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Case presentation1. Acute LVF 2. Community acquired pneumonia with BHR 3. LRTI + LVF 4. Pulmonary...

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Case presentation DR C D J COLOMBAGE REGITRAR EMERGENCY MEDICINE
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Case presentation

DR C D J COLOMBAGE

REGITRAR EMERGENCY MEDICINE

History: • 65 yr old, female

• DM,HT,IHD,hypothyroidism

• Presented to the ED

• C/O: Chest pain

• Shortness of breath 1/365

• Sweating

• HPC: Central, non pleuritic type, moderate intensity, no radiation,

• No N & V, PND or orthopnea

• No cough, sputum or fever

• No recent hospitalizations or exposure to health

• care facility

• No hx of recent Immobilization

• No calf pain or swelling.

PMH: DM x13yrs :Gliclazide 60mg bd

HT x 13yrs: Nifedipine 20mg bd

Hypothyroidism: levothyroxine 75 mg/d

IHD:TVD, NSTEMI 11/2015

on statin & dual antiplatelets.

PSH : not significant

FH :

SH: mother of 2, lives with husband & children.

Allergy: no known

O/E:

concious, rational.

sweating & mild dyspneic.

afebrile.

no ankle edema or calf tenderness.

RS

RR 32/min, Coarse creps on B/L lower zones with

B/L few rhonchi.

SPO2 95% on air.

CVS

JVP not elevated

PR 110bpm/regular/good volume

BP 170/70 mmHg

Working diagnosis: ACS + LVF.

INVESTIGATIONS:

ECG: No acute ischemic change.

repeated in ½ hr: no any changes of ischemia.

Troponin I : negative.

FBC :sent.

Treated with:

O2 via face mask

IV morphine 2.5 mg stat

IV phenergan 25mg stat

was admitted to the casuality medical ward.

10hrs after the admission,

Became more dyspneic .

RR of 38/min,SpO2 89% on air,

B/L difffuse rhonci and B/L fine creps,

+ R/ lower zonal coarse creps

PR 118bpm, BP 180/70mmHg

Ix: Urgent ECG repeated : NAD

Urgent CXR taken

ABG done

Blood cultures taken

ABG pH 7.29

pCO2 33

pO2 50

HCO3 15.9

BE -9.8

Working DD:

1. Acute LVF

2. Community acquired pneumonia with BHR

3. LRTI + LVF

4. Pulmonary embolism

Management:

1. propped up

2. O2 via face mask 6l/min– spo2 to 96 %

3. Nebulized salbutamol 5mg (back to back)+ Ipravent

4. IVI furosemide 5mg/hr

5. IV Merapenam 1g bd

6. IV Levofloxacin 500mg daily

7. moved to the HDU in the ward.

Other Investigations

1. Trop T :negative

2. Trop I :negative

3. WBC :14000/µl

N% :85%

L% :9.1%

Hb :10g/dl

Plt :350 x 10^3/µl

4. CRP :12mg/l (<6mg/l)

5. BU :6.2mmol/l (2.9-8.2)

6. Blood cultuers: NG after 24hrs & 5 days incubation.

7. Sputum cultures: She did not produce any sputum.

8. D dimer: < 0.2mg/l

9. Na :131 mmol/l

10. K : 5.1mmol/l

11. SGOT: 45

12. SGPT: 30

13. Thyroid profile : normal.

14. S.Cr : 102µmol/l (60-120)

15. 2D echo: EF 56%,mild LVH, Grade I DD

• Mild anterior wall dyskinesia

• Mild MR

• Preserved LV & RV sys. Functions

Further management

1. IVI Frusemide 5mg/hr continued

2. IVI GTN added

3. IV Hydrcortisone 100mg 6hrly

4. Nebulisation with sal & ipra 6 hrly

5. S/C enoxparin 40mg /d + DVT stockings

6. Glycemic control acieved with SI: target 140-180mg/dl

7. Catheterised IP/OP monitored.

8. RR, PR,BP,SpO2 was monitored.

9. Intake 1.2l/d

CXR repeated due to poor response!

Mycoplasma antibody IgM titre : 1/160 (positive)

Legionella Ag test : negative

Final diagnosis

Community acquired pneumonia complicated

with

1. Type I RF

2. Acute LVF

COMMUNITY ACQURED

PNEUMONIA

(CAP)

IN ADULTS

Definition of CAP is a syndrome in which, acute infection of

the lungs develops in a person who have not

been hospitalized recently and not have had

regular exposure to the health care system. n engl j med 371;17 nejm.org october 23, 2014

Epidemiology

1. Annual incidence in the community: 5–11 per 1000

adult population. [Ib]

2. Sixth leading cause of death world wide.

3. The leading cause of death from infectious diseases

worldwide.

Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434

ETIOLOGY

Common

Streptococcus pneumoniae,

1. Haemophilus influenzae,

2. Staphylococcus aureus,

3. Influenza virus

4. Other respiratory viruses

5. n engl j med 371;17 nejm.org october 23, 2014

Less common

• Pseudomonas aeruginosa or other gram-negative rods. Pneumocystis jirovecii.

• Moraxella catarrhalis.

• mixed microaerophilic and

• anaerobic oral flora.

• n engl j med 371;17 nejm.org october 23, 2014

UNCOMMON

Mycobacterium tuberculosis,

Nontuberculous mycobacteria,

Nocardia species,

Legionella species,

Mycoplasma pneumoniae,

Chlamydophila pneumoniae,

Chlamydophila psittaci,

Coxiella burnetii,

Histoplasma capsulatum,

Coccidioides species,

Blastomyces dermatitidis,

Cryptococcus

Aspergillus species n engl j med 371;17 nejm.org october 23, 2014

CLINICAL FEATURES

• Pneumonia should be suspected in patients

• with:

• ● fever

• ● new cough

• ● rigors

• ● change in sputum colour

• ● pleuritic chest pain

• ● dyspnoea • Many patients with these features: will not have pneumonia

In certain groups (esp in the elderly): classic clinical

features are unlikely.

Clin Infect Dis.(2000)31 (4)

My patient

66yr old

Presented with

Non pleuritic chest pain

SOB

Sweating

No history of

Fever

Cough

Sputum

therefore a high index of suspicion is needed !

INVESTIGATIONS

• 1.Radiological

2.General

3.Microbiological

RADIOLOGICAL

1.Role of CXR

Out patients

Not necessary unless [D] :

1. The diagnosis is in doubt.

2. Progress following treatment not satisfactory at review.

3. Pt at risk of underlying lung pathology such as lung CA

Hospitalized pts

Needed in all patients ASAP to confirm/refute the

diagnosis.[D]

2.Role of CT lung

Currently has no routine role in CAP.

Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434

GENARAL INVESTIGATIONS

Out patients

1. Not necessary for the majority.

2. Pulse oximetry assessment of oxygenation is adequate.

Hospitalized patients

All should have the following performed on admission:

1. Oxygen sat by pulse oximetry. [B+]

2. Arterial blood gases (when necessary)[B+]

3. CXR to allow accurate diagnosis. [B+]

4. BU and SE for severity assessment[B+]

5. CRP to aid diagnosis and as a baseline measure. [B+]

6 FBC. [B2]

7. LFTs. [D]

Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434

Role of inflammatory markers in CAP

MICROBIOLOGICAL INVESTIGATIONS

Out patients

Not recommended routinely.[D]

Thorax 2009;64(Suppl III):iii1–iii55 doi:10.1136/thx.2009.121434

MICROBIOLOGICAL Ix cont…..

Hospitalized patients

1.Blood cultures: are recommended for all patients with

moderate to severity CAP, preferably before

antibiotic therapy is commenced. [D]

2.Culture of sputum: or other lower respiratory tract

samples should also be performed for all patients with

moderate to severe CAP

3.Sputum Gram stain: can give an immediate

indicator of the likely pathogen.

Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434

4.Tests for Streptococcus pneumoniae

5.Tests for Legionnaires’ disease

6.Tests for Mycoplasma pneumoniae

Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434

RISK STRATIFICATION

NEEDED:

1. For triaging pts for the site of Rx.

2. For ordering Ixs.

3. For starting empiric Rx.

4. For prognostication.

• Aided by various scoring systems. o

Scoring systems

Well validated scoring systems:

• 1. CURB 65

• 2. Pneumonia severity index (PSI)

• 3. SMART COP

• 4. ATS/IDSA criteria

Other (poorly validated):

• 1. A DROP

• 2. REA-ICU index

• 3. CAP-PIRO

• 4. ESPANA scale

CURB65 score Guide in triaging pts for site of care.

5 prognostic variables

• c Confusion: New mental confusion.

• c Urea: >7 mmol/l

• c Respiratory rate: ≥ 30/min.

• c Blood pressure: SBP<90 mmHg and/or DBP ≤60 mmHg

• c Age≥ 65 years.

• Score Decision

• 0,1 probably Rxed as out pt.

• 2 should be admitted.

• 3 or > should be considered for ICU care.

PNEUMONIA SEVERITY INDEX (PSI) 1. A prognosis prediction rule

2. 20 variables, stratified into 5 classes

3. Defines severity based on predicted risk of mortality at

30 days.

4. Five classes I-V

• 0- 50 points (class i) : 0.1% mortality

• 51-70 points (class ii) : 0.6%

• 71-90 points (class iii): 0.9%

• 91-130 points (class iv): 9.3%

• 130-395 points (class v) : 27%

PSI

Factor Score Demographic

• Age Age in years

• Sex −10 if female

• Nursing home (not hostel) resident +10

Coexisting illness

• Neoplastic disease +30

• Liver disease +20

• Congestive cardiac failur e +10

• Cerebrovascular disease +10

• Chronic renal disease +10

Signs on examination

• Acutely altered mental state +20

• Respiratory rate ≥30/min +20

• Systolic blood pressure <90 mmHg +20

• Temperature <35°C or ≥40°C +15

• Pulse rate ≥125/min +10

Investigations

• Arterial pH <7.35 +30

• Serum urea ≥11 mmol/L +20

• Serum sodium <130 mmol/L +20

• Serum glucose ≥14 mmol/L +10

• Haematocrit <30% +10

• PaO2 <60 mmHg or SpO2 <90% +10

• Pleural effusion on CXR +10

To treat as out patient or as in patient?

Factors to consider…..

1.Severity of illness : most critical factor.

2 Ability of maintaining oral intake.

3 Likelihood of compliance.

4 Mental illness & cognitive impairement.

5 Living situation.

6 Pt functional status.

7 Hx of substance abuse.

MANAGEMENT

• 1. General management

• 2. Antibiotic management

GENERAL MANAGEMENT

Out patients

Should be advised

1. To rest,

2. To drink plenty of fluids,

3. Not to smoke. [D]

4. Pleuritic pain :simple analgesics such as paracetamol. [D]

5. Review policy: recommended after 48hrs

• Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434

Hopitalized pts: Initial Mx

1. Appropriate oxygen therapy for all [D]

2. Assess for volume depletion: IV fluids as needed

3. Prophylaxis of VTE with LMWH: for all who are not fully

mobile[A+]

4. Nutritional support :in prolonged illness. [C]

5. Uncomplicated pts with CAP should be mobilized[A+]

6. Advice regarding expectoration of sputum. [D] Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434

When should the first dose of antibiotics be given to

patients admitted to hospital?

As soon as the diagnosis of CAP is confirmed. [D]

Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434

COMPLICATIONS OF CAP •

1. Para pneumonic effusion. [D]

2. Empyema

3. Lung abscess. [D]

4. Respiratory failure

5. Vascular complications : common!

4. Cardio vascular: AMI

5. New or worsening HF

6. Cerebro vascular: Stroke

6. Cardiac arrhythmias.

Clin Infect Dis.(2007)31 (4)

References

1. Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434

2. n engl j med 371;17 nejm.org october 23, 2014

3. uptodate

THANK YOU!


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