Cagayan State University

COLLEGE OF MEDICINE
Carig Campus, Tuguegarao City

PEDIA WARD DECURY

Submitted by: (Year III Section Beta C1 – Group 3)

Bunuan, Kristine Xandra D.
Demegillo, Ron Andrie V.
Juvarajiya, Nikita Mahesh

Submitted to: Romeo Calubaquib, M.D.

PATIENT’S PROFILE

Name (Initials) : A.C.

Age : 9mon.
Gender : Female
Address : Baggao, Cagayan
Birth place : Baggao, Cagayan
Birth date : February 11, 2018

Present Hospital of Admission : Cagayan Valley Medical Center

Date of Admission : November 22, 2018
Time of Admission : 7:00 PM
Number of Admission : 2

Date of Interview : November 23, 2018

Time of History Taking : 1:20 PM
Informant : Mother and Father
Reliability 90%

Chief Complaint
- Cough and difficulty of breathing

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 HEALTH HISTORY
History of Present Illness:

12 days prior to admission (PTA), patient AC’s mother noticed that the patient has been
having cough and colds. As a remedy, she gave her water and breast fed her frequently and
tapped her back to loosen secretion. 8 days PTA, they consulted a health center because of
the persistent cough, they were prescribed with ambroxol drops .2ml q8hr and advised to
nebulize the patient to loosen secretion and alleviate the difficulty of breathing. All the
symptoms subsided after a few days, however on November 20, Tuesday, 2 days PTA,
patient AC’s mother noticed yet another cough, difficulty of breathing but this time it is much
worse than before and accompanied by fever (38C). As a remedy, they continued the same
medication that was prescribed to them by the health center. On the day of admission, patient
AC’s mother got so worried because of her worsening condition so they decided to have a
consult on the health center, they were advise to go to CVMC for confinement and further
management and intervention.

Past Medical History

Childhood Illness:
• Diagnosed with Atopic Dermatitis on May 2018
• Diagnosed with pneumonia and was hospitalized for 3days in Tungel District
hospital in Baggao, Cagayan.
Surgical:
• No history of surgery
Immunization:
• Vaccine given
• BCG, Hepatitis B, Pentavalent, OPV, IPV and Measles,
Allergies:
• No known Allergy
Psychological
• Not assessed

Pregnancy and Birth History:

 Patient AC was born to a 23 year old mother with OB history of G3T2P0A1L1.
 She had total of 6 prenatal checkups in the health center and Tungel District Hospital. She
had cough and tonsillitis on the 5th month of her pregnancy and was prescribed with
Cefalexin capsule 500mg 3x a day for 5 days.
 Patient AC was carried in full term with a birth weight of 2.7kg. Her mother gave birth in
Tungel District Hospital via NSD assisted by a midwife.

Nutritional History:
 The patient AC was exclusively breast fed for a month. Water and vitamins was
introduce after.
 Table food or other complementary feeding was not yet introduce.
Growth & Development:
 Smile 1 mon.
 Rolls over 3mon.
 Sits with support 7mon
 Hold bottle 5mon.
 1st word 9mon.
Family History:

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  Her older sibling died at 8mon. old due to pneumonia
 Has a family history of asthma on her 2nd and 3rd degree relative
 No known family history of diabetes, cancer, hypertension and PTB
 His father had cough and cold for 5 days followed by her mother for 3 days
Personal and Social History:
 Patient AC is the 2nd child among 2 siblings.
 Her father is 27y/o who works in the construction and farm while her mother is 23
housewife.
 Their house is made of light material with 2 floors and 2 rooms located near the main
road with few meters apart from other neighbor.
 Patient AC drinking water is from commercial distilled water while the rest of her
family is from deep well. The water is boiled before consumption.
 Their main source of income is farming and part-time construction work
 2 of their neighbor has PTB who frequently visits them.

REVIEW OF SYSTEMS
General:
• No fever and chills
• Weight not assess
Integuments:
• Crust of 3-4 inch on left leg
• No lumps, itching, dryness, color change, and changes in nails
HEENT:
• Head – not assessed
• Eyes – not assessed
• Ears – not assessed
• Nose – (+) white nasal discharges
• Throat – no dyspagia
Respiratory:
• (+)Dyspnea
• (+)Cough white color
Cardiovascular:
• Not assessed
Gastrointestinal:
• No dysphagia
• No diarrhea and abdominal pain
Genitourinary:
• Not assessed
Endocrine:
• No cold/heat intolerance
• Weight change not assessed
Musculoskeletal:
• No muscle pain, stiffness and weakness
Psychiatric:
• Irritated mood

PHYSICAL EXAM

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General Survey:
 Patient AC was seen cradled by her mother while breast feeding
 Awake, conscious and irritated mood
 She was hook to an IV line with D5.9NaCl and O2 at 3-4 L/min
Vital Signs:
 BP: not asssess
 HR: 124 bpm
 RR: 36 cpm
 Temp: 36.3 Co
Anthropometric Measurement:
 Wt: 6.2kg
 Ht: 69cm
 HC: 37cm
 CC: 45cm
 AC: 44cm
Integumentary:
 Minimal perspiration, moist skin
 Brown in complexion
 No jaundice
 Good skin turgor (1sec.)
 (+)pallor
Head and Neck
 Hair is fine and evenly distributed
 Facial features are symmetrical
 (+) palpable cervical and clavicular nodes
 No mass palpated
 Patent Anterior fontanel
Eyes:
 Pale conjunctiva
 Crossed eyed
 Anicteric sclera
Ears:
 No swelling, redness and discharge obseved
Nose:
 Both nares are patent and non tender
 (+)nasal discharged
Mouth and throat:
 Lip are dry and pale
 No tooth eruption yet
Chest and Lungs:
 Normal rate and symmetrical lung expansion
 (+) Intercostal and Subcostal retraction
 (+) bilateral whizzes and crackles
Heart:
 Normal rate, regular rhythm, no murmur
 PMI is at the 4th intercostal space midclavicular line
 No murmur, thrills, click and gallops
Gastrointestinal:
 Globular, normoactive bowel sound
 No abdominal pain

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  2 bowel elimination since 6 am
Genitourinary:
 3 diaper used moderately soak
 No dysuria
Peripheral Vascular:
 No gross diformity
 No edema, cyanosis and clubbing
Neurologic
 (-) rooting and palmar grasp reflex
 (+) Babinski reflex
 No history of seizure
 GCS 15
Hematologic:
 No bruises and cyanosis
 (+)palor skin and conjuctiva

SALIENT FEATURES:

INITIAL IMPRESSION:

 Pediatric Community Acquired Pneumonia MR

DIFFERENTIAL DIAGNOSES:
1. A
2. B
3. C

Rule In Rule Out

CASE DISCUSSION:

Community-acquired pneumonia is one of the most common infectious diseases. Typically,

it is often caused by bacterial pathogens which includes S. pneumoniae, H. influenza, and M.
catarrhalis. Atypically, it is caused by viral pathogens most commonly rhinovirus and influenza.

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 Typical pneumonia classically presents with:
 Fever
 Tachypnea – most significant clinical sign

 Increasingly labored breathing

 Rhonchi
 Crackles
 Wheezing
Hydration status, activity level and oxygen saturation are important and may indicate
need for hospitalization.
In febrile children with tachypnea, findings of chest retractions, grunting, nasal flaring and
crepitation increase likelihood of pneumonia.
Atypical pneumonia most often presents subacute and frequently indolent.

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Workup diagnostics:
 Chest Xray
 Sputum Gram stain and/or culture
 Antigenic tests
 Blood Culture
 Others: CBC with differential, serum Na, BUN, creatinine, transaminase, phosphorus
levels, Lactic acid level, CPK, CRP

Treatment:

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