Download fever

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 Grandparents
 Reliability: 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
History of Present Illness
 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
History of Present Illness
 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
History of Present Illness
 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
PCGH ER
 (+) cyanosis of distal
extremities
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




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
(+) 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
49
43
II
20
18
III
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, wellnourished
 Vital signs:
 HR 165, RR 38, Temp 40.5oC
 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
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http://www.who.int/childgrowth/standards/en
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http://www.who.int/childgrowth/standards/en
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http://www.who.int/childgrowth/standards/en
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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




Physical Examination
 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
Physical Examination
 Abdomen:




globular abdomen, (-) masses or scars
Normoactive bowel sounds
tympanitic abdomen
(-) tenderness, (-) organomegaly
 Genital exam:
 grossly male, (-) deformities
 Descended testes
Physical Examination
 Extremities:
 full and equal pulses, (-) edema, (-) cyanosis
Neurologic Examination
 Cranial Nerves:



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
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
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CN I - not tested
CN II – 3-4 mm equally reactive to light
CN III, IV, VI – intact EOMs
CN V – reacts to facial sensory stimulation
CN VII – no facial asymmetry, able to smile and cry
CN VIII – responds to sound and verbal stimuli
CN IX, X – able to feed, good suck
CN XI – able to turn head from side to side
CN XII – tongue midline
Neurologic Examination
 Sensory: responds to stimuli (light touch)
 Motor: good muscle tone and strength
 Reflexes
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(+) 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 colds
 PLUS findings on PE: (+) tachycardia, (+)
intercostal/subcostal retractions,(+) rhinorrhea, (+)
rhonchi, (+) crackles
Differential Diagnosis
Differential 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 Diagnosis
Differential 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 1
SOAP
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 medications
IVF to ff: D5 IMB (maintenance +24%)
CBC:
Hgb 105
Plt 336
Seg .54
Hct 0.33
WBC 8.0
Lym 0.46
Urinalysis
Albumin trace
PC 0-3/hpf
Bacteria few
Chest X-ray (AP)
Chest X-ray (Lateral)
Chest X-ray (AP/Lat) findings:
 Unofficial reading
 Hazy 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 medications
IVF to ff: D5 IMB (maintenance + 24%)
Course in the wards – Day 3
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
P
continue medications
IVF to ff: D5 IMB (maintenance + 24%)
Course in the wards – Day 4
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
P
continue medications
IVF to ff: D5 IMB (maintenance + 24%)
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-year
 Annual 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 pneumonia
among 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 mortality
 Under 1 year – 235.4/100,000 (1997)
 1-4 years –50/100,000
 5-9 years – 43/100,000
Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society
Etiology
 Viral etiology - most common in PCAP
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
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Respiratory Syncytial virus (50%)
Parainfluenza (25%)
Influenza A or B
Adenovirus
 Best predictor: AGE
Epidemiology
Age
Most common pathogens
Neonatal period
•S. agalactiae (GBS)
•E. coli
•L. monocytogenes
Infants (1-3 mos.)
C. trachomatis
RSV
Parainfluenza virus 3
S. pneumoniae
B. pertussis
S. aureus
4 months – 4 years
RSV, Parainfluenza viruses,
influenza virus, adenovirus,
rhinovirus
S. pneumoniae
H. influenzae
M. pneumoniae
M. tuberculosis
5 – 15 years
M. pneumoniae
C. pneumoniae
S. pneumoniae
M. tuberculosis
McIntosh, K. 2002. Community acquired Pneumonia in children. N Engl J Med, Vol. 346, No. 6, 429-437.
Pathophysiology
Infectious organisms
Inoculation of respiratory tract
Acute weakened resistance
Impaired defense mechanisms
Acute inflammatory host response
viral
bacterial
Clinical Manifestations
Viral 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 Classification
Variables
PCAP A
Minimal risk
PCAP B
Low risk
PCAP C
Moderate risk
PCAP D
High 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/min
40/min
30/min
>50/min
>40/min
>30/min
>60/min
>50/min
>35/min
>70/min
>50/min
>35/min
Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society
Risk Classification
Variables
Signs of
respiratory failure
PCAP A
Minimal risk
PCAP B
Low risk
PCAP C
Moderate risk
PCAP D
High risk
a)Retraction
b)Head bobbing
c)Cyanosis
d)Grunting
e)Apnea
f)Sensorium
None
None
None
None
None
Awake
None
None
None
None
None
Awake
Intercostal/Subcostal
Present
Present
None
None
Irritable
Supraclavicular/Intercostal/
Subcostal
Present
Present
Present
Present
Lethargic/Stuporous/Comat
ose
Complication
(effusion,
pneumothorax)
None
None
Present
Present
Action plan
OPD followup
OPD followup
Admit to regular
ward
Admit to ICU
Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society
Factors suggesting need for
hospitalization
 Age <6 mos.
 Sickle cell anemia with
acute chest syndrome
 Multiple lobe involvement
 Requirement for
supplemental oxygen
 Dehydration
 Vomiting
 Immunocompromised state  No response to appropriate
oral antibiotic therapy
 Toxic appearance
 Noncompliant parents
 Severe respiratory distress
Kliegman, et. al. 2007. Nelson Textbook of Pediatrics, 18th edition.USA: Saunders Elvesier
Diagnostics
Diagnostic
Tool
PCAP C
PCAP D
Chest X-ray
routine
routine
CBC
WBC
WBC
ESR and CRP
Culture and
sensitivity
Oxygen
saturation
and/or blood
gas
PCAP A and B
No diagnostic Not routinely requested
aids are
Not routinely •Blood
initially
•Pleural fluid
requested in requested
•Tracheal aspirate
an ambulatory
setting
recommended
Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society
Treatment/Management
 Antibiotics
PCAP A and B
PCAP C
PCAP D
•2 years OR
•> 2 years OR
•(+) high grade fever •(+) high grade fever
WITHOUT wheezes
WITHOUT wheezes OR
•(+) alveolar
consolidation on CXR OR
•WBC >15,000
•required
•Prerequisite: No
previous antibiotic
use
•DOC: Oral
amoxicillin (40-50
•consult specialist
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)
Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society
Treatment
 Ancillary treatment




Oxygen supplementation
Hydration (for dehydrated patients)
Bronchodilators when (+) wheezing
OTC Cough medicines not better than placebo
Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society
Risk factors
 Prematurity
 Malnutrition
 low socio-economic status
 passive exposure to smoke
 underlying disease
 Cystic Fibrosis
 Attendance at day care centers
Kliegman, et. al. 2007. Nelson Textbook of Pediatrics, 18th edition.USA: Saunders Elvesier
Complications
 Pleural effusion
 empyema
 pericarditis
 Rare
 Meningitis
 Suppurative arthritis
 osteomyelitis
Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society
Kliegman, et. al. 2007. Nelson Textbook of Pediatrics, 18th edition.USA: Saunders Elvesier
Prognosis
 Patients with uncomplicated pneumonia
 Clinical 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
Kliegman, et. al. 2007. Nelson Textbook of Pediatrics, 18th edition.USA: Saunders Elvesier
Prevention
 Breast feeding
 Avoidance of environmental tobacco smoke
 hand washing
 Vaccination
 Haemophilus influenza type B
 Influenza
 Pneumococcal
 Zinc supplementation (10 mg for infants, 20 mg >2 yrs,
for 4-6 months)
Clinical Practice Guidelines for Pediatric Community Acquired Pneumonia. Philippine Pediatric Society
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