Grand Rounds

Group Names Date

General Data
     

J.D. 12 y/o male Roman Catholic Tondo, Manila Informant: mother Reliability: 90% Chief Complaint: Difficulty of breathing Date of Admission: June 18, 2007

 

History of Present Illness

4 days PTA
 

Intermittent fever (highest temp 39.4 ˚C) Accompanied by productive cough with yellowish sputum and 4 episodes of nonbilious, nonprojectile vomiting of previously ingested food and ~10 episodes of post-tussive vomiting Paracetamol (12mkdose) Intermittent, moderate to severe crampy abdominal pain on the epigastric area which eventually became generalized, aggravated by coughing, accompanied by difficulty of breathing; (-)changes in bowel movement, no cyanosis

History of Present Illness
 Consult:

hospital

government

A>dyspepsia r/o acute appendicitis  P> CXR, CBC and Urinalysis > THM: Lansoprazole

History of Present Illness

1 day PTA
 Persistence

of fever, cough, abdominal pain, difficulty of breathing (inc. RR, alar flaring, chest pain)

ADMISSION

Review of Systems = pertinent for your patient
     

(-) (-) (-) (-) (-) (-)

weight loss, anorexia excessive lacrimation palpitations jaundice hematuria, dysuria, urinary frequency seizures

Past Medical History

(+) Bronchitis - 4 mos old, 7 y/o - S/Sxs: - Consult: A> P> (+) PTB disease (7y/o)
 

   

(+) skin asthma (9 y/o)

(+) PPD, (+)CXR, (+) recurrent cough?, fever? & difficulty of breathing Treated anti-Koch’s medication (HRZ) for 6 months D works

(+) varicella (5 y/o) (-) mumps, measles (-) previous operations

Immunizations
     

(+) BCG – 1 dose (+) DPT – 3 doses (+) OPV- 3 doses (+) Hepa B- 3 doses (+) Measles- 1 dose All given at a local health center, unrecalled dates, no booster doses were given

HEADDS
 

   

H – good relationship with his family E- average (passing grades 70s, Gr. 6 public school student) A- Fond of sketching and playing basketball D- mixed diet D- (-) drug abuse/use S- (-) suicidal ideation S- (-) sexual relationships

Family History
  

(+) DM- paternal aunt (+) HPN- both sides (+) PTB- maternal aunt
 (+) 

CXR, (+) PPD, (+) symptoms treated for 6 months, (HRZ)

(-) thyroid disease, renal disease, cancer

Family Profile
JD Father 32 y/o Smoker; alcoholic beverage drinker; unemployed Non-smoker; nonalcoholic beverage drinker; employee at a pawnshop Apparently healthy

CD Mother 34 y/o

Apparently healthy

JD

Sister

7 y/o

complete Apparently immunizations done Healthy at a local health center

Socioeconomic & Environmental Profile
 

   

Lives in a concrete, owned house, that is well-lit and well- ventilated with his family and 10 other family members (paternal uncle+ wife + 4 kids, 2 paternal grandmothers, 2 paternal aunts) Garbage collection daily water source: MWSS, drinking water is boiled for 30 minute 1 pet dog No nearby factories

PE on Admission
        

Awake, alert, in respiratory distress, prefers to be seated in tripod position Well hydrated, well nourished, well developed BP: 100/60 (%) RR: 30 (12-18 cpm) PR: 90 (55-85 bpm) T: 39.6 ˚C (35-36.5) Ht: 145 cm (p25-50) Wt: 41 kg (p50) Warm, moist skin, (+) multiple hyperpigmented / erythematous papules and plaques with erosions and crusting with some areas of lower extremities

PE on Admission
 

Eyes: Pink palpebral conjunctiva, anicteric sclera Ear: no aural discharge, no tragal tenderness, tympanic membranes intact Nose: Midline nasal septum, No alar flaring, No discharge, turbinates not congested Neck: supple neck, no palpable cervical lymph nodes Mouth: moist buccal mucosa hyperemic posterior pharyngeal wall, tonsils are not enlarged

PE on Admission

  

Chest: Rapid and shallow breathing, symmetrical chest expansion, no retractions, dullness on R hemithorax T6 down, decreased breath sounds and decrease vocal fremiti on R hemithorax, (+) bronchophony RLL ; (+) crackles on L hemithorax, more prominent at T8 level Heart: Adynamic precordium, apex beat 5th LICS MCL, no mumurs, heaves or thrills Abdomen: Flat abdomen, normoactive bowel sounds, soft (+) direct tenderness (R>L) Extremities: pulses full and equal, no edema, no clubbing

Salient Features

Subjective
   

12 y/o male 4 day history of fever Productive cough with yellowish sputum Progressive difficulty of breathing

Objective  Awake, alert, in respiratory distress, prefers to be seated in tripod position  Tachypneic, febrile  Chest:

(+) retractions, dullness on R hemithorax, T6 down, decreased breath sounds on R hemithorax ; (+) Bronchophony RLL (+) crackles on L hemithorax, more prominent at T8 level

Presenting Manifestation
   

Difficulty of breathing Tachypnea Fever Rapid shallow breathing

Approach to Diagnosis

Look for a symptom, sign or laboratory finding pointing to the involvement of an organ system RESPIRATORY SYSTEM

Initial Impression

Pneumonia

Dyspnea

Abnormally uncomfortable awareness of breathing Work of breathing is excessive
 Increased

force generation  Ventilation is excessive for the level of activity

Dyspnea

Excessive or abnormal activation of the respiratory centers in the brainstem
 Intrathoracic

receptors (vagal nerves)  Afferent somatic nerves (respiratory muscles and chest wall)  Chemoreceptors (brain, aortic and carotid bodies)  Higher cortical centers  Afferent fibers (phrenic nerves)

Pathophysiology

Pathophysiology

Dyspnea
    

Restrictive disease of the lungs Obstructive disease of airways Parenchymal Lung disease Cardiovascular Pulmonary vascular occlusive disease

Dyspnea
Restrictive disease Chest pain with tenderness Chest wall deformityDecrease d respiratory muscle strength Obstructive diseases of the airways Cough Stridor Retractions of suprclavicular fossa Wheezing Sputum production ronchi, crackles Asthma, Bronchitis, Pneumonia, TB Cardiac Venous occlusive disease Sudden onset Phlebitis Dyspnea at rest Near syncope

Chest pain Palpitations Exertional dyspnea History of heart disease or HPN Nocturnal paroxysmal dyspnea CHF

COPD, kyphosis, scoliosis, diaphragmatic paralysis

Pulmonary embolism

Differentials
   

PTB reactivation Asthma Bronchitis Pneumonia

PTB

Mycobacterium tuberculosis
 acid-fast

bacilli, obligate anaerobes, slow-growing  Mycolic acid  transmission: airborne, inhalation of droplet nuclei produced by an adult or adolescent with contagious, cavitary PTB  Incubation period: 2-12 weeks from infection to development

Post primary TB
 

reactivation of a latent primary infection and rarely from the repeat infection of a previously sensitized host Approximately 10% of all infected patients are likely to develop reactivation, highest risk within 2 years of primary infection Factors contributing to reactivation
  

 

typically a disease of adolescence and adulthood The major determinants

immunosuppression Inadequate treatment Trauma

of the type and extent of disease are the patient's age and immune status, the virulence of organism, and the mycobacterial load

Post primary TB

Pulmonary reactivation usually occurs in the apical and posterior segments of the upper lobes or in the superior segments of the lower lobes classical clinical presentation
    

cough, fever, weight loss, night sweats, hemoptysis, and acid-fast bacilli in the sputum None of these is universally present minimal signs or symptoms Patients with postprimary cavitary TB are more infectious than those with miliary TB Cavitation into a bronchus results in a high bacterial load in the sputum and, thus, higher infectivity.

Differentials
   

PTB reactivation Asthma Bronchitis Pneumonia

Asthma

 

Chronic inflammation of airways that is characterized by incresed responsiveness of the tracheobronchial tree to a multitude of stimuli Widespread narrowing of air passages Paroxysms of dyspnea, cough and wheezing Episodic disease with acute exacerbations interspersed with symptom-free periods

Asthma
    

Atopy is the single largest risk factor for development of asthma (+) personal or family history of allergic disease Triad of symptoms: dyspnea, cough, wheezing Dry coughing, expiratory wheeze, chest thightness, dyspnea Provoked by physical exertion and airway irritants

Differentials
   

PTB reactivation Asthma Bronchitis Pneumonia

Bronchitis
  

Usually viral in origin Cough is a pertinent feature Tracheobronchial epithelium is invaded by an infectious agent Activation of inflammatory cells and release of cytokines Leads to destruction of epithelium

Bronchitis

 

Nonspecific upper respiratory infection symptoms 3-4 days frequent, dry hacking cough Sputum becomes purulent, this may produce emesis Cough gradually abates

Bronchitis

Clinical Manifestation
 Low-grade

fever  Upper respiratory signs  Cough worsens  Breath sounds become coarse  Coarse and fine crackles  Scattered high-pitched wheeze

Differentials
   

PTB reactivation Asthma Bronchitis Pneumonia

Pneumonia

Inflammation of the parenchyma of the lungs An infection of the alveoli, distal airways, and interstitium of the lungs Viral- spread of infection along airways Bacterial –lung parenchyma

Epidemiology

 

Viral pathogens most common cause of LRTI in infants and children <5 years of age Peak attack of viral pneumonia is between ages 2-3 years and decreases thereafter RSV major pathogen in <3 year old kids Bacterial more common >5 years of age

Etiology according to age group
Age 1-48 hrs 1-14 days Common pathogens Group B streptococcus E. coli, Klebsiella, Enterobacteriaceae, Listeria, S. aureus, Anaerobes, GB Enterobacteriaceae, GBS, S. aureus, C. albicans, H. influenzae, S. pnuemonia H. influenzae, S. pneumonia S. pneumonia, M. pneumonia

2 wks-2 mos

2 mos-5 yrs 5-21 yrs

Streptococcus pneumoniae

 

Gram positive, lancet shaped, encapsulated diplococcus Only encapsulated strains cause serious disease in humans a-hemolysis on solid media Bile soluble and optochin-sensitive

Epidemiology

 

>90% of children between 6 months to 5 years of age harbor S.pneumoniae in the nasopharynx at some time Pneumococcal carriage rate peak during the first 2 years of life Most common cause of community acquired bacterial pneumonia and otitis media Most common cause of bacterial meningitis in children Most common cause of meningitis in adults Transmitted person-person by respiratory droplets

Clinical Manifestation
        

Preceded by several days of symptoms of URTI (rhinitis, cough) Fever- higher in bacterial pneumonia than viral Tachypnea most consistent clinical manifestation Subcostal, intercostal, suprasternal retractions, nasal flaring and use of accessory muscles Crackles, wheezing, ronchi Diminished breath sounds Dullness on percussion Respiratory lag on excursion Abdominal distention

Diagnosis

CXR
 confirms

diagnosis of pneumonia however, radiographic appearance alone is not diagnostic and other clinical features must be considered  Pleural effusion or epyema  Confluent lobar consolidation

Diagnosis

Bacterial pneumonia characterized by
 

  

Lobar consolidation Elevated WBC 15000-40000/mm3 w/ predominance of granulocytes Definitive diagnosis is isolation of organism from blood, pleural fluid or lung Sputum culture has no value Blood cultures + in 10-30% of cases ASO titer for group A strep. Pneumoniae

Treatment

Empirical treatment

IV Penicillin G is the doc for penicillin-sensitive strains

200,000-250,000 U/kg/24 hr divided into q 4-6 hrs Cefotaxime (225-300 mg/kg/24 hrs divided into q8 IV) Ceftriaxone (100mg/kg/24 hrs divided into q 12-14 IV) Vancomycin (60 mg/kg/24 hrs divided into q6 IV) Rifampin (20 mg/kg/24 hrs divided into q12 PO)

For intermediately resistant strains
 

For highly penicillin-resistant strains
 

Complications
 Pleural

effusion  Pericarditis  Empyema

Prognosis
 

  

Integrity of host immune system Virulence and numbers of infecting organism Age of the host Site and extent of infection Adequacy of treatment

Course in the ward

On Admission
   

CXR (PA and Lateral decubitus) Urinalysis, CBC and platelet was done Hooked to O2 per nasal cannula at 2-5 LPM IVF: D5 0.3% NaCl 500cc to run at 22 gtts/min (110%) Medications:
 Penicillin

G 1,000,000 u/SIVP q 4 hours  Paracetamol 500 mg/tab q 8 hrs for T> 38.5  Ranitidine 50 mg/SIVP q 8 hrs

Course in the ward

1st hospital day 6/19

clinically improved, although bronchophony and dullness still persisted Upon passage of stools, patient reported to have resolution of abdominal pain and there was no more direct tenderness upon palpation of the RLQ Persistence of rhonchi and decreased breath sounds on the right Sputum AFB smear and Gram stain was done

Course in the ward ? 2nd

Seen by Pedia-Pulmo
 Afebrile  Increased

BS, RLL  Increased vocal femiti RLL  (+) crackles, bilateral  (+) wheezing R>L

Course in the ward

3rd hospital day 6/23
 

 

History of asthma? Salbutamol nebulization, 3 doses, 20 minutes apart Referred to allergology Salbutamol 100mcg, 2 puffs at 4 pm
 pre=

290 post= 300

 

Salmeterol + Fluticasone 25 mcg,1 puff BID Salbutamol 100mcg, 2 puffs every 6 hours

Course in the ward

5th hospital day
 Predilator

(AM): 290  Postdilator (PM): 310  Peak Flow Variability: 13.7% Mild intermittent

Thank you and good day

CBC at JRMMC
CBC
HGB RBC HCT MCV MCH MCHC RDW PLATELET WBC NEUTROPHILS METAMYELOCTES BANDS SEGMENTED LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS BLASTS ---0.93 0.07 0.00-0.05 0.50-0.70 0.20-0.40 0.00-0.07 0.00-0.05 0.00-0.01 433 28.81 0.40

6/15/07
132

Normal values
120-170 4.0-6.0 0.37-0.54 87 +/- 5 29 +/- 2 34 +/- 2 11.6-14.6 150-450 4.5-10.0 0.50-0.70

back

Complete Blood Count
CBC
HGB RBC HCT MCV MCH MCHC RDW PLATELET WBC NEUTROPHILS METAMYELOCTES BANDS SEGMENTED LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS BLASTS

6/19/07
116 g/L 4.11 x10^2 /L 0.36 86.50 U^3 28.30 32.70 12.70 510 15.70 0.84 --0.84 0.14 0.02 ----

Normal values
120-170 4.0-6.0 0.37-0.54 87 +/- 5 29 +/- 2 34 +/- 2 11.6-14.6 150-450 4.5-10.0 0.50-0.70

0.00-0.05 0.50-0.70 0.20-0.40 0.00-0.07 0.00-0.05 0.00-0.01

back

Urinalysis
URINALYSIS Color Transparency Ph Specific Gravity Albumin Sugar RBC Pus Cells Squamous Cells Renal Cells Bacteria Mucus Threads Amorphous urates 06/18/07 Dark Yellow Slightly cloudy 6.00 1.020 + Negative 11/hpf 5/hpf 38hpf 3/hpf
back

•Remarks: centrifuged specimen: Bacteria ++

CXR PA view

back

CXR Lateral Decubitus

back

Official X-ray results

  

There is homogenous density in the right lower hemithorax There are also infiltrates in the right infraclavicular area Rest of the lungfields is clear Heart is not enlarged IMPRESSION:
  

Pneumonia, right lower lobe PTB, right upper lobe Right lateral decubitus failed to demonstrate any layering of free pleural fluid.
back

Sputum AFB and Gram stain results
date Acid fast bacilli seen Gram (+) cocci n pairs and in short chains Gram (-) bacilli 6/20/07 None 6/21/07 None 6/22/07 None

++

++

++

+

+

Polymorphonucle ar cells Squamous epithelial cells

More than 25/LPF

More than 25/LPF

15-20/LPF

10-15/LPF

0-5/LPF

15-20/LPF

back

GINA classification based on level of control

Treatment
Classificatio Controller n Intermittent None Mild persistent Moderate persistent Severe persistent Reliever

ICS +/- other controllers Inhaled B2 ICS +/- LABA agonist when needed +/- other controllers ICS/oral CS + LA dilators

Sign up to vote on this title
UsefulNot useful