Kimberly Ann A.

Leorag Block 9-B1 Pediatric History

Date and time gathered: May 7, 2020, 2pm

Source of history/ Informant: Mother
% Reliability: 95%

Identifying Data
M.C., 2 years and 3 months old, female, Filipino, Roman Catholic currently residing at Mandaue
City, born on January 25, 2018 at University of Cebu Medical Center, sought consult at
University of Cebu Medical Center.

Chief Complaint: Productive cough & Fever

Prenatal History
Mother is 40 years old with an OB score of G6P5 (5015). Mother had her prenatal check-ups at
UCMed Hospital starting at 2 months AOG then regularly thereafter. CBC and Urinalysis taken
first few trimesters and were unremarkable. Increased blood sugar level were noted towards the
end of the pregnancy and was given Insulin with varying units (5, 10, 15) depending on her diet.
At 8 months AOG, mother was admitted at UCMed Hospital due to Urinary Tract Infection and
was prescribed with Antibiotic and “pampakapit” (unrecalled) on top of her Insulin. Mother is
non-smoker and non-alcoholic beverage drinker. Medications taken include prenatal
multivitamins (OB Max) taken once daily.

Natal History
Patient was delivered full term via Caesarian section due to Fetal Distress at UCMed Hospital
by an Obstetrician. Birth rank: 5/5. Birthweight: 9 lbs. Apgar score is unrecalled but mother
claimed to have a healthy baby with normal pinkish skin, cried upon delivery, and has good
pulse rate. Mother stayed in the hospital for 5 days. The patient, however, stayed for 10 days
due to jaundice presenting in less than 24 hours after birth and was given Ampicillin with
unrecalled dosage.

Feeding History
Patient was breast-fed every 2-3h until age 1 with about 4 breast-feeding sessions in between
solid food intakes. Solid foods were started at 5 months old, consisting of “lugaw” approximately
3 tsps (~ 14mL), thrice a day. Current diet consisted of vegetables and fish. No noted pickiness
of food or changes in eating habits until onset of symptoms when patient has a lack in appetite.

Growth and Development

At 1 year old, she was able to walk alone and respond whenever her name was called. Recently
at 2 years of age, she was able to scribble and noted to be playing with her hands. She babbles
and cannot say sentences with 1-4 words as of yet.
Immunization History
Patient received vaccination at a barangay health center at age 6 weeks. Mother mentioned that
the patient had the 6 in 1 vaccine but cannot recall what those vaccines are. Patient had 3 shots
of the said vaccine but unrecalled the age of patient upon follow up vaccinations.

Past Medical History

At 11 months, patient was hospitalized at University of Cebu Medical Center for 5 days due to
urinary tract infection with fever and vomiting. Patient was given an antibiotic (unrecalled) for 10
days. Patient has no known food and drug allergies.

Family History
Mother is currently healthy. Meanwhile, father had a cough since last week. Both have no
chronic illnesses. All the other siblings of the patient are healthy as well. Known heredofamilial
diseases are hypertension and diabetes.

Personal/Social History
Father is 52 years old and works as a driver. Mother is 40 years old and is a teacher. They live
in a 1-storey owned house. There are currently 9 of them living together, including the 2 in-laws.
Waste management is by open burning in the backyard. The family’s water source is from
MCWD.

History of Present Illness

5 days PTA, patient had an onset of colds. Mother self-medicated with Phenylephrine HCl +
Chlorphenamine maleate (Disudrin) syrup, 1 teaspoon per day.

3 days PTA, colds persisted but now noted an onset of non-productive cough. Disudrin was
continued for the colds with no medication given for the cough. No consult done. No associated
symptoms of rashes, vomiting or loose watery stool.

2 days PTA, non-productive cough persisted, still no medication given. Disudrin was stopped
due to the resolution of the colds.

1 day PTA, patient experienced an onset of intermittent fever (Tmax: 38.5C). Persistent cough
is now productive, with phlegm seen in vomitus. Mother self-medicated with Paracetamol
(Tempra) syrup, 1 tsp (approx. 5 mL) with temporary relief and repeated every time the fever
returns. Patient was now noted to have decrease in appetite and difficulty in going to sleep.
Worsening of the symptoms prompted consult.
Primary Impression:
Based on the acquired history, my primary impression is pediatric acute bronchitis. Acute
bronchitis is a clinical syndrome produced by inflammation of the trachea, bronchi, and
bronchioles. In children, acute bronchitis usually occurs in association with viral lower
respiratory tract infection, to which the patient manifested as productive cough and fever. Acute
bronchitis begins as a respiratory tract infection that manifests as the common cold. The cough
in these children is usually accompanied by a nasal discharge. The discharge is watery at first,
then after several days becomes thicker and colored or opaque. It then becomes clear again
and has a mucoid watery consistency before it spontaneously resolves within 7-10 days.
Initially, the cough is dry and may be harsh or raspy sounding. The cough then loosens and
becomes productive. Children younger than 5 years rarely expectorate. In this age group,
sputum is usually seen in vomitus (ie, posttussive emesis). During PE, lungs may sound normal.
Crackles, rhonchi, or large airway wheezing, if any, tend to be scattered and bilateral. The
pharynx may be injected. A complete blood count with differential may be obtained.
Procalcitonin levels may be useful to distinguish bacterial infections from nonbacterial infections.
Sputum cytology may be helpful if the cough is persistent. To rule out pneumonia, do chest
radiography. Bronchoscopy may be needed to exclude foreign body aspiration, tuberculosis,
tumors, and other chronic diseases of the tracheobronchial tree and lungs.

Differentials:
As mentioned previously, the father having a cough since last week raises an alarm for possible
COVID-19 infection. Possible source of infection could be from his line of work being a driver.
Common reported symptoms of COVID-19 have included fever (98%), cough (76%), and
shortness of breath (55%). A pooled analysis of 181 confirmed cases of COVID-19 outside
Wuhan, China, found the mean incubation period to be 5.1 days and that 97.5% of individuals
who developed symptoms did so within 11.5 days of infection. The timeline of onset of the
father’s cough and the onset of the patient’s symptoms coincide with the number of days for the
virus to present signs and symptoms although symptoms in children with infection appear to be
uncommon. To rule this out, patient as well as the father should be reported immediately to
infection-control personnel at their healthcare facility and the local health department, following
DOH guidelines for management and workup. This condition should not be taken lightly as in
today’s times, this condition can progress in an alarmingly fast rate.

Another possible differential for the patient is community-acquired pneumonia. Patient already
presented signs of lower respiratory tract infection such as productive cough and fever.
Community-acquired pneumonia (CAP) is one of the most common infectious diseases and is
an important cause of mortality and morbidity worldwide. In the physical examination, these
characteristic pulmonary findings may be present: tachypnea; rales over involved lobe or
segment; increased tactile fremitus, bronchial breath sounds, and egophony if consolidation has
occurred; and decreased tactile fremitus and dullness on chest percussion from parapneumonic
effusion or empyema. Chest radiography, CBC with differential, serum BUN and creatinine
levels should be taken, along with sputum gram stain and/or culture, molecular assay for
influenzae as additional workup.
Lastly, the other possible differential for the patient is Rhinovirus Infection (Common Colds) with
postnasal drip. Most children have about 8 to 10 colds during the first 2 years of life. It was also
mentioned that her father had a prior cough and could have easily passed it to the patient.
Common colds may present with sneezing, low-grade fever (38.3 oC - 38.9oC), cough, and a
decrease in appetite to which the patient mostly manifest. Fever is not common, though
temperatures of 38-39°C are possible in younger children. During physical examination, a red
nose with a profuse, dripping nasal discharge may be present. The discharge can be clear and
watery or mucopurulent (yellow or green). Purulent secretions are common after the first few
days of illness because a large number of white blood cells (WBCs) migrate to the site of viral
infection. Such secretions should not be taken as implying bacterial infection unless they persist
for more than 10-14 days. The nasal mucous membranes have a glistening, glassy appearance,
usually (though not always) without obvious erythema or edema. Despite the sore throat, the
pharynx typically appears normal, without any erythema, exudate, or ulceration. If marked
erythema, edema, exudates, or small vesicles are observed in the oropharynx or if conjunctivitis
or polyps in the nasal mucosa occur, consider other etiologies, including infection with
adenovirus, herpes simplex virus, mononucleosis, diphtheria, coxsackievirus A, or group A
streptococci (GAS). Mildly enlarged, nontender cervical lymph nodes are present. Auscultation
of the chest may reveal rhonchi.