Case: Diagnosis of Pediatric Pneumonia
● Chief Complaint: Fever, cough, shortness of breath 3 days.
● is now history: 3 days ago no obvious incentive for fever, body temperature 38 ~ 39 ℃, no chills, accompanied by cough, sputum and throats are not easy to cough. 1 day ago increased cough, accompanied by wheezing, difficulty breathing, poor spirit, self-serving “pneumonia cough syrup,” “re-forest”, the temperature drops, asthma, cough without apparent ease, since the disease has been the spirit of eating less sodium good, normal urine.
● medical checkup: T 37 ℃, P 150 beats / min, R 60 times / min, Wt 9kg. Developed normally, nutrient medium, clear consciousness, mental ill, the body mucosa of non-stained and bleeding points, superficial lymph nodes are not touched, no skull deformities, anterior fontanelle 1.0cm × 1.0cm, full, nose flap, mouth slightly Week cyanosis, red pharynx, tonsil little thoracic symmetry no deformity, three concave sign (+). Lungs coarse breath sounds can be heard and extensive wheezing, sputum and lung mingyin bottom line of small wet sound. Heart circles little heart sounds strong, law Qi, heart rate 150 beats / min, no smell and pathological murmur. Abdomen soft, liver, ribs 3cm, soft. The nervous system revealed no abnormalities.
● Diagnosis: respiratory syncytial virus pneumonia
Diagnostic evidence in this case:
(A) history characteristics of
Mainly manifested as fever, cough, shortness of breath, and difficulty in breathing.
(B) physical characteristics of Cha
1. Nasal flap, slightly perioral cyanosis, three concave sign (+)
2. Lung auscultation, coarse breath sounds can be heard and extensive wheezing, lungs can be heard and fixed at the end of a small wet sound.
Diagnosis points:
Bronchial pneumonia based on history, clinical manifestations and X-ray examination, diagnosis is not difficult. It is important to make further conditions (light, heavy) and pathology diagnosis, to guide the correct and effective treatment.
(A) to determine the diagnosis of pneumonia
Mainly based on cough, fever, shortness of breath, lung and other clinical manifestations of small wet sound, combined with chest X-ray film can be clearly pneumonia diagnosis.
(B) to determine the condition of pneumonia
Light and heavy pneumonia, the clinical diagnostic criteria are:
1. A light to the main respiratory symptoms, no respiratory failure and other organ or system function of the apparent damage or failure.
2. Heavy In addition to respiratory symptoms, the concurrent heart failure, respiratory failure, disseminated intravascular coagulation, high fever or body temperature did not rise, toxic encephalopathy and toxic paralytic ileus, and one of liver and kidney dysfunction, congenital children with heart disease, malnutrition, infant, newborn, etc., when pneumonia, are severe.
● Treatment:
1. General Treatment: Maintain good indoor ventilation, digestible diet.
2. Antiviral therapy: interferon-α100 million U intramuscularly, ribavirin aerosol inhalation.
3. Antibiotics: ampicillin intravenous drip.
4. Symptomatic treatment: intermittent oxygen, salbutamol inhalation.
After treatment five days later, signs and symptoms relieved and discharged to continue oral amoxicillin 3 days.