PRIMARY

WORKING
IMPRESSION
Congestive
Heart Failure 2O
Congenital Heart
Disease probably
Atrial Septal
defect with
concomitant
pneumonia and
moderate
dehydration

RULE IN

Hx: repeated pulmonary infection

Hacking cough, watery nasal discharge
Irritability, poor feeding
Dyspnea
Orthopnea(difficulty breathing in supine)
Diaphoresis
PE:
cardiorespiratory distress
tachypnea, tachycardia
cool, wet to touch
Nasal flaring
clear nasal discharge
pale lips, gums, teeth
Intercostal, suprasternal & subcostal retractions
Crackles
Signs of dehydration: irritability, slightly
depressed fontanel , dark yellow urine
ROS: poor weight gain, dyspnea
Course in the ward:
Decreased breath sounds in both lungs
Grade 2/6 systolic murmur
Hepatomegaly
DIFFERENTIAL DIAGNOSIS
Bronchial
Hx:
Asthma in
symptomatic improvement with bronchodilators
severe
Family hx of asthma (maternal)
exacerbations
Hacking cough, watery nasal discharge
Irritability & poor feeding
Difficulty breathing
Orthopnea: difficulty breathing in supine
PE:
cardiorespiratory distress
tachypnea, tachycardia
Nasal flaring
clear nasal discharge
Intercostal, suprasternal & subcostal retractions
Crackles & wheezes are heard over both lung fields
with occasional grunting
Aspiration
Hx: cyanosis & tachypnea noted after
Pneumonia
breastfeeding
PE:
Irritability
Cardiorespiratory distress tachycardia, tachypnea
Nasal flaring
Crackles heard over both lung fields
Course in the ward:
Decreased breath sounds in both lungs
Viral Pneumonia
Hx:
Hacking cough
watery nasal discharge
Irritability, poor feeding

RULE OUT

Cannot be ruled out

Cannot be ruled out

Cannot be ruled out

(-)fever, chills

Acute Bronchitis

Cystic Fibrosis

Dyspnea
Orthopnea(difficulty breathing in supine)
Diaphoresis
PE:
cardiorespiratory distress
tachypnea, tachycardia
Nasal flaring
clear nasal discharge
Intercostal, suprasternal & subcostal retractions
Crackles & wheezes are heard over both lung fields
with occasional grunting
Hx: Hacking cough
watery nasal discharge
Irritability, poor feeding
Dyspnea
Orthopnea(difficulty breathing in supine)
Diaphoresis
PE: cardiorespiratory distress
tachypnea, tachycardia
Nasal flaring
clear nasal discharge
Intercostal, suprasternal & subcostal retractions
Crackles & wheezes are heard over both lung fields
with occasional grunting
Hx: prolonged pulmonary infection
Hacking cough, watery nasal discharge
Irritability, poor feeding
Dyspnea
Diaphoresis
PE:
cardiorespiratory distress
tachypnea, tachycardia
Nasal flaring
clear nasal discharge
Intercostal, suprasternal & subcostal retractions
Crackles & wheezes are heard over both lung fields
with occasional grunting
Signs of dehydration: irritability, slightly depressed
fontanel , dark yellow urine
ROS: poor weight gain, dyspnea

(-) fever
(-) environmental
exposure
(-)localized
lymphadenopathy

(-) increased chest AP

diameter
(-) skin manifestations:
frosting of skin, salty
taste skin
(-) GI manifestations:
meconium ileus
(-) pancreatic
insufficiency:
steatorrhea, polyuria

In severe exacerbations of asthma, the greater extent of airways obstruction causes labored breathing &
respiratory distress, which manifest as inspiratory wheezing, suprasternal & intercostal retractions, nasal
flaring. These manifestations are present in our patient.