PNEUMONIA

PEDIATRICS – DR.CLAIRE MANZO-VILLA

27A – GROUP 16
ROLL NO. 61-64
DEMOGRAPHICS
• NAME: JM JR. SL
• AGE: 4 Y.O.
• GENDER: MALE
• ADDRESS:ZONE 4 SAN JUAN
• RELIGION:CATHOLIC
• SOURCE OF INFORMATION:MOTHER
• RELIABILITY: 95%
• DATE OF ADMISSION : 7 MAY 2025
CHIEF COMPLAINT
• COUGH
HISTORY OF PRESENT ILLNESS
• 1 DAY PTA THERE WAS PRODUCTION OF DRY COUGH THROUGHOUT
THE DAY, WHICH LATER BACAME MUCOPURULENT WITH FOUL
ODOR AND GREENISH COLOR. THE PATIENT WAS SELF MEDICATED
WITH SALBUTAMOL AND RELIEF WAS NOTED. THERE WERE NO
FACTORS AGGEREVATING THE COUGH. PAIN OF 8/10 WAS
ASSOCIATED WITH COUGH RADIATING TO EPIGASTRIC REGION .
• ON THE DAY OF ADMISSION THE MOTHER NOTED THAT
PATIENTS COUGH HAD FOUL SMELL AND WAS THEREFORE
BROUGHT TO CONSULTATION
PAST MEDICAL HISTORY
• PNEUMONIA – 6 MONTHS OF LIFE ( 2021) – 1ST ADMISSION –
PALAWAN DISTRICT HOSPITAL – NOT TREATED
SUCESSFULLY
• PNEUMONIA – 7 MONTHS OF LIFE (2021) – 2ND ADMISSION – SPMC –
TREATED SUCESSFULLY – NO FOLLOW UP NEEDED- DRUGS GIVEN –
SALBUTAMOL - SALINE
• NO HISTORY OF PREVIOUS SURGERIES , TRAUMA, OR
KNOWN ALLERGIES
MEDICATION
• IRON SUPPLEMENTS 125 MG ONCE A WEEK
PRENATAL HISTORY
• AGE OF MOTHER AT THE TIME OF BIRTH : 29
• OB SCORE : G4P4(4004)
• 9 PRENATAL CHECK UPS
• NO GESTATIONAL DIABETES OR HYPERTENSION
• TERM DELIVERY, NSVD
• MOTHER DRANK ALCOHOL DURING PREGNANCY 2 LITRES A MONTH
• TOOK FOLIC ACID, CALCIUM, MAGNESIUM, VITAMINS
BIRTH HISTORY
• NSVD DELIVERY
• REST NOT RECALLED
NEONATAL HISTORY
• GOOD ACTIVITY BUT POOR CRY DURING BIRTH
• PINKISH IN COLOR
• 3 DAYS IN HOSPITAL BEFORE DISCHARGE
• UNREMARKABLE NEWBORN SCREENING
• HEARING TEST NORMAL
NUTRITIONAL HISTORY
• BREAST FEEDING TILL 8 MONTHS
• AFTER 8 MONTHS STARTED FORMULA MILK
• AFTER 6 MONTHS STARTED BANANA RICE FRUITS
• HAS 3 MEALS A DAY
• FORMULA MILK 1:1 DILTUTION WITH 4 SPOON OF
FORMULA POWDER
• JUNK FOOD – PIZZA, CHOCOLATE, HOTDOG
IMMUNIZATION

• NOT RECALLED EXACT DATES

• COMPLETELY VACCINATED
• LAST VACCINATION : MMR
GROWTH AND DEVELOPMENTAL
HISTORY

• GROSS MOTOR : WALK 12 MONTHS

• FINE MOTOR : SCRIBBLE 3 Y.O.
• LANGUAGE : FIRST WORDS – PAPA 10 MONTHS
• SPEAKS MORE THAN 50 WORDS
• REST HISTORY IS NOT RECALLED
FAMILY HISTORY
• ASTHMA – PATERNAL GRANDFATHER
• NO HISTORY OF DIABETES OR HYPERTENSION
PERSONAL AND SOCIAL HISTORY
• PRIMARY CARE GIVER – MOTHER
• FEEDING THE BABY – MOTHER
• FATHER – LABOURER – 3RD YEAR HIGHSCHOOL GRAD
• MOTHER – MARY GRACE – COMPANY CLERK – 3RD YEAR HIGHSCHOOL
• NO KNOWN ALLERGIES
• TAP WATER
• 6 PEOPLE IN HOUSEHOLD
• LIVES WITH 1 BROTHER AND 2 SISTERS
• PLAYS WITH SISTER
• HOUSE IS WELL VENTILATED
• CROWDED NEIGHBOURHOOD.
• WATCHES PHONE 2 HOURS A DAY
ENVIRONMENTAL HISTORY
• NO COMMUNICABLE DISEASES IN SURROUNDING AREA
• SEGREGATE TRASH WHICH IS COLLECTED ONCE A WEEK
PHYSICAL EXAMINATION
-HEART RATE : 160 bpm
-RESPIRATORY RATE: 28/min
-BLOOD PRESSURE : 80/60 MM HG
-TEMPERATURE: 36.5*C
-WEIGHT: 13
-HEIGHT: 97CM
-SKIN: NO RASHES OR MASSES
-HEAD: NO INJURY, NO ABNORMAL ASYMMETRY, NO LEISON
-EYES: NO SUNKEN EYE BALLS, NO DISCHARGE, NO PTOSIS.
-EARS: EARS POSITIONED SYMMETRICALLY, NO DISCHARGE,NO EXTERNAL
DEFORMITY OF EAR PINNA
REVIEW OF SYSTEMS
GENERAL: (-)WEIGHT LOSS, (-) FATIGUE PERIPHERAL VASCULAR: (-) LEG CRAMPS, (-) FOOT
SWELLING
SKIN: (-) RASHES, (-) ITCHING
URINARY: (-) DYSURIA, (-) HEMATURIA
HEENT: (-) DYSPHAGIA, (-) HEADACHE
GENITAL: (-) HERNIA, (-) PENILE DISCHARGE
NECK: (-) LUMPS, (-) PAIN
MUSCULOSKELETON: (-) ARHTRALGIA; (-) STIFFNESS
BREASTS: (-) LUMPS, (-) NIPPLE DISCHARGE
PSYCHIATRIC: (-) MEMORY CHANGE; (-) CHANGES IN
RESPIRATORY: (-) SHORTNESS OF BREATH, (-) MOOD
ORTHOPNEA
HEMATOLOGIC: (-) EASY BRUISING; (-) EASY BLEEDING
CARDIOVASCULAR: (-) PALPITATION, (-) PND
ENDOCRINE: (-) EXCESSIVE SWEATING, (-)
GASTROINTESTINAL: (-) CONSTIPATION, (-) POLYPHAGIA

MELENA
SOAP NOTES
• Patient Name: John Marcel V.
Age/Sex: 4-year-old Male
Date of Admission: May 7, 2025
Time: 2:50 AM
MRN: 3624178
Chief Complaint: Cough
SUBJECTIVE
 History of Present Illness:  Medications: Iron supplements once a week
o 1-day history of dry cough which progressed to
 Family History: Asthma in paternal grandfather
mucopurulent, foul-smelling, greenish sputum.

o Pain associated with cough, radiating to  Social History: Lives in a crowded

epigastric region (Pain score: 8/10). household, well-ventilated; consumes junk
food.
o Self-medicated with Salbutamol with
temporary relief.
 Immunization: Reported as complete; last
o No reported shortness of breath or orthopnea. vaccine MMR

 Past Medical History:  Feeding: Formula-fed after 8 months; mixed

o Pneumonia at 6 months (untreated diet with junk food
successfully), and 7 months (treated).
 Review of Systems: Generally negative except for
o No allergies, surgeries, or trauma. foul cough and pain
OBJECTIVE
 Vital Signs:

o Temp: 37.5°C

o RR: 28/min

o HR: 160 bpm

o BP: 80/60 mmHg

o Weight: 13 kg

 General Appearance: Carried in, awake, alert

 Skin: No rashes or lesions

 HEENT: No discharge, deformities, or asymmetries

 Chest/Lungs: Pending auscultation data; likely rales/rhonchi based on case

 CVS: Tachycardic

 Abdomen: Epigastric pain on coughing

 Neurological: Alert and oriented

ASSESSMENT
Primary Impression:

 Community-Acquired Pneumonia (CAP), likely bacterial origin

Differentials:

 Aspiration pneumonia

 Recurrent bronchopulmonary infection (bronchiectasis)

 TB (less likely – no exposure or weight loss)

 Asthma with secondary infection

PLAN
1. Investigations:

o CBC with differential

o Chest X-ray

o Sputum Gram stain and culture

o CRP, ESR

o Pulse oximetry

2. Pharmacologic Treatment:

o IV Ceftriaxone (50–100 mg/kg/day)

o Nebulized Salbutamol PRN for wheezing

o Paracetamol for pain/fever

o IV fluids for hydration