4. 2 months PTA
• Patient experienced an acute episode of cough
• Non-productive
• No associated night time awakening, fever, difficulty of breathing,
dyspnea, colds, nor audible wheezing
• No consult was done.
• No interventions done.
5. 1 month PTA
• Patient persistence of cough
• Non-productive
• With associated tachypnea, difficulty of breathing, and colds
• No associated fever and audible wheezing
• Consult was done with her private Pediatrician
• Patient was given Salbutamol + Guaifenesin 1 mg/50 mg
syrup, 5 mL TID x 5 days and Cetirizine 3.5 mL OD x 5 days
• Persistence of non-productive cough
• Relief of other symptoms
6. 2 days PTA
• Progression of the cough
• Occurs more frequently
• With associated tachypnea, difficulty of breathing, audible
wheezing, shallow subcostal retractions, and colds
• No associated fever
• Consult was done with her private Pediatrician
• Patient was prescribed with Procaterol Hydrochloride 5 mcg/5
mL syrup x 7 days and Montelukast 4 mg/tab ODHS x 2
weeks
7. 1 day PTA
• Progression of the cough
• Productive
• Occurs more frequently
• With associated tachypnea, difficulty of breathing, audible
wheezing, colds, and deep supraclavicular and subcostal
retractions
• Steam inhalation with PNSS was done
• 1 episode of vomiting
• Previously ingested milk with whitish sputum
• Approximately 30 cc
• Consult was done with her private Pediatrician and was
advised admission
8. Prenatal History
• Mother was 32 y/o (G1P0) (0-0-0-0)
• Cognizant of pregnancy at 5 weeks age of gestation
• Prenatal checkups, unrecalled number of visits, done
regularly
• UTZ results were unrecalled
• No history of exposure to smoking, alcohol, radiation
9. Natal History
• Born term via LSCS at Pines City Doctors Hospital
• BW: 2.65 kg,
• Unrecalled Birth Length, Head Circumference, Chest
circumference, APGAR score and Ballard score
• No congenital malformations and resuscitative measures
done
10. Neonatal History
• Patient was breastfed with good suck for 18 days and was
shifted to formula milk due to low breast milk production.
• The umbilical stump fell off after unrecalled days without
signs of infection.
• Newborn screening results are normal
11. FEEDING HISTORY
BREAKFAST Rice, egg, cereals, mashed potato, pancakes,
banana
100 +70 + 65 + 120
LUNCH Rice, chicken/fish 100 + 180
DINNER Rice, pork, mixed vegetables 100 + 120 + 60
SNACK Cookies, yogurt 150 + 50
TOTAL CALORIC INTAKE PER DAY 1, 115 kcal/day
RECOMMENDED DAILY ENERGY AND NUTRIENT
INTAKE PER DAY OF A 2 YEAR OLD FEMALE
1, 070 kcal/ day
Patient was bottle fed per demand consuming about 2-3, 210 mL bottles in a day. Semisolid
foods were introduced at 6 months. The patient was noted to be a picky eater.
12. Growth and Developmental History
BIRTH WEIGHT 2.65 kg
PRESENT WEIGHT 12.5 kg
BIRTH LENGTH unrecalled
PRESENT LENGTH 88 cm
BMI 15.1
AT BIRTH HC:
unrecalled
CC:
unrecalled
AC:
unrecalled
16. Developmental Milestones
ASPECT MILESTONE
GROSS MOTOR Walks well
FINE MOTOR Imitates vertical strokes/scribing, builds
tower cubes
LANGUAGE Names pictures, 10 words, identifies 1 or
more body parts
PERSONAL/SOCIAL Feeds self, complains when in pain
17. Growth and Developmental History
SOCIAL DEVELOPMENT
Sleeps at 10:30 pm and wakes up at 8:30 am
Toilet Trained
Interact with family and peers without discipline problems
20. Past Medical History
• No previous hospitalizations and surgeries
• No known allergy to any food or medication
21. Family History
• History of Bronchial Asthma and Hypertension on both
maternal and paternal side
• Maternal side:
o Colon cancer, gouty arthritis, and twinning
• No family history of Diabetes Mellitus, Cardiovascular and
Coronary Disease
22. Social and Environmental History
• Father:
o 62-year-old, retired tour guide
o Primary care giver
• Father:
o 34-year-old, OFW nurse
• No exposure to tobacco smoke and indoor or outdoor air
pollution
24. Physical examination
• Awake, active, irritable with loud cry, not in cardiopulmonary distress with and
SpO2 of 98% at room air
GENERAL SURVEY
• Temp: 36.5˚C
• HR: 132 bpm
• RR: 32 cpm
• SPO2: 98% @ RA
VITAL SIGNS
• Weight: 12.5 kg
• Height: 88 cm
• BMI: 16.14 kg/m2 : Z-score = 0
(Normal)
ANTHROPOMETRICS
25. Physical examination
03
S
kin/
HE
E
NT
- Nopallor, nocyanosis,good
skinturgor
- Pinkishpalpebralconjunctiva,
anictericsclerae
- Moistlipsandbuccalmucosa
- Withsupraclavicular
retractions,noneckvein
engorgement, nocervicalLA
D
04
L
u
ng
s
- Symmetrical chest
wall expansion
- Subcostalretractions
- Diffusewheezing
05
- Tachycardic
- Regular rhythm
- Nomurmurs
He
a
rt
- Flat, nondistended,
normoactivebowel
sounds,tympanitic,
soft,
- Notenderness
- Nomasses
- Noorganomegaly
06
A
b
d
o
m
e
n
27. Problem: Productive Cough
SUBJECTIVE FINDINGS: OBJECTIVE FINDINGS:
• 2-year-old female
• Familial history of bronchial asthma
• 2 MONTHS PTA: intermittent non-productive cough occurring
throughout the day and during the night, with no nighttime awakening,
with no associated tachypnea, difficulty breathing, fever, colds, audible
wheezing
• 1 MONTH PTA: persistence of non-productive cough with associated
tachypnea and difficulty breathing and colds.
• Salbutamol + Guaifenesin 1 mg/50 mg syrup, 5 mL TID and Cetirizine
3.5 mL syrup ODHS for 5 days > RELIEF
• 2 DAYS PTA: Non-productive cough occurring frequently with
associated tachypnea, difficulty breathing, audible wheezing, with
observed shallow subcostal retractions, and colds. There was no
associated fever.
• 1 DAY PTA: Productive cough without expectoration of sputum with
associated tachypnea, difficulty breathing, audible wheezing, colds,
now with observed deep supraclavicular and subcostal retractions. One
episode of vomiting of previously ingested milk with whitish sputum
approximately 30 mL after steam inhalation.
• General survey: Awake, active, irritable,
ambulatory with loud cry, in cardiopulmonary
distress with an SpO2 of 98% at room air
• Vital signs: CR: 132 bpm RR: 32 cpm
Temperature: 36.5ºC
• Skin: No pallor, no jaundice, no rashes, no
petechiae, no pigmentation, warm to touch,
good skin turgor
• HEENT: non-sunken eyeballs, no periorbital
edema, anicteric sclera, pink palpebral
conjunctiva. Nasal area has clear, watery
discharge, no congestion, and no alar flaring.
Mouth and throat have moist lips & buccal
mucosa.
• Chest and lungs: Symmetrical chest wall
expansion, with supraclavicular and subcostal
retractions, with diffuse occasional wheezes
28. Bronchial Asthma
in Mild Acute Exacerbation; Pediatric
Community Acquired Pneumonia - C
CLINICAL IMPRESSION
29. Basis of Impression
Patient’s Manifestations and Salient History Bronchial asthma in mild acute
exacerbation
SUBJECTIVE FINDINGS:
• 2-year-old female
• Familial history of bronchial asthma
• Productive cough, cannot expectorate sputum, with
associated tachypnea, difficulty of breathing,
audible wheezing, colds. No fever
OBJECTIVE FINDINGS:
• General survey: Awake, active, irritable, ambulatory
with loud cry, in cardiopulmonary distress with an
SpO2 of 98% at room air
• Vital signs: CR: 132 bpm RR: 32 cpm
Temperature: 36.5ºC
• Skin: No pallor, no jaundice, no rashes, no
petechiae, no pigmentation, warm to touch, good
skin turgor
• HEENT: Non-sunken eyeballs, no periorbital
edema, anicteric sclera, pink palpebral conjunctiva.
The nose has clear, watery discharge, no
congestion, and no alar flaring. Mouth and throat
have moist lips & buccal mucosa.
• Chest and lungs: Symmetrical chest wall expansion,
with supraclavicular and subcostal retractions, with
diffuse occasional wheezes
• Onset early in life (often childhood)
• Family History of asthma in first-degree
relatives
• >1 type of symptom (wheeze, shortness of
breath, cough, chest tightness)
• Cough: Recurrent or persistent
non-productive
• Difficulty of breathing occurring
with exercise, laughing or crying
• Wheezing: Recurrent
• Symptoms often worse at night or in the
early morning
• Symptoms vary over time and in intensity
(intermittent)
• Acute exacerbation are triggered by viral
infections
31. Basis of Impression
Patient’s Manifestations and Salient History PEDIATRIC COMMUNITY ACQUIRED
PNEUMONIA-C
SUBJECTIVE FINDINGS:
• 2-year-old female
• Productive cough, cannot expectorate sputum,
with associated tachypnea, difficulty of
breathing, audible wheezing, colds. No fever
• Pneumonia can occur at any age,
although it is more common in younger
children.
• Pneumonia accounts for 13% of all
infectious illnesses in infants younger
than 2 years of age.
• SYMPTOMS: fever, cough (productive
or nonproductive), congestion, chest
pain, dehydration, and lethargy
32. Basis of Impression
Patient’s Manifestations and Salient History PEDIATRIC COMMUNITY ACQUIRED
PNEUMONIA-C
OBJECTIVE FINDINGS:
• General survey: Awake, active, irritable, ambulatory with loud
cry, in cardiopulmonary distress with an SpO2 of 98% at room
air
• Vital signs: CR: 132 bpm RR: 32 cpm Temperature:
36.5ºC
• Skin: No pallor, no jaundice, no rashes, no petechiae, no
pigmentation, warm to touch, good skin turgor
• HEENT: Non-sunken eyeballs, no periorbital edema, anicteric
sclera, pink palpebral conjunctiva. The nose has clear, watery
discharge, no congestion, and no alar flaring. Mouth and
throat have moist lips & buccal mucosa.
• Chest and lungs: Symmetrical chest wall expansion, with
supraclavicular and subcostal retractions, with diffuse
occasional wheezes
• SIGNS: Tachypnea, C/L: rales,
dullness, decreased tactile and vocal
fremitus & intercostal retractions
• Increased work of breathing
accompanied by intercostal,
subcostal, and suprasternal
retractions, nasal flaring, and
use of accessory muscles is
common
• Prodrome of upper respiratory
tract infection leading to the
abrupt onset of fever,
restlessness, apprehension,
and respiratory distress.
37. Diagnostic Tests
Chest X-ray (APL)
02
TEST Bronchial asthma Pediatric Community
Acquired Pneumonia
COVID - 19
Pneumonia
Bronchiolitis
Chest X-
ray
expected
findings
Plain chest radiographs
can be normal in up to
75% of patients with
asthma.
Reported features with
asthma include:
• Pulmonary
hyperinflation
• Bronchial wall
thickening:
peribronchial cuffing
• Hyperinflation
• Bilateral interstitial
infiltrates
• Peribronchial cuffing
• Multifocal and
bilateral ground
glass opacities and
consolidations with
peripheral and
basal
predominance
• Hyperinflation with
patchy atelectasis
38. Diagnostic Tests
Chest X-ray (APL)
02 Chest X-ray (March 27, 2022)
CHEST:
Interstitial densities are seen in the
inner lung zones
Cardiac shadow is normal in size and
contour
Intact diaphragm with clear
costophrenic recesses
Bones and soft tissue shadows
appear unremarkable
IMPRESSION:
Pneumonia, both inner lung
46. Management Plan
• Initial ER department management
o Oxygen inhalation at 1 lpm
o Salbutamol nebule 20 minutes for the 1st hour
o IV methylprednisolone 1 mg/kg every 6 hours
52. Genetic Factors Environmental Factors
Atopy
Exposure to triggers of airway hyperresponsiveness
↑ levels of inflammatory and bronchoconstrictive mediators and cells
Inflammation of lower airway
Mucus production 2° to
WBC & epithelial cell debris
Airflow past inflamed
airways ↑ irritation
and cough response
Dry cough
Mechanical obstruction of airflow in lower airways
Smooth muscle constriction in lower airways
↓ ventilation of alveoli
Hypoxemi
a
HR ↑ to improve
perfusion to tissues
Respiratory centers ↑
RR to compensate
Tachycardia Tachypnea
Productive
cough
↑ RV and ↑ PCO2
causes ↑ RR
Retractions
↑↑airway obstruction
Narrow airways →
turbulent airflow
Expiratory wheeze
↑ work of
breathing
53. CREDITS: This presentation template was created by
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