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General dataE.C.6 month old FemaleBorn on March 7, 2013Taguig CityCHIEF COMPLAINTDifficulty of breathing

History of Present IllnessPast Medical HistoryNo previous illnessNo previous hospitalizationNo previous surgical procedureFamily history(+) Diabetes mellitus(-) asthma, allergy, heart disease, hypertension, stroke, cancer

Birth and Maternal historyBorn full term delivered via CS (breech delivery) to a 35 year old G1P1Birth weight of 5lbs 6ozAttended by OBGYN, St. Christianas hospitalWith no fetomaternal complicationsNutritional historyNot breastfedOn formula feeding, started on solid foods

Immunization historyBCG 1DPT/Polio 2Hib 2Hepatitis B 2Pneumococcal 1 Rotavirus 1MMR 0Measles 0Varicella 0Influenza 0Hepatitis A 0Typhoid 0

Developmental historyPhysical ExaminationGeneral survey: alert, crying, but consolable Vital signs: BP 90/60mmHg, HR 140bpm, RR 32 cpm, T 36.5degAnthropometrics: Hgt 63cm, Wgt 5.4 kg Head circumference 42cm, Chest circumference 45cm, Abdominal circumference 43 cmPhysical ExaminationHEENT: anicteric sclerae, pink palpebral conjunctivae, no alar flaring, no cervical lymphadenopathy, flat neck veins, no tonsillopharyngeal congestion

PULMONARY: equal and symmetric chest expansion, with shallow subcostal retractions, harsh breath sounds, occasional rales, no wheezes

CARDIOVASCULAR: adynamic precordium, PMI at 4th left ICS, midclavicular line, regular cardiac rhythm, no murmurPhysical ExaminationABDOMEN: normoactive bowel sounds, soft, no masses, no organomegalyEXTREMITIES: normal skin color, good skin turgor, no cyanosis, no edema, full and equal pulsesPhysical ExaminationNEUROLOGIC: alert Cranial nerves: pupils 2-3 mm equally brisk and reactive to light, tracks objects, no nystagmus, no facial asymmetry, responds to sound, (+) gag reflex Motor: normal tone, no atrophy, 5/5 on all extremities Reflexes: normal reflex (++) on all extremities Sensory: responds to touch in all extremities No Babinski No meningeal signs

Admitting diagnosisPneumoniaGoals of careFor the patient to have resolution of respiratory distress by the time of dischargeRespiratory rate < 50 cpmNo retractions, no alar flaringNo vomitingNo cyanosisDecreased cough episodesDiagnostics & TherapeuticsCBCPC to check for infectionChest Xray to check for pneumonia

Nebulization with Salbutamol, Salbutamol+Ipratropium, HydrocortisoneIV Ampicillin (100mg/kg/day) IV support: D5IMB at maintenance rateLaboratory resultsHgb139 g/LHct0.42WBC10.0 x 10^9/LNeutrophil0.52Lymphocyte0.43Monocyte0.05Eosinophil0Platelet448 x 10^9/LInsert Chest XrayOfficial reading (9/14/13): hyperaerated lungs, bilateral interstitial infiltrates without consolidation suggestive of viral pneumonia

18Course in the Wards: Day 1Course in the Wards: Day 2Pedia Pulmonology notesPedia Cardiology notesCARDIOPULMONARY: Cyanosis: not documented but presents with occasional desaturations to mid-80% O2 at room airMay be due to Pulmonary arterial hypertension due to pneumoniaMay be an idiopathic persistent pulmonar y hypertension secondary to large VSDRESPIRATORY: Pneumonia: patient presents with occasional cough, with rales and occasional wheezing, with shallow subcostal retractions and grunting Chest xray: bilateral interstitial pneumonia

PROBLEMSPedia Cardiology notesCARDIAC:VSD Patient has no murmur, with regular cardiac rhythm, no history of cyanotic episodes; noted to have a loud S2Patient was initially tachypneic, with edema, which may be due to congestion brought about by the large VSD4-extremity BP: 80/50, all extremitiesEKG: RVH 2dECHO: large VSD inlet to muscular, 10-12mm, with severe pulmonary hypertension

Insert EKGInsert 2dechoPedia Cardiology notesAssessment: CHF functional class II secondary to CHD, VSD (12mm) inlet to muscular, with severe Pulmonary Hypertension; Pneumonia, community acquired

Plans: Furosemide (1mg/kg) for diuresis and to relieve congestionCaptopril 1mg/pptab Q12 as an afterload unloaderLanoxin 50mcg/ml 0.5ml BID for inotropic supportOral KCL (1meq/kg) BID for 6 dosesSildenafil 3mg/pptab Q6 Continue IV antibiotics and nebulizations for pneumoniaContinue o2 support and monitoringIVF rate at 5ml/hrFamily Conference to discuss options for treatment: PA banding as temporary solution vs definitive surgery

Pedia Cardiology notesCourse in the Wards: Day 328Course in the Wards: Day 429Course in the Wards: Day 530Course in the Wards: Day 6 (12nn)31Course in the Wards: Day 6 (4:30pm)32Prior to transfer to PICUIntubation HR 50sCPR doneBag-tube-ventilation deliveredPNSS 10cc/kg given, 2 bolusesEpinephrine 0.5mg/ET for 5 dosesIJ catheter, right, inserted for IV accessPrior to transfer to PICUIntubation HR 50sCPR doneBag-tube-ventilation deliveredPNSS 10cc/kg given, 2 bolusesEpinephrine 0.5mg/ET for 5 dosesEpinephrine drip started 0.1 meq/kg/minMilrinone drip started 0.8mcg/kg/minIJ catheter, right, inserted for IV accessPrior to transfer to PICULaboratory exams requested:ABGCBCPCICAL, Na, K, ClBlood typingHgtPrior to transfer to PICUABG: mixed respiratory + metabolic acidosis (on PPV)pH 7.176, pCO2 52.6, pO2 24.4, HCO3 19.4, Base 9.3, O2 sat 31.4

CBCHgb92 g/LHct 0.29WBC7.50x!0^9/LNeutrophil0.12Lymphocyte0.86Monocyte 0.02Eosinophil0Platelet271 x 10^9/LNa134 mmol/LK4.40 mmol/LChloride91.00 mmol/LIcal3,68 mg/dl (dec)Hgt338 mg/dl36