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

2. 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

3. 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

4. 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

5. 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

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

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

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

10. 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

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

12. Aq-PCN
Vancomycin
Aq-PCN
Ceftriaxone

13. Hospitalization Course ~~ PICU~~
Chest tube
ETT

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

15. 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

16. 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

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

18. 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

19. 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

20. 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.

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

22. VATS On 12/08

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

24. Extubation
Chest tube
Chest CT OP
ETT

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

26. 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(-)

29. Thanks For Your Attention!!