Admitting

Conference
Bantasan, Anna Lee
Clinical Clerk
 2 y/o, 4
mos
Kias, Jehova
Baguio h’sWitn
City ess

BGH
Baguio Filipino
City

12/30/
Toddler
2015
Chief Complaint: Cough
 History of Present Illness

Days PTA

Non productive cough • Fever

Colds • Fast
breathing
• Cyanosis
• Dyspnea
 Interval History
Persistence of symptoms
Cough occurs throughout the day
No precipitating factors noted
No consult done or medications taken
 Day PTA

• Poor oral intake Loose watery stool

• Weakness
• One episode of vomiting of
water previously ingested
food around ½ cup non bloody
non mucoid
• Undocumented fever
 Hours PTA

• One episode of post

tussive vomiting of whitish
phlegm
 Hours PTA
Sought consult with a
private pediatrician
Bromhexine 1 teaspoon TID
 AD
MI
Poor Oral Intake SSI
ON

Weakness

(-) Urine Output

Past Personal
History
Feeding History
Bottle fed since birth.
S26 milk up to 6months
Promil 6months to 2 years
Bonakid
Patient consumed around six 8 oz bottle
per feeding with a frequency of feeding
every 2 hours, with a computation of
3scoops in 8oz.

Multivitamins: 6mos to 2 years old.

Presently: No multivitamins
 Feeding History

  Sample Food Calorie

s (kCal)
Breakfast 1 pandesal + tilapia 125+12
9
Lunch 2 tablespoon + meat/chicken 165+70
Dinner 2 tablespoon+ meat/chicken 165+70
Snacks 5 packs of biscuit 350
TOTAL CALORIC RENI: 1070 1074
INTAKE
Growth and
Development

Birth weight – 2.3kg

Birth length –
unrecalled
Present Weight: 11 kg
Present Height: 96 cm
Developmental
Milestones
Feeding History
Immunization
Past Medical History

previous hospitalizations
history of surgery or trauma
history of measles, mumps,
chickenpox
history of asthma
recent antibiotic use
allergies to drugs or
medication
 Family History

Father: Mother:
Hypertension Hypertension
Paternal history of
arthritis and CAD
No family history of asthma, diabetes mellitus,
cancer, cerebrovascular disease or any form of
malignancy
 Socioenvironmental

42-year-old 39-year-old
BS Agricultural 👦👦 BS Ed
Engineering Housewife
Retired refinery
supervisor

👦
(+) cough and colds
• Non-congested neighborhood
• 2 storey with three rooms with 5 occupants.
• water for domestic use: water delivery and water
for drinking water: filtered water
• No pets
• Father has cough
General: (+) febrile episodes, (-) chills, (-) significant weight loss,
poor oral intake, (+) irritability (+) generalized weakness (-)
lethargy, (-) restlessness

Integument: (-) rashes, (-) pallor, (-) jaundice, (-) dryness (-)
itching

Head and Neck: (-) trauma, (-) nuchal rigidity

Eyes: (+) tears when crying (-) discharges, (-) redness

Ears: (-) hearing loss, (-) discharges

 Nose: (+) nasal discharge clear watery; (-) bleeding, (-)
sneezing
Mouth and Throat: (+) dryness, (-)pallor, (-) ulcers, (-)
bleeding, (-) tongue lesions
Respiratory: (+) cough nonproducrive, (-) exposure to PTB
(-) dyspnea (-) hemoptysis
Cardiovascular: (-) chest pain, (-) cyanosis (-) orthopnea
(-) fatigue
GIT: (+) poor oral intake, (+) vomiting, (-) abdominal pain
(-) diarrhea (-) hematemesis, (-) hematochezia/melena
GUT: (+) lack of urine output 12 hours(-) hematuria,
(-) frequency, (-) dysuria
Musculoskeletal: (-) deformities, (-) swelling, (-)
stiffness

Hematological: (-) easy bruisability (-) bleeding

Endocrine: (-) excessive sweating, (-) chills, (-)

weight change, (-) temperature intolerance
Nervous: (-) altered sensorium (-) seizures (-)
tremors
Physical
Examination
Irritable, Fairly nourished,
ambulatory, afebrile

Blood Pressure:90/60 CR:133

bpm RR: 37 cpm, T: 36.8oC,
spO2 98%

Present Weight: 11kg; Present

Height: 88cm; BMI: 14.20
kg/m2
good skin turgor; no pallor; no cyanosis,
smooth and warm to touch, no rashes.

Normal hair distribution, no scars seen, no

lumps or swelling, no aural discharge, with
watery nasal discharge, dry lips moist
buccal mucosa, no tonsillopharyngeal
congestion, no palpable lymph nodes

Symmetrical chest wall expansion, no

retractions, no lagging, resonant, equal
tactile fremitus, fine bibasal crackles, no
wheezes
Adynamic precordium, PMI at the
4th ICS, Left MCL, increased rate,
regular rhythm, no murmur

flat, non-distended with

normoactive bowel sounds,
tympanic, soft, with no tenderness
noted

no edema, full and equal pulses on

all extremities. Nail beds are
pinkish with a capillary refill of less
than 2 seconds
Cerebrum: awake, irritable
Cerebellum: no tremors, no nystagmus
Cranial nerves:
I: able to smell
II: 2-3mm Equally reactive to light
III, IV, VI: intact visual tracking
V: able to chew, (+) corneal reflex
VII: no facial asymmetry, symmetric nasolabial folds
VIII: can hear
IX, X: able to swallow, uvula midline
XI: able to move head from side to side
XII: able to protrude tongue, midline
Motor: 5/5 on all extremities
Sensory: equal sensory perception in all extremities
Reflexes: +2 on all extremities
 POMR
PROBLEM LIST
1. Cough, Fever, No urine output, Poor oral intake
• 2 year old female
 Six days history of non productive cough with colds, no
associated fever, fast breathing, cyanosis, dyspnea.
 One day history of poor oral intake, weakness, one episode
of vomiting of water previously ingested food around ½ cup
non bloody non mucoid and undocumented fever.
 Poor oral intake, no urine output for 12 hours, generalized
weakness
 No urine output for 12 hours, with tears when crying
• With Influenza, Hib, Pneumococcal vaccination
• No recent antibiotic use, no history of asthma
• No personal or family history of asthma
• Exposure to a person with cough
GS: Irritable, afebrile
VS: Blood Pressure: 90/60 CR:133 bpm RR: 37 cpm, T:
36.8oC, spO2 98%
Skin: good skin turgor; no pallor; no cyanosis, smooth and
warm to touch
HEENT: Watery nasal discharge, dry lips moist buccal
mucosa, no palpable lymph nodes
C/L: Symmetrical chest wall expansion, no retractions, no
lagging, resonant, equal tactile fremitus, fine bibasal
crackles, no wheezes
Extremities: no edema, full and equal pulses on all
extremities
Pediatric Community Acquired Pneumonia C
moderate signs of dehydration
Bronchitis Pneumonia
 Pneumonia

inflammation of the Leading cause of death

lung parenchyma globally

Mycoplasma
Streptococcus pneumoniae
pneumoniae and Chlamydophila
(3 wk to 4 yr of age) pneumoniae (5 yr and
older)
• Viral prominent: infants; 1mos-5 yr of age
• Respiratory syncytial virus (RSV) and rhinoviruses: most
commonly identified pathogens, especially in <2 yr of age.
CLINICAL QUESTION 1. WHO SHALL BE
CONSIDERED AS HAVING COMMUNITY-ACQUIRED
PNEUMONIA?
may be considered even without a chest radiograph
• Cough and/or respiratory difficulty plus any of the following
• tachypnea 3 months to 5 years
• fever at any age
• oxygen saturation less than or equal to 92% at room air at any
age
should be determined using a chest radiograph in a
patient with
• cough and/or respiratory difficulty in the following
situations:
• dehydration aged 3 months to 5 years
• severe malnutrition aged less than 7 years
• high grade fever and leukocytosis aged 3 to 24
 Nonspecific bronchial Rhinitis,cough, fever,
inflammation nasopharyngits,
conjunctivitis

Bronchitis

follows a viral upper C/L:

respiratory tract Early: Normal
infection Late: crackles/wheeze
Absence of abnormality of vital signs (tachycardia, tachypnea,
fever)Pneumonia
and a normal physical examination ofBronchitis
the chest reduce the
likelihood of pneumonia
 Bronchitis

Pneumonia
 pCAP A or B pCAP C pCAP D
---/Nonsevere Pneumonia I/ Severe Pneumonia II/ Very severe
Dehydration None/Mild Moderate Severe
Malnutrition None Moderate Severe
Pallor None Present Present
Respiratory rate
3 to12 months >50/min to <60/min >60/min to <70 >70/min
1 to 5 years >40/min to <50/min >50/min >50/min
>5 yeasrs >30/min to <35/min >35/min >35/min

Signs of respiratory
failure None IC/subcostal Supraclavicular/IC/SC
a. Retraction None Present Present
b. Head bobbing None Present Present
c. Cyanosis None None Present
d. Grunting None None Present
e. Apnea None Irritable Lethargic/stuporous/comat
f. Sensorium ose
Chest x ray findings of None Present Present
any of the following:
effusion; abscess; air
leak or lobar
consolidation
Oxygen saturation at 95% <95% <95%
room air using pulse
oximetry
Site-of-care Outpatient Admit to ward Admit to a critical care
facility
 MILD MODERATE SEVERE
• Thirsty • Tachycardia • Rapid and weak
• Normal or • Little or no urine pulse
increased pulse rate output • Decreased blood
• Decreased urine • Irritable/lethargic pressure
Output • Sunken eyes and • No urine output
• Normal physical fontanel • Very sunken eyes
examination • Decreased tears and fontanel
• Dry mucus • No tears
membranes • Parched mucous
• Mild tenting of the membranes
skin • Tenting of the skin
• Delayed capillary • Very delayed
refill capillary refill
• Cool and pale • Cold and mottled
extremities
Diagnostics:
a.Chest xray APL
b.Pulse oximetry
c.Complete Blood Count
Clinical Question 4. WHAT DIAGNOSTIC
AIDS ARE INITIALLY REQUESTED FOR A
PATIENT CLASSIFIED AS EITHER pCAP C
or pCAP D BEING MANAGED IN A
HOSPITAL SETTING?
should be done:
Gram stain and/or culture and sensitivity of pleural
fluid when available
-to determine etiology:
Oxygen saturation using pulse oximetry or Arterial
blood gas
- to assess gas exchange:
 to confirm clinical suspicion of multilobar consolidation,
lung abscess, pleural effusion,
• pneumothorax or pneumomediastinum:
• Chest x-ray PA-lateral
 to determine appropriateness of antibiotic usage:
• C-reactive protein (CRP) [A]
• Procalcitonin (PCT) [B]
• Chest x-ray PA-lateral [C]
• White Blood Cell (WBC) count [D]
• Gram stain of sputum or nasopharyngeal aspirate [D]
 to determine etiology
• Sputum culture and sensitivity [C]
• Blood culture and sensitivity [C]
 to predict clinical outcome:
• Chest x-ray PA-lateral [B]
• Pulse oximetry [B]
 to determine the presence of tuberculosis if clinically
suspected:
• Mantoux test (PPD 5-TU) [D]
• Sputum smear for aid fast bacilli
 to determine metabolic derangement:
• Serum electrolytes [C]
• Serum glucose [C]
 COMPLETE BLOOD COUNT
Parameter Result Normal values Parameter Result Normal
values
RBC count 4.76 3.3-4.3 x WBC count 18.7 4-12
1012/L x109/L
Hgb 124 115-140 g/L Neutrophils 53.7 54-62%
Hct 0.376 0.33-0.43 Lymphocytes 42.2 25-33%
MCV 79 76-96 fl Eosinophils 0.4 1-3%
MCH 26 27-32 pg Monocytes 3.5 3-7%
MCHC 330 320-360 g/L Basophils 0.2 1-3%
Platelet 469 150-400 x Morphology: Normocytic,
count 109/L normochromic
Pneumonia bilateral inner lung zones
Therapeutics
• IV Hydration: PLRS 1L FD 110cc now then
regulate at 49-50gtts. Min at % 10 DT
• Paracetamol 120/5 5 mL every 4 hours as needed
for fever (T >37.8 C) (ED: 10-20mg/kg/day; CD:
10.9)
• Penicillin (ED: 100,000 units/kg/day in 4 divided
doses CD: 100,000) 275, 000units q6
Clinical Question 5. WHEN IS ANTIBIOTIC
RECOMMENDED?
pCAP A or B may be administered
beyond 2 years of age
high grade fever without wheeze
pCAP C
should be administered if alveolar consolidation
on chest x-ray is present

may be administered if a patient is with any of the

following:
• Elevated serum C-reactive protein [CRP]
• Elevated serum procalcitonin level [PCT]
• Elevated white cell count
• High grade fever without wheeze
Clinical Question 6. WHAT EMPIRIC TREATMENT
SHOULD BE ADMINISTERED IF A BACTERIAL ETIOLOGY
IS STRONGLY CONSIDERED?
pCAP C, without previous antibiotic
HOSPITALIZED

completed the primary immunization against

Haemophilus influenza type b,
penicillin G [100,000 units/kg/day in 4 divided doses]

has not completed the primary immunization or

immunization status unknown
ampicillin [100 mg/kg/day in 4 divided doses]
Clinical Question 11. WHAT ANCILLARY
TREATMENT CAN BE GIVEN?
pCAP C,
• oxygen and hydration should be administered whenever
applicable
• Nasal catheter is as effective as using nasal prong

• bronchodilator only in the presence of wheezing.

• Steroid may be added to a bronchodilator
• probiotic may be administered

• cough preparation, elemental zinc, vitamin A, vitamin D

and chest physiotherapy should not be routinely given
during the course of illness
 DEFICIT THERAPY (DT)
MILD MODERATE SEVERE
<2 y/o or 5% 10% 15%
<15kg Wt x 50 Wt x 100 Wt x 150

15kg
11x 100=1100ml
>2 y/o or > 3%
Wt x 30
6%
Wt x 60
9%
Wt x 90
** Run DT for 6 hours then re –assess
Clinical Question 8. WHEN CAN A
PATIENT BE CONSIDERED AS
RESPONDING TO TaHE CURRENT
ANTIBIOTIC?
Decrease in respiratory signs and/or
defervescense within 72 hours after
initiation of antibiotic
Clinical Question 9. WHAT SHOULD BE DONE IF A
PATIENT IS NOT RESPONDING TO CURRENT
ANTIBIOTIC THERAPY?
Inpatient pCAP C
. • Other diagnosis
• Coexisting illness
• Conditions simulating pneumonia.
• Consider other etiologic agents for which C-reactive
protein, chest x-ray or complete blood count may be
used to determine the nature of the pathogen.
• May add an oral macrolide if atypical organism is
highly considered.
• May change to another antibiotic if microbial resistance
is highly considered.
• May refer to a specialist.
 Clinical Question 10. WHEN CAN SWITCH
THERAPY IN BACTERIAL PNEUMONIA BE
STARTED?

3 days after initiation of current antibiotic IF

• Responsive to current antibiotic therapy
• Tolerance to feeding and without vomiting or
diarrhea.
• Without any current pulmonary (effusion/empyema;
abscess; air leak, lobar consolidation, necrotizing
pneumonia) or extrapulmonary complications
• Without oxygen support.
Amoxicillin [40-50 mg/kg/day for 4 days]
Clinical Question 12. HOW CAN
PNEUMONIA BE PREVENTED?

Should be given:
• Vaccine against: Streptococcus pneumonia
(conjugate type), Influenza, Diphtheria, Pertussis,
Rubeola, Varicella, Haemophilus Influenzae type b
• Elemental zinc for ages 2 to 59 months to be given
for 4 to 6 months

Vitamin D3 supplementation

Vitamin A
Thank You