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SOB Story

SOB Story. Group 14 Jack De Wolf, Etaoin Farmer, Yumi Lee, Oliver Manley, Kavita Patel, Lord Lyazzat Toleubekova. Patient. 69 Female Retired clerical worker at university. Presenting Complaint. SOB Lethargy. History Presenting Complaint. 5/7 ago suddenly felt very tired

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SOB Story

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  1. SOB Story Group 14 Jack De Wolf, Etaoin Farmer, Yumi Lee, Oliver Manley, Kavita Patel, Lord Lyazzat Toleubekova

  2. Patient • 69 Female • Retired clerical worker at university

  3. Presenting Complaint • SOB • Lethargy

  4. History Presenting Complaint • 5/7 ago suddenly felt very tired • Unable to do housework • SOB walking around house (can normally walk for miles, now only yards, used to be able to walk 2 flights of stairs, now none) • Cough producing brown sputum 5/7 • Decreased appetite for 4/7

  5. History PMH- Osteoarthritis Known bronchitis since childhood FH- Nothing significant SH- 40 pack years (20/d for 40 years) Lives with husband Four children DH- was given inhalers years ago by practice nurse but has never used them as she doesn’t feel like she needs them NKDA

  6. General Observations On arrival to A&E • Pyrexial 37.6 • Tachypnoeic 22 • Heart Rate 80 • BP 112/65 • Sats 91% on breathing 24% O2

  7. Respiratory System • Positive Findings • Tar stained Nails • Increased vocal resonance in right middle lobe • Widespread respiratory crepitations • Pyrexia: 37.6 • Tachypnoea: 22/min

  8. Examinations Normal

  9. Differential Diagnosis • Pneumonia • Acute exacerbation of asthma • Acute exacerbation of COPD • Acute bronchitis • URTI • Influenza • Lung Ca • TB • HF • PE

  10. Investigations?

  11. Emergency Bloods • Hb 11.9 (11.6-16.5) • WCC 11.0 (4.0-11.0) • Neutrophils 5.95 (2.0-7.5) • MCV 80 (80.0-97.0) • Plts 230 (150-400) • Na+ 132 (132-144) • K+ 3.9 (3.5-5.0) • Urea 4.79 (2.7-7.5) • Creatinine 70 (50-120) • CRP 385

  12. ABGs • pH 7.45 (7.35-7.45) • pCO2 4.94 (4.5-6.0) • pO2 7.31 (10.5- 13.5) • Lactate 1.0 • BE 0.0 (-3 to +3) • HCO3 24.5

  13. CXR • Shadowing/consolidation right middle lobe

  14. Working Diagnosis Community Acquired Pneumonia

  15. Initial Treatment • Started on Augmentin 1.2g IV • Clarithromycin 500mg IV • Prednisolone 40mg IV • IV saline

  16. Further Management Plan • Continue antibiotics • IV fluids • Sputum Sample • Blood Cultures • If no improvement → CT thorax

  17. Pneumonia • Acute respiratory illness associated with recently developed radiological pulmonary shadowing which may be segmental, lobar or multilobar.

  18. Community-acquired pneumonia (CAP) • 5-11/1000 adults suffer from CAP each year • Incidence increases with age • M=F • Most cases are spread by droplet infection • Strep. pneumoniae most common

  19. Risk Factors • Preceding Hx of viral infection • Smoking • Age > 60 years • Autumn/Winter Season • Aspiration in elderly patients • Immunosuppression

  20. Causative Agents of CAP

  21. Causative Agents of CAP

  22. Clinical Features -Confusion -cyanosis Hypotension Tachycardia -Tachypnoea -myalgia Arthralgia

  23. Assessment of severity

  24. Investigations • CXR • Sputum: direct smear by Gram and Ziehl-Neelsen stains. Culture and antimicrobial sensitivity testing • Blood culture • Serology: acute and convalescent titres for Mycoplasma, Chlamydia, Legionella, and viral infections. Pneumococcal antigen detection in serum or urine • Bronchoscopy and BAL

  25. Management British Thoracic Society Guidelines 2009

  26. Complications of Pneumonia • Abscess formation • Empyema • ARDS • Pleural Effusion • Lobar collapse • Pneumothorax (particularly with Staph. Aureus) • Hepatitis, pericarditis, meningoencephalitis, myocarditis (particularly with Mycoplasma pneumonia)

  27. Follow-up • Clinical review around 6 weeks later • Chest X-ray if there are persistent symptoms, physical signs or reasons to suspect underlying malignancy.

  28. Prevention • Reduce factors that predispose to pneumonia • Influenza and pneumococcal vaccination should be considered in selected patients

  29. Hospital Acquired Pneumonia New episode of pneumonia occurring at least 2 days after admission to hospital • Second most common hospital-acquired infection (HAI) and the leading cause of HAI-associated death • Early onset HAP occurs within 4-5 days. The organisms involved are similar to those involved in CAP • Late-onset HAP is more often attributable to Gram-negative bacteria (e.g. Escherichia, Pseudomonas and Klebsiella species), Staph. aureus (including methicillin-resistant Staph. aureus (MRSA)) and anaerobes

  30. Management Adequate Gram-negative cover is usually provided by: • A third-generation cephalosporin (e.g. cefotaxime) with an aminoglycoside (e.g. gentamicin) • Thienomycin (meropenem, imipenem) • Anti-pseudomonal penicillin (piperacillin, tazobactam) • Consider anti-staphylococcal +/- MRSA cover (flucloxacillin/vancomycin)

  31. Prevention • GOOD HYGIENE • Minimise the chances of aspiration and limit the use of stress ulcer prophylaxis with proton pump inhibitors • Oral antiseptic (chlorhexidine 2%) may be used to decontaminate the upper airway

  32. References • Davidson Principles and Practice of Medicine • Medicine at a glance Patrick Davey, 2nd Ed • Kumar and Clark Clinical Medicine • Oxford Clinical Handbook • British Thoracic Society

  33. Thank You

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