PEDRIATRIC WARD

WORKS
GROUP 1
 HISTORY TAKING

Date History Taken: February 3,2020 8:10 AM

Date of Admission: January 31, 2020, 9:00 AM
Informant: MOTHER
Reliability: Reliable, 90%
 GENERAL DATA

• This is a case of patient A.M, 4 year-old, female, single, Filipino, Roman

Catholic, currently residing in Sta. Barbara, Pangasinan, and was
admitted for the first time in Pangasinan Provincial Hospital.
 CHIEF COMPLAINT

• Difficulty of breathing
 HISTORY OF PRESENT ILLNESS

The patient was apparently well until 3 days prior to admission, at around 8 AM, patient
started to have sudden onset of unproductive cough, did not take any medications. The next
day, the cough became productive with white sputum but in small amount. The cough is
worst in the afternoon and at nightime. no associated signs and symptoms was reported.
One day prior to admission, the patient had fever, but temperature was not taken.
Cough still persists but the mother noted yellow to geenish sputum. The patient took
paracetamol, dosage cannot recall, every four hours.
Few hours prior to admission, the fever subsided, however the cough persists with white
phlegm accompanied by difficulty of breathing, nebulization with salbutamol was given but
no relief. They opted to seek consults at PPH. 
 PAST MEDICAL HISTORY

PREVIOUS HOSPITALIZATION: According to the mother the

patient was admitted on November 2019 at Mapandan Hospital
due to persistent cough. The institution diagnosed the patient
with bronchial asthma with home medication of salbutamol
syrup. The mother also bought a nebulizer as advised.
ILLNESS: cough and colds
IMMUNIZATION: Complete according to the mother
ALLERGIES: NONE
 PERSONAL AND SOCIAL HISTORY

• Patient A.M, is a 4-year-old child. She had 1 brother and 2 sisters, she is the third
among the four. Her father is a farmer and her mother is a housewife. The family lives
in a bungalow typed, semi concrete with 2 rooms. The house is well ventilated. Their
house located near a farm.
• The father smokes 3 cigarette sticks per day outside and inside their house and
consumes alcohol occasionally
• They manually flush their toilet with a pail fetched water. They do not segregate their
garbage, rather they burnt it in their backyard. They use mineral water for drinking.
• The patient eats 3-4 times a day consisting of rice, fish, meats, vegetables, biscuits,
noodles and drinks milk often. Usually sleeps 9-10 hours a day.
 FAMILY HISTORY
 

• Mother claims to have an asthma

 REVIEW OF SYSTEMS
 

• General: (-) significant change in weight, (-) generalized body weakness, (-) fever, (-) chills, (+) decreased appetite

• Skin: (-) itchiness, (-) excessive dryness or sweating, (-) cyanosis, (-) pallor, (-) jaundice, (-) erythema

• Head: (-) headache, (-) dizziness, (-) vertigo

• Eyes: (-) pain,(-) blurring of vision, (-) double vision, (-) lacrimation), (-) photophobia, (-) use of eyeglasses

• Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge

• Nose and sinuses: (-) changes in smell, (-) nose bleeding, (-) nasal obstruction, (+)nasal discharge, (-) pain over paranasal sinuses

• Mouth and throat: (-) toothache, (-) gum bleeding, (-) disturbance in taste, (-) sore throat, (-) hoarseness

• Neck: (-) pain, (-) limitation of movement, (-) mass

• Breast: (-) pain, (-) lumps, (-) nipple discharge

• Respiratory: (-) pleuritic chest pain, (+) cough, (+) sputum production, (-) hemoptysis, (+) audible wheezing, (+) dyspnea

• Cardiovascular: (-) easy fatigability,(-) palpitations, (-) substernal pain, (-) syncope, (-) orthopnea, (-) ankle edema

•  
 REVIEW OF SYSTEMS

• GIT: (-) abdominal pain, (-) nausea, (-) vomiting, (-) dysphagia, (-) diarrhea, (-) constipation,
(-) hematemesis, (-) melena, (-) hematochezia, (-) regurgitation
• GUT: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hematuria, (-) polyuria, (-)
incontinence, (-) urethral discharge, (-) genital pruritus
• Extremities: (-) edema, (-) swelling of joints, (-) stiffness, (-) numbness, (-) intermittent
claudication, (-) limitation of movement
• Nervous: (-) loss of consciousness, (-) focal weakness, (-) paresthesia, (-) speech disorder,
(-) loss of memory, (-) confusion
• Hematologic: (-) bleeding tendency (-) easy bruising
• Endocrine: (-) intolerance to heat/cold (-) excessive weight change (-) polyuria (-) polydipsia
PHYSICAL EXAMINATION
 GENERAL SURVEY

• The patient is awake, conscious and coherent. Patient was cooperative

but too shy to talk.
 VITAL SIGNS

BP: 90/60 mmHg

PR: 118 bpm
RR: 34 breaths/min
Weight: 11 kg, 10th percentile
Height: 91.5 cm
BMI: 13.3 Underweight
• SKIN: Skin is brown in color, with good skin turgor. Nails are smooth
with normal folds with good capillary refill.
• HEAD: Normocephalic, without deformities and swelling, no
tenderness, no masses. Has long, thick black hair, evenly distributed,
no dandruff, lice and no lesions on the scalp.  
• FACE: round shaped, normal facie
• EYES: Pink palpebral conjunctiva, anicteric sclera. Lens are
transparent. Iris are black with normal contour, no lid edema.
• EARS: External ears are symmetrical, without deformities.
External canal is patent, with some cerumen but without
lesions.
• NOSE: Nose is symmetrical, no tenderness, with clear
discharge 
• ORAL CAVITY: complete primary teeth, with some dental
carries, no lesions
• NECK: No cervical lymphadenopathy, no lumps, no tenderness
• CHEST/LUNGS: noted rales and wheezing on both lung fields but more prominent
on right lung field. Noted substernal retractions, and intercostal retractions,
shortness of breath, yellow to greenish sputum
• HEART: Heart sound is regular and has a normal rhythm. no murmur
• ABDOMEN: soft, non tender abdomen, no palpable mass
• EXTREMITIES: No edema. No cyanosis. No deformities. No swelling. Normal ROM.
• RECTAL and GENITAL EXAMINATION:Not done
• MUSCULOSKELETAL: no deformities, full range of motion
 ASSESSMENT

• ADMITTING IMPRESSION: Bronchial Asthma

 SOAP
Subjective: Difficulty of breathing
Objective: Tachypneic, SOB, substernal and intercostal
retractions
Assessment: Pulmonary Obstruction, Impaired Gas Exchange
Plan of management
Diagnostic: X-RAY AP- LAT
Therapeutic:
- Bronchodilator medication/ nebulization/oxygen therapy
- Proper ventilation
- Chest physiotherapy
 SOAP

• Subjective: Persistent cough

• Objective: productive cough, white to greenish secretions
• Assessment: Pulmonary consolidation
• Plan of management
• Diagnostic: Sputum AFB
• Therapeuthic:
- Mucolytic medications/ nebulization of bronchodilator/oxygen
therapy
- Antibiotic
- Chest physio therapy
 SOAP

• Subjective: “Payat ang anak ko”

• Objective: weight of 11 kg, 10th percentile
• Assessment: Failure to thrive
• Plan of management
- - Diet for age
- Encourage feeding
- Multivitamins
- Appetite stimulant
DIFFERENTIAL
DIAGNOSIS
SALIENT FEATURES

• Dyspnea
• Cough
• Tachypnea
• Use of accessory muscle
• Wheezing and rales
ASTHMA

In childhood asthma, the lungs and airways become easily inflamed

when exposed to certain triggers, such as inhaling pollen or catching a
cold or other respiratory infection. Childhood asthma can cause
bothersome daily symptoms that interfere with play, sports, school and
sleep.
SIGNS AND SYMPTOMS

• Frequent coughing that worsens when your child has a viral infection,
occurs while your child is asleep or is triggered by exercise or cold air
• A whistling or wheezing sound when breathing out
• Shortness of breath
• Chest congestion or tightness
DIAGNOSTIC TEST

• Pulmonary Function Test

Spirometry measures how much air the child can exhale and how
quickly. The child might have lung function tests at rest, after exercising
and after taking asthma medication.
• Chest Xray
Reveals hyperinflation and increased bronchial markings; radiography
may also show evidence of parenchymal disease, atelectasis, pneumonia
PNEUMONIA

Inflammation of lung parenchyma. The air sacs in the lungs (called alveoli)
fill up with pus and other fluid maybe caused by bacteria or virus.
Signs and syptoms
• Tachypnea
• Wheezing or rales
• Use of accessory muscle
• Fever
• Cough
DIAGNOSTIC TEST

• Chest X ray
• CBC
• Sputum GS/CS
PRIMARY COMPLEX

Children exposed to Mycobacterium tuberculosis may develop a

tuberculosis (TB) infection called Primary Complex. The most common
route of infection is through inhalation. A person with active TB coughs
up the germ and it is inhaled by a healthy child. The TB then travels to
the lungs. The child remains healthy and usually has no symptoms. They
may remain symptom free until their immune system declines and the
disease becomes active.
SIGNS AND SYMPTOMS

• Lymphadenopathy
• Fever, night sweats
• Cough
• Failure to thrive and difficulty gaining weight
DIAGNOSTIC TEST

• Chest Xray
• PPD or Mantoux test
• AFB smear