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YJM 6 months/Female San Miguel, Manila Roman Catholic

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Page 1: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 2: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

YJM 6 months/Female San Miguel, Manila Roman Catholic

Page 3: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 4: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 5: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 6: 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

Page 7: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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.

Page 8: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 9: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 10: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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%

Page 11: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

  No other illnesses, previous

hospitalizations, surgeries, or blood transfusions

No known allergies 

Page 12: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

The patient had complete immunization done at local health center:

Vaccine No. of Dose

BCG 1

Hep B 3

OPV 3

DPT 3

Page 13: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

(+)Asthma – mother (-)Hypertension, Diabetes Mellitus,

allergies, renal disease, TB, seizures, malignancy, thyroid diseases

Page 14: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 15: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 16: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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.

Page 17: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 18: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 19: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 20: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 21: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 22: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 23: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 24: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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.

Page 25: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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.

Page 26: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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.

Page 27: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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.

Page 28: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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.

Page 29: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

Swas given Hydrocortisone 30mg/SIVP every 6 hours (4.2 mkdose).

Midazolam was decreased 1mL/hr.

Page 30: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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.

Page 31: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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%.

Page 32: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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.

Page 33: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 34: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

Bacterial Viral

Streptococcus pneumoniae

Haemophilus influenzae

Staphylococcus aureus

Influenza virus Respiratory

syncytial virus (RSV)

Page 35: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

Airway infectionAirway infection

Injury of the Respiratory epithelium

Injury of the Respiratory epithelium

Airway obstructionAirway obstruction

Page 36: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

S. pneumoniaeLocal edemaProliferation of organismsSpread to adjacent portions of lungLobar involvement

Page 37: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

S. aureusConfluent bronchopneumoniaUnilateralExtensive areas of hemorrhagic necrosis,

irregular areas of cavitations of the lung parenchyma

Pneumatoceles, empyema, bronchopulmonary fistulas

Page 38: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 39: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

• 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

Page 40: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

• 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

Page 41: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 42: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 43: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 44: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 45: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 46: YJM  6 months/Female  San Miguel, Manila  Roman Catholic
Page 47: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

Soothe the throat, relieve cough with a safe remedyBreastmilk for exclusively breastfedTamarind, calamansi, ginger

Harmful remediesCodeine cough syrupOther cough syrusOral and nasal decongestants

Page 48: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 49: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

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

Page 50: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

Age Vitamin A capsule

100,000 IU 200,000 IU

6-12mos 1 capsule ½ capsule

12mos-5yrs 2 capsules 1 capsule

Page 51: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

• 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

Page 52: YJM  6 months/Female  San Miguel, Manila  Roman Catholic

• 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