pneumonia ppt
TRANSCRIPT
PNEUMONIABY:
NABILAH BINTI MOHD KAMARUZAMAN
0501000839
SITI FATIMAH BINTI ABDUL AZIZ
050100849
DEFINITION Inflammation of lung parencymal
ETIOLOGY
Infective causes: Bacterial:
Gram +ve: Strep pneumoniae, Staph aureus Gram –ve: H. influenzae, Klebsiella, Legionella Anaerobes
Viral: Varicella virus, Influenza virus Fungal: Candida, Aspergillus Atypical: Mycoplasma, Chlamydia Helminths: Filariasis
Non infective causes: Physical agents Allergic diseases Collagenic diseases
PATHOGENESIS Main mechanisms by which bacteria
reaches lung: Inhalation: organisms bypass normal
respiratory defense mechanisms or patient inhales aerobic organisms that colonize the upper respiratory tract or respiratory support equipment
Aspiration: occurs when patient aspirates colonized upper respiratory tract secretions
Hematogenous: originate form a distant source and reach the lungs via blood stream
Congestion stage :
•The lung is a dark red and frothy due to the presence of inflammatory exudate and air in the alveolar lumen.
•The alveolar capillaries are engorged with increased numbers of neutrophils and bacteria.
•Fine “indux” crepitations without bronchial breathing on auscultation.
Red hepatization stage :
•The lung is firm red, liver-like and the pleural surface shows serofibrinous inflammation.
•The alveolar capillaries are dilated and congested with marked fibrinous exudate, neutrophils and increased bacteria.
•Medium-sized crepitations, bronchial breathing.
Gray hepatization stage :
•The lung is more solid and the pleural surface covered by a confluent fibrinous exudate.
•The alveolar exudate is increased in amount, dense fibrin strands and very numerous neutrophils, the congestion of capillaries is reduced.
•Coarse non-consonating “redux” crepitations on ausculation.
Resolution stage :
•The lung returns to normal, the fibrinous adhesions between the visceral and parietal pleura are liquified by proteolytic enzymes.
•The liquid products together with neutrophils are coughed up and macrophages invade the alveoli.
•Pleural rub may be present in this stage on auscultation.
CLASSIFICATIONS Site of infection:
LobarBronchopneumonia
Origin of infction:Community acquired pneumoniaNosocomial pneumonia ( hospital acqiures
pneumonia): occur 48 hours after admission which was not incubating at the time of admission
Aspiration pneumonia: occur when aspirate foreign matter into lungs
Immunocompromised pneumonia
Based on etiology:BacterialViralFungalAtypicalAspiration
DIAGNOSIS History taking: suggestive signs and
symptoms Physical examination Investigation Chest X-ray or other imaging techniques
SYMPTOMS AND SIGNS General symptoms:
Fever - MalaiseChills and rigors - Nausea and
vomitingLoss of appetiteMyalgia
Respiratory symptoms:Productive coughSputum +/- hemoptysisShortness of breathPleuritic chest pain
Specific symptoms:Abdominal pain
Advanced symptoms:CyanosisAlteration of mental status
PHYSICAL EXAMINATION Inspection: use of accessory muscles Palpation: decreased chest expansion,
increased tactile fremitus Percussion: maybe dullness on affected
lung, increased vocal resonance Auscultation: bronchial breathing,
crepitations
INVESTIGATION Basic:
Full Blood Count Blood Urea and Serum Electrolytes (BUSE) Creatinine Arterial Blood Gases (ABG) Chest X-Ray
Specific: Sputum FEME, C&S, AFB Blood C&S Pleural aspiration Bronchoscopy Serology (Mycoplasma, Chlamydia,Legionella) Immunoflourosence or Giemsa stain for PCP
CLINICAL DIAGNOSTIC: CXR Demonstrable infiltare by CXR or other
imaging technique:Establish diagnosis and presence of
complications (pleural effusion, etc)May not be possible in some outpatient
settingsCXR: classically thought of as the gold
standard
INFILTRATE PATTERNSPATTERN POSSIBLE DIAGNOSIS
Lobar Strep pneumoniae, Klebsiella, H. influenzae
Patchy Atypical, Viral, Legionella
Interstitial Viral, PCP, Legionella
Cavitary Anaerobes, Klebsiella, TB, Staph aureus, Fungal
Large effusion Staph, Anaerobes, Klebsiella
MANAGEMENT General considerations:
Monitor vital signs and SpO2 4 hourlyKeep SpO2 > 92%Oxygen therapyAdequate hydrationAssisted ventilation when necessary
Symptomatic: Analgesics, Mucolytic agents
Antibiotics
EMPIRICAL ANTIBIOTIC TREATMENT Community Acquired pneumonia
IV beta-lactam antibiotic plus IV/ oral macrolides or flouroquinolones
Nosocomial pneumoniaCephalosporin 2nd generation,
aminoglycosides Atypical pneumonia
Macrolides
Aspiration pneumonia:Cephalosporin 2nd generation plus
metronidazole Pneumocystic carinii pneumonia:
Co-trimoxazoleClindamycin
SWITCH TO ORAL THERAPY Four criteria:
Improvement in cough and dyspneaAfebrile on two occasions 8 hourly apartWBC decreasingFunctioning GI tract with adequate oral
intake If overall clinical picture is otherwise
favorable, can switch to oral therapy while still febrile
MANAGEMENT OF POOR RESPONDERS Consider non-infectious illnesses Consider less common pathogens Consider serologic testing Broaden antibiotic therapy Consider bronchoscopy
COMPLICATIONS Respiratory failure Bacteremia Exacerbation of comorbid illnesses Metastatic infections: brain abscess,
endocarditis Lung abscess Pleural effusion
PREVENTION Smoking cessation Vaccination recommendations:
Influenza Inactivated vaccine for people > 50 yo, those at
risk for influenza complications, household contacts of high-risk persons and healthcares workers
Intranasal live, attenuated vaccines for 5-49 yo without chronic underlying disease
Pneumococcal Immunocompromised > 65 yo chronic illness
and immunocompromised < 64 yo
CASE REPORT
ANAMNESIS Date of Admission : 24th January 2010 ,
Sunday Time of Admission : 6.00 pm
PERSONAL IDENTIFICATION Name : Rokiah binti Hanafi Age : 67 years old Race : Malay Address : Arau, Perlis Occupation : Farmer ( paddy-field)
CHIEF COMPLAINT
Fever 5/7, cough and lethargy
HISTORY OF PRESENTING ILLNESS
Previously patient is well until fever is started 5days ago, which was low grade,on and off. It was associated with chills and rigors and usually worsen at night. Patient took Paracetamol tablet but fever temporarily resolved.
Patient also developed cough during fever. It was non productive cough (dry cough). She had no vomiting and did not coughing out blood. She also had occasional shortness of breath and pleuritic pain when coughing. The pleuritic pain is dull in nature. She prefers to lie down as it can relieve the pain. Otherwise, no orthopnea, no wheezing and no night sweats.
She also had poor appetite but she can tolerating well. On day 5 of her illness, patient’s condition became worse and she also complained of lethargy. Patient went to emergency department yesterday and temperature was documented at 37.5⁰ C. Patient was then warded to ward 5.
PAST MEDICAL HISTORY
This is the patient’s 3rd admission. First admission was due to tonsil operation when she was 16 years old. Second was due to eye procedure 10 years ago.
Patient is a known case of hypertension (HPT) , diagnosed for more than 10 years. She is now under treatment and follow up at Klinik Kesihatan Arau. She is compliance to her medication.
She has no previous history of IHD or CVA. No history of Diabetes Mellitus or asthma.
Allergies : The patient has no allergy to any food or drugs.
PAST SURGICAL HISTORY Cataract operation Tonsil operation No complications occur pre or post operations.
FAMILY HISTORY
The patient is the 2nd child out of 7 siblings.The parents and her 3rd and youngest brother died of nature causes. There are no history of atopy, asthma and TB in the family.
SOCIAL HISTORY
She is married with 3 children. Her husband just passed away and
currently she is staying home alone. She is a non- smoker, non alcoholic
drinker She has cats in her house
PHYSICAL EXAMINATION1. GENERAL EXAMINATION:
The patient is alert and conscious, well oriented to time, place and people. She is lying comfortably in supine position. She is not in pain and respiratory distress.She is mildly dehydrated.
Blood pressure: 128/ 70 mmHg Pulse rate: 90 beats/minute. Good volume
and regular rhythm Respiratory rate: 22 breaths /minute Temperature: 37.0˚C SpO2: 97 % Pallor : no conjunctival pallor noted Cyanosis : no peripheral or central cyanosis
not Jaundice : no jaundice noted Clubbing : no clubbing noted Oedema : no pitting oedema
Head / neck : normocephalic Neck : The jugular venous pressure is not
raised and no lymph nodes enlargement detected. No neck stiffness
Eyes : not sunken, arcus angle Oral cavity : Oral hygiene is poor Ears : no discharge, normal shape Throats : not injected, tonsil bilaterally not
enlarged Abdomen : no scar, abdomen is soft and non-
tender Hands: There are no muscle wasting and no
gross deformity.(-) clubbing ,no palmar erythema, not pallor
CVS : Ejection systolc murmur,grade 3/6 and radiates to right aortic on auscultation.
RESPIRATORY SYSTEMSign observed Interpretation
Inspection Chest structure
Chest movement
Symmetry
Symmetrical & abdomino-thoracal respiratory
Palpation Chest expansionTactile vocal fremitus
SymmetricalIncreased at lower zone of right side
Percusion Lung sounds Dullness at lower lobe of right lung
Auscultation Breath sound
Additional sounds
Vocal resonance
Bronchial breathing on both sideFine crepitations > right side, no ronchiNot done
SUMMARY Rokiah bt hanafi, 67 years old,malay
came with chieft complaint of fever for 5 days, cough and lethargy. She is known case pf HPT for more than 10 years. No family hx of asthma and Tb. On chest examination revealed increase of vocal fremitus, dullnes on percussion and fine crepitation on auscultation on lower lobe of right lung.
DIAGNOSIS1. DIFFERRENTIAL DIAGNOSIS :
- PNEUMONIA- BRONCHIECTASIS- TB
2. WORKING DIAGNOSIS :- Pneumonia
INVESTIGATION
BASIC :• Full Blood Count• Blood Urea and• Serum Electrolytes (BUSE)• Creatinine • Arterial Blood Gases (ABG)• Chest X-Ray
SPECIFIC :
• Sputum FEME, C&S, AFB• Blood C&S• Pleural aspiration• Bronchoscopy • Serology (Mycoplasma,• Chlamydia,Legionella)• Immunoflourosence or Giemsa stain for PCP
PLAN Monitor vital signs and SpO2 4 hourly Paracetamol tablet 1000 mg 8 hourly Tepid sponging prn Nasal Prong O2 3L prn Syrup Benadyl 15 ml TDS Septic management if fever more than
38⁰C IV Augmetin 1.2 g TDS To review all investigations results
FOLLOW UP24th january 2010,day 1
1. CXR
INTERPRETATION
PA view, erect position Trachea : centrally located Clavicle : symmetrical in position , no
fracture Bone : normal Homogenic opacity at right side of lung Honey-comb appearance on lower zone
of right lung Diaphragm : dome shape Impression : pneumonia
2. Result of Vital sign monitoring 4 hourly
24/01/2010 Pulse
(x/minute)
Blood
Pressure
(mmHg)
Temperature
(oC)
6.00 pm 97 138 / 71 37.5
10.00 pm 83 121 / 63 37.0
4.00 am 84 128/ 70 37.0
8.00 am 72 128/ 70 37.0
Vital signs are in normal range
2. FBC (Day 1)
Result Normal range
White Blood Cell 17 ( ) 4- 11
Red blood cell 4.9 ( ) 3.8-4.8
Hemoglobin 11.7 ( ) 12-15
Hematocrite 35.4 ( ) 36-46
MCV 72.8 ( ) 83-101
MCH 24.1 ( ) 27-32
Platelet 203 150-450
Neutrophil 14.62 ( ) 2-10
Lymphocyte 1.36 1-3
Monocyte 1.02 ( ) 0.2-1.0
Eosinophils 0 ( ) 0.02-0.5
Basophils 0 ( ) 0.02-0.1
Impression of FBC result
Leukocytosis: WBC increased, neutrophil predominates
suggestive of bacterial infection Plan: broad spectrum antibotics unitl blood C&S
result came back
3. Renal profile( day 1), 7.28 pm
Result Normal range
(mmol)
Sodium 138 135-145
Potassium 2.9 ( ) 3.3 – 5.3
Urea 18.5 ( ) 1.7-8.3
Creatinine 174 ( ) < 97
Impression of renal profile:
Hypokalemia: Potassium was 2.9 mmol Correction by adding 1g KCl IV
High urea: Urea level was 18.5, correlates with mild dehydration Plan: IVD normal saline in 24 hours
4. ECHO, ( day 2 ), 8am
Chambers : LV,RV,RA,LA are all normal Mild calcified of aortic valve ECHO was indicated as ejection systolic
murmur can be heard on auscultation.
DISCUSSION Patient is 67 years old, malay old woman came with chieft complaint of fever
for 5 days, cough and lethargy. pati On chest examination revealed increase of vocal fremitus, dullnes on percussion and fine crepitation on auscultation. Chest X-ray revealed the patchy infiltration at lower lobe of right lung. Patient is diagnosed to have Community-acquired pneumonia. Empirical antibiotic of IV amoxicillin with clavulanic acid ( beta-lactam antibiotic) is chose to treat the pneumonia.
To exclude bronchiectasis because : no history of obstructive lung disease, along with bronchitis and cystic
fibrosis. No history of frequent respiratory infections or chronic lung disease No CT scan was done to establish diagnosis and localize the bronchiectasis
To exclude TB because: Negative AFB No history of weight loss No night sweats
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