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PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)


COLLEGE OF MEDICINE

DEPARTMENT OF PEDIATRICS

A CASE OF A 17-MONTH OLD FEMALE WITH


COMMUNITY-ACQUIRED PNEUMONIA

3-B
GUERRA, TASHA ADELLE F.

I. GENERAL DATA
NY, 19 months old, female, Filipino, Catholic, is born on January 22, 2015 in Paco, Manila. She
currently lives in Pandacan, Manila. She was admitted at Ospital ng Maynila for the first time on October
5, 2016 at around 9:00 A.M.
The interview was done on October 7, 2016 at 10:30 A.M. The patients mother, PY, was the
informant. The reliability of informant is 95%.

II. CHIEF COMPLAINT


Cough

III. HISTORY OF PRESENT ILLNESS


Fourteen days PTA, the patient was noted to have nonproductive cough which was present
throughout the day but more severe at night. This was associated with shortness of breath. She became
less playful/active and irritable than usual. Her mother noted a decrease in appetite from usual 4 (4 oz)
bottles of milk per day to 2 bottles/day. No diarrhea, fever, and vomiting were noted. No intervention and
consult were done.
Nine days PTA, symptoms such as cough, now productive with green sputum, and shortness of
breath persisted. The patient had two episodes of vomiting of previously ingested food, approximately the
same amount of milk ingested (4 oz), which was precipitated by coughing. The patient also had fever, 38
C being the highest documented temperature. She was given a sponge bath which provided temporary
relief. No other intervention and consult were done.
Three days PTA, the patient still had cough, fever, and presence of soft stool. Her mother noted
a significant weight loss when she was able to see her spine which was not visible before. She consulted
at their Barangay Health Center and was given the following medications: Amoxicillin drop 100mg/ml
three times a days for 7 days, Paracetamol drop 100mg/ml every four hours for fever, and

Multivatamins. However, she was only able to give Amoxicillin for 2 days. She also
mentioned to the doctor about the passing worm in stool but no intervention was
given.
One day PTA, still with the above manifestations, the patient passed another
white worm in her stool. No intervention and consult were done.
Few hours PTA, still with cough, fever, and fast breathing. The mother prompted to seek consult
at Ospital ng Maynila Medical Center. The patient was then admitted.

IV. REVIEW OF SYSTEM


General: (+) Weight loss (8 kg 7.7 kg); (+) decreased activity level; (+) decreased appetite
Cutaneous: No lumps, sore, changes in hair and nails
Head: No lumps or head trauma; no eye pain, redness; no lacrimation; no ear and nasal discharges; no
excessive salivation
Cardiovascular: No orthopnea; no cyanosis
Respiratory: (+) Difficulty of breathing, (+) cough, (-) wheezing, (+) sputum (green), no hemoptysis
Gastrointestinal: (+) Diarrhea, (+) vomiting, (+) passage of worms; no abdominal pain, constipation,
hematochezia, melena, jaundice

Genitourinary: No pain, discharge, swelling; no, hematuria, dysuria, flank pain, edema
Neurologic: No convulsion; no paralysis; no behavioural changes, (+) sleeping problems (frequent
night-waking)
Musculoskeletal: No history of musculoskeletal trauma; no weakness, stiffness, swelling or deformities of
extremities
Hematologic: No easy bleeding/bruising; no pallor

V. PERSONAL HISTORY
A. FEEDING HISTORY
The patient drinks 4 bottles of milk per day.

B. DEVELOPMENTAL HISTORY
Dental eruption at 8 months (Lower central incisors followed by upper central incisors). She uses
4 diapers/day. No episodes of temper tantrums, head banging, sleep disturbances. She sleeps 10 hrs/day
with 3 hrs siesta.

C. PAST ILLNESSES
The patient had no history of measles, varicella, mumps or pertussis. No history of surgical
operations. No surgical operations done. No known allergy to food or drugs.

VI. IMMUNIZATION HISTORY


The patient received complete immunization against BCG, DPT, Polio, Hepa B, and Measles. No
other immunizations were given.

VII.FAMILY HISTORY
The patients father, 36 years old, a street vendor, is generally healthy. Her mother, 22 years old,
a housewife, is generally healthy. She has a 6-year-old sibling, female, who is generally healthy.
They have a family history of hypertension and diabetes. There are no known family history of
tuberculosis, cancer, epilepsy, allergy, heart and kidney disease, hematologic disorders and congenital
defects

VIII. SOCIOECONOMIC HISTORY


The patient has been living in their current residence for 3 years in a bungalow-type house with 2
rooms. There are more than 10 occupants in the house. Only the father who works as a vendor is the
source of funds for the family.

IX. ENVIRONMENTAL HISTORY


The patient has no exposure to cigarette smoke and other pollutants. The source of drinking and
washing water is from the tap. The garbage is collected daily. The toilet is pour-flush type. There are no
pets being kept.

PHYSICAL EXAM
A. GENERAL APPEARANCE
The patient was awake, quietly and comfortably seated on her mothers lap, appears wellnourished and developed for her age. She cries softly and often clings to her mother only when gently
touched by the examiner. She turns to direction of her mothers or the examiners voice. No facial
expressions indicating distress but fast rate of breathing is observed

B. VITAL SIGNS
Temperature: 36.3C
RR: 48 cpm, regular
HR: 144 bpm, regular

C. ANTHROPOMETRIC DATA
1. Weight:
2. Length:
3. BMI:
4. Chest Circumference
5. Abdominal Circumference
6. Lower Segment

7.7 kg
64 cm
18.8 (Normal)
46 cm
51 cm
~31 cm

Interpretation: Normal

Interpretation:

Interpretation:

Interpretation: Normal

D. SKIN
Skin is fair, generally warm, and moist, with good skin turgor and nails without clubbing or
cyanosis. No pallor, jaundice, or cyanosis noted. With ~1 cm circular ecchymosis on the right antecubital
area and <1cm linear ecchymosis on ventral aspect of right hand, both from previous attempts at IV
insertion.

E. HEAD
The head is normocephalic. There are no lumps, lesion nor tenderness. Hair is black, smooth and
strong, with fine distribution, no lice, and no dandruff.

F. FACE
Face is symmetrical. No deformities, lumps, bumps.

G. EYES
The eyelids and eyes are symmetrical. No abnormal discharges. Eyebrows are evenly distributed
without scaling, inflammation or discharge. Palpebral conjunctiva is pink without opacities. Sclera is
anicteric. No edema, ptosis, entropion, or ectropion. Vision is grossly normal.

H. EARS
Ears are symmetrical. No auricular skin lesions, no skin tags. No abnormal discharges, swelling
or redness.

I. NOSE AND PARANASAL SINUSES


The nasolabial fold is symmetrical. Septum is at midline. Mucosa is pink with clear discharge. No
abnormal discharges, congestion and nasal flaring.

J. MOUTH
Lips are pink, moist, and without lesions. Oral mucosa and gingiva are pink. No swelling lesions
or inflammation noted. Hard palate, soft palate, and anterior pillar are pink. Tongue and uvula are pink
and at midline. Tonsils not enlarged. Dentition: Four upper and four lower incisors, two upper and two
lower first molars. White teeth without mottling or fluorosis and dental carries.

K. NECK
Trachea is at midline. There is no difficulty in swallowing. Jugular veins are not distended. Lymph
nodes are not palpable.

L. CHEST AND LUNGS


Thorax is symmetrical without deformities. Transverse diameter greater than anteroposterior.
Symmetrical chest expansion. No bony deformities, nodules or masses. Crackles heard over the left
posterior lung fields.

M. HEART
Precordium is adynamic with no heaves, vibrations, and thrills. No visible pulsation over chest
and epigastrium. S1 and S2 are tapping and constant. At the apex, S1 is greater than S2. At the base, S2
is greater than S1. There are no murmurs or extra sounds.

N. ABDOMEN
Abdomen is slightly globular with fair skin. No masses, deformities, and hernias. No visible
superficial blood vessels, pulsations or peristaltic waves. Bowel with 27/min bowel sound. No bruits and
venus hum. Tympanitic upon percussion. No palpable mass upon palpation.

O. EXTREMITIES
Symmetrical and strong peripheral pulses. No signs of clubbing, cyanosis, and joint inflammation.
Nails are pink.

NEUROLOGICAL EXAMINATION
Patient is awake, makes eye contact, and cries briefly then stops
A. CRANIAL NERVES

I. Olfactory Nerve
Not assessed
II. Optic Nerve
Not assessed
III. Oculomotor Nerve
Opening of the eyelids is symmetrical. Eyes can move inward, upward, and downward.
IV. Trochlear Nerve

Eyes can move downward.


V. Trigeminal Nerve
Facial sensory is intact.
VI. Abducens Nerve
Eyes can move laterally.
VII. Facial Nerve
She can wrinkle forehead and can close eyes symmetrically.
VIII. Vestibulocochlear
Intact gross hearing
IX & X. Glossopharyngeal Nerve and Vagus Nerve
Rising of soft palate is noted.
XI. Spinal Accessory Nerve
She can twist head symmetrically.
XII. Hypoglossal Nerve
Not assessed
B. MOTOR
No involuntary muscle movement of hands and feet. Normal muscle bulk and muscle tone. Gait
was not assessed.The strength in right biceps, triceps, quadriceps, hamstring, and ankle flexor and
extensor were not assessed.
C. SENSORY
Intact light touch sensation on all extremities
D. REFLEX
Absence of babinski, moro, grasp, rooting, and sucking reflexes

CASE DISCUSSION
SALIENT FEATURES

PERTINENT POSITIVE
Cough for 2 weeks
Tachypnea
Loss of appetite
Vomiting
Fever for 9 days
Soft, non foul smelling stool with (+) white
worm
Weight loss
Diarrhea
Decreased level of activity
Difficulty of breathing

PERTINENT NEGATIVE
No dyspnea, chills
No constipation
No hemoptysis
No convulsions

APPROACH TO DIAGNOSIS

Cough
Non-Infectious

Infectious

Asthma

Acute

URTI

Chronic

LRTI

Influenza

Pneumoni
a

Viral

Tuberculos
is
Bronchitis

Bacteria

DIFFERENTIAL DIAGNOSIS
ASTHMA
Asthma is a chronic inflammatory disorder of the airways characterized by an obstruction of
airflow, which may be completely or partially reversed with or without specific therapy. Airway
inflammation is the result of interactions between various cells, cellular elements, and cytokines
(Sharman, 2015). With childhood asthma, the lungs and airways become easily inflamed when exposed
to certain triggers, such as airborne pollen. In other cases, childhood asthma flares up with a cold or other
respiratory infection.
ASTHMA
RULE IN
(+) Cough
(+) Shortness of breath
(+) Tachypnea

RULE OUT
(-) Chest pain
(+) Fever
CANNOT TOTALLY RULE OUT
INFLUENZA

Influenza is the one of the most significant acute upper respiratory tract infections. Influenza
viruses cause a broad array of respiratory illnesses responsible for significant morbidity and mortality in
children. Typical symptoms of influenza begin 2-3 days after exposure to the virus. Influenza produces an
acute febrile respiratory illness with cough, headache, and myalgia for 3-4 days, with symptoms that may
persist for as long as 2 weeks (Brook, 2014).
INFLUENZA
RULE IN
(+) Cough
(+) Fever

RULE OUT
(-) Chills
(-) Myalgia
(-) Headache
(-) Conjunctivitis
(-) Sore throat
RULED OUT
TUBERCULOSIS

Tuberculosis (TB) is the most common cause of infection-related death worldwide. Pulmonary
tuberculosis (TB) may manifest itself in several forms, including endobronchial TB with focal
lymphadenopathy, progressive pulmonary disease, pleural involvement, and reactivated pulmonary
disease. Symptoms of primary pulmonary disease in the pediatric population are often meager. Fever,
night sweats, anorexia, nonproductive cough, failure to thrive, and difficulty gaining weight may occur.
Signs of disease depend on the site involved (pulmonary or extrapulmonary) (Batra, 2015).
TUBERCULOSIS
RULE IN
(+) Cough
(+) Fever
(+) Weight loss

RULE OUT
(-) Night sweats
(-) Family history of TB
RULED OUT

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BRONCHITIS
Bronchitis is an inflammation of the main air passages (bronchi) to the lungs. Coughing often
brings up yellow or greenish mucus. There are two main types of bronchitis: acute and chronic. Acute
bronchitis, often caused by the same viruses that cause colds, usually starts as a sore throat, runny nose
or sinus infection, then spreads to your airways. It can cause a lingering dry cough, but it usually goes
away on its own. In chronic bronchitis, a type of COPD (chronic obstructive pulmonary disease), the
inflamed bronchi produce a lot of mucus, leading to cough and difficulty getting air in and out of the lungs.
BRONCHITIS
RULE IN
(+) Cough
(+) Shortness of breath
(+) Malaise
(+) Fever

RULE OUT
(-) Sore throat
(-) Chest pain
(-) Chills
RULED OUT
PNEUMONIA
PNEUMONIA

RULE IN
(+) Cough with sputum
(+) Fever
(+) Tachypnea
(+) Difficulty of breathing
(+) Diarrhea
(+) Malaise, fatigue

RULE OUT
No chills
No chest pain

CANNOT TOTALLY RULE OUT

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WORKING DIAGNOSIS
COMMUNITY-ACQUIRED PNEUMONIA
Pneumonia is one of the most common medical problems encountered in clinical practice and is
one of the leading causes of infectious diseaserelated death worldwide. The pathogenesis of
community-acquired pneumonia (CAP) involves the inhalation of a pulmonary pathogen; the severity of
pneumonia depends on inoculum size, virulence of the organism, and adequacy of the patients host
defenses.

EPIDEMIOLOGY
Pneumonia is a substantial cause of morbidity and mortality in childhood throughout the world,
rivaling diarrhea as a cause of death in developing countries. With an approximately 158 million episodes
of pneumonia per year, of which 154 million are occurring in developing countries, pneumonia is
estimated to cause 3 million deaths, or an estimated 29% of all deaths, among children younger than 5
yr worldwide. The incidence of pneumonia is more than 10-fold higher in developing than in developed
countries. In the USA from 1939 to 1996, pneumonia mortality in children declined by 97% (Kleigman, et
al., 2011).

PATHOPHYSIOLOGY
Viral pneumonia usually results from spread of infection along the airways, accompanied by direct
injury of the respiratory epithelium, which results in airway obstruction from swelling, abnormal secretions,
and cellular debris. The small caliber of airways in young infants makes such patients particularly
susceptible to severe infection. Atelectasis, interstitial edema, and ventilation- perfusion mismatch
causing significant hypoxemia often accompany airway obstruction. Viral infection of the respiratory tract
can also predispose to secondary bacterial infection by disturbing normal host defense mechanisms,
altering secretions, and modifying the bacterial flora (Kleigman, et al., 2011)..
Bacterial pneumonia most often occurs when respiratory tract organisms colonize the trachea
and subsequently gain access to the lungs, but pneumonia may also result from direct seeding of lung
tissue after bacteremia. When bacterial infection is established in the lung parenchyma, the pathologic
process varies according to the invading organism. M. pneumoniae attaches to the respiratory epithelium,
inhibits ciliary action, and leads to cellular destruction and an inflammatory response in the submucosa.
As the infection progresses, sloughed cellular debris, inflammatory cells, and mucus cause airway
obstruction, with spread of infection occurring along the bronchial tree, as it does in viral pneumonia
(Kleigman, et al., 2011).

CLINICAL MANIFESTATIONS
Common clinical symptoms of CAP include cough, fever, chills, fatigue, dyspnea, rigors, and
pleuritic chest pain. Depending on the pathogen, a patients cough may be persistent and dry, or it may
produce sputum. Other presentations may include headache and myalgia. Certain etiologies, such as
legionella, also may produce gastrointestinal symptoms.

DIAGNOSTIC WORK-UP
An infiltrate on chest radiograph supports the diagnosis of pneumonia. Viral pneumonia is usually
characterized by hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing. The
radiographic appearance alone is not diagnostic, and other clinical features must be considered.

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The peripheral white blood cell (WBC) count can be usefulin differentiating viral from bacterial
pneumonia. In viral pneumonia, the WBC count can be normal or elevated but is usually not higher than
20,000/mm3, with a lymphocyte predominance. Bacterial pneumonia is often associated with an elevated
WBC count, in the range of 15,000-40,000/mm 3, and a predominance of granulocytes. A large pleural
effusion, lobar consolidation, and a high fever at the onset of the illness are also suggestive of a bacterial
etiology.
The definitive diagnosis of a viral infection rests on the isolationof a virus or detection of the viral
genome or antigen in respiratory tract secretions. Serologic techniques can also be used to diagnose a
recent respiratory viral infection but generally require testing of acute and convalescent serum samples
for a rise in antibodies to a specific viral agent. The definitive diagnosis of a bacterial infection requires
isolation of an organism from the blood, pleural fluid, or lung(Kleigman, et al., 2011).

TREATMENT AND MANAGEMENT


Treatment of suspected bacterial pneumonia is based on the presumptive cause and the age and
clinical appearance of the child.
For mildly ill children who do not require hospitalization, amoxicillin is recommended. In
communities with a high percentageof penicillin-resistant pneumococci, high doses of amoxicillin (80-90
mg/kg/24 hr) should be prescribed. Therapeutic alternatives include cefuroxime axetil and
amoxicillin/clavulanate. For school-aged children and in children in whom infection with M. pneumoniae
or C. pneumoniae is suggested, a macrolide antibiotic such as azithromycin is an appropriate choice
(Kleigman, et al., 2011).
The World Health Organization and other international groups have developed systems to train
mothers and local health care providers in the recognition and treatment of pneumonia.The empiric
treatment of suspected bacterial pneumonia in ahospitalized child requires an approach based on the
clinicalmanifestations at the time of presentation. Parenteral cefotaximeor ceftriaxone is the mainstay of
therapy when bacterial pneumoniais suggested. If clinical features suggest staphylococcal pneumonia
(pneumatoceles, empyema), initial antimicrobial therapy should also include vancomycin or clindamycin.
If viral pneumonia is suspected, it is reasonable to withhold antibiotic therapy, especially for those patients
who are mildly ill, have clinical evidence suggesting viral infection, and are in no respiratory distress
(Kleigman, et al., 2011).
In developing countries, oral zinc (20 mg/day) helps accelerate recovery from severe pneumonia.
The optimal duration of antibiotic treatment for pneumonia has not been well-established in controlled
studies (Kleigman, et al., 2011).

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REFERENCES
Batra, V. (2015).Pediatric tuberculosis.Retrieved from http://emedicine.medscape.com/article/969401overview#a1 on October 25, 2015.
Brook, I. (2014). Pediatric influenza.Retrieved from http://emedicine.medscape.com/article/972269overview#a2 on October 25, 2015.
Kliegman, R., Stanton, B., Geme, J., Schor, N., & Behrman, R. (2011).Nelson Textbook of Pediatrics, 19th
Edition. Philadelphia, PA : Elsevier/Saunders.
Sharman, G. (2015). Pediatric asthma.Retrieved from http://emedicine.medscape.com/article/1000997overview#a2 on October 25, 2015.

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