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CASE STUDY ON PEDIATRIC COMMUNITY AQUIRED PNEUMONIA (PCAP)

Submitted by: Neri, Tiffany Julia B.

Submitted to: Mrs. Denise Katherine A. Amora

I. INTRODUCTION
Pneumonia is an infection of the lung parenchyma. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. There are different types of pneumonia one is community-acquired pneumonia which refers to pneumonia acquired outside of hospitals or extended-care facilities. The agents that most frequently cause CAP are: S.Pneumoniae, H. Influenzae, Legionella, Pseudomonas aeruginosa, and other gramnegative rods. PCAP or pediatric community acquired pneumonia is a type of community acquired pneumonia that occurs in children. CAP is a common illness in all parts of the world. It is a major cause of death among all age groups. In children, the majority of deaths occur in the newborn period, with over two million worldwide deaths a year. In fact, the WHO estimates that one in three newborn infant deaths are due to pneumonia. Mortality decreases with age until late adulthood; elderly individuals are particularly at risk for CAP and associated mortality. Despite a broad armamentarium of antimicrobials available to treat the disease, pneumonia remains the seventh leading cause of death in the United States. In 2003, the age-adjusted death rate caused by influenza and pneumonia was 20.3 per 100,000 persons. Estimates of the incidence of community-acquired pneumonia range from 4 million to 5 million cases per year, with about 25% requiring hospitalization.

The United Nations Children's Fund (UNICEF) estimates that 3 million children die worldwide from pneumonia each year; these deaths almost exclusively occur in children with underlying conditions, such as chronic lung disease of prematurity, congenital heart disease, and immunosuppression. According to the WHOs Global Burden of Disease 2000 Project, lower respiratory infections were the second leading cause of death in children younger than 5 years (about 2.1 million [19.6%]). My patient is a toddler, the one year old Euan James suffered cough and on and off fever 5 days prior to admission, the child was then admitted with chief complaints of fever, cough and coryza. Upon admission the child was weak due to high fever. During my two days observation, I noticed that the cough was unproductive and crackles were heard on the right upper lung. However there is no difficulty in breathing. The x-ray result then showed that the patient has pneumonia, specifically pediatric community acquired pneumonia. A case with a diagnosis of Pneumonia may catch ones attention, though the disease is just like an ordinary cough and fever, it can lead to death especially when no intervention or care is done. Since the case is a toddler, an appropriate care has to be done to make the patients recovery faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.

II. ASSESSMENT
Name: Banaban, Euan James Age: 1yr old Sex: Male Religion: Protestant Impression on Diagnosis: PCAP Birth History The child was born last October 10, 2010 weighing 6.5lbs. in a normal spontaneous vaginal delivery in a cephalic presentation assisted by a midwife at SM Lao Memorial Hospital. According to the mother, she had no difficulty of delivering the baby. The baby had a loud cry and he was able to position from supine to prone position. Family History There are five members in the family; my patient is the youngest among the three children 1st child-6years old 2nd child- 4years old His mother is a plain housewife and his father is a chef in one of the ships abroad. Both parents has no hereditary diseases. History of Present Illness Five days prior to admission he had already suffered from cough and on and off fever. The child was then admitted yesterday with chief complaints of fever, cough and coryza. Upon admission the child was weak due to high fever and so he was cuddled by his mother. He had dry lips and tongue with whitish lesion in the buccal mucosa as observed by the doctor. Date and Time admitted: 7-30-12/1:17pm Chief Complaints: fever, cough, coryza Diet: DAT Attending Physician: Dr. Lilia Cacho

History of Past Illness It is his second time in the hospital, the first one was last year October 9, 2011,he was admitted for the same diagnosis, pneumonia. At home he would experience minor illness like cough or fever and would treat it with paracetamol and Solmux. NORMAL Physical Steady growth in height and weight Average weight: 10.9kg Has complete body parts Motor Gross: Runs fairly well he can walk without assistance he can run Fine: Tries to feed self Language Uses Da-da and Mama correctly Has 4 to 6 word vocabulary Indicated wants by pulling, pointing Or appropriate verbalization he can say ate, mama, papa and he calls his sister lala he has his own word like meme for milk and he can say inum he feeds himself with a biscuit steady growth in height and weight 10.5kg has complete body parts ACTUAL

Sensory/Cognitive Can hear, see, and feel, identifies taste he can hear, see, feel, he knows what taste is pleasing and what is not like when I give medication. Socialization Likes to tell others what to do Negativistic, stubborn Engages in pretend play May bite, slap or hit Wants own way in everything Affectionate he likes to play with his brother and sister he hit me he was asking me to get the chocolate and would not stop until he gets it

Pattern of Functioning Respiratory His respiratory rate is within the normal range 8am-29 cpm 12nn-33cpm (+) crackles heard on right upper lung he is unable to cough out secretions

Circulatory His pulse rate is within the normal range 8am-130 bpm 12nn- 130bpm capillary refill- 2 seconds there is no discolored parts of the body

No swollen edematous area no parts of the body colder or warmer than adjacent parts

Sleeping Habit Prior to admission, he usually sleeps at 7pm and wakes up at 5:30am and sleeps again at 9am, he does not sleep in the afternoon. Upon admission he slept at 9pm,wakes up at 6am,during this period of sleep he tends to wake up from time to time due to the humid environment and also the cough interferes with rest. Eating Habit He eats 3 times a day. He eats lugaw and usually drinks milk three times a day,6 oz. He also eats rice with viand seldomly but his meal is usually milk. During his stay in the hospital he eats less because of his oral sores.

Elimination Habit He does bedwetting and so a diaper was used. He would usually urinate five times a day and defecate once, usually in the afternoon, During my shift he havent defecated yet, he excreted 200 cc of urine, it is light yellow in color.

Personal Hygiene He takes a bath every day, his nails were trimmed, hair is fixed, no unpleasant odor can be observed. In his hospital stay, his mother would change him new clothing .Children doesnt have a care in the world so they tend to soil their shirts. During my shift he was eating, his shirt was soiled and so we had to change new clothing

Pain and Discomfort He experienced discomfort and pain because of his oral sores.

Allergy He has no known allergy, his mother suspected that he has allergies since there is some rashes on his skin, it was itchy, it was not discovered whether it is caused from an allergic reaction or because of bacteria.

Immunization

Early Childhood care and Development Card

10-13-10 11-10-10 12-10-10 2-9-11 2-23-11 3-9-11 3-9-11 6-1-11 7-13-11

BCG Hep 1 DPT, OPV OPV2, HB2 DPT2 OPV3 HB3 DPT3 Measles

III.LABORATORY RESULTS
CHEST AP Findings: Accentuated bronchovascular markings with interstitial haziness at both lung fields Cardiac shadow is within normal size and configuration Tracheal shadow in midline Bone and other chest structures are unremarkable Impression: Pneumonia URINALYSIS REPORT Macroscopic Color: pale yellow Transparency: clear PH-6.0 Sp Gr: 1.015 Chemical Protein: Negative Glucose: Negative Microscopic WBC: 1-2/HPF Epithelial cells: Rare

HEMATOLOGY REPORT RBC: M-4.6-6.2x10^12/L Hemoglobin:M-13.5-18.0g/dl Differential Count Lymphocyte:0.20-0.40 Eosinophil: 0.01- 0.04 0.53 0.01 Segmenters: 0.50-0.70 Monocyte: 0.03- 0.08 0.42 0.04 4.28 11.4 Hematocrit :M-0.40-0.54 WBC- 4.50-10.0x 10^9/L O.34 11.33

IV.ANATOMY AND PHYSIOLOGY

LUNGS: The lungs are paired cone-shaped organs which take-up most of the space in the chest with the heart. Their role is to take oxygen into the body which we need for the cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. There are two divisions of the lungs, the left and the right lung. These are divided up into lobes or big secretions of tissues separated by fissures or dividers. The right lung has three lobes but the left lung has only two, it is because the heart takes up some of the space in the left side of the chest. The lungs can also be divided up into even smaller portions, called bronchopulmonary segments. These are pyramidal shaped areas which are also separated from each other membranes. Each segment receives its own blood supply

and air supply. Air enters the lungs through a system pipes called the bronchi. Theses pipe start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are important in the gas exchange where it takes place between the air and the blood. Covering alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can diffuse between them.

VI.MEDICAL MANAGEMENT
Doctors Order 7-30-12 1:17pm > pls admit under Dr.Cacho >TPR every 4 hours >Lab: CBC, U/A,CXR-AP View >D5 0.3 % NaCl 500 cc @ 50 cc/hr >Meds: paracetamol 100mg/ml 1.2ml every 4 hours PRN for fever >Nebulize with salbutamol 1 neb every 8 hours > I and O every shift > Inform AP > Refer accordingly

7-30-12

> cefuroxime 375mg IV every 8 hours ANST >IVF TF: D5 0.3 % NaCl 500 cc @ 50 cc/hr

7-31-12 >Revised Nebulization with one salbutamol nebule every 6 hours >cetirizine gtts 1ml O.D h.s >Ceelin gtts 1ml O.D >Refer accordingly > Daktarin oral solution apply to affected area 2x daily >use Daktarin oral gel instead of Daktarin oral solution 8-1-12 >azithromycin 200mg/ 5ml 2.5 ml O.D > D5 1MB 500cc @ 50 cc/hr