Case Discussion #4

De Los Reyes, Maalim, Mandal, Sandoval

General Data:

AB, 55 year old female, married, born on February 20, 1966, Roman Catholic,
currently residing in Caloocan City, consulted for the first time in MCU-FDTMF
hospital on January 21, 2020 at 12pm.
History of Present Illness

One month prior to consult the patient developed non-productive,

non-distressing cough accompanied with colds and intermittent low grade fever. No
medications were taken, no consult was done.

3 days prior to consult, her cough became productive with rusty colored sputum
accompanied by high grade fever and shortness of breath.

Persistence of these symptoms prompted consult to our institution.

Past Medical History

● Known diabetic for 10 years, takes of gliclazide

● No known childhood illnesses
● Complete childhood immunization
● No allergies to food or medication
● No past surgeries, hospitalizations or blood transfusions.
Family History

Father and mother has a hx of diabetes.

No other heredofamilial diseases noted such as diabetes, cancer, thyroid, liver,

kidney or hematologic or psychiatric illnesses.
Personal Social History

Patient works as a business woman. Non-smoker, non-alcoholic, denies use of

illicit substances. Lives with her family in apartment with good ventilation. Garbage
is collected daily. Covid-19 is prevalent in their community.
OB-GYNE History

Menarche at 13 with regular interval which last for 5 days. No dysmenorrhea.

Thelarche at 26 years old. G3P3.
Review of Systems

+ generalized body weakness

+ fever
+ fatigue
+ cough
+ difficulty of breathing
+ palpitation
Physical Examination:

General survey: Patient is seen coughing very frequent, is awake, alert and not in
cardiopulmonary distress. Appears ill and uncomfortable. Can maintain eye contact.
No involuntary movements.

Vital signs: BP: 130/90, RR: 25 bpm, PR: 110, Temp: 39.6 0C
Physical Exam:
Skin: Hyperthermic. Dry skin. no cyanosis noted.

Head: No swollen lymph nodes.

Eyes: Unremarkable findings.

Ears: Unremarkable findings.

Nose: No alar flaring. No discharge or tenderness.

Throat: No swollen lymph nodes. No tracheal deviation. No sore throat.

Heart: Tachycardic, others unremarkable.

Lungs: Tachypneic and with labored breathing. Both lungs resonant by percussion,
except for right mid-anterior and right mid-lateral lung fields which are dull.
Bilateral diminished breath sounds on auscultation. Bilateral egophony noted to be
significant especially on right lung fields. Ronchi and late inspiratory crackles in
right mid-anterior and mid-lateral lung field. Remaining lung fields clear with
unremarkable findings.

Abdomen: unremarkable findings

Extremities: No clubbing of fingers noted.

Neurological: No neurological deficits.

Differential Diagnosis:
Rule in Rule out

Bacterial pneumonia High grade fever, cold,

cough, rusty colored
sputum, shortness of
breath,tachypnea,tachycardi
a, diminished breath
sounds,crackles.

COPD cough, fever, shortness of High grade fever, crackles,

breath, diminished breath rusty colored sputum
sounds, crackles

Pulmonary TB fever, cold, cough, Absence of

diminished breath lymphadenopathy, cough
sounds,Rales. less than < 2 weeks, rusty
colored sputum.
Final Impression:

Community-acquired Pneumonia, low-risk

Discussion:
● PNEUMONIA is defined as “inflammation of the lung, in which the air sacs
become filled with inflammatory cells and the lungs become solid”
● A severe form of acute respiratory infection that specifically affects the lungs.

Risk Factors:

● Children (<2y/o)
● Adults (>65y/o)
● With chronic disease
● Smoking
● Immunosuppression or weakened immune system
Stages of Pneumonia:
Consolidation
● Occurs in the first 24 hours
● Cellular exudates containing neutrophils, lymphocytes and fibrin replaces the alveolar air
● Capillaries in the surrounding alveolar walls become congested
● The infections spreads to the hilum and pleura fairly rapidly Pleurisy occurs Marked by
coughing and deep breathing

Red Hepatization
● Occurs in the 2-3 days after consolidation
● At this point the consistency of the lungs resembles that of the liver
● The lungs become hyperemic
● Alveolar capillaries are engorged with blood Fibrinous exudates fill the alveoli
● This stage is "characterized by the presence of many erythrocytes, neutrophils,
desquamated epithelial cells, and fibrin within the alveoli
Stages of Pneumonia:
Grey Hepatization
● Occurs in the 2-3 days after Red Hepatization
● This is an avascular stage
● The lung appears "gray-brown to yellow because of fibrinopurulent exudates, disintegration of
red cells, and hemosiderin“
● The pressure of the exudates in the alveoli causes compression of the capillaries
● Leukocytes migrate into the congested alveoli
Resolution
● This stage is characterized by the "resorption and restoration of the pulmonary architecture"
● A large number of macrophages enter the alveolar spaces
● Phagocytosis of the bacteria-laden leukocytes occurs
● Consolidation tissue re-aerates and the fluid infiltrate causes sputum
● Fibrinous inflammation may extend to and across the pleural space, causing a rub heard by
auscultation, and it may lead to resolution or to organization and pleural adhesions
Classification:
COMMUNITY-ACQUIRED PNEUMONIA

Pneumonia occurring in patients who have not been hospitalized or living in

nursing home during the 2 weeks prior to onset of symptoms

HOSPITAL-ACQUIRED PNEUMONIA

Pneumonia that occurs 48 hours or more after admission and not incubating at

the time of admission

Classification of CAP:
1. Low Risk CAP
● Associated with low morbidity and mortality rate <5%
● Suitable for outpatient care
2. Moderate Risk CAP
● Associated with complicated outcome and higher mortality rate of 21%
● Patients need to be hospitalized for parenteral therapy
3. High Risk CAP
● Patients with impending or frank respiratory failure
● Associated with mortality rate of 36%
 Features Typical Atypical

Presentation Acute Gradual

Cough Productive with purulent or Non-productive

bloody expectoration

Fever + +

Chills + -

Pleuritic pain + -

Systemic complaints - Prominent

WBC Leukocytosis Normal

Chest X-ray Lobar consolidation Ill-defined infiltrates

Pathogen Step Pneumonia, M. pneumoniae, Chlamydia,

Haemophilus influenza, C.
Klebsiella pneumonia burnetti, Viruses
Hospital Acquired Pneumonia:
A. Ventilation-Associated Pneumonia (VAP)

● Pneumonia that arises more than 48 – 72 hours after endotracheal intubation

B. Health Care-Associated Pneumonia (HCAP)

● Pneumonia in a patient:

● Hospitalized in an acute care hospital for 2 or more days within 90 days of infection
● Resided in a nursing home or long term care facility
● Received recent intravenous antibiotic therapy.
● Chemotherapy or wound care within the past 30 days of the current infection
● Attended a hospital or hemodialysis clinic
Diagnostic tests and work-ups:
Chest X-ray
● Gold standard
● Essential in the diagnosis of CAP
● For assessing severity, differentiating pneumonia from other conditions,
prognostication
● PA and lateral view
● Does not predict etiologic agent

Increased vascularity due to pulmonary congestion

● Hyper densities
● Pleural effusion
● Infiltrates
● Atelectasis
Sputum Gram Stain & Culture:

● Strongly influenced by the quality of collection, transport, and processing

● Ensure that the sample is suitable for culture
● >25 neutrophils/LPF
● <10 squamous epithelial cells/LPF

Blood Cultures:
● Should be obtained before the administration of antibiotics
● Used to detect septicemia when it is suspected that infection has spread from
the lungs to the blood or from the blood to the lungs
● 40% sensitivity.
Arterial blood gas – hypoxia and respiratory acidosis may be present

CBC count
● Leukocytosis with a left shift may be observed in any bacterial infection.
● Leukopenia (usually defined as a WBC count < 5000 cells/µL) may be an
ominous clinical sign of impending sepsis.
● evaluates the type and number of white blood cells; results may indicate that an
infection is present

Serum chemistry panel (sodium, potassium, bicarbonate, blood urea nitrogen

[BUN], creatinine, glucose) - help determine the severity of the illness
● AFB staining – to rule out tuberculosis
● Mycoplasma testing —blood test or special culture to help diagnose a
mycoplasma infection
● Legionella testing —blood test for the specific antigen, culture or molecular test
to diagnose a suspected Legionella infection
Management:
Respiratory support
Indicated for patients who have bronchospasm with infection benefit from inhaled
bronchodilators, administered by means of a nebulizer metered-dose inhaler.
Oxygen support, depends on severity of dyspnea and hypoxia

Fluid resuscitation
Patients with hypotension and/or tachycardia may benefit from an intravenous
crystalloid. Many individuals with pneumonia also have volume depletion.
● Immunization
○ PCV13 (pneumococcal conjugate vaccine)
○ PPSV23 (pneumococcal polysaccharide vaccine)
○ Flu vaccine

● Indication
○ Infants as a series of 4 doses, one dose at each of these ages: 2 months, 4
months, 6 months, and 12 through 15 months.
○ All adults 65 years or older
○ Adults 19 years or older with certain health conditions
Thank you!