CAP Progress Note Grading Rubric FALL 2021

NOT NEEDS COMPETENT Excellent (100%)

ACCEPTAB IMPROVEME (85%)
LE NT
(0%) (70%)

S Reason for Consult Incorrect or Correct statement of reason for consult is included.
missing reason
O (5%) This 55 yo African American male with a PMH significant for HTN and DM and dyslipidemia
for consult
is diagnosed with multilobar pneumonia in the ED after presenting with worsening
productive cough, chest pain, and fevers over one week. He was prescribed levofloxacin
750mg daily as an outpatient; however, did not fill due to financial reasons. Pharmacy was
consulted to provide recommendations on the empiric treatment of CAP.

Subjective/ Inaccurate or Appropriate, complete & accurate sub/obj information provided related to pertinent problems and
Objective irrelevant drug therapy.
Information information is
provided. Data
S/O:
(10%) provided does
HPI: students should mention the course related to pneumonia and not filling the antibiotic
not relate to
due to financial reasons (here or in the reason for consult ok)
patient
Vitals: Temp 39.5OC, HR 127, RR 30, BP 155/85mmHg, O2 87% on RA,
problems.
Wt: 110kg
Labs: WBC 23.1 x 103/mm bands 15%, BUN/Scr 42/1.4 BG 295mg/dL
CrCl: estimated ~63ml/min
procalcitonin 1.9ng/ml
lactic acid
Streptococcus pneumoniae urine antigen – pending
Legionella pneumophila urine antigen pending
Culture data:
- Sputum Gram stain: many GPC in pairs; >25WBC/hpf; <10 epithelial cells
- Sputum culture (date) pending
- Blood culture (date) pending

PE: Chest: labored breathing, course rhonchi throughout right lung fields, decreased breath
sounds in RML and RLL lung fields
Imaging:
- CXR (date): RML and RLL consolidative airspace disease – likely pneumonia
- Chest CT (date): RLL, RML consolidation

Allergy: NKDA

Complete and accurate assessment of patient problem(s) and drug therapy. Written succinctly in
A Assessment of Inaccurate or Incomplete, yet Appropriate
professional terminology.
Patient Problem(s) missing some accurate assessment of
& Drug Therapy assessment of assessment of patient problem(s)
Problem Assessment:
the problem(s) patient & drug therapy.
(25%) and/or current problem(s) and Includes some
Pneumonia: Patient with severe CAP as evidenced by clinical presentation, physical exam
drug therapy. drug therapy is extraneous or
findings, and chest x-ray and CT scan. 3 minor criteria of disease severity indicate severe
Inappropriate provided. non-pertinent info
CAP (multilobar pneumonia, uremia, RR). Patient’s PSI (125) and CURB-65 scores support
or
inpatient treatment with IV therapy to reduce mortality risk. Empiric therapy should include
unprofessional
coverage for the most common causative CAP organisms including S. pneumoniae, H.
terminology.
influenza, M. catarrhalis, and atypical organisms. IDSA/ATS guidelines recommended a β-
lactam (amp/sulbactam, cefotaxime, ceftriaxone, ceftaroline) + ( advanced macrolide or
levofloxacin) as empiric therapy. Pt has no history of recent IV antibiotic use or history of
MRSA or Pseudomonas so not necessary to provide coverage for these organisms.
 Goals of Therapy Inaccurate Incomplete, yet Appropriate goals Complete list of evidence-based and measurable goals of therapy included which are patient
goals of some accurate of therapy and disease-state specific. Written succinctly in professional terminology.
(15%) therapy goals of included. Includes
included. Goals therapy non-patient
 Eradicate the infecting organism/cure the infection
of therapy not provided. specific goals..
 Resolve the patient’s symptoms (cough, shortness of breath, pleuritic chest pain,
provided.
fever)
 Prevent recurrence and/or complications

P Recommended Some or all of Complete and Complete and Complete and optimal patient and disease state-specific drug treatment plan included.
Drug Therapy drug therapy reasonable reasonable drug
All appropriate preventative and/or OTC drug therapies included (if applicable).
plan missing drug treatment treatment plan
(25%) (missing drug plan included. included. Written succinctly in professional terminology
name, route,
Continued/disc No unapproved/inappropriate abbreviations and/or terminology present.
dose, or
ontinued drug
frequency).
therapy not
Inappropriate/i appropriately Empiric Therapy for inpatient CAP:
naccurate drug listed. - Recommend empiric treatment with (see chart below for all options)
therapy - ceftriaxone 1 or 2g IV q24 hours plus azithromycin 500mg IV q24 hours
Drug name(s) until patient is clinically stable and able to take oral therapy. Will follow
recommendatio
misspelled. clinical status to determine recommendations for oral therapy.
ns.
Unapproved/ina - Influenza vaccine (IIV3 or IIV4) 0.5ml IM x 1 now
Treatment plan - Pneumococcal vaccine (DM diagnosis) - PPSV23 now, then PCV13 at age
ppropriate
may result in 65, followed by PPSV23 at age 66 (12 months apart)
abbreviations
harm to the - Tdap 0.5ml x1 now if not received previously (Optional, not needed for
and/or
patient. excellent)
terminology
present - Also a candidate for Hep B series (DM) if not up to date (Optional, not needed
for excellent)

Monitoring Plan & Incomplete, Some Appropriate All appropriate monitoring parameters and patient education points (if applicable) included.
Patient Education inaccurate appropriate monitoring
Optimal frequencies for the monitoring parameters are provided.
monitoring monitoring parameters and
(20%) parameters parameters and patient education Written succinctly in professional terminology.
and patient patient points (if
education education applicable) are MONITORING PLAN
points (if points (if included. Most  Symptoms of infection daily while in hospital (decrease in cough severity,
applicable). applicable) parameters have shortness of breath)
included. a reasonable  Vital signs: Every 6 hr: temperature, HR, and RR, O2 sate – all should improve
frequency. or resolve within 48 hrs
Significant
extraneous  Oxygen consumption daily
information  Follow-up on culture and susceptibility testing, antigen results
included or  Assess ability to tolerate oral medications
several PATIENT EDUCATION PLAN
parameters
without  Pharmacy will educate patient on adherence to antibiotic regimen at discharge,
reasonable antibiotic side effects, and signs/symptoms of worsening infection
frequencies

Of note for those familiar with this previous case

 Dyslipidemia was added
 Procalcitonin/lactic acid added
  Previous penicillin allergy changed to NKDA

Talking points:
1. Discuss prioritization of patient problems

2. S/O information
 interpretation of sputum gram stain
 review procalcitonin significance
 review lactic acid significance
 include the date on culture results
 Students have not had ABG interpretation and I do not expect you to review this with them.

Assessment
 CAP severity – this patient diagnosed with Severe CAP. Book key still lists site of treatment (old guidelines) as a determining factor of disease
severity – do not use this --- us the major/minor criteria for determining severity.
o no major criteria.
o Minor criteria include: RR (> 30bpm); multilobar infiltrates, uremia

 Risk Stratification
 o PSI – students should go through the PSI criteria and calculate a score. Intent is not for them to memorize this – but to understand
what contributes to mortality and disease severity. This patient’s PSI score = 125 indicating risk class IV and hospitalization
recommended.
o CURB-65 – this needs to be memorized by students. This patient has a CURB-65 score = 2 (uremia, respiratory rate). Scores >2
support hospitalization.

Plan

This patient has no known prior MRSA or pseudomonal respiratory isolates or recent hospitalization. Standard regimen should be sufficient

B-lactam + macrolide or fluroquinolone. – see footnotes of the chart.

 Any additional discussion on antibiogram interpretation is helpful. Guidelines list also consider coverage for resistant organisms based
upon locally validated risk factors. Too complicated and I did not discuss with students.
 Pneumococcal vaccine info: https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
 Students can pull up updated vaccine and influenza information to review current recommendations.
https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf

 Discuss other disease state management but not required for note.
 o HTN – hypertension not at goal per ACC/AHA recommendations (goal <130/80mmHg). Patient admits noncompliance with medications
HTN – suggest to reinforce compliance and restart current regimen of lisinopril 10mg po daily & hydrochlorothizide 25mg po dail. Avoid
ibuprofen.
o DM – random BG above the desired goal range (<200mg/dL) Suggest A1C.
DM – reinitiate metformin 1,000mg po BID (may need to titrate up to this) and check an A1C.
o Dyslipidemia – no lipid values currently. Pt needs to follow-up with PCP for labs and ASCVD risk assessment.

Questions to pose
 Review Clinical Course with students
o When is it appropriate to switch to oral therapy?
 Consider bioavailability of agent
 Functioning GI tract with adequate PO intake
 Clinically stable (no more than one of the following)
- Temp > 37.8o C
- HR > 100 beats/min
- RR > 24 beats/min
- SBP < 90mmHg
- O2 saturation < 90%
- Inability to maintain oral intake

o Students should determine an outpatient regimen would be recommended based on PSSP in this patient.
o Have students review drug pricing on GoodRX.com (or alternative)
 How would your recommendation change if this patient developed pneumonia 72 hours after a hospital admission?
o HAP pneumonia (students can use Methodist antibiogram in Tuohy’s lecture)
 Should cover for MRSA as >20% resistant
 Single coverage for gram neg. bacilli sufficient (pip/tazo, cefepime, levofloxacin)