University of Santo Tomas

Faculty of Medicine and Surgery

Department of Pediatrics
Clinical Division

Room/Bed : 226C HEENT: (-) epistaxis, (-) salivation, (-) aural discharge, (-) tearing
Hospital number : 17-200000106251 Cardiovascular: (-) orthopnea, (-) cyanosis
Admission number : 17K00252 Gastrointestinal: (-) constipation, (-) hematochezia
Patient : TANANGUNAN, SOPHIA ANGELA VIDUYA Genitourinary: (-) hematuria
Age/Sex : 1/ F Neurologic: (-) seizures, (-) altered sensorium
Date of birth : 11/07/16 Hematologic: (-) bleeding
Civil Status : Single Musculoskeletal: (-) deformities
Nationality/Citizenship: Filipino
Home Address : 622 A. Paltoc St., Sta. Mesa, Manila Developmental History- 12 months
Religion : Roman Catholic 2 words other than mama and dada
Date of Admission : 11/18/2017 Begins to feed with fingers
Time of Admission : 7:48 PM Kisses on request
Contact Number : 715- 3047 Releases object on request
Informant/s : Mother Obeys commands with gestures
Reliability : Good Cannot walk alone with one hand held yet
Attending Physician : Dr. Citadel de Castro Cannot stand alone
Resident-in-Charge : Dr. Abegail Paguyo

Chief Complaint 24hour Food Recall (PREMORBID- November 12, 2017)

Difficulty of breathing and fever Food Kcal
¼ pandesal + ½ boiled egg + breastmilk (15 33 + 43+
History of Present Illness Breakfast
mins., 1 breast) 120= 196
Patient was born term (39-40 weeks AOG by LMP and ultrasound) via normal 80 +
spontaneous delivery to a 35 year old G4P3 (3003). The mother is a college graduate, AM Snack 1 Stick-O wafer + breastmilk (15 mins., 1 breast)
120= 200
seafarer, Roman Catholic with O+ blood type, married to a 29 year old college 2 spoonfuls of rice + adobo soup + pork shreds 33 + 63
graduate working as a seaman with B+ blood type. Lunch
+ breastmilk (15 mins., 1 breast) 120=216
75 +
Prenatal check up started at 8 weeks age of gestation in a ship’s clinic, later on in a PM Snack 1 Nissin wafer+ breastmilk
120= 195
private clinic in Spain then in La Union, Philippines, and UST Hospital for a total of 8
2 spoonfuls of rice + porkchop shreds + 33+ 33+
visits. There was no exposure to viral exanthems, radiation, intake of abortifacient Dinner
breastmilk (15 mins., 1 breast) 120= 186
drugs, no history of alcohol intake and smoking during pregnancy. Non-reactive for
ACI 993
Hepatitis B. The patient’s mother was diagnosed to have Gestational Diabetes
RENI 1070
Mellitus on DM screening in 2016. No history of antibiotic intake, chioamnionitis,
% Deficit 7.1%
hypertension, diabetes, thyroid disorder, allergies during pregnancy.

The patient was breastfed exclusively for 6 months, and was introduced with
complementary food at 6 months, and started on table food at 7 months. The patient Past Medical History
is currently being introduced to milk formula (Enfagrow A+). Previous illnesses: Cough at 5 months old- given Salbutamol unrecalled dose, Colds
at 10 months old- given Cetirizine unrecalled dose. Cough at unrecalled age- given
6 days prior to admission, the patient had colds with clear nasal discharge. There unrecalled antibiotic for 4 days
were no other accompanying symptoms like fever, cough, diarrhea. No medications Previous surgeries: None
were given and no consult was done. Previous accidents: None
Known allergies: None
Interval history showed persistence of colds with clear nasal discharge. Previous hospitalizations: None
Previous blood transfusion: None
2 days prior to admission, patient had non-productive cough and colds with clear
nasal discharge. The patient had loss of appetite for solid food and preferred Immunization History
breastmilk throughout the day. No other accompanying symptoms, like fever. No Vaccine Date Adverse Place Given
consult was done. Given Reaction

1 day prior to admission, there was persistence of symptoms accompanied with fever BCG 11/07/16 - USTH
(maximum temperature of 38.3oC). The patient was given Paracetamol (13 mkdose)
120mg/ 5mL every 4 hours, which lysed the fever. She was noted to be irritable and Hep B 1 11/07/16 - USTH
still preferred breastmilk. No consult was done.
OPV 1 Unrecalled - La Union
Few hours prior to admission, the patient had persistence of fever, non-productive Health Center
cough and colds with clear nasal discharge. There was also 1 episode of loose
greenish mucoid stools of unrecalled amount. Upon waking up from her afternoon OPV 2 Unrecalled - La Union
nap, the patient was noted to be irritable, with difficulty of breathing. The patient Health Center
then had 1 episode of vomiting of previously ingested breastmilk, again of unrecalled
amount.
OPV 3 Unrecalled - La Union
Health Center
Persistence of symtoms prompted consult hence admission.
Pentavalent Vaccine Unrecalled - La Union
(DTP/Hib/HepB) 1 Health Center
Review of Systems
General: (-) weight loss, (-) weight gain Pentavalent Vaccine Unrecalled - La Union
Skin: (-) rashes, (-) pruritus

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 University of Santo Tomas
Faculty of Medicine and Surgery
Department of Pediatrics
Clinical Division

(DTP/Hib/HepB) 2 Health Center CN III, IV, VI:, EOMS intact

CN V: V1-V3 intact
Pentavalent Vaccine Unrecalled - La Union CN VII: Can smile and puff cheeks without asymmetry , and close eyes against
(DTP/Hib/HepB) 3 Health Center resistance
CN VIII: Gross hearing intact
Measles Unrecalled - La Union CN IX and X: Can swallow
Health Center CN XI: Can turn head side to side and shrug shoulders against resistance
CN XII: Tongue protrusion midline
Cerebellum: not assessed
Motor: 5/5 MMT on both L and R upper and lower extremities
Family History
Sensory: not assessed
(+) Asthma –mother and brother
Reflexes: Deep tendon reflex +2 on all extremities
(+) Hypertension- maternal grandmother
Meningeal: not assessed
(-) Allergies
(-) Diabetes Mellitus
(-) Seizures
(-) Malignancies
(-) PTB Salient Features

Family Profile 1 year old / female

Awake, irritable, ill-looking, well-hydrated, well-nourished, irritable, not in
Age/Sex Education Occupation Health Status respiratory distress, carried
(+) 6-day history of colds
(+) 2-day history of cough
College
Father 29/ M Pet groomer Healthy (+) Fever (max temp = 38.3oC)
Graduate
(+) Tachypnea
(+) Family history of asthma (mother and brother)
College
Mother 35/F Office staff Asthmatic (+) congested turbinates
Graduate
(-) retractions, (+) bilateral rhonchi, crackles, wheeze
Brother 11/M Grade 6 Student Healthy PR 105 bpm RR 43 cpm T 37.0oC

Brother 10/M Grade 4 Student Healthy

Assessment
Brother 4/M Kindergarten 1 Student Asthmatic Pneumonia PCAP C

Plans
Socio-economic and Environmental History 1. Monitor vital signs closely every 2 hours and record. Maintain O2
The patient lives in a two-bedroom apartment with 6 relatives (parents, aunts). The saturation greater than or equal to 95%.
primary caregiver is the mother and the primary source of income is both the mother 2. Monitor input and output accurately every shift and record.
and father. Drinking water is filtered water. Garbage is collected everyday, segregated 3. Diet for age but with strict aspiration precaution; hold feeding if
and recycled. There is exposure to cigarette smoke, but no exposure to other respiratory rate is greater than 40 cpm
allergens (factories, pets). 4. Start IVF at mild (D5 0.3% NaCl 500 mL to run at a rate of 14-15 gtts/min)
5. For gentle chest physiotherapy after every nebulization
Physical Examination on Admission 6. Do gentle physiotherapy after every nebulization
General Survey: awake, irritable, ill-looking, well-hydrated, well-nourished, not in 7. Watch out for sigs of respiratory distress
respiratory distress, carried Diagnostics:
PR 105 bpm RR 43 cpm T 37.0oC O2Sat 94% at room air 1. CBC with platelet count
Weight: 9 kg (z at 0) Height: 75 cm (z above 0) Weight for length: (z at 0) 2. Chest X-ray (AP, lat)
Skin: no jaundice, no rash, warm to touch 3. Urinalysis
Head: normocephalic, fontanels not sunken or bulging Therapeutics:
Eyes: pink palpebral conjunctiva, anicteric sclerae, no eye discharge 1. Ampicillin-sulbactam 250mg/slow IV infusion over 30 mins every 6 hours
Ear: normal set ears, impacted cerumen AU, intact tympanic membrane based on ampicillin content (111 mg/kg/day)
Nose: nasal septum midline, clear nasal discharge, pale boggy turbinates 2. Paracetamol 120mg/5ml, give 5 ml orally every 4 hours as needed for
Mouth and Throat: dry lips and moist buccal mucosa, non-hyperemic posterior fever greater than or equal to 38.0oC
pharyngeal wall, no palatal petechiae, no oral ulcers 3. 0.65% NaCl nasal drops, instill 2-3 drops on each nostril then suction
Neck: no palpable cervical lymph nodes, thyroid not enlarged gently every 4-6 hours as needed
Chest/Lung: (-) subcostal retractions, (-) intercostal retractions (-) supraclavicular 4. Salbutamol nebulization (oxygen-driven) 2.5 mg/ 2.5 ml nebule, 1 nebule
retractions (-) substernal retractions, symmetrical chest expansion, (+) rhonchi (+) every 6 hours
crackles, (+) wheezes 5. Zinc Sulfate 27.5mg/ml drops (10 mg elemental zinc), 2 mL OD for 14 days
Heart: adynamic precordium, apex beat at 4th LICS MCL, (-) heaves, (-) lifts, (-) thrills
no murmurs Discussion
Abdomen: globular, no pulsations, no striae, normoactive bowel sounds, soft, Our patient presented with difficulty of breathing and fever (maximum temperature
tympanitic on all quadrants at 38.3 degree celsius), subcostal retractions, and rhonchi, crackles and wheezes,
Genitalia: grossly female genitalia, (-) diaper rash, (-) sacral dimpling which led us to consider pneumonia as a diagnosis.
Extremities: pulses full and equal, CRT < 2 seconds, no cyanosis, no deformities
Neurologic Examination
Cerebral: Awake, irritable
Cranial Nerves:
CN I: not assessed
CN II:, 3-4 mm ERTL, OU; pupils isocoric
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 University of Santo Tomas
Faculty of Medicine and Surgery
Department of Pediatrics
Clinical Division
Community-Acquired Pneumonia
Pneumonia is the inflammation of lung parenchyma that is usually caused by an
infecting organism; other cause also includes aspiration, hypersensitivity reactions,
and radiation. The exact cause of pneumonia in an individual patient is difficult to
determine because direct culture of lung tissue is invasive and not routinely done,
however the most common cause of pneumonia depends on the age group. Our
patient is 1 year old, for this age group respiratory syncytial virus is the most common
cause. Also common etiology for pneumonia in this age group are other respiratory
viruses (rhinovirus, parainfluenza, influenza, adenovirus) along with S. pneumoniae
and H. influenza.
Viral pneumonia usually results from spread of infection along the airways,
accompanied by direct injury of the respiratory epithelium, which results in airway
obstruction from swelling, abnormal secretions and cellular debris. The small caliber
of airways in young infants makes such patients particularly susceptible to severe
infection. Viral infection of the respiratory tract can also predispose to secondary
bacterial infection by disturbing the normal host defense mechanisms, altering
secretions and modifying the bacterial flora.
Bacterial pneumonia can occur when pathogens colonize the trachea and
subsequently spreads to the lungs or it could gain access to the lungs through direct
seeding due to pathogens in the blood (bacteremia). The pathologic process,
however, depends on the infecting organism. M. pneumoniae attaches to ciliary
epithelium and inhibits its ciliary action, leads to cellular destruction and an
inflammatory response in the submucosa. S. pneumoniae produces local edema,
spread of organisms produces focal lobar involvement. Group A streptococcus
produce necrosis of tracheobronchial mucosa, it can lead to formation of large
amount of exudate, edema and local hemorrhage. S. aureus often produce unilateral
confluent bronchopneumonia, presence of extensive areas of hemorrhagic necrosis
and irregular areas of cavitation of lung parenchyma, resulting into pneumatoceles,
empyema and sometimes bronchopulmonary fistula.
Clinical manifestation of pneumonia usually starts with upper respiratory traction
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symptoms of cough and rhinitis that is seen in our patient. Tachypnea is also present
in our patient, this symptom is the most consistent clinical manifestation of
pneumonia. Increased work of breathing accompanied by alar flaring and intercostal,
subcostal and supraclavicular retractions are signs of respiratory distress, subcostal
retractions were not found in our patient. Rhonchi, crackles and wheezes were also
heard in our patient. Other physical exam findings may include dullness on
percussion, diminished breath sounds, and lagging of the affected side.
The diagnosis of bacterial pneumonia is supported using history and physical exam,
chest radiograph, or laboratory findings. An infiltrate found on chest x-ray (PA and
lateral view) supports the diagnosis of pneumonia, pleural effusions or empyema
indicates complications that may also be seen. Our patient had perihilar infiltrates on
both lung fields and hyperaeration which is supporting the diagnosis of pneumonia
(pCAP C). A CBC can be useful in differentiating viral from bacterial pneumonia. WBC
count can be normal or elevated, not higher than 20,000/mm3 with lymphocytic
predominance. A large pleural effusion, lobar consolidation and high fever at the
onset of the illness are also suggestive of bacterial etiology.
Treatment
Treatment of pneumonia is based on the presumptive cause, age and clinical
appearance of child. Factors that suggestive hospitalization of children with
pneumonia. For mildly ill children who do not require hospitalization, amoxicillin is
recommended; high dose of amoxicillin is prescribed in high prevalence of resistance.
Alternative antibiotics include cefuroxime and co-amoxiclav. Macrolide antibiotics,
azithromycin, are prescribed in school-aged children suspected to have M.
pneumoniae or C pneumoniae. Respiratory fluoroquinolone such as levofloxacin or
moxifloxacin can be used in adolescent patient.
Ampicillin or penicillin G are used as empiric treatment of suspected bacterial
pneumonia in hospitalized child who have received immunization against Hib and S
pneumoniae. For this patient, ampicillin- sulbactam 250 mg/slow IV infusion every 6
hours (111 mg/kg/day) was given. The patient presented with a respiratory rate of
more than 40 upon consult at the emergency room, with subcostal retractions. 02
saturation at room air was <95%.
References
Nelson’s Textbook of Pediatrics, 20th Edition
Prepared by:
Benin, BB / Benitez, DB / Beronilla, AC
JI ALTERNATES
Noted by:
______________________
Dr. Abegail Paguyo
Resident-in-Charge