PEDIATRIC CLINICAL ENCOUNTER FORM

GENERAL INFORMATION
NAME: JR CLERK IN CHARGE: Regrine B. Lagarteja
DATE OF BIRTH: 03/03/2019 DATE OF ADMISSION: April 1, 2019
AGE: 30 days SEX: M CIVIL STATUS: DATE OF INTERVIEW: April 3, 2019
Single
RELIGION: Roman Catholic PLACE OF INTERVIEW: PCMC
ADDRESS: INFORMANT: LF
North Caloocan RELATION: Mother
RELIABILITY: Excellent Very Good Good Fair
Poor
CLINICAL HISTORY
CHIEF COMPLAINT: Difficulty Breathing
HISTORY OF PRESENT ILLNESS:
5 days PTC, the mother of the patient noted productive cough, characterized as hacking. No difficulty of
breathing, no cyanosis, no hemoptysis, no abdominal breathing, no intercostal or subcostal retractions noted
at this time. Still with good suck and activity. No consults done. No medications were taken. In the interim,
cough persisted, with no note of character of the phlegm.
3 days PTC, cough is now accompanied with onset of clear nasal discharge. Still with no fever, no difficulty of
breathing, no cyanosis, no hemoptysis, no intercostal or subcostal retractions noted at this time. Still, no
consults were done and no medications were taken.
On the day of consult, cough and nasal discharge were still persistent, now with development of fever (Tmax
38.2 C) and 5 episodes of loose stools, characterized as non-bloody, non-mucoid, watery in consistency,
diapers fully soaked. There is also note of development of difficulty of breathing, characterized as fast
breathing, with abdominal breathing, and subcostal retractions. Patient initially consulted at East Avenue
Medical Center, but opted to transfer to PCMC.
TEMPORAL PROFILE

REVIEW OF SYSTEMS
General No weight loss/gain, good appetite, no delay in growth and
development
Musculoskeletal/ Integumentary No jaundice, no pruritus, no easily bruising, no pigmentation
problems, no rash, no muscle weakness, no changes in muscle
tone, able to move all extremities spontaneously
HEENT No blurring of vision, no excessive tearing, no blurring/doubling
of vision, no headache, no palpable lymph nodes, no hearing
loss, no ear discharge, no tinnitus, no bleeding, no stuffing of
nose, no dysphagia, no hoarseness, no excessive salivation, no
bleeding gums
Respiratory (+) dyspnea, (+) subcostal retractions, (+) shallow breathing
Cardiovascular No palpitations, no chest pain, no cyanosis, no pallor
Gastrointestinal (+) diarrhea, (-) bloody stools, (-) melena
Genitourinary No tea-colored urine, no frequency, nocturia, dysuria,
hematuria, no discharge
Neurological No seizures, no neurologic deficits, no weakness, no change in
sensorium
FAMILY HISTORY
GENOGRAM

BIRTH/ MATERNAL HISTORY

Patient was born via NSD to a 16 year old G1P1 (1001) mother, non-smoker, occasional alcoholic beverage
drinker but stopped upon knowledge of pregnancy. Started pre-natal check-ups at 12 weeks AOG, >5
PNCUs done at EAMC. Denies maternal infections, accidents, complications, exposure to infectious
disease, radiation. Mother then developed UTI at 5th and 7th month AOG, treated with unrecalled antibiotics.
UTZ done at 5 months AOG. Congenital anomaly scan and GBS not done.
Patient was delivered full term at 39 weeks AOG with birthweight of 2.9 kg. Unrecalled APGAR but noted
good cry and good air entry at the time. No cord coil, no post-natal infections, no meconium aspiration. NBS
and hearing tests were done which yielded unremarkable results. Discharged after 48 hours
NUTRITIONAL HISTORY
Infant Feeding Complementary Food preferences/ Feeding Problems/ Food
Breastfeeding Period: up to 2nd Day of life Feeding Allergies
then shifted to formula feeding Not yet started  No known allergies to food and drugs
(Nestogen) with appropriate formula
preparation and bottles regularly cleaned
and sterilized.
Diet OTHERS
Formula diet

IMMUNIZATION HSITORY DEVELOPMENTAL HISTORY

1 2 3 Booster At par with age
BCG  Raises head from prone position, although not yet fully at this
time
DPT
 With visual fixation
HIB  Tight grasp
Hepatitis B  Alerts to sounds
MMR  (+) Babinski
 (+) Sucking and Rooting Reflex
Measles  (+) Palmar and Plantar Grasp Reflex
Rotavirus
Pneumococcal
Influenza
Varicella
Hepatitis A
Typhoid
Others

PERSONAL-SOCIAL AND ENVIRONMENTAL HISTORY

Number of Lives with 6 other household Type of Made up of mixed materials
household members members: maternal grandparents, dwelling with good ventilation and is
mother’s siblings, and his mother. well-lit
Electricity Meralco Drinking NAWASA but boils water for
water source milk feeding for 10 minutes
prior to consumption
Exposure to (+) tobacco exposure from Waste/ 2x a week
tobacco/ toxins/ neighbors Garbage
biohazards, etc. disposal
Others Pertinent none
history of
travel

STAKEHOLDER’S ANALYSIS
Name/Role Stake/WIIFM Stand on Intensity Degree of Insight/Action
the Issue of Stand influence
Mother Wants her child Ally High High Primary caretaker of the
to be well child; Must learn how to
properly take care of her child
Grandparents Wants their Ally High Moderate Convinced the mother to
grandchild to be admit the child at PCMC;
well Pays for hospitalization
Father Unknown stake Unknown High Low Unknown status regarding
the action he wants for his
child

PHYSICAL EXAMINATION
ANTHROPOMETRICS NECK
Weight: 3.5 kg Height: 6 cm No lymphadenopathies; neck veins not distended
HC: 36 cm AC: 34 cm
CC: 32 cm RR: 100
HR: 154 T: 37.2
BP: 80/50 O2 sat: 90-92% at room air
GENERAL APPEARANCE CHEST
Awake, irritable, in distress Retractions: Subcostal
Deformities
Symmetry: symmetric chest expansion
Breath sounds: bilateral crackles
COLOR HEART
Pink Apex Beat: 5th ICS L MCL
Cyanotic Heart Sounds: normal rate, regular rhythm
Acrocyanosis Murmur: none
Jaundiced
Pale
Plethoric
SKIN ABDOMEN
Texture: Globular abdomen; soft, non-tender; no organomegaly
Bruising
Birthmarks
Rashes
Other findings:
Good skin turgor, wam, moist skin
HEAD GENITALIA
Flat anterior and posterior fontanelles, dry lips Discharge Mucosal Tag
Hydrocoele Hernia Urethral defect
Others:
Grossly male
EYES EXTREMITIES
Sclerae: anicteric Pulses full and equal
 Conjunctivae: pink Warm extremities
Pupils: 2-3 mm EBRTL CRT <2 seconds
Red Orange Reflex: present and equal on both
eyes
discharge tearing swelling
corneal light reflex
Non-sunken eyeballs
EARS
Pinnae
Canal
sinus skin tag
LABORATORY EXAMINATIONS DONE
CBC Electrolytes: Normal
 Hb- 128 mg/dl  Na- 144
 Hct- 0.39  K- 3.9
 RBC- 3.8 x10^12/L  Cl- 124
 MCV- 101.3 fL  Ca- 2.65
 MCH- 33.4 pg ABG
 MCHC- 33 g/dL  pH- 7.29
 RDW- 13.7 %  pCO2-22
 PLt-250  pO2- 181
 WBC- 10.8  HCO3- 10.6
 Seg- 0.27 (2916) Interpretation: Metabolic Acidosis, Partially
 Lymph- 0.6 (6480) Compensated
 Mono- 0.12
 Eos- 0.11
INTERPRETATION: Unremarkable CBC

Initial Impression:
Neonatal Pneumonia, AGE with no signs of dehydration, Partially Compensated Metabolic Acidosis secondary
to pneumonia, Late onset sepsis

Differential Diagnosis
Neonatal Pneumonia

Rule In Rule Out Diagnostic Tests to be Requested to

Rule out Differential

PCAP (+) tachypnea (-) fever  Cannot be totally ruled out at this
(+) low O2 time, however CXR or Chest
saturation ultrasound may be done to confirm
(+) crackles diagnosis
(+) subcostal
retractions

Acute (+) cough (+) crackles  Chest X-ray usually unremarkable

Bronchitis (-) fever

PTB (+) cough Acute onset cough  Chest X-ray, apicolordotic view to
(-) hemoptysis check for granuloma formation at
(-) night sweats lung apices
No loss of appetite
(-) CLADs
 Asthma In (+) tachypnea Very acute onset in terms  Chest X-ray would show normal
Exacerbation (+) low O2 of presentation of findings or hyperaerated lungs in
saturation symptoms and age of exacerbation
patient
(-) wheezing or stridor

Acute Gastroenteritis
Rule In Rule Out Diagnostic Test/s
Infectious Diarrhea (+) loose watery stools of Only one in the Fecalysis, with Fecal
more than 5 episodes household with such Smear examination
(+) no history of rotavirusepisode however still using pNSS and Kato-
immunization cannot be totally ruled Katz Technique
out Stool CS
Osmotic Diarrhea (+) loose watery stools of Cannot be totally ruled
more than 5 episodes out
Only one in the
household with such
episode
Secretory Diarrhea (+) loose watery stools of Only one in the
more than 5 episodes household with such
episode
Parasitic Gastroenteritis (+) loose watery stools of Only one in the
more than 5 episodes household with such
(+) water source is from episode however still
tap water cannot be totally ruled
out

Sepsis
Development of sepsis is likely a sequela of the existing pneumonia of the patient.

Discussion
Neonatal Pneumonia
Neonatal pneumonia is pneumonia among infants <30th day of life. Routes of acquisition of pneumonia as well
as commonly associated pathogens per route are listed in Table 1. In terms of onset, it can be early or late. Early
onset pneumonia happens within 48 hours to six days of birth. It is usually acquired through intrauterine
aspiration of infected fluid, transplacental transmission of pathogen, or aspiration during or after birth of infected
amniotic fluid. Late onset pneumonia happens after the sixth day of life. For our patient, the neonatal pneumonia
is considered late onset.

Table 1: Common organisms associated with neonatal pneumonia according to route of aspiration
Pneumonia happens when a pathogen escapes the inherent protective mechanisms of the lungs. It begins with
inhalation of the pathogen. Usually, these pathogens are cleared through coughing, mucociliary clearance, and
action of alveolar macrophages. However, once these pathogens escape these mechanisms, it then colonizes
the bronchioles and/or the alveoli, leading to inflammatory response.
Based on the 2016 PCAP guidelines, pneumonia is considered if any of the following positive predictors of
radiographic pneumonia is present at the ER: O2 sat <94% at room air, Tachypnea (2-11 months: >50/min; 1-5
years: >40/min), Chest wall retractions, Fever, grunting, wheezing, decreased breath sounds, nasal flaring,
cyanosis, crackles, or localized chest findings, Consolidation in UTZ. Based on the patient’s presentation of O2
saturation of 90-92%, tachypnea of 100/min, subcostal retractions, crackles, and fever, the patient was then
subsequently admitted. The guideline further categorizes PCAP into A-D, however this classification holds true
only for patients >3 months of age. Using the classification of the WHO (table 2), the patient falls under severe
pneumonia.

Table 2: WHO Classification of the severity of pneumonia

Neonatal Sepsis is a sequela of any infection when not treated or has incubated long enough to travel to the
bloodstream. In this patient, the suspected etiology of sepsis is the underlying pneumonia of the patient.

Neonatal Gastroenteritis
Adequate fluid balance in humans depends on the secretion and reabsorption of fluid and electrolytes in the
intestinal tract; diarrhea occurs when intestinal fluid output overwhelms the absorptive capacity of the
gastrointestinal tract. The 2 primary mechanisms responsible for acute gastroenteritis are (1) damage to the
villous brush border of the intestine, causing malabsorption of intestinal contents and leading to an osmotic
diarrhea, and (2) the release of toxins that bind to specific enterocyte receptors and cause the release of chloride
ions into the intestinal lumen, leading to secretory diarrhea.
In diarrhea, there is excess loss of water, electrolytes (sodium, potassium, and bicarbonate) and zinc in liquid
stools. Dehydration occurs when these losses are not adequately replaced and there are deficits of water and
electrolytes. The degree of dehydration is graded according to symptoms and signs that reflect the amount of
fluid lost. The rehydration regimen is selected according to the degree of dehydration. All children with diarrhea
should receive zinc supplements.
During diarrhea, decreased food intake and nutrient absorption and increased nutrient requirements often
combine to cause weight loss and failure to grow. Malnutrition can make diarrhea more severe, more prolonged
and more frequent than in well-nourished children. This vicious circle can be broken by giving nutrient-rich foods
during and continuing after the diarrhea episode, when the child is well.

Diagnostic Plans
Pneumonia
Based on PCAP guidelines, Diagnostic test should be based on clinically important endpoints. These endpoints
and appropriate tests to order are listed in Table 3.
Table 3: Tests to be ordered for pneumonia work-up
Endpoint Diagnostic Test

Assessment of Gas Exchange  Pulse Oximetry

 ABG (PCAP C and D)

Determination of Underlying Etiology  Sputum GS/CS

 Anaerobic Cultures
o PCAP C with lung abscess
o PCAPD

Clinical suspicion of necrotizing  CXR PA/Lateral

pneumonia, multilobar consolidation,  Chest UTZ
lung abscess, pleural effusion,
pneumothorax or pneumomediastinum

Surrogate markers for possible  CRP

presence of pathogens requiring initial  Procalcitonin
empiric antibiotic with microbiology as  CXR
the reference standard  WBC Count

Determine Metabolic Derangement  pH in ABG

 Na, K

Predictor of clinical course  Mortality: pH in ABG

 Treatment Failure: Pulse oximetry for oxygen saturation
less than 90% at room air, chest x-ray PA-lateral for
pleural effusion or consolidation, or WBC for leukocytosis
or leukopenia, Blood culture for bacteremia, serum
hemoglobin for anemia, or serum glucose for
hypoglycemia
 Prolonged hospitalization/ Pneumatocele Formation:
Lung ultrasound showing impaired perfusion and
hypoechoic lesions

AGE
To determine the etiologic agent and proper treatment of AGE, fecalysis with fecal microscopy using pNSS and
Kato-Katz technique should be done to rule out parasitic causes of infection. Stool culture and sensitivity may
also be done to determine bacteriologic causes and response to therapy.
Sepsis
Blood culture and antibiotic sensitivity testing may be done to determine the etiologic agent and provide targeted
treatment based on etiology.

Treatment
Pneumonia
Given the tachypnea and low oxygen saturation levels, the initial treatment that should be given to neonates with
pneumonia should be oxygenation. It is given to all children with O2 saturation of < 90%. Nasal prongs are
preferred as mode of oxygen delivery. Pulse oximetry should be use to guide oxygen therapy. Trial of removal
of oxygen should be done each day while continuing to use pulse oximeter to determine oxygen saturation.
Oxygen may be discontinued if the saturation remains stable >90% for at least 15 minutes on room air, and with
no evidence of DOB such as tachypnea and use of accessory muscles for breathing.
Empiric therapy includes administration of Ampicillin 50 mg/kg every 6 hours for at least 5 days and Gentamicin
7.5 mg/kg/IM once a day for at least 5 days. If no clinical improvement is seen within 48 hours of therapy, and/or
staphylococcal pneumonia is suspected, antibiotics should be shifted to Gentamicin 7.4 mg/kg/IM or IV once a
day and Cloxacillin 50 mg/kg/IM every 6 hours.
Any thick secretions should be removed by gentle suction. If the child has fever, paracetamol may be given.
Hydration status must also be ensured through proper breastfeeding or giving maintenance fluid appropriate for
age. An NGT tube may be given if the child is not able to tolerate fluid intake.
Children with severe pneumonia can be discharged when:
 Respiratory distress has resolved.
 There is no hypoxemia (oxygen saturation, > 90%).
 They are feeding well.
 They are able to take oral medication or have completed a course of par- enteral antibiotics.
 The parents understand the signs of pneumonia, risk factors and when to return

AGE with No Dehydration

The three essential elements in the management of all children with diarrhea are rehydration therapy, zinc
supplementation and counselling for continued feeding and prevention.
To manage this patient, prevention of dehydration is done by giving extra fluid of 50-100 mL after every
episode of loose stools. Zinc supplement should be given, ½ tab (10 mg) per day. This can be incorporated in
the milk of the patient. Follow-up is done if the child becomes sicker, is unable to drink or breastfeed, drinks
poorly, develops a fever or has blood in the stool. If the child shows none of these signs but is still not
improving, advise the mother to return for follow-up after 5 days.
Antibiotics should not be used except for children with bloody diarrhea (probable shigellosis), suspected cholera
with severe dehydration and other serious non-intestinal infections such as pneumonia and urinary tract infection.
Antiprotozoal drugs are rarely indicated. ‘Antidiarrheal’ drugs and anti-emetics should not be given to young
children with acute or persistent diarrhea or dysentery: they do not prevent dehydration or improve nutritional
status, and some have dangerous, sometimes fatal, side-effects.

Neonatal Sepsis
Empiric treatment for different types of causes of neonatal sepsis is shown in the succeeding table. Given that
the patient has concurrent pneumonia at this time, Empiric treatment iincludes administration of IV ampicillin at
50 mg/kg every 6 h plus IV gentamicin 7.5 mg/kg once a day for 7–10 days; alternatively, give ceftriaxone at 80–
100 mg/kg IV once daily over 30–60 min for 7–10 days.
Monitor Hb or EVF, and, when indicated, give a blood transfusion of 20 ml/kg fresh whole blood or 10 ml/kg of
packed cells, the rate of infusion depending on the circulatory status.
The child should be checked by a nurse at least every 3 h and by a doctor at least twice a day. Check for the
presence of new complications, such as shock, cyanosis, reduced urine output, signs of bleeding (petaechiae,
purpura, bleeding from venepuncture sites) or skin ulceration.
Treat septic shock with rapid IV infusion of 20 ml/kg of normal saline or Ringer’s lactate. Reassess. If the child
is still in shock, repeat 20 ml/kg of fluid up to 60 ml/kg. If the child is still in shock (fluid-refractory shock), start
adrenaline or dopamine if available.
Metabolic Acidosis
Metabolic acidosis was corrected through administration of sodium bicarbonate at 20 mEqs.
Prevention and Anticipatory Guidelines
Sepsis, Pneumonia
Women with GBS bacteriuria should be treated during pregnancy when the condition is diagnosed and during
the intrapartum period. The committee also recommends that women who have previously given birth to an infant
with invasive GBS disease receive antibiotic prophylaxis during labor and delivery.
To minimize the risk of early-onset GBS disease, practitioners should obtain screening vaginal and rectal cultures
at 35-37 weeks’ gestation in all pregnant women unless the patients have had GBS bacteriuria in the current
pregnancy or have previously had a child with invasive GBS disease. Implementation of a screening protocol
has led to a significant decrease in the incidence of neonatal GBS disease.
Prevention of pneumonia includes vaccination with PCV 10/13, as well as Hib.
As the child grows, pneumonia and sepsis of different pathogen may recur. Given this, the mom should be taught
of signs to watch out for recurrence of pneumonia, as well as identify when the patient needs to be sent to a
tertiary care hospital. The IMCI guideline for patients with cough can be taught to the mother or caretaker of the
patient:

AGE
Once discharged, the child should continue proper nutrition and feeding as part of the recovery process. To
minimize recurrence of AGE in the future, hygiene and food handling practices should be taught. These include
proper handwashing, minimizing contact of the newborn to other people, and proper food preparation. The IMCI
guideline for patients with diarrhea can be taught to the mother as well to identify danger signs that suggest
prompt referral to a tertiary hospital:
Immunization
The child should have his immunization updated once treatment is completed. The mother or the caretaker/s
should be informed the importance of timely vaccination, and these vaccinations are free in health centers.

Anticipatory Guidance for the Mother

Patient was born to a teenage mother. The mother can be assessed for psychosocial issues as well as plans in
the future for her and her child. She should also be taught on proper child rearing. She should also be given
lectures on reproductive health in order to prevent unwanted pregnancies in the future.

Prognostication
The prognosis of neonatal pneumonia depends upon the severity of the disease, the gestational age of the
patient, underlying medical conditions, and the infecting organism. Increased mortality is associated with preterm
birth, preexisting chronic lung disease, or immune deficiencies. Most term neonates managed in resource-rich
settings recover well without long-term sequelae. Given that the patient developed sepsis during the course of
the illness, prognosis is worse compared to an infant with just plain pneumonia.

Since the patient has AGE with no warning signs, and the diarrhea is now decreased in severity, with no
symptoms of malnutrition, no changes in feeding habits, and no negative fluid balance was noted, it is deemed
to have good prognosis.

Public Health Issues

Pneumonia
In the Philippines, 57,809 pneumonia deaths were reported in 2016, nearly 10 percent of 582,183 registered
deaths in 2016. This made pneumonia the 3rd top killer behind ischemic heart disease and cancer. The
Philippines is one of the 15 countries that together account for 75% of childhood pneumonia cases worldwide.
In children aged under 5 years, pneumonia is the leading cause of mortality with a mortality rate of 23.4 x 100,000
population recorded in 2009.

Gastroenteritis
Although often considered a benign disease, acute gastroenteritis remains a major cause of morbidity and
mortality in children around the world, accounting for 1.34 million deaths annually in children younger than 5
years, or roughly 15% of all child deaths. [1] As the disease severity depends on the degree of fluid loss, accurately
assessing dehydration status remains a crucial step in preventing mortality.

Sepsis
Sepsis is an important cause of morbidity and mortality among newborn infants. Although the incidence of sepsis
in term and late preterm infants is low, the potential for serious adverse outcomes, including death, is of such
great consequence that caregivers should have a low threshold for evaluation and treatment for possible sepsis
in neonates.