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Pediatric Community Acquired Pneumonia

This document summarizes information about cough from Feigin & Cherry's Textbook of Pediatric Infectious Diseases. It classifies cough based on anatomy, etiology, age, and whether it involves the upper or lower respiratory tract. For the upper respiratory tract, common causes are viral infections like RSV, adenovirus, and rhinovirus or bacterial infections such as H. influenzae and S. pyogenes. For the lower respiratory tract, main causes include viral and bacterial pneumonia. Signs differ between upper vs lower respiratory tract infections.

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CASE MANAGEMENT CONFERENCE Presented by: Allan Joseph O. Santos Nurol Iman L. Cabugatan Amer Hussien P. Samporna Department of Pediatrics November 21, 2014 8:00 – 10:00 am Basilio Valdes Hall
IDENTIFYING DATA • M.D. • 2 yr & 2 mos old • Female • Filipino • Roman Catholic • Makati City • 2nd admission • October 25, 2014 ( 3:19 pm )
CHIEF COMPLAINT Cough with fever
SOURCE & RELIABILITY • SOURCE : Mother • RELIABILITY : Good ( 95% )
HISTORY OF PRESENT ILLNESS • Fever : intermittent : high grade : Tmax : 40o C • No other symptoms • Self medicated : Paracetamol (15mkdose) 9 days PTA .
HISTORY OF PRESENT ILLNESS • Consult OLLH-ER : laboratory exam 9 days PTA . . CBC PC RESULT Hemoglobin 124 Hematocrit 0.37 WBC 3.9  Segmenters 0.64 Stabs 0.01 Lymphocytes 0.30 Monocytes 0.05 Platelet count 268 URINALYSIS RESULT Color Yellow Transparency Slightly Cloudy Reaction 6.0 Specific gravity 1.015 Glucose Negative Albumin Negative Epithelial cells Few RBC 2-4/hpf Pus cells 0-1/hpf Amorphous urates Few Mucus threads Occasional Bacteria Occasional
HISTORY OF PRESENT ILLNESS • Consult OLLH-ER : PE : Normal : Dx : AVI : Tx : Paracetamol (15mkdose) : sent home • Symptoms : resolved 9 days PTA . . .
HISTORY OF PRESENT ILLNESS • Afebrile • Cough : occasional : non productive • No : other signs and symptoms : consult • Self medicated : Salbutamol + Bromhexine + Guaifenesin syrup : Salbutamol + Ipratropium nebule • Symptom : temporary relief 7 days PTA
HISTORY OF PRESENT ILLNESS • Cough : persisted : productive • Fever : recurrent : intermittent : high grade : Tmax : 39o C • Other symptoms : body malaise : poor appetite • No consult 1 day PTA
• Fever • Cough • Poor appetite • Body malaise • Consult AMD : PE : weak looking, dry lips : admission Few hours PTA HISTORY OF PRESENT ILLNESS
MATERNAL HISTORY • Mother : 27 year old : G3P2 (2002) • Pre-natal check up : regular • Maternal illness : UTI • Exposure to radiation : none • Multivitamins : compliant • Folic Acid : compliant • Ferrous Sulfate : compliant
BIRTH HISTORY • Full term, NSD • Lying-in clinic • Birth date : August 23, 2012 • BW : 3.5 kg ( 3,500 grams ) ( 7.7 lbs. ) • BL : 50 cm • NST : normal • NHT : not done • Given at Birth : Vit K : Hepa B
VACCINE 1ST DOSE 2ND DOSE 3RD DOSE BCG 13 days (9/5/2012) Hepatitis B Birth (8/23/2012) 2 mos & 1 day (10/24/2012) 3 mos (11/21/2012) DPT 2 mos & 1 day (10/24/2012) 3 mos (11/21/2012) 4 mos & 12 days (1/2/2013) OPV 2 mos & 1 day (10/24/2012) 3 mos (11/21/2012) 4 mos & 12 days (1/2/2013) Hib 2 mos & 1 day (10/24/2012) 3 mos (11/21/2012) 4 mos & 12 days (1/2/2013) Measles 9 mos & 17 days (6/9/2013) MMR 1 yr & 1 mo (9/18/13) IMMUNIZATION HISTORY Patient’s immunization Record
Childhood Immunization Schedule 2014
NUTRITIONAL HISTORY • Breast fed : Birth until 6 mos • Milk formula : 6 mos onwards • Solid : 6 mos onwards • Current diet : 8oz of milk TID : rice, meat, fruits • Multivitamins : Regular
DEVELOPMENTAL HISTORY GROSS MOTOR ADAPTIVE FINE MOTOR LANGUAGE PERSONAL/SOCIAL • Runs well • Up, down, stairs alone • Imitates circular strokes • Draw shapes • Combine two or three words in sentence • Point to one body part • Removes garment • Toilet trained
ADMISSION HOSPITAL DATE AGE DIAGNOSIS 1 OLLH Feb 2013 6 months old AGE PAST MEDICAL HISTORY OPD CLINIC DATE AGE DIAGNOSIS 1 Other AMD Nov 2013 1 yr & 3 mos PCAP A 2 AMD Jan 2014 1 yr & 5 mos PCAP A 3 AMD Feb 2014 1 yr & 8 mos PCAP A
( + ) : Asthma (Mother) : Hypertension (Maternal grand parent) : CVA (Maternal Grandfather) ( - ) : Mental/Psychiatric disorder : Tuberculosis : Diabetes mellitus : Malignancy : Thyroid disease FAMILY MEDICAL HISTORY
• Youngest among three siblings • Father : 60 year old : Government employee • Mother : 30 year old : Call center agent PERSONAL & SOCIAL HISTORY
• Home : 2-storey rented house ( with 2 siblings and 1 helper ) • Water : Refilling station • Garbage : Collected daily PERSONAL & SOCIAL HISTORY
• General: no weight loss • Skin : no jaundice : no bruising • HEENT : no head injury, no trauma : no ear discharge : no nasal discharges, no epistaxis : no mouth sores : no mass REVIEW OF SYSTEMS
• Neurologic : no seizure : no loss of consciousness • Respiratory : no colds : no hemoptysis Cardiovascular : no cyanosis REVIEW OF SYSTEMS
• Gastrointestinal : no vomiting : no change in bowel movement • Musculoskeletal : no swelling : no arthralgia : no myalgia : no limitation of movement • Genitourinary : no hematuria : no dysuria : no polyuria : no urinary frequency : no foul smelling vaginal discharge REVIEW OF SYSTEMS
• GENERAL SURVEY : awake, conscious, weak-looking, carried by mother • VITAL SIGNS : BP : 90/60 mmHg : HR : 115 bpm : RR : 33 cpm : Temp : 37.8 o C : O2 Sat : 98 % • ANTHROPOMETRICS : Weight : 13.9 kg (z-score +1: normal) : Height : 89 cm (z-score +1: normal) : BMI : 17.5 kg/m2 (z-score +1: normal) : HC : 49 cm : CC : 51 cm : AC : 53 cm PHYSICAL EXAMINATION
• SKIN : warm, fair, no lesion, flushed skin, good skin turgor • HEENT : anicteric sclerae, pink palpebral conjunctivae, no hemorrhage, no exudates, no discharges, dry lips and oral mucosa, no oral lesions, no lymphadenopathies • RESPIRATORY : shallow retractions, symmetrical chest expansion. rales on all lung fields. • CARDIOVASCULAR : adynamic precordium, no heaves and thrills, regular heart rhythm. distinct heart sounds, no murmurs PHYSICAL EXAMINATION
• GASTROINTESTINAL : flat, no surgical scars, normoactive bowel sounds, no bruits, tympanitic abdomen, no organomegaly, no tenderness. • EXTREMETIES : CRT <2 sec., no gross deformity, no edema, full and equal pulses. • GENITALIA : labia majora covers labia minora, no vaginal discharge, no lesions PHYSICAL EXAMINATION
• NEUROLOGICAL Cerebral : GCS 15 (E4V5M6) Cerebellar : Not done Cranial Nerves CN I : able to smell CN II : intact papillary and consensual light reflexes (+) ROR CN III, IV, VI : full EOMs CN V : intact; no sensory deficits CN VII : no facial asymmetry; able to perform different facial expressions CN VIII : intact gross hearing CN IX, X : intact gag reflex; uvula midline CN XI : SCM and trapezius muscle symmetric with muscle strength of 5/5 CN XII : tongue midline PHYSICAL EXAMINATION
• NEUROLOGICAL Motor : 5/5 on both lower and upper extremities normal tone; no atrophy; symmetrical movements Sensory : responsive to light touch and pain DTRs : ++ on biceps and knee Meningeal Signs : no kernig’s and brudzinski’s, nuchal rigidity Pathologic Reflex : no babinski, clonus PHYSICAL EXAMINATION
Gen. data : 2yr & 2mos old, female CC : Cough with fever HPI : fever (Tmax : 40OC) : productive cough : body malaise : poor appetite PE : weak-looking, flushed skin, dry lips and oral mucosa, shallow retractions, rales on all lung field, tachypnea (33cpm) febrile (37.8o C) SALIENT FEATURES
1. Pediatric Community Acquired Pneumonia C 2. Rule out : Dengue Fever (without warning signs) ADMITTING DIAGNOSIS
1. Pediatric Community Acquired Pneumonia C 2. Rule out : Dengue Fever without warning signs ADMITTING DIAGNOSIS
COUGH
Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification : CAUSE NON INFECTIOUS Aspiration of food and gastric acid Foreign bodies Hypersensitivity reactions INFECTIOUS Viral fungal Bacterial
Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification : CAUSE NON INFECTIOUS Aspiration of food and gastric acid Foreign bodies Hypersensitivity reactions INFECTIOUS Viral fungal Bacterial
Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: ANATOMY UPPER Nasal cavity Pharynx Larynx LOWER Trachea Bronchus Bronchioles Lungs Upper Respiratory Tract Lower Respiratory Tract
Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: ANATOMY UPPER Nasal cavity Pharynx Larynx LOWER Trachea Bronchus Bronchioles Lungs Upper Respiratory Tract Lower Respiratory Tract
Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: ANATOMY UPPER Nasal cavity Pharynx Larynx LOWER Trachea Bronchus Bronchioles Lungs Upper Respiratory Tract Lower Respiratory Tract
Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: SIGNS and SYMPTOMS UPPER Cough Sore throat Rhinorrhea Nasal congestion Headache Low grade fever Facial pressure Sneezing LOWER Cough Fever Chest pain Tachypnea Sputum production Retractions Upper Respiratory Tract Lower Respiratory Tract
Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: SIGNS and SYMPTOMS UPPER Cough Sore throat Rhinorrhea Nasal congestion Headache Low grade fever Facial pressure Sneezing LOWER Cough Fever Chest pain Tachypnea Sputum production Retractions Upper Respiratory Tract Lower Respiratory Tract
COUGH Classification: Etiology UPPER Virus • Adenovirus • Influenza • Parainfluenza • Respiratory syncytial • Rhinovirus Bacteria • H. influenzae • S. pyogenes Fungi • Candida spp. LOWER Virus • Adenovirus • Influenza • Parainfluenza • Respiratory syncytial • Rhinovirus Bacteria • H. influenzae • S. pyogenes • B. pertusiss • S. pneumonia • S. aureus Other • M. Pneumoniae • C. pneumoniae Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
COUGH Classification: Etiology UPPER Virus • Adenovirus • Influenza • Parainfluenza • Respiratory syncytial • Rhinovirus Bacteria • H. influenzae • S. pyogenes Fungi • Candida spp. LOWER Virus • Adenovirus • Influenza • Parainfluenza • Respiratory syncytial • Rhinovirus Bacteria • H. influenzae • S. pyogenes • B. pertusiss • S. pneumonia • S. aureus Other • M. Pneumoniae • C. pneumoniae Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
COUGH Classification: AGE < 2 years Bronchiolitis Pneumonia Croup > 2 years Croup Pharyngitis Pulmonary Tuberculosis Pneumonia Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
COUGH Classification: AGE < 2 years Bronchiolitis Pneumonia Croup > 2 years Croup Pharyngitis Pulmonary Tuberculosis Pneumonia Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
COUGH Classification Upper Respiratory Infection Lower Respiratory Infection Anatomy Nasal cavity Pharynx Larynx Trachea Bronchus Bronchioles Lungs Etiologic agents Respiratory syncytial virus Adenovirus H. infuenzae Parainfluenzae Rhinoviruses S. pyogenes S. pneumoniae Respiratory syncytial virus Adenovirus H. infuenzae Parainfluenzae S. pneumoniae M. pneumoniae S. aureus M. tuberculosis Signs & symptoms Cough Sore throat Rhinorrhea Nasal congestion Headache Low grade fever Facial pressure Sneezing Cough Fever Chestpain Tachypnea Sputum production Retractions Differential Diagnosis Tonsillitis Pharyngitis Laryngitis Sinusitis Rhinitis Bronchitis Pulmonary Tuberculosis Pneumonia Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
COUGH Classification Upper Respiratory Infection Lower Respiratory Infection Anatomy Nasal cavity Pharynx Larynx Trachea Bronchus Bronchioles Lungs Etiologic agents Respiratory syncytial virus Adenovirus H. infuenzae Parainfluenzae Rhinoviruses S. pyogenes S. pneumoniae Respiratory syncytial virus Adenovirus H. infuenzae Parainfluenzae S. pneumoniae M. pneumoniae S. aureus M. tuberculosis Signs & symptoms Cough Sore throat Rhinorrhea Nasal congestion Headache Low grade fever Facial pressure Sneezing Cough Fever Chestpain Tachypnea Sputum production Retractions Differential Diagnosis Tonsillitis Pharyngitis Laryngitis Sinusitis Rhinitis Bronchitis Pulmonary Tuberculosis Pneumonia Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
PNEUMONIA Definition • Leading cause of death in children world wide • Lung parenchymal inflammation Nelson Textbook of Pediatrics 19 th ed. 2011
PNEUMONIA WHO : Common diseases of children under 5 y/o Nelson Textbook of Pediatrics 19 th ed. 2011
PNEUMONIA WHO : Common diseases of children under 5 y/o Nelson Textbook of Pediatrics 19 th ed. 2011
Revised Risk Classification for Pneumonia-related Mortality Philippine Academy of Pediatric Pulmonologists 2012
Revised Risk Classification for Pneumonia-related Mortality Philippine Academy of Pediatric Pulmonologists 2012
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS World Health Organization 2005
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS World Health Organization 2005
PNEUMONIA SOURCES Pediatrics by Nelson Fundamentals of Pediatrics by Navarro Pediatrics Infectious Disease By feign & cherry Definition Inflammation of the parenchyma of the lungs Most common cause of morbidity and mortality Is an acute lung infection that results most commonly from viral or bacterial pathogens Signs & Symptoms Fever Cough IC/SC Retraction Cyanosis Tachypnea Rales/crackles Nasal flaring Respiratory fatigue Fever Chills Cough Retraction Tachypnea Restlessness Irritability Poor feeding Chest indrawing Chest pain Hypoxemia Tachypnea Grunting Fever Cough Retraction Body Malaise Tachycardia Dyspnea Altered mental status Rales Diagnostics Chest X-ray CBC Blood culture Chest x-ray ABG CBC Blood culture Pulse oximetry Chest X-ray CBC
PNEUMONIA SOURCES Pediatrics by Nelson Fundamentals of Pediatrics by Navarro Pediatrics Infectious Disease By feign & cherry Definition Inflammation of the parenchyma of the lungs Most common cause of morbidity and mortality Is an acute lung infection that results most commonly from viral or bacterial pathogens Signs & Symptoms Fever Cough IC/SC Retraction Cyanosis Tachypnea Rales/crackles Nasal flaring Respiratory fatigue Fever Chills Cough Retraction Tachypnea Restlessness Irritability Poor feeding Chest indrawing Chest pain Hypoxemia Tachypnea Grunting Fever Cough Retraction Body Malaise Tachycardia Dyspnea Altered mental status Rales Diagnostics Chest X-ray CBC Blood culture Chest x-ray ABG CBC Blood culture Pulse oximetry Chest X-ray CBC
1. Pediatric Community Acquired Pneumonia C 2. Rule out : Dengue Fever without warning signs ADMITTING DIAGNOSIS
DENGUE FEVER Definition • Is an acute febrile illness • Arthropod-borne virus • Characterized : biphasic fever : myalgia : rash : leukopenia : lymphadenopathy Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
DENGUE FEVER Epidemiology • Southeast Asia and Western Pacific Region – World wide : 1.8 billion – >70 % of the population who are at risk of dengue. • PHILIPPINES : 2013 (127,861) : 2014 (49,591) Jan – Aug Department of health Philippines
DENGUE FEVER Aedes Aegypti • Daytime-biting mosquito • highly domesticated • breeds in water stores – Drinking – Washing – container collecting fresh water Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
DENGUE FEVER DENGUE FEVER DENGUE HEMORRHAGIC FEVER Clinical Manifestation : • Fever • Pharyngeal inflammation • Rhinitis • Cough • Body malaise • anorexia Clinical Manifestation : • Cold clammy extremities • Warm trunk • Flushed face • Restlessness • Irritability • Mild epigastric pain and decrease urinary output Nelson’s textbook of pediatrics 19th edition
DENGUE FEVER DENGUE FEVER DENGUE HEMORRHAGIC FEVER Clinical Manifestation : • Fever • Pharyngeal inflammation • Rhinitis • Cough • Body malaise • anorexia Clinical Manifestation : • Cold clammy extremities • Warm trunk • Flushed face • Restlessness • Irritability • Mild epigastric pain and decrease urinary output Nelson’s textbook of pediatrics 19th edition
DENGUE FEVER OLD (Revised 1997/2011 Case Definition of Dengue & Levels of Severity) NEW (Revised DOH/PPS Classification and Levels of severity 2011) Case definition for Dengue Fever Probable Dengue: An acute febrile illness with 2 or more of the following: • Headache • Retro-orbital pain • Arthralgia • Rash • Hemorrhagic manifestations • Leukopenia; AND • Supportive serology (a reciprocal HI antibody titers ≥1280, a comparable IgG assay ELISA titer or IgM antibody test on a late or acute convalescent phase serum specimen Confirmed: A case confirmed by laboratory criteria Case definition for Dengue with out warning signs Probable Dengue: Lives in or travel to dengue-endemic area, with fever, plus two of the following: • Headache • Body malaise • Myalgia • Arthralgia • Retro-orbital pain • Anorexia • Nausea • Vomiting • Diarrhea • Flushed skin • Rash (petechial, hermann’s rash) • Tourniquet test (+) AND • Laboratory test, at least CBC (leukopenia with or without thrombocytopenia) and/or dengue NS1 antigen test or dengue IgM antibody test (optional) Confirmed dengue: • Viral culture isolation • PCR PPS Revised Dengue Guidelines 2012
DENGUE FEVER OLD (Revised 1997/2011 Case Definition of Dengue & Levels of Severity) NEW (Revised DOH/PPS Classification and Levels of severity 2011) Case definition for Dengue Fever Hemorrhagic Fever (DHF) The following must be all presented: 1. fever, or history of fever lasting 2-7 dayss, occasionally biphasic 2. Hemorrhagic evidenced by at least one of the following: a. (+) tourniquest test b. Petechiae,ecchymosis, purpura c. Bleeding from the mucosa, GIT, injection site or other locations d. Hematemesis or melena 3. Thrombocytopenia (100, 000 cells/mm3 or less) 4. Evidence of plasma leakage due to increased vascular permeabilit, manifested by atleast one of the following: a. A rise in the hematocrit equal to or greater than 20% above average for age, sex and popultion b. A drop in the hematocrit following volume replacement treatment equal to or greater than 20% of baseline. c. Signs of plasma leakage such as pleural effusion ascites and hypoproteinemia Case definition for Dengue with warning signs Lives or travel to dengue-endemic area with fever lasting for 2- 7 days, plus any one of the following: • Abdominal pain or tenderness • Persistent vomiting • Clinical signs of fluid accumulation • Mucosal bleeding • Lethargy, restlessness • Liver enlargement • Decreased or no urine output with in 6 hours • Laboratory: increased in HCT and or decreasing platelet Confirmed Dengue: • Viral culture isolation • PCR PPS Revised Dengue Guidelines 2012
DENGUE FEVER OLD (Revised 1997/2011 Case Definition of Dengue & Levels of Severity) NEW (Revised DOH/PPS Classification and Levels of severity 2011) Case definition for Dengue Shock syndrome (DSS) All of the four criteria for the DHF must present, plus evidence of circulatory failure manifested by: • Rapid and weak pulse, AND • Narrow pulse pressure (<20mmHg ) or manifested by: • Hypotension for age, AND • cold clammy skin and restlessness Case Definition for Severe Dengue Lives in or travel to a dengue-endemic area with fever 2- 7 days and any of the above clinical manifestations for dengue with or without warning signs, plus any of the following • Severe plasma leakage, leading to: • shock • Fluid accumulation with respiratory distress • Severe bleeding • Severe organ impairment • Liver : AST or ALT≥1000 • CNS : e.g seizures, impaired consciusness • Heart : e.g myocarditis • Kidney e.g renal failure PPS Revised Dengue Guidelines 2012
DENGUE FEVER OLD (Revised 1997/2011 Case Definition of Dengue & Levels of Severity) NEW (Revised DOH/PPS Classification and Levels of severity 2011) Grading of Severity of DHF/DSS • DHF Grade 1 Fever accompanied by non specific constitutional signs and symptoms such as anorexia, vominting abdominal pain, the only hemorrhagic manifestatin is a (+) tourniquet test and or easy bruising • DHF Grade 2 Spontaneous bleeding in addition to manifestatations of grade 1 patient usually in the form of skin or other hemorrhages • DHF Grade 3 (DSS) Circulatory failure manifested by rapid, weak pulse and narrowing of pulse pressure or hypotension,with the presence of cold clammy skin and restlessness. • DHF Grade 4 (DSS) Profound shock with undetectable blood pressure or pulse PPS Revised Dengue Guidelines 2012
Course in the ER PPS Revised Dengue Guidelines 2012
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment PICTURE
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment REASONS FOR ADMISSION : 1. Moderate dehydration 2. Weak looking 3. Loss of appetite
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment DIET : • Diet for AGE • No dark color foods
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever P: ADMIT Diet Hydration Diagnostics Nelson Textbook of Pediatrics 19th ed Treatment ASSESSMENT OF DEGREE OF DEHYDRATION MILD MODERATE SEVERE Infant 5% 10% 15% Adolescent 3% 6% 9% Infants and young children Thirsty, alert, restless Thirst, restless or lethargic, irritable Drowsy, limp, cold, sweaty, comatose Older children Thirsty, alert Thirst, alert Conscious, apprehensive, cold, sweaty, cyanotic extremities SIGNS AND SYMPTOMS Tachycardia Absent Present Present Palpable pulses Present Present Decreased Blood pressure Normal Orthostatic hypotension Hypotension Cutaneous perfusion Normal Normal Reduced and mottled Skin turgor Normal Slight reduction Reduced Fontanelle Normal Slightly depressed Sunken Mucous membrane Moist Dry Very dry Tears Present Present or absent Absent Respirations Normal Deep, may be rapid Deep and rapid Urine output Normal Oliguria Anuria and severe oliguria
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever P: ADMIT Diet Hydration Diagnostics Nelson Textbook of Pediatrics 19th ed Treatment ASSESSMENT OF DEGREE OF DEHYDRATION MILD MODERATE SEVERE Infant 5% 10% 15% Adolescent 3% 6% 9% Infants and young children Thirsty, alert, restless Thirst, restless or lethargic, irritable Drowsy, limp, cold, sweaty, comatose Older children Thirsty, alert Thirst, alert Conscious, apprehensive, cold, sweaty, cyanotic extremities SIGNS AND SYMPTOMS Tachycardia Absent Present Present Palpable pulses Present Present Decreased Blood pressure Normal Orthostatic hypotension Hypotension Cutaneous perfusion Normal Normal Reduced and mottled Skin turgor Normal Slight reduction Reduced Fontanelle Normal Slightly depressed Sunken Mucous membrane Moist Dry Very dry Tears Present Present or absent Absent Respirations Normal Deep, may be rapid Deep and rapid Urine output Normal Oliguria Anuria and severe oliguria
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment HYDRATION : Plain LR (20cc/k) fast drip
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment CBC 10/25 Hemoglobin 129 Hematocrit 0.38 WBC 4.10 ↓ Segmenters 0.65 Stabs 0.07 Lymphocytes 0.26 Monocytes 0.02 Platelets 283,000 Dengue NS1Ag Positive
DIAGNOSTIC • Nonstructural protein 1 • 2006 : test for dengue by Bio Rad Laboratories and Pasteur Institute • Allows rapid detection on the D1 illness before antibodies appear D5 illness • NS1 antigen as an early diagnostics marker in dengue • Comparison : – NS1 antigen : good sensitivity (70-100%) till D3 illness – IgM : sensitivity of 0-50% till D3 illness Dengue NS1 Ag Singh et al DMID 2010 Sept; 68(1):50-4)
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment FINDINGS: Hazy infiltrates in right inner lung zone, with confluency in right middle lobe IMPRESSION : pneumonia right with consolidation, right middle lobe
COURSE IN THE ER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment TREATMENT : • Cefuroxime 100 mkd • Paracetamol 15 mkd
CEFUROXIME • Class : Second generation Cephalosporins • MOD : inhibit bacterial cell wall • Coverage : Gram (+) cocci : S. pneumonia : S. pyogenes : A. streptococci Gram (-) cocci : N. gonorrhea Gram (-) rods : Enterobacter aerogenes : E. coli : H. influenzae : K. pneumoniae : Proteus mirabilis Katzung & Trevors Pharmacology 10th ed
CEFUROXIME • Class : Second generation Cephalosporins • MOD : inhibit bacterial cell wall • Coverage : Gram (+) cocci : S. pneumonia : S. pyogenes : A. streptococci Gram (-) cocci : N. gonorrhea Gram (-) rods : Enterobacter aerogenes : E. coli : H. influenzae : K. pneumoniae : Proteus mirabilis Katzung & Trevors Pharmacology 10th ed
COURSE IN THE WARD HOSPITAL DAY (HD) 1 (D3 illness) S/O: CR 120 BP 100/60 UO : 1.5 ckh RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd
COURSE IN THE WARD HD 1 (D3 illness) S/O: CR 120 BP 100/60 RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd
COURSE IN THE WARD HD 1 (D3 illness) S/O: CR 120 BP 100/60 RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd
COURSE IN THE WARD HD 1 (D3 illness) S/O: CR 120 BP 100/60 RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd CBC 10/25 10/26 Hemoglobin 129 122 ↓ Hematocrit 0.38 0.36 ↓ WBC 4.10 ↓ Segmenters 0.65 Stabs 0.07 ↑ Lymphocytes 0.26 Monocytes 0.02 Platelets 283,000 212,000 ↓
COURSE IN THE WARD HD 1 (D3 illness) S/O: CR 120 BP 100/60 RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd
DENGUE T : 39oC CR 120 BP 100/60 RR 26 Full & equal pulses CRT < 2sec Weak-looking UO : 1.5ckh Hct : 0.38  0.36 Plt : 283212 COURSE OF ILLNESS
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain UO : 1.3 ckh A PCAP C Dengue Fever (with warning signs) P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide STOOL EXAM WITH CONCENTRATION TECHNIQUE 10/27 1st specimen 10/27 2nd specimen 10/27 3rd specimen MACROSCOPIC Color Yellow Yellowish green Yellowish brown Consistency Unformed Unformed Mucoid MICROSCOPIC Ova None seen None seen None seen Cyst None seen None seen None seen Trophozoites None seen None seen None seen Pus cells 0-1/hpf 0-1/hpf 0-1/hpf RBC 0-1/hpf 0-2/hpf 0-1/hpf Others Yeast cell: few Stool exam with concentration technique
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide CBC 10/25 10/26 10 am 10/27 10am Hemoglobin 129 122 ↓ 129 ↑ Hematocrit 0.38 0.36 ↓ 0.38 ↑ WBC 4.10 ↓ Segmenters 0.65 Stabs 0.07 ↑ Lymphocytes 0.26 Monocytes 0.02 Platelets 283,000 212,000 ↓ 194,000↓
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole 20mg IV Albumin transfusion Furosemide
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole 20 mg IV Albumin transfusion Furosemide
OMEPRAZOLE Class: Proton pump inhibitor MOA : Suppress the secretion of hydrogen ions into the gastric lumen • Duration of action is approximately 24h
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 53 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide TPAG NV 10/26 Total protein 66-87 43.6 ↓ Albumin 38-54 22.71 ↓ Globulin 23-35 20.89 ↓ A/G 1.8:1-2.3:1 1.09:1↓
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
Albumin Transfusion MOA: increases intravascular oncotic pressure Indications: hemorrhagic shock nephrotic syndrome burn hypoalbuminemia hypovolemia emedicine.medscape.com
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
COURSE IN THE WARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: D5 NSS 3.7 4ckh 3.2 ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
DENGUE T 38.8 HR 120 BP 90/60 RR 34 CRT < 2 sec vomiting Abdominal distension Abdominal pain Hct 0.35  0.38 UO: 1.3 ckh COURSE OF ILLNESS
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/50 AC 55 57 cm dec breath sounds, R RR 69 T 38.6 cold clammy extremities irritable mottled skin weak pulse CRT > 2 sec UO: 0.7 ckh A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip hook to O2 via mask Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak pulse CRT > 2 sec A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip hook to O2 via mask Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
Dengue Case Classification & Levels of Severity
Dengue Case Classification & Levels of Severity
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip hook to O2 via mask Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip hook to O2 via mask Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG CBC 10/25 10/26 10 am 10/27 10am 10/28 5am Hemoglobin 129 122 ↓ 129 ↑ 154 ↑ Hematocrit 0.38 0.36 ↓ 0.38 ↑ 0.46 ↑ WBC 4.10 ↓ 4.9 Segmenters 0.50 0.47 Stabs 0.07 ↑ 0.02 Lymphocytes 0.26 0.49 ↑ Monocytes 0.02 0.02 Platelets 283,000 212,000 ↓ 194,000↓ 172, 000 ↓
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG TPAG NV 10/26 10/28 Total protein 66-87 43.6 ↓ 39.3 ↓ Albumin 38-54 22.71 ↓ 23.16 ↓ Globulin 23-35 20.89 ↓ 16.14 ↓ A/G 1.8:1-2.3:1 1.09:1 ↓ 1.43:1 ↓
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG ABG 10/28 pH 7.251 pCO2 14 PO2 112.5 O2 sat 97.6 HCO3 6 TCO2 6.4 BE -21.2 Metabolic acidosis
COURSE IN THE WARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III(SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
RAPID ASSESSMENT • Irregular respirations or rate >60 • Heart ranges: – Child ≤2 yrs of age : <80/min or >180/min – Child >2 yrs of age : <60/min or >160/min • Poor perfusion with weak/absent distal pulses • Increased work of breathing • Cyanosis • Altered consciousness • Seizures • Fever with petechiae • Trauma • Burns involving >10% of BSA
RAPID ASSESSMENT • Irregular respirations or rate >60 • Heart ranges: – Child ≤2 yrs of age : <80/min or >180/min – Child >2 yrs of age : <60/min or >160/min • Poor perfusion with weak/absent distal pulses • Increased work of breathing • Cyanosis • Altered consciousness • Seizures • Fever with petechiae • Trauma • Burns involving >10% of BSA
CBC Assess Categorize Decide / Act Consciousness Irritable Respiratory Distress ; Shock • call for help • activate emergency system • hook to pulse ox & cardiac monitor • O2 per face mask • SPO2 monitoring Breathing Increased effort Circulation pale COURSE IN THE WARD (4pm) Initial Assessment
COURSE IN THE WARD (4pm) Primary Assessment ABCDE Assess Categorize Decide / Act Airway Maintainable Respiratory distress Compensated shock • O2 mask: 10 LPM • IV double line • PNSS 20 cc/kg fast drip • Transfer to ICU • NPO • Hgt monitoring Breathing RR : 55/min SPO2 : 95% SC retractions Rales Circulation HR : 140 fair pulse BP 80/50 CRT >2 Disability GCS 15 (E4M6V5) Exposure Temp 39C
SAMPLE Assess Categorize Decide / Act S/Sx irritable tachypnea Subcostal retractions Rales, bilateral tachycardia, Abdominal distension CRT > 2 sec Respiratory distress secondary to lung parenchyma disease; severe dengue with compensated shock • continue medications • continue cardiac monitoring • continue SPO2 monitoring • request for: repeat CBC PC PT APTT D Dimer Chest X ray ABG Allergies None Medications Cefuroxime ; Paracetamol Past Med Hx No PCV Acute gastroenteritis 2013 PCAP A (Nov 2013, Jan 2014, April 2014) Last Meal 4 hours COURSE IN THE WARD (4pm) Secondary Assessment
SAMPLE Assess Categorize Decide / Act Events Respiratory distress Worsened work of breathing Respiratory distress secondary to lung parenchyma disease; severe dengue with compensated shock • continue medications • continue cardiac monitoring • continue SPO2 monitoring • request for: repeat CBC PC PT APTT D Dimer Chest X ray ABG COURSE IN THE WARD (4pm) Secondary Assessment
PHYSICAL EXAMINATION • BP 80/50, CR 140, RR 55, T 39OC • pink palpebral conjunctivae, anicteric sclera, no alar flaring, dry and pale lips and oral mucosa • adynamic precordium, tachycardic, apex beat at 4th ICS left mid clavicular line, no murmur • equal chest expansion, subcostal retractions, rales both lung fields • distended abdomen • fair and fast pulses, CRT > 2 seconds • neuro exam: normal
Laboratory Tests Results CBC I PC Hgb 130, hct 0.38, wbc 8.7, seg 0.32, stabs 0.08, lymph 0.59, mono 0.01, platelet 175 Pro-thrombin Time 15 ↑ Control 11.21 INR 1.46 Protime Activity 51.5 APTT 78.3 ↑ Control 34.1 D- dimer 627.22 ↑ CXR progression of pneumonia right, mild to moderate pleural effusion, right ABG pH- 7.251 pCO2- 14 pO2- 112.5 O2 sat- 97.6 HCO3- 6 TCO2- 6.4 BE-(-)21.2 COURSE IN THE WARD (4pm) Tertiary Assessment
Findings : Show progression of pneumonic infiltrates in the right middle lobe and homogenous density in the right hemithorax obscuring the right cardiac border and blunting of the right costophrenic sulcus with lateral ascending border pneumonia IMPRESSION : progression of pneumonia right, mild to moderate pleural effusion, right
1st-12th hour of PICU stay • awake, conscious, irritable • VS: BP 80/50, CR 130, RR 40, T 38.9oC • Subcostal retraction, rales • abdominal distention • full pulses, CRT < 2 seconds
CBC Assess Categorize Decide / Act Consciousness Irritable Respiratory Distress/ failure • call for help • activate emergency system • continue O2 facemask • continue SPO2 monitoring Breathing labored breathing Circulation pale COURSE IN THE ICU (6am)13th hour Initial Assessment
ABCDE Assess Categorize Decide / Act Airway Non-Maintainable Respiratory distress and failure 2° to lung parenchymal disease • intubate • continue cardiac monitoring • continue SPO2 monitoring Breathing RR : 65/min SPO2 : 89% SC retractions Rales, decreased breath sounds R mid to base lung Circulation HR : 168 full pulse BP 80/50 CRT <2 Disability GCS 15 (E4M6V5) Exposure Temp 39C COURSE IN THE ICU (6am) Primary Assessment
SAMPLE Assess Categorize Decide / Act S/Sx irritable, weak-looking tachypnea, increase work of breathing (alar flaring subcostal retractions), decreased breath sounds mid to base right lung field tachycardia Respiratory distress/failure 2° to lung parenchymal disease • shift Cefuroxime to Ceftriaxone • continue cardiac monitoring • continue SPO2 monitoring • request for: CKMB, Trop-I, BUN, Crea, Blood C&S, USG Allergies None Medications Cefuroxime ; Paracetamol Past Med Hx day I ICU Last Meal 19 hours COURSE IN THE ICU (6am) Secondary Assessment
SAMPLE Assess Categorize Decide / Act Events Severe Respiratory distress Desaturation Worsened work of breathing Respiratory distress/failure 2° to lung parenchymal disease • shift Cefuroxime to Ceftriaxone • continue cardiac monitoring • continue SPO2 monitoring • request for: CKMB, Trop-I, BUN, Crea, Blood C&S, USG COURSE IN THE ICU (6am) Secondary Assessment
PHYSICAL EXAMINATION • BP 80/50, CR 160, RR 55, T 39OC • pink palpebral conjunctivae, anicteric sclera, no alar flaring, dry and pale lips and oral mucosa • adynamic precordium, tachycardic, apex beat at 4th ICS left mid clavicular line, no murmur • labored breathing, subcostal retractions, rales both lung fields, decreased breath sounds mid to base right lung field • distended abdomen • full pulses, CRT < 2 seconds • neuro exam: normal
Laboratory Tests Results CKMB 58.1 Troponin I 0.05 BUN 3.07 Creatinine 34.5 BLOOD CS negative 5 days ABG pH- 7.352 pCO2-30.7 pO2 -95.5 O2 sat- 97.1 HCO3- 16.7 TCO2- 17.6 BE-(-)8.9 CXR no significant change in the previously noted pneumonia, pleural effusion on the right COURSE IN THE ICU (6am) Tertiary Assessment
COURSE IN THE ICU There is no significant change in the previously noted pneumonia and pleural effusion in the right, heart and the rest of the chest finding are unchanged
COURSE IN THE ICU DAY 5, 2nd PICU DAY Problem: PCAP D, DHF III S/O: CR 136 BP 90/60 AC 56 57 cm RR 51 T 37. 9 Urine output: 0.7ckh Petechial rash , face Urine Sp.G: 1.025 Rales BLF A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Hydration: PNSS 10ck as fast drip Diet: milk feeding 2oz per OGT q 4h 7ckh Labs : ABG Meds: Ceftriaxone (day 1) Amikacin (day 1) Domperidone
LABORATORY ABG 10/28 10/29 10/30 pH 7.251 7.352 7.362 pCO2 14 30.7 29.8 PO2 112.5 95.5 162.9 O2 sat 97.6 97.1 99 HCO3 6 16.7 17 TCO2 6.4 17.6 17.9 BE -21.2 -8.9 -8.6
COURSE IN THE ICU DAY 6, 3rd PICU DAY Problem: PCAP D, DHF III S/O: CR 160 BP 90/60 AC 57 cm RR 62 T 39 Urine output: 1.2 ckh pale & dry lips rales both lung field A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Labs : repeat CBC Hydration : D5 IMB 5ckh to KVO repeat PT, PTT repeat D dimer Meds: Ceftriaxone (day 2) Amikacin (day 2) Furosemide
CBC 10/25 10/26 10 am 10/27 10am 10/28 5am 10/28 2 pm 11/1 5am Hemoglobin 129 122 ↓ 129 ↑ 154 ↑ 151 ↓ 93 ↓ Hematocrit 0.38 0.36 ↓ 0.38 ↑ 0.46 ↑ 0.44 ↓ 0.28 ↓ WBC 4.10 ↓ 4.9 ↑ 8.7 ↑ 10.7↑ Segmenters 0.50 0.47 0.27 ↓ 0.40 ↑ Stabs 0.07 ↑ 0.02 0.05 0.04 Lymphocytes 0.26 0.4 ↑ 0.67 0.56 ↓ Monocytes 0.02 0.02 0.01 Platelets 283 212 ↓ 194 ↑ 172 ↓ 170 ↓ 194 ↑
LABORATORY NV 10/28 11/1 Pro-thrombin Time 10-14 sec 15 14.8 Control 11.21 11.23 INR 1.46 1.43 Protime Activity % 51.5 53.1 APTT 28-36 sec 78.3 ↑ 49.3 Control 34.1 34.7 D- dimer 100-446.8 ng/mL 627.22 ↑ 2973.21↑
COURSE IN THE ICU DAY 7, 4th PICU S/O: CR 173 BP 80/50 AC 57 cm 55cm RR 65 T 39 O2 sat : 70% 98% Alar flaring Rales BLF Puffy eyelids A: PCAP D pulmonary congestion P: Mgt : Re-intubation 4.5 depth and 13 mm, mech vent set up NPO Labs : repeat CXR ABG Meds: Ceftriaxone (day 3) Furosemide IVF Heplock Amikacin (day 3) Dobutamine
CHEST X RAY Shows significant resolution of the previously noted right sided leural effusion, hazy infiltrates are seen in the right mid and both lower lobes Imp: significant resolution of right sided pleural effusion, new infiltrates on right mid and both lower lobes
ABG 10/28 10/29 10/30 11/1 pH 7.251 7.352 7.362 7.457 pCO2 14 30.7 29.6 36.6 PO2 112.5 95.5 162.9 27 O2 sat 97.6 97.1 99 57.4 HCO3 6 16.7 17 26 TCO2 6.4 17.6 17.9 27.2 BE -21.2 -8.9 -8.6 2 LABORATORY
COURSE IN THE ICU DAY 8 S/O: CR 160 BP 110/60 AC 55cm RR 55 T 38.9 A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Mgt : OGT resumed Meds: Ceftriaxone (day 4) MEROPENEM 60mkd Amikacin (day 4) Furosemide every 4h 8h kalium durule every 8h
COURSE IN THE ICU DAY 9 S/O: CR 128 BP 90/60 AC 55cm 53cm RR 52 T 37.3 Rales BLF No alar flaring No SC retraction A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Mgt : continued Meds: Meropenem(day1) Amikacin (day 5) Furosemide every 8h kalium durule every 8h
COURSE IN THE ICU DAY 10 S/O: CR 180 BP 90/60 AC 55cm 53cm RR 52 T 38.4 UO 3.5ckh Pale conjunctivae Pale & dry lips A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Diagnostics: repeat CXR repeat CBC w/ PC urine KOH repeat ABG serum Na, K Meds: Meropenem(day2) salbutamol neb Amikacin (day 6) dexamethasone Furosemide every 8h kalium durule every 8h-----12h
CHEST X-RAY Partial clearing of both infiltration right mid and both lower lobes Imp: Partial clearing of both infiltration right mid and both lower lobes
LABORATORY ABG 10/28 10/29 10/30 11/1 11/4 pH 7.251 7.352 7.362 7.457 7.399 pCO2 14 30.7 29.6 36.6 34.8 PO2 112.5 95.5 162.9 27 57.6 O2 sat 97.6 97.1 99 57.4 89.6 HCO3 6 16.7 17 26 21.7 TCO2 6.4 17.6 17.9 27.2 22.7 BE -21.2 -8.9 -8.6 2 -3.4
LABORATORY CBC 10/25 10/26 10 am 10/27 10am 10/28 5am 10/28 2 pm 10/28 6 pm 11/1 5am 11/4 5am Hemoglobin 129 122 ↓ 129 ↑ 154 ↑ 151 ↓ 130 93 ↓ 88 ↓ Hematocrit 0.38 0.36 ↓ 0.38 ↑ 0.46 ↑ 0.44 ↓ 0.38 0.28 ↓ 0.28 WBC 4.10 ↓ 4.9 ↑ 8.7 ↑ 11 6.7 ↓ 10.4 ↑ Segmenters 0.50 0.47 0.27 ↓ 0.32 0.40 ↑ 0.64 Stabs 0.07 ↑ 0.02 0.05 0.08 0.04 0.02 ↓ Lymphocytes 0.26 0.4 ↑ 0.67 0.59 0.56 ↓ 0.34 ↓ Monocytes 0.02 0.02 0.01 0.01 Platelets 283 212 ↓ 194 ↑ 172 ↓ 170 ↓ 175 194 ↑ 265 ↑
LABORATORY Electrolytes NV 11/1 Sodium 132-152 mmol/L 142.9 potassium 3.60-5.30 mmol/L 5.04 URINE KOH No fungal elements
COURSE IN THE ICU DAY 11 S/O: CR 160 BP 90/60 AC 53cm RR 60 afebrile O2 sat 78% A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Meds: Meropenem(day 3) salbutamol neb Amikacin (day 7) dexamethasone Furosemide every 8h kalium durule every 8h-----12h Vit A 100,000 , 2 cap SD Zinc Sulfate started
COURSE IN THE ICU DAY 12 S/O: CR 110 BP 90/60 AC 53cm RR 35 afebrile O2 sat 99% A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Mgt : extubated FC removed NGT removed----clear liquid diet w/SAP Meds: Meropenem(day 4) salbutamol neb Amikacin (day 8) dexamethasone Furosemide d/c Kalium durule every 8h-----12h Zinc Sulfate (day 1)
COURSE IN THE WARD HD 13(D15 of illness) S/O: CR 96 BP 90/60 decreased rales RR 31 afebrile CRT <2 sec O2 sat 99% UO : 1.4 ckh Equal & full pulses A: PCAP D resolving Dengue Hemorrhagic Fever III ( SEVERE DENGUE) resolved P: Transferred to HDU ST. Martin Meds: Meropenem(day 5) Amikacin (day 9) Zinc Sulfate (day 2) Kalium durule d/c FeSO4 started
COURSE IN THE WARD HD 13(D15 of illness) S/O: CR 96 BP 90/60 decreased rales RR 31 afebrile O2 sat 99% A: PCAP D resolving Dengue Hemorrhagic Fever III ( SEVERE DENGUE) resolved P: Transferred to HDU ST. Martin Meds: Meropenem(day 5) Amikacin (day 9) Zinc Sulfate (day 2) Kalium durule d/c FeSO4 started
COURSE IN THE WARD HD 13(D15 of illness) S/O: CR 96 BP 90/60 decreased rales RR 31 afebrile O2 sat 99% A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Transferred to ST. Martin High Dependecy Unit Meds: Meropenem(day 5) Amikacin (day 9) Zinc Sulfate (day 2) Kalium durule d/c FeSO4 started
COURSE IN THE WARD HD 14(D16 of illness) S/O: CR 100 BP 90/60 UO : 1.4 ckh RR 33 afebrile decreased rales comfortable A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Meds: Meropenem(day 6) Amikacin (day 10) Zinc Sulfate ( day 3) FeSO4 (day 1) Clarithromycin 7.5mkd per orem
COURSE IN THE WARD HD 15(D17 of illness) S/O: CR 99 BP 90/60 comfortable RR 30 afebrile clear breath sounds A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Meds: Meropenem(day 7) Amikacin (day 11) Zinc Sulfate (day 4) FeSO4 (day 2) oral clarithromycin (day1)
COURSE IN THE WARD HD 16(D18 of illness) S/O: CR 99 BP 90/60 RR 30 afebrile comfortable A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Diet: soft diet Meds: Meropenem(day 8) Amikacin discontinued Zinc Sulfate (day 5) FeSO4 (day 3) oral clarithromycin (day2)
COURSE IN THE WARD HD 17(D19 of illness) S/O: Stable vital signs A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Diet: soft diet Meds: Meropenem(day 9) Zinc Sulfate (day 5) FeSO4 (day 3) oral clarithromycin (day3) MAY GO HOME
Home Meds: 1. Clarithromycin 15mkd BID 2. FeSO4 10mkd OD 3. Zinc Sulfate 5ml OD
COMPLICATION • Sequelae of dengue virus infection are rare but may include the following: – Cardiomyopathy – Encephalopathy – Hepatic injury – Pneumonia – Ophoritis/orchitis
PREVENT BREEDING 235 Cover water containers, wells, and water tanks tightly Keep drains free from blockage Change the water in vases and for aquatic plants at least once a week and leave no water in the saucers underneath the plants Cover up tires before disposal to prevent water from collecting. Dispose of unwanted containers where water may collect such as lunch boxes and soft drink cans into covered bins Repair uneven surfaces of the ground to prevent water from collecting Check whether there is water collecting on the tray under an air- conditioner and in the drainage system, and remove stagnant water
PREVENT BITES 10/12/2010 236 Wear light-coloured and long-sleeved clothing and pants Apply mosquito repellents containing DEET to exposed parts of the body Use mosquito nets or screens when the room is not air-conditioned Avoid visiting scrubby areas Install screens on windows and doors, or place mosquito coils /electric mosquito mats /anti-mosquito liquid near the windows
FINAL DIAGNOSES • PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA D • DENGUE HEMORRHAGIC FEVER III (SEVERE)
THANK YOU

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Pediatric Community Acquired Pneumonia

  • 1.
    CASE MANAGEMENT CONFERENCE Presented by: AllanJoseph O. Santos Nurol Iman L. Cabugatan Amer Hussien P. Samporna Department of Pediatrics November 21, 2014 8:00 – 10:00 am Basilio Valdes Hall
  • 2.
    IDENTIFYING DATA • M.D. •2 yr & 2 mos old • Female • Filipino • Roman Catholic • Makati City • 2nd admission • October 25, 2014 ( 3:19 pm )
  • 3.
  • 4.
    SOURCE & RELIABILITY •SOURCE : Mother • RELIABILITY : Good ( 95% )
  • 5.
    HISTORY OF PRESENTILLNESS • Fever : intermittent : high grade : Tmax : 40o C • No other symptoms • Self medicated : Paracetamol (15mkdose) 9 days PTA .
  • 6.
    HISTORY OF PRESENTILLNESS • Consult OLLH-ER : laboratory exam 9 days PTA . . CBC PC RESULT Hemoglobin 124 Hematocrit 0.37 WBC 3.9  Segmenters 0.64 Stabs 0.01 Lymphocytes 0.30 Monocytes 0.05 Platelet count 268 URINALYSIS RESULT Color Yellow Transparency Slightly Cloudy Reaction 6.0 Specific gravity 1.015 Glucose Negative Albumin Negative Epithelial cells Few RBC 2-4/hpf Pus cells 0-1/hpf Amorphous urates Few Mucus threads Occasional Bacteria Occasional
  • 7.
    HISTORY OF PRESENTILLNESS • Consult OLLH-ER : PE : Normal : Dx : AVI : Tx : Paracetamol (15mkdose) : sent home • Symptoms : resolved 9 days PTA . . .
  • 8.
    HISTORY OF PRESENTILLNESS • Afebrile • Cough : occasional : non productive • No : other signs and symptoms : consult • Self medicated : Salbutamol + Bromhexine + Guaifenesin syrup : Salbutamol + Ipratropium nebule • Symptom : temporary relief 7 days PTA
  • 9.
    HISTORY OF PRESENTILLNESS • Cough : persisted : productive • Fever : recurrent : intermittent : high grade : Tmax : 39o C • Other symptoms : body malaise : poor appetite • No consult 1 day PTA
  • 10.
    • Fever • Cough •Poor appetite • Body malaise • Consult AMD : PE : weak looking, dry lips : admission Few hours PTA HISTORY OF PRESENT ILLNESS
  • 11.
    MATERNAL HISTORY • Mother: 27 year old : G3P2 (2002) • Pre-natal check up : regular • Maternal illness : UTI • Exposure to radiation : none • Multivitamins : compliant • Folic Acid : compliant • Ferrous Sulfate : compliant
  • 12.
    BIRTH HISTORY • Fullterm, NSD • Lying-in clinic • Birth date : August 23, 2012 • BW : 3.5 kg ( 3,500 grams ) ( 7.7 lbs. ) • BL : 50 cm • NST : normal • NHT : not done • Given at Birth : Vit K : Hepa B
  • 13.
    VACCINE 1ST DOSE2ND DOSE 3RD DOSE BCG 13 days (9/5/2012) Hepatitis B Birth (8/23/2012) 2 mos & 1 day (10/24/2012) 3 mos (11/21/2012) DPT 2 mos & 1 day (10/24/2012) 3 mos (11/21/2012) 4 mos & 12 days (1/2/2013) OPV 2 mos & 1 day (10/24/2012) 3 mos (11/21/2012) 4 mos & 12 days (1/2/2013) Hib 2 mos & 1 day (10/24/2012) 3 mos (11/21/2012) 4 mos & 12 days (1/2/2013) Measles 9 mos & 17 days (6/9/2013) MMR 1 yr & 1 mo (9/18/13) IMMUNIZATION HISTORY Patient’s immunization Record
  • 14.
  • 15.
    NUTRITIONAL HISTORY • Breastfed : Birth until 6 mos • Milk formula : 6 mos onwards • Solid : 6 mos onwards • Current diet : 8oz of milk TID : rice, meat, fruits • Multivitamins : Regular
  • 16.
    DEVELOPMENTAL HISTORY GROSS MOTORADAPTIVE FINE MOTOR LANGUAGE PERSONAL/SOCIAL • Runs well • Up, down, stairs alone • Imitates circular strokes • Draw shapes • Combine two or three words in sentence • Point to one body part • Removes garment • Toilet trained
  • 17.
    ADMISSION HOSPITAL DATEAGE DIAGNOSIS 1 OLLH Feb 2013 6 months old AGE PAST MEDICAL HISTORY OPD CLINIC DATE AGE DIAGNOSIS 1 Other AMD Nov 2013 1 yr & 3 mos PCAP A 2 AMD Jan 2014 1 yr & 5 mos PCAP A 3 AMD Feb 2014 1 yr & 8 mos PCAP A
  • 18.
    ( + ): Asthma (Mother) : Hypertension (Maternal grand parent) : CVA (Maternal Grandfather) ( - ) : Mental/Psychiatric disorder : Tuberculosis : Diabetes mellitus : Malignancy : Thyroid disease FAMILY MEDICAL HISTORY
  • 19.
    • Youngest amongthree siblings • Father : 60 year old : Government employee • Mother : 30 year old : Call center agent PERSONAL & SOCIAL HISTORY
  • 20.
    • Home :2-storey rented house ( with 2 siblings and 1 helper ) • Water : Refilling station • Garbage : Collected daily PERSONAL & SOCIAL HISTORY
  • 21.
    • General: noweight loss • Skin : no jaundice : no bruising • HEENT : no head injury, no trauma : no ear discharge : no nasal discharges, no epistaxis : no mouth sores : no mass REVIEW OF SYSTEMS
  • 22.
    • Neurologic :no seizure : no loss of consciousness • Respiratory : no colds : no hemoptysis Cardiovascular : no cyanosis REVIEW OF SYSTEMS
  • 23.
    • Gastrointestinal :no vomiting : no change in bowel movement • Musculoskeletal : no swelling : no arthralgia : no myalgia : no limitation of movement • Genitourinary : no hematuria : no dysuria : no polyuria : no urinary frequency : no foul smelling vaginal discharge REVIEW OF SYSTEMS
  • 24.
    • GENERAL SURVEY: awake, conscious, weak-looking, carried by mother • VITAL SIGNS : BP : 90/60 mmHg : HR : 115 bpm : RR : 33 cpm : Temp : 37.8 o C : O2 Sat : 98 % • ANTHROPOMETRICS : Weight : 13.9 kg (z-score +1: normal) : Height : 89 cm (z-score +1: normal) : BMI : 17.5 kg/m2 (z-score +1: normal) : HC : 49 cm : CC : 51 cm : AC : 53 cm PHYSICAL EXAMINATION
  • 25.
    • SKIN :warm, fair, no lesion, flushed skin, good skin turgor • HEENT : anicteric sclerae, pink palpebral conjunctivae, no hemorrhage, no exudates, no discharges, dry lips and oral mucosa, no oral lesions, no lymphadenopathies • RESPIRATORY : shallow retractions, symmetrical chest expansion. rales on all lung fields. • CARDIOVASCULAR : adynamic precordium, no heaves and thrills, regular heart rhythm. distinct heart sounds, no murmurs PHYSICAL EXAMINATION
  • 26.
    • GASTROINTESTINAL :flat, no surgical scars, normoactive bowel sounds, no bruits, tympanitic abdomen, no organomegaly, no tenderness. • EXTREMETIES : CRT <2 sec., no gross deformity, no edema, full and equal pulses. • GENITALIA : labia majora covers labia minora, no vaginal discharge, no lesions PHYSICAL EXAMINATION
  • 27.
    • NEUROLOGICAL Cerebral :GCS 15 (E4V5M6) Cerebellar : Not done Cranial Nerves CN I : able to smell CN II : intact papillary and consensual light reflexes (+) ROR CN III, IV, VI : full EOMs CN V : intact; no sensory deficits CN VII : no facial asymmetry; able to perform different facial expressions CN VIII : intact gross hearing CN IX, X : intact gag reflex; uvula midline CN XI : SCM and trapezius muscle symmetric with muscle strength of 5/5 CN XII : tongue midline PHYSICAL EXAMINATION
  • 28.
    • NEUROLOGICAL Motor :5/5 on both lower and upper extremities normal tone; no atrophy; symmetrical movements Sensory : responsive to light touch and pain DTRs : ++ on biceps and knee Meningeal Signs : no kernig’s and brudzinski’s, nuchal rigidity Pathologic Reflex : no babinski, clonus PHYSICAL EXAMINATION
  • 29.
    Gen. data :2yr & 2mos old, female CC : Cough with fever HPI : fever (Tmax : 40OC) : productive cough : body malaise : poor appetite PE : weak-looking, flushed skin, dry lips and oral mucosa, shallow retractions, rales on all lung field, tachypnea (33cpm) febrile (37.8o C) SALIENT FEATURES
  • 30.
    1. Pediatric CommunityAcquired Pneumonia C 2. Rule out : Dengue Fever (without warning signs) ADMITTING DIAGNOSIS
  • 31.
    1. Pediatric CommunityAcquired Pneumonia C 2. Rule out : Dengue Fever without warning signs ADMITTING DIAGNOSIS
  • 32.
  • 33.
    Feigin & Cherry’s,Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification : CAUSE NON INFECTIOUS Aspiration of food and gastric acid Foreign bodies Hypersensitivity reactions INFECTIOUS Viral fungal Bacterial
  • 34.
    Feigin & Cherry’s,Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification : CAUSE NON INFECTIOUS Aspiration of food and gastric acid Foreign bodies Hypersensitivity reactions INFECTIOUS Viral fungal Bacterial
  • 35.
    Feigin & Cherry’s,Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: ANATOMY UPPER Nasal cavity Pharynx Larynx LOWER Trachea Bronchus Bronchioles Lungs Upper Respiratory Tract Lower Respiratory Tract
  • 36.
    Feigin & Cherry’s,Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: ANATOMY UPPER Nasal cavity Pharynx Larynx LOWER Trachea Bronchus Bronchioles Lungs Upper Respiratory Tract Lower Respiratory Tract
  • 37.
    Feigin & Cherry’s,Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: ANATOMY UPPER Nasal cavity Pharynx Larynx LOWER Trachea Bronchus Bronchioles Lungs Upper Respiratory Tract Lower Respiratory Tract
  • 38.
    Feigin & Cherry’s,Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: SIGNS and SYMPTOMS UPPER Cough Sore throat Rhinorrhea Nasal congestion Headache Low grade fever Facial pressure Sneezing LOWER Cough Fever Chest pain Tachypnea Sputum production Retractions Upper Respiratory Tract Lower Respiratory Tract
  • 39.
    Feigin & Cherry’s,Textbook of Pediatric Infectious Diseases 7th ed. COUGH Classification: SIGNS and SYMPTOMS UPPER Cough Sore throat Rhinorrhea Nasal congestion Headache Low grade fever Facial pressure Sneezing LOWER Cough Fever Chest pain Tachypnea Sputum production Retractions Upper Respiratory Tract Lower Respiratory Tract
  • 40.
    COUGH Classification: Etiology UPPER Virus •Adenovirus • Influenza • Parainfluenza • Respiratory syncytial • Rhinovirus Bacteria • H. influenzae • S. pyogenes Fungi • Candida spp. LOWER Virus • Adenovirus • Influenza • Parainfluenza • Respiratory syncytial • Rhinovirus Bacteria • H. influenzae • S. pyogenes • B. pertusiss • S. pneumonia • S. aureus Other • M. Pneumoniae • C. pneumoniae Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
  • 41.
    COUGH Classification: Etiology UPPER Virus •Adenovirus • Influenza • Parainfluenza • Respiratory syncytial • Rhinovirus Bacteria • H. influenzae • S. pyogenes Fungi • Candida spp. LOWER Virus • Adenovirus • Influenza • Parainfluenza • Respiratory syncytial • Rhinovirus Bacteria • H. influenzae • S. pyogenes • B. pertusiss • S. pneumonia • S. aureus Other • M. Pneumoniae • C. pneumoniae Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
  • 42.
    COUGH Classification: AGE < 2years Bronchiolitis Pneumonia Croup > 2 years Croup Pharyngitis Pulmonary Tuberculosis Pneumonia Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
  • 43.
    COUGH Classification: AGE < 2years Bronchiolitis Pneumonia Croup > 2 years Croup Pharyngitis Pulmonary Tuberculosis Pneumonia Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
  • 44.
    COUGH Classification Upper RespiratoryInfection Lower Respiratory Infection Anatomy Nasal cavity Pharynx Larynx Trachea Bronchus Bronchioles Lungs Etiologic agents Respiratory syncytial virus Adenovirus H. infuenzae Parainfluenzae Rhinoviruses S. pyogenes S. pneumoniae Respiratory syncytial virus Adenovirus H. infuenzae Parainfluenzae S. pneumoniae M. pneumoniae S. aureus M. tuberculosis Signs & symptoms Cough Sore throat Rhinorrhea Nasal congestion Headache Low grade fever Facial pressure Sneezing Cough Fever Chestpain Tachypnea Sputum production Retractions Differential Diagnosis Tonsillitis Pharyngitis Laryngitis Sinusitis Rhinitis Bronchitis Pulmonary Tuberculosis Pneumonia Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
  • 45.
    COUGH Classification Upper RespiratoryInfection Lower Respiratory Infection Anatomy Nasal cavity Pharynx Larynx Trachea Bronchus Bronchioles Lungs Etiologic agents Respiratory syncytial virus Adenovirus H. infuenzae Parainfluenzae Rhinoviruses S. pyogenes S. pneumoniae Respiratory syncytial virus Adenovirus H. infuenzae Parainfluenzae S. pneumoniae M. pneumoniae S. aureus M. tuberculosis Signs & symptoms Cough Sore throat Rhinorrhea Nasal congestion Headache Low grade fever Facial pressure Sneezing Cough Fever Chestpain Tachypnea Sputum production Retractions Differential Diagnosis Tonsillitis Pharyngitis Laryngitis Sinusitis Rhinitis Bronchitis Pulmonary Tuberculosis Pneumonia Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
  • 46.
    PNEUMONIA Definition • Leading causeof death in children world wide • Lung parenchymal inflammation Nelson Textbook of Pediatrics 19 th ed. 2011
  • 47.
    PNEUMONIA WHO : Commondiseases of children under 5 y/o Nelson Textbook of Pediatrics 19 th ed. 2011
  • 48.
    PNEUMONIA WHO : Commondiseases of children under 5 y/o Nelson Textbook of Pediatrics 19 th ed. 2011
  • 49.
    Revised Risk Classificationfor Pneumonia-related Mortality Philippine Academy of Pediatric Pulmonologists 2012
  • 50.
    Revised Risk Classificationfor Pneumonia-related Mortality Philippine Academy of Pediatric Pulmonologists 2012
  • 51.
    INTEGRATED MANAGEMENT OF CHILDHOODILLNESS World Health Organization 2005
  • 52.
    INTEGRATED MANAGEMENT OF CHILDHOODILLNESS World Health Organization 2005
  • 53.
    PNEUMONIA SOURCES Pediatrics by Nelson Fundamentals of Pediatrics byNavarro Pediatrics Infectious Disease By feign & cherry Definition Inflammation of the parenchyma of the lungs Most common cause of morbidity and mortality Is an acute lung infection that results most commonly from viral or bacterial pathogens Signs & Symptoms Fever Cough IC/SC Retraction Cyanosis Tachypnea Rales/crackles Nasal flaring Respiratory fatigue Fever Chills Cough Retraction Tachypnea Restlessness Irritability Poor feeding Chest indrawing Chest pain Hypoxemia Tachypnea Grunting Fever Cough Retraction Body Malaise Tachycardia Dyspnea Altered mental status Rales Diagnostics Chest X-ray CBC Blood culture Chest x-ray ABG CBC Blood culture Pulse oximetry Chest X-ray CBC
  • 54.
    PNEUMONIA SOURCES Pediatrics by Nelson Fundamentals of Pediatrics byNavarro Pediatrics Infectious Disease By feign & cherry Definition Inflammation of the parenchyma of the lungs Most common cause of morbidity and mortality Is an acute lung infection that results most commonly from viral or bacterial pathogens Signs & Symptoms Fever Cough IC/SC Retraction Cyanosis Tachypnea Rales/crackles Nasal flaring Respiratory fatigue Fever Chills Cough Retraction Tachypnea Restlessness Irritability Poor feeding Chest indrawing Chest pain Hypoxemia Tachypnea Grunting Fever Cough Retraction Body Malaise Tachycardia Dyspnea Altered mental status Rales Diagnostics Chest X-ray CBC Blood culture Chest x-ray ABG CBC Blood culture Pulse oximetry Chest X-ray CBC
  • 55.
    1. Pediatric CommunityAcquired Pneumonia C 2. Rule out : Dengue Fever without warning signs ADMITTING DIAGNOSIS
  • 56.
    DENGUE FEVER Definition • Isan acute febrile illness • Arthropod-borne virus • Characterized : biphasic fever : myalgia : rash : leukopenia : lymphadenopathy Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
  • 57.
    DENGUE FEVER Epidemiology • SoutheastAsia and Western Pacific Region – World wide : 1.8 billion – >70 % of the population who are at risk of dengue. • PHILIPPINES : 2013 (127,861) : 2014 (49,591) Jan – Aug Department of health Philippines
  • 58.
    DENGUE FEVER Aedes Aegypti •Daytime-biting mosquito • highly domesticated • breeds in water stores – Drinking – Washing – container collecting fresh water Feigin & Cherry’s, Textbook of Pediatric Infectious Diseases 7th ed.
  • 59.
    DENGUE FEVER DENGUE FEVERDENGUE HEMORRHAGIC FEVER Clinical Manifestation : • Fever • Pharyngeal inflammation • Rhinitis • Cough • Body malaise • anorexia Clinical Manifestation : • Cold clammy extremities • Warm trunk • Flushed face • Restlessness • Irritability • Mild epigastric pain and decrease urinary output Nelson’s textbook of pediatrics 19th edition
  • 60.
    DENGUE FEVER DENGUE FEVERDENGUE HEMORRHAGIC FEVER Clinical Manifestation : • Fever • Pharyngeal inflammation • Rhinitis • Cough • Body malaise • anorexia Clinical Manifestation : • Cold clammy extremities • Warm trunk • Flushed face • Restlessness • Irritability • Mild epigastric pain and decrease urinary output Nelson’s textbook of pediatrics 19th edition
  • 61.
    DENGUE FEVER OLD (Revised 1997/2011Case Definition of Dengue & Levels of Severity) NEW (Revised DOH/PPS Classification and Levels of severity 2011) Case definition for Dengue Fever Probable Dengue: An acute febrile illness with 2 or more of the following: • Headache • Retro-orbital pain • Arthralgia • Rash • Hemorrhagic manifestations • Leukopenia; AND • Supportive serology (a reciprocal HI antibody titers ≥1280, a comparable IgG assay ELISA titer or IgM antibody test on a late or acute convalescent phase serum specimen Confirmed: A case confirmed by laboratory criteria Case definition for Dengue with out warning signs Probable Dengue: Lives in or travel to dengue-endemic area, with fever, plus two of the following: • Headache • Body malaise • Myalgia • Arthralgia • Retro-orbital pain • Anorexia • Nausea • Vomiting • Diarrhea • Flushed skin • Rash (petechial, hermann’s rash) • Tourniquet test (+) AND • Laboratory test, at least CBC (leukopenia with or without thrombocytopenia) and/or dengue NS1 antigen test or dengue IgM antibody test (optional) Confirmed dengue: • Viral culture isolation • PCR PPS Revised Dengue Guidelines 2012
  • 62.
    DENGUE FEVER OLD (Revised 1997/2011Case Definition of Dengue & Levels of Severity) NEW (Revised DOH/PPS Classification and Levels of severity 2011) Case definition for Dengue Fever Hemorrhagic Fever (DHF) The following must be all presented: 1. fever, or history of fever lasting 2-7 dayss, occasionally biphasic 2. Hemorrhagic evidenced by at least one of the following: a. (+) tourniquest test b. Petechiae,ecchymosis, purpura c. Bleeding from the mucosa, GIT, injection site or other locations d. Hematemesis or melena 3. Thrombocytopenia (100, 000 cells/mm3 or less) 4. Evidence of plasma leakage due to increased vascular permeabilit, manifested by atleast one of the following: a. A rise in the hematocrit equal to or greater than 20% above average for age, sex and popultion b. A drop in the hematocrit following volume replacement treatment equal to or greater than 20% of baseline. c. Signs of plasma leakage such as pleural effusion ascites and hypoproteinemia Case definition for Dengue with warning signs Lives or travel to dengue-endemic area with fever lasting for 2- 7 days, plus any one of the following: • Abdominal pain or tenderness • Persistent vomiting • Clinical signs of fluid accumulation • Mucosal bleeding • Lethargy, restlessness • Liver enlargement • Decreased or no urine output with in 6 hours • Laboratory: increased in HCT and or decreasing platelet Confirmed Dengue: • Viral culture isolation • PCR PPS Revised Dengue Guidelines 2012
  • 63.
    DENGUE FEVER OLD (Revised 1997/2011Case Definition of Dengue & Levels of Severity) NEW (Revised DOH/PPS Classification and Levels of severity 2011) Case definition for Dengue Shock syndrome (DSS) All of the four criteria for the DHF must present, plus evidence of circulatory failure manifested by: • Rapid and weak pulse, AND • Narrow pulse pressure (<20mmHg ) or manifested by: • Hypotension for age, AND • cold clammy skin and restlessness Case Definition for Severe Dengue Lives in or travel to a dengue-endemic area with fever 2- 7 days and any of the above clinical manifestations for dengue with or without warning signs, plus any of the following • Severe plasma leakage, leading to: • shock • Fluid accumulation with respiratory distress • Severe bleeding • Severe organ impairment • Liver : AST or ALT≥1000 • CNS : e.g seizures, impaired consciusness • Heart : e.g myocarditis • Kidney e.g renal failure PPS Revised Dengue Guidelines 2012
  • 64.
    DENGUE FEVER OLD (Revised 1997/2011Case Definition of Dengue & Levels of Severity) NEW (Revised DOH/PPS Classification and Levels of severity 2011) Grading of Severity of DHF/DSS • DHF Grade 1 Fever accompanied by non specific constitutional signs and symptoms such as anorexia, vominting abdominal pain, the only hemorrhagic manifestatin is a (+) tourniquet test and or easy bruising • DHF Grade 2 Spontaneous bleeding in addition to manifestatations of grade 1 patient usually in the form of skin or other hemorrhages • DHF Grade 3 (DSS) Circulatory failure manifested by rapid, weak pulse and narrowing of pulse pressure or hypotension,with the presence of cold clammy skin and restlessness. • DHF Grade 4 (DSS) Profound shock with undetectable blood pressure or pulse PPS Revised Dengue Guidelines 2012
  • 65.
    Course in theER PPS Revised Dengue Guidelines 2012
  • 66.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment PICTURE
  • 67.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment
  • 68.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment REASONS FOR ADMISSION : 1. Moderate dehydration 2. Weak looking 3. Loss of appetite
  • 69.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment DIET : • Diet for AGE • No dark color foods
  • 70.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever P: ADMIT Diet Hydration Diagnostics Nelson Textbook of Pediatrics 19th ed Treatment ASSESSMENT OF DEGREE OF DEHYDRATION MILD MODERATE SEVERE Infant 5% 10% 15% Adolescent 3% 6% 9% Infants and young children Thirsty, alert, restless Thirst, restless or lethargic, irritable Drowsy, limp, cold, sweaty, comatose Older children Thirsty, alert Thirst, alert Conscious, apprehensive, cold, sweaty, cyanotic extremities SIGNS AND SYMPTOMS Tachycardia Absent Present Present Palpable pulses Present Present Decreased Blood pressure Normal Orthostatic hypotension Hypotension Cutaneous perfusion Normal Normal Reduced and mottled Skin turgor Normal Slight reduction Reduced Fontanelle Normal Slightly depressed Sunken Mucous membrane Moist Dry Very dry Tears Present Present or absent Absent Respirations Normal Deep, may be rapid Deep and rapid Urine output Normal Oliguria Anuria and severe oliguria
  • 71.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever P: ADMIT Diet Hydration Diagnostics Nelson Textbook of Pediatrics 19th ed Treatment ASSESSMENT OF DEGREE OF DEHYDRATION MILD MODERATE SEVERE Infant 5% 10% 15% Adolescent 3% 6% 9% Infants and young children Thirsty, alert, restless Thirst, restless or lethargic, irritable Drowsy, limp, cold, sweaty, comatose Older children Thirsty, alert Thirst, alert Conscious, apprehensive, cold, sweaty, cyanotic extremities SIGNS AND SYMPTOMS Tachycardia Absent Present Present Palpable pulses Present Present Decreased Blood pressure Normal Orthostatic hypotension Hypotension Cutaneous perfusion Normal Normal Reduced and mottled Skin turgor Normal Slight reduction Reduced Fontanelle Normal Slightly depressed Sunken Mucous membrane Moist Dry Very dry Tears Present Present or absent Absent Respirations Normal Deep, may be rapid Deep and rapid Urine output Normal Oliguria Anuria and severe oliguria
  • 72.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment HYDRATION : Plain LR (20cc/k) fast drip
  • 73.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment CBC 10/25 Hemoglobin 129 Hematocrit 0.38 WBC 4.10 ↓ Segmenters 0.65 Stabs 0.07 Lymphocytes 0.26 Monocytes 0.02 Platelets 283,000 Dengue NS1Ag Positive
  • 74.
    DIAGNOSTIC • Nonstructural protein1 • 2006 : test for dengue by Bio Rad Laboratories and Pasteur Institute • Allows rapid detection on the D1 illness before antibodies appear D5 illness • NS1 antigen as an early diagnostics marker in dengue • Comparison : – NS1 antigen : good sensitivity (70-100%) till D3 illness – IgM : sensitivity of 0-50% till D3 illness Dengue NS1 Ag Singh et al DMID 2010 Sept; 68(1):50-4)
  • 75.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment FINDINGS: Hazy infiltrates in right inner lung zone, with confluency in right middle lobe IMPRESSION : pneumonia right with consolidation, right middle lobe
  • 76.
    COURSE IN THEER DAY OF ADMISSION S/O: CR 115 BP 90/60 O2 sat 98-99% RR 33 T 37.8 weak-looking dry lips flushed skin shallow SC retractions rales BLF A: PCAP C Dengue Fever (without warning signs) P: ADMIT Diet Hydration Diagnostics Treatment TREATMENT : • Cefuroxime 100 mkd • Paracetamol 15 mkd
  • 77.
    CEFUROXIME • Class :Second generation Cephalosporins • MOD : inhibit bacterial cell wall • Coverage : Gram (+) cocci : S. pneumonia : S. pyogenes : A. streptococci Gram (-) cocci : N. gonorrhea Gram (-) rods : Enterobacter aerogenes : E. coli : H. influenzae : K. pneumoniae : Proteus mirabilis Katzung & Trevors Pharmacology 10th ed
  • 78.
    CEFUROXIME • Class :Second generation Cephalosporins • MOD : inhibit bacterial cell wall • Coverage : Gram (+) cocci : S. pneumonia : S. pyogenes : A. streptococci Gram (-) cocci : N. gonorrhea Gram (-) rods : Enterobacter aerogenes : E. coli : H. influenzae : K. pneumoniae : Proteus mirabilis Katzung & Trevors Pharmacology 10th ed
  • 79.
    COURSE IN THEWARD HOSPITAL DAY (HD) 1 (D3 illness) S/O: CR 120 BP 100/60 UO : 1.5 ckh RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd
  • 80.
    COURSE IN THEWARD HD 1 (D3 illness) S/O: CR 120 BP 100/60 RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd
  • 81.
    COURSE IN THEWARD HD 1 (D3 illness) S/O: CR 120 BP 100/60 RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd
  • 82.
    COURSE IN THEWARD HD 1 (D3 illness) S/O: CR 120 BP 100/60 RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd CBC 10/25 10/26 Hemoglobin 129 122 ↓ Hematocrit 0.38 0.36 ↓ WBC 4.10 ↓ Segmenters 0.65 Stabs 0.07 ↑ Lymphocytes 0.26 Monocytes 0.02 Platelets 283,000 212,000 ↓
  • 83.
    COURSE IN THEWARD HD 1 (D3 illness) S/O: CR 120 BP 100/60 RR 26 T 39 weak–looking full and equal pulses Rales, BLF CRT <2 sec A: PCAP C Dengue Fever (without warning signs) P: IVF : D5NSS 3.7 ckh Labs : Repeat CBC w/ PLT Meds: Cefuroxime (day 1) Paracetamol 15mkd
  • 84.
    DENGUE T : 39oC CR120 BP 100/60 RR 26 Full & equal pulses CRT < 2sec Weak-looking UO : 1.5ckh Hct : 0.38  0.36 Plt : 283212 COURSE OF ILLNESS
  • 85.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain UO : 1.3 ckh A PCAP C Dengue Fever (with warning signs) P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
  • 86.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
  • 87.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
  • 88.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide STOOL EXAM WITH CONCENTRATION TECHNIQUE 10/27 1st specimen 10/27 2nd specimen 10/27 3rd specimen MACROSCOPIC Color Yellow Yellowish green Yellowish brown Consistency Unformed Unformed Mucoid MICROSCOPIC Ova None seen None seen None seen Cyst None seen None seen None seen Trophozoites None seen None seen None seen Pus cells 0-1/hpf 0-1/hpf 0-1/hpf RBC 0-1/hpf 0-2/hpf 0-1/hpf Others Yeast cell: few Stool exam with concentration technique
  • 89.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide CBC 10/25 10/26 10 am 10/27 10am Hemoglobin 129 122 ↓ 129 ↑ Hematocrit 0.38 0.36 ↓ 0.38 ↑ WBC 4.10 ↓ Segmenters 0.65 Stabs 0.07 ↑ Lymphocytes 0.26 Monocytes 0.02 Platelets 283,000 212,000 ↓ 194,000↓
  • 90.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole 20mg IV Albumin transfusion Furosemide
  • 91.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole 20 mg IV Albumin transfusion Furosemide
  • 92.
    OMEPRAZOLE Class: Proton pumpinhibitor MOA : Suppress the secretion of hydrogen ions into the gastric lumen • Duration of action is approximately 24h
  • 93.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever (with warning signs) P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
  • 94.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distention (AC 53 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: PLR 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
  • 95.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide TPAG NV 10/26 Total protein 66-87 43.6 ↓ Albumin 38-54 22.71 ↓ Globulin 23-35 20.89 ↓ A/G 1.8:1-2.3:1 1.09:1↓
  • 96.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
  • 97.
    Albumin Transfusion MOA: increasesintravascular oncotic pressure Indications: hemorrhagic shock nephrotic syndrome burn hypoalbuminemia hypovolemia emedicine.medscape.com
  • 98.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: D5 NSS 3.7 4ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
  • 99.
    COURSE IN THEWARD HD 2(D4 illness) S/O: CR 120 BP 90/60 abdominal distension (AC 55cm) RR 34 T 38.8 puffy eyelids loose watery stools, 3x rales BLF vomits, 3x abdominal pain A PCAP C Dengue Fever P: IVF: D5 NSS 3.7 4ckh 3.2 ckh Labs: Stool exam w/ CT Meds: Cefuroxime (day 2) repeat CBC Paracetamol 15mkd TPAG Omeprazole Albumin transfusion Furosemide
  • 100.
    DENGUE T 38.8 HR 120 BP90/60 RR 34 CRT < 2 sec vomiting Abdominal distension Abdominal pain Hct 0.35  0.38 UO: 1.3 ckh COURSE OF ILLNESS
  • 101.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/50 AC 55 57 cm dec breath sounds, R RR 69 T 38.6 cold clammy extremities irritable mottled skin weak pulse CRT > 2 sec UO: 0.7 ckh A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip hook to O2 via mask Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
  • 102.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
  • 103.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak pulse CRT > 2 sec A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip hook to O2 via mask Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
  • 104.
    Dengue Case Classification& Levels of Severity
  • 105.
    Dengue Case Classification& Levels of Severity
  • 106.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip hook to O2 via mask Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
  • 107.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip hook to O2 via mask Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG CBC 10/25 10/26 10 am 10/27 10am 10/28 5am Hemoglobin 129 122 ↓ 129 ↑ 154 ↑ Hematocrit 0.38 0.36 ↓ 0.38 ↑ 0.46 ↑ WBC 4.10 ↓ 4.9 Segmenters 0.50 0.47 Stabs 0.07 ↑ 0.02 Lymphocytes 0.26 0.49 ↑ Monocytes 0.02 0.02 Platelets 283,000 212,000 ↓ 194,000↓ 172, 000 ↓
  • 108.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG TPAG NV 10/26 10/28 Total protein 66-87 43.6 ↓ 39.3 ↓ Albumin 38-54 22.71 ↓ 23.16 ↓ Globulin 23-35 20.89 ↓ 16.14 ↓ A/G 1.8:1-2.3:1 1.09:1 ↓ 1.43:1 ↓
  • 109.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
  • 110.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
  • 111.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III (SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG ABG 10/28 pH 7.251 pCO2 14 PO2 112.5 O2 sat 97.6 HCO3 6 TCO2 6.4 BE -21.2 Metabolic acidosis
  • 112.
    COURSE IN THEWARD HD 3(D5 illness) S/O: CR 164 BP 80/70 AC 55 57 cm RR 69 T 38.6 cold clammy extremities irritable mottled skin weak-looking CRT > 2 sec weak pulse A: PCAP D Dengue Hemorrhagic Fever III(SEVERE DENGUE) Compensated shock P: IVF: D5NSS 3.2 ckh 4ckh Mgt : hook to pulse oximeter PNSS 20ck as fast drip O2 via mask @ 6-7 lpm Meds : Cefuroxime (day 3) Labs: Repeat CBC PT, PTT Paracetamol Repeat TPAG D- Dimer albumin transfusion repeat CBC repeat CXR HCO3 correction ABG
  • 113.
    RAPID ASSESSMENT • Irregularrespirations or rate >60 • Heart ranges: – Child ≤2 yrs of age : <80/min or >180/min – Child >2 yrs of age : <60/min or >160/min • Poor perfusion with weak/absent distal pulses • Increased work of breathing • Cyanosis • Altered consciousness • Seizures • Fever with petechiae • Trauma • Burns involving >10% of BSA
  • 114.
    RAPID ASSESSMENT • Irregularrespirations or rate >60 • Heart ranges: – Child ≤2 yrs of age : <80/min or >180/min – Child >2 yrs of age : <60/min or >160/min • Poor perfusion with weak/absent distal pulses • Increased work of breathing • Cyanosis • Altered consciousness • Seizures • Fever with petechiae • Trauma • Burns involving >10% of BSA
  • 115.
    CBC Assess CategorizeDecide / Act Consciousness Irritable Respiratory Distress ; Shock • call for help • activate emergency system • hook to pulse ox & cardiac monitor • O2 per face mask • SPO2 monitoring Breathing Increased effort Circulation pale COURSE IN THE WARD (4pm) Initial Assessment
  • 116.
    COURSE IN THEWARD (4pm) Primary Assessment ABCDE Assess Categorize Decide / Act Airway Maintainable Respiratory distress Compensated shock • O2 mask: 10 LPM • IV double line • PNSS 20 cc/kg fast drip • Transfer to ICU • NPO • Hgt monitoring Breathing RR : 55/min SPO2 : 95% SC retractions Rales Circulation HR : 140 fair pulse BP 80/50 CRT >2 Disability GCS 15 (E4M6V5) Exposure Temp 39C
  • 117.
    SAMPLE Assess CategorizeDecide / Act S/Sx irritable tachypnea Subcostal retractions Rales, bilateral tachycardia, Abdominal distension CRT > 2 sec Respiratory distress secondary to lung parenchyma disease; severe dengue with compensated shock • continue medications • continue cardiac monitoring • continue SPO2 monitoring • request for: repeat CBC PC PT APTT D Dimer Chest X ray ABG Allergies None Medications Cefuroxime ; Paracetamol Past Med Hx No PCV Acute gastroenteritis 2013 PCAP A (Nov 2013, Jan 2014, April 2014) Last Meal 4 hours COURSE IN THE WARD (4pm) Secondary Assessment
  • 118.
    SAMPLE Assess CategorizeDecide / Act Events Respiratory distress Worsened work of breathing Respiratory distress secondary to lung parenchyma disease; severe dengue with compensated shock • continue medications • continue cardiac monitoring • continue SPO2 monitoring • request for: repeat CBC PC PT APTT D Dimer Chest X ray ABG COURSE IN THE WARD (4pm) Secondary Assessment
  • 119.
    PHYSICAL EXAMINATION • BP80/50, CR 140, RR 55, T 39OC • pink palpebral conjunctivae, anicteric sclera, no alar flaring, dry and pale lips and oral mucosa • adynamic precordium, tachycardic, apex beat at 4th ICS left mid clavicular line, no murmur • equal chest expansion, subcostal retractions, rales both lung fields • distended abdomen • fair and fast pulses, CRT > 2 seconds • neuro exam: normal
  • 120.
    Laboratory Tests Results CBCI PC Hgb 130, hct 0.38, wbc 8.7, seg 0.32, stabs 0.08, lymph 0.59, mono 0.01, platelet 175 Pro-thrombin Time 15 ↑ Control 11.21 INR 1.46 Protime Activity 51.5 APTT 78.3 ↑ Control 34.1 D- dimer 627.22 ↑ CXR progression of pneumonia right, mild to moderate pleural effusion, right ABG pH- 7.251 pCO2- 14 pO2- 112.5 O2 sat- 97.6 HCO3- 6 TCO2- 6.4 BE-(-)21.2 COURSE IN THE WARD (4pm) Tertiary Assessment
  • 121.
    Findings : Show progressionof pneumonic infiltrates in the right middle lobe and homogenous density in the right hemithorax obscuring the right cardiac border and blunting of the right costophrenic sulcus with lateral ascending border pneumonia IMPRESSION : progression of pneumonia right, mild to moderate pleural effusion, right
  • 122.
    1st-12th hour ofPICU stay • awake, conscious, irritable • VS: BP 80/50, CR 130, RR 40, T 38.9oC • Subcostal retraction, rales • abdominal distention • full pulses, CRT < 2 seconds
  • 123.
    CBC Assess CategorizeDecide / Act Consciousness Irritable Respiratory Distress/ failure • call for help • activate emergency system • continue O2 facemask • continue SPO2 monitoring Breathing labored breathing Circulation pale COURSE IN THE ICU (6am)13th hour Initial Assessment
  • 124.
    ABCDE Assess CategorizeDecide / Act Airway Non-Maintainable Respiratory distress and failure 2° to lung parenchymal disease • intubate • continue cardiac monitoring • continue SPO2 monitoring Breathing RR : 65/min SPO2 : 89% SC retractions Rales, decreased breath sounds R mid to base lung Circulation HR : 168 full pulse BP 80/50 CRT <2 Disability GCS 15 (E4M6V5) Exposure Temp 39C COURSE IN THE ICU (6am) Primary Assessment
  • 125.
    SAMPLE Assess CategorizeDecide / Act S/Sx irritable, weak-looking tachypnea, increase work of breathing (alar flaring subcostal retractions), decreased breath sounds mid to base right lung field tachycardia Respiratory distress/failure 2° to lung parenchymal disease • shift Cefuroxime to Ceftriaxone • continue cardiac monitoring • continue SPO2 monitoring • request for: CKMB, Trop-I, BUN, Crea, Blood C&S, USG Allergies None Medications Cefuroxime ; Paracetamol Past Med Hx day I ICU Last Meal 19 hours COURSE IN THE ICU (6am) Secondary Assessment
  • 126.
    SAMPLE Assess CategorizeDecide / Act Events Severe Respiratory distress Desaturation Worsened work of breathing Respiratory distress/failure 2° to lung parenchymal disease • shift Cefuroxime to Ceftriaxone • continue cardiac monitoring • continue SPO2 monitoring • request for: CKMB, Trop-I, BUN, Crea, Blood C&S, USG COURSE IN THE ICU (6am) Secondary Assessment
  • 127.
    PHYSICAL EXAMINATION • BP80/50, CR 160, RR 55, T 39OC • pink palpebral conjunctivae, anicteric sclera, no alar flaring, dry and pale lips and oral mucosa • adynamic precordium, tachycardic, apex beat at 4th ICS left mid clavicular line, no murmur • labored breathing, subcostal retractions, rales both lung fields, decreased breath sounds mid to base right lung field • distended abdomen • full pulses, CRT < 2 seconds • neuro exam: normal
  • 128.
    Laboratory Tests Results CKMB58.1 Troponin I 0.05 BUN 3.07 Creatinine 34.5 BLOOD CS negative 5 days ABG pH- 7.352 pCO2-30.7 pO2 -95.5 O2 sat- 97.1 HCO3- 16.7 TCO2- 17.6 BE-(-)8.9 CXR no significant change in the previously noted pneumonia, pleural effusion on the right COURSE IN THE ICU (6am) Tertiary Assessment
  • 129.
    COURSE IN THEICU There is no significant change in the previously noted pneumonia and pleural effusion in the right, heart and the rest of the chest finding are unchanged
  • 130.
    COURSE IN THEICU DAY 5, 2nd PICU DAY Problem: PCAP D, DHF III S/O: CR 136 BP 90/60 AC 56 57 cm RR 51 T 37. 9 Urine output: 0.7ckh Petechial rash , face Urine Sp.G: 1.025 Rales BLF A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Hydration: PNSS 10ck as fast drip Diet: milk feeding 2oz per OGT q 4h 7ckh Labs : ABG Meds: Ceftriaxone (day 1) Amikacin (day 1) Domperidone
  • 131.
    LABORATORY ABG 10/28 10/2910/30 pH 7.251 7.352 7.362 pCO2 14 30.7 29.8 PO2 112.5 95.5 162.9 O2 sat 97.6 97.1 99 HCO3 6 16.7 17 TCO2 6.4 17.6 17.9 BE -21.2 -8.9 -8.6
  • 132.
    COURSE IN THEICU DAY 6, 3rd PICU DAY Problem: PCAP D, DHF III S/O: CR 160 BP 90/60 AC 57 cm RR 62 T 39 Urine output: 1.2 ckh pale & dry lips rales both lung field A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Labs : repeat CBC Hydration : D5 IMB 5ckh to KVO repeat PT, PTT repeat D dimer Meds: Ceftriaxone (day 2) Amikacin (day 2) Furosemide
  • 133.
    CBC 10/25 10/26 10am 10/27 10am 10/28 5am 10/28 2 pm 11/1 5am Hemoglobin 129 122 ↓ 129 ↑ 154 ↑ 151 ↓ 93 ↓ Hematocrit 0.38 0.36 ↓ 0.38 ↑ 0.46 ↑ 0.44 ↓ 0.28 ↓ WBC 4.10 ↓ 4.9 ↑ 8.7 ↑ 10.7↑ Segmenters 0.50 0.47 0.27 ↓ 0.40 ↑ Stabs 0.07 ↑ 0.02 0.05 0.04 Lymphocytes 0.26 0.4 ↑ 0.67 0.56 ↓ Monocytes 0.02 0.02 0.01 Platelets 283 212 ↓ 194 ↑ 172 ↓ 170 ↓ 194 ↑
  • 134.
    LABORATORY NV 10/28 11/1 Pro-thrombin Time10-14 sec 15 14.8 Control 11.21 11.23 INR 1.46 1.43 Protime Activity % 51.5 53.1 APTT 28-36 sec 78.3 ↑ 49.3 Control 34.1 34.7 D- dimer 100-446.8 ng/mL 627.22 ↑ 2973.21↑
  • 135.
    COURSE IN THEICU DAY 7, 4th PICU S/O: CR 173 BP 80/50 AC 57 cm 55cm RR 65 T 39 O2 sat : 70% 98% Alar flaring Rales BLF Puffy eyelids A: PCAP D pulmonary congestion P: Mgt : Re-intubation 4.5 depth and 13 mm, mech vent set up NPO Labs : repeat CXR ABG Meds: Ceftriaxone (day 3) Furosemide IVF Heplock Amikacin (day 3) Dobutamine
  • 136.
    CHEST X RAY Showssignificant resolution of the previously noted right sided leural effusion, hazy infiltrates are seen in the right mid and both lower lobes Imp: significant resolution of right sided pleural effusion, new infiltrates on right mid and both lower lobes
  • 137.
    ABG 10/28 10/2910/30 11/1 pH 7.251 7.352 7.362 7.457 pCO2 14 30.7 29.6 36.6 PO2 112.5 95.5 162.9 27 O2 sat 97.6 97.1 99 57.4 HCO3 6 16.7 17 26 TCO2 6.4 17.6 17.9 27.2 BE -21.2 -8.9 -8.6 2 LABORATORY
  • 138.
    COURSE IN THEICU DAY 8 S/O: CR 160 BP 110/60 AC 55cm RR 55 T 38.9 A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Mgt : OGT resumed Meds: Ceftriaxone (day 4) MEROPENEM 60mkd Amikacin (day 4) Furosemide every 4h 8h kalium durule every 8h
  • 139.
    COURSE IN THEICU DAY 9 S/O: CR 128 BP 90/60 AC 55cm 53cm RR 52 T 37.3 Rales BLF No alar flaring No SC retraction A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Mgt : continued Meds: Meropenem(day1) Amikacin (day 5) Furosemide every 8h kalium durule every 8h
  • 140.
    COURSE IN THEICU DAY 10 S/O: CR 180 BP 90/60 AC 55cm 53cm RR 52 T 38.4 UO 3.5ckh Pale conjunctivae Pale & dry lips A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Diagnostics: repeat CXR repeat CBC w/ PC urine KOH repeat ABG serum Na, K Meds: Meropenem(day2) salbutamol neb Amikacin (day 6) dexamethasone Furosemide every 8h kalium durule every 8h-----12h
  • 141.
    CHEST X-RAY Partial clearingof both infiltration right mid and both lower lobes Imp: Partial clearing of both infiltration right mid and both lower lobes
  • 142.
    LABORATORY ABG 10/28 10/2910/30 11/1 11/4 pH 7.251 7.352 7.362 7.457 7.399 pCO2 14 30.7 29.6 36.6 34.8 PO2 112.5 95.5 162.9 27 57.6 O2 sat 97.6 97.1 99 57.4 89.6 HCO3 6 16.7 17 26 21.7 TCO2 6.4 17.6 17.9 27.2 22.7 BE -21.2 -8.9 -8.6 2 -3.4
  • 143.
    LABORATORY CBC 10/25 10/26 10am 10/27 10am 10/28 5am 10/28 2 pm 10/28 6 pm 11/1 5am 11/4 5am Hemoglobin 129 122 ↓ 129 ↑ 154 ↑ 151 ↓ 130 93 ↓ 88 ↓ Hematocrit 0.38 0.36 ↓ 0.38 ↑ 0.46 ↑ 0.44 ↓ 0.38 0.28 ↓ 0.28 WBC 4.10 ↓ 4.9 ↑ 8.7 ↑ 11 6.7 ↓ 10.4 ↑ Segmenters 0.50 0.47 0.27 ↓ 0.32 0.40 ↑ 0.64 Stabs 0.07 ↑ 0.02 0.05 0.08 0.04 0.02 ↓ Lymphocytes 0.26 0.4 ↑ 0.67 0.59 0.56 ↓ 0.34 ↓ Monocytes 0.02 0.02 0.01 0.01 Platelets 283 212 ↓ 194 ↑ 172 ↓ 170 ↓ 175 194 ↑ 265 ↑
  • 144.
    LABORATORY Electrolytes NV 11/1 Sodium132-152 mmol/L 142.9 potassium 3.60-5.30 mmol/L 5.04 URINE KOH No fungal elements
  • 145.
    COURSE IN THEICU DAY 11 S/O: CR 160 BP 90/60 AC 53cm RR 60 afebrile O2 sat 78% A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Meds: Meropenem(day 3) salbutamol neb Amikacin (day 7) dexamethasone Furosemide every 8h kalium durule every 8h-----12h Vit A 100,000 , 2 cap SD Zinc Sulfate started
  • 146.
    COURSE IN THEICU DAY 12 S/O: CR 110 BP 90/60 AC 53cm RR 35 afebrile O2 sat 99% A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Mgt : extubated FC removed NGT removed----clear liquid diet w/SAP Meds: Meropenem(day 4) salbutamol neb Amikacin (day 8) dexamethasone Furosemide d/c Kalium durule every 8h-----12h Zinc Sulfate (day 1)
  • 147.
    COURSE IN THEWARD HD 13(D15 of illness) S/O: CR 96 BP 90/60 decreased rales RR 31 afebrile CRT <2 sec O2 sat 99% UO : 1.4 ckh Equal & full pulses A: PCAP D resolving Dengue Hemorrhagic Fever III ( SEVERE DENGUE) resolved P: Transferred to HDU ST. Martin Meds: Meropenem(day 5) Amikacin (day 9) Zinc Sulfate (day 2) Kalium durule d/c FeSO4 started
  • 148.
    COURSE IN THEWARD HD 13(D15 of illness) S/O: CR 96 BP 90/60 decreased rales RR 31 afebrile O2 sat 99% A: PCAP D resolving Dengue Hemorrhagic Fever III ( SEVERE DENGUE) resolved P: Transferred to HDU ST. Martin Meds: Meropenem(day 5) Amikacin (day 9) Zinc Sulfate (day 2) Kalium durule d/c FeSO4 started
  • 149.
    COURSE IN THEWARD HD 13(D15 of illness) S/O: CR 96 BP 90/60 decreased rales RR 31 afebrile O2 sat 99% A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Transferred to ST. Martin High Dependecy Unit Meds: Meropenem(day 5) Amikacin (day 9) Zinc Sulfate (day 2) Kalium durule d/c FeSO4 started
  • 150.
    COURSE IN THEWARD HD 14(D16 of illness) S/O: CR 100 BP 90/60 UO : 1.4 ckh RR 33 afebrile decreased rales comfortable A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Meds: Meropenem(day 6) Amikacin (day 10) Zinc Sulfate ( day 3) FeSO4 (day 1) Clarithromycin 7.5mkd per orem
  • 151.
    COURSE IN THEWARD HD 15(D17 of illness) S/O: CR 99 BP 90/60 comfortable RR 30 afebrile clear breath sounds A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Meds: Meropenem(day 7) Amikacin (day 11) Zinc Sulfate (day 4) FeSO4 (day 2) oral clarithromycin (day1)
  • 152.
    COURSE IN THEWARD HD 16(D18 of illness) S/O: CR 99 BP 90/60 RR 30 afebrile comfortable A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Diet: soft diet Meds: Meropenem(day 8) Amikacin discontinued Zinc Sulfate (day 5) FeSO4 (day 3) oral clarithromycin (day2)
  • 153.
    COURSE IN THEWARD HD 17(D19 of illness) S/O: Stable vital signs A: PCAP D Dengue Hemorrhagic Fever III ( SEVERE DENGUE) P: Diet: soft diet Meds: Meropenem(day 9) Zinc Sulfate (day 5) FeSO4 (day 3) oral clarithromycin (day3) MAY GO HOME
  • 154.
    Home Meds: 1. Clarithromycin15mkd BID 2. FeSO4 10mkd OD 3. Zinc Sulfate 5ml OD
  • 155.
    COMPLICATION • Sequelae ofdengue virus infection are rare but may include the following: – Cardiomyopathy – Encephalopathy – Hepatic injury – Pneumonia – Ophoritis/orchitis
  • 156.
    PREVENT BREEDING 235 Cover watercontainers, wells, and water tanks tightly Keep drains free from blockage Change the water in vases and for aquatic plants at least once a week and leave no water in the saucers underneath the plants Cover up tires before disposal to prevent water from collecting. Dispose of unwanted containers where water may collect such as lunch boxes and soft drink cans into covered bins Repair uneven surfaces of the ground to prevent water from collecting Check whether there is water collecting on the tray under an air- conditioner and in the drainage system, and remove stagnant water
  • 157.
    PREVENT BITES 10/12/2010 236 Wearlight-coloured and long-sleeved clothing and pants Apply mosquito repellents containing DEET to exposed parts of the body Use mosquito nets or screens when the room is not air-conditioned Avoid visiting scrubby areas Install screens on windows and doors, or place mosquito coils /electric mosquito mats /anti-mosquito liquid near the windows
  • 158.
    FINAL DIAGNOSES • PEDIATRICCOMMUNITY ACQUIRED PNEUMONIA D • DENGUE HEMORRHAGIC FEVER III (SEVERE)
  • 159.

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  • #63  PPS Revised Dengue Guidelines 2012
  • #64 ENCODE
  • #65 ENCODE
  • #66 ENCODE
  • #67 ENCODE
  • #68 Reasons for admission
  • #69 Reasons for admission
  • #70 Reasons for admission
  • #71 Reasons for admission
  • #72 Reasons for admission
  • #73 Reasons for admission
  • #74 Reasons for admission
  • #75 Reasons for admission
  • #76 NS1 stands for nonstructural protein 1 full name is Platelia Dengue NS1 Ag assay, is a test for dengue made by Bio-Rad Laboratories andPasteur Institute, introduced in 2006. It allows rapid detection on the first day of fever, before antibodies appear some 5 or more days later.[1][2] It has been adopted for use in some 40 nations. The method of detection is through enzyme-linked immunosorbent assay.[3] India has introduced in 2010 the NS1 test costing 1,600 rupees at a private hospital in Mumbai. Now available at Rs 1100 at many private hospitals and laboratories in Delhi.Results available the same day[4]
  • #77 Reasons for admission
  • #78 Reasons for admission
  • #79 Katzung & Trevors Pharmacology 10th ed
  • #80 Katzung & Trevors Pharmacology 10th ed
  • #85 Cefuroxime is a 2nd gen Cephalosphorins Its action is to
  • #86 Temp 39 Weak looking Hematocrit decreased from 0.38-0.36
  • #90 Stool exam with concentration technique
  • #94 Katzung & Trevors Pharmacology 10th Edition
  • #102 Temp 38.8 Loose watery stool Abdominal pain Hypoalbuminemia, hypoproteinemia------plasma leak into the pleural and abdominal cavities HCT 0.35 increased to 0.38 Hematocrit decreased from 0.38-0.36
  • #103 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #104 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #105 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #108 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #109 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #110 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #111 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #112 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #113 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #114 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #115 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #116 After 3 hours -----puffy eyelids and rales on both lung fields FUROSEMIDE was given and BLOOD typing
  • #117 emedicine.medscape.com
  • #118 164 Febrile Weak pulse Cold clammy extremities Mottled skin Prolonged CRT But BP 80/70
  • #119 164 Febrile Weak pulse Cold clammy extremities Mottled skin Delayed CRT But BP 80/70
  • #136 Intubated size 4 mm depth level 10
  • #154 RD appearance: may be compensating and may have tachypnea but otherwise appear normal a child with more severe disease may be alert and interactive but anxious RF may appear very ill and have tachypnea, sweating, half-closed eyelids, and a look that says HELP ME a child with resp symptoms who is lethargic or unresponsive is very worrisome and suggests repiratory failure and possible imminent resp[iratoy arrest Work of breathing-----inc RR, inc respi effort, abnormal airway and audible lung sound (grunting or wheezing) head bobbing or seesawing res[pirations . Circulations---normal or pale skin or frank cyanosis, cyanosis or oral mucosa____ severe hypoxemia……
  • #159 Intubated size 4 mm depth level 10
  • #160 Intubated size 4 mm depth level 10
  • #161 Intubated size 4 mm depth level 10
  • #162 Intubated size 4 mm depth level 10
  • #163 Intubated size 4 mm depth level 10
  • #164 Intubated size 4 mm depth level 10
  • #165 Intubated size 4 mm depth level 10
  • #166 Intubated size 4 mm depth level 10
  • #167 Intubated size 4 mm depth level 10
  • #169 Intubated size 4 mm depth level 10