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General data

General data. E.C. 6 month old Female Born on March 7, 2013 Taguig City. CHIEF COMPLAINT. Difficulty of breathing. History of Present Illness. Past Medical History. No previous illness No previous hospitalization No previous surgical procedure. Family history. (+) Diabetes mellitus

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General data

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  1. General data • E.C. • 6 month old • Female • Born on March 7, 2013 • Taguig City

  2. CHIEF COMPLAINT • Difficulty of breathing

  3. History of Present Illness

  4. Past Medical History • No previous illness • No previous hospitalization • No previous surgical procedure

  5. Family history • (+) Diabetes mellitus • (-) asthma, allergy, heart disease, hypertension, stroke, cancer

  6. Birth and Maternal history • Born full term delivered via CS (breech delivery) to a 35 year old G1P1 • Birth weight of 5lbs 6oz • Attended by OBGYN, St. Christiana’s hospital • With no fetomaternal complications

  7. Nutritional history • Not breastfed • On formula feeding, started on solid foods

  8. Immunization history • BCG 1 • DPT/Polio 2 • Hib 2 • Hepatitis B 2 • Pneumococcal 1 • Rotavirus 1 • MMR 0 • Measles 0 • Varicella 0 • Influenza 0 • Hepatitis A 0 • Typhoid 0

  9. Developmental history

  10. Physical Examination • General survey: alert, crying, but consolable • Vital signs: BP 90/60mmHg, HR 140bpm, RR 32 cpm, T 36.5deg • Anthropometrics: Hgt 63cm, Wgt 5.4 kg Head circumference 42cm, Chest circumference 45cm, Abdominal circumference 43 cm

  11. Physical Examination • HEENT: anictericsclerae, pink palpebral conjunctivae, no alar flaring, no cervical lymphadenopathy, flat neck veins, no tonsillopharyngeal congestion • PULMONARY: equal and symmetric chest expansion, with shallow subcostal retractions, harsh breath sounds, occasional rales, no wheezes • CARDIOVASCULAR: adynamicprecordium, PMI at 4th left ICS, midclavicular line, regular cardiac rhythm, no murmur

  12. Physical Examination • ABDOMEN: normoactive bowel sounds, soft, no masses, no organomegaly • EXTREMITIES: normal skin color, good skin turgor, no cyanosis, no edema, full and equal pulses

  13. Physical Examination • NEUROLOGIC: alert Cranial nerves: pupils 2-3 mm equally brisk and reactive to light, tracks objects, no nystagmus, no facial asymmetry, responds to sound, (+) gag reflex Motor: normal tone, no atrophy, 5/5 on all extremities Reflexes: normal reflex (++) on all extremities Sensory: responds to touch in all extremities No Babinski No meningeal signs

  14. Admitting diagnosis • Pneumonia

  15. Goals of care • For the patient to have resolution of respiratory distress by the time of discharge • Respiratory rate < 50 cpm • No retractions, no alar flaring • No vomiting • No cyanosis • Decreased cough episodes

  16. Diagnostics & Therapeutics • CBCPC to check for infection • Chest Xray to check for pneumonia • Nebulizationwith Salbutamol, Salbutamol+Ipratropium, Hydrocortisone • IV Ampicillin (100mg/kg/day) • IV support: D5IMB at maintenance rate

  17. Laboratory results

  18. Insert Chest Xray • Official reading (9/14/13): hyperaerated lungs, bilateral interstitial infiltrates without consolidation suggestive of viral pneumonia

  19. Course in the Wards: Day 1

  20. Course in the Wards: Day 2

  21. PediaPulmonology notes

  22. Pedia Cardiology notes PROBLEMS • CARDIOPULMONARY: Cyanosis: not documented but presents with occasional desaturations to mid-80% O2 at room air • May be due to Pulmonary arterial hypertension due to pneumonia • May be an idiopathic persistent pulmonar y hypertension secondary to large VSD • RESPIRATORY: Pneumonia: patient presents with occasional cough, with rales and occasional wheezing, with shallow subcostal retractions and grunting Chest xray: bilateral interstitial pneumonia

  23. Pedia Cardiology notes • CARDIAC: VSD Patient has no murmur, with regular cardiac rhythm, no history of cyanotic episodes; noted to have a loud S2 Patient was initially tachypneic, with edema, which may be due to congestion brought about by the large VSD 4-extremity BP: 80/50, all extremities EKG: RVH 2dECHO: large VSD inlet to muscular, 10-12mm, with severe pulmonary hypertension

  24. Insert EKG

  25. Insert 2decho

  26. Pedia Cardiology notes • Assessment: CHF functional class II secondary to CHD, VSD (12mm) inlet to muscular, with severe Pulmonary Hypertension; Pneumonia, community acquired

  27. Pedia Cardiology notes • Plans: • Furosemide (1mg/kg) for diuresisand to relieve congestion • Captopril 1mg/pptab Q12 as an afterloadunloader • Lanoxin 50mcg/ml 0.5ml BID for inotropic support • Oral KCL (1meq/kg) BID for 6 doses • Sildenafil 3mg/pptab Q6 • Continue IV antibiotics and nebulizations for pneumonia • Continue o2 support and monitoring • IVF rate at 5ml/hr • Family Conference to discuss options for treatment: PA banding as temporary solution vs definitive surgery

  28. Course in the Wards: Day 3

  29. Course in the Wards: Day 4

  30. Course in the Wards: Day 5

  31. Course in the Wards: Day 6 (12nn)

  32. Course in the Wards: Day 6 (4:30pm)

  33. Prior to transfer to PICU • Intubation • HR 50s • CPR done • Bag-tube-ventilation delivered • PNSS 10cc/kg given, 2 boluses • Epinephrine 0.5mg/ET for 5 doses • IJ catheter, right, inserted for IV access

  34. Prior to transfer to PICU • Intubation • HR 50s • CPR done • Bag-tube-ventilation delivered • PNSS 10cc/kg given, 2 boluses • Epinephrine 0.5mg/ET for 5 doses • Epinephrine drip started 0.1 meq/kg/min • Milrinone drip started 0.8mcg/kg/min • IJ catheter, right, inserted for IV access

  35. Prior to transfer to PICU • Laboratory exams requested: • ABG • CBCPC • ICAL, Na, K, Cl • Blood typing • Hgt

  36. Prior to transfer to PICU • ABG: mixed respiratory + metabolic acidosis (on PPV) • pH 7.176, pCO2 52.6, pO2 24.4, HCO3 19.4, Base 9.3, O2 sat 31.4

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