yjm 6 months/female san miguel, manila roman catholic
TRANSCRIPT
YJM 6 months/Female San Miguel, Manila Roman Catholic
General: no weight loss/gain ,no chills Skin: no pruritus, rashes, discoloration HEENT: no eye redness, itchiness, pain,
discharge; no aural tenderness, discharge; no epistaxis, no gum bleeding, oral sores
Respiratory: see HPI Cardiovascular: no cyanosis, no clubbing GI: no diarrhea, no constipation, no vomiting, no
melena, hematochezia GUT: no dysuria, hematuria, oliguria; no
discharge from genitalia Extremities: no cyanosis, swelling, limitation in
the range of motion Nervous/Behaviour: no tremors, no muscle
weakness or paralysis
born to a 19 year old G1P0 (0-0-0-0), living in with a 20 year old billboard maker.
monthly prenatal checkup in a health center with a physician starting at 2 months AOG
regular intake of multivitamins and Ferrous sulfate.
No screening for diabetes and hepatitis B. Recurrent urinary tract infection (2-7 mos
AOG) diagnosed via urinalysis and was treated with Cefalexin 500 mg/tab TID for seven days.
no exposure to viral exanthems, smoke, radiation, and chemicals.
preterm at 34 AOG at Sampaloc Hospital via NSD (with amniotomy) with the aid of an obstetrician with no complications.
birth weight was 1.9 kg. Nursery stay:11 days
Development is at par with age
able to keep visually track of objects, good head control on prone and looks around and sustained smiling at 3 months of age
at 6 months of age, can reach with either hand, roll over, laugh and play, imitate speech sounds and on lying prone, patient is able to raise chest up
Breastfed until 2 mos Shifted to S26 (1:2 dilution) Shifted to Bonnamil (1:2 dilution) at 5 mos
Breakfast 6 oz milkCerelac 1 scoop
120 kcal27 kcal
Lunch 8 oz milk 160 kcal
Snack 4 oz milk 80 kcal
Dinner 18 oz milk 360 kcal
TOTAL: 747 kcal
RENI 702 ACI 103%
No other illnesses, previous
hospitalizations, surgeries, or blood transfusions
No known allergies
The patient had complete immunization done at local health center:
Vaccine No. of Dose
BCG 1
Hep B 3
OPV 3
DPT 3
(+)Asthma – mother (-)Hypertension, Diabetes Mellitus,
allergies, renal disease, TB, seizures, malignancy, thyroid diseases
Name Age/ Gender Educational Attainment Occupation Health Status
Father 20 y.o./M Highschool graduate
Billboard maker
Healthy
Mother 19 y.o./F 1st year college
Housewife Asthma
Patient lives with extended family of 11 members in a 4 storey house made of wood and concrete.
House is well- ventilated and well-lit; no factories nearby
Water source for drinking is purified, mineral water
Garbage collected everyday; not segregated
They have 2 pet cats in the house No exposure to cigarette smoke
General Survey: awake, irritable, in cardiorespiratory distress, carried by her mother well hydrated, well nourished, ill looking
Vital Signs: HR 147 bpm, regular, RR 76 cpm, Temp 38.4oC
Anthropometrics: Wt 7kg (z score : -1 normal), Lt 72cm (z score: -1 normal), BMI 17.94 (z score: 0 normal) HC: 41cm
Skin: warm, moist skin, no rashes, good skin turgor HEENT: normocephalic, anterior fontanelle depressed,
normal hair distribution. No gross facial deformities. Pink palpebral conjunctiva, anicteric sclera, (+) ROR, pupils 2-3 mmERTL. Midline septum, (+) nasal discharge, (+) alar flaring. Non hyperemic EAC, no tragal tenderness, (-) aural discharge. Moist buccal mucosa, no gum bleeding and sores, non hyperemic posterior pharyngeal wall, tonsils not enlarged. Supple neck. No palpable cervical lymph nodes, thyroid gland not enlarged.
Chest and lungs: Symmetrical chest expansion, (+) supraclavicular, suprasternal, intercostal and subcostal retractions. (+) coarse crackles on both lung fields. Chest Circumference:44 cm
Cardiovascular: adynamic precordium, AB 4th LICS MCL, no murmurs
Abdomen: Flat, soft, non tender, AC: 42cm normoactive bowel sounds, no hepatosplenomegaly, no masses
Genitourinary: grossly female, majora covers minora Extremities: pulses full and equal, no cyanosis, no
edema, no limitation in range of motion,(-) sacral dimpling, (-) tufts of hair
Mental status: awake, alert, irritable Cranial nerves: Intact Cranial nerves I-XII intact
(Pupils 2-3 mm ERTL, OU, isocoric, conjugate gaze, EOM full and equal, (+) direct and consensual light reflex; No gross facial asymmetry, gross hearing intact, (+) gag reflex, uvula midline
Cerebellum: cannot be assessed Motor: good muscle tone on all extremities, no
limitation in movement, no rigidity, spasticity, flaccidity
Sensory: No sensory deficits Deep tendon reflexes: 2+ Pathologic reflexes: (-) nuchal rigidity (-)
Brudzinski’s, (-) Kernig’s
Patient profile HISTORY PHYSICAL FINDINGS
6 monthsfemale
Cough and colds (9 days)Fever (Tmax 39.9oC)Tachypnea (described as fast breathing)
in cardiorespiratory distress (+) nasal discharge(+) alar flaring(+) supraclavicular, suprasternal, intercostal and subcostal retractions (+) coarse crackles on both lung field
Factors Suggesting Need for Hospitalization
Age <6 mo
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
Patient presented with respiratory distress and fever.
Given oxygen supplementation at 4-5 liters per minute via mask.
She was put on NPO and was started on IVF of D5 0.3 NaCl to run at 29 -30 drops/hr.
CBC with platelet count and Chest X-ray were requested.
CBC showed leukocytosis (WBC18.20) and chest x-ray showed the presence of infiltrates on both lung fields.
Patient was given Cefuroxime 250mg/Iv (107 mkd), Paracetamol 100 mg/SIVP for fever and 0.65 % NaCl nasal drops.
Patient was started on Gentamycin 30 mg/SIVP. Patient had showed progression of respiratory distress ABG was requested and it showed respiratory acidosis
with hypoxemia. The patient was intubated, a nasogastric tube inserted
and was admitted to the pediatric intensive care unit. She was hooked to a cardiac monitor, pulse oximeter and
mechanical ventilator. Chest x-ray after intubation showed progression of the
previously noted infiltrates bilaterally and the presence of endotracheal tube at the level of T2-T3.
Blood culture and sensitivity were requested. Patient was referred to pediatric pulmonology for further
evaluation and management. Cefuroxime was discontinued and patient was started on
Vancomycin. Patient was also started on nebulization with Salbutamol.
Midazolam was given. Nebulization with Salbutamol alternating
with salbutamol + Ipratropium was continued followed by chest physiotherapy.
Tracheal aspirate grams stain showed absence of microorganisms.
Repeat CBC showed low hemoglobin (82 mg/dL)
Patient was transfused with 70 mL PRBC. Serum Na, K, SGPT and creatinine were
requested and results were normal. Indwelling catheter was inserted.
Meropenem 300 mg/dose IV infusion every 8 hours (128 mkd).
Started feeding with milk formula was started at 30 ml every 3 hours given via nasogastric tube.
Arterial blood gas determination showed metabolic alkalosis.
Chest x-ray showed confluence of densities in right upper lobe with slight shifting of minor fissure upwards, alveolar infiltrates are again seen in left upper and right lower lobe, and lung fields are slightly hyperaerated.
Endotracheal tube aspirate culture and sensitivity showed presence of Haemophilus haemolyticus.
Repeat CBC showed increased in hemoglobin from 82 to 119, and decrease in WBC from 17.8 to 11.1.
Swas given Hydrocortisone 30mg/SIVP every 6 hours (4.2 mkdose).
Midazolam was decreased 1mL/hr.
Extubation was done. Salbutamol nebulization was done and she was hooked to O2 per mask at 5 lpm.
Serum Na and K were done with normal results.
IV hydrocortisone was shifted to oral 2.5mL BID (Prednisone 10mg/5ml).
O2 was also shifted to funnel at 2-3lpm to maintain O2sat >95%.
O2/funnel was discontinued, NGT was removed.
Patient was transferred to ward. Medications
Meropenem 300mg/SIV infusion (128mkd) every 8 hours to complete 10 days
Gentamycin 35mg/SIVP (5mkd) everyday until 11/22/10
Prednisone 10mg/5ml 3.5 ml (1.4mkd) BID after feeding
Zinc 10mg/ml 1ml QD Salbutamol nebulization 1ml + 1 ml NSS q6h Zinc oxide cream apply over perianal area after
each diaper change.
Bacterial Viral
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
Influenza virus Respiratory
syncytial virus (RSV)
Airway infectionAirway infection
Injury of the Respiratory epithelium
Injury of the Respiratory epithelium
Airway obstructionAirway obstruction
S. pneumoniaeLocal edemaProliferation of organismsSpread to adjacent portions of lungLobar involvement
S. aureusConfluent bronchopneumoniaUnilateralExtensive areas of hemorrhagic necrosis,
irregular areas of cavitations of the lung parenchyma
Pneumatoceles, empyema, bronchopulmonary fistulas
Recurrent pneumonia2 or more episodes in a single year, OR3 or more episodes ever, with radiographic
clearing between occurencesConsider an underlying disorder
Slowly resolving pneumoniaPersistence of symptoms or radiographic
abnormalities beyond the expected time course
• Preceded by URTI• Fever • Restlessness • Tachypnea • Increased work of breathing• Asymmetrical chest expansion• Decreased breath sounds• Dullness on percussion• Crackles, ronchi• Abdominal distension• Rapid progression
• Direct spread of bacterial infection within the thoracic cavity (pleural effusion, empyema, pericarditis), OR
• Bacteremia and hematologic spread• Empyema and parapneumonic effusions– S. aureus, S. pneumonia, S. pyogenes– Imaging studies – Treatment is based on stage
• Antibiotic + Chest tube thoracostomy
Peripheral WBC count Chest radiograph
Viral pneumonia Pneumococcal pneumonia Atypical pneumonia
Viral genome or antigen RSV Parainfluenza Influenza Adenovirus
Bacterial culture and sensitivity testing Sputum Blood
Does the child have cough or difficulty breathing? If YES
Does the child have cough or difficulty breathing? If YES
General Danger Signs-Lethargy or unconciousness
-Inability to drink or breastfed-Vomiting
-Convulsions
General Danger Signs-Lethargy or unconciousness
-Inability to drink or breastfed-Vomiting
-Convulsions
Soothe the throat, relieve cough with a safe remedyBreastmilk for exclusively breastfedTamarind, calamansi, ginger
Harmful remediesCodeine cough syrupOther cough syrusOral and nasal decongestants
Age or Weight
Cotrimoxazole BID for 5 days
AmoxycillinTID for 5 days
Adult tab 80mg TMP 400mg SMX
Syrup 50mg TMP 200mg SMX
Tablet 250mg
Syrup 125mg/5ml
2-12 mos 1/2 5.0ml 1/2 5.0ml
12mos-5yrs 1 7.5ml 1 10ml
Pathogen Antimicrobial % resistance
2000 2002 2003 2004
ARI pathogens
S. Pneumoniae
H. influenzae
ChloramphenicolCotrimoxazolePenicillin
ChloramphenicolCotrimoxazoleAmpicillin
7.011.818.4
4.0113.0
396
5115
399
31813
5155
53610
Gram (+) cocci
S. aureus
S. epidermis
OxacillinCotrimoxazoleCiprofloxacinVancomycin
OxacillinCotrimoxazoleVancomycin
24.220.9
13.1
3.0
18860.7
47420.3
18870
51500
17680
39370
Age Vitamin A capsule
100,000 IU 200,000 IU
6-12mos 1 capsule ½ capsule
12mos-5yrs 2 capsules 1 capsule
• Midly ill– Amoxicillin
• High dose if penicillin-resistant pneumococci (80-90 mg/kg/day)
– Cefuroxime axetil– Amoxicillin/Clavulanate
• Atypical pneumonia– Azithromycin – Levofloxacin
• Hospitalized – Cefuroxime IV 150mg/kg/day– Cefotaxime – Ceftriaxone – Staphylococcal: Vancomycin, Clindamycin
• Respond to therapy with improvement of clinical symptoms within 48-96hr– Radiographs lag
• If no improvement with antibiotic, consider:– Complications– Bacterial resistance– Nonbacterial etiology– Bronchial obstruction from endobronchial
lesions, foreign body, or mucous plugs– Pre-existing diseases such as
immunodeficiencies, ciliary dyskinesia, cystic fibrosis, pulmonar sequestration, or cystic adenomatoid malformation
– Other noninfetious causes • Repeat chest x-ray