Pulmonology Conference

Guanzon, Guerrero, Guerzon, Guevarra, Guinto, Gutierrez, Hermoso, Icasas, Ignacio Pulmonology Conference

General Data • JA • 16yo / M • Lives in Caloocan City • Roman Catholic • Single

Chief Complaint: Difficulty of Breathing

(+) productive cough with yellowish sputum (-) fever, malaise, dyspnea No consult was done and no medications were taken. 1 month PTA 3 weeks PTA (+) easy fatigability and shortness of breath after walking for 15 meters and after 2 quarters in a basketball game (as compared to before?) (+) fever (Tmax 39.8 C) Paracetamol500 mg/tab taken after meals (+) fever in the afternoon and at night (?) night chills, sweating (?) persistence of productive cough (?) known asthmatic?

(+) consult at a local clinic CXR: “Infiltrates over the lung fields” Assessment: Pneumonia Medications: Carbocisteine250 mg/5 mL, 15 mL (1 tbsp) BID for 7 days (?mkd) Ascorbic acid 500 mg/tab BID Ciprofloxacin 500 mg/tab BID for 7 days temporary resolution of symptoms 3 weeks PTA? 1 week PTA (+) symptoms (what?) persisted (+) consult at another clinic CXR: “Massive pleural effusion on the left” Medication: Cefuroxime500 mg/tab BID for 7 days (+) resolution of fever and easy fatigability (+) productive cough with whitish sputum 1 day PTA Follow-up  USTH-OPD ADMISSION

Review of Systems • General: (-) weight change, (-) loss of appetite • Cutaneous: (-) rash • Heent: (-) excessive lacrimation, (-) epistaxis, (-)excessive salivation, • (-) nasal structures, • Cardiovascular: (-)cyanosis, (-) fainting spells • Respiratory: (-) cough, • Gastrointestinal: (-) nausea, vomiting, (-)constipation, (-)abdominal pain • Genito-urinary: (-) frequency,(-)hematuria • Nervous/Behaviour: (-) convulsions, stiffness • Musculoskeletal: (-) joint swelling, (-) limitation of motion, (-)limping • Hematopoietic: (-)pallor, (-) abnormal bleeding, (-) easy bruisability

Personal History • H: Patient lives with his mother and father. At home, he likes to watch cartoons on TV and sleep. Aside from that, he does not do anything else at home. He spends most of his free time outside playing basketball with his friends. • E: Currently in his 3rd year of high school. He prefers to play basketball than go to class or study. • E: Patient eats 3 meals a day and has no preference on the food that he eats. • A: Varsity player of the school’s basketball team; computer games • D: Patient claims that he has never smoke, drink alcohol or took illicit drugs. • S: He had 4 past girlfriends. He claimed that they had never engaged in any sexual activity. • S: Patient claims that he is very contented with his life and would never think of taking his own life.

Past Medical History • (+) Trauma due to fall (1994) – had the wound on his left ear dressed • (-) HPN, (-) DM • (-) asthma, allergies

Family History • (+) HPN – paternal and maternal grandfather, father • (+) PTb – maternal grandfather • (+) DM – maternal grandfather • (+) Thyroid disease - mother • (-) Allergies, Asthma • (-) Cancer, Kidney disease, Stroke

Family Profile

Socioeconomic & Environmental History • Patient lives with his parents and stays in the same room as them. Their house is a single level cemented bungalow, well ventilated and well lit. Drinking water is obtained from a nearby water refilling station. Garbage is collected everyday by a local garbage collector.

Physical Examination • VS: BP 110/70 HR 76 bpm RR 26/min T 36.4 C • Ht: 170 cm Wt: 53 kg • Conscious, coherent, ambulatory, not in cardiorespiratory distress • Warm moist skin, not jaundiced, no active dermatoses • Pink palpebral conjunctivae, anicteric sclera • Nasal septum midline, no nasoaural discharge, turbinates not congested • No tragal tenderness, nonhyperemic EAC AU, TM intact AUMoist buccal mucosa, nonhyperemic PPW, tonsils enlarged • Supple neck, no palpable cervical lymph nodes

Physical Examination • Asymmetric chest expansion, no retractions, trachea deviated to the right with lagging on the left, decreased vocal and tactile fremiti on the left, dullness on the left infrascapular area (T6 down), decreased breath sounds on the left upper and lower lung fields • Adynamicprecordium, AB 5th LICS MCL, no murmurs • Flat abdomen, normoactive bowel sounds, soft, nontender • Pulses full and equal, no edema, no cyanosis

Neurologic Examination • Conscious, coherent, oriented to 3 spheres • Pupil size 3-4 mm equally reactive to light; no ptosis OU • No facial asymmetry, (+) corneal reflex, (+) gag reflex • Symmetric palpebral fissures and nasolabial fold • MMT 5/5 on all extremities • No involuntary movement, no spasticity, no atrophy • No sensory deficits • No nuchal rigidity, (-) Brudzinski, (-) Kernig’s

Salient Features

Differential Diagnosis • Pleural Effusion vs. Consolidation vs. Atelectasis, etc.  clinically first then via CXR • Degree of Pleural Effusion (Massive, etc?) • Why suspect Pneumonia? • Why suspect PTB?

Asymmetrical chest expansion • Unilateral impairment or lagging of respiratory movement suggests disease of the underlying lung or pleura. • No retractions • Trachea deviated to the right • Lagging on the left • Causes of unilateral decrease or delay in chest expansion include chronic fibrotic disease of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, and unilateral bronchial obstruction. Bates’ Guide to Physical Examination

Decreased vocal and tactile fremiti on the left • Fremitus is decreased or absent when the voice is soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded. Causes include an obstructed bronchus; COPD; separation of the pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), air (pneumothorax), or an infiltrating tumor; and also a very thick chest wall. • Dullness on the left infrascapular area (T6 down) • Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space. • Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor. • Decreased breath sounds on the left upper and lower lung fields • Breath sounds may be decreased when air flow is decreased (as by obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or emphysema).

Bates’ Guide to Physical Examination

Impression • t/c Pneumonia

Pneumonia • Definition • Etiologies by age • Criteria for Dx • Criteria for confinement • Ancillary procedures • Expected clinical and lab findings • Complications • Correlate with px

Clinical Assessment • Pneumonia can be defined clinically as the presence of lower respiratory tract dysfunction in association with radiographic opacity. • WHO has promoted an algorithm to assess children who present with cough and fever. • Tachypnea, considers an increased respiratory rate • >50 breaths/min in infants • >40 breaths/min in children >11 months • Suprasternal, subcostal or intercostalretractions indicates greater severity. Canadian Medical Assoc J: A practical guide for the diagnosis and treatment of pediatric pneumonia; 1997

Radiographic confirmation is considered the gold standard. • However, no finding in itself can be used to diagnose or rule out pneumonia. The absence of the symptom cluster of respiratory distress, tachypnea, crackles and decreased breath sounds accurately (100% specificity) excludes the presence of pneumonia (level II evidence). • Assessment of oxygenation gives a good indication of the severity of disease. • Oximetry should be considered in the assessment of a child with suspected pneumonia and in all children admitted to hospital with pneumonia, because the results correlate well with clinical outcome and length of hospital stay (level II evidence). Canadian Medical Assoc J: A practical guide for the diagnosis and treatment of pediatric pneumonia; 1997

Two classic presentations have been described for pneumonia: • Typical pneumonia: fever, chills, pleuritic chest pain and a productive cough. • Atypical pneumonia: gradual onset over several days to weeks, dominated by symptoms of headache and malaise, nonproductive cough and low-grade fever. • Unfortunately, the overlap of microbial agents responsible for these presentations thwarts identification of the causal pathogen on the basis of clinical presentation. Canadian Medical Assoc J: A practical guide for the diagnosis and treatment of pediatric pneumonia; 1997

The best predictor of the cause of pediatric pneumonia is age. During the first 2 years of a child’s life viruses are most frequently implicated. As age increases, and the incidence of pneumonia decreases, bacterial pathogens, including S. pneumoniae and Mycoplasmapneumoniae, become more prevalent. Canadian Medical Assoc J: A practical guide for the diagnosis and treatment of pediatric pneumonia; 1997

In developing countries acute respiratory infections cause up to 5 million deaths annually among children less than 5 years old. • Several risk factors increase the incidence or severity of pneumonia in children: prematurity, malnutrition, low socioeconomic status, passive exposure to smoke and attendance at day-care centres.10 Underlying disease, especially that affecting the cardiopulmonary, immune or nervous systems, also increases the risk of severe pneumonia Canadian Medical Assoc J: A practical guide for the diagnosis and treatment of pediatric pneumonia; 1997

Academy of American Family Physicians: CAP in Infants & Children; 2004

Radiographic Findings • A confirmatory chest radiograph is necessary to diagnose pneumonia. Bronchiolitis and asthma may cause hyperinflation and atelectasis and must be distinguished from pneumonia. • Two main patterns of pneumonia are recognized: interstitial and alveolar. However, these patterns cannot be used to identify the cause. Peribronchial thickening, diffuse interstitial infiltrates and hyperinflation tend to be seen with viral infections (level III evidence).

Radiologic Findings • Bacterial - Lobar infiltrates, pneumatoceles, abscesses • Alveolar infiltrates, however, are also seen in bacterial as well as viral disease and in Mycoplasmapneumonia. • Pneumococcal - Circular infiltrates in the early stages • M. pneumoniaeinfection - Diffuse infiltration out of proportion with the clinical findings, lobar consolidation, plate-like atelectasis, nodular infiltration and hilaradenopathy • Chlamydialpneumonia may be indistinguishable from mycoplasmal pneumonia. • P. cariniipneumonia - reticulonodularinfiltrate that progresses to alveolar infiltrates • Tuberculosis - Hilaradenopathyespecially if the patient has epidemiologic risk factors

Canadian Medical Assoc J: A practical guide for the diagnosis and treatment of pediatric pneumonia; 1997

Course in the Ward

Management

Pulmonology Conference