“PEDIATRICS-

Case Presentation

-Sumanga, Juan Cheska

Eunice A.

PEDIATRICS
PATIENT PROFILE
T.A.
3/F
JULY 7,2015
TUMAUINI, ISABELA

ROMAN CATHOLIC
SINGLE
 CHIEF COMPLAINT
➤ Cough
 HISTORY OF PRESENT ILLNESS

4 days PTA, patient was noted with:

(+) productive cough and colds
(+) fever
(-) consult
 HISTORY OF PRESENT ILLNESS

3 days PTA, still with above condition

(+) consult - Cefaclor 38 mkD and Paracetamol 10mkd q4
(+) temporary relief

FHPTA. (+) DOB, hence consult at CVMC

 PRENATAL HISTORY
(+) regular check up
(+) ferrous sulphate
(+) tetanus toxoid vaccination
(-) smoker & alcoholic beverage drinker
(+) fever (2nd trimester) consultation was done and adviced not to take
any medications
(-) bleeding/fall/accident
 BIRTH HISTORY
33 year old G3P3 (3003) mother
Term, cephalic, delivered via 1 E LSCS
(-)Complications
 POSTNATAL HISTORY
Born vigorous
Good suck & good cry
No respiratory distress
 IMMUNIZATION HISTORY
BCG: 1 dose
Hepa B: 1 dose
Penta: 3 doses
OPV: 3 doses
Measles: 1 dose
MMR: 1 dose
PCV: 0 dose
RV: 0 dose
JE: 0 dose
Varicella: 0 dose
Hep A: 0 dose
Influenza: 0 dose
GROWTH AND DEVELOPMENT
 NUTRITIONAL HISTORY
Breastfed since birth to present
Complementary feeding of alaska was introduced at 1 year old
Table food was introduced at 1 year & 3 months
 PAST MEDICAL HISTORY
(-) asthma
(-) allergies
(-) TB exposure
No previous surgical procedures done
1 previous hospitalization
2017 - Pneumonia (Delfin Albano District Hospital)
 FAMILY HISTORY
Father Mother

- Hypertension -

+ Diabetes -

- Cancer -

- Heart disease

- Tuberculosis -

- Asthma/allergies -

- Blood disorder -

Arthritis -
 PERSONAL & SOCIAL HISTORY
Youngest in a brood of 3
Lives in a bungalow-type house with 2 rooms
Television & toys
Eat all sorts of edible food
Drinking water-pump well, boiled
No pets at home
 (-)pruritus
(-) headache
(-) hemoptysis
(-) weight loss

REVIEW OF SYSTEMS

(-) vomiting
(-)hematuria
(-) dysuria
(-) epistaxis
 PHYSICAL
EXAMINATION
 PHYSICAL EXAMINATION
General survey:
Irritable, in respiratory distress

Vital signs:
BP = 90/60 PR = 152 bpm
RR = 46cpm Temp = 38.3 C
Wt = 10 kg. O2 sat = 91%
 PHYSICAL EXAMINATION
Skin: (-) pallor, (-) cyanosis,(-) jaundice, warm to touch, with good skin
turgor

HEENT: anicteric sclera, pink palpebra, (-) cervical LAD, (-) nasoaural
discharge, (-) neck engorgement

Chest/Lungs: symmetric chest expansion, (+) tchypneic (+) rales both

lung fields (+) wheezes (+) subcostal retractions
 PHYSICAL EXAMINATION
Heart: Adynamic precordium, PMI at 4th ICS, tachycardic, regular
rhythm, (-) murmur

Abdomen: flat, soft, non-tender, normal active bowel sounds

Genitalia: Grossly female

GUT: grossly female

 PHYSICAL EXAMINATION
Extremities: no gross deformity, CRT<2sec, full & equal pulses
Neurologic:
:
MSE: Awake
Cranial Nerves:
CN I: can smell coffee
CN II: pupils ERLA. Pupil: 2mm in size
CN III, IV, VI: able to follow examiner hand at different direction
CN V: positive blinkreflex
CN VII: (-) facial asymmetry
CN VIII: can hear
CN IX, X: (+) gag reflex
CN XI: symmetrical shoulders
CN XII: no tongue deviation
Motor: 5/5 in all extremities, it can move against gravity and full resistance
Sensory: Grade-100%. Withdraws to pain. Sensation is intact to light touch and pinprick on both
upper and lower extremities
HEMATOLOGY
COMPLETE BLOOD COUNT

LABORATORIES FINDING INTERPRETATION

HGB 126
HCT 0.39
RBC 4.99
PC 200
MCV 78.3
MCH 25.2
MCHC 320
WBC 15.62 High
NEUTROPHILS 42.3 LEUKOCYTOSIS
LYMPHOCYTES 48.2 High
MONOCYTES 9.1 LYMPHOCYTOSIS
EOSINOPHILS 0.1
BASOPHILS 0.3
CT ratio = 0.52
 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

COURSE IN THE WARD DAY 1 AM

D5 0.3 NaCl 1/2 L 62-

Vital signs: 63ugtts/min x8*
Temp: 38.3 Cefuroxime 340mg/IV
CR: 123 q8
(+) cough RR: 46 Paracetamol 100mg/IV
(+) fever Weight: 10kg q4 for fever
PCAP-MR
(+) DOB Salbutamol q20 minsx 3
(+) Retraction doses
(+) wheezes 02 via NC at 2-3LPM
(+) rales Salbu+Iprat neb q6
 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

COURSE IN THE WARD DAY 1 PM

D5 0.3 NaCl 1/2 L 72-

Vital signs:
73ugtts/min x8*
Temp: 37.5
Cefuroxime
CR: 102
340mg/IV q8
RR: 35
(+) cough Paracetamol
Weight: 10kg
(-) fever 100mg/IV q4 for
PCAP-MR
(-) DOB fever
⬇tachypnea
Salbutamol q2
(-) cyanosis
02 via NC at 2-3LPM
SCE, (-) retractions
Salbu+Iprat neb q6
(-) rales
 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

COURSE IN THE WARD DAY 2

Vital signs: D5 0.3 NaCl 1/2 L 72-

Temp: 36.2 73ugtts/min x8*
CR: 100 Cefuroxime
RR: 33 340mg/IV q8
(+) cough Weight: 10kg Paracetamol
(-) fever 100mg/IV q4 for
PCAP-MR
(-) tachypnea fever
(-) cyanosis Salbutamol q4
SCE D/C 02
(-) retractions Salbu+Iprat neb q6
(-) rales
 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

COURSE IN THE WARD DAY 3

Vital signs:
Temp: 36.2
MGH
CR: 104
Cefuroxime
RR: 34
250mg/5ml 3ml BID
(+) cough Weight: 10kg
for 3 days
(-) fever
PCAP-MR Salbutmol syrup 2.5
(-) DOB (-) tachypnea
ml TID for 5 days
(-) cyanosis
Zinc syrup 5ml OD
SCE
for 4 weeks
(-) retractions
(-) rales
 3/F
Cough
Difficulty of Breathing

Fever
Subcostal retractions

Rales
Wheezes
Approach to Diagnosis
COUGH
 COUGH
EXTRAPULMO
NARY DISEASE INFLAMMATORY

Community-
Gastroesophageal Acquired Acute
Reflux Disease Pneumonia Bronchitis
Differential Diagnosis
EXTRAPULMONARY DISEASE
Gastroesophageal
Reflux Disease

INFLAMMATORY
Acute Bronchitis

INFLAMMATORY
Community-Acquired
Pneumonia
Differential Diagnosis
EXTRAPULMONARY DISEASE
Gastroesophageal
Reflux Disease Most common esophageal disorder in
children of all ages. Physiologic GER is
exemplified by effortless regurgitation,
which becomes pathologic in infants and
children who manifest or report
bothersome symptoms

INFLAMMATORY
Acute Bronchitis

INFLAMMATORY
Community-Acquired
Pneumonia
Differential Diagnosis Gastroesophaeal Reflux Disease
EXTRAPULMONARY DISEASE
Gastroesophageal
Reflux Disease RULE IN
Cough
Wheezes

INFLAMMATORY
Acute Bronchitis

INFLAMMATORY
Community-Acquired
Pneumonia
Differential Diagnosis
EXTRAPULMONARY DISEASE
Gastroesophageal
Reflux Disease Gastroesophaeal Reflux Disease
Tachypnea

Heartburn

Vomiting
INFLAMMATORY
Acute Bronchitis Esophagitis

INFLAMMATORY
Community-Acquired
Pneumonia
Differential Diagnosis Gastroesophaeal Reflux Disease
EXTRAPULMONARY DISEASE
Gastroesophageal
RULE
OUT
Reflux Disease

INFLAMMATORY
Acute Bronchitis

INFLAMMATORY
Community-Acquired
Pneumonia
Differential Diagnosis
EXTRAPULMONARY DISEASE
Gastroesophageal
Reflux Disease

INFLAMMATORY When the tracheobronchial epithelium

Acute Bronchitis is invaded by the infectious agent leading
to activation of inflammatory cells and
release of cytokines. Symptoms (fever &
malaise). The epithelium become
significantly hypersensitized leading to
protracted cough lasting 1-3 wk.

INFLAMMATORY
Community-Acquired
Pneumonia
Differential Diagnosis ACUTE BRONCHITIS
EXTRAPULMONARY DISEASE
Gastroesophageal
Reflux Disease RULE IN
Cough
INFLAMMATORY
Acute Bronchitis
Fever

Difficulty of Breathing

Tachypnea
INFLAMMATORY
Community-Acquired
Pneumonia
Differential Diagnosis
EXTRAPULMONARY DISEASE
Gastroesophageal Acute Bronchitis
Reflux Disease
Rhinitis
Conjunctivitis
INFLAMMATORY
Nasopharyngitis
Acute Bronchitis
Chills

INFLAMMATORY
Community-Acquired
Pneumonia
Differential Diagnosis ACUTE BRONCHITIS
EXTRAPULMONARY DISEASE
Gastroesophageal
RULE
OUT
Reflux Disease

INFLAMMATORY
Acute Bronchitis

INFLAMMATORY
Community-Acquired
Pneumonia
Differential Diagnosis
EXTRAPULMONARY DISEASE
Gastroesophageal
Reflux Disease

INFLAMMATORY
Acute Bronchitis

INFLAMMATORY
Community-Acquired Defined as inflammation of the lung
Pneumonia parenchyma, leading cause of death
globally among children younger than 5
yr– caused by microorganisms & non
infectious causes.
Differential Diagnosis COMMUNITY ACQUIRED PNEUMONIA
EXTRAPULMONARY DISEASE
Gastroesophageal
Reflux Disease RULE IN
Cough
INFLAMMATORY Difficulty of breathing
Acute Bronchitis
Fever
Subcostal retractions
Rales
INFLAMMATORY
Community-Acquired Wheezes
Pneumonia
Differential Diagnosis
EXTRAPULMONARY DISEASE
Gastroesophageal CROUP
Reflux Disease

INFLAMMATORY
Acute Bronchitis

INFLAMMATORY
Community-Acquired
Pneumonia
differential diagnosis ACUTE BRONCHIOLITIS

Acute RULE
OUT
Bronchitis

Acute
Bronchiolitis

CROUP
Discussion

PEDIATRICS
PNEUMONIA
Infection
Inflammed alveoli—decreased oxygen

Infants, toddlers, preschool-aged children

Viral-RSV
Bacterial-S. pneumonia

PEDIATRICS
PNEUMONIA
Etiologic agent
AGE GROUP FREQUENT PATHOGEN
NEONATES GBS, E. COLI, OTHER GRAM
<3 WEEKS NEGATIVE, S. PNEUMONIAE, Hib
3WK-3MO RSV, OTHER RESPIRATORY VIRUSES
(RHINOVIRUSES, PARAINFLUENZA
VIRUSES, INFLUENZA VIRUSES,
ADENOVIRUSES, S. PNEUMONIAE,
Hib, if patient is afebrile consider
CHLAMYDIA TRACHOMATIS
4MO=4YR RSV, OTHER RESPIRATORY VIRUSES
(RHINOVIRUSES, PARAINFLUENZA
VIRUSES, INFLUENZA VIRUSES,
ADENOVIRUSES, S. PNEUMONIAE,
Hib, MYCOPLASMA PNEUMONIAE,
GAS

>/= 5YR M. PNEUMONIAE, S. PNEUMONIAE,

CHLAMYDOPHILA PNEUMONIAE,
Hib, INFLUENZA VIRUSES,
PEDIATRICS
ADENOVIRUS, other respiratory virus,
PNEUMONIA
Transmission: person to person
Leading cause of death in children

Risk: compromised immune system

Crowded homes
Parental smoking
Indoor air pollution

PEDIATRICS
 PNEUMONIA
Etiologic factors
Precipitating factors
Entry
Sneeze
Cough
Inflammatory process
Immune response invasion of Lung
Parenchyma
Fever
Mucus Cough &
secretion Sputum prod

Dyspnea Massive Consolidation

inflammation
Chest Retraction & Crackles/
nasal flaring Cyanosis Wheezes
Decreased
breath sounds
PNEUMONIA

DIAGNOSIS
PEDIATRICS
PNEUMONIA
Clinical symptoms
Chest Radiography

Blood cultures EDIT

Complete Blood Count

PEDIATRICS
PNEUMONIA

PEDIATRICS
MANAGEMENT
➤ An antibiotic is recommended
➤ 1. For a patient classified as either PCAP A or B is
➤ a. beyond 2 years of age [Grade B];or
➤ b. having high grade fever without wheeze [Grade D]

➤ 2. For a patient classified as PCAP C and is

➤ a. beyond 2 years of age [Grade B]; or
➤ b. having high grade fever without wheeze [Grade D]; or
➤ c.having alveolar consolidation in the chest xray[Grade
B]; or PEDIATRICS
 MANAGEMENT
➤ MICROBIAL AGENT

FEATURES BACTERIAL VIRAL

FEVER T >38.5 T<38.5

WHEEZE Absent Present

PEDIATRICS
 MANAGEMENT
➤ What empiric treatment should be administered if a
bacterial etiology is strongly considered

➤ 1.
For a patient lassified as PCAP A or B without previous
antibiotic, oral amoxicillin (40-50mg/kg/day in 3 divided
doses) is the drug of choice [Grade D]

➤ 2.
For a patient classified as PCAP C without previous
antibiotic & who has completed the primary immunization
against Heamophus influenza type b, penicillin G (100,000
units/kg/day in 4 divided doses) is the drug ofPEDIATRICS
choice [Grade
 MANAGEMENT
➤ CRITERIA FOR DISCHARGE

PEDIATRICS
 MANAGEMENT
➤ What treatment should be initially given if a viral etiology is strongly considered?

➤ 1. Ancillary treatment should only be given [Grade D]

➤ 2. Oseltamivir [2mkd BID for 5 days] or amantadine [4.4-8.8 mkD for 3-5 days] may be given
for influenza that is either confirmed by laboratory [Grade B] or occuring as an outbreak
[Grade D]

PEDIATRICS
PNEUMONIA-complications
Pleural effusion
Empyema
Lung abscess
Bacteremia
Septicemia
Meningitis
Septic Arthritis
Endocarditis or Pericarditis
PEDIATRICS
PNEUMONIA-prognosis
Recover rapidly and completely
Tx: bacterial pneumonia be cured 1-2weeks

Viral > Bacterial Pneumonia

Long term alteration of pulmonary
function-rare

PEDIATRICS
PNEUMONIA-prevention
Frequent hand washing
Good personal hygiene
Zinc supplementation- 10mg for infants
& 20mg for children >2yrs for a total of
4-6mos

Vitamin A immunomodulators and

Vitamin C should not be routinely
administered as a preventive strategy

PEDIATRICS
PNEUMONIA-prevention
Pneumococcal vaccine
Hib
<6 months-4 doses (1st 3 doses-2months apart
6-12 mos- 2 doses -1month apart booster-1 yr after the 2nd dose
1 y.o. 1 dose only
13 valent pneumococcal vaccine
4 dose, 2,4,6 mos
Booster at 15 mos
2 y.o. 1 dose
1-2 y.o. 2 doses 2 mos apart
7-11 mos 2 doses 1 mon after, 3rd dose @ 2y.o.

Pneumo23
After 2 y.o.
given every 5 yrs if high risk
If not 1 dose
High risk adults given every 5 yrs
PEDIATRICS