CAPITOL MEDICAL CENTER, INC.

DEPARTMENT OF PEDIATRICS
WARD AUDIT, MORBIDITY AND MORTALITY CONFERENCE
SEPTEMBER 2021
_____________________________________________________________________________________

WARD AUDIT PROTOCOL

Presenter: Marielle Eunice C. Ramajo, MD

Moderator: Alisa B. Ascutia, MD
Date: October 11, 2021

I. According to Sex
Male 8 47%

Female 9 53%

Total 17 100%

II. Old or New

Old 9 53%

New 8 47%

Total 17 100%

III. HMO or Non-HMO

HMO 14 82%

Non-HMO 3 18%

Total 17 100%

IV. According to Age

<1 1 6%

1-2 4 24%

3-6 2 12%

7-11 4 24%

1
 12-14 2 12%

15-19 4 24%

Total 17 100%

COVID 19 Census
Initially admitted as Results of COVID RT-PCR
Negative Confirmed
Non-Covid case 3 3 -
Suspect 12 8 4
Probable 1 - 1
Confirmed 1 - 1
Total Patients 17 11 6
Total 100% 65% 35%

Type of Accommodation
Frequency Percentage
Pay 16 94%
Service 1 6%
Total 17 100%

PICU Admissions
Frequency Percentage
PICU Admissions 2 12%

Condition of Discharge
Frequency Percentage
Improved 17 100%
Transferred - -
HAMA/DAMA - -
Absconded - -
Expired 0 0%
Total 17 100%

EARLY INFANCY (<1 YR OLD)

Bronchiolitis J29 1

Total 1

LATE INFANCY (1-2 YRS OLD)

COVID Pneumonia, moderate U07.1 2

2
 Pneumonia, moderate risk J18.92 1

A09.9 1
Acute Gastroenteritis with moderate dehydration
E86.1

Total 4

EARLY CHILDHOOD (3-6 YRS OLD)

Dengue Fever with warning signs A97.1 1

COVID Confirmed, mild; U07.1 1

Dermatomyositis, not in flare; E03.9
Subclinical Hypothyroidism M33

Total 2
LATE CHILDHOOD (7-11 YRS OLD)
Dengue Fever with warning signs A97.1 2

Ruptured Appendicitis with localized peritonitis; K35.8 1

S/P Appendectomy; U07.1
COVID Confirmed, mild; E66.0
Obese

COVID Pneumonia, severe J12.82 1

Total 4

PUBESCENT (12-14 YRS OLD)

Dengue Fever with warning signs A97.1 2

Total 2

POST PUBESCENT (15-19 YRS OLD)

Dengue Fever with warning signs A97.1 2

Acute Bacterial Myopericarditis; I30.9 1

Pleural Effusion J90

COVID Pneumonia, severe; J12.82 1

Obese E66.9

Total 4

3
4
 MORBIDTY CASE #1

GENERAL DATA
This is a case of patient DG, a 15-year old, female, Filipino, Roman Catholic, from Quezon City
admitted last September 21, 2021 for the first time at our institution.

CHIEF COMPLAINT: Vomiting

SOURCE AND RELIABILITY: Data came from the patient’s father with fair reliability.

HISTORY OF PRESENT ILLNESS

6 days prior to admission, the patient had intermittent fever with maximum temperature of 38
o
C associated with occasional non-distressing non-productive cough and generalized headache, graded
6/10, heavy in character, partially relieved by sleep. The patient was still noted to have good appetite
and activity. No colds, difficulty of breathing, loose stools, vomiting or rashes were noted. Paracetamol
(adult dose) every 4 hours as needed for fever and multivitamins once a day were given. No consult was
done.
5 days prior to admission, the patient still had intermittent fever with maximum temperature of
o
38 C, non-productive cough and generalized headache, now with accompanying colds and nasal
congestion. Still, no consult was done and no other medications were given.
In the interim, the patient was still noted with intermittent fever with maximum temperature of
o
39 C now with increasing frequency of non-productive cough and now accompanied by new onset of
anosmia and ageusia. No consultation or isolation done.
1 day prior to admission, still with the above signs and symptoms, now with 3 episodes of non-
bilious, non-projectile vomiting of previously ingested food amounting to ½ cup per bout. The patient
was brought to our institution wherein CBC, urinalysis, Dengue blot, chest Xray and COVID RT-PCR were
done. CBC showed leukopenia and dengue blot had negative result. Urinalysis and chest Xray were
normal. The patient was sent home with medications of Paracetamol for the fever, Vitamin C once a
day, Vitamin D3 once a day and Sodium Chloride nasal spray every 4 to 6 hours. The patient was advised
to observe proper precautions and home isolation.
Few hours prior to admission, the patient was now afebrile with no recurrence of headache but
still had non-productive cough. She also had 5 episodes of non-bilious, non-projectile vomiting of
previously ingested food, scanty to ¼ cup in amount and accompanied by localized epigastric pain,
burning in character, graded by 5/10. The patient was then brought to our institution and was
subsequently admitted.

REVIEW OF SYSTEMS
General: (-) weight loss or weight gain
Skin: (-) pallor, (-) rashes, (-) jaundice
HEENT: (-) eye discharge or lesions, (-) ear discharge, (-) oral lesions, (-) throat pain
Cardiovascular: (-) cyanosis, (-) palpitations; (-) easy fatigability
Pulmonary: (-) difficulty of breathing; (-) chest pain
Gastrointestinal: (-) diarrhea, (-) hematemesis, (-) hematochezia, (-) melena, (-) constipation
Genitourinary: (-) hematuria, (-) dysuria, (-) oliguria
Hematologic: (-) pallor, (-) mucosal bleeding, (-) easy bruising
Extremities: (-) joint swelling, (-) joint pain
Neurologic: (-) loss of consciousness, (-) changes in behavior, (-) altered sensorium

5
PAST MEDICAL HISTORY
This is the patient’s first admission. She has no history of allergy to food or medication, simple
febrile seizure, primary Koch’s infection, previous trauma, surgeries nor any invasive procedures done.

IMMUNIZATION HISTORY
Vaccine Doses Vaccine Doses
BCG 1 PCV 3
Hepatitis B 4 Measles 1
OPV 3 MMR 2
DPT 3 Varicella 2
HiB 3 Hepatitis A 2

FAMILY HISTORY
There is history of hypertension on the maternal side. No family history of diabetes mellitus,
pulmonary tuberculosis, stroke, bronchial asthma or cancer.

PERSONAL, SOCIAL AND DEVELOPMENTAL HISTORY

The patient is an only child and lives in Quezon City with her father, paternal aunt and paternal
cousin. Her father and paternal aunt go out for errands once a week and had completed 2 doses of
COVID vaccine. Other family members deny having cough, colds, loose stool, ageusia or anosmia and
deny recent travel nor any exposure to COVID confirmed patients.
2 weeks prior to the onset of the patient’s signs and symptoms, she went out to a convenience
store with her father. Proper precautions were observed as claimed by the patient.
She is a Grade 9 student currently attending her classes online. She usually eats three times a
day consisting of rice, meat and occasional vegetables and drinks mineral water. She has no food
preference as claimed.
The patient’s developmental milestones where at par with age according to the father.

BIRTH HISTORY
The patient was born full term via normal spontaneous delivery at Tandang Sora Hospital with
no feto-maternal complications. Newborn screening was allegedly not done as claimed by the father.

MENSTRUAL HISTORY
The patient had her menarche at 10 years old. She would have her menstrual period every 28-30
days with a duration of 5-6 days, using an average of 2-3 moderately soaked pads per day. Occasional
dysmenorrhea is noted during menstruation relieved by Paracetamol 500mg tablet as needed.

HEADSSS ASSESSMENT
Home: She has a harmonious relationship with the members of the household, with no note of
significant issues in the family.
Education: She has no difficulties with her class subjects and describes herself as an average student.
She occasionally experience technical difficulties or problems with the internet connection during her
online class. She had no repetitions of a certain year level and there were no sanctions encountered.
Eating: She has a mixed diet with preference to meat. She is occasionally fond of eating salty, fatty, and
processed foods and seldom eat vegetables.
Activity: She is fond of browsing the internet during her free time.

6
Drugs: The patient denies use of illicit drug, cigarette or alcohol intake.
Spirituality: She is a Roman Catholic, believes in the Supreme Being, however, the family seldom attend
church online.
Safety/Suicide: She has no risk-taking activities, suicidal thoughts, nor complaints of violence in the
household or in the community. No history of depression or suicidal attempts as stated.
Sexuality: She sees herself as a female and is attracted to the opposite sex. She currently has no sexual
partner and allegedly has never engaged in any sexual activity.

PHYSICAL EXAMINATION
BP: 110/80 mmHg (90th percentile) Weight: 75 kgs Height for Age: -1 (Normal)
HR: 114 bpm Height: 154 cm BMI for Age: Above 2
(Obese)
RR: 31 cpm IBW: 46 kgs
Temp: 37.4 oC BMI: 32 kg/m2
O2 sat: 90-93% O2 saturation at room air

General: awake, in mild cardiorespiratory distress

Skin: (-) skin lesions, (-) pallor
Head: no gross deformities
Eyes: slightly sunken eyeballs, pink palpebral conjunctiva, anicteric sclera
Ears: non-hyperemic external auditory canal on both ears, intact tympanic membrane on both ears, no
ear discharge
Nose: no alar flaring, (+) congested turbinates, with mucoid nasal discharge
Mouth: slightly dry lips, moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not
enlarged, no exudates, no oral lesions, no circumoral cyanosis
Neck: (+) acanthosis nigricans, no palpable cervical lymphadenopathy
Cardio-Thoracic: (+) shallow subcostal retractions retractions, bibasal crackles, no wheezes, good air
entry; adynamic precordium, tachycardic, regular rhythm, no murmurs
Abdomen: (+) striae, non-distended abdomen, normoactive bowel sounds, non-tympanitic, soft, (+)
epigastric tenderness, no organomegaly
Extremities: no gross deformities, pink palms and soles, no joint swelling and erythema, full and equal
pulses, CRT <2 seconds, warm extremities
Sexual Maturity Rating: Tanner stage III

NEUROLOGIC EXAMINATION
General: awake, conscious, coherent
Cranial Nerves:
I Cannot be assessed VIII Intact gross hearing
II Pupils 3-4mm, reactive to light IX, Able to swallow; With gag reflex upon insertion
X of swab
III, IV, Intact extraocular muscles; No XI Can shrug shoulders
VI nystagmus
V Intact V1-V3 XII Tongue midline upon protrusion
VII No facial asymmetry

Cerebellum: no nystagmus, able to do rapid alternating movements

Motor: 5/5 in all extremities

7
Sensory: 100% in all extremities
Pathologic Reflexes: (-) Babinski
Meningeal signs: (-) Kernig’s, (-) Brudzinki
ADMITTING DIAGNOSIS:
COVID pneumonia, moderate
Obese

COURSE IN THE EMERGENCY ROOM

Upon arrival at the emergency room, the patient was tachypneic at 31 cpm with oxygen
saturation of 90-93% at room air. Upon assessment, the patient had shallow subcostal retractions, with
bibasal crackles, no wheezes and with good air entry. Oxygen support at 1 lpm via nasal canula was
given. Upon reassessment, she was still tachypneic at 30 cpm with oxygen saturation of 96%. The
patient was instructed nothing per orem temporarily, started on IV hydration at mild correction and
given intravenous Omeprazole (adult dose). Laboratories such as CBC, serum sodium, potassium,
chloride, ionized calcium and magnesium, inflammatory markers (ESR, CRP, D-dimer, LDH, procalcitonin
and serum ferritin), arterial blood gas and random blood sugar were requested. Results showed
leukopenia at CBC, hypochloremia and hypocalcemia. Elevated CRP, LDH, procalcitonin, serum ferritin
were noted with respiratory alkalosis in the arterial blood gas. Other laboratories showed normal
results. COVID RT-PCR showed positive result. Repeat chest Xray showed interval appearance of hazy
opacities in the right lung and left mid to lower lung due to pneumonia. The patient was then started
with Remdesivir 200mg IV (5mg/kg/dose) as loading dose then continued at 100mg (2.5mg/kg/dose),
Dexamethasone 6mg IV (adult dose) once a day, Ceftriaxone 2g IV (55mg/kg/day) every 12 hours, and
Paracetamol 500mg/tab (adult dose) every 4 hours as needed for fever. The patient then complained of
sudden onset of difficulty of breathing after going to the comfort room. She was tachypneic at 42cpm
with oxygen saturation of 85%. Referral to a pediatric intensivist was facilitated for further evaluation
and management with orders to increase the oxygen support to 14lpm via non-rebreather mask and for
repeat arterial blood gas. 1 hour after increasing the oxygen support, repeat blood gas showed
improvement of the respiratory alkalosis. Oxygen support was adjusted accordingly. The patient was
admitted in the intensive care unit for close monitoring.

COURSE IN THE INTENSIVE CARE UNIT

Upon admission (9/22/2021), the patient was normotensive, afebrile, tachycardic (105 bpm),
tachypneic (33 cpm), with oxygen saturation of 100% at 12lpm via non-rebreather mask and with good
urine output. She still had non-productive cough and colds now with nocturnal awakening. No
recurrence of vomiting or abdominal pain were noted. Upon assessment, patient had non-sunken
eyeballs, with no alar flaring or cyanosis, with slightly dry lips, moist buccal mucosa, shallow subcostal
retractions, bibasal crackles, no wheezes, good air entry, adynamic precordium, tachycardia and regular
rhythm. Abdomen was soft, with normoactive bowel sounds, non-tympanitic and non-tender. Pulses
were full and equal, with warm extremities. Weaning of oxygen support to 10lpm via non-rebreather
mask was started. Upon assessment, patient still had tachypneic episodes (33-36 cpm) but with oxygen
saturation of 97-98% at 10lpm via non-rebreather mask. She was positioned in a moderate to high back
rest and maintained on nothing per orem temporarily. Other medications such as Zinc tablet once a day,
Vitamin C 500mg tablet once a day and Vitamin D3 2000 IU capsule once a day were started. Present
management was continued.

On the 1st hospital day at the PICU (09/23/2021), the patient remained normotensive and
afebrile with no recurrence of tachycardia. Episodes of occasional tachypnea (31-42cpm) were still
observed but with no episodes of desaturation (95-100% at 10lpm via non-rebreather mask). The

8
patient still had colds, anosmia, ageusia, now with productive cough accompanied by nocturnal
awakening and occasional difficulty of breathing when talking in sentences and upon bed turning. The
patient was also on her day 1 of menses, scanty in amount. Upon assessment, patient had no alar flaring
or cyanosis, with shallow subcostal retractions, bibasal crackles, no wheezes and good air entry,
Abdomen was soft, with normoactive bowel sounds, non-tympanitic and non-tender. Pulses were full
and equal, with warm extremities. Repeat serum sodium, potassium, chloride and calcium showed
normal results. Present management was continued.

On the 2nd hospital day at the PICU (09/24/2021), the patient no tachycardia and had less
tachypneic episodes (30-37 cpm), no desaturations (97-99% at 10 lpm) and with adequate urine output.
She still had anosmia and ageusia but now with decrease episodes of productive cough, colds, nocturnal
awakening and difficulty of breathing upon exertion. Upon assessment, no retractions were noted but
still with bibasal crackles, no wheezes and with good air entry. Other physical examination were
unremarkable. Gradual weaning of oxygen support was done until 5 lpm is reached. During weaning,
respiratory rate were 21-32 cpm with oxygen saturation of 97-98%. No complaints of difficulty of
breathing or episodes of desaturations noted. Repeat inflammatory markers still showed elevated
results of ESR and Ferritin but with slight improvement in CRP, LDH, D-dimer and Procalcitonin. CBC still
showed leukopenia. The patient was then started with soft diet in small frequent feedings. Present
management was continued.

On the 3rd to 4th hospital day at the PICU (09/25 to 9/26/2021), the patient had occasional
tachypneic episodes (21-35cpm) noted during exertion with decreased productive cough and colds now
with resolution of the ageusia and anosmia. Upon assessment, patient had no retractions, now with
harsh breath sounds, no wheezes and with good air entry. Other physical examination were
unremarkable. Gradual weaning of oxygen support was continued but the patient had occasional
episodes of desaturation at 91-92% at 5lpm via face mask hence, oxygen support was temporarily
increased to 8lpm. Upon reassessment, respiratory rate were 24-28 cpm with oxygen saturation of 97-
100%. No recurrence of desaturation noted. The patient was noted to have improving intake hence, diet
was progressed. Adequate urine output noted. Present management was continued.

On the 5th hospital day at the PICU (09/27/2021), the patient was afebrile and normotensive but
with occasional episodes of bradycardia (57-59 bpm) during sleep. Occasional episodes of tachypnea
(21-37 cpm) were still noted but had no episodes of desaturation. The patient had decreased cough and
colds, now with less episodes of difficulty of breathing upon exertion. Upon assessment, patient had no
retractions, with harsh breath sounds, no wheezes and with good air entry. Patient had adynamic
precordium, regular rhythm with no murmur. Other physical examination were unremarkable. 15-L ECG
and Troponin I were requested along with repeat inflammatory markers. 15-L ECG showed sinus
bradycardia and Troponin I was normal. Repeat inflammatory markers now showed normal results of
ESR, CRP, LDH, D-dimer and Procalcitonin. Serum Ferritin remained elevated but with marked
improvement. Gradual weaning of oxygen support was continued.

On the 6th hospital day at the PICU (09/28/2021), the patient now had no episodes of
bradycardia, tachypnea and desaturation. Continuous gradual weaning of oxygen support to 3 lpm via
nasal cannula was tolerated. Patient now had very occasional non-productive cough with no colds and
no difficulty of breathing upon exertion. Upon assessment, patient now had clear breath sounds with
unremarkable physical examination. The patient was cleared to transfer to a regular room. Present
management was continued.

9
COURSE IN THE WARDS
On the 7th to 8th hospital day (09/29 to 09/30/2021), the patient was comfortable with very
occasional non-productive cough with no colds or complaints of difficulty of breathing. Vital signs were
stable and physical examination was unremarkable. The patient tolerated continued weaning from
oxygen support until 0.5lpm via nasal canula. Repeat chest Xray showed interval decrease in the
pneumonic opacities in both lungs. Present management was continued.

On the 9th to 12th hospital day (10/01 to 10/04/2021), the patient was comfortable with no
subjective complaints. Vital signs were stable and physical examination was unremarkable. Oxygen was
eventually discontinued and tolerated. No episodes of difficulty of breathing, tachypnea or
desaturations were noted. The patient was eventually cleared for discharge on the 12 th hospital day and
was sent home with Vitamin C 500mg tablet once a day and Zinc tablet twice a day. Proper precautions
and isolation were advised.

FINAL DIAGNOSIS:
COVID Pneumonia, severe
Obese

LABORATORIES
COVID Rapid Antigen (09/20/2021): Positive
COVID RT-PCR (09/21/2021): Positive

RBS: 183.96 mg/dL

Complete Blood 09/20/2021 09/21/2021 09/24/2021 09/27/2021 Reference

Count Range
Hemoglobin 159 147 139 152 120-150 g/dL
Hematocrit 0.46 0.44 0.42 0.46 0.37-0.45
WBC 4.3 3.7 2.5 4.8 5-10 x10^9/L
Segmenters 0.68 0.64 0.71 0.82 0.55-0.65
Lymphocytes 0.25 0.30 0.21 0.11 0.25-0.40
Monocytes 0.07 0.06 0.28 0.07 0.02-0.06
Platelet 267 220 281 540 150-440
x10^9/L

Dengue Antibody Test (09/20/2021)

Dengue IgG: Negative Dengue IgM: Negative

Arterial Blood Gas 09/21/2021 09/22/2021 Reference Range

pH 7.49 7.47 7.35-7.45
pCO2 37 40 35-45 mmHg
pO2 24 168 80-100 mmHg

10
 HCO3 28.2 29.1 22-27 mmol/L
BE 4.9 5.4 (-) 2 – (+) 2 mmol/L
TCO2 29.3 30.3 23-29 mmol/L
SaO2 50 100% 95-100%

Serum Electrolytes 09/21/2021 09/23/2021 Reference Range

Potassium 3.6 3.9 3.5-5.1 mmol/L
Sodium 137 139 135-145 mmol/L
Chloride 93 99 98-107 mmol/L
Total Calcium 2 2.02 2.20-2.65 mmol/L
Magnesium 0.71 --- 0.66-1.07 mmol/L

09/21/2021 09/24/2021 09/27/2021 Reference Range

CRP 27 18.4 5 <5 mg/L
ESR 18 23 16 0-20 mm/hour
LDH 315 224 215 100-190 U/L
Ferritin 690.45 831.49 516.70 9.3-159 ng/mL
D-Dimer 0.28 0.21 0.10 0-0.499 mg/L
Procalcitonin 0.78 0.12 0.05 <0.09 ng/mL

Troponin I 1.50 0-11 ng/L

Urinalysis
Physical Examination 09/20/2021
Color Dark yellow
Clarity Cloudy

Chemical Examination Result Reference Range

Specific Gravity 1.034 -
pH 5.5 -
Protein +1 Less than 0.25
Sugar Normal Less than 3
Urine Ketone +2 Less than 0.5
Blood Negative Less than 10
Leuko Esterase Negative Less than 25
Nitrite Negative Negative
Bilirubin +1 Less than 17
Urobilinogen +2 Less than 17
Ascorbic acid +2 -

Sediment Analysis Result Reference Range

RBC 1 0-2 / HPF
WBC 11 0-5 / HPF
Epithelial cells 6 0-3 / HPF
Bacteria 123 0-17 / HPF
Mucus Threads 45 0-3 / HPF

11
ECG (09/21/2021):
Sinus Bradycardia
Normal QRS axis
No signs of chamber hypertrophy
Normal duration of waveforms and intervals

Chest Xray:

09/20/2021 No active parenchymal infiltrates

Cardiac silhouette is unremarkable
Pulmonary vascularity is within normal limits
Diaphragm and costophrenic sulci are intact
The visualized osseous structures are unremarkable
09/22/2021 Interval appearance of hazy opacities in the right lung and left mid to lower lung which
may be due to pneumonia
Heart is magnified probably due to positioning
Pulmonary vascularity is within normal limits
Diaphragm and costophrenic sulci are intact
The visualized osseous structures are unremarkable
09/25/2021 Both lungs are hypoinflated
There is slight interval increase of hazy pneumonic opacities in the right mid to upper
lung and left mid to lower lung
Heart is magnified probably enlarged
Pulmonary vascularity is within normal limits
Diaphragm and costophrenic sulci are intact
The visualized osseous structures are unremarkable
The rest of the chest findings are unchanged
09/29/2021 Both lungs remains hypoinflated
There is interval decrease of hazy pneumonic opacities in both lungs
Heart is magnified
Pulmonary vascularity is within normal limits
Diaphragm and costophrenic sulci are intact
The visualized osseous structures are unremarkable
The rest of the chest findings are unchanged

12
 MORBIDITY CASE #2

GENERAL DATA
This is a case of patient RL, a 7-year old, female, Filipino, Roman Catholic, from Quezon City
admitted last September 21, 2021, for the first time at our institution.

CHIEF COMPLAINT: Difficulty of breathing

SOURCE AND RELIABILITY: Data came from the patient’s parents with fair reliability.

HISTORY OF PRESENT ILLNESS

8 days prior to admission, the patient had intermittent fever with maximum temperature of
38.8C accompanied by generalized headache (unquantified) and 1 episode of non-bilious, non-projectile
vomiting approximately 1/4 cup in amount of previously food. The patient was still noted to have good
appetite and activity. Teleconsultation was done with a private physician and was prescribed with Co-
Amoxiclav (30mg/kg/day) twice a day given for 10 doses, Ambroxol and Paracetamol. Assessment at this
time was not disclosed. No cough, colds or loose stools noted.
6 days prior to admission, the patient still had undocumented fever accompanied by occasional
generalized headache now with non-productive cough and colds. No follow up consult done and
medications were continued.
3 days prior to admission, still with undocumented fever now noted with increasing frequency
of coughing episodes. No difficulty of breathing or other signs and symptoms noted. Follow up consult
with the attending physician was done wherein Co-Amoxiclav was shifted to Cefixime (4mg/kg/dose)
every 12 hours taken for 6 doses.
2 days prior to admission, patient had persistence of signs and symptoms and now with
decreased appetite and activity. The patient was brought to an another institution wherein CBC and
chest Xray were done. CBC showed normal results and chest Xray showed findings of pneumonia. The
patient was advised admission but opted to be discharged against medical advice.
1 day prior to admission, patient now had increased frequency of productive cough and
accompanied by occasional episodes of shortness of breath. No other signs and symptoms noted. No
follow up consult was done. No other medications were taken.
Few hours prior to admission, still with cough now with difficulty of breathing hence, the patient
was brought to our institution and was eventually admitted.

REVIEW OF SYSTEMS
General: (-) weight loss or weight gain
Skin: (-) pallor, (-) rashes, (-) jaundice
HEENT: (-) eye discharge or lesions, (-) ear discharge, (-) anosmia, (-) ageusia, (-) throat pain
Cardiovascular: (-) cyanosis, (-) chest pain
Gastrointestinal: (-) diarrhea, (-) hematemesis, (-) hematochezia, (-) melena, (-) constipation
Genitourinary: (-) hematuria, (-) dysuria
Hematologic: (-) pallor, (-) mucosal bleeding, (-) easy bruising

13
Extremities: (-) joint swelling, (-) joint pain
Neuro: (-) loss of consciousness, (-) altered sensorium, (-) changes in behavior

PAST MEDICAL HISTORY

This is the patient’s 3rd admission. Her last admission was at 2 years old due to pneumonia. She
has no history of allergy to food or medication, simple febrile seizure, primary Koch’s infection, previous
trauma, surgeries nor any invasive procedures done.

IMMUNIZATION HISTORY
Vaccine Doses Vaccine Doses
BCG 1 PCV 3
Hepatitis B 4 Measles 1
OPV 3 MMR 2
DPT 3 Varicella 2
HiB 3 Hepatitis A 2

FAMILY HISTORY
There is history of hypertension on the paternal side. No family history of diabetes mellitus,
pulmonary tuberculosis, stroke, bronchial asthma or cancer.

PERSONAL, SOCIAL AND DEVELOPMENTAL HISTORY

The patient is an only child and lives in Quezon City with 6 other household members consisting
of his parents, paternal grandparents and 2 paternal uncle. His father and one of his paternal uncle
usually go out for errands once a week. All adult household members had completed 2 doses of COVID
vaccine.
3 days prior to the onset of the patient’s signs and symptoms, the patient’s maternal aunt
visited their household. She was initially asymptomatic during her visit but then claimed to have fever
and cough. The maternal aunt underwent RT-PCR test which eventually turned out positive. The patient
and the other household were informed and observed proper precautions. During the interim, the
patient’s paternal grandfather and uncle developed non-productive cough but no swab test or isolation
done. Other household members were asymptomatic as claimed and did not undergo swab testing.
She is a Grade 2 student currently attending her classes online. She usually eats three times a
day consisting of rice, meat and occasional vegetables and drinks mineral water. She has no food
preference as claimed.
The patient’s developmental milestones where at par with age according to the parents.

BIRTH HISTORY
The patient was born full term via cesarean section due to arrest in cervical dilatation at Chinese
General Hospital with no feto-maternal complications. Newborn screening had normal results as
claimed.

PHYSICAL EXAMINATION
BP: 110/70mmHg (90th percentile) Weight: 35 kgs Weight for Age: Above 2 (Normal)
HR: 146 bpm Height: 130 cm Height for Age: Above 1 (Normal)

14
 RR: 38 cpm IBW: 22 kgs BMI for Age: Above 2 (Overweight)
o
Temp: 38.6 C BMI: 20 kg/m2
O2 sat: 80% O2 saturation at room air

General: awake, in cardiorespiratory distress

Skin: (-) lesions, (-) pallor
Head: no gross deformities
Eyes: non-sunken eyeballs, pink palpebral conjunctiva, anicteric sclera
Ears: non-hyperemic external auditory canal on both ears, intact tympanic membrane on both ears, no
ear discharge
Nose: (+) alar flaring, (+)congested turbinates, (+) watery nasal discharge
Mouth: slightly dry lips, moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not
enlarged, no exudates, no oral lesions, no circumoral cyanosis
Neck: no palpable cervical lymphadenopathy
Cardio-Thoracic: (+) subcostal retractions, bibasal crackles, no wheezes, good air entry; adynamic
precordium, tachycardic, regular rhythm, no murmur
Abdomen: non-distended abdomen, normoactive bowel sounds, non-tympanitic, soft, non-tender, no
organomegaly
Extremities: no gross deformities, pink palms and soles, no joint swelling and erythema, full and equal
pulses, CRT <2 seconds, warm extremities

NEUROLOGIC EXAMINATION
General: awake, conscious, coherent
Cranial Nerves:
I Cannot be assessed VIII Intact gross hearing
II Pupils 3-4mm, reactive to light IX, Able to swallow; With gag reflex upon insertion
X of swab
III, IV, Intact extraocular muscles; No XI Can shrug shoulders
VI nystagmus
V Intact V1-V3 XII Tongue midline upon protrusion
VII No facial asymmetry

Cerebellum: no nystagmus, able to do rapid alternating movements

Motor: 5/5 in all extremities
Sensory: 100% in all extremities
Pathologic Reflexes: (-) Babinski
Meningeal signs: (-) Kernig’s, (-) Brudzinki

ADMITTING DIAGNOSIS:
Pneumonia, high risk
COVID probable

COURSE IN THE EMERGENCY ROOM

Upon arrival at the emergency room, the patient was tachycardic at 146bpm, tachypneic at 38
cpm and with oxygen saturation of 80% at room air. Oxygen support at 10 lpm via non-rebreather mask
was provided. Upon reassessment, the patient was still tachyneic at 30 cpm but with improvement of
oxygen saturation to 98%. The patient was instructed nothing per orem temporarily and IV hydration at

15
mild correction was started. Laboratories such as CBC, serum electrolytes, inflammatory markers (ESR,
CRP, D-dimer, LDH, Procalcitonin and serum Ferritin), arterial blood gas, random blood sugar, chest Xray
and COVID RT-PCR swab test were requested. COVID rapid antigen test was also done which showed
negative results. CBC, arterial blood gas and random blood sugar showed normal results. Serum
electrolytes showed hypokalemia. All the inflammatory markers were elevated and chest Xray showed
hazy opacities at the right lung and left mid to upper lung due to bilateral pneumonia. Blood culture was
also done. Cefuroxime 750mg IV (64mg/kg/day) every 8 hours was started and Paracetamol
(11mg/kg/dose) was given as needed for fever. The patient was then referred to a pediatric intensivist
for further evaluation and management. Dexamethasone 6mg IV (0.17mg/kg/dose) once a day was
started. The patient was initially admitted in the intensive care unit for close monitoring.

COURSE IN THE INTENSIVE CARE UNIT

Upon admission (9/22/2021), the patient was tachypneic (30-37 cpm) with oxygen saturation of
95% at 10 lpm via non-rebreather mask. Other vital signs were stable and with adequate urine output.
She still had productive cough and colds now with epigastric pain during coughing episodes. Upon
assessment, patient had non-sunken eyeballs, with no alar flaring or cyanosis, slightly dry lips, moist
buccal mucosa, still with subcostal retractions, bibasal crackles, no wheezes, good air entry, adynamic
precordium, tachycardic, regular rhythm with no murmur. Abdomen was soft, with normoactive bowel
sounds, non-tympanitic and non-tender. Pulses were full and equal, with warm extremities. Gradual
weaning of oxygen support was started until 4lpm via nasal cannula is reached but was observed to have
desaturations at 88-90%, aggravated by coughing episodes. Hence, patient was hooked back to 14 lpm
via non-rebreather mask and positioned in a moderate to high back rest. RT-PCR swab test eventually
showed positive results. The patient was then started on Remdesivir 175mg IV (5mg/kg/dose) as loading
dose then continued at 90mg IV (2.5mg/kg/day) once a day, Azithromycin syrup (10.3 mg/kg/day) once
a day, Vitamin C+Zinc tablet once a day, Vitamin D3 2000 IU capsule once a day and N-Acetylcysteine
twice a day. She was then given soft diet in small frequent feedings. Present management continued.

On the 1st to 2nd hospital day at the PICU (09/23-09/24/2021), the patient had occasional
tachypneic episodes (26-37 cpm), no desaturations (97-100% at 14 lpm) and with adequate urine
output. The patient now had decreased episodes of productive cough and colds with no difficulty of
breathing. Upon assessment, no retractions were noted, still with bibasal crackles, no wheezes and with
good air entry. Other physical examination were unremarkable. Repeat serum electrolytes showed
normal results. Repeat chest Xray showed interval decrease in the lung opacities in the left mid to upper
lung. Gradual weaning of oxygen support to 12lpm via non-rebreather was done but observed to have
desaturations at 93-94% hence, patient was temporarily maintained at 14 lpm. Present management
was continued.

On the 3rd to 4th hospital day at the PICU (09/25 to 9/26/2021), the patient was normotensive,
afebrile, with occasional tachypnea (21-37 cpm) and now with occasional bradycardia (54-59 cpm)
during sleep. The patient now had decreased productive cough and colds with no difficulty of breathing.
Upon assessment, no retractions noted, with harsh breath sounds, no wheezes, with good air entry,
adynamic precordium, normal rate, regular rhythm and no murmur. Other physical examination were
unremarkable. 15-L ECG and Troponin I were requested. 15-L ECG showed sinus bradycardia and
Troponin I was slightly elevated. Gradual weaning of oxygen support was continued until 5lpm via face
mask was tolerated. No desaturations noted. Present management was continued.

On the 5th to 6th hospital day at the PICU (09/27 to 9/28/2021), no recurrence of bradycardia,
now with less episodes of tachypnea (15-34 cpm) and no episodes of desaturation were noted. Other

16
vital signs were stable. Patient had decreased non-productive cough with no colds. Upon assessment,
patient had no retractions, now with clear breath sounds, no wheezes, and with good air entry. Other
physical examination were unremarkable. Repeat CBC showed thrombocytosis hence, Aspirin 80mg (2.3
mg/kg/day) once a day was started. Repeat chest Xray showed further interval decrease of the hazy
opacities in both lungs. Patient was gradually weaned off from the oxygen which she tolerated well. The
patient was eventually transferred to a regular room. Present management was continued.

COURSE IN THE WARDS

On the 7th to 10th hospital day (09/29 to 10/2021), the patient was comfortable with very
occasional non-productive cough with no difficulty of breathing. Vital signs were stable and physical
examination was unremarkable. Repeat CBC showed normal results and chest Xray showed interval
decrease of pneumonic opacities in both lungs. The patient was eventually cleared for discharged.
Patient was sent home with Multivitamins once a day and Aspirin 80mg tablet once a day for 6 weeks.
Proper precautions and isolation were advised.

FINAL DIAGNOSIS: COVID Pneumonia, severe

LABORATORIES
COVID Rapid Antigen (09/21/2021): Negative COVID RT-PCR (09/21/2021): Positive

RBS: 117 mg/dL

Complete Blood 09/21/2021 09/25/2021 09/27/2021 09/29/2021 Reference

Count Range
Hemoglobin 117 118 119 116 120-150 g/dL
Hematocrit 0.36 0.36 0.35 0.35 0.37-0.45
WBC 6.9 5.5 6.1 9.4 5-10 x10^9/L
Segmenters 0.81 0.72 0.77 0.55 0.55-0.65
Lymphocytes 0.11 0.22 0.22 0.35 0.25-0.40
Monocytes 0.08 0.06 0.01 0.10 0.02-0.06
Platelet 259 494 580 635 150-440
x10^9/L

09/22/2021 Reference Range

Creatinine 24 53-106 umol/L
eGFR 187 90-120 mL/min/1.73
BUN 5.60 5-18 mg/dL
SGOT / AST 40 15-60 U/L
SGPT / ALT 51 <33 U/L

Arterial Blood Gas 09/21/2021 Reference Range

pH 7.43 7.35-7.45
pCO2 41 35-45 mmHg
pO2 94 80-100 mmHg
HCO3 27.2 22-27 mmol/L

17
 BE 2.9 (-) 2 – (+) 2 mmol/L
TCO2 28.5 23-29 mmol/L
SaO2 98 95-100%

Serum Electrolytes 09/22/2021 09/24/2021 Reference Range

Potassium 142 4 3.5-5.1 mmol/L
Sodium 3.4 141 135-145 mmol/L
Chloride 101 99 98-107 mmol/L
Total Calcium 2.08 2.18 2.20-2.65 mmol/L

09/21/2021 09/25/2021 Reference Range

CRP 83 5 <5 mg/L
ESR 44 --- 0-20 mm/hour
LDH 530 --- 100-190 U/L
Ferritin 926.36 842.56 9.3-159 ng/mL
D-Dimer 0.63 0.63 0-0.499 mg/L
Procalcitonin 1.68 --- <0.09 ng/mL
Troponin I 25.90 0-11 ng/L

Blood Culture (09/29/2021): No growth after 7 days of aerobic incubation (final report)
ECG (09/21/2021): Sinus Bradycardia

Chest Xray:
09/21/2021 Hazy opacities are seen in the right lung and left mid to upper lung
Heart is not enlarged
Aorta and pulmonary vascularity are within normal limits
Diaphragm and costophrenic sulci are intact
The visualized osseous structures are unremarkable
09/23/2021 There is progression of the pneumonic infiltrates seen in the right lung and left mid to
upper lungs with interval increase in the degree of confluences
Heart is not enlarged
Aorta and pulmonary vascularity are within normal limits
Diaphragm and costophrenic sulci are intact
The visualized osseous structures are unremarkable
09/24/2021 Slight interval decrease in the hazy and patchy opacities in the left mid to upper lung
as well as in the degree of its confluence with slight interval increase in the right lung
due to pneumonia
Heart is not enlarged
Aorta and pulmonary vascularity are within normal limits
Diaphragm and costophrenic sulci are intact
The visualized osseous structures are unremarkable
09/27/2021 Significant interval decrease in the pneumonic opacities in both lungs. Residual
opacities predominantly in the hilar/inner lung regions
Cardiac silhouette is within normal limits
Aorta and pulmonary vascularity are within normal limits
Diaphragm and costophrenic sulci are intact
The visualized osseous structures are unremarkable

18
09/29/2021 There is an interval decrease of pneumonic opacities in both lungs. Few streaky and
hazy opacities are still appreciated in both inner lung zones ans right mid to lower
lung
Cardiac silhouette is within normal limits
Aorta and pulmonary vascularity are within normal limits
Diaphragm and costophrenic sulci are intact
The visualized osseous structures are unremarkable

19