A 4-year-old boy is brought to the clinic due to fever for the past 5 days. He has also had a cough productive of yellow-green mucus. The patient had pneumonia a year ago that required hospitalization for hypoxia. Currently, he takes no daily medications other than acetaminophen as needed for fever. The patient has received all of his vaccinations except for an annual influenza vaccine. His family is originally from Peru, but he was born in the United States and has not traveled outside of the country. Temperature is 38.9 C (102 F), blood pressure is 90/60 mm Hg, pulse is 112/min, and respirations are 20/min. Pulse oximetry is 99% on room air. His weight is at the 75th percentile, and review of his medical records reveals that he is growing well. Physical examination reveals a young child with moist mucous membranes, rales and decreased breath sounds over the left lower lung, and comfortable work of breathing. Chest x-ray demonstrates an opacity over the lower left lung with minimal layering of fluid on lateral decubitus film. Which of the following is the most appropriate next step in management of this patient?

Question

A 4-year-old boy is brought to the clinic due to fever for the past 5 days.  He has also had a cough productive of yellow-green mucus.  The patient had pneumonia a year ago that required hospitalization for hypoxia.  Currently, he takes no daily medications other than acetaminophen as needed for fever.  The patient has received all of his vaccinations except for an annual influenza vaccine.  His family is originally from Peru, but he was born in the United States and has not traveled outside of the country.  Temperature is 38.9 C (102 F), blood pressure is 90/60 mm Hg, pulse is 112/min, and respirations are 20/min.  Pulse oximetry is 99% on room air.  His weight is at the 75th percentile, and review of his medical records reveals that he is growing well.  Physical examination reveals a young child with moist mucous membranes, rales and decreased breath sounds over the left lower lung, and comfortable work of breathing.  Chest x-ray demonstrates an opacity over the lower left lung with minimal layering of fluid on lateral decubitus film.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d717_0693_bc81_3d01e1d8cef2_MD0003_00 This patient presents with a history and radiographic findings suggestive of pneumonia and a parapneumonic pleural effusion. Pleural inflammation secondary to bacterial pneumonia can lead to leakage of exudative fluid into the pleural space. Patients may present with symptoms of bacterial pneumonia (eg, fever, cough), and examination usually reveals focal rales, decreased or absent breath sounds, or dullness to percussion over the affected area. Children with small effusions may be breathing comfortably with normal vital signs, although those with moderate to large effusions typically exhibit signs of respiratory distress (eg, grunting, nasal flaring, subcostal retractions), tachypnea, and hypoxia. Although the diagnosis can be suspected from history and physical examination, chest x-ray confirms the presence of pleural fluid (eg, obscuring of costophrenic angle, layering fluid on lateral decubitus film). For small pleural effusions in patients without respiratory distress, such as this patient, management includes oral antibiotics and close follow-up on an outpatient basis. (Choice A) Chest physiotherapy can aid in the mobilization of secretions in patients with cystic fibrosis or bronchiectasis. It is not recommended in the treatment of pneumonia or pleural effusions as it is not shown to shorten hospital stay and may prolong cough. (Choices B and C) In patients with moderate or large effusions, ultrasonography and drainage (eg, chest tube, video-assisted thorascopic surgery [VATS]) are indicated. CT scan is typically only performed to assess for rare complications (eg, pulmonary necrosis, abscess). (Choice E) Diuretics can be used to decrease effusions in the presence of transudative pleural effusions (eg, secondary to cardiac failure or cirrhosis). Diuretics are not indicated in the treatment of parapneumonic effusions. (Choice F) Pleural effusions from Mycobacterium tuberculosis are exudative and result from a delayed hypersensitivity reaction. The absence of travel, upper lobe parenchymal disease, and weight loss makes tuberculosis much less likely than a primary bacterial pneumonia complicated by parapneumonic effusion. Educational objective: Parapneumonic effusions occur after bacterial pneumonias lead to pleural inflammation and exudation of fluid into the pleural space. Small effusions in children without respiratory distress can be managed with oral antibiotics and close outpatient follow-up. Moderate or large effusions require drainage. References: Pleural effusions. (http://www.ncbi.nlm.nih.gov/pubmed/17505279) Current evidence for the management of paediatric parapneumonic effusions. (http://www.ncbi.nlm.nih.gov/pubmed/22502916)

A 4-Year-Old Boy Is Brought to the Clinic Due to Fever