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NCKUH Pediatric Department Morning Meeting Case Presentation

NCKUH Pediatric Department Morning Meeting Case Presentation. 2009/09/08 4C 日光室 Presenter: Intern 李京軒. Identifying Information. 陳 O 瑄 5y4m /o Girl Admission Date: 2009-09-01. Chief Complaint. Fever up to 39 + ℃ with cough and sputum for 3 days. Present Illness.

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NCKUH Pediatric Department Morning Meeting Case Presentation

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  1. NCKUH Pediatric DepartmentMorning Meeting Case Presentation 2009/09/08 4C日光室 Presenter: Intern 李京軒

  2. Identifying Information • 陳O瑄 • 5y4m /o Girl • Admission Date: 2009-09-01

  3. Chief Complaint Fever up to 39+ ℃ with cough and sputum for 3 days

  4. Present Illness 5y4m /o Girl No underlying systemic disease Asthma, cough variant 2009-08-30 Morning Fever up to 39+ ℃ Intermittent Cough with Sticky and Yellowish sputum (but not easily to be coughed out) Poor appetite (+, mild), Poor activity (only when fever) No short of breathe, wheezing, Stridor, increased work of breathe Sore throat (-), rhinorrhea (-), vomiting(-), diarrhea(-), abdominal pain(-), Dysuria(-), discomfort while urination(-), urinary urgency(-) (observed by her mother). Her younger sister was just recovered from URI.

  5. Visited local clinic “Common cold” was told, and some symptomatic Mx was given. Fever had response to antipyretic agents, but it recurred within hours. 2009-09-01 Because of persistent fever, her family brought her to徐慶鐘小兒科. Physical examination revealed injected throat and rales over left lower lung. As a result, she was transferred to our ER. In ER T/P/R = 37.3/140/21, BP=114/71mmHg PE : Injected throat without ulceration, Coarse breathe sound Lab. results Chest X-Ray

  6. Past History Birth History: G2P2, NSD ,GA: FT weeks, BBW: 2980Kg, DOIC(-), PROM(-) Feeding: On full diet Vaccination: On schedule H. influenza B(+), Pneumococcus (+, conjugated), Influenza (-) Growth and Development: BW: 18.9 Kg(75 – 90 th%), BL: 111cm( 50 -- 75th%) Developmental milestones: WNL Past History: 1. Asthma, (cough variant ?) 2. Denied hospitalization history Social History: Nothing particular Travel History: Denied Drug Allergy History: Not known drug allergy history

  7. Review of Systems General Poor activity (+, while fever, but seems easy while no fever), Fever (+, for 3 days), Body weight loss(-), Malaise (-) Cardiovascular Tachycardia (-), Central cyanosis (-) Pulmonary Cough(+) with sputum(+, yellowish, sticky), Wheezing(-), tachpnea(-) with retraction (-) Alimentary Poor appetite ((+, mild), abdominal discomfort (-), nausea (-), vomiting (-) bowel habit change (-), diarrhea (-) Genitourinary Dysuria (-), nocturia (-) Skeletal ROM: no limitation

  8. PE Consciousness: clear Appearance: Fair looking Vital sign: T/P/R = 36.9 ℃/ 145 /min/ 28/min BP: 117/80mmHg Activity: Fair, Spirit: Fair Head: Conj: not anemic , sclera: not icteric Throat: not injected , tonsil: not enlarged Neck: supple, LAP(-)

  9. PE Chest: symmetric expansion, subcostal retraction( - ) B.S.: coarse, some rales over left lung (especially while taking a deep breath), no wheezing H.S.: regular heart beat, no murmur Abd: soft, not distended L/S: impalpable / impalpable, No tenderness, No rebounding pain BS: normoactive Extremities: freely movable, pitting edema (-) Skin: turgor fine, no rash

  10. Hemogram <緊急血液檢驗報告> 醫師: 謝旻玲 採檢:98/09/01 全血 8262A30452 -------- ------------- ------------- -------- ------------- ---------- WBC 8.9 K/cmm 3.2-9.2 | RBC 4.38 M/cmm 3.73-4.93 Hb 12.5 g/dl 11.6-14.8 | Hct 37.9 % 33.8-43.4 MCV 86.6 fl 82.7-95.5 | MCH 28.5 pg 28.2-33 MCHC L 33.0 g/dl 33.2-35.2 | RDW 12.5 % 11.6-13.6 Pl L 144 K/cmm 151-366 | Blast - % Pro - % | Myelo 1 % Meta - % | Band 8 % Seg 51 % 43-64 | Eos - % 0-6 Baso - % 0-1 | Mono H 11 % 3-9 Lymph 29 % 27-47 | Aty-lym - % NRBC - % | Remarks -

  11. Biochemistry Study <緊急生化檢驗報告> 醫師: 謝旻玲 採檢:98/09/01 血漿 8261A15687 -------- ------------- ------------- -------- ------------- --------- ALK-P H 144 U/L 30-110 | AST 35 U/L 0-39 ALT 10 U/L 0-54 | CK 68 U/L 30-135 CRP H 88.2 mg/L 0-8 |

  12. Influenza Rapid Antigen Test <病毒培養及快速診斷檢> 醫師: 謝旻玲 檢查:98/09/01 其他 8236A12778 第 01次報告 -------- ------------- ------------- -------- ------------- ------------- Item Result 二病毒抗原檢驗 Rapid antigen diagnosis 301 influenza virus type A+B antigen -Negative-Flu A -Negative-Flu B

  13. Chest X Ray AP view

  14. Lateral View

  15. Tentative Diagnosis • Pneumonia, Left lower lobe => suspect Mycoplasma pneumoniae infection

  16. Plan • Diagnostic plan: • Check serum Mycoplasma pneumoniae Ab • Check sputum routine/ culture • Check blood culture • Therapeutic plan: • Empiric antiobiotc • Ampicillin/ Sulbactam 1g Q8H • Azithromycin 250mg 3/4# qd*3 days) • Guaphen 5 ml QID use • Adequate hydration & nutrition supplement • Educational plan: • Encourage the family to performe chest care

  17. Clinical course

  18. Ampicillin/Sulbactam 1g IVD Q8H Azithromycin 10mg/Kg po QD* 3 days Discharged Mycoplasma pneumoniae Ab=1:40(+-)

  19. Discussion Mycoplasma pneumoniae infection

  20. Mycoplasma pneumonia • “ Walking ” Pneumonia • Mycoplasma pneumoniae infections prevail in children older than 2-5 years of age. • In Taiwan, Atypical pneumonia in children • M. pneumoniae(26%) • Chlamydophila pneumoniae (15%)

  21. Asymmetric Infiltrates “Time lagging” character Lower lobe preference(52%) Atelectasis (29%) Small pleural effusion(20%) Hilar lymphadenopathy(7~22%) Discrepancy with S/S Chest X-ray of Mycoplasma pneumonia Radiology review, 4th edition

  22. Diagnostic Methods for M. pneumonia International Journal of Dermatology 2009, 48, 673–681: Mycoplasma pneumoniae-induced cutaneous disease

  23. Antibiotics of Choice [1/3]

  24. Antibiotics of Choice [2/3]

  25. Antibiotics of Choice [3/3] • A Mycoplasma pneumonia • May be treated by appropriate oral antibiotics for 10 days. • If azithromycin is used, the treatment should be continued for only 3-5 days

  26. 謝謝收看

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