An 8-month-old boy with cough (page 1/3)
Prepared by.... .Kraison Pongwilairat M.D.
Meijinee Densriwiwat M.D.
Thanyawee Puthanakit M.D
Patient: An 8-month-old Burmese boy, Mae Jan province, Chiang Rai
CC : Cough for 5 days
PI:
> 5 days PTA: He developed paroxysmal cough for 5 days. The cough occurred in cluster ranged from 15 to 20 times at each episode. He also had a low grade fever.
> 1 day PTA: The cough and respiratory distress got worse. He developed high grade fever.
Past History:
> History of unsterile delivery at home
> No previous immunization
> Normal development
Family history: No history of respiratory disease in his family in the past one month.
Physical examination:
  GA: A boy with dyspnea, no cyanosis
V/S: BT 38.5 C, PR 178/min, RR 60/min, BP 117/78 mmHg (crying), O2 saturation at room air 94%,
OFC 43 cm., W/A 81%, H/A 100%
HEENT: not pale, no jaundice
pharynx and tonsils not injected, no patch
no rhinorrhea, no conjuntivitis, no subconjunctival hemorrhage
TM: ear wax both ears
Heart: regular rhythm, normal S1 S2, no murmur
Lungs: suprasternal and subcostal retraction, paroxysmal cough, crepitation both lung, no wheezing
Abdomen: soft, normal bowel sound
liver 2 cm below RCM, spleen just palpable
Ext: normal
Skin: no petechial hemorrhage
Initial laboratory investigations:
  CBC: Hb 11.6 g/dl, Hct 38.8 %, WBC 62,100 (N 38%, L 57 % E 4%, B 1%) Platelet 885,000
PBS: normochromic normocytic, toxic 1+ no vacuolization, no atypical lymphocyte
U/A: pH 5, Spgr.1.025, albumin neg, sugar neg, epithelium 1-2, rbc 0-1, wbc 1-2
CXR: bilateral perihilar infiltration (fig. 1)
 
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