General data E.C. 6 month old Female Born on March 7, 2013 Taguig City

CHIEF COMPLAINT Difficulty of breathing

History of Present Illness 2 days PTA 2 episodes of vomiting after feeding No other associated symptoms Brought to TMC-ER; Impression: Vomiting unspecified, Home medication: ORS During the interim Parents still noted the patient to have labored breathing, described as raising of shoulders during inspiration. With occasional cough No recurrence of vomiting, no fever Few hours PTA Consult with AP; advised admission.

Past Medical History No previous illness No previous hospitalization No previous surgical procedure

Family history (+) Diabetes mellitus (-) asthma, allergy, heart disease, hypertension, stroke, cancer

Birth and Maternal history Born full term delivered via CS (breech delivery) to a 35 year old G1P1 Birth weight of 5lbs 6oz Attended by OBGYN, St. Christiana’s hospital With no fetomaternal complications

Nutritional history Not breastfed On formula feeding, started on solid foods

Immunization history BCG 1 DPT/Polio 2 Hib 2 Hepatitis B 2 Pneumococcal 1 Rotavirus 1 MMR 0 Measles 0 Varicella 0 Influenza 0 Hepatitis A 0 Typhoid 0

Developmental history

Physical Examination General survey: alert, crying, but consolable Vital signs: BP 90/60mmHg, HR 140bpm, RR 32 cpm, T 36.5deg Anthropometrics: Hgt 63cm, Wgt 5.4 kg Head circumference 42cm, Chest circumference 45cm, Abdominal circumference 43 cm

Physical Examination HEENT: anicteric sclerae, pink palpebral conjunctivae, no alar flaring, no cervical lymphadenopathy, flat neck veins, no tonsillopharyngeal congestion PULMONARY: equal and symmetric chest expansion, with shallow subcostal retractions, harsh breath sounds, occasional rales, no wheezes CARDIOVASCULAR: adynamic precordium, PMI at 4 th left ICS, midclavicular line, regular cardiac rhythm, no murmur

Physical Examination ABDOMEN: normoactive bowel sounds, soft, no masses, no organomegaly EXTREMITIES: normal skin color, good skin turgor, no cyanosis, no edema, full and equal pulses

Physical Examination NEUROLOGIC: alert Cranial nerves: pupils 2-3 mm equally brisk and reactive to light, tracks objects, no nystagmus, no facial asymmetry, responds to sound, (+) gag reflex Motor: normal tone, no atrophy, 5/5 on all extremities Reflexes: normal reflex (++) on all extremities Sensory: responds to touch in all extremities No Babinski No meningeal signs

Admitting diagnosis Pneumonia

Goals of care For the patient to have resolution of respiratory distress by the time of discharge Respiratory rate < 50 cpm No retractions, no alar flaring No vomiting No cyanosis Decreased cough episodes

Diagnostics & Therapeutics CBCPC to check for infection Chest Xray to check for pneumonia Nebulization with Salbutamol, Salbutamol+Ipratropium, Hydrocortisone IV Ampicillin (100mg/kg/day) IV support: D5IMB at maintenance rate

Laboratory results Hgb139 g/L Hct0.42 WBC10.0 x 10^9/L Neutrophil0.52 Lymphocyte0.43 Monocyte0.05 Eosinophil0 Platelet448 x 10^9/L

Insert Chest Xray Official reading (9/14/13): hyperaerated lungs, bilateral interstitial infiltrates without consolidation suggestive of viral pneumonia

Course in the Wards: Day 1 Subjective (+) Occasional cough Fair milk intake (-)vomiting (+) “puffy” eyes according to parents Objective Irritable, crying T 36.5deg HR 120bpm, RR 35cpm (+) shallow subcostal retractions, Good air entry, harsh breath sounds, (-) rales, wheezes (+) slight periorbital edema on inspection Assessment Pneumonia Plan Nebulization with salbutamol, salbutamol+Iprat ropium, IV hydrocortisone IV ampicillin Decrease IV fluid to 75% maintenance

Course in the Wards: Day 2 Subjective (+) Occasional cough Fair milk intake (-)vomiting “puffy” eyes Objective Irritable, crying T 36.4deg HR 132bpm, RR 32cpm (+) shallow subcostal retractions, harsh breath sounds, (-) rales, wheezes (+) grunting (-) periorbital edema Assessment Pneumonia Plan Hook to Pulse Oximeter O2 Support (2-3 lpm via nasal cannula) Revision of nebulization schedule: salbutamol every 2 hours to alternate with salbutamol+ipratropiu m every 6 hours IV hydrocortisone IV ampicillin Referral to Pediatric Pulmonologist

Pedia Pulmonology notes Subjective Chest xray reviewed: straightened cardiac border, obliterated retrosternal space, pneumonia Parents claim that the patient seems to be edematous Objective RR 30s, fair air entry, (+) grunting, (+) rales, wheezing on both lung fields HR 140 bpm, regular cardiac rhythm, no cardiac murmur appreciated No cyanosis, no edema Assessment Pneumonia r/o congestive heart disease Plan ABG to check for oxygenation status Furosemide (1 mg/IV) given Shift IV ampicillin to IV Ceftriaxone (55.6mkday) Revise nebulization: Salbutamol every 6 hours to alternate With Salbutamol +Ipratropium every 6hours CARDIO REFERRAL

Pedia Cardiology notes CARDIOPULMONARY: Cyanosis: not documented but presents with occasional desaturations to mid-80% O2 at room air May be due to Pulmonary arterial hypertension due to pneumonia May be an idiopathic persistent pulmonar y hypertension secondary to large VSD RESPIRATORY: Pneumonia: patient presents with occasional cough, with rales and occasional wheezing, with shallow subcostal retractions and grunting Chest xray: bilateral interstitial pneumonia PROBLEMS

Pedia Cardiology notes CARDIAC: VSD Patient has no murmur, with regular cardiac rhythm, no history of cyanotic episodes; noted to have a loud S2 Patient was initially tachypneic, with edema, which may be due to congestion brought about by the large VSD 4-extremity BP: 80/50, all extremities EKG: RVH 2dECHO: large VSD inlet to muscular, 10-12mm, with severe pulmonary hypertension

Insert EKG

Insert 2decho

Pedia Cardiology notes Assessment: CHF functional class II secondary to CHD, VSD (12mm) inlet to muscular, with severe Pulmonary Hypertension; Pneumonia, community acquired

Plans: Furosemide (1mg/kg) for diuresis and to relieve congestion Captopril 1mg/pptab Q12 as an afterload unloader Lanoxin 50mcg/ml 0.5ml BID for inotropic support Oral KCL (1meq/kg) BID for 6 doses Sildenafil 3mg/pptab Q6 Continue IV antibiotics and nebulizations for pneumonia Continue o2 support and monitoring IVF rate at 5ml/hr Family Conference to discuss options for treatment: PA banding as temporary solution vs definitive surgery Pedia Cardiology notes

Course in the Wards: Day 3 Subjective (+) Occasional cough improving milk intake (-)vomiting More comfortable- looking according to the parents Objective Comfortable, not in distress T 37deg HR 143bpm, RR 36cpm BP 90/60, O2 98% at room air (-) retractions, harsh breath sounds, (+) rales, (-) wheezes (-) grunting (-) edema (-) cyanosis Assessment CHF functional class II secondary to CHD, VSD (12mm) inlet to muscular, with severe Pulmonary Hypertension; Pneumonia, community acquired Plan Salbutamol +Ipratropium nebulization discontinued Family Conference: The parents are considering patching of VSD instead of temporary PA banding, to be scheduled 2 weeks after pneumonia has resolved

Course in the Wards: Day 4 Subjective (+) Occasional cough improving milk intake (-)vomiting More comfortable- looking according to the parents Objective Comfortable, not in distress T 36.3deg HR 130bpm, RR 34cpm BP 90/60, O2 100% at room air (-) retractions, harsh breath sounds, (-) rales, (-) wheezes (-) grunting (-) edema (-) cyanosis Assessment CHF functional class II secondary to CHD, VSD (12mm) inlet to muscular, with severe Pulmonary Hypertension; Pneumonia, community acquired Plan Coninue present care

Course in the Wards: Day 5 Subjective (+) Occasional cough improving milk intake (-)vomiting With 3 scanty loose watery stools No episodes of desaturations, no difficulty of breathing Objective Comfortable, not in distress T 36.3deg HR 130bpm, RR 40cpm BP 90/60, O2 100% at room air (-) retractions, harsh breath sounds, (-) rales, (-) wheezes (-) grunting (-) edema (-) cyanosis Full and equal pulses Assessment CHF functional class II secondary to CHD, VSD (12mm) inlet to muscular, with severe Pulmonary Hypertension; Pneumonia, community acquired Plan Zinc Bacillus clausii IVF support Stool exam requested (normal result)

Course in the Wards: Day 6 (12nn) Subjective (+) Occasional cough improving milk intake (-)vomiting With 1 episode of pasty stool No episodes of desaturations, no difficulty of breathing Objective Comfortable, not in distress T 36.deg HR 120bpm, RR 32cpm BP 90/60, O2 98% at room air (-) retractions, harsh breath sounds, (+) occasional rales, (-) wheezes (-) grunting (-) edema (-) cyanosis Full and equal pulses Assessment CHF functional class II secondary to CHD, VSD (12mm) inlet to muscular, with severe Pulmonary Hypertension; Pneumonia, community acquired Plan Continue present care

Course in the Wards: Day 6 (4:30pm) Subjective Referred for pallor and difficulty of breathing The patient was crying and irritable and just finished feeding Objective Irritable, generalized pallor T 36.3deg HR 141bpm, RR 32cpm, 96% at room air at 6lpm (-) retractions, Tight air entry (+) grunting (-) edema (-) cyanosis Full and equal pulses Mottled skin Assessment CHF functional class II secondary to CHD, VSD (12mm) inlet to muscular, with severe Pulmonary Hypertension; Pneumonia, community acquired Plan Stat Salbutamo l nebulizati on Intubation Transfer to PICU

Prior to transfer to PICU Intubation HR 50s CPR done Bag-tube-ventilation delivered PNSS 10cc/kg given, 2 boluses Epinephrine 0.5mg/ET for 5 doses IJ catheter, right, inserted for IV access

Prior to transfer to PICU Intubation HR 50s CPR done Bag-tube-ventilation delivered PNSS 10cc/kg given, 2 boluses Epinephrine 0.5mg/ET for 5 doses Epinephrine drip started 0.1 meq/kg/min Milrinone drip started 0.8mcg/kg/min IJ catheter, right, inserted for IV access

Prior to transfer to PICU Laboratory exams requested: ABG CBCPC ICAL, Na, K, Cl Blood typing Hgt

Prior to transfer to PICU ABG: mixed respiratory + metabolic acidosis (on PPV) pH 7.176, pCO2 52.6, pO2 24.4, HCO3 19.4, Base 9.3, O2 sat 31.4 CBC Hgb92 g/L Hct0.29 WBC7.50x!0^9/L Neutrophil0.12 Lymphocyte0.86 Monocyte0.02 Eosinophil0 Platelet271 x 10^9/L Na134 mmol/L K4.40 mmol/L Chloride91.00 mmol/L Ical3,68 mg/dl (dec) Hgt338 mg/dl