1. GENERAL CLINICS case 4

2. HISTORY
SHILPA.G.KAMATH
080201360

3. Personal Data
• Patient name- Shreya
• Age- 1 year 4 months
• Date of birth- 29/03/2011
• Address- Bantwala
• Informant- Mother – 7th std (reliable)
• Date of admission- 2/8/2012

4. Presenting complaints
• Cough with expectoration – 6 days
• Breathlessness – 6 days

5. History of presenting illness
• Cough – associated with expectoration
Onset- insiduous
Gradually progressive
Present throughout the day
No aggravating factors
Relieved on medication

6. • Expectoration
Scanty, white, mucoid, non foul smelling,
not blood stained

7. • Breathlessness
Associated with cough and expectoration
Associated with occasional wheeze
Worsens on lying down, at night
Relieved when mother holds baby upright

8. • Came to GWH on 30th July with above
complaints
• Nebulization done
• Symptoms subsided
• Patient discharged the same day
• Symptoms recurred 3 days later,
admitted.

9. Past history
• Has had similar episodes in the past
since the age of 1.5months
• 3 admissions
• Nebulization done each time

10. Antenatal history
• Age at first pregnancy: 26 years
• Birth order-5
• h/o 3 abortions – 4th, 5th and 6th month of
gestation
• Age at 4th pregnancy: 29 years (baby
healthy)
• Age at 5th pregnancy : 31 years

11. • Spontaneous conception
• 1st trimester- No history of fever with rash,
exposure to drugs or radiation, increased
frequency or burning micturition. IFA
tablets taken.
• 2nd trimester- No history suggestive of PIH/
GDM. T.T injections taken
• 3rd trimester- No history suggestive of
PIH/GDM
• 4 USG done. Anomaly detected at 8th
month POG (Down’s syndrome)

12. Natal and postnatal history
LSCS at 9th month
Cried immediately after birth
Birth weight – 2.8kg
Breast feeding initiated after 2 hrs
NICU admission- 4days – phototherapy
Passed urine and meconium

13. At 1.5 months age:
• Diagnosed to have Down’s syndrome
• Child being taken for physiotherapy twice
a week since the age of 1.5 months
• h/o recurrent respiratory infections
• No h/o constipation / vomiting/ bleeding
gums or from other sites
• No h/o impaired vision or hearing
• No h/o nasal regurgitation of food/choking

14. • h/o feeding difficulty since 1.5 months
of age
• Inability to feed continuously
• h/o inadequate weight gain
• No history of orthopnoea, cyanosis,
syncope or edema

15. Developmental history
• Social smile - 8 months
• Recognized mother- 9 months
• Stranger anxiety – 1 year
• Head control – 1 year
• Rolling over – 1 year
• Unidextrous grasp – 1 year
• Monosyllables- 14 months
• Bisyllables- 16 months

16. Immunization history
• Appropriate for age

17. Diet history
• Exclusively breast fed till 6 months of
age
Calories(kcal) Proteins(g)
Breakfast 226 6.4
Lunch 302 7.7
Snacks 290 4.1
Dinner 88 1. 7
Total 791+ 402= 1190 18.5+6.6=25
Expected 1030 22

18. Family history
• Total family members- 4
• Non consanguineous marriage
• Parents healthy.
• No history of TB/ congenital defects/
allergy in the family

20. Summary
• 16 months old baby , a known case of
Down’s syndrome, came to RAPCC with
cough and expectoration and
breathlessness 6 days prior to admission.
Patient has history of recurrent respiratory
tract infections, feeding difficulty since 1.5
months , was diagnosed to have a cardiac
anomaly at 1.5months of age.She has
global developmental delay. She is
immunized up to date and no calorie
deficit

21. EXAMINATION
Tamanna ahemad
080201372

22. VITALS
• Pulse rate-104 beats per min (normal)
• Respiratory rate-36 per min
(tachypnea)
• Afebrile during examination

23. ANTHROPOMETRY
• Weight for age
• Less than 3rd percentile
• Grade 1 PEM (IAP)
• undernutrition (wellcome trust)

24. • Length
• Less than 3rd percentile
• Grade III stunting (waterlow
classification)
• Weight for height
• No wasting (waterlow classification)

25. • Head circumference
• Microcephaly (less than 3rd percentile)
• Brachycephaly is present
• Mid arm circumference-14
cm(normal)
• Chest circumference is greater than
head circumference

26. Head to toe examination
• Sparse thin shiny hair
• Flat occiput
• Ant fontanelle-1*1cm
• Depressed nasal bridge
• Hypertelorism
• Epicanthic fold present

27. • Up-slanting of eyes
• Low set ears
• Mouth kept open with protruding
tongue
• Short neck
• Short broad hands
• Hypotonia,hyperflexible limbs
• Kennedy crease

28. Developmental assesment
• Gross motor-sits without support (8
months)
• DQ-50
• Fine motor-radial grasp present (8
months)
• DQ-50
• Social-stranger anxiety (6 months) DQ-
38
• Language-bisyllables (9 months) DQ-
56

29. SYSTEMIC EXAMINATION

30. RESPIRATORY SYSTEM
• Respiratory rate-36/min
• On Inspection,abdominothoracic
respiration,movements bilaterally
symmetrical
• On Palpation,trachea is central,inspectory
findings confirmed
• On percussion,resonant note heard in all
areas
• On auscultation,breath sounds of equal
intensity bilaterally,vesicular,crepitations
heard bilaterally

31. • Cardiovascular system
• S1 S2 heard,no murmurs
• CNS
• Hypotonia,power cannot be
assessed,reflexes are normal
• P/A
• Soft nontender,no organomegaly

32. Summary
• Tachypnea
• Grade 1 PEM
• Grade III Stunting
• Microcephaly,brachycephaly
• Mongoloid facies
• Developmental delay
• Bilateral crepitations

33. DIFFERENTIAL
DIAGNOSIS
- Naseeba(080201378)

34. ON HISTORY ON EXAMINATION
• COUGH WITH • MONGOLOID FACIES
EXPECTORATION • HYPOTONIA
• BREATHLESNESS • B/L CREPITITIONS
• WHEEZING • DEVELOPMENTAL
• FEEDING DIFFICULTY DELAY
• DEVELOPMENTAL
DELAY

35. CHARACTERISTIC FACIAL
FEATURES
SUGGESTIVE OF
DOWN SYNDROME

36. RESPIRATORY
COUGH WITH EXPECTORATION
• PNEUMONIA
• TB
• FB
WHEEZE
• WALRI
• BRONCHIOLITIS
• FB

37. BREATHLESSNESS
• PNEUMONIA
• BRONCHIOLITIS
• BA
• FB

38. CARDIAC
• CHD
• PULMONARY EDEMA

39. HYPOTONIA
• DOWN SYN
• HYPOTHYROIDISM
• MYOPATHIES

40. INVESTIGATIONS
- Aiswarya . S (080201390)

41. INVESTIGATIONS FOR DOWN S
SYNDROME
• Karyotyping.
• To diagnose complications-
• Complete blood count.
• Peripheral smear
• Radiological findings
• X ray spine
• X ray chest.
• X ray bones.
• X ray pelvis.

42. • AUDIOLOGY
• OPHTHALMOLOGICAL.
• THYOID FUNCTION TESTS.
• ECHO-PDA with Left to Right shunt.
• BLOOD SUGAR.

43. INVESTIGATIONS
• BIOCHEMISTRY—
LFT,RFT,Electrolytes;ABG analysis
• HEMATOLOGY—
Hb,Counts,ESR,Plateletes,PeripheralS
mear
• RADIOLOGY—ChestX ray.
• MICROBIOLOGY—Blood culture;Stool
& Urine examination
• KARYOTYPING

44. INVESTIGATIONS FOR PNEUMONIA
• Chest radiography
• Total and differential count.
• Haemoglobin count.
• Culture studies

45. HAEMATOLOGICAL
INVESTIGATIONS
 HEMOGLOBIN—9gm%
 COUNTS —
Total count-6500/cc.
 ESR—27.9
 PLATELETS —3,40,000/cc

46. BIOCHEMICAL INVESTIGATIONS
• ELECTROLYTES
Na+,K+,Cl-,HCO3
‘LIVER FUNCTION’ TESTS
Total and Direct Bilirubin ; ALT
• ARTERIAL BLOOD GAS ANALYSIS
• THYOID FUNCTION TESTS.

47. Electrolytes.
• Na+=139meq/l((136-149meq/L)
• K+=5.2meq/l (3.5-5.3meq/L)
• Cl-=99meq/l (98-111meq/L)
• Hco3-=27.4meg/l. (22-26mmol/L)
• BLOOD GAS ANALYSIS
• PH-7.55 (7.35-7.45)
PCO2-17.2mmHg. (35.0-45.0mmHg)
PO2-159mm Hg
• LIVER FUNCTION TESTS
• Total bilurubin-.2 mg/dl (0.2-1.2mg/dL)
• Direct bilirubin-.1mg/dl. (upto 0.3mg/dL)
• SGOT-33U/L. (15-55U/L)
• SGPT-22U/L. ( 5-40 U/L)
• ALP-107U/L.

48. THYROID FUNCTION TESTS
• T3-1o7ng/dl.(70-190ng/dl)
• T4-8.05ng/dl(.8-2.2ng/dL)
• TSH-1.60mIU/L(.7-6.4mIU/L)
• KARYOTYPING
• T(21,22)

49. MICROBIOLOGICAL EXAMINATION
• STOOL EXAMINATION
• Stool pus cells-2-3hpf.
• Stool RBC-nil.
• Stool fat globules-present.
• Stool mucous-nil.
• Occult blood-nil.
• Ova,cyst-nil.

50. INVESTIGATIONS
• BIOCHEMISTRY—
LFT,RFT,Electrolytes;ABG analysis
• HEMATOLOGY—
Hb,Counts,ESR,Plateletes,PeripheralS
mear
• RADIOLOGY—ChestX ray.
• MICROBIOLOGY—Blood culture;Stool
& Urine examination
• KARYOTYPING

51. TREATMENT
- Prithvishree Ravindra (080201366)

52. IMNCI guIdelINes

53. PNeuMONIA
• INdICAtIONs fOr hOsPItAlIsAtION :
• At tIMe Of dIAgNOsIs:
 Features of hypoxia ( restlessness, anxiety, cyanosis. Inability
to sleep, talk, walk, unconsciousness, seizures) ; Reduced
urine output/ dehydrated ; Vomiting/ poor oral intake
 High risk factors
• durINg treAtMeNt
 No improvement/ progressive deterioration when on treatment
as outpatient

54. OutPAtIeNt MANAgeMeNt
• 1 – 5 years age :
• Paediatric Tablet Cotrimoxazole (Sulphamethoxazole 100 mg
and trimethoprim 20 mg ) - 3 tablets twice a day
• Reassess after 48 hours
• If improves – continue for 3 more days. No improvement –
continue for 48 hours and reassess.
• Explain parents WARNING SIGNS – return immediately

55. INPAtIeNt MANAgeMeNt
Specific Supportive
Antibiotics Hydration
Nutrition
Oxygen
Antipyretics
Physiotherapy
Asthalin nebulisation if wheeze is
present

56. ANtIbIOtICs
• Benzyl penicillin/ ampicillin / 3rd generation cephalosporin +/-
aminoglycosides
• Inj. Benzyl penicillin – 5000IU per kg/dose 6th hourly IM
• Inj. Ampicillin – 50mg/kg/dose 6th hourly IM
• Inj. Gentamicin – 2.5 mg/kg/dose 8th hourly IV
• Continue for 10-14 days
• Assess twice a day – if deterioration :
CXR to look for staphylococcal infection
(pneumatoceles ) – change to cloxacillin
• Atypical pneumonia - macrolides

57. suPPOrtIVe CAre
• Fever – Paracetamol (10-15 kg/dose ) every 4 to 6 hourly
• Tachypnea, cyanosis, chest indrawing – oxygen by oxygen
hood, oxygen mask, nasal catheter, nasopharyngeal catheter
• Not drinking/dehydrated – IV fluids
• Asthalin nebulisation : if wheeze present

58. treAtMeNt Of the INdex CAse
• Nebulisation with asthalin
• IV fluids Iso – P
• Inj. Ampicillin IV
• Injection Gentamycin IV
• Syp PCT

59. dOWN sYNdrOMe – heAlth
suPerVIsION

60. dOWN sYNdrOMe – heAlth
suPerVIsION
Condition Time to screen Comment
Congenital heart Birth 50% risk for congenital
disease Young adult for heart disease.
acquired valve disease Increased risk for
pulmonary
hypertension
Strabismus, cataracts, Birth or by 6 months 15% - cataracts
nystagmus Check vision annually 50% - refractory errors
Hearing impairment or Birth or by 3 months – Congenital hearing loss
loss ABER 70% risk – serious
If tympanic membrane otitis media
not visualised- 6
monthly for 3 years
Annually therafter
Constipation Birth Hirschsprung disease

61. dOWN sYNdrOMe – heAlth
suPerVIsION
Condition Time to screen Comment
Celiac disease 2 years/ symptomatic Screen – IgA and
tissue transglutamase
antibodies
Hematologic disease At birth , adoloscence Neonatal polycythemia
and when symptoms Leukemoid reaction
develop Leukemia
Hypothyroidism Birth, repeat at 6 – 12 1% - congenital
months and then 5% acquired
annually
Growth and At each visit Discuss school
development Use Down syndrome placement options
growth curves Proper diet to avoid
obesity

62. For index case

63. For index case

64. dOWN sYNdrOMe – heAlth
suPerVIsION
Condition Time to screen Comment
Obstructive sleep apnea Start at 1 year. Then at Monitor for snoring,
each visit restless sleep
Atlantoaxial subluxation/ Each visit – history and Maybe asymptomatic
instability physical exam
Radiographs at 3 -5
years or when planning to
participate in contact
sports / Transient
neurological symptoms
Gynaecological care Adoloscent girls Menstruation/
contraception use
Recurrent infections When present Check IgG subclass and
IgA levels
Psychiatric, behavioral Each visit Depression,anxiety,
disorders OCD, schizoprenia.
Autism , Early onset
alzheimers

65. PdA - left tO rIght shuNt
• Catheter based treatment – occlusive devices or coils
• Surgery if :
• Large PDA ( larger than size of available devices)