Transcript Decreased breath sounds on the left upper and lower lung fields

PULMONOLOGY CONFERENCE
Guanzon, Guerrero, Guerzon, Guevarra, Guinto,
Gutierrez, Hermoso, Icasas, Ignacio
General Data
 JA
 16yo / M
 Lives in Caloocan City
 Roman Catholic
 Single
Chief Complaint:
Difficulty of Breathing
1 month PTA
(+) productive cough with yellowish sputum
(-) fever, malaise, dyspnea
No consult was done and no medications were taken.
3 weeks PTA
(+) easy fatigability and shortness of breath after walking for
15 meters and after 2 quarters in a basketball game (as
compared to before?)
(+) fever (Tmax 39.8 C)
Paracetamol 500 mg/tab taken after meals
(+) fever in the afternoon and at night
(?) night chills, sweating
(?) persistence of productive cough
(?) known asthmatic?
3 weeks PTA?
(+) consult at a local clinic
CXR: “Infiltrates over the lung fields”
Assessment: Pneumonia
Medications:
Carbocisteine 250 mg/5 mL, 15 mL (1 tbsp)
BID for 7 days (?mkd)
Ascorbic acid 500 mg/tab BID
Ciprofloxacin 500 mg/tab BID for 7 days
temporary resolution of symptoms
1 week PTA
(+) symptoms (what?) persisted
(+) consult at another clinic
CXR: “Massive pleural effusion on the left”
Medication:
Cefuroxime 500 mg/tab BID for 7 days
(+) resolution of fever and easy fatigability
(+) productive cough with whitish sputum
1 day PTA
Follow-up  USTH-OPD
ADMISSION
Review of Systems
 General: (-) weight change, (-) loss of appetite
 Cutaneous: (-) rash
 Heent: (-) excessive lacrimation, (-) epistaxis, (-)excessive salivation,
 (-) nasal structures,
 Cardiovascular: (-)cyanosis, (-) fainting spells
 Respiratory: (-) cough,
 Gastrointestinal: (-) nausea, vomiting, (-)constipation, (-)abdominal
pain
 Genito-urinary: (-) frequency,(-)hematuria
 Nervous/Behaviour: (-) convulsions, stiffness
 Musculoskeletal: (-) joint swelling, (-) limitation of motion, (-)limping
 Hematopoietic: (-)pallor, (-) abnormal bleeding, (-) easy bruisability
Personal History
 H: Patient lives with his mother and father. At home, he likes to






watch cartoons on TV and sleep. Aside from that, he does not do
anything else at home. He spends most of his free time outside
playing basketball with his friends.
E: Currently in his 3rd year of high school. He prefers to play
basketball than go to class or study.
E: Patient eats 3 meals a day and has no preference on the food
that he eats.
A: Varsity player of the school’s basketball team; computer
games
D: Patient claims that he has never smoke, drink alcohol or took
illicit drugs.
S: He had 4 past girlfriends. He claimed that they had never
engaged in any sexual activity.
S: Patient claims that he is very contented with his life and would
never think of taking his own life.
Past Medical History
 (+) Trauma due to fall (1994) – had the wound
on his left ear dressed
 (-) HPN, (-) DM
 (-) asthma, allergies
Family History
 (+) HPN – paternal and maternal grandfather,





father
(+) PTb – maternal grandfather
(+) DM – maternal grandfather
(+) Thyroid disease - mother
(-) Allergies, Asthma
(-) Cancer, Kidney disease, Stroke
Family Profile
Name
Age
Relation
Occupation
Health
Evangeline
47
Mother
Vendor
(+) toxic goiter
Nestor
61
Father
Retired supervisor
(+) HPN
Nesty John
21
Brother
Unemployed
Healthy
Ana Carmela
19
Sister
Call center agent
Healthy
Rose Anne
18
Sister
Saleslady
Healthy
Socioeconomic & Environmental History
 Patient lives with his parents and stays in the
same room as them. Their house is a single
level cemented bungalow, well ventilated and
well lit. Drinking water is obtained from a
nearby water refilling station. Garbage is
collected everyday by a local garbage
collector.
Physical Examination
 VS: BP 110/70
HR 76 bpm RR 26/min T 36.4 C

Ht: 170 cm
Wt: 53 kg
 Conscious, coherent, ambulatory, not in cardiorespiratory





distress
Warm moist skin, not jaundiced, no active dermatoses
Pink palpebral conjunctivae, anicteric sclera
Nasal septum midline, no nasoaural discharge, turbinates
not congested
No tragal tenderness, nonhyperemic EAC AU, TM intact AU
Moist buccal mucosa, nonhyperemic PPW, tonsils enlarged
Supple neck, no palpable cervical lymph nodes
Physical Examination
 Asymmetric chest expansion, no retractions,
trachea deviated to the right with lagging on the
left, decreased vocal and tactile fremiti on the
left, dullness on the left infrascapular area (T6
down), decreased breath sounds on the left
upper and lower lung fields
 Adynamic precordium, AB 5th LICS MCL, no
murmurs
 Flat abdomen, normoactive bowel sounds, soft,
nontender
 Pulses full and equal, no edema, no cyanosis
Neurologic Examination
 Conscious, coherent, oriented to 3 spheres
 Pupil size 3-4 mm equally reactive to light; no






ptosis OU
No facial asymmetry, (+) corneal reflex, (+) gag
reflex
Symmetric palpebral fissures and nasolabial fold
MMT 5/5 on all extremities
No involuntary movement, no spasticity, no
atrophy
No sensory deficits
No nuchal rigidity, (-) Brudzinski, (-) Kernig’s
Salient Features
Differential Diagnosis
 Pleural Effusion vs. Consolidation vs.
Atelectasis, etc.  clinically first then via CXR
 Degree of Pleural Effusion (Massive, etc?)
 Why suspect Pneumonia?
 Why suspect PTB?
 Asymmetrical chest expansion
 Unilateral impairment or lagging of
respiratory movement suggests disease
of the underlying lung or pleura.
 No retractions
 Trachea deviated to the right
 Lagging on the left
 Causes of unilateral decrease or delay in chest
expansion include chronic fibrotic disease of
the underlying lung or pleura, pleural effusion,
lobar pneumonia, pleural pain with associated
splinting, and unilateral bronchial obstruction.
Bates’ Guide to Physical Examination

Decreased vocal and tactile fremiti on the left

Fremitus is decreased or absent when the voice is soft or when the
transmission of vibrations from the larynx to the surface of the
chest is impeded. Causes include an obstructed bronchus; COPD;
separation of the pleural surfaces by fluid (pleural effusion),
fibrosis (pleural thickening), air (pneumothorax), or an infiltrating
tumor; and also a very thick chest wall.

Dullness on the left infrascapular area (T6 down)
 Dullness replaces resonance when fluid or solid tissue replaces
air-containing lung or occupies the pleural space.
 Dullness replaces resonance when fluid or solid tissue replaces
air-containing lung or occupies the pleural space beneath your
percussing fingers. Examples include: lobar pneumonia, in which
the alveoli are filled with fluid and blood cells; and pleural
accumulations of serous fluid (pleural effusion), blood
(hemothorax), pus (empyema), fibrous tissue, or tumor.

Decreased breath sounds on the left upper and lower lung fields
 Breath sounds may be decreased when air flow is decreased (as
by obstructive lung disease or muscular weakness) or when the
transmission of sound is poor (as in pleural effusion,
pneumothorax, or emphysema).
Bates’ Guide to Physical Examination
Impression
 t/c Pneumonia
Pneumonia
 Definition
 Etiologies by age
 Criteria for Dx
 Criteria for confinement
 Ancillary procedures
 Expected clinical and lab findings
 Complications
 Correlate with px
Clinical Assessment
 Pneumonia can be defined clinically as the
presence of lower respiratory tract dysfunction in
association with radiographic opacity.
 WHO has promoted an algorithm to assess
children who present with cough and fever.
 Tachypnea, considers an increased respiratory rate
 >50 breaths/min in infants
 >40 breaths/min in children >11 months
 Suprasternal, subcostal or intercostal
retractions indicates greater severity.
Canadian Medical Assoc J: A practical guide for the diagnosis
and treatment of pediatric pneumonia; 1997
 Radiographic confirmation is considered the gold standard.
 However, no finding in itself can be used to diagnose or rule
out pneumonia. The absence of the symptom cluster of
respiratory distress, tachypnea, crackles and decreased
breath sounds accurately (100% specificity) excludes the
presence of pneumonia (level II evidence).
 Assessment of oxygenation gives a good indication of the
severity of disease.
 Oximetry should be considered in the assessment of a child
with suspected pneumonia and in all children admitted to
hospital with pneumonia, because the results correlate well
with clinical outcome and length of hospital stay (level II
evidence).
Canadian Medical Assoc J: A practical guide for the diagnosis
and treatment of pediatric pneumonia; 1997
 Two classic presentations have been described
for pneumonia:
 Typical pneumonia: fever, chills, pleuritic chest pain
and a productive cough.
 Atypical pneumonia: gradual onset over several days
to weeks, dominated by symptoms of headache and
malaise, nonproductive cough and low-grade fever.
 Unfortunately, the overlap of microbial agents
responsible for these presentations thwarts
identification of the causal pathogen on the
basis of clinical presentation.
Canadian Medical Assoc J: A practical guide for the diagnosis
and treatment of pediatric pneumonia; 1997
 The best predictor of the cause of pediatric
pneumonia is age. During the first 2 years of a
child’s life viruses are most frequently
implicated. As age increases, and the
incidence of pneumonia decreases, bacterial
pathogens, including S. pneumoniae and
Mycoplasma pneumoniae, become more
prevalent.
Canadian Medical Assoc J: A practical guide for the diagnosis
and treatment of pediatric pneumonia; 1997
 In developing countries acute respiratory
infections cause up to 5 million deaths annually
among children less than 5 years old.
 Several risk factors increase the incidence or
severity of pneumonia in children: prematurity,
malnutrition, low socioeconomic status, passive
exposure to smoke and attendance at day-care
centres.10 Underlying disease, especially that
affecting the cardiopulmonary, immune or
nervous systems, also increases the risk of severe
pneumonia
Canadian Medical Assoc J: A practical guide for the diagnosis
and treatment of pediatric pneumonia; 1997
Academy of American Family Physicians: CAP in Infants & Children; 2004
Radiographic Findings
 A confirmatory chest radiograph is necessary to
diagnose pneumonia. Bronchiolitis and asthma
may cause hyperinflation and atelectasis and
must be distinguished from pneumonia.
 Two main patterns of pneumonia are recognized:
interstitial and alveolar. However, these patterns
cannot be used to identify the cause.
Peribronchial thickening, diffuse interstitial
infiltrates and hyperinflation tend to be seen
with viral infections (level III evidence).
Radiologic Findings
 Bacterial - Lobar infiltrates, pneumatoceles, abscesses
 Alveolar infiltrates, however, are also seen in bacterial as





well as viral disease and in Mycoplasma pneumonia.
Pneumococcal - Circular infiltrates in the early stages
M. pneumoniae infection - Diffuse infiltration out of
proportion with the clinical findings, lobar consolidation,
plate-like atelectasis, nodular infiltration and hilar
adenopathy
Chlamydial pneumonia may be indistinguishable from
mycoplasmal pneumonia.
P. carinii pneumonia - reticulonodular infiltrate that
progresses to alveolar infiltrates
Tuberculosis - Hilar adenopathy especially if the patient has
epidemiologic risk factors
Canadian Medical Assoc J: A practical guide for the diagnosis
and treatment of pediatric pneumonia; 1997
Academy of American Family Physicians: CAP in Infants & Children; 2004
Course in the Ward
Management
Academy of American Family Physicians: CAP in Infants & Children; 2004
Academy of American Family Physicians: CAP in Infants & Children; 2004