EVIDENCE BASED

MEDICINE
Group 4A
Beltran
Berberabe
Bernabe
Bernardes
Bernardo

General Data
MA, male, 1 year old, Filipino, Roman Catholic, born
on December 2, 2014 at General Trias, Cavite and
currently residing at Tagaytay City, was admitted for
the 5th time.
Chief Complaint: Cough and Fever, and Seizure

History of Present Illness

4 days prior to admission
- the patient developed cough and colds
- having difficulty of breathing
- irritable with loss of appetite
-

given Paracetamol 1 ml every 4 hours as

previously prescribed which offered temporary
relief.

2 days prior to admission

- Symptoms persisted thus sought consult to a
nearby clinic
- Prescribed with Clarithromycin 3 ml twice a
day and an unrecalled antihistamine 0.5 ml
twice a day.

1 day prior to admission

- the patient had an episode of vomiting after feeding
- developed fever 37.40C at around 3pm and 38.4oC at around 6pm
-

Paracetamol 1ml was given which offered slight relief.

Few hours prior to admission

- the patients cough and fever still persisted
-

He also had an episode of seizure which lasted for 10min., hence,

immediate consult to the emergency department of DLSUMC at

Past Medical History

1 yr PTA
- patient was diagnosed with Hydrocephalus and
had a Ventriculo-Peritoneal Shunting done.
8 months PTA
- patient was diagnosed with seizure disorder
and was started with Phenobarbital twice a day
initially but was shifted to valproic acid three
times a day.
FAMILY HISTORY is UNREMARKABLE

Birth and Maternal History

- Mother is a G1P1(1001) and gave birth to the
patient at the age of 22
- She had complete prenatal care. Multivitamins
were taken during pregnancy and no recorded
exposure to any kinds of radiation and no
reported complications.
-

She gave birth via elective Cesarean Section

at General Trias Hospital. Birth weight is 3.3
kg, term without complications

- No contraceptives were used by the parents.

Developmental History
Developmental Milestones
Despite some milestones that still cannot be performed (i.e. pulls
up, walk with support and stand alone) at the appropriate age, the
patient is still generally not delayed with regards to developmental
milestone.
Motor
Despite some gross motor activities (i.e. standing and walking)
that still cannot be performed by the patient, he is still not
considered delayed in the motor area of behavior.
Language, Personal and Social
There are no developmental delays in both language (expressive
and receptive) and personal-social behavior.

Nutritional History
From birth to 3 weeks, the patient was on mixed
breastfeeding and bottlefeeding. The mother cannot
recall the milk formula that was used to feed the child
but it was on 1:1 dilution. After 3 weeks, he was
already on exclusive bottle feeding with a milk
formula (Enfalac) 1:1 dilution 3 ounce every 2 hours.
At 7 months, she was started on complementary
feeding and was able to eat rice. At 12 months, the
patient eats rice, fruits and vegetables.

Personal/Social History
The patient lives with his mother and father,
grandparents and 2 uncles. The mother works as a
teller, non-smoker,and non-alcoholic drinker. His
father works as a supervisor and is also a non-smoker
and an occasional alcoholic drinker. However, the
patients grandfather is a cigarette smoker and the
patient is exposed occasionally. Their house is made
of concrete with adequate ventilation and lighting.
Garbage is collected weekly and they use mineral
water for drinking.

Immunization History
The patient has incomplete immunization due
to seizures. The patient is noted to have the
following immunizations: PCV, measles, BCG,
Hep B, and a missing dose for both DPT and OPV.

REVIEW OF SYSTEMS
Pertinent findings were:
- (+) weight loss (from 9.8kg to 9.3kg)
- Loss of appetite
- Fever
- Difficulty of breathing

PHYSICAL EXAM
General Survey
Patient is well developed, well nourished,
tachycardic not in respiratory distress, conscious and
coherent. Patient looked his chronological age of
1year old. IV line is present at her left arm inserted at
the left MCV. No Foley Catheter, O2 cannula, NGT or
ET tube attached.

Vital Signs

Patient's Values

Normal Values

Pulse Rate

138bpm

80-130bpm

Heart Rate

138bpm

80-130bpm

Respiratory Rate

27cpm

20-30cpm

Temperature

38.4

36.5-37.5

Anthropometric
Measurements
Head Circumference- 48cm
Chest Circumference- 44cm
Abdominal Circumference- 42.5cm
Length- 80cm
Weight- 9.5kg

SKIN
skin is fair in color, soft and resilient with good skin
turgor, no masses noted
No cyanosis and hyperpigmentation of skin noted
No pallor and jaundice of the skin
Neither hair loss/excess nor edema is present. No
koilonychia, nail, nail fold lesions, and clubbing
noted. On palpation, the skin is warm to touch.
Good capillary refill at 2 seconds.

EYES
eyes are symmetrical with pink palpebral
conjunctiva
Direct light and consensual light reflex are present,
with pupils reactive light
No presence of corneal and lens opacities
Intact EOMs

HEAD & NECK

Hair color is black, thin and well distributed, smooth in texture and no
patterns of hair loss
Skull is megacephalic, non-symmetrical, with no tenderness
Patients facial features are symmetrical with no masses and swelling
the scalp has no scales and flakes
No parotid and submandibular gland enlargement
No cervical lymphadenopathy is seen
Trachea is in midline and thyroid cartilage moves with deglutition,
with no tenderness or crepitation. Thyroid is not palpable, no
tenderness. Thyroid cartilage prominence moves with deglutition.
JVP was not measured. No jugular vein distension noted, nor bruits
heard at the carotid arteries.

NOSE
Nose is symmetrical, with no gross deformities,
masses or lesions.
A clear thin discharge from the nose is seen. Both
nostrils are patent and equal in size and shape.
Septum located midline.
Nasal mucosa is pinkish and moist with no edema
or congestion. He is breathing equally on both
sides.

EARS
Pinna and periauricular area is mobile with no
lesions, mass, deformity, tenderness.
External ear canal opening of both ears are patent,
with scanty amount of cerumen, no swelling, mass,
or discharge.
Tympanic membrane is pink bilaterally with no
perforation. Tuning fork tests were not done.

MOUTH
Lips are pink, symmetric with no masses or
ulcerations
Tongue in midline and mobile with no ulcerations or
masses
Oral mucosa is pink with no lesions, masses,
ulceration
Palatine tonsils are not enlarged, no exudates seen.
There is symmetrical movement of uvula and soft
palate.

RESPIRATORY
There was symmetrical chest expansion with a respiratory rate
of 27 cycles per minute.
No defects or deformities were noted, nor were there skin
lesions in the anterior and posterior wall. No lagging was noted.
The trachea was at the midline and no prominent lymph nodes
in the neck area were palpable. There was no tenderness and
palpable skin lesions as well.
No dullness was noted upon percussion. Tactile fremitus are
equal. There were no adventitious breath sounds heard on all
lung fields.
Crackles were heard on auscultation
The lung fields were difficult to auscultate due to the incessant
crying of the patient.

CARDIOVASCULAR
There were no precordial bulging, masses,
deformities, skin lesion on the chest wall.
PMI is at the 5th ICS Left MCL.
No heaves or thrills were palpated.
Peripheral pulses are full and equal.
Heart rhythm was regular, S1>S2 on the apex,
S2>S1 on the base.

ABDOMEN
The abdomen is flat and symmetrical with no
visible masses, veins, pulsations or peristalsis.
Character of bowel sounds was low pitched, with
normoactive frequency.
The abdomen was soft with no tenderness,
guarding, palpable masses or organomegaly.
Percussion revealed tympanitic sounds for all
quadrants.

EXTREMITIES
There was no tenderness or swelling of the joints
noted.
Arm and leg circumference was equal on both
sides.
There were no limitations in movements, masses
and deformities of the extremities as well.
All peripheral pulses were palpable and equal.
Capillary refill time was 2 seconds with no pallor
or clubbing of digits observed.

NEUROLOGIC EXAM
Mental Status Examination
The patient is awake and conscious but was
irritable, he acts according to age.

CRANIAL NERVES
CN I - not assessed
CN V - not assessed
CN VII - no facial asymmetry
CN IX, X - uvula in midline and has symmetrical upward movement upon
saying ahh
CN XI - not assessed
CN XII - tongue in midline, no fasciculations and atrophy
Sensory Not assessed
Motor No tremors, tics or fasciculations, muscle atrophy or
hypertrophy. Normal muscle tone with no muscle tenderness.
Reflexes - No pathologic reflexes seen
Cerebellar - Not assessed
Meningeal - Not assessed
Higher cortical - Not assessed

PATIENT ASSESSMENT
Primary Impression:
Pediatric Community Acquired Pneumonia C,
Simple Partial Seizure - Jacksonian Seizure
Basis:
4 day history of cough and colds
Fever of 38.4oC
Heart Rate: 138 bpm

CASE DISCUSSION
Summary of Pertinent Data
HPI
This is a case of M.A, a 1 year old boy who presented with 4 days
history of cough and colds, difficulty of breathing, loss of appetite
and fever which presented 1 day prior to admission. There was one
episode of seizure which lasted for 10 minutes few hours prior to
admission hence consult
Past Medical History:
The patient had a history of hydrocephalus 1 year prior to
admission and Ventriculo-Peritoneal shunting was done. 8 months
prior to admission, patient was diagnosed with seizure disorder and
was started with Phenobarbital twice a day initially but was shifted
to valproic acid three times a day.

ROS
(+) weight loss (9.8kg-9.3kg)
(+) loss of appetite
(+) DOB
(+) diarrhea
PE
(+) tachycardic
(+) Fever 38.4oC

Differential Diagnosis
Disease
Influenza

Rule In
> fever
> cough
> loss of appetite

Bronchitis

> fever
> there was no wheezes or stridor which indicates
> cough
obstruction of the bronchi
> difficulty of breathing >no sputum production noted
>use of accessory muscles not noted

Pertussis

> fever
> cough
> vomiting
> difficulty of breathing

> usually starts with nasal congestion, rhinorrhea and

sneezing rather than a cough
> cough is intense and followed by an inspiratory
whoop

Cystic Fibrosis

> cough

> recurrent pneumonia

> cough is usually associated with non-respiratory
symptoms like GI including meconium ileus, abdominal
distention, intestinal obstruction, failure to thrive as well
as jaundice

Pulmonary Tuberculosis > cough

> weight loss
> fever

Rule Out
> there was no noted weakness, rhinorrhea

Can be ruled out upon sputum smear examination,

chest radiography and PPD

EVIDENCE BASED MEDICINE: APPRAISING A

DIAGNOSTIC ARTICLE
Performance of lung ultrasonography in
children with community-acquired pneumonia
Susanna Esposito1*, Simone Sferrazza Papa1,
Irene Borzani2, Raffaella Pinzani1, Caterina
Giannitto2, Dario Consonni3 and Nicola
Principi1

I. Evaluating Directness
1. Does the study provide a direct enough answer to
your clinical question in terms of type of patients
(P), exposure/intervention (E), and outcome (O)?
CLINICAL SCENARIO

JOURNAL

Patient

Male and female children between 1 month and 14 years w/

a mean age of 4.6 years old w/ fever and signs and
symptoms consistent with CAP with no previous chest
radiograph from a different hospital.

Intervention

Lung ultrasonography

Comparison

Diagnostic performance of ultrasonography compared to

chest radiograph

Outcome

Identify the lung lesions that are diagnostic for CAP

Methodology

Cohort

II. Appraising Validity

1. Was the reference standard an acceptable one?
The performance of Ultrasound in diagnosing CAP
(i.e. its sensitivity, specificity, and positive and
negative predictive values) was compared with that
of CR, considered the gold standard for CAP diagnosis
in children according to published guidelines. (Based
on page 2 under statistical analysis, first paragraph)

II. Appraising Validity

2. Was the reference standard interpreted independently
from the test questions?
Upon enrolment, all of the children with suspected CAP
underwent CR, both posteroanterior and lateral views as
recommended in recently published guidelines. The
radiographs were evaluated by an independent expert
radiologist, who classified the findings as alveolar
pneumonia, non-alveolar (interstitial) pneumonia, mixed
interstitial and alveolar pneumonia, or no pneumonia in
accordance with the World Health Organisation (WHO)
criteria for the standardised interpretation of pediatric chest
radiographs for the diagnosis of pneumonia. (Based on
page 2 under Radiologic examinations, first paragraph)

III. Interpreting Results

sensitivity= 94%
specificity= 98.11%
p. 3 Table 1

III. Interpreting Results

LR+ = a/(a+c)
b/(b+d)
LR+ = 47/(47+3)
1/(1+52)
LR+ = 49.8145%
A positive lung CAP ultrasound is 49.7354% more likely to be
found in a person with positive CAP chest radiography result
compared to those with negative result. LR+>10 indicates a
strong positive test result and an increased probability of the
presence of CAP.

III. Interpreting Results

LR- = c/(a+c)
d/(b+d)
LR- = 3/(47+3)
52/(1+52)
LR- = 0.0612%
A negative lung CAP ultrasound is 0.0612% more likely
to be found in a person without CAP than in a person
with it. LR-<0.1indicates a strong negative result.

IV. Assessing
Applicability
1. Are there biologic issues that may affect accuracy of the test?
(Consider the influence of sex, co-morbidity, race, age and pathology)
NO. There are no biologic issues that may affect the accuracy of the test.
In terms of age... The subjects included in the study were with a mean age
of 5.6 years (page 1, Abstract, Methods)
Page 2, Methods, Study design and patients, 2nd paragraph states..
All of the otherwise healthy children born at term aged between 1 month
and 14 years admitted with fever (i.e. an axillary temperature of >38C)
and signs and symptoms consistent with CAP (i.e. cough, tachypnea,
dyspnea or respiratory distress, and breathing with grunting or wheezing
sounds with rales) and hospitalized in our pediatric ward were considered
eligible for inclusion.

IV. Assessing Applicability

The patient is 1 year old, therefore, in terms of age, there are no issues to be
considered that might affect the accuracy of the test since all subjects belong to
the pediatric group and ultrasound findings does not actually vary greatly in
children.
Race: The study took place in Pediatric Highly Intensive Care Unit of the
Department of Pathophysiology and Transplantation of the University of Milan
(Page 2, Methods, Study design and patients, 1st paragraph). It can be assumed
that most subjects are European, however it is not explicitly stated in the
research protocol that all . The patient is a Filipino. Although, There are no racial
differences that have been identified in previous studies that may affect the
results of lung ultrasound.
Co-morbidity: The study subjects include all otherwise healthy
children...admitted with fever and signs and symptoms consistent with CAP. The
patient however have a seizure disorder but there were no identified comorbidities that can affect the accuracy of the results of a lung ultrasound.

IV. Assessing Applicability

2. Are there socio-economic issues that may affect
accuracy of the test?
There are no socio-economic issues that may
affect accuracy of the test since lung ultrasonography
is commercially available.

V. Individualizing the
Result
Computations
Pre test probability- 60%
Pre test odds - 60/40 = 1.5
Post test odds = LR x Pretest odds
= (LR = A/(A+C) all over B/ (B+D))
= 49.81 x 1.5
= 74.72
Post test probability Using the Normogram= 98%
With a pre test probability of 60% and a positive likelihood ratio of 49.81
the post test probability computed was 98% which falls to the
therapeutic threshold therefore, the use of ultrasonagraphy can now be
used to diagnose with more conviction and commitment.

V. Individualizing the
Result
No Action

Testing Threshold

Therapeutic Threshold

60%-----> 98%