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Health History and Physical Examination, Respiration rate increased to…
Health History and Physical Examination
history if present illness
coughing with yellow sputum x 3/7
decrease oral intake
high grade fever : 38.0 °C
SpO2 : 93%
Blood pressure : 44/46 mmHg (MAP: 43)
Other Current Condition
Dehydration
Past History
Past Medical History
Neonatal Jaundice
Past Social History
The child has been brought to attend the Gawai celebration.
The father started to feel unwell on the 4th of June.
The child is sleeping with the parents on the mattress.
The bedsheet is regularly cleaned by the mother.
Past Surgical History
Nill
Examinatiom Findings
On Admission
Palpitation
Abdomen is soft and no distended.
Strong, palpable and regular pulses.
Symmetry lung expansion
No pitting edema at upper limb and lower limb.
No palpable mass on abdomen.
Skin is warm
Percussion
Resonance sound was heard at the lung area.
Dull sound was heard at dense area (Heart and liver area)
Auscultation
Generalized rhonchi sounds were heard in the lungs.
No wheezing sounds were heard in the lungs.
Generalized crackles sounds were heard in the lungs.
No stridor sounds were heard in the lungs
inspection
Runny nose
Skin is intact and no tenderness was found
Patient is alert and conscious.
Both conjunctives are pinkish colour
No finger clubbing
Patient is having tachypnea with moderate subcostal recession
During Interview
Palpitation
Abdomen is soft and no distended.
Strong, palpable and regular pulses.
Symmetry lung expansion
No pitting edema at upper limb and lower limb.
No palpable mass on abdomen.
Skin is warm
inspection
Patient is having tachypnea with mild subcostal recession
No runny nose
Skin is intact and no tenderness was found
Patient is alert and conscious.
Both conjunctives are pinkish colour
No finger clubbing
Percussion
Resonance sound was heard at the lung area.
Dull sound was heard at dense area (Heart and liver area)
Auscultation
Less rhonchi sounds were heard in the lungs.
No wheezing sounds were heard in the lungs.
Less crackling sounds were heard in the lungs.
No stridor sounds were heard in the lungs
Pathophysiology
Viral pneumonia is caused by Respiratory Syncytial Virus (RSV)
Bronchopneumonia is commonly caused by Streptococcal Pneumoniae
Can be transmitted from person to person through:
air by coughing and sneezing
direct contact such as touching the face of the child
touching an object or surfaces with the virus on it, the touching mouth/nose/eyes before without washing hands.
RSV virus and Streptococcus Pneumoniae passed through the nasal hairs and/or oral mucosa, then into the respiratory tract and invaded the alveoli.
Alveoli become inflamed and exudate starts filling the alveolar spaces.
gaseous exchange is not effective due to the exudate/fluids on the wall of alveoli
Vagus nerve stimulates the coughing mechanism.
trachea
branching points bronchus
bronchioles
the pharynx
Patient presented with cough and runny nose
Patient presented with tachypnea with moderate subcostal recession
Patient is on oxygen therapy to
supply adequate oxygen to the body
Hypothalamus increase the body temperature.
The heat boost the performance of immune cells, induces stress on pathogens and infected cells directly.
Patient presented with fever.
Respiration rate increased
to compensate the
lack of oxygen in the body