SGD Group 1C

CASE PRESENTATION
GENERAL DATA
 Patient X is a 71 year old female, window
retired lawyer, liver in the city

CHIEF COMPLAINT
 Fever and productive cough
HISTORY OF PRESENT ILLNESS

4 days PTA 2 days PTA

 cough.  she had a temp 38.9 0 C.  Hemoptysis

 productive of yellowish  The fever, cough and  weight loss
sputum chest pain continued  sore throat
 left sided chest pain  next 48 hr. so she came  Sinustitis
to the Emergency  back pain,
Department diarrhea, rash
 joint pain or
headaches
PAST MEDICAL HISTORY : PMH
• Lasix : Furosemide
• ACE- inhibitor : Such as Enalapril and Captopril et.
• Lopressor : Metoprolol tartrate

PERSONAL SOCIAL HISTORY : SH

 Former smoker but quit 3 months ago
 Denies alcohol use
 No recent travel, domestic pets or any risk factors for HIV
exposure.
 PERTINENT FINDINGS IN MEDICAL HISTORY

PERTINENT (-) PERTINENT (+)

 hemoptysis, weight loss, sore throat, sinusitis, back  71 years old

pain, diarrhea, rash, joint pain or headaches
 denies alcohol use, recent travel, domestic pets or
any risk factors for HIV exposure
 Female
 38.9oC
 Productive cough and Yellow sputum
 Chills
 left sided chest pain
 history of congestive HF related to IHD that has been
controlled with Furosemide, an ACEI, and Metoprolol
 former smoker : husband died of lung cancer
PHYSICAL
EXAMINATIO
N
 PHYSICAL EXAMINATION PERTINENT POSITIVE (+) PERTINENT POSITIVE (-)
GENERAL SURVEY  Thin
 in mild respiratory distress
ITAL SIGNS  emperature: 38.9°C  BP : 128/84 mmHg
 RR: 28 cycles per min  O2 saturation: is 89% on
 PR: 120 beats per min  room air
SKIN  Decrease turgor
HEENT  TMs mildly red  sinuses nontender
 oropharynx is mildly red  no middle ear fluid
 oropharynx no exudate.
CHEST AND LUNGS  remarkable for splinting to the left side on deep  Right chest is clear
inspiration
 dullness to percussion ≈ 1/4 way up on left side
 decreased breath sounds at left base
 Egophony and bronchial breath sounds are evident as one
listens more superiorly on the left side. The right chest is
clear. COR RRR without murmurs or rubs.
 PERTINENT FINDINGS
PERTINENT (+) PERTINENT (-)

 HCO3: 29 (NV: 22 to 28 mEq/L)  Na : 143 (NV: 135-145 mEq/L)

 Glu : 150 (NV: 70 to 99 mg/dL)  K: 4.2 (NV:3.6-5.2 mmol/L)
 WBC:18.0 (NV: (4.5 to 11.0 ×109 /L)  Cl: 100 (NV: 96-106 mEq/L)
 41 lymphs (NV: 20-40%)  Cr: 1.0 (NV:0.59 to 1.04 mg/dL)
 Sputum Gram’s stain: a few PMN, many epithelial  Hb : 13.8 (NV: 12.1 to 15.1g/dL)
cells, and scattered Gram positive and  Hct :39.8 (NV:36% to 48%)
 Gram negative cocci and rods are seen  54 segmenters (NV:40-60%)
 size/left lower lobe infiltrate is present thatobscures the  5 bands (NV: 0-5%)
left heart borde  Platelets 255K (NV: 150,000 to 450,000)
 EKG: NSR/normal rate, intervals and no ischemic
changes
 CXR: Normal heart size
 UA : clear/1.020/1+ protein/no cells or casts
PROBLEM REPRESENTATION
Differential Diagnosis
Typical Community Acquired Pneumonia

Pulmonary TB

COPD

Rheumatic Fever
Comparison of Signs and Symptoms

+ + + +

+ + + + +

+ + + + +

+ + + + +
Comparison of Signs and Symptoms

-
P R I M A RY
I

E
HOW WE ARRIVED IN OUR PRIMARY IMPRESSION?

1. Patient experienced the following signs and symptoms:

• Fever
• chills
• Yellow sputum
• Productive cough
• Tachypnea with pleuritic chest pain
• remarkable for splinting to the left side on deep inspiration
• Dullness on percussion
• Decreased breath sounds

*Reference:
Htun, T. P., Sun, Y., Chua, H. L., & Pang, J. (2019). Clinical features for diagnosis of pneumonia
among adults in primary care setting: A systematic and meta-review. Scientific reports, 9(1),
7600. https://doi.org/10.1038/s41598-019-44145-y
HOW WE ARRIVED IN OUR PRIMARY IMPRESSION?

2. Patient X has a History of Congestive Heart failure

 Chronic heart failure patients has an increased risk of pneumonia due to

alveoli flooding and reduced microbial clearance. A study by Mor
and Thompson suggest that patients with chronic heart failure, in particular
those using loop diuretics, have markedly increased risk of hospitalization
with pneumonia.

*Reference:
Mor A, Thomsen RW, Ulrichsen SP, Sørensen HT. Chronic heart failure and risk of
hospitalization with pneumonia: a population-based study. Eur J Intern Med. 2013
Jun;24(4):349-53. doi: 10.1016/j.ejim.2013.02.013. Epub 2013 Mar 17. PMID: 23510659
RISK FACTORS
• Patient X is a former smoker

 The risk of ex-smokers was similar to current smokers, about 2.14 to

1.According to the study of American College of Chest Physician-The number of
cigarettes smoked per day and the life-time pack-years showed a positive dose-
response relationship, with a significant trend in pneumonia.

*Reference:
Mor A, Thomsen RW, Ulrichsen SP, Sørensen HT. Chronic heart failure and risk of
hospitalization with pneumonia: a population-based study. Eur J Intern Med. 2013
Jun;24(4):349-53. doi: 10.1016/j.ejim.2013.02.013. Epub 2013 Mar 17. PMID: 23510659
RISK FACTORS
• Patient X is 71 years old

 Age is one of the primary risk factors for pneumococcal pneumonia, and even healthy
adults 65 years or older are at increased risk for pneumococcal disease. Our immune
systems naturally weaken with age, it's harder for our bodies to fight off infections and
diseases like pneumococcal pneumonia — even for healthy adults.

*Reference:

Stupka, J. E., Mortensen, E. M., Anzueto, A., & Restrepo, M. I. (2009). Community-
acquired pneumonia in elderly patients. Aging health, 5(6), 763–774.
https://doi.org/10.2217/ahe.09.74
RISK FACTORS
• Patient X has a History of Congestive Heart failure

 Chronic heart failure patients has an increased of pneumonia due to alveoli

flooding and reduced microbial clearance. A study by Mor and Thompson suggest
that patients with chronic heart failure, in particular those using loop diuretics,
have markedly increased risk of hospitalization with pneumonia.

*Reference:
Mor A, Thomsen RW, Ulrichsen SP, Sørensen HT. Chronic heart failure and risk of
hospitalization with pneumonia: a population-based study. Eur J Intern Med. 2013
Jun;24(4):349-53. doi: 10.1016/j.ejim.2013.02.013. Epub 2013 Mar 17. PMID: 23510659
 MOST
COMMON
ETIOLOGIC
AGENT?
Streptococcus pneumoniae
Streptococcus pneumoniae
• Gram-positive
• α-hemolytic
• Lancet-shaped diplococcus
• Bile soluble
• Optochin sensitive
• Catalase-negative but produces hydrogen
peroxide.
• Can cause a range of different illnesses
including sinusitis, otitis media, pneumonia,
bacteraemia, osteomyelitis, septic arthritis and
meningitis
• frequent colonizer of the human
nasopharynx with a colonization rate of
27–65%
F
i
g
u
r
EPIDEMIOLOGY
PNEUMONIA IS COMMON AND SERIOUS

• 150.7 million new cases worldwide in 2020

• 2nd leading cause of hospitalization worldwide
~20% of patients with pneumonia require hospitalization
• 6th leading cause of death in the world
~10% of patients with pneumonia die
Variations in rates of disease:

• More common in men • More common in children and older

• More common in African Americans adults
compared to Caucasians and Asians (overall rate for 18-49 yo is ~5 per 1000
overall rate for >65 yo is 75 per 1000 )
EPIDEMIOLOGY
• Spread via air-borne droplets from a cough or sneeze.
• Outbreaks usually occur in close communities
• Incubation period: 1-3 days
• Susceptibility of population: immunity after infection is short
and unsteady, no cross-immune
PATHOGENESIS
CLEARANCE vs. COLONIZATION

Microbes constantly enter airways

but many factors prevent
colonization:
• mucous entrapment
• ciliary clearance
• immune surveillance
• intact epithelial barrier
• secreted factors such as:
‒ secretory IgA
‒ surfactant proteins (SP-a, SP-d)
‒ defensins

Disrupting or overwhelming these defense mechanisms can allow microbes to

colonize the lungs, resulting in PNEUMONIA
COMMUNITY ACQUIRED PNEUMONIA
• Infection of the pulmonary parenchyma acquired from
exposure in the community
• Classically divided into “typical” and “atypical”
syndromes:
I. “Typical” CAP:
• presents with “typical” severe, acute infection
• infectious agent (usually S. pneumo or H. flu) is culturable/
identifiable
• responsive to cell-wall active antibiotics
II. “Atypical” CAP:
• presentation is usually sub-acute
• causative pathogens are difficult to culture/identify by standard
methods
CLINICAL
Describe the physical findings in the
chest and what they indicate?
• Splinting to the left side on deep inspiration: Splinting is a reduce in inspiratory effort
through shallow breathing to lessen the sharp pain felt with inspiration

• Dullness to percussion indicates denser tissue, such as zones of effusion or consolidation. Once an
abnormality is detected, percussion can be used around the area of interest to define the extent of the
abnormality. Normal areas of dullness are those overlying the liver and spleen at the anterior bases of
the lungs

• Decrease breath sounds at left base or decreased sounds can mean: Air or fluid in or around
the lungs (such as pneumonia, heart failure, and pleural effusion) Increased thickness of the chest wall.
Over-inflation of a part of the lungs
Describe the physical findings in the
chest and what they indicate?
• Egophony is increased resonance of voice sounds heard when auscultating the
lungs. When spoken voices are auscultated over the chest, a nasal quality is imparted
to the sound which resembles the bleating of a goat.

• Bronchial breath sounds are tubular, hollow sounds which are heard when
auscultating over the large airways (e.g. second and third intercostal spaces). They
will be louder and higher-pitched than vesicular breath sounds
42

TYPICAL CAP PRESENTATION

History
• sudden onset of fever and cough
Physical signs and symptoms
• fever
• tachycardia
• tachypnea
• productive cough with purulent sputum and possible hemoptysis
• pallor and cyanosis
• localized:
− dullness to percussion
− decreased breath sounds
− crackles , ronchi , egophony (“E” -to-”A” change)
Investigations
• CXR showing lobar consolidation
• CBC showing leukocytosis w/ left shift
• Sputum sample contains neutrophils, RBCs; Gram stain may be
positive depending on organism
COMPLICATIONS
Don’t SLAP HER:
• Septicemia
• Lung abscess
• ARDS
• Para-pneumonic effusion
• Hypotension
• Empyema
• Respiratory failure/Renal failure
WORK UP/LABS
46

ROUTINE LABORATORY TEST

The following laboratory tests may not be useful for diagnostic purposes but
are useful for classifying illness severity and site-of-care/admission decisions:
• Serum electrolyte panel (sodium, potassium, bicarbonate, blood urea nitrogen [BUN], creatinine,
glucose)
• Arterial blood gas (ABG) determination (serum pH, arterial oxygen saturation, arterial partial
pressure of oxygen and carbon dioxide) – Hypoxia and respiratory acidosis may be present.
• Venous blood gas determination (central venous oxygen saturation)
• Complete blood cell (CBC) count with differential
• Serum free cortisol value
• Serum lactate level
47

BLOOD CULTURE
• Blood cultures should be
obtained before the
administration of antibiotics.
These cultures require 24
hours (minimum) to incubate.
When blood cultures are
positive, they correlate well
with the microbiologic agent
causing the pneumonia.

Figure 4.S. pneumoniae colonies with a surrounding

green zone of alpha-hemolysis (black arrow) on a BAP
49

SPUTUM EVALUATION
• Sputum Gram stain and culture
should be performed before
initiating antibiotic therapy (if a
good-quality, contaminant-
sparse specimen containing < 10
squamous epithelial cells per
low-power field can be
obtained). The white blood cell
(WBC) count should be more
than 25 per low-power field in
non-
immunosuppressed patients. Figure.S. pneumoniae in sputum specimens
50

CHEST RADIOGRAPH
• Chest radiography is considered
the standard method for
diagnosing the presence of
pneumonia, that is, the presence
of an infiltrate is required for the
diagnosis. However, it must be
noted that the accuracy of plain
chest radiography for detecting
pneumonia decreases depending
on the setting of

infection Figure. A chest X-ray of a patient who have bacterial

pneumonia
51

CHEST ULTRASONOGRAPHY
• Ultrasonography (US) is useful
in evaluating suspected
parapneumonic effusions. US can
identify septations within the
fluid collection that may not be
visible on CT scans. US also has
great utility for directing needle
placement for pleural fluid
aspiration (throacentesis) at the
patient's bedside.

Figure. Chest Ultrasonography showing lung

consolidation of a patient who have pneumonia
MANAGEMENT
APPROACH TO
PATIENT X

Figure 5. A concept map showing the approach to a

71 year old female who came in due to fever and
productive cough
Should the patient be hospitalized or
could she be treated as an outpatient?

• Yes, the patient should be hospitalized and monitored since

patient is categorized under moderate-risk community acquired
pneumonia until signs of improvement is manifested.
When should antibiotics be initiated for
the empiric treatment of community-
acquired pneumonia (CAP)?

• Antibiotics, the mainstay for the treatment of pneumonia,

should be initiated as soon as a diagnosis of CAP is made.
Patient X is under moderate-risk
community acquired pneumonia

• Clinical Features of
patients with CAP
according to risk
categories
EMPIRIC THERAPY B:
For patients with
moderate risk
CAP
What initial antibiotics
are recommended for
the empiric treatment
of moderate-risk
community-acquired
pneumonia?
• For moderate-risk CAP, a
combination of an IV
nonantipseudomonal β-lactam
(BLIC, cephalosporin) with either
an extended macrolide or a
respiratory fluoroquinolone is
recommended as initial
antimicrobial treatment.
When should de-escalation of empiric
antibiotic therapy be done?
• De-escalation of initial empiric broad-spectrum antibiotic or combination
parenteral therapy to a single narrow spectrum parenteral or oral agent
based on available laboratory data is recommended once the patient is
clinically improving, is hemodynamically stable and has a functioning
gastrointestinal tract.
SIGNS OF IMPROVEMENT

• In the absence of any unstable coexisting illness or other life

threatening complication, the patient may be discharged once
clinically stable and oral therapy is initiated
• A repeat chest radiograph prior to hospital discharge is not needed in a
patient who is clinically improving
• A repeat chest radiograph is recommended during a follow-up visit,
approximately 4 to 6 weeks after hospital discharge to establish a new
radiographic baseline and to exclude the possibility of malignancy
associated with CAP, particularly in older smokers
REASONS ON LACK OF RESPONSE OF
PATIENTS TO EMPIRIC THERAPY

• The following are the reasons

why patients have lack of
response to empiric therapy
Recommended Hospital discharge criteria
 PREVENTION
 Get the flu vaccine each year. People can develop bacterial pneumonia after a case of the flu. You can
reduce this risk by getting the yearly flu shot.
 Get the pneumococcal vaccine. This helps prevent pneumonia caused by pneumococcal bacteria.
 Practice good hygiene. Wash your hands frequently with soap and water or an alcohol based hand
sanitizer.
 Don’t smoke. Smoking damages your lungs and makes it harder for your body to defend itself from
germs and disease. If you smoke, talk to your family doctor about quitting as soon as possible.
 Practice a healthy lifestyle.Eat a balanced diet full of fruits and vegetables. Exercise regularly. Get plenty of
sleep. These things help your immune system stay strong.
 Avoid sick people. Being around people who are sick increases your risk of catching what they have.
 GROUP MEMBER 1C
 Kumal Sharma 201100481 Leader group
 Jamshed Khan 201100344
 Nikhila Pachikapalam 201100591
 Shanmukhi Sai Priya Kandikattu 201100578
 Shobansai Vijayan 211000465
 Thanigaivel Krishnamoorthy 211000279
 Vitika Dhamija 201100279
 Cheewanon Pipattanapongpun 201100390
 Primprapa Duangseswong 201100386
 Siriphatson Jeamprasit 201100422