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Pulmonary Case Conference

Pulmonary Case Conference. General Data. DC 1 year 6 months Male Phase 1 Lot 29 Block 2 St. Michael St. Camacho Nangka , Marikina City Roman Catholic. Chief Complaint. Fever. HPI. 4DaysPTC fever (max temp 38.9 0 C, axillary ) (+)clear watery nasal discharge

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Pulmonary Case Conference

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  1. Pulmonary Case Conference

  2. General Data • DC • 1 year 6 months • Male • Phase 1 Lot 29 Block 2 St. Michael St. Camacho Nangka, Marikina City • Roman Catholic

  3. Chief Complaint • Fever

  4. HPI • 4DaysPTC • fever (max temp 38.90C, axillary) • (+)clear watery nasal discharge • (+)decrease in appetite, • Paracetamol 25mg/kg/dose • 3DaysPTC • (+) persistence of symptoms • PhenylpropanolamineHCl drops (Disudrin) 1.6mg/kg/dose

  5. HPI • 2DaysPTC • Persistence of symptoms • (+) productive cough • 3 episode of post tussive vomiting of previously ingested fluids with sputum amt 5-15ml/ episode • Prefer drinking than eating

  6. HPI • 1Day PTC • one episode of vomiting, with fever, colds, cough, decreased level of activity and decreased fluid and food intake • consult at a local hospital • CBC (Hb 103g/L, Hct 0.32, WBC 4.8 x 109/L, platelet 270 x 109/L, Neutrophil 0.49, Lymphocytes 0.51 • Diagnosis: Lower Respiratory Tract infection • Med: Cefixime 6mg/kg/day ; Salbutamolnebulization q8

  7. HPI • Few hours PTC • bloody nasal discharge • blood-tinged sputum • Persistence of fever, decreased level of activity, and poor oral intake • sought consult at USTH Pedia-SBC,

  8. Review of Systems General: (-) weight loss Skin: (-) rashes, (-) jaundice, (-) cyanosis Head: (-) injuries/lacerations, (-) eye redness, (-) eye discharge/exudates, (-) tearing, (-) aural discharge, (-) cleft lip or palate Pulmonary: HPI Cardiac: (-) edema, (-) cyanosis Gastrointestinal: (-) diarrhea, (-) constipation, (-) melena, (-) hematochezia Genitourinary: (-) hematuria, (-) anuria/oliguria Neurologic/Psychiatric: (-) convulsions Hematopoietic: (-) easy bruisability, (-) bleeding manifestations Extremities: (-) joint deformities, (-) joint swelling

  9. Gestational History • 28 year old, G3P2 (2002). • Frequent prenatal check-up at a local clinic • No hepatitis B screening and gestational diabetes screening done • Denied: • use of illicit drugs, smoking, and drinking alcohol during pregnancy. She also denied exposure to radiation or other chemicals • Medications: • multivitamins • anti-Koch’s medication for a month

  10. Birth History • Term at 39-40 weeks AOG delivered via NSD. • Lying-in clinic. • Attended by a midwife • labor for 2 hours • Birth weight was 6.5kg. Neonatal History • spontaneous cry; no resuscitation was needed. • poor suck at birth • No congenital abnormalities were noted.

  11. Feeding History • Patient was not breastfed due to inability of mother to excrete milk. • Milk (0-6months) - Bona (2:1 dilution) 2oz – 10-12x/day • (6 months – 1year) – Bonamil (2:1 dilution) 4oz – 10-12x/day • Current: Bear Brand Jr (1:1 dilution) 6oz – 4-6x/day • Complementary Feeding started at 9 months (gruel, chicken, bread)

  12. Feeding History

  13. Past Medical History • Pneumonia (2009) Immunization History • Completed EPI at a local health center • BCG 1 dose • Hepatitis B 3 doses • OPV 3 doses • DPT 3 doses • Measles 1 dose Developmental/ Behavioral history • Patient’s development is at par with age. • Motor: walks and runs well, ascends stairs one foot at a time, • Language: knows more than 10 words including mama and papa, • Fine: drinks from a cup and uses spoon. • Social: Understands simple directions, Shows affection by kissing parents

  14. Socioeconomic and Environmental History • Lives with his parents and 2 older brothers • 2-storey house • made of wood and concrete • well lit and well ventilated. • Main water: NAWASA and water used for drinking is boiled for 30 minutes. • Garbage is collected 3x/week and segregates and recycles. • Father often smokes inside the house. • They have no pets and no nearby factories.

  15. Family History • (+) Hypertension – maternal grandmother • (+) PTB – mother – took medications for only a month, stopped since pregnant with child • (-) DM, cancer, asthma, allergies, kidney and thyroid disorders

  16. Family Profile

  17. Physical Examination Awake, irritable, ill looking, not in cardiorespiratory distress, well nourished, moderately dehydrated Vital signs: CR: 145bpm,regular RR: 33cpm, regular Temp: 37.00C Anthropometric measurement: Weight: 10kg (z score 0 normal) Length: 80cm (z score 0 normal) Weight for length (z score 0 normal) BMI: 15.63 (z score 0 normal)

  18. Physical Examination Warm, moist skin, no active dermatoses, good skin turgor, CRT <2sec No scalp lesions, tauma, deformities, sutres and fontanels closed Pink palpebral conjunctiva, anicteric sclera, pupils 2-3mm ERTL, (+) sunken eyes Midline nasal septum, (+) turbinates congested, (+) clear nasal discharge Nonhyperemic external auditory canal, intact tympanic membrane, (+) retained cerumen, AU

  19. Physical Examination Moist buccal mucosa, hyperemic posterior pharyngeal wall, tonsils grade II, bilateral Supple neck, no palpable cervical lymph nodes Symmetrical chest expansion, (-) retractions, clear breath sounds Adynamicprecordium, apex beat at 4th LICS MCL, no murmurs Globular abdomen, normoactive bowel sounds, soft, no palpable masses Redundant prepuce, bilateral descended testes Pulses full and equal, no edema, no cyanosis

  20. Neurologic Examination • Awake, irritable, with spontaneous eye movement, pupils isocoric 2-3mm ERTL, no facial asymmetry, uvula midline, gross movements on all extremities, no muscle atrophy

  21. Course in the Wards

  22. VS on PE • Carl Justine Decallos 316DCR:152 RR:52 T:36.6 BW:10 kg BL:80cm BSA: 0.47

  23. 1st Hospital Day Admitted on 1-26-11 • Ill looking, poor oral intake, sunken eyeballs • Diet for age • Precaution given to progression of dehydration and signs of respiratory distress • IVF: D5 0.3 Nacl 500cc 20-21 drops for 8 hrs • Losses were replaced via oral rehydration • Labs done: CBC with platelet • Medications started: • Paracetamol250mg/5ml 0.25ml q4 • 0.65% NaCl nasal drops, 2-3gtts/nostril every 6 hours, then suction • Kamilosanoral spray for irritated throat 2 sprays TID

  24. Admitting Impression • Acute nasopharyngitis with moderate signs of dehydration

  25. 2nd Hospital Day Jan 27 • IVF rate was decreased to 10-11gtts/minand shifted to IVF D5IMB • Fair oral intake • No signs of dehydration • Clear and equal breath sounds

  26. 3rd Hospital Day Jan 28 • Chest X-Ray (PA, LAT) was requested • Salbutamol challenge • RR: 50, CBS, febrile 38-39 7:00pm • Ampicillin 250mg/SIVP q6h after negative skin test • PE: febrile 38-39, RR: 40-50, (+) rhonchi, tachypnea, retractions • Suction nasal secretions q4-6hrs • Strict aspiration precautions

  27. 4th Hospital Day Jan 29 • Day 1 of Ampicillin • PE: (-) fever, retractions(+) crackles, RR: 30-40 • Chest xray: pneumonia bilateral • IVF increased to D5IMB 41-42ml/hr

  28. 5th Hospital Day Jan 30 • SalbutamolNebulization, 1 neb q3 • IVF decreased to 31-32ml/hr • PE: (+) fair fluid intake and appetite 3:40pm • (+) nocturnal cough, (+) crackles, good air entry • Ampicillin is increased to 375mg/SIVP every 6 hrs • Increased Salbutamol neb 1 neb q2 7:50pm • Ampicillin is once more increased to 500mg/SIVPSame IVF regimen

  29. 6th Hospital Day Jan 31 • Salbutamol frequency was tapered to Q3

  30. 7th Hospital Day Feb 1 • Salbutamol frequency was further lowered to Q4 • Patient advised to consume Ampicillin and start Amoxicillin 250mg/5ml 3ml q8 (45mkd) • The remaining HD’s were unremarkable and patient was subsequently discharged.

  31. Subjective data • 1 year 6 months • Male • Fever • Nasal discharge • Decrease in appetite • Productive cough • Post-tussive vomiting • Eager to drink • Decreased level of activity • Blood tinged sputum • No weight loss • Tears while crying (?) • No diarrhea • PMH: pneumonia • Exposure to cigarette smoke • FH: mother - PTB

  32. Objective data • CBC: anemia, leukopenia, neutropenia, lymphocytosis • Awake, irritable, ill looking, not in cardiorespiratory distress?, well nourished, moderately dehydrated • VS: tachycardia, tachypneic • Warm, moist skin, good skin turgor, CRT <2sec • (+) sunken eyes, pulses full and equal • (+) turbinates congested, (+) clear nasal discharge • Moist buccal mucosa, hyperemic posterior pharyngeal wall, tonsils grade II, bilateral, oral lesions? • Symmetrical chest expansion, (-) retractions, clear breath sounds

  33. Approach to Diagnosis Sign or symptom pointing to an organ or part of an organ system

  34. Subjective findings

  35. Objective findings

  36. Management Assess airway patency, breathing and circulatory status of the patient

  37. Goals • Imminent concerns • Stabilize the patient • Address the disease • Monitor the status • Educational concerns • Provide general prevention and measures regarding specific disease entities • Provide alternatives to what was used on the patient • Provide a broad view regarding handling the patient’s concerns even after the imminent disease has resolved

  38. Initial survey • Awake, irritable, ill looking, in cardiorespiratory distress, well nourished, moderately hydrated • Poor oral intake, sunken eyeballs • (+) turbinates congested, (+) clear nasal discharge • tonsils grade II, bilateral, hyperemic PPW • Pulses? Buccal mucosa? Tears? Skin turgor? • Vital signs: • CR: 145bpm, irregular • RR: 33cpm, irregular • Temp: 37.00C

  39. Dehydration • General Prevention • Early institution of adequate oral maintenance fluid therapy in children with gastroenteritis, with particular attention to replacement of ongoing stool losses and slow administration of fluids to children with vomiting. • Use of appropriate solutions is essential to prevent electrolyte disturbance and worsening of diarrhea.

  40. Dehydration • General Measures • ORS 2.0-2.5% glucose and 75mmol/L Na (WHO solution) or 45-50mmol/L Na (Pedialyte, Infalyte) • Replace entire deficit in 4 to 6 hours. • Mild – 50mL/kg • Moderate to severe – 80-100mL/kg • Ongoing losses – approximately 5mL/kg • Slow administration -> increased volume and rate (after1 hour) with strict limits when vomiting is present • 5mL q1-2 min • Participation of the caregiver • Monitor weight, intake and output and clinical signs • Intractable vomiting, clinical deterioration, lack of improvement after 4 hours

  41. Dehydration • Pharmacologic • Curative • Treat underlying cause • Therapeutic • Vomiting – ondansetron 0.15mg/kg • Non Pharmacologic/Supportive • IV fluids • Severe dehydration, shock, poor gag/suck, depressed mental status, preterm infant, severe hypernatremia (>160 mmol/L), suspected surgical abdomen • Monitor weight, intake and output, and clinical signs. • For mild to moderate isonatremic dehydration • Rapid replacement over 2 to 6 hours (25-50 cc/kg/hr)

  42. Dehydration • Patient – 10 kg; moderately dehydrated • Maintenance (Holiday-Segar) = 10x100 = 1000mL • Deficit (Ludan) = 10x100 = 1000 mL • Total = 2000 mL / 24 hours = 83.33 mL/hr • D5 LRS IMB NaCl20-21 drops/ minute to run for 24 hours

  43. Dehydration

  44. Dehydration

  45. Dehydration • Follow up recommendations • Admission criteria • Failure of oral or IV hydration within 4 hours • Severe hypernatremia • Substansial ongoing losses suggesting high likelihood of recurrence of dehydration • Discharge criteria • After initiating ORT – tolerate oral fluids at an acceptable rate to replace their deficit over 4-6 hours may be discharged with a willing and reliable caregiver and complete ORT at home

  46. Dehydration • Expected course/prognosis • Excellent • Possible complications • Severe -> hypovolemic shock and ARF • Hyponatremia -> hypotonia, hypothermia, seizures • Overly rapid correction of hypernatremia -> cerebral edema • Patient monitoring • On going losses -> maintenance solution • 5-10mL/kg for each diarrheal stool • Avoid clear liquids with excessive glucose (juices, punches, cola) • <6 months -> do not give large amount of water -> hyponatremia

  47. Pneumonia • General Prevention • Vaccination: influenza and pneumococcal • Lowers rate of all-cause mortality during hospitalization, respiratory failure, and shortens median length of hospital stay • General Measures • Outpatient: empiric treatment • Unlike adults, there is no validated tool to identify those patients at low risk who can be treated as outpatients. In general, children, especially neonates should be managed as in patients. • If specific pathogen is known or suspected, use appropriate antibiotic therapy • For patients with more severe disease, beta lactam antibiotic may be combined with a macrolide

  48. Pneumonia • Pharmacologic • Curative • Amoxicillin (80-100mkd TID) • H. influenzae non-type B • Amoxicillin/clavulanate (25-45 mkd BID/TID) • Cefuroxime or cefprozil (30mkd BID), cefdinir (14mkd BID), cefpodoxime (10mkd BID) • Ceftriaxone 50 mg/kg IM to initiate therapy • Macrolide or cephalosporin • Therapeutic • Paracetamol (10mkd) • Non-pharmacologic • Avoid strenous activities and exposure to smoke • Adequate nutrition and hydration • Watchful monitoring of deterioration of patient’s status

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