iNterns casepreseNtation

m a x A n g e l o G T e r r e n a lF r a n c i s c o P T r i a

GENERAL INFORMATION• TA

• 1 yo and 4mos

• Male

• Block 28, Lot 15, Salawikain St. Lagro Subdivision Quezon City

• Christian

• Mother: Good reliability

chief complaintD i f f i culty of B r eath ing

history OF present illness

2 days PTA• (+) Colds and productive cough• (–) Fever, difficulty of breathing• Given phenylpropanolamine + Bromocriptine maleate 1.7mkd

• Afforded temporary relief

1 day PTA• Persistence of symptoms• (+) Difficulty of breathing• Given salbutamol 0.1mkd

• Afforded temporary relief• No consultation

5 hours pta• Persistence of symptoms• (+) aggravation of difficulty of breathing

• Not relieved with salbutamol and budesonide nebulization (given every 20mins)

• (+) loss of appetite• (-) Nausea, vomiting

Few hours PTA• Persistence of symptoms

Consult

GESTATIONAL HISTORY• Mother: 31 yo, G2P2 (2002), with monthly prenatal

check-up

– No co-morbid conditions

– (-) exposure to radiation, (-) smoking, (-) alcohol intake, (-)

illicit drug use

– Ferrous sulfate, Folic acid supplements and Anmum milk were

taken during pregnancy

• Term pregnancy (39 weeks) via repeat LTCS at VMMC

• Birth weight: 2892g

• Birth length: 48cm

• Head Circumference: 33cm

• Chest Circumference: 32cm

• Abdominal Circumference: 28cm

• No birth/neonatal complications and injuries

BIRTH AND NEONATAL history

• Exclusively breastfed only up to 1 month

• Breastfeeding was every 2-3 hours for 30 minutes to 1 hour

• Multivitamins once daily

• Cereals introduced by 8-9mos

• Fruits: by 1yr old

• Vegetables: by 10mos

• Meat: by 1yr old

• Table food: by 1yr old

FEEDING HISTORY

• Regard: 2mos

• Social smile: 2mos

• Turned over: 5-6mos

• Crept: 7mos

• Sat aided: 6mos

• Sat alone: 7-8mos

• Walked aided: 1yr

• 1st word: 10-11mos “mama”

• Puts 3 words together: N/A

• Bower and bladder control: N/A

• Clothes self: N/A

GROWTH AND DEVELOPMENT

• BCG 1

• HepaB 1, 2, 3

• HepaA 1

• DPT 1, 2, 3

• OPV 1, 2, 3

• For MMR and Hib

IMMUNIZATIONS

• (+) Lactose intolerance

• (+) Hyper-reactive airway disease

• Previous hospitalization: PCAP B (Feb 12-14, 2014) at VMMC

• No previous accident/injury/surgery

PAST MEDICAL HISTORY

• Mother: 32yo, apparently well, nurse

• Father: 31yo, apparently well, branch manager

• Sibling: 2yo M, with CHD (VSD, subaortic), asymptomatic

• Maternal Grandparents– Grandmother: 60yo, skin eczema, apparently well

– Grandfather: 59yo, seizure disorder, apparently well

• Paternal Grandparents– Grandmother: 47yo, MVA, deceased

– Grandfather: 53yo, apparently well

FAMILY HISTORY

• Living circumstances: Patient lives in a cemented, bungalow-type house, well lit, with adequate space and ventilation

• Economic circumstances: both father and mother are the sources of income

• Environmental circumstances: Patient has no exposure to cigarette smoke, no factory or on-going construction nearby; regular garbage collection twice a week but not segregated. Family’s source of water is from purified water

• No recent contact with a sick person

SOCIOECONOMIC AND ENVIRONMENTAL

REVIEW OF SYSTEMSGeneral: (-) weight loss, normal growth, behavioural change

Cutaneous: (-) rash, pruritus, skin pigmentation

Head: See HPI

Cardiovascular: (-) cyanosis, (-) easy fatigability, (-) palpitation

Respiratory: See HPI

Gastrointestinal: (-) abdominal pain, (-) melena, (-) hematochezia

Genitourinary: (-) hematuria, (-) edema of hands and feet

Nervous/Behavioral:

(-) LOC, (-) tremors, (-) sleep problems, (-) convulsions, (-) weakness or paralysis, (-)eating problems, (+) tantrums

Musckuloskeletal: (-) pain and swelling in bone, joints, muscles, full range of motion, (-) stiffness, (-)limping

physical examination

General Survey: Awake, alert, irritable, in respiratory distress, well nourished, well hydrated, well-groomed

Vital Signs: CR 128 beats/min regular and strong, RR 63 regular cycles/min, sO2 = 98%, axillary temperature 37.0C

Anthropometric Data:

• Weight of 11kg (z = 0)• Height of 77 cm (z = 0)• BMI: 18.5 (z = above +1) overweight• HC of 43cm, CC of 46cm, AC of 44cm

Skin: Warm, moist, good skin turgor, well-hydrated, no active dermatoses,no scars, no edema, no pallor nor jaundice

Hair/Head: Black smooth dry hair, no lice and nits, no abnormal swelling

Face: Symmetrical face, no abnormal facies, no deformities

Eyes: No matting of the eyelashes, anicteric sclerae, pinkish palpebral conjunctiva, nostrabismus, no opacities, no discharge, (+) ROR on both eyes, no periorbital edema, 2-3 mm ERTL

Ears and Mastoids: No deformity, no skin lesions or tags, no tragal tenderness, (+) retained cerumen AU, no redness or swelling of ear canal, tympanic membrane intact

Nose and paranasal sinuses:

No deformity, septum at midline, no alar flaring, no sinus tenderness, no discharge, turbinates congested and not hyperemic

Mouth and Throat: Moist lips, pink and moist buccal mucosa, non-hyperemic posterior pharynx, midline uvula

Neck: (+) palpable occipital lymph nodes

Chest and Lungs: sO2 98%, (+) subcostal retractions, symmetrical chest expansion, equal tactile and vocal fremiti, resonant on both lung fields, (+) coarse bilateral crackles, (+) wheeze R

Heart and vascular system:

Adynamic precordium, no heaves, no lifts, no thrills, apex beat at the 4th LICS MCL, no murmurs

Abdomen: Soft, flat, symmetrical abdomen, no visible pulsation and peristalsis, normoactivebowel sounds, tympanitic, no mass, no tenderness

Extremities: No clubbing, no cyanosis, no swelling, no edema

Neurological Exam

Cerebrum Active, alert, recognizes familiar faces and objects

Cranial Nerves CN I – not assessedCN II – pupil 2-3mm ERTLCN III, IV, VI – intact EOM movements, (-) ptosisCN V – (+) corneal reflex, (+) sucking reflexCN VII – no facial asymmetryCN VIII – able to respond to soundsCN IX, X – (+) gag reflexCN XII – tongue midline

Cerebellum Can stand without support, good body tone, no hypotonia, no nystagmus

Motor Good muscle tone

Reflexes (+) Babinski, (+) parachute reflex, (-) palmar reflex

SALIENT FEATURES• 1yo, 4 mos

• Male

• CC: Difficulty of breathing

• 2–day history of colds and productive cough

• Loss of appetite

• (-) fever

• Breast fed for only 1mo

• (-) MMR and Hib vaccine yet

• (+) Hyper-reactive airway disease

• Previous hospitalization due to PCAP B

• In respiratory distress - tachypneic

• Intercostal retractions

• Congested turbinates

• No signs of dehydration

• Palpable CLAD

• (+) coarse bilateral crackles

• (+) wheeze, R

ASSESSMENT1. Pediatric Community Acquired

Pneumonia C

2. Hyper-reactive Airway Disease

PLAN• Admit

• NPO

Diagnostics

• CBC with PC

• CXR

Therapeutics

• IVF: D3 0.3% NaCl, 260mL to run for the first 8 hours to run for 32-33 ugtts/min

• Paracetamol (125mg/5mL), 5mL (11.36 mkdose) every 4 hours for fever

• Ampicillin 300mg/IV Q6 (109 mkday)

• Hydrocortisone 90mg IV loading dose, the 60mg q6 x 3 doses (8.2mkdose)

Discussion

Pneumonia

Inflammation of the lung parenchyma

InfectiousVs

Non infectious

InfectiousAGE GROUP FREQUENT PATHOGENS (IN ORDER OF FREQUENCY)

Neonates (<3 wk)Group B streptococcus, Escherichia coli, other gram-negative bacilli, Streptococcus

pneumoniae, Haemophilus influenzae (type b,* nontypable)

3 wk-3 moRespiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza

viruses, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypable)

4 mo-4 yrRespiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza

viruses, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypable), Mycoplasma pneumoniae, group A streptococcus

≥5 yrM. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae (type b,* nontypable), influenza viruses, adenovirus, other respiratory viruses, Legionella

pneumophila

NON-Infectiousa s p i r a t i o n o f f o o d o r g a s t r i c a c i d

f o r e i g n b o d i e sh y d r o c a r b o n s

h y p e r s e n s i t i v i t y r e a c t i o n sd r u g - o r r a d i a t i o n - i n d u c e d p n e u m o n i t i s .

Who shall be considered as having community-acquired

Pneumonia?

Cough + R es p i ratory D i f f i culty

+ Predictors of Radiographic Pneumonia

<92%SpO2

Emergency Sett ing

Out-Pat ient Sett ing

OBTAIN

Chest Xray

Dehydration Malnutrition

or

H igh -grade Fever

Leukocytos is

Who will require admission?

Pediatr icCommunity

AcquiredPneumonia

What Diagnostic Aids are initially requested for a patient classified as either pCAP C being managed in a

hospital setting?

SHOULD BE DONEGram sta in and/or culture and

sens it iv ity of pleural flu i d

SHOULD BE DONEOxygen saturat ionArter ial blood gas

MAY BE DONEChest x-ray PA-lateral

C-reactive protein (CRP)

Procalcitonin (PCT)

Chest x-ray PA-lateral

White Blood Cell (WBC) count

Gram stain of sputum or nasopharyngeal aspirate

MAY BE DONEto determine etiology

Sputum culture and sensitivityBlood culture and sensitivity

to predict clinical outcome:Chest x-ray PA-lateral

Pulse oximetry

MAY BE DONEto determine the presence of TB if clinically suspected:

Mantoux test (PPD 5-TU) Sputum smear for aid fast bacilli

to determine metabolic derangement:Serum electrolytes

Serum glucose

When is antibioticrecommended?

SHOULD BE GIVEN

MAY BE CONSIDEREDElevated serum C-reactive protein

Elevated serum procalcitonin level [PCT]Elevated white cell count

High grade fever without wheeze Beyond 2 years of age

Hemoglobin 121

Hematocrit 0.36

WBC 16.26

Segmenters 0.72

Lymphocytes 0.27

Eosinophils 0.01

Platelets 390

CBC

What empiric treatment should be administered if a bacterial

etiology is strongly considered?

100mg/kg/d in 4 divided doses

D R U G O F C H O I C Eampicillin

100mkd in 1 1 kg pat i ent

Ampicillin 275mg/IV every 6 hours

When can a patient be considered as responding to the current

antibiotic?

decrease in respiratory signsdefervescence

72h r s

What ancillary treatment can be given?

SHOULD BE DONEoxygen

andhydrat ion

MAY BE DONEb r o n c h o d i l a t o r

s t e r o i dp r o b i o t i c

Cough preparation, elemental zinc, vitamin A, vitamin D and chest

physiotherapy should not be routinely given during the course of illness

How can pneumonia be prevented?

SHOULD BE GIVEN

z inc

SHOULD BE GIVENvacc ines

S . p n e u m o n i aI n f l u e n z a

D i p h t h e r i aP e r t u s s i s

R u b e o l aV a r i c e l l a

H i b

MAY BE GIVEN

vitamin D3

SHOULD NOT BE GIVEN

vitamin A

THANK YOU!!