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The Second Affiliated Hospital of Sun Yat-sen University
Tan Wei-ping
The Second Affiliated Hospital of Sun Yat-sen University
Tan Wei-ping
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Contents Upper Respiratory Infection Acute infectious Laryngitis Acute Bronchitis Bronchiolitis Pneumonia
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AnatomyAnatomy upper respiratory tract(URT)
• Cricoid Cartilage lower respiratory tract(LRT)
• URT : Nose 、 pharynx 、 Uvula 、 Larynx 、 auditory tube 、 paranasal sinuses
• LRT : Trachea 、 bronchia 、 bronchiole 、the respiratory bronchiole 、 the alveolar duct and the alveolus
upper respiratory tract(URT)
• Cricoid Cartilage lower respiratory tract(LRT)
• URT : Nose 、 pharynx 、 Uvula 、 Larynx 、 auditory tube 、 paranasal sinuses
• LRT : Trachea 、 bronchia 、 bronchiole 、the respiratory bronchiole 、 the alveolar duct and the alveolus
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Anatomy characteristics upper respiratory tract Nose: cilia↓, capillary↑ Sinuses: mucous
Auditory tube
tonsil
Larynx
Anatomy characteristics upper respiratory tract Nose: cilia↓, capillary↑ Sinuses: mucous
Auditory tube
tonsil
Larynx
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lower respiratory tract: Weak Cartilage Supporting , ciliary
function impairment
Right bronchus :straight , large
Collagen and elastin
fibers , capillary , interstitial tissue
Thorax : chest wall, respiratory
muscle ; diaphragm , mediastinum
lower respiratory tract: Weak Cartilage Supporting , ciliary
function impairment
Right bronchus :straight , large
Collagen and elastin
fibers , capillary , interstitial tissue
Thorax : chest wall, respiratory
muscle ; diaphragm , mediastinum
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Physiological characteristics The compensatory ability ↓
Respiratory rate↑
Pattern of respiration
Gas-exchanging membrane :diffuse rate
CO2 > O2
Resistance of airway: child > adult
Physiological characteristics The compensatory ability ↓
Respiratory rate↑
Pattern of respiration
Gas-exchanging membrane :diffuse rate
CO2 > O2
Resistance of airway: child > adult
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Arterial blood gas examination
(1) pH↓acidosis ;(2) PaO2↓ SaO2 ↓ hypoxemia ;
(3)PaCO2↑ carbon dioxide retention
mal-ventilation
Arterial blood gas examination
(1) pH↓acidosis ;(2) PaO2↓ SaO2 ↓ hypoxemia ;
(3)PaCO2↑ carbon dioxide retention
mal-ventilation
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The Immunological Characteristics:Impaired mucociliary clearance function
SIgA↓ 、 IgA↓ 、 IgG↓ subtype of IgG ↓
Alveolar macrophages ↓ , lysozyme ↓
lactoferrin ↓ 、 interferon ↓
complement ↓
The Immunological Characteristics:Impaired mucociliary clearance function
SIgA↓ 、 IgA↓ 、 IgG↓ subtype of IgG ↓
Alveolar macrophages ↓ , lysozyme ↓
lactoferrin ↓ 、 interferon ↓
complement ↓
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Upper Respiratory Infection (URI, or Common Cold)
Upper Respiratory Infection (URI, or Common Cold)
1. Etiology 90% viruses, the majority of colds.
rhinoviruses ,coronaviruses.
parainfluenza virus, adenovirus, enterovirus,
respiratory syncytial virus.
2. season fall and winter
3. Frequency three to eight colds a year.
1. Etiology 90% viruses, the majority of colds.
rhinoviruses ,coronaviruses.
parainfluenza virus, adenovirus, enterovirus,
respiratory syncytial virus.
2. season fall and winter
3. Frequency three to eight colds a year.
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Inoculation by virus
Invasion of epithelium ofRelease of nasopharynx,sinuses and URT cellular damageInflammatory of nasopharynxmediators in Cholinergicnasal secretions stimulation
Increased Increased vascular mucusPermeability production
bronchial constriction
Nasal Rhinorrhea postnasalStuffiness drip sore cough throat Pathophysiology of the common cold
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The clinical manifestation Common cold congestion a runny nose sneezing Cough,sore throat sometimes vomiting and diarrhea Fever,malaise,abdominal pain
The clinical manifestation Common cold congestion a runny nose sneezing Cough,sore throat sometimes vomiting and diarrhea Fever,malaise,abdominal pain
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Specific type of URI Herpangina:coxsackie-viruses group A.
summer /fall.High fever, sore throat ,
1-4mm vesicles /ulcers on anterior tonsillar
pillars, softpalate,uvula,tonsils pharyngeal wall.
Pharyngoconjunctival fever :type 3,7
adenovirus, spring /summer.
High fever, sore throat , pharyngitis,
conjunctivitis, cervical lymphadenopathy.
Specific type of URI Herpangina:coxsackie-viruses group A.
summer /fall.High fever, sore throat ,
1-4mm vesicles /ulcers on anterior tonsillar
pillars, softpalate,uvula,tonsils pharyngeal wall.
Pharyngoconjunctival fever :type 3,7
adenovirus, spring /summer.
High fever, sore throat , pharyngitis,
conjunctivitis, cervical lymphadenopathy.
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Complicationssinusitis
otitis media
cervical lymphadenopathy
Mesentery lymphadenopathyretropharngeal abscesspneumonia rheumatic fever acute glomerulonephritis
Complicationssinusitis
otitis media
cervical lymphadenopathy
Mesentery lymphadenopathyretropharngeal abscesspneumonia rheumatic fever acute glomerulonephritis
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Differential diagnosis
•Flu•Appendicitis•Early phase of acute
infectious disease
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Cold FluLow or no fever High fever
Sometimes headache Commonly headache
Stuffy, runny nose Sometimes stuffy nose
Sneezing Sometimes sneezing
Mild, hacking cough Cough, may progress
Slight aches and pains severe aches and pains
Mild fatigue Fatigue, may persist
Sore throat Sometimes sore throat
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Treatment increased fluid intakeavoidance of secondhand smokeSaline nose drops bulb syringe remove the mucuscool mist humidifierantipyretics, such as
acetaminophen,ibuprofen, decrease the discomfort of colds.
Do not give aspirin (associated with Reye syndrome)
Treatment increased fluid intakeavoidance of secondhand smokeSaline nose drops bulb syringe remove the mucuscool mist humidifierantipyretics, such as
acetaminophen,ibuprofen, decrease the discomfort of colds.
Do not give aspirin (associated with Reye syndrome)
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PreventionKeep your child away from a
person with a cold.Encourage your child to wash
his/her hands frequently and not to touch his/her mouth, eyes, or nose until their hands are washed.
Make sure toys and play areas are properly cleaned, especially if multiple children are playing together.
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Acute infectious LaryngitisAcute infectious Laryngitis
Etiology
• Virus or bacteria
• Typical anatomy
Etiology
• Virus or bacteria
• Typical anatomy
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Clinical manifestations
Barking cough, hoarseness, inspiratory
stridor, nasal flaring, suprasternal ,
infrasternal, intercostal retraction
Fever, dyspnea, cyanosis restlessness,
tachycardia . Worsen at night.
Congestion of pharynx, vocal cord edema
Clinical manifestations
Barking cough, hoarseness, inspiratory
stridor, nasal flaring, suprasternal ,
infrasternal, intercostal retraction
Fever, dyspnea, cyanosis restlessness,
tachycardia . Worsen at night.
Congestion of pharynx, vocal cord edema
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Grade of laryngic obstruction Ⅰ : inspiratory stridor, respiratory difficulty only after activity Ⅱ : symptoms occurs at rest. tachycardia, rhonchi Ⅲ : Ⅱ + hypoxia, diminished breath sounds Ⅳ : exhaustion, lethargy , pallor , breath sounds diminish or disappear. dull of heart sounds, arrhythmia
Grade of laryngic obstruction Ⅰ : inspiratory stridor, respiratory difficulty only after activity Ⅱ : symptoms occurs at rest. tachycardia, rhonchi Ⅲ : Ⅱ + hypoxia, diminished breath sounds Ⅳ : exhaustion, lethargy , pallor , breath sounds diminish or disappear. dull of heart sounds, arrhythmia
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Diagnosis & differential diagnosis laryngeal diphtheria laryngeal spasm bronchial foreign bodies
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treatment Maintaining of airway : steam
inhalation, clearing of secretion.
antibiotics corticosteroid oxygen supply sedatives (phenergan) Ⅲ ↑ tracheotomy
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Acute Bronchitis(tracheobronchitis)Acute Bronchitis(tracheobronchitis)
Etiology
• Virus or bacteria
• Allergy, climate, air pollution, chronic infection of URT, particularly sinusitis.
• Rickets, malnutrition
Etiology
• Virus or bacteria
• Allergy, climate, air pollution, chronic infection of URT, particularly sinusitis.
• Rickets, malnutrition
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Clinical manifestations• unproductive cough 3~4days →
productive cough, purulent sputum → 5~10days
• Chest pain, shortness of breath
• Vomiting
• Physical finding: low-grade fever, roughening of breath sounds, rhonchi, coarse moist rales.
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Asthmatic bronchitis: ﹤3yrs old, eczema, allergy symptoms resemble asthma recurrent episodes reduced
after 3~4yrs old.
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Treatment
increased fluid intake
frequent shifts of position
antibiotics
cough suppressants
expectorants , antihistamines
acetaminophen
Treatment
increased fluid intake
frequent shifts of position
antibiotics
cough suppressants
expectorants , antihistamines
acetaminophen
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Bronchiolitis Etiology and epidemiology 50 % respiratory syncytial
virus(RSV) parainfluenza 3 virus,
mycoplasma, adenoviruses north——winter and early
spring Guangdong——spring ,summer
and early autumn
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2.PathophysiologyLesion: small air passages (diameter75 ~ 300um)Edema, accumulation of mucus and
cellular debris, spasm of smooth mussle→ ↑ resistance of small airway →expiratory difficulty →overinflation or atelectasis →hypoxemia, hypercapnia, acidosis
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Clinical manifestation
Infant 2yrs old, peak at 3~ 6 mo of ﹤age, male, non breast-feed
URI 3 ~ 4daysparoxysmal wheezy coughdyspnea develop rapidlymild or moderate fever
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Physical examinationR 60~80/minHR 160 ~ 200/minNasal flare, intercostal and subcostal
retractionsPallor, cyanosisHyperexpanded chest , expiratory phase ↑
wheeze , widespread fine crackles Liver and spleen palpable below the costal
marginCritical phase 48 ~ 72h afer onset of
dyspnea; recover during 5 ~ 15days
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Laboratory examination
WBC and differential cells count normal
Virus detected by antigen detection, PCR, or culture.
X-ray: hyperinflation of the lungs, emphysema, scattered areas of consolidation
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Differential diagnosis
AsthmaCystic fibrosisHeart failureForeign body in the tracheapertussis
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两侧肺纹理粗重。两肺中内带多数小斑片状及小结节病灶影。无病灶之肺部透过度增高。
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Treament Supportive treatment cool, humidified oxygen supply,
maintain SaO2 94%~96%; increased fluid intake : oral
intake, intravenous solutions head and chest slightly elevated
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Ribavirin Antibiotics corticosteroids
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Pneumonia
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What’s PneumoniaWhat’s Pneumonia An abnormal inflammatory condition
of the lung infections (bacterial, viral or fungal) chemical injury (gastric acid/
aspiration of food/ hydrocarbon and lipoid pneumonia/ radiation induced pneumonia)
An abnormal inflammatory condition of the lung
infections (bacterial, viral or fungal) chemical injury (gastric acid/
aspiration of food/ hydrocarbon and lipoid pneumonia/ radiation induced pneumonia)
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Definition• Defined by clinical features or with the
addition of radiologic findings• Tachypnea: indicator of pneumonia(WHO) < 2m, R≥60/min 2~12m, R≥50/min > 12m, R≥40/min sensitivity of 74% and a specificity of 67%
compared with radiology
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Epidemiology• A leading killer of children≤5yr
1.9 million death worldwide/year
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Etiology
Viruses:40% ( < 2yr)
Bacteria:27~44%– Streptococcus pneumoniae
– Staphylococcus aureus, Moraxhella catarrhalis,
– group A Streptococci, and Haemophilus
MP, CP:9~14%Mixed:23%
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Contributing Etiology: risk foctors
Malnutrition Rickets Iron-deficiency Immuno-deficency Congenital heart disease Low born bodyweight
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Clinical manifestation
fever
cough
Dyspnea(Tachypnea,cyanosis)
Localized crackles(fine moist rales)
Abnormal chest x-ray
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Classification Pathologic (anatomic changes)
lobar pneumonia: involves a single lobe
Bronchial pneumonia: patches around the tubes
Interstitial pneumonia: areas between the alveoli
Pathogenic (microorganisms )
bacteria
viruses
fungi
parasites
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Classification course of disease
– Acute
– subacute
– chronic
State of disease
– common
– severe
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Classification
Clinical manifestation– Typical
– atipical
The combined clinical classification
– community-acquired pneumonia(CAP)
– hospital-acquired pneumonia (HAP)
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BronchopneumoniaBronchopneumonia
1.Etiology viruses, bacteria, MP, CP.
2~3yrs old
2.pathology edema,infiltration
1.Etiology viruses, bacteria, MP, CP.
2~3yrs old
2.pathology edema,infiltration
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3 pathophysiologyhypoxemia, hypercapnia, toxemia
respiratory insufficiency
acidosis
myocarditis, heart failure, shock, DIC
toxic encephalopathy
toxic intestinal paralysis
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4.Clinical manifestation
(1) mild (commone)pneumonia : fever
cough
dyspnea ( tachypnea, cyanosis)
crackles
Chest x-ray
4.Clinical manifestation
(1) mild (commone)pneumonia : fever
cough
dyspnea ( tachypnea, cyanosis)
crackles
Chest x-ray
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两肺纹理增粗。两肺中下野中内带见斑片状阴影,密度较均匀。部分病灶融合成范围稍大的片状影
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(2) Severe pneumonia :
other systems involved
myocarditis
heart failure
toxic encephalopathy
toxic intestinal paralysis
(2) Severe pneumonia :
other systems involved
myocarditis
heart failure
toxic encephalopathy
toxic intestinal paralysis
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Heart failure① R > 60/min② HR > 180/min③ Sudden onset of restlesseness,Pallor,
cyanosis, delayed capillary refill( >3~5s)
④ Dull heart sound, gallop rhythm, Jugular vein congestion
⑤ Liver enlarged rapidly⑥ Oliguria or anuria, edema
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5.Complications
• Empyema
• Pyopneumothorax
• pneumatocele
5.Complications
• Empyema
• Pyopneumothorax
• pneumatocele
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6.Laboratory findings:
WBC, NBT,CRP
Pathogen(antigen and/or antibody)
chest x-ray
6.Laboratory findings:
WBC, NBT,CRP
Pathogen(antigen and/or antibody)
chest x-ray
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7.diagnosis
Fever, cough, tachypnea, dyspnea, localized
fine moist rales, chest x-ray
8.differential diagnosis acute bronchitis
tuberculosis
foreign bodies of trachea
7.diagnosis
Fever, cough, tachypnea, dyspnea, localized
fine moist rales, chest x-ray
8.differential diagnosis acute bronchitis
tuberculosis
foreign bodies of trachea
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男 2 岁半。 4 个月前吃蚕豆后发生呛咳,经常发烧,左侧呼吸音低。胸片:左侧阻塞性肺气肿。心 影稍右移,经支气管检查于左支气管取出蚕豆碎块。
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9. treament
(1) general therapy
(2) antipathogen therapy
antibiotics
antivirus
9. treament
(1) general therapy
(2) antipathogen therapy
antibiotics
antivirus
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(3)symptomatic therapy
oxygen supply
airway management
abdominal distention
fever
(4) Corticosteroid
(5) complications /underling disease
(6)Immunotherapy
(3)symptomatic therapy
oxygen supply
airway management
abdominal distention
fever
(4) Corticosteroid
(5) complications /underling disease
(6)Immunotherapy
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Characteristics of pneumonia caused by different pathogen
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1.respiratory syncytial virus pneumonia
age: 2~7mon fever:mild or moderate main signs: acute onset, wheeze,
expiratory difficulty, palpable liver and spleen.
Pallor, cyanosis, restlesseness Auscultation: diffuse rhonchi, fine
rales Chest X-ray:peribronchial thickening
or interstitial pneumonia
1.respiratory syncytial virus pneumonia
age: 2~7mon fever:mild or moderate main signs: acute onset, wheeze,
expiratory difficulty, palpable liver and spleen.
Pallor, cyanosis, restlesseness Auscultation: diffuse rhonchi, fine
rales Chest X-ray:peribronchial thickening
or interstitial pneumonia
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2.Adenovirus pneumonia
Age: 6mon-2yrs
main signs: acute onset, long duration
of high fever , 7~ 10days or 2~3weeks
then pelter
Systemic toxic symptoms are obvious
Frequent cough , paroxysmal wheeze,
dyspnea, cyanosis
2.Adenovirus pneumonia
Age: 6mon-2yrs
main signs: acute onset, long duration
of high fever , 7~ 10days or 2~3weeks
then pelter
Systemic toxic symptoms are obvious
Frequent cough , paroxysmal wheeze,
dyspnea, cyanosis
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late appearance of rales(3~7days)
myocarditis, heart failure, and
encephalopathy
X-ray changes early
late appearance of rales(3~7days)
myocarditis, heart failure, and
encephalopathy
X-ray changes early
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右肺中上野散在小灶状浸润阴影。左肺野中外带见大片状融合状阴影。其余肺野含气量增高。
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3.Staphylococcal aureus pneumonia < 1 year are most commonly affected
Acute onset, severe systemic symtoms
High fever, respiratory distress, GI .
Physical examinations: early appearance of rales
Effusion, empyema, pyopneumothorax , abscess of other organs , Sepsis
WBC↑, polymorphonuclear cells ↑
chest x-ray:infiltration, multiple abscesses
3.Staphylococcal aureus pneumonia < 1 year are most commonly affected
Acute onset, severe systemic symtoms
High fever, respiratory distress, GI .
Physical examinations: early appearance of rales
Effusion, empyema, pyopneumothorax , abscess of other organs , Sepsis
WBC↑, polymorphonuclear cells ↑
chest x-ray:infiltration, multiple abscesses
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4. Gram-negative bacillary pneumonia, GNBP
Haemophilus influenza , pneumonia bacilli
severe, hard to treament, poor prognosis
Systemic toxic symptoms , shock
Rales, Infiltration, consolidation, hemorrhagic necrosis
X-ray: lobar, or segmental, effusion, abscess
DIC
4. Gram-negative bacillary pneumonia, GNBP
Haemophilus influenza , pneumonia bacilli
severe, hard to treament, poor prognosis
Systemic toxic symptoms , shock
Rales, Infiltration, consolidation, hemorrhagic necrosis
X-ray: lobar, or segmental, effusion, abscess
DIC
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5. Mycoplasma pneumonia Usually over 5yrs, also infant sore throat, headache, myalgia Mild or moderate fever, 1~3weeks Unproductive cough, wheeze in infant Multiple system damage Auscultation: scattered rhonchi or rales. X-ray: “walking pneumonia”, effusions
5. Mycoplasma pneumonia Usually over 5yrs, also infant sore throat, headache, myalgia Mild or moderate fever, 1~3weeks Unproductive cough, wheeze in infant Multiple system damage Auscultation: scattered rhonchi or rales. X-ray: “walking pneumonia”, effusions
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6. Chlamydial pneumonia (c.Trachomatis)
age: 2~12weeks
Chronic onset, nasal stuffiness, cough,
tachypnea, rales, few wheezes
no fever
Eye sticky
6. Chlamydial pneumonia (c.Trachomatis)
age: 2~12weeks
Chronic onset, nasal stuffiness, cough,
tachypnea, rales, few wheezes
no fever
Eye sticky
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