PCC Case

UNIVERISTY OF SANTO TOMAS
Faculty of Medicine and Surgery

PCC CASE
K.T., 5yo/female from Quezon City
Chief Complaint: Fast breathing
History of Present Illness

Patient was apparently well until nine days prior to admission (PTA), patient was
noted to have colds and occasional dry cough. No fever, vomiting, or loose stools were
noted at that time. Patient had good oral intake and good activity. She was given
phenylephrine + chlorpheniramine maleate by the mother. SAME
Four days PTA, patient developed fever highest of 38.6 C, still with the colds and
now with productive cough. She was brought to a local center where she was prescribed
Amoxicillin at 45mkday. Interval history showed presitence of fever and cough. NOT
SAME
On the day of consult, patient was noted to be less active and with fast breathing
prompting consult the emergency room hence susequent admission. NOT SAME
Review of Systems ALMOST SAME naglagay lang siya sa general ng with

decreased level of activity
General: no weight loss
Skin: no jaundice, no pallor
HEENT: no eye discharge, no matting, no aural discharge, no nasal discharge
Cardiovascular: no cyanois, no orthopnea
Gastrointestinal: no diarrhea, no vomiting
Genitourinary: no straining, no hematuria, no tea-colored urine
Endocrine: no plyuria, no polydipsia, no polyphagia
Hematopoietic: no pallor, no bleeding, no easy bruisability
Musculoskeletal: no limitation of movement
Neurology: no seizures , no weakness, no temper outburst
Nutritional History
24hr food recall (pre-morbid):
Breakfast – 1 slice of bread; 1 glass of chocolate milk
AM snack – 2 pieces of crackers
Lunch – 1/2 cup rice, soup, 1 piece chicken
PM snack – cupcake
Dinner – 1/2 cup rice, fish, 1/2 vegetables
Developmental History CHECK IF AT PAR SA DEVELOPMENTAL HISTORY

Gross motor: can skip
Fine motor: can copy triangle; can dress/undress
Language: asks about word meanings
Social: participates in domestic role-playing
Immunization History CHECK IF MAY KULANG PA SA IMMUNIZATION

BCG x 1
Hep B x 3
DTAP x 3
OPV x 3
Measles x1
MMR x 1
Varicella x 1
Influenza – last 2 years ago
Past Medical History

Less than 1 yo – admitted due to Acute Gastroenteritis
2yo – admitted due to Pneumonia
No allergies
Family History
Maternal grandfather – hypertension
Paternal uncle – bronchial asthma
Socioecomonic History SAME

Father, 32 yo., is the breadwinner while the mother, 30 yo., is the the primary caregiver.
Both parents are apparently healthy. The patient has one three-year old brother who is
also apparently healthy.
Environmental History SAME

The family of four lives in a one-storey, well-lit and well-ventilated concrete house. No
pets at home. No nearby environmental hazards. Garbage is not segregated but
collected daily.
Physical Examination:
General: Awake, irritable, in respiratory distress, ill-looking, well-nourished, mildly
dehydrated SAME
Vital Signs: BP: 90/60 PR: 118 bpm RR: 48/min Temp: 38.7 O2 sat: 92% at room air
Wt: 18.2 kg Ht: 106 cm CHECK FOR WEIGHT FOR AGE, LENGTH FOR
AGE, WEIGHT FOR LENGTH
Skin: No active dermatoses SAME
HEENT: No head deformity with adequate hair; Anicteric sclera, pale palpebral
conjunctivae, slightly sunken eye balls, with alar flaring, non-congested turbinates, dry
lips, moist buccal mucosa, non-hyperemic posterior pharyngeal walls SAME
Neck: No gross deformities; (+) 2cm, posterior cervical lymph node, nontener, not
matted, right
Lungs: (+) Lagging of the right hemithorax; with subcostal and intercostal retractions;
increased tactile fremitus on the right upper lung field, decreased tactile fremiti right mid
to lower lung field; dullness on percussion at the right mid to lower lung fiels; bronchial
breath sound on the right upper lung field, diminished breath sounds on right mid to
lower lung fields; end-inspiratory fine crackles on both lung fields, no wheeze
Heart: Adynamic precordium, apex beat on the 5th LICS MCL; no murmur
Gastrointestinal: Abdomen not distended, normoactive bowel sounds, no masses
SAME
Musculoskeletal: No swelling, no limitation of movement SAME
Extremities: Pulses full and equal on all extremities, no edema, CRT less than 2 sec,
pink palms, pink soles, pink nail beds SAME
Neurologic exam:
Conscious, coherent, oriented
Cranial Nerves:
CN I – not assessed
CN II – 2-3 mm ERTL
CN III, IV, VI – EOMs intact
CN V – V1-V3 sensory and motor intact
CN VII – no facial asymmetry
CN VIII – no hearing impairment
CN IX, X – uvula midline
CN XI – can move head from side to side against resistance red lang naiiba dito sa CN
CN XII – tongue midline upon protrusion
Motor: 5/5 on all extremities
Reflexes: ++ on all extremities, (-) Babinski
Meningeal: (-) nuchal rigidity, (-) Kernig’s, (-) Brudzinski
COURSE IN THE WARD:
Patient was immediately hooked to an oxygen at 2LPM/nasal cannula to maintain

oxygen saturation of more than 95%. Moderate IV hydration was started. SAME
Complete blood count (results below) and chest radiograph (picture below) were
done. The patient was then started on Ceftriaxone IV. Chest ultrasound done showed
approximately 339mL of pleural fluid with septations. She was referred to Pulmonology
and Pediatric Surgery services. Pulmonology service requested for a Blood culture and
CRP and suggested drainage of pleural fluid c/o Pediatric Surgery.
Patient was immediately scheduled for thoracentesis for possible CTT under
anesthesia. Intraoperatively, approximately 300mL of pleural fluid was drained and was
sent for analysis (results below).
On the first to third hospital days, patient’s breathing improved. Fever lysed on the
third hospital day. On physical examination, repiratory rate (RR) range 28-44/min, O2 sat
06-97% at 1LPM, shallower subcostal and intercostal retractions, improved breath
sounds on the right lung field, decreased fine crackles. Repeat CXR, CBCP and CRP
were done. IV antibiotics were continued. She was also instructed to do breathing
exercises every 1-2 hours.
On the next hospital days, patient’s condition further improved. She was more
playful and eating well. On physical examination, RR 24-28, minimal subcostal
retraction, better air entry on the right mid to lower lung field, occasioanal fine crackles.
Repeat CXR (shown beloew) and ultrasound showing approximatey 80mL of pleural
fluid and no septation.
She was discharged on the 7th hospital with take-home medication of oral
cefuroxime for one week
CBCP on admission:
CBC
Hmg g/L 108
HCT 0.32
MCV U3 82.3
MCH pg 28.2
MCHC g/dL 34.3
Platelet x109/mL 506
WBC x109/mL 24.6
Neutrophils 0.78
Metamyelocytes -
Bands -
Segmenters 0.78
Lymphocytes 0.18
Monocytes 0.03
Eosinophils 0.01
Basophils -
CBCP on 4th hospital day:
CBC
Hmg g/L 128
HCT 0.37
MCV U3 82.4
MCH pg 28.0
MCHC g/dL 34.1
Platelet x109/mL 432
WBC x109/mL 16.7
Neutrophils 0.69
Metamyelocytes -
Bands -
Segmenters 0.60
Lymphocytes 0.24
Monocytes 0.10
Eosinophils 0.06
Basophils -
Blood culture: Negative for 7 days
CRP on admission: 64
CRP on the 4th hospital day: 16
Serum: Protein 32mg/dL, LDH 108 mg/dL

Pleural Fluid:
Yellow, slightly turbid fluid, pH: 7.30
Protein 85mg/dL, LDH 240 mg/dL
Gram stain negative
AFB negative
Culture negative
CHEST XRAY ON ADMISSION:

Chest ultrasound on admission:
REPEAT CHEST XRAY ON THE 4TH Hospital day
CXR prior to discharge:

PCC Case

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PCC Case

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UNIVERISTY OF SANTO TOMAS

Faculty of Medicine and Surgery

K.T., 5yo/female from Quezon City

Chief Complaint: Fast breathing

History of Present Illness

Review of Systems ALMOST SAME naglagay lang siya sa general ng with

Developmental History CHECK IF AT PAR SA DEVELOPMENTAL HISTORY

Immunization History CHECK IF MAY KULANG PA SA IMMUNIZATION

Past Medical History

Socioecomonic History SAME

Environmental History SAME

COURSE IN THE WARD:

Patient was immediately hooked to an oxygen at 2LPM/nasal cannula to maintain

CBCP on 4th hospital day:

Blood culture: Negative for 7 days

Serum: Protein 32mg/dL, LDH 108 mg/dL

CHEST XRAY ON ADMISSION:

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