CLINICAL CASE

PRESENTATION
AQUINO, ASPREC, BALINGIT, BARCENAS,
BASILIO, BAUTISTA D., BAUTISTA M.
 OBJECTIVES

GENERAL OBJECTIVE
● Present a case of a 3-month-old boy who was brought
to the ER because of difficulty of breathing.

SPECIFIC OBJECTIVE
● Discuss relevant concepts, pathophysiology,
diagnostics and management related to the case.
 GENERAL DATA

Religion
J.M. Roman Catholic

Race Filipino

No. of Consult 1
Age/Sex 3 months/Male
DOA 05/02/2023
Residence Caloocan City

Birthdate: 1/29/2023 Informant Mother

Birthplace: Caloocan City Reliability Good

CHIEF COMPLAINT

DIFFICULTY OF
BREATHING
 01
HISTORY AND PHYSICAL
EXAMINATION
HISTORY OF PRESENT ILLNESS
1 month PTC
● (+) productive cough for >5 days
○ (+) sputum production, greenish in color.
● (+) difficulty of breathing/shortness of breath
● (+) undocumented, non relapsing/continuous fever (1 full day)
● (-) colds, vomiting, loss of appetite, diarrhea.
● Paracetamol drops, 10 mkd (0.6 mL; 1x), which provided relief.
HISTORY OF PRESENT ILLNESS
● OCA Hospital
○ Co-amoxicillin syrup, 40 mkD (1 mL) TID for 7 days
○ Salbutamol inhaler for 3 days
○ Chest X-ray: bilateral pneumonia

● Follow up: April 11, 2023

○ Apparently well: cleared
○ No medications given
HISTORY OF PRESENT ILLNESS

Interim
● (+) increased breathing
● (+) productive cough
○ (+) sputum production, greenish in color.
● Good suck and good cry.
● No medications given. No consult done.
HISTORY OF PRESENT ILLNESS

1 week PTC
● Symptoms persisted
● (+) vomiting
○ previously ingested milk
○ 3-4 episodes
○ 4 bouts, 5 tbsp per bout.
● OCA Hospital: Referred
● Admission.
REVIEW OF SYSTEMS
General: [-] weight loss [-] malaise, [-]easy fatigability
Skin: [-] pruritus, [-] pigmentation, [-] rashes, [-] lumps, [-] excessive
dryness, [-] excessive sweating, [-] changes in nails
HEENT: [-] diplopia, [-] photophobia, [-] discharge [-] gum bleeding
Cardiovascular: [-] orthopnea
Respiratory: [-] hemoptysis
Gastrointestinal: [-] constipation [-] melena [-] hematemesis, [-]
hematochezia
Genitourinary: [-] dysuria [-] hematuria, [-] oliguria
Musculoskeletal: [-] muscle weakness
Hematologic: [-] pallor [-] easy bruising, [-] bleeding
PAST MEDICAL HISTORY
(-) Hospitalizations
(-) Surgery
(-) Allergies to food and medications
FAMILY MEDICAL HISTORY
Paternal: Maternal: Siblings:
(+) PTB, clinically (-) Hypertension (+) PTB, clinically
diagnosed (2022) (-) Diabetes Mellitus diagnosed (2023)
- completed treatment (-) Bronchial Asthma - Eldest brother
(6 mos) - Ongoing treatment
(-) Heart Disease
(-) Hypertension (-) Hypertension
(-) PTB
(-) Diabetes Mellitus (-) Diabetes Mellitus
(-) Allergy
(-) Bronchial Asthma (-) Bronchial Asthma
(-) Malignancy
(-) Heart Disease (-) Heart Disease
(-) Allergy (-) Allergy
(-) Malignancy (-) Malignancy
PERSONAL AND SOCIAL HISTORY
HOME:
● Patient lives with parents, 2 brothers, aunt, and 3 cousins in a
rented house near the highway, with good ventilation and well
lit room, away from factories
● Drinking water: refilling station
● Garbage: twice a week
● Electricity: Meralco
● Source of water: NAWASA
PERSONAL AND SOCIAL HISTORY
Mother:
R.F., 24 y/o, housewife, junior high school, roman catholic
Covid vaccine: Pfizer, 2 doses + 1 booster (AstraZeneca)
Father:
R.M., 31 y/o, trucking helper/”pahinante”, elementary, roman catholic
Covid vaccine: Pfizer, 2 doses
Siblings:
F.M., 5 y/o, Male
Y.M., 3 y/o, Male
BIRTH HISTORY
● Born term (40 weeks) via NSD at Dotarot Lying-in Clinic assisted
by midwife to a 24-year-old G3P3 (3003) Mother.
● APGAR and Ballard scores: unrecalled
● Hearing test: normal findings
● ENBS: not done.
● Discharged with no complications.
MATERNAL HISTORY
● G3P3 (3003)
○ G1: 2018, Term, NSD, Lying-in assisted by midwife, no
complications, BW: 2.8 kg
○ G2: 2020, Term, NSD, Lying-in assisted by midwife, no
complications, BW: 3 kg
○ G3: 2023, Term, NSD, Lying-in assisted by midwife, no
complications, BW: 2.8 kg
MATERNAL HISTORY
● First Trimester: 1 PNCU
○ HIV Screening test - Negative
○ Medications: Ferrous Sulfate OD, Folic Acid OD

● Second Trimester: 3 PNCU

○ Medications: Ferrous Sulfate OD, Folic Acid OD

● Third Trimester: 2 PNCU

○ Medications: Ferrous Sulfate OD, Folic Acid OD
MATERNAL HISTORY

● (-) Alcohol intake

● (-) Smoking
● (-) Radiations/Teratogens
● (-) History of physical injury
DEVELOPMENTAL HISTORY

● 1 month: at par with age

○ Spontaneous motor activity
○ Lifts head when prone
○ Begins to regard surroundings
○ Follows objects to midline
● 2 months: at par with age
○ Generalized motor activity
○ Smiles and coos socially
○ Follows objects past midline
DEVELOPMENTAL HISTORY

● 3 months: at par with age

○ Visually tracks objects well
○ Good head control when prone
○ Improved head control when sitting
○ Sustained smiling and cooing
FEEDING HISTORY
● Exclusively breastfed since birth until present
○ Every 1-2 hours/day
IMMUNIZATION HISTORY
Local Health Center
● BCG ● Pneumococcal Conjugate
○ Dose 1: 1-29-2023 (90 mins Vaccine (PCV)
after birth) ○ Dose 1: 4-12-2023
○ Dose 2: 5-15-2023 ● Pentavalent Vaccine
● Vitamin K (DPT-HepB-HiB)
○ Given on left upper thigh ○ Dose 1: 4-12-2023
● Crede’s Prophylaxis ● Oral Polio Vaccine (OPV)
○ Given on both eyes ○ Dose 1: 4-12-2023
● Hepatitis B
○ Dose 1: 1-30-2023
PHYSICAL EXAMINATION:

GENERAL SURVEY
The patient is awake, alert, irritable, not in cardiorespiratory distress

VITAL SIGNS
CR: 131 bpm
RR: 35 cpm
T: 36.4 C
O2: 99 % at RA
 ANTHROPOMETRIC MEASUREMENTS
Z score
HC: 38 cm 0
CC: 43 cm
AC: 48 cm
Length: 56 cm
Weight: 6 kg
Length for age Above median
Weight for length Above +2
BMI for age (BMI: 19.1) Above +1
Weight: 6 kg
z-score: 0 SD
(below median)
Interpretation:
Normal
Length: 56 cm
z-score: 0 SD
(above median)
Interpretation:
Normal
Weight: 6 kg
Length: 56 cm
z-score: +2 SD (above
+2 SD)
Interpretation:
Overweight
HC: 38 cm
z-score: -2 SD
(along -2 SD)
BMI: 19.1 kg/m2
z-score: +1 SD
(above +1)
Interpretation:
Possible risk of
overweight
PHYSICAL EXAMINATION:

SKIN
I Skin is brown, smooth, no rashes , lesions, nails are pink,
no active dermatoses
P Warm to touch, with good skin turgor, and CRT < 2 secs
PHYSICAL EXAMINATION:

HEENT
H Cranium is normocephalic, symmetrical, no gross
deformities/facies, no visible vessels/mass, open
non-bulging anterior and posterior fontanelle
E pink palpebral conjunctivae, anicteric sclerae, equal pupil
dimension, reactive to light, symmetric with normal
extraocular movement
PHYSICAL EXAMINATION:
HEENT
E Normal pinna, no external abnormalities, no discharges
noted
N No alar flaring, nasal septum is in the midline, no mucosal
discharge and swelling/inflammation
T Moist lips, moist oral mucosa, gums are pinkish, no
exudates noted, symmetrical tongue, no lesion seen and is
in the midline upon protrusion, tonsils pinkish in color, uvula
is in the midline, no exudates noted
PHYSICAL EXAMINATION:

NECK
I Supple neck, no rashes, no lesions noted, no vein
distension
P No cervical lymphadenopathy, midline trachea, thyroid gland
not palpable.
PHYSICAL EXAMINATION:
CHEST and LUNGS
I No deformities, no chest lagging, (+) subcostal
retractions, no dilated superficial blood vessels, skin
lesions, symmetrical chest expansion
P No lagging
P Dull (bibasal)
A (+) wheezes, (+) bilateral basal fine crackles
PHYSICAL EXAMINATION:

HEART
I Adynamic precordium, no visible pulsations
P PMI is in the 4th ICS LMCL, no lifts, no heaves, no thrills
A Normal rate and regular rhythm, no murmurs
PHYSICAL EXAMINATION:

ABDOMEN
I Flat, symmetrical, inverted umbilicus, no lesions, no bruises,
no discoloration, no visible pulsations
A Normoactive bowel sounds (20 bowel sound/minute)
P Soft and non tender
P Tympanitic on all quadrant, no organomegaly
PHYSICAL EXAMINATION:
EXTREMITIES
I Grossly normal extremities, no joint swelling, no pallor, no
cyanosis.
P Warm extremities , symmetrical length measures,
Full, equal pulses on upper and lower extremities,
No edema, CRT <2 seconds

SPINE
I Spine is in the midline, no visible lesions
PHYSICAL EXAMINATION:

GENITALIA
I Grossly normal male genitalia
P Bilaterally descended testes

ANUS and RECTUM

I No laceration, no skin tags, no prolapse
P Patent anus
PHYSICAL EXAMINATION:
NEUROLOGIC EXAMINATION

Cerebrum GCS 15 (E4V5M6)

Cerebellum No involuntary movements noted

Cranial Nerves

I Grimace upon subjecting coffee bean

II, III Pupils equally round (2-3mm), reactive to direct, consensual light reflex, and accommodation
III, IV, VI Intact extraocular muscle movements, No nystagmus, No ptosis
V Sensory: Intact
Motor: Good suck
VII Sensory: Intact
Motor: No facial asymmetry
VIII Startles
IX, X Uvula in the midline
XI No shoulder asymmetry
XII Can protrude the tongue, is in the midline
PHYSICAL EXAMINATION:

NEUROLOGIC EXAMINATION
Physiologic reflex (+) Babinski sign, (+) Moro Reflex, (-) Rooting Reflex

Meningeal signs (-) Kernig Sign (-) Brudzinski sign

 Pneumonia

02
DIFFERENTIAL DIAGNOSIS
 Salient Features
● 3 mos/M ● (+) Moist lips
● (+) Productive cough ● (+) Subcostal retractions
● (+) Rapid breathing ● (+) Wheezes
● (+) Irritability ● (+) Bibasal crackles
● (+) Vomiting
● (-) Fever
Initial Diagnosis

PCAP-C
 Differential Diagnosis

Rule In Rule Out

Bronchial asthma ● (+) Rapid breathing ● (+) Productive cough

● (+) Subcostal ● (-) Interrupted
retractions laughing or crying
● (+) Wheezes ● No family history of
Asthma

Bronchiolitis ● Age: <2 y/o (3 months ● (-) Fever

old) ● (-) Nasal congestion
● (+) Productive cough ● (-) Loss of appetite
● (+) Rapid breathing
● (+) Vomiting
● (+) Wheezes
 Differential Diagnosis
Rule In Rule Out

PTB ● (+) History of ● (-) Fever

exposure to TB ● (-) Night sweats
patient ● (-) Weight loss
● (+) Productive cough ● (-) TST

COVID 19 ● (+) Productive cough (-) Exposure to people

● (+) Rapid breathing with
● (+) Crackles symptoms/positive
COVID-19 infection
(-) Fever
(-) Loss of appetite
 Pneumonia

03
DIAGNOSTICS
 DIAGNOSTICS

● Chest X-ray
● Point-of-care chast ultrasonography (POCUS)
● Procalcitonin
● Sputum Gram stain and culture
● CBC, ABG, Serum electrolytes
 Hemoglobin 109 95.0-135.0

CBC Hematocrit 32.100 29.000-41.000

RBC 4.22 3.10-4.50

Mcv 76.1 74.0-108.0

Mch 25.8 25-35

Mchc 34.0 30-36

Rdw 14.1 11.5-16

Wbc 16.49 6-17.5

Neutrophils 32.40 15-33

Lymphocytes 53.50 41-71

Monocytes 13.9 4-7

Eosinophil 0.10 0-3

Basophil 0.10 0-1

Platelet count 358 150-450

CXR 5/2/2023
CHEST X-RAY 5/5/23
 ABG
Parameters Result Reference values

pH 7.48 7.35-7.45

Pco2 26 35-45 mmHg

P02 96 80-100 mmHg

Hco3 22.8 22-26meq/L

Be+- -4.1 -1- +2 meq/L

O2sat 98% 95-100%

DISCUSSION
 Pneumonia

04
EPIDEMIOLOGY AND
PATHOPHYSIOLOGY
 EPIDEMIOLOGY
● In the Philippines, pneumonia is the third leading cause of death across all
ages and is the most common cause of death among children <5 years of
age.
● Worldwide according to WHO, pneumonia is the single most common
cause of death in children, estimated at 1.2 million every year. This
represents 18% of all deaths below 5 years of age worldwide.

Reference: Pediatric Infectious Disease Society of the Philippines Journal Vol 22 No 2, pp.6-11 July-December 2021. Santos JA. A Review of Pneumonia in the Philippines
PATHOPHYSIOLOGY
 PEDIATRIC PNEUMONIA
- INFECTION OF THE LOWER RESPIRATORY TRACT
- LEADING INFECTIOUS CAUSE OF DEATH GLOBALLY
- 99% MORTALITY RATE IN LOW AND MIDDLE INCOME
COUNTRIES
- PNEUMOCOCCAL CONJUGATE VACCINE

2021 Clinical Practice Guidelines in the evaluation and management of Pediatric Community Acquired Pneumonia
 RISK FACTORS
- BREASTFEEDING INFANTS WHO IS YOUNGER THAN
6 MONTHS
- UNDERNUTRITION: ZINC DEFICIENCY
- LOW BIRTHWEIGHT
- CROWDING AND EXPOSURE TO INDOOR AIR
POLLUTION

2021 Clinical Practice Guidelines in the evaluation and management of Pediatric Community Acquired Pneumonia
2021 Clinical Practice Guidelines in the evaluation and management of Pediatric Community Acquired Pneumonia
 Pneumonia

05
CLINICAL FEATURES
 CLINICAL MANIFESTATIONS
SYMPTOMS:

CLINICAL TRIAD:
1. FEVER
2. COUGH
3. TACHYPNEA

SIGNS:
- EARLY: Diminished breath sounds, scattered crackles, rhonchi.
- LATER: Dullness on percussion and lag in respiratory excursion on affected
side
- RESPIRATORY FAILURE IN SEVERE CASES: Refractions, head bobbing,
cyanosis, grunting, apnea, changes in sensorium.
2021 Clinical Practice Guidelines in the evaluation and management of Pediatric Community Acquired Pneumonia
 CLINICAL MANIFESTATIONS
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS

1. TACHYPNEA
A. 3 MONTHS TO 12 MONTHS OLD, >/= 50 BREATHS PER MINUTE
B. >1 YEAR OLD TO 5 YEAR OLD, >/= 40 BREATHS PER MINUTE
C. > 5 YEARS TO 12 YEARS OLD, >/= 30 BREATHS PER MINUTE
D. > 12 YEARS OLD, >/= 20 BREATHS PER MINUTE
2. RETRACTIONS OR CHEST INDRAWING
3. NASAL FLARING
4. OXYGEN SATURATION <95% AT ROOM AIR
5. GRUNTING

2021 Clinical Practice Guidelines in the evaluation and management of Pediatric Community Acquired Pneumonia
2021 Clinical Practice Guidelines in the evaluation and management of Pediatric Community Acquired Pneumonia
 CLASSIFICATION
LOW RISK/NON-SEVERE:
- OUTPATIENT MANAGEMENT
- RETURN TO FACILITY

HIGH RISK/ SEVERE:

- ADMISSION

2021 Clinical Practice Guidelines in the evaluation and management of Pediatric Community Acquired Pneumonia
 Pneumonia

06
DIAGNOSTIC TESTS
 Pneumonia

06
MANAGEMENT
Some Factors to Consider
● Bacterial vs Viral
● Severity of the Disease
● Pathogen Profile
● Host Hypersensitivity
● Economics and Practicality
For patients with known hypersensitivity to Penicillin
● Non-type 1 Hypersensitivity:
- Cephalosporins such as Cefuroxime PO 20-30 mg/kg/day Q12
OR IV 100-150 mg/kg/day Q8 OR Ceftriaxone at 75-100
mg/kg/day Q12-Q24
● Type I Hypersensitivity:
- Azithromycin at 10 mg/kg/day PO or IV Q24 for 3-5 days OR 10
mg/kg/day on day 1 followed by 5 mg/kg/day Q24 for days
2-5
- Clarithromycin at 15 mg/kg/day Q12 for 7 days
- Clindamycin at 10-40 mg/kg/day PO OR 20-40 mg/kg/day IV
Q6-Q8 for 7 days
When an atypical pathogen is highly suspected
● Azithromycin at 10 mg/kg/day PO or IV Q24 for 5 days, particularly
in infants less than 6 months old whom pertussis is entertained, OR
10 mg/kg/day on day 1 followed by day 5
● Clarithromycin 15/mg/kg/day Q12 for 7 days

● Specific Pathogen: modify empiric treatment based on antibiotic

susceptibility pattern and or/drug of choice
● When treating for uncomplicated bacterial PCAP, 7-10 days
treatment is considered but a longer duration may be required
depending on the patient’s clinical response, virulence of the
causative organism, and eventual development of complications
Treatment for PCAP of Viral Etiology
● Oseltamivir
● For suspected or confirmed influenza pneumonia with severe
illness
● Non-severe illness: treatment is indicated in 1. High-risk children
(<5 years old, those with comorbidities), 2. Children with high-risk
contacts
● Oseltamivir within 48 hours of symptoms
● <1 y/o: 3 mg/kg/dose
● >/= 1 y/o: depending on weight - </= 15 kg, 30 mg; >15-23, 45 mg;
>23-40 kg, 60 mg; >40 kg, 75 mg
Switch Therapy
Considered when ALL of the ff are present:

1. Current parenteral antibiotic has been given for at least 24 hours

2. Afebrile for at least 8 hours w/o use of any antipyretics
3. Able to feed and without vomiting or diarrhea
4. Presence of clinical improvement as defined by ALL of the ff:
a. Absence of hypoxia
b. Absence of danger signs
c. Absence of tachypnea
d. Absence of fever
e. Absence of tachycardia
 Adjunctive Treatment for PCAP
VITAMIN A ✅ (Strong recommendation; High-grade evidence)

ZINC ❌ (Conditional recommendation; Low-grade evidence)

VITAMIN D ❌ (Conditional recommendation; Low-grade evidence)

BRONCHODILATORS ✅ (Conditional recommendation; Expert Opinion)

MUCOKINETIC, SECRETOLYTIC, ❌ (Conditional recommendation; Low-grade evidence)

MUCOLYTIC AGENTS

ORAL FOLATE, PROBIOTICS, ❌ (Very Low-Grade Evidence)

VITAMIN C, VCO, NEBULIZATION
WITH NSS, STEAM INHALATION
Prevention Measures against PCAP
● VACCINATION: Pneumococcus, Hib, Pertussis, Measles, and
Influenza virus
● Breastfeeding
● Avoidance of environmental tobacco smoke or Indoor
biomass fuel exposure
● Zinc Supplementation
● Vitamin A, C, D (Insufficient evidence to recommend)
REFERENCES
● 2021 Clinical Practice Guidelines in the Evaluation and Management of Pediatric
Community-Acquired Pneumonia retrieved from 2021 PAPP-PIDSP PCAP CPG – PAPP – Philippine
Academy of Pediatric Pulmonologists
● Nelson, W.E. (2019) Nelson Textbook of Pediatrics. 21st Edition, Elsevier, Amsterdam.
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