Chest CT can play an important role in evaluating patients with COVID-19 and detecting alternative diagnoses or complications. Common CT findings of COVID-19 include ground-glass opacities, vascular enlargement, bilateral lung involvement especially in the lower lobes, and a posterior predominance. CT may show normal findings early in infection but often demonstrates progressive abnormalities from ground-glass opacities to consolidation over the course of illness. Complications seen on CT include acute respiratory distress syndrome, pulmonary embolism, superimposed pneumonia, heart failure, and pericardial effusions.
This document provides guidelines from the American Society for Gastrointestinal Endoscopy on the role of endoscopy in evaluating patients with dyspepsia. It recommends that patients over 50 years old or those exhibiting alarm features should undergo endoscopic evaluation, while those under 50 without alarm features can be initially treated with noninvasive H. pylori testing and treatment if positive or a short course of PPIs. For patients who do not respond to or have recurring symptoms after these initial approaches, endoscopy is recommended to exclude structural diseases. The guidelines aim to optimize the use of endoscopy for diagnosing conditions like peptic ulcer disease or malignancy while avoiding unnecessary endoscopies.
Avascular necrosis, also known as osteonecrosis or bone infarction, is the death of bone tissue due to a lack of blood supply. It most commonly affects the femoral head. There are many potential causes including trauma, alcohol use, steroid use, and idiopathic cases. Diagnosis is made through imaging like x-rays, CT scans, MRIs, and bone scans. Treatment depends on the stage of necrosis and other factors, and may include observation, core decompression, vascularized bone grafts, partial or total hip replacement, or hip resurfacing. Staging is important for determining treatment and can range from pre-symptomatic changes visible only on MRI to complete femoral head destruction indistinguishable from osteo
This document summarizes various shoulder injuries including sprains, dislocations, tendinitis, fractures, and nerve injuries. It describes the mechanisms of injury, signs and symptoms, special tests used for diagnosis, and recommends referring patients to an orthopedist. Key details are provided for sternoclavicular joint sprains, acromioclavicular joint sprains, glenohumeral dislocations, rotator cuff injuries, bicep tendon injuries, clavicle and scapula fractures, and thoracic outlet syndrome.
Tokyo guidelines for cholangitis and cholecystitis Thorsang Chayovan
The document presents the Tokyo Guidelines for the management of acute cholangitis and cholecystitis. It was created by an international working group to address the lack of standardized diagnostic criteria and treatment guidelines for biliary infections. The working group conducted an extensive literature review, found little high-level evidence, and thus developed the guidelines through international consensus meetings. The Tokyo Guidelines provide evidence-based diagnostic criteria, severity assessments, and management recommendations for acute cholangitis and cholecystitis. They aim to establish international standards for evaluating and treating biliary infections.
The role of ercp in diseases of the biliary tract and pancreasThorsang Chayovan
This document provides guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) on the role of endoscopic retrograde cholangiopancreatography (ERCP) in diseases of the biliary tract and pancreas. It was developed using an evidence-based methodology including a literature review. The guidelines are intended to apply to all physicians performing GI endoscopy. ERCP is described as useful for diagnosing and treating conditions like gallstones, biliary strictures, pancreatic disease, and leaks or injuries to the biliary tract. Outcomes of ERCP for various conditions are discussed along with appropriate patient selection and techniques.
This guideline discusses the appropriate use of endoscopy in evaluating patients with dyspepsia. It recommends that patients over 50 years old or those with alarm features should undergo endoscopy due to their higher risk of structural diseases like cancer or peptic ulcers. Younger patients without alarm features may initially receive noninvasive testing for H. pylori infection and be treated if positive, or try acid suppression therapy. If these approaches do not resolve symptoms, endoscopy is recommended to check for structural causes. The guideline aims to help clinicians determine which dyspepsia patients most need endoscopy versus other initial treatment strategies.
This document provides guidelines for the role of endoscopy in evaluating suspected choledocholithiasis (gallstones in the common bile duct). It recommends a risk-stratified approach based on initial evaluation. For low risk patients, only cholecystectomy is needed. For intermediate risk, additional imaging like EUS, MRCP or preoperative ERCP is recommended to further evaluate need for ductal stone removal. For high risk, preoperative ERCP or operative cholangiography is recommended due to frequent need for therapy. Non-endoscopic options like CT, MRCP, IOC and laparoscopic ultrasound are also discussed. The guidelines are meant to help endoscopists provide care while considering individual clinical factors.
This clinical guideline provides recommendations for diagnosing and treating pneumonia in children. Pneumonia is common in children under 2 years old and can be caused by bacteria, viruses, or mixed infections depending on the child's age. Clinical features like fever, cough, difficulty breathing, and fast breathing should prompt consideration of pneumonia. Chest x-rays are not needed for most cases but can help in complicated cases. Most children can be treated with oral antibiotics at home, while those with more severe symptoms require hospital admission and intravenous antibiotics. Complications like lung abscesses may occur and require longer treatment and follow up to ensure full recovery. Recurrent pneumonia may indicate underlying conditions that require further investigation.
This document provides guidelines for treating fever and neutropenia in children with cancer. It defines low-risk and high-risk patients based on their condition and symptoms. For low-risk patients, initial treatment with ceftazidime is recommended, while high-risk patients should receive ceftazidime and vancomycin. Treatment is modified based on blood culture results and patient stability. Persistent fever may warrant adding antifungal drugs or investigating non-bacterial causes.
Rectal procidentia, or rectal prolapse, is the full-thickness circumferential intussusception of the rectum through the anal verge. It can be incomplete involving just the mucosa, or complete involving the full rectal wall. Complete prolapse is classified as first degree if the prolapse remains outside the anus, second degree if it reduces spontaneously on lying down, or third degree if it requires manual reduction. Predisposing factors include constipation, pelvic floor weakness, rectocele, and increased intra-abdominal pressure. Treatment options include pelvic floor repair, rectopexy to elevate the rectum, and resection of redundant sigmoid colon.
The document discusses acute calculous cholecystitis, a complication of gallstones where the gallbladder becomes inflamed. It provides details on the pathogenesis, symptoms, diagnosis and treatment strategies. Regarding treatment strategies, it indicates that early laparoscopic cholecystectomy within 1 week of symptoms starting is considered the best treatment for most patients based on randomized trials showing shorter hospital stays compared to delayed surgery 2-3 months later. However, it notes the risk of bile duct injuries may be higher for early surgery on an inflamed gallbladder based on large registry studies, though randomized trials were too small to definitively assess this risk. It concludes that while early laparoscopy is usually best, open surgery or postponing surgery may
3. A 3- month-old infant develops a severe hacking cough and appears
to choke on or to vomit profuse thick mucus, after 10 days of nasal
congestion and rhinorrhea. Although afebrile, he is admitted to the
hospital, after 14 days, the coughing continues unabated and he has
mild tachypnea and dyspnea.
Investigation
CXR shows bilateral interstitial infiltration. His WBC count is 24000
with 15% polymorphonuclear cells, 82% lymphocytes and
3%monocytes.
4. Nasal congestion and rhinorrhea 10 days
Hacking cough with choking and vomiting
Persistent cough 14 days
Tachypnea and dyspnea
CXR: bilateral interstitial infiltration
Leukocytosis and lymphocytosis
6. Pertussis pneumonia
Bordetella pertussis
Cough of 100 days
Acute cough illness lasting at least 14 days
accompanied by
Damage ciliated respiratory epithelium
1. Paroxysms of coughing
2. Inspiratory whoop
3. Post- tussive vomiting
8. Usual interstitial pneumonitis
Interstitial fibrosis
Usaul=most common form of interstitial fibrosis
Causes:asbestosis,systemic sclerosis,
rheumatoid arthritis
Symptom&finding
-CXR shows bilateral interstitial infiltration
-Slowly progressive dyspnea
-Productive cough
-No nasal congestion and rhinorrhea
-No choking and vomiting
9. Broncheal hyperactive airway
Bronchospasm
Hallmark of asthma
Symptom&finding
-Nasal congestion and rhinorrhea
-Hacking cough with choking and vomiting
-Afebrile
-Tachypnea and dyspnea
-Wheezing
-CXR ปกติ
-CBC มี eosinophilia
Bronchial challenge test: by methacoline,
histamine
10. Diffuse panbronchiolitis
Inflamatory lung disease
Severe and progressive form of bronchiolitis
Symptom&finding
-Intense cough
-Choking and vomiting
-Tachypnea and dyspnea
-large amount of sputum
-Fever
-Wheezing
-Associates with chronic sinusitis
-Neutrophilia
11. GE reflux
Relaxation of LES
Symptom&finding
-Persistent cough
-Choking and vomiting
-Afebrile
-Tachypnia and dyspnea
-Feeding problem,failure to gain weight,
refuse food
-Recurrence pneumonia
-Normal CXR and CBC
14. Stage Length Clinical Features
Stage 1:
Catarrhal
Usually 7-10 d;
range 4-21 d
Characterized by:
• Coryza (runny nose)
• Low-grade fever
• Mild, occasional cough
(gradually becomes more severe)
Stage 2:
Paroxysmal
Usually lasts 1-6
wks, may persist
for up to 10 wks
Characterized by:
• Paroxysms coughs
• Long aspiratory effort accompanied by "whoop"
• Cyanosis
• Vomiting and exhaustion
• Increase frequency during the first 1-2 weeks,
stable for 2-3 weeks, and then gradually decrease.
Stage 3:
Convalescent
Usually 7-10 d;
range 4-21 d
Characterized by:
• Gradual recovery
• Disappear in 2-3 weeks
CDC. http://www.cdc.gov/pertussis/clinical/features.html
15. Disease in infants< 6 months of age can be atypical
and severe
• Short catarrhalstage
• Early manifestations: gagging, gasping, or apnea
• Absence of whoop
• Prolonged convalescence
• Sudden unexpecteddeath
AAP. Red Book 2009.
16. CBC
• WBC with an absolute lymphocytosis in infants and
young children but not in adolescents
Culture :
• Gold standard, 100% specific, but insensitive
(if previously Rx, > 3 wks after onset, inappropriate
handling)
PCR:
• Interpreted with clinical and epidemiological info
• Vary in specificity (high rates of false+)
AAP. Red Book 2009.
CDC. http://www.cdc.gov/vaccines/pubs/surv-manual/chpt10-pertussis.htm#7
17. b Preferred macrolide because of risk of idiopathic hypertrophic pyloric stenosis associated
with erythromycin
FDA has not approved azithromycinor clarithromycin for use in infants you< 6 mo
CDC. MMWR 2005;54(RR14):1-16.
AAP. Red Book 2009.
18. Underlying neurological conditions
(seizure, epilepsy or febrile convulsion)
Severe adverse events from previous
DTwP
high grade fever, seizure, persistent, severe,
inconsolable screaming/crying, hypotonic-
hyporesponsive episodes (collapse or shock-
like) within 48 hrs
At risk with high fever eg.
Congenital heart disease
19.
20. A 6 - month –old boy (first time). He was admitted with
two days history of nasopharyngitis and having had
severe coughing and dyspnea on the day of
admission.
21. Physical examination
V/S: T 38.8 c RR 60/min P140/min
GA: a well nourished infant, mild dyspnea
RS: tachypnea, increased AP diameter, resonance
note on percussion, diminished bronchovesicular
breath sound , fine crepitations bilaterally,
occasional wheeze
GI: Liver - 2 cm. below right costal margin with sharp
edge and normal consistency.
23. 1. Cough 1 day
2. Respiratory distress 1 day
3. Fever 1 day
4. History of URI 2 days
5. diminished bronchovesicular breath
sound
6. fine crepitation bilaterally
7. occasional wheezing
8. palpable liver
25. Acute bronchiolitis
PROS CONS
o Age group (<2YO)
oHistory of URI progress to cough,
respiratory distress
oPE: fine crepitation, wheeze,
diminished bronchovesicular
breath sounds
signs of hyperaeration – increase
AP diameter, palpable liver
oCBC: normal
29. Acute bronchiolitis
Management:
Supportive treatment
- oxygen therapy
Joseph J. Zorc and Caroline Breese Hall
Bronchiolitis:Recent Evidence on Diagnosis and Management
Pediatrics 2010;125;342-349
Routine use of
bronchodilators
or corticosteroids
30. Viral pneumonia
PROS CONS
o Short history of fever, severe
coughing, respiratory distress
o PE: fine crepitation, wheezing
36. Complication in this patient
Pneumothorax of right lung
-trachea shifts to left side
-hyperresonance on percussion and
decreased breath sounds at right chest wall
pneumothorax
-spontaneous primary: male,smoking,family Hx
secondary: chronic obstructive
lung disease
-traumatic
37. Most likely organism
Staphylococcus aureus
- high fever suggest bacterial pneumonia
- pustules at both legs
- complications: Pleural effusion, Lung
abscess, Pneumatocele , Pneumothorax
39. Management
Specific treatment
- Antibiotic :Cloxacillin 50-100 mg/kg/day IV
until clinical symptoms improved then switch to
oral form, continue to 3 weeks
- Incision and drainage, wet dressing at the
abscesses both legs
- Pneumothorax :Thoracocentesis,ICD
42. ตรวจร่างกายพบว่า
V/S: T = 38.0 ºC, RR = 36 /min, BP = 90/60 mmHg, PR =
110 /min, BW = 18 kg, Ht. = 105 cm
GA: good consciousness, mild subcostal retraction,
dry lips, no lymphadenopathy
Lung: trachea in midline, left chest decreased
movement, dullness on purcussion over the lower half
of left lung, decreased breath sound, vocal fremitus
and vocal resonance on the left lung
Heart : normal S1, S2, no murmur,
Abdomen: liver : spleen -negative
43. การตรวจเพิ่มเติมจากการเจาะน้าในโพรงเยื่อหุ้มปอดด้านซ้ายพบว่า
pleural fluid: straw color fluid, sp. gr 1.015, protein 4
gm/dl, LDH 2150 U/L, pH 7.02, cell:wbc 2000/mm3, N 20% L
80%, no organism ย้อมแบบ AFB ไม่พบเชื้อ
คาถาม
1. จงให้การวินิจฉัยโรคที่น่าจะเป็นมากที่สุด พร้อมให้เหตุผลประกอบ
2. นอกจากโรคที่เป็นคาตอบในข้อที่ 1 แล้วจงให้การวินิจฉัยแยกโรค (2
โรค)
3. จากคาตอบในข้อที่ 1 จงวางแนวทางการซักประวัติ การตรวจพิเศษ
การตรวจทางห้องปฏิบัติการที่สาคัญ เพื่อสนับสนุนโรคที่ท่านคิดถึง
45. Measurement[*] Transudate Exudate[†]
Specific gravity <1.016 >1.016
Protein (g/dL) <3.0 >3.0
Fluid:serum ratio <0.5 >0.5
LDH (IU) <200 >200
Fluid : serum ratio (isoenzymes not
useful)
<0.6 >0.6
WBCs[‡] <1000/μL >1000/μL
RBCs <10,000 Variable
Glucose Same as serum Less than
serum
pH[§] 7.4–7.5 <7.4
48. 1. จงให้การวินิจฉัยโรคที่น่าจะเป็นมากที่สุด พร้อมให้เหตุผล
ประกอบ
• จากประวัติผู้ป่วยมีไข้ ไอ respiratory distress มา 5
วัน นึกถึง infection มากที่สุด
• Tuberculous pleuritis
Type of effusion: straw color
Lymphocytic effusion (WBC
1,500-5,000/mm3 with L > 50%
cough, pleuritic chest pain, dyspnea, low-
grade fever, and other nonspecific
constitutional symptoms
49. The presence of > 3 of the following should
strongly suggest a diagnosis of TB:
Chronic symptoms suggestive of TB
• Chronic cough: unremitting cough > 21 d that is
not improving
• Fever: T >38 °C for 14 days
• Weight loss or FTT
Physical signs highly of suggestive of TB
Positive tuberculin skin test
Chest X-ray suggestive of TB
WHO/HTM/TB/2006.371
50. 1. จงให้การวินิจฉัยโรคที่น่าจะเป็นมากที่สุด พร้อมให้เหตุผล
ประกอบ
Acid-fast smears of the pleural fluid are
rarely positive. Cultures of the fluid are
positive in only <30% of cases
• จากประวัติผู้ป่วยมีไข้ ไอ respiratory distress มา 5
วัน นึกถึง infection มากที่สุด
• Tuberculous pleuritis
Type of effusion: straw color
L ymphocytic effusion (WBC
1,500-5,000/mm3 with L > 50%
53. 1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Arthritis
6. Serositis
7. Kidney disease
a. > 0.5 g/d proteinuria, or
b. 3+ dipstick proteinuria, or
c. Cellular casts
8. Neurologic disease
a. Seizures, or
b. Psychosis (without other cause)
9. Hematologic disorders
a. Hemolytic anemia, or
b. Leukopenia (< 4000/mcL), or
c. Lymphopenia (< 1500/mcL), or
d. Thrombocytopenia (< 100,000/mcL)
10. Immunologic abnormalities
a. Positive LE cell preparation, or
b. Antibody to native DNA, or
c. Antibody to Sm, or
d. False-positive serologic test for syphilis
11. Positive ANA
55. Paucibacillary TB
• Children < 12 y rarely produce sputum
• Best specimen: early morning gastric aspirates
• Yield of AFB from respiratory specimens
• Sputum- 70% in adults
• Gastric aspirates < 20% in children
Strumpf IJ. Am Rev Resp Dis 1979;119:599-602.
Lipsky BA. Rev Infect Dis 1984;6:214-22.
• Positive TB C/S in 3 gastric aspirates
• 70% in infants
• 30-50% in older children
Vallejo J. Pediatrics 1994;94:1-7.
56. Gastric aspirate C/S yield 20-52% for children with
pulmonary TB
Pomputius W, et al. Pediatr Infect. Dis J 1997;16:222–226
3 consecutive-day gastric larvage is better than BAL
for isolation of M. tuberculosis in childhood
pulmonary TB (50% vs 20%, p < 0.05)
Abadco DL, et al. Pediatr Infect Dis J 1992;11(9):735-8.
.
57. Overall sensitivity of TB PCR was 78.3%, pulmonary 82.3% and extrapulmonary 72.0%
Cheng VC, et al. J Clin Pathol 2004;57:281-5.
58. CDC included nucleic acid amplification test in smear+
cases as confirmation of TB diagnosis
Differentiation of M. TB and M. bovis is based on PZA resistance
Respiratory sample
(AFB Smear)
PCR
Sensitivity (%) Specificity (%)
+ 95 98
- 48-53 95
ATS 1997. Am. J. Respir. Crit. Care Med 1997. 155:1804–1814.
Catanzaro A, et al. JAMA 2000;283:639–645.
59. Meta-analysis of 2,796 patients with TB pleural effusion and
5,297 non-TB pleural effusion were analyzed (cut off ~ 40)
* Patients with TBPE have 9-fold higher chance of +ADA vs
patients without TBPE
** If ADA is negative, chance of TBPE is 10%
ADA in pleural fluid is useful but negative results does not R/O
TBPE
Liang QL, et al. Resp Med 2008;102:744-754.
95% CI
Sensitivity 0.92 0.90-0.93
Specificity 0.90 0.89-0.91
Positive likelihood ratio* 9.03 7.79-11.35
Negative likelihood ratio** 0.10 0.07-0.14
61. 3. จากคาตอบในข้อที่ 1 จงวางแนวทางการซักประวัติ การตรวจ
พิเศษ การตรวจทางห้องปฏิบัติการที่สาคัญ เพื่อสนับสนุนโรคที่ท่าน
คิดถึง
การรักษาใช้สูตรยา และระยะเวลาเช่นเดียวกับวัณโรคปอด
รายที่มีไข้สูง เจ็บหน้าอก และหอบเหนื่อยมาก การให้
prednisolone ช่วยทาให้อาการต่างๆ แต่ไม่ช่วยลดผลแทรก
ซ้อนระยะยาว
ท่านจะให้การดูแลรักษาอย่างไรต่อไป
A. Switch เป็น Meropenem
B. CXR ทุกคนในบ้าน
C. Start 2IRZE/4IR
D. Start 2IRZE/4IR + prednisolone 2 mg/kg/d 4-6
weeks
62. Drugs Dose (mg/kg/d) Max/d
(mg)
INH 10 (10-15) 300
Rif 15 (10-20) 600
PZA 35 (30-40)
ETB 20 (15-25)
RAPID ADVICE. Treatment of tuberculosis in children
WHO/HTM/TB/2010.13
• Regimen for TB meningitis: IRZE, IRZEto, or IRZS
* Ethionamide has good CNS penetration
63. Site Length of Rx
(m)
Rating Comments
CNS/meningitis 9-12 BII WHO 12 m, AAP 9-12 m
Bone and joint 6-9 AI WHO 12 m
Disseminated
disease
6 AII
Pulmonary 6
Pleural disease 6 AII
GU 6 AII
Pericarditis 6 AII
Lymph node 6 AI
Peritoneal 6 AII
ATS/CDC. MMWR 2003;52(RR-11):1-77.
64. Limited data in children
Corticosteroid are indicated for TB meningitis
(decrease mortality and long term neurologic
impairment)
Corticosteroid may be considered for:
• Pleural effusion
• Pericardial effusion
• Severe miliary disease (to mitigate alveolocapillary block)
• Endobronchial disease (to relief obstruction, and atelectasis)
• Abdominal TB (to decrease risk of stricture)
Prednisolone 2 mg/kg/d (max 60 mg/d) for 4
wks with tapering 1-2 wks
hasten reabsorption
AAP. Red Book 2009.
70. Problem list
1. fever for 7 days (body T 39.8 C)
2.severe cough for 7 days, mild dyspnea, and
tachypnea
3.diminished breath sound and fine crepitation on
right lower lung
4.unresponed to amoxycillin
5.CXR ; right lower lobe infiltration with minimal
pleural effusion.
78. Mycoplasma pneumoniae
symptom
headache, malaise, and low-grade fever
More patients have a respiratory tract illness
without pneumonia
Cough ranges from nonproductive to mildly
productive
Wheezing and dyspnea may occur
Dyspnea is not a common complaint
Additional symptoms; pharyngitis, rhinorrhea,
ear pain, hemolysis, maculopapular rash
*http://www.uptodate.com/contents/mycoplasma-pneumoniae-infection-in-children?source=search_result&selectedTitle=2~96
80. Mycoplasma pneumoniae
Diagnosis
Gradual onset of symptoms, less respiratory
distress, and normal WBC count
Gram stain and sputum culture ; 2-3 weeks
Cold agglutinins ; neither sensitive nor specific
Serology: IgM or IgG antibody (four-fold or 1:32)
81. Mycoplasma pneumoniae
medication
Erythromycin
30 to 40 mg/kg/day qid for 10 days
Clarithromycin
15 mg/kg/day bid for 10 days
Azithromycin
10 mg/kg in one dose on the first day
and 5 mg/kg in one dose for 4 days
82. Chlamydophila pneumophila
most common in aged 65 to 79 year
Symptom
gradual onset of symptoms, dry cough, Fever,
chills, malaise, pharyngitis, hoarseness, Sinusitis
CBC
normal white blood cell count
CXR
one patchy area of subsegmental infiltration.
*http://www.uptodate.com/contents/pneumonia-in-children-caused-by-chlamydophila-chlamydia-
species?source=search_result&selectedTitle=3~52
89. ท่านเป็นกุมารแพทย์ที่ รพ.ศูนย์แห่งหนึ่ง
• เด็กชายอายุ 2 ปี มีไข้ และหอบมา 2 วัน
• 1 สัปดาห์ก่อนมีอาการไอมาก ไม่มีน้ามูก จึงไปตรวจที่ รพ.แห่ง
หนึ่งแพทย์ทา CXR ไม่พบความผิดปกติ
• 2 วันนี้ไอมาก มีไข้ หายใจหอบจึงมา รพ.
ตรวจร่างกาย
V/S T 38 ºC, RR 40 /min
GA dyspnea with subcostal retraction
Lungs decreased breath sound
occasianal wheeze over the Rt. Lung,
trachea shift to the right
1.จงให้การวินิจฉัยโรคที่น่าจะเป็นมากที่สุด
2.ท่านจะตรวจเพิ่มเติมอะไรที่ได้ประโยชน์มากที่สุด (ตอบมาเพียง 1
ข้อ) พร้อมบอกเหตุผลในการส่งตรวจ
90. 1. Cough 1 wk
2. Fever and cough 2 days
3. Respiratory distress 2 days
4. Occasional wheeze over the Rt. Lung
5. Decreased breath sounds
6. Tracheal shift to the right
91. ต่อมามีไข้ ไอ และ sign of
respiratory distress
(tachypnea, subcostal
retraction) 2 days
Acute respiratory
tract infection
ผู้ป่วยเด็กอายุ 2 ปีป่วย
มาด้วย URI
PE พบ wheezing
Lower tract lesion
(obstruction)
92. ต่อมามีไข้ ไอ และ sign of
respiratory distress
(tachypnea, subcostal
retraction) 2 days
Acute respiratory
tract infection
ผู้ป่วยเด็กอายุ 2 ปีป่วย
มาด้วย URI
Lower tract lesion
(obstruction)
Acute bronchiolitis?
PE พบ wheezing
100. A, Normal inspiratory chest radiograph in a toddler with a peanut fragment
in the left main bronchus. B, Expiratory radiograph of the same child
showing the classic obstructive emphysema (air trapping) on the involved
(left) side. Air leaves the normal right side, allowing the lung to deflate. The
mediastinum shifts toward the unobstructed side.