Transcript Pulmonary Case Conference

Pulmonary Case Conference
General Data
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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 38.90C, axillary)
•(+)clear watery nasal discharge
•(+)decrease in appetite,
•Paracetamol 25mg/kg/dose
3DaysPTC
(+) persistence of symptoms
Phenylpropanolamine HCl drops (Disudrin)
1.6mg/kg/dose
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
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 ;
Salbutamol nebulization q8
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,
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
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:
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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
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.
Feeding History
• Patient was not breastfed due to inability of
mother to excrete milk.
• Milk (0-6months) - Bona (2:1 dilution) 2oz – 1012x/day
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(6 months – 1year) – Bonamil (2:1 dilution)
4oz – 10-12x/day
• Current: Bear Brand Jr (1:1 dilution) 6oz – 46x/day
• Complementary Feeding started at 9 months
(gruel, chicken, bread)
Feeding History
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
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.
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
Family Profile
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)
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 23mm ERTL, (+) sunken eyes
Midline nasal septum, (+) turbinates congested, (+)
clear nasal discharge
Nonhyperemic external auditory canal, intact
tympanic membrane, (+) retained cerumen, AU
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
Adynamic precordium, 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
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
Course in the Wards
VS on PE
• Carl Justine Decallos 316D
CR:152 RR:52 T:36.6 BW:10 kg
BL:80cm BSA: 0.47
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:
– Paracetamol 250mg/5ml 0.25ml q4
– 0.65% NaCl nasal drops, 2-3gtts/nostril every 6 hours, then suction
– Kamilosan oral spray for irritated throat 2 sprays TID
Admitting Impression
• Acute nasopharyngitis with moderate signs of
dehydration
2nd Hospital Day
Jan 27
• IVF rate was decreased to 10-11gtts/min
and shifted to IVF D5IMB
• Fair oral intake
• No signs of dehydration
• Clear and equal breath sounds
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
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
5th Hospital Day
Jan 30
• Salbutamol Nebulization, 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/SIVP
Same IVF regimen
6th Hospital Day
Jan 31
• Salbutamol frequency was tapered to Q3
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.
Subjective data
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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
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No weight loss
Tears while crying (?)
No diarrhea
PMH: pneumonia
Exposure to cigarette
smoke
• FH: mother - PTB
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
Approach to Diagnosis
Sign or symptom pointing to an organ or part
of an organ system
signs
symptom
Organ
system
Subjective findings
Eager to
drink
Vomiting,
multiple
episodes
Decreased
level of
activity
Moderate
Dehydration
Decrease
in
appetite
Objective findings
Good skin
turgor
Warm,
moist skin
(+) sunken
eyeballs
CRT < 2
secs.
Moderate
Dehydratoin
Pulses full
and equal
SYMPTOM
MINIMAL OR NO
DEHYDRATION
(<3% loss of BW)
MILD TO MODERATE
DEHYDRATION
(3-9% loss of BW)
SEVERE DEHYDRATION
(>9% loss of BW)
Mental Status
Well; alert
Normal, fatigued or
restless, irritable
Apathetic, lethargic,
unconscious
Thirst
Drinks normally;
might refuse liquids
Thristy; eager to drink
Drinks poorly; unable to
drink
Heart rate
Normal
Normal to increased
Tachycardia with
bradycardia in most
severe cases
Quality of pulses
Normal
Normal to decreased
Weak, thready, or
impalpable
Breathing
Normal
Normal; fast
deep
Eyes
Normal
Slightly sunken
Deeply sunken
Tears
Present
Decreased
absent
Mouth and tongue
Moist
Dry
parched
Skinfold
Instant recoil
Recoil in <2 sec
Recoil in >2 sec
Capillary refill time
Normal
Prolonged
Prolonged; minimal
Extremities
Warm
Cool
Cold; mottled; cyanotic
Urine Output
Normal to decreased
Decreased
Minimal
Respiratory
System
URTI
Acute
Nasopharyngitis
LRTI
Acute
tonsillopharyngitis
Pneumonia
Management
Assess airway patency, breathing and
circulatory status of the patient
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
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
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.
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
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)
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 NaCl 20-21 drops/ minute to run
for 24 hours
Dehydration
Dehydration
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
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
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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
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
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
Pneumonia
• General Measures
– Inpatient
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Failure of outpatient therapy
Hypoxemia
Inability to maintain oral hydration
Respiratory distress/apnea
Toxic appearance
Complications (effusion/empyema)
Risk to infection ( <2 months/immunocompromised)
Pneumonia
• Pharmacologic
– Curative
• Erythromycin (10 mg/kg IV q6h), azithromycin (2.5 mg/kg IV q12h)
• If febrile – cefotaxime (200mkd q8h)
• Atypical pathogen not suspected – ceftriaxone (50-75mkd q1224h), cefotaxime (200mkd q8h)
– Therapeutic
• Paracetamol (10mkd)
• Non-pharmacologic/supportive
– Oxygen as needed to keep saturation >95%
– Intubation and positive pressure ventilation if clinically
indicated
Pneumonia
• Follow up recommendations
– Expected course/prognosis
• Uncomplicated pneumonia -> 3-5 days
– Possible complications
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Pleural effusion
Empyema
Lung abscess
Pneumatoceles
Pneumothorax
Bacteremia/sepsis
Pneumonia
• Patient monitoring
– Outpatient – follow up after 3 days
– Worsening or not improving – repeat or additional
diagnostic studies
• Persistent fever – loculated pleural fluid or empyema
– CXR – abnormal up to 10 weeks after successful treatment
• Follow up CXR – indicated for severe disease or complications
(effusion/empyema)
– Recurrent bacterial pneumonia – underlying anatomical or
immunologic disorder
• Abnormal antibody production, cystic fibrosis, tracheoesophangeal
fistula, pulmonary sequestration
Acute Nasopharyngitis
• General Prevention
– Can return to school or day care 24 hours after
starting antimicrobial therapy
• General Measures
– Usually no therapy indicated, except for
streptococcal origin (rare: fungal/bacterial)
– May withhold treatment for GAS pharyngitis until
throat culture is available
– Steroids – not recommended
Acute Nasopharyngitis
• Pharmacologic
– Curative
• Oral penicillin V, IM benzathine penicillin G
• Amoxicillin, Clindamycin, 1st generation oral cephalosporin
• Azithromycin, Clarithromycin
– Therapeutic
• Paracetamol
• Non-pharmacologic/supportive
– Oral hygiene
– Surgical (?)
• Tonsillectomy
Acute Nasopharyngitis
• Follow up recommendations
– Duration of therapy
• 10d = 3-5d -> similar cure rates
– Streptococcal pharyngitis
• Clinical improvement is rapid
• Expected course/prognosis
– Streptococcal -> associated with ARF and APGN
– Viral -> self limited
Acute Nasopharyngitis
• Possible complication
– Streptoccal pharyngitis
• Suppurations
• ARF
• APGN
– Lemierre Syndrome
• Pharyngitis -> sepsis + suppurative thrombophebitis of IJV
• Seeding of septic thromboemboli
– Pediatric Autoimmune Neuropsychiatric Disorders
Associated with Streptococcal infection (PANDAS)
Herpangina
• General Prevention
– Avoid contact with infected individual
– MOT: feco-oral-> general hygeine
• General Measures
– Self limited
– Palliative and supportive
– Hydration
Herpangina
• Pharmacologic
– Curative
• None
– Therapeutic
• Analgesics
– Paracetamol
• Topical anesthetics
• Mouth wash
• Non pharmacologic/supportive
– Hydration
– Clear liquids, non irritating foods
– Proper hygeine
Herpangina
• Follow up recommendations
– Complete recovery
• Possible complications
– Exanthem
– Aseptic meningitis
– Myocarditis
– Encephalitis
Growth and development
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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)
HC: 47cm
Teeth (deciduous): all except second molars
Age
Weight gain (oz/mon)
Growth in length
(cm/mon)
HC
(cm/month)
1-3
8 oz
1.0
0.25
Growth and development
• Monitor progression of developmental
milestones
– Gross motor: runs well; walks up, down stairs one
step at a time
– Fine motor: builds tower of 7 cubes, imitates a
circular stroke
– Language: combines two to three words in
sentences; 2 step commands
– Social: removes garment; toilet trained by day;
turns pages one at a time
Nutrition
• Multivitamins 10 mL QD
• RENI – 1070 kcal (CHO – 161g - 642 kcal;
CHON 28 g - 112kcal; fats 30g – 268kcal)
Immunization
• Completed EPI at a local health center
– BCG 1 dose
– Hepatitis B 3 doses
– OPV 3 doses
– DPT 3 doses
– Measles 1 dose
• Update vaccinations
– DPT, OPV booster – 1 year after primary
– MMR, varicella, Hib vaccines, pneumococcal
Preventive Pediatrics
• Injury prevention
– Car restraints, protect from falls, supervise play near street,
never leave unattended in car or house, water safety
• Good parenting practices
– Read simple stories regularly, play games, praise/show affection;
short ritual before bedtime, night fears, night awakening, toilet
training readiness
• Discipline
– Need for autonomy and independence, self-comforting
behavior, thumb-sucking, masturbation, favorite toy or
possession
• Nutrition
– Wean from bottle, fluoride when needed
Sources
• American Academy of Pediatrics. Group A streptococcal infections. Report
of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL:
American Academy of Pediatrics; 2006:610-620
• Bisno, A.L. et al., Diagnosis and Management of Group A Streptococcal
Pharyngitis: A practice guideline. Clin Infect Dis. 1998; 26:1020-1021.
• Casey, J.R. et al, Meta-analysis of cephalosporin vs penicillin treatment of
group A sstreptococcal tonsillopharyngitis in children. Pediatrics. 2004;
q113:866-882.
• Swedo, S.E. et al., Pediatric Autoimmune neuropsychiatric disorders
associated with streptococcal infections: Clinical description of the first 50
cases. Am J Psychiatry. 1998; 155:264-271.
• Armon, K. et al. An Evidence and Consensus based on Guideline for Acute
Diarrhea Management. Arch Dis Child. 2001; 85:132-142.
• Centers for Disease Control and Prevention. Managing acute
gastroenteritis among children: Oral rehydration, maintenance, and
nutritional therapy. MMWR.
• Chang, L.Y. et al. Transmission and clinical features of enterovirus 71
infections in household contacts in Taiwan. JAMA 2004; 291: 222-227.
and Philippine
Sources
• Behrman, R. E. et al. Nelson’s Textbook of Pediatrics, 16th ed.
• Committee on Immunization, Infectious disease society, and
Philippine Foundation for Vaccination. Childhood Immunization
Schedule. 2002.
• DOH & Health Services for Disease Control and Prevention.
Recommended Childhood and Adolescent Immunization Schedule.
2005.
• Bradley, J. S. Management of community acquired pediatric
pneumonia in an era of increasing antibiotic resistance and
conjugate vaccines. Pediatr Infect Dis J. 2002; 21:592-598.
• Kabra, S.K. Antibiotics for community acquired pneumonia in
children. Cochrane Database Syst Rev. 2006.
• Winters R.W.: Principles of Pediatric Fluid Therapy. Little, Brown,
1982.
• Hay, W.W. et al. Current Diagnosis and treatment in Pediatrics. 19th
ed.
Clk. Alexander L. Gonzales II
DISCUSSION
NASOPHARYNGITIS
DEHYDRATION
PNEUMONIA
DISCUSSION
NASOPHARYNGITIS
NASOPHARYNGITIS
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Principal involvement is in the throat
Uncommon below 1 year
Peak at 4-7 years & continues throughout childhood
Prominent in cases of Diphtheria, herpangina,
adenovirus & Infectious mononucleosis
ETIOLOGY
• Viral: Adenovirus, enterovirus, EB virus,
Herpes simplex virus.
• Bacterial: Group A  hemolytic streptococcus.
• Mycoplasma
CLINICAL MANIFESTATIONS
• Fever, variable depending on etiology.
• Throat: erythema, exudates, ulceration, enlarged
tonsils & peticheal mottling of the soft palate
• Conjunctivitis, rhinitis, hoarseness , cough
• Cervical lymphadenopathy
• Headache, abdominal pain
ASSESSMENT CRITERIA
• Younger child:
• Fever.
•Sneezing.
•Irritability.
•Vomiting.
•Diarrhea.
•Restlessness
• Older child:
•Dryness & irritation of nose& throat.
•Sneezing.
•Muscular aches.
•Chilly.
•Cough.
DIAGNOSIS
• Clinical
• Throat culture
• Rapid streptococcal detection kits
DIFFERENTIAL DIAGNOSIS
• Infectious mononucleosis, when a
membranous exudate is present
• Diphtheria, especially in the underimmunized
• Herpangina, with many vesiculoulcerative
lesions in the anterior pillars & soft palate
• Agranulocytosis, yellowish dirty white
exudates covering the tonsils & post ph wall
• Kawasaki disease
COMPLICATIONS
 Low rate with viral infection
 Spectrum of illness extend from pharyngitis to
tonsillitis, retropharyngeal abscess or
peritonsillar abscess
 In debilitated children, large chronic ulcers in
the pharynx (viral or bacterial)
 Mesenteric adenitis ( viral or bacterial)
abdominal pain with or without vomiting
 Acute glomerulonephritis & Rheumatic fever,
may follow streptococcal infections
TREATMENT
• Penicillin for 10 days in proven streptococcal
pharyngitis (125-250mg every 8 hrs) Or
erythromycin if allergic to penicillin
• Symptomatic Rx, warm saline gargle, steam
inhalation, cool bland liquids as ginger ale.
Acetaminophen for throat pain.
DISCUSSION
DEHYDRATION
DEHYDRATION
• Fluid and electrolytes requirements
• Water: Constitutes about 70% of infant's body
weight as compared to 60% in adults
• Total body water = intracellular space +
intravascular space + interstitial space
• Average daily requirement of water (ml/kg):
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First year: 130 – 150
2 to 4 years: 100 – 130
4 to 10 years: 70 – 100
10 to 18 years: 50- 70
DEHYDRATION
• Dehydration occurs when the amount of
water leaving the body is greater than the
amount being taken in.
• We lose water routinely when:
– We breathe and humidified air leaves the body;
– We sweat to cool the body; and,
– We urinate or have a bowel movement to get rid
the body waste products.
DEHYDRATION
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Diarrhea: is the most common reason for loss of excess water. Worldwide, more
than four million children die each year because of dehydration from diarrhea.
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Vomiting: can also be a cause of fluid loss .
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Sweat: The body can lose significant amounts of water when it tries to cool itself
by sweating whatever the cause of hotness of the body such as intense exercising
in a hot environment, or presence of fever .
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Diabetes: In people with diabetes, elevated blood sugar levels cause sugar to spill
into the urine and water then follows. For this reason, frequent urination and
excessive thirst are among the symptoms of diabetes.
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Chronic renal failure: dehydration occurs due to polyuria.
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Burns: dehydration occur because water moves into the damaged skin. Other
inflammatory diseases of the skin are also associated with fluid loss.
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Inability to drink fluids: The inability to drink adequately is the other potential
cause of dehydration.
MORTALITY/MORBIDITY
• Morbidity varies with the degree of volume depletion and
the underlying cause.
• The severely volume-depleted infant or child is at risk for
death from cardiovascular collapse.
• Hyponatremia resulting from replacement of free water
alone may cause seizures.
• Improper management of volume repletion may cause
iatrogenic morbidity or mortality.
PHYSICAL FINDINGS SEEN WITH DIFFERENT LEVELS OF
PEDIATRIC DEHYDRATION
Symptom
Mild (<3% body
weight lost)
Moderate (3-9% body
weight lost)
Severe (>9% body
weight lost)
Mental
status
Normal, alert
Restless or fatigued,
irritable
Apathetic, lethargic,
unconscious
Heart rate
Normal
Normal to increased
Tachycardia or
bradycardia
Quality of
pulse
Normal
Normal to decreased
Weak, thready,
impalpable
Breathing
Normal
Normal to increased
Tachypnea and
hyperpnea
Eyes
Normal
Slightly sunken
Deeply sunken
Fontanelles Normal
Slightly sunken
Deeply sunken
Tears
Normal to decreased
Absent
Normal
PHYSICAL FINDINGS SEEN WITH DIFFERENT LEVELS OF
PEDIATRIC DEHYDRATION
Mucous
membranes
Moist
Dry
Parched
Skin turgor
Instant recoil
Recoil <2 seconds
Recoil >2 seconds
Capillary
refill
<2 seconds
Prolonged
Minimal
Extremities
Warm
Cool
Mottled, cyanotic
Mental
status
Normal, alert
Restless or fatigued,
irritable
Apathetic, lethargic,
unconscious
Heart rate
Normal
Normal to increased
Tachycardia or
bradycardia
PHYSICAL FINDINGS SEEN WITH DIFFERENT LEVELS OF
PEDIATRIC DEHYDRATION
Quality of pulse
Normal
Normal to
decreased
Weak, thready,
impalpable
Breathing
Normal
Normal to
increased
Tachypnea and
hyperpnea
Eyes
Normal
Slightly sunken
Deeply sunken
Fontanelles
Normal
Slightly sunken
Deeply sunken
Tears
Normal
Normal to
decreased
Absent
Mucous
membranes
Moist
Dry
Parched
Skin turgor
Instant
recoil
Recoil <2 seconds
Recoil >2 seconds
Capillary refill
<2 seconds
Prolonged
Minimal
Extremities
Warm
Cool
Mottled, cyanotic
IMCI MANAGEMENT: Integrated
management of childhood illness ( WHO)
• Plan A:
– Give fluid and food to treat diarrhea at home
– If child is 2 years or older and there is Cholera in your area, give antibiotic for
cholera.
– Advise mother when to return immediately
– Follow-up in 5 days if not improving
• Plan B:
– Give fluid and food for some dehydration
– If child has also a severe classification:
• Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
• Advise the mother to continue breast-feeding
– If child is 2 years or older and there is Cholera in your area, give antibiotic for
cholera.
– Advise mother when to return immediately
– Follow-up in 5 days if not improving
IMCI MANAGEMENT: Integrated
management of childhood illness ( WHO)
• Plan C:
– Give fluids for severe dehydration or If child has also
another severe classification:
• Refer URGENTLY to hospital with mother giving
frequent sips of ORS on the way
• Advise the mother to continue breast-feeding
• If child is 2 years or older and there is Cholera in your
area, give antibiotic for cholera
DISCUSSION
PNEUMONIA
PNEUMONIA
• Inflammation of the parenchyma of the lungs
• May be caused by:
– Microorganisms
– Aspiration
– Hypersensitivity reactions
– Drug or Radiation induced pneumonitis
EPIDEMIOLOGY
EPIDEMIOLOGY
• Each year it cause approximately 2-3 million
deaths among children <5 years old and are
the leading cause of death in this age group
• About 1% of pneumonia cases result in
sequelae (e.g., bronchiectasis)
• In the Philippines, it ranks 3rd in the ten
leading causes of mortality in all age groups
(CPG on Pneumonia, PPS)
Leading Etiologic Agents of Pneumonia
Infants and Children
Age
Bacterial
pathogens
Viral
Pathogens
Neonate
Group B Streptocaccus
Gram-negative bacilli(
E.coli,K.pneumoniae,P
roteus spp.,others)
S.aureus
RSV
Herpes simplex
virus
CMV
Adenovirus
1-3 mo.
S.pneumoniae
H.Infuenzae type b
RSV
4 mo.-5 yrs
S.pneumoniae
H.Influenzae type b
Parainflenza
virus1 and 3,
Adenovirus
Influenza viruses
A and B
5 yrs and older
S.pneumoniae
Other
C.trachomatis
M.pneumoniae
C.pneumoniae
Clues to The Etiology of Pneumonia
Obtained Through History - Taking
Type of Contact or Prodrome
Disease or Organism
- Contact with an individual with a lung
infection
Tuberculosis
M.pneumoniae
RSV
S.pneumoniae
- Infant/young child in day care
H.Influenzae type B
N.meningitis
Respiratory viruses
Clues to The Etiology of Pneumonia
Obtained Through History – Taking
Type of Contact or
Prodrome
Disease or Organism
-Animal contact
Psittacosis
Tularemia
Plaque, Q fever
Geographic regions
Histoplasmosis
Coccidioidomycosis
Rickettsial infections
Building construction
Aspergillus spp.
Air conditioning cooling towers
Legionaires’ disease
Clues to The Etiology of Pneumonia
Obtained Through History – Taking
Type of Contact or
Prodrome
Disease or Organism
-Outbreak/epidemic
Group A Streptococcus
Influenza
RSV
- Smoker,smoking in
household,wood-burning stove
Increase in all lower respiratory
infections
- Short prodrome
Bacterial agents such as
S.pneumoniae,H.influenzae type
b, Group A Streptococcus
Clues to The Etiology of Pneumonia
Obtained Through History – Taking
Type of Contact or
Prodrome
Disease or Organism
- Long prodrome
M.pneumoniae
C.pneumoniae or C.trachomitis
RSV
- Preceding rash
Measles
N.meningitidis
M.pneumoniae
S.aureus
Preceding focal abscess;intra-or
extrapulmonary
S.aureus
PATHOGENESIS
• Primary inhalation: when organisms bypass
normal respiratory defense mechanisms or when
the patient inhales aerobic microorganisms that
colonize the upper respiratory tract or respiratory
support equipment
• Aspiration: occurs when the patient aspirates
colonized upper respiratory tract secretions
• Hematogenous: originate from a distant source
and reach the lungs via the blood stream.
COMMUNITY ACQUIRED PNEUMONIA
• Infection of the lung parenchyma in a person
who is not hospitalized or living in a longterm care facility for ≥ 2 weeks
• Most common pathogen = S. pneumoniae (6070% of CAP cases)
NOSOCOMIAL PNEUMONIA
• Hospital-acquired pneumonia (HAP)
– Occurs 48 hours or more after admission, which
was not incubating at the time of admission
• Ventilator-associated pneumonia (VAP)
– Arises more than 48-72 hours after endotracheal
intubation
NOSOCOMIAL PNEUMONIA
• Healthcare-associated pneumonia (HCAP)
– Patients who were hospitalized in an acute care hospital
for two or more days within 90 days of the infection;
resided in a nursing home or LTC facility; received recent IV
abx, chemotherapy, or wound care within the past 30 days
of the current infection; or attended a hospital or
hemodialysis clinic
CLINICAL MANIFESTATIONS
NON-SPECIFIC
Fever
Malaise
Headache
GI complaints
Apprehension
Restlessness
LOWER RESPIRATORY
Tachypnea/Dyspnea
Shallow or grunting
respiration
Cough
Nasal flaring
intercostal
retraction
PLEURAL EFFUSION/
EMPYEMA
PLEURITIC
Referred pain to neck and back
Abdominal pain if diaphragmatic involvement
EXTRAPULMONARY
Disseminated disease
Skin and soft tissue involvement arising from
bacteremia, meningitis
DIAGNOSIS
• Diagnostic evaluation of lower respiratory
infections:
– WBC count Blood cultures
– C-reactive protein
– Chest radiograph
– Bacterial antigen assays
– Nasopharyngeal cultures
Epidemiology,Clinical,and Laboratory Features of
Acute Pneumonia in Normal Infants and
Children According to Etiologic Agents
Bacteria
Virus
Mycoplasma
Historical clues
- Age
Any,esp.infant
- Temp.
Majority ≥ 39° C < 39° C
Majority < 39° C
- Onset
Abrupt
Gradually
worsening URI
Gradually
worsening cough
- Others in home ill
Infrequent
Frequent
Frequent,wk.apart
- Ass. Signs,
symptom
Meningitis,otitis, Myalgia,rash,con Headache,sorethro
arthritis
junctivitis
at,myalgia
- Cough
Productive
- Pleuritic chest pain Frequent
Any
School
age,adolescent
Nonproductive
Hacking
Infrequent
Infrequent
Epidemiology,Clinical,and Laboratory Features of
Acute Pneumonia in Normal Infants and
Children According to Etiologic Agents
Bacteria
Virus
Mycoplasma
Physical Findings
- Auscultatory
Confined
rales,no
rales.Occasio
nal dullness to
percussion,di
minished
tubular
sounds
Diffuse,bilat.
Rales.Wheez
es in young
infant
Unilateral
rales in most
-Toxicity
Degree illness Degree illness Degree illness
> findings
≤ findings
< findings
Epidemiology,Clinical,and Laboratory features of
Acute Pneumonia in Normal Infants and
Children According to Etiologic Agents
Bacteria
Virus
Mycoplas
ma
Radiographic
Findings
- Initial
examination
-Progression
Hyperaeration Hyperaeration Alveolar± alveolar
± interstitial
interstitial
infiltrate
infiltrate
patchy
infiltration
Frequent,
rapid
Infrequent
May be
migratory
-Pleural fuild
May be large,
rapidly
progressive
Infrequent,
small, not
progressive
Infrequent,
small, not
progressive
Epidemiology,Clinical,and Laboratory Features of
Acute Pneumonia in Normal Infants and
Children According to Etiologic Agents
Bacteria
Virus
Mycoplasma
Laboratory
Findings
- Peripheral
WBC/cu.mm
Majority>
15,000.Granu
locytes
predominate
Majority<15,0
00.Lymphocy
tes
predominate
Majority
normal or
less than
15,000
- C-reactive
protein
Majority
Infrequent
Infrequent
- Sed rate ≥
30 mm/hr
Majority
Majority
Majority
Considerations for Inpatient Management
of Children with Pneumonia
•
•
•
•
Toxic appearance
Respiratory distress
Pleural effusion
Age considerations:
– <3 months
– <3 years, with lobar pneumonia
– <5 years, with lobar pneumonia (more than 1
lobe)
Considerations for Inpatient Management
of Children with Pneumonia
• Existing chronic disease
–
–
–
–
–
–
–
Pulmonary (including asthma)
Cardiac
Renal
Diabetes mellitus
Metabolic disorders
Anemia (including sickle cell disease)
Malignancies
• Immunocompromised host
• Progression of pneumonia during outpatient
therapy
Initial Therapy of Pneumonia
Treatment
Outpatient
Principal pathogens
Hospitalized
Age
0-4 wks.
-
Ampicillin and
Gentamicin (+/cefotaxime)
Group B Streptococcus(++)
Enteric gram negativea bacilli(+)
1-5 mo.
Amoxicillin ( or
amoxicillinclavulanate)
Cefotaxime*
Pneumococcus(++);virus(++);S.aureus(+)
6 mo.-6 yr.
Amoxicillin ( or
amoxicillinclavulanate)
Cefotaxime* +/macrolide†
Pneumococcus(++);virus(++);S.aureus(+);
Group A Streptococcus(+);Mycoplasma(+)
6 yr.
Macrolide † (+/amoxicillin)
Cefotaxime* and
macrolide †
Mycoplasma(
++);pneumococcus(+);S.aureus(+);Group
A Streptococcus(+);Chlamydia(+)
Immunocompromised
-
Cefazidime‡ and
Vancomycin +/macrolide†
Many
+Occasional cause ++common cause *or ceftriazone or cefuroxime ,†Erythromycin azithromycin or clarithromycin ,‡cefepime
PREVENTION
• HIB conjugate vaccine approved 1990 resulted in
virtual eliminated of disease in infants and children
• Vaccine group 11% reduction in clinical episodes
• 35% decrease in radiologically-diagnosed pneumonia
• 63% decrease in radiologically-confirmed lobar
pneumonia
Pneumococcal Vaccine Linked To
Less Hospitalizations, Costs For
Children Under Age 2
Arch Pediatr Adolesc Med.
2007;161(12):1162-1168.
• Pneumonia is the leading cause of childhood illness
and death worldwide, accounting for 2 million
childhood deaths per year, mainly in developing
countries.
• In 2000, American children began receiving the 7valent pneumococcal conjugate vaccine (PCV7)--which
protects against pneumococcal pneumonia, caused by
the Streptococcus pneumoniae bacteria--as part of the
routine immunization schedule.
• This vaccine is recommended for:
– all children age 2 months to 23 months
– children age 24 months to 59 months
Methodology
• health records were analyzed from a database of
approximately 40 large employers each year from
1997 to 2004.
• The researchers used claims data and coding
from hospitals and physician visits to determine
the number and cost of health care visits due to
all-cause and pneumococcal pneumonia.
– More than 40,000 children younger than age 2 are
represented in the database each year.
Fangjun Zhou, Ph.D., and colleagues at the Centers for Disease Control and
Prevention, Atlanta
Results
• Comparing the rates in 2004 with those in the baseline
period of 1997 to 1999 among children younger than 2
years:
– Hospitalizations due to all-cause pneumonia:
• declined from 11.5 to 5.5 per 1,000 children (52.4 percent decline)
– Outpatient visits due to all-cause pneumonia:
• declined from 99.3 to 58.5 per 1,000 children (41.1 percent decline)
• Rates of hospitalization due to pneumococcal pneumonia:
– declined from 0.6 to 0.3 per 1,000 children (57.6 percent
decline)
• rates of ambulatory visits:
– declined from 1.7 to 0.9 per 1,000 children (46.9 percent
decline)
Conclusion
• "These results add to the growing evidence
base of benefits of PCV7 vaccination and
suggest an important role for the vaccine in
reducing the burden of pneumonia and
associated medical costs."
Pneumococcal Vaccine Reduces
Child Deaths In Developing
Countries
Editorial adaptations by ScienceDaily from
materials provided by Academy of Finland
• Infections caused by the pneumococcus (Streptococcus
pneumoniae) bacterium are the major causes of child
mortality worldwide.
• The World Health Organisation (WHO) estimates that more
than a million children die from pneumococcal meningitis
and pneumonia every year. Furthermore, pneumococci
cause a far greater number of minor respiratory tract
infections. Severe infections can cause children to be at
high risk for permanent hearing impairment, which in turn
may lead to delays in development and learning difficulties.
• In the Philippines, pneumonia is the leading cause of severe
morbidity and mortality among children under five years of
age.
Results
• A total of 12 190 children aged between six weeks and six months
participated in the ARIVAC vaccine trial. The results showed that
there was a 23 percent reduction in X-ray-confirmed pneumonia
among children under two years of age who received the
pneumococcal vaccine. However, the vaccine did not reduce
clinically diagnosed pneumonia.
• The children were given three doses of either a pneumococcal
conjugate vaccine or placebo. At the same time, they were also
given vaccines included in the Filipino national vaccination
programme as well as a Hib vaccine. A subset of approximately
thousand children was studied separately to analyze the ability of
the vaccine to induce antibodies and prevent nasopharyngeal
carriage of pneumococcus.
• The pneumococcal vaccine was highly effective in producing
antibodies and proved to be a safe vaccine overall.
Conclusion
• The results of this ARIVAC trial can be put to good use
in pneumococcal vaccine development and in assessing
the burden of disease of pneumococcal infections
among children.
• The results can also provide robust support to decisionmakers at a national level, especially in Asia. Despite
the efficacy of the vaccine, price is still a big hurdle to
overcome: for resource-poor countries that do not
receive international financial aid, it may take several
years if not decades before they can add the vaccine to
the national vaccination program.
Conclusion
• One of the merits of the vaccine trial was the
extent to which it fused together international
research and development co-operation.
• “The pooling of funds from several different
sources successfully ensured both the
scientific quality of the research and the
supply of local know-how and knowledge, in
accordance with the principles of sustainable
development.”
Academy Research Fellow Hanna Nohynek at THL