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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