Morning Report July 3, 2012 Good Morning!

Symptoms Acute /subacuteChronic LocalizedDiffuse SingleMultiple StaticProgressive ConstantIntermittent Single EpisodeRecurrent AbruptGradual SevereMild PainfulNonpainful BiliousNonbilious Sharp/StabbingDull/Vague Problem Characteristics Ill-appearing/ Toxic Well-appearing/ Non-toxic Localized problemSystemic problem AcquiredCongenital 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

CXR #1

Predisposing Conditions 35-40/1000 incidence in <5yo 7/1000 incidence in adolescents colder months lower socioeconomic status smoke exposure boys> girls Medical history Sickle cell BPD GERD Cystic Fibrosis Heart disease Immunodeficiency Increased aspiration Neuromuscular d/o Seizure d/o

Pathophysiology 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 Organisms  Streptococcus pneumonia = MOST COMMON  Others: S. aureus, Group A Strep, GNR (<3mo), anaerobes

Clinical Manifestations Abrupt onset High fever Cough  Sometimes productive Toxic appearance Respiratory distress  Tachypnea (most sensitive/specific)  Retractions  Nasal Flaring  Grunting  Hypoxia Chest pain

Clinical Manifestations Focal findings on lung exam  Crackles  Diminished breath sounds  Bronchial breath sounds  Egophany Unilateral focal infiltrate on CXR

Organisms**

Treatment** Outpatient therapy (7-10days total)  First line: High dose Amoxicillin at mg/kg/day  Penicillin allergy: Cephalosporin (non-type 1);  Clinda/Azithro (type 1 allergy)  Atypical organisms: Azithromycin x 5 days Inpatient therapy (duration varies)  Ceftriaxone or Ampicillin  More extensive disease/failed treatment  Vancomycin  Clindamycin  Azithromycin (adjunctive coverage sometime given)

Admission** Criteria for admission  <3 months  Respiratory distress  Hypoxemia  Dehydrated  Highly febrile/toxic Underlying disease Testing  CBC  Blood culture  CXR  +/- Sputum culture

Complications** Lung abscess  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 effusion Purulent 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

CXR #2

Thanks!! Almost every content spec  “Pneumonia.” Pediatrics in Review. 2008, volume 29, 147 Noon conference = YOGA (12:15)