SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.

DEPARTMENT OF PEDIATRICS
4th Floor Jaime Cardinal L. Sin Bldg.
2772 Roxas Blvd., Pasay City

Presenter: Maria Cristina S. Amat Date: December 29, 2018

Moderator: Dr. Pamela C. Basco Venue: 2nd floor, JCLS
Building
Reactor: Pedia Residents
CASE PROTOCOL
Informant: Mother Reliability: 85% (Good)

General Data
Patient A.V., a 10-month old male, Filipino, born on January 3, 2018 and currently
residing at Maricaban, Pasay City, admitted for the first time at San Juan de Dios Hospital on
November 24, 2018.

Chief Complaint
fever

History of Present Illness

Patient was apparently well until five days prior to consult when he experienced fever with
a maximum temperature of 39.0C for which he was given paracetamol at 11.4mg/kg/dose which
afforded temporary relief. There were no other associated symptoms such as cough, colds,
rashes, vomiting, or loose stools. No consult was done at the time.
Two days prior to admission, due to the persistence of fever (tmax 40.0C), now associated
with productive cough and colds with watery nasal discharge, patient was brought a private
institution where CBC was done revealing leukocytosis with segmenter predominance and
urinalysis revealing normal results. Patient was sent home as a case of influenza like illness with
home medications of paracetamol at 11.4 mg/kg/dose and ibuprofen at 6.8 mg/kg/dose which he
was given with compliance.
On the day of admission, patient still had fever with a maximum temperature of 39.8C,
productive cough, and colds now associated with difficulty of breathing but with good suck and
good activity. No note of vomiting, rashes, or loose stools. Persistence of symptoms prompted
consult at the Out-Patient Department and subsequent admission.

Past Medical History

The patient has no previous hospitalizations and has no allergies to food or medications.

Family History
The patient has a history of diabetes on the maternal side. There is no history of asthma
on either side.

Socioeconomic History
The patient’s mother is a 32-year old housewife and his father is a 40-year old security
guard. He lives with her biological parents in a single storey house.
Nutritional History
The patient was exclusively breastfed for 2 months and was started on mixed feeding
with Bona thereafter. He was started on complementary feeding at 6 months and is being given
multivitamins (Nutrillin).

Immunization History
The patient received BCG, Hep B, first 2 doses of PentaHib, and first 2 doses of OPV at
the SJDH Out-Patient Department. He then received the 3rd dose of PentaHib, 3rd dose of OPV,
1 dose of IPV, and measles at a local health center.

Birth and Maternal History

The patient was born full term to a 31-year old G4P2 (2022) via normal spontaneous
delivery at SJDH with no fetomaternal complications.

Developmental History
At par with age
Gross motor:
 2 months: holds head
 4 months: rolls over
 6 months: sits with support
 10 months: pulls to stand
Fine motor:
 4 months: able to hold toys
 6 months: transfers objects
 10 months: picks up objects with thumb and index finger
Language:
 2 months: coos
 4 months: babbles
 6 months: responds to name
 10 months: says mama and papa
Social:
 2 months: smiles at people
 4 months: copies expressions
 6 months: recognizes someone is a stranger
 10 months: understands no

Environmental History
The patient lives with 3 other family members in a well-lit, well-ventilated house. They
have no pets nor exposure to second-hand smoking. Water used for drinking is distilled water.

Review of Systems
• General: (-) weight loss (-) decreased appetite (-) weakness
• Integument: (-) wound (-) rashes (-) erythema (-) pallor (-) lesion (-) clubbing of nails (-)
hyperpigmentation (-) hypopigmentation
• Head and neck: (-) distension of veins (-) mass
• Eyes: (-) redness (-) mass (-) lesion (-) discharge (-) icteric sclera
• Ears: (-) mass (-) discharge
• Nose and Sinuses: (-) mass (-) obstruction (-) lesion (-) discharge (-) epistaxis
• Mouth and Throat: (-) hoarseness (-) ulcers
• Respiratory Tract: (-) hemoptysis
 • Gastrointestinal: (-) abdominal distension (-) anorexia (-) vomiting (-) constipation (-) diarrhea (-)
melena (-) hematemesis (-) hematochezia (-) retching
• Genitourinary: (-) hematuria
• Hematopoietic: (-) easy bruising (-) easy bleeding (-) pallor
• Musculoskeletal: (-) bipedal edema (-) weakness
• Nervous: (-) drowsiness (-) tremors (-) seizure (-) syncope
• Endocrine: (-) polyuria
• Autonomic deficiency: (-) fecal incontinence

PHYSICAL EXAMINATION

General Survey
The patient is well developed, awake, irritable, in mild cardiorespiratory distress

Vital Signs
Heart Rate: 126 beats/min
Respiratory Rate: 70 cycles/min
Temperature: 36.3C

Anthropometrics
Weight: 8.8 kg
Length: 73 cm
Weight-for-age: below 0 (normal)
Length-for-age: 0 (normal)
Weight-for-height: below 0 (normal)

Integument
The patient has a fair complexion, with no pallor, no jaundice, no cyanosis, no hypo- or
hyperpigmented lesions, no visible masses. He has good skin turgor with good capillary refill.

HEENT
The patient has flat fontanelles, symmetrical facial features, no mass or lesions on the
head or face. He has no eye discharge or redness, anicteric sclerae with pink palpebral
conjunctivae. Patient has patent nostrils with no nasoaural discharge and no alar flaring. His
ears have mobile pinna without masses, lesions or discharge. He has moist lips and oral
mucosa, slightly hyperemic posterior pharyngeal walls, non-hypertrophic tonsils, no exudates
and no cervical lymphadenopathies

Chest and Lungs

The patient has no chest wall deformities, masses or lesions, with symmetrical chest
expansion. There is note of intercostal and subcostal retractions, with harsh breath sounds, no
wheezes and good air entry.

Heart and Vascular

The patient has an adynamic precordium, with the apex beat at the 5th intercostal space
left midclavicular line. He has a normal rate and regular rhythm with no murmurs.

Abdomen
The patient has a flat, non-distended abdomen without visible scars, discoloration,
visible veins or peristalsis. Abdomen has normoactive bowel sounds, soft with no guarding.
Extremities
The patient has no gross deformities, no edema, with full and equal peripheral pulses
and full range of motion on all extremities.

Cranial Nerves
I Not assessed
II Pupils : 2-3 mm, equally and briskly reactive to light
III,IV,VI Full & intact extra ocular muscle movement
V Good suck, (+) bicorneal reflex
VII No facial asymmetry
VIII Turns to sound
IX,X (+) Gag reflex
XI Good head control
XII Tongue midline

Motor strength:
 Normal muscle bulk, good tone and head control
 Can move all extremities equally
 No tremors

Sensory:
 Withdraws to pain: all extremities

Deep Tendon Reflex +2 +2

+2 +2

Meningeal Signs: No Brudzinski sign, No Kernig’s sign, No Nuchal rigidity

Pathologic Reflex: (-) Babinski

SALIENT FEATURES:
 10 month old male

ADMITTING IMPRESSION: Pediatric Community Acquired Pneumonia C

COURSE IN THE WARDS

On admission, diagnostics requested included CBC, urinalysis, chest xray AP/L, CRP, and
blood CS. Patient was then started on Cefuroxime at 85mg/kg/day, salbutamol nebulization every
8 hours, and paracetamol prn at 11.4mg/kg/dose.
On the first hospital day, patient still had productive cough, colds with watery nasal
discharge, and fever with a tmax of 38.8C without episodes of dyspnea. He still has shallow
intercostal retractions with occasional rales. CRP was negative and blood CS showed no growth
after 48 hours of incubation. Antibiotics, nebulization, and paracetamol were continued.
On the second and third hospital day, patient had decreased cough without febrile
episodes or dyspnea. Intravenous fluids were consumed, antibiotics and nebulization were
continued.
 On the fourth hospital day, patient has no more subjective complaints and has good suck
and good activity. Intravenous antibiotics were shifted to oral and was tolerated well. Patient was
discharged well on the fifth hospital day.

CBC (OP) UA (OP) CRP Negative

Hgb 9.6 Color Yellow Blood CS Final Report: No growth after
48 hours of incubation
Hct 28.0 Reaction 6.0 CXR Pneumonia with partial
AP/L atelectasis considered, right
upper lung
WBC 34780 Trans Sl. turbid
Seg 78.7 SG 1.005
Lymph 14.6 Albumin Trace
Mono 5.9 Sugar Negative
Eos 0.4 Pus cells 0-1/hpf
Plt 467 RBC 0-1/hpf
Epith cells Rare

FINAL DIAGNOSIS: PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA C