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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
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
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 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

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