English Meeting Case Presentation 2011/12/15 R3陳旻吟 / VS 沈靜芬

Basic Information Chief Complaint Name: 龔 O 宇 Age: 4y6m Gender: Male Date of Admission: 2011/12/05 Chief Complaint Intermittent fever for 4 days

Present Illness Poor activity and appetite Decreased urine output Fever Nausea /Vomiting Left side abdominal pain Productive cough Rhinorrhea 12/02(-3) 12/03 (-2) 12/05 < ED > Dry lip RR=20 /min SpO2: 98% under RA

Past History Birth History: G2P2, GA: Full term, BBW:3200 g, DOIC(-), PROM(-) Apgar score: unknown 　 Vaccination: As Taiwanese schedule, Self-paid vaccine: PNEUMOVAX® 23 Growth and Development: BW: 18Kg(50-75th%), BL: 110 cm(85th%), Developmental milestones: Within normal range Social History: Nothing particular Travel History: Nil Current Medications: Trimetoquino (βagonist) Tipepidine (Cough suppresant) Domperidone (antidopaminergic drug) Gascon

Physical Examination Consciousness: clear Appearance: ill-looking,irritable Vital sign: BT:38C, P:180 /min, R:40 /min, BP:118/65 mmHg Activity: decreased Head: conj: not anemic sclera: not icteric throat: injected tonsil: not enlarged eardrum: intact Neck:supple, LAP(+) : bilateral multiple small LNs < 1cm Chest: symmetric expansion, subcostal retraction( + ) Nasal flaring(+) B.S.:corase, no crackles, decreased BS over left lung H.S.:regular heart beat, no murmur Abd:soft, not distended L/S: impalpable / impalpable, No tenderness, No rebounding pain BS: normoactive Extremities: freely movable,pitting edema (-) Skin: turgor fine, no rash Capillary refilling time<2 sec

Image– CXR on 12/05 Chest Echo: Pleural Effusion 0.5cm

Laboratory Data Microgas (at ED): PH=7.357, PCO2=38.9, HCO3: 21.8, BE:-4

Tentative Diagnosis (1) Left lower lobe pneumonia with pleural effusion (2) Moderate dehydration

After Admission Admitted to 4C ward initially: O2 mask 5L/min: SpO2: 90% HR: 140~150 /min, RR: 40/min Transferred to PICU under respiratory distress Vital Sign: T/P/R=36.8/161/41, BP=122/4569/36 mmHg IV Fluid challenge / Dopamine/ Dobutamine /Levophed O2 supply: non-rebreathing mask Antibiotic: Aq-Penicillin + Ceftriaxone + Azithromycin + Tamiflu

Image on 12/06 AM Bedside Chest Echo: 1~1.5 cm pleural effusion

Aq-PCN Vancomycin Aq-PCN Ceftriaxone

Hospitalization Course ~~ PICU~~ Chest tube ETT

Pleural Effusion Analysis <Serum> LDH: 253 U/L T Protein: 5.1 g/dL Exudate !!

Management of pleural effusion and empyema With one of the following conditions, drainage of pleural fluid should be required: Pus-like effusion. Positive finding of gram stain or bacterial culture of pleural fluid. Large amount of fibrinous substances or septations in pleural cavity. Massive pleural effusion associated with respiratory distress. pH of pleural fluid < 7.2. Community-acquired pneumonia From Acta Paediatr Tw Vol. 48, No. 4, 2007

CXR F/U 12/06 PM 12/07 AM Microgas: PH=7.309, PCO2=43.7, HCO3: 21.5, BE:-4.7 Microgas: PH=7.341, PCO2=40.8, HCO3: 21.6, BE:-3.9

Hospitalization Course ~~ PICU~~ Chest tube ETT Chest CT

When to arrange Chest CT ? Computerized tomography (CT) of the chest may provide details of pneumonia, including the extent of consolidation, cavitation, lung abscess, and empyema It is indicated before surgical interventions, such as Videoassisted thoracoscopic surgery (VATS), and Decortication of empyema Community-acquired pneumonia From Acta Paediatr Tw Vol. 48, No. 4, 2007

Management of pleural effusion and empyema Indications for surgical therapy: (1) Lack of clinical and radiologic response to initial medical management (ex: antibiotics, chest tube drainage, fibrinolytic therapy) (2) Persistent sepsis in association with persistent pleural collection (3) Complex empyema with significant lung pathology (4) Bronchopleural fistula with pyopneumothorax From UptoDate

Chest CT 1. Right pleural effusion and left empyema, small amount. 2. Pneumonic consolidation at sup. seg. of RLL, LUL and LLL. 3. Suspect early change of necrotizing pneumonitis at the medial aspect of left hemilung. No cavitation and abscess formation so far. 4. Mediastianl lymphadenopathy. 5. Subcutaneous edema and periportal edema.

Hospitalization Course ~~ PICU~~ Chest tube ETT OP Chest CT

VATS On 12/08

CXR F/u After OP 12/09 12/10 12/12

Extubation Chest tube Chest CT OP ETT

CXR On 12/14 < After Extubation > Room Air !!

Survey For Pneumonia Pneumococcus rapid screen (urine): Positive Sputum: Normal Flora Influenza PCR: Negative Adenovirus Ag test: Negative Pleural Effusion culture: No growth Mycoplasma pneumonia Ab: 1:40(-)

Thanks For Your Attention!!