Case Presentation

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Case Presentation

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Identification

• Name Yossef E.
• I.D 407826551.
• DOB 05/01/2001. (11years old)
• Address Gaza Elshaaf.
• Date of admission17/12/2012
• Date of discharge 24/12/2012

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Complaint

• Fever (38.5-39).
• Persistent Cough.
• Throat pain.
• Breathing difficulty.
• Poor appetite.

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Present History

• Source of history (Pt and mother)
• The condition started 5 days before admission by
  fever in the 1st day reaching 38.5,and on the 2nd
  day developed persistent dry cough, throat pain
  and poor appetite.
• During that time the pt did not seek any medical
  advice.
• On 17/12 the condition became more worse
  developed general weakness and increasing the
  spike of coughing.
• So the Pt presented to ER asking for medical
  help.

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Past Medical History

• No history of serious medical conditions.
• No H/O hospitalization.

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• Perinatal history normal.
• Nutritional history normal.
• Immunization history up to age.
• Developmental history normal.
• Family history the parents not relative both are
  healthy, 5 males and 7 females.

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Vital Sign
bwt O2 sat Temp B/p RR HR
39kg 95 39 110/65 22 110
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General Examinations

• Pt looks ill, pale tachypnic.
• Head normal size and shape.
• Neck lax no lymphodenopathy.
• Throat congested and hyperemic.
• Chest
• General inspection symmetric form no retractions
  no skin rash
• Percution stony dulness at Rt lower lobe.
• Auscultation no air entry at Rt lower lobe with
  good air entry for others parts of both lungs.
• Heart reg. heart rate normal sounds no murmurs.

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General Examinations

• Abdomen soft and lax no organomegally
• L.N are not palpable.
• Genitalia is normal.
• Upper and lower extremities are normal no
  clubbing.
• CNS Pt conscious and oriented.
• Neuromuscular normal.

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Provisional diagnosis

• Pneumonia.
• Pleural effusion.
• F.B inhalation.
• So the following investigations requested
• CBC
• ABGs
• Chest X-Ray

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Lab investigations
CBCs
PLT Hb WBCs WBCs
PLT Hb 14.2 14.2
463 10.0 N L
463 10.0 79.1 12.2
ABGs
ABE HCO3 O2 sat PO2 PCO2 PH
-6 18 95 85 42 37.40
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Radiological

• Chest X-Ray

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• The film radiograph shows opacity in Rt L lobe,
  presence blunted of Rt costophrenic angle with
  air fluid level. And present multiple LN
  enlargement in perihilum both sides.
• abnormal heart configuration.
• Rt lower lobe bronchectasis with Rt pleural
  effusion
• Lymphodenopathy
• Advice CT chest for more investigation

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Chest X-Ray report

• The film radiograph shows opacity in Rt L lobe,
  presence blunted of Rt costophrenic angle with
  air fluid level. And present multiple LN
  enlargement in perihilum both sides.
• abnormal heart configuration.
• Rt lower lobe bronchectasis with Rt pleural
  effusion
• Lymphodenopathy
• Advice CT chest for more investigation

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• After chest X-ray re-evaluation.
• range of differential diagnosis increased, the
  following diagnosis added
• FB inhalation
• (Mother and the Pt denied any FB inhalation)
• Lung mass.
• CT chest ESR LDH Uric Acid (tumor markers)
  immediately
• Congenital lung anomaly.
• Congenital cystic adenomatoid formation of Rt
  lower lobe.
• (bronchoscope put in mind)
• Others brochiactasis atelectasis.

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Management (until the others results)

• Rp. cefatriaxon 1 g iv/12h.
• Rp. vancomycin 600 iv/8h.
• Rp. O2 Mask 5L/min.
• Rp. iv fluid.
• chest PT

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Follow up

• On 2nd day the general cond. Better afebrile,
  less tachypnic more active.
• Chest examenation the sam.

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Chest / thorax CT
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Chest And Thorax CT Report

• Right lung lower lobe mass with mediastinal
  lymphodenopathy.

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• ESR 90mm/h.
• LDH 463 u/l.
• Uric acid 5.7 mg/dl.
• Blood film
• Normochromic normocytic.

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Thorathic surgery consultation

• ?? F.B obstruction.
• ?? Congenital cystic adenomatoid formation of
  right Lower lobe
• Advice bronchoscope and follow up .
• And me be need for Rt lower lobe resection.
• Dr. Abed Elgafar Elzaaneen

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22/12/2012

• Good general condition no any complaint
• On exam pt looks will active not dyspnic at all.
• Chest stony dullness Rt side, absent air entry Rt
  lower lobe.
• Heart abdomen NAD.
• Pt discharge at home on oral antibiotic as
  prophylactic. With follow up after bronchoscope.

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28/12/2012

• Fibroptic bronchoscope under GA at Elshfa
  hospital in the operative room.
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• Bronchoscop report.

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Break
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Causes

• Obstruction of an airway or diminished distention
  of alveoli may cause atelectasis.
• The most common causes involving airway
  obstruction include the following
• Airway obstruction due to a mucous plug or other
  airway secretions, such as with bronchiolitis.
• Bronchospasm airway secretions and airway
  inflammation in patients with asthma.
• Abnormal airway secretions in cystic fibrosis.
• Abnormal airway clearance, such as with ciliary
  dyskinesia syndrome.
• (recurrent or persistent respiratory
  infections, sinusitis, otitis media, and male
  infertility)
• Congenital Lung Malformations.
• (Laryngomalacia, Pediatric Tracheomalacia,
  Pediatric Pulmonary Hypoplasia, Cystic
  Adenomatoid Malformation, and Pediatric
  Bronchogenic Cyst).

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..Causes

• Airway foreign body
• Extrinsic compression on an airway (eg,
  compression due to an enlarged or aberrant
  vessel)
• Enlarged lymph nodes that compress the airway
• Masses in the chest that compress the airway or
  alveoli
• Cardiomegaly or enlarged pulmonary vessels that
  compress adjacent airways

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..Causes

• Causes of diminished alveolar distention include
  the following
• Small or dysmorphic chest wall
• Severe scoliosis
• Neuromuscular diseases
• Anesthesia or sedation
• Pain from upper abdominal surgery
• Abdominal distention
• Chest wall or upper abdominal pain
• http//emedicine.medscape.com/article/1001160-clin
  icala0218

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• F.B apiece of plastic measuring 0.5x2cm at Rt
  lower main bronchus where removed .
• Lifting behind a mass of fibrous and granulation
  tissue.

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F.B
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• The film radiograph shows opacity in Rt L lobe,
  presence blunted of Rt costophrenic angle with
  air fluid level. And present multiple LN
  enlargement in perihilum both sides.
• abnormal heart configuration.
• Rt lower lobe bronchectasis with Rt pleural
  effusion
• Lymphodenopathy

• Rt midile lobe collapse
• Rt lower lobe pneumonia
• Bilateral hilium lymphodenopathy

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• The film radiograph shows opacity in Rt L lobe,
  presence blunted of Rt costophrenic angle with
  air fluid level. And present multiple LN
  enlargement in perihilum both sides.
• abnormal heart configuration.
• Rt lower lobe bronchectasis with Rt pleural
  effusion
• Lymphodenopathy

• Rt midile lobe collapse
• Rt lower lobe pneumonia
• Bilateral hilium lymphoadenopathy

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