Post on 14-Apr-2018
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Pulmo Conference
Pediatrics OPD
Presented by:
Francesca Dolendo
Margaux Mae Rayos
Angelo Miguel RealinaJose Gabriel Recio
Allen Lester Reyes
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GENERAL DATA
NAME:
AGE: 11 y.o.SEX: Male
DATE OF BIRTH:
RACE: Filipino
RELIGION: Catholic
INFORMANT: Mother RELIABILITY: Good
CC: Cough
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4 mos PTC
• Experienced cough, productive of greenish sputum
• Generalized body malaise, anorexia
• Fever (38-39oC), Headache (5/10 rotatory)
• Amoxicillin 250 mg/mL, Paracetamol 250 mg/mL
IntervalHistory
• Resolution of symptoms
1 weekPTC
• Cough, productive of greenish sputum
• (-) fever and headache
• Amboroxol, unrecalled dose
• Symptom persisted, hence consult
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REVIEW OF SYSTEMS
General: (-) weight loss, (-) loss of appetite, (-) fever, (-) easy fatigability
Skin: (-) rashes
Respiratory: see HPI
Cardiovascular: (-) exertional dyspnea, (-) chest pain
Gastrointestinal: (-) constipation, (-) diarrhea, (-) abdominal pain, (-)
vomiting
Musculoskeletal: (-) joint pains or swelling, (-) limitation of movement
Genitourinary: (-) dysuria, (-) hematuria, (-) flank pains
Endocrine: (-) Heat/Cold intolerance, (-) polyuria, polydipsia, polyphagia
Hematologic: (-) easy bruisability, (-) gum bleeding
Nervous: (-) seizures, (-) dizziness, (-) headache
Special Senses: (-) blurring of vision, (-) hearing loss
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DEVELOPMENTAL ASSESSMENT
School Performance: Grade 3, topnotcher
Behavior: Friendly, has a group of 4 friends; no reports of behavioralproblems at school or at home
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PSYCHOSOCIAL HISTORY
Home: Up and down apartment, well ventilated, well lit
Education/School: Topnotcher in Grade 3Abuse: No reports of abuse
Drugs: Denies alcohol, tobacco and illicit drug use
Safety: No potential hazards in home/school
Sexuality: Male, identifies with male intents, prefers girls
Famiy and Friends: Harmonious family relationshipImage: Good self-image
Recreation: TV and computer games
Spiritual and Connection: Frequent mass goer
Threats and violence: No reported threats and incidents of violence
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24 HOUR FOOD RECALL
QUANTITY CALORIES
BREAKFAST
½ bowl plain lugaw 100
LUNCH ½ bowl plain lugaw 100
SNACK ½ bowl plain lugaw 100
DINNER 3 pcs. Biscuits, 1 cup milo 100+200
ACTUAL CALORIC INTAKE: 650
RENI: 1920
% OF DEFICIENCY: 33.86%
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PHYSICAL EXAM
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GENERAL SURVEY
Mental state Conscious, coherent,
oriented to 3 spheres
Cardiopulmonarystatus
Not in distress
Nutritional status Normal
Appearance Well-looking
Hydration status Well hydrated
Ambulation Ambulatory
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VITAL SIGNS
BP 100/80 mmHg
CR 90 bpm, regularly
regular
RR 17 cpm
Temp 36.8C
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ANTHROPOMETRICS
Height 131 cm (z below -1)
Weight 28.5 kg (z below 0)
BMI 16.6 (z below 0)
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Skin Warm, moist, non-jaundiced, no active
dermatoses
Head Normocephalic, no masses, no lesions, hair evenly distributed
Eyes Eyelids not swollen, eyelashes not matted,
anicteric sclerae, pink palpebral
conjuctivae, normal EOM, pupils 3 mmERTL, peripheral vision intact
Ears No tragal tenderness, no deformities, no
discharge, clear EAC, non-hyperemic TM,
cone of light visualizedNose No deformities, midline septum, no
discharge, turbinates not congested, no
sinus tenderness
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Mouth/throat Pink buccal mucosa, no mucosal bleeding,
no mucosal lesions, non-hyperemic
posterior pharyngeal wall
Neck Supple, no venous engorgement, no
masses, no palpable cervical
lymphadenopathy, thyroid not enlarged
Lungs/Chest Symmetrical chest expansion, regular
breathing pattern, no retractions, normaltactile fremiti, all lung fields resonant to
percussion, normal vocal fremiti, fine
crackles on right lung base
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Heart Adynamic precordium, apex beat 5th LICS
MCL, no heaves, lifts or thrills, S1>S2 on
apex, S2>S1 on base, no murmurs
Abdomen Flat, symmetrical, normoactive bowel
sounds, tympanitic in all quadrants, liver
and spleen not enlarged, no tenderness, no
masses palpable
Pulses/Extremities
Pulses full and equal, no clubbing, cyanosis,swelling or joint deformities
Lymph Nodes No palpable lymph nodes
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Cerebrum Mood, affect and thought content all
appropriate
Motor 5/5 all extremities
Sensory No sensory deficits
Cranial Nerves All intact
Cerebellar Can do alternate pronation supination
and finger to nose test
Reflexes +2 all extremities
Meningeal
Signs
None
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SALIENT FEATURES
Subjective Objective
- 11 yo Male
- Cough with greenish
sputum
- Previously diagnosed
pneumonia 5 months
PTC
- RR 17 cpm
- Breathing pattern
regular, not in distress
- No retractions,
normal tactile and
vocal fremiti, lung fieldsresonant
- Fine crackles on right
lung base
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APPROACH TO DIAGNOSIS
• Look for a symptom, sign or laboratory finding
pointing to an organ or organ system• Productive cough Respiratory system
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11 yo male
Productive cough
Acute <3
Weeks
Chronic
>3Weeks
• Most Common causes:
• Infections
• Acute bronchitis
• Pneumonia
• Bacterial
•Viral• Atypical
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Acute Bronchitis Pneumonia
Risk factors Preceded by a viral
URTI, smoking
Preceded by viral or
bacterial URTI
Cough Dry hacking cough
that may or may not
be productive
May be productive
(bacterial)
Adventitious breath
sounds
Coarse breath
sounds, coarse and
fine crackles,
wheezing
Diminished breath
sounds and other
signs of consolidation,
Crackles over affected
lung field and
wheezing
tachypnea none common
Fever Low grade Usually present
CXR nomal Abnormal chest x-ray
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PREDICTORS OF CAP IN A PATIENT WITH
COUGH:
1. For ages 3 months to 5 years:
Tachypnea and/or chest indrawing
2. For ages 5 to 12 years:
fever, tachypnea and crackles
3. Beyond 12 years:
Fever, tachypnea, tachycardia and: At least one abnormal chest finding of diminished breath
sounds, rhonci, crackles or wheezes
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MOST COMMON ETIOLOGIC AGENTS BY AGE
GROUP
AGE GROUP FREQUENT PATHOGENSNeonates (<1 mo) Group B Strep, E. coli, other
gram (-) bacilli, S. pneumoniae,
H. influenza B
1-3 mo
Febrile
Non-febrile
RSV, other respiratory viruses(parainfluenza, influenza,
adenovirus), S. pneumoniae, H.
influenza
C. trachomatis, M. hominis, U.
urealyticum, CMV
3-12 mo RSV, other respiratory viruses, S.
pneumoniae, H. influenza, C.
trachomatis, M. pneumoniae,
group A strep
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MOST COMMON ETIOLOGIC AGENTS BY AGE
GROUP
AGE GROUP FREQUENT PATHOGENS2-5 yr Respiratory viruses, S.
pneumoniae, H. influenzae, M.
pneumoniae, C. pneumoniae, S.
aureus, group A strep
5-18 yr M. pneumoniae, S.pneumoniae, C. pneumoniae,
H. influenzae, influenza
viruses, adenoviruses, other
respiratory viruses
≥18 yr M. pneumoniae, S. pneumoniae,
C. pneumoniae, H. influenzae,influenza viruses, adenoviruses,
L. pneumophila
Nelson’s Textbook of Pediatrics 18th ed
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Bacterial
Pneumonia
Viral
Pneumonia
Atypical
Pneumonia
Age any any 5-15 yrsOnset abrupt variable variable
Fever high variable Low-grade
Tachypnea common common uncommon
Cough productive nonproductive nonproductive
Associated
symptoms
Mild coryza,
abdominal pain
coryza Bullous
myringitis,
pharyngitis
Physical
findings
Evidence of
consolidation,
crackles
variable Fine crackles,
wheezing
Leukocytosis common variable uncommon
Radiographic
Findings
consolidation Bilateral diffuse
infiltrates
variable
Pleural
Effusion
common rare small
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RISK CLASSIFICATION FOR PNEUMONIA-RELATED
MORTALITY
Variables PCAP A
Minimal
Risk
PCAP B
Low Risk
PCAP C
Moderate
Risk
PCAP D
High Risk
1. Co-morbid illness None Present Present Present
2. Compliant caregiver Yes Yes No No
3. Ability to follow-up Possible Possible Not
possible
Not possible
4. Presence of Dehydration None Mild Moderate Severe
5. Ability to feed Able Able Unable Unable
6. Age >11 mo >11 mo < 11 mo < 11 mo
7. Respiratory rate
2-12 months
1-5 years
> 5 years
> 50/min
> 40/min
> 30/min
> 50/min
> 40/min
> 30/min
> 60/min
> 50/min
> 35/min
> 70/min
> 50/min
> 35/min
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8. Signs of respiratory
failure
a. Retraction
a. Head Bobbing
b. Cyanosis
c. Grunting
d. Apnea
e. Sensorium
None
None
None
None
None
Awake
None
None
None
None
None
Awake
Intercostal/
Subcostal
Present
Present
None
None
Irritable
Supraclavicular
/Intercostal/
Subcostal
Present
Present
Present
Present
lethargic./stuporous/
comatose
9. Complications(effusion , pneumothorax)
None None Present Present
ACTION PLAN OPD
follow-up atthe end of
treatment
OPD
follow-up after
3 days
Admit to
regular ward
Admit to a critical
care unit
Refer to specialist
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ASSESSMENT
Pneumonia, PCAP-A
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TREATMENT
PCAP A or B without previous antibiotic,
Amoxicillin (40-50 mg/kg/day) in 3 divideddoses
PCAP C without previous antibiotic and who has
completed the primary immunization againts H.
influenzae type B,Pen G 100 u/kg/day in 4 divided doses
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If primary immunization against H. influenzae type
B has not been completed and below 5 years of age, IV penicillin (100mg/kg/day) in 4 divided
doses
PCAP D, a specialist should be consulted
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TREATMENT FOR VIRAL ETIOLOGY
Antiviral agents reduces the duration of illness by
1- 1 ½ days
For influenza A infection- amantadine (4.4-4.8
mg/kg/day) can be given for 3-5 days
For inluenza B infection- oseltamivir (2mg/kg/dose
BID) for 5 days
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RESPONSE TO CURRENT ANTIBIOTICS
Decrease in the respiratory signs and
defervescence within 72 hours after initiation of antibiotic
Persistence of symptoms beyond 72 hours after
initiation of antibiotics requires reevaluation
End of treatment CXR, WBC, ESR, or CRP shouldnot be done to assess therapeutic response to
antibiotic
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If classified as out patient PCAP A/B and is not
responding to the current antibiotic within 72hours
Change the initial antibiotic
Start oral macrolide
Reevaluate diagnosis
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PCAP C is not responding to the current antibiotic
within 72 hours consider consultation with aspecialist for the following possibilities:
Penicillin resistant S. pneumoniae
Presence of complications
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PCAP D is not responding within 72 hours,
consider immediate re-consultation with aspecialist
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We can switch from IV antibiotics to oral form 2-3
days after initiation of antibiotic isrecommended in patients:
Responding to initial antibiotic therapy
Able to feed with intact GI absorption
Does not have any pulmonary or extrapulmonarycomplications
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ANCILLARY TREATMENT
Cough preparations
Chest physiotherapy
Bronchial hygiene
Nebulization using NSS
Steam inhalationTopical solutions
bronchodilators
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EPIDEMIOLOGY
• Leading cause of mortality in underdeveloped countries
158 M episodes of pneumonia / year 154 M occur in developing countries
3 M deaths worldwide in children <5 y/o; 29% of all deaths
• 3rd leading cause of morbidity and mortality in all ages
(Philippines)
• 2nd leading cause of death in infants
Kliegman, et.al Nelson’s Textbook of Pediatrics,19th ed. Elsevier (Singapore) Pte Ltd. Pages
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ETIOLOGY
Kliegman, et.al Nelson’s Textbook of Pediatrics, 19
th
ed.Elsevier (Singapore) Pte Ltd. Pages 1474-1479.
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Noninfectious Causes:
Aspiration of food / gastric acid
Foreign bodies
Hydrocarbons
Lipoid substances
Hypersensivity reactions
Drug or radiation – induced pnemanumonitis
Kliegman, et.al Nelson’s Textbook of Pediatrics,
19th ed. Elsevier (Singapore) Pte Ltd. Pages
1474-1479.
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PATHOGENESIS
ALTERED HOST FACTORS PREDISPOSING TO
PNEUMONIA
• Bypass the upper airway
• Impaired cough reflex or cougheffectiveness
• Aspiration of oral or stomach contents
• Disruption of the mucociliary blanket
• Cellular or humoral deficiency
• Altered lung parenchyma Kliegman, et.al Nelson’s Textbook of Pediatrics,
19th ed. Elsevier (Singapore) Pte Ltd. Pages
1474-1479.
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VIRAL PNEUMONIA
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BACTERIAL PNEUMONIA
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RECURRENT PNEUMONIA
2 or more episodes / 1 year
3 or more episodes w/ radiographic clearing between occurencesConsider underlying disorder
Kliegman, et.al Nelson’s Textbook of Pediatrics,
19th ed. Elsevier (Singapore) Pte Ltd. Pages
1474-1479.
TYPICAL FEATURES OF BACTERIAL VIRAL AND
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TYPICAL FEATURES OF BACTERIAL, VIRAL AND
ATYPICAL PNEUMONIAS IN CHILDREN
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DIAGNOSIS
Chest X-ray
confirm presence and location of the pulmonary
infiltrate
detect pleural involvement, pulmonary cavitation,lymphadenopathy
WBC
Differentiate viral from bacterial
Viral – normal / elevated but not higher than
20,000/mm3
Bacterial – elevated 15,000 – 40,000/mm3,
predominance of granulocytesKliegman, et.al Nelson’s Textbook of Pediatrics, 19
th
ed. Elsevier (Singapore) Pte Ltd. Pages 1474-1479.
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Definitive diagnosis (Viral) – isolation of virus / detection of viral genome / antigen
on respiratory tract secretions
Definitive diagnosis (Bacterial) – isolation of
organism in blood, pleural fluid / lung
Kliegman, et.al Nelson’s Textbook of Pediatrics, 19th
ed. Elsevier (Singapore) Pte Ltd. Pages 1474-
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SUPPORTING JOURNALS FOR DIAGNOSIS
• In the developed world a positive chest
x-ray is preferred as the gold standard.However, this has been challenged
because radiographic signs may lag
behind clinical parameters.
• A number of studies have also
highlighted the difficulty of using lobar
consolidation to diagnose bacterialpneumonia as interstitial and alveolar
changes can also be associated with
bacterial pneumonia.
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COMPLICATIONS
Pleural effusion
Empyema
Pericarditis
Bacteremia and hematologic disorders
Kliegman, et.al Nelson’s Textbook of Pediatrics,th