Difficulty
breathing in a 2-month-old infant
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Prepared
by...
Virat Sirisanthana, M.D.
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Department
of Pediatrics, Faculty of Medicine, Chiang Mai University
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Chief
Complaint and Present Illness: A 2-month-old
female infant had a 7-day history of subacute onset
of difficulty in breathing. She was born in the community
hospital without any complication. Her birth weight
was 3350 grams. She had been healthy until this illness.
Her mother denied any history of fever. At the community
hospital she had respiratory distress so she was intubated
and refered to our hospital with intravenous penicillin
G.
Family History : was not available at the time
of admission |
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Physical
examination:
GA: BW: 4050 grams, was intubated, not pale,
no jaundice
VS: T= 38.4 C (max), RR= 60/min, P = 160/min,
Anterior fontanelle 1.5 x 1.5 cm., not bulging
Lung: she was on respirator
Abdomen: liver 2 cm below RCM , spleen 2 cm below
LCM. |
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Laboratory
Findings:
Complete blood count: Hemoglobin 9.3 g/dl, hematocrit
29 % , platelets 174,000, WBC 18,500, differential:
62 % polys , 38 % lymphocytes.
Electrolyte: Na 131 , K 3.8 , Cl 106 , CO2 22 mEq/L,
BUN 9 mg% , Cr 0.4 mg%
Chest radiograph: (see below).
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