CASE PRESENTATION in Pediatric

ward
Assessment
SCAP

BY ;Firomsa Geremu

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 Patient demographics

 Name :G.Z
 Sex: M
 Age:2
 Address:kombolcha
 Region: oromiya
 Card number:630181
 Bed number :19
 Date of Admission:6|6|14
 Ward :pediatric
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loss of consciousness for 3hr duration

c/c

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 HPI
The patient was relatively healthy until 2 days back at
which started to develop vomiting which is non
projectile ,non bloody of 4 episode and non mucoid ,non
bloody diarrhea of 3 episode .
1 day back he develop inability to pass urine for this
compliant he was taken to local healthy center where he
was given amoxicillin and metronidazole but he was to
weak to take the medication .

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Cont…

His consciousness began to decrease and was again taken to health

center where 1 dose of ceftriaxone and gentamycin was given and
referred to HFSH for better management .
otherwise no history of
 cough
Chocking episode
Drug intake
Abnormal body movement
Fever
Chronic illness

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 Con…
He is finally vaccinated and he was exclusively breast feeding for the first
6 month he started on complementary feeding with smashed potato.
He stopped breast feeding 2 months back.
FH :No family history of chronic disease
SH :He lives with his family
PMH :He took amoxicillin ,metronidazole ,ceftriaxone and gentamycin
ADR: No known adverse drug reaction
Drug allergy: No drug allergy is reported

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 physical examination
vital sign
date PR(beat/ RR(beat/ TºC SO2 BP(mmhg)
min) min)
6/6/14 180 50 36.6 68% 90/51

8/6/14 134 34 36.6 94% 90/51

9/6/14 136 30 36.6 95%

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 cont….

 GA - AS L
 Respiratory distress
 comatose GCS
 Vital sign
 P R =180 beat per minute
 RR= 50 beat per minute
 T =36.6ºC
 SPO2 =68% off oxygen
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= 95% INO2 4L per minute
Cont…

HEENT
pink conjunctiva
 no ear discharge
 there is thin secretion in air way
LGS

no palpable lap
Chest

moderate IC/SC criptation
There is a transmitted sound heard all over the chest

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Cont……
 CVS
S1 and S2 well heard
No added sound
Pulse are palpable full in volume
Capillary refill < 3 sec
ABD

 flat ,moves with respiration
No organ megally
There is supra pubic fullness

GUS

un circumcised
MSS


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 cont ….

no deformity
IS

no edema

NS

GCS 3/15
Tone hypotonic
Power difficult to assess
DTR +2/4
Pupil mid size and reactive


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 laboratory investigation 6/6/2014
Test items Lab results Normal range

HCT 34 36-46%

HGB 9 12-16 g/dl

MCV 77 80-100fl

ALT 20.8 10-40 Units/l

AST 39.6 8-33 Units/l

Creatinine 0.47 0.5-1.2mg/dl

Ca2+ 2.41 8.7-10mmol/l

Na+ 133 136-146mmol/l

K+ 4.37 3.5-5mmol/l 12
 Goal of therapy

 To normalize the laboratory values

 To alleviate the sign and symptoms
 To prevent complication of SCAP+AUR
 Stabilize the child
 To improve quality of life
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 drug therapy

Currently he is taking ceftriaxone 500mg IV BID and

Azithromycin
100mg per oral daily then 50mg for the next four days .

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 DTP

 There is no any drug therapeutic problem

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Care plan
 To continue the above medication

 Closely follow response of the patient

 To give advice on the benefit of medications

 To treat SCAP and AUR

 To do urine analysis and abdominal ultrasound

 Put on INO2 1L/min

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Monitoring parameter

 Monitoring RBS for 6hr

 Frequent positioning of 2 hr
 Do frequent suctioning
 V/S : Bp, PR,RR ,SO2
 Blood hemoglobin

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Patient education

I was advised to his mother

 how to keep her and her child hygiene

 the purpose of vaccination

 To get plenty of bed rest even after discharge

 Getting enough sleep will give the strength it needs to fight the illness

 To take deep breath

 Cough several times each hour to loosen up mucus and get it out of his lungs
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THANK YOU !!!!!!

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