History and Physical — Patient 59

History

Chief Complaint: Tachypnea

Present Illness: The patient is a six week old male with intermittent tachypnea since birth, resulting in extended hospitalization for four days after delivery. At his first visit with his pediatrician at two weeks of age, intermittent tachypnea was again noted. At six weeks of age, he presented to the emergency department at the Texas Children's Hospital with "gasping" respirations. His parents reported that since birth the patient had been tachypneic while awake, but that they had not noticed any abnormal breathing while he was asleep. His breathing pattern showed occasionally normal to slow, regular breathing lasting seconds to minutes, interspersed with runs of rhythmic tachypnea lasting for minutes, reaching a rate of 130 breaths per minute. The patient has never had cyanosis or sweating with feedings. There have been brief periods of apnea at home, all lasting less than a minute. The patient has had no fevers, cough, sputum production, known exposures to individuals with communicable illnesses, rashes, excessive irritability, or difficulty with feeding.

Past Medical History: The patient is a full-term infant, weighing 7 pounds, 3 ounces at birth. He was born to a 22 year old, healthy mother by spontaneous vaginal delivery. Weight at the 2-week checkup was 7 pounds, 7 ounces, which had increased slightly by six weeks. According to the parents, he regards faces, puts his hands together, and lifts his head slightly when prone. He does not smile yet. There is no history of surgical or invasive procedures.

Allergies: No known drug allergies or adverse events.

Medications: None.

Family History: No consanguinity in the family. Both parents and their two-year old daughter are healthy. There are no family members with known neurologic or cardiopulmonary abnormalities, and no known serious illnesses during infancy.

Social History: The patient resides with his parents and sister, and has not traveled outside the U.S.

Review of Systems: No fevers, weight loss or sweats. No diarrhea or vomiting. No skin rashes or lesions, and no limitation of joint motion. Otherwise, the review of systems is unremarkable.

Physical Exam

General: Thin African-American male infant in no apparent distress despite episodes of obvious tachypnea.

Vital Signs: Temperature 98.3 F, BP 95/55 mmHg, HR 70/min, length 45 cm (50th percentile), weight 3.5 kg (20th percentile), head circumference (OFC) 38 cm (50th percentile).

HEENT: No cranial dysmorphic abnormalities, or evidence of trauma. Large anterior fontanelle (4 x 4 cm), not depressed or bulging. No iris or anterior chamber defects were noted on inspection of the eyes. Nasal passages and oropharynx clear; tongue appeared normally shaped. Ears were not clearly low-set. Neck supple. No lymphadenopathy, thyromegaly or masses. No excess nuchal skin.

Chest: Normal jugular venous pulsations. Clear to auscultation with normal breath sounds.

Cardiovascular: Regular heart rate and rhythm without murmurs or gallops.

Abdomen: Soft, without organomegaly or masses. Normal bowel sounds.

Genitourinary: Normal Tanner stage I male genitalia with bilaterally descended testes.

Spine: No scoliosis or sacral dimples.

Extremities: No clubbing or edema, normal skin color without jaundice, abnormal pigmentation, rashes, lesions. No dysmorphic features.

Neurological Examination

Mental Status: Awake and alert, with good crying effort.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIPupils 4 mm, reactive to light. Funduscopy at the bedside was normal in both eyes.
III / IV / VIIntermittent spontaneous disconjugate movements of either eye, without reduced responsiveness. Full range of extraocular movements in all directions.
V / VIIResponds to pinprick throughout face; opens and closes mouth well; normal facial symmetry, sucking, and tearing.
VIIIResponds to voice or soft sounds bilaterally.
IX / XPalate and uvula midline with normal elevation.
XINormal strength of head rotation to either side; no atrophy of sternocleidomastoids.
XIITongue protruded in midline, with normal bulk and no fasciculations.

 

Motor: Normal bulk with mildly decreased axial tone. Normal appearing movements of all extremities.

Reflexes: Tendon reflexes were 2/4 in arms and legs. Moro, Babinski, suck, root, tonic neck, and snout responses were present.

Sensation: Withdrawal and grimace to pinprick in all extremities.

Gait: Not tested.

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