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6/F, Tracheal bronchus, Right / fever, cough, sputum ( onset : 4 days ago, 2003. 10.4)
Chief complaint
or Title
Tracheal bronchus, Right / fever, cough, sputum ( onset : 4 days ago, 2003. 10.4)
Difficulty For student/For resident
Ji-Eun Oh, MD, Byong-Kwan Son, MD, Jeong-Hee Kim, MD[kimjhmd@inha.ac.kr],
2005.03.22
Department of Pediatrics, College of Medicine, Inha University
* History
Present illness; In June, 2003, she was admitted to our hospital because of mycoplasma pneumonia and pleural effusion, by treatment her condition was improved so, she was discharged. After discharge, intermittently cough and sputum developed, so she was admitted to the hospital again and again. The diagnosis of her disease was pneumonia and after treatment, her condition was improved , and she was discharged. But, on 4 days ago, fever, cough, and sputum developed and were aggravated, and she became irritable. So, she visited the hospital again, and was admitted.
Family history; no remarkable finding
Past history
1.birth history ; gestational age; 39weeks+4days, IBW; 2.83 kg,
C-sec delivery due to oligohydramnios ,
Apgar score : 1 min. ? 7 points, 5min. ? 9 points
                    Perinatal problem (-)
2.operation history ; PDA ligation on 2 months after birth
3.medical treatment history :
1> on 3 months after birth :
  1. Acute gastroenteritis
  2. Urinary tract infection
  3. Tuberculosis lymphadenitis
2> on 10 months after birth( 2nd admission )
  1. URI
  2. Delayed development : development state around 6months old              
  3. round face, ocular hypertelorism, low set ear, abnormal crying sound
      ? R/O Chromosomal anomaly
        
     Brain MRI :.1. Thinning out of cerebral white matter.                  
                  ? R/O Hypoxic damage.
                 2. Small posterior fossa.
                 3. Hydrocephalus with hemispheric atrophic change.        
             Chromosomal analysis : 46, XX

3> on 13 months after birth
   # Focal seizure ? EEG : Normal sleep EEG
                            No epileptiform discharge
4> on 15 months after birth ( 3rd admission ) :
   # Viral pneumonia (admission for 7 days)
     Chest PA : No active lesion in lung
5> Fever, frequent URI : several visits to local clinics and ER

cf)There was generalized tonic type seizure attacks four times when she was 5 years  old, so she has taken anticonvulsant medicine(orfil+rivotril) from then, in these days there has been no general tonic type seizure attacks, but intermittently mild clonic type attacks on right hand and left eyeball deviation developed.

6>on 6 years old (4th admission) ; 2003. 4. 13 ~ 2003. 4. 16
  1. Complex partial seizure
     -controlled by orfil, topamax, rivotril.

     EEG : This is a moderately abnormal stage I-II sleep record
           due to occasional spike discharges in the right centro-
           parietal area
           Clinical correlation : partial seizure              
     Brain MRI :
           Irregular enlargement of ventricle with decreased                
           periventricular white matter volume.
           ? Periventricular leukomalacia, most likely      
  2. URI

7>5th admission (2003. 6. 24 ~ 2003. 7. 8)  
   # Mycoplasma pneumonia with pleural effusion
     Lab; CBC (Hgb-hematocrit-WBC(% neutrophil)-platelet) 11.6-36.4-6300(65%)-98K, CRP 4.75
     Mycoplasma Ab 1:40 ? 1:1280
     Mantoux test : negative              
     Thoracentesis : Volume 270 cc,
        PH 7.5
        WBC 350(seg: 2%, lympho: 24%)
        Glucose 99mg/dL
        Protein 3g/dL
        AFB stain and culture : negative
        Tbc PCR : negative
        Pleural fluid Culture : No-growth
    Chest PA
        Pneumonia in RLL with right pleural effusion
8>6th admission (2003. 7. 9 ~ 2003. 7. 13)
   # Mycoplasma pneumonia
     C/C fever after dischare
     P/E Chest : coarse breathing sound with intermittent wheezing
     Lab CBC 11.4-35-16200(81%)-376K
         CRP 3.54
         Mycoplasma Ab  above than 1:5120
     Chest PA : Increased opacity on Rt. Lung  

9> 7th admission(2003. 8. 27 ~ 2003. 9. 1)
   # Pneumonia
     C/C fever, cough, sputum ( onset : 8 days ago )    
     P/E HR 132/min, RR 52/min, BT 37.3?
       Chest : Crackle on RLF
               subcostal retraction(+)
       Lab  SaO2 94-96% ? O2 2L/min SaO2 99%
            CBC 12.3-36.9-18100(76%)-267K
            CRP 2.45
            Mycoplasma Ab 1:1280
       Chest PA
            peribronchial haziness of right upper and both lower lobes.
       Tx: Antibiotics ( Cefuroxime+Rulid )
10> 8th admission(2003. 10. 8 ~ 2003. 10. 12 )
  1. Pneumonia
  2. Bronchial hyperresponsibility
     C/C fever, cough, sputum ( onset : 7days ago )
     P/E Chest : Crackle on RLF with low-pitch wheezing
     Lab CBC 12.3-37-9500(40%)-259K, CRP 1.36
         Mycoplasma Ab 1:1280
         IgG/A/M 1242/93/125 mg/dl
         lymphocyte subset : T cell subsets are not remarkable
         IgE 17.51 IU/ml, Eosinophil count 100/ul
         D1/D2/F1/F2 : 0/0/0/0
     Chest PA : No active lesion in lungs
     Tx Antibiotics ( Cefuroxime+Rulid )
* R.O.S.& P/Ex
vital sign, body temperature 39.0?, pulse rate 124/min, respiration rate 28/min, crackle on both lung fields
* Lab
CBC 12.1-36.5-8200(29/52)-285K
  CRP 1.57 mg/dl
  Chest PA :  Ill-defined opacities of right upper lobe
               ? Pneumonia of right upper lobe
  Chest CT :  1. Tracheal bronchus, Rt.
              2. Post-inflammatory change in both lungs
* Clinical Course
she stayed for 9days in the hospital for treatment. During admission, she took antibiotics and ventilator apply, after treatment, her condition was improved and discharged. After discharge, intermittently she visited to the hospital because of intermittent cough and sputum, and took supportive care.


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