TAKE MY BREATH AWAY…... Ali Hasan May Harker Anna Harrison-Murray Amer Ullah.
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Transcript of TAKE MY BREATH AWAY…... Ali Hasan May Harker Anna Harrison-Murray Amer Ullah.
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TAKE MY BREATH AWAY…...
Ali Hasan
May Harker
Anna Harrison-Murray
Amer Ullah
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MB
• A 62 year old Caucasian woman breathing quickly, who arrived in England from Australia three weeks ago
• Complained of feeling “lousy”
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•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
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• 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 …
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• 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
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• Occasional headaches when overworked.
• Neurodermatitis which has not recurred for years.
AND …
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SURGICAL HISTORY
• Removal of fibroadenoma in the right breast
• Tubal ligation
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CURRENT MEDICATION
• Remifem, an OTC HRT “replacement”
ALLERGIES
• An adverse reaction to voltarol which caused paraesthesia in her foot.
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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.
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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
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SYSTEMS REVIEWCVS:
• No palpitations, swelling, or previous history of SOB
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Respiratory system:
• No cough
• No wheezing
• Occasional “nasal drip”
SYSTEMS REVIEW CONT.
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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
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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
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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
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INVESTIGATIONS
ECG Blood Analysis Chest Radiography CT Scan Microbiology
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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
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ECG Tachycardic sinus rhythm
CHEST RADIOGRAPHY Patchy consolidation left lung Slight left pleural effusion
CT SCAN
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MICROBIOLOGY
Blood Cultures Blood and Sputum Gram Stains Antibiotic Sensitivity Tests Legionella Titre
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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
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• 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
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MORE FOLLOW UP• Patient now eating small meals and resumed bowel movements
• No further dizziness, but still the occasional flush
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AND FINALLY…
• Some lethargy.
• Vital signs good. Pulse around 76, temp 36.6, resp rate around 15.
• Discharge planned 3/7 after.
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PATHOLOGY
• DEFINITION
Inflammation of the lung parenchyma - exudative solidification (consolidation)
• CAUSES
Bacterial (most common) Other
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EPIDEMIOLOGY
• Incidence of CAP - 12 per 1000 adults
• CAP accounts for 5-12 % of all LRTI’s
• Approximately 10% require hospitalisation
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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%
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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
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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
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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
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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
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COMPLICATIONS
• Respiratory failure
• Hypotension
• Atrial fibrilation
• Pleural effusion
• Empyema
• Lung abscess
• Organisation of exudate
• Bacteremic dissemintion
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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
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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
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MANAGEMENT OF MB
Severe community acquired pneumonia
No causative organism identified but L. pneumophilia Ag test (urine) negative
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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)
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DRUGS 2
As Required DIHYDROCODEINE 30 mg oral (for
pleuritic chest pain) CYCLIZINE (for nausea/vomiting) 50
mg oral Saline
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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.