Cover your mouth when you CAP

Cover your mouth when you CAP

Cristina M. Garcia

ASMPH LEC Group 1

PCGH Pediatrics Rotation

General Data

AP

4 mos./Male

Filipino

Roman Catholic

Residing in San Miguel, Pasig City

Informant: Mother, Father, and Paternal GrandparentsReliability: 70%

Admitted at PCGH on December 3, 2010

Chief Complaint

Fever (2 days)

History of Present Illness

3 weeks PTA intermittent cough, productive of whitish phlegm

No associated signs and symptoms

consult at a private clinic Ambroxol (unrecalled

dosage) No relief Amoxicillin 6.75 mg

No relief


2 weeks PTA persistence of symptoms

consult at a private clinic Carbocisteine Co-trimoxazole (unrecalled

dosage) Phenylpropanolamine (Disudrin)

0.5 ml QID Phenylephrine HCl,

chlorphenamine (Neozep) 0.5 ml QID

No relief


2 days PTA persistence of symptoms

(+) undocumented fever

(+) Difficulty of breathing

No consult done

Parents self-medicated patient with Paracetamol drops 8.45 mg/kg/dose


Morning PTA persistence of symptoms

(+) rhinorrhea, productive of yellowish-green mucous

(+) vomiting milk and phlegm (about 4 oz)

Consult at health center Cephalexin 32.43

mg/kg/day Paracetamol 8.45

mg/kg/dose

Increase in fever

(+) cyanosis of distal extremities

PCGH ER

Review of Systems

Constitutional: no weight loss, no weakness

Integument: (+) rashes (diaper), no changes in color

Respiratory: no hemoptysis

Gastrointestinal: no changes in bowel movement

Genitourinary: no frequency

Past Medical History

no previous hospitalization

no previous operations

no history of trauma

Family Medical History

Liver disease, Tuberculosis - Maternal side

Breast cancer - Paternal side

(-) Asthma

(-) DM

(-) Hypertension, cardiac disease

Developmental History

patient is a 4 mo., male (+) grasps object placed in hand (+) moves head toward sound (+) reaches for objects (+) chews (+) roll over (-) chest up, arm support

Immunization History

BCG - 1 dose

OPV - 1 dose

Hepa B - 1 dose

No HiB

Birth History

Born Full Term to a 17 year old G1P1, delivered via Normal Spontaneous Delivery with birth weight 3.6 kg, at a lying-in clinic, attended by midwife, (-) perinatal/neonatal complications

Nutritional History

Breast fed for 2 weeks then shifted to milk formula (8 oz. per feeding x 4 feedings a day)

No known food allergy

Genogram (12/030/10)

I

II

III

49 43

20 18

4 mos.

Personal Social history

Only Child

Mother - 18 y/o

not employed

Father - 20 y/o

factory worker

Parents not married

Families are not on good terms

Environmental history

Patient does not stay permanently in one household. He is shuttled from the mother’s household to the father’s household and vice versa

Lives in a 1 story wooden house near the streets with 2 bedrooms.

The house is well ventilated and well lighted.

Environmental history

Their water supply comes from Manila Waters.

Drinking water of the patient was previously Wilkins, but now the water comes from a refill station

Garbage is collected every day.

Physical Examination

General Survey:Conscious, alert, in mild respiratory distress, well-

nourished

Vital signs: HR 165HR 165, RR 38, Temp 40.5Temp 40.5ooCC

Anthropometrics: Length 59 cm (<3rd percentile)weight 7.4 kg (50-85th percentile for age, >97th

percentile for length)HC 40.5 cm (15th percentile), CC 44.3 cm, AC 46.4 cm

http://www.who.int/childgrowth/standards/en/




Physical Examination Skin:

normal skin color, good turgor (CRT<2 sec), flushed skin (+) diaper rash, inguinal area extending to buttocks, (-)

lesions, flushed skin

HEENT and neck: flat, open anterior fontanel; closed posterior fontanel Normal hair distribution, (-) masses/depressions anicteric sclerae, pink palpebral conjunctivae, pupils 3-4mm

ERTL (-) ear deformities, (-) discharge, (+) intact tympanic

membrane, (+) cone of light (-) nasal deformities, (+) rhinorrhea, yellow-green discharge

slightly dried (-) Tonsillopharyngeal congestion, (-) cervical

lymphadenopathy, supple neck, flat neck veins


Heart: adynamic precordium, apex beat at 5th ICS LMCL,

tachycardic, regular rhythm (-) murmurs, good S1/S2

Lungs: (-) scars or masses, (+) intercostal/subcostal

retractions symmetric chest expansion, resonant on percussion,

(+) rhonchi lower lung fields, (+) crackles on bilateral lower lung fields


Abdomen: globular abdomen, (-) masses or scarsNormoactive bowel sounds tympanitic abdomen (-) tenderness, (-) organomegaly

Genital exam:grossly male, (-) deformitiesDescended testes


Extremities: full and equal pulses, (-) edema, (-) cyanosis

Neurologic Examination

Cranial Nerves:CN I - not testedCN II – 3-4 mm equally reactive to lightCN III, IV, VI – intact EOMsCN V – reacts to facial sensory stimulationCN VII – no facial asymmetry, able to smile and cryCN VIII – responds to sound and verbal stimuliCN IX, X – able to feed, good suckCN XI – able to turn head from side to sideCN XII – tongue midline

Neurologic Examination

Sensory: responds to stimuli (light touch)

Motor: good muscle tone and strength

Reflexes (+) Babinski (+) palmar grasp (-) rooting (-) moro (-) tonic neck

Salient Features

4 mo./M

fever (2 days) associated with cough and colds, difficulty of breathing, peripheral cyanosis, and vomiting

medications given afforded no relief

on PE, (+) tachycardia, (+) intercostal retractions, (+) rhinorrhea, (+) rhonchi on lower lung fields, (+) crackles on lower lung fields

Admitting Diagnosis

Pediatric Community Acquired Pneumonia, Category C (+) fever, difficulty of breathing, cyanosis, cough and

coldsPLUS findings on PE: (+) tachycardia, (+)

intercostal/subcostal retractions,(+) rhinorrhea, (+) rhonchi, (+) crackles

Differential DiagnosisDifferential Diagnosis

Rule IN Rule OUT

Bronchiolitis •Tachycardia•retractions•Fever•rales•Dyspnea•common in infants •Cyanosis•noisy breathing•Vomiting•Irritability•crackles

•high grade fever •(-)diffuse, fine wheezing•(-) otitis media•(-) palpable liver and spleen•(-) Tachypnea

Asthma •Difficulty of breathing•nocturnal cough•Cyanosis•retractions

•(-) wheezing•(-) family history of atopy•(-) non-productive cough

Differential DiagnosisDifferential Diagnosis

Rule IN Rule OUT

Pneumonia, Viral •Fever•Cough•Rhinorrhea•Rales•Shortness of breath•Vomiting•crackles

•(-) wheezing•Usually low grade fever

Pneumonia, Bacterial

•Irritability•Vomiting•Tachycardia•Cyanosis•Rhonchi•rales

•(-) lethargy

Course in the wards

A - Admitted to Broncho ward

D - NPO x 4 hrs then resume feeding once with no vomiting

M - monitor vital signs every hour, urine input/output per shift

I - IVF to follow: D5 IMB (maintenance + 24%)

T – Cefuroxime 100 mg/kg/day (every 8 hours) Salbutamol nebulization (every 6 hrs) Paracetamol 10 mg/kg/d TIV (every 4 hrs) for T > 38oC Zinc oxide + Calamine ointment, apply to diaper rash TID

Course in the wards – Day 1SOAP

Findings

S with febrile episodes, good suck, patient awake, alert, not lethargic,(+) cough, (+) visible diaper rash

O •HR 140 bpm, RR 42 bpm, T 38.7oC•(+) rhinorrhea, (+) post-tussive vomiting of previously ingested milk•(+)rales and (+) crackles, bilateral lung bases•Urinalysis•CBC

A PCAP - C

P continue medicationsIVF to ff: D5 IMB (maintenance +24%)

UrinalysisAlbumin trace

PC 0-3/hpfBacteria few

CBC:

Hgb 105 Hct 0.33 Plt 336 WBC 8.0 Seg .54 Lym 0.46

Chest X-ray (AP)

Chest X-ray (Lateral)

Chest X-ray (AP/Lat) findings:

Unofficial readingHazy and reticular densities in the lower lung fields

as well as nodular opacities in the hilar regions. Cardiothymic shadow is normal in size and configuration. Diaphragm, costophrenic sulci, and included osseous structures are intact.

Impression: Pneumonia, bilateral

Hilar adenopathies

Course in the wards – Day 2

SOAP

Findings

S with febrile episodes, good suck, patient awake, alert, not lethargic, decrease in diaper rash

O HR 139 bpm, RR 42 bpm, T 39.4C(+) rales and (+) crackles, bilateral lung bases

A PCAP - C

P continue medicationsIVF to ff: D5 IMB (maintenance + 24%)


SOAP

Findings

S (-) febrile episodes, good suck, patient awake, alert, not lethargic,(-) signs of respiratory distress

O HR 152 bpm, RR 59 bpm, T 36.6oC(+) rales and (+) crackles, bilateral lung bases

A PCAP - C



SOAP

Findings

S (-) febrile episodes, good suck, patient awake, alert, not lethargic,(-) signs of respiratory distress

O HR 134 bpm, RR 46 bpm, T 36.60oC(+) rales (-) crackles

A PCAP - C


Discussion

Definition

Pneumonia Inflammation of lung tissue caused by an infectious

agent that results in acute respiratory signs and symptoms.

It can either be acquired outside (community-acquired) or within the hospital (hospital-acquired)

Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society

Epidemiology

Mean global incidence – 0.28 episodes per child-yearAnnual incidence of 150.7 million cases

11-20 million (7-13%) require hospital admission 95% of all episodes occur in developing countries

Rudan I, Tomaskovic L, Boschi-Pinto C, Campbell H. Global estimate of the incidence of clinical pneumoniaamong children under five years of age. Bull World Health Organ. Dec 2004;82(12):895-903.

Incidence - Philippines

Ranked 3rd in the 10 leading causes of morbidity (2000) and mortality (1997) for all age groups

Cases have been increasing from 380.3/100,000 (1990) to 829.0/100,000 (2000)

Rate of mortalityUnder 1 year – 235.4/100,000 (1997)1-4 years –50/100,0005-9 years – 43/100,000


Etiology

Viral etiology - most common in PCAPRespiratory Syncytial virus (50%)Parainfluenza (25%) Influenza A or BAdenovirus

Best predictor: AGE

EpidemiologyAge Most common

pathogens

Neonatal period •S. agalactiae (GBS)•E. coli•L. monocytogenes

Infants (1-3 mos.)

C. trachomatisRSVParainfluenza virus 3S. pneumoniaeB. pertussisS. aureus

4 months – 4 years

RSV, Parainfluenza viruses, influenza virus, adenovirus, rhinovirusS. pneumoniaeH. influenzaeM. pneumoniaeM. tuberculosis

5 – 15 years M. pneumoniaeC. pneumoniaeS. pneumoniaeM. tuberculosisMcIntosh, K. 2002. Community acquired Pneumonia in children. N Engl J Med, Vol. 346, No. 6, 429-437.

Pathophysiology

Inoculation of respiratory tract

Infectious organisms

Acute inflammatory host response

Impaired defense mechanismsAcute weakened resistance

viral bacterial

Clinical ManifestationsViral Pneumonia Bacterial Pneumonia

•Wheezing•Fever <38.5oC•tachypnea

•(-) wheezing•Fever >38.5oC•Tachypnea•Associated GI manifestations: vomiting, anorexia, diarrhea, abdominal distention

•Increased work of breathing + retractions, nasal flaring, use of accessory muscles

•Cyanosis and respiratory fatigue for severe infection•Crackles and wheezing

•Rhonchi•Tachycardia•Air hunger•cyanosis

Kliegman, et. al. 2007. Nelson Textbook of Pediatrics, 18th edition.USA: Saunders Elvesier

Risk ClassificationVariables PCAP A

Minimal riskPCAP BLow risk

PCAP CModerate risk

PCAP DHigh risk

Co-morbid illness

None Present Present Present

Compliant caregiver

Yes Yes No No

Ability to follow-up

Possible Possible Not possible Not possible

Presence of dehydration

None Mild Moderate Severe

Ability to feed Able Able Unable Unable

Age >11 mos >11 mos. <11 mos. <11 mos.

Respiratory rate

2-12 mos.1-5 yrs.>5 yrs

50/min40/min30/min

>50/min>40/min>30/min




Risk ClassificationVariables PCAP A

Minimal risk

PCAP BLow risk

PCAP CModerate risk

PCAP DHigh risk

Signs of respiratory failurea)Retractionb)Head bobbingc)Cyanosisd)Gruntinge)Apneaf)Sensorium

NoneNoneNoneNoneNone

Awake

NoneNoneNoneNoneNone

Awake

Intercostal/SubcostalPresentPresentNoneNone

Irritable

Supraclavicular/Intercostal/Subcostal

PresentPresentPresentPresent

Lethargic/Stuporous/Comatose

Complication (effusion, pneumothorax)

None None Present Present

Action plan OPD follow-up

OPD follow-up

Admit to regular ward

Admit to ICU


Factors suggesting need for hospitalization


DiagnosticsDiagnostic Tool

PCAP A and B

PCAP C PCAP D

Chest X-ray

No diagnostic aids are initially

requested in an

ambulatory setting

routine routine

CBC WBC WBC

ESR and CRP Not routinely requested

Culture and sensitivity

Not routinely requested

•Blood•Pleural fluid•Tracheal aspirate

Oxygen saturation and/or blood gas

recommended


Treatment/Management

PCAP A and B PCAP C PCAP D

•2 years OR •(+) high grade fever WITHOUT wheezes

•> 2 years OR •(+) high grade fever WITHOUT wheezes OR •(+) alveolar consolidation on CXR OR•WBC >15,000

•required

•Prerequisite: No previous antibiotic use•DOC: Oral amoxicillin (40-50 mg/kg/day in 3 divided doses)

•Prerequisite: No previous antibiotic use •(+) HiB immunization = DOC: Penicillin G (100,000 units/kg/day in 4 divided doses)

•(-) HiB immunization = DOC: IV Ampicillin (100 mg/kg/day in 4 divided doses)

•consult specialist

Antibiotics


Treatment

Ancillary treatmentOxygen supplementationHydration (for dehydrated patients)Bronchodilators when (+) wheezingOTC Cough medicines not better than placebo


Risk factors

Prematurity

Malnutrition

low socio-economic status

passive exposure to smoke

underlying disease

Cystic Fibrosis

Attendance at day care centers


Complications

Pleural effusion

empyema

pericarditis

RareMeningitisSuppurative arthritisosteomyelitis



Prognosis

Patients with uncomplicated pneumoniaClinical improvement within 48-96 hours of

treatment If no improvement, or slow improvement, think

Complications Bacterial resistance Other etiology Bronchial obstruction from endobronchial lesions,

foreign body, or mucous plugs pre-existing disease


Prevention

Breast feeding

Avoidance of environmental tobacco smoke

hand washing

VaccinationHaemophilus influenza type B InfluenzaPneumococcal

Zinc supplementation (10 mg for infants, 20 mg >2 yrs, for 4-6 months)


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Cover your mouth when you CAP