Monterozo, Ronel Von O.

Prime 4

Date: February 20, 2019 Informant: Mother

Time of consultation: 8am % Reliability: 80%

ABS., 5y/o, Male, Filipino, Catholic, born on Jan. 20, 2014, currently residing at Novaliches, Quezon
City

Cough for 4 days

3 days prior to consult

- With productive, non-distressing cough
- With watery nasal discharge
- no fever, no vomiting, no loose stools
- With good appetite (consuming ½ cup of rice with viand per 3x day with snacks in between)
- With good activity, playful
- No medications given nor consult done

2 days prior to consult

- Still with productive, non-distressing cough and watery nasal discharge
- no fever, no vomiting, no loose stools
- still with good appetite and good activity
- self-medicated with Lagundi syrup 5ml 3x a day which offered slight relief
- still no consult was done

1 day prior to consult

- Still with productive, non-distressing cough and watery nasal discharge
- With intermittent fever w/ maximum temp of 38C
- With 1 episode of posttusive vomiting
- still with good appetite and good activity
- Lagundi syrup was continued but no relief
- Given Paracetamol 250mg/ml, 5ml every 4hrs which offered relief fever
- still no consult was done

Few Hours prior to consult – with persistence of symptoms, sought consult.

● No history of mumps, measles, chickenpox

 ● No known allergies to food and medication
● No bronchial asthma or primary pulmonary TB
● No previous hospitalization
IMMUIZATION HISTORY
VACCINES DOSE PLACE GIVEN
BCG 1 Barangay Health Center
Hep B 4 Barangay Health Center
Diphtheria, Pertussis, 3 Barangay Health Center
Tetanus toxoid, Hep B,
Hib
OPV 3 Barangay Health Center

NUTRITIONAL HISTORY
Patient was exclusively breast fed up to 6 months old and was then started on
complementary feeding. Currently, consumes 1/2cup of rice with viand per meal 3x a day with snacks in
between. The patient prefers to eat anything except vegetable, fruits and fish.

Mother: 28 years old, high school graduate, housewife, apparently well

Father: 30 years old, high school graduate, taxi driver, apparently well
The patient has no siblings
No heredofamilial disease such as diabetes, hypertension, heart, liver, kidney or thyroid disease

PERSONAL AND SOCIAL HISTORY

He lives in a bungalow house, well-lit, well-ventilated. Primary caregiver is the mother while
financial provider is the father. Water source is from Maynilad. Drinking water is distilled. Garbage is
collected and segregated every other day.

GENERAL SURVEY: Awake, alert, not in distress, well-hydrated

BP: 90/60 HR: 95 bpm RR: 30cpm O2sat: 98% Temp: 37.0 C
Weight: 18 kg Length: 105 cm
BMI: 16
 Interpretation: a boy aged 5 years old. Who weighs 18 kg and 105 cm tall. Weight-for-age is above 3 z-
score line and his height-for-age is above 2 z-score line. His BMI-for-age and weight-for-height are both
in normal range

HEENT: Pink palpebral conjunctiva, white sclera, with brownish material totally occluding both ear
canals, pink turbinates, with watery nasal discharge, moist lips, moist buccal mucosa, pink pharyngeal
walls with postnasal drip
NECK: Supple neck, no palpable lymph nodes
CHEST/LUNGS: Symmetrical chest expansion, no retraction, with occasional crackles, good air entry
HEART: Adynamic precordium, normal rate, regular rhythm
ABDOMEN: Slightly globular, soft abdomen, normoactive bowel sounds, no palpable masses
EXTREMITIES: No gross deformities, full and equal pulses, capillary refill time < 2 seconds
SKIN: no active dermatoses

1. What are your salient features?

- Patient is a 5 year old male
- With history of cough for 4 days
- With productive- non-distressing cough
- With watery nasal discharge
- Intermittent fever (38ºC)
- 1 episode of post-tusive vomitting
- No vaccine: MMR, PCV, Varicella
- Hypotensive (90/60) [N: 95-110/60-75]
- Tachypnea (≥30 cpm)
- Good appetite
- Brownish material totally occluding both ear canals
- Crackles on auscultation
- With no loose stools
2. What will be your differential diagnosis?
1. Common colds
Rule In Rule out
Watery Nasal discharge Tachypneic
Nasal obstruction Crackles on auscultation
Fever
Rhinorrhea
cough

2. PCAp-A (viral)
Rule In Rule out
Tachypneic Cannot be totally ruled out
Fever, episodes of vomitting
Crackles on auscultation
With history of URTI
 3. Acute Bronchitis
Rule In Rule out
Without wheeze
Cough for 4 days

Productive Cough

Occasional crackles

3. What is your main diagnosis? Why?

1. Pediatric Community Acquired Pneumonia (PCAP) A, Probably Viral
1. Cough for 4 days
2. Tachypnea
3. Watery nasal discharge
4. Fever
5. episodes of vomiting
6. Crackles on auscultation
7. With history of URTI
2. Impacted ear canal, bilateral
1. Brownish material totally occluding ear canals
4. What laboratory tests will you do?
1. Chest radiograph revealing bilateral interstitial infiltrates
2. CBC revealing elevation of WBC county with lymphocytic predominance
5. What is your management?
1. Supportive treatment
2. Soothe the throat and relief cough with safe remedy
1. Increase fluid intake
2. Give calamansi juice / ginger tea
3. Nasal symptoms:
1. Nasal suction
2. Saline nasal drops, spray or irrigation
1. Nasal spray instill 2-4 drops
3. Cool mist humidifier
4. Cough:
1. Honey
2. lozenges
3. ORS rehydration solution every episode of vomiting
1. Encourage sips of ORS (5 mL or 1 teaspoon) every 2 minutes in accordance to the
estimation of volume of emesis for each episode of vomiting.
4. Encourage diet as tolerated
5. Paracetamol 10-20 mg/kg q4 oral (180-360mg)
1. Calpol/tempra: 1 tsp every 4 hours
 6. Vitamin C: 45 mg / day
7. Vitamin A: 200,000 units
8. Zinc sulfate: 20mg/day for 14 days
9. Probiotics & Chest physiotherapy
10. Follow up 5 days if not improving
11. Return immediately: if any of the following is present
1. Not able to drink
2. Convulsion
3. profuse vomiting
4. lethargic/unconscious
5. convulsing
6. difficulty in breathing
12. gentle irrigation of the ear canal with warm NSS (tympanic membran should be intact)
1. instillation of a solution such as diluted H2O2 in the ear canal for a few minutes to soften
the wax for suction removal or irrigation

6. What will be you home instruction for the patient

1. Assess clinical stability within 24-48 hours after consultation
2. Advice
1. Rest
2. Drink plenty of fluids adequate hydration
3. Proper diet:
1. lean meat, fish and boiled vegetables
2. Vitamin C and antioxidant rich food
3. Beans, nuts, whole grain
4. Salmon, sardines, egg yolks
4. Practice proper cleaning or ear
1. avoid ear manipulation
2. Avoid inserting cotton-tipped swabs or any foreign materials into the ear canal
3. Avoid ear candling
5. Zinc and Vitamin C supplementation proper hand washing
6. Avoid water activities
7. Avoid polluted air and smoke
8. Use cool mist humidifier
9. Update Immunization:
1. MMR: first dose booster after 12-24 months
2. PCV – 1 dose PCV 13 or 2 doses PCV 10 given atleast 8 weeks apart
3. Varicella – 1st dose, 2nd dose given after 4 weeks
4. Annual immunization of influenza vaccine
5. Booster dose for HiB vaccine