Geronimo, Maria Angelica; Geronimo, Ralph Ernesto; Go, Camille-Marie; Go, Crystal Karen January 24, 2011 Pulmonology Conference

General Data J.M. 3 months old Male Sampaloc, Manila Roman Catholic

CC: Difficulty of Breathing 10 days PTA Colds, non-productive cough USTH ERCD – suction of secretions – discharged improved and stable Interval History Persistence of difficulty of breathing Good suck, good activity 6 days PTA USTH-SBC: Acute Nasopharyngitis 0.65% NaCl Solution (Salinase) 2-3 drops/nostril Erythromycin (3.5 mkd) for 7 days

CC: Difficulty of Breathing Few hours PTA Persistence of the difficulty of breathing Whitish-yellow nasal secretions No fever, loss in appetite, decrease activity, vomiting ADMISSION

Review of Systems General: (-) weight changes Cutaneous: (-) rashes, (+) jaundice HEENT: (-) eye redness (-) eye discharge (-) ear discharge (-) gum bleeding Cardiovascular: (-) cyanosis Respiratory: see HPI Gastrointestinal: (-) acholic stools

Review of Systems Genitourinary: (-) tea-colored urine (-) oliguria (-) discharge Nervous/Behavior: (-) seizures (-) tremors (-) mood/behavioral changes Endocrine: (-) polyuria (-) polydipsia (-) polyphagia (-) heat/cold intolerance Musculoskeletal: (-) edema (-) swelling (-) limitation of motion (-) tenderness Hematopoietic (-) bleeding tendencies (-) easy bruisability

Gestational History Mother: 36 year-old G1P0 housewife Father:37 year old seaman Regular prenatal checkups USTH OPD for 7 times (-) viral exanthem, radiation and any intake of illicit, prohibited or abortifacient drugs, intake of alcohol and smoking UTI (September 2010) - Cefalexin for 7 days and claimed to be compliant; Repeat UA - normal OGCT and Hepatitis screening were not done

Gestational History HPN (HBP 160/100; UBP is /70mmHg) Magnesium sulfate Nicardipine drip Betamethasone Emergency CS secondary to preeclampsia

Birth History Live, preterm, singleton male, delivered via “E” CS secondary to preeclampsia BW 1.66 kg BL 44 cm HC 31 cm CC 25 cm AC 22 cm AS 8,9 MT weeks AGA

Neonatal History 1 st hour if life – CXR: air bronchogram with densities on the right lower lobe Persistent respiratory distress  intubated (NICU) PDA: grade II continuous murmur 2 nd day of life – hyperbilirubinemia (6.8) Phototherapy on the 5 th HD Neonatal hepatitis

Neonatal History 2D echocardiography: PDA, patent foramen ovale, LVE, LAE and pulmonary arterial hypertension Blood CS: Klebsiella pneumonia Assessment: sepsis Discharged at his 52nd day of life

Feeding History Mixed Breastfed and Milk formula 15 minutes/breast 3x a day alternating with Formula S26 lactose free 1 scoop in 2 ounces every 3 hours Mother claims that there is not enough milk being produce that’s why she started on powdered milk Good appetite with no feeding difficulties

24 Hour Food Recall CHOCHONFatsKcal Breakfast Milk 2 ounce64585 Merienda Milk 2 ounce64585 Lunch Milk 4 ounce Merienda Milk 2 ounce64585 Dinner Milk 2 ounce64585 ACI510 RENI560 %91%

Developmental History Good motor activity Visually tracks objects and looks around Has social smile Mother do not practice him to sit with support or do prone position Has head lag when pulled

Past Medical History October 10, 2010: sepsis, neonatal hepatitis and PDA No previous surgeries done No allergy, eczema, asthma, food or drug sensitivities

Immunization History Hepatitis B – 11/22/10, 12/22/10 BCG - 11/24/10 DTP and OPV - 12/22/10

Family Profile NameAgeRelationEducational Attainment OccupationHealth SG38FatherCollege graduate SeamanHealthy CG36MotherCollege graduate UnemployedPreeclampsia

Family History (+) Asthma – paternal grandmother (+) HPN – maternal grandmother (-) DM, blood dyscrasia, autoimmune disease, congenital disorders, thyroid diseases, cancer, allergy

Socioeconomic and Environmental History Rented studio type made of concrete Adequate space for each household member, well-lit and well ventilated Water station Meals are home-cooked prepared by his mother or sometimes they buy cooked-meals No pets, no factories or other industrial establishments within the vicinity of the residence Garbage is not segregated and is being collected everyday Not exposed to second hand smoke

Physical Examination Awake, alert, in respiratory distress, ambulatory, well- hydrated, well nourished, ill-looking HR 135 bpm, regular, RR 48 cpm, regular, T36.7 o C, SpO2 (?) Wt: 3.26 kg (z score below -3 severely underweight) Lt: 51 cm (z score below -3 severely stunted) BMI: (z score below -2 severely wasted) Warm, moist skin, no jaundice(?) jaundice siya noong pinuntahan namin!!!!!, no visible gross skin lesions, good skin turgor

Physical Examination Normocephalic head, no visible scalp lesions, patent anterior fontanel Pink palpebral conjunctivae, anicteric sclerae, pupils 2- 3 mm ERTL No tragal tenderness, intact tympanic membrane No nasoaural discharge, nasal septum midline, turbinates not congested Moist buccal mucosa, nonhyperemic posterior pharyngeal walls, tonsils not enlarged,

Physical Examination Supple neck, no palpable cervical lymphadenopathy, thyroid gland not enlarged Symmetrical chest expansion, (+) subcostal retractions, equal tactile and vocal fremiti, (+) crackles over both lung field with occasional wheezes at left lung field Adynamic precordium, apex beat at 4 th LICS MCL, no heaves/lifts, no thrills, normal rhythm, S1 louder than S2 at the apex, S2 louder than S1 at the base, (+) Grade II continuous murmur

Physical Examination Globular abdomen, normoactive bowel sounds, soft, no tenderness, no palpable masses, Traube’s space not obliterated Genitalia: grossly male with both descended testes Pulses are full and equal, no edema, no cyanosis

Neurologic Examination Awake, alert Cranial nerves: CNI not assessed, pupils 2-3mm equally reactive to light, (+) direct and consensual light reflex, (+) ROR, EOM full and equal, no gross facial asymmetry, gross hearing intact (able to localize sound), CN IX, X, XI, XII not assessed No spasticity, rigidy, flaccidity, no limitation in movement No sensory deficits DTR +2 No nuchal rigidity, Brudzinski’s and Kernig’s (+) Moro, grasp, plantar, sucking reflex

Salient Features 3 month old male History of colds, non-productive cough PE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung field

3 month old male History of colds, non-productive cough, difficulty of breathing PE: tachypneic, (+) subcostal retractions, (+) crackles over both lung field with occasional wheezes at left lung field Pulmonary Pathology Pneumonia Approach to the Diagnosis

PPS Clinical Practice Guideline for PCAP 2004

Complete Blood Count BacterialViral WBC 15,000 – 40,000WBC < 20,000 GranulocytesLymphocytes Chest Xray (PA Lat) Gold standard for the diagnosis of pneumonia Indicates complications PCAP such as a pleural effusion or empyema

In our patient...

Course in the wards

Pneumonia