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Review of a clinical case

of Pediatrics

VCC

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Clinical History

Female of 22 months.

Reason for consultation:

She had fever (> 39 C) for 4 days of evolution before going to thedoctor. In the weekend , Lara went to the doctor but he diagnosedher of otitis media. She got worse, with fever, cough and vomiting,

so she returned to hospital on 16th

Wednesday and income. Personal Histoy:

No relevant disease before

No surgery

Lactose intolerance: She eats special products without lactose

No treatment before the disease

She is not vaccinated against pneumococcal

Family Histoy:

Her grandmother was ill too. After than Lara was admitted to thehospital, the grandmother was diagnosed with pneumonia.

Steger Lara

Birth: 20.04.2009

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Clinical course

Lara income on 16th

February with malaise, cough,fever (37,1C) and dehydration. She was tired.

She was drinking quite normal but was eating less

In the exploration at the income, she was diagnosted ofbacterial pneumonia and of Molluscum contagiosum.

The following day she seemedto improve, not vomited, but was soft, and in the night somedays she was bad.

The lung wasnt improve, it was humid and poorly ventilated

On 20th

, she had fever again and she vomited, but with thetreatment she looks good

She plays at times but gets tired easily

The last days she looks better, she has not vomited, and she iseating, drinking and playing good, but her lung is not good

still and she soon tires

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Testing for diagnosis

16/Feb/2011: Chloride 95mmol/l (96-108)

Phosphate, inorganic: 0,86mmol/l (1,10-1,95)

RCP: 30,97mg/dl (0,00-0,70)

Co2 partil pressure: 32,7 mmHg (37,5-50,0)

O2 partil pressure: 79 mmHg (36-44)

Standard base excess: -5,3 mmol/l (-2,0-3,0)

Standard bicarbonate: 20,3 mmol/l (21.0-26,0)

02 Saturation: 95,7 % (70,0 80,0) Leukozyten 27,2 G/l ( 6,0-15,5)

Segment-nuclear neutrophil: 73,0%(21,0-67,0)

Lymphocyte: 11,5% (20,0-64,0)

Monocytes: 11.5% (5,0-11,0)

Plasma cell: 0,5% (0,0-0,0)

21/Feb/2011: RCP: 6,41mg/dl (0,00-0,70)

Erythrocyte: 3,46 T/l (3,9-5,50)

Hemoglobin: 92 g/l (110-140)

Hematocrit: 0,273 l/l (0,330-0,400)

Thrombocyte: 597 G/l ( 223-515)

Absolute reticulocyte 27,7 G/l(34,0-124,0)

Leukozyten 27,2 G/l ( 6,0-15,5)

Segment-nuclear neutrophil:69,0 % (21,0-67,0)

Lymphocyte: 18,8 % (20,0-64,0)

Monocytes: 11.5% (5,0-11,0)

Laboratory:

Blood gas analysis

Complete blood count

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Testing for diagnosis

Lobar or segmental pneumonia is

a type of pneumonia characterized

by lesions of an

entire lobe or a large segment of the

lung and usually affects or commits all lung

structures in the affected region.

She has an alveolar infiltrate of the middle

lobe in the right lung .

Rx Thorax:

Analytical Stool

Adenovirus? Rotavirus?

Pulmonary auscultation:

Crackles

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Actual Investigation ANAMNESIS INVESTIGATION: His mother says she eats and drinks more and has not

needed oxygen since the last fever two days ago. She dont have diarrhea.

She has not returned to vomit since two days ago

FISICAL INVESTIGATION:

Good general condition, but she is somewhat nervous and she coughs a bit

Temp. 36.6C, height 86cm, weight 10,3kg, BMI 13,9, Pulse 93pm,

Pink skin and mucous membranes. But She is mildly dehydrated. The skin is dry. Shepresents a few papules of molluscum contagiosum, but they seem to be improving.

No bruising / petechiae / bleeding Head and face:

Humid Tongue. Pink, She has normal tonsiles

Neck: no adenopathies or vascular breaks.

Thorax: moves well. AP: Still wet with ventilation deficit

AC: Normal. No murmur. Easily palpable peripheral pulses

Abdomen: no organomegaly. Painless. Soft.

Tips / Locomotor: Superior, inferior and Hip: normal mobilization, painless, nor limited.

SN: cranial nerves normal. Strength, tone and ROT preserved. No alteration of thesensitivities, No Babinski. Initiating and coordinating normal. No meningeal signs.

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Judgment diagnosis

Pneumonia

Steptococo?

Dehydratation

Vmitos

Adenovirus?

Rotavirus?

Norovirus?

Mollusco contagioso

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Treatment Noko

Claforan i.v 3x 350mg=100 mg /kg/d 7 days

Elo Mel brasis 40ml/l iv.

Elo Mel isodon 500ml iv.

Biocef 100mg/5ml ov. (start when finished Claforan iv.)1 week (38,5C max.3xd

O2

If saturation < 93%