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com/millenialdesigns

Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

http://www.companyofbadgers.com/millenialdesigns

Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Objectives
• Present history and physical examination of a patient with community acquired pneumonia

• Discuss Community Acquired Pneumonia

• Outline the differential diagnosis for this case

• Discuss the work-ups to be requested

• Administer proper care and management to our patient

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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

• B.C.
• 86-year old
• Female
Case
Present Illness
Past Medical
Obstetric
CC: Cough
Family
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

2 days PTA Day of Admission

• Non-productive cough • Cough gradually worsened and
• No apparent triggers or associated patient was still febrile
difficulty of breathing • Associated weakness developed
• Associated intermittent fever such that the patient had difficulty
standing even with support
• No consult done
Case
Present Illness
Past Medical
Obstetric 1 day PTA
Family • Cough worsened

Personal/Social • Now productive with whitish sputum

• No associated difficulty of breathing and still
Review of Systems febrile
Physical Examination • No consult done
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Transient Ischemic Attack

• 5 years prior
• Fully recovery with no signs
Case
Present Illness Diabetes Mellitus
Past Medical
• Diagnosed 4 years prior
Obstetric
Family • Maintained on metformin, uncompliant
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Hypertensive
• Diagnosed 4 years prior
• Maintained on losartan, uncompliant
Case
Present Illness • No allergies
Past Medical
• No previous accidents
Obstetric
Family • No previous surgeries
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

• G9P9 (9009)

• Menopause at the age of 55

Case
Present Illness
Past Medical
Obstetric
Family
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

• Diabetes mellitus on the mother’s side

• Hypertension on both sides of the family

Case
Present Illness
Past Medical
Obstetric
Family
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

• Lives together with family (daughter, in-laws,

grandchildren)
• Unemployed

Case
Present Illness • Denies smoking
Past Medical • Denies drinking alcoholic beverages
Obstetric
• Denies elicit drug use
Family
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

GENERAL
• Unremarkable. No fatigue, sleeplessness, weight loss,
fever or night sweats
Case
Present Illness SKIN
Past Medical • Unremarkable. No itching and petechial rashes
Obstetric
• No changes in color, hair or nails, or size or color of
Family
moles
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

HEENT
• Unremarkable. No yellow discoloration in the palpebral
conjunctiva, no visual changes, blurring of visions, pain,
discharge, cataract, and glaucoma
Case
• No earaches, ear discharge, tinnitus and vertigo
Present Illness
Past Medical • No colds, nasal stuffiness, discharge, itching and
Obstetric epistaxis
Family • No bleeding, sore tongue, dry mouth, hoarseness,
Personal/Social excessive salivation, dysphagia
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

RESPIRATORY
• Unremarkable. No signs of wheezing, and hemoptysis
observed
Case
Present Illness CARDIOVASCULAR
Past Medical • Unremarkable. No signs of chest pain or discomfort
Obstetric
• No orthopnea, edema, and paroxysmal nocturnal
Family
dyspnea
Personal/Social
Review of Systems • No electrocardiogram results
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

GASTROINTESTINAL
• Unremarkable. No trouble swallowing, heartburn,
nausea, or changes in appetite
• No change in bowel movements or habits, rectal
Case
bleeding, black or tarry stools, hemorrhoids,
Present Illness
constipation, diarrhea, abdominal pain, food intolerance,
Past Medical
excessive belching or passing of gas
Obstetric
Family • No jaundice, liver or gall bladder problems, or hepatitis
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

URINARY
• Unremarkable. No flank pain, dysuria, incontinence,
passage of stone, nocturia, polyuria, oliguria, frequency
on urination, hematuria, discharge and pain on urination
Case
Present Illness
Past Medical NERVOUS
Obstetric • Unremarkable. No headache, dizziness and
Family lightheadedness
Personal/Social
• No head injury, no seizure, tremors, loss of memory,
Review of Systems
paralysis, involuntary movements, and loss of sensation
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

MUSCULOSKELETAL
• Unremarkable. No muscle pain, joint pain, stiffness and
limitation of motion
• No bone deformity
Case
Present Illness
Past Medical ENDOCRINE
Obstetric
• Unremarkable. No goiter, heat or cold intolerance,
Family
polydipsia, and polyphagia
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

PSYCHIATRIC
• Unremarkable. No mood swings, behavioural changes,
anxiety or depression
Case
Present Illness HEMATOLOGIC
Past Medical • Unremarkable. No bruising, bleeding, or past
Obstetric transfusions
Family
Personal/Social
Review of Systems
Physical Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

VITAL SIGNS
• BP – 130/80 HR – 124
• RR – 33 Temp – 40.0
Case
Present Illness
Past Medical ANTHROPOMETRICS
Obstetric • Weight – 72kg Height – 162cm
Family
• BMI – 27.4
Personal/Social
Review of Systems
Physical
Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

GENERAL SURVEY
• Awake, appears acutely ill, not in cardiorespiratory
distress
Case
Present Illness
SKIN
Past Medical
Obstetric • Skin is consistent with a women her age
Family • No presence of bruises or sites of bleeding in the body
Personal/Social
Review of Systems
Physical
Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

HEENT
• Atraumatic head
• Anicteric sclerae, pink palpebral conjunctivae
Case
• No nasoaural discharge
Present Illness
Past Medical • Pinkish mouth and throat
Obstetric
Family
Personal/Social
Review of Systems
Physical
Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

CHEST & LUNGS

• No retractions, alar flaring, or use of accessory muscles
• Symmetrical chest expansion
Case
• Bi-basal crackles appreciated on auscultation
Present Illness
Past Medical
Obstetric CARDIOVASCULAR
Family
• Adynamic precordium
Personal/Social
Review of Systems • No adventitious heart sounds
Physical • Normal rate, regular rhythm
Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

ABDOMEN
• Soft, flabby
• Normoactive bowel sounds
Case
• Non-tender, non-distended
Present Illness
Past Medical
Obstetric BACK & SPINES
Family
• No abnormal curvature
Personal/Social
Review of Systems
Physical
Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

EXTREMITIES
• No gross deformities
• Full and equal pulses on all extremities
Case
• CRT <2 seconds
Present Illness
Past Medical
Obstetric NEUROLOGIC
Family
• No focal neurologic deficits
Personal/Social
Review of Systems
Physical
Examination
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Overview • One of the most common infectious diseases and an

Pathophysiology important cause of mortality and morbidity worldwide
Etiology
Epidemiology
• Morbidity and mortality due to this disease are common
in the elderly population as well as
immunocompromised hosts

• Presence of co-morbidities such as structural lung

disease or cancer, anemia, and hypoxia are associated
with increased morbidity
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Overview
Pathophysiology
Etiology
Epidemiology
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Overview • S. pneumoniae
Pathophysiology
• H. influenzae
Etiology
Epidemiology • M. catarrhalis

• C. pneumoniae
• Legionella spp.
• Respiratory viruses
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Overview • More than 5 million CAP cases occur annually in the

Pathophysiology United States
Etiology
Epidemiology
• 80% treated as outpatients and 20% as inpatients

• Mortality rate of outpatients is ≤1%, whereas among

hospitalized patients the rate can range from ∼12% to
40%

• CAP results in more than 1.2 million hospitalizations and

more than 55,000 deaths annually.
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Risk Stratification • Low-Risk CAP

• Moderate-Risk CAP
• High-Risk CAP
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Community Acquired Pneumonia (Internal Med)
Clinical Clerk Borja, Alexandra
History About
Risk Stratification Signs and Symptoms
LOW RISK CAP
Stable Vital signs
RR 90 mm Hg
DBP> 60 mm Hg Temp
>36C or <40C
• No altered mental state of
acute onset
• No suspected aspiration
• No or stable co-morbid
conditions
• Chest X ray:
- localized infiltrates
- No evidence of
- pleural effusion
Differentials
Potential Pathogens
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Moraxella catarrhalis Enteric
Gram-negative bacilli
(among those with co-
morbid illness)
Work-up Management
Empiric Antibiotic
Treatment
Without co-morbid illness
Amoxicillin 1 gm TID OR
Extended macrolides:
Azithromycin 500 mg OD
OR Clarithromycin 500 mg BID
With stable co-morbid illness
β-lactam/β-lactamase
inhibitor combination
(BLIC OR 2nd gen oral
cephalosporin +/- extended
Macrolides
Co-amoxiclav 1 gm BID OR
Sultamicillin 750 mg BID OR
Cefuroxime axetil 500 mg BID
+/-
Azithromycin 500 mg OD OR
Clarithromycin 500 mg BID
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Risk Stratification Signs and Symptoms

Sypmtoms Potential Pathogens Empiric Antibiotic
MODERATE-RISK Treatment
CAP
Unstable Vital Signs: Streptococcus pneumoniae WithoutIVco-morbid
non-antipseudomonal
illness
Amoxicillin 1 gm β-lactam
TID OR
RR > 30/min Haemophilus influenzae Extended(BLIC, cephalosporin)
macrolides:
PR > 125/min
Chlamydophila + extended macrolides
Azithromycin 500 mg OD
Temp < 36o C or > 40oC or 500 mg BID
OR Clarithromycin
pneumoniae Mycoplasma respiratory fluoroquinolones
SBP<90 mmHg
DBP<60 mmHg Mycoplasma pneumoniae
pneumoniae Moraxella With stable co-morbid illness
Cefuroxime 1.5 g q8h IV OR
β-lactam/β-lactamase
Moraxella
catarrhaliscatarrhalis
Enteric Gram- Ceftriaxone
inhibitor 2 g OD
combination
Altered mental state of acute Enteric
negativeGram-negative
bacilli (among (BLIC OR 2nd+ gen oral
Azithromycin +/-
cephalosporin 500extended
mg OD
onset bacilli
those with co-morbid PO OR
Macrolides
Legionella
illness) pneumophila Clarithromycin 500 mg BID
Suspected aspiration Co-amoxiclav PO OR
1 gm BID OR
Anaerobes (among those
Levofloxacin
Sultamicillin 750 500mg ODOR
mg BID
with risk of aspiration) Cefuroxime PO OR500 mg BID
axetil
Moxifloxacin+/-400 mg OD PO
Azithromycin 500 mg OD OR
Clarithromycin 500 mg BID
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Risk Stratification Signs and Sypmtoms Potential Pathogens Empiric Antibiotic

MODERATE-RISK Treatment
CAP (continued)
Unstable /Decompensated
Vital Signs: Streptococcus pneumoniae If aspiration
Without pneumonia
co-morbid is
illness
suspected
Amoxicillin and,
1 gma regimen
TID OR
comorbid
RR > 30/mincondition Haemophilus influenzae containing ampicillinsulbactam and/or
Extended macrolides:
-uncontrolled
PR > 125/min DM
Chlamydophila moxifloxacin is used, there
Azithromycin 500 mg OD
-active
Temp <malignancies
36o C or > 40oC is no need to add another
OR Clarithromycin 500 mg BID
pneumoniae Mycoplasma antibiotic for additional
-neurologic
SBP<90 mmHg disease in
evolution,
DBP<60 mmHg Mycoplasma pneumoniae
pneumoniae Moraxella anaerobic
With stable coverage.
co-morbid If illness
another combination is
β-lactam/β-lactamase
-congestive heart failure Moraxella
catarrhaliscatarrhalis
Enteric Gram- used may inhibitor
add clindamycin
combination
(CHF)
AlteredClassII-IV
mental state of acute Enteric
negativeGram-negative
bacilli (among to the regimen
(BLIC ORto cover
2nd gen oral
microaerophilic streptococci.
cephalosporin +/- extended
-unstable
onset coronary artery bacilli
those with co-morbid Macrolides
disease aspiration
Suspected Legionella pneumophila
illness) Clindamycin 600mg q8h IV
Co-amoxiclav 1 gm BID OR
Anaerobes (among those OR
-renal failure
Unstable on dialysis
/Decompensated Sultamicillin 750 mg BID OR
with risk of aspiration) Ampicillin-Sulbactam 3g
Cefuroxime axetil 500 mg BID
-uncompensated
comorbid condition COPD
q6h+/- IVOR
-decompensated
-uncontrolled DMliver Azithromycin 500 mg OD OR
Moxifloxacin 400mgODPO
diseasemalignancies
-active Clarithromycin 500 mg BID
-neurologic disease in
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Risk Stratification Signs and Symptoms

Sypmtoms Potential Pathogens Empiric Antibiotic
HIGH-RISK CAP Treatment
Any of theVital
Unstable clinical feature
Signs: Streptococcus pneumoniae
Streptococcus pneumoniae No risk
Without for P.illness
co-morbid aeruginosa
Amoxicillin 1 gm TID OR
of
RRModerate
> 30/min risk CAP Haemophilus
Haemophilusinfluenzae
influenzae IV non-antipseudomonal
Extended macrolides:
plus
PR >any of the following:
125/min Chlamydophila pneumoniae β-lactam
Chlamydophila Azithromycin 500 mg OD
Temp < 36o C or > 40oC Mycoplasma pneumoniae + IV extended macrolidesa
OR Clarithromycin 500 mg BID
pneumoniae Mycoplasma
Severe
SBP<90Sepsis
mmHg and Septic Moraxella catarrhalis or IV respiratory
Shock
DBP<60 mmHg pneumoniae Moraxella
Enteric Gram-negative bacilli
With stable co-morbid illness
Fluoroquinolone
β-lactam/β-lactamase
catarrhalis Enteric Gram-
Legionella pneumophila inhibitor combination
OR
Altered mental state of acute negative
Anaerobesbacilli
(among(among
those with Ceftriaxone 2 gm
(BLIC OR 2nd gen OD
oral OR
cephalosporin +/- extended
onset risk of aspiration)
those with co-morbid Ertapenem 1 gm OD +
Macrolides
Need for aspiration
Suspected Staphylococcus
illness) aureus Azithromycin dihydrate
Mechanical Ventilation Pseudomonas aeruginosa 500 mg OD
Co-amoxiclav IVBID
1 gm OROR
Unstable /Decompensated Levofloxacin
Sultamicillin 750500mg
mg BID OD
OR
Cefuroxime axetil 500 mg BID
comorbid condition IV OR
+/-
-uncontrolled DM Moxifloxacin 400mg
Azithromycin 500 mg ODOD
ORIV
-active malignancies Clarithromycin 500 mg BID
-neurologic disease in
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Community Acquired Pneumonia (Internal Med)
Clinical Clerk Borja, Alexandra
History About
Risk Stratification Signs and Symptoms
Sypmtoms
HIGH-RISK CAP
Unstable Vital Signs:
RR > 30/min
PR > 125/min
Temp < 36o C or > 40oC
SBP<90 mmHg
DBP<60 mmHg
Altered mental state of acute
onset
Suspected aspiration
Unstable /Decompensated
comorbid condition
-uncontrolled DM
-active malignancies
-neurologic disease in
Differentials Work-up Management
Potential Pathogens Empiric Antibiotic
Treatment
Streptococcus pneumoniae Riskco-morbid
Without for P. aeruginosa
illness IV
Amoxicillin 1 gm TID OR
Haemophilus influenzae antipneumococcal
Extended macrolides:
antipseudomonal β-lactam
Chlamydophila Azithromycin 500 mg OD
(BLIC, cephalosporinBID
OR Clarithromycin 500 mg or
pneumoniae Mycoplasma
carbapenem) + IV extended
pneumoniae Moraxella With stable co-morbid illness
macrolidesa + aminoglycoside
β-lactam/β-lactamase
catarrhalis Enteric Gram- inhibitor combination
negative bacilli (among Piperacillin-tazobactam
(BLIC OR 2nd gen oral 4.5
cephalosporin +/- extended
those with co-morbid gmq6h OR Cefepime 2 gm q8-
Macrolides
illness) 12h OR Meropenem 1 gm q8h
+ Azithromycin
Co-amoxiclav 1dihydrate
gm BID OR 500
mg OD IV +750
Sultamicillin Gentamicin
mg BID OR 3
Cefuroxime axetil 500 mg BID
mg/kg OD OR Amikacin 15
+/-
Azithromycin 500OD
mg/kg mg OD OR
Clarithromycin 500 mg BID
OR
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Community Acquired Pneumonia (Internal Med)
Clinical Clerk Borja, Alexandra
History About
Risk Stratification Signs and Symptoms
Sypmtoms
HIGH-RISK CAP
Unstable Vital Signs:
RR > 30/min
PR > 125/min
Temp < 36o C or > 40oC
SBP<90 mmHg
DBP<60 mmHg
Altered mental state of acute
onset
Suspected aspiration
Unstable /Decompensated
comorbid condition
-uncontrolled DM
-active malignancies
-neurologic disease in
Differentials Work-up Management
Potential Pathogens Empiric Antibiotic
Treatment
Streptococcus pneumoniae IV antipneumococcal
Without co-morbid illness
Amoxicillin 1 gm TID OR
Haemophilus influenzae antipseudomonal β-
Extended macrolides:
lactamf(BLIC,
Azithromycincephalosporin
Chlamydophila 500 mg OD
OR Clarithromycin 500 mg BID
or carbapenem) + IV
pneumoniae Mycoplasma
ciprofloxacin / high
pneumoniae Moraxella With stable co-morbid illness dose
levofloxacin
β-lactam/β-lactamase
catarrhalis Enteric Gram- inhibitor combination
negative bacilli (among (BLIC OR 2nd gen oral
Piperacillin-tazobactam
cephalosporin +/- extended 4.5
those with co-morbid
gmq6hORMacrolides
Cefepime 2 gms
illness)
q8-12h OR Meropenem 1 gm
Co-amoxiclav 1 gm BID OR
q8hSultamicillin
+ Levofloxacin 750
750 mg BID ORmg
ODCefuroxime
IV OR Ciprofloxacin
axetil 500 mg BID400
+/-
Azithromycin 500 mgIV
mg q8-12h OD OR
Clarithromycin 500 mg BID
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Community Acquired Pneumonia (Internal Med)
Clinical Clerk Borja, Alexandra
History About
Risk Stratification Signs and Symptoms
Sypmtoms
HIGH-RISK CAP
Unstable Vital Signs:
RR > 30/min
PR > 125/min
Temp < 36o C or > 40oC
SBP<90 mmHg
DBP<60 mmHg
Altered mental state of acute
onset
Suspected aspiration
Unstable /Decompensated
comorbid condition
-uncontrolled DM
-active malignancies
-neurologic disease in
Differentials Work-up Management
Potential Pathogens Empiric Antibiotic
Treatment
Streptococcus pneumoniae If MRSA
Without co-morbidpneumonia
illness is
Amoxicillin 1 gm TID OR
Haemophilus influenzae suspected, add Vancomycin
Extended macrolides:
Chlamydophila 15Azithromycin
mg/kg q8-12 500 mghOD
OR
OR Clarithromycin 500 mg BID
pneumoniae Mycoplasma Linezolid 600mg q12h IV OR
pneumoniae Moraxella Clindamycin
With 600mg
stable co-morbid illnessq8h IV
β-lactam/β-lactamase
catarrhalis Enteric Gram- inhibitor combination
negative bacilli (among (BLIC OR 2nd gen oral
cephalosporin +/- extended
those with co-morbid Macrolides
illness)
Co-amoxiclav 1 gm BID OR
Sultamicillin 750 mg BID OR
Cefuroxime axetil 500 mg BID
+/-
Azithromycin 500 mg OD OR
Clarithromycin 500 mg BID
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Picture
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis About

Aspiration
Pneumonia • Inflammation of the bronchi, the air passages that
Atypical Myocardial extend from the trachea into the small airways and
Infarction alveoli
COPD

Presentation
• Presents as productive cough, febrile episode, dyspnea,
general malaise, sore throat, and runny nose
• Chest pain can be observed in severe cases
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis Diagnostics

Aspiration
Pneumonia • Complete Blood Count
Atypical Myocardial
Infarction
• Chest x-ray
COPD • Serum electrolytes
• Arterial blood gas
• 12-lead ECG
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis About

Aspiration
Pneumonia • Inhalation of either oropharyngeal or gastric contents
Atypical Myocardial into the lower airways –act of taking foreign material
Infarction into the lungs
COPD

Presentation
• Presents as productive cough with purulent sputum,
febrile episode, chills dyspnea on exertion, shortness of
breath, pleuritic chest pain, malaise, and myalgia
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis Diagnostics

Aspiration
Pneumonia • Complete Blood Count
Atypical Myocardial
Infarction
• Lipid profile
COPD • Chest x-ray
• Serum electrolytes
• Arterial blood gas
• 12-lead ECG
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis About

Aspiration
Pneumonia • Inhalation of either oropharyngeal or gastric contents
Atypical Myocardial into the lower airways –act of taking foreign material
Infarction into the lungs
COPD

Presentation
• Presents as chest discomfort characterized as intense
and unremitting for 30-60 minutes; usually described as
squeezing, aching, burning, or even sharp; atypically
epigastric in origin
• Also as fatigue and malaise
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis Diagnostics

Aspiration
Pneumonia • Complete Blood Count
Atypical Myocardial
Infarction
• 12-lead ECG
COPD • Lipid profile
• Troponin-T levels
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis Chronic Bronchitis

Aspiration
Pneumonia • Presence of a chronic productive cough for 3 months
Atypical Myocardial during each of 2 consecutive years
Infarction
COPD
Presentation
• Obese
• Makes use of accessory muscles of respiration
• Signs of right heart failure such as edema and cyanosis
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis Emphysema

Aspiration
Pneumonia • Abnormal, permanent enlargement of the air spaces
Atypical Myocardial distal to the terminal bronchioles, accompanied by
Infarction destruction of their walls and without obvious fibrosis
COPD

Presentation
• May be very thin with a barrel chest
• Breathing through pursed lips and use of accessory
respiratory muscles
• Adopts the tripod sitting position
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis Signs and Symptoms

Aspiration
Pneumonia • Cough – usually worse in the mornings and productive
Atypical Myocardial
Infarction
• Breathlessness – not apparent until the sixth decade of
COPD
life
• Wheezing – particularly during exertion
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Acute Bronchitis Diagnostics

Aspiration
Pneumonia • Complete Blood Count
Atypical Myocardial
Infarction
• Lipid profile
COPD • Chest x-ray
• Serum electrolytes
• Arterial blood gas
• 12-lead ECG
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Complete Blood
Count
• Patient’s chief complaint clinically resembles an infection
Chest X-ray (PA view)
Na, K, Crea • Document infection or malignancies of the blood
Random Blood Sugar
Lipid Profile
12 lead ECG • Determine platelet status
Urinalysis

• To rule out hypercoagulable states

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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Complete Blood Erythrocyte NUMC 3.90 ▼ 4.60-6.20 x1012/L

Count Hemoglobin 11.1 ▼ 12.0-16.0 g/dL
Chest X-ray (PA view) Hemoglobin SUBSTC 1.7205 ▼ 1.86-2.58
Na, K, Crea
Erythrocyte VOLFR 0.34 ▼ 0.36-0.40
Random Blood Sugar
Leukocyte NUMC 6.0 4.5-11 x109/L
Lipid Profile
segmenter 0.83 ▲ 0.56
12 lead ECG
lymphocyte 0.10 0.34
Urinalysis
monocyte 0.06 ▲ 0.04

Thrombocyte 223 150-400 x109/L

MCV 87.50 80-96 fL

MCH 23 ▼ 27-31 pg

MCHC 0.33 0.32-0.36

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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Complete Blood
Count
• Clinical picture of an infection localized to the lungs
Chest X-ray (PA
(cough)
view)
Na, K, Crea
• To visualize the state of the lungs
Random Blood Sugar
Lipid Profile
12 lead ECG • To rule out CAP from other lung pathologies such as
Urinalysis Pulmonary edema, COPD, and malignancy
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Complete Blood • Opacity is noted in the right

Count
upper lobe
Chest X-ray (PA
view) • Minimal interstitial infiltrates
Na, K, Crea
are likewise noted in the right
lower lobe
Random Blood Sugar
• Heart is not enlarged
Lipid Profile
12 lead ECG
• Aorta is segmentally calcified
Urinalysis • Both hemidiaphragms and
right costophrenic sulci are
intact
• Mild rightward deviation of
thoracic spine with
degenerative changes
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Complete Blood
Count
• Patient also presents with weakness
Chest X-ray (PA view)
Na, K, Crea • Document any fluctuations in electrolytes that may be
Random Blood Sugar the cause of weakness or may contribute to worsening
Lipid Profile of the patient’s condition
12 lead ECG
Urinalysis Result
Sodium 132.03 ▼ 135-148 mmol/L

Potassium 3.51 3.5-5.0 mmol/L

Creatinine 118.00 ▲ 53-106 umol

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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Complete Blood
Count
• Patient is known diabetic who is non-compliant with
Chest X-ray (PA view)
medications
Na, K, Crea
Random Blood • Document any derangements in blood sugar which may
Sugar
be an additional co-morbidity that would further
Lipid Profile
complicate this condition
12 lead ECG
Urinalysis

Result
92 72-99 mg/dL
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Complete Blood
Count
• Patient is a known hypertensive who is non-compliant
Chest X-ray (PA view)
with medications
Na, K, Crea
Random Blood Sugar • Document any derangements in lipid profile that may be
Lipid Profile an additional co-morbid that would further complicate
12 lead ECG this condition
Urinalysis

• Also to rule out the possibility of infarction secondary to

lipid plaque formation
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Complete Blood
Count
• Patient is elderly with cough and difficulty of breathing
Chest X-ray (PA view)
Na, K, Crea • Patient is known diabetic and hypertensive who is non-
Random Blood Sugar compliant with medications
Lipid Profile
12 lead ECG
Urinalysis • Rule out the possibility of atypical myocardial infarction
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Complete Blood
Count
• Clinically picture of an infection localized to the lungs
Chest X-ray (PA view)
but given the patient’s age co-infection else where
should be ruled out
Na, K, Crea
Random Blood Sugar
Lipid Profile • Also assess the state of the Kidneys
12 lead ECG
Urinalysis
• Gives a picture of end-organ damage due to diabetes
mellitus
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Low-risk • Amoxicillin 1gm, TID

Mod-risk
• Azithromyzin 500mg, OD
High-risk
• Clarithromycin 500mg, BID
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Low-risk • Ampicillin-Sulbactam 1.5g, q6 IV

Mod-risk
• Cefuroxime 1.5g, q8 IV
High-risk
• Ceftriaxone 2g, OD
+
• Azithromycin 500mg, OD PO
• Clarithromycin 500mg, BID PO
• Levofloxacin 500mg, OD PO
• Moxiflocain 400mg, OD PO
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Low-risk • Clindamycin 600mg, q8 IV

Mod-risk
• Ampicillin-Sulbactam 3g, q6 IV
High-risk
• Moxifloxacin 400mg, OD PO
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Final Diagnosis Community Acquired Pneumonia – Moderate Risk

Management
Rule In Rule Out
References
o CC: cough o No signs of shock
o No hypotension
o PR - 124 o No altered mental status
o RR - 33 o No signs of aspiration
o T - 40.0
o No history of smoking
o CXR: effusion o Acute in presentation
o CXR: no hyperinflation of the lungs

o Sinus Rhythm
o Troponin T: <50
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Final Diagnosis Community Acquired Pneumonia – Moderate Risk

Management
Theoretical Actual
References
Ampicillin-Sulbactam 1.5g, q6 IV
Azithromycin 500mg/tablet once a
Cefuroxime 1.5g, q8 IV
day*
Ceftriaxone 2g, OD
+
Ceftriaxone 2g/IV once a day*
Azithromycin 500mg, OD PO
Clarithromycin 500mg, BID PO
Levofloxacin 500mg, OD PO
* For 7 days
Moxiflocain 400mg, OD PO
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management

Final Diagnosis References:

Management
References
Harrison’s 20th Edition
CPG CAP by PSMID
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Community Acquired Pneumonia (Internal Med)

Clinical Clerk Borja, Alexandra

History About Differentials Work-up Management