Approach to a Patient with Cough and Fever

Slides:



Advertisements
Similar presentations
Preeti Prerna M. Vaswani
Advertisements

General Data E. V. 15/M Single Sampaloc, Manila Roman Catholic.
History of Present Illness 9 months Terminal pain during urination UTI – cefuroxime 250mg/5mL BIDx7 days 6 months Fever and loss of appetite; U/A - WBC:
General Data R.G. 2 years 4 months (May 22, 2008) Male Filipino Roman Catholic Sampaloc, Manila Informant: Mother Reliability: Good.
General Data C.D. Age/Sex/Status: 81/F/Widow Address: San Miguel, Manila Date of birth: May 19, 1929 Place of birth: Manila Occupation: Unemployed Religion:
Brugada Group 6 Ateneo School of Medicine and Public Health.
Objective To present a case of a Hemophagocytic Lymphohistiocytosis (HLH)
General Data Name: Y.F. Age & Gender: 67/Female Civil Status: Widow Occupation: Housewife Chief Complaint: Left neck pain.
Physical Examination On admission Upon PE General Survey Vital Signs
Acute Respiratory Distress Syndrome(ARDS)
Case present By Intern 劉一璋. Patient data Name: 陳 ○ 富 Sex: 男 Age: 71 歲 Date of admission: 96/08/09 Chart No:
Cardiovascular diseases and pulmonary diseases in elderly Ahmad Osailan.
Approach to a patient with cough B4 – Dr. Remedios Coronel Garcia, Garcia, Garzon, Gaspar, Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo Geronimo, Go,
Sickle Cell Disease: Core Concepts for the Emergency Physician and Nurse Acute Chest Syndrome Spring 2013.
Pneumonia Esmaeli, A.; Francisco U.; Golpeo, K.. A. G. 75 year old Male Single From Sta. Mesa, Manila Unemployed CC: progressive and productive cough,
Pneumonia Jen Denno RN, BSN, CEN.
Approach to a Patient with Cough B4 – Dr. Remedios Coronel Garcia, Garcia, Garzon, Gaspar, Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo Geronimo, Go,
General Information S.A. 21 y/o female Single, unemployed Born April 5, 1988 Resident of Laloma City Chief complaint: Left flank pain for 1 day.
Management of Patients With Chronic Pulmonary Disease.
Symptoms In newborns: – Delayed growth – Failure to gain weight normally during childhood – No bowel movements in first 24 to 48 hours of life – Salty-tasting.
Clinical Pathological Conference Kartikya Ahuja, M.D. Resident Physician Department of Medicine NYU School of Medicine July 20 th, 2007.
PROBLEM BASED LEARNING
Respiratory System.
J.M. 21 y/o female cc: scalp mass. History of Present Illness Slowly enlarging, firm, occasionaly tender mass on R parietoocipital area (3x3cm) Consult.
Approach to a Patient with Diabetic Foot
بسم الله الرحمن الرحيم Prepared by: Ala ’ Qa ’ dan Supervisor :mis mahdia alkaunee Cor pulmonale.
PHARMACOLOGY CONFERENCE
ADMISSION CONFERENCE. General Data Name: L.D. Age & Gender: 68/Male Chief Complaint: Difficulty of Breathing.
Case No. 12 SH, 25 years old with a history of asthma since childhood presented to the OPD clinic with complaints of worsening dyspnea and wheezing. He.
Approach to a Patient with Productive Cough and Fever
Pneumonia Dr. Meg-angela Christi Amores. Definition infection of the pulmonary parenchyma often misdiagnosed, mistreated, and underestimated community-acquired.
ANCILLARY PROCEDURES. 11/23/0911/28/09 UnitNV Hgb g/L RBC X10^12/L Hct MCV U^ MCH
Dengue Fever with Warning Signs. Objectives To identify warning signs seen in Dengue Fever To manage a case of Dengue Fever with warning signs.
Patient History  TO  14 year old male  Lives in Palau  Right-handed  Informant: Patient, good reliability Chief Complaint: Wrist Injury.
NYU Medical Grand Rounds Clinical Vignette Maryann Kwa, MD PGY-3 March 20, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Pediatric Diagnosis Observation –Eye contact –Establish rapport with the parents & the child History taking –Investigation –Asking “relevant” questions.
General Data Name: Y.F. Age & Gender: 67/Female Civil Status: Widow Occupation: Housewife Chief Complaint: Left neck pain.
 28 y/o, Female  Chief Complaint: Dyspnea 3 days PTA Underwent dental procedures 2 days PTA Productive cough with yellowish sputum accompanied by colds.
Differential diagnosis
 This is a case of M.T, 37 year-old female, married, Christian, right-handed, from Malate, Manila who came in due to stiffening and pain in the neck.
1 By Dr. Zahoor. Question 1 A 36 year old male patient presents with tiredness, headaches and following is the blood count:  Hb 9.2 g/dl  MCV 109 fl.
Pneumonia Egan’s Chapter 22. Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2 Introduction Infection involving the.
INFLAMMATION LAB Amira F. Gohara, MD Dept. of Pathology Thursday, October 18, 2012.
ALCARAZ, ALLEGRE, ALMORA, ALONZO, AMARO, AMOLENDA, ANACTA, ANDAL, ANG, J.
Management Course in the Wards Discharge Plans. Management: Course in the Wards Hospital Day 1: Admission Day – Requested to be started on: Ceftriaxone.
MUNEZ. 3 months PTA, patient had fever, cough and colds. Consult done at a local health center where she was given amoxicillin for 1 week with noted resolution.
Maria Febi C. Billones January 13,  R.Q.  61 y/o  Female  Married  Bicutan.
Differential diagnosis
Presented by: GAW, Gem Minnie Mae GO, Stephanie M. GONZALES, Alexander II.
ANCILLARY PROCEDURES. Done in the patient CBC Na, K Creatinine SGOT, SGPT 12-L ECG.
UNIVERSITY OF SANTO TOMAS HOSPITAL Clinical Division Department of Neurology and Psychiatry SECTION OF NEUROLOGY.
 IR  45 years old, female  Right handed  Manila  Chief complaint: purulent discharge from surgical wound.
Mark Anthony Melitante Leviste Ateneo School of Medicine and Public Health Batch 2013.
 J.Y.  13 y/o Female  Single  Filipino  Roman Catholic  from Butuan City, Agusan del Norte.
PAKI CHECK NAMAN KUNG TAMA MGA NILAGAY KO TNX DI PA KUMPLETO YAN.
Approach to a Patient with Productive Cough and Fever B4 – Dr. Remedios Coronel Garcia, Garcia, Garzon, Gaspar, Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo.
Pneumonia המצגת הוכנה ע " י אסא טל סטודנט שנה 4 בית הספר לרפואה אוניברסיטת תל - אביב מחלקה פנימית ג ' המרכז הרפואי שיבא טיוטור : דר ' חוסם קאסם.
History and PE Fiona Javelosa. The Curious Case of John Dick Group 3 Clinical Clerk Batch 2012 SY
1 Respiratory System. 2 Main functions: Provide oxygen to cells Eliminate carbon dioxide Works closely with cardiovascular system to accomplish gas exchange.
Case Conference Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea R2 임효석 / Prof. 장재영.
ABDULLAH M. AL-OLAYAN MBBS, SBP, ABP. ASSISTANT PROFESSOR OF PEDIATRICS. PEDIATRIC PULMONOLOGIST. PNEUMONIA.
Echo- Conference R2 조경민. History 강 O 은 (F/77) Chief Complaint Chief Complaint Chest pain o/s) On the day hospitalization Chest pain o/s) On the.
Echo-Conference R2 조경민. History 박 O 화 (F/31) Chief Complaint Chief Complaint Fever.chilling & Chest discomfort O/S) 10 days ago Fever.chilling.
Echo-Conference R2 조경민. History 송 O 규 Chief Complaint Lt.side weakness O/S) Recent onset 3-4 days ago Present illness A 75 year old woman had.
Respiratory System Disorders
Arm Injury A Case Discussion
Course in the Wards Discharge Plans
General data T. E. 39 year old Male Catholic From Mandaluyong City
Pneumonia Dr. Gerrard Uy.
Presentation transcript:

Approach to a Patient with Cough and Fever Subsection B4 Facilitator: Remedios F. Coronel, M.D. December 7, 2009

Objectives To present a case of a patient with cough and fever To discuss the pathogenesis of the signs and symptoms of the patient To interpret the laboratory and ancillary procedures appropriate for a patient with cough and fever To plan an effective management for a patient with cough and fever

General Data Name: RM Age: 60 Sex: Male Status: Married Address: Quiapo, Manila Religion: Roman Catholic Race: Filipino Occupation: Vendor

History of Present Illness 1 week PTA Cough with whitish sputum Easy fatigability Low grade fever – relieved by Paracetamol 500mg/tab (-) Accompanying symptoms 1 day PTA Persistent cough with yellowish sputum Dyspnea Fever recurred (-) Drug intake November 23, 2009 Admission Chief Complaint: Productive Cough and Fever

Past Medical History HPN (2005) - Highest BP 200/160; Usual BP – 120/80 Nifedipine, - unrecalled dosage; “Amcor” from a Chinese store Non-compliant LVH (2005) “ Food poisoning” (unrecalled cause) – UST Hospital (2005) External Hemorrhoids (2005) - resolved Claims to have complete childhood immunizations No history of surgery (-) DM (-) Bronchial asthma (-) PTB (-) Blood transfusion (-) Allergies (-) Trauma/ accident

Family History (+) HPN – parents and siblings (+) Heart disease – parents and siblings (+) DM - sister (-) Cancer (-) Allergy (-) Asthma (-) PTB (-) Thyroid diseases

Personal/Social History Drinks a lot of soft drinks (approximately 1L/ meal) (+) Smoking - 25 years (1969-1994); 2 pack/year Drinks alcoholic beverages occasionally Mixed diet, preference to salty foods Used to work for customs as a “checker” for 2O years and retired in 2009 Currently sells candles candles in Quiapo church with his wife Married with eight children Currently lives with his 20-year old son in a small apartment located in Abad Santos - no ventilation and sunlight coming in Running as a form of exercise

Review of Systems (-) anorexia, (+) weight loss (2 inches in waistline in the past month) (-) itchiness (-) headache, (-) blurring of vision (+) dizziness (-) colds (-) chest pain, (-) palpitations (-) abdominal pain (-) vomiting, (-) diarrhea, (-) constipation (-) hematuria, (-)flank pain

Review of Systems (-) dysuria, (+) paroxysmal nocturia every 2 hours, 4 times/night for the past 2-3 months, (+) polydipsia (1.5 L/night) (-) bleeding, (-) easy bruisability (-) heat/cold intolerance (-) muscle pain (-) edema

Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Physical Examination Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Conscious, coherent, ambulatory, not in CP distress BP: 160/100mmHg, PR: 92bpm, regular, RR: 21cpm, regular, T: 37.5 °C Ht=160 cm Wt=45 kg BMI=18 Warm dry skin, no active dermatoses Pale palpebral conjunctivae, anicteric sclera, pupils 2-3mm ERTL Septum midline, no nasoaural discharge No tragal tenderness, non-hyperemic, no pain on mastoid area BP: 120/80 mmHg, PR: 89bpm, RR: 20cpm, T: 36°C Ht=160 cm Wt=45 kg BMI=18

Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Physical Examination Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Neck not rigid, no palpable cervical lymphadenopathy No chest wall deformity, symmetric chest expansion, no retractions, equal vocal and tactile fremiti, clear breath sounds Adynamic precordium, AB at 6th LICS AAL, (-) parasternal heave, (-) thrills, base: S2>S1, loud P2, apex: S1>S2 and (+) S3, carotid artery: rapid upstroke, gradual downstroke, JVP 3 cm at 30° angle Flat abdomen, NABS, soft, no mass, no tenderness, 8 cm liver MCL, Traube’s space not obliterated, (-) hepatojugular reflux No palpable inguinal nodes, no CVA tenderness Pulses full and equal, (-) cyanosis No chest wall deformity, symmetric chest expansion, no retractions, resonant both lungs, equal vocal and tactile fremiti, clear breath sounds Adynamic precordium, AB at 6th LICS AAL, (-) heave, (-) thrills, base: S2>S1, apex: S1>S2 and (+) S3, carotid artery: rapid upstroke, gradual downstroke, JVP 3cm at 30° angle Flat abdomen, NABS, soft, no mass, no tenderness, 8 cm liver span MCL, Traube’s space not obliterated, (-) hepatojugular reflux

Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Physical Examination Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Conscious, coherent, oriented to three spheres, GCS 15 Sense of smell intact Isocoric pupils: 2-3mm ERTL, no visual field cuts Fundoscopy: (+) ROR, no papilledema, no hemorrhages, clear disc margins EOMs full and equal, (+) conjugate eye movements Intact V1-V3 Can clench teeth, raise eyebrows, frown, no gross facial asymmetry Gross hearing intact, (-) lateralization on Weber’s test Uvula midline on phonation Conscious, coherent, oriented to three spheres GCS 15

Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Physical Examination Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Can shrug shoulders, turn head side to side against resistance Tongue midline on protrusion MMT: 5/5 on all extremities No sensory deficits No atrophy, no fasciculations, no spasticity Cerebellar functions intact DTRs: (++) on all limbs No Babinski, no Chaddocks, no Oppenheims No nuchal rigidity, no Brudzinski, no Kernigs

Salient Subjective Features Pertinent Positives Pertinent Negatives 60 years old Male Productive cough with whitish  yellowish sputum (1 week) Easy fatigability Fever Dyspnea Known HPN (2005) LVH (2005) (+) Smoking 2 pack/year  Occasional alcohol drinker Currently sells candles Currently lives in a small apartment (+) weight loss (+) dizziness (-) colds (-) orthopnea and PND (-) Bronchial asthma (-) PTB (-) Allergies (-) edema

Salient Objective Features Pertinent Positives Pertinent Negatives Conscious, coherent, ambulatory, not in CP distress BP: 160/100mmHg, PR: 92bpm, regular RR: 21cpm, regular T: 37.5 °C BMI 18 Pale palpebral conjunctivae Adynamic precordium AB at 6th LICS AAL (+) S3 at apex 8 cm liver span MCL Septum midline (-) nasoaural discharge (-) palpable cervical lymphadenopathy S2>S1 at base,S1>S2 at apex No chest wall deformity Symmetric chest expansion No retractions Resonant both lungs Equal vocal and tactile fremiti Clear breath sounds (-) parasternal heave, (-) thrills JVP 3cm at 30° angle (-) hepatojugular reflux Traube’s space not obliterated

Connective Tissue Disease Cough and Fever Infectious Pulmonary Lung Abscess URTI LRTI Pneumonia - CAP Tuberculosis Extra Pulmonary Pericarditis Pleuritis Pulmonary Vasculitis Non-Infectious CHF Connective Tissue Disease Pulmonary Embolism Allergy COPD Neoplasm (-) orthopnea, PND normal JVP AB at 6th LICS AAL S3 at apex (-) hepatojugular reflux (-) edema Dyspnea 8 cm liver span MCL Weight loss No musculoskeletal Manifestation No Dermatomal manifestation (Rash) Cough is not sudden in onset No varicosities Not in RDS No history of cramping No history of trauma Unremarkable Pulmonary PE No history of allergen Cough did not spontaneously resolve No wheezes on PE Unremarkable Pulmonary findings No dyspnea on exertion No expiratory wheeze Cough is not chronic

No pleuritic chest pain No pain in movement Cough and Fever Infectious Pulmonary Lung Abscess URTI LRTI Pneumonia - CAP Tuberculosis Extra Pulmonary Pericarditis Pleuritis Pulmonary Vasculitis No chest pain No pleuritic chest pain No pain in movement No multisystem manifestations No hemoptysis No purpura or petechiae

Differential Diagnosis Cough with Fever Lung Abscess URTI LRTI Tuberculosis Pneumonia - CAP Differential Diagnosis (-) colds Septum midline (-) nasoaural discharge (-) palpable cervical lymphadenopathy (-) wheezes Weight loss (+) Productive cough Fever Dyspnea Unremarkable lung findings AFB not performed (-) pleuritic chest pain Fever Cough Dyspnea

Clinical Impression Community-Acquired Pneumonia Tuberculosis suspect Hypertensive Cardiovascular Disease Left Ventricular Hypertrophy, NYHA Functional Class I Stage B DM suspect

Philippine Clinical Practice Guidelines Diagnosis of Community Acquired Pneumonia Cough Abnormal vital signs: tachypnea, tachycardia, fever At least one abnormal chest finding: diminished breath sounds, rhonchi, crackles, wheezes Radiographic chest examination- new infiltrates with no clear alternative cause- required to confirm diagnosis (Grade A) The Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and Prevention of Community-Acquired Pneumonia in Immunocompetent Adults According to the Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and Prevention of CAP in Immunocompetent Adults, the diagnosis of CAP must have the following: cough, abnormal vital signs (tachypnea, tachycardia, fever) and at least one abnormal chest finding (diminished breath sounds, rhonchi, crackles, wheezes). However, these clinical findings are not sufficiently accurate in diagnosing pneumonia. A radiographic chest examination showing new infiltrates that has no clear alternative cause such as lung cancer or pulmonary edema, is required to confirm the diagnosis (Grade A).

European Clinical Practice Guidelines To differentiate pneumonia from other LRTIs, the patient should have the following clinical findings: Acute onset of cough Dyspnea New focal chest signs Tachypnea Fever of four days duration Presence of an infiltrate on a chest radiograph European Respiratory Journal by Woodhed et. Al European Respiratory Society European Society of Clinical Microbiology and Infectious Diseases According to the European Respiratory Society and European Society of Clinical Microbiology and Infectious Diseases, pneumonia may be differentiated from other lower respiratory tract infections by the following clinical findings: acute onset of cough, dyspnea, new focal chest signs, tachypnea, fever of four days duration, presence of an infiltrate on a chest radiograph. As can be noticed, these recommendations are also in accordanct to Philippine Clinical Practice Guidelines.

Chest X-Ray Findings

Midline alignment of trachea: normal

Sharp costophrenic angle: no pleural effusion

obliterated right cardiac base – consolidation at right lung base Silhouette Sign: obliterated right cardiac base – consolidation at right lung base

Laboratory Procedures

Complete Blood Count 11/23/09 11/28/09 Unit NV Hgb 96 118 g/L 120-170 RBC 2.93 3.73 X10^12/L 4.0-6.0 Hct 0.28 0.35 0.37-0.54 MCV 94.3 94.60 U^3 87 + -5 MCH 32.6 31.50 pg 29 + -2 MCHC 34.6 33.30 g/dL 34 + -2 RDW 13.40 14.10 11.6 – 14.6 Platelet 481 830 X10^9/L 150-450 WBC 17.70 15.39 4.5-10.0 Neutrophils 0.75 0.50-0.70 Segmenters 0.74 0.72 Bands 0.01 0-0.05 Metamyelocytes Lymphocytes 0.24 0.23 0.20-0.40 Monocytes 0.00-0.07 Eosinophils 0.02 0.00-0.05 Basophils Myelocytes

Biochemical Blood Test 11/23/09 11/28/09 Unit N.V. SGPT-ALT 37.8 U/L 0-31 SGOT-AST 55.3 0-38 Creatinine 5.2 3.5 mgl/dL 0.5-1.2 Sodium 130 mmol/L 137-147 Potassium 5.4 3.8 - 5

ECG Sinus rhythm Left ventricular hypertrophy Peak T-waves Pathological reaction to cardiovascular disease, or high blood pressure Increase afterload that the heart has to contract against Causes of increased afterload that can cause LVH include aortic stenosis, aortic insufficiency, and hypertension Peak T-waves Due to hyperkalemia

Other Laboratory Exams Test Rationale for Requesting Expected Result iCa Asses for kidney injury Decreased iPO Increased BUN Uric acid Lipid Profile Asses risk of heart disease ABG Determination of pH, partial pressure of carbon dioxide and oxygen, and the bicarbonate level Metabolic acidosis U/S of KUBP Assess the size, location, and shape of the kidneys and related structures such as the ureters bladder, and prostate Sputum GS, culture Identify certain pathogens by their characteristic appearance Sputum AFB Screening for TB

Pneumonia An infection of the pulmonary parenchyma Categorized as either community-acquired pneumonia (CAP) or health care–associated pneumonia (HCAP) Results from the proliferation of microbial pathogens at the alveolar level and the host's response to those pathogens Microorganisms gain access to the lower respiratory tract most commonly by aspiration from the oropharynx Clinical manifestation when the capacity of mechanical barriers fail and the capacity of alveolar macrophages to ingest or kill the microorganisms is exceeded

Respiratory Tract Defense Mechanisms Mechanical factors: hairs and turbinates of the nares, branching of tracheobronchial tree, gag reflex, cough mechanism, normal flora Resident alveolar macrophages, local proteins with intrinsic opsonizing or antibacterial/antiviral activity Initiation of host inflammatory response to bolster lower respiratory tract defenses Host inflammatory response, rather than the proliferation of microorganisms, triggers the clinical syndrome of pneumonia

Pneumonia: Pathophysiology Inflammatory mediators: interleukin (IL) 1 and tumor necrosis factor (TNF) fever Chemokines: IL-8 and granulocyte colony-stimulating factor release of neutrophils producing peripheral leukocytosis and increased purulent secretions Inflammatory mediators released by macrophages and the newly recruited neutrophils create an alveolar capillary leak radiographic infiltrate and rales detectable on auscultation Alveolar filling hypoxemia

Pneumonia: Pathology Initial phase: edema, presence of a proteinaceous exudate—and often of bacteria—in the alveoli; rarely evident in clinical or autopsy specimens Red hepatization: presence of erythrocytes in the cellular intraalveolar exudate, neutrophils, and bacteria 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, bacteria have disappeared; corresponds with successful containment of the infection and improvement in gas exchange Resolution: macrophage is the dominant cell type in the alveolar space, debris of neutrophils, bacteria, and fibrin has been cleared

Pneumonia: Etiology Countries #1 #2 #3 #4 #5 Philippines USA Canada S. pneumoniae M. tuberculosis Chlamydia spp. L. pneumophila M. pneumoniae USA H. influenzae G (-) bacilli Canada C. psitacci Influenza virus Coxiella burnetti Australia Viruses The Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and Prevention of Community-Acquired Pneumonia in Immunocompetent Adults

Pneumonia: Clinical Manifestations Febrile Tachycardia Chills and/or sweats Cough (non-productive or productive of mucoid, purulent, or blood-tinged sputum) Dyspnea Pleuritic chest pain Nausea Vomiting Diarrhea Fatigue Headache Myalgia

Pneumonia: Prognosis Age, co-morbidities, site of treatment (inpatient or outpatient) Complicated course: age > 65 years old, co-morbid illness, temperature > 38.3 °C, immunosuppressive therapy, high-risk etiology Young patients without co-morbidities: full recovery in about two weeks Overall mortality rate (outpatient group): <1% Overall mortality rate (inpatient group): 10% The prognosis of pneumonia is defined by age, presence of co-morbidities and site of treatment. Young patients without co-morbidities will usually recover fully with adequate management in about two weeks. However, ages above 65, presence of co-morbidities, temperature elevation of more than 38.3 °C, immunosuppressive therapy and high-risk etiology predict a more complicated course.

Co-morbidities Present in the Patient Hypertension- non-compliant with medications Major co-morbid condition associated with a complicated course of pneumonia Risk factors for pneumonia in the elderly by Koivula I, Sten M, Makela P in The American Journal of Medicine. 2000; 96(4):313-320 Acute kidney injury- laboratory findings suggestive of declining kidney function Systemic hypertension Probable infection Probable diabetes Warrants further examination Hypertension is a major co-morbid condition associated with a complicated course of pneumonia as stated in the study, Risk Factors for pneumonia in the Elderly by Koivula et. Al. in the American Journal of Medicine. The presence of acute kidney injury in the patient may be suspected due to laboratory findings suggestive of declining kidney function. This may be due to systemic hypertension, probable direct infection (although rare), and long-standing diabetes. However, further examinations must be done in order to definitely define the condition in our patient.

Management

Management Stabilize patient (address hypertension, cardio-respiratory distress, etc. if present) Empiric antibiotic therapy must be started Based on the most likely etiology of pneumonia Elderly patients with co-morbid conditions S. pneumoniae, Legionella sp., Gram negative bacilli including anaerobes Parenteral beta-lactams with anaerobic coverage (co-amoxyclav, ampicillin/sulbactam, cefoxitin and other 2nd generation cephalosporins; erythromycin if Legionella is suspected) Empiric antibiotic therapy must be started based on the most likely etiology of pneumonia. For elderly patients with co-morbid conditions, S. pneumoniae, Legionella and Gram negative bacilli including anaerobes should be suspected. Parenteral beta-lactams with anaerobic coverage may be used. The recommended empiric antibiotic therapy should subsequently be modified based on the isolated pathogen. If microbiologic data is available, the revised treatment should be pathogen-directed based on antimicrobial susceptibility test.

Course in the Wards Hospital Day 1: Admission Day Requested to be started on: Ceftriaxone 2g/IV OD Azithromycin 500mg/tab 1tab OD for 3 days Erdosteine 300mg/cap 1cap BID Paracetamol 500mg/tab 1tab q4 prn for T > 38 °C Amlodipine 5mg/tab 1tab OD Note: Medications were not started due to financial constraints Furosemide 40mg/IV 1dose and Salbutamol nebulization q4 were requested

Course in the Wards Hospital Day 2 Patient was hypertensive at 180/100 mmHg Given Amlodipine 10mg/tab Ceftriaxone was started

Course in the Wards Hospital Day 3 Salbutamol was shifted to combivalent nebulization q12, with gentle chest physiotherapy after each nebulization Patient had a BP of 140/90mmHg Started on Metoprolol 50mg/tab 1tab BID

Course in the Wards Hospital Day 4 Hospital Day 5 Ceftriaxone was shifted to Cefuroxime 500mg/tab 1tab BID to complete 7days Was not done due to financial constraints Hospital Day 5 Azithromycin, FeSO4 + FA, Metoprolol, as previously ordered, were started

Course in the Wards Hospital Day 6 Hospital Day 7 Cefuroxime, as previously ordered, was started Hospital Day 7 Condition of the patient improved and was stable Approved for discharge

Discharge Plans Azithromycin MOA: blocks transpeptidation by binding to 50s ribosomal subunit of susceptible organisms and disrupting RNA-dependent protein synthesis at the chain elongation step AE: Mild to moderate nausea, vomiting, abdominal pain, dyspepsia, flatulence, diarrhea, cramping, angioedema, cholestatic jaundice, dizziness, headache, vertigo, somnolence, transient elevations of liver enzyme values Dosage: 500 mg/tab 1 tablet OD for 3 days SRP: Php 150.00

Discharge Plans Cefuroxime MOA: binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death AE: large doses- cerebral irritation and convulsions, nausea, vomiting, diarrhea, GI disturbances, erythema multiforme, Stevens-Johnson syndrome, epidermal necrolysis, anaphylaxis, nephrotoxicity, pseudomembranous colitis Dosage: 500mg/tab 1 tablet BID for 7 days SRP: Php 75.00

Discharge Plans Amlodipine MOA: relaxes peripheral and coronary vascular smooth muscle; produces coronary vasodilation by inhibiting the entry of calcium ions into the voltage-sensitive channels of the vascular smooth muscle and myocardium during depolarization; increases myocardial O2 delivery in patients with vasospastic angina AE: headache, peripheral edema, fatigue, somnolence, nausea, abdominal pain, flushing, dyspepsia, palpitations, dizziness; rarely: pruritus, rash, dyspnea, asthenia, muscle cramps; potentially fatal: hypotension, bradycardia, conductive system delay Dosage: 10mg/tab 1 tablet BID SRP: Php 22.00

Discharge Plans Metoprolol MOA: selectively inhibits β-adrenergic receptors but has little or no effect on β2-receptors except in high doses; has no membrane-stabilizing nor intrinsic sympathomimetic activity AE: bradycardia, hypotension, arterial insufficiency, chest pain, CHF, edema, palpitation, syncope, gangrene, dizziness, fatigue, depression, confusion, headache, insomnia, short-term memory loss, nightmares, somnolence, pruritus, rash, increased psoriasis, reversible alopecia, heart failure, heart block, bronchospasm Dosage: 50mg/tab 1 tablet BID SRP: Php 4.00

Discharge Plans Erdosteine MOA: contains two sulfhydryl groups, which are freed after metabolic transformation in the liver; the liberated sulfhydryl groups break the disulphide bonds, which hold the glycoprotein fibers of mucus together; makes the bronchial secretions more fluid and enhances elimination AE: epigastralgia, nausea, vomiting, loose stools, spasmodic colitis, headache Dosage: 300mg/cap 1 capsule BID SRP: Php 19.00

Discharge Plans Ferrous Sulfate + FA MOA: facilitates O2 transport via hemoglobin; used as iron source as it replaces iron found in hemoglobin, myoglobin and other enzymes AE: GI irritation, abdominal pain and cramps, nausea, vomiting, constipation, diarrhea, dark stool and discoloration of urine, heartburn Dosage: 500mg/tablet 1tablet BID SRP: Php 20.00

Discharge Plans Getting plenty of rest and drinking lots of fluids Active lifestyle Lifestyle interventions: Reduction of dietary salt intake (<6g NaCl/day) Moderate alcohol consumption Men: </= 2 drinks per day Women: </= 1 drink per day Adapt DASH dietary plan Diet high in fruits and low-fat dairy products, reduced saturated and total fat Physical activity Regular aerobic activity (e.g. brisk walking for 30 mins/day)

Discharge Plans Return to UST Hospital for check-up after one week or immediately when condition worsens

Prevention Vaccination effective for high-risk populations Age > 65 years old Presence of chronic illness: cardiovascular disease, diabetes, liver disease Functional or anatomic asplenia Smokers Living in nursing homes or chronic use of health care facilities Immunocompromised The Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and Prevention of Community-Acquired Pneumonia in Immunocompetent Adults

Prevention Efficacy of Pneumococcal Vaccination in Adults: A Meta-analysis Huss A, Scott P, Stuck AE, Trotter C, Egger M Canadian Medical Association Journal. 2009;180:48-58 Pneumonia in the Elderly: A Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features Chong CP, Street PR Southern Medical Journal . 2008; 101:1141-1145

References Basic and Clinical Pharmacology 10th edtion by Katzung Harrison’s Principles of Internal Medicine 17th edition by Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, and Loscalzo The Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and Prevention of Community Acquired Pneumonia in Immunocompetent Adults Journals: Efficacy of Pneumococcal Vaccination in Adults: A Meta-analysis by Huss A, Scott P, Stuck AE, Trotter C, Egger M in the Canadian Medical Association Journal. 2009;180:48-58 Guidelines for the diagnoses and treatment of adult lower respiratory tract infections: a true ‘‘European cooperative effort’’ by Restrepo MI and Anzueto A in European Respiratory Journal. 2005; 26: 979–981 Pneumonia in the Elderly: A Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features by Chong CP, Street PR in the Southern Medical Journal . 2008; 101:1141-1145 Risk factors for pneumonia in the elderly by Koivula I, Sten M, Makela P in The American Journal of Medicine. 2000; 96(4):313-320

Thank You