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DEPARTMENT OF PEDIATRICS
HEALTH HISTORY
DEPARTMENT OF PEDIATRICS
DEPARTMENT OF PEDIATRICS
Patients mother is 28 years old, a housewife, while his father is 25 years old and a waiter.
Patient is third among his siblings. He has a 10 year old half brother and a 5 year-old half
sister. Household members have no present illnesses or similar conditions as patient. Great
grandfather on his mothers side has history of asthma. No history of cancer, mental illness,
other infectious diseases, cardiovascular diseases, hereditary hematological disorders,
mental retardation and congenital defects.
SOCIOECONOMC HISTORY
Patient lives with his parents and grandmother at Paco, Manila in an apartment. Primary
caregiver is the mother, with the aid of his maternal grandparents. Father provides for the
family and works as a waiter in a restaurant.
ENVIRONMENTAL HISTORY
None of the family members is a known smoker. Their residence is exposed to cigarette
smoking and fumes from burning garbage. Also, mother claimed increasing incidence of
childen coughing in their neighborhood.
They own a flush type toilet and their source of drinking water is from a refilling station.
Water used for bathing and washing clothes is from Maynilad. Garbage is collected every
morning by truck.
DEPARTMENT OF PEDIATRICS
PHYSICAL ASSESSMENT
VITAL SIGNS
T: 36.9 (axillary)
RR: 46 cpm (tachypneic)
HR: 126 bpm (Tachycardic)
ANTHROPOMETRIC MEASUREMENT
HT: 70 cm (0.7 meters)
Weight: 6.2 kg
BMI: 12.65
Head circumference: 34.4 cm
Chest Circumference: 41.9 cm
Abdominal Circumference: 40 cm
GENERAL SURVEY
Patient is ectomorphic, poorly developed and appears younger than actual age. He is
conscious but irritable.There are no signs of distress and pain.
DEPARTMENT OF PEDIATRICS
SKIN
The skin is fair, pale but smooth and with good skin turgor. There are no visible scars,
rashes, and hemorrhages. No jaundice, flushing or cyanosis present.
HEENT
Head
Eyes
skin
The eyes are symmetrical. There are no lid lags, ptosis, swelling, edema, bulges,
and
Ears
patient
lesions and lid slanting. The sclerae are anicteric, palpebral conjunctivae are pink
cornea was clear. The pupils are equally round and reactive to light and
accommodation constricting from 3 mm to 2 mm. Extraocular muscles are intact.
Fundoscopy was not done.
Ears are symmetrical. Masses and discharge are not present on both ears. The
turns her head towards mothers voice. Tympanic membranes are intact and the
cone
Nose
in
There are no swelling or scars noted. Lymph nodes and thyroid gland are not
The trachea was in midline.
Inspection
Palpation
Auscultation
ABDOMEN
Inspection
Auscultation
Percussion
DEPARTMENT OF PEDIATRICS
GENITALIA
No discharge, mass, lesion, inflammation
Equal size scrotal sac with descended testes
EXTREMITIES
There are no deformities, scars, and skin discoloration seen on the extremities. Patients
nail beds were pale but without clubbing. CRT is 3sec. There are no joint swelling and
tenderness. No edema present. Muscle tone and symmetry are normal.
History
Physical Examination
DEPARTMENT OF PEDIATRICS
CASE DISCUSSION
SALIENT FEATURES
1 year-old Male
diagnosed with VSD at 5 months old
recurrent pneumonia for the past months
3 day history of productive cough
(+) mucus phlegm and nasal watery discharge
(+) difficulty of breathing
(+) irritability and inconsolable crying
poor feeding history
(+) weight loss for the past several months
(+) exposure to secondhand smoke from the neighborhood
(+) increased incidence of pneumonia in the neighborhood
Maternal grandfather has asthma
No pneumococcal vaccine
Severely wasted, stuntend and underweight
Tachycardic
Tachypneic
irritable
Pale nailbeds, conjunctiva and lips
(+) Intercostal and subcostal retractions
Abdomen scaphoid
APPROACH TO DIAGNOSIS
Clinical manifestations of the patient indicated that the main organ system involved in our
case is the respiratory system. Fever allowed us to further eliminate non-infectious entities for the
probable diagnosis. The three main diseases that we entertained are the following: Bronchiolitis,
Pneumonia, and Pulmonary Tuberculosis.
DEPARTMENT OF PEDIATRICS
These diseases were considered mainly due to its clinical presentation. Basing on history,
the patient had cough with whitish phlegm and nasal discharge. Patient also had fever and had
became dyspneic as the disease progresses along with increasing irritability as evidenced by report
of inconsolable crying resulting to a decreased appetite. Furthermore, the physical examination
showed a tachypneic and tachycardic patient with subcostal and intercostal retractions. All of three
conditions considered in this case is known to present with fever, dyspnea, tachypnea, tachycardia,
retractions, and irritability in an infant patient.
Bronchiolitis was taken into consideration mainly because of the infants exposure to smoke
and fumes (e.g. cigarette smoking) in the neighborhood. Cases are usually tachypneic and in
respiratory distress. Physical examination is dominated by wheezing which is not seen in our patient
upon physical examination. Auscultation of the lungs usually reveals fine crackles and wheezes, with
prolongation of expiratory phase of breathing. Hyperinflation also suggests this condition. Findings
of the physical examination in our patient are inconsistent with the usual presentation of this
condition. Acute bronchiolitis is unlikely the diagnosis for this case but further evaluation is needed
to completely rule it out.
Pneumonia is also considered for the probable diagnosis of this case. It was noted that the
patient has missed her immunization schedule for pneumococcal vaccine. This is an important risk
factor of this disease. Clinical manifestations seen in this patient are consistent and points out to
this disease. Tachypnea is the most consistent clinical manifestation of pneumonia. It may be
accompanied with colds, fever, retractions, and dyspnea. Auscultation may reveal crackles and
wheezing but its absence on our findings cannot strongly rule out pneumonia as our diagnosis.
Furthermore, the history of the patient revealed that the patient had been hospitalized for three
times in the past due to recurrences of pneumonia which strongly suggest that the present
admission strongly suggest another recurrence.
Pulmonary tuberculosis in very young children may manifest the same symptoms with
pneumonia. Distinguishing pneumonia from PTB is often not possible clinically. But usually, patients
present with non-productive cough, weight loss, night sweats, and failure to thrive. As we can see,
our has been reported to have weight loss for the past several months and as seen in the WHO
growth chart, the patient is severely wasted, stunted and underweight. Further evaluation and
workup is needed to completely rule out.
Deliberation of these three diseases lead us to pneumonia as our primary diagnosis.
Pneumonia is a more likely diagnosis due to the increased predisposition of the patient to such
respiratory infection having been diagnosed with ventral septal defect on his 5 th month of life.
Infants with VSD oftentimes presents with poor feeding, rapid and difficulty of breathing, trouble of
gaining weight and frequent and recurrent lung infections, most especially lower respiratory tract
infection involving the parenchyma, 66% of which is pneumonia. These are very similar clinical
findings and manifestation in this case.
WORKING IMPRESSION
COMMUNITY ACQUIRED PNEUMONIA SECONDARY TO VENTRAL SEPTAL DEFECT
TO RULE OUT BRONCHIOLITIS AND PRIMARY TUBERCULOSIS
DEPARTMENT OF PEDIATRICS
implicated and as age increases bacterial pathogens become more prevalent. The Philippines is one
of the 15 countries that together account for 75% of childhood pneumonia cases worldwide. In
children aged under 5 years, pneumonia is the leading cause of mortality with a mortalitily rate of
23.4 x 100,000 population recorded in 2009 and 22.3 X 100,000 pop in 2014. In NCR together
with regions VI, VII and VIII of the Philippines, the total number of children under five years of age
with pneumonia that have been seen and given treatment from January to December 2012 were
89,221 and 85,923, respectively.
Major risk factors for developing pneumonia are:
Pneumonia may have a range of symptoms depending on the age and the cause of the
infection. Viral and bacterial pneumonia have similar symptoms, although there may be more
symptoms with viral pneumonia. Cough and difficult and painful breathing are key symptoms of
pneumonia; fever is also common.
In children under five years of age, difficult breathing manifests as (WHO protocol):
Rapid breathing (>50 bpm for 2-12 months old; >40 bpm for >12 months - 5years
old)
Lower chest indrawing, where chest moves in or retracts during inhalation, also
called retraction (Figure 1)
Severely ill infants may be unable to feed or drink and may experience
unconsciousness, hypothermia, and convulsions
DEPARTMENT OF PEDIATRICS
episode will thus be worthwhile, since pneumonia is a major contributor to under five mortality. This
is more so as the co-existence of pneumonia and CHD may increase the mortality associated with
pneumonia in children. The age at onset of and the severity of symptoms in children with CHD is
dependent on the size of the defects. Children with large sized VSD and PDAs tend to present early
and have more severe disease including pneumonia. (Sadoh et al., 2013)
DIAGNOSTIC WORK-UP
DEPARTMENT OF PEDIATRICS
Source: Clinical Practice Guidelines in the Evaluation and Management of Pediatric Community Acquired
Pneumonia
DEPARTMENT OF PEDIATRICS
Serology may be done if etiologic agent was not isolated with culture and sensitivity
testing.
2D Echo
Monitor and evaluate the degree of severity of the ventral septal defect and
also to provide proper treatment for the defect.
MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA
Pharmacologic
Bacterial Etiology
According to the guidelines, for a patient classified as PCAP C without previous antibiotic
and who has completed or without the primary immunization against Haemophilus influenza type b,
Pen G 100,000u/kg/day in 4 divided doses should be given. However, since patient had been
having recurrent hospitalizations due to pneumonia, it suggested previous antibiotic medications, so
if above drug is not effective within 72 hours, antibiotic can be shifted to IV Ampicillin
(100mg/kg/day in 4 divided doses) or cefuroxime, co-amoxiclav, sultamicillin or cefpodoxime.
Viral Etiology
Oseltamivir (30 mg twice a day for 15 kg body weight, 45 mg twice a day for >15-23 kg,
60 mg twice a day for >23- 40 kg, and 75 mg twice a day for >40 kg) remains to be the drug of
choice for laboratory confirmed or clinically suspected cases of influenza.
Ancillary treatment
Inhaled B2 agonists if with good response such as nebulization with salbutamol for
management of airway secretions.
Observe cautious hydration. Give isotonic intravenous fluid titrated as indicated (e.g.
D5W. Provide oxygenation to facilitate adequate ventilation and perfusion.Tepid
sponge bath every 1 or 2 hours is indicated to help in alleviating the fever.
Note: Cough preparations, chest physiotherapy, bronchial hygiene, nebulization using normal saline
solutions, steam inhalation, topical solution, bronchodilators and herbal medicines
are not
routinely given in community-acquired pneumonia (Grade D).
Monitoring
Decrease in respiratory signs (particularly tachypnea ) and defervescence within 72 hours after
initiation of antibiotic are predictors of favorable therapeutic response.
Persistence of symptoms beyond 72 hours after initiation of antibiotics requires reevaluation.
If the patient is not responding to the current antibiotic within 72 hours, consider consultation with a
specialist because of the following possibilities.
a. penicillin resistant Streptococcus pneumoniae; or
b. Presence of complications (pulmonary or extrapulmonary ); or
c. Other diagnosis
Switch from intravenous antibiotic administration to oral form 2-3 days after initiation of antibiotic is
recommended in a patient who
a. Is responding to the initial antibiotic therapy ,
b. Is able to feed with intact gastrointestinal absorption; and
c. Does not have any pulmonary or extrapulmonary complications
PREVENTION AND CONTROL OF COMMUNITY ACQUIRED PNEUMONIA
DEPARTMENT OF PEDIATRICS
Immunization against pathogens that directly cause pneumonia (S. pneumonia and H.
influenza type b) and pathogens that lead to pneumonia as complication of the infection (eg.
measles and pertussis)
Adequate nutrition to improve natural defense and strength of respiratory muscles (which
aid in clearance of secretions)
In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk
of contracting pneumonia
pneumococcal
EPIDEMIC MEASURES
Addressing environmental factors such as indoor air pollution by providing affordable clean
indoor stoves and encouraging good hygiene in crowded homes can reduce the number of
children who fall ill with pneumonia
Immunization against S. pneumonia, H. influenza type b, pertussis and measles are the
most effective way to prevent pneumonia when the cause of pneumonia has been identified
n 2013, WHO and UNICEF launched the integrated Global action plan for pneumonia and
diarrhoea (GAPPD). The aim is to accelerate pneumonia control with a combination of
interventions to protect, prevent and treat pneumonia in children with actions to:
DEPARTMENT OF PEDIATRICS
Prevent pneumonia with vaccinations, hand washing with soap, reducing household
air pollution, HIV prevention and cotrimoxazole prophylaxis for HIV-infected and
exposed children
Treat pneumonia which are focused on making sure that every sick child has access
to the right kind of care -- either from a community-based health worker, or in a
health facility if the disease is severe -- and can get the antibiotics and oxygen they
need to get well .
REFERENCE
WHO (2009). Dengue Guidelines for diagnosis,Treatment, prevention and control. World Health
Organization catalogue.Geneva: Switzerland.
DEPARTMENT OF PEDIATRICS
Sadoh, W., & Osarogiagbon, W. (2013). Underlying congenital heart disease in Nigerian children with
pneumonia. African Health Sciences, 13(3), 607612. http://doi.org/10.4314/ahs.v13i3.13
DEPARTMENT OF PEDIATRICS
DEPARTMENT OF PEDIATRICS