UNIVERSITY OF PERPETUAL HELP – DR. JOSE G.

TAMAYO MEDICAL UNIVERSITY

Along Old National Hi – Way, Sto. Nino, City of Binan, Laguna
COLLEGE OF MEDICINE
CORPUZ, ROXANNE C. 23 September 2019
PEDIATRICS 2 DR. GRACE L. VILLA-MALAYAN

YEAR III DECURY CASE 02-2019

Name of the patient: R.M. Age: 7 years old

Gender: Male Birthdate: -
Address: Biñan City, Laguna Civil Status: Single
Place of Birth: - Nationality: -
Informant: Mother Religion: -
Informant Reliability: 95% reliability

I. General Data:

This is a case of patient, RM, 7 years old, male, from Biñan City, Laguna was admitted
for the first time on December 3, 2018 at UPH – Perpetual Help Medical Center at 5:00 pm

II. Chief complaint:

Difficulty in breathing

III. History of Present Illness:

16 days PTA, the patient had undocumented high fever relieved by taking Paracetamol
at 11mkd. Noted to have productive cough and was given Ambroxol 1tsp TID
10 days PTA, still febrile and patient is weak. No medication given and no consultation.
Fever lasted for 5 days prior to admission. Patient had productive cough and chest
discomfort. Brought to a physician, prescribed Amoxicillin at 45mkd with unrecalled
preparation which afforded slight relief and fever persisted.
3 days PTA, cough and fever persisted patient is weak looking with fair appetite.
Medications continuously taken however patient remained symptomatic with excessive
coughing.
2 hours PTA developed progressive chest discomfort and difficulty of breathing. Brough
to the Emergency room and admitted.

IV. Maternal and Obstetrical History:

31-year-old G1P1 (1001) mother, had irregular prenatal checkup and no multivitamins.
No history of exposure to radiation nor intake of teratogenic drugs. No maternal illness.

V. Birth History:
Born term via NSD at home by a midwife with good cry and spontaneous respiration,
uncomplicated.

VI. Neonatal History:

No history of cyanosis and jaundice after birth.
VII. Nutritional History:
Breastfed from birth until 6 months then shifted to milk formula. Supplementary food like
cereals, fish meat and potatoes started at 8 months. Multivitamins given at 1ml OD. Presently
he takes his meals with junk foods in between. He takes 1 to 2 glasses of full cream milk daily.

VIII. Growth and Development History:

 8-9months
o Crawls
o “mama” and “dada” indiscriminately
 11 months
o Walks with one hand held
o “mama” and “dada” appropriately
o Shakes head “no”
 12 months
o Walks with few steps
o 2-3 words with meaning
 2 years old
o Running well
o Stacks 5-7 blocks
o 2 words sentences
 3-4 years old
o Copies circles and squares
o 3-4-word sentences
 5 years old
o Can catch ball with 2 hands
o Can tell stories
 Present
o Grade 1 with no academic deficiencies

IX. Immunization:
(+) BCG
(+) DPT 3 doses
OPV
(-) Measles/MMR
(-) Hep B
(-) HIB

X. Past Medical History:

(+) Varicella 1 ½ year old
(+) Recurrent URTI and fever

XI. Family History:

 (+) PTB Mother on antikocks for 4 weeks

XII. Socio-Environmental History:

 The patient lives in a congested neighborhood, water supply comes from deep well,
toilet flush type.

Review of Systems:
CNS: sleeping most of the time
RESPI: (-) difficulty in breathing
CVS: (-) no easy fatigability
GIT: (+) anorexia
GUT: no hematuria, no dysuria, urine highly colored and scanty in amount

Physical Examination:

General Survey: Lethargic, fairly nourished, in respiratory distress

Vital Signs: BP = 90/60mmHG

CR = 120/min.
RR = 58/min. (Tachypneic)
T̊ = 40̊C (Febrile)
Wt = 25.6kg
Ht = 119cm

Skin: Dry skin

(-) Pallor
(-) Jaundice

HEENT: normocephalic, pinkish palpebral conjunctiva, anicteric sclerae, pupils equally reactive
to otoscopic examination revealed injected tympanic membrane, (-) light reflex perforated
tympanic, no oral discharge, dry lips, (-) tonsillopharyngeal congestion.

Neck: No nuchal rigidity; enlarged, non-tender, cervical lymph nodes, bilateral

C/L: symmetrical on expansion, (+) crackles on the right lung field, decreased breath on left
lung, decrease vocal and tactile fremitus on left lung, resonant on the right lung field.

Heart: adynamic precordium, AB at he 4th left intercostal space along the midclavicular line,
tachycardic, regular rhythm; no murmur

Abdomen: flat, soft; intercoastal normo active bowel sounds, no organomegaly

Extremities: no gross deformities, CRT < 2 seconds

Neurologic Exam:
Cerebral: Lethargic
Cerebellum: Cannot be assessed/tested
CN I: cannot be tested
II: (-) papilledema
 III, IV, VI: pupils equally reactive to light and accommodation; can move
eyeballs in all directions; no nystagmus nor ptosis
V: (+) corneal reflex
VII: cannot raise both eyebrows; face asymmetrical: upon smiling
VIII: can hear; follows command
IX, X: (+) gag reflex, uvula in the midline
XI: can turn head against one’s hand
XII: no tongue deviation

(-) Kernigs and Brudzinski

(-) Babinski, left

SALIENT FEATURES:
 Recurrent fever
 Productive cough/excessive cough
 Chest discomfort
 Weak looking
 Anorexic
 Perforated tympanic
 Decreased breath sound on left lung
 Decreased vocal and tactile fremitus on left lung
 (+) Crackles on right lung

DIFFERENTIAL DIAGNOSIS:

1. Pulmonary Tuberculosis
Tuberculosis (TB) is an ongoing (chronic) infection caused by bacteria. It usually infects the
lungs. But other organs such as the kidneys, spine, or brain may be affected. TB is most often
spread through droplets breathed or coughed into the air.
TB bacteria is spread through the air when an infected person coughs, sneezes, speaks, sings,
or laughs. A child usually does not become infected unless he or she has repeated contact
with the bacteria. Good air flow is the most important way to prevent the spread of TB.

Rule in Rule out

 Cough  Cannot totally rule out TB.
 Fever
 Anorexic
 Crackles
 Lives with someone who has TB
 Lives in the Philippines
 Chest discomfort
The patient has BCG vaccine but is exposed to someone who has the disease that’s why
the probability of the patient acquiring the disease is high. Further diagnostic testing is
needed to rule out TB like TB skin test, may also need a chest X-ray and sputum test.
2. Bronchiectasis
Characterized by irreversible abnormal dilation and anatomic distortion of the bronchial tree
and represents a common end stage of a many nonspecific and unrelated antecedent
events.

Rule in Rule out

 Cough  Hemoptysis
 Fever  Wheezing
 Anorexic  Clubbing of fingertips
 Crackles  Chronic disease (patient is
symptomatic for 16 days only)

Bronchiectasis is the result of recurrent tract infection it is the end stage of all respiratory
diseases. This is the first incidence where the patient experience difficulty of breathing and
chest pain thus ruling out Bronchiectasis.

3. Acute bronchiolitis
Bronchiolitis is more common in boys, in those who have not been breastfed, and in those
who live in crowded conditions. Risk is higher for infants with young mothers or mothers who
smoked during pregnancy. The clinical manifestations of lower respiratory tract illness seen
in young infants may be minimal in older patients, in whom bronchiolar edema is better
tolerated.

Rule in Rule out

 Cough  Dyspnea
 Fever  Wheezing
 Male  Exposure to an older contact
 Crowded living conditions with a minor respiratory
syndrome within the previous
week.
 Sneezing
 Rhinorrhea
 < 2 years old
 < 5 days old very acute
manifestations

FINAL DIAGNOSIS: PNEUMONIA (Community Acquired Type D)

EPIDEMIOLOGY
Pneumonia, defined as inflammation of the lung parenchyma, it is the leading cause of death
globally among children younger than age 5 years old. Haemophilus influenzae type B is a
bacterium that causes bacterial pneumonia in young children. Improved access to vaccines
were also important contributors to the further reductions in pneumonia-related deaths.
ETIOLOGY
Streptococcus pneumoniae (pneumococcus) is
the most common bacterial pathogen in children
3 weeks to 4 year of age, whereas Mycoplasma
pneumoniae and Chlamydophila pneumoniae
are the most frequent bacterial pathogens in
children age 5 year and older. Table 400-3 shows
the etiologic agents that can cause Pneumonia
based on their age groups.

PATHOGENESIS
The lower respiratory tract is normally kept sterile
by physiologic defense mechanisms, including
ciliary clearance, normal secretions such as
secretory immunoglobulin (Ig) A, and clearing of
the airway by coughing. Macrophages have
immunologic defense mechanisms that limit the
invasion by pathogenic organisms, that are
present in alveoli and bronchioles, secretory IgA,
and other immunoglobulins.

CLINICAL MANIFESTATIONS
Pneumonia is frequently preceded by several days of symptoms of an upper respiratory tract
infection, typically rhinitis and cough. Tachypnea is the most consistent clinical manifestation of
pneumonia.

Bacterial pneumonia in adults and older children typically begins suddenly with high fever,
cough, and chest pain. Other symptoms that may be seen include drowsiness with intermittent
periods of restlessness; rapid respirations; anxiety; and, occasionally, delirium.

Physical findings depend on the stage of pneumonia. Early in the course of illness, diminished
breath sounds, scattered crackles, and rhonchi are commonly heard over the affected lung
field.

DIAGNOSIS
An infiltrate on chest radiograph (posteroanterior and lateral
views) supports the diagnosis of pneumonia; the film may also
indicate a complication such as a pleural effusion or empyema.

Physical examination of the symmetrical chest expansion should

be tested. Presence of egophony should be ruled out for the
diagnosis of consolidation.

Blood culture

Complete Blood Count: Leukocytosis (Neutropenia)

Arterial Blood Test
TREATMENT

First line of treatment:

 Penicillin G if (+) HIB
 Ampicillin if (-) HIB
 Ceftriaxone
 Isoniazid if (+) PPD
 Steroids if there is wheezing beta 2 agonist

If there is no improvement
STOP the steroids

 Macroglide antibiotic could be given if the patient is not responding to antibiotic

treatment.

PROGNOSIS
Typically, within 48-96 hours upon initiation of antibiotics, patients with uncomplicated
community-acquired bacterial pneumonia show response to therapy.

A repeat chest radiograph is the first step in determining the reason for delay in response to
treatment. Bronchoalveolar lavage may be indicated in children with respiratory failure; high-
resolution CT scans may better identify complications or an anatomic reason for a poor
response to therapy.

PREVENTION
Some evidence exists to suggest that vaccination has reduced the incidence of pneumonia
hospitalizations.