1. Presented by R1魏意萱 Supervisor: VS 沈靜芬 2008. 11. 12
Case presentation
Presented by R1魏意萱
Supervisor: VS 沈靜芬

2. Identification Name :方x淳 Age : 4-year-6-month old Gender : female
Admission Date : 2008/11/08

3. Chief Complaints
Intermittent fever with cough and vomiting for 4 days

4. Present illness
11/05 :
Intermittent fever up to 39 ℃ along with dry cough and vomiting once LMD
11/06:
Persisted fever, cough, along with abdominal pain ER
CXR

5. 11/6 at ER

6. Present illness 11/07 Fever on every 6-7 hours interval
4-5 episode of vomiting, productive cough with sputum, and rhinorrhea.
Appetite decreased, general activity decreased. ER
11/08
OPD and admitted.

7. Past History
Birth History : G2P2, GA:38+5 weeks , BBW=2850g , Apgar score 89
Feeding : regular diet
Vaccination : as schedule, pneumococcus(+) 1x Hib vaccine(+) 1x
Growth: BW= 15 Kg(10-25th%), BL=104.8cm (25-50th%), development milestones: WNL
Past History : no known drug allergy
no other systemic disease　
Hospitalization: 96/12/09-96/12/12 Right lower lobe bronchopneumonia
Family history: non-contributory

8. Physical examination Appearance: fair
Vital sign: T/P/R= 39.3 C/161 /44 BP:110/58mmHg
HEENT:
throat: mild injected (+)
tonsil: enlarged (-)
Neck:supple, LAP(-)
Chest: symmetric expansion, dullness on percussion at left chest area
B.S.: diminished BS over left chest field ,
wheezing over right chest
H.S.: tachycardia, no murmur
Abd: soft, not distended
L/S: impalpable / impalpable,
No tenderness, No rebounding pain
BS:normoactive
Extremities:freely movable, pitting edema (-)
Skin: fine turgor, no rash

9. 11/8

11. 11/8 Lab data AST 25 U/L 0-39 | LD 157 U/L 100-200
ALT U/L | CRP H mg/L
NA L 134 mmol/L | K mmol/L
GLU.P.C. H 221 mg/dL |
CA mg/dL |
CREA L 0.5 mg/dL | BIL-T mg/dL
BIL-D mg/dL | BUN mg/dL
WBC H 22.9 K/cmm | RBC M/cmm
Hb g/dl | Hct %
MCV L 82.6 fl | MCH pg
MCHC g/dl | RDW %
Pl K/cmm | Blast / %
Pro / % | Myelo %
Meta / % | Band %
Seg H 81 % | Eos / %
Baso / % | Mono L 1 %
Lymph L 5 % | Aty-lym / %
NRBC / % | Remarks /

12. Tentative diagnosis
Left lower lobe pneumonia

13. Plan Etiology workup Sputum routine, gram stain and bacterial culture
B/C
Throat swab for viral isolation
Cold agglutinin test, Mycoplasma Ab
Urine pneumococcus Ag test
Antimicrobial treatment for community acquired pneumonia
Aq-penicillin 150MU q6h ivd (S. pneumoniae)
Ceftriaxone 600mg q12h (penicillin non-susceptible S. pneumoniae or Hib )

14. Lab Data STREPTOCOCCUS PNEUMONIAE ANTIGEN
Pneumococcus rapid screen (urine): Negative
Sputum Routine Report
Routine:
W.B.C : /LPF
Epithelial cell:<5 /LPF
Gram stain: Gram-positive cocci:Moderate
Gram-negative cocci:Rare
Gram-negative bacilli:Rare
Gram-positive bacilli:Rare

15. Lab Data PRIMARY BLOOD CULTURE REPORT
Gram-negative bacilli were isolated from an anaerobic
bottle (1/2)  Salmonella
Sputum culture
Streptococcus pneumoniae Moderate
S:Susceptible R:Resistant
I:Intermediate M:Moderate Susceptible
Penicillin S Clindamycin R
Vancomycin S Erythromycin R
Ampicillin S
Levofloxacin S
Co-Trimoxazole S Moxifloxacin S

16. 11/9

17. 11/8 chest echo

18. Thoracocentesis pH 7.280 | PCO2 56.1 mmHg
LD H 1547 U/L |
pH | PCO mmHg
PO mmHg | HCO mmol/L
TCO mmol/L | BEb mmol/L
BEecf mmol/L | SBC mmol/L
%sO2c % | 檢體Type PLEURAL
GLU mg/dl | GRAM NF
T.P mg/dl | Appear. CLOUDY
RBC /cmm | WBC /cmm
SEG % | EOS / %
BASO / % | MACRO/MO 4 %
LYM % | ATY-LYM. 2 %
ABN-LYM. / % | MESOTHEL / %
TUMOR / % | BLAST / %
REMARK / % | SP.GR

19. 11/11 Recurrent pleural effusion or pleural thickness
Chest echo : minimal pleural effusion (<1 cm) noted
However, this patient was transferred to PICU for further observation and possible tube drainge.

20. Discussion

21. Transudate vs. Exudate Pleural fluid serum protein ratio more than 0.5
Pleural fluid serum lactate dehydrogenase (LDH) ratio more than 0.6
Pleural fluid LDH more than two thirds of normal serum value
 Exudate

22. Causes of Transudate Congestive heart failure
Cirrhosis (hepatic hydrothorax)
Atelectasis (which may be due to malignancy or pulmonary embolism)
Hypoalbuminemia
Nephrotic syndrome
Peritoneal dialysis
Myxedema
Constrictive pericarditis

23. Causes of Exudate Parapneumonic
Malignancy (carcinoma, lymphoma, mesothelioma)
Pulmonary embolism
Collagen-vascular (rheumatoid arthritis, lupus)
Tuberculous
Asbestos-related
Pancreatitis
Trauma
Postcardiac injury syndrome
Esophageal perforation
Radiation pleuritis
Drug-induced
Chylothorax
Meigs syndrome
Sarcoidosis
Yellow nail syndrome

24. Indication for urgent drainage
Frankly purulent fluid (empyema)
Pleural fluid pH less than 7.2
Loculated effusions
Bacteria on Gram stain or culture

25. The End

26. 11/9 Lab data <緊急生化檢驗報告> 醫師: 沈靜芬 採檢:97/11/09 血漿 8261N08859
GLU.A.C. H 120 mg/dL | CREA L 0.4 mg/dL
BUN L 5 mg/dL | CRP H mg/L
<緊急血液檢驗報告> 醫師: 沈靜芬 採檢:97/11/09 全血 8262M30187
WBC H 14.4 K/cmm | RBC M/cmm
Hb g/dl | Hct %
MCV L 82.5 fl | MCH pg
MCHC g/dl | RDW %
Pl K/cmm | Blast / %
Pro / % | Myelo / %
Meta / % | Band %
Seg % | Eos / %
Baso / % | Mono %
Lymph L 16 % | Aty-lym / %
NRBC / % | Remarks /

27. Clinical Course 11/08 Admission 11/09 11/10 11/11
Chest echo revealed minimal pleural effusion found at left 9th-10th ICS ~0.5cm thickness  observation
Rx: Aq-penicillin 150MU q6h ivd
Rocephin 600mg q12h ivd (80mg/kg/day)
11/09
Due to high CRP with LLL patch and Urine pneumococcus Ag (-)  Mycoplasma infection can’t be ruled out
Cold aggultinin test (+) 
Rx: add Azithromycin susp 4ml po qd x 3day
Pleural effusion and patch haziness found on CXR Consider complicate pleural effusion or emphyema
11/10
Preliminary B/C result : Salmonella
Check stool culture
Rx: change Rocephin to 750mg q12h ivd (100mg/kg/day)
Echo done revealed pleural effusion and suggest pleural tapping
Yellowish-cloudy pleural effusion around 70ml was drainaged
Pleural effusion smear for Gram stain: PMN predominate, no bacteria found
11/11
General condition did not improved after pleural tapping
Transferred to PICU