General Data

Patient N.H., an 8 month old, female, born on December 12, 2020. She was born at Sorsogon Provincial
Hospital and currently lives in Brgy. Balaguer, Daraga, Albay. The informant is her mother and is 98% reliable.
Admission date was August 16, 2021 at 3:00 in the afternoon.

Chief Complaint
According to the mother, patient has intermittent fever.

HPI
7 days PTA, patient is active and plays with her cousin.
6 days PTA, patient has fever, cough and cold, and becomes inactive. When crying, coughing becomes
prominent and is stopped when breastfeeding. The mother gave paracetamol (Calpol) for the fever. The fever
subsided at night with temp. of 36C but started to become high again in the morning with temp. of 38 C.
2 days PTA, still with persistent symptoms hence consultation to AP. AP prescribed cefixime and
paracetamol. Patient was sent home.
Few hours PTA, fever, cough and cold, and inactivity were still present. Sought for follow up check up
to AP and was referred for further assessment and management.

Ancillary History
Past Medical History
 Diagnosed with pneuomonia last Aug 14, 2021 by Dr. Ludovice. No other history of diseases and surgery.
 Medications:
Gives the child paracetamol at 0.75 mL and cefixime at 1.5 mL since August 13, 2021.

Immunization history
Vaccine Dose and Date Given
1st 2nd 3rd
BCG At birth
Hepa B
OPV 2/22/21 3/21/21 5/19/21
Penta 3/24/21
IPV 5/19/21
PCV 2/22/21 3/24/21 6/16/21
MMR Not yet given
BCG and Hepatitis B vaccine were given at birth. OPV was given in three doses during 2nd, 3rd and 5th
month, respectively. Pentavalent was given during the 2nd and 3rd month of life. IPV given together with OPV
during 5th month. PCV given in three doses, 2nd, 3rd, and 6th months of age, respectively. MMR is not yet given
since patient is <9 months.

Pediatric History
 During birth, patient weighs 2.9 kg and was delivered via normal spontaneous delivery.
 Developmental Milestone
a) Grass motor: can sit with assistance, can turn to side but not rollover
b) Fine motor: can hold object and transfer from one to another
c) Language: can speak “mama”, “papa” and “ate”
d) Social: cries when other people tends her

Family History
Patient has paternal history of diabetes. No other family diseases.

Social and Environmental History

The mother gives sterilized drinking water to the patient for drinking. The uncle is a smoker but usually
smokes outside. The mother is unemployed and separated with the father.
Nutritional History
Exclusively breastfed from birth to present. At 6 mos., introduced with soft foods like rice porridge. At 8
mos., fed with cooked white rice.

Review of System
For the general, there is weight loss, inactivity and irritability. There is cold and cough present. For the
gastrointestinal, there is diarrhea described as watery with flatus and color orange and green. The other
system is unremarkable.

Physical Examination
General
The patient is awake, irritable and inactive.
Vital signs:
Temperature is 38.8 celsius. Cardiac rate is 123 beats per minute. Respiratory rate is 50 breaths per minute
with oxygen saturation of 97%. The weight is 6.6 kg and height is 67.8 cm.
Skin:
Patient has fair skin and not cyanotic, no rashes or lesions, soft texture, warm to touch, with normal skin turgor.
HEENT
Head:
Normocephalic, no deformity, no frontal bossing, no lesion and masses, closed posterior fontanel and open
anterior fontanel
Eyes:
Anicteric sclerae, symmetric, no redness or discharge, pink palpebral conjunctiva
Ears:
Symmetric. No noted mass/ lesion on the external ear, pain and discharge,
Nose:
No deformity, deviation and perforation, No nasal discharge. No tendersness.
Throat:
No bleeding. Tonsils are normal in size, no exudates.
Neck, Axilla and Breast:
symmetric, no limitation in movement, no lesion/deformity, no tenderness, no lymphadenopathy
Heart:
Adynamic precordium, regular heart rhythm but tachycardic. No murmurs heard
Lungs/thorax:
Tachypneic, symmetric chest expansion, (+) subcostal retraction, Crackles heard on bibasally.
Abdomen:
Globular abdomen, no pulsation and herniation. Normal bowel sound. Soft and nontender.
Musculoskeletal:
Can sit with assistance. Growth is at par with age
Extremities:
no clubbing, gross deformities, and edema. Capillary refill time <2 seconds. Full equal pulses.
Nervous:
Irritable and inactive.

LABORATORY FINDINGS
Hematology Result:
White blood cell is normal at 10.68. Hemodilution is present with Hct of 0.36. Hemoglobin is within
normal, 121. There is neutropenia with segmenters of 0.13. Lymphocytosis is present with lymphocyte of 0.87.
The platelet count is within normal, 232.
Chest xray
Findings:
Hazy densities in both inner lower lungs, more in the right. Normal heart size and configuration. Diaphragm
and chest bones are intact.
Impression:
Pneumonia
DIFFERENTIAL DIAGNOSIS

PRIMARY WORKING IMPRESSION

Pneumonia
 Inflammation of the lung parenchyma.
 Leading infectious disease cause of death among children <5yr.
 Risk factor: poverty
 Poorly developed countries in Africa and South Asia  highest mortality rate
 Causes:
a) Microorganisms – most common cause
b) Noninfectious cause – aspiration, hypersensitivity reactions, and drug- or radiation-induced
pneumonitis
Etiology
 Bacterial causative agent – most common cause of pneumonia
1. Streptococcus pneumoniae (pneumococcus)  most common bacterial pathogen in children 3 wk
to 4 yr of age
2. Mycoplasma pneumoniae and Chlamydophila pneumoniae  most frequent bacterial pathogens in
children age 5 yr and older.
3. S. pneumoniae, H. influenzae, and S. aureus  major causes of hospitalization and death.
 Viral Pathogens  LRT infections in infants and children > 1mo and < 5yrs.
1. RSV and rhinovirus  children < 2yrs of age

Pathogenesis
Categories of Pediatric Community Acquired Pneumonia

Management of Pneumonia
• Admission is required for moderate and severe pneumonia.
• Parenteral antibiotic
a. Ampicillin 150-200 mg/kg/day or
b. Ceftriaxone 100 mg/kg/day divided q 12-24 hours or
c. Cefotaxime 150 mg/kg/day divided q 8 hours
• Supplemental Oxygen if O2sat is <90%
• Give IVF if there are signs of dehydration.
 Bicol Christian College of Medicine
Ago General Hospital Rotation
Group L Subgroup 2

Pediatric Case
Presentation

Submitted by:
Bertis, Jill Eizavel J.
Mohammed, Nayyan
Nasol, Cheyenne Chelsea Ll.

Submitted to:
Dr. Sonia Rosario