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PEDIATRICS WORKSHEET
SUBMITTED TO: Dr. Desiree Reyes- Gubantes
DATE OF SUBMISSION: December 18, 2014
SUBMITTED BY:
MD III
Pasuquin, Alvin G.
Rodriguez, Arianne S.
PRESENTATION OF HISTORY
Identifying Information
This is a case of ZM, 3-month old, female, from Dumaguete City came in at Silliman Medical Center last February 16, 2014
Chief Complaint: fast breathing
HISTORY OF PRESENT ILLNESS
Condition started three weeks prior to admission when patient was noted to have occasional cough. Two weeks prior to
admission, with persistence of cough, consult was done at a local Health Center and was given Amoxicillin drops for one week,
but no relief was noted. One week prior to admission, cough persisted, this time, associated with decreased in appetite and
undocumented fever. Three days prior to admission, the patient was noted to have episodes of difficulty breathing, feeds for a
shorter period of time, accompanied by incessant crying.
Four hours prior to admission, she was noted to have fast and deep breathing, hence was brought to the ER and was admitted.
REVIEW OF SYSTEMS
Unremarkable.
BIRTH HISTORY
This baby was born term to a primigravid, 20-year-old mother in Provincial hospital, assisted by a doctor, with good cry and
activity at birth. Mother had irregular prenatal check-up but denies any illness during pregnancy. Birth weight was 3.2
kilograms. No meconium staining noted.
NEONATAL HISTORY
APGAR score was 8/9.
IMMUNIZATION HISTORY
BCG was given already at birth as well as the first dose of hepatitis B right before discharge from the hospital. First dose of
tetanus plus oral polio was given already at 6 weeks of age. Hep B2 and HiB1 were also given.
FEEDIG HISTORY
Exclusively breastfed since birth
PAST MEDICAL HISTORY
Unremarkable. The newborn screening was normal
FAMILY HISTORY
No family history of asthma, diabetes and hypertension reported.
DEVELOPMENTAL HISTORY
Social smile and head control developed at 3 months.
PHYSICAL EXAMINATION
General Survey: The patient was examined cuddled, irritable, pale looking, and in cardiorespiratory distress.
Vital Signs:
HR = 160bpm
RR = 65cpm
O2 saturation in room air = 93%
O2 saturation after O2 was given at 2 liters/min = 99%
Temperature = 38C
Anthropometric Data:
Weight = 4.2 kg
Length = 58 cm
BMI = 12.72 kg/m2
Skin:
HEENT:
No rashes. No lesions
Pale lips. No tonsillopharyngeal congestion. No oral lesions noted. No eye and ear discharges. No sunken
eyeballs. No dysmorphic features. There is presence of nasal flaring. Oral mucosa is dry.
C/L:
GUT:
Symmetrical chest expansion with shallow subcostal retractions. There are coarse rales, crackles, and
occasional wheezes on both lung fields.
The precordium is dynamic. Apex beat at 5th ICS LMCL. S1 is normal with a splitting of a 2nd heart sound. A
3/6 murmur is noted on pansystolic left lower sternal border.
Abdomen is slightly globular with normoactive bowel sounds. Liver is palpable at 2 cm below the subcostal
regions. No masses. Spleen is not palpable.
grossly female
Ext:
Cold extremities with fair pulses. CRT is 3 seconds. No edema. No clubbing. No cyanosis.
CVS:
Abd:
NEUROLOGIC EXAMINATION
Unremarkable
PRIMARY WORKING
IMPRESSION
RULE IN
RULE OUT
History:
(+) cough, (+)poor feeding, , (+) fever, (+) vomiting,
(+) poor weight gain, (+) tachypnea,
Acyanotic Heart Disease to
consider Ventricular Septal
Defect, with severe
pneumonia
Physical Exam:
(+)hypoxemia,(+) irritability ,(+) increased
respiratory rate, (+) crackles, (+) rales, (+)
wheezing, (+) cardiorespiratory distress, (+)
retractions, (+) dehydration, (+) nasal flaring, (+)
coryza, (+) pallor (+) heart murmurs
Bronchiolitis
History:
(+) cough, (+) low grade fever
Physical Exam:
(+) respiratory distress, (+) wheezing, (+)
subcostal retractions, (+) hypoxemia, (+)
dehydration, (+) tachycardia
History:
(-) congestion, (-) dyspnea, (-) cyanosis
Moderate Dehydration
Physiologic Anemia
Physical
Exam:
(+)
pale-looking,
(+)
cardiorespiratory symptoms such as tachycardia,
tachypnea, (+) flow murmurs
Labs: (+) low hemoglobin
Hematocrit
28-42%
29 %
40% (repeat)
WBC
5,00019,500/cumm
12,500/cumm
12,000/cumm
(repeat)
-Neutrophil(seg)
54-62%
30%
58% (repeat)
-Lymphocyte
25-33%
38%
35% (repeat)
-Monocyte
3-7%
2%
5% (repeat)
-Eosinophil
1-3%
-Basophil
0-0.75%
0%
2 (repeat)
0%
AVAILABILITY
COST
(Pesos)
SUMC, HCH,
NOPH, Private
Laboratories
250
Platelet Count
84-478/uL
254,000/uL
267, 000
(repeat)
SERUM ELECTROLYTES
Potassium
3.5-6.0 mmol/L
SUMC, HCH,
NOPH, Private
Laboratories
250
SUMC, HCH,
NOPH
50
Ketones
Protein:
WBC:
RBC:
1.016- 1.022
negative
Negative
0-3 cells/hpf
1.015
+1
Negative
2-3
0-3
Bacteria:
Rare
few
IMAGIG STUDIES
Chest x-ray
Pneumonic
Chest radiography is considered the
infiltrates are criterion standard for diagnosing the
seen on both
presence of pneumonia. The
lung fields.
presence of infiltrate is required for
Cardiomegaly the diagnosis. It may also reveal
with
VSDs, heart size, increased cardiac
pulmonary
silhouette, etc.
congestion is
also seen.
Two-dimensional
unremarkable
CHD with left
This is used to determine the size and
echocardiography
atrial and
location of virtually all VSDs and to
with Doppler
ventricular
check for blood flow if theres
echocardiography
enlargement,
shunting. Also, this is to monitor and
good
check for ejection fraction.
(2D echo)
ventricular
function and
Doppler echocardiography provides
estimated
additional physiologic information
pulmonary
( RV pressure, PA pressure, and
pressure of
interventricular pressure difference).
60 mmHg.
OTHER LAB TESTS AND DIAGNOSTIC PROCEDURES TO ORDER
TEST
TEST NECESSITY
Blood Typing
This is essential for possible transfusions
ABG Determination
Electrocardiography
(ECG)
unremarkable
The test is used to determine the pH of the blood, the partial pressure of
carbon dioxide and oxygen, and the bicarbonate level. In pneumonia,
hypoxi and respiratory acidosis may be present.
In patients with small VSDs, ECG findings are normal.
In patients with moderate-sized VSDs and with moderate or large left-toright shunts with volume overload in the LV, LV hypertrophy is the rule.
Combined ventricular hypertrophy is common.
SUMC, HCH,
NOPH
350
SUMC, HCH,
NOPH
3,747
AVAILABILITY
SUMC, HCH,
NOPH
SUMC, HCH,
NOPH
SUMC, HCH,
NOPH
LIST OF PROBLEMS:
1. tachypnea
2. persistent cough
3. decreased appetite
4. poor weight gain
5. fever
6. episodes of difficulty breathing
7. feeds for a shorter period of time
accompanied by incessant crying.
8. Hypoxemia
9. tachycardia
10. pallor
11. irritability
12. cardiorespiratory distress
13. shallow subcostal retractions
14. nasal flaring
15. dry oral mucosa
16. rales, crackles, and occasional wheezes on
both lung fields.
17. murmur
18. cold extremities
19. abnormal capillary refill time
THERAPEUTICS
THERAPEUTIC OBJECTIVES:
1. The infant will be free from further complications of condition.
2. The infant will be normothermic.
3. Febrile convulsions are prevented.
4. The infant will be free from anemia.
5. Absence of cough.
7. Minimize frequency and severity of respiratory infections.
8. The infant will achieve its high degree of wellbeing.
9. Normalize infants growth and development.
10. Control the symptoms of heart failure to allow the baby time to
grow.
11. Increase comfort and decrease parental anxiety.
MANAGEMENT
PARENTS ADVICE AND INFORMATION
Educate the parents/guardians about the babys condition: possible etiology, risk factors, course of disease, signs and
symptoms, complications if left untreated, prognosis and medical options for treatment including its benefits, side
effects, risk and alternatives. Increasing their knowledge about the childs condition to improve medical compliance
and assist in symptom management.
Emphasize importance of medication compliance in optimum management of his condition.
Provide parents with instruction about management of their childs condition. This will empower them to care for
their child.
Educate the parents of the advantages of breastfeeding.
Educate the parents about the importance of immunizations.
Emphasize that the baby is on trust vs. mistrust stage: the needs must be met for a healthy emotional development.
NON-PHARMACOLOGIC MANAGEMENT
Admit. Children and infants who have moderate to severe CAP, as defined by several factors, including respiratory
distress and hypoxemia (sustained saturation of peripheral oxygen, 90 % should be hospitalized for management,
including skilled pediatric medical care.
Vital signs monitoring q 2h. Rectal temperatures are the gold standard for measuring central body temperature
Monitoring Pulse oximetry with or without cardiac monitoring
Place the child on NPO temporarily for an 8-hour-observation
Start Venoclysis with D5 0.3% Sodium Chloride at 20 cc/hr
Provide neutral environmental temperature. Avoid hot or cold extremes which increase oxygen and energy demands
Nutrition: Increase caloric density of feedings to ensure adequate weightv gain. Initiate orogastric feeding (OGT) with
expressed breastmilk 30 cc every 3 hours, increasing gradually to every 3 hours. More than 150 kcal/kg per day
Transfuse packed RBC. Possible red blood cell transfusion for significant anemia in the setting of heart failure, poor
weight gain and respiratory difficulties.
Elevate the head via carrier/ pillows. Positioning of the infant to minimize aspiration risk
Bronchial hygiene: Pulmonary toilet may include chest physiotherapy, positioning to promote dependent drainage,
and incentive spirometry to enhance elimination of purulent sputum and to avoid atelectasis.
Allow rest periods between care; disturb only when necessary for care and procedures.
Assess usual family coping methods and effectiveness.
POSSIBLE SURGERY
INTRACARDIAC REPAIR OF DEFECT
The symptoms of children with heart failure from left-to-right shunts can improve with medical therapy, postponing and possibly
avoiding the need for surgical correction. However, despite maximum medical management, 50 percent of patients with moderate
to large VSDs continue to have tachypnea and or/failure to thrive. These patients undergo surgical closure in infancy, preferably
before six months of age
Indications
Infants <6 months (<3 months for those with trisomy 21) who have uncontrolled heart failure despite maximal
medical and dietary interventions or who have pulmonary hypertension.
Children with a persistent significant shunt (Qp:Qs >2:1) with elevated PA pressures should undergo surgical repair.
Children with a persistent significant shunt and normal PA pressures may be considered for surgical closure.
Subpulmonic and membranous defects, regardless of size, with aortic regurgitation should be surgically corrected
before the aortic valve is permanently damaged.
Drug Name
Efficacy
OXYGEN ADMINISTRATION
O2 inhalation
at 2 L per nasal
cannula
ANTIBIOTICS
Cefuroxime
450 mg IV q8 for
7 days
PHARMACOLOGIC MANAGEMENT
Safety
Side Effects
Prolonged exposure to high
inspired fractions of oxygen
causes damage to the retina.
Side Effects
Diarrhea. Decreased
haemoglobin or hematocrit,
nausea, vomiting, transient rise
in hepatic transaminase,
diaper rash,
Precaution
Oxygen should be used with
caution since it is a pulmonary
vasodilator and may decrease
PVR, increasing left-to-right
shunt, and exacerbating failure
Precaution
Bacterial or fungal overgrowth
of nonsuceptible organisms
may occur with prolonged or
repeated therapy
Suitability
Cost
Oxygen is used as a
medical treatment in
both chronic and acute
cases, and can be used
in
hospital,
prehospital or entirely out
of hospital, dependent
on the needs of the
patient.
diminished
blood oxygen levels
(oxygen
saturation
levels of <92%) is an
indication
for
an
oxygen
supplementation.
Empiric antimicrobial
therapy
must
be
comprehensive
and
should cover all likely
pathogens. Cefuroxime
has
been
recommended as a
component
of
treatment
for
community-acquired
pneumonia
Contraindications
Documented hypersensitivity
ANTIPYRETIC
Paracetamol
(TEMPRA
FORTE)
drops 100 mg/ml
0.5 ml every 4
Side Effects
Angioedema, dizziness, pruritic
maculopapular rash, Steven
Johnson syndrome, Toxic
epidermal necrolysis, urticaria,
gastrointestinal hemorrhage,
Paracetamol
is
approved for reducing
fever in people of all
ages.
P447
80
mg/0.8
ml
hours for
temperature 37.8
C and above
leukopenia. Neutropenia,
Side Effects
Tremor, nausea, fever,
bronchospasm, vomiting,
headache, dizziness, cough,
allergic reactions, epistaxis,
dry mouth,
Side Effects
Hyperuricemia, hypokalemia,
anaphylaxis, anemia, anorexia,
diarrhea, dizziness, glucose
intolerance, glycusoria,
headache, hypotension,
hypomagnesemia, muscle
cramps, photosensitivity, rash,
restlessness, weakness
Syrup
Precaution
Use with caution in patients
with G6PD deficiency
Contraindications
Hypersensitivity and severe
active liver disease
BRONCHODILATOR
Salbutamol
(VENTOLIN)
nebulisation
every 6 hours
Bronchodilator
treatments such as
albuterol may or may
not be required
depending on your
symptoms.
P659.80
Precaution
Risk of hypokalemia,
Paradoxical bronchospasm
may occur
Contraindications
Tachycardia secondary to a
heart condition
LOOP DIURETICS
Furosemide
(LASIX) 4 mg IV
every 12 hours
Precaution
Agent is a potent diuretic, that,
if given in excessive amounts,
may lead to profound dieresis
with water and electrolyte
depletion. There is risk of
ototoxicity.
Contraindications
Anuria, documented
hypersensitivity to furosemide
or sulfonamides
ACE INHIBITORS
Captopril
Side Effects
P430
(CAPOTEN)
2 mg/pptab every
12 hours
of angiotensin I to angiotensin II
by inhibition of ACE, a
peptidyldipeptide carboxy
hydrolase. Inhibition of ACE
results in decreased plasma
angiotensin II and increased
plasma renin activity (PRA), the
latter resulting from loss of
negative feedback on renin release
caused by reduction in angiotensin
II. The reduction of angiotensin II
leads to decreased aldosterone
secretion,
Systemic vascular resistance may
increase in children with VSD for a
variety of reasons. In this setting,
antegrade flow through the aortic
valve decreases and left-to-right
shunting through the defect
increases. Afterload reducing
agents, such as the angiotensin
converting enzyme inhibitors
captopril or enalapril are used to
reduce systemic vascular
resistance, promoting antegrade
flow through the aortic valve and
decreasing the magnitude of the
shunt
Hyperkalemia, hypersensitivity
reactions, skin rash, dysgeusia,
hypotension, pruritus, cough,
chest pain, palpitations,
proteinuria and tachycardia
Precaution
Risk of hyperkalemia
especially with Potassium
sparing diuretics
used to treat
congestive heart
failure. They may be
used to treat systemic
afterload. This
medication reduces
both systemic and
pulmonary pressure,
thereby reducing the
left-to-right shunt.
Contraindications
CAPOTEN is contraindicated in
patients who are
hypersensitive to this product
or any other angiotensinconverting enzyme inhibitor
INOTROPIC AGENTS
Dopamine
Hydrochloride
(DOPAMAX)
5 ug/kg/min
Digoxin
(LANOXIN) 50
mcg/ml given at
0.3 ml every 12
Dopamine is a natural
catecholamine formed by the
decarboxylation of 3,4dihydroxyphenylalanine (DOPA).
Dopamine produces positive
chronotropic and inotropic effects
on the myocardium, resulting in
increased heart rate and cardiac
contractility. This is accomplished
directly by exerting an agonist
action on beta-adrenoceptors and
indirectly by causing release of
norepinephrine from storage sites
in sympathetic nerve endings.
Dopamine 's onset of action occurs
within five minutes of intravenous
administration, and with plasma
half-life of about two minutes, the
duration of action is less than ten
minutes.
Side Effects
ventricular arrhythmia (at very
high doses), ectopic beats,
tachycardia, palpitation,
cardiac conduction
abnormalities, widened QRS
complex, bradycardia,
hypotension, hypertension,
vasoconstriction, dyspnea,
nausea, vomiting
Precaution
Careful monitoring required Close monitoring of the
following indices-urine flow,
cardiac output and blood
pressure
Contraindications
This should not be
administered in the presence
of uncorrected
tachyarrhythmias or
ventricular fibrillation.
Side Effects
Nausea, vomiting, abdominal
pain, intestinal ischemia, and
hemorrhagic necrosis of the
intestines, headache,
DOPAMINE is
indicated for the
correction of
hemodynamic
imbalances present in
the shock syndrome
due to myocardial
infarctions, trauma,
endotoxic septicemia,
open heart surgery,
renal failure, and
chronic cardiac
decompensation as in
congestive failure.
LANOXIN increases
myocardial
contractility in
pediatric patients with
per box
of 50s
hours
heart failure.
Precaution
The earliest and most frequent
manifestation of digoxin
toxicity in infants and children
is the appearance of cardiac
arrhythmias, including sinus
bradycardia.
Contraindications
LANOXIN is contraindicated in
patients with ventricular
fibrillation
DISCHARGE
The infant is eligible for discharge when she has documented overall clinical improvement, including level of activity,
appetite, and decreased fever for at least 1224 hours.
Infant is eligible for discharge when she demonstrates consistent pulse oximetry measurements .90% in room air for
at least 1224 hours.
Clinicians should demonstrate that parents are able to administer and children are able to comply adequately with
taking those antibiotics before discharge.
MONITORING AND FOLLOW-UP
PRESCRIPTION:
Alvin Pasuquin, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________
___________________________
SIGNATURE
Arianne Rodriguez, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:_____________________________ Date: ________________
___________________________
SIGNATURE
Alvin Pasuquin, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________
___________________________
SIGNATURE
Arianne Rodriguez, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________
___________________________
SIGNATURE
REFERENCES:
Atienza, M. et al. (2006). Guide for history taking, physical examination and diagnosis of pediatric patients. 2nd ed. UST.
Philippines.
Bickley, A. et. Al. (2009).BatesGuide to Physical Examination and History Taking. 10thed.
Chernecky, C & Berger B., (2008). Laboratory Test and Diagnostic Procedures. 5th ed. Saunders Elseviers: Philadelphia
Fauci, A. et Al. (2012). Harrisons Principles of Internal Medicine. 18th ed. McGraw-Hill
Medical Publishing Division, USA.
Kliegman, R.M. et al. (2012). Nelson textbook of pediatrics. 19th ed. Elsevier Saunders. Singapore.