1. Pneumonia Esmaeli, A.; Francisco U.; Golpeo, K.

2. A. G. 75 year old Male Single From Sta. Mesa, Manila Unemployed CC: progressive and productive cough, 3 days duration

3. TEMPORAL PROFILE

4. Past Medical History PTB (2002) – sputum AFB (+); 6 months quad-tab treatment completed; Chest X-ray after treatment – resolved S/P Cataract surgery (2002) COPD (2011) – Symbicort 2 puffs BID  1 puff BID (2012) Allergy to seafood and chicken (-) HTN, (-) DM Family History (+) HTN (father and younger brother) (+) stroke (father) (+) Lung CA (brother)

5. Social and Environmental History Smoker (51 pack years); started 14 years old, stopped 2002, 1 pack per day Occasional alcohol drinker (1960 -1970); Last drink was 1985, 1 small bottle of pale pilsen per week Denies illicit drug use

6. Review of Systems (-) anorexia (-) vomiting (-) diarrhea (-) blood in sputum (+) exertional dyspnea (+) sputum production Weight loss

7. Physical Examination Awake, weak-looking, alert, ambulatory, febrile VS: 110/60 > 72 > 32 > 39 degrees celsius AS, PPC, (-) TPC, (-) CLADS ECE, (+) crackles in L lower lung AP, NRRR, distinct S1 and S2, (-) murmur Flat abdomen, NABS FEP, (-) cyanosis, (-) edema

8. Primary Impression Community Acquired Pneumonia, Moderate Risk (CAP, MR); Chronic Obstructive Pulmonary Disease (COPD)

9. Laboratories Ordered CBC UA Blood CS Sputum GS/CS Na, K, Crea, BUN Chest Xray

10. CBC ReferenceCBC Hemoglobin Mass C120-140 g/L144 Hematocrit37-47%43 RBC4.0-4.5 x10^12/L MCHC32-37% MCH27.5-33.2 pg MCV80-94 fL RDW11-15% WBC5-10 x10^9/L8.1 Diff count Neutrophil40-75%83 Stabs Lymphocyte2-6%17 Monocytes Eosinophil Platelet N

11. Chest Xray Impression: 1. Pneumonitis/ Bronchitis Right Lower Lung 2. Pneumonia Left Lower Lung 3. Residual Fibrosis Right Upper Lung

12. Urinalysis Reference07.14.12 ColorVarying degrees of yellowyellow TurbidityClear ReactionVariable (usually acidic)Acidic Specific GravityVariable but 1.023 and above, usually no significant kidney damage 1.030 ProteinaNegative(-) SugarNegative(-) RBC0-1/hpf0-1 WBCMale: 0-2/hpfnone Female: 0-5/hpf Casts None Bacteria Few Epithelial Cells none Yeast Cell noen Mucus threads none Crystals none

13. Blood Chemistries July 14, 2012 Na134 K3.1 Crea99 BUN5.6 BCR13.97 ECC @ 6013.37

14. Cultures Sputum GS – Gram (+) cocci in pairs with neutrophils Sputum CS – Blood CS, 2 sites –

15. IV FLUID: 1 liter D5NSS to run to 10 hours (100 cc/hr) DIET: 2100 kcal/day TFR

16. Antibiotic started upon admission Ceftriaxone 2 gm IV Q24 Levofloxacin 750mg/tab, 1 tab Q48 (Azithromycin)

17. COPD Symbicort 2 puffs BID

18. Hypokalemia Kalium Durule, 1 durule TID

19. Pneumonia

20. Plan Moderate Risk 1. RR>30/min 2. PR> 125/min 3. Temp >40 or <36.0 0 C 4. SPB <90mmHg or DBP <60mmHg 5. Altered mental status of acute onset 6. Suspected aspiration 7. Unstable comorbids 8.CXR: multilobar, pleural effusion, abscess

21. High risk 1. Severe sepsis and septic shock 2. Need for mechanical ventilarion

22. Outpatients Previously healthy and no antibiotics in past 3 months A macrolide [clarithromycin (500 mg PO bid) or azithromycin (500 mg PO once, then 250 mg qd)] or Doxycycline (100 mg PO bid) Comorbidities or antibiotics in past 3 months A respiratory fluoroquinolone [moxifloxacin (400 mg PO qd), gemifloxacin (320 mg PO qd), levofloxacin (750 mg PO qd)] or A B-lactam [preferred: high-dose amoxicillin (1 g tid) or amoxicillin/clavulanate (2 g bid) plus a macrolide

23. Inpatients, Non-ICU A respiratory fluoroquinolone [moxifloxacin (400 mg PO or IV qd), gemifloxacin (320 mg PO qd), levofloxacin (750 mg PO or IV qd)] A B-lactam [cefotaxime (1–2 g IV q8h), ceftriaxone (1–2 g IV qd), ampicillin (1–2 g IV q4–6h), ertapenem (1 g IV qd in selected patients)] plus a macrolide [oral clarithromycin or azithromycin (as listed above for previously healthy patients) or IV azithromycin (1 g once, then 500 mg qd)]

24. Inpatients, ICU A B-lactam [cefotaxime (1–2 g IV q8h), ceftriaxone (2 g IV qd), ampicillin-sulbactam (2 g IV q8h)] plus Azithromycin or a fluoroquinolone (as listed above for inpatients, non-ICU)

25. If Pseudomonas is a consideration An antipneumococcal, antipseudomonal B-lactam [piperacillin/tazobactam (4.5 g IV q6h), cefepime (1–2 g IV q12h), imipenem (500 mg IV q6h), meropenem (1 g IV q8h)] plus either ciprofloxacin (400 mg IV q12h) or levofloxacin (750 mg IV qd) The above -lactams plus an aminoglycoside [amikacin (15 mg/kg qd) or tobramycin (1.7 mg/kg qd) and azithromycin] The above - lactams f plus an aminoglycoside plus an antipneumococcal fluoroquinolone

26. If CA-MRSA is a consideration Add linezolid (600 mg IV q12h) or vancomycin (1 g IV q12h).