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

2. 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

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

4. 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

5. 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

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

7. Personal/Social History
Drinks a lot of soft drinks (approximately 1L/ meal)
(+) Smoking - 25 years ( ); 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. 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).

21. 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.

22. Chest X-Ray Findings

23. Midline alignment of trachea: normal

24. Sharp costophrenic angle: no pleural effusion

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

26. Laboratory Procedures

27. 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
Hct
0.28
0.35
MCV
94.3
94.60
U^3
MCH
32.6
31.50 pg
MCHC
34.6
33.30
g/dL
RDW
13.40
14.10
11.6 – 14.6
Platelet
481
830
X10^9/L
WBC
17.70
15.39
Neutrophils
0.75
Segmenters
0.74
0.72
Bands
0.01
0-0.05
Metamyelocytes
Lymphocytes
0.24
0.23
Monocytes
Eosinophils
0.02
Basophils
Myelocytes

28. 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
Sodium
130
mmol/L
Potassium
5.4

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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.

38. 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):
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.

39. Management

40. 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.

41. 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

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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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)

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

54. 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

55. 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 ; 101:

56. 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 ; 101:
Risk factors for pneumonia in the elderly by Koivula I, Sten M, Makela P in The American Journal of Medicine. 2000; 96(4):

57. Thank You