“Insert Title Here”

Presented By : Insert Name Here, MD

Pediatrics Resident
Region II Trauma and Medical Center
A case of a caterpillar
molting to a butterfly
 Objectives
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GENERAL DATA
• JN

• 11 YEARS OLD

• MALE

• BAMBANG, NUEVA VIZCAYA

Chief Complaints:
SKIN RASHES
Maternal History
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 BIRTH HISTORY
1ST
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4TH 5TH 6TH

FAMILY
GENOGRAM
Physical Examination
General: awake, concious coherent not in respi-
cardio distress
Anthropometrics: Weight: 45kg (Z score: 0)
Height: cm (Z score:

Vital Signs:
BP: 100/70mmHg
HR: tachycardic at
125bpm
RR: tachypneic at 96cpm
Temp: afebrile at 37°C
Oxygen saturation was
 PHYSICAL
EXAMINATION GENERAL
 awake, concious coherent not in
respi-cardio distress
ANTHROPOMETRICS

Weight: 45kg
Height:146 cm SKIN
BMI: 21.1 Normal  noted with erythematous dusky red
macules, with some vesicular and blister
formation. (+) nilosky sign (skin with gentle
tangential pressure) only in the areas of
erythema normal capillary refill.
VITAL SIGNS
BP: 90/60mmHg
HR: tachycardic at 115bpm
RR: 23 cpm
1
Temperature: febrile at 38°COxygen saturation was 98% 2
 noted with erythematous dusky red macules, with some
vesicular and blister formation. (+) nilosky sign (skin with
gentle tangential pressure) only in the areas of erythema
SKIN normal capillary refill.
Head: The patient has a normocephalic cranium. Hair is color
black, medium length, well distributed, has no flakes and lice.
No palpable masses or tenderness.
Eyes: swelling of the eyelids, Pinkish palpebral conjunctiva.
HEENT Pupils equally reactive to light at 2-3mm.

Ears: blister on posterior auricular area, bilateral

Nose: No nasoaural discharges, non erythmatous terbinates, no
polyps, no lesions.
HEENT Throat: hemorrhagic crusting lips. no swollen tonsils. no
palpable masses nor cervical lymphadenopathies
 • Symmetrical chest expansion, no
Chest
retraction, resonant upon
and
percussion with vesicular breath
Lungs
sounds

• No murmur, bruit, adynamic

Cardiov
precordium. There are no heaves
ascular/
or lifts .Point of maximal impulse
heart
(PMI) at 5th intercostal space.

• The abdomen is soft, globular,

symmetrical, noted erythematous
Abdome
maculo-vesicular rashes all quadrant.
n Normactive bowel sounds. No bruit, no
visible pulsations or peristalsis.
 • erythematous dusky red macules,
Upper and lower extremities. full
EXTREMETIES
range of motion . Full and equal
pulses noted.
 Genital Examination:
GENITO URINARY
SYSTEM
Tanner Stage II:
there is enlargement of testes and
scrotum with reddening and
thinning of scrotum, but no
enlargement of penis

Noted with some erythematous

purpuric macules at pubic
symphysis
 • No edema on extremities, full and
Extremities equal pulses, capillary refill time
of 1-2 seconds

Neurologic • Normal muscular tone, symmetric

examinatio and spontaneous movement of all
n extremities.
 Salient feature
• Ocular sequelae:
• Fever
Photophobia, pain, dry eye,
• Skin Rashes inflammed conjunctiva
• Body Maliase • Oral complications:
• Pruritus discomfort, dry mouth
• Burning Pain feeling
• Nail dystrophy • Genital lesions

• Medication: Antibiotics, antiepileptic

drugs, Nonsteroidal anti-inflammatory
drugs (NSAIDs), allopurinol,
corticosteriods (topical and systemic) and
antiretroviral drugs
 ADMITTING IMPRESSION

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 APPROACH TO ________________
1ST
ST Text Patient AS:
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2nd
nd Text  TEXT

3rd 3rd 3rd

4th 4th
4th

5th
5th
5th 5th

 6TH
6TH  6TH
 6TH
COURSE IN THE WARD
 Course in the Wards:
• CBC
• Hgb: 126
• Hct: 38.8 • RBS: 7.51mmol/L
• WBC: 5.79 • Urea: 3.84
• Segmenters: 78
• Crea: 58.6
• Lymphocytes 20
• Monocytes 02
• Na: 127.4 mmol/L
• Platelet 263 • K: 3.81
• Blood type: “O”RH + • Cl: 96.3
• Ica: 1.26
• Urinalysis was normal. 
• Chest XRay: No significant chest findings
• BCS

•
1st Hospital Day
ward
S O A P
skin rashes V/S
BP: 90/60
bollous impetigo vs. Vital signs monitored
SJS IVF: D5LR IL
CR: 126 (maintenance rate)
RR: 24
Temp: 40C
Wt. 45kgs On Day 1 of Medications:
Ht: 130 cm (200 mkd) Oxacillin
Paracetamol for fever
rashes reddish-brown Mupirucin ointment
erythematous with vesicular Diphenhydramine BID
then become bullae on face
and trunk D/C anticonvulsant
(+) lips: reddish brown or
purplish rash with some
erosions of lips.
(+) eyes: hardly to open with
irritation and some erosions
1st Hospital Day
ward S O A P
skin rashes (2cc/kg) Inc. D5LRs

RBS,Serum
electrolytes,BUN, Referred to Derma
Crea, Punch started
(5mkd)Hydrocortisone q12
biopsy- if available chlorhexidine solution for gargling
and bathing
Mometasone lotion right after
bathing on entire body except face
wet lips with NSS soaked gauze
then apply topical petroleum jelly

referred to ENT-ORL
referred to OPHTHA
2nd Hospital Day
1st PICU Day
S O A P
skin rashes V/S TEN (2.5cc/kg) D5NSS
BP: 110/90
CR:98 On Day 2 of Medications:
RR 24
temp: 39.8 C Oxacillin (200mkD)
Diphenydramine
o2:97% Hydrocortisone
Ranitidine
I:1800 mometasone
chlorhexidine solution
O:390
OU: 0.5cc/kg/hr- Ongoing Na correction x
16hrs 24hrs
HGT q8 hs
2nd Hospital Day
1st PICU Day
S O A P
skin rashes BP:110/70 (4cc/kg)PNSS
CR:126 Ophtha:
RR: 35 Blepheroconjunctivitis systane eye drops every 3hrs to OU
Temp: 37C , bilateral with corneal (not available)
O2: 98% epithelial defect prob Erythromycin EIO TID
Na Hyaluronate q3 to OU
2 to SJS daily lid hygiene

Referred to COD possible shifting of

antibiotic

PIDS:
Maximize hydration
continue Oxacillin
refer back to DERMA for IVIG
3rd Hospital Day
2nd PICU day
S O A P
skin rashes (2.5 cc/kg) PNSS
On Day 3 of Medications:

Oxacillin (200mkD)
Diphenydramine
Hydrocortisone
Ranitidine
mometasone lotion
chlorhexidine solution

Derma
agree with IVIG but explained that it may not be benificial

ENT:
seen and examined
referred to consultant
well ff- up.
4th Hospital Day
3rd PICU day
S O A P
skin rashes (2 cc/kg) PNSS

On Day 4 of Medications:

Oxacillin (200mkD)
Diphenydramine
Hydrocortisone
Ranitidine
claricort TID
nabuphine
paracetamol
mometasone lotion
chlorhexidine solution
Na hyaluronate
erythromycin ointment TID
4th Hospital Day
3rd PICU day
S O A P
skin rashes
CXR IVIG started
(500mg/kg/day) x 3days
CRP: >200mg/dl
ENT notes
No noted blister, no noted
exudates or swelling tonsils
5th Hospital Day
4th PICU

S O A P
skin rashes (2cc/kg) PNSS
CBC: BCS: No Growth after 5 IVIG started
hgb: 96/hct: 30/WBC: days of incubation (500mg/kg/day) on 2nd day
2.68/
Neu:64/lymp:28/plt: 337 Woung GS/CS: No On Day 5 of Medications:
Oxacillin
growth after 24 hours of hydrocortisone
BP: 110/70 incubation claricort
CR: 117 diphenhydramine
RR: 31 AST: 67 paracetamol
nalbuphene
temp: 37.2 ALT: 59 mometasone lotion
O2: 99% Ca: 2.02 Na Hyaluronate
Na: 137 erythromycin
chlorhexidine sol.
Ou: 3.3cc/kg/hr-24 K: 3.7 ranitidine

hypoaalergenic diet
6th Hospital Day
5th PICU

S O A P
skin rashes (2cc/kg) PNSS
BP: 110/70 IVIG started
CR: 112 (500mg/kg/day) on 3rd day
RR: 34
temp: 37.8 On Day 6 of Medications:
Oxacillin
O2: 99% hydrocortisone
claricort
Ou: 1 cc/kg/hr-24h diphenhydramine
paracetamol
nalbuphene
mometasone lotion
Na Hyaluronate
erythromycin
chlorhexidine sol.
ranitidine
7th Hospital Day
6th PICU
S O A P
skin rashes (2cc/kg) PNSS
BP: 110/70 IVIG started
CR: 112 (500mg/kg/day) completed
RR: 34
temp: 37.8 On Day 7 of Medications:
Oxacillin
O2: 99% hydrocortisone
claricort
Ou: 1.8 cc/kg/hr-24h diphenhydramine
paracetamol
nalbuphene
mometasone lotion
Na Hyaluronate
erythromycin
chlorhexidine sol.
ranitidine
gyne pro
jergens ultrahealing lotion
7th Hospital Day
6th PICU
S O A P
skin rashes (2cc/kg) PNSS
BP: 110/70 refered to PIDS due to persistent
CR: 112 Blood GSCS prior to fever
RR: 34 start antibiotic tmax: 38-39C
temp: 37.8 D/C oxacillin shifted to
O2: 99% (150mkd) Cefepime q8
(15mkd) Vancomycin q6
Ou: 1.8 cc/kg/hr-
24h
8th Hospital Day
7th PICU Day

S O A P
skin rashes (2cc/kg) PNSS
BP: 110/70
CR: 116 Blood GSCS prior to start refered to PIDS due to persistent fever
tmax: 38-39C
RR: 35 antibiotic
temp: 37.6 On 8 Day of Medication
O2: 99% (150mkd) Cefepime q8
(15mkd) Vancomycin q6
Ou: 1.8 cc/kg/hr-24h hydrocortisone
claricort
diphenhydramine
paracetamol
nalbuphene
mometasone lotion
Na Hyaluronate
erythromycin
chlorhexidine sol.
ranitidine
gyne pro
jergens ultrahealing lotion
8th Hospital Day
7th PICU Day

S O A P
skin rashes (2cc/kg) PNSS
BP: 110/70
CR: 116 Urine culture referred to Derma
RR: 35 May put soaked nss gauze
temp: 37.6 with petroleum and covered
O2: 99% with dry gauze
when changing dressing wet
with nss before removing.
Ou: 1.8 cc/kg/hr-
24h
9th Hospital Day
8th PICU Day

S O A P
skin rashes (2.5cc/kg) PNSS
BP: 110/70 On 9 Day of Medication
CR: 116 (150mkd) Cefepime q8
RR: 35 (15mkd) Vancomycin q6
temp: 37.4 hydrocortisone
claricort
O2: 99% at 2lpm diphenhydramine
via nc paracetamol
nalbuphene
mometasone lotion
Ou: 1 cc/kg/hr-24h Na Hyaluronate
erythromycin
(+) serosanguinous chlorhexidine sol.
soaked pad ranitidine
gyne pro
jergens ultrahealing lotion
10th Hospital Day
9th PICU Day

S O A P
11th Hospital Day
10th PICU Day
 On admission
Intervention
Signs and Diagnostics
symptoms

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3rd HD 8th HD

 Antibiotic
completed and
discontinued
 Insert Text here  Transfer to NICU 3
as grower babies
 Grower
medications
started
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3rd HD 8th HD

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32 to 42nd HD

Impression

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DIAGNOSTICS:
CBC 10/13 10/16 10/24/2 10/26 11/3 11/9 11/16 11/21

Hemoglobin 130 149 66 195 133 119 109 114

Hematocrit 431 46.6 20 64.3 44.8 36.6 33 36.5

WBC 14.60 10.50 29.78 27.60 11.60 16.10 21.70 32.7

Segmenters 76 53 741 56 46 51 67 742

Lymphocyte 22 33 18 26 42 49 28 22

Platelet 249 363 575 487 594 574 811 646

 SERUM ELECTROLYTES:

Serum 11/4/2020 11/5/2020 11/6/2020 Normal

electrolytes values
Sodium 127.2 130.5 133.1 Preterm:130-
145nmol/L

Potassium 4.23 4.05 4.45 Preterm: 3.0-6.0nmol/L

Chest X-ray: Blood Culture
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 Final Diagnosis

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Discussion
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 Epidemiology
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 Pathophysiology

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Signs and symptoms:
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Diagnostics
 Diagnostics

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 Treatment

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Patient AS:

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 Long term Outcome

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 Patient Education
1st
5th

2nd
6th

7th 3rd

8th if there’s
more 4th
PROGNOSIS:

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 Prevention

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 Long term Monitoring

0-6 months: Patient AS:

 Monthly Monthly Follow ups:
 January
 February
7-12 months:
 March
 Every 2 months

13-36 months:
 Every 3 months

3years old
 Every 4-6 months
 Laboratory Parameter Patient AS:
text

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Update on patient AS
Patient AS at ____ Patient AS at ___ months

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 Follow-ups of Patient AS
Patient Follow ups:
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 Monitoring of Laboratory result:

• 140.3 nmol/L (Normal)

Sodium • N: 130-145 nmol/L

• 4.81 nmol/L( Normal)

Potasium • N: 4.1-5.3 nmol/L

Random blood • 4.83 nmol/L ( Normal)

sugar • N:4.39-7.78 nmol/ L
March 30,2021

TEXT

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• N: < 50nmol/L
Current treatment

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Conclusion

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 Mentor: Reactor:
Name, Title Name, Title
Position Position