ADMITTING

CONFERENCE


JI MEDRIANO, ROXANNE F.
Pediatric junior intern
MCG
1 year and 3 months old
Female
Infant
Roman catholic
March 03, 2013
BGH-Baguio City
#145 Poliwes, Kennon Road, Baguio City.
admitted for the 1
st
time in this institution, SLU-HSH on July 1, 2014.
The informant is the mother with a percentage reliability of 92%.

Cough, fever, diarrhea, convulsion
8 days prior to admission
(+) non-productive cough, with associated colds, nasal secretions
was characterized as clear and watery
no associated fever, vomiting, diarrhea, no nasal congestion, no
signs of difficulty of breathing such as fast breathing, chest
indrawing and alar flaring
good oral intake and sleep was uninterrupted.
According to her mother, maybe the patient had acquired it form
her grandmother since the grandmother had cough and colds
that time.
no medications given.
No consultations done.
7 days prior to the admission
increase in the frequency of the patients coughing episodes,
and it became productive- not able to expectorate the
phlegm.
The colds with clear and watery secretion also persisted.
Post-tussive vomiting 2x: vomitus was characterized as whitish
in color which is probably the ingested milk with phlegm.
(+) fever with a Tmax of 38.5 degree Celsius per axillary, and
nasal congestion
(+) signs of difficulty of breathing such as fast breathing,
and alar flaring.
(+) irritability as manifested by incessant crying and
interrupted sleep,
decrease in appetite noted.
Consult: meds given :Amoxicillin 0.8 ml TID, Carbocysteine
(Solmux) 1 ml TID, Phenylpropanolamine HCl (Disudrin)1
ml TID, and Paracetamol 100/1 1ml every 4 hours for
fever.
1 day prior to the admission
(+) diarrhea: 4x--- stool was described to be yellowish in color
and watery, non- bloody, non- mucoid and foul smelling,
amounting to approximately 30-40 cc per episode
cough and colds persisted despite completion of the
antibiotics.
(-)vomiting, nasal congestion, signs of difficulty of breathing
such as fast breathing, chest indrawing and alar flaring.
(+) increasing irritability as manifested by incessant crying and
interrupted sleep
decrease in appetite
(-) medications were given
tepid sponge bath was done by the grandmother which
offered temporary lysis of fever.

Few hours PTA,
the fever, cough and colds and diarrhea persisted.
One episode of seizure was noted which was characterized as
upward rolling of the eyeballs and stiffening and jerking of the legs,
lasting about less than 5 minutes.
first time that the patient had seizure.
(-) episodes of vomiting
(+) poor oral intake, disturbed sleep, and became more irritable.
No medications were given and no other relief measures were done
to address the problem.
Consult present admission.
PAST PERSONAL HISTORY

BIRTH HISTORY

PRENATAL HISTORY
26 years old, G1P0
cognizant of pregnancy at 6 weeks AOG pregnancy test done at home
Prenatal care was instituted at 6 weeks AOG by an obstetrician
Total: 7 prenatal checkups done regularly
ultrasound revealing a singleton, live baby girl, pregnancy in utero,
cephalic in presentation
No history of exposure to viral exanthematous disease, radiation, or
alcohol and other drugs
(+) certain exposure to cigarette smoke since some of her friends smoke.

No maternal illness during the course of pregnancy such as UTI or
Hypertension.

NATAL HISTORY
Term via NSD
Baguio General Hospital
Birth weight: 2.1 kg
birth length and other anthropometric measurements were
unrecalled
Upon birth: (+) pink body with good cry and active limb
movements
No congenital malformations
Apgar score and Ballard score were unrecalled.
NEONATAL HISTORY
Breastfed with good suck,
Hospital stay: 3 days
Newborn screening: normal
Hearing test: passed for both ears.

FEEDING HISTORY

Breastfed with good suck per demand up to 6 months
Complementary milk was given at 6 months with
Nestogen at a dilution of 3scoops in 120 mL, consuming
about 20 mL per feeding, with a frequency of about 6-8
bottles of 60 mL milk in a day

No episodes of feeding intolerance like loose bowel
movement noted

Semi-solid foods like rice, mashed vegetable (potato, squash)
were introduced at 6 months of age. At present, sample diet
includes:










Multivitamins of Appebon at 2.5ml and Ascorbic Acid 2.5 ml,
suggested by a friend, were started when patient was 5
months old and is given once a day.


Breakfast
Cerelac/ Mashed rice + milk 60 ml
4-5 spoonfuls
Lunch
Cerelac/ Mashed rice + milk 60 ml
4-5 spoonfuls
Dinner
Cerelac/ Mashed rice + milk 60 ml
4-5 spoonfuls
Snacks 2 pcs of bread
GROWTH AND DEVELOPMENTAL HISTORY
PHYSICAL GROWTH

BIRTH WEIGHT = 2.1kg PRESENT WEIGHT = 9kg
BIRTH LENGTH = unrecalled PRESENT LENGTH = 75 cm
Head Circumference = unrecalled Arm Circumference = unrecalled
Chest Circumference = unrecalled
DEVELOPMENTAL MILESTONES
Gross Motor: stands alone, walks with assistance
Fine Motor: makes line with crayon
Language: can say mama/ dada
Social: shy with strangers, feeds self

Prior to admission, the patient is playful and active.
Developmental milestones at par for age.

SOCIAL DEVELOPMENT
Sleeps: 8:00 pm at night
Wakes: 6:00 or 6:30 am
Takes several naps during the day
She is not-toilet- trained yet
interacts with family and peers without discipline
problems.

IMMUNIZATIONS
The childs immunization record is unavailable at the time of
interview since it has been left at home. As far as the
informant can recall, the vaccination were as follows:
Vaccine 1
st
dose 2
nd
dose 3
rd
dose Booster Place Reaction
BCG + BGH (+) Scar
DPT + + + Private physicians clinic None
OPV + + + Private physicians clinic None
Hepatitis B + + +
1
st
dose at BGH,
succeeding at Physicians
clinic
None
Measles + Private physicians clinic Fever
MMR + Health Center None
HiB + + + Private physicians clinic None
Pneumococcal
(conjugate)

Rotavirus + Health Center None
Mother claimed that patients immunization was completed; Additional vaccine received was
Rotavirus.


PAST MEDICAL HISTORY
No history of previous hospitalization or surgical
intervention
No history of viral exanthematous disease
No known allergies to drugs and food

FAMILY HISTORY
Both parents are presently well
(+) family history of HPN and bronchial asthma
maternal side
No family history of diabetes mellitus, arthritis, Cancer,
CVD and CAD twinning, multi-fetal gestation, seizure
disorders, or congenital anomalies.
SOCIAL AND ENVIRONMENTAL HISTORY
Mother, 28 year old, call center agent at Sitel, a
graduate of BS HRM
Primary caregiver is the grandmother- has the same
illness as that of the patient : (+) cough and colds
Patient is an only child.

Lives in a non-congested neighborhood, in a building type
house with 3 rooms and 6 occupants
Source of water for domestic purpose comes from Baguio Water
District
Drinking water is also from BAWADI: not properly boiled
They have 1 dog, which stays outside
Garbage is collected regularly every week
Toilet is indoor and flush-type
Hand washing is practiced especially before eating meals and
when preparing the patients food
The mother claimed that the patients has the habit of picking
things inside their house and put it in his mouth.

REVIEW OF SYSTEMS
General: (+) febrile episodes, (-) weight loss, (+) decreased oral
intake, (+) irritability
Integument: (-) rashes, (-) pallor, (-) jaundice, (-) dryness (-)
diaphoresis
Special Sensory:
Head and Neck: (-) trauma, (-) nuchal rigidity, (-) cervical
lymphadenopathy, (-) headache
Eyes: (-) discharges, (-) redness, (-) infection, (-) pain
Ears: (-) hearing loss, (-) discharges
Nose: (+) colds; (-) bleeding, (-) sneezing
Mouth and Throat: (-) dryness, (-) circumoral pallor, (-) ulcers, (-)
bleeding, (-) tongue lesions
Respiratory: (+) productive cough, (-) wheezing, (-) tachypnea, (-)
dyspnea

Cardiovascular: (-) edema, (-) cyanosis, (-) known CHD
GIT: (-) abdominal distention, (-) abdominal pain (-) anorexia, (+)
vomiting, (+) diarrhea, (-) constipation, (-) change in bowel
habits, (-) melena, (-) hematochizia
GUT: (-) dysuria, (-) hematuria, (-) frequency, (-) discharge
Musculoskeletal: (-) deformities, (-) swelling, (-) tenderness
Hematological: (-) easy bruisability, (-) bleeding
Endocrine: (-) excessive sweating, (-) chills, (-) weight change,
Nervous: (-) altered sensorium, (+) convulsions
PHYSICAL EXAMINATION FINDINGS
General Survey: awake, febrile, and irritable, in moderate
cardiopulmonary distress
Vital Signs and Anthropometric Measurements
CR= 137 bpm, RR= 57 cpm, T= 38.9 C per axilla SPO2 = 90%
Weight: 9 kg
Height: 75 cm
Length for age Z score: 0 (interpretation: normal)
Weight for age Z score: 0 (interpretation: normal)
Skin: (-) pallor, (-) cyanosis, (-) jaundice, (-) lesions, warm to touch, with
good skin turgor
HEENT: anicteric sclera; pale palpebral conjunctiva; sunken eyeballs; (+)
tears, normally set ears; (-) aural discharge; (+) alar flaring; turbinates not
congested; pinkish and moist lips and buccal mucosa; (-) enanthems; (-
)tonsillopharyngeal wall congestion, (-) cervical lymphadenopathy
Chest and Lungs: symmetrical chest wall expansion; (+) shallow
subcostal retractions, (+) coarse crackles on mid and bibasal
lung fields, (-) wheezes, (-) rhonchi
Heart: adynamic precordium, PMI is at the 4
th
ICS LMCL,
tachycardic with regular rhythm; no murmurs noted
Abdomen: slightly globular, non- distended, hyperactive bowel
sounds, tympanitic, soft, (-) direct tenderness (-) rebound
tenderness, (-) organomegaly
Genitalia: grossly female
Extremities: (-) cyanosis, no lesions and no deformities, with
symmetrical peripheral pulses on both upper and lower
extremities, and with good capillary refill.

Neurologic: Cerebral: awake, irritable
Cerebellar: (-) tremors
Cranial Nerves: CN I: can smell
CN II: can see
CN III, IV, VI: intact EOMs
CN V: can blink the eyes, (+) corneal reflex
CN VII: no facial asymmetry when smiling
CN VIII: can hear
CN IX, X: (+) gag reflex
CN XI: moves head side to side
CN XII: can protrude tongue


Motor: good muscle tone, bulk and activity
Sensory : able to respond to touch and painful
stimuli
Reflexes: (+) Babinski, bilateral, (-) Ankle clonus
2++
Meningeal Signs: (-) nuchal rigidity, (-) Kernigs sign, (-)
Brudzinkis sign
PROBLEM-ORIENTED MEDICAL RECORD


PROBLEM #1: Cough and Colds, Fever, Poor Oral Intake
SUBJECTIVE


S - 1 year, 3 months old female infant
- (+) febrile episodes: Tmax of 38.5 C
- (+) productive cough for a week; (+) whitish phlegm
- (+) colds for a week : nasal secretions characterized as watery and clear
- (+) history of post-tussive vomiting: 2x
- (+) dyspnea: fast breathing, alar flaring
- Primary caregiver is having the same illness/ condition
- (+) family history of BA


OBJECTIVE
General Survey: awake, febrile, and irritable, in moderate CP
distress
Vital signs: CR= 137 bpm, RR= 57 cpm, T= 38.9 C per
axilla SPO2 = 90%
HEENT: sunken eyeballs; (+) tears, (+) alar flaring, pinkish and
moist lips and buccal mucosa; (-)tonsillopharyngeal wall
congestion
Chest and Lungs: symmetrical chest wall expansion; (+)
shallow subcostal retractions, (+) coarse crackles on mid and
bibasal lung fields, (-) wheezes, (-) rhonchi
Extremities: (-) cyanosis, with symmetrical peripheral pulses on
both upper and lower extremities, and with good capillary
refill.

ASSESSMENT

PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA-C
with Moderate signs of Dehydration
SYMPTOM MINIMAL OR NO
DEHYDRATION
MILD TO MODERATE
DEHYDRATION
SEVERE
DEHYDRATION
Mental status Well, alert Normal, fatigues or
restless, irritable
Apathetic, lethargic,
unconscious
Thirst Drinks normally,
might refuse liquids
Thirsty, eager to drink Drinks poorly, unable
to drink
Heart rate Normal Normal to increased Tachycardia, with
bradycardia in most
severe cases
Quality of pulses Normal Normal to increased Weak, thready, or
impalpable
Breathing Normal Normal, fast Deep
Eyes Normal Slightly sunken Deeply sunken
Mouth and tongue Moist Dry Parched
Skinfold Instant recoil Recoil in <2 sec Recoil in >2 secs
CRT Normal Prolonged Prolonged; minimal
Extremities Warm cool Cold; mottled;
cyanotic
PLAN
DIAGNOSTICS
CBCP
CXR - APL
CBCP
Complete Blood Count
07/01/14
Patients Value Normal range
RBC Count 5.35 4.5 6.0 x 10
12
/L
HGB 138 120-170g/L
HCT 0.382 0.40-0.54
MCV 72 76-96 fl
MCH 26 27-32pg
MCHC 362 320-360g/L
WBC Count 22 5-10 x 10
9
/L
Bands --- 0-7%
Neutrophils 81.1 45-70%
Lymphocytes 15.1 20-40%
Eosinophils 0.2 0-8%
Monocytes 3 0-12%
Basophils 0.6 0-2%
Platelet 295 150-400
RBC morphology Normocytic, normochromic
CXR- APL


- Therapeutics:
Medications:
Ceftriaxone 200 mg IV q 12 hrs
50-75 mkd CD: 57.14 mkd
Paracetamol 100 mg IV 1q 4 hours RTC
10-20 mkd CD: 14.28 mkd

PLRS 1L x 58-59 ugtts/min (5% DT)
O2 at 1-2 lpm/NC


PROBLEM #2: LBM

S:
1 year, 3 months old female infant
(+) febrile episodes: Tmax of 38.5 C
4-5x diarrhea for 1 day, and stool was described to be
yellowish in color and watery, non- bloody, and foul smelling,
amounting to approximately 30-40 cc per episode
Drinking water is from the BAWADI also; however, it is not
properly boiled
The primary caregiver of the patient who is her grandmother is
the one who prepares her food.
Proper handwashing was said to be practiced at home
O:
General Survey: awake, febrile, and irritable
Vital signs: CR= 137 bpm, RR= 57 cpm, T= 38.9 C per
axilla SPO2 = 90%
HEENT: sunken eyeballs; (+) tears, , pinkish and moist lips and
buccal mucosa
Abdomen: slightly globular, non- distended, hyperactive
bowel sounds, tympanitic, soft, (-) direct tenderness (-)
rebound tenderness, (-) organomegaly
Extremities: (-) cyanosis, with symmetrical peripheral pulses on
both upper and lower extremities, and with good capillary refill

ASSESSMENT:

ACUTE GASTROENTERITIS WITH MODERATE SIGNS OF
DEHYDRATION
Diagnostics:
Stool Exam
- Therapeutics:
PLRS 1L x 58-59 ugtts/min (5%
DT)
STOOL EXAM
FECALYSIS Parasitology (5/9/2014)
COLOR Brown Consistency
Soft
METHOD OVA OR PARASITE CYST OR TROPHOZOITE
Direct Fecal Smear Negative Entamoeba histolytica/
entamoeba dispar cyst: 0-2/hpf
Concentration
Method
-
Occult blood Method: - Result: -
Other
examinations
Pus cells:5-10/hpf
Red Blood cells: 5-10
Yeast Cells: Negative
AIA
With moderate signs of dehydration
MEDICATION:
METRONIDAZOLE 100G iv EVERY 8 HOURS
ED: 35-50 MKD
CD: 42.85 MKD


PROBLEM #3: Convulsion, Fever

S:
1 year, 3 months old female infant
(+) febrile episodes: Tmax of 38.5 C
Few hours PTA: One episode of seizure was noted which
was characterized as upward rolling of the eyeballs and
stiffening and jerking of the legs, lasting about less than 5
minutes.
(-) family history of seizure disorder

General Survey: awake, febrile, and irritable
Vital signs: CR= 137 bpm, RR= 57 cpm, T= 38.9 C per
axilla SPO2 = 90%
Neurologic: Cerebral: awake, irritable
Cerebellar: (-) tremors
Cranial Nerves: CN I: can smell
CN II: can see
CN III, IV, VI: intact EOMs
CN V: can blink the eyes, (+) corneal reflex
CN VII: no facial asymmetry when smiling
CN VIII: can hear
CN IX, X: (+) gag reflex
CN XI: moves head side to side
CN XII: can protrude tongue

Motor: good muscle tone, bulk and activity
Sensory : able to respond to touch and painful stimuli
Reflexes: (+) Babinski, bilateral, (-) Ankle clonus
++ ++
++ ++
Meningeal Signs: (-) nuchal rigidity, (-) Kernigs sign, (-)
Brudzinkis sign

BENIGN FEBRILE CONVULSION, PROBABLY SEOCNDARY TO
PCAP-C AND AGE WITH MODERATE SIGNS OF
DEHYDRATION
- Diagnostics:
None at the moment
- Therapeutics:
Medications:
Diazepam 2mg IV PRN for frank
seizure
ED: 0.2- 0.5 mkd CD: 0.285mkd

SEIZURE PRECAUTION!
Acute intestinal amoebiasis
(DISCUSSION)
Amoebiasis is a parasitic protozoan disease that affects the
gut mucosa and liver, resulting in dysentery, colitis and liver
abscess.
Entamoeba histolytica infects up to 10% of the world's
population; endemic foci are particularly common in the
tropics, especially in areas with low socioeconomic and
sanitary standards.
2 most common forms of disease
amebic colitis
amebic liver abscess

Two morphologically identical but genetically distinct species of
Entamoeba:
Entamoeba dispar
does not cause symptomatic disease
Entamoeba histolytica
pathogenic species, causes a spectrum of disease and can become invasive
Mode of transmission
Feco-oral route
Cyst passers are the main source of infection.
Cysts are resistant to harsh environment including concentration
of chlorine but can be killed by heating 55C.




Amebiasis is the 3rd leading parasitic cause of death
worldwide
It is estimated that infection with E. histolytica leads to 50
million cases of symptomatic disease and 40,000-110,000
deaths annually



AMEBIC COLITIS
Parasitic invasion of the intestinal
mucosa
Non-dysenteric colitis
Occur within 2 weeks of infection or
delayed for months
Gradual with colicky abdominal pain
and frequent bowel movement (6-
8/day)
Diarrhea with tenesmus, blood stained,
with fair amount of mucus with few
leukocytes
High incidence in 1-5 years of age
Dysentery
Not very common (1% of total
prevalence of amebiasis in the whole
world)
Very fatal
Rare
Fever, chills, severe diarrhea,
dehydration and electrolyte
disturbances

AMEBIC LIVER ABSCESS
Dissemination of the
parasite to the liver
Rare in children
Diffuse liver enlargement
<1%
Fever (hallmark) with
abdominal pain, distention,
enlargement and
tenderness of liver
Rupture of abscess
Cause of death

Mouth - Cyst ingested
Invades gut mucosa cyst formation
Cyst
Passed in stool
Excyst to trophozoite
Trophozoite
Amoebic disease
GAL-GAL/NAC
ATTACHMENT
EPITHELIAL LAYER
PENETRATION
FLASK- SHAPED ULCERS
INVASION
A diagnosis of amebic colitis is made in the presence of
compatible symptoms with detection of E. histolytica antigens
in stool.
E. histolytica II stool antigen detection test is able to distinguish E.
histolytica from E. dispar infection.
Microscopic examination of stool samples has a sensitivity of
60%. Sensitivity can be increased to 85-95% by examining 3
stools, since excretion of cysts can be intermittent
Microscopy cannot differentiate between E. histolytica and E.
dispar unless phagocytosed erythrocytes (specific for E. histolytica)
are seen
Amoeboma.
(localized granulomatous mass
misdiagnosed with carcinoma)
Hemorrhage.

Perforation of ulcer.
(secondary peritonitis --- rare but fatal)

Stricture of colon.
(secondary to fibrosis)

Appendicitis.
Dr. RAAFAT MOHAMED
Invasive amebiasis is treated with a nitroimidazole such as
metronidazole or tinidazole and then a luminal amebicide

Metronidazole: 35-50 mg/kg/day for 7-10 days
Tinidazole: 50 mg/kg/day for 3 days for colitis or 50 mg/kg/day
for 3-5 days for liver abscess
Followed by:
Paromomycin (preferred): 25-35 mg/kg/day for 7 days
Diloxanide furoate: 20 mg/kg/day for 7 days or
Iodoquinol 30-40 mg/kg/day for 20 days

Most infections evolve to either an asymptomatic carrier
state or eradication. Extraintestinal infection carries about
a 5% mortality rate.
Exercising proper sanitation and avoiding fecal-oral
transmission
Regular examination of food handlers and thorough
investigation of diarrheal episodes may help identify the
source of infection
No prophylactic drug or vaccine is currently available for
amebiasis
Immunization with a combination of GAL/Gal/Nac lectin and
CpG oligodeoxynucleotides
Protective in amebic trophozoite challenge in animals

PCAP- C
Acute intestinal Amoebiasis w/
moderate signs of Dehydration
Benign Febrile Convulsion secondary

Thank you for listening!



HAVE A NICE DAY!


- Roxieee