Nicer, Stefi Diane

Olarte, Carla Mae

Palatino, John Paul
Pangan, Kimberly Anne
Pangilinan, Mary Juneve
Pascua, Krinzel Mae
Perez, William
Pescante, Nina Carmela

Pediatrics 2: Ward Case

#4

GENERAL DATA
Informant: Mother of patient
Reliability: 90%

GENERAL DATA

C.M.
1 month and 3 weeks old
Female
Birthdate: August. 30, 2014
Birthplace: lying-in clinic Dasmarinas, Cavite
1st admission at OMMC
Date of admission: October 8, 2014
Time of admission: 11:00 pm

DIFFICULTY OF
BREATHING
CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

2 WEEKS PTA
Patient had colds with a clear nasal discharge.
Medical consult was done in the lying-in clinic
phenylephrine HCl, chlorphenamine maleate
(Disudrin)
0.3 mL every 6 hours with afforded relief in 2 days

No other associated symptoms like fever,

cough, chills, change in appetite were note.
Patient was apparently well until 3 days PTA

3 DAYS PTA
Patient had productive cough of yellowish
sputum accompanied by colds
Patient was irritable and cannot be easily
pacified.
Weight loss noted as described by mother.
Same medication, frequency and dosage was
taken
No other accompanying symptoms. No consult
was done.

DAY OF ADMISSION
Patients condition persisted and mother noticed
difficulty of breathing described as effortful and
Patient was referred to OMMC, hence the
admission and slower than usual.
Presence of grunting, subcostal retractions and
alar flaring were noted.
Patient was irritable and has a weak cry
Patient was brought to OMMC, hence admission.

REVIEW OF SYSTEMS

REVIEW OF SYSTEMS
Skin

(+) skin rashes (-) color change (-) changes in nails

(-) lumps

Head

(-) trauma

Eyes

(-) excessive lacrimation (-)redness

Ears

(-) discharge

Nose

(-) epistaxis

Mouth and Throat (-) bleeding gums

REVIEW OF SYSTEMS
Gastrointestinal

(+)posttussive vomiting (-)diarrhea (-)constipation

(-)hematochezia (-)melena

Genitourinary

(-) gross hematuria (-) dyscharge (-)genital swelling

Hematologic

(-) easy bruising

Endocrine

(-) excessive sweating

Nervous/
behavioral

(-) paralysis (-) convulsion

Musculoskeletal

(-) stiffness

PERSONAL HISTORY

A. Gestational History
27 years old with OB index of G3P2 (2-0-0-2)
when the patient was being conceived.
no complications throughout the course of
pregnancy.
In good health, and denied intake of any drugs
during the time of conception.
Duration of gestation: 9 months (37 weeks).

 OB index: G3P3 (3003)

Birthdate

Place

Manner of
Delivery

Attendant

Sex

Status

08/9/08

Lying in
clinic in
Dasma

NSD

Doctor

No
reported
diseases

10/14/10

Lying in
clinic in
Dasma

NSD

Doctor

No
reported
diseases

08/30/14

Lying in
clinic in
Dasma

NSD

Doctor

Curently in
the hospital

B. Birth History

Term
via NSD
in a lying-in clinic in Damarinas City, Cavite
attended by a physician.
Birth weight at birth: 3.2 kg
born as a well-baby.

C. Neonatal History

no complications upon delivery

good cry
spontaneous respiration
no cyanosis, pallor, nor jaundice.
no convulsions, hemorrhage, congenital
abnormalities, nor birth injury.

D. Feeding History
breastfed most of the time
given formula milk ~once a week, whenever
the mother has to go somewhere leaving the
patient behind.
9x/day
12 minutes in each breast/about 24 minutes
per session.
Ascorbic acid and multivitamins (Tiki-Tiki Star)

Past Illnesses
No allergies to food, medications, pollen nor
animals
Hasnt had any other illnesses nor injuries

Immunization History
Hepatitis B 1 dose at birth

Family History
Family Member

Age

Occupation

Diseases

Father

28

Container van driver

None

Mother

28

Housewife

None

Siblings

None

None

None

None

No medical problems for blood-relatives such as

tuberculosis, diabetes, cancer, epilepsy, rheumatic
fever, allergy, asthma, hypertension, heart disease,
stroke, kidney disease, blood disorder nor mental
disorder.

Socioeconomic History
Living conditions
Currently lives in an apartment with one
bedroom, occupied by 5 other family members

Economic circumstances
Two members of the family, the patients father
and uncle have jobs and their incomes are the
familys source of funds

Environmental History
Has exposure to cigarette smoke from her
father and uncle
No other pollutants identified
Garbage collected periodically however they
resort to burning of garbage materials when
theres none, about once weekly

PHYSICAL EXAMINATION

General Survey
Quality of cry: slightly weak cry (whimpering)
Reaction to parent stimulation: Cries briefly then
stops
State of variation: if asleep and stimulated, then
wakes up quickly
Color: Pink
Hydration: Skin Normal and and eyes, mouth
moist; CRT <2 secs
Response to social overtures: alerts
Not in cardiorespiratory distress

Vital Signs

T: 38.3 C, axillary
HR: 120 bpm , regular
RR: 50 bpm, regular
Acute Ilness Observational Scale: 8

Anthropometric Data

Weight: 6.5 kg
Length: 62 cm
Head circumference: 39cm
Chest circumference: 36cm
Abdominal circumference: 37cm
BMI: 15.61

Skin

(-) pallor, jaundice, flushing, cyanosis

pinkish
fair skin tone
smooth, no breaks
(+) erythematous papulovesicular rash (diaper
area)
moist in skin folds
normal skin turgor

Head

no trauma
normocephalic
Scalp: no infestations, clean
Hair: fine, normal distribution
(-) swelling, hematoma, abscess
Symmetrical facial expression
Fontanels:
AF: slightly depressed, pulsatile, open
PF: closed

Eyes

Eyelids: symmetrical
No periorbital edema
pinkish conjuctiva
anicteric scelra
equal pupil size
equal accomodation and convergence

Ears

normoset external pinnae

no discharge
(-) tenderness
(+) gross hearing

Nose

symmetrical nasolabial folds

midline septum
pinkish mucosa
no discharge
both nostrils are patent

Mouth and Pharynx

midline tongue
lips: pinkish, cutest
gums pinkish
no teeth
uvula midline

Neck
midline
(-) palpable thyroid, lymph nodes

Chest and Lungs

AP diameter = transverse diameter
Movements with respiration: mostly
abdominal
(-) chest retractions
symmetrical chest expansion
vesicular breath sounds: all lung fields
(-) adventitious breath sounds

Cardiovascular
Inspection: No observed precordial bulging.
No visible pulsations in the chest
Palpation: PMI measures approximate 2cm on
left 4th intercostals space MCL, no thrills.
Percussion: Not done
Auscultation: No abnormal murmurs or heart
sounds (S3 and S4) noted. No pericardial
friction rub

Abdomen
Inspection: Abdomen is globular and symmetric.
No visible superficial veins, scars, or localized area
of bulging, masses and other lesions.
Auscultation: With audible normoactive bowel
movement sounds (7/min) gurgling in quality. No
bruits auscultated.
Palpation: Soft and non-tender abdomen. No
noted involuntary rigidity or muscle guarding. Liver
edge is not palpable over the right costal margin.
Non palpable spleen.
Percussion: Not assessed

Genitalia
Grossly female
Size, location of labia, clitorius, meatus and
vaginal opening are normal for age
Tanner stage 1
No discharge or pseudomenses

Peripheral vascular & Extremities

No tremors, no twitching, no involuntary
movements
No clubbing, edema, swelling and deformities
noted
No tenderness noted
Capillary refill < 2 seconds
Pink nail beds
Radial, and dorsalis pedis pulses 2+ for both left
and right extremities

NEUROLOGICAL EXAM

Cranial Nerves
CRANIAL
NERVES

FINDINGS

I
II
III
IV
V
VI

N/A
N/A
N/A
N/A
N/A
Eyes are symmetrical. Pupillary size equal, equally reactive to
light, direct and consensual pupillary reflex, accommodation and
converegence
N/A
Gross hearing is intact
N/A
N/A
N/A
Tongue is at the midline. No atrophy, grooving or fascuculations

VII
VIII
IX
X
XI
XII

Neurological Exam
Motor Testing
o Examination of the gait and posture, muscle
bulk, muscle tone and strength and
coordination is not applicable in the
examination of the patient
Cerebellar Function (N/A)
Sensory Testing (N/A)

Reflexes
Reflexes
Deep Tendon Reflex
Patellar reflex
Primitive reflexes
Moro reflex
Rooting reflex
Grasp (Palmar and Plantar) reflex
Babinski
Tonic neck reflex

Score
2+
+
+
+
+
+

Reflexes
Deep Tendon Reflex
Patellar Reflex 2+

Primitive Reflexes (all positive)

Moro
Rooting
Palmar and Plantar Grasp
Tonic Neck
Babinski

SALIENT FEATURES

< 2 months old

Previously healthy
Parental smoking
History of mild upper respiratory infection manifested by colds with clear
rhinorrhea.
No fever
Cough
Signs of respiratory distress:
Dyspnea
Irritable
Effortful breathing
Weak cry
Grunting
Alar flaring
Subcostal Retractions
No tachypnea
No crackles
No wheezing
No other systemic symptoms

APPROACH TO DIAGNOSIS

COUGH

w/ signs of
respiratory
distress

No other
systemic
symptoms

Respiratory
system

Other
Systems

Acute (<3
weeks)

Chronic (>3
weeks)

Obstructive
Symptoms

Bronchial
asthma

Viral
Pneumonia

Restrictive
Symptoms

Acute
Bronchiolitis

Asthma
Congenital
causes (cystic
fibrosis,
congenital
web, reflux)

Viral Pneumonia
Rule in

Rule Out
(-) Fever
(usually present in viral pneumonia
and temperatures are generally
lower than in bacterial pneumonia)
(-) Tachypnea
(Tachypnea is the most consistent
clinical manifestation of pneumonia)
(-) adventitious breath sounds

<2 months old

Productive cough
Difficulty of breathing
Subcostal retractions
Nasal flaring
Grunting

RULED OUT

Bronchial Asthma
Rule in

Rule Out

Epidemiology: Most common chronic disease

of Childhood and 33% before 2 y.o.
Parental smoking
History of mild upper respiratory infection
manifested by colds with clear rhinorrhea
No fever
Cough
Dyspnea
Irritable
Effortful breathing
Weak cry
Grunting
Alar flaring
Subcostal Retractions
No other systemic sxs

RULED OUT

No family history of Asthma

No Intermittent dry coughing
No expiratory wheezing

Acute Bronchiolitis
Rule in

Rule Out

1 month old
The infant first develops a mild upper
respiratory tract infection with clear
rhinorrhea
Temperature can range from subnormal to
markedly elevated
Respiratory distress ensues, with paroxysmal
wheezy cough, dyspnea, and irritability.
The child does not usually have other
systemic complaints, such as diarrhea or
vomiting
Apnea may be more prominent than
wheezing early in the course of the disease,
particularly with very young infants (<2 mo
old)
RULED IN

Cannot rule out

Working Diagnosis

ACUTE BRONCHIOLITIS

DIAGNOSTIC WORK-UP

Diagnostic Work-Up
Diagnosis is basically made clinical and based
upon history and physical examination
(Kliegman et al., 2010).
However, because concurrent bacterial
infection is highly unlikely, confirmation of
viral bronchiolitis may obviate the need for a
sepsis evaluation in a febrile infant (Kliegman
et al., 2010).

CBC and Differentials

To look for coexisting bacterial infection
WBC and RBC differential counts usually normal
(without the lymphopenia seen with other viral
illnesses) (Kliegman et al., 2010)
WBC count (8000-15000/ul) and may be left-shifted as
a result of stress (DeNicola, 2014)
However, it is noted that mong infants with a febrile
illness, WBC values are highly variable. No WBC count
threshold has good discriminatory value for the
presence of bacterial infection (DeNicola, 2014)

Chest Radiography
Useful in excluding unexpected congenital
anomalies or other conditions (e.g. lobar
pneumonia, congestive heart failure)
AP and lateral views
May reveal hyperinflated lungs with patchy
atelectasis
difficult to distinguish from early bacterial
pneumonia (Nelson, 2003)

Pulse Oximetry
To determine severity of illness but does not rule
out other diagnoses (e.g. asthma, pneumonia)
Transcutaneous oxygen saturation
good indicator of the severity of bronchiolitis
correlates best with tachypnea; however, correlates
poorly with wheezing and retractions (DeNicola, 2014)

Persistent resting oxygen saturations <92% in

room air (lower limit) require a period of
observation and possible hospitalization
(DeNicola, 2014)

Viral Testing
To determine the viral pathogen to help guide
treatment
Rapid immunofluorescence, ELISA, PCR
Viral culture
Standard for a definitve diagnosis

RSV most commonly isolated organism (2695%) (DeNicola, 2014)

MANAGEMENT
Management for patients with Acute
Bronchiolitis is directed toward symptomatic
relief and and maintenance of hydration and
oxygenation since there is no definitive
treatment for specific viruses.

INITIAL MANAGEMENT
Patient should be made as comfortable as
possible.
Administer saline nose drops and perform
nasal and oral suctioning if needed.
Careful monitor for presence of apnea.
Pay attention to temperature regulation in
small infants
Adequate hydration should be maintained and
careful fluid monitoring.

CRITERIA FOR ADMISSION

Persistent resting oxygen saturation below 92% in room air before
beta-agonist trial
Markedly elevated respiratory rate (>70-80 breaths/min)
Dyspnea and intercostal retractions, indicating respiratory distress
Desaturation in 40% oxygen (3-4 L/min oxygen), cyanosis
Chronic lung disease, especially if the patient is on supplemental
oxygen
Congenital heart disease, especially if associated with cyanosis or
pulmonary hypertension
Prematurity
Age younger than 3 months, when severe disease is most common
Inability to maintain oral hydration in patients younger than 6
months
Difficulty in feeding as a consequence of respiratory distress
Parent unable to care for child at home

CRITERIA FOR ADMISSION IN ICU

Worsening hypoxemia or hypercapnia
Worsening respiratory distress
Continuing requirement for more than 40%
oxygen
Apnea
Acidosis
Extrapulmonary symptoms
Worsening mental status
Unclear etiology of symptoms

OXYGEN SUPPLEMENTATION
Oxygen therapy should be started when:
oxygen saturations are persistently below 92%
significant respiratory distress.

Maximum oxygenation via nasal prongs is 2.5

L/min

MAINTENANCE OF HYDRATION
Oral feeds can be continued if the child is able to
take greater than 50% of usual feeds without
significantly increased work of breathing.
Feeding 2-3 times hourly with decreased volume
may be helpful.
Encourage to continue breastfeeding
Mothers should also maintain their oral fluids and
dietary intake to prevent reduction in the supply
of breast milk.

PHARMACOLOGIC THERAPY
BRONCHODILATORS
Produce modest short-term improvement in
clinical features
Ipatropium bromide appears to be effective as an
adjunct therapy.
Not recommended routinely
Not recommended for infants <6months
(CPG Acute Management of Bronchiolitis)

PHARMACOLOGIC THERAPY
ANTIINFLAMMATORY AGENTS
Corticosteroids whether parenteral, oral or
inhaled have been used for bronchiolitis despite
conflicting and often negative studies.
Corticosteroids are not recommended in
previously healthy infants with RSV (Kliegman,
2007)

PHARMACOLOGIC THERAPY
ANTIVIRAL AND ANTIBIOTICS
Ribavirin, an antiviral agent administered by aerosol, has
been used for infants with congenital heart disease or
chronic lung disease.
There is no convincing evidence of a positive impact on
clinically important outcomes such as mortality and
duration of hospitalization.
Antibiotics have no value unless there is secondary
bacterial pneumonia.

Prognosis
Acute Bronchiolitis
At highest risk for further respiratory
compromise in the first 48-72 hours after
onset of cough and dyspnea
Child may be desperately ill with:
Air hunger
Apnea
Respiratory acidosis

Prognosis

Case fatality: <1%

COD attributable to:
Apnea
Respiratory arrest
Severe dehydration

Prognosis
After critical period of symptoms,
symptoms can persist
Median duration of symptoms in
ambulatory patients: ~12 days

Complications
Subsequent airway reactive disease
Recurrent wheezing
asthma

Prevention
Pooled hyperimmune RSV intravenous
immunoglobulin
Palivizumab
An intramuscular monoclonal antibody to the RSV
F protein
For infants <2 y/o
Administered before and during RSV season

Meticulous hand hygiene

best measure to prevent nosocomial transmission

References
Kliegman, R. 2007. Nelson textbook of
pediatrics.18th ed. USA: Saunders Elsevier. p.
1474-1479.
Mejias, A., M.W. Hall and O. Ramilo. 2013.
Ummune monitoring of children with
respiratory syncytial virus infection. Retrieved
on 26 October, 2014 from www.patient.
Co.uk/doctor/bronchiolitis-pro

References
Kliegman RM et al. 2010 Nelson Textbook of
Pediatrics. 19ed. Elsevier, Inc.
DeNicola, LC. 2014. Bronchiolitis Workup.
Medscape. Retrieved on 26 Oct, 2014 at
http://emedicine.medscape.com/article/9619
63-workup#showall