15-北医讲课-2013.6.ppt

1、CASE REPORT AND DISCUSS,Dr. CHANG LI The Affiliated Childrens Hospital of Capital Institute of Pediatrcis,50% of consultation with general practitioners or acute illness in young children and a third of consultations in older children 20-35% of acute pediatric admissions to hospital, some of which a

2、re life-threatening Asthma is the most common chronic illness of childhood,Respiratory Disorders,Respiratory infections are very common; Pathogens: viruses ,bacterial, mycoplasma and other pathogens; Infectious Diseases: upper respiratory tract infection (common cold),tonsillitis, bronchitis, bronch

3、iolitis, pneumonia, etc. Others: Asthma, foreign body aspiration, etc.,Respiratory Disorders,CASE 1,11 months, male, sneeze, runny nose, low temperature for 2 days occasional cough,CASE 1,physical examination: throat congestion lung auscultation-clear,CASE 1,LAB WBC 4.0109/L Hb 120g/L,PLT 323109/L N

4、eutrophile 0.30 Lymphocyte 0.55 Monocyte 0.10,What do you find in the results?,Diagnosis,Acute Upper Respiratory Tract Infection (common cold),Upper and Lower Respiratory Tract,cricoid cartilage,upper respiratory tract,nose, nasal cavity - rhinitis sinus -sinusitis pharynx-pharyngitis pharyngotympan

5、ic tubepharyngotympanic salpingitis tonsil-suppurative tonsillitis middle ear-otitis media epiglottis-epiglottitis larynx-laryngitis,13 years, girl chief complaint: Pharyngalgia and fever for four days,CASE 2,CASE 2,Physical examination T 39.5, pharynx was congestive, tonsils were red and enlarged w

6、hite pus-filled spots on the tonsils,CASE 2,physical examination lung auscultation: No abnormal breath sound （No wheezes and rales),CASE 2,LAB WBC: 12.9109/L，Hb:121g/L, PLT 345 109/L, N 79%, L 12% CRP: 30mg/L,Diagnosis,suppurative tonsillitis,tonsil,度：扁桃体 有肿大但仍在 咽腭弓范围内 度：扁桃体 肿大超过咽腭弓， 但未达到咽后壁中线 度:扁桃体

7、肿大达到或超过咽后壁中线;,0: Tonsils fit within tonsillar fossa 1+: Tonsils 75% of space between pillars,suppurative tonsillitis,The most common cause is bacterial infection of which the predominant is Group A -hemolytic streptococcus (GABHS),Lower Respiratory Tract,trachea -Trachitis bronchus-bronchitis bronch

8、iole-bronchiolitis terminal bronchioles respiratory bronchioles alveolar ducts -pneumonia pulmonary alveoli -pneumonia,11months, male; sneeze, runny nose, low temperature for 4 days; cough and wheezing for 2 days;,CASE 3,irritable and restless RR 56 breaths per minutes Lung Auscultation: rales, rhon

9、chus, wheezing,Physical Examination,M, 8个月,Hyperinflation increased lung markings,Chest X-ray,Blood test,WBC 6.5 x 109/L, N 0.35 Hb 123g/L PLT 234 x 109/L CRP 3mg/L,Whats up with him?,BRONCHIOLITIS,Bronchiole-bronchiolits,1. Trachea 2. Mainstem bronchus 3. Lobar bronchus 4. Segmental bronchus 5. Bro

10、nchiole 6. Alveolar duct 7. Alveolus,Bronchial Tree,The human trachea (windpipe) divides into two main bronchi (also mainstem bronchi), the left and the right. The right main bronchus is wider, shorter, and more vertical than the left main bronchus.,Bronchial Tree,The right main bronchus subdivides

11、into three lobar bronchi, while the left main bronchus divides into two. The lobar bronchi divide into tertiary bronchi. There are ten segments per lung,Bronchial Tree,The segmental bronchi divide into many primary bronchioles which divide into terminal bronchioles, each of which then gives rise to

12、several respiratory bronchioles, which go on to divide into two to 11 alveolar ducts.,Bronchial Tree,The terminal bronchiole is the most distal segment of the conducting zone. The bronchioles or bronchioli are the passageways by which the air passes through the nose or mouth to the air sacs of the l

13、ungs in which branches no longer contain cartilage or glands in their submucosa.,Bronchial Tree,Bronchiole Anatomic structure,Narrow Mucous memberance- tender and thin rich in vascularity and lymphatic tissue contain no cartilage or glands in their submucosa,DEFINITION,Bronchiolitis is an acute, inf

14、ectious, inflammatory disease of the lower respiratory tract resulting in obstruction of the small airways bronchioli.,Epidemiology,Pathogen RSV (respiratory syncytial viruses) Winter and early spring under the age of 2 with a peak age of 2 to 6 months Male,Bronchiole Anatomic structure,Narrow Mucou

15、s memberance- tender and thin rich in vascularity and lymphatic tissue infection- obstruction Clinical diagnosis,CLINICAL FEATURES,premonitory symptomcommon “cold” congested or runny nose sneezing low grade fever,CLINICAL FEATURES,Symptoms continuous cough paroxysmal wheezing fever (variable) irrita

16、bility others,CASE 4,male，8months fever accompanied by cough and intermittent wheezing for 2days rapid, laboured breathing and poor feeding,T:39.5 RR: 60 breaths/min cyanosis weak response,PHYSICAL EXAMINATION,Lung Auscultation-crackles and wheezes.,PHYSICAL EXAMINATION,WBC: 6.11109/L，Neutrophils 30

17、.7%, Lymphocytes 69.3% CRP: 22 mg/L,LAB,increased lung markings, slignt shadow in right lower lung,CHEST X-RAY,Do you have any comments or what do you conclude anything from this case?,DIAGNOSIS,Adenovirus pneumonia,Adenovirus pneumonia,PATHOGEN -ADV Winter and spring and early summer under the age

18、of 2 Male,Epidemiology -ADV,For unexplained reasons, adenovirus 3 and 7 cause severe epidemics of pneumonia in children of northern China and Korea, with mortality rates of 515%,Clinical manifestation,High fevera continued fever flu-like symptoms inflammation of the pharynx, sore throat, inflammatio

19、n of nasal membranes, or a congested, runny nose,Clinical manifestation,coughAdenovirus can also produce a dry, harsh cough wheezing Pale Weak Rale,CASE 5,an 18-month old infant, be at the hospital with a troublesome cough, wheeze and breathlessness. His mother said he developed eczema at the age of

20、 2 months.,From the age of 8 months he has suffered from intermittent but frequent chest symptoms.,CASE 5,His mother described a pattern of recurrent symptoms typically a runny nose, followed by a cough and then within 12 hours the onset of wheezing and breathlessness.,CASE 5,However, she has also n

21、oted some symptoms of coughing at night and after exercise at times when he does not have a cold.,CASE 5,He has also had persistent rhinitis even when he does not have a cold.,CASE 5,His mother has asthma and uses a bronchodilator from time to time. His father had eczema as a child.,CASE 5,His mothe

22、r had tried giving him her salbutamol through her spacer. She noticed that it had helped his symptoms,CASE 5,mild subcostal recession; the chest with a prominent and widespread wheeze. eczema,PHYSICAL EXAMINATION,Lab and Image normal,Differential diagnosis,Adenovirus pneumonia,Asthma in infant,Asthm

23、a in infant,GINAThe following categories of symptoms are highly suggestive of a diagnosis of asthma,GLOBLE INITIATIVE FOR ASTHMA,frequent episodes of wheeze (more than once a month) activity-induced cough or wheeze nocturnal cough in periods without viral infections absence of seasonal variation in

24、wheeze,GLOBLE INITIATIVE FOR ASTHMA,major risk factor parental history of asthma or eczema minor risk factor eosinophilia, wheezing without colds, allergic rhinitis,CASE 6,female，1year and 10months recurrent cough and wheezing for five months,sometimes accompanied by fever treated by antibiotics and

25、 bronchodilators, symptoms can alleviated, but cant be solved No asthma family history and no ecsema. Lung auscultation: wheezing in both lungs,CASE 6,CHEST CT: obstructive pulmonary emphysema in left lower lung lobe; obstruction in left main bronchus.,Differential diagnosis,Adenovirus pneumonia,Ast

26、hma in infant,Foreign bodies in bronchus,1. Trachea 2. Mainstem bronchus 3. Lobar bronchus 4. Segmental bronchus 5. Bronchiole 6. Alveolar duct 7. Alveolus,The human trachea (windpipe) divides into two main bronchi (also mainstem bronchi), the left and the right. The right main bronchus is wider, sh

27、orter, and more vertical than the left main bronchus.,Foreign body,More foreign body aspirations occur in children younger than 3 years than in other age groups, with a peak between the first and second birthdays Children are more prone to aspirate foreign material for several reasons.,Foreign body,

28、The lack of molar teeth in children decreases their ability to sufficiently chew food, leaving larger chunks to swallow.,Foreign body,The propensity of children to talk, laugh, and run while chewing also increases the chance that a sudden or large inspiration may occur with food in the mouth.,Foreig

29、n body,The most common entities aspirated are small food items such as nuts, raisins, sunflower seeds.,Foreign body,the child presents after a sudden episode of coughing or choking while eating with subsequent wheezing, coughing, or stridor,Foreign body,persistent or recurrent cough, wheezing, persi

30、stent or recurrent pneumonia, lung abscess, focal bronchiectasis, or hemoptysis (Coughing up blood),Aspirated foreign body (backing to an earring) lodged in the right main stem bronchus.,obstructive pulmonary emphysema in left lung,Foreign body,Major findings include new abnormal airway sounds, such

31、 as wheezing, stridor, or decreased breath sounds. These sounds are often, but not always, unilateral,Differential diagnosis,Adenovirus pneumonia,Asthma in infant,Foreign bodies,acute infectious laryngitis,Acute infectious laryngitis,acute infection of the larynx characterized by hoarseness and coug

32、h Viral-influenzae, rhinovirus, adenovirus Bacterial-group A beta-hemolytic streptococcus,Acute infectious laryngitis,pharyngeal hyperemia (inflammation),Acute infectious laryngitis,Severe cases severe respiratory stridor retractions dyspnea restlessness,Treatment,Asthmainhaled glucocorticosteroids

33、Foreign bodybronchoscopy laryngitisintravenous glucocorticosteroids tracheotomy,Case 7,10 years, girl fever 5 days, 39 cough 3 days, dry and not bloody no chill,PHYSICAL EXAMINATION,breathing sound in right lung is low no wheezing and no crackles,LAB,WBC 10.0109/L N 0.79 CRP 16 mg/L serum MP-IgM (+)

34、 Mp-Ab1:640,CHEST X-RAY,Consolidation in the right lower lung,Diagnosis,Mycoplasma pneumonia,Treatment,Macrolides -Azithromycin,CHEST X-RAY,Consolidation in the right lower lung is decreased.,Case 8,5 yrs, girl fever 5 days, 39 cough 3 days purulent sputum chill,PHYSICAL EXAMINATION,breathing sound in right upper lung is low crackles in both lungs,Case 8,LAB wbc 20.0109/L N 0.80 CRP 78 mg/L X-ray,CHEST X-RAY,A large consolidation in the left upper lung,Diagnosis,lobar pneumonia,bacteria Streptococcus pneumoniae Haemophilus influenzae Staph aureus.,PATHOGEN,Treatment,penicillin cephalosporins,