Transcript Skin

 YJM
6
months/Female
 San Miguel, Manila
 Roman Catholic
9 days
PTA
• Cough and colds
• No associated symptoms
• No medications taken, No
consult done
4 days
PTA
• Persistence of cough and colds
• (+) Fever, max Temp 39.9C
• Paracetamol 100mg/ml 1 mL q4 (14.2
mkdose)
• Sought consult: Paracetamol 100
mg/mL , 1mL every 4 hours and
Amoxicillin 100 mg/mL, 1 mL
TIDx7days ( 42.8 mkd )
1 day
PTA
• Persistence of symptoms
• (+)tachypnea, upward rolling of
the eyeballs (convulsion)
• Sought consult at a local hospital
A> Pneumonia, advised admission
• Transferred to Ospital ng
Sampaloc: given Paracetamol
suppository. No available beds
• Private clinic: Salbutamol 2 mL
syrup, Paracetamol , and
Cefuroxime 3.5 mL BID. Patient
was also given Gentamycin IM (
dose unrecalled) and was again
advised admission
• Mother did not comply
Few
Hours
PTA
•Recurrence
of
symptoms
•CONSULT
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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
 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.
 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
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
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Breastfed until 2 mos
Shifted to S26 (1:2 dilution)
Shifted to Bonnamil (1:2 dilution) at 5 mos
Breakfast
6 oz milk
Cerelac 1
scoop
120 kcal
27 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%
 No
other illnesses, previous hospitalizations,
surgeries, or blood transfusions
 No known allergies
 The
patient had complete immunization done
at local health center:
Vaccine
No. of Dose
BCG
1
Hep B
3
OPV
3
DPT
3
 (+)Asthma
– mother
 (-)Hypertension, Diabetes Mellitus, allergies,
renal disease, TB, seizures, malignancy,
thyroid diseases
Educational
Attainment
Occupation
Health Status
20 y.o./M
Highschool
graduate
Billboard
maker
Healthy
19 y.o./F
1st year
college
Housewife
Asthma
Name
Age/ Gender
Father
Mother
 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
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General Survey:
awake, irritable,
in cardiorespiratory
distress, carried by her mother well hydrated, well nourished,
ill looking
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Vital Signs: HR 147 bpm, regular, RR 76 cpm, Temp 38.4oC
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Anthropometrics: Wt 7kg (z score : -1 normal), Lt 72cm (z
score: -1 normal), BMI 17.94 (z score: 0 normal) HC: 41cm
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Skin: warm, moist skin, no rashes, good skin turgor
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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.
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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
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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
Patient profile
HISTORY
PHYSICAL FINDINGS
6 months
female
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
Presenting
manifestation
(sign, symptom,
or laboratory
finding) pointing
to a disease
Fever, Cough,
Dyspnea,
crackles,
Tachypnea
Pneumonia
Pneumonia
Aspiration
Infectious
Non-infectious
Foreign Bodies
Chemical
exposure
Hypersensitivoty
reaction
Drug induced
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
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.
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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.
 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.
 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.
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.
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 Swas
given Hydrocortisone 30mg/SIVP every
6 hours (4.2 mkdose).
 Midazolam was decreased 1mL/hr.
 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.
 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%.
O2/funnel was discontinued, NGT was removed.
 Patient was transferred to ward.
 Medications
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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.
Streptococcus
pneumoniae
 Haemophilus
influenzae
 Staphylococcus
aureus
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Bacterial
Influenza virus
 Respiratory syncytial
virus (RSV)
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Viral
Airway infection
Injury of the
Respiratory
epithelium
Airway obstruction
 S.
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pneumoniae
Local edema
Proliferation of organisms
Spread to adjacent portions of lung
Lobar involvement
 S.
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aureus
Confluent bronchopneumonia
Unilateral
Extensive areas of hemorrhagic necrosis,
irregular areas of cavitations of the lung
parenchyma
Pneumatoceles, empyema, bronchopulmonary
fistulas
 Recurrent
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2 or more episodes in a single year, OR
3 or more episodes ever, with radiographic
clearing between occurences
Consider an underlying disorder
 Slowly
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pneumonia
resolving pneumonia
Persistence of symptoms or radiographic
abnormalities beyond the expected time course
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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
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Direct spread of bacterial infection within
the thoracic cavity (pleural effusion,
empyema, pericarditis), OR
Bacteremia and hematologic spread
Empyema and parapneumonic effusions
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S. aureus, S. pneumonia, S. pyogenes
Imaging studies
Treatment is based on stage
•
Antibiotic + Chest tube thoracostomy
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Peripheral WBC count
Chest radiograph
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Viral genome or antigen
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Viral pneumonia
Pneumococcal pneumonia
Atypical pneumonia
RSV
Parainfluenza
Influenza
Adenovirus
Bacterial culture and sensitivity testing
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Sputum
Blood
Does the child have cough or difficulty
breathing? If YES
ASK
For how long?
-Count the RR in 1
min
-Look for chest
indrawing
-Look and listen for
stridor
LOOK, LISTEN, FEEL:
Age
2 mos. – 12 mos.
12 mos. – 5 yrs.
Fast breathing
50/minute or more
40/minute or more
General Danger Signs
-Lethargy or unconciousness
-Inability to drink or breastfed
-Vomiting
-Convulsions
 Soothe
the throat, relieve cough with a safe
remedy
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Breastmilk for exclusively breastfed
Tamarind, calamansi, ginger
 Harmful
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remedies
Codeine cough syrup
Other cough syrus
Oral and nasal decongestants
Age or
Weight
Cotrimoxazol
e BID for 5
days
Amoxycillin
TID 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
Pathogen
Antimicrobial
% resistance
2000
2002
2003
2004
Chloramphenicol
Cotrimoxazole
Penicillin
7.0
11.8
18.4
3
9
6
3
9
9
5
15
5
Chloramphenicol
Cotrimoxazole
Ampicillin
4.0
11
3.0
5
11
5
3
18
13
5
36
10
Oxacillin
Cotrimoxazole
Ciprofloxacin
Vancomycin
24.2
20.9
18
8
6
0.7
18
8
7
0
17
6
8
0
Oxacillin
Cotrimoxazole
Vancomycin
3.0
47
42
0.3
51
50
0
39
37
0
ARI pathogens
S. Pneumoniae
H. influenzae
Gram (+) cocci
S. aureus
S. epidermis
13.1
Age
Vitamin A capsule
100,000 IU
200,000 IU
6-12mos
1 capsule
½ capsule
12mos-5yrs
2 capsules
1 capsule
•
Midly ill
–
Amoxicillin
•
–
–
•
Cefuroxime axetil
Amoxicillin/Clavulanate
Atypical pneumonia
–
–
•
High dose if penicillin-resistant pneumococci (80-90
mg/kg/day)
Azithromycin
Levofloxacin
Hospitalized
Cefuroxime IV 150mg/kg/day
– Cefotaxime
– Ceftriaxone
– Staphylococcal: Vancomycin, Clindamycin
–
•
Respond to therapy with improvement of clinical
symptoms within 48-96hr
–
•
If no improvement with antibiotic, consider:
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–
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–
–
–
•
Radiographs lag
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