“ PEDIATRICS-

Case
Presentation

-Sumanga, Juan
Cheska Eunice
A.

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

SINGLE
➤ Cough
CHIEF
COMPLAINT
 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
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
(-) vomiting
SYSTEMS
(-)hematuria
(-) dysuria
(-) epistaxis
 PHYSICAL
EXAMINATION
PHYSICAL EXAMINATION
General survey:
Awake, febrile, in cardiorespiratory 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, wet skin, warm to touch, with
good skin turgor

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

Chest/Lungs: symmetric chest expansion, (+) rales (+) 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 corneal reflex
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 6.62
NEUTROPHILS 42.3 LYMPHOCYTOSI
LYMPHOCYTES 48.2 High S
MONOCYTES 9.1
EOSINOPHILS 0.1
BASOPHILS 0.3
ESR 40 mm/hr High
CT ratio = 0.52
 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

COURSE IN THE WARD DAY 1 AM

D5 0.3 NaCl 1/2 L 62-

63ugtts/min x8*
Vital signs:
Cefuroxime
Temp: 38.3
340mg/IV q8
CR: 123
Paracetamol
(+) cough RR: 46
100mg/IV q4 for
(+) fever Weight: 10kg
PCAP-MR fever
(+) DOB
Salbutamol q20 minsx
(+) Retraction
3 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

D5 0.3 NaCl 1/2 L 72-

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

COURSE IN THE WARD DAY 3

Vital signs:
Temp: 36.2
CR: 104
RR: 34
(+) cough
Weight: 10kg
(-) fever MGH
PCAP-MR
(-) DOB
(-) cyanosis
SCE, (-) retractions
(-) rales
 3/F
Cough
Difficulty of Breathing

Fever
Subcostal retractions

Rales
Wheezes
approach
to diagnosis
differential diagnosis

Acute Bronchitis

Acute
Bronchiolitis

Croup
differential diagnosis

Acute
Bronchitis

Acute
Bronchiolitis

Croup
differential diagnosis Acute Bronchitis

Acute
bronchitis

Acute
Bronchiolitis

Croup
differential diagnosis Acute Bronchitis

RULE IN
Cough
Acute Fever
Bronchitis
Difficulty of breathing

Tachypnea
Acute
Bronchiolitis

Croup
differential diagnosis

ACUTE BRONCHITIS
Rhinitis
Acute Conjunctivitis
Bronchitis
Nasopharyngitis

Chills
Acute
Bronchiolitis

Croup
differential diagnosis ACUTE BRONCHITIS

RULE
Acute
Bronchitis

Acute
OUT
Bronchiolitis

Croup
differential diagnosis ACUTE BROCHIOLITIS

Acute
Bronchitis

Acute
Bronchiolitis

Croup
differential diagnosis CROUP

Acute
Bronchitis
RULE IN
Cough

Difficulty of breathing
Croup
Rales

Croup
differential diagnosis
CROUP
Acute
Bronchitis Ha

Croup

Croup
differential diagnosis ACUTE BRONCHIOLITIS

Acute RULE
OUT
Bronchitis

Acute
Bronchiolitis

Croup
differential diagnosis CROUP

Acute
Bronchitis

Acute
Bronchiolitis

CROUP
differential diagnosis CROUP

Acute
Bronchitis
RULE IN
Cough
Difficulty of breathing
Acute Fever
Bronchitis

CROUP
differential diagnosis
CROUP
Acute
Bronchitis Harsh barking cough
Stridor

Acute
Bronchiolitis

CROUP
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
PNEUMONIA
Transmission: person to person
Leading cause of death in children

Risk: compromised immune system

Crowded homes
Parental smoking
Indoor air pollution
 PNEUMONIA
Etiologic factors
Precipitating factors
Entry
Sneeze

Cough
Inflammatory process
Immune response
invasion of Lung
Parenchyma
Fever
Mucus Cough &
secretion Sputum prod

Massive Consolidation
Dyspnea inflsmmation
Chest Retraction &
Crackles/
nasal flaring Cyanosis Wheezes
Decreased
breath sounds
PNEUMONIA

DIAGNOSIS
PEDIATRICS
PNEUMONIA
Clinical symptoms
Chest Radiography

Blood cultures
Complete Blood Count
PNEUMONIA
MANAGE
➤ An antibiotic is recommended
MENT
➤ 1.

➤ a.
For a patient classified as either PCAP A or B is
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
MANAGE
➤ MICROBIAL AGENT

MENT
FEATURES BACTERIAL VIRAL

FEVER T >38.5 T<38.5

WHEEZE Absent Present

 MANAGE
➤ What empiric treatment should be administered if a
MENT
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 of choice [Grade
➤
MANAGE
What treatment should be initially given if a viral etiology is strongly considered?

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

Viral > Bacterial Pneumonia

Long term alteration of pulmonary
function-rare
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
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
ABDOMINAL PAIN INTERMITTENT FEVER JOINT PAINS BIPEDAL EDEMA

VASCULAR INFECTIOUS ENDOCRINE CARDIAC AUTOIMMUNE

PAST HISTORY OF HEART DISEASE ANEMIA GRADE 4 MURMUR HIGH ASO TITER