CASE

PRESENTATIO
N
SOUTHWESTERN UNIVERSITY-MATIAS H. AZNAR
MEMORIAL COLLEGE OF MEDICINE
ASOY, GABUCO, PANILAGAO, MALAQUE, MAñEZ

INTERNAL MEDICINE - CHONG HUA HOSPITAL

 Objectives:
To present a case of a 39-year old female presenting with
cough and fever.

To be able to learn how to approach a patient presented with

cough.

To be able to classify a patient with pneumonia and manage

accordingly

To review the pathophysiology of the diagnosis, clinical

features, diagnostic criteria, and management of pneumonia.
General Data
 J.P.
 Female
 39 y.o.
 Single
 Housewife
 Roman Catholic
 Filipino
 Residing in Capitol Cebu City
Chief Complaint

 Cough and fever

History of Present Illness

• Onset of nonproductive cough

and coryza assoc. with
intermittent fever (Tmax= 390 C)

• Paracetamol, 500 mg/tab, 1 tab

q 4 hours
7 days • Levodropropizine (Levopront)
PTA 30mg/5ml, 15mL TID X 5days- no
relief
History of Present Illness

• Symptoms persisted, patient

took Oregano herbal syrup.

• Productive cough with greenish

2 days sputum, non blood streaked

• Body malaise
PTA
History of Present Illness

• Symptoms persisted now

associated with anorexia and chest
pain (sharp, on sternal area,
1 day nonradiating, occurs upon
coughing, pain scale 5/10)

PTA
History of Present Illness

• Symptoms persisted now

associated with chills

• Sought consult in CHH-OPD

Morning • CBC (inc. WBC) and Dengue

screening Test (-) done
PTA • Advised for admission
Past Medical History

 Non-hypertensive
 Non-diabetic
 Non-asthmatic
 2004- S/P Cesarean Section x1 20 to prolonged
labor (CDUH)
Past Medical History

 2005- Vertigo 20 to an ear problem (CHH)-

resolved
 2005- diagnosed with Sinusitis- recurrent
 Cetirizine (Zyrtec) 10mg/tab, OD PO
 Mumps- 7 y.o.
 Measles- 5 y.o.
Ob-Gyn History
 Menarche-11 y.o.
 Regular, 7 days, 4 pads/day
 (+) dysmenorrhea
 FeSO4

 G5P4(4014)
 G4 Spontaneous abortion- D&C (2002)
 G5 Cesarean Section (BT- 1 u PRBC)

 LMP- 12/22/14
Family History

 Heredofamilial Diseases
 (+) DM- both
 (+) HPN- both
 (+)BA- both
 (+) Lung cancer- paternal
Personal and Social History
 High School graduate
 Allergy- perfume, dust, crustaceans
 Non-smoker
 Non-alcoholic
 Non-drug user
Personal and Social History
 No history of travel
 Patient lives in an uncongested area
 No pets or animals at home
 Sister- PTB- treatment completed
 Patient’s live-in partner has
nonproductive cough (asthmatic), known
smoker
 Review of Systems
 General: No weakness, no sweats
 Skin: No pruritus, no lesions, no burns, no bruising
 Head: No headache, no dizziness, no history of trauma
 Eyes: No acuity change, pain, and diplopia
 Ears: No ear ache
 Nose and Sinuses: No history of nosebleed, No nasal congestion
 Throat: No bleeding of gums, no dentitions
 Breasts: No lumps, no nipple discharge, no pain
 Cardiovascular: No history of cardiovascular problems, no palpitations,
no easy fatigability
Review of Systems

 GIT: No heartburn, no changes in stool frequency, no hemorrhoids,

no constipation
 Peripheral Vascular: No varicosities, no swelling of calves and legs
 Urinary: No polyuria, no dysuria, no nocturia, no history of kidney
disease
 Genital: No dysmenorrhea, no vaginal discharges
 Musculoskeletal: No limitation of movement, no muscle or joint pain
 Neurologic: No changes in mood, attention, orientation, or judgment
 Hematologic: no history of easy bruising
 Endocrine: No palpitations, no diaphoresis
Physical Examination
 Awake, alert, coherent, cooperative,
febrile, not in respiratory distress
 V/S:
 BP: 90/60mmHg
 HR: 102bpm
 RR: 19cpm
 T: 380C/axilla
 Wt: 63kg
 Ht: 149cm
 BMI: 28.37 kg/m2 (Overweight)
 Physical Examination

 Skin: warm, good turgor and mobility, no lesions, no cyanosis

 Head: symmetrical
 Eyes: anicteric sclerae, pale palpebral conjunctivae;
 Ears: intact tympanic membrane, (-) discharges
 Nose/Sinuses: (-) nasal discharge, (-) alar flaring, (-) tenderness on
maxillary and frontal sinuses
 Mouth: moist oral and buccal mucosa, tonsils are not inflamed nor
hyperemic,
 Neck: (-) lymphadenopathy
Physical Examination
 Chest/Lungs:
I: Symmetric, no deformities, no retractions, no lag
P: Trachea at midline, equal chest expansion, no masses,
no tenderness, normal tactile fremitus
P: Resonant
A: (+) Rales on bibasal lung fields, no wheezing, no stridor
Physical Examination
 CVS: adynamic precordium, PMI located at the 5th LICS, MCL no thrills,
no heaves,, regular rate and rhythm, distinct heart sounds, (-) murmurs

 PVS: strong and equal distal and peripheral pulses, CRT < 2 seconds

 GIT: Flabby abdomen, NABS, tympanitic, (-) tenderness, (-) mass

palpated

 GUT: (-) KPS, bilaterally

 Extremities: full ROM, (-) deformities, (-) swelling, (-) edema,

Neurologic Examination
CEREBRAL:
Awake, coherent, cooperative, oriented to time, place and person

CRANIAL NERVES:
CN I: intact sense of smell
CN II: pupils equally round and reactive to light
CN III, IV, VI: EOMs intact
CN V: intact corneal reflex
CN VII: (-) facial asymmetry
CN VIII: intact sense of hearing and balance
CN IX, X: intact gag reflex
CN XI: able to shrug shoulders with or without resistance
CN XII: tongue is midline at rest and upon protrusion
 Physical Examination
CEREBELLAR:
Well coordinated finger to nose test, no ataxia, no nystagmus

SENSORY:
intact light touch, pain, and temperature sensation
100 100
MOTOR: 100 100
5/5 on all extremities

REFLEX:

MENINGEAL SIGNS: (-) Kernig’s and Brudzinki’s sign

Salient Features
History:
 39 year old
 Female
 Filipino
 Initially nonproductive cough with coryza noted 7 days PTA
 productive cough with greenish sputum and fever (Tmax 39C)
 Anorexia, chest pain, chills
 No dyspnea, sore throat, headache, muscle aches, extreme fatigue, hemoptysis,
nausea and vomiting, weight loss
 diagnosed with sinusitis – recurrent (2005)
 Allergies to crustaceans, perfume and dust
 Sister diagnosed with PTB- completed treatment
 Patient’s live-in partner has nonproductive cough (asthmatic), known smoker
 No Co-morbidities
Salient Features
Physical Examination:
 No altered mental state
 BP: 90/60mmHg
 HR: 102bpm (tachycardic)
 RR: 19cpm
 T: 37.9C/axilla (febrile)
 Pale palpebral conjunctivae
 (+) bilateral basal rales
 (-) tenderness on maxillary and frontal sinuses
 Impression:

COMMUNITY ACQUIRED
PNEUMONIA-LOW RISK
Community Acquired Pneumonia-
Low Risk
CLINICAL PRESENTATION RULE IN/OUT
Acute cough 
Fever 
Shortness of Breath 
Sputum Production 
Crackles, bronchial breath sounds 
Stable Vital Signs: 
RR< 30/min
PR< 125bpm
T> 36C or <40
BP >90/60
No altered mental state of acute onset 

No suspected Aspiration 
No or stable Co-morbid Condition 
DIFFERENTIAL DIAGNOSES

 Pulmonary Tuberculosis
 Bronchial Asthma
 Acute Bronchitis
Pulmonary Tuberculosis

RULE IN RULE OUT

Filipino Acute cough
Productive cough No hemoptysis
Fever/chills No weight loss
Body malaise No night sweats
Anorexia (-) history of exposure
(+) rales on bibasal lung
fields
 Bronchial Asthma
RULE IN
Atopy ( Allergic Rhinitis or
atopic Dematitis)
Acute Cough
RULE OUT
No exertional dyspnea
No Wheeze/rhonchi
Symptoms worse at night and in the
early morning hours
Increased Ventilation/ Use of
accessory muscles
Acute Bronchitis

RULE IN RULE OUT

Cough (>5days) Fever is unusual
Sputum Production Other Symptoms (Sore throat, Runny
or stuffy nose, Headache, Muscle
aches Extreme fatigue)
Diffuse wheeze/ inspiratory stridor

No history of smoking
DIAGNOSTICS
DIAGNOSTICS

 Imaging test: Chest X-ray

 Complete blood count
 Gram stain and Culture of Sputum
DIAGNOSTICS

 Supportive diagnostics
 AFB smear
 Pulmonary Function Test
 Further Work-Up
 CT scan and MRI
 PCR test
 Serology test: IgM
 Antigen test
Patient’s Actual Management
HEMATOLOGY REPORT
1/16/15 3:51 AM
COMPLETE BLOOD RESULT Serology Report
COUNT 1/16/15 4:39AM
BLOOD COUNT DENGUE NS1 RESULT
ANTIGEN
WBC 23.49 ↑
RBC 4.57 NS1 Antigen Negative
HGB 11.8 ↓
HCT 35.3 ↓ Ig M Antibody Negative
PLATELET 225
Ig G Antibody Negative
DIFFERENTIAL COUNT
RELATIVE DIFFERENTIAL
COUNT
91.2 ↑
NEUTROPHIL (%) 4.0 ↓
LYMPHOCYTE (%) 2.8 ↓
MONOCYTE (%) 1.3 OUT PATIENT
EOSINOPHILS (%) 0.2
BASOPHILS (%) 0.5
LUC (%)
CLINICAL CHEMISTRY REPORT
1/16/2015 05:10 pm
Test Result Referrence unit

Creatinine 0.9 0.6-1.5 MG/DL

SGPT-ALT 96 5.0-50.0 U/L

SODIUM 137.0 1314-148 MMOL/L

(SERUM)
POTASSIUM 3.0 3.3-5.3 MMOL/L
Chest X-ray – PA and LATERAL/AP and LATERAL
1/16/2015

IMPRESSION:
RIGHT MIDDLE LOBE PNEUMONIA
BILATERAL PLEURAL THICKENING AND/OR MINIMAL EFFUSION
X-ray- Paranasal Sinuses- complete Waters
and CALDW

IMPRESSION:
MILD LEFT MAXILLARY SINUS DISEASE
ACID FAST result 1/17/2015
STAIN
Sputum Negative for
acid fast
GRAM STAIN 1/17/2015
Sputum 200-220/LPF pus
cells
20-25/LPF
epithelial cells
Occasional gram (+)
cocci in pairs and in
clusters
Occasional gram (+)
bacilli
Rare gram (-)
bacilli
Community Acquired Pneumonia- Moderate Risk
CLINICAL PRESENTATION RULE IN/OUT
Acute cough 
Fever 
Shortness or Breath 
Sputum Production 
Crackles, bronchial breath sounds 
Stable Vital Signs: 
RR>30/min
PR> 125bpm
T >40 or <36
BP <90/60
Altered mental state of acute onset 
suspected Aspiration 
Decompensated Co-morbid Condition 
Chest X-Ray 
• Multilobar infiltrates
• Pleural effusion
• Abscess
Final diagnosis

COMMUNITY ACQUIRED
PNEUMONIA- MODERATE RISK

ACUTE RHINOSINUSITIS
Patient’s Actual Treatment
IDEAL MANAGEMENT ACTUAL TREATMENT
Antibiotic Treatment Azithromycin dehydrate (Zithromax)
500 mg tablet OD
Piperacillin Sodium Tazobactam Sodium
(PIPTAZ 4gm/500 mg vial) q 8 hrs IV

Paracetamol (Biogesic 500mg tablet

500’s) q 4 hrs PRN
Acetylcysteine (fluimucil 600
mg/tablet) BID
Levocetirizine Dihydrochloride (xyzal)
50 mg/tablet BID
Ipratropium Salbutamol (duavent 2.5ml
pulmoneb 20’S) 1 neb q 6 hrs
Potassium Chloride (Kalium Durule)
750mg/tab TID x6 doses
Community
Acquired
Pneumonia
CASE DISCUSSION
Pneumonia
 results from the proliferation of microbial pathogens at the alveolar level
and the host’s response to those pathogens
 aspiration from the oropharynx, inhalation, hematogenous, contiguous
extension
 Only when the capacity of the alveolar macrophages to ingest or kill the
microorganisms is exceeded does clinical pneumonia become manifest.
 The host inflammatory response triggers the clinical syndrome of
pneumonia.
Pathology

 Initial Phase – Edema

 with the presence of a proteinaceous exudate—and often of bacteria—in the alveoli
 Rarely evident in in clinical or autopsy specimens

 Red Hepatization Phase

 (+) erythrocytes in the cellular intraaveolar exudate
 Bacteria are usually seen in specimens
Pathology

 Gray Hepatization
 no new erythrocytes are extravasating, and those already
present have been lysed and degraded
 neutrophil is the predominant cell, fibrin deposition is
abundant, and bacteria have disappeared
 successful containment of the infection and improvement in
gas exchange

 Resolution
 the macrophage reappears as the dominant cell type
 The debris of neutrophils, bacteria, and fibrin has been
cleared, as has the inflammatory response
Etiology
 TYPICAL BACTERIAL PATHOGENS
 S. pneumoniae
 Haemophilus influenzae
 (in selected patients) S. aureus
 gram-negative bacilli such as Klebsiella pneumoniae and Pseudomonas
aeruginosa

 ATYPICAL BACTERIAL PATHOGENS

 Mycoplasma pneumoniae
 Chlamydia pneumoniae (in outpatients) and Legionella spp. (in inpatients)
 respiratory viruses such as influenza viruses, adenoviruses, and respiratory
syncytial viruses
Etiology

 Anaerobes
 only when an episode of aspiration has occurred days to
weeks before presentation for pneumonia
 often complicated by abscess formation and significant
empyemas or parapneumonic effusions
 S. aureus pneumonia
 known to complicate influenza infection
 MRSA
 reported as the primary etiologic agent of CAP
 serious consequence: necrotizing pneumonia
Etiology
Epidemiology

 CA-MRSA pneumonia
 more likely in patients with skin colonization or infection
with CA-MRSA

 Enterobacteriaceae
 recently been hospitalized and/or received antibiotic
therapy
 or who have comorbidities such as alcoholism, heart
failure, or renal failure
Epidemiology

 P. aeruginosa
 with severe structural lung disease, such as bronchiectasis,
cystic fibrosis, or severe COPD

 Legionella infection
 diabetes, hematologic malignancy, cancer, severe renal
disease, HIV infection, smoking, male gender, and a recent
hotel stay or ship cruise
Epidemiologic Factors
Epidemiologic Factors
Clinical Manifestations

 Febrile
 tachycardia
 History of chills and/or sweats
 Cough
 Shortness of breath
 Chest pain
 GI symptoms
 Fatigue
 Headache
 Myalgias and arthralgias
Clinical Manifestations

 Increased respiratory rate, use of accessory muscles

 Increased or decreased tactile fremitus
 Dull to flat
 Crackles, bronchial breath sounds, pleural friction rub
 New-onset or worsening confusion
 Septic shock
 Organ failure
 DIAGNOSIS

 Is this pneumonia?
 What is the etiology?
 Clinical Diagnosis
 Importance of History and PE cannot be
overemphasized
 Epidemiologic clues, such as travel to areas
with known endemic pathogens may alert
the physician to specific possibilities.
 Sensitivity and specificity of findings on PE
average 58% and 67%, respectively.
 Chest radiography is often necessary to
differentiate CAP from other conditions.
 Radiographic findings may include risk
factors for increased severity (cavitation
or multilobar involvement).
 Etiologic Diagnosis
 The benefit of establishing a microbial
etiology can be questioned, esp. with cost
of diagnostic testing.
 Except for 2% of CAP patients who are
admitted to the ICU, NO data exist to show
that treatment directed at a specific
pathogen is statistically superior to empiric
therapy.
 Identification of an unexpected pathogen
allows narrowing of the initial empirical
regimen that decreases antibiotic
selection pressure, lessening the risk of
resistance.
 Without C&S data, trends in resistance
cannot be followed accurately, and
appropriate empirical therapeutic
regimens are harder to devise.
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.
 >25 neutrophils and <10 squamous
epithelial cells/lpf
 Even in cases of proven bacteremic
pneumococcal pneumonia, the yield of
positive cultures from sputum samples is
≤50%
 The greatest benefit of staining and
culturing respiratory secretions is to alert
the physician of unsuspected and or
resistant pathogens ans to permit
appropriate modification of treatment.
Blood Cultures

 Only 5-14% of cultures of blood from

patients hospitalized with CAP are
positive, and the most frequently isolated
pathogen is S. pneumonia
 Because of the low yield of significant
impact on outcome, blood cultures are no
longer considered de rigeuer for all
hospitalized CAP patients.
Antigen tests

 Two commercially available test detect

pneumococcal and certain Legionella
antigens in urine.
 L. pneumophila detects only serogroup 1,
which accounts for most community
acquired cases of Legionnaires’ disease.
Sensitivity and Specificity is 90% and 99%,
respectively.
 Pneumococcal urine test is also quite
sensitive and specific (80% and >90%,
respectively.
 CLASSIFICATION
Low-Risk CAP
Vital signs Stable:
• RR <30/min
• PR <125bpm
• T> 36˚C or < 40˚C
• BP > 90/60
Features • No altered mental state of
acute onset
• No suspected aspiration
• No or stable comorbid
conditions
Chest X-Ray • Localized infiltrates
• No pleural effusion
• No abscess
Disposition • Outpatient
Moderate-Risk CAP
Vital signs Unstable:
• RR ≥ 30/min
• PR ≥ 125bpm
• T ≥ 40˚C or ≤ 36˚C
• SBP < 90/60
Features • Altered mental state of acute
onset
• Suspected aspiration
• Decompensated co-morbid
condition
Chest X-Ray • Multilobar infiltrates
• Pleural effusion
• Abscess
Disposition • Ward admission
High-Risk CAP
Vital signs Any of the criteria under
moderate-risk CAP, PLUS:

Features • Severe sepsis and septic shock

• Need for mechanical
ventilation
Chest X-Ray

Disposition • ICU admission

 CURB65

Parameter Scoring System

C: Confusion • 0 Points: May treat as outpatient
U: Urea > 7 mmol/L • 2 Points: Treat as in-patient
R: RR ≥ 30/min • ≥ Points: Treat as in-patient ICU
B: BP ≤ 90/60mmHg
65: Age ≥ 65 years old
Empiric Microbial therapy for
CAP
Phase Description
Streptococcus pneumoniae
Haemophilus influenza
Low-risk Chlamydophilia pneumonia
Mycoplasma pneumonia
CAP
Moraxella catarrhalis
Enteric Gram-negative bacilli
(among those with co-morbid disease)
Empiric Therapy
Previously healthy:
Amoxicillin
OR
Extended macrolides
(suspected atypical pathogens)
With stable comorbid illness:
ß-lactam/ß-lactamase inhibitor
combination (BLIC) or second-
generation oral cephalosporins
+ extended macrolides
Alternative:
Third-generation oral
cephalosporin + extended
macrolide
 Phase Description Empiric Therapy

Streptococcus pneumoniae
IV non-antipseudomonal ß-
Haemophilus influenza
lactam (BLIC, cephalosporin or
Chlamydophilia pneumonia
carbapenem) + extended
Mycoplasma pneumonia
Moderate-risk macrolide
Moraxella catarrhalis
CAP OR
Enteric Gram-negative bacilli
IV non-antipseudomonal ß-
Legionella pneumophila
lactam + respiratory
Anaerobes
fluoroquinolones
(among those with co-morbid disease)
 Phase Description
Streptococcus pneumoniae
Haemophilus influenza
Chlamydophilia pneumonia
Mycoplasma pneumonia
High-risk Moraxella catarrhalis
Enteric Gram-negative bacilli
CAP
Legionella pneumophila
Anaerobes
(among those with co-morbid disease)
Staphylococcus aureus
Pseudomonas aeruginosa
Empiric Therapy
Previously healthy:
Amoxicillin
OR
Extended macrolides
(suspected atypical pathogens)
With stable comorbid illness:
ß-lactam/ß-lactamase inhibitor
combination (BLIC) or second-
generation oral cephalosporins
+ extended macrolides
Alternative:
Third-generation oral
cephalosporin + extended
macrolide
Assessing Response to
Therapy
 Response to therapy expected within 24 to
72 hours of initiating treatment
 Fever should decrease within 72 hours
 Temp. should normalize within 5 days
 Respiratory signs should return to normal
 HR, BP, sensorium, O2 saturation, and inspired
oxygen concentration
 Follow-up cultures of blood and sputum are
not indicated for patients who are
responding to treatment
 Failure to improve after 3 days of
treatment is an indication for
reassessment
 Incorrect diagnosis
 Presence of a complicating non-infectious
condition (PE,CHF, vasculitis, MI
 Resistant microorganism o an unexpected
pathogen
 Antibiotic is ineffective or causing an allergic
reaction
 Impaired local or systemic host defences
 Local or distant complications of pneumonia
(e.g. parapneumonic effusion, empyema, lung
abscess, ARDS, metastatic infection,
endocarditis)
 Overwhelming infection
 Slow response in the elderly patient
 Exacerbation of co-morbid illnesses
 Nosocomial superinfection
 PROGNOSIS
 Depends on patient’s age,
comorbidities, and site of treatment
(inpatient or outpatient)
 Young patient without comorbidity do
well and usually recover fully after
approximately 2 weeks
 Older
patients and those with
comorbid conditions can take several
weeks longer to fully recover
 Overall mortality rate for the
outpatient group is <1%
 Patients requiring hospitalization
have an overall mortality rate at
10%, with 50% of deaths directly
attributable to pneumonia
 PREVENTION
 Main preventive measure is
vaccination
 Influenza
vaccination is
recommended for the prevention of
CAP.
 Pneumococcal vaccination is
recommended for the prevention of
invasive pneumococcal disease (IPD)
in adults.
 Smoking cessation is recommended
for all persons with CAP who smoke.
 Datasuggests that cigarette
smoking(passive or otherwise) is the
major avoidable risk factor for
acute pneumonia in adults.