Case Write Up Paediatric (Pneumonia)

Patient ID

Name                             : Muhammad                                            

Date of Birth                : 10 April 2017                          

Age                                 : 14 months                         

Gender                          : Male                                           

Race                               : Malay                                  

Religion                         : Muslim                               

Address                          : Setapak, Kuala Lumpur

Informant                     : Siti Sarah (mother)

Chief Complaint

Patient was presented to emergency department at 8am on 20 May 2018 with chief complaint of difficulty in breathing for 5hours.

History of Presenting Illness

Patient was known case of bronchitis. He was hospitalized when he was 9months old at Hospital Kuala Lumpur due to difficulty in breathing. This is the 2^nd hospitalization due to difficulty in breathing.

Patient was previously well, until 17 May 2018 on Thursday night, patient developed rised in body temperature. It was sudden and resolved with medication. The mother had measured the temperature, it was 38.8°C. The fever was continuous and did not fluctuate, unless decreases with medication.  The medication resolved the fever to 37°C. No night peak. The medication was given in 6hours interval. Before the fever, the mother said that she was having fever. The fever did not associate with vomiting and rash. The fever lasted for 4days.

One day after that, on Friday, he started to developed runny nose. It started on onset of sudden and the patient is still having runny nose until clerking day. It is always there and continuous. It became worsen since the discharge was clear in the beginning but started to turn greenish. The flow was subtle on Friday but started to become heavy flow the next day. It got worse when he cries.

On Saturday the next day after the patient started to have runny nose, cough had developed. It was sudden, and on and off. The cough was same since first event until today. It is a wet cough and become worse at night. There is no post tussive vomiting.

On Sunday, at 2am, he developed difficulty in breathing when he was sleeping. Mother commented that the breathing become more rapid than usual. The event lasted or 5hours, prior to admission. The progression was same. The difficulty in breathing has no relieving factor. No noisy breathing was noted upon patient.

Then, the mother brought him to Emergency Department(ED) in HKL at 8am and was advised to go back. Patient was given antipyretic and nasal normal saline, but the symptoms did not subside. The difficulty in breathing came back and got worse. The mother brought him to ED again, at 11pm and he was given nebulizer, but did not respond. 3 nebulizers were repeated but patient had no response towards treatment. Then he was referred to paediatrician and admitted into the ward KK2 at 11.30pm.

System Review

No vomiting

No rash

No abnormal movement

Decreased bowel movement, no loose stool or straining.

Decreased urine output

Appetite was reduced, he refused any meal intake

Weight reduced

Sleep was disturbed

Past Medical History

Patient was diagnosed to have bronchitis on December 2015. He also was diagnosed as Iron Dificiency Anemia.

Birth history

For perinatal history, during pregnancy of the mother, or prenatal, the mother had low hemoglobin level and fever. For antenatal, he was delivered mature, normal without any complication or problem. The weight was 3.01 kilogram. For postnatal, patient had attack of jaundice 2days after delivery for 1week. No admission due to jaundice.

Past Admission History and Surgical History

Patient had admission due to acute bronchitis on December 2015 in Hospital Kuala Lumpur. No significant surgical history.

Immunization History

Completed all vaccination and never missed any.

Feeding History

The child is still breastfeeding. The child was purely breastfeeding until age of 6months. Then, he started to have mix meals which are breastfeed and solid food. No cow’s milk or formula milk was given. After delivery, the child was breastfed immediately within 2hours. The bottle hygiene is good. The mother sterilized the bottle after usage.

Developmental History

Gross motor : walking without support at 1year and practicing to run. He sits without support

Fine motor : able to scribble, mature pincing

Social : strangers anxiety

Speech : understands many phrases, able to call the father and mother

Drugs and Allergy History

Antipyretics, nasal normal saline. No cough syrup was given during illness. No food allergy. There is iron syrup given for IDA.

Family history

Patient is 3^rd among 3siblings. The first brother is 5years old, healthy and second brother is 3years old, known asthmatic. The has history of asthma during childhood. The father has allergy rhinitis and a smoker. No eczema runs in the family.

Social History

The child is living with his family in a flat house Setapak, Kuala Lumpur. The mother is a housewife, and take care of the child herself. The father is a technician, a smoker, but smokes outside the house. Patient is a non-passive smoker. No travel history was noted. The area was known as hotspot area of dengue. The drainage is good. And water supply is clean. They did not use filter but they boil water for drinking. No contact with person with same illness. But before the illness, they did take meal from outside.

Summary

A 14months old child presented with difficulty in breathing for 5hours on Sunday (20/5/2018). He had fever, cough and runny nose 2-3days prior to admission. Fever was sudden and low grade. It resolved by medication. The runny nose was sudden and continuous. It becomes increase of flow and mucous turns from clear to greenish. The cough was sudden and dry cough. It was on and off, and wet cough. It peaks at night with same progression. The rapid breathing was sudden. The progression is same. No aggravating and relieving factor. The patient was brought to ED for treatment and admitted in KK2.

PHYSICAL EXAMINATION

General Examination

On inspection, the patient was alert, conscious, communicative and active. Patient appeared well nourished and well hydrated. The child appeared pink. There was a sign of breathlessness and he was tachypneic. There was no accessory muscles were used during respiration. The subcostal recession and Harrison sulcus can be seen.

Vital signs-

Blood pressure                   :           98/54 mmHg (normal 90-105/55-70)

Pulse rate                             :           146bpm (normal 80-140), good volume and

                                                            regular rhythm

Respiratory rate                 :           35/min (normal 25-30)

Temperature                       :           38.2C

Face-

Patient’s conjunctiva were pink on both sides,  and there were no sign of jaundice at the sclera of both eyes. There was no nasal flaring but positive nasal discharge. There was no central cyanosis at the tongue, no ulcers and the lips were moist. There were no rashes or any deformities on the face. The face shows toxic-ill look.

Neck-

There were no sign of enlarged lymph nodes and no raised jugular venous pressure. Trachea cannot be assessed because patient was not cooperative.

Hands-

There were no signs of pallor at the palmar crease, no peripheral cyanosis, no nail clubbing and no palmar erythema. The capillary filling was normal (less than 2 seconds). There was no scars on the hand.

Legs-

No pitting edema was seen in both legs. The pulses of the dorsalis pedis artery were felt in both legs.

Weight                                  :           8.5kg (below 5^th percentile)

Height                                   :           85cm (below 5^th percentile)

Head circumference         :           47.5cm (at 25^th percentile)

SYSTEMIC EXAMINATION

Respiratory system-

On inspection, there were no scars, no deformitites and no masses can be seen on the anterior and posterior chest. There were no hyperpigmentation, no rashes seen. The chest was symmetrical. The subcostal recession and Harrison sulci were seen. Percussion of the chest was not done since the child is still under 5 years old. Upon auscultation, normal vesicular breath sounds were heard. There was generalized rhonchi heard in both lungs during expiration with prolonged expiratory phase with bilateral crepitation.

Cardiovascular system-

On inspection of the chest, there were no surgical scars or any deformities. No dilated veins and no visible pulsations were seen. Upon auscultation, both first and second heart sounds were heard. No abnormal murmur sound was heard.

Gastrointestinal system-

On inspection, the abdomen was symmetrical and there was no distention. The umbilicus was inverted and centrally located. No smilling umbilicus (denoting ascites) was seen. There was no dilated veins and no caput medusa. No visible peristalsis or pulsations were seen. There were no scars, no hyperpigmentation and no spider naevi seen. Upon palpation, there was no tenderness. On percussion, there were no shifting dullness and no fluid thrills.

PROVISIONAL DIAGNOSIS

Left lobar pneumonia with bronchospasm, due to chest x-ray shows left lower consolidation of the lung. Lobar pneumonia usually caused by Streptococcus Pnuemonia. The bronchospasms was diagnosed due to rhonchi at end expiration, and prolonged expiration in the child.

DIFFERENTIAL DIAGNOSIS

Asthma

Patient has positive family history of atopy. Family history of atopy give strong diagnosis to asthma. But the patient developed toxic-ill look and basal crepitation which shows fluid accumulation.

Acute bronchitis

The child developed cough before he had rapid breathing. The cough lasted for  about 2 weeks or longer in acute bronchitis. But the patient did not yet reach 2weeks cough. The patient also has rise in body temperature. The child was having wet cough since the beginning.

INVESTIGATIONS

Based on the history and physical examination, a provisional diagnosis was made. In order to confirm the diagnosis, a few laboratory investigations were requested. A full blood count to look for infection (raised white blood cell) and chest X-ray was ordered.

Full blood count-

Test	Patient’s value	Normal range	Interpretation
White blood cell (x10^9/L)	11.0	4.0-9.0	High
Red blood cell (x10^12/L)	5.31	3.8-6.0	Normal
Haemoglobin (g/dL)	11.6	10.5-14.0	Normal
Haematocrit )%)	37.5	29-59	Normal

Chest X-Ray

Left lower consolidation of lung.

MANAGEMENT

1.    Antibiotic therapy

2.    Give inhaled bronchodilators

3.    Supplemental oxygen through nasal canula

4.    Fluid resuscitation

5.    Empiric antibiotic therapy

6.    Corticosteroids

DISCUSSION

            The incidence of pneumonia peaks in infancy and old age, but is relatively high in childhood. Pneumonia is a major cause of childhood mortality in resource-poor countries. It is caused by variety of viruses and bacteria, although in over 50% no causative pathogen is identified. Viruses is more common is young children, while bacteria are more common in older children. In clinical practice, sometimes it is difficult to distinguish between viral and bacterial pneumonia.

            The pathogen causing pneumonia vary according to the child’s age. In this patient, he is 14months old which is considered young child. In this age, respiratory viruses, particularly RSV(respiratory syncytial virus) are more common, but bacterial infections include Streptococcus pneumonia or Haemophilus influenza. Bordetella pertussis and Chlamydia trachomatis can also cause pneumonia at this age. In an infrequent but serious cause, is Staphylococcus aureus.

            Usually, for pneumonia, the clinical features of fever and difficulty in breathing are the commonest symptoms, usually preceded by an upper respiratory tract infection. Other symptoms include cough, lethargy, poor feeding and an ‘unwell’ child. Localized chest, abdominal, or neck pain is a feature of of pleural irritation and suggests bacterial infection. Examination reveals tachypnea, nasal flaring and chest indrawing – the best clinical sign of pneumonia in children is increased respiratory rate, which in this patient, the respiratory was a bit higher than normal border. To confirm the diagnosis of pneumonia is by using chest X-ray, but in exception of lobar pneumonia.

           

Lobar pneumonia is an acute exudative inflammation of an entire pulmonary lobe, produced in 95 % of cases by Streptococcus pneumoniae (pneumococci).

If not treated, lobar pneumonia evolves in four stages. Common to all stages is the enlargement of the affected lobe with loss of it's spongy appearance.

In the first stage, congestion (day 1 - 2), the affected lung parenchyma is partially consolidated, and red-purple, partially aerated. Microscopy: alveolar lumen contains serous exudate, bacteria and rare leucocytes.

In the second stage, red hepatization (day 3 - 4), the pulmonary lobe appears consolidate, red-brown, dry, firm, with a liver-like consistenc. The cut surface is dry, rough. Microscopy : the characteristic aspect of this stage is determined by the accumulation in the alveolar spaces of an exudate rich in fibrin (mainly), with bacteria, leucocytes, and erythrocytes. Alveolar walls are thickened due to capillary congestion and edema.

The third stage, gray hepatization (day 5 - 7), the affected lobe has a liver-like consistency, with uniform gray colour. On the cut surface, a grayish purulent liquid drains. It is because alveolar lumens are filled with leukocytic (suppurative) exudate (neutrophils and macrophages, in order to remove the fibrin). Capillary congestion and edema are still present, therefore alveolar walls are thick.

The resolution stage begins on day 8 and continues for 3 weeks (uncomplicated cases), while the exudate within the alveolar spaces will be drained through lymphatics and airways ("productive" cough) with gradually aeration of the affected segment.

The management of pneumonia usually is antibiotic which determined by the child age, severity of illness and appearance on chest Xray. Most older infants can be managed by oral amoxicillin, with broad spectrum antibiotics.

REFERENCES

•                Kleigman, R.M., et al. Nelson Textbook of Pediatrics, 19th ed. Philadelphia: Saunders, 2011.

•                Illustrated textbook of paediatrics 4th ed. :Lissauer and Clayden

•                Paediatrics protocol for Malaysian Hospitals 3rd edition

•                http://www.pathologyatlas.ro/lobar-pneumonia-leukocytic-alveolitis.php