Pulmo Conference CAP Edits

7/30/2019 Pulmo Conference CAP Edits

http://slidepdf.com/reader/full/pulmo-conference-cap-edits 1/52

Pulmo Conference

Pediatrics OPD

Presented by:

Francesca Dolendo

Margaux Mae Rayos

Angelo Miguel RealinaJose Gabriel Recio

Allen Lester Reyes



GENERAL DATA

NAME:

AGE: 11 y.o.SEX: Male

DATE OF BIRTH:

RACE: Filipino

RELIGION: Catholic

INFORMANT: Mother RELIABILITY: Good

CC: Cough



4 mos PTC

• Experienced cough, productive of greenish sputum

• Generalized body malaise, anorexia

• Fever (38-39oC), Headache (5/10 rotatory)

• Amoxicillin 250 mg/mL, Paracetamol 250 mg/mL

IntervalHistory

• Resolution of symptoms

1 weekPTC

• Cough, productive of greenish sputum

• (-) fever and headache

• Amboroxol, unrecalled dose

• Symptom persisted, hence consult



REVIEW OF SYSTEMS

General: (-) weight loss, (-) loss of appetite, (-) fever, (-) easy fatigability

Skin: (-) rashes

Respiratory: see HPI

Cardiovascular: (-) exertional dyspnea, (-) chest pain

Gastrointestinal: (-) constipation, (-) diarrhea, (-) abdominal pain, (-)

vomiting

Musculoskeletal: (-) joint pains or swelling, (-) limitation of movement

Genitourinary: (-) dysuria, (-) hematuria, (-) flank pains

Endocrine: (-) Heat/Cold intolerance, (-) polyuria, polydipsia, polyphagia

Hematologic: (-) easy bruisability, (-) gum bleeding

Nervous: (-) seizures, (-) dizziness, (-) headache

Special Senses: (-) blurring of vision, (-) hearing loss



DEVELOPMENTAL ASSESSMENT

School Performance: Grade 3, topnotcher

Behavior: Friendly, has a group of 4 friends; no reports of behavioralproblems at school or at home



PSYCHOSOCIAL HISTORY

Home: Up and down apartment, well ventilated, well lit

Education/School: Topnotcher in Grade 3Abuse: No reports of abuse

Drugs: Denies alcohol, tobacco and illicit drug use

Safety: No potential hazards in home/school

Sexuality: Male, identifies with male intents, prefers girls

Famiy and Friends: Harmonious family relationshipImage: Good self-image

Recreation: TV and computer games

Spiritual and Connection: Frequent mass goer

Threats and violence: No reported threats and incidents of violence



24 HOUR FOOD RECALL

QUANTITY CALORIES

BREAKFAST

½ bowl plain lugaw 100

LUNCH ½ bowl plain lugaw 100

SNACK ½ bowl plain lugaw 100

DINNER 3 pcs. Biscuits, 1 cup milo 100+200

ACTUAL CALORIC INTAKE: 650

RENI: 1920

% OF DEFICIENCY: 33.86%



PHYSICAL EXAM



GENERAL SURVEY

Mental state Conscious, coherent,

oriented to 3 spheres

Cardiopulmonarystatus

Not in distress

Nutritional status Normal

Appearance Well-looking

Hydration status Well hydrated

Ambulation Ambulatory



VITAL SIGNS

BP 100/80 mmHg

CR 90 bpm, regularly

regular

RR 17 cpm

Temp 36.8C



ANTHROPOMETRICS

Height 131 cm (z below -1)

Weight 28.5 kg (z below 0)

BMI 16.6 (z below 0)



Skin Warm, moist, non-jaundiced, no active

dermatoses

Head Normocephalic, no masses, no lesions, hair evenly distributed

Eyes Eyelids not swollen, eyelashes not matted,

anicteric sclerae, pink palpebral

conjuctivae, normal EOM, pupils 3 mmERTL, peripheral vision intact

Ears No tragal tenderness, no deformities, no

discharge, clear EAC, non-hyperemic TM,

cone of light visualizedNose No deformities, midline septum, no

discharge, turbinates not congested, no

sinus tenderness



Mouth/throat Pink buccal mucosa, no mucosal bleeding,

no mucosal lesions, non-hyperemic

posterior pharyngeal wall

Neck Supple, no venous engorgement, no

masses, no palpable cervical

lymphadenopathy, thyroid not enlarged

Lungs/Chest Symmetrical chest expansion, regular

breathing pattern, no retractions, normaltactile fremiti, all lung fields resonant to

percussion, normal vocal fremiti, fine

crackles on right lung base



Heart Adynamic precordium, apex beat 5th LICS

MCL, no heaves, lifts or thrills, S1>S2 on

apex, S2>S1 on base, no murmurs

Abdomen Flat, symmetrical, normoactive bowel

sounds, tympanitic in all quadrants, liver

and spleen not enlarged, no tenderness, no

masses palpable

Pulses/Extremities

Pulses full and equal, no clubbing, cyanosis,swelling or joint deformities

Lymph Nodes No palpable lymph nodes



Cerebrum Mood, affect and thought content all

appropriate

Motor 5/5 all extremities

Sensory No sensory deficits

Cranial Nerves All intact

Cerebellar Can do alternate pronation supination

and finger to nose test

Reflexes +2 all extremities

Meningeal

Signs

None



SALIENT FEATURES

Subjective Objective

- 11 yo Male

- Cough with greenish

sputum

- Previously diagnosed

pneumonia 5 months

PTC

- RR 17 cpm

- Breathing pattern

regular, not in distress

- No retractions,

normal tactile and

vocal fremiti, lung fieldsresonant

- Fine crackles on right

lung base



APPROACH TO DIAGNOSIS

• Look for a symptom, sign or laboratory finding

pointing to an organ or organ system• Productive cough Respiratory system



11 yo male

Productive cough

Acute <3

Weeks

Chronic

>3Weeks

• Most Common causes:

• Infections

• Acute bronchitis

• Pneumonia

• Bacterial

•Viral• Atypical



Acute Bronchitis Pneumonia

Risk factors Preceded by a viral

URTI, smoking

Preceded by viral or

bacterial URTI

Cough Dry hacking cough

that may or may not

be productive

May be productive

(bacterial)

Adventitious breath

sounds

Coarse breath

sounds, coarse and

fine crackles,

wheezing

Diminished breath

sounds and other

signs of consolidation,

Crackles over affected

lung field and

wheezing

tachypnea none common

Fever Low grade Usually present

CXR nomal Abnormal chest x-ray



PREDICTORS OF CAP IN A PATIENT WITH

COUGH:

1. For ages 3 months to 5 years:

Tachypnea and/or chest indrawing

2. For ages 5 to 12 years:

fever, tachypnea and crackles

3. Beyond 12 years:

Fever, tachypnea, tachycardia and: At least one abnormal chest finding of diminished breath

sounds, rhonci, crackles or wheezes



MOST COMMON ETIOLOGIC AGENTS BY AGE

GROUP

AGE GROUP FREQUENT PATHOGENSNeonates (<1 mo) Group B Strep, E. coli, other

gram (-) bacilli, S. pneumoniae,

H. influenza B

1-3 mo

Febrile

Non-febrile

RSV, other respiratory viruses(parainfluenza, influenza,

adenovirus), S. pneumoniae, H.

influenza

C. trachomatis, M. hominis, U.

urealyticum, CMV

3-12 mo RSV, other respiratory viruses, S.

pneumoniae, H. influenza, C.

trachomatis, M. pneumoniae,

group A strep



MOST COMMON ETIOLOGIC AGENTS BY AGE

GROUP

AGE GROUP FREQUENT PATHOGENS2-5 yr Respiratory viruses, S.

pneumoniae, H. influenzae, M.

pneumoniae, C. pneumoniae, S.

aureus, group A strep

5-18 yr M. pneumoniae, S.pneumoniae, C. pneumoniae,

H. influenzae, influenza

viruses, adenoviruses, other

respiratory viruses

≥18 yr M. pneumoniae, S. pneumoniae,

C. pneumoniae, H. influenzae,influenza viruses, adenoviruses,

L. pneumophila

Nelson’s Textbook of Pediatrics 18th ed



Bacterial

Pneumonia

Viral

Pneumonia

Atypical

Pneumonia

Age any any 5-15 yrsOnset abrupt variable variable

Fever high variable Low-grade

Tachypnea common common uncommon

Cough productive nonproductive nonproductive

Associated

symptoms

Mild coryza,

abdominal pain

coryza Bullous

myringitis,

pharyngitis

Physical

findings

Evidence of

consolidation,

crackles

variable Fine crackles,

wheezing

Leukocytosis common variable uncommon

Radiographic

Findings

consolidation Bilateral diffuse

infiltrates

variable

Pleural

Effusion

common rare small



RISK CLASSIFICATION FOR PNEUMONIA-RELATED

MORTALITY

Variables PCAP A

Minimal

Risk

PCAP B

Low Risk

PCAP C

Moderate

Risk

PCAP D

High Risk

1. Co-morbid illness None Present Present Present

2. Compliant caregiver Yes Yes No No

3. Ability to follow-up Possible Possible Not

possible

Not possible

4. Presence of Dehydration None Mild Moderate Severe

5. Ability to feed Able Able Unable Unable

6. Age >11 mo >11 mo < 11 mo < 11 mo

7. Respiratory rate

2-12 months

1-5 years

> 5 years

> 50/min

> 40/min

> 30/min

> 50/min

> 40/min

> 30/min

> 60/min

> 50/min

> 35/min

> 70/min

> 50/min

> 35/min



8. Signs of respiratory

failure

a. Retraction

a. Head Bobbing

b. Cyanosis

c. Grunting

d. Apnea

e. Sensorium

None

None

None

None

None

Awake

None

None

None

None

None

Awake

Intercostal/

Subcostal

Present

Present

None

None

Irritable

Supraclavicular

/Intercostal/

Subcostal

Present

Present

Present

Present

lethargic./stuporous/

comatose

9. Complications(effusion , pneumothorax)

None None Present Present

ACTION PLAN OPD

follow-up atthe end of

treatment

OPD

follow-up after

3 days

Admit to

regular ward

Admit to a critical

care unit

Refer to specialist



ASSESSMENT

Pneumonia, PCAP-A



TREATMENT

PCAP A or B without previous antibiotic,

Amoxicillin (40-50 mg/kg/day) in 3 divideddoses

PCAP C without previous antibiotic and who has

completed the primary immunization againts H.

influenzae type B,Pen G 100 u/kg/day in 4 divided doses



If primary immunization against H. influenzae type

B has not been completed and below 5 years of age, IV penicillin (100mg/kg/day) in 4 divided

doses

PCAP D, a specialist should be consulted



TREATMENT FOR VIRAL ETIOLOGY

Antiviral agents reduces the duration of illness by

1- 1 ½ days

For influenza A infection- amantadine (4.4-4.8

mg/kg/day) can be given for 3-5 days

For inluenza B infection- oseltamivir (2mg/kg/dose

BID) for 5 days



RESPONSE TO CURRENT ANTIBIOTICS

Decrease in the respiratory signs and

defervescence within 72 hours after initiation of antibiotic

Persistence of symptoms beyond 72 hours after

initiation of antibiotics requires reevaluation

End of treatment CXR, WBC, ESR, or CRP shouldnot be done to assess therapeutic response to

antibiotic



If classified as out patient PCAP A/B and is not

responding to the current antibiotic within 72hours

Change the initial antibiotic

Start oral macrolide

Reevaluate diagnosis



PCAP C is not responding to the current antibiotic

within 72 hours consider consultation with aspecialist for the following possibilities:

Penicillin resistant S. pneumoniae

Presence of complications



PCAP D is not responding within 72 hours,

consider immediate re-consultation with aspecialist



We can switch from IV antibiotics to oral form 2-3

days after initiation of antibiotic isrecommended in patients:

Responding to initial antibiotic therapy

Able to feed with intact GI absorption

Does not have any pulmonary or extrapulmonarycomplications



ANCILLARY TREATMENT

Cough preparations

Chest physiotherapy

Bronchial hygiene

Nebulization using NSS

Steam inhalationTopical solutions

bronchodilators



EPIDEMIOLOGY

• Leading cause of mortality in underdeveloped countries

158 M episodes of pneumonia / year 154 M occur in developing countries

3 M deaths worldwide in children <5 y/o; 29% of all deaths

• 3rd leading cause of morbidity and mortality in all ages

(Philippines)

• 2nd leading cause of death in infants

Kliegman, et.al Nelson’s Textbook of Pediatrics,19th ed. Elsevier (Singapore) Pte Ltd. Pages



ETIOLOGY

Kliegman, et.al Nelson’s Textbook of Pediatrics, 19

th

ed.Elsevier (Singapore) Pte Ltd. Pages 1474-1479.



Noninfectious Causes:

Aspiration of food / gastric acid

Foreign bodies

Hydrocarbons

Lipoid substances

Hypersensivity reactions

Drug or radiation – induced pnemanumonitis

Kliegman, et.al Nelson’s Textbook of Pediatrics,

19th ed. Elsevier (Singapore) Pte Ltd. Pages

1474-1479.



PATHOGENESIS

ALTERED HOST FACTORS PREDISPOSING TO

PNEUMONIA

• Bypass the upper airway

• Impaired cough reflex or cougheffectiveness

• Aspiration of oral or stomach contents

• Disruption of the mucociliary blanket

• Cellular or humoral deficiency

• Altered lung parenchyma Kliegman, et.al Nelson’s Textbook of Pediatrics,


1474-1479.



VIRAL PNEUMONIA



BACTERIAL PNEUMONIA



RECURRENT PNEUMONIA

2 or more episodes / 1 year

3 or more episodes w/ radiographic clearing between occurencesConsider underlying disorder

Kliegman, et.al Nelson’s Textbook of Pediatrics,


1474-1479.

TYPICAL FEATURES OF BACTERIAL VIRAL AND



TYPICAL FEATURES OF BACTERIAL, VIRAL AND

ATYPICAL PNEUMONIAS IN CHILDREN



DIAGNOSIS

Chest X-ray

confirm presence and location of the pulmonary

infiltrate

detect pleural involvement, pulmonary cavitation,lymphadenopathy

WBC

Differentiate viral from bacterial

Viral – normal / elevated but not higher than

20,000/mm3

Bacterial – elevated 15,000 – 40,000/mm3,

predominance of granulocytesKliegman, et.al Nelson’s Textbook of Pediatrics, 19

th

ed. Elsevier (Singapore) Pte Ltd. Pages 1474-1479.



Definitive diagnosis (Viral) – isolation of virus / detection of viral genome / antigen

on respiratory tract secretions

Definitive diagnosis (Bacterial) – isolation of

organism in blood, pleural fluid / lung

Kliegman, et.al Nelson’s Textbook of Pediatrics, 19th

ed. Elsevier (Singapore) Pte Ltd. Pages 1474-



SUPPORTING JOURNALS FOR DIAGNOSIS

• In the developed world a positive chest

x-ray is preferred as the gold standard.However, this has been challenged

because radiographic signs may lag

behind clinical parameters.

• A number of studies have also

highlighted the difficulty of using lobar

consolidation to diagnose bacterialpneumonia as interstitial and alveolar

changes can also be associated with

bacterial pneumonia.



COMPLICATIONS

Pleural effusion

Empyema

Pericarditis

Bacteremia and hematologic disorders

Kliegman, et.al Nelson’s Textbook of Pediatrics,th

Pulmo Conference CAP Edits

Documents

Transcript of Pulmo Conference CAP Edits