Grand Rounds

Group
Names
Date
General Data
 J.D.
 12 y/o male
 Roman Catholic
 Tondo, Manila
 Informant: mother
 Reliability: 90%

 Chief Complaint: Difficulty of breathing

 Date of Admission: June 18, 2007
History of Present Illness
 4 days PTA
 Intermittent fever (highest temp 39.4
˚C)
 Accompanied by productive cough with
yellowish sputum and 4 episodes of
nonbilious, nonprojectile vomiting of
previously ingested food and ~10
episodes of post-tussive vomiting
 Paracetamol (12mkdose)

 Intermittent, moderate to severe crampy

abdominal pain on the epigastric area
which eventually became generalized,
aggravated by coughing, accompanied by
difficulty of breathing; (-)changes in
bowel movement, no cyanosis
History of Present Illness

 Consult: government
hospital
 A>dyspepsia r/o acute
appendicitis
 P> CXR, CBC and

Urinalysis
> THM: Lansoprazole
 History of Present Illness
 1 day PTA
 Persistence of fever,
cough, abdominal pain,
difficulty of breathing
(inc. RR, alar flaring,
chest pain)

ADMISSION
 Review of Systems = pertinent for your
patient
 (-) weight loss, anorexia
 (-) excessive lacrimation
 (-) palpitations
 (-) jaundice
 (-) hematuria, dysuria, urinary frequency
 (-) seizures
 Past Medical History
 (+) Bronchitis
- 4 mos old, 7 y/o
- S/Sxs:
- Consult:
A>
P>
 (+) PTB disease (7y/o)
 (+) PPD, (+)CXR, (+) recurrent cough?, fever? & difficulty of breathing
 Treated anti-Koch’s medication (HRZ) for 6 months
 (+) skin asthma (9 y/o)
 D works
 (+) varicella (5 y/o)
 (-) mumps, measles
 (-) previous operations
Immunizations
 (+) BCG – 1 dose
 (+) DPT – 3 doses
 (+) OPV- 3 doses
 (+) Hepa B- 3 doses
 (+) Measles- 1 dose
 All given at a local health center,
unrecalled dates, no booster doses were
given
HEADDS
 H – good relationship with his family
 E- average (passing grades 70s, Gr. 6
public school student)
 A- Fond of sketching and playing
basketball
 D- mixed diet
 D- (-) drug abuse/use
 S- (-) suicidal ideation
 S- (-) sexual relationships
Family History
 (+) DM- paternal aunt
 (+) HPN- both sides
 (+) PTB- maternal aunt
 (+) CXR, (+) PPD, (+) symptoms
 treated for 6 months, (HRZ)
 (-) thyroid disease, renal disease,
cancer
 Family Profile
JD Father 32 y/o Smoker; alcoholic Apparently
beverage drinker; healthy
unemployed

CD Mother 34 y/o Non-smoker; non- Apparently

alcoholic beverage healthy
drinker; employee
at a pawnshop
JD Sister 7 y/o complete Apparently
immunizations done Healthy
at a local health
center
Socioeconomic & Environmental
Profile
 Lives in a concrete, owned house, that is
well-lit and well- ventilated
 with his family and 10 other family
members (paternal uncle+ wife + 4 kids,
2 paternal grandmothers, 2 paternal
aunts)
 Garbage collection daily
 water source: MWSS, drinking water is
boiled for 30 minute
 1 pet dog
 No nearby factories
PE on Admission
 Awake, alert, in respiratory distress, prefers to be
seated in tripod position
 Well hydrated, well nourished, well developed
 BP: 100/60 (%)
 RR: 30 (12-18 cpm)
 PR: 90 (55-85 bpm)
 T: 39.6 ˚C (35-36.5)
 Ht: 145 cm (p25-50)
 Wt: 41 kg (p50)
 Warm, moist skin, (+) multiple hyperpigmented /
erythematous papules and plaques with erosions
and crusting with some areas of lower extremities
 PE on Admission
 Eyes: Pink palpebral conjunctiva, anicteric
sclera
 Ear: no aural discharge, no tragal tenderness,
tympanic membranes intact
 Nose: Midline nasal septum, No alar flaring, No
discharge, turbinates not congested
 Neck: supple neck, no palpable cervical lymph
nodes
 Mouth: moist buccal mucosa hyperemic
posterior pharyngeal wall, tonsils are not
enlarged
 PE on Admission
 Chest: Rapid and shallow breathing,
symmetrical chest expansion, no retractions,
dullness on R hemithorax T6 down,
decreased breath sounds and decrease vocal
fremiti on R hemithorax, (+) bronchophony
RLL ; (+) crackles on L hemithorax, more
prominent at T8 level
 Heart: Adynamic precordium, apex beat 5th
LICS MCL, no mumurs, heaves or thrills
 Abdomen: Flat abdomen, normoactive bowel
sounds, soft (+) direct tenderness (R>L)
 Extremities: pulses full and equal, no edema,
no clubbing
 Salient Features
 Subjective
 12 y/o male
 4 day history of fever
 Productive cough with
yellowish sputum
 Progressive difficulty of
breathing
 Objective
 Awake, alert, in respiratory
distress, prefers to be
seated in tripod position
 Tachypneic, febrile
 Chest:
 (+) retractions, dullness
on R hemithorax, T6
down, decreased breath
sounds on R hemithorax ;
(+) Bronchophony RLL
 (+) crackles on L
hemithorax, more
prominent at T8 level
Presenting Manifestation
 Difficulty of breathing
 Tachypnea
 Fever
 Rapid shallow breathing
Approach to Diagnosis
 Look for a symptom, sign or
laboratory finding pointing to the
involvement of an organ system

 RESPIRATORY SYSTEM
Initial Impression
 Pneumonia
Dyspnea
 Abnormally uncomfortable
awareness of breathing
 Work of breathing is excessive
 Increased force generation
 Ventilation is excessive for the level of
activity
Dyspnea
 Excessive or abnormal activation of
the respiratory centers in the
brainstem
 Intrathoracic receptors (vagal nerves)
 Afferent somatic nerves (respiratory
muscles and chest wall)
 Chemoreceptors (brain, aortic and
carotid bodies)
 Higher cortical centers

 Afferent fibers (phrenic nerves)

Pathophysiology
Pathophysiology
Dyspnea
 Restrictive disease of the lungs
 Obstructive disease of airways
 Parenchymal Lung disease
 Cardiovascular
 Pulmonary vascular occlusive
disease
 Dyspnea
Restrictive Obstructive Cardiac Venous
disease diseases of the occlusive
airways disease
Chest pain with Cough Chest pain Sudden onset
tenderness Stridor Palpitations Phlebitis
Chest wall Retractions of Exertional Dyspnea at
deformityDecrease suprclavicular dyspnea rest
d respiratory fossa History of heart Near syncope
muscle strength Wheezing disease or HPN
Sputum Nocturnal
production ronchi, paroxysmal
crackles dyspnea
COPD, kyphosis, Asthma, CHF Pulmonary
scoliosis, Bronchitis, embolism
diaphragmatic Pneumonia,
paralysis TB
Differentials
 PTB reactivation
 Asthma
 Bronchitis
 Pneumonia
PTB
 Mycobacterium tuberculosis
 acid-fast bacilli, obligate anaerobes,
slow-growing
 Mycolic acid
 transmission: airborne, inhalation of
droplet nuclei produced by an adult or
adolescent with contagious, cavitary
PTB
 Incubation period: 2-12 weeks from
infection to development
 Post primary TB
 reactivation of a latent primary infection and rarely
from the repeat infection of a previously sensitized host
 Approximately 10% of all infected patients are likely to
develop reactivation, highest risk within 2 years of
primary infection
 Factors contributing to reactivation
 immunosuppression
 Inadequate treatment
 Trauma
 typically a disease of adolescence and adulthood
 The major determinants
 of the type and extent of disease are the patient's age and
immune status, the virulence of organism, and the
mycobacterial load
Post primary TB
 Pulmonary reactivation usually occurs in the
apical and posterior segments of the upper lobes
or in the superior segments of the lower lobes
 classical clinical presentation
 cough, fever, weight loss, night sweats, hemoptysis,
and acid-fast bacilli in the sputum
 None of these is universally present
 minimal signs or symptoms
 Patients with postprimary cavitary TB are more
infectious than those with miliary TB
 Cavitation into a bronchus results in a high bacterial
load in the sputum and, thus, higher infectivity.
Differentials
 PTB reactivation
 Asthma
 Bronchitis
 Pneumonia
Asthma
 Chronic inflammation of airways that is
characterized by incresed responsiveness
of the tracheobronchial tree to a
multitude of stimuli
 Widespread narrowing of air passages
 Paroxysms of dyspnea, cough and
wheezing
 Episodic disease with acute exacerbations
interspersed with symptom-free periods
Asthma
 Atopy is the single largest risk factor for
development of asthma
 (+) personal or family history of allergic
disease
 Triad of symptoms: dyspnea, cough,
wheezing
 Dry coughing, expiratory wheeze, chest
thightness, dyspnea
 Provoked by physical exertion and airway
irritants
Differentials
 PTB reactivation
 Asthma
 Bronchitis
 Pneumonia
Bronchitis
 Usually viral in origin
 Cough is a pertinent feature
 Tracheobronchial epithelium is
invaded by an infectious agent
 Activation of inflammatory cells and
release of cytokines
 Leads to destruction of epithelium
 Bronchitis
 Nonspecific upper respiratory infection
symptoms
 3-4 days frequent, dry hacking cough
 Sputum becomes purulent, this may
produce emesis
 Cough gradually abates
Bronchitis
 Clinical Manifestation
 Low-grade fever
 Upper respiratory signs

 Cough worsens

 Breath sounds become coarse

 Coarse and fine crackles

 Scattered high-pitched wheeze

Differentials
 PTB reactivation
 Asthma
 Bronchitis
 Pneumonia
Pneumonia
 Inflammation of the parenchyma of
the lungs
 An infection of the alveoli, distal
airways, and interstitium of the
lungs
 Viral- spread of infection along
airways
 Bacterial –lung parenchyma
 Epidemiology

 Viral pathogens most common cause of LRTI

in infants and children <5 years of age
 Peak attack of viral pneumonia is between
ages 2-3 years and decreases thereafter
 RSV major pathogen in <3 year old kids
 Bacterial more common >5 years of age
Etiology according to age group

Age Common pathogens

1-48 hrs Group B streptococcus

1-14 days E. coli, Klebsiella,

Enterobacteriaceae, Listeria,
S. aureus, Anaerobes, GB
2 wks-2 mos Enterobacteriaceae, GBS, S.
aureus, C. albicans, H.
influenzae, S. pnuemonia
2 mos-5 yrs H. influenzae, S. pneumonia
5-21 yrs S. pneumonia, M. pneumonia
Streptococcus pneumoniae

 Gram positive, lancet shaped, encapsulated

diplococcus
 Only encapsulated strains cause serious disease
in humans
 a-hemolysis on solid media
 Bile soluble and optochin-sensitive
Epidemiology

 >90% of children between 6 months to 5 years

of age harbor S.pneumoniae in the
nasopharynx at some time
 Pneumococcal carriage rate peak during the
first 2 years of life
 Most common cause of community acquired
bacterial pneumonia and otitis media
 Most common cause of bacterial meningitis in
children
 Most common cause of meningitis in adults
 Transmitted person-person by respiratory
droplets
Clinical Manifestation

 Preceded by several days of symptoms of URTI

(rhinitis, cough)
 Fever- higher in bacterial pneumonia than viral
 Tachypnea most consistent clinical
manifestation
 Subcostal, intercostal, suprasternal retractions,
nasal flaring and use of accessory muscles
 Crackles, wheezing, ronchi
 Diminished breath sounds
 Dullness on percussion
 Respiratory lag on excursion
 Abdominal distention
Diagnosis
 CXR
 confirms diagnosis of pneumonia
however, radiographic appearance
alone is not diagnostic and other
clinical features must be considered
 Pleural effusion or epyema

 Confluent lobar consolidation

Diagnosis

 Bacterial pneumonia characterized by

 Lobar consolidation
 Elevated WBC 15000-40000/mm3 w/ predominance
of granulocytes
 Definitive diagnosis is isolation of organism from
blood, pleural fluid or lung
 Sputum culture has no value
 Blood cultures + in 10-30% of cases
 ASO titer for group A strep. Pneumoniae
Treatment

 Empirical treatment
 IV Penicillin G is the doc for penicillin-sensitive strains
 200,000-250,000 U/kg/24 hr divided into q 4-6 hrs
 For intermediately resistant strains
 Cefotaxime (225-300 mg/kg/24 hrs divided into q8 IV)
 Ceftriaxone (100mg/kg/24 hrs divided into q 12-14 IV)
 For highly penicillin-resistant strains
 Vancomycin (60 mg/kg/24 hrs divided into q6 IV)
 Rifampin (20 mg/kg/24 hrs divided into q12 PO)
Complications

 Pleural effusion
 Pericarditis

 Empyema
Prognosis
 Integrity of host immune system
 Virulence and numbers of infecting
organism
 Age of the host
 Site and extent of infection
 Adequacy of treatment
 Course in the ward
 On Admission
 CXR (PA and Lateral decubitus)
 Urinalysis, CBC and platelet was done
 Hooked to O2 per nasal cannula at 2-5 LPM
 IVF: D5 0.3% NaCl 500cc to run at 22 gtts/min
(110%)
 Medications:
 Penicillin
G 1,000,000 u/SIVP q 4 hours
 Paracetamol 500 mg/tab q 8 hrs for T> 38.5

 Ranitidine 50 mg/SIVP q 8 hrs

Course in the ward
 1st hospital day 6/19
 clinically improved, although bronchophony
and dullness still persisted
 Upon passage of stools, patient reported to
have resolution of abdominal pain and there
was no more direct tenderness upon palpation
of the RLQ
 Persistence of rhonchi and decreased breath
sounds on the right
 Sputum AFB smear and Gram stain was done
Course in the ward ? 2nd
 Seen by Pedia-Pulmo
 Afebrile

 Increased BS, RLL

 Increased vocal femiti RLL

 (+) crackles, bilateral

 (+) wheezing R>L

 Course in the ward
 3rd hospital day 6/23
 History of asthma?
 Salbutamol nebulization, 3 doses, 20 minutes
apart
 Referred to allergology
 Salbutamol 100mcg, 2 puffs at 4 pm
 pre= 290 post= 300
 Salmeterol + Fluticasone 25 mcg,1 puff BID
 Salbutamol 100mcg, 2 puffs every 6 hours
Course in the ward
 5th hospital day
 Predilator (AM): 290
 Postdilator (PM): 310

 Peak Flow Variability: 13.7%

Mild intermittent
Thank you and good day
 CBC at JRMMC
CBC 6/15/07 Normal values

HGB 132 120-170

RBC 4.0-6.0
HCT 0.40 0.37-0.54
MCV 87 +/- 5
MCH 29 +/- 2
MCHC 34 +/- 2
RDW 11.6-14.6
PLATELET 433 150-450
WBC 28.81 4.5-10.0
NEUTROPHILS 0.50-0.70
METAMYELOCTES
BANDS
SEGMENTED 0.93 0.00-0.05
LYMPHOCYTES 0.07 0.50-0.70
MONOCYTES 0.20-0.40
EOSINOPHILS -- 0.00-0.07
BASOPHILS -- 0.00-0.05
BLASTS -- 0.00-0.01

back
 Complete Blood Count
CBC 6/19/07 Normal values

HGB 116 g/L 120-170

RBC 4.11 x10^2 /L 4.0-6.0
HCT 0.36 0.37-0.54
MCV 86.50 U^3 87 +/- 5
MCH 28.30 29 +/- 2
MCHC 32.70 34 +/- 2
RDW 12.70 11.6-14.6
PLATELET 510 150-450
WBC 15.70 4.5-10.0
NEUTROPHILS 0.84 0.50-0.70
METAMYELOCTES --
BANDS --
SEGMENTED 0.84 0.00-0.05
LYMPHOCYTES 0.14 0.50-0.70
MONOCYTES 0.02 0.20-0.40
EOSINOPHILS -- 0.00-0.07
BASOPHILS -- 0.00-0.05
BLASTS -- 0.00-0.01

back
 Urinalysis
URINALYSIS 06/18/07

Color Dark Yellow

Transparency Slightly cloudy
Ph 6.00
Specific Gravity 1.020
Albumin +
Sugar Negative
RBC 11/hpf
Pus Cells 5/hpf
Squamous Cells -
Renal Cells -
Bacteria -
Mucus Threads 38hpf
Amorphous urates 3/hpf
•Remarks: centrifuged specimen: Bacteria ++ back
CXR PA view

back
CXR Lateral Decubitus

back
Official X-ray results
 There is homogenous density in the right lower
hemithorax
 There are also infiltrates in the right
infraclavicular area
 Rest of the lungfields is clear
 Heart is not enlarged
 IMPRESSION:
 Pneumonia, right lower lobe
 PTB, right upper lobe
 Right lateral decubitus failed to demonstrate any
layering of free pleural fluid.
back
Sputum AFB and Gram stain results

date 6/20/07 6/21/07 6/22/07

Acid fast bacilli None None None

seen

Gram (+) cocci n ++ ++ ++

pairs and in short
chains

Gram (-) bacilli + +

Polymorphonucle More than 25/LPF More than 25/LPF 15-20/LPF

ar cells

Squamous 10-15/LPF 0-5/LPF 15-20/LPF

epithelial cells

back
GINA classification based on level of
control
 Treatment
Classificatio
Controller Reliever
n
Intermittent None

Mild ICS +/- other

persistent controllers Inhaled B2
Moderate ICS +/- LABA agonist when
persistent +/- other needed
controllers
Severe ICS/oral CS +
persistent LA dilators