CASE STUDY

Supervisor :
Dr Putri Nor Baiti, Dr Norhasni
Presentor :
Dr Leong ka yee, Dr Aisyah
Patient N, boy, 11 months old
- 7th admission

Underlying :
1/ Multitrigger wheeze
- 6 previous hospitilisations
I. 1st (7/8/17-13/8/17) - Viral pneumonia
II. 2nd (28/1/18 - 2/2/18) - Viral induced wheeze, covered for atypical infection
III. 3rd (27/2/18 - 1/3/18) - Viral induced wheeze
IV. 4th (10/4/18 - 14/4/18) - Recurrent viral induced wheeze
V. 5th ( 16/5/18 - 24/5/18) - Severe recurrent viral induced wheeze (Enterovirus/
Rhinovirus detected), intubated and ventilated for 3 days in view of severe respiratory
distress, not responding to continuous nebulisations
VI. 6th (26/5/18 - 3/6/18) - Hospital Acquired Pneumonia, was on BIPAP x2/7, then Airvo
x5/7. Given IVI Mgso4 50mg/kg over 30mins and IVI Salbutamol 2mcg/kg/min

2/ G6PD deficient
• MDI hx
I. 2nd admission (2/2/18) : Started on MDI Salbutamol and MDI
Budesonide 200mcg BD
II. 5th admission (24/5/18) : On discharge, change to MDI Flixotide
125mcg BD
III. 6th admission (3/6/18) : Discharged with MDI Salbutamol and MDI
Budesonide 200mcg BD
• Nebulisation hx
First neb at the age of 2 months old
This is 8th neb
Trigger : URTI
No family hx of asthma
Grandmother has allergic rhinitis
No cold induced symptoms
No EIA
No carpets/cat at home
Brother in law smoking at home (stay together)
• Birth hx
Term @39weeks

• Immunization hx
Due to for 1y/o vaccine

• Diet hx
Taking scoop of soft rice, with vegetables and chicken soup, 3x/day
FM Lactogen 4-5oz 3 hourly

• Development hx
Crawling on all four, stand up with assistance
Reach out & throw objects
Say "baa, maa"
Stranger anxiety, laugh
• HOPI
Presented with fever x3/7
On D2 of illness, started to have cough and runny nose, associated with post tussive
vomiting x1
On D3 of illness, cough worsening with rapid breathing
Given MDI Salbutamol 3 puff at 8pm, 10pm and 1am at home
Still having rapid breathing, thus came to ED

+ sick contact with 1y/o child taking care by grandmother

Otherwise,
No vomiting/diarrhea
No rashes
No hx of recent travelling
• Upon arrival to ED

Alert, pink
Good pulse volume, Warm peripheries, CRT <2secs
Tachypnoic, RR 50-60
+SCR, ICR, Suprasternal recessions

Temp 37.2;C
SPO2 91% under RA

Lungs : Reduce air entry, generalized crepitations, Prolonged expiratory phase

CVS DRNM

Neb Salbutamol 1:3 mls given

Put on NP1l/min

Reassessment after neb :

Still tachypnoic, RR 50-54, + SCR, ICR, Suprasternal recessions
SPO2 100% under NP1L/min
Lungs : Air entry improving, crepitations over right lower zone
• Investigation
FBC : WCC 22.2 (N : 70.8, L 24.9), Hb 12.8, hCT 37.2, plt 381
RP : Urea 2.0, Na 139, K 3.7
CXR : Hyperinflated lungs, perihilar hazziness
• In ward
Alert, conscious, good perfusion
Still tachypnoiec, RR 66, Mild SCR
HR : 170bpm
Temp : 38.2'C
Lungs : Equal air entry, crepitations over the right side

IMP : Broncopneumonia cover for Hospital Acquired Pneumonia

Plan (9.28kg)
KNBM
Start IVD HSD5% 2/3rd maintenance, run at 35mls/hr
Airvo FiO2 30%, Flow 18L/min (2L/kg)
IV Hydrocortisone 35mg 6 hourly x3/7
IV C-Penicillin 470,000U 6 hourly
Neb Ventolin 2 hourly, Neb Atrovent 4 hourly
Send NPA
• Progress in ward
D1OA (at night)
Noted child had deep SCR & ICR, RR 50
Lungs reduce air entry bilaterally, PEP, coarse crepitations
Started on IVI Salbutamol 5 mic for 1 hour over hour, then weaned down to 2 mic over 1 hour

D2OA
Started to tolerate feeding 90mls/3hourly
Still tachypnoic, SCR, ICR
Lungs : Slight reduce air entry bilaterally, bilateral crepitations

Plan
Off IVD
Start Oral Montelukast 5mg ON x2/52
Reduce IVI Salbutamol to 1mcg/kg/min, then 0.5cg/kg/min
Neb VN 2 hourly, Neb Atrovent 4 hourly
D3OA
Child condition was improving, RR 46, Mild SCR
No fever, T 36.8'C

Plan
Off IVI Salbutamol
Reduce Neb VN 3 hourly, Neb Atrovent 6 hourly
Change to FM 5L/min ---> Room air

NPA : Enterovirus/Rhinovirus detected

• Upon discharge (D4OA)
-Child is well
-Afebrile
-Not tachycardic, not tachypnoic
-No recessions

BP 107/56mmHg, PR 122bpm, RR 36, T 37'C, SPO2 100% under RA

Lungs equal air entry, clear

CVS DRNM

Plan
Allow discharge
Oral Montelukast 5mg ON X2/52
MDI Salbutamol 4 puff 4 hourly, then taper down accordingly
MDI Budesonide 2 puffs BD
TCA paeds clinic x2/52 for follow up
Thank you