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Extern conference 20 sep 2007

Extern conference 20 sep 2007. HEMOPTYSIS. History. Admit september 6 ,2007 14-year-old Thai boy CC: hemoptysis for 2 hours PI :

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Extern conference 20 sep 2007

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  1. Extern conference20 sep 2007 HEMOPTYSIS

  2. History Admit september 6 ,2007 14-year-old Thai boy • CC: hemoptysis for 2 hours • PI : • 2 hr. PTA, after school, the patient felt like something caught in his throat so he went into the bathroom and cough up a large amount of bright red blood (about 1 cola can) , no air bubble, food particles, sputum or clotted blood was seen • He continued to have hemoptysis since then, the total amount was about 3 cola cans • 1 hr. PTA , he started to have nose bleeding • He had palpitation but no fainting or dizziness

  3. History : Present illness • He never had unexplained bleeding, petechiae, epistaxis, hemoptysis, hematemesis, hematuria, melena • He denied history of chronic cough, recurrent pneumonia, jaundice, weight loss, low grade fever, anorexia • None of his family memberor friends have similar symptoms • No history of trauma

  4. History • PMI: • Underlying disease : • asthma • for 10 years, last attack 3 years ago • No current medication • Personal history • No smoking, no alcohol drinking, no IVDU • Family history • No history of hematologic disease • No history of tuberculosis • Medication • No history of drug allergy • No current medication • Developmental history: normal • Vaccination • Complete EPI programme

  5. History : Present illness • First, his mother took him to Srivichai hospital • At Srivichai hospital • Massive hemoptysis with epistaxis • Physical examination • V/S : BP 140/80 mmHg., T 38.3oC, RR 40/min, • GA : dyspnea • HEENT : Epistaxis in nasal cavity, Bloody discharge at posterior pharynx • RS : wheezing both lungs with transmitted sounds form upper tract : after ventolin NB –> crepitation RML field • CVS, Abdomen : WNL • Cervical lymph node : not palpable • Management • Ventolin & adrenaline aerosol – wheezing improved but hemoptysis continued.

  6. History : Present illness • At ER Siriraj • Physical examination • V/S : BP 121/75 mmHg., T 37oC, PR 108/min, RR 32/min • O2 sat. 86% • HEENT : • nose : blood clot in Rt. Nasal canal, normal Lt. side, pale mucosa • Pharynx : not injected • Oropharynx : mild injected • ENT : TM- no erythema, bleeding • CVS : normal S1 & S2, no murmur • RS : mild dyspnea, substernal retraction, decreased breathsounds RLL, crepitation RML, wheezing both lungs, secretion sounds • LN : no superficial lymphadenopathy

  7. Investigations • CBC (6/9/07) • Hb 11.6 mg/dl., Hct 37.2% • WBC 12,770/mm3 (N 82.5%, L 13.4%, Mo 3%) • Platelet 275,000/mm3 • Blood chemistry (6/9/07) • Na 141 mmol/l • K 4.1 mmol/l • Cl 106 mmol/l • HCO3 26 mmol/l • BUN : Cr = 10 : 0.6

  8. Rt. Middle lobe silhouette to Rt. heart border, no perihilar lymphadenopathy, reticulonodular infiltration Rt. lower lung field

  9. Right lateral decubitous: no pleural effusion was seen

  10. Problem lists • Massive Hemoptysis for 2 hours • Bleeding per nose for 1 hours • Underlying disease : asthma for 10 years

  11. Differential diagnosis • Infectious cause : most likely • Atypical pneumonia • Pulmonary tuberculosis • Pulmonary hypertention: • congenital heart disease • Trauma: lung contusion • Tumor: • pulmonary adenoma • Adenoid tumor

  12. Approach to hemoptysis

  13. Hemoptysis • Hemoptysis : the coughing up of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage. • Classification • Non-massive : blood vol. < 200 ml./day • Massive : usually from bronchial system (systolic pressure)

  14. First step : hemoptysis VS. pseudohemoptysis or hematemesis

  15. Massive hemoptysis • Common • Tuberculosis • Bronchiectasis (including cystic fibrosis) • Nontuberculous mycobacteria • Lung abscess • Mycetoma (aspergilloma, or fungus ball) • Pulmonary contusion or trauma

  16. Management • Based on 2 important issues • The underlying cause • The severity of bleeding

  17. Management • To protect airway, maintain oxygenation(ET tube/rigid bronchoscopy in case of severe respiratory distress) • Maintain sufficient blood volume • Stop hemorrhage • Treat the underlying cause

  18. How to approach

  19. Progress note

  20. Progress note

  21. Management 6 september 2007 • To protect airway, maintain oxygenation • NPO • On oxygen canula 3 LMP • Position: lying right side down • Arterial blood gas stat • Maintain sufficient blood volume • 5%D/N/2 (1000ml) iv drip 100cc/hr • recordV/S q 2 hr • G/M PRC 550 cc

  22. Management 6 september 2007 • Observe bleeding • Serial Hct q 6 hr • Treatment the underlying cause • CXR lateral decubitous stat,then F/U again tomorrow • Claforan 100 MKD> sig 1 gm IV q 6 hr • Paracetamol (500mg) 1 tab oral prn

  23. V/S: T 37.5 P 98/min, BP 124/64 mmHg, RR 32/min RS: decreased breath sound RLL, coarse crepitation RML, Dullness on percussion & Decreased vocal resonance at RLL, trachea in midline, decreased chest movement on Rt. side Progress note 7 Sep 2007 1.30am

  24. Opacity area at RLL silhouette to Rt. Diaphragm and Rt heart border minimal mediastinal shift to the right

  25. Progress note 7 Sep 2005 1.30am • DDX: (film) • - Atelectasis • - Consolidation from pneumonia • - Hemorrhage • - Pleural effusion

  26. Film right lateral decubitus -Minimal pleural effusion, -pneumothorax, -haziness at RLL&lateral side of Rt.lung suspected atelectasis

  27. Progress note 7 September 2007 • A&P -5% D/N/2 1000 cc IV drip rate 100 cc/hr - Oxygen cannula 3 LPM -Pleural fluid gram stain, AFB,modified AFB, fresh smear ,culture for bacteria fungus ,LDH,sugar (Pleural fluid gram stain ,AFB,modified AFB : neg )

  28. Progress note 7 September 2007 • CXR all members of the family • Result: All negative

  29. Management 7 September 2007 -ATB: - Claforan - Azithromycin(250mg)sig 2 tab oral OD • Blood for Clamydia Ab, Mycoplasma Ab titer • Tuberculine skin test • Sputum for AFB x 3 days

  30. Progress note 8 September 2007 • Lab sputum AFB (8 sep 07) not found

  31. Progress note 9 September 2007 • Lab sputum AFB (9 sep 07) : positive 5 cells/slide • Tuberculin skin test results: • 48 hr.: 13 mm. • 72 hr.: 18 mm.

  32. Question for medical student !!!

  33. Progress note 10 September 2007 • S: dyspnea , no fever • Massive pneumothorax at right lung • Massive loss of lung volume right side • Blunt costophrenic angle

  34. Progress note 10 September 2007 • Right lateral decubitous • Fluid level was seen • Atelectasis

  35. Progress note 10 September 2007 • Consult CVT for applied ICD • After ICD insertion: Air + pleural effusion • CXR after ICD insertion • Applied intermittent suction 20 mmH2O • CXR again after applied suction • Sputum AFB day 3 : negative

  36. Progress note 10 September 2007 • Oxygen 8 LPM keep Oxygen > 95 % • CXR tomorrow • Pleural fluid for cell count, cell diff, gram stain, AFB, modified AFB, fresh smear ,Culture for bacteria , fungus, mycobacteria, LDH, sugar, protien, pH, ADA , PCR, pleural fluid cytology • H/C • serum LDH, protein

  37. Progress note 10 September 2007 • Off Azithromycin • INH(100mg)(6mg/kg/day) sig 3 tab oral hs • Rifampicin(600mg)sig 1 tab oral hs • Pyrazinamide (500mg) sig 2 tab oral hs • Ethambutol (500mg) sig 2 tab oral hs • Vitamin B6 sig 1tab oral OD

  38. After applied ICD • Haziness at right lung

  39. After ICD insertion with intermittent suction • Increase lung expansion

  40. Progress note 10 September 2007 • ICD content : 50 mL. • lab investigation • sputum AFB not found • Pleural effusion gram stain (10sep07) • : moderate PMN , no bacteria seen

  41. Progress note 10 September 2007 • Pleural effusion modifiedAFB(10sep07) • :moderate PMN ,not found modified acid fast baccili • Pleural effusion : total protein 3.8 g/dl , glucose 74 mg/dl • LDH 1880 u/litre • Blood chemistry :total protein 6.8 g/dl ,LDH 254 u/litre • Conclusion: pleural fluid is exudate

  42. Progress note 11 September 2007 • Asymmetrical CXR • Rt. Main bronchus was not seen • Airway trapping • Diff Dx – atelectasis or pleural effusion

  43. Progress note 11 September 2007 • pleural fluid (11 sep 07) :serosanguinous fluid, negative for malignancy ,reactive cellular changes associated with inflammation • H/C : NG • Plan: Treat pulmonary TB at least 2 weeks then F/U CXR

  44. Progress note 12 September 2007 • Increased lung expansion

  45. Management 12 September 2007 • Plan: • after improvement of Rt. Lung atelectasis off ICD • Pleural effusion will improve after starting anti-TB drugs • Lung expansion therapy:suck triflow 4 times a day • Start steroid: Prednisolone (2mg/kg/day)3 tab oral tid pc

  46. Progress note 13 September 2007 • S&O: He got exhausted after going to the bathroom • O2 sat. 77% on O2 mask with bag 15 LPM O2 sat 95% • ICD content(13/9/07): 20 ml. • The 3rd ICD bottle was wrong connection correct ICD connection

  47. Progress note 14 September 2007 • ICD(14/9/07) 70 ml. • O2mask with bag 10 LPM keep O2 >95%

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