CPT CASE 4 PNEUMONIA

PNEUMONIA
BASIS OF THE DIAGNOSIS
I. Clinical Scenario
II. Pneumonia - Productive cough with rust-colored sputum
III. COPD
- Moderate to high grade fevers with chills
IV. Drug-induced Gastritis
- Chest pain
V. Alcohol Withdrawal Syndrome
- Vitals: tachycardia, tachypneic, fever
- Chest and lung findings: bi-basal rales and rhonchi, dullness
on the right lower lung field
CLINICAL SCENARIO - Chest X-ray: Right lower lobe consolidation
- Increased values of laboratory Findings
– FDM, male, 57 year old
– Fever, severe right-sided chest pain and difficulty of breath
ETIOPATHOGENESIS
– 2 days PTA: productive cough with rust-colored sputum, fever
until few hours
– Few Hours PTA: Increasing malaise, fever with chills, epigastric - Lower respiratory tract infection (pulmonary parenchyma)
pain described as burning aggravated by intake of prednisone acquired in the community within 24 hours to less than 2
weeks
Past Medical History - Results from the proliferation of microbial pathogens at the
– Long history of COPD with 2 inhalers, alveolar level and the host’s response to those pathogens
o metaproterenol 2-4 puffs PRN and - Most common access of microorganisms to the lower
o ipratonium 2-4 puffs PRN, respiratory tract is through aspiration from the oropharynx
– with prednisone 30mg PO daily tablet 2 months ago - Classic pneumonia (lobar pneumococcal) evolves through a
– Phenytoin 400 mg PO HS due to Alcohol Withdrawal Seizure series of changes

Personal and Social History PHASE DESCRIPTION

– Smoker for 25 years Edema - Initial phase with the presence of a proteinaceous
– Alcohol abuser (stopped with rehab 1 year ago) exudate and often of bacteria in the alveoli
– Allergic to Ampicillin Red - Erythrocytes in the cellular intraalveolar exudate
Hepatization - Neutrophil influx is more important from the
General survey: Diaphoretic, agitated, weak looking and in CR distress standpoint of host defense
Vital Signs: - Bacteria are occasionally seen in pathologic
BP: 140/90 mmHg RR: 35/min T: 39.5C HR: 125/min specimens
Weight: 65 kg; Height: 163 cm BMI 24.46 (OVERWEIGHT) Gray - No new erythrocytes are extravasating and those
Hepatization already present have been lysed and degraded
Physical Exam - The neutrophilis the predominant cell, fibrin
– CVS- tachycardia, regular rhythm deposition is abundant and bacteria have
– Chest and Lungs: prolonged expiratory phase, bi-basal rales and disappeared
rhonchi, dullness on the right lower lung field - This phase corresponds with successful containment
– GIT: (+) epigastric tenderness of the infection and improvement in gas exchange
– Neurologic: lethargic Resolution - Macrophage reappears as the dominant cell type in
(Final Phase) the alveolar space and the debris of neutrophils,
LAB TESTS VALUE NORMAL (IM PLAT) bacteria and fibrin has been cleared, as has the
↑ HCO3 33mEq/L (33mmol/L) 22-28 mEq/L inflammatory response
↑ BUN 59 (21) 7-17 mg/dL
↑ Creatinine 106.1 (1.2) 0.52-1.0 mg/dL CLINICAL MANIFESTATIONS
↑ Phenytoin 59.4mg/dL(15mcg/L) 10-20 mcg/L - Commonly presents with acute cough, abnormal vital signs of
↑ WBC 18.6 x 10ˆ9 4.5-11 x109/L tachypnea, tachycardia, and fever with at least one abnormal
RBC 4.5 x 10ˆ9 4.5-5.5 chest finding of diminished breath sounds, rhonchi, crackles or
↑ Hct 0.49 0.38-0.47 wheezes
↑ Hgb 180 12.0-16.0 g/dL
NOTES:
↑ PMN 0.88 0.40-0.75
– Review Classification per Etiology
↑ Leukocytes 0.22 0.20-0.40
o CAP, HAP, VAP
ABG Respiratory Acidosis
Partially compensated
- PO2 70 75-100
- PCO2 47 35-45
- pH 7.3 7.35-7.45
Peak Flow
- FEV1 60% (pre-B2-agonist)
- FEV1/FVC 70% (post-B2-Agonist)
Sputum Gram’s stain >50 leukocytes/hpf, 0-5 epithelial cells/hpf,
gram(+) cocci in pairs- many
GUIAC TEST Positive
Chest Xray Right lower lobe consolidation

WHISKY CPT CASE 4: PNEUMONIA CPT 1 | 7

 CLASSIFICATION AND DISPOSITION THERAPEUTIC OBJECTIVES

LOW-RISK CAP MODERATE-RISK HIGH-RISK – Stabilize the patients vitals

CAP CAP – To administer proper antimicrobial therapy for the patient
Vital Signs - Stable - Unstable - Any of the – Eradicate the causative pathogens
- RR <30/min - RR > 30/min criteria – Resolving the clinical signs and symptoms
- PR <125bpm - PR >125bpm under – Minimize hospitalization
- Temp 36-40C - Temp > 40C or Moderate – To prevent further complications of the disease
- BP > <36C Risk CAP, – Decrease mortality
90/60mmHg - BP < 90/60 plus:
mm/Hg NON-PHARMACOLOGICAL THERAPY
Features - No altered - Altered mental - Severe
mental state of state of acute sepsis and – Adequate hydration
acute onset onset septic shock – Oxygen therapy for hypoxemia
- No suspected - Suspected - Need for – Assisted ventilation when necessary are critical to successful
aspiration aspiration mechanical treatment
- No or stable - Decompensated ventilation – Adequate nutrition
comorbids co-morbidities – Smoking cessation
Chest X- - Localized - Multilobar – IMMUNIZATION
Ray infiltrates infiltrates
- No pleural - Pleural effusion MANAGEMENT
effusion - Abscess
- No abscess – For patients requiring hospitalization, empiric therapy should
Disposition - outpatient - ward admission - ICU be initiated as soon as possible after a diagnosis

Patient is classified as MODERATE RISK CAP: RISK POTENTIAL PATHOGENS EMPIRIC THERAPY
– Unstable vital signs Low-Risk Streptococcus pneumoniae Previously healthy:
– Altered mental state CAP Haemophilus influenza Amoxicillin or extended macrolides
– Uncompensated COPD Chlamydphila pneumoniae (suspected atypical pathogen)
Mycoplasma pneumoniae
DIAGNOSTICS OF CAP Moraxella catarrhalis With stable comorbid illness:
Enteric Gram-negative β-lactam / β-lactamase inhibitor
bacilli combination (BLIC) or second-
DIAGNOSTICS COMMENTS generation oral cephalosporin +
(among those with co-
Chest Radiography - Essential in the diagnosis of CAP, assessing extended macrolides
morbids)
severity, differentiating pneumonia from other
conditions and in prognostication Alternative:
- Best radiologic evaluation consists of standing 3rd-generation oral cephalosporin
posterioanterior and lateral views of the chest + extended macrolide
- Does not predict the likely etiologic agent Moderate Streptococcus pneumoniae IV non-antipseudomonal β-lactam
Sputum Gram Stain - Strongly influenced by the quality of collection, -Risk CAP Haemophilus influenza (BLIC, cephalosporin or
and Culture transport, and processing Chlamydphila pneumoniae carbapenem)
- Main purpose of gram stain is to ensure that a Mycoplasma pneumoniae + extended macrolide
sample is suitable for culture – an adequate Moraxella catarrhalis OR
sputum sample must have: Enteric Gram-negative
- >25 neutrophils/LPF bacilli; Legionella IV non-antipseudomonal β-lactam
- <10 squamous epithelial cells/LPF pneumophila; Anaerobes +IV extended macrolide or IV
Blood Culture - Yield is relatively low, therefore it is optional for (risk of aspiration) respiratory FQ
hospitalized patients High-Risk Streptococcus pneumoniae No risk for P. aeruginosa:
- Most common isolate: S. pneumonia CAP Haemophilus influenza
- Strongest indication for blood cultures: severe Chlamydphila pneumoniae IV non-antipseudomonal β-lactam
CAP (more likely to be infected with S.aureus, Mycoplasma pneumoniae +IV extended macrolide or IV
P.aeruginosa, other gram negative bacilli) Moraxella catarrhalis respiratory FQ
Invasive Procedures - Options for non-resolving pneumonia, Enteric Gram-negative With risk for P. aeruginosa:
(e.g., transtracheal, immunocompromised patients and in whom no bacilli
transthoracic, biopsy, adequate respiratory specimens can be sent Legionella pneumophila IV antipneumococcal
bronchoalveolar despite sputum induction and routine diagnostic Anaerobes (risk of antipseudomonal β-lactam + IV
lavage, protected testing aspiration) extended macrolide +
brush specimen) Staphylococcus aureus aminoglycoside
Pseudomonas aeruginosa OR
Pneumonia Risk Score (CURB-65): predicts mortality in CAP IV antipneumococal
antipseudomonal β-lactam + IV
C - Confusion of new onset - Interpretation: ciprofloxacin/levofloxacin (high-
U - Urea (BUN) ≥ 7mmol/L (19mg/dL) - 0-1: out-patient dose)
R - RR ≥30 breaths per minute - 2: admit
B - BP <90/60 - ≥3: consider ICU
65 - Age ≥ 65 years old

WHISKY CPT CASE 4: PNEUMONIA CPT 2 | 7

Common Antibiotics Used in CAP
COPD
GROUP COMMON ANTIBIOTICS
Extended macrolides - azithromycin dehydrate 500 mg OD PO or IV BASIS OF THE DIAGNOSIS
- clarithromycin 500 mg BID PO or IV
Oral β-lactam/β- - Amoxicillin-clavulanic acid 1g BID PO – Productive cough
lactamase inhibitor - Sulatamicillin 750 mg BID PO – Difficulty of breathing
(BLIC) - amoxicillin-sulbactam – Patient has long history of COPD
Oral second- - Cefuroxime axetil 500 mg BID PO – Patient is a smoker for 25 years
generation - cefaclor – General survey: Patient in cardiorespiratory distress
cephalosporin – Chest and lungs: Prolonged expiratory and ronchi is heard
Oral third-generation - cefdinir, cefixime, cefpodoxime proxetil upon auscultation
cephalosporin – Intake of Metaproterenol, Ipratropium Br, prednisone
IV non- - ampicillin-sulbactam 1.5g q6 IV
antipseudomonal β- - Cefuroxime 1.5g q8 IV ETIOPATHOGENESIS
lactam (BLIC, - Ceftriaxone 2g OD IV
cephalosporin or - Ertapenem 1g OD IV – Characterized by expiratory airflow limitation that is not fully
carbapenem) reversible (hallmark: airflow obstruction)
Repiratory - Levofloxacin 500-750mg OD PO or IV – Unusual in the absence of smoking or prior history of smoking,
Fluoroquinolones - Moxifloxacin 400mg OD PO or IV except for patients with A1-antitrypsin deficiency
IV antipneumococal, - Piperacillin-tazobactam 4.5g q6 IV – Elastase-Antielastase Hypothesis: remains a prevailing
antipseudomonal β- - Cefepime 2g q8-12 IV mechanism for its pathophysiology
lactam (BLIC, - Meropenem 1g q8 IV – Smoking tobacco is the main risk exposure for COPD
cephalosporin or
carbapenem) A. The Pathological Changes include:
Aminoglycosides - Gentamicin 3 mg/kg OD IV - Chronic inflammation
- Amikacin 15 mg/kg OD IV - Increased numbers of specific inflammatory cell types in
different parts of the lung
Duration of Treatment - Structural changes resulting from repeated injury and repair

ETIOLOGIC ORGANISMS DURATION OF TREATMENT B. Encompasses the Following Conditions:

Most Bacterial - 5-7 days (3-5 for azalides for S. - Emphysema: anatomically-defined condition characterized by
Pneumonias pneumoniae) enlargement and destruction of alveoli “pink puffers”)
Enteric Gram negative - Chronic bronchitis: clinical condition characterized by chronic
pathogens, S. aureus, cough and phlegm (“blue bloaters”)
P.aeruginosa - Small airways disease: condition where bronchioles are
- MSSA-CAP - 7-14 days (up to 21 days if bacterimic) narrowed
- MRSA-CAP - 7-21 days (up to 28 days if bacterimic)
- P.aeruginosa - 14-21 days (up to 28 days if bacterimic) CLINICAL MANIFESTATION
Mycoplasma and - 10-14 days
Chlamydophila CARDINAL SYMPTOMS SIGNS
Legionella - 14-21 days (10 for azalides) Most common: - May be normal in early stages
Cough, - Pink puffers (predominantly emphysema):
Discharge Criteria sputum production, thin, non-cyanotic, prominent use of
During 24 hours before discharge, the patient should have: exertional dyspnea accessory muscles
– Temperature of 36-27.5 deg C - Blue bloaters (predominantly chronic
– Pulse <100/min COPD may be punctuated bronchitis): heavy and cyanotic
– RR between 16-24/min by exacerbations (acute - “Tripod position”: to facilitate use of
– SBP >90 mmHg worsening of symptoms) accessory muscles
– Blood O2 saturation >90% - Signs of hyperinflation: barrel chest,
– Functioning GI tract (allowing use of oral antibiotics) enlarged lung volumes on percussion
(hyperresonance)
- Others: pursed-lip breathing, expiratory
DRUG OF CHOICE wheezing, systemic wasting, weight loss
- Signs of cor pulmonale (bipedal edema,
ascites) in severe cases
– Cephalosporin + Macrolide
- Clubbing is not a sign of COPD
– Cephalosporin + Respiratory quinolone

ROUTE OF ADMIN: DIAGNOSIS

– Cephalosporin: Ceftriaxone – IV
– Macrolide: Azithromycin – Oral - A clinical diagnosis of COPD should be considered in any patient
who has dyspnea, chronic cough or sputum production, and a
history of exposure to risk factors for the disease
- Risk factors: tobacco smoke (including popular local
preparations), smoke from home cooking and heating fuels,
occupational dusts and chemical

WHISKY CPT CASE 4: PNEUMONIA CPT 3 | 7

DIAGNOSTIC COMMENTS/EXPECTED FINDINGS Classification Based on Exacerbation
TEST - Exacerbation of COPD: defined as an acute event characterized by
Spirometry - Required to make the diagnosis worsening of the patient’s respiratory symptoms that is beyond
- Post-bronchodilator FEV1/FVC <0.70 confirms presence of normal day-to-day variations and leads to a change in medication
persistent airflow limitation - Best predictor of having frequent exacerbations (2 or more per year)
- FEV1, FEV1/FVC and all other measures of expiratory is a history of previously treated events
airflow are reduced
- TLC, FRC and RV may be increased indicating air trapping Modified Medical Research Council (mMMRC) Questionnaire for
- DLCO may be reduced
Assessing the Severity of Breathlessness
Chest - Useful for excluding other differential diagnoses
radiograph - Low flattened diaphragms
mMMRC DESCRIPTION
- Increase in the volume of retrosternal airspace
0 I only get breathless with strenuous exercise
(hyperinflation)
- Hyperlucent lung zones with possible bullae formation 1 I get short of breath when hurrying of the level or walking up a
and diminished vascular markings slight hill
CT scan - Not routinely requested 2 I walk slower than people of the same age on the level because of
- May be helpful when the diagnosis is in doubt to rule out breathlessness, or I stop for breath when walking on my own
concomitant diseases pace on the level
- Useful if surgical procedure such as lung volume reduction 3 I stop for breath after walking 100 meters or after a few minutes
is contemplated on the level
Pulse - To evaluate a patient’s oxygen saturation and need for 4 I am too breathless or I am breathless when I’m dressing or
oximetry supplemental oxygen therapy undressing
- Should be used to assess all stable patients with
FEV1<35% predicted or with clinical signs suggestive of THERAPEUTIC OBJECTIVES
respiratory failure or right heart failure
- If peripheral saturation is <92%, ABGs should be assessed Reduce symptoms:
Arterial - Resting or exertional hypoxemia - Relieve symptoms
blood gas - Increased alveolar-arterial oxygen tension gradient - Improve exercise tolerance
(ABG) - In long-standing disease, may have chronically increased - Improve health status
arterial PaCO2 but metabolic compensation (increased
Reduce risk:
HCO3) maintains pH near normal
- Prevent disease progression
- Prevent and treat exacerbations
CLASSIFICATION OF COPD - Reduce mortality

Classification based on Severity of Airflow Limitation in COPD using NON-PHARMACOLOGICAL THERAPY

Spirometry (Post-Bronchodilator FEV1)
Spirometry should be performed after the administration of an adequate
Smoking - Biggest impact in the natural history of COPD
dose of a short-acting inhaled bronchodilator (to minimize variability) Cessation - Nicotine replacement therapy (gum, inhaler, nasal
spray, transdermal patch) reliably increases long term
SPIROMETRY FINDINGS smoking abstinence rates
STAGE CLINICAL FINDINGS
FEV1/FVC FEV1 - Brief (3-minute) period of counseling to urge a
- Chronic cough and sputum smoker to quit results in smoking cessation rates of 5-
GOLD 1 production ≥ 80% 10% or enrolment in a smoking cessation program as
Mild - Patient unaware that lung predicted part of intervention
function is abnormal - Varenicline, bupropion, and nortriptyline: increases
- Chronic cough and sputum long-term quit rates, but should be used as part of a
production program
GOLD 2 - Shortness of breath on 50 – <80% - E-cigarettes as a smoking cessation aid: uncertain
Moderate exertion Post- predicted benefit at present
- Stage patients typically seek bronchodilator Oxygen Therapy - Only pharmacologic therapy demonstrated to
medical attention FEV1 / FVC unequivocally decrease mortality rates in COPD
- Greater shortness of breath <0.70 - For chronically hypoxemic patients
GOLD 3 - Reduced exercise capacity 30 – <50% - >15 hours / day (long term oxygen therapy)
Severe - Fatigue predicted Lung Volume - Segmentectomy or lobectomy of focal
- Repeated exacerbations Reduction Surgery emphysematous areas of the lung
- Signs or symptoms of
GOLD 4
respiratory failure (PaO2< 60 <30%
Very
mmHg + PaCO2>50 mmHg) predicted
Severe
- Cor pulmonale

GROUP SPIROMETRIC EXACERBATIONS

CLASSIFICATION PER YEAR
A Low exacerbation risk GOLD 1-2 ≤1
Less symptom severity
B Low exacerbation risk GOLD 1-2 ≤1
More symptom severity
C Low exacerbation risk GOLD 3-4 ≥2
Less symptom severity
D Low exacerbation risk GOLD 3-4 ≥2
More symptom severity

WHISKY CPT CASE 4: PNEUMONIA CPT 4 | 7

 PHARMACOLOGICAL THERAPY MANAGEMENT OF STABLE COPD

- None of the existing medications for COPD have been shown to Non-Pharmacologic Management of COPD
modify the long-term decline in lung function
- Bronchodilator medications are central to the symptomatic GRP ESSENTIAL RECOMMENDED DEPENDING ON
management of COPD (principal bronchodilator treatment includes LOCAL GUIDELINE
B2-agonists, anticholinergics and methylxanthines) A Smoking cessation Physical activity Flu vaccination
B-D Smoking cessation Pneumococcal
MEDICATIONS COMMENTS ADVERSE EFFECTS Pulmonary rehabilitation vaccination
Beta2 – Agonists - Alters airway smooth - Sinus tachycardia
muscle tone improving - Arrhythmias Pharmacologic Management of COPD
Short acting: emptying of the lungs - Tremors
Salbutamol - Effects usually wear off - Hypokalemia GRP Preferred Next Step if no Other Possible
Terbutaline within 4-6 hours (short Treatment improvement Treatment
acting) and >12 hours (long A Any Continue, stop or try Antioxidant
Long acting: acting) bronchodilator alternative class of mucolytics
Formoterol - Regular treatment with bronchodilator
Salmeterol LABA is more effective and B Start with LAMA LAMA + LABA if no Plus SAMA, SABA
Vilanterol convenient than treatment or LABA improvement
Olodaterol with SABA C Start with LAMA Use LAMA + LABA if Plus SAMA, SABA
Indacaterol - Appears to provide with further
subjective benefit in acute exacerbations
episodes but is not Alternative: LABA + ICS
necessarily helpful in stable D LAMA + LABA LAMA + LABA + ICS Plus SAMA, SABA
disease Alternative: try LABA + Consider PDE-4 inh if
ICS before going to FEV1 <50% predicted
Anticholinergics - Blocks acetylcholine’s effect - Dryness of the mouth triple therapy and patient has
(antimuscarinics) on muscarinic receptors - Bitter metallic taste chronic bronchitis
- Bronchodilating effects of - Arrhythmias Consider macrolide
Short acting: short-acting inhaled (in former smokers)
Ipratropium Br anticholinergics lasts longer
Oxitropium Br than that of short-acting
B2-agonists
OTHER NOTES:
Long Acting:
Tiotropium
- routine use of antibiotics during exacerbation of COPD because
Ulmeclidinium it frequently involves bacterial infection of the lower airways
Glycopyrronium o used in COPD with increased dyspnea, sputum
volume and purulence
Methylxanthines - Acts as nonselective - Tachycardia - Use for the relief of acute symptoms of COPD:
phosphodiesterase - Arrhythmias o Inhalation of SABA
Theophylline inhibitor - Seizures o Inhalation of anticholinergic drug
Aminophylline - Improves FEV1 and - Headaches - Bronchodilators are the mainstay treatment for symptomatic
Doxofylline breathlessness when added - Insomnia COPD
to salmeterol - Inflammation pays a key role in the pathophysiology of COPD
but use of and response to anti-inflammatory medications are
Inhaled - Addition of ICS to - Hoarseness different with that of asthma
corticosteroids bronchodilator treatment - Oral candidiasis
appropriate for:
Beclomethasone - Symptomatic patients
Budesonide with FEV1<50%
Mometasone predicted (Stages III, IV)
Fluticasone - Repeated
exacerbations
- Chronic treatment with
systemic glucocorticoids
should be avoided
- ICS combined with LABA in
moderate to severe COPD is
more effective than either
component alone

PDE-4 inhibitors - Improves lung function and - Anorexia

reduces moderate and - Weight loss
Roflumilast severe exacerbations in - Diarrhea
patients with chronic - headache
bronchitis or those who are
in fixed-dose LABA/ICS
combination

WHISKY CPT CASE 4: PNEUMONIA CPT 5 | 7

 PHARMACOLOGICAL THERAPY
DRUG-INDUCED GASTRITIS
I. ANTACIDS
BASIS OF THE DIAGNOSIS a. Neutralising buffering capacity of 2 hrs
b. Best given 1 hr after meals and at bedtime
- 2 days PTA, patient experienced epigastric pain described as c. AlOH, MgOH, NaHCO3, CaCO3
burning, aggravated by intake of prednisone (oral)
- Patient has long history of COPD and was prescribed with II. ACID SECRETORY INHIBITORS
prednisone 30 mg PO daily tablet 2 months ago a. PPI
- Smoker, Alcoholic drinker i. 24 hrs gastric acid inhibition
- Diaphoretic, tachycardic ii. Full acid inhibiting effect - 3 days
- GIT: (+) epigastric tenderness iii. Omeprazole, Pantoprazole, Rebeprazole,
Lansoprazole, Esomeprazole
THERAPEUTIC OBJECTIVES
b. H2RA
- To provide relief to patient signs and symptoms i. Blocks histamine receptors at parietal cells -
- To prescribe the patient with most effective, most suitable, reduce acid secretion
safest drug and cost-effective treatment for drug-induced ii. Cimetidine (CYP450 inhibitor), Ranitidine
gastritis (less CYP450 inhibitor), Famotidine,
- To provide a dietary and lifestyle management appropriate to Nizatidine
his diagnosis upon discharge
- To develop an appropriate monitoring and follow up plan for c. Antimuscarinics
his condition i. Decrease gastric acid secretion but also
- To treat drug-induced gastritis without the cessation of decrease mucus and bicarbonate secretion
causative drug ii. Pirenzipine, Telenzipine
- To potentiate mucosal defense mechanism and repair gastric
injury; and III. LOCAL MUCOSAL PROTECTIVE AGENTS
- To prevent further complications such as gastric ulceration or a. PG Analog
bleeding i. Misoprostol
ii. PGE1 analog that exogenously replaces PG
stores (PGE1 and PGE2)
NON-PHARMACOLOGICAL THERAPY
iii. Prevent NSAID induced ulcers
iv. Abortifacient
- Surgical treatment was originally designed to decrease gastric acid b. Sucralfate
secretion c. Carbenoxolone
- Vagotomy is a component of each of these procedures and is aimed d. Bismuth
at decreasing acid secretion through ablating cholinergic input to the
stomach.
- Both truncal and selective vagotomy (preserves the celiac and
hepatic branches) result in gastric atony despite successful reduction
of both basal acid output (BAO; decreased by 85%) and maximal acid
output (MAO; decreased by 50%).
- Drainage through pyloroplasty or gastroduodenostomy is required
in an effort to compensate for the vagotomy-induced gastric motility
disorder.
- To minimize gastric dysmotility, highly selective vagotomy (also
known as parietal cell, super-selective, or proximal vagotomy) was
developed. Only the vagal fibers innervating the portion of the
stomach that contains parietal cells is transected, thus leaving fibers
important for regulating gastric motility intact.
- Antrectomy is aimed at eliminating an additional stimulant of gastric
acid secretion, gastrin.
- Laparoscopic surgery has led several surgical teams to successfully
perform highly selective vagotomy, truncal vagotomy/pyloroplasty,
and truncal vagotomy/antrectomy through this approach.
- Endoscopic approaches for the treatment of peptic disease and its
complications has led to a substantial decrease in the number of
operations needed for this disorder with a drop of >90% for elective
IV. DOC: H2RA or PPI (PANTOPRAZOLE)
ulcer surgery over the last four decades
Pantoprazole:
Food to avoid:
- Spicy foods - Pantoprazole is less likely than omeprazole and esomeprazole
- Alcohol to interact with other drugs, in fact has no noted significant
- Coffee and other beverages that contains caffeine drug interaction at all.
- Fatty foods - In a patient with drug induced gastritis who required continued
- Fried food use of prednisone or other NSAID, Pantoprazole more reliably
promotes ulcer healing

WHISKY CPT CASE 4: PNEUMONIA CPT 6 | 7


ALCOHOL WITHDRAWAL SEIZURE
BASIS OF THE DIAGNOSIS
- Alcohol Abuser
- Stopped alcohol 1 year ago under rehabilitation
- Chills and sweating
- General Survey: Agitated
- Older Age (57 yrs old)
- Intake of Phenytoin for Alcohol Withdrawal Seizure
o Antiseizure activity
o Referred as diphenylhydantoin
o Have anti-arrhythmic activity
o MOA: Na+ channel blocker
o A/E: diplopia and ataxia
- Diaphoretic
- RR – 35/min (Increased)
- Febrile (39.5)
- (+) Guaiac test: indicate Alcohol withdrawal symptoms
ALCOHOL WITHDRAWAL SEIZURE
- A characteristic syndrome of motor agitation, anxiety, insomnia and
reduction of seizure threshold due to abrupt alcohol discontinuation
in an individual with alcohol dependence.
- Wide spectrum of manifestations – ranging from anxiety, decreased
cognition and tremulousness
- One of the most common causes of seizures in adults.
- Severity of the syndrome is usually proportionate to the degree and
duration of alcohol abuse.
- Can be categorized as mild, moderate or severe withdrawal,
withdrawal seizures and deliriumtremens
- Can occur 8 hours after the last drink but usually do not manifest
more than 48 hours after alcohol cessation
- Can during the first 1-5 days of withdrawal
- More prevalent in persons with history of withdrawal syndromes
- Seizures are generalized tonic-clonic seizures which are brief in
duration and resolve spontaneously
If the patient agrees to stop drinking, sudden decreases in alcohol intake
can produce withdrawal symptoms:
- Tremor of the hands (shakes)
- Agitation and anxiety
- Increase in pulse, Respiratory rate and body temperature
- Sweating
- Insomnia
- Abrupt cessation of alcohol intake after prolonged heavy drinking may
trigger alcohol withdrawal seizures.
- Increase risk in: older age, concomitant medical problems, misuse of
additional drugs, and higher alcohol quantities.
- Generalized tonic-clonic seizures are the most characteristic and severe
type of seizure that occur in this setting.
- One of the most common causes of seizures in adults.
- Several days later, individuals can develop the syndrome of delirium
tremens
WHISKY CPT CASE 4: PNEUMONIA
NON-PHARMACOLOGICAL THERAPY
Alcoholic rehabilitation
- Core components of the rehabilitation phase of treatment
include cognitive-behavioral approaches to help patients
recognize the need to change, while working with them to alter
their behaviors to enhance compliance.
Relapse prevention education
- Helps patients identify situations in which a return to drinking is
likely (e.g., spending time with heavily drinking friends or
stopping in a bar to meet friends but planning to only have a
nonalcoholic beverage), formulate ways to avoid the risky
situation and if not possible to mitigate the risks to which they
are exposed.
- It is also important to develop coping strategies that increase
the chances of a return to abstinence quickly after an episode
of drinking.
Self-help groups such as Alcoholics Anonymous (AA)
- To assist them in developing a sober peer group and to learn
how to deal with life’s stresses while remaining sober.
Counseling
- Focuses on areas of improved functioning in the absence of
alcohol (i.e., why it is a good idea to continue abstinence),
helping patients to manage free time without alcohol,
encouraging them to develop a nondrinking peer group, and
discussions of ways to handle stress without drinking.
THERAPEUTIC OBJECTIVES
Major objective: Prevention of seizures, delirium and arrhythmias
Potassium, magnesium, and phosphate balance should be restored as
rapidly as is consistent with renal function
PHARMACOLOGICAL THERAPY
Thiamine therapy is initiated in all cases
- Water soluble vitamin, combines with ATP to form thiamine
pyrophosphate, an essential coenzyme in carbohydrate
metabolism.
- Mild alcohol withdrawal does not need any other
pharmacologic assistance
- For severe cases – detoxification
- Administration of a long acting sedative-hypnotic drug for
alcohol and gradually reducing (tapering) the dose of the long
acting drug
- Benzodiazepines:
o Chlordiazepoxide and diazepam
o Lorazepam and oxazepam
DOC: BENZODIAZEPINES
- Help reduce agitation and prevent more severe withdrawal
symptoms, such as seizures and delirium tremens (DT)
- specific drug treatment for detoxification in more severe cases
- substituting a long-acting sedative-hypnotic drug for alcohol
and then gradually reducing (“tapering”) the dose of the long-
acting drug.
Assuming patient has no liver disease: DIAZEPAM
MOA: Positive allosteric modulator of GABAA receptors
Individuals with Alcohol Used disorder are often deficient in vital
nutrients, so medical treatment also includes:
- Thiamine (100mg)
- Folic Acid (1mg)
CPT 7 | 7