Veterans Memorial Medical Center Philippines Intern's Case Report of Pediatric Community Acquired Pneumonia C

1. iNterns case
preseNtation
m a x A n g e l o G T e r r e n a l
F r a n c i s c o P T r i a

2. GENERAL INFORMATION
• TA
• 1 yo and 4mos
• Male
• Block 28, Lot 15, Salawikain St. Lagro Subdivision
Quezon City
• Christian
• Mother: Good reliability

3. chief complaint
Difficulty of Breathing

4. history OF present illness

5. 2 days PTA
• (+) Colds and productive cough
• (–) Fever, difficulty of breathing
• Given phenylpropanolamine + Bromocriptine maleate 1.7mkd
• Afforded temporary relief
1 day PTA
• Persistence of symptoms
• (+) Difficulty of breathing
• Given salbutamol 0.1mkd
• Afforded temporary relief
• No consultation

6. 5 hours pta
• Persistence of symptoms
• (+) aggravation of difficulty of breathing
• Not relieved with salbutamol and budesonide nebulization
(given every 20mins)
• (+) loss of appetite
• (-) Nausea, vomiting
Few hours PTA
• Persistence of symptoms
Consult

7. GESTATIONAL HISTORY
• Mother: 31 yo, G2P2 (2002), with monthly prenatal
check-up
– No co-morbid conditions
– (-) exposure to radiation, (-) smoking, (-) alcohol intake, (-)
illicit drug use
– Ferrous sulfate, Folic acid supplements and Anmum milk were
taken during pregnancy

8. • Term pregnancy (39 weeks) via repeat LTCS at VMMC
• Birth weight: 2892g
• Birth length: 48cm
• Head Circumference: 33cm
• Chest Circumference: 32cm
• Abdominal Circumference: 28cm
• No birth/neonatal complications and injuries
BIRTH AND NEONATAL history

9. • Exclusively breastfed only up to 1 month
• Breastfeeding was every 2-3 hours for 30 minutes to 1 hour
• Multivitamins once daily
• Cereals introduced by 8-9mos
• Fruits: by 1yr old
• Vegetables: by 10mos
• Meat: by 1yr old
• Table food: by 1yr old
FEEDING HISTORY

10. • Regard: 2mos
• Social smile: 2mos
• Turned over: 5-6mos
• Crept: 7mos
• Sat aided: 6mos
• Sat alone: 7-8mos
• Walked aided: 1yr
• 1st word: 10-11mos “mama”
• Puts 3 words together: N/A
• Bower and bladder control: N/A
• Clothes self: N/A
GROWTH AND DEVELOPMENT

11. • BCG 1
• HepaB 1, 2, 3
• HepaA 1
• DPT 1, 2, 3
• OPV 1, 2, 3
• For MMR and Hib
IMMUNIZATIONS

12. • (+) Lactose intolerance
• (+) Hyper-reactive airway disease
• Previous hospitalization: PCAP B (Feb 12-14, 2014) at
VMMC
• No previous accident/injury/surgery
PAST MEDICAL HISTORY

13. • Mother: 32yo, apparently well, nurse
• Father: 31yo, apparently well, branch manager
• Sibling: 2yo M, with CHD (VSD, subaortic), asymptomatic
• Maternal Grandparents
– Grandmother: 60yo, skin eczema, apparently well
– Grandfather: 59yo, seizure disorder, apparently well
• Paternal Grandparents
– Grandmother: 47yo, MVA, deceased
– Grandfather: 53yo, apparently well
FAMILY HISTORY

14. • Living circumstances: Patient lives in a cemented,
bungalow-type house, well lit, with adequate space and
ventilation
• Economic circumstances: both father and mother are the
sources of income
• Environmental circumstances: Patient has no exposure to
cigarette smoke, no factory or on-going construction
nearby; regular garbage collection twice a week but not
segregated. Family’s source of water is from purified water
• No recent contact with a sick person
SOCIOECONOMIC AND ENVIRONMENTAL

15. REVIEW OF SYSTEMS
General: (-) weight loss, normal growth, behavioural change
Cutaneous: (-) rash, pruritus, skin pigmentation
Head: See HPI
Cardiovascular: (-) cyanosis, (-) easy fatigability, (-) palpitation
Respiratory: See HPI
Gastrointestinal: (-) abdominal pain, (-) melena, (-) hematochezia
Genitourinary: (-) hematuria, (-) edema of hands and feet
Nervous/
Behavioral:
(-) LOC, (-) tremors, (-) sleep problems, (-) convulsions, (-) weakness or paralysis, (-)
eating problems, (+) tantrums
Musckuloskeletal: (-) pain and swelling in bone, joints, muscles, full range of motion, (-) stiffness, (-)
limping

16. physical examination

17. General Survey: Awake, alert, irritable, in respiratory distress, well nourished, well
hydrated, well-groomed
Vital Signs: CR 128 beats/min regular and strong, RR 63 regular cycles/min,
sO2 = 98%, axillary temperature 37.0C
Anthropometric
Data:
• Weight of 11kg (z = 0)
• Height of 77 cm (z = 0)
• BMI: 18.5 (z = above +1) overweight
• HC of 43cm, CC of 46cm, AC of 44cm
Skin: Warm, moist, good skin turgor, well-hydrated, no active dermatoses,
no scars, no edema, no pallor nor jaundice
Hair/Head: Black smooth dry hair, no lice and nits, no abnormal swelling
Face: Symmetrical face, no abnormal facies,
no deformities

18. Eyes: No matting of the eyelashes, anicteric sclerae, pinkish palpebral conjunctiva, no
strabismus, no opacities, no discharge, (+) ROR on both eyes, no periorbital edema, 2-
3 mm ERTL
Ears and Mastoids: No deformity, no skin lesions or tags, no tragal tenderness, (+) retained cerumen AU,
no redness or swelling of ear canal, tympanic membrane intact
Nose and
paranasal sinuses:
No deformity, septum at midline, no alar flaring, no sinus tenderness, no discharge,
turbinates congested and not hyperemic
Mouth and Throat: Moist lips, pink and moist buccal mucosa, non-hyperemic posterior pharynx, midline
uvula
Neck: (+) palpable occipital lymph nodes
Chest and Lungs: sO2 98%, (+) subcostal retractions, symmetrical chest expansion, equal tactile and
vocal fremiti, resonant on both lung fields, (+) coarse bilateral crackles,
(+) wheeze R
Heart and
vascular system:
Adynamic precordium, no heaves, no lifts, no thrills, apex beat at the 4th LICS
MCL, no murmurs

19. Abdomen: Soft, flat, symmetrical abdomen, no visible pulsation and peristalsis, normoactive
bowel sounds, tympanitic, no mass, no tenderness
Extremities: No clubbing, no cyanosis, no swelling, no edema
Neurological Exam
Cerebrum Active, alert, recognizes familiar faces and objects
Cranial Nerves CN I – not assessed
CN II – pupil 2-3mm ERTL
CN III, IV, VI – intact EOM movements, (-) ptosis
CN V – (+) corneal reflex, (+) sucking reflex
CN VII – no facial asymmetry
CN VIII – able to respond to sounds
CN IX, X – (+) gag reflex
CN XII – tongue midline

20. Cerebellum Can stand without support, good body tone, no hypotonia, no nystagmus
Motor Good muscle tone
Reflexes (+) Babinski, (+) parachute reflex, (-) palmar reflex

21. SALIENT FEATURES
• 1yo, 4 mos
• Male
• CC: Difficulty of breathing
• 2–day history of colds and productive
cough
• Loss of appetite
• (-) fever
• Breast fed for only 1mo
• (-) MMR and Hib vaccine yet
• (+) Hyper-reactive airway disease
• Previous hospitalization due to PCAP B
• In respiratory distress - tachypneic
• Intercostal retractions
• Congested turbinates
• No signs of dehydration
• Palpable CLAD
• (+) coarse bilateral crackles
• (+) wheeze, R

22. ASSESSMENT
1. Pediatric Community Acquired
Pneumonia C
2. Hyper-reactive Airway Disease

23. PLAN
• Admit
• NPO
Diagnostics
• CBC with PC
• CXR
Therapeutics
• IVF: D3 0.3% NaCl, 260mL to run for the first 8 hours to run for 32-33 ugtts/min
• Paracetamol (125mg/5mL), 5mL (11.36 mkdose) every 4 hours for fever
• Ampicillin 300mg/IV Q6 (109 mkday)
• Hydrocortisone 90mg IV loading dose, the 60mg q6 x 3 doses (8.2mkdose)

24. Discussion

25. Pneumonia
Inflammation of the lung parenchyma

26. Infectious
Vs
Non infectious

27. Infectious
AGE GROUP FREQUENT PATHOGENS (IN ORDER OF FREQUENCY)
Neonates (<3 wk)
Group B streptococcus, Escherichia coli, other gram-negative bacilli, Streptococcus
pneumoniae, Haemophilus influenzae (type b,* nontypable)
3 wk-3 mo
Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza
viruses, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypable)
4 mo-4 yr
Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza
viruses, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypable),
Mycoplasma pneumoniae, group A streptococcus
≥5 yr
M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae (type
b,* nontypable), influenza viruses, adenovirus, other respiratory viruses, Legionella
pneumophila

28. NON-Infectious
a s p i r a t i o n o f f o o d o r g a s t r i c a c i d
f o r e i g n b o d i e s
h y d r o c a r b o n s
h y p e r s e n s i t i v i t y r e a c t i o n s
d r u g - o r r a d i a t i o n - i n d u c e d p n e u m o n i t i s .

29. Who shall be considered as
having community-acquired
Pneumonia?

30. Cough + Respiratory Difficulty
+ Predictors of Radiographic Pneumonia

31. <92
%SpO2
Emergency Setting

32. Out-Patient Setting

33. OBTAIN
Chest Xray

34. Dehydration Malnutrition
or

35. High-grade Fever
Leukocytosis

36. Who will require admission?

40. Pediatric
Community
Acquired
Pneumonia

41. What Diagnostic Aids are initially
requested for a patient classified as
either pCAP C being managed in a
hospital setting?

42. SHOULD BE DONE
Gram stain and/or culture and
sensitivity of pleural fluid

43. SHOULD BE DONE
Oxygen saturation
Arterial blood gas

44. MAY BE DONE
Chest x-ray PA-lateral
C-reactive protein (CRP)
Procalcitonin (PCT)
Chest x-ray PA-lateral
White Blood Cell (WBC) count
Gram stain of sputum or nasopharyngeal aspirate

45. MAY BE DONE
to determine etiology
Sputum culture and sensitivity
Blood culture and sensitivity
to predict clinical outcome:
Chest x-ray PA-lateral
Pulse oximetry

46. MAY BE DONE
to determine the presence of TB if clinically suspected:
Mantoux test (PPD 5-TU)
Sputum smear for aid fast bacilli
to determine metabolic derangement:
Serum electrolytes
Serum glucose

47. When is antibiotic
recommended?

48. SHOULD BE GIVEN

49. MAY BE CONSIDERED
Elevated serum C-reactive protein
Elevated serum procalcitonin level [PCT]
Elevated white cell count
High grade fever without wheeze
Beyond 2 years of age

50. Hemoglobin 121
Hematocrit 0.36
WBC 16.26
Segmenters 0.72
Lymphocytes 0.27
Eosinophils 0.01
Platelets 390
CBC

51. What empiric treatment should
be administered if a bacterial
etiology is strongly considered?

52. 100mg/kg/d in 4 divided doses
D R U G O F C H O I C E
ampicillin

53. 100mkd in 11kg patient
Ampicillin 275mg/IV
every 6 hours

54. When can a patient be considered
as responding to the current
antibiotic?

55. decrease in respiratory signs
defervescence
72
h r s

56. What ancillary treatment can be
given?

57. SHOULD BE DONE
oxygen
and
hydration

58. MAY BE DONE
bronchodilator
steroid
probiotic

59. Cough preparation, elemental zinc,
vitamin A, vitamin D and chest
physiotherapy should not be routinely
given during the course of illness

60. How can pneumonia
be prevented?

61. SHOULD BE GIVEN
zinc

62. SHOULD BE GIVEN
vaccines
S . p n e u m o n i a
I n f l u e n z a
D i p h t h e r i a
P e r t u s s i s
R u b e o l a
V a r i c e l l a
H i b

63. MAY BE GIVEN
vitamin D3

64. SHOULD NOT BE GIVEN
vitamin A

65. THANK YOU!!