KA, a 7-month-old Malay boy, was admitted to the hospital due to shortness of breath, coughing, and vomiting. On examination, he showed signs of respiratory distress including rapid breathing and recession of the ribs. Auscultation revealed widespread crackles and wheezes throughout both lungs. A provisional diagnosis of pneumonia was made, with bronchiolitis and asthma considered as differentials. Blood tests and renal function were normal.

1. Case Presentation SYED ARIFF AMIR SYED AWALY MUHAMMAD NIZAR MOHAMMAD YATIM FAIZUL HARIS MOHD HATTA

2. DEMOGRAPHIC DETAILS Name : KA Date of Birth : 31 st May 2010 Age : 7 months old Gender : Male Ethnic Group : Malay Date of Admission : 18 th December 2010 Date of Clerking : 20 th December 2010 Informant : Mother Ward of Admission : 8C, Hospital Sungai Buloh Address : Sekinchan

3. CHIEF COMPLAINT KA, a 7 month old malay boy a known case of PDA & ASD was admitted to HSB on 18 th December 2010 due to shortness of breath one day prior to admission associated with vomiting and chesty cough 2 days prior to admission.

4. HISTORY OF PRESENTING COMPLAINT KA was previously well until 2 days prior to admission when he started to develop chesty cough , & shortness of breath . 1. CHESTY COUGH Sudden onset, continuous throughout whole day, no relieving factor, aggravated at night, disturbed his sleep, loss his appetite 2. SHORTNESS OF BREATH Sudden in onset, breath using mouth, rapid movement of the abdomen

5. On the same day, the mother brought him to KK Sekinchan due to these symptoms and he was prescribed with anti – tussive drug, and antibiotic. Mother claimed that the medication doesn’t relieved the symptoms.

6. One day prior to admission, patient developed vomit in the morning associated with cough and shortness of breath; post – tussive vomiting, 3 episodes, vomitus contained mucous, whitish in colour, no blood stain, no bile and it was about 1/3 of a cup in each episode. Mother brought patient to HTK and was prescribed with syrup PCM, anti-tussive drug and antibiotic. Symptoms became worsened

7. On the day of admission, his shortness of breath became worsened at 3 a.m; patient was slept, his breath became noisy, no aggravating and no relieving factor. Mother brought him to HSB due to his shortness of breath at 7.00 a.m

8. SYSTEMIC REVIEW SYSTEM COMPLAINTS General No fever, no irritability Cardiovascular No pedal edema, no sweating Respiratory Shortness of breath , cough, no haemoptesis Gastrointestinal Vomit , loss appetite , no abdominal pain, no haemetemesis and no alter bowel habits Genitourinary No polyuria, no dysuria and no haematuria Central Nervous System No loss of consciousness, no neck stiffness, no weakness ENT No runny nose, no ears discharge MSK no gross deformities

9. PAST MEDICAL AND SURGICAL HISTORY Was admitted to HSB on September due to shortness of breath. He was then diagnosed to have viral bronchopneumonia. DRUG ADMISSION Spironolactone Frusamide *Both are for ASD & PDA ALLERGY No know allergy

10. BIRTH HISTORY No complication to the mother during pregnancy He was delivered at 30 weeks of gestation via spontaneous vaginal delivery with weight of 1.55kg at Hospital Tanjung Karang. He was admitted to NICU for 22 days due to respiratory distress syndrome. He was also diagnosed with PDA & ASD .

11. FEEDING HISTORY Mix (breast milk + formula milk) since 1 st day of life. He started to consume semisolid food at 6 months old.

12. IMMUNISATION HISTORY Up to age DEVELOPMENTAL HISTORY (corrected age: 5 months old) Gross motor- Can sit with hands on couch for support. Can roll from supine to prone Vision and Fine motor- Can transfer objects from one hand to the other hand and can feed independently with biscuits Speech and language- Can babble in combined syllables. Social- Looks for fallen toy and understand NO!

13. FAMILY HISTORY Patient is the second child of 2 siblings - His elder sister, 2 years old, healthy Father-35 years old, healthy Mother-32 years old, healthy No consaguinity

14. SOCIAL AND ENVIRONMENTAL HISTORY Father - Technician Mother - Housewife Total income –RM900 Live in a small village house; utilities are good with no pets and carpet in house. Father is a smoker, about 1 packs of 20’s per day.

15. HISTORY OF CONTACT Uneventful EFFECTS OF ILLNESS ON THE PATIENTS AND THE FAMILY Since their average monthly income was low, the illness affected their economic status as they have to pay the medical costs and transportation cost.

16. Physical Examination

17. General Examination KA, a 7 month old boy was lying in supine position supported by one pillow. He does not look ill, not pale He was conscious and alert. He was in respiratory distress but not in pain and his hydrational status was adequate. There was no muscle wasting, no gross deformity and no abnormal movement. There was one branula located on the dorsum of his right hand.

18. Vital sign Temperature : 37.5 °C Blood Pressure : 107/34 mmHg Pulse Rate : 166 beats/ min, Respiratory Rate: 66 breaths/min Sp O 2 : 97 % Anthropometry Weight : 4.86 kg (below 3 rd centile) Height : 63 cm (at 25 th centile) HC : 38 cm (3 rd centile)

19. Examination for hydration status His hydrational status was adequate. The mucous membrane was moist and there was normal skin turgor. No sunken of anterior fontanelle, no sunken eye, CRT less than 2 sec.

20. Examination of face, head, neck and limbs Appearance : No face deformity Head : No frontal bossing Hair : No hair loss, no bald spot Face :No cyanosis, no pallor and no puffiness of face Oral cavity : Fair oral hygiene, moist mucous membrane, no ulcers and no central cyanosis Eyes : No pallor and no jaundice Ear, nose and throat : Throat not injected and tonsil was enlarged and red . No ear discharge but had runny nose Neck : No thyroid enlargement, no nodes are palpable. Skin : No rashes, eczema or any abnormal finding Extremities : Warm peripheries, no clubbing fingers and toes, no koilonychias, no pedal edema, no muscle wasting

21. Developmental assessment Gross motor : Can roll from supine to prone Vision and fine motor : Reaches for objects, plays with toes Speech and language : Babbling in single syllables Personal social : Mouthing

22. Systemic Examination Respiratory System Inspection : - No chest deformity, no dilated veins, moves symmetrically with respiration, no visible pulsation, mild subcostal and intercostal recession, chest looked hyperinflated Palpation : - Trachea is centrally located not deviated, symmetrical and equal chest expansion. - The apex beat is located at the 6 th intercostal space at midclavicular line . Percussion : Was not done Auscultation: - Normal bronchovesicular breath sound at both lungs with equal air entry on both sides there was additional sounds - generalise rhonchi heard louder during expiration at right lung posteriorly -generalise crepitation heard louder duing inspiration at both lung anteriorly -Crepitation was louder than Rhonchi.

23. Cardiovascular system Inspection : The chest was symmetrical and normal in shape. There was no scar, no precordial bulging, no visible apex beat and no prominent dilated veins. Palpation : The apex beat was located at the sixth intercostal space at the midclavicular line. There was no thrill and heave. The peripheral pulses were present with normal rhythm and volume. all arterial pulses are present ( radial, brachial, carotid, popliteal, dorsalis pedis, posterior tibial artery), there was collapsing pulses . There is no Radio-Femoral delay,or pulsus paradoxus. there is no raised in Jugular Venous Pressure Auscultation : systolic murmur best heard, at upper left sternal edge, not radiated, S1S2 heard

24. Abdominal Examination Inspection : The abdomen was not distended, symmetrical in shape and moved with respiration. The umbilicus was centrally located and inverted. There was no scar, prominent dilated vein, skin discolouration, visible peristalsis and visible pulsation. Palpation : The abdomen was soft and non tender on light palpation. On deep palpation, the liver and spleen were not palpable. Both kidney were not ballotable. Percussion : No shifting dullnes Auscultation : Normal bowel sounds were present.

25. Central Nervous System Examination Mental status : he was alert and respond to his surrounding, not active. Muscle tone: There was no hypertonia or hypotonia Muscle power: not was performed Reflexes :all present with positive Babinski’s sign

26. CLINICAL SUMMARY KA, a 7 month old malay boy a known case of PDA & ASD was admitted to HSB due to shortness of breath one day prior to admission associated with vomiting and chesty cough 2 days prior to admission. On examination, he has signs of mild respiratory distress evidence by tachypnoea (66 breaths/min), subcostal and intercostal recession, on auscultation there was additional sounds - generalise rhonchi heard louder during expiration at right lung posteriorly -generalise crepitation heard louder duing inspiration at both lung anteriorly -Crepitation was louder than Rhonchi

27. PROVISIONAL DIAGNOSIS Pneumonia Difficulty in breathing Chesty cough, running nose lethargy and poor feeding Preceded by upper respiratory infection Decreased oxygen saturation Signs of respiratory distress Widespread crepitation and rhonci. But crepitation more prominent.

28. DIFFERENTIAL DIAGNOSIS Differential diagnosis Support Against Bronchiolitis Breathlessness Signs of respiratory distress hyperinflated chest - No fever - No noisy breathing (wheezing) -Crepitations more prominent than rhonci Asthma Breathlessness No fever - no history of asthma no wheezing No family hx of asthma Cardiac failure Breathlessness Signs of respiratory distress no signs of peripheral or central cyanosis.

29. General Investigation Full Blood Count 18/12/2010 Normal Range Impression WBC 16.93 6.0-16.0 x 10 9 /L increase RBC 4.09 4.0-6.0 x 10 12 /L normal RBC Distribution 14.0% normal Hemaglobin 11.3 11.1-14.1 g/dL normal Hematocrit 38.6 37.0-45.0 % normal MCH 24.6 24-33 Pg normal MCV 77.1 77-95 fL Normal MCHC 31.6 31-40 pg/cell Normal Platelet 445 110-450 x 10 9 /L Normal

30. Automated Differential Renal Profile 18/12/2010 Normal Range Neutrophil (%) 57.8 40-75% Lymphocyte 50.0 20-45% Monocyte 5.6 2-10% Eosinophil 1.8 0-5% Basophil 0.1 0-0.2% 25/07/08 Normal Range Urea 3.3 2.5-8.0 mmol/L Sodium 139 133-145 mmol/L Potassium 3.9 3.5-6.0 mmol/L Creatinine 35.8 20-65 µmol/L

31. Liver profile Normal range Value Interpretation Total protein 64.0-83.0 g/L 74.0 Normal Albumin 35-50 g/L 35 Normal Globulin 20-35 g/L 33 Normal Albumin/Globulin Ratio 0.89 1 Normal Total bilirubin 3.4- 20.5 umol/L 3.4 Normal Alkaline phosphatase 40-150 U/L 145 Normal Alanine Aminotransferase 7-53 U/L 14 Normal

32. Urine FEME , urine C&S- all normal, no abnormal microorganism growth detected throat swab - Parainfluenza 2 Virus Antigen detected nasopharyngeal aspirate for RSV study – No RSV detected C-Reactive Protein- 1.20mg/dl normal value < 1 mg/ dl increase

33. Chest x-ray Interpretation :hyperinflated lungs, hazziness in both lungs , cardiomegaly

34. Final diagnosis Bronchopneumonia with underlying congenital heart disease (ASD, VSD)

35. MANAGEMENTS (taken from Malaysian CPG and Paediatrics Protocols) Assessment of severity of pneumonia Assessment of oxygenation Criteria for hospitalization Antibiotic therapy Supportive treatment

36. Management Admit to ward Medication - Continues syrup spironolactone 6.25mg BD - Continues syrup frusemide 4mg BD - iv ampicilin 120mg 6hrly - neb 2hrly salbutamol - neb 4hrly atrovent - cont syrup tamiflu keep face mask oxygen Close monitoring vital signs and oxygen saturation encourage orally Refer to dietician

37. Discussion

38. Problems… Preterm Congenital Heart Disease Bronchopneumonia

39. Complications of Preterm Respiratory Distress Syndrome (RDS) Persistent Ductus Arteriosus (PDA) Necrotizing Enterocolitis Infections Retinopathy of Prematurity (ROP) Apnea and Bradycardia Anemia Bronchopulmonary Dysplasia Hernias and Hydroceles.

40. ASD & PDA Manifested as: Recurrent chest infection Poor weight gain Tachypnoe Tachycardia Cardiomegaly Collapsing pulse Systolic murmur

41. Why failure to thrive?

42. Why recurrent chest infection?

43. Management of heart disease in the patient Given spirinolactone and furosemide. Was referred to dietician for high calories diet. Appointment in June 2011 with IJN.

44. Pneumonia

45. Definition Infection of the lower respiratory tract that involves the airways and parenchyma with consolidation of the alveolar spaces. Highest in infancy, remains relatively high in childhood, low in adult and increases again in old age.

46. Etiology Virus (common in younger children) RSV Influenza A and B Adenovirus Parainfluenza 1,2,3

47. Bacteria Age Bacterial pathogens Newborns Group B streptococcus, E. coli, Klebsiella, Enterobacteriaceae 1-3months Chlamydia trachomatis Preschool Strp. pneumoniae, HiB, Staph. Aureus school Mycoplasma pneumoniae, Chlamydia pneumoniae

48. Microorganisms entry Inhalation of the microbes Aspiration of the organism Hematogenous spread from a distant focus Direct spread from an adjoining site of infection

49. Types Bronchopneumonia Inflammation of the lung that is centered in the bronchioles and leads to the production of an exudates that obstructs smaller airways and causes patchy consolidation of the adjacent lobules. Lobar pneumonia Pneumonia localized to one or more lobes of the lung in which the affected lobe or lobes are completely consolidated.

51. Why consolidation occurs?

53. Symptoms Fever Fast breathing Cough Lethargy Pleuritic chest pain Poor feeding

54. Signs Tachypnoe Nasal flaring Chest indrawing Dullness on percussion Decreased breath sound Crackles on auscultation

55. Investigations Full blood count Renal profile Chest X-ray Blood culture Pleural tap analysis Serology

56. Viral vs Bacterial Characteristics Viral Bacterial Fever Low grade, acute High grade, gradual onset Mucosal congestion and inflammation of upper airway Suggestive Not suggestive FBC WBC normal or mildly elevated, lymphocytes predominance WBC elevated, neutrophils elevated X-ray Usually characteristics of bronchopneumonia Usually lobar consolidation

57. Treatment Factors like the clinical or investigation findings, age of the child, local epidemiological agents, sensitivity to microbial agents and the severity of the pneumonia should be considered.

58. Macrolide antibiotic is used if Mycoplasma or Chlamydia are the causative agents. 1 st line Beta-lactam drugs Ampicillin , amoxycillin, benzylpenicillin 2 nd line Cephalosporins Cefotaxime, cefuroxime, ceftazidime 3 rd line Carbapenam Imipenam others aminoglycosides Gentamicin, amikacin

59. Supportive treatment Nebulized bronchodilators Fluids Must be given in appropriate amount Oxygen Concentration determined by pulse oximetry Anti-pyretic

60. Others… Had to go to 3 health care centers before getting proper treatments. Mother had to stay away from husband and daughter. Working father had to drive every night to HSB Got tired Economy Leaves daughter with sister in law.

61. Take home message Treat every patient seriously. Never treat any case lightly. Job is not gained by us, but granted by Allah. Be sincere & always istiqamah.

62. Thank you