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USC Case 01: Pneumonia Updated 1/18/2011 Mr.

Regney is a 74 year-old black male who presents with a three-day history of fatigue, myalgia, arthralgia, chills and a fever of 102 to 104. He denies sore throat or cough. His appetite has been poor but he is forcing himself to eat a small amount of soup. He has a history of chronic sinusitis and almost always has a yellowish nasal discharge. He denies nausea or vomiting but had a loose stool this morning. He is noticing night sweats with his fever. He lives with his wife who is well, but his granddaughter, who came to visit a few days ago on Halloween, had a cold. Given this history, what are your working diagnoses and why? The working diagnoses should include: 1. Viral Illness/Influenza: With a history of exposure to a granddaughter with a cold, one should consider viral illnesses. The fact that it is early November (after Halloween), we need to be aware of the beginning season of influenza. Patient's symptoms of myalgia, arthralgia and a fever of 102 to 104 degrees accompanied with chills and sweats is highly suggestive of influenza. 2. Sinusitis: Patient has history of chronic sinus problems now with purulent nasal discharge and a fever can be suggestive of a sinus infection. 3. Occult Infection: Pneumonia, UTI, or pyelonephritis can also cause the symptoms that the patient has. 4. Tuberculosis: With the resurgence of TB, especially in the elderly population, it needs to be included in the differential diagnosis. However, the acute onset of the illness and high fever make TB less likely What other history would be helpful to clarify our thinking? What illness did the granddaughter have and how sick was she? Did she have a mild URI or did she have influenza? What is the health status of the patient? Are there other co-existing medical problems which compromise the patient's immune status (such as COPD, diabetes, chronic renal failure, congestive heart failure, chronic liver disease)? Are the patient's immunizations up to date - specifically has he gotten his flu shots or pneumococcal vaccine?

P=72. respiratory rate. but is non-toxic in appearance.What is the patient's social history . Focus exams would include: HEENT. The granddaughter who visited had a mild URI. RR=16. Nose: slight congestion. He is able to move from the chair to the examining table with some assistance. Has 1-2 drinks a day for many years but does not smoke. blood pressure and pulse. looking specifically at his temperature.specifically does he smoke. appears pale. PAST MEDICAL HISTORY: Hypertension: well controlled Osteoarthritis: stable Chronic Sinusitis: status post two sinus surgeries Barrett's Esophagus: status post esophageal dilatation (1994) PAST SURGICAL HISTORY: Vein stripping in 1960 Right inguinal hernia repaired X2 Sinus surgery X2 MEDICATIONS: Corgard 80mg 1 poq/day Procardia XL 60mg 1 poq/day SOCIAL HISTORY: He is married. and cardiovascular system. On HEENT: his eye exam is normal. does he consume alcohol. nasal mucosa is . patient is alert. 3. Vital signs would be important. Vital signs show a T=99o. lungs. He is retired. Abdominal exam to look for any signs of infectious processes in the abdomen. Is he comfortable and relaxed or does he look distressed and toxic in appearance? 2. Ear: normal tympanic membrane with normal landmarks and reflexes. BP=122/72. neck. The general appearance of the patient would be very important. One should also check for CVA tenderness (Lloyd’s punch) to test for pyelonephritis. does he eat a balanced diet? All of these can contribute to how well he fights off infection. Osteopathic Structural findings PHYSICAL EXAM: On exam. What data would be important to gather in your physical exam? 1. Works as a bartender part-time. with two grown children.

Examination of the facial bones was normal with no tenderness. chronic liver diseases. no murmur or gallop noted. functional or anatomic asplenia (e. What is your most likely diagnosis at this time? 1. diabetes mellitus. non-tender. Routine use of PPSV is not recommended for American Indians/Alaska Natives or persons aged <65 years unless they have underlying medical conditions . Extremities: no edema tenderness or cyanosis noted. The best treatment for them is prevention through annual administration of trivalent influenzae vaccine and the Polyvalent Pneumococcal vaccine. chronic alcoholism. What immunization history is important in this patient? Patients in this age group are especially at risk for influenza and pneumococcal pneumonia with high morbidity and mortality. CDC Guidelines: 2011 Updated Pneumococcal polysaccharide (PPSV) vaccination Vaccinate all persons with the following indications.. Thoracic Somatic Dysfunction * Even though patient reports drinking 1-2 drinks a day. immunocompromising conditions including chronic renal failure or nephrotic syndrome. Viral Illness/Influenza: Giving the history and the benign exam.g. normal S1-S2.somewhat boggy with a small amount of yellowish discharge. Throat: normal. liver and spleen are benign. vaccinate at least 2 weeks before surgery]). Lungs: clear to auscultation and percussion. sickle cell disease or splenectomy [if elective splenectomy is planned. alcoholics are more at risk for serious illness. There is TART findings at T1-T5. * 2. 3. one needs to be aware of alcohol abuse with his occupation as a bartender. normal bowel sounds. It is a bit early for influenza given that this is only in the early part of November. and cochlear implants and cerebrospinal fluid leaks. There is no CVA tenderness noted. Chronic Sinusitis: It is doubtful that this is contributing to the patient's acute illness. Medical: Chronic lung disease (including asthma). chronic cardiovascular diseases. Abdomen: soft. the most likely diagnosis at this time are viral illness and possibly influenza. Other: Residents of nursing homes or long-term care facilities and persons who smoke cigarettes. as alcohol abuse impairs the immune system. Neck: supple. Vaccinate as close to HIV diagnosis as possible. cirrhosis. with a few small cervical nodes. Cardiac exam: regular rhythm.

g. However. public health authorities may consider recommending PPSV for American Indians/Alaska Natives and persons aged 50 through 64 years who are living in areas where the risk for invasive pneumococcal disease is increased Revaccination with PPSV One-time revaccination after 5 years is recommended for persons with chronic renal failure or nephrotic syndrome.that are PPSV indications.. 2. one-time revaccination is recommended if they were vaccinated ≥5 years previously and were younger than aged <65 years at the time of primary vaccination Indications for Influenza Vaccine: Updated 1/2011 per the CDC Who should get the inactivated influenza vaccine? CDC: 2010-2011: All people 6 months of age and older should get the flu vaccine. Pregnant women should not receive the live Flu Mist vaccine: but they should receive the inactivated vaccine. This year the one vaccine covers H1N1 and 2 other influenza viruses. People who have had an allergic reaction to previous Flu vaccines. 3. People who are allergic to chicken or eggs. functional or anatomic asplenia (e. and for persons with immunocompromising conditions. As last year 2 shots were needed for both. . 4. vs. For persons aged ≥65 years. past years had specific criteria. Contraindications for Influenza Vaccine 1. sickle cell disease or splenectomy). Guillain-Barre’ syndrome within 6 weeks following a previous dose of influenza vaccine is a precaution for vaccination. New recommendation.

What are your working diagnoses now? 1. Regney reported that he still has the same symptoms of myalgia. . chills and anorexia. no murmur or gallop. Bacterial pneumonia is also a high possibility in that a secondary bacterial infection is common after a viral illness. abdominal pain. 2. Neck: supple without masses. Vital signs are a T= 98. He denies exposure to tuberculosis. He was advised to call you if his symptoms are not better in a couple of days. You also performed OMT to his Thoracic spine using muscle energy technique. patient's wife called to report that Mr. Sinusitis: is lower in the differential at this time. 3. He has no back pain or chest pain. Since yesterday he has been very fatigued and spends most of the day in bed.8. He denies vomiting. Abdomen: soft and non-tender. Even though the patient's lung exam has been clear. this differential is less likely. He is taking Tylenol alternating with Advil for his fever. normal S1-S2. He had lost 10 pounds in one week because of his anorexia and mild nausea. Cardiac exam: regular rhythm. arthralgia. liver and spleen are benign. Bacterial Endocarditis: without a history of precipitating events such as dental work or abnormal valvular disease. Regney is not better and continues to have a temperature of 102 to 104. On exam. Mrs. His HEENT exam is unremarkable except that his lip is somewhat bluish in color. Influenza: patient's symptoms and persisting fever is still consistent of influenza. Lungs: clear to auscultation. P=85 and a RR=16. In your office. Pneumonia: viral pneumonia is certainly can be a complication of influenzae or other viral illness. Minor illnesses with or without fever DO NOT contraindicate use of influenza vaccine You decided that the most likely diagnosis for this patient is viral illness and advised the patient to rest and take Tylenol as needed for the fever. he is alert and appears weak. but is in no acute distress. Since his last visit he developed a slight cough which is productive of yellowish sputum. fever. Three days later. You advised the patient to be seen the same day. BP=110/60. 4. tenderness or cyanosis.5. or dysuria. TART findings have returned at T1-T5 levels. Extremities: no edema. he may well have pneumonia since the elderly patients may often have atypical presentation of pneumonia and may not have rhonchus or crepitus in their lung exam.

00 36.00 38.00 56. Each test should be ordered with a specific question in mind.00 20.00 19.e.00 39.00 29.00 15.00 25.00 451.00 49. Diagnostic Work-up Select from the following menu the diagnostic test(s) you think are appropriate.5.00 40. avoid a "shotgun" approach].00 59.00 170.00 39.00 150.00 68. [i.) Lab Test Acid phosphatase Amylase Blood Culture BUN and Creatinine CBC w/ Differential Chest X-ray PA & Lateral Unenhanced CT of the Chest Enhanced CT of the Chest EKG Sed Rate Fasting Glucose GGT TB Skin Test Liver panel Lumbar plain film series (AP/Lateral/Oblique) Platelet Count PSA Psychiatric Consult Renal Ultrasound Serum Calcium and Phosphates Serum Electrolytes Serum Protein Electrophoresis Serum Total Protein and Albumin Serum Uric Acid Sinus X-ray Sputum C&S Thyroid Profile (T3) TSH Cost 27.00 19. (You should order these diagnostic studies necessary to evaluate your working diagnosis/diagnoses.00 57.00 679.00 200. Somatic Dysfunction: the patient continues to present with TART findings suggestive of viscerosomatic reflex from his infection.00 13.00 41.00 . Calculate the cost of your workup.00 753.00 47.00 143.00 11.

00 32.U/S of abdomen Urinalysis (dipstick and micro) What are your working diagnoses now? Pneumonia What are the common pathogens causing communityacquired pneumonia? 413.00 Table C: Common Pathogens causing Pneumonia in Adults Community-Acquired Streptococcus Pneumoniae * Mycoplasma pneumoniae * Group A beta-hemolytic Streptococcus Haemophilus influenzae* Staphylococcus aureus * Moraxella catarrhalis @ Klebsiella pneumonia * Pseudomonas aeruginosa * Mixed Anaerobes (aspiration) * Legionella pneumophila Pneumocystis carinii Chlamydia psittaci Chlamydia pneumoniae * Viral agents* Influenza A virus* Hospital-Acquired Klebsiella pneumoniae * Pseudomonas aeruginosa * Other gram-negative aerobes * Staphylococcus aureus * Streptococcus pneumoniae Anaerobes Legionella pneumophila Fungus (Aspergillus) * Most common @= Uncommon What features are important to keep in mind when considering pneumonia in the elderly? Table D: Features to consider in Elderly Patients with Pneumonia Organisms • Similar to those in younger adults .

. relapse of congestive heart failure) Gait disturbance and falls Examination • • • • • • Often lack fever Increased respiratory rate (may be early clue) Tachycardia Auscultation unremarkable (i.. diabetes mellitus out of control.g.e.e.. sputum production and fever Change in mental status common (new or worsening confusion) General decline in functional status Deterioration of previously stable condition (e. rales present in premorbid state for other reasons Dehydration common White blood cell count and chest x-ray initially normal Difficult differential diagnoses • • • • • Congestive heart failure Atelectasis Pulmonary embolus Pneumonia Chemical pneumonitis (gastric aspiration) .• • • Gram-negative aerobes and Staphylococcus aureus more prevalent May have mixed causes At risk for influenza Often insidious Onset: Presentation • • • • • Often lack of cough. normal) or not helpful (i.

o If out patient with comorbidites: oral ciprofloxacin (Cipro). Your first clue may be mental status changes or just a general decline in their functional status. If Legionella pneumophila is suspected. Unipen) should be used. Comorbidities vs. cefazolin (Ancef. Antibiotic dosage usually lowered Drug interactions and polypharmacy to be considered Prevention • • • • • Pneumococcal vaccination Annual influenza vaccination Limit use of drugs that impair swallowing Regular dental care If Staphylococcus aureus is suspected. Regney need hospitalization? What factors influence the decision to hospitalize the patient? . Table D delineates this in more detail: Does Mr. Empiric therapy for community-acquired pneumonia: Hospitalized. Hence. Regney's case. They may not even have a fever. Often there is lack of cough and sputum production. However. • • • • • • Community Acquired Out Patient: No comorbidities: zithromax. or cefuroxime (Ceftin) are possible alternatives Remember to discuss black box warning of quinolones. Levaquin. Kefzol) and vancomycin (Vancocin) are alternatives. Elderly patients often present with pneumonia in an atypical fashion.Treatment: Sanford is the most up to date and comprehensive reference. As in Mr. biaxin. high index of suspicion and prevention is the best treatment. the morbidity and mortality rate of elderly with pneumonia is much higher than the younger population. lung exam may not reveal rales and crackles and CBC may not show leukocytosis. erythromycin should be added. Don’t forget Allergies.generation cephalosporin or quinolones Empiric therapy for hospital-acquired pneumonia-parenteral AntiPseudomonas penicillin and an aminoglycoside: depends on local resistance also. inpatient. None.parenteral second-or third. or doxyxcycline. amoxicillin-clavulanate potassium (Augmentin). Always check the most up to date and local resistance is important: Out patient vs. nafcillin (Nafcil.

There are a number of risk factors which have been associated with complication and mortality in patient with community acquired pneumonia.There are no firm guidelines for when to hospitalize a patient. hospitalization should be considered. Advanced age and co morbid conditions are the two most important factors that predict a complicated course of the disease. Table E: Risk Factors that Increase Mortality and Complications Age > 65 Years Presence of coexisting illness • • • • • Chronic obstructive airway disease Diabetes mellitus Chronic liver disease of any etiology Chronic renal failure Congestive heart failure Other findings • • • • • Hospitalization within the last year Suspicion of aspiration (gastric or Oropharyngeal secretions) Chronic alcohol abuse or malnutrion Altered mental status Postsplenectomy state Table F: Physical Findings Predictive of a Complicated Course • • • • • Respiratory rate above 30 breaths per minute Diastolic blood pressure less than or equal 60 mm Hg or systolic blood pressure less than or equal to 90 mm Hg Fever greater than 101 º F Evidence of confusion Signs of extra pulmonary dissemination of infection Table G: Laboratory Findings Predictive of a Complicated Course • PaO2 less than 60 mm Hg or PaCO2 of greater than 50 mm Hg on room air . Ultimately. When multiple risk factors are present. it will be the individual physician's decision with input from the patient and family.

Regney requests that the patient be hospitalized.• • • • • White blood cell count less than 4 x 10 º /L or greater than 30 x 10 º /L Abnormal renal function with BUN greater than 20 mg/dL Need for mechanical ventilation Rapidly progressive chest radiographic abnormalities Sepsis or sepsis syndrome (Adapted from the American Thoracic Society) Mrs. weight loss of 10 pounds. O2 saturation should be checked as the patient may need O2 supplementation. With the suggestion of cyanosis of his lip. and high fever all support significant illness. Regney was admitted to the hospital for further evaluation and treatment. His age of 74. significant fatigue. . Mr.