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Cover your mouth when you CAP

Cover your mouth when you CAP. Cristina M. Garcia ASMPH LEC Group 1 PCGH Pediatrics Rotation. General Data. AP 4 mos./Male Filipino Roman Catholic Residing in San Miguel, Pasig City Informant: Mother, Father, and Paternal Grandparents Reliability: 70%

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Cover your mouth when you CAP

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  1. Cover your mouth when you CAP Cristina M. Garcia ASMPH LEC Group 1 PCGH Pediatrics Rotation

  2. General Data • AP • 4 mos./Male • Filipino • Roman Catholic • Residing in San Miguel, Pasig City • Informant: Mother, Father, and Paternal Grandparents • Reliability: 70% • Admitted at PCGH on December 3, 2010

  3. Chief Complaint • Fever (2 days)

  4. History of Present Illness • 3 weeks PTA • intermittent cough, productive of whitish phlegm • No associated signs and symptoms • consult at a private clinic • Ambroxol (unrecalled dosage)  No relief • Amoxicillin 6.75 mg  No relief

  5. History of Present Illness • 2 weeks PTA • persistence of symptoms • consult at a private clinic • Carbocisteine • Co-trimoxazole (unrecalled dosage) • Phenylpropanolamine (Disudrin) 0.5 ml QID • Phenylephrine HCl, chlorphenamine (Neozep) 0.5 ml QID • No relief

  6. History of Present Illness • 2 days PTA • persistence of symptoms • (+) undocumented fever • (+) Difficulty of breathing • No consult done • Parents self-medicated patient with Paracetamol drops 8.45 mg/kg/dose

  7. History of Present Illness • Morning PTA • persistence of symptoms • (+) rhinorrhea, productive of yellowish-green mucous • (+) vomiting milk and phlegm (about 4 oz) • Consult at health center • Cephalexin 32.43 mg/kg/day • Paracetamol 8.45 mg/kg/dose • Increase in fever • (+) cyanosis of distal extremities PCGH ER

  8. Review of Systems • Constitutional: no weight loss, no weakness • Integument: (+) rashes (diaper), no changes in color • Respiratory: no hemoptysis • Gastrointestinal: no changes in bowel movement • Genitourinary: no frequency

  9. Past Medical History • no previous hospitalization • no previous operations • no history of trauma

  10. Family Medical History • Liver disease, Tuberculosis - Maternal side • Breast cancer - Paternal side • (-) Asthma • (-) DM • (-) Hypertension, cardiac disease

  11. Developmental History • patient is a 4 mo., male • (+) grasps object placed in hand • (+) moves head toward sound • (+) reaches for objects • (+) chews • (+) roll over • (-) chest up, arm support

  12. Immunization History • BCG - 1 dose • OPV - 1 dose • Hepa B - 1 dose • No HiB

  13. Birth History • Born Full Term to a 17 year old G1P1, delivered via Normal Spontaneous Delivery with birth weight 3.6 kg, at a lying-in clinic, attended by midwife, (-) perinatal/neonatal complications

  14. Nutritional History • Breast fed for 2 weeks then shifted to milk formula (8 oz. per feeding x 4 feedings a day) • No known food allergy

  15. Genogram (12/030/10) I 43 49 II 20 18 III 4 mos.

  16. Personal Social history • Only Child • Mother - 18 y/o not employed • Father - 20 y/o factory worker • Parents not married • Families are not on good terms

  17. Environmental history • Patient does not stay permanently in one household. He is shuttled from the mother’s household to the father’s household and vice versa • Lives in a 1 story wooden house near the streets with 2 bedrooms. • The house is well ventilated and well lighted.

  18. Environmental history • Their water supply comes from Manila Waters. • Drinking water of the patient was previously Wilkins, but now the water comes from a refill station • Garbage is collected every day.

  19. Physical Examination • General Survey: • Conscious, alert, in mild respiratory distress, well-nourished • Vital signs: • HR 165, RR 38, Temp 40.5oC • Anthropometrics: • Length 59 cm (<3rd percentile) • weight 7.4 kg (50-85th percentile for age, >97th percentile for length) • HC 40.5 cm (15th percentile), CC 44.3 cm, AC 46.4 cm

  20. http://www.who.int/childgrowth/standards/en/

  21. http://www.who.int/childgrowth/standards/en/

  22. http://www.who.int/childgrowth/standards/en/

  23. http://www.who.int/childgrowth/standards/en/

  24. Physical Examination • Skin: • normal skin color, good turgor (CRT<2 sec), flushed skin • (+) diaper rash, inguinal area extending to buttocks, (-) lesions, flushed skin • HEENT and neck: • flat, open anterior fontanel; closed posterior fontanel • Normal hair distribution, (-) masses/depressions • anicteric sclerae, pink palpebral conjunctivae, pupils 3-4mm ERTL • (-) ear deformities, (-) discharge, (+) intact tympanic membrane, (+) cone of light • (-) nasal deformities, (+) rhinorrhea, yellow-green discharge slightly dried • (-) Tonsillopharyngeal congestion, (-) cervical lymphadenopathy, supple neck, flat neck veins

  25. Physical Examination • Heart: • adynamic precordium, apex beat at 5th ICS LMCL, tachycardic, regular rhythm • (-) murmurs, good S1/S2 • Lungs: • (-) scars or masses, (+) intercostal/subcostal retractions • symmetric chest expansion, resonant on percussion, (+) rhonchi lower lung fields, (+) crackles on bilateral lower lung fields

  26. Physical Examination • Abdomen: • globular abdomen, (-) masses or scars • Normoactive bowel sounds • tympanitic abdomen • (-) tenderness, (-) organomegaly • Genital exam: • grossly male, (-) deformities • Descended testes

  27. Physical Examination • Extremities: • full and equal pulses, (-) edema, (-) cyanosis

  28. Neurologic Examination • Cranial Nerves: • CN I - not tested • CN II – 3-4 mm equally reactive to light • CN III, IV, VI – intact EOMs • CN V – reacts to facial sensory stimulation • CN VII – no facial asymmetry, able to smile and cry • CN VIII – responds to sound and verbal stimuli • CN IX, X – able to feed, good suck • CN XI – able to turn head from side to side • CN XII – tongue midline

  29. Neurologic Examination • Sensory: responds to stimuli (light touch) • Motor: good muscle tone and strength • Reflexes • (+) Babinski • (+) palmar grasp • (-) rooting • (-) moro • (-) tonic neck

  30. Salient Features • 4 mo./M • fever (2 days) associated with cough and colds, difficulty of breathing, peripheral cyanosis, and vomiting • medications given afforded no relief • on PE, (+) tachycardia, (+) intercostal retractions, (+) rhinorrhea, (+) rhonchi on lower lung fields, (+) crackles on lower lung fields

  31. Admitting Diagnosis • Pediatric Community Acquired Pneumonia, Category C • (+) fever, difficulty of breathing, cyanosis, cough and colds • PLUS findings on PE: (+) tachycardia, (+) intercostal/subcostal retractions,(+) rhinorrhea, (+) rhonchi, (+) crackles

  32. Differential Diagnosis

  33. Differential Diagnosis

  34. Course in the wards • A - Admitted to Broncho ward • D - NPO x 4 hrs then resume feeding once with no vomiting • M - monitor vital signs every hour, urine input/output per shift • I - IVF to follow: D5 IMB (maintenance + 24%) • T – • Cefuroxime 100 mg/kg/day (every 8 hours) • Salbutamol nebulization (every 6 hrs) • Paracetamol 10 mg/kg/d TIV (every 4 hrs) for T > 38oC • Zinc oxide + Calamine ointment, apply to diaper rash TID

  35. Course in the wards – Day 1 CBC: Hgb 105 Hct 0.33 Plt 336 WBC 8.0 Seg .54 Lym 0.46 Urinalysis Albumin trace PC 0-3/hpf Bacteria few

  36. Chest X-ray (AP)

  37. Chest X-ray (Lateral)

  38. Chest X-ray (AP/Lat) findings: • Unofficial reading • Hazy and reticular densities in the lower lung fields as well as nodular opacities in the hilar regions. Cardiothymic shadow is normal in size and configuration. Diaphragm, costophrenic sulci, and included osseous structures are intact. • Impression: Pneumonia, bilateral Hilar adenopathies

  39. Course in the wards – Day 2

  40. Course in the wards – Day 3

  41. Course in the wards – Day 4

  42. Discussion

  43. Definition • Pneumonia • Inflammation of lung tissue caused by an infectious agent that results in acute respiratory signs and symptoms. • It can either be acquired outside (community-acquired) or within the hospital (hospital-acquired) Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society

  44. Epidemiology • Mean global incidence – 0.28 episodes per child-year • Annual incidence of 150.7 million cases • 11-20 million (7-13%) require hospital admission • 95% of all episodes occur in developing countries Rudan I, Tomaskovic L, Boschi-Pinto C, Campbell H. Global estimate of the incidence of clinical pneumonia among children under five years of age. Bull World Health Organ. Dec 2004;82(12):895-903.

  45. Incidence - Philippines • Ranked 3rd in the 10 leading causes of morbidity (2000) and mortality (1997) for all age groups • Cases have been increasing from 380.3/100,000 (1990) to 829.0/100,000 (2000) • Rate of mortality • Under 1 year – 235.4/100,000 (1997) • 1-4 years –50/100,000 • 5-9 years – 43/100,000 Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society

  46. Etiology • Viral etiology - most common in PCAP • Respiratory Syncytial virus (50%) • Parainfluenza (25%) • Influenza A or B • Adenovirus • Best predictor: AGE

  47. Epidemiology McIntosh, K. 2002. Community acquired Pneumonia in children. N Engl J Med, Vol. 346, No. 6, 429-437.

  48. Pathophysiology Infectious organisms Inoculation of respiratory tract Acute weakened resistance Impaired defense mechanisms Acute inflammatory host response viral bacterial

  49. Clinical Manifestations Kliegman, et. al. 2007. Nelson Textbook of Pediatrics, 18th edition.USA: Saunders Elvesier

  50. Risk Classification Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society

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