PCAP presentation.pdf

CASE
PRESENTATION
PRESENTED BY
1. CAESAR MADHU NISHA
2. CATHERINE JOSEPH
3. CHAKKA VEERA VENKATA CHANDRA SEKHAR
GUPTHA
4. CHANDIRI NITHISH REDDY
5. CHANDRAKUMAR HARIRAM

PATIENT’S IDENTIFYING DATA
AGE
3-YEAR
INFORMANT
MOTHER
NAME
Y.V
ADDRESS
SEX
MALE
RELIGION
CATHOLIC
A B
F
E D
C
MATINA, DAVAO CITY
RELIABILITY-95%

HISTORY OF PRESENT ILLNESS
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4 weeks PTA Patient had onset of cough and nasal
congestion with no other associated symptoms like
fever, vomiting, loss of appetite. Sought consult
with AP Presecribed with disudrin (4ml), procaterol
(4ml), cetirizine (4ml) which provided temporary
relief.
1 day PTA patient still have the above symptoms
with onset of fever (Tmax-39c) associated with
decreased appetite and slightly fatigue was given
with paracetamol ( 4ml) at 15mkd which provided
temporary relief.
On the day of admission symptoms persisted and
sought consulted at DDH ER.

PAST MEDICAL HISTORY
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Patient had no bronchial asthma.
Patient has no other history of medical
illness.
Patient has no history of surgeries.
Patient has no history of allergies to
any food and drugs.
Patient has no antibiotic medication
past 3 months .
Patient has no history of allergic rhinitis.

FAMILY HISTORY
(-) Asthma
(-) Allergic rhinitis
(+) Diabetes mellitus – Maternal side
(+) Hypertension - Paternal side
(-) History of cancer
(-) Genetically transmittable disease

BIRTH AND PREGNANCY HISTORY
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Mother’s OB score of G2P2 (2-0-0-2).
Our patient is the second child for the
mother

MATERNAL AND PREGNANCY HISTORY:
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Patient mother was a healthy fertile woman
with age of 34 at the time of birth of patient.
Mother doesn't have any comorbidities or
medical illness before or during pregnancy.
Mother had regular Prenatal checkup (6)
since she got to know about her pregnancy.
Mother did not develop any diabetes or
hypertension during pregnancy.
Mother did not have any infection during
pregnancy.

LABOR & DELIVERY HISTORY
• Patient was born via CS, no
complications or noted
during delivery.

NEONATAL HISTORY:
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Patient had good cry at birth, pink in color, had
good movements
Mother could not recall APGAR score.
Birth weight of patient was 3.4 kg
No feeding diﬃculties
Length of stay in hospital birth – 3 days
New born and hearing screening test was
positive.

IMMUNIZATION HISTORY
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Received immunization at DDH by the attending physician as claimed by the
Mother
BCG and HEPA- B – 1 Dose at birth
Rotavirus- 2 Doses
DTaP – 4 Doses
Hib – 3 Doses
PCV – 3 Doses
IPV- 3 Doses
Inﬂuenza – 2 Doses
MMR- 3 Doses

GROWTH AND DEVELOPMENT
● MOTHER CLAIMED NORMAL GROWTH AND DEVELOPMENT FOR HER CHILD

GROSS MOTOR
MILESTONE AGE IN MONTHS
HOLDS HEAD STEADY WHILE SITTING 2
PULLS TO SIT , WITH NO HEAD LAG 3
BRINGS HAND TO MIDLINE 3
ASYMMETRIC TONIC NECK REFLEX
GONE
4
SITS WITHOUT SUPPORT 6
ROLLS BACK TO STOMACH 6.5
WALKS ALONE 12
RUNS 16
RIDE TRICYCLE 36

FINE MOTOR
GRASPS RATTLE 3.5
REACHES FOR OBJECTS 4
PALMAR GRASP GONE 4
TRANSFERS OBJECT HAND TO HAND 5.5
THUMB-FINGER GRASP 8
TURNS PAGES OF BOOK 12
SCRIBBLES 13
BUILD TOWER OF 2 CUBES 16
BUILD TOWER OF 6 CUBES 22
DRAW A CIRCLE 36

Communication & Language
SMILES IN RESPONSE TO FACE, VOICE 1.5
MONOSYLLABIC BABBLE 6
INHIBITS TO ”NO” 7
FOLLOW ONE-STEP COMMAND WITHOUT
GESTURE
10
SPEAKS FIRST REAL WORD 12
SPEAKS 4– 6 WORDS 15
SPEAKS TWO WORD SENTENCE 19
SPEAKS 3-4 WORD SENTENCE 36

Cognitive
STARES MOMENTARILY AT SPOT WHERE
OBJECT DISAPPEARED
2
STARES AT OWN HAND 4
BANGS TWO CUBES 8
UNCOVERS TOYS 18
EGOCENTRIC SYMBOLIC PLAY 12
USES STICK TO REACH TOY 17
PRETEND TO PLAY WITH DOLL 17
DRESS UNDER SUPERVISION 36

DIET AND NUTRITIONAL HISTORY
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Exclusive breastfed for 6 months
Complimentary breastfeeding with Formula milk and vegetable Pureed at the age of 1
Soft boiled veggies, meat, milk till age of 2
Normal Filipino diet from age of 2
Patient was not a picky eater
Until the Patient was sick, he had good appetite

PERSONAL AND SOCIAL HISTORY
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There are 5 adults and 1 elder sibling in
their house.
They live in house.
Older sibling and grandfather was noted
having cough with no medications taken.
There is no history of alcohol/ smoking
in family members
Patient has an active lifestyle and
interactive among others

ENVIRONMENTAL HISTORY
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Patient lives in a well ventilated area with no community spread of CAP
Patient practices good hygiene
Patient consume mineral water
Garbage disposed regularly

REVIEW OF SYSTEMS
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General: (-) weight change, (-) change in sleep habits
Skin: (-) rashes, (-) lumps
Head: (-) headache, (-) trauma
Eyes: (-) redness, (-) pain, blurring.
Ears: (-) ear discharge
Nose and sinus: (-) nose bleed
Respiratory: (-) dyspnea
Cardiovascular: (-) exercise or feeding intolerance, (-)chest pain
GIT: (-)diarrhea, (-)constipation.
GUT: (-)decreased urine output,(-)dysuria, (-)hematuria
HEMATOLOGICAL: (-) bleeding, (-) easy bruising
Endocrine: (-)Heat or cold intolerance, (-)excessive sweating
Neurologic : (-) seizures, (-)loss of consciousness

PHYSICAL EXAMINATION
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GENERAL SURVEY:
Awake, irritable on examination, not in respiratory
distress
ANTHROPOMETRIC MEASURES:
Height: 98 cm
Weight: 14.55 kg
BMI: 15.1 kg/m2
VITAL SIGNS:
BP – 117/78 mmHg (NORMOTENSIVE)
HR -166 BPM (TACHYCARDIA)
RR – 25 CPM (WITHIN RANGE)
Temp – 39°C (HIGH FEVER)
SpO2 - 100% (WITHIN RANGE)

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General: Awake, Irritable, Not in respiratory distress
Skin: Pink skin , No presence of cyanosis, No rashes, No discoloration
HEENT:
Head:
Inspection- Symmetric with no deformities
Palpation – No lumps, No palpable nodules
Eyes: Anicteric sclerae, No sunken eyeballs, No redness, No discharge
Ears: Bilaterally symmetrical, No deformities at the level of eye, No
discharge, No pain
Nose: No alar ﬂaring, No septal deviation, (-) nasal discharge, (-) redness
Mouth and throat: normal buccal mucosa, moist lips, No
tonsillopharyngeal congestion, No oral lesions, No cervical
lymphadenopathy

Chest and lungs:
Inspection- Equal chest expansion, No retractions
Palpation- No tenderness, tactile fremitus is normal on
both lung fields
Percussion- Dullness on Bibasal lung fields
Auscultation- Course Crackles on both lung fields, (-)
Wheezing

Cardiovascular:
Inspection- Adynamic precordium
Palpation- No heaves and thrills, PMI at 5th ICS at
midclavicular line left
Auscultation- S1 and S2 present, Regular rate and Rhythm,
No murmur
Abdomen:
Inspection- Flat abdomen
Auscultation- Normoactive bowel sounds
Palpation- Soft, non tender abdomen with no
organomegaly
Percussion- Tympanic sound all over

Genitourinary: Grossly male, No rash, No discharge
Extremities: Warm to touch, CRT < 2sec, No muscle
wasting, No skeletal deformities
Peripheral vascular: Full and strong pulses, No edema
Neurological:
General – GCS 15
Cranial nerves- Intact and functioning
Motor- Intact, functional (5/5)
Reﬂexes- Present

SALIENT FEATURES:
PERTINENT HISTORY
Cough
Nasal congestion
Fever
Sputum
Decreased appetite
(+) Fatigue
(-) weight loss
PERTINENT PE
(+) Crackles on both lung ﬁelds
(+) Dullness on bibasal lung ﬁelds
(+) Tachycardic

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RULE IN
PRODUCTIVE COUGH
CRACKLES ON
AUSCULTATION OF LUNG
FIELDS
DULLNESS ON
PERCUSSION
LOSS OF APPETITE
BRONCHIOLITIS
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RULE OUT
NO WHEEZING
NO CORYZA
NO TACHYPNEA
NO HYPERRESONANCE

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RULE IN
COUGH
NASAL CONGESTION
BRONCHIAL ASTHMA
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RULE OUT
NO WHEEZING
NO HISTORY OF
ASTHMA , INCLUDING
THE PARENTS
NO HISTORY OF
ALLERGIC RHINITIS
NO DRY COUGH

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RULE IN
PRODUCTIVE COUGH FOR
DURATION ~ 4WEEKS
FEVER
POOR APPETITE
CRACKLES ON BIBASAL
LUNG FIELDS
TUBERCULOSIS
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RULE OUT
NO FATIGUE
NO CHEST PAIN
NO NIGHT SWEATS
NO HEMOPTYSIS
NEED PPD SKIN TEST
TO RULE OUT

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RULE IN
PRODUCTIVE
COUGH FOR
DURATION ~
4WEEKS
FEVER
COVID 19
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RULE OUT
NO SORE THROAT
NO MYALGIA
NO DYSGEUSIA AND
ANOSMIA
NEED RT-PCR TO RULE
OUT

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CBC w/ diff
Chest X-Ray
RT- PCR
LABORARTORIES REQUESTED

CHEST XRAY
AP VIEW
Heart size is within the normal limits. Its conﬁguration is
unremarkable. Pulmonary vascularity is normal. Hili are not enlarged.
Alveolar opacities are seen in both lungs with airspace consolidation
in the medial segment of the right middle lobe. The lateral
costophrenic sinuses, anterior and posterior recesses are sharp.
Visualized osseous structures are normal.
IMPRESSION:
Suggestive of an Inﬂammatory lung disease compatible with
pneumonia with consolidation.

DIAGNOSIS
PEDIATRIC COMMUNITY ACQUIRED
PNEUMONIA – MODERATE RISK C

Hospital day 1
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Patient has cough, nasal
congestion and fever
Awake, irritable
Nonsunken eye balls, no alar
ﬂaring, moist lips and oral
mucosa
AP, DHS, Regular rhythm, no
murmur
No retractions, good air entry,
crackles(+) on both lung ﬁelds
Soft, non tender abdomen
Warm extremities, CRT < 2sec,
full pulse
CBC:
Hgb 120, Hct 0.35(low), WBC
27.32 (leukocytosis), platelet
344, Neutrophils 0.67
(Neutrophilia), Lymphocytes
0.18, Monocytes 0.15
PCAP - Moderate risk IVF D5 0.45 Nacl at 56 ml/hr
CBC, CXR APL done as OPD
Meds:
1. Paracetamol 250mg/5ml, 4
ml every 4 hours PO as needed
for fever(Temp >/= 37.5 degree
Celsius)
2. Amphiciliin + Sulbactum 728
mg IVTT every 6 hours
3. Salbutamol + Guaifenesin
1mg/50mg/5ml, give 5 ml three
times a day

Hospital day 1
CXR:
Pneumonia with
consolidation
Vitals:
BP: 117/79 mmHg
PR: 166 bpm
RR: 25 bpm
Temp: 39 degree Celsius
O2 sat: 95 %

Hospital day 2
Patient still with cough, no
fever reoccurrence, patient
had fair intake and activity,
improved sleep
Awake, comfortable, Not in
respiratory distress
mucosa
murmur
No retractions, good air
entry, decreasing crackles
on lung ﬁelds
Warm extremities, CRT <
2sec, full pulse
PCAP - Moderate risk 1. Paracetamol 250mg/5ml,
4 ml every 4 hours PO as
needed for fever(Temp >/=
37.5 degree Celsius)
2. Amphiciliin + Sulbactum
728 mg IVTT every 6 hours
3. Salbutamol + Guaifenesin
1mg/50mg/5ml, give 5 ml
three times a day

Hospital day 3
Patient had decresed cough
frequency, no fever
reoccurrence, patient had good
intake and activity, good sleep
Awake, comfortable, not in
mucosa
murmur
decreasing crackles on both
lung ﬁelds
full pulse
Adequate urine output
PCAP - Moderate risk To ﬁnish IVF and discontinue
Shift to Heplock
Give last dose of ampisul
tonight at 6pm then shift to
oral
Continue medication and
monitoring

Hospital day 4
Patient had decresed cough
frequency, no fever
reoccurrence, patient had good
intake and activity, good sleep
Awake, comfortable, not in
mucosa
murmur
decreasing crackles on both
lung ﬁelds
full pulse
Adequate urine output
PCAP - Moderate risk Patient cleared for discharge
May go home today
Take home medications as
directed

CASE DISCUSSION
PEDIATRIC COMMUNITY ACQUIRED
PNEUMONIA

Discussion
◦Etiology
◦Epidemiology
◦Pathophysiology
◦Clinical presentation
◦Diagnostic test
◦Treatment
◦Prognosis

Introduction
◦Globally, pneumonia is a leading cause of morbidity and mortality in children younger than the age of 5
years. Although the majority of deaths attributed to pneumonia in children are mostly in the developing
world, the burden of disease is substantial, and there are signiﬁcant healthcare-associated costs related
to pneumonia in the developed world.

Etiology
◦The etiology of pneumonia in the pediatric population can be classified by age-specific versus pathogen-
specific organisms.
◦Neonates are at risk for bacterial pathogens present in the birth canal, and this includes organisms such
as group B streptococci, Klebsiella, Escherichia coli, and Listeria monocytogenes.
◦Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus can be identified in
late-onset neonatal pneumonia. Viruses are the main cause of pneumonia in older infants and toddlers
between 30 days and 2 years old.

◦ In children 2 to 5 years old, respiratory viruses are also the most common. The rise of cases related to S.
pneumoniae and H. inﬂuenzae type B is observed in this age group.
◦ Mycoplasma pneumonia frequently occurs in children in the range from 5 to 13 years old. however, S.
pneumoniae is still the most commonly identiﬁed organism

Epidemiology
◦There are an estimated 120 million cases of pneumonia annually worldwide, resulting in as many as 1.3
million deaths. Younger children under the age of 2 in the developing world, account for nearly 80% of
pediatric deaths secondary to pneumonia.

Pathophysiology
◦Pneumonia is an invasion of the lower respiratory tract, below the larynx by pathogens either by
inhalation, aspiration, respiratory epithelium invasion, or hematogenous spread. There are barriers to
infection that include anatomical structures (nasal hairs, turbinates, epiglottis, cilia), and humoral and
cellular immunity.
◦Once these barriers are breached, infection, either by fomite/droplet spread (mostly viruses) or
nasopharyngeal colonization (mostly bacterial), results in inflammation and injury or death of
surrounding epithelium and alveoli. This is ultimately accompanied by a migration of inflammatory cells
to the site of infection, causing an exudative process, which in turn impairs oxygenation.
◦In the majority of cases, the microbe is not identified, and the most common cause is of viral etiology

There are four stages of lobar pneumonia. The ﬁrst stage occurs within 24 hours and is characterized
byalveolar edema and vascular congestion. Both bacteria and neutrophils are present.
◦Red hepatization is the second stage, and it has the consistency of the liver. The stage is characterized
by neutrophils, red blood cells, and desquamated epithelial cells. Fibrin deposits in the alveoli are
common.
◦The third stage of gray hepatization stage occurs 2-3 days later, and the lung appears dark brown.
There is an accumulation of hemosiderin and hemolysis of red cells.
◦The fourth stage is the resolution stage, where the cellula inﬁltrates is resorbed, and the pulmonary
architecture is restored. If the healing is not ideal, then it may lead to parapneumonic effusions and
pleural adhesion

CLINICAL PRESENTATION
◦Patients associated with pneumonia are nonspecific, including cough, fever, tachypnea, and difficulty
breathing. Young children may present with abdominal pain. Important history to obtain includes the
duration of symptoms, exposures, travel, sick contacts, baseline health of the child, chronic diseases,
recurrent symptoms, choking, immunization history, maternal health, or birth complications in neonates
◦Physical exam should include observation for signs of respiratory distress, including tachypnea, nasal
flaring, lower chest in-drawing, or hypoxia on room air. Note that infants may present with reported
inability to tolerate feeds, with grunting or apnea.

◦Auscultation for rales or rhonchi in all lung fields with the appropriately sized stethoscope can also aid
in diagnosis. In the developed world, other adjuncts like laboratory testing and imaging can be a helpful
part of the physical exam.
◦ No isolated physical exam finding can accurately diagnose pneumonia. However, the combination of
symptoms, including fever, tachypnea, focal crackles, and decreased breath sounds together, raises the
sensitivity for finding pneumonia on x-ray.
◦Pneumonia is a clinical diagnosis that should take into consideration the history of present illness,
physical exam findings, adjunct testing, and imaging modalities

Diagnostics
◦Chest radiography
◦Chest ultrasonography
◦Procalcitonin
◦CBC
◦Sputum GS/CS

Treatment
◦For a patient who has been classiﬁed as PCAP A or PCAP B without previous antibiotic, regardless of
the immunization status against Haemophilus inﬂuenzae type b or Streptococcus pneumoniae,
1.Amoxicillin trihydrate may be given.
◦It may be given at 40-50 mg/kg/day, maximum dose of 1500 mg/day in 3 divided doses in areas with
proven low antibiotic resistance to amoxicillin.
◦ It may be given at 90 mg/kg/day in areas with proven high amoxicillin resistance.
◦It may be given for a minimum of 3 days.
◦ It may be given in 2 divided doses for a minimum of 5.

2. Azithromycin [10 mg/kg/day OD for 3 days, or 10 mg/kg/day at day 1 then 5 mg/ kg/day for day 2 to
5, maximum dose of 500 mg/day], or Clarithromycin [15 mg/kg/day, maximum dose of 1000 mg/day in
divided doses for 7 days] may be given if there is, known hypersensitivity to amoxicillin
◦And if there is suspicion of atypical organisms particularly Mycoplasma pneumoniae.

◦For a patient who has been classified as PCAP C without previous antibiotic requiring hospitalization,
has completed the primary immunization against Haemophilus influenzae type b,
Penicillin G [100,000 units/kg/day in 4 divided doses] may be given.
has not completed the primary immunization, or immunization status unknown,
against Haemophilus influenzae type b, Ampicillin [100 mg/kg/day in 4 divided doses] may be given.
who can tolerate oral feeding and does not require oxygen support, Amoxicillin [40-50 mg/
kg/day in areas of proven low amoxicillin resistance and 90 mk/kg/day maximum dose of 1500 mg/day
in 3 divided doses for at most 7 days in areas of proven high amoxicillin resistance] may be given on an
outpatient basis.

◦For a patient who has been classiﬁed as PCAP D, a specialist may be consulted.
◦For a patient suspected to have community-acquired methicillin-resistant Staphylococcus aureus,
vancomycinmay be started and a specialist may be consulted

Viral pneumonia
1.For PCAP A, B, C or D in which a non-influenza virus is the suspected pathogen, antiviral drug therapy
may not be beneficial.
2.For PCAP C or D, antiviral drug therapy for clinically suspected or laboratory-confirmed influenza virus
to reduce risk of pneumonia may not be beneficial but time to symptom resolution may be beneficial.

1. Oseltamivir
for infants 3-8 months old at 3 mg/kg per dose twice daily x 5 days
for infants 9-11 months old at 3.5 mg/kg per dose twice daily x 5 days
for >12 months old: body weight 15-23 kg at 45 mg twice daily x 5 days, >23-40 kg at 60 mg
twice daily x 5 days, >40 kg at 75 mg twice daily x 5 days; doses to be started within 48 hours of onset of
influenza-like symptoms.
2. Zanamivir
for children >7 years old at 10 mg (two 5-mg inhalations) twice daily x 5 days, within 36 hours of
onset of influenza-like symptoms
3. Oseltamivir or zanamivir may be beneficial to reduce the burden of pneumonia during a flu epidemic.
4. Symptomatic and ancillary treatment may be beneficial

Prognosis
◦For most children, the prognosis is good. Viral pneumonia tends to resolve without treatment. Long-
term sequelae are rare. However, both staphylococcal and varicella pneumonia have guarded outcomes
in children.
◦Children with tuberculosis are at high risk for disease progression if the condition is not treated
Immunocompromized children have the worst prognosis. Each year, roughly 3 million children die from
pneumonia and the majority of these children also have other comorbidities like congenital heart disease,
immunosuppression, or chronic lung disease of prematurity.

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