CASE NO. 119 RAYMOND SERRANO SESSION I TUTOR GUIDE: 1 First 1 hour Give Chief Complaints of Raymond Serrano. Let students extract the medical history and physical examination findings. Do not give information unless asked for. 2 Next 45 minutes Let the students formulate their hypotheses and let them identify and prioritize learning issues, 2 Last 15 minutes Processing and feedback LEARNING ISSUES: Anatomy of the lower respiratory tract Physiology of breathing Mechanism of transport of blood gases Causes of dyspneaCASE NO. 119 RAYMOND SERRANO SESSION I Chief Complaints: high-grade fever, chills and difficulty of breathing. Case Scenario: Raymond Serrano, an 11-year old male child. residing at San Miguel Village, is admitted to the Mercy Community Hospital for the chief complaints of high-grade fever. chills and difficulty of breathing. About a day prior to admission, his teacher, at the Living Spring Academy, noticed that he was feverish, with a runny nose, dry, hacking cough and teary eyes. He was brought to the school linic at recess time and was told to increase his fluid intake. rest. and take paracetamol for fever and vitamin C-rich beverages. The next day, although the cough gersisted, the runny nose and teary eyes cleared up, and Raymond felt well enough to return to schocl. By midmoming, however, his fever retumed, ranging from 39-40°C, his cough worsened and he seemed to be in respiratory distress as ‘manifested by his rapid respiration and cyanosis around the mouth. He also started shaking violently ‘and complained that he felt cold, despite his high temperature. The alarmed teachers called his parents who fetched him from school and brought him directly to the hospital for admission, Raymond is the only child of Elaine, 36. a high-school teacher in MSU-IIT, and Jude, 37, an ‘engineer employed by Global Steel Corporation. According to his parents, this is Raymond's first hospitalization as he had never been seriously lil except for the usual cough and colds. Immunization is complete, including boosters. Developmental milestones were normal for his age. He is a fith- grader at the Living Spring Academy and an average student. PHYSICAL EXAMINATION: General Survey: Anxious, tachypneic, restless. well nourished, well developed, febrile child Vital signs: 8P= 90/60 mm Hg Weight = 35 kg HR= 110/min Height = 138 om R= 60/min 40.5°C HEENT: + Normocephatic No conjunctival injections With flaring of the alae nasi Very red throat Enlarged and red tonsils Neck: (+) cervical lymphadenopathy both sides of the neck Chest and Lungs: ‘© Symmetrical, with intercostal and retrosternal retractions + (#) duliness, right lower lobe + Diminished vocal and tactile fremitus on the right lower lobe 60+ Diminished breath sounds with fine crackles on the right lower lobe Heart: * Tachycardic + No murmurs heard Abdomen: «Slightly globular +) right lower quadrant pain + Diminished to absent bowel sounds = No organomegaly Extremities: wer extremities Equal palpable pulses both upoer Genitalia: + Normal circumcised, male extemal gen’ + Both testes descended and palpable (For submission during the next tutorial) 4. Let the students write the mecicai ristory and PE findings of the case. 2. Let them write their pmary rationale for considering these 4 sion and differential diagnoses, including their 'Ses and for ruling them out. 3. Let them include pian Allow them to suggest dia using the P(ersonal) treatment guidelines. lures they may want to request.CASE NO. 119 RAYMOND SERRANO SESSION II TUTOR GUIDE: 1. First 1 hour and 15 minutes. Let the students present the case history and give their primary impressions and differential diagnoses. Answer the tasks and discuss the learning issues identified in the previous session 2. Next 30 minutes Give the case scenario. Compare the Preatment of the students with the treatment plan in the scenario. Identify new leaming issues 3 Last 15 minutes Processing and feedback LEARNING ISSUES: 1. Community-acquired pneumonia Common causes according to 2 Pathophysiology Clinical manifestations Diagnostic tests Complications 2. Current guidelines in the management of CAP in adults and pediatric age group 2CASE NO. 119 RAYMOND SERRANO SESSION II CASE SCENARIO Raymond was admitted with the following orders: (What are the reasons for admission? What are the current guidelines in the treatment of pneumonia?) Non-pharmacologic treatment: + Vital signs every 4 hours ‘+ Tepid sponge bath for temper + Increase intake of oral fluids Pharmacologic treatment: + Paracetamol 325 mg (Tempra; + tablet every 4 hours + Cefuroxime Na (Zinacef) 250 mg 2 vials slow IV ANST q 8 hrs (Do you agree with the choice of antibiotic? Are there other drugs that you can use?) + Oxygen inhalation at 2 Limin ‘+ IVF: 40.3 NaCl at 73 mlnr (Compute for the IV rate) Laboratory request: = Complete biood count + Blood cutture + Urinalysis + Chest X-ray (PA and TASK: Give the rationale for the above orders. “What results do you expect to receive? 63CASE NO. 119 RAYMOND SERRANO SESSION Ill TUTOR GUIDE: 1. First 1 hour Answer the tasks and discuss the learning issues identified in the previous session 2. Next 45 minutes. Give the case scenario. Discuss the laboratory results Identify new leaming issues 3. Last 15 minutes Processing and feedback 64CASE NO. 119 RAYMOND SERRANO ‘SESSION III All the laboratory results, except for the blood culture, came in two hours later. Complete Blood Cou Hemoglobin = 140 g/t Hematocrit = 0.40 Red blood cell 3 White blood cells = 48 x 10°71 Polymorphonuctears Lymphocytes = 0.19 Eosinophils = 0.01 Platelets= 229 x 10°/1 Urinalysis: Color - straw Sp. Gravity - 1.020 Transparency - clear Albumin ~ () pH-6.5 Sugar - ¢) Microscopic: Pus cells - 0-t/hpf RBC - 0 Epithelial cells -none Casts - none Bacteria - none Chest X-ray (PA, Lateral) : Consolidation in the right lower lobe TASK1: Interpret the laboratory results. How will these affect your management? By the second hospital day, Raymond seemed to be feeling better. Physical examination revealed that he was still febrile (38.5°C), and his heart rate was 92/min. and respiratory rate was 45/min. However, examination of the lungs revealed an increase in fremitus on the right lower lobe and disappearance of the rales. (How would you now assess your patient?) Later that aftemoon, the blood culture results arrived st Blood culture (24 hours} -ptococcus pneumoniae TASK2: ‘What is your plan of management now? 65CASE NO. 119 RAYMOND SERRANO SESSION IV TUTOR GUIDE: 1. First 1 hour Answer the tasks and discuss the leaming issues identified in the previous session 2, Next 45 minutes Give the case scenario, Identify new leaming issues 3. Last 15 minutes Processing and feedbackCASE NO. 119 RAYMOND SERRANO SESSION IV CASE SCENARIO: All of the medications were continued. By the third hospital day, Raymond's fever has subsided, and his respiratory difficulty lessened, although there was still flaring of the alae nasi. RR was 30/min and HR was 85/min. (Assess Raymond’s condition. What is your plan of management now?) Oxygen inhalation and the IV fluids were discontinued and the patient was shifled to cefuroxime axetil 500 mg 1 capsule 3 x a day. His cough loosened and he was putting out large amounts of mucus, some of which were blood-tinged. By the 5" hospital day, Raymond was afebrile and was not in respiratory distress .He was discharged with instructions to go back to his doctor for check-up after 3 days.