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CLINICO-Radiologic Conference

CLINICO-Radiologic Conference. General Data. YJM 6 months/Female San Miguel, Manila Roman Catholic. Chief Complaint: Fever. ROS:. General: no weight loss/gain ,no chills Skin: no pruritus , rashes, discoloration

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CLINICO-Radiologic Conference

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  1. CLINICO-RadiologicConference

  2. General Data • YJM • 6 months/Female • San Miguel, Manila • Roman Catholic

  3. Chief Complaint: Fever

  4. ROS: • General: no weight loss/gain ,no chills • Skin: no pruritus, rashes, discoloration • HEENT: no eye redness, itchiness, pain, discharge; no aural tenderness, discharge; no epistaxis, no gum bleeding, oral sores • Respiratory: see HPI • Cardiovascular: no cyanosis, no clubbing • GI: no diarrhea, no constipation, no vomiting, no melena, hematochezia • GUT: no dysuria, hematuria, oliguria; no discharge from genitalia • Extremities: no cyanosis, swelling, limitation in the range of motion • Nervous/Behaviour: no tremors, no muscle weakness or paralysis

  5. Gestational, birth and Neonatal History • born to a 19 year old G1P0 (0-0-0-0), living in with a 20 year old billboard maker. • monthly prenatal checkup in a health center with a physician starting at 2 months AOG • regular intake of multivitamins and Ferrous sulfate. • No screening for diabetes and hepatitis B. • Recurrent urinary tract infection (2-7 mos AOG) diagnosed via urinalysis and was treated with Cefalexin 500 mg/tab TID for seven days.

  6. no exposure to viral exanthems, smoke, radiation, and chemicals. • preterm at 34 AOG at Sampaloc Hospital via NSD (with amniotomy) with the aid of an obstetrician with no complications. • birth weight was 1.9 kg. • Nursery stay:11 days

  7. Developmental Milestones Development is at par with age • able to keep visually track of objects, good head control on prone and looks around and sustained smiling at 3 months of age • at 6 months of age, can reach with either hand, roll over, laugh and play, imitate speech sounds and on lying prone, patient is able to raise chest up

  8. Feeding history • Breastfed until 2 mos • Shifted to S26 (1:2 dilution) • Shifted to Bonnamil (1:2 dilution) at 5 mos

  9. Past medical history • No other illnesses, previous hospitalizations, surgeries, or blood transfusions • No known allergies

  10. IMMUNIZATION HISTORY • The patient had complete immunization done at local health center:

  11. FAMILY HISTORY • (+)Asthma – mother • (-)Hypertension, Diabetes Mellitus, allergies, renal disease, TB, seizures, malignancy, thyroid diseases

  12. Family profile

  13. SOCIOECONOMIC and ENVIRONMENTAL HISTORY • Patient lives with extended family of 11 members in a 4 storey house made of wood and concrete. • House is well- ventilated and well-lit; no factories nearby • Water source for drinking is purified, mineral water • Garbage collected everyday; not segregated • They have 2 pet cats in the house • No exposure to cigarette smoke

  14. PHYSICAL EXAMINATION • General Survey: awake, irritable, in cardiorespiratory distress, carried by her mother well hydrated, well nourished, ill looking • Vital Signs: HR 147 bpm, regular, RR 76 cpm, Temp 38.4oC • Anthropometrics: Wt 7kg (z score : -1 normal), Lt 72cm (z score: -1 normal), BMI 17.94 (z score: 0 normal) HC: 41cm • Skin: warm, moist skin, no rashes, good skin turgor • HEENT: normocephalic, anterior fontanelle depressed, normal hair distribution. No gross facial deformities. Pink palpebral conjunctiva, anicteric sclera, (+) ROR, pupils 2-3 mmERTL. Midline septum, (+) nasal discharge, (+) alar flaring. Non hyperemic EAC, no tragal tenderness, (-) aural discharge. Moist buccal mucosa, no gum bleeding and sores, non hyperemic posterior pharyngeal wall, tonsils not enlarged. Supple neck. No palpable cervical lymph nodes, thyroid gland not enlarged.

  15. Physical examination • Chest and lungs: Symmetrical chest expansion, (+) supraclavicular, suprasternal, intercostal and subcostal retractions. (+) coarse crackles on both lung fields. Chest Circumference:44 cm • Cardiovascular: adynamic precordium, AB 4th LICS MCL, no murmurs • Abdomen: Flat, soft, non tender, AC: 42cm normoactive bowel sounds, no hepatosplenomegaly, no masses • Genitourinary: grossly female, majora covers minora • Extremities:pulses full and equal, no cyanosis, no edema, no limitation in range of motion,(-) sacral dimpling, (-) tufts of hair

  16. NEUROLOGIC EXAM • Mental status: awake, alert, irritable • Cranial nerves: Intact Cranial nerves I-XII intact (Pupils 2-3 mm ERTL, OU, isocoric, conjugate gaze, EOM full and equal, (+) direct and consensual light reflex; No gross facial asymmetry, gross hearing intact, (+) gag reflex, uvula midline • Cerebellum: cannot be assessed • Motor: good muscle tone on all extremities, no limitation in movement, no rigidity, spasticity, flaccidity • Sensory: No sensory deficits • Deep tendon reflexes: 2+ • Pathologic reflexes: (-) nuchal rigidity(-) Brudzinski’s, (-) Kernig’s

  17. SALIENT FEATURES

  18. Approach to Diagnosis

  19. 1ST Hospital Day • Patient presented with respiratory distress and fever. • Given oxygen supplementation at 4-5 liters per minute via mask. • She was put on NPO and was started on IVF of D5 0.3 NaCl to run at 29 -30 drops/hr. • CBC with platelet count and Chest X-ray were requested. • CBC showed leukocytosis (WBC18.20) and chest x-ray showed the presence of infiltrates on both lung fields. • Patient was given Cefuroxime 250mg/Iv (107 mkd), Paracetamol 100 mg/SIVP for fever and 0.65 % NaCl nasal drops.

  20. 2nd Hospital Day • Patient was started on Gentamycin 30 mg/SIVP. • Patient had showed progression of respiratory distress • ABG was requested and it showed respiratory acidosis with hypoxemia. • The patient was intubated, a nasogastric tube inserted and was admitted to the pediatric intensive care unit. • She was hooked to a cardiac monitor, pulse oximeter and mechanical ventilator. • Chest x-ray after intubation showed progression of the previously noted infiltrates bilaterally and the presence of endotracheal tube at the level of T2-T3. • Blood culture and sensitivity were requested. • Patient was referred to pediatric pulmonology for further evaluation and management. • Cefuroximewas discontinued and patient was started on Vancomycin. • Patient was also started on nebulization with Salbutamol.

  21. 3rd Hospital Day • Midazolamwas given. • Nebulizationwith Salbutamol alternating with salbutamol + Ipratropium was continued followed by chest physiotherapy. • Tracheal aspirate grams stain showed absence of microorganisms. • Repeat CBC showed low hemoglobin (82 mg/dL) • Patient was transfused with 70 mL PRBC. • Serum Na, K, SGPT and creatinine were requested and results were normal. • Indwelling catheter was inserted.

  22. 4th Hospital Day • Meropenem 300 mg/dose IV infusion every 8 hours (128 mkd). • Started feeding with milk formula was started at 30 ml every 3 hours given via nasogastric tube.

  23. 7th Hospital Day • Arterial blood gas determination showed metabolic alkalosis. • Chest x-ray showed confluence of densities in right upper lobe with slight shifting of minor fissure upwards, alveolar infiltrates are again seen in left upper and right lower lobe, and lung fields are slightly hyperaerated. • Endotrachealtube aspirate culture and sensitivity showed presence of Haemophilushaemolyticus. • Repeat CBC showed increased in hemoglobin from 82 to 119, and decrease in WBC from 17.8 to 11.1.

  24. 8th Hospital Day • Swas given Hydrocortisone 30mg/SIVP every 6 hours (4.2 mkdose). • Midazolam was decreased 1mL/hr.

  25. 10th Hospital Day • Extubation was done. Salbutamol nebulization was done and she was hooked to O2 per mask at 5 lpm. • Serum Na and K were done with normal results.

  26. 11th Hospital Day • IV hydrocortisone was shifted to oral 2.5mL BID (Prednisone 10mg/5ml). • O2 was also shifted to funnel at 2-3lpm to maintain O2sat >95%.

  27. 12th Hospital Day • O2/funnel was discontinued, NGT was removed. • Patient was transferred to ward. • Medications • Meropenem300mg/SIV infusion (128mkd) every 8 hours to complete 10 days • Gentamycin35mg/SIVP (5mkd) everyday until 11/22/10 • Prednisone 10mg/5ml 3.5 ml (1.4mkd) BID after feeding • Zinc 10mg/ml 1ml QD • Salbutamolnebulization 1ml + 1 ml NSS q6h • Zinc oxide cream apply over perianal area after each diaper change.

  28. DISCUSSION

  29. Etiology • Streptococcus pneumoniae • Haemophilus influenzae • Staphylococcus aureus • Influenza virus • Respiratory syncytial virus (RSV) Bacterial Viral

  30. Viral Pneumonia Airway infection Airway obstruction Injury of the Respiratory epithelium

  31. Bacterial Pneumonia • S. pneumoniae • Local edema • Proliferation of organisms • Spread to adjacent portions of lung • Lobar involvement

  32. Bacterial Pneumonia • S. aureus • Confluent bronchopneumonia • Unilateral • Extensive areas of hemorrhagic necrosis, irregular areas of cavitations of the lung parenchyma • Pneumatoceles, empyema, bronchopulmonary fistulas

  33. Pneumonia • Recurrent pneumonia • 2 or more episodes in a single year, OR • 3 or more episodes ever, with radiographic clearing between occurences • Consider an underlying disorder • Slowly resolving pneumonia • Persistence of symptoms or radiographic abnormalities beyond the expected time course

  34. Clinical Manifestations • Preceded by URTI • Fever • Restlessness • Tachypnea • Increased work of breathing • Asymmetrical chest expansion • Decreased breath sounds • Dullness on percussion • Crackles, ronchi • Abdominal distension • Rapid progression

  35. Complications • Direct spread of bacterial infection within the thoracic cavity (pleural effusion, empyema, pericarditis), OR • Bacteremia and hematologic spread • Empyema and parapneumonic effusions • S. aureus, S. pneumonia, S. pyogenes • Imaging studies • Treatment is based on stage • Antibiotic + Chest tube thoracostomy

  36. Differentiation of Pleural Fluid

  37. Diagnosis • Peripheral WBC count • Chest radiograph • Viral pneumonia • Pneumococcal pneumonia • Atypical pneumonia • Viral genome or antigen • RSV • Parainfluenza • Influenza • Adenovirus • Bacterial culture and sensitivity testing • Sputum • Blood

  38. Treatment - IMCI Does the child have cough or difficulty breathing? If YES • General Danger Signs • Lethargy or unconciousness • Inability to drink or breastfed • Vomiting • Convulsions • ASK • For how long? • LOOK, LISTEN, FEEL: • Count the RR in 1 min • Look for chest indrawing • Look and listen for stridor Age 2 mos. – 12 mos. 12 mos. – 5 yrs. Fast breathing 50/minute or more 40/minute or more

  39. Soothe the throat, relieve cough with a safe remedy • Breastmilk for exclusively breastfed • Tamarind, calamansi, ginger • Harmful remedies • Codeine cough syrup • Other cough syrus • Oral and nasal decongestants

  40. Treatment for Pneumonia or Very Severe Disease

  41. Vitamin A Supplementation for Severe Pneumonia or Very Severe Disease

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