Jeyakumar Dhileeban Rrroll 41

DAVAO MEDICAL SCHOOL FOUNDATION
DEPARTMENT OF PEDIATRICS
PRECEPTOR – Dr. Maria Theresa Carin
RESIDENT – Dr. Ederlyn Jane E. Nono
NAME: JEYAKUMAR DHILEEBAN, IMD 22
IDENTIFYING DATA
Name: S.M
Age: 5 years
Gender: Female
Address: sasa, Davao City
Religion: Roman Catholic
Informant: Mother
Reliability: 90%
Date and time of interview: March 13, 2023; 10:00AM
CHIEF COMPLAINT: difficulty in breathing
HISTORY OF PRESENT ILLNESS

4 days prior to consultation, patient had onset of non productive cough, no associated
symptoms like cough and fever, no consultation were done, no medications were given.
2 days prior to consultation, patient had onset of intermittent fever, temperature was 37.6
c along with non productive cough, mother medicated the patient with paracetamol 250mg/5
ml 17.8 mkd every 4 hours which gave temporary relief.
On the day of consultation, had onset abdominal pain, relieved after passing stool, 2
episodes of post tussive vomiting( non bloody, non bilious) 2-3 spoon and 2 episodes of post
prandial vomiting( non bloody, non bilious) 2-3 spoons.
Few hours prior to consultation patient had onset of difficulty in breathing, due to the
persistence of symptoms the patient’s mother prompted to consultation.
PAST MEDICAL HISTORY

Patient had bronchopneumonia at 2 months old admitted for 10 days and treated with
antibiotics.
No history of previous surgeries
No history of allergies
PRENATAL HISTORY
Patient had bronchopneumonia at 2 months old admitted for 10 days and treated with
antibiotics.
No history of previous surgeries
No history of allergies
No smoking or no alcohol
BIRTH HISTORY
Baby was delivered via NSVD at local hospital .
Born at 8 months 3 days with birth weight of 2.4 kg.
NEONATAL HISTORY
Baby had good cry, pinkish and good activity
No resuscitation was done
No difficulty in feeding
No jaundice
Patient transferred to NICU for 24 hours for observation.
Length of stay in hospital is 5 days
Newborn screening test was done and results are normal
NUTRITION/ FEEDING HISTORY

Patient was breastfed for 2 years and 8 months. and then introduced with supplemental
feeding
IMMUNIZATION
BCG - 1 dose
DPT - 4 doses
OPV - 3 doses
Measles - 2 doses
Hib - 3 doses
Hepa B - 1st dose given after birth, 3 doses given later
GROWTH AND DEVELOPMENT

Gross motor:
Crawled at 8 months
Walking with support at 10 months
Can walk upstairs
Hop on one foot
Language development:
Started cooing at 3 months of age
Can say mama, papa at 11 months old
Able to speak fluently with complex sentences.
FAMILY HISTORY
Mother has asthma
Maternal grandparents has hypertension.
No history of cancer in the family
No history of genetically transmitted disease like sickle cell anemia, hemophilia
PERSONAL AND SOCIAL HISTORY
Primary care giver is mother and grand father
Patient family is occasional alcoholic drinker.
Mother is nurse and father is driver
ENVIRONMENTAL HISTORY
Water supply is from water district Davao City
Patient lives in a 7 bedroom house
There are 12 people in the house
Clean surroundings and no communicable diseases in the locality
Garbage disposal is twice a week
REVIEW OF SYSTEMS
GENERAL: (+) Fever, (+) weight change.
SKIN: (-) Rashes, (-) Lumps
HEAD: (-) Headache, (-) Trauma
EYES: (-) Redness, (-) Pain
EAR: (-) Ear discharge
NOSE: (+) coryza, (-) Nose bleed
MOUTH AND THROAT: (-) Lesions
NECK: (-) Neck masses
RESPIRATORY: (+) difficulty in breathing, (-) epistaxis.
CARDIOVASCULAR: (-) Feeling of heart racing, (+) chest pain
GASTROINTESTINAL: (-) Diarrhea, (+) Vomiting,
URINARY: (-) Hematuria
NEUROLOGIC: (-) Loss of consciousness
PHYSICAL EXAMINATION
Temperature: 38 c
Heart rate: 128 bpm
Respiratory rate: 30 cpm
O2 95
GENERAL: Awake, Alert, (+) Febrile, not in respiratory distress

SKIN: Warm, No rashes, No discoloration
HEAD: Normocephalic, equal hair distribution
EYES: They are symmetric in Size, Shape, Color & Position. Pupils are round, equal & black. They
are equally reactive to light and accommodation. No dryness, conjunctiva moist and pink in
color.
EARS: No discharges, Good auditory response, Auricles are symmetric, normally placed
NOSE: Nose is symmetric, Nasal mucosa is pink & moist, with small amount of discharge .
Septum is at midline, Maxillary and frontal sinuses transilluminate. No discharge or polyps, No
nose bleeds were noted
MOUTH AND THEOAT: No dryness in mouth, No speech disorder, Trachea is midline,
Symmetric, Mobile, No nodules, grade 3 swollen tonsils.
NECK: Neck is symmetric without any scars /masses.
CHEST AND LUNGS:

INSPECTION: Chest is symmetric, Equal chest expansion, (+)retractions, AP diameter is 1:2.
PALPATION: No masses, No tenderness, Equal tactile fremitus
PERCUSSION: Resonant on all lung field were noted
AUSCULTATION: coarse crackles are heard
CARDIOVASCULAR:
INSPECTION: Adynamic precordium,
PALPATION: No heaves and no thrills
AUSCULTATION: Distinct S1 and S2 sounds are heard, No murmurs heard, Regular rhythm
ABDOMEN:
INSPECTION: Soft, Flat, no rashes seen
AUSCULTATION: Normoactive bowel sounds heard, 20 clicks and girgles heard, no hums, no
bruits, no friction rubs are heard.
PERCUSSION: No hepatomegaly, No splenomegaly
PALPATION: No tenderness on light to deep palpation
EXTREMITIES:
Warm, full pulses, CRT <2 secs
Normal range of motion
NEUROLOGIC EXAMINATION
GCS 15
All cranial nerve functions are intact
No regression noted
Anthropometric measures
Height: 106 cm
Weight: 14 kg
BMI: 12.5kg/m2
SALIENT FEATURES:
Pertinent positives Pertinent negatives
5 year old female
(+)Having intermittent fever No cyanosis
(+)Non productive cough No chills
(+) coryza No diarrhea
(+) chest retractions
(+) coarse crackles
(+) chest pain
(+) dyspnea
(+) tachypnea
Temperature: 38 C
INITIAL IMPRESSION:
Lower respiratory tract infection, Pediatric Community Acquired Pneumonia (High risk)
DIFFERENTIAL DIAGNOSIS
1. ASTHMA
Rule in: non productive cough, retractions, tachypnea
Rule out: No cyanosis, No wheezing
2. BRONCHIOLITIS
Rule in: Rhinorrhea, cough, intermittent fever
Rule out: No cyanosis, No vomiting
3. INFLUENZA
Rule in: Cough, Rhinorrhea, Fever
Rule out: No sweating, No nausea, No chills
4. PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA
Rule in: Having intermittent fever, cough, rhinorrhea, subcostal chest retractions, harsh breath
sounds, coarse crackles heard
Rule out: Need lab tests to rule out
ADMITTING ORDER:
A - Admit the patient to room 333 under the service of Dr. Carin
D – NPO for RR > 30 cpm
M - Monitor vital signs for every 4 hours
I - Intake and output every 8 hours
T – CBC, Chest X ray PAL view, Urinalysis, CRP
T – D5 0.45 NACL500 cc/hr at 50 cc/hr
Ceftriaxone 1.4 gm IVTT 500 cc at 50cc/hr
Cetrizine + phenylephrine 5mg/5ml 3.5 ml q12hrs
Salbutamol+ ipratropium 1 neb q6hrs
Domperidone 5mg/5ml 3.5 ml q6hr PRN for vomiting
Paracetamol 250 mg/ 5ml drops, 4 ml (14.2mkd) q4 hours
Continue monitoring
LAB TEST RESULTS:
HEMATOLOGY
CBC RESULTS UNITS REFERENCE RANGE
Hemoglobin (L)109 g/L 123 – 153
Hematocrit 0.34 % 0.32 – 0.40
12
RBC 4.19 X 10 /L 3.9 – 5.0
WBC 10.5 X 109/L 4.3 – 11.4
MCV 81 fL 75 – 88
MCH 26.0 pg 25.0 – 29.0
MCHC 32.1 g/L 31.8 – 34.9
DIFFERENTIAL RESULTS UNITS REFERRAL RANGE

COUNT
Segmenters 0.78 % 0.23 – 0.52
Lymphocytes 0.13 % 0.4 – 0.69
Monocytes 0.09 % 0.03 – 0.12
Eosinophil (L) 0.00 % 0.01 – 0.06
Basophil 0.00 % 0.00 – 0.01
Platelet count 297 109/L 150 - 400
CHEST X RAY:
• There are hazy densities are seen in both inner lung zones.
• Heart is normal in size
• Diaphragm and sulci are intact
• No other significant findings
• Impression: bronchopneumonia
URINALYSIS:
Physical examination
Color Light yellow
Clarity Clear
Chemical analysis
pH 6.5
Specific gravity 1.015
Glucose Negative
Protein Negative
Urine flow cytometry
WBC 2.7/ µL (0.0 – 17.0)
RBC 2.0/ µL (0.0 – 11)
Epithelial cells 0.4/µL (0.0 – 17.0)
Cast 0.00/ µL (0 – 1)
Bacteria 16.4/ µL (0.0 – 278.0)
Mucus threads 0.00
SOAP 1, DAY 1 0F HOSPITAL DAY, Date: March 11, 2023
IDENTIFYING DATA
Name: salac,Maria Nena Age: 5 years Gender: Female
Address: Sasa, Davao City, Religion: Roman Catholic, Informant: Mother
Reliability: 90%, Date of Admission: March 7, 2023
S O A P
Objective Assessmen Plan
Hospital Day 1, Day GENERAL: Awake, Alert, Febrile, Not in t • D5 0.45 NACL
4 of illness respiratory distress Pediatric 500 cc at 50
• Intermitten Vital signs: Communit cc/hr
t fever TEMP: 38° C y Acquired Meds
• Non HR: 128 bpm Pneumonia • Ceftriaxone
Productive RR: 30 cpm (High risk) 1.4 gm IVTT
cough O2 sat: 95% q24 hrs ( 100
• Coryza SKIN: Warm, No rashes, No discoloration mkD)
• Reduced HEAD: Normocephalic, equal hair distribution • Salbutamol
appetite EYES: They are symmetric in Size, Shape, Color & and
• Chest pain Position. Pupils are round, equal & black. They ipratropium 1
are equally reactive to light and accommodation. neb q6hrs
No dryness, conjunctiva moist and pink in color. • Cetrizine +
EARS: No discharges, Good auditory response phenylephrin
NOSE: No nasal flaring e 5 mg/5ml
MOUTH/ THROAT: Neck is symmetric, grade 3 syrup 3.5 ml
non exudative swollen tonsils. No dryness in q12hrs
mouth • Paracetamol
CHEST AND LUNGS: 250 mg/ 5ml
Inspection: Chest is symmetric, Equal chest (14.2 mkd)
expansion, (+) retractions, AP diameter is 1:2. 4ml q4hr
Palpation: No masses, No tenderness, Equal • Domperidone
tactile fremitus 5 mg/5ml 3.5
Percussion: Resonant on all lung field were noted ml q6hr prn
Auscultation: coarse crackles are heard for vomiting
CARDIOVASCULAR:
Inspection: Adynamic precordium,
Palpation: No heaves and no thrills
Auscultation: Distinct S1 and S2 sounds are
heard, No murmurs heard, Regular rhythm
ABDOMEN:
Inspection: Soft, Flat, no rashes seen
Auscultation: Normoactive bowel sounds heard,
10-12 clicks and gurgles heard, no hums, no
bruits, no friction rubs are heard.
Percussion: No hepatomegaly, No splenomegaly
Palpation: No tenderness on light to deep
palpation
EXTREMITIES:
GCS 15
No regression noted
CBC RESULT UNIT REFERENC
S S E RANGE
Hemoglobi (L) 109 g/L 123 – 153
n
Hematocrit 0.34 % 0.32– 0.40
RBC 4.19 X 3.8 – 5.0
1012/L
WBC 10.5 X 4.3 – 11.4
109/L
MCV 81 fL 75 – 88
MCH 26.00 Pg 25.0 – 29.0
MCHC 32.1 g/L 31.8 – 34.5
DIFFERENTIA RESULT UNIT REFERRA

L COUNT S S L RANGE
Segmenters (H) 0.78 % 0.23 –
0.52
Lymphocytes (L)0.13 % 0.4 – 0.69
Monocytes 0.09 % 0.03 –
0.12
Eosinophil (L) 0.00 % 0.01 –
0.06
Basophil 0.00 % 0.00 –
0.01
Platelet 297 109/L 150 - 400
count
CHEST X RAY:
• There are hazy densities are seen in
both inner lung zones.
• Heart is normal in size
• Diaphragm and sulci are intact
• No other significant findings
• Impression: bronchopneumonia
SOAP 2, DAY 2 0F HOSPITAL, Date: March 12, 2023

IDENTIFYING DATA
Name: salac Maria nena Age: 5 year Gender: Female
Address: sasa, Davao City Religion: Roman Catholic, Informant: Mother
S O A P
Subjective Objective Assessment Plan
Hospital Day 2, Day 5 GENERAL: Awake, Alert, Not in Pediatric Continue
of illness respiratory distress Community • IVF D5 0.45
• Non Vital signs: Acquired NACL at 50
Productive TEMP: 38.1° C Pneumonia (High cc/hr.
cough HR: 103 bpm risk) • Ceftriaxone
• Febrile RR: 25 cpm 1.4 gm q24 hr
• Coryza O2 sat: 98% (100mkD)
• Good appetite SKIN: Warm, No rashes, No IVTT D1
discoloration complted.
HEAD: Normocephalic, equal hair • Salbutamol
distribution and
EYES: They are symmetric in Size, iprtropium 1
Shape, Color & Position. Pupils are neb q4 hrs
round, equal & black. They are equally • Cetrizine and
reactive to light and accommodation. phenylephrine
No dryness, conjunctiva moist and pink 5mg/5ml 3.5
in color. ml q12hrs
EARS: No discharges, Good auditory • Domperidone
response syrup 5
NOSE: No nasal flaring mg/5ml 3.5
MOUTH/ THROAT: Neck is symmetric ml q 6hr prn
grade 3 non exudative swollen tonsils. for vomiting
No dryness in mouth
CHEST AND LUNGS:
Inspection: Chest is symmetric, Equal
chest expansion, shallow intercostal
retractions, AP diameter is 1:2.
Palpation: No masses, No tenderness,
Equal tactile fremitus
Percussion: Resonant on all lung field
were noted
Auscultation: coarse sounds are heard
CARDIOVASCULAR:
Auscultation: Distinct S1 and S2 sounds
are heard, No murmurs heard, Regular
rhythm
ABDOMEN:
Auscultation: Normoactive bowel
sounds heard, 12 clicks and gurgles
heard, no hums, no bruits, no friction
rubs are heard.
Percussion: No hepatomegaly, No
splenomegaly
Palpation: No tenderness on light to
deep palpation
EXTREMITIES:
GCS 15
No regression noted
URINALYSIS:
Physical examination
Color Light yellow
Clarity Clear
Chemical analysis
pH 6.5
Specific gravity 1.015
Glucose Negative
Protein Negative
Urine flow cytometry
WBC 2.7/ µL
(0.0 – 17.0)
RBC 2.0/ µL
(0.0 – 11)
Epithelial cells 0.4/µL
(0.0 – 17.0)
Cast 0.00/ µL
(0 – 1)
Bacteria 16.4/ µL
(0.0 – 278.0)
Mucus threads 0
URINE OUTPUT: 4.76 cc/hour
SOAP 3, DAY 3 0F HOSPITAL Date: March 13, 2023

IDENTIFYING DATA
Name: salac maria nena Age: 5 year, Gender: Female
Address: sasa, Davao City, Religion: Roman Catholic, Informant: Mother
S O A P
Hospital Day 3, Day 6 of GENERAL: Awake, Alert, Not in Pediatric Continue
illness respiratory distress Community • IVF D5 0.45
• Afebrile Vital signs: Acquired NACL at 40
• NonProductive TEMP: 37.5° C Pneumonia (High cc/hr
cough BP: 106/60 risk) • Ceftriaxone
• coryza HR:125 bpm (100mkD)
• Reduced RR: 26 cpm 1.4gm q24hr
appetite O2 sat: 97% IVTT D2
SKIN: Warm, No rashes, No completed
discoloration • Cetrizine and
HEAD: Normocephalic, equal hair phenylephrine
distribution 5mg/ 5ml 2.5
EYES: They are symmetric in Size, ml q 12 hrs.
Shape, Color & Position. Pupils are • Paracetamol
round, equal & black. They are equally 14.2 mkd
reactive to light and accommodation. 250mg/5ml
No dryness, conjunctiva moist and pink 4ml prn for
in color. fever
EARS: No discharges, Good auditory • Salbutamol
response and
NOSE: No nasal flaring ipratropium 1
MOUTH/ THROAT: Neck is symmetric neb q12 hrs
without any scars /masses. No dryness
in mouth
CHEST AND LUNGS:
chest expansion, no retractions, AP
diameter is 1:2.
Palpation: No masses, No tenderness,
Equal tactile fremitus
were noted
Auscultation: fine crackles sounds are
heard
CARDIOVASCULAR:
Auscultation: Distinct S1 and S2
sounds are heard, No murmurs heard,
Regular rhythm
ABDOMEN:
sounds heard, 10-12 clicks and gurgles
rubs are heard.
splenomegaly
deep palpation
EXTREMITIES:
NEUROLOGIC EXAMINATION:
GCS 15
No regression noted
URINE OUTPUT: 8.8 cc/Hour

IDENTIFYING DATA
Name: salac, Maria nena Age: 5 years Gender: Female
Address: sasa, Davao City Religion: Roman Catholic Informant: Mother
Reliability: 90% Date of Admission: March 11, 2023
S O A P
Hospital Day 4, Day 7 GENERAL: Awake, Alert, Not in • Pediatric Continue
of illness respiratory distress Community • IVF D5 IMB at
• Afebrile Vital signs: Acquired 40cc/hr
• Non TEMP: 37.3° C Pneumonia • Ceftriaxone
Productive HR:120 bpm (High risk) 100 mkD 1.4
cough RR: 24 cpm gm IVTT
• Coryza O2 sat: 99% q24hr D3
• Good SKIN: Warm, No rashes, No completed.
appetite discoloration • Paracetamol
HEAD: Normocephalic, equal hair 14.2 mkd 4 ml
distribution 250mg/5ml
EYES: They are symmetric in Size, q4 hrs prn for
Shape, Color & Position. Pupils are fever
round, equal & black. They are • Salbutamol
equally reactive to light and and
accommodation. No dryness, ipratropium 1
conjunctiva moist and pink in color. neb q6hr
EARS: No discharges, Good auditory • Cetrizine +
response phenylephrine
NOSE: No nasal flaring 5mg/5ml 2.5
MOUTH/ THROAT: Neck is ml q12 hrs
symmetric without any scars
/masses. No dryness in mouth
CHEST AND LUNGS:

chest expansion, No retractions, AP
diameter is 1:2.
Palpation: No masses, No
tenderness, Equal tactile fremitus
were noted
Auscultation: fine crackles are heard
CARDIOVASCULAR:
sounds are heard, No murmurs
heard, Regular rhythm
ABDOMEN:
sounds heard, 12 clicks and gurgles
rubs are heard.
splenomegaly
deep palpation
EXTREMITIES:
GCS 15
No regression noted
URINE OUTPUT: 18 cc/hour

IDENTIFYING DATA
Name: salac, Maria nena Age: 5 year Gender: Female
Reliability: 90%, Date of Admission: March 11,2023
S O A P
of illness respiratory distress Community • IVF D5 IMB
• Afebrile Vital signs: Acquired 500 cc at 30
• Good TEMP: 36.2° C Pneumonia cc/hr
appetite HR: 108 bpm
• Non RR: 26 cpm (High risk) • Ceftriaxone
Productive O2 sat: 98% Improving 100 mkD 1.4
cough SKIN: Warm, No rashes, No gm IVTT q24
• No coryza discoloration hr D4
• No vomiting HEAD: Normocephalic, equal hair completed
• Reduced distribution • Salbutamol
appetite EYES: They are symmetric in Size, and
Shape, Color & Position. Pupils are ipratropium 1
round, equal & black. They are neb q6hr
equally reactive to light and • Cetrizine +
accommodation. No dryness, phenylephrine
conjunctiva moist and pink in color. 5mg/5ml 2.5
EARS: No discharges, Good auditory ml q12hr
response • Paracetamol
NOSE: No nasal flaring 14.2 mkd 250
MOUTH/ THROAT: Neck is mg/5ml q4hr
symmetric without any scars prn for fever
/masses. No dryness in mouth • Domperidone
5mg/ml q6 hr
CHEST AND LUNGS: prn for
Inspection: Chest is symmetric, Equal vomiting
chest expansion, No shallow
intercostal retractions, AP diameter
is 1:2.
were noted
on both the lung fields.
CARDIOVASCULAR:
ABDOMEN:
sounds heard, 10-12 clicks and
gurgles heard, no hums, no bruits,
no friction rubs are heard.
splenomegaly
deep palpation
EXTREMITIES:
GCS 15
No regression noted

IDENTIFYING DATA
Name: salac, Maria nena Age: 5 year, Gender: Female
S O A P
of illness respiratory distress Community • D5 IMB 500 cc
• afebrile Vital signs: Acquired at 30 cc/ hr
• Non TEMP: 36.2° C Pneumonia • Ceftriaxone
Productive HR: 114bpm (High risk) 100 mkD 1.4
cough BP: 90/60 mm/hg Improving gm IVTT q24
• Coryza RR: 23 cpm hr D5
• Reduced O2 sat: 99% completed
appetite SKIN: Warm, No rashes, No • Salbutamol +
discoloration ipratropium 1
HEAD: Normocephalic, equal hair neb q6 hr
distribution • Cetrizine +
EYES: They are symmetric in Size, phenylephrine
Shape, Color & Position. Pupils are 5mg/5ml q12
round, equal & black. They are hr
equally reactive to light and • Paracetamol
14.2 mkd 250
accommodation. No dryness, mg/5ml q4 hr
conjunctiva moist and pink in color. prn for fever
EARS: No discharges, Good auditory
response
NOSE: No nasal flaring
MOUTH/ THROAT: Neck is
symmetric without any scars
/masses. No dryness in mouth
CHEST AND LUNGS:

chest expansion, No shallow
intercostal retractions, AP diameter
is 1:2.
were noted
CARDIOVASCULAR:
ABDOMEN:
sounds heard, 10-12 clicks and
gurgles heard, no hums, no bruits,
no friction rubs are heard.
splenomegaly
deep palpation
EXTREMITIES:
GCS 15
No regression noted
SOAP 7, DAY 7 OF HOSPITAL DATE MARCH 17,2023

IDENTIFYING DATA Address: sasa, davao city
Name: salac, maria nena Religion: Roman catholic
Gender: female Informant: mother
Age: 5 year Reliability: 90
Date of admission: march 11 2023
S O A P
Hospital day 7, day Objective Assessment Plan
10 illness GENERAL: Awake, Alert, Pediatric Community Continue
Not in respiratory distress Acquired Pneumonia • D5 IMB 500 cc at
• Poor appetite Vital signs: (High risk) Improving 30 cc/ hr
• Productive TEMP: 36.3° C • Ceftriaxone 100
cough HR: 120 bpm mkD 1.4 gm IVTT
• No coryza BP: 90/60 mm/hg q24 hr D5
RR: 27 cpm completed
• No chest pain
O2 sat: 98% • Salbutamol +
• No vomiting SKIN: Warm, No rashes, ipratropium 1
No discoloration neb q6 hr
HEAD: Normocephalic, • Cetrizine +
equal hair distribution phenylephrine
EYES: They are symmetric 5mg/5ml q12 hr
in Size, Shape, Color & • Paracetamol
Position. Pupils are 14.2 mkd 250
round, equal & black. mg/5ml q4 hr
They are equally reactive prn for fever
to light and
accommodation. No
dryness, conjunctiva
moist and pink in color.
EARS: No discharges,
Good auditory response
MOUTH/ THROAT: Neck
is symmetric without any
scars /masses. No dryness
in mouth
CHEST AND LUNGS:
Inspection: Chest is
symmetric, Equal chest
expansion, No shallow
intercostal retractions, AP
diameter is 1:2.
tenderness, Equal tactile
fremitus
Percussion: Resonant on
all lung field were noted
Auscultation: fine
crackles are heard
CARDIOVASCULAR:
Inspection: Adynamic
precordium,
Palpation: No heaves and
no thrills
Auscultation: Distinct S1
and S2 sounds are heard,
No murmurs heard,
Regular rhythm
ABDOMEN:
Inspection: Soft, Flat, no
rashes seen
Auscultation:
Normoactive bowel
sounds heard, 10-12
clicks and gurgles heard,
no hums, no bruits, no
friction rubs are heard.
Percussion: No
hepatomegaly, No
splenomegaly
Palpation: No tenderness
on light to deep palpation
EXTREMITIES:
Warm, full pulses, CRT <2
secs
NEUROLOGIC
EXAMINATION
GCS 15
All cranial nerve functions
are intact
No regression noted
URINE OUTPUT: 2.6

cc/hour
SOAP 8, DAY 8 OF HOSPITAL DATE MARCH 18,2023

IDENTIFYING DATA Address: sasa, d avao city
Name: salac, maria nena Religion: Roman catholic
Gender: female Informant: m other
Age: 5 year Reliability: 90
Date of admission: march 11 2023
S O A P
Hospital Day 7, illness Objective Assessment • Ceftriaxone
day 11 GENERAL: Awake, Alert, Pediatric Community
100 mkD 1.4
Not in respiratory distress Acquired Pneumonia
• No cough Vital signs: (High risk) Improving
gm IVTT D6
• Afebrile TEMP: 36.4° C completed at
• No chest pain HR: 102 bpm 2AM
• No vomiting BP: 100/60 mm/hg • Discontinue
RR: 22 cpm
• No shortness IV
O2 sat: 99%
of breath SKIN: Warm, No rashes, • Continue
• No coryza No discoloration monitoring
• Good HEAD: Normocephalic, • Discharge
equal hair distribution with no home
appetite
EYES: They are symmetric
medications.
in Size, Shape, Color &
Position. Pupils are
round, equal & black.
They are equally reactive
to light and
accommodation. No
dryness, conjunctiva
moist and pink in color.
EARS: No discharges,
Good auditory response
MOUTH/ THROAT: Neck
is symmetric without any
scars /masses. No dryness
in mouth
CHEST AND LUNGS:

Inspection: Chest is
symmetric, Equal chest
expansion, No shallow
intercostal retractions, AP
diameter is 1:2.
tenderness, Equal tactile
fremitus
Percussion: Resonant on
all lung field were noted
Auscultation: both the
lungs are clear with no
adventitious sounds.
CARDIOVASCULAR:
Inspection: Adynamic
precordium,
Palpation: No heaves and
no thrills
Auscultation: Distinct S1
and S2 sounds are heard,
No murmurs heard,
Regular rhythm
ABDOMEN:
Inspection: Soft, Flat, no
rashes seen
Auscultation:
Normoactive bowel
sounds heard, 10-12
clicks and gurgles heard,
no hums, no bruits, no
friction rubs are heard.
Percussion: No
hepatomegaly, No
splenomegaly
Palpation: No tenderness
on light to deep palpation
EXTREMITIES:
Warm, full pulses, CRT <2
secs
NEUROLOGIC
EXAMINATION
GCS 15
All cranial nerve functions
are intact
No regression noted
URINE OUTPUT: 6.42

cc/kg/hour
FINAL DIAGNOSIS: Pediatric Community Acquired Pneumonia (High risk) , bronchial asthma
with acute exacerbation
CASE DISCUSSION:
ETIOLOGY
• Noninfectious causes - aspiration (of food or gastric acid, foreign bodies, hydrocarbons,
and lipoid substances), hypersensitivity reactions, and drug- or radiation-induced
pneumonitis.
• The most common bacterial pathogen in children
o Streptococcus pneumonia - 3 weeks to 4 years of age
o Mycoplasma pneumonia and Chlamydophila pneumonia- 5 years and older
• Other bacterial causes of pneumonia in previously healthy children include Group A
Streptococcus and Staphylococcus aureus.
• S. aureus pneumonia often complicates an illness caused by influenza viruses.
EPIDEMIOLOGY
• Pneumonia is the leading infectious cause of death globally among children younger than
5 year, accounting for an estimated 920,000 deaths each year.
• Pneumonia mortality is closely linked to poverty.
• More than 99% of pneumonia deaths are in low- and middle-income countries, with the
highest pneumonia mortality rate occurring in poorly developed countries in Africa and
South Asia
PATHOPHYSIOLOGY
RISK FACTORS
• Pneumonia can affect anyone. But the two age groups at the highest risk are:
– Children who are 2 years old or younger
– People who are age 65 or older
• Being hospitalized.
• Chronic disease – asthma, chronic obstructive pulmonary disease (COPD), or heart
disease.
• Smoking.
• Weakened or suppressed immune system - HIV/AIDS, organ transplant, or who receive
chemotherapy or long-term steroids are at risk.
CLINICAL MANIFESTATIONS
• Tachypnea is the most consistent clinical manifestation of pneumonia
• Rhinitis and cough
• Intermittent Fever
• Intercostal, subcostal, and suprasternal retractions,
• Nasal flaring,
• Use of accessory muscles is common.
• Cyanosis and lethargy, especially in infants.
• Crackles and wheezing
• Hyperresonant chests.
• Bacterial pneumonia in adults and older children typically begins suddenly with high
fever, cough, and chest pain.
DIAGNOSTIC TEST
• Chest X ray
• Blood tests: CBC, CRP levels
• Pulse oximetry: O2 saturation
• Sputum culture
• Point-of-care chest ultrasonography (POCUS)
TREATMENT
If Bacterial Etiology is considered regardless of immunization status against Strep pneumoniae
and/or Haemophilus influenzae type b (Hib), any of the following is considered:
Non severe Severe
Amoxicillin Trihydrate at 40-50 mkD q8 for 7 Penicillin G at 200,000 units/kg/day q6 if
days OR at 80-90 mkD q 12 for 5 to 7days with complete Haemophilus influenzae type
b (Hib) vaccination OR Ampicillin at 200mkD
q6 if with no or incomplete or unknown
Haemophilus influenzae type b (Hib)
vaccination
Amoxicillin-clavulanate at 80-90 mkD q12 Cefuroxime at 100-150 mkD q8 OR

(based on Amoxicillin content using a 14:1 Ceftriaxone at 75-100 mkD q12 to q24 OR
amoxicillin:clavulanate Ampicillin-sulbactam at 200 mkD q6 (based
formulation) for 5 to 7 days on ampicillin content) in settings with
documented high-level penicillin-resistant
pneumococci or beta- lactamase-producing
H. influenzae based on local resistance data
or hospital antibiogram
Non- severe Severe
Cefuroxime at 20- 30 mkD q12 for 7 days Clindamycin at 20-40 mkD q6 to q8 when
Staphylococcal pneumonia is highly
suspected based on clinical and chest
radiograph features
In cases of severe and life-threatening

conditions such as sepsis and shock,
Vancomycin at 40-60 mkD q6 to q8 is
preferred.
For patients with known hypersensitivity to penicillin, classified as

Non Type 1 Hypersensitivity to Penicillin Type 1 Hypersensitivity to Penicillin
Cephalosporins such as Cefuroxime PO 20- Azithromycin at 10mkD PO or IV q24 for 3
30 mkD Q12 or IV 100-150 mkD Q8 OR days OR 10mkD on day 1 followed by 5
Ceftriaxone at 75-100 mkD q12 to q24 is mkD q24 for 2 to 5 days
considered.
Clarithromycin at 15mkD q12 for 7 days
Clindamycin at 10-40mkD PO or 20-

40mkDIV q6 to q8 for 7 days
When an atypical pathogen is highly suspected, macrolide is considered

• Azithromycin at 10 mkD PO or IV q24 for 5 days OR 10 mkD q24 for 3-5 days OR 10 mkD
on day 1 followed by 5 mkD q24 for days 2 to 5
• Clarithromycin at 15 mkD q12 for 7 to 14 days
When treating for uncomplicated bacterial PCAP, 7 to 10 days treatment is considered but a
longer duration may be required depending on the patient’s clinical response, virulence of the
causative organism and eventual development of complications.
The addition of a macrolide to standard beta-lactam antibiotic therapy is not considered in the
empiric treatment of bacterial PCAP.
If Viral Etiology is considered: Oseltamivir is started immediately within 36 hours of laboratory-
confirmed influenza infection.
Clinical and Ancillary Parameters to determine good response to current treatment
Good clinical response to current therapeutic management is considered when clinical stability
is sustained for the immediate past 24 hours as evidenced by
Non severe Severe
Improvement of cough within 24 to 72 hours Absence or Resolution of hypoxia
Normalization of fever in the absence of Absence or Resolution of danger signs

antipyretics within 24 to 72 hours
Absence or Resolution of tachypnea10
Absence or Resolution of fever11
Absence or Resolution of tachycardia12
Resolving or Improving radiologic pneumonia
Resolving or Absent chest ultrasound findings
Normal or Decreasing CRP
Normal or Decreasing PCT
Adjunctive treatment effective for community-acquired pneumonia

• Vitamins A is strongly recommended as an adjunctive treatment for measles
pneumonia.
• Zinc is given for 3 months in severe PCAP to shorten the recovery time
• Bronchodilators are considered an adjunctive treatment for PCAP in the presence of
wheezing
PREVENTION
• Influenza vaccine may also prevent pneumonia hospitalizations among children and
should be administered to all children >6 month of age.
• For infants <6 month of age, household contacts and other primary caregivers should be
immunized.
• Maintaining high rates of vaccination for H. influenza type b, pertussis, and measles
remains important for the prevention of pneumonia from these causes.
PROGNOSIS
• Typically, patients with uncomplicated community-acquired bacterial pneumonia show
response to therapy, with improvement in clinical symptoms (fever, cough, tachypnea,
chest pain), within 48-72 hours of initiation of antibiotics.
• Radiographic evidence of improvement lags substantially behind clinical improvement.
A chest radiograph is the first step in determining the reason for a lack of response to
initial treatment.

Jeyakumar Dhileeban Rrroll 41

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DAVAO MEDICAL SCHOOL FOUNDATION

CHIEF COMPLAINT: difficulty in breathing

HISTORY OF PRESENT ILLNESS

PAST MEDICAL HISTORY

NUTRITION/ FEEDING HISTORY

GROWTH AND DEVELOPMENT

GENERAL: Awake, Alert, (+) Febrile, not in respiratory distress

CHEST AND LUNGS:

DIFFERENTIAL RESULTS UNITS REFERRAL RANGE

DIFFERENTIA RESULT UNIT REFERRA

SOAP 2, DAY 2 0F HOSPITAL, Date: March 12, 2023

URINE OUTPUT: 4.76 cc/hour

SOAP 3, DAY 3 0F HOSPITAL Date: March 13, 2023

URINE OUTPUT: 8.8 cc/Hour

CHEST AND LUNGS:

URINE OUTPUT: 18 cc/hour

SOAP 5, DAY 5 0F HOSPITAL Date: March 15, 2023

SOAP 6, DAY 6 0F HOSPITAL Date: March 16, 2023

CHEST AND LUNGS:

URINE OUTPUT: 9.33 cc/hour

SOAP 7, DAY 7 OF HOSPITAL DATE MARCH 17,2023

URINE OUTPUT: 2.6

SOAP 8, DAY 8 OF HOSPITAL DATE MARCH 18,2023

CHEST AND LUNGS:

URINE OUTPUT: 6.42

Amoxicillin-clavulanate at 80-90 mkD q12 Cefuroxime at 100-150 mkD q8 OR

Non- severe Severe

In cases of severe and life-threatening

For patients with known hypersensitivity to penicillin, classified as

Clarithromycin at 15mkD q12 for 7 days

Clindamycin at 10-40mkD PO or 20-

When an atypical pathogen is highly suspected, macrolide is considered

Improvement of cough within 24 to 72 hours Absence or Resolution of hypoxia

Normalization of fever in the absence of Absence or Resolution of danger signs

Absence or Resolution of fever11

Absence or Resolution of tachycardia12

Resolving or Improving radiologic pneumonia

Resolving or Absent chest ultrasound findings

Normal or Decreasing CRP

Normal or Decreasing PCT

Adjunctive treatment effective for community-acquired pneumonia

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