iNterns case

preseNtation
max Angelo G Terrenal
Francisco P Tria
 GENERAL INFORMATION
• TA
• 1 yo and 4mos
• Male
• Block 28, Lot 15, Salawikain St. Lagro Subdivision
Quezon City
• Christian
• Mother: Good reliability
chief complaint
Difficulty of Breathing
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
 BIRTH AND NEONATAL history
• 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
 FEEDING 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
 GROWTH AND DEVELOPMENT
• Regard: 2mos • 1st word: 10-11mos “mama”
• Social smile: 2mos • Puts 3 words together: N/A
• Turned over: 5-6mos • Bower and bladder control: N/A
• Crept: 7mos • Clothes self: N/A
• Sat aided: 6mos
• Sat alone: 7-8mos
• Walked aided: 1yr
 IMMUNIZATIONS
• BCG 1
• HepaB 1, 2, 3
• HepaA 1
• DPT 1, 2, 3
• OPV 1, 2, 3

• For MMR and Hib

 PAST MEDICAL HISTORY
• (+) Lactose intolerance
• (+) Hyper-reactive airway disease
• Previous hospitalization: PCAP B (Feb 12-14, 2014) at
VMMC
• No previous accident/injury/surgery
 FAMILY 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
SOCIOECONOMIC AND ENVIRONMENTAL
• 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
 REVIEW OF SYSTEMS
General: (-) 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/ (-) LOC, (-) tremors, (-) sleep problems, (-) convulsions, (-) weakness or paralysis, (-)
Behavioral: 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 • Weight of 11kg (z = 0)
Data: • 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, no
strabismus, 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 No deformity, septum at midline, no alar flaring, no sinus tenderness, no discharge,
paranasal sinuses: 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 Adynamic precordium, no heaves, no lifts, no thrills, apex beat at the 4th LICS
vascular system: MCL, no murmurs
Abdomen: Soft, flat, symmetrical abdomen, no visible pulsation and peristalsis, normoactive
bowel 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 assessed
CN II – pupil 2-3mm ERTL
CN III, IV, VI – intact EOM movements, (-) ptosis
CN V – (+) corneal reflex, (+) sucking reflex
CN VII – no facial asymmetry
CN VIII – able to respond to sounds
CN IX, X – (+) gag reflex
CN 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 • In respiratory distress - tachypneic
• Male • Intercostal retractions
• CC: Difficulty of breathing
• Congested turbinates
• 2–day history of colds and productive
cough • No signs of dehydration
• Loss of appetite • Palpable CLAD
• (-) fever • (+) coarse bilateral crackles
• Breast fed for only 1mo • (+) wheeze, R
• (-) MMR and Hib vaccine yet
• (+) Hyper-reactive airway disease
• Previous hospitalization due to PCAP B
 ASSESSMENT
1. 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
 P n eum onia

Inflammation of the lung parenchyma

 Infectious
Vs
Non infectious
 Infectious
AGE GROUP FREQUENT PATHOGENS (IN ORDER OF FREQUENCY)
Group B streptococcus, Escherichia coli, other gram-negative bacilli, Streptococcus
Neonates (<3 wk)
pneumoniae, Haemophilus influenzae (type b,* nontypable)
Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza
3 wk-3 mo
viruses, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypable)

Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza

4 mo-4 yr viruses, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypable),
Mycoplasma pneumoniae, group A streptococcus
M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae (type
≥5 yr b,* nontypable), influenza viruses, adenovirus, other respiratory viruses, Legionella
pneumophila
 NON-Infectious
aspiration of food or gastric acid
foreign bodies
hydrocarbons
hypersensitivity reactions
drug- or radiation-induced pneumonitis.
Who shall be considered as
having community-acquired
Pneumonia?
 Cough + Respiratory Difficulty

+ Predictors of Radiographic Pneumonia

Emergency Setting

%SpO2
<92
Out -Patient Setting
 OBTAIN

Chest Xray
 or

Dehydration Malnutrition
H igh -gr ad e Fever

Leukocytosis
Who will require admission?
 Pediatric
Community
Acquired
Pneumonia
 What Diagnostic Aids are initially
requested for a patient classified as
either pCAP C being managed in a
hospital setting?
 SHOULD BE DONE
Gram stain and/or culture and
sensitivity of pleural fluid
SHOULD BE DONE
Oxygen saturation
Arterial blood gas
 MA Y BE DONE
Chest 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
MA Y BE DONE
to determine etiology
Sputum culture and sensitivity
Blood culture and sensitivity

to predict clinical outcome:

Chest x-ray PA-lateral
Pulse oximetry
 MA Y BE DONE
to 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 antibiotic
recommended?
SHOULD BE GIVEN
MAY BE CO NSIDERED
Elevated serum C-reactive protein
Elevated serum procalcitonin level [PCT]
Elevated white cell count
High grade fever without wheeze
Beyond 2 years of age
 CBC
Hemoglobin 121
Hematocrit 0.36
WBC 16.26
Segmenters 0.72
Lymphocytes 0.27
Eosinophils 0.01
Platelets 390
What empiric treatment should
be administered if a bacterial
etiology is strongly considered?
 DRUG OF CHOICE
ampicillin
100mg/kg/d in 4 divided doses
 100mkd in 11kg patient
Ampicillin 275mg/IV
every 6 hours
When can a patient be considered
as responding to the current
antibiotic?
 72
hrs

decrease in respiratory signs

defervescence
What ancillary treatment can be
given?
SHOULD BE DONE
oxygen
and
hydration
MA Y BE DONE
bronchodilator
steroid
probiotic
 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
zinc
SHOULD BE GIVEN
v a c c i nes
S. pneumonia Rubeola
Influenza Varicella
Diphtheria Hib
Pertussis
MA Y BE GIVEN
v i t a m in D 3
SHOULD NOT BE GIVEN
v i t a m in A
THANK YOU!!