TAKE MY BREATH AWAY…...

Ali Hasan

May Harker

Anna Harrison-Murray

Amer Ullah

MB

• A 62 year old Caucasian woman breathing quickly, who arrived in England from Australia three weeks ago

• Complained of feeling “lousy”

•One episode of haemoptysis

•A tight chest affecting breathing - RR 20 on admission

• 3/7 before attending A+E – first presentation of illness was aching knee and ankle joints.

• Left shoulder pain later emerged

SYMPTOMS

• Anorexia, nausea, and vomiting

• Dizziness, with one marked episode of confusion and loss of balance

• Hot and cold flushes

• Feeling very tired

• Hot and cold flushes

• Profound lethargy

• Nausea and vomiting

ALSO …

• Previous episode of pneumonia, age 31.

• Hot and cold flushes – previously well controlled by HRT.

• Hallux rigidus

• High cholesterol – 7.5 (normal 4 - <6).

PAST MEDICAL HISTORY

• Occasional headaches when overworked.

• Neurodermatitis which has not recurred for years.

AND …

SURGICAL HISTORY

• Removal of fibroadenoma in the right breast

• Tubal ligation

CURRENT MEDICATION

• Remifem, an OTC HRT “replacement”

ALLERGIES

• An adverse reaction to voltarol which caused paraesthesia in her foot.

FAMILY HISTORY

• No illnesses mentioned in daughters

• Mother had a cholesterol problem, for which she had an endarterectomy – and subsequently suffered a stroke which left her senile.

• Maternal grandmother died of rheumatic heart disease.

SOCIAL HISTORY

• An English woman who lives in Australia

• Migrated to Australia, age 17

• Lives with her husband, a cattle farmer, two daughters

• Smoked for 12 pack years, age 18-35

SYSTEMS REVIEWCVS:

• No palpitations, swelling, or previous history of SOB

Respiratory system:

• No cough

• No wheezing

• Occasional “nasal drip”

SYSTEMS REVIEW CONT.

GU System:

• Increased thirst

• Went to the toilet 5x/24h

• No urinary urgency, and usually one episode of nocturia per night

• Two past urinary infections

SYSTEMS REVIEW CONT

GI System:

• Patient has not eaten, and there were no bowel motions since presentation 3/7 ago.

• Patient suffered from “plenty of wind”.

• No tenderness or pain.

SYSTEMS REVIEW CONT

VITAL SIGNSBP 135/69

Temp. 38.6

Pulse 100 reg

RR 20

O2 Sat 91% (air)

GCS 15

CLINICAL EXAMINATIONCVS ° abnormalities detected

Resp

GI ° abnormalities detected

XXXX

INVESTIGATIONS

ECG Blood Analysis Chest Radiography CT Scan Microbiology

BLOOD ANALYSIS

BloodGases

pH 7.471pCO2 4.95 kPapO2 5.31 kPa

FBC WCC 24.4 x109/LPlat 232 x109/LNeut 23.4 x109L

Oximetry sO2 82.4%Hb 10.8 g/dL

Bloodcoag.

INR 0.9APTT-R 1.31TT 11

U and E Na+ 130 mmol/LK+ 4.0 mmol/LCa2+ 1.14 mmol/LCl- 95 mmol/LUrea 4.7 mmol/LCreat 87 µmol/L

Cardiacenzymes

CK 123iu/LTrop T <0.01

ECG Tachycardic sinus rhythm

CHEST RADIOGRAPHY Patchy consolidation left lung Slight left pleural effusion

CT SCAN

MICROBIOLOGY

Blood Cultures Blood and Sputum Gram Stains Antibiotic Sensitivity Tests Legionella Titre

FOLLOW UP3/7 later

• Patient appeared visibly better

• IV antibiotics and fluid had been stopped – antibiotics were now oral

• Nausea stopped 2/7 after admission

• Chest no longer “tight”. Breaths deeper but still some pain on left side when taking very deep breaths

• An intermittent dry unproductive cough appeared 2/7 after admission. No further sputum production or haemoptysis - referred to physio

FOLLOW UP CONT

MORE FOLLOW UP• Patient now eating small meals and resumed bowel movements

• No further dizziness, but still the occasional flush

AND FINALLY…

• Some lethargy.

• Vital signs good. Pulse around 76, temp 36.6, resp rate around 15.

• Discharge planned 3/7 after.

PATHOLOGY

• DEFINITION

Inflammation of the lung parenchyma - exudative solidification (consolidation)

• CAUSES

Bacterial (most common) Other

EPIDEMIOLOGY

• Incidence of CAP - 12 per 1000 adults

• CAP accounts for 5-12 % of all LRTI’s

• Approximately 10% require hospitalisation

EPIDEMIOLOGY CONT

• Mortality reduced by effective use of antibiotics but remains dangerous condition and a major cause of death in over 70’s

- Mx community < 1%- Mx in hospital Approximately 10%

CLASSIFICATION (1)

• COMMUNITY AQCUIRED (CAP)

- Primary or secondary

- Mainly Gram +ve bacteria

• HOSPITAL ACQUIRED

- Acquired > 48hrs after admission

- Mostly caused by Gram -ve bacteria

- Problem with antibiotic resistance

CLASSIFICATION (2)

BY SITE

• LOCALISED (LOBAR)

- involvement of large portion / entire lobe

- infrequent due to antibiotic effectiveness

• DIFFUSE (LOBULAR)

- patchy consolidation

- extension of pre-existing disease

- extremely common esp. infancy and old age

CLASSIFICATION (3)

• BY AETIOLOGY

COMMON ORGANISMS

- Streptococcus Pneumoniae (60-75%)

- Mycoplasma Pneumoniae (5-18%)

- Influenza A (usually with bacterial)

- Haemophilus influenzae

- Staphylococcus aureus

- Legionella species

- Chlamydia psittaci

CLINICAL FEATURES

• Vary according to immune system and infecting agent

• Symptoms

- Malaise

- high temp (up to 39.5)

- pleuritic pain

- dyspnoea

- cough

- purulent / rusty sputum

• Signs

- fever

- cyanosis

- confusion

- tachypnoea

- tachycardia

- consolidation signs

- pleural rub

COMPLICATIONS

• Respiratory failure

• Hypotension

• Atrial fibrilation

• Pleural effusion

• Empyema

• Lung abscess

• Organisation of exudate

• Bacteremic dissemintion

MANAGEMENT 1

Mild community acquired

Nonsmoking adults < 60 yrs

Smoking adults & > 60 yrs

Erythromycin 500 mg X 3 or Clarithromycin 250 mg x 2

Cefaclor 500 mg x3

MANAGEMENT 2

Patients with severe pneumonia best managed on an intensive care unit

Severe community acquired

i.v. 6 h Cefuroxime 1.5 g & Clarithromycin 500 mg 12 h

MANAGEMENT OF MB

Severe community acquired pneumonia

No causative organism identified but L. pneumophilia Ag test (urine) negative

DRUGS 1

Regular CEFOTAXIME (broad spectrum

antibiotic) 1g i.v. tds ERYTHROMYCIN 500 mg oral qds PARACETAMOL 1g oral qds METOCLOPRAMIDE 10mg i.v. tds (for

nausea - side-effect of antibiotics)

DRUGS 2

As Required DIHYDROCODEINE 30 mg oral (for

pleuritic chest pain) CYCLIZINE (for nausea/vomiting) 50

mg oral Saline

OTHER

O2 therapy for hypoxaemia Fluids encouraged to avoid dehydration Seen by chest physiotherapist due to

inability to expectorate Antibiotics shifted to oral route after 3

days of i.v.