morning report july 23, 2013 good morning. symptoms acute /subacutechronic localizeddiffuse...
TRANSCRIPT
Morning ReportJuly 23, 2013
Good Morning
Symptoms
Acute /subacute Chronic
Localized Diffuse
Single Multiple
Static Progressive
Constant Intermittent
Single Episode Recurrent
Abrupt Gradual
Severe Mild
Painful Nonpainful
Bilious Nonbilious
Sharp/Stabbing Dull/Vague
Problem Characteristics
Ill-appearing/Toxic
Well-appearing/Non-toxic
Localized problem
Systemic problem
Acquired Congenital
New problem Recurrence of old problem
Semantic Qualifiers
Illness Script
Predisposing Conditions Age, gender, preceding events
(trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)
Pathophysiological Insult What is physically happening in
the body, organisms involved, etc.
Clinical Manifestations Signs and symptoms Labs and imaging
Predisposing Conditions
Incidence: 35-40/1000 in <5yo, 7/1000 in older children and adolescents
Boys > girlsList 2 environmental risk factors for PNA
Lower socioeconomic status Smoke exposure-cigarette smoke or wood smoke Cold weather Alcohol
Question B….aspiration
Predisposing Conditions
Name 4 medical conditions that increase PNA risk Medical history
Sickle cell BPD GERD Cystic Fibrosis Heart disease Immunodeficiency
Increased aspiration Neuromuscular disorder Seizure disorder
Question E. Viral agents are the most common cause of PNA
in infants and young children
Pathophysiology
What method of transmission is reponsible for the spread of PNA? Spread by droplets
Typically follows URI
Mechanism Colonization of nasopharynx with further inhalation
of microorganisms, leading to a pulmonary focus of infection Less commonly…bacteremia results from the initial
upper airway colonization with subsequent seeding of
lungs
Pathophysiology
What is the most common organism causing bacterial PNA? Streptococcus pneumonia
What are 3 additional pathogens that cause bacterial PNA? S. aureus, Group A Strep, GNR (<3mo),
anaerobes6 week old, afebrile infant with tachypnea,
cough, and CXR showing interstitial changes? Chlamydia pneumoniae
What are 2 viral causes of PNA? RSV, Parainfluenza, Influenza, Metapneumovirus,
etc.
Pathophysiology
Question C. Mycoplasma
pneumoniae
Microbiology of PNA changes based on the age of the patient, and this should be kept in mind when making management decisions!
Clinical Manifestations
Bacterial PNAAbrupt onsetHigh feverCough
Sometimes productiveToxic appearanceRespiratory distress
Tachypnea (most sensitive/specific) Retractions Nasal Flaring Grunting Hypoxia
Chest painEmesis and abdominal pain
Focal findings on lung exam Crackles Diminished breath sounds Bronchial breath sounds Egophany
Clinical Manifestations
Atypical PNASchool age or olderConstitutional symptoms
Fever Malaise Myalgias Headache
Gradual development of dry cough later in the illness as other symptoms improve
Clinical Manifestations
Bacterial Atypical Tuberculosis
Clinical Manifestations
Question C. Development of an empyema
Name 3 possible complications of pneumonia Lung abscess Pleural effusion Empyema Necrotizing pneumonia Pneumothorax Sepsis Bronchopulmonary fistula Pneumatoceles
Complications
Lung abscess Often develop following aspiration Thick-walled cavity with air/fluid level TB should be considered Needle aspiration for culture
Necrotizing pneumonia Rare complication of bact PNA Liquefaction/necrosis caused by toxins of virulent organisms VERY ill IV abx for at least 4 weeks
Complications
Sterile para-pneumonic effusionPurulent effusions with resultant empyema
Persistent fever, ill-appearing, tachypnea, increased WOB,
chest pain and splinting Dullness to percussion/decreased air entry
CXR with decubitus, US, CT
Treatment
Question C. Outpatient treatment with high dose Amoxicillin
Outpatient therapy (7-10days total) First line: High dose Amoxicillin at 80-100mg/kg/day Penicillin allergy?
Cephalosporin (non-type 1) Clindamycin/Azithromycin (type 1 allergy)
Atypical organisms: Azithromycin x 5 days Aspiration PNA: Augmentin or Clindamycin
Inpatient therapy (duration varies) Ceftriaxone or Ampicillin More extensive disease/failed treatment
Vancomycin, Clindamycin Azithromycin (adjunctive coverage sometime given)
Treatment
Admission
Criteria for admission <3 months Respiratory distress Hypoxemia Dehydrated Highly febrile/toxic
Underlying diseaseTesting (once admitted)
CBC Blood culture CXR +/- Sputum culture
Treatment
Tests to consider for patient who is not improving clinically? Bronchoscopy, lung aspiration, open lung biopsy
MORE CONTENT SPECS Recurrent PNA: >1 episode/year, >3 episodes in lifetime
Anatomic lesions: vascular rings, cysts, pulmonary sequestration
Respiratory tract disorders: CF, GERD, aspiration Immunodeficiency: HIV, CGD, hypogammaglobulinemia **REFER if documented
Congenital lesions of the lung (CCAM, sequestration, etc) can
mimic PNA Prevention of PNA
Good handwashing, personal respiratory hygeine, proper immunization, breastfeeding, limiting sick contacts,
decrease smoke exposure
Thanks!!
Almost every content spec “Pneumonia.” Pediatrics in Review. 2008, volume
29, p147
Class Housestaff Today!1st years – Board Room B2nd years – Board Room A
3rd years – 2 center
Bon Voyage Rocky!
He’s headed to Indonesia on a medical service trip!!!