GENERAL DATA

Name: E.R.
Age: 1
Gender: Male
Address: Attulayan Norte, Tuguegarao City
Birthday: January 6, 2018
Date of Admission: February 11, 2019
Time of Admission: 10:15 PM
Hospitalizations: 1
Informant: Mother (98%)

CHIEF COMPLAINT
FEVER and DIFFICULTY OF BREATHING

HISTORY OF PRESENT ILLNESS

Few days prior to admission, the mother noticed that the patient had colds because of the
presence of scanty clear,watery nasal discharge. She gave Ascorbic Acid (Poten-Cee) 1 mL
prescribed by his paediatrician at CVMC during his consultation on January 31.
2 days prior to admission, the patient started to have intermittent fever. His temperature
falls between 38-39°C. His mother gave her Paracetamol drops and his temperature becomes
normal. The child also had noisy breathing and he vomits food contents. He began to have
decreased appetite because he consumes half bottle of milk from 5 bottles before he got sick. The
child had difficulty of breathing especially at dawn as evidenced by irritability when laid in bed.
1 day prior to admission, the symptoms persisted and same management was employed.
His stool has watery consistency and defecates 1-2 times a day.
Several hours prior to admission, the patient had a high grade fever with the highest
temperature of 39.7°C accompanied by tachypnea. The fever drops to normal by giving
Paracetamol but it recurs after a few hours. The mother also noticed that he had sunken eyeballs
and dry lips. Few minutes prior to admission, he experienced severe difficulty of breathing. The
child was inconsolably crying which started about 9:30 PM until 10:00 PM, hence admission.
Upon admission, the mother discovered that the patient has lost weight because his weight is 9kg
which was previously 10.5 kg.

PAST MEDICAL HISTORY

There were no previous hospitalization and surgical procedures undergone. He did not
suffer from common childhood illnesses such as chickenpox or measles.

MATERNAL HISTORY

The mother, G2P2 (2-0-0-2), claimed that she had regular prenatal check-up in the Rural
Health Unit. She acquired cough during his last trimester and took antibiotics prescribed by a
physician. She did not smoke nor drink alcohol. She also took necessary supplements such as
Iron sulphate.

NEONATAL AND BIRTH HISTORY

The patient was born was born at term pregnancy via Cesarean Section in CVMC with a
birthweight of 3.5 kgs. According to the mother, the doctor told her that the baby was
meconium-stained so they transferred him to Neonatal Intensive Care Unit immediately after
delivery. He also had jaundice so they gave him antibiotics parenterally and regular
phototherapy. She stayed in the NICU for 1 week before they brought him to the ward.

NUTRITIONAL HISTORY

He was exclusively breastfed per demand for 1 week in the NICU. Afterwhich, they gave
him formula milk (Bonna) as a supplement for breastmilk. At 6 months, they started to give
Cerelac. They also tried wetting his lips with bagoong as per tradition in the family. They
believed that this could prevent the child from being picky-eater in the future.

DEVELOPMENTAL HISTORY
At 1 month, he started to smile to everyone who interacts with him. At 11 months, he was
able to walk, and say his first words which are Papa and Mama.

IMMUNIZATION HISTORY
VACCINE 1ST DOSE 2ND DOSE 3RD DOSE
BCG ̷
Hepatitis B ̷ ̷ ̷
DPT ̷ ̷ ̷
OPV ̷ ̷ ̷
Hib ̷ ̷ ̷
PCV ̷ ̷ ̷
Measles ̷
MMR ̷

FAMILY HISTORY
There is no history of familial illnesses such as hypertension, diabetes mellitus,
tuberculosis, or asthma.

PERSONAL AND SOCIAL HISTORY

 The patient has only one sibling who is 8 years old. Their family live in a bungalow type
house with 2 rooms and galvanized roofing. They buy their drinking water from a water refilling
station.
According to the mother, the patient is loved by his sibling and cousins. One of his cousin
recently had cough and colds who visits him regularly. His sibling sometimes bring home sweets
and ice cream from school and would let him taste it.

REVIEW OF SYSTEMS

Constitutional: Significant weight loss, (+) fever

Skin: (+) dry lips, denied jaundice and pallor
Head: no trauma
Eyes: deep set eyes
Ears: no discharge
Nose: whitish discharge
Throat: No history of tonsillitis
Endocrine: Decreased in milk and food intake
Cardiovascular: No history of rheumatic fever or any heart disease
Respiratory: cough, colds, difficulty of breathing, chest ratractions, tachypnea, (+)
respiratory grunting
GI: (+) vomiting, no melena, defecates 1-2 times a day, watery stool

PHYSICAL EXAMINATION

General Survey: The patient is awake, with active movements held by mother, appears well, no
apparent distress
Vital Signs:
Heart/Cardiac Rate: 132 bpm
Respiratory Rate: 55 cpm
Temperature: 36.4ºC
O2 sat: 98%
Blood pressure: not assessed
Anthropometric Measurements:
Height (cm): 70 cm
Weight: 9 Kg
Chest Circumference: 48 cm
Abdominal Circumference: 52 cm

Skin: No visible lesions or rashes. No jaundice. With good skin turgor.

Head: Normocephalic
Eyes: pink palpebral conjunctiva. Pupils react to light and accommodation
Ears: No discharge or drainage is noted in the external canals.
Nose: no discharge
Mouth and throat: Lips are not dry; Moist mucous membranes. No hypersalivation and cleft
lip/palate
Neck: No palpable cervical lymphadenopathy
Respiratory: Symmetrical chest expansion with mild subcostal retractions , (+) Use of
accessory muscles (scalene), Coarse Crackles over the trachea, Upper and lower left lobe
noted
CV: No murmur, regular rhythm and rate
Abdomen: Globular, Normoactive bowel sounds.
Extremities: No edema, no cyanosis, no gross deformities
GU: No discharge, no swelling nor redness

NEUROLOGIC EXAM
Patient is awake, conscious alert & moves all extremities symmetrically.

CN I =Not performed
CN II = (+) pupillary light reflex; equal reaction to light
CN III, IV, VI = intact extraocular muscles
CN V = shows teeth
CN VII = facial symmetry
CN VIII = not assessed
CN IX, X = not assessed
CN XI = turns head from side to side
CN XII= no tongue deviation

SALIENT FEATURES

 1 year old
 Cough
 High-grade fever
 Tachypnea
 Difficulty of breathing
 Vomiting
 Difficult feeding
 Respiratory grunting
 Subcostal retractions
 Use of accessory muscles
 Weight loss
 Exposure to cousin who has cough and colds

IMPRESSION

PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA, CLASS C

CASE DISCUSSION
A. Epidemiology
A.1. International
Pneumonia and other lower respiratory tract infections are the leading cause of death
worldwide. The WHO Child Health Epidemiology Reference Group estimated the
median global incidence of clinical pneumonia to be 0.28 episodes per child-year. This
equates to an annual incidence of 150.7 million new cases, of which 11-20 million (7-
13%) are severe enough to require hospital admission. Ninety-five percent of all episodes
of clinical pneumonia in young children worldwide occur in developing countries.
Approximately 150 million new cases of pneumonia occur annually among children
younger than 5 years worldwide, accounting for approximately 10-20 million
hospitalizations. A WHO Child Health Epidemiology Reference Group publication cited
the incidence of community-acquired pneumonia among children younger than 5 years in
developed countries as approximately 0.026 episodes per child-year.
 Pneumonia affects children and adults everywhere, however most child deaths
occur in the world’s poorest regions with highest incidence in sub-Saharan Africa
and South Asia Streptococcus pneumonia, Haemophilus influenzae type b (Hib) and
respiratory syncytial virus are the most common causes of pneumonia in healthy
people.

A.2 Philippines
 The Philippines is one of the 15 countries that together account for 75% of
childhood pneumonia cases worldwide. In children aged under 5 years, pneumonia is
the leading cause of mortality with a mortality rate of 23.4 x 100,000 population
recorded in 2009 In Regions VI, VII and VIII of the Philippines, the total number of
children under five years of age with pneumonia that have been seen and given
treatment from January to December 2012 were 89,221 and 85,923, respectively
Major risk factors for developing pneumonia are: (1) a weakened immune system due to
malnutrition or undernourishment (especially in infants not exclusively breastfed), HIV
and other pre-existing illnesses such as measles; (2) environmental factors including
indoor air pollution (cooking/heating with wood, dung, or other biomass fuels), living
in crowded houses and parental smoking.
B. Diagnostics and Laboratory
Chest x-rays and laboratory tests can be used to confirm the presence of pneumonia
and to identify the causative pathogen. In resource-poor environments, pneumonia
diagnosis is based on clinical signs and symptoms.

WORKUP VIRAL PNEUMONIA BACTERIAL PNEUMONIA

Chest Hyperinflation w/ bilateral Confluent lobar consolidation

Radiograph interstitial infiltrates and
peripheral bronchial
cuffing

Peripheral White Can be normal or elevated Elevated w/in the range of 15,000-
Blood Cell Count but is usually not higher 40,000/mm3,with a granulocyte
than 20,000/mm3, with a predominance
lymphocyte predominance

Definitive DX Isolation of virus/detection Isolation of organism from the blood,

of viral genome/antigen in pleural fluid, or lung
respiratory tract secretions

C. Classification Risk
Classification Provided By Philippine Academy 0f Pediatric Pulmonologists
Classification pCAP A or B Pcap c Pcap c
--- Pneumonia I Pneumonia II
Nonsevere Severe Very Severe
VARIABLES
Clinical
1. None Mild Moderate Severe
Dehydration
2. None Moderate Severe
Malnutrition
3. Pallor None Present Present
4.
Respiratory ≥50/min - >60/min - >70/min
Rate ≤60/min ≤70/min >50/min
3-12 ≥40/min - >50/min >35/min
months ≤50/min >35/min
1-5 >30/min -
years <35/min
>5
years
5. Signs Of
Respiratory
Failure None IC/Subcostal Supraclavicular/IC/SC
A. Retraction None Present Present
B. Head None Present Present
Bobbing None None Present
C. Cyanosis None None Present
D. Grunting None Irritable Lethargic/Stuporous/Comatose
E. Apnea
F. Sensorium
Diagnostic Aid At Site-Of-Care
1. Chest X- None Present Present
Ray Findings
Of Any Of
The Ff:
Effusion;
Abscess; Air
Leak Or
Lobar
Consolidatio
n
2. Oxygen 95% <95% <95%
Saturation At
Room Air
Using Pulse
Oximetry
Action Plan
1. Site-Of- Outpatient Admit to ward Admit to critical care facility
Care
2. Follow-Up End of treatment
 DIFFERENTIAL DIAGNOSES
ASTHMA
RULE IN RULE OUT
Cough No expiratory wheezing
Crackles No family history
Respiratory grunting
Difficulty feeding

ACUTE BRONCHITIS
RULE IN RULE OUT
Cough & Colds No high-pitched wheezing
Fever
Coarse crackles

CYTIC FIBROSIS
RULE IN RULE OUT
Cough No family history
Crackles No constipation
No recurrent lung
infection

TREATMENT
1. IV Fluids: D5 0.9 NaCl (Isotonic solution)
2. Antibacterial
First Line: Ampicillin 50 mg/kg ; or Benzyl Penicillin 50 000 units per kg IM/IV every 6
hours for at least five days
Additional: Gentamicin 7.5 mg/kg IM/IV once a day for at least five days
Second Line: Ceftriaxone
3. Paracetamol IV
4. Small, frequent feedings