Pediatrics

6 year old girl with shortness of breath

Shilpa Gulati on May 27, 2013

New admit to the peds floor from the ED: a 6 year old female with a 1 day history of shortness of breath who was transferred from a nearby hospital ED for status asthmaticus requiring albuterol, magnesium and steroids, and CXR suggestive of pneumonia.

This morning the patient’s school called home with report of her being unable to catch her breath. She was sent home and received an albuterol breathing treatment which improved her symptoms mildly. When her respiratory distress continued to worsen, she came into the ED. She was persistently hypoxic with albuterol treatments so she received magnesium and continuous albuterol. She also received a dose of intramuscular ceftriaxone. A few hours later she was weaned off continuous albuterol treatments down to 8 puffs q 2 hours. She continued to be hypoxic and tachypneic with removal of her oxygen and was subsequently admitted for persistent hypoxia.

ROS: She denies any nausea, vomiting, recent illness, chest pain, or sick contacts.

PMH:

- Recurrent ear infections (per mom's report)

- 2 past episodes of SOB addressed in emergency care (in Oct. 2012, when she was diagnosed with pneumonia and treated with steroids and abx; and in early Feb. 2013, when she was diagnosed with bronchitis and given home albuterol)

- Pt's mother denies any history of asthma, eczema, or allergies

- Immunizations up to date, unremarkable neonatal/developmental history

Surgical Hx: No past surgeries.

Family Hx: No family history of asthma, allergies, or lung disease. Great grandfather with lung cancer at late age.

Social Hx: Lives with her mother, 3 year old sister, and pets (1 dog, 1 cat). No smokers in the household, no known recent sick contacts.

Meds: Albuterol

Allergies: Penicillin

  • Temp  37 C
  • HR  124
  • BP  101/50
  • RR  32
  • O2  99% on 1L Nasal Canula
  •  

Physical exam - 

General: Patient sitting comfortably in bed in no acute distress, conversant. Appears well hydrated.

Eyes: PERRL, sclera slightly injected

HENT: MMM, tonsils enlarged and erythematous. Cheeks are reddened, skin is not scaly

CV: Tachycardia with regular rhythm, no m/r/g. Distal pulses 2+ throughout with brisk capillary refill.

Resp: No obvious chest retraction or accessory muscle use. Decreased breath sounds at bilateral bases; increased expiratory phase. Crackles audible at the base of left upper lobe, and rhonchi and expiratory wheeze audible throughout.

GI/ABD: Soft, nontender, nondistended, normal bowel sounds auscultated.

MS: Normal bulk and tone.

Skin: No skin lesions visible, a couple resolving petichie at knees and shins bilaterally.

New admit to the peds floor from the ED: a 6 year old female with a 1 day history of shortness of breath who was transferred from a nearby hospital ED for status asthmaticus requiring albuterol, magnesium and steroids, and CXR suggestive of pneumonia.

This morning the patient’s school called home with report of her being unable to catch her breath. She was sent home and received an albuterol breathing treatment which improved her symptoms mildly. When her respiratory distress continued to worsen, she came into the ED. She was persistently hypoxic with albuterol treatments so she received magnesium and continuous albuterol. She also received a dose of intramuscular ceftriaxone. A few hours later she was weaned off continuous albuterol treatments down to 8 puffs q 2 hours. She continued to be hypoxic and tachypneic with removal of her oxygen and was subsequently admitted for persistent hypoxia.

ROS: She denies any nausea, vomiting, recent illness, chest pain, or sick contacts.

PMH:

- Recurrent ear infections (per mom's report)

- 2 past episodes of SOB addressed in emergency care (in Oct. 2012, when she was diagnosed with pneumonia and treated with steroids and abx; and in early Feb. 2013, when she was diagnosed with bronchitis and given home albuterol)

- Pt's mother denies any history of asthma, eczema, or allergies

- Immunizations up to date, unremarkable neonatal/developmental history

Surgical Hx: No past surgeries.

Family Hx: No family history of asthma, allergies, or lung disease. Great grandfather with lung cancer at late age.

Social Hx: Lives with her mother, 3 year old sister, and pets (1 dog, 1 cat). No smokers in the household, no known recent sick contacts.

Meds: Albuterol

Allergies: Penicillin

  • Temp  37 C
  • HR  124
  • BP  101/50
  • RR  32
  • O2  99% on 1L Nasal Canula
  •  

Physical exam - 

General: Patient sitting comfortably in bed in no acute distress, conversant. Appears well hydrated.

Eyes: PERRL, sclera slightly injected

HENT: MMM, tonsils enlarged and erythematous. Cheeks are reddened, skin is not scaly

CV: Tachycardia with regular rhythm, no m/r/g. Distal pulses 2+ throughout with brisk capillary refill.

Resp: No obvious chest retraction or accessory muscle use. Decreased breath sounds at bilateral bases; increased expiratory phase. Crackles audible at the base of left upper lobe, and rhonchi and expiratory wheeze audible throughout.

GI/ABD: Soft, nontender, nondistended, normal bowel sounds auscultated.

MS: Normal bulk and tone.

Skin: No skin lesions visible, a couple resolving petichie at knees and shins bilaterally.

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