Case Discussion || Pneumonia
Summary
TLDRThis medical transcript details a 63-year-old male's emergency room visit for fever, chills, and breathlessness, indicative of pneumonia. The patient, with a history of COPD and prostate hypertrophy, presents with low oxygen saturation and a thick-walled lung cavity. The discussion covers diagnostic steps, potential malignancy concerns due to low hemoglobin, and treatment strategies, including antibiotics for pseudomonas infection and the importance of physiotherapy and postural drainage.
Takeaways
- 🌡️ The patient presented with high fever, chills, and breathlessness, indicative of a severe infection.
- 🏥 Initial assessment revealed the patient was conscious, with no issues in airway or breathing, but had a respiratory rate of 30 breaths per minute and low oxygen saturation at 92%.
- 🩺 The patient's low blood pressure and heart rate could suggest sepsis, a serious complication of infection.
- 🌡️ The patient's temperature was noted, which is crucial in managing sepsis as hypothermia can be a poor prognostic sign.
- 🧬 The patient had a history of COPD and benign prostate hypertrophy, which complicates the clinical picture.
- 🫁 Auscultation revealed bilateral equal air entries with basal crepitations, suggesting pneumonia.
- 🩸 Hemoglobin levels were lower than expected for a COPD patient, potentially indicating malignancy.
- 🦠 Sputum culture grew Pseudomonas, a gram-negative bacteria often found in patients with compromised lung function.
- 💊 Treatment included oxygen therapy, nebulization, and antibiotics targeting pseudomonas.
- 🔍 Follow-up will involve monitoring inflammatory markers, hemoglobin levels, and imaging to assess resolution of the lung cavity.
Q & A
What are the initial symptoms presented by the 63-year-old male patient?
-The patient presented with high-grade fever, chills, dry cough, productive cough with mucopurulent sputum, and breathlessness for one week.
What are the common conditions that can produce chills according to the script?
-Common conditions that can produce chills include urinary tract infection, malaria, and pneumonia.
What was the patient's respiratory rate and oxygen saturation upon initial assessment?
-The patient's respiratory rate was 30 breaths per minute, and his oxygen saturation was 92% in room air.
What are the common causes of tachypnea in the emergency room as mentioned in the script?
-Common causes of tachypnea include hypoxia, metabolic acidosis, and hyperventilation syndromes.
What is the significance of the patient's blood pressure being 90/70 mmHg?
-A blood pressure of 90/70 mmHg is considered low for a 63-year-old male, which could indicate a long-term condition or be due to the current infection.
What could be the reasons for the patient's heart rate not increasing despite low blood pressure?
-Reasons could include the patient being on beta blockers, myocarditis, hypothyroidism, or inaccuracies in examination or documentation.
Why is maintaining body temperature important in a septic patient?
-Hypothermia is a dangerous prognostic factor in sepsis. Maintaining body temperature is crucial as hypothermia can increase mortality.
What does the ABG result indicate about the patient's respiratory status?
-The ABG results show a reduced pH (7.51), pCO2 (29.4), and pO2 (62.2), indicating hypoxemia with hypocarbia, which could be a sign of respiratory distress.
What is the significance of the patient having a history of COPD?
-A patient with COPD is more susceptible to pneumonia, and the type of pneumonia they develop might be different from someone without COPD, often involving gram-negative organisms.
What does the sputum culture report indicate about the patient's infection?
-The sputum culture report indicates the presence of Pseudomonas, which is typically found in damaged lungs and suggests a more severe infection.
What treatment approaches are suggested for the patient with a lung cavity?
-Treatment includes oxygen therapy, nebulization with hypertonic saline or ambroxyl, and physiotherapy including percussion, vibration, and postural drainage.
What are the follow-up considerations for this patient after discharge?
-Follow-up should include monitoring inflammatory markers, checking for a normal or increasing hemoglobin level, and possibly performing an FNAC for the left supraclavicular node, as well as ultrasound examinations of the abdomen and testes.
Outlines
🌡️ Initial Assessment and Symptoms of Sepsis
The paragraph discusses the case of a 63-year-old male admitted to the ER with a high fever, chills, and breathlessness for a week. The patient's symptoms suggest possible conditions such as urinary tract infection, malaria, or pneumonia. The initial assessment reveals the patient is conscious, with no issues in the airway, and able to speak in full sentences, indicating no severe respiratory distress. However, he exhibits tachypnea with a respiratory rate of 30 breaths per minute and low oxygen saturation at 92%. The paragraph also explores potential reasons for tachypnea, including hypoxia, metabolic issues, and hyperventilation syndromes. The patient's circulation is assessed with a heart rate of 100 beats per minute and low blood pressure, which is unusual for his age, suggesting a possible sepsis-induced drop in blood pressure.
🏥 Detailed Examination and Sepsis Management
This section delves deeper into the patient's examination, noting a heart rate that is unexpectedly low for his blood pressure, which could be due to medication like beta blockers or conditions such as myocarditis. The importance of maintaining body temperature in septic patients is emphasized, as hypothermia can be a poor prognostic indicator. The patient's ABG results show respiratory acidosis with low pH and pCO2, indicating issues with oxygen and carbon dioxide levels. The secondary survey reveals a history of COPD, benign prostate hypertrophy, and smoking, with the patient's condition progressing from mild to severe over a week. The paragraph also discusses the differences in pneumonia presentation between patients with normal lung function and those with COPD.
🔎 Further Diagnostics and Differentials
The paragraph focuses on further diagnostics, with the patient's hemoglobin level indicating potential hypoxemia and the possibility of malignancy if lower than expected for a COPD patient. The patient's white blood cell count shows a high neutrophil percentage, suggesting infection. Creatinine, urea, liver enzymes, and bilirubin levels are also noted, along with the patient's negative sputum AFB culture but positive for Pseudomonas, indicating a secondary infection often seen in damaged lungs. The discussion highlights the difference between upper lobe cavities, often due to TB or fungal infections, and lower lobe cavities, typically due to bacterial pneumonias like necrotizing pneumonia.
💊 Treatment Approach and Considerations
This section outlines the treatment approach for the patient, including the use of oxygen due to low saturation, nebulization with hypertonic saline and bronchodilators for COPD, and mucolytics for thick lung secretions. The choice of antibiotics for Pseudomonas infection is discussed, with options like ceftazidime or meropenem, and the potential need for long-term nebulization with Tobramycin if the cavity persists. Postural drainage and physiotherapy are recommended to help clear the lung cavity. The paragraph also covers the importance of monitoring the patient's condition, including inflammatory markers, hemoglobin levels, and the potential need for further diagnostic tests like FNAC for the left supraclavicular node.
📈 Follow-up and Prognosis
The final paragraph discusses the importance of follow-up care for the patient. It highlights the need to monitor the patient's recovery, including checking for decreasing inflammatory markers and performing a chest X-ray after six weeks to assess lesion resolution. The paragraph also emphasizes the need to reevaluate the patient's hemoglobin levels to rule out malignancy and to perform additional tests like ultrasounds of the abdomen and testes to check for any metastatic spread, considering the initial finding of a left supraclavicular lymph node.
Mindmap
Keywords
💡High grade fever
💡Pneumonia
💡COPD
💡Tachypnea
💡Hypoxia
💡Hypothermia
💡Sepsis
💡Malignancy
💡Pseudomonas
💡Necrotizing pneumonia
💡Postural drainage
Highlights
63-year-old male patient presents with high-grade fever, chills, and dry cough for one week.
Patient also complains of productive cough with mucopurulent sputum and breathlessness.
Initial assessment reveals the patient is conscious and oriented.
No abnormalities found in the airway or breathing during primary survey.
Patient is able to talk normally, indicating no severe respiratory distress.
Bilateral equal air entries with basal crepitations noted on auscultation.
Respiratory rate is 30 breaths per minute, and oxygen saturation is 92% in room air.
Tachypnea could be due to hypoxia, metabolic acidosis, or anxiety hyperventilation syndrome.
Circulation shows a pulse rate of 100 beats per minute and blood pressure of 90/70 mmHg.
Glasgow Coma Scale (GCS) is 15, indicating the patient is alert and responsive.
Low blood pressure could be due to the infection or long-term physiological conditions.
Heart rate is not increased despite low blood pressure, possibly due to beta blockers or myocarditis.
Temperature is 97.8°F, which is crucial in managing sepsis.
Arterial Blood Gas (ABG) shows respiratory acidosis with low pCO2 and pO2.
Past medical history includes COPD and benign prostate hypertrophy.
Left supraclavicular lymph node is enlarged, hard, and fixed, which could indicate malignancy.
Hemoglobin level is lower than expected for a COPD patient, suggesting possible malignancy.
Sputum culture grows Pseudomonas, indicating a damaged lung is more susceptible to gram-negative infections.
Chest X-ray shows cavities in the left upper lobe and lower lobe, suggesting necrotizing pneumonia.
Treatment includes oxygen therapy, nebulization with hypertonic saline, and antibiotics for pseudomonas infection.
Postural drainage and physiotherapy are advised for the patient to help drain the cavity.
Follow-up care includes monitoring hemoglobin levels, inflammatory markers, and possible malignancy.
Transcripts
foreign
[Music]
63 year old male was brought to the ER
with complaints of high grade fever and
chills and dry cuffs since one week it
was associated with productica and
breathlessness since one week initial
conditions you get chills along with
fever
urinal tract infection
my lady
malaria
pneumonia pneumonia consolidation mostly
pneumococcaline then
abscess pass somewhere in the body these
are the common conditions which can
produce chills okay initial 10 second
assessment patient was conscious and
oriented obey comments primary survey
coming to Airway patient with no pooling
of secretion or abnormal Airway sounds
can pneumonia produce altered sensory
listen
wait
[Music]
um
it's called as toxic hypoxemia itself
can produce sometimes
altered Behavior
he was able to talk normal and be able
to complete full sentence
spine appear normal the importance of
able to complete one sentence
you are telling every case
what is important
so whenever there is distrust patient
will not be able to talk properly that's
why we are telling patient is able to
talk full sentence so that means he is
not in respiratory distress but he's
having respiratory problem
will not be able to talk at all
breathing on auscultation just
bilaterally equal air entries
with bile with bilateral basic and
repetition plus let's say more than
Right Said
see that condition you have to ask the
patient to cough and you have to
ascultate again then only you you have
to confirm your finding okay
he had respiratory rate of 30 per minute
and oxygen saturation of 92 percentage
in room air
coming to circulation good peripheral
pulses respiratory rate is 30 oxygen
saturation is 92. what are the reasons
for tachypnea in emergency room
hypoxia one of the common cause here
hypoxemic hypoxemia is there then
metabolicism metabolical storage is the
next important cause then
hyperventilation syndromes
can be psychological it can be due to
Central cause
these are the common condition what we
see in Amazon zero like mostly it is
hypoxia second thing is
metabolic acidosis third one is anxiety
hyperventilation syndrome okay
circulation good peripheral pulses pulse
rate of 100 per minute and blood
pressure of 90 70 millimeter Market
disability GCS E4 B5 M5 M6 15 bar 15 90
by 70.
do you think that this baby is normal
for this patient
slightly low normally a 60 year old male
patients will have slightly higher BP or
even if it is normal it will be upper
upper limit of the normal because of the
arteriosclerosis many will have a
slightly higher systolic BP here it is
90 by 60 70.
so you think it is normal
what what happened
what is happening to the BP BP is low
you think it is low is it
physiologically you know or that means
he is having low BP for a long time or
due to this infection it is due to this
infection what is the first sign of
hypertension
here we are telling uh pulse rate is
only 100 normally when the BP is very
low like this you get a higher heart
rate either the like whatever your
documented is wrong or there may be some
other reason to reduce the heart rate
what are the reasons which can reduce
the heart rate in asepsis
like you are telling 100 only heart rate
but BP is very low comparing its normal
BP may be 130 90 or something it is low
we don't know what this is BP but even
then mostly this type of radiation level
BP of 130 by 90.
but here it is uh heart rate is only 100
that means there is something has
reduced the heart rate or something is
preventing the heart rate to increase
either your method of examination or
your documentation is wrong or some
other reason is that what are the
reasons which can reduce the heart rate
in a hypertensive patient due to sepsis
elderly individual
beta blockers ominous causes patience on
beta blocker that is a first and
important cause which can reduce the
heart rate second thing
carditis myocarditis myocarditis can
produce both tachycardia and bradycardia
when the conduction system is involved
it can produce biodically okay so that
we have to give or
patient can have conditions like
hypothyroidism or something like that so
we have to remember all these things
VP is low but heart rate is not
increased what is the reason that is
very important okay
exposure temperature 97.8
adjacent to primary survey what is
importance of exposure and temperature
in a patient with sepsis
high fever is not a problem anybody is
having infection IP or has to be there
let everybody know
why an emergency doctor should be
concerned about exposure and temperature
in a septic patient or septicemic
patient
hypothermia hypothermia is one of the
most dangerous prognostic factor in
substitution if you keep the patient
without covering the patient in
emergency room the two AC cold MRI
mortality can be high so exposure is
very important maintaining body
temperature to higher level is very
important low temperature can actually
kill the patient what are the Triads in
sepsis or trauma patients which can
aggravate the problem one of the problem
is hypothermic okay
ABG pH
7.51 and pco2 is 29.4 by coordinate 23.5
and po2 is 62.2 creating 0.69 is
abnormal in that anything I'm down
everything is normal
trees 29th 29 pco2 standard po2 is 62
both are reduced that means what oxygen
is reduced CO2 is also reduced what do
you suspect then
suppose you have acute pneumonia cute
not uh like five six days it is acute to
three days pneumonia what is the first
sign
what is your respiratory rate here
hi so you have
but even after that oxygenation is not
increasing but what happened to the
carbon dioxide it will be washed out so
that is the first sign of respiratory
distress hypoxemia with hypocarbia after
sometimes what will happen hypoxia with
hypercarbia then what will happen
hypoxemia hypercarbia respiratory
acidosis then only compensation occurs
okay
with
no significant stt changes okay
coming to secondary survey 63 years old
male came to the emergency room with
history of high grade fever with chills
and trica since one week associated with
productive cuff with mucoperlin sputum
and breathless breathing difficulty was
initially mmrc grade one and which was
progressed to grade 3
in one week associated with
decrease up it appetite but no
significant
no history of loose tools abdomen pain
vomiting no chest why you are thinking
about loose tools Innovation with
respiratory infection
one of the presentation is loose tools
for this complaint the patient went to
nearby hospital and diagnosed as
pneumonia hence patient was referred to
our hospital for further management and
evaluation
fast medical and surgical history
history of uh is a known case of COPD
and history of benign prostate
hypertrophy
for which turp was done four months back
he said non-co-pd patient it's a smoker
non COPD patient trp has done foreign
COPD patient how do we differ from a
patient who resign or a normal length or
an infection differ from a COPD patient
to a person with normal length
a normal person is getting pneumonia a
patient who is saying COPD is getting
pneumonia what is the difference
will be triggered at exacerbation
okay all the seopd excess elevations are
infected accessories
so a person coming from Community who is
egg pneumonia coming to your hospital
person who is already having COPD he is
also coming from Community to your
hospital with the pneumonia what is the
difference between these two pneumonias
fresh lung pneumonia that means a normal
length pneumonies are mostly
gram-positive cocky virus or gram
possible but a damaged length person who
is hanging monuments it can be gram
positive or gram negative both are
possible okay so here we have to think
about gram negative so other condition
we are not thinking about gram negative
mostly it is gram posture so that is a
major difference when you are starting
antibiotic you have to cover gram
positive in a normal length person with
pneumonia
here you have to start a antibiotic with
gram positive gram negative average okay
no history of hypertension
there is no significant past history of
relevant for his present complaint
General examination patient conscious
and oriented purely built and averagely
nourished
on examination left supraclavicular
lymph node scene left
no palette no interest no clubs you have
to tell lymph node properly what is the
size of the lymph node whether it is
hard mobile fixed mobile mobile only one
node it's a hard or soft painful
non-paintable fixed
what is importance
left
why left is very important
causes to opposite side mostly left from
where it comes
thoracic deck not only drain from the
lungs it drains from the lower abdomen
onwards so inhalation in the scrotum
abdomen everything can go directly to
the left Supra clocker this is called as
what is that not called as
which of node
so that is a sign of malignancy in the
abdomen or below like uh in the below
the diaphragm but it is all lymph nodes
are always not malignant so you have to
examine you have to suppose you have a
doubt you have to take a biopsy or a
fnacy but left-sided lymph node
supractor lymph nodes are always modern
okay you have to keep in mind
pulse rate of 100 permit and BP was 90
to 70. what is the drainage of lens
lymph node wise
where it drains suppose you have a
problem in the lungs very dry
the pleura brain to axillary
other one straight into the surprise
okay
mediation and then supracellular
systemic examination respiratory rate
to bilaterally equal bilateral
repetition and base on left side more
than right shape
cardiovascular system is
no added sound
palpable Mass
central nervous system no focal
neurologist
always examine the testis is very
important because testicular Mass
patient you miss only evidence may be
left superclipse okay
no signs of manager irritation
investigation
and hemoglobin was 12.2 and platelet was
40 lakhs what do you think about
hemoglobin percentage in this patient
is it important
why it is important
what is the expected hemoglobin in a
real COPD patient
what happened to hemoglobin
increase
increase
if it is not in decrease it is it has to
increase when there is hypoxemia what
will happen to your erythropoietin
erythropoietin will produce more and
that will increase the hemoglobin so
normally if you follow if you are
following a patients with COPD you can
see that HP percent is very high that is
because of the secondary policythemia so
in a patient who is
like somebody saying real copy and is
hemoglobin is slightly lower you have to
be very careful that indicates
malignancy okay that indicates
malignancy so we have to be very careful
when a lower
hemoglobin in a COPD patient there can
be other reasons for like a hemorrhoids
all these things can also produce uh
blood loss and anemia but always you
have to roll out a malignancy when the
HP percent is low
and neutrophil is 90 97
and lymphocyte is 8.5
creatine 0.72
urea is 16.1 sgot
29.8 and sdpt 30.9 okay
total bilirubin is 1.48
and total protein 7.4 and grbs is on 98.
98
it's a diabetic or non-diabetic
non-diabetic how do you know that he is
diabetic or not
no X3 will not be the only he is coming
to the hospital first time he doesn't
know whether he is diabetic or not how
do you rule out so you have to always
ask for a HP airnc suppose it is more
than 6.5 you can tell that there is a
possible diabetes since last three four
months or more than three months okay
and sodium is 130 potassium 3.3
130 slightly lower not normal
space 243 okay
and we did a sputum AFV his potent FB
was negative and the sputum's mere
report was showing but the yeast cell
with pseudo hyphae okay sputum culture
report has grown
pseudomonasa okay
pseudomonas is
normally occurring in a damaged link
that is very much that's why I told
previously Whenever there is a damage
length if patient develops pneumonia
there can be gram negative organs if the
patient has already gone to many many
hospitals many time then there is a high
chance for multi truck resistant gram
negative organism like pseudomonas okay
just ice today left
okay
upper lobe cavity and lower lobe cavity
what is the difference
cavity is mostly due to DB or fungal
infection lower low cavities are mostly
due to infections especially gram
negative infections
the redness is lower respiratory tract
infection probably bacterial pneumonia
here you have to use the term
necrotizing pneumonia why necrotizing
that part of the lung is damaged and
destroyed necrotizing pneumonia very few
organism will produce dexodometers all
these things produce necrotizing
pneumonia that part is lost that's why
there is a cavity there
okay
a fungal pneumonia okay we don't know
whether fungus is there or fungus is a
Associated pathogen with the pseudomonas
already there is a cavity so in that
whether the patient is growing fungus or
only oral common cell we don't know but
we had to treat the fungus also because
that also can produce a thick walled
cavity
COPD okay
and BP BPH so Etc shows a cavity
it's a thick wall cavity that in that
you are getting pseudomonas infection
sputum and you're also getting fungal
Hypha in the sputum okay
but you have anemia patient design
still it can be malignancy malignancy
itself also can produce cavity in the
lungs okay
treatment oh so what treatment do you
give for this patient
why you are giving oxygen he's already
saturation is low he's having a lung
cavity okay so you have to start oxygen
okay what toxin you have started it's an
initial prongs or nasal mask or BiPAP
what you have started Hazel Bronx okay
how much oxygen you can give through
natural prongs up to four liters you can
give more than that you should not give
through nasal funks you have to put the
mask okay
can you use BiPAP in this patient or
CPAP in this patient what are the
dangers of CPAP starting in this patient
this patient may return sometimes you'll
have to start but you have to explain
everything to the patient by Center
there is a high chance of
there is a high chance of rupture of the
cavity and that can reduce pneumothorax
okay but this is a thick wall cavity
rupture is unlikely very rarely it can
produce rupture
you want to give nebulization
what nebulization what all nebulizations
you can give
salvation
bromide that is one then
that is for COPD part and these can be
subsided with your hypertropium bromide
okay then
he's having a cavity why cavity is
formed in pneumonia because of the
was collected in the lungs first will be
very thick what do you do for that
what are the broncholites you know
mucolides
you can give ambroxyl tablet or you can
give any steel system nebulization okay
here he has got pseudomonas infection in
that so what antibiotics you give what
are Roots you'll select
what are the drugs can be given in
pseudomonas infection
we can give a prevalent as a victim
there is one drug or mirror present as a
victim the second drug can be
nebulization so suppose this cavity
remaining for a longer period Then you
have to give a longer period uh
nebulization with Tobramycin okay what
posture you advise to the patient is
postural treatment is required for this
patient physical Physiotherapy
physiotherapy or dual advice
breathing exercise is
COPD anyway we have to give breathing
access that is a different issue that we
have to advise the vision but current
problem is a cavity
which is containing pus and fungus how
do you treat that
just physiotherapy is very important
percussion of chest vibrators you can
use third thing is positional drainage
postural drainage so suppose it's a
right side cavity you ask the patient to
lag on the left side so that it will
drain fast otherwise what will happen
till soar in the cavity and it will
become a like again it will become first
in the cavity so for we have to train
the patient for postural drainage such
cavities and mucolytics can be used okay
what happened to the patient afterwards
suppose she is stable you start
injection patient has become better
patient will be discharged he'll come
back for Fallout what are the important
things you look in this patient
workers oh okay any infection we have to
see the decreasing inflammatory markers
when will you take a chest x-ray chest
exercises should be taken ideally only
after six weeks okay if you want to see
whether the lesion is increasing you can
take suppose you want to see the
resolution of the X-ray then it takes
many days so six weeks is the minimum
time so xray can be taken then
it is another important problem what is
that you have to see
hemoglobin here to see whether the
hemoglobin is getting normal or becoming
high that is very important it is not
increasing you have to roll out
malignancy then one more thing is there
left sided supraclavator node if
possibly you have to take an fnac then
roll out malignancy examine the testis
ultrasound abdomen ultrasound testis all
these things are important because
Suppose there is a testicular malignancy
this lesion can be due to malignancy but
normally malignancy with metastasis what
will be the character
uh just
to be multiple that's why you told Canon
multiple ball like this one single
editions in metastatic relation is not
common but this lesion alone can produce
a lymph node in the left side okay
normally produces lymph node on the
right side itself but sometimes it can
reduce left side also okay so all these
things you have to tell the patient on
follow-up you have to do all these
things
thanks
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