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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

Cover your mouth when you CAP

Cristina M. Garcia

ASMPH LEC Group 1

PCGH Pediatrics Rotation


General data

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


Chief complaint

Chief Complaint

  • Fever (2 days)


History of present illness

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


History of present illness1

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


History of present illness2

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


History of present illness3

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


Review of systems

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


Past medical history

Past Medical History

  • no previous hospitalization

  • no previous operations

  • no history of trauma


Family medical history

Family Medical History

  • Liver disease, Tuberculosis - Maternal side

  • Breast cancer - Paternal side

  • (-) Asthma

  • (-) DM

  • (-) Hypertension, cardiac disease


Developmental history

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


Immunization history

Immunization History

  • BCG - 1 dose

  • OPV - 1 dose

  • Hepa B - 1 dose

  • No HiB


Birth history

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


Nutritional history

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


Genogram 12 030 10

Genogram (12/030/10)

I

43

49

II

20

18

III

4 mos.


Personal social history

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


Environmental history

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.


Environmental history1

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.


Physical examination

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


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Physical examination1

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


Physical examination2

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


Physical examination3

Physical Examination

  • Abdomen:

    • globular abdomen, (-) masses or scars

    • Normoactive bowel sounds

    • tympanitic abdomen

    • (-) tenderness, (-) organomegaly

  • Genital exam:

    • grossly male, (-) deformities

    • Descended testes


Physical examination4

Physical Examination

  • Extremities:

    • full and equal pulses, (-) edema, (-) cyanosis


Neurologic examination

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


Neurologic examination1

Neurologic Examination

  • Sensory: responds to stimuli (light touch)

  • Motor: good muscle tone and strength

  • Reflexes

    • (+) Babinski

    • (+) palmar grasp

    • (-) rooting

    • (-) moro

    • (-) tonic neck


Salient features

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


Admitting diagnosis

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


Differential diagnosis

Differential Diagnosis


Differential diagnosis1

Differential Diagnosis


Course in the wards

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


Course in the wards day 1

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


Chest x ray ap

Chest X-ray (AP)


Chest x ray lateral

Chest X-ray (Lateral)


Chest x ray ap lat findings

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


Course in the wards day 2

Course in the wards – Day 2


Course in the wards day 3

Course in the wards – Day 3


Course in the wards day 4

Course in the wards – Day 4


Discussion

Discussion


Definition

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


Epidemiology

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.


Incidence philippines

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


Etiology

Etiology

  • Viral etiology - most common in PCAP

    • Respiratory Syncytial virus (50%)

    • Parainfluenza (25%)

    • Influenza A or B

    • Adenovirus

  • Best predictor: AGE


Epidemiology1

Epidemiology

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


Pathophysiology

Pathophysiology

Infectious organisms

Inoculation of respiratory tract

Acute weakened resistance

Impaired defense mechanisms

Acute inflammatory host response

viral

bacterial


Clinical manifestations

Clinical Manifestations

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


Risk classification

Risk Classification

Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society


Risk classification1

Risk Classification

Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society


Factors suggesting need for hospitalization

Factors suggesting need for hospitalization

  • Age <6 mos.

  • Sickle cell anemia with acute chest syndrome

  • Multiple lobe involvement

  • Immunocompromised state

  • Toxic appearance

  • Severe respiratory distress

  • Requirement for supplemental oxygen

  • Dehydration

  • Vomiting

  • No response to appropriate oral antibiotic therapy

  • Noncompliant parents

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


Diagnostics

Diagnostics

Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society


Treatment management

Treatment/Management

  • Antibiotics

Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society


Treatment

Treatment

  • Ancillary treatment

    • Oxygen supplementation

    • Hydration (for dehydrated patients)

    • Bronchodilators when (+) wheezing

    • OTC Cough medicines not better than placebo

Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society


Risk factors

Risk factors

  • Prematurity

  • Malnutrition

  • low socio-economic status

  • passive exposure to smoke

  • underlying disease

  • Cystic Fibrosis

  • Attendance at day care centers

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


Complications

Complications

  • Pleural effusion

  • empyema

  • pericarditis

  • Rare

    • Meningitis

    • Suppurative arthritis

    • osteomyelitis

Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society

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


Prognosis

Prognosis

  • Patients with uncomplicated pneumonia

    • Clinical improvement within 48-96 hours of treatment

    • If no improvement, or slow improvement, think

      • Complications

      • Bacterial resistance

      • Other etiology

      • Bronchial obstruction from endobronchial lesions, foreign body, or mucous plugs

      • pre-existing disease

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


Prevention

Prevention

  • Breast feeding

  • Avoidance of environmental tobacco smoke

  • hand washing

  • Vaccination

    • Haemophilus influenza type B

    • Influenza

    • Pneumococcal

  • Zinc supplementation (10 mg for infants, 20 mg >2 yrs, for 4-6 months)

Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society


Thank you for listening

Thank you for listening!


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