Pneumonia

Mikhail G. Tenazas

Demographic data

Name: CTA Age: 11/12 Sex: Male Birthdate: November 18, 2009 Informant: CA (mother), 90% reliability JA (father), 90% reliability

CHIEF COMPLAINT

Difficulty of breathing of 1 day duration

history of present illness

2 weeks PTA: Patient developed intermitted low-grade fever with occasional non-productive cough & colds Whitish watery nasal discharge

history of present illness

2 weeks PTA: Patient developed intermitted lowgrade fever with occasional non-productive cough & colds Whitish watery nasal discharge No medications/co nsult

history of present illness

2 weeks PTA: Patient developed intermitted lowgrade fever with occasional non-productive cough & colds Whitish watery nasal discharge No medications/co nsult

1 day PTA: Worsening of cough and colds, with yellowish mucoid nasal discharge 1 episode of vomiting after feeding, nonbilous, 1/2 cup Decreased appetite

history of present illness

2 weeks PTA: Patient developed intermitted lowgrade fever with occasional non-productive cough & colds Whitish watery nasal discharge No vomiting No weakness or decreased appetite No medications taken No consult sought

Few hours PTA: Persistence of symptoms Consult at ER: Difficulty breathing (chest indrawing)

ADMISSION

REVIEW OF SYSTEMS

REVIEW OF SYSTEMS

General: No fever, weight loss Musculoskeletal/Dermatologic: No rashes, muscle/joint pains HEENT: No headache, nosebleeds, gum bleeding, or enlarged lymph nodes Respiratory: No dyspnea, cough, or wheezing

REVIEW OF SYSTEMS

Cardiovascular: No palpitations or chest pains Gastrointestinal: No dysphagia, rectal bleeding, or jaundice Genitourinary: No dysuria, urinary frequency or hematuria Endocrine: No excess sweat, heat/cold intolerance, or polyuria

PAST MEDICAL HISTORY

Antenatal History: No history of maternal illnesses, drug use or abuse during pregnancy. Past Illnesses/Medications/Hospitalizations: None.

BIRTH HISTORY

Patient was born full-term via repeat CS to a 31 yearold G2P2, attended by an Ob-Gyn Birth Wt. = 3.68 No perinatal/neonatal complications.

NUTRITIONAL HISTORY

Patient is still being breastfed until present Solid foods introduced at 6 months of age; no difficulties encountered. No food allergies.

IMMUNIZATION HISTORY

BCG (1) DPT/Polio (1-2-3) Hep B (1-2-3) HiB (1-2-3) Measles (1) No immunization against Rotavirus, Pneumococcus, Influenza, Typhoid, or Hep A.

DEVELOPMENTAL HISTORY
GROSS MOTOR
Pulls self to stand Walks holding on.

ADAPTIVE LANGUAGE FINE MOTOR

Thumb finger Two words grasp with Bangs object meaning. together.

PERSONAL SOCIAL
Helps dress, holding arm or foot out. Attempts to use a spoon

FAMILY HISTORY

Asthma: Uncle (maternal) Hypertension: Grandfather (maternal) Diabetes: None. Tuberculosis: None. Heart disease: None. Cancer: None. Stroke: None. Kidney Disease: None.

ENVIRONMENTAL HISTORY

Water source: NAWASA Drinking water: Distilled water. Feeding bottles boiled. Bathing & handwashing with body soap. No smokers at home. Garbage collected everyday. All food cooked well prior to consumption.

Physical Exam

Physical Exam

General Survey: Alert, conscious, not in respiratory distress. Anthopometrics: Weight Length HC 72 9.1 46 WHO -2 - 0 -2 - 0 0-1 CDC 10-25% 10-25% 25-50% CC 44 AC 39 MAC 44

Weight for Length: Between 1-2 (WHO), 50-75% (CDC) ER Vital Signs: HR 140s, RR 60s Temp 38.4OC Vital Signs (Wards): HR 113, RR 56, Temp 37.2OC

Physical Exam

Skin: No rashes, lumps, or lesions. No clubbing, no cyanosis. HEENT: Anicteric sclerae, pale palpebral conjunctivae. Flat, open anterior fontanelle. No TPC or CLAD, neck veins not engorged. Moist buccal mucosae. Chest: Symmetric chest expansion. Equal tactile fremiti. Lungs resonant to percussion. Harsh breath sounds. Bilateral rales. No wheezes, no stridor. Heart: Adynamic precordium. Apex beat at 5th ICS MCL. Normal rate, regular rhythm. Clear and distinct S1 & S2.

Physical Exam

Skin: No rashes, lumps, or lesions. No clubbing, no cyanosis. HEENT: Anicteric sclerae, pale palpebral conjunctivae. Flat, open anterior fontanelle. No TPC or CLAD, neck veins not engorged. Moist buccal mucosae. Chest: Symmetric chest expansion. Equal tactile fremiti. Lungs resonant to percussion. Harsh breath sounds. Bilateral rales. No wheezes, no stridor. Heart: Adynamic precordium. Apex beat at 5th ICS MCL. Normal rate, regular rhythm. Clear and distinct S1 & S2.

Physical Exam

Abdomen: Flat abdomen. No scars, no abnormal masses. No abdominal distention. Hyperactive BS. No signs of organomegaly. No tenderness. Digital Rectal Exam: No gross blood. No masses or skin tags. Extremities: Full & equal pulses. Extremities warm & dry. No edema. No cyanosis, or changes in skin color. Good skin turgor. CRT 2-3. Genitals: No discharge or bleeding. No hypospadias. Testes descended.

SALIENT FEATURES

History: 11 month-old male 2-week history of cough & colds, on & off fever Difficulty of breathing, cyanosis Vaccination: (+) Hib, (-) pneumococcal, influenza Physical Exam: Difficulty of breathing, cyanosis Tachypnea, subcostal retractions, rales Harsh breath sounds No wheezes

INITIAL IMPRESSION PCAP-C

Differentials

Differentials

Given: History of URTI Fever Tachypnea Subcostal retractions Age of patient

Differentials

Pneumonia Bronchiolitis Asthma

Pertinent positives

Pneumonia

Bronchiolitis

Fever

Tachypnea

Rales

+/-

Age

Common in Occurs at any age children <2, peak at <6 months

Pertinent negatives

Pneumonia

Bronchiolitis

Cyanosis Wheezing

+/+/-

Commonly found Commonly found

INITIAL IMPRESSION PCAP-C

COURSE IN THE WARDS

Date/Time
Day 1 12:35 AM (1st hour of admission)

SUBJECTIVE

ASSESSMENT

11 month old male 2 week history of cough &

colds, on & off fever 1 day history of difficulty breathing & circumoral cyanosis OBJECTIVE

PCAP-C

PLAN

Weight = 9.1 kg HR 140 RR Monitor & record vital signs every 4 hours Diet: NPO for RR>50 64 Temp = 38.4C Irritable, with nasal congestion Diagnostics No alar flaring, no CLAD, no CBC with platelet count Chest x-ray AP-L TPC IVF: D5IMB 500 ml x 41-42 ml/hour (M + 10%) Harsh breath sounds Medications: (+) Rales, no wheezing Salbutamol nebulization, 1 nebule every 6 Normal rate, regular rhythm hours Soft abdomen, non-tender Paracetamol 100 mg/ml, 1 ml every 4 hours Full pulses, CRT<2 Others: No cyanosis Hook to pulse oximeter, maintain O2 sat
>=95% Stand by O2 at 5 LPM via face mask

LAb results

CBC Hb: 120 Hct: 0.46 RBC: 4.29 WBC: 27.60 Platelet: 400 Differential: Neutrophil: 0.61 Lymphocyte: 0.32 Monocyte: 0.06 Eosinophil: 0.01

LAb results

CBC Hb: 120 Hct: 0.46 RBC: 4.29 WBC: 27.60 Platelet: 400 Differential: Neutrophil: 0.61 Lymphocyte: 0.32 Monocyte: 0.06 Eosinophil: 0.01

COURSE IN THE WARDS

Date/Time
Day 1 6:00 AM (6th hour of admission)

SUBJECTIVE

ASSESSMENT

Awake, comfortable Improved appetite Afebrile

PCAP-C

OBJECTIVE

PLAN

Weight = 9.1 kg HR 120 RR 48

Temp = 37.2C Irritable, with nasal congestion Subcostal retractions (+) Rales, no wheezing Normal rate, regular rhythm Soft abdomen, non-tender Full pulses, CRT<2 No cyanosis Chest x-ray findings: Interstitial infiltrates, bilateral

Start Cefuroxime 325 mg IV q8

(107 mg/kg/day), do test dose IVF to follow: D5IMB 500 ml x 4142 ml/hr or 110 ml/kg/day (M+10%) For blood culture & sensitivity

COURSE IN THE WARDS

Date/Time
Day 2 11:30 AM (12th hour of admission)

SUBJECTIVE

ASSESSMENT

Afebrile for 9 hours PCAP-C Still with coughing episodes 1 episode of post-tussive vomiting

OBJECTIVE

PLAN

Weight = 9.1 kg HR 120 RR 26

Temp = 37.2C Alert, awake, not in distress No alar flaring Subcostal retractions (+) Rales, bilateral Normal rate, regular rhythm Soft abdomen, non-tender Full pulses, CRT<2 No cyanosis

Continue Cefuroxime 325 mg IV q8

hours (107 mg/kg/day) Continue Salbutamol nebulization q6 hours Refer if with RR of >50 IVF to follow: D5IMB 500 ml x 4142 ml/kg/hour

LAb results

Urinalysis

Yellow, slightly turbid Specific gravity: 1.010 Pus cells: 0-1/hpf Red blood cells: 0-1/hpf Epithelial (squamous): Few

LAb results

Urinalysis

Yellow, slightly turbid Specific gravity: 1.010 Pus cells: 0-1/hpf Red blood cells: 0-1/hpf Epithelial (squamous): Few

COURSE IN THE WARDS

Date/Time
Day 3 11:30 AM

SUBJECTIVE

ASSESSMENT

Afebrile for 32 hours Decreased coughing episodes Improving appette, tolerates

breastfeeding OBJECTIVE

PCAP-C

PLAN

Weight = 9.1 kg HR 102 RR 26 Temp

= 36.4 C Awake, comfortable No retractions (+) Rales, bilateral, no wheezes Normal rate, regular rhythm Soft abdomen, non-tender Full pulses, CRT<2 No cyanosis UO 1.6 cc/kg/hr Blood culture: No growth after 24 hours

Decrease current IVF rate to

30-31 ml/hr (75% maintenance) Continue antibiotics (Day 2 Cefuroxime)

COURSE IN THE WARDS

Date/Time
Day 4 9:45 AM

SUBJECTIVE

ASSESSMENT

Afebrile for 3 days Good appetite Decreased coughing episodes No difficulty of breathing
OBJECTIVE

PCAP-C

PLAN

Weight = 9.1 kg HR 104 RR 28 Temp

= 36.4 C Awake, comfortable No alar flaring, no retractions Clear breath sounds, good air entry Normal rate, regular rhythm Soft abdomen, non-tender Full pulses, CRT<2 No cyanosis

Watch out for difficulty of

breathing Discontinue IV antibiotics, shift to Cefuroxime oral 250 mg/5ml give 2 ml twice a day

COURSE IN THE WARDS

Date/Time
Day 5 9:30 AM

SUBJECTIVE

ASSESSMENT

Afebrile for 4 days Good appetite Decreased coughing episodes No difficulty of breathing
OBJECTIVE

PCAP-C

PLAN

Weight = 9.1 kg HR 95 RR 24 Temp =

36.6 C Awake, comfortable No alar flaring, no retractions Clear breath sounds, good air entry Normal rate, regular rhythm Soft abdomen, non-tender Full pulses, CRT<2 No cyanosis

May go home after attending

physicians rounds Take home meds: Continue Cefuroxime to complete 10 days Salbutamol nebulization q6 hours at home Follow up after 1 week

FINAL DIAGNOSIS
PCAP

-C

DISCUSSION

Pneumonia

Inflammation of the parenchyma of the lungs Substantial cause of morbidity and mortality in childhood Philippines: No.1 killer for children aged 5 & below, with 9000 children dying from it each year Bacterial or viral cause can be identified in 4080% of PCAP patients Streptococcus pneumoniae most common bacterial pathogen, followed by Chlamydia pneumoniae and Mycoplasma pneumoniae

DISCUSSION

Pneumonia

Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus - major causes of hospitalization and death among children in developing countries Viruses: prominent cause of LRTIs in children <5 yr of age, peak between the ages of 2 and 3 yr, decreasing slowly thereafter

Respiratory syncytial virus, other respiratory viruses (parainfluenza 312 mo viruses, influenza viruses, adenoviruses), S. pneumoniae, H. influenzae (type b, nontypable), C. trachomatis, Mycoplasma pneumoniae, group A streptococcus

Viral vs bacterial

PATHOGENESIS OF Pneumonia

Microorganism s gain access to the lower respiratory tract

Aspiration from oropharynx

Inhalation of contaminated droplets

Mechanical factors in host defense: Hairs and turbinates of the nares Branching architecture of the tracheobronchial tree Mucociliary clearance and local antibacterial factors Gag reflex and the cough mechanism

Overcoming of barriers

Inhalation to alveolar level

Inhalation to alveolar level

Alveolar macrophages

Macrophages assisted by local proteins (surfactant proteins A & D)

Once engulfed, pathogens are eliminated via either the mucociliary elevator or the lymphatics

capacity of the alveolar macrophages to ingest or kill the microorganisms is exceeded

clinical pneumonia

inflammatory mediators, interleukin (IL) 1 & tumor necrosis factor (TNF)

fever

Chemokines (IL-8 and GM-CSF) stimulate release of neutrophils

peripheral leukocytosis and increased purulent secretions

Chemokines (IL-8 and GM-CSF) stimulate release of neutrophils

peripheral leukocytosis and increased purulent secretions

inflammatory mediators + neutrophils = alveolar capillary leak

radiographic infiltrate and rales detectable on auscultation, and hypoxemia due to alveolar filling

Decreased compliance due to capillary leak, hypoxemia, increased respiratory drive, increased secretions, and occasionally infection-related bronchospasm dyspnea changes in lung mechanics due to reductions in lung volume and compliance and intrapulmonary shunting of blood death

Pathology

edema: vascular congestion and alveolar edema, many bacteria and few neutrophils red hepatization: presence of erythrocytes in cellular intraalveolar exudate + neutrophils (host defense) gray hepatization: gray-brown to yellow because of fibrinopurulent exudate, disintegration of red cells, and hemosiderin resolution: macrophage dominant; debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory response

MANAGEMENT

DIAGNOSTIC AIDS
RECOMMENDATIONS
The

PATIENT
Labs

following should be routinely requested:Chest xray PA-Lateral White blood cell count The following should not be routinely requested: Erythrocyte sedimentation rate C-reactive protein

requested:Chest x-ray PA-Lateral CBC

USE OF ANTIBIOTICS
RECOMMENDATIONS
are recommended:For a PCAP-C patient: Beyond 2 years of age, or Having high grade fever w/o wheeze, or Having alveolar consolidation in the chest x-ray, or Having white blood cell count>15,000
Antibiotics

PATIENT
Findings:11 months old Tmax = 38.4C No wheeze No alveolar consolidation WBC count = 27.6

CHOICE OF ANTIBIOTICS
RECOMMENDATIONS
For

PATIENT

a PCAP-C patient w/o Antibiotics given:Cefuroxime previous antibiotic with complete 107 mg/kg/day primary Hib immunization:Penicillin G [100,000 U/kg/day in 4 doses] Without primary Hib immunization: IV ampicillin [100 mg/kg/day in 4 doses]

CHOICE OF ANTIBIOTICS
RECOMMENDATIONS
When can

PATIENT

a patient be considered Findings:Afebrile after 6 hours as responding to current Tachypnea antibiotic:Decrease in respiratory signs (tachypnea) & defervescence within 72 hours of initiation of antibiotic Persistence of symptoms beyond 72 hours requires reevaluation End of treatment chest x-ray, WBC should not be done to assess therapeutic response

RESPONSE TO ANTIBIOTICS RECOMMENDATIONS

If

patient is not responding to current antibiotic within 72 hours, consider consultation with specialist because of the following possibilities:penicillin resistant Streptococcus pneumoniae, or presence of complications [pulmonary or extrapulmonary], or other diagnosis

SWITCH THERAPY
RECOMMENDATIONS
Switch

PATIENT

from IV antibiotics to oral Switch therapy initiated:On form 2-3 days after initiation is third day of antibiotic use recommended when patient:is Patient responding well, and responding to initial antibiotic with intact GI absorption therapy able to feed with intact GI absorption does not have any pulmonary or extrapulmonary complications

SWITCH THERAPY
RECOMMENDATIONS
Ancillary

PATIENT
Ancillary treatment:Hydration Patient responding well, and

treatment:Oxygen & hydration should be given if needed Bronchodilator may be administered in the presence of wheezing

with intact GI absorption

Prognosis

Patients with uncomplicated bacterial pneumonia respond to therapy with improvement in clinical symptoms within 4896 hr of initiation of antibiotics Radiographic evidence of improvement substantially lags behind clinical improvement

Prevention

PREVENTION

Vaccination Influenza vaccines: recommended for young children and those with chronic pulmonary disease, including asthma H influenzae type b vaccine Varicella vaccine Injection of RSV-specific immunoglobulins