ADMISSION

CONFERENCE
January 21-22, 2018
Drs. Lusung/Villena
Drs. Feliciano/Timbol/David/Miclat/Guevarra/
Penuliar/Jayme/Quizon/Sy
PGIs Flores/Dela Pena/Feliciano/Punzalan
JIs Vergara/Villanueva
ER ADMISSIONS
• Admissions:
WARD CENSUS
Area 5th 6th TOTAL
Pink
Yellow
White
Green
TOTAL
 Age/Sex/ Chief Admitting
Name
Weight Complaint Impression

Right sided T/C CNS Infection, R/O

SUBA, Erica Joy 8/F/19.8kg
weakness Stroke in the Young

GUMBAN, Difficulty of
3mo/F/3.8kg Pertussis Suspect
Athena Kendra breathing
 Age/Sex/ Chief Admitting
Name
Weight Complaint Impression

QUIOC, Nisha Bluish

NB/F/1.65kg Sepsis Meningitis
Clarrise discoloration

NERONIA, Difficulty of
15days/F/3.2kg Neonatal Pneumonia
Maria Andrea breathing
 Age/Sex/ Chief Admitting
Name
Weight Complaint Impression

FELICISIMO,
11/M/36kg Fever Dengue S/P Dengvaxia
Aaron James

MIRANDA, Pediatric Community

2mos/F/4.3kg Cough
Cassey Jade Acquired Pneumonia-C
 Age/Sex/ Chief Admitting
Name
Weight Complaint Impression

Pneumonia with Viral

KIM, Daniel 8mos/M/8.9kg Cough
Exanthem

BANDOQUILLO, Difficulty of Pediatric Community

1/F/8kg
Roxanne breathing Acquired Pneumonia-C
 Age/Sex/ Chief Admitting
Name
Weight Complaint Impression

Upward rolling Febrile-Related Seizure

SOLLO, Dion 10mos/M/10kg
of eyeballs secondary to SVI

Erratic Intestinal
Vomiting out
OSI, Reynavil 14/F/22kg Parasitism with
of worms
Moderate Dehydration
 Age/Sex/ Chief Admitting
Name
Weight Complaint Impression

Acute Gastroenteritis
CANLAS, Cain 3/M/43kg Vomiting with Moderate
Dehydration

MACAPAYAG, Difficulty of Bronchial Asthma in

2/M/14kg
Alren breathing Acute Exacerbation
RB | 1y4m | F | 8kg

Name: Roxanne Bandoquillo

AGE: 1 year and 4 months old
GENDER: Female
ADDRESS: Santo Tomas, Pampanga
CITIZENSHIP: Filipino
RELIGION: Roman Catholic
BIRTH DATE: September 24, 2016
INFORMANT: Mother
RELIABILITY: 95%
RB | 1y4m | F | 8kg

Chief Complaint
Difficulty of Breathing
RB | 1y4m | F | 8kg

History of Present Illness

Patient had colds and on-and-off cough, non-productive,
1 mo non-distressing, with no difficulty of breathing and fever.
PTA No consult was done. No medications were given.

Patient had persistence of symptoms of fever and cough

which was then productive, clear sputum, no difficulty of
1 wk breathing. Mother self-medicated with Carbocisteine
PTA 50mg/ml drops, 1.2ml every 8 hours, and Paracetamol
100mg/ml drops, 1.1ml every 4 hours when with fever,
which afforded temporary relief of symptoms. No consult
was done.
RB | 1y4m | F | 8kg

History of Present Illness

Few Patient still had persistence of cough and fever. Her
mother also noted fast breathing and difficulty of
hours breathing, prompting consult to our institution, thus this
PTA admission.
RB | 1y4m | F | 8kg

Birth History
Prenatal:
• The mother had 6 prenatal check up at our institution
throughout pregnancy, starting at 3 months AOG.
• She took multivitamins daily.
• Screening tests for diabetes and hepatitis B were
negative.
• She did not smoke, drink or use drugs during the
pregnancy.
• No history of UTI, DM, HPN during pregnancy.
RB | 1y4m | F | 8kg

Birth History
Natal:
• She was born term, via spontaneous vaginal delivery to
a G2P2 (2002) mother.
• She had spontaneous cry after delivery.
• BW unrecalled.

Neonatal History:
• There was no cyanosis, difficulty of breathing, vomiting
or jaundice.
• She was immediately brought to the mother for
breastfeeding.
• She had normal Newborn Screening result.
RB | 1y4m | F | 8kg

Immunization History
• Patient had BCG and Hepatitis B vaccine at birth.
• Mother claimed that patient had been immunized as per
RHU basis, however could not recall specific doses of
vaccines given.
RB | 1y4m | F | 8kg

Past Medical History

• OPERATIONS: none
• INJURIES: none
• HOSPITALIZATIONS: none
• ALLERGIES: none
RB | 1y4m | F | 8kg

Family History
• (-) Bronchial Asthma
• (-) Atopy
• (-) Hypertension
• (-) Diabetes Mellitus
• (-) Pulmonary TB
• (-) Heart disease
• (-) Kidney disease
RB | 1y4m | F | 8kg

Personal and Social History

• Mother – house wife
• Father – driver

ENVIRONMENT, & LIFESTYLE HISTORY

• Patient lives in a bungalow-type house made up
of wood and concrete, well-ventilated and well-
lit, however in a relatively crowded
neighborhood.
• No factories or garbage disposal areas nearby.
RB | 1y4m | F | 8kg

Personal and Social History

FEEDING HISTORY
• She is in complementary feeding: formula milk
(Bearbrand) 1:1, and solid foods.
• He consumes about 4 oz/feeding, x 5 feedings in
24 hours. She eats rice, porridge, bread, and
biscuits. He does not eat meat yet.
• Drinking water is commercial distilled water
(Absolute, 6 Li) non boiled.
RB | 1y4m | F | 8kg

Review of Systems
• GENERAL: no weight loss
• SKIN: no pallor, no jaundice, no cyanosis
• EYES: no redness, no discharge
• EARS: no discharge
• NOSE and SINUSES: no congestion
• MOUTH and THROAT: no swelling, no bleeding
gums, no sores
RB | 1y4m | F | 8kg

Review of Systems
• NECK: no lumps, no swollen glands
• RESPIRATORY: (See HPI), no hemoptysis
• GASTROINTESTINAL: no diarrhea, no vomiting
• GENITOURINARY: no foul smelling discharge
• MUSCULOSKELETAL: no weakness
• HEMATOLOGIC: no hematomas
• NEUROLOGIC: no seizures
RB | 1y4m | F | 8kg

Physical examination
• GENERAL
▫ awake, active, irritable
• VITAL SIGNS
▫ CR: 125 RR: 54 Temp: 36.7C
• Anthropometric measurement:
▫ Weight: 8kg (z score=below -2; underweight)
▫ Length: 74cm (z score=below -2; stunted)
▫ Weight for Length: (z score=below -1; normal)
RB | 1y4m | F | 8kg

Physical examination
• Skin: No jaundice, no pallor, no rashes, no cyanosis,
fair skin turgor
• HEENT: Anicteric sclerae, pink palpebral conjuctivae,
no sunken eyeballs, moist lips and mucosa
• Chest: Symmetric chest expansion, tachypneic, with
occasional subcostal retractions, resonant upon
percussion, harsh breath sounds with rales on both
lung fields
• CVS: Adynamic precordium , tachycardic and with
regular rhythm, no murmurs
RB | 1y4m | F | 8kg

Physical examination
• Abdomen: Globular, with normoactive bowel
sounds, tympanitic, soft, non-tender
• Extremities: Fair equal pulses, CRT <2 sec
RB | 1y4m | F | 8kg

Salient Features
SUBJECTIVES OBJECTIVES
• 1y, 4m/F • Awake, active, irritable
• (+) colds • Tachycardic (125bpm)
• (+) cough, productive, clear • Tachypneic (54cpm)
sputum • Afebrile (36.7C)
• (+) fast breathing • (+) fever fhptc
• (+) difficulty of breathing • Underweight
• (+) unrecalled vaccines given • Stunted
• (-) grunting • (-) Cyanosis; Fair skin turgor
• (-) Sunken EB
• SCE, (+) occ. SC rets, (+) harsh
BS with rales BLF
• Fair equal pulses
RB | 1y4m | F | 8kg

Admitting Diagnosis
Pediatric Community Acquired
Pneumonia-C
 RB | 1y4m | F | 8kg

Diagnostics
PARAMETER RESULT REF RANGE
Hemoglobin 12.4 12.0-16.0 g/dL
Hematocrit 37.4 35.0-49.0
RBC 5.16 3.5-5.2 x1012 /L
WBC 14.21 4.0-12.0 x109/L
Differential Count
Neutrophils 64.3 50.0-70.0
Lymphocytes 29.5 20.0-60.0
Monocytes 5.6 3.0-12.0
Eosinophils 0.3 2.0-4.0
Platelet count 330 150-450 x109/L
RB | 1y4m | F | 8kg

Chest X-ray
RB | 1y4m | F | 8kg

Therapeutics
• NPO
• IVF:
▫ D5NSS 1L at 200cc to run for 8 hours at 26 ugtts/min
• Medications:
▫ Cefuroxime 270mg IV q 8h ANST
▫ Paracetamol 80mg IV q 4h PRN for fever T>38C
▫ Salbutamol neb, 1 neb q 4h
• O2 inhalation at 1-2lmp
• Do inhalation after every nebulization
• WOF: respiratory distress
• VS q 4h
• Refer accordingly
CASE DISCUSSION
 Approach to the Diagnosis

Aspiration
pneumonia
Non infectious
causes
Hypersensitivity
Clinical features of reaction
suggestive of
pneumonia
Bronchiolitis Low Risk
Infectious causes
Community-
Moderate Risk
acquired

High Risk
RB | 1y4m | F | 8kg

Salient Features
SUBJECTIVES OBJECTIVES
• 1y, 4m/F • Awake, active, irritable
• (+) colds • Tachycardic (125bpm)
• (+) cough, productive, clear sputum • Tachypneic (54cpm)
• Afebrile (36.7C)
• (+) fast breathing
• Underweight
• (+) difficulty of breathing
• Stunted
• (+) unrecalled vaccines given • (-) Cyanosis; Fair skin turgor
• (-) grunting • (-) Sunken EB
• Born full term • SCE, (+) occ. SC rets, (+) harsh BS with
• (+)family exposure with cough & rales BLF
colds • Fair equal pulses
• (-) history of aspiration • CXR:
• (-)history of hypersesiivity reaction • (+) infiltrates (lateral view)
• (+)Hyperaerated
• (+) lobar consolidation
ASPIRATION PNEUMONIA
RULE IN RULE OUT
(-)Difficulty of breathing (-)foreign body
(-)Tachypneic (54cpm) (-) post natal aspiration:
(-)prematurity
(-)gastroesophageal reflux
(-)improper feeding practices
(-)esophageal and duodenal
obstruction
(-) depressant medicines

(+) occ. SC rets

HYPERSENSITIVITY PNEUMONIA
RULE IN RULE OUT
(+)Difficulty of breathing (-)exposure to agricultural aerosols,
animals and other chemicals (no
antigen exposure)
(+)Tachypneic (54cpm) (-) ground glass appearancce
(+) occ. SC rets (-) lymphocytosis
(+) rales (-) recurrent pneumoia
(+) cough
BRONCHIOLITIS
RULE IN RULE OUT
(+)Difficulty of breathing (-)toxic fume inhalation
(+) undocumented fever fhptc (-)wheeze
(-) cyanosis
(+) good perfusion
(-) history of post infection &
connective tissuee disease
(-) aspiration
(+)Tachypneic (54cpm) CXR:
(+) occ. SC rets (-) may be relatively normal
(+) rales (-) hyperlucency (mosaic pattern)
(+) cough
COMMUNITY ACQUIRED PNEUMONIA
RULE IN RULE OUT
(+) <5 years old (-)history of aspiration
(+)Difficulty of breathing
(+)Tachypnea (54cpm) (-) cyanosis
(+) occ. SC rets (-)lethargy,
(+) rales (-) gastrointestinal disturbances
(+) cough (vomiting, anorexia,
(+) family exposure with cough and diarrhea)
colds
(+) elevated WBC
CXR:
(+) infiltrates (lateral view)
(+)Hyperaerated
(+) lobar consolidation
 Pneumonia
• Pneumonia is and infection of the lower
respiratory tract that involves the airways and
parenchyma with consolidation of the alveolar
spaces.
 Epidemiology
• Although pneumonia can often be treated and
cured, 1.1 million children under the age of five
die due to pneumonia every year (18% of all
deaths of children under five years old
worldwide).
• Immunizations have had a great impact on the
incidence of pneumonia caused by pertussis,
diphtheria, measles, H. influenza type b and S.
pneumoniae.
 Epidemiology
• Risk factors for lower respiratory tract infections
include gastroesophageal reflux, neurologic
impairment (aspiration), immunocompromised
states, anatomic abnormalities of the respiratory
tract, residence in residential care facilities, and
hospitalization, especially in an intensive care
unit.
 Etiology
• Most cases of pneumonia are caused by
microorganisms
• Non-infectious causes:
▫ Aspiration (of food or gastric acid, foreign bodies,
hydrocarbons, and lipoid substances)
▫ Hypersensitivity reactions
▫ Drug- or radiation-induced pneumonitis
 Etiology
AGE GROUP FREQUENT PATHOGENS
Neonates Group B streptococcus, E. coli, other Gram negative bacilli,
(<3wks) S. pneumoniae, H. influenza (type b, non-typable)
Respiratory syncytial virus, other respiratory viruses
(rhinoviruses, parainfluenza viruses, influenza viruses,
3wks-3mos adenoviruses), S. pneumoniae, H. influenza (type b, non-
typable), if patient is afebrile, consider Chlamydia
trachomatis
4mos-4yrs Respiratory syncytial virus, other respiratory viruses, S.
pneumoniae, H. influenza (type b, non-typable),
Mycoplasma pneumoniae, group A streptococcus
>5yrs M. pneumoniae, S. pneumoniae, Chlamydophilia
pneumoniae, H. influenza, Influenza viruses, adenoviruses,
other respiratory viruses, Legionella pneumophilia
 Etiology
• Streptococcus pneumoniae (pneumococcus) is
the most common bacterial pathogen in children
3 weeks to 4 years of age.
• Mycoplasma pneumoniae and Chlamydophila
pneumoniae are the most frequent bacterial
pathogens in children age 5 years and older.
 Etiology
• Viral pathogens are a prominent cause of lower
respiratory tract infections in infants and
children older than 1 mpnth but younger than 5
years of age.
• Of the respiratory viruses, respiratory syncytial
virus (RSV) and rhinoviruses are the most
commonly identified pathogens.
 Diagnostic Criteria
WHO HAS
3mos-5yrs 5-12yrs >12yrs
PNEUMONIA?
Tachypnea >20
Fever >37.8C
Tachypnea Tachycardia >100
Tachypnea
Cough plus Fever Decreased BS
Chest indrawing
Crackles Rhonchi
Crackles
Wheezes
 Diagnostic Workup
FOR PCAP A or B
• Chest X-Ray
• May be done to r/o pneumonia-
related complications or
pulmonary conditions simulating
NOT ROUTINELY
pneumonia
DONE
• CBC
• CRP
• ESR
• Blood culture
 Diagnostic Workup
FOR PCAP C
• To determine etiology
• GS/CS of pleural fluid
SHOULD BE
• To determine oxygenation
DONE
• Pulse Oximetry
• Arterial Blood Gas
 Diagnostic Workup
FOR PCAP C
• To determine other pulmonary
pathology
• CXR AP/Lat
• To determine appropriateness of
antibiotic usage
MAY BE DONE
• C-reactive protein
• Procalcitonin
• WBC count
• GS of sputum of nasopharyngeal
aspirate
 Diagnostic Workup
FOR PCAP C
• To determine etiology
• Sputum CS
• Blood CS
• To predict clinical outcome
• CXR AP/Lat
MAY BE DONE
• Pulse Oximetry
• To predict presence of PTB
• PPD
• Sputum AFB