Morning ReportJuly 3, 2012

Good Morning!

Symptoms

Acute /subacute Chronic

Localized Diffuse

Single Multiple

Static Progressive

Constant Intermittent

Single Episode Recurrent

Abrupt Gradual

Severe Mild

Painful Nonpainful

Bilious Nonbilious

Sharp/Stabbing Dull/Vague

Problem Characteristics

Ill-appearing/Toxic

Well-appearing/Non-toxic

Localized problem

Systemic problem

Acquired Congenital

New problem Recurrence of old problem

Semantic Qualifiers

Illness Script

Predisposing Conditions Age, gender, preceding events

(trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)

Pathophysiological Insult What is physically happening in

the body, organisms involved, etc.

Clinical Manifestations Signs and symptoms Labs and imaging

CXR #1

Predisposing Conditions

35-40/1000 incidence in <5yo

7/1000 incidence in adolescents

colder monthslower socioeconomic

statussmoke exposureboys> girls

Medical historySickle cellBPDGERDCystic FibrosisHeart diseaseImmunodeficiency

Increased aspirationNeuromuscular d/oSeizure d/o

Pathophysiology

Spread by droplets Typically follows URIMechanism

Colonization of nasopharynx with further inhalation of

microorganisms, leading to a pulmonary focus of infection Less commonly…bacteremia results from the initial

upper airway colonization with subsequent seeding of

lungsOrganisms

Streptococcus pneumonia = MOST COMMON Others: S. aureus, Group A Strep, GNR (<3mo),

anaerobes

Clinical Manifestations

Abrupt onsetHigh feverCough

Sometimes productiveToxic appearanceRespiratory distress

Tachypnea (most sensitive/specific) Retractions Nasal Flaring Grunting Hypoxia

Chest pain

Clinical Manifestations

Focal findings on lung exam Crackles Diminished breath

sounds Bronchial breath

sounds Egophany

Unilateral focal infiltrate on CXR

Organisms**

Treatment**

Outpatient therapy (7-10days total) First line: High dose Amoxicillin at

80-100mg/kg/day Penicillin allergy: Cephalosporin (non-type 1); Clinda/Azithro (type 1 allergy) Atypical organisms: Azithromycin x 5 days

Inpatient therapy (duration varies) Ceftriaxone or Ampicillin More extensive disease/failed treatment

Vancomycin Clindamycin

Azithromycin (adjunctive coverage sometime given)

Admission**

Criteria for admission <3 months Respiratory distress Hypoxemia Dehydrated Highly febrile/toxic

Underlying diseaseTesting

CBC Blood culture CXR +/- Sputum culture

Complications**

Lung abscess Thick-walled cavity with air/fluid level TB should be considered Needle aspiration for culture

Necrotizing pneumonia Rare complication of bact PNA Liquefaction/necrosis caused by toxins of virulent organisms VERY ill IV abx for at least 4 weeks

Complications**

Sterile para-pneumonic effusionPurulent effusions with resultant empyema

Persistent fever, ill-appearing, tachypnea, increased WOB,

chest pain and splinting Dullness to percussion/decreased air entry

CXR with decubitus, US, CT

CXR #2

Thanks!!

Almost every content spec “Pneumonia.” Pediatrics in Review. 2008, volume

29, 147

Noon conference = YOGA (12:15)