 58 57.5 57.5 Differenc e 3 3 3 2 2 2 1 1 1 1 2 3 Ratio

Interpretation : reduced of air entry on xyphoid and 10th rib level because patient use apical breathing.

6.ADL Functional ActivityActivities Walking Bathing Eating Sleeping Running Dressing Good Fair Poor

Interpretation : reduced of ADL functional activity in walking,running and sleeping d/t SOB.

7.Lung Function TestModalities :Triflow . Result : One and half ball up ( 750cc).

Analysis1.Cough. 2. Secreation retention inside the lower lobes both lung. 3.SOB when doing more activity. 4. Reduced of lung expansion on upper and lower lateral costal level. 5.Reduced works of breathing. 6.Reduced of ADL functional activity.

Intervention To reduced secreation

Tx : MPD+vibration Position pt : high sitting + body line forward + support by pillow on anterior of body. To increased lung expansion 1.Tx : TEE Position pt : high sitting Duration : 3repetition. 2.Tx : DBE Position pt : high sitting Duration : 3repetition.

To increased work of breathing

1.Tx : breathing control. Position pt : high sitting. Duration : 3repitition. 2.Tx : pursed lips breathing Position pt : high sitting. Duration : 3repitition.