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OBJECTIVE: To present a case of Pneumonia

GENERAL DATA: RS 90 years old female Married Roman Catholic From Paco Manila Informant: Relative Reliability: 80%

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HISTORY OF PRESENT ILLNESS • • • • 5 days PTA • (+) productive cough with whitish sputum (-) fever (-)eadache (-) nausea or vomiting .

5 mg ½ tab.CBC.sought consult at her attending physician labs reqeusted. sodium and chest xray 1 day PTA- Acarbose 100 mg TID. advised for admission----refused . crea. spironolactone 25 mg+ Butizide 2. Endosteine 300 mg BID. moxifloxacin 400 mg tab OD.

Few hours PTA (+)persistence of productive cough associated with difficulty of breathing. 30 minutes PTA (+)unresponsive. after coughing rushed immediately to the ER ADMISSION .

stopped Acarbose 50mg TID •(+)Hypertension stage 2 =20 years •Verapamil 40 mg tab BID •Losartan 100 mg ½ tab BID (-) asthma (-) PTB (-) allergy for food or drugs .PAST MEDICAL ILLNESS •(+)Diabetes mellitue type 2=20 years Glimepiride 4 mg tab OD .stopped Metformin 500 mg tab BID .

both maternal and maternal side (-) Diabetes (-) Kidney Disease (-) Tuberculosis (-) Stroke .FAMILY HISTORY (+) Hypertension.children (+) Asthma.

PERSONAL AND SOCIAL HISTORY (+) stopped smoking 30 years ago (-)non-alcoholic beverage drinker -usual activity was walking 1 block away from their house and usually sleeps after resting for a couple of minutes .

(-)abdominal pain. (-) constipation (+) nocturia. (-) clubbing of nails. (-) sneezing. (-) injury (+) blurring of vision (-) tinnitus.REVIEW OF SYSTEM (-) weight loss. (-) allergies (+) 2 pillow orthopnea. (-) loss of appetite (-) rashes. (-) hematuria. (-) erythema. (-) dysuria (-) edema. (+) easy fatigability. (-) headache. (+) paroxysmal nocturnal dyspnea (-) bleeding gums. (-) discharge (-) epistaxis. (-) joint swelling (+) loss of consciosness (+) dizziness . (+) urgency. (-) hemoptysis (-) chest pain (-) diarrhea.

in cardio-respiratory arrest VITAL SIGNS BP: 0 wt: 54kg (estimated PR:0 ht: 160 (estimated) RR:0 BMI:22 T:36 ⁰C .GENERAL SURVEY Patient is unconscious. stretcher-borned.

PHYSICAL EXAMINATION SKIN: • • • no active lesion good skin turgor no jaundice .

Physical examination • HEENT: • No facial asymmetry/ deformity • Anicteric sclera. nodular well-circumscribed mass on the left side of the neck • (+) dry oral mucosa . (+) pupils dialted. not reactive to light 4-5 mm • (-) nasal discharge • (-) lymph node enlargement • (+) firm. pink palpebral conjunctiva.

(-)scars • (+) coarse crackles.PHYSICAL EXAMINATION • Chest and Lung: • Symmetrical chest expansion • (-) deformities . bibasal • (-) wheezes .

Physical examination • Cardiovascular: • Adynamic precordium • no rate • no rhythm • (-) murmur .

PHYSICAL EXAMINATION
• Abdomen: • Flabby • Normoactive bowel sounds • No scar, • no striae • Soft

Physical Examination
• Extremities: • (-) clubbing of nails • No deformities • (-) cyanosis • (-) edema • (-) pulses

INITIAL DIAGNOSIS
Acute respiratory failure secondary to aspiration pneumonia T2 Diabetes Mellitus HASCVD, CAD, CHF FC IV

13 ABG: 7.900/12.LABORATORY EXAMS • • • • • CBG: 249 mg/dL CBC: 12. anterior septal wall ischemia. RAD.9/ 39/85/15/adequate BUN. NSSTTWC .46/35/202/24.9/100 12L ECG: sinus tachycardia. poor R wave prog.21 HI/ Crea-1.

atherosclerotic aorta. osteoarthritis. right shoulder .Chest x ray • pneumonia both lower lung intercurrent pleural effusion and not ruled out cardiomegaly.

MANAGEMENT • Diet: DM diet. Clindamycin 300 mg IV q8. low fat low salt • IVF: PNSS IL x 16 • Meds: Moxifloxacin 400 mg IV OD. Simvastatin 10 mg tab/NGT OD HS .

FINAL DIAGNOSIS • Acute respiratory failure secondary to Aspiration Pneumonia • HASCVD. CHF FC IV • T2 DM . CAD.

SALIENT FEATURES • Subjective: • 90 years old • female • Objective: • • • • easy fatigability Noctura Urgency Coarse crackles .

DIFFENTIAL DIAGNOSIS DISEASE COPD RULE IN History of cigarette smoking. and pale skin Pulmonary edema shortness of breath or breathlessness Shortness of breath can manifest as orthopnea (inability to lie down flat due to breathlessness) and/or paroxysmal nocturnal dyspnea (episodes of severe sudden breathlessness at night) . frothy sputum). dyspnea RULE OUT decreased intensity of breath sounds. excessive sweating. wheezing coughing up blood (classically seen as pink. anxiety. and prolonged expiration on physical examination.

Asthma affects people of all ages. and coughing. causes recurring periods of wheezing (a whistling sound when you breathe) The coughing often occurs at night or early in the morning. but it most often starts during childhood. shortness of breath. .Differential Diagnosis Asthma chest tightness.

PNEUMONIA • Pneumonia is an infection of the parenchyma. • Categorized as: – Community-acquired pneumonia (CAP) – Health care–associated pneumonia (HCAP) • Hospital-acquired pneumonia (HAP) • Ventilator-associated pneumonia (VAP) .

1 cause of mortality.000 (2004) • No.924/100.000 (2003) • The incidence rates are highest at the extremes of age.861/100. 1 cause of morbidity. .PNEUMONIA • No.

pneumo . • vary from indolent to fulminant in presentation and from mild to fatal in severity. • Most common pathogen = S. fevers.COMMUNITY ACQUIRED PNEUMONIA • Evidence of systemic illness (temperature >38°C and/or the symptom complex of sweating. aches and pains). shivers.

Health care–associated pneumonia (HCAP) • Hospital Acquired Pneumonia • . which was not incubating at the time of admission .defined as pneumonia that occurs 48 hours or more after admission.refers to pneumonia that arises more than 48–72 hours after endotracheal intubation • Ventilator Associated Pneumonia • .

Physiology • Defences of the pulmonary system – Mechanical factors • Hairs and turbinates of the nares catch larger inhaled particles before they reach the lower respiratory tract • Branching architecture of the tracheobronchial tree traps particles on the airway lining • Mucociliary clearance and local antibacterial factors either clear or kill the potential pathogen – Gag reflex and the cough mechanism offer critical protection from aspiration. – The normal flora adhering to mucosal cells of the oropharynx prevents pathogenic bacteria from binding and thereby decreases the risk of pneumonia caused by these more virulent bacteria .

Pathogenesis • 3 main mechanisms by which bacteria reaches the lungs 1.) Primary inhalation: – organisms bypass normal respiratory defense mechanisms – inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment .

)Aspiration – occurs when the Pt aspirates colonized upper respiratory tract secretions – Stomach: reservoir of GNR that can ascend.) Hematogenous – originate from a distant source and reach the lungs via the blood stream.2. colonizing the respiratory tract 3. .

most investigators cannot identify a specific etiology for CAP in ≥ 50% of patients.Pathogens • CAP usually caused by a single organism • Even with extensive diagnostic testing. S. • In those identified. pneumo is causative pathogen 60-70% of the time .

shaking chills. cough) • Lobar infiltrate on CXR • Suppressed host • 25% bacteremic . fever. malaise. rusty sputum.g.Streptococcus pneumonia • Most common cause of CAP • Gram positive diplococci • “Typical” symptoms (e. pleuritic hest pain.

non-productive cough. URI Sx. water-borne outbreaks. no focal infiltrate on CXR • Mycoplasma: younger Pts. rashes). diarrhea .Atypical Pneumonia • #2 cause (especially in younger population) • Commonly associated with milder Sx’s: subacute onset. hyponatremia. extra-pulm Sx’s (anemia. sore throat • Chlamydia: year round. headache. sore throat • Legionella: higher mortality rate.

especially during winter months • Post-influenza pneumonia (secondary bacterial infection) – S. parainfluenza • Influenza most important viral cause in adults. Staph aureus . influenza.Viral Pneumonia • More common cause in children – RSV. pneumo.

skin disease.sinus disease. putrid sputum. otitis. prosthetic joints) prior viral pneumonia .Other bacteria • Anaerobes – Aspiration-prone Pt. dental disease • Gram negative – Klebsiella .alcoholics – Branhamella catarrhalis . influenza • Staphylococcus aureus – IVDU. foreign bodies (catheters. COPD – H.

chest radiography should be performed. – • Chest x-ray is also essential in assessing severity of disease & in prognostication.CLINICAL DIAGNOSIS Value of the chest radiograph in the diagnosis of CAP--• For diagnostic certainty in the management of a patient with suspected pneumonia. . – • It may suggest possible etiology & help differentiate pneumonia from other conditions.

Infiltrate Patterns .

. aureus. a sputum sample must have >25 neutrophils and <10 squamous epithelial cells per low-power field – Low sensitivity but specific . and gram-negative bacteria) by their characteristic appearance – To be adequate for culture. S.g. S.ETIOLOGIC DIAGNOSIS • Gram's Stain and Culture of Sputum – The main purpose of the sputum Gram's stain is to ensure that a sample is suitable for culture – Gram's staining may also help to identify certain pathogens (e. pneumoniae.

or severe CAP—should have blood cultured • Antigen Tests – Pneumococcal and certain Legionella antigens in urine – The sensitivity and specificity of the Legionella urine antigen test are as high as 90% and 99%. asplenia. respectively) . or complement deficiencies. chronic liver disease. respectively – The pneumococcal urine antigen test is also quite sensitive and specific (80% and >90%.• Blood Cultures – Certain high-risk patients—including those with neutropenia secondary to pneumonia.

pneumoniae. including L. pneumophila and mycobacteria – A multiplex PCR can detect the nucleic acid of Legionella spp. and C. pneumoniae – use of these PCR assays is generally limited to research studies • Serology – Recently have fallen out of favor because of the time required to obtain a final result for the convalescentphase sample .. M.• Polymerase Chain Reaction – Available for a number of pathogens.

SITE OF CARE • • • • • • • • • • Low Risk CAP .stable vital signs: RR <30 breaths/min temp>36⁰C or <40 ⁰C PR <125 beats/min DPB >60 mmHg No altered mental state of acute onset No suspected aspiration No or stable co-morbid conditions Chest xray: localized infiltrates and no evidence of pleural effusion nor abscess .

DBP < 60 – Temp ≤36⁰C or ≥40⁰C – RR ≥125 beats/min uncontrolloed DM.MODERATE RISK CAP • Unstable vital signs – RR ≥30 breaths/min • – SBP <90 mmHg. class I-IV. renal failure dialysis. acitvemalignancies. decompensated liver disease • Altered mental state of acute onset • Suspected aspiration • CHEST XRAY – MULTILOBAR INFILTRATES – PLEURAL EFFUSION OR ABSCESS . neurologic disease in evolution. unstable CAD. CHF. uncompensated COPD.

HIGH RISK CAP • ANY OF THE CLINICAL FEATURE OF MODERATE RISK CAP PLUS ANY OF THE FOLLOWI NG • SEVERE SEPSIS AND SEPTIC SHOCK • NEED FOR MECHANICAL VENTILATION .

Site of Care .

Treatment • Empiric antibiotic treatment should be initiated within 4 hours of diagnosis of CAP • Directed against most likely pathogen • Rapidly shifted to narrower spectrum antibiotics once sensitivity patterns are known .

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can can switch to oral therapy while still febrile .Switch to Oral Therapy • Four criteria: – Improvement in cough and dyspnea – Afebrile on two occasions 8 h apart – WBC decreasing – Functioning GI tract with adequate oral intake • If overall clinical picture is otherwise favorable.

Complications • • • • • Respiratory failure Shock Multiorgan failure Bleeding diatheses Exacerbation of comorbid illnesses .

P. or (rarely) S.• Metastatic infection. aeruginosa. – E.g. pneumoniae – Aspiration pneumonia is typically a mixed polymicrobial infection involving both aerobes and anaerobes .. such CA-MRSA. brain abscess or endocarditis • Lung abscess – Lung abscess may occur in association with aspiration or with infection caused by a single CAP pathogen.

then the fluid should be drained.2 mmol/L.• Complicated pleural effusion. – A significant pleural effusion should be tapped for both diagnostic and therapeutic purposes – If the fluid has a pH of <7. and a lactate dehydrogenase concentration of >1000 U/L or if bacteria are seen or cultured. a chest tube is usually required . a glucose level of <2.

comorbidities. and the site of treatment (inpatient or outpatient) • Young patients without comorbidity do well and usually recover fully after ~2 weeks • Older patients and those with comorbid conditions can take several weeks longer to recover fully .PROGNOSIS • Prognosis of CAP depends on the patient's age.

attenuated vaccine: 5-49yo without chronic underlying dz – Pneumococcal • Immunocompetent ≥ 65 yo.Prevention • Smoking cessation • Vaccination recommendations – Influenza • Inactivated vaccine for people >50 yo. household contacts of high-risk persons and healthcare workers • Intranasal live. those at risk for influenza compolications. chronic illness and immunocompromised ≤ 64 yo .

. aureus (skin wounds) and GN bacteria (aspiration) • Pneumonia in Older Residents of Long-term Care Facilities. 70: 1495-1500.Pneumonia in the Elderly • • • • Prevention important Presentation can be subtle Antibiotic choice in CAP is same as other adults Healthcare associated pneumonia – Consider S. AFP 2004.

alcoholics. insidious onset in AIDS. bedridden. pneumo – Mycoplasma • Pneumocystis Carinii Pneumonia – P.Pneumonia in Immunocompromised Pts • Smokers. immunocompromised. jirovecii – Fever. elderly • Common still common – S. non-prod cough (triad 50%). acute in other immunocompromised Pts – CXR: bilateral interstitial infiltrates – Steroids for hypoxia – TMP-SMZ still first line . dyspnea.

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chest xray What is your presumptive diagnosis? .