PNEUMONIA

BY:
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
Pathology

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:
Lobar
Bronchopneumonia
Origin of infction:
Community acquired pneumonia
Nosocomial 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:
Bacterial
Viral
Fungal
Atypical
Aspiration
DIAGNOSIS
History taking: suggestive signs and
symptoms
Physical examination
Investigation
Chest X-ray or other imaging techniques
SYMPTOMS AND SIGNS
General symptoms:
Fever - Malaise
Chills and rigors - Nausea and vomiting
Loss of appetite
Myalgia
Respiratory symptoms:
Productive cough
Sputum
+/- hemoptysis
Shortness of breath
Pleuritic chest pain
 Specific symptoms:
Abdominal pain
Advanced symptoms:
Cyanosis
Alteration 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:
FullBlood 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 settings
CXR: classically thought of as the gold standard
INFILTRATE PATTERNS
PATTERN 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 hourly
Keep SpO2 > 92%
Oxygen therapy
Adequate hydration
Assisted ventilation when necessary
Symptomatic: Analgesics, Mucolytic agents
Antibiotics
EMPIRICAL ANTIBIOTIC
TREATMENT
Community Acquired pneumonia
IVbeta-lactam antibiotic plus IV/ oral macrolides
or flouroquinolones
Nosocomial pneumonia
Cephalosporin 2nd generation, aminoglycosides
Atypical pneumonia
Macrolides
 Aspiration pneumonia:
Cephalosporin 2nd generation plus metronidazole
Pneumocystic carinii pneumonia:
Co-trimoxazole
Clindamycin
SWITCH TO ORAL THERAPY
Four criteria:
Improvement in cough and dyspnea
Afebrile on two occasions 8 hourly apart
WBC decreasing
Functioning 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, patients condition became worse and she also complained of
lethargy. Patient went to emergency department yesterday and
temperature was documented at 37.5 C. Patient was then warded to ward
5.
PAST MEDICAL HISTORY

This is the patients 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 EXAMINATION
1. 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: 37.0C
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 SYSTEM
Sign observed Interpretation
Inspection Chest structure Symmetry

Chest movement Symmetrical & abdomino-

thoracal respiratory

Palpation Chest expansion Symmetrical

Tactile vocal fremitus Increased at lower zone of
right side
Percusion Lung sounds Dullness at lower lobe of
right lung

Auscultation Breath sound Bronchial breathing on

both side
Additional sounds Fine crepitations > right
side, no ronchi
Vocal resonance Not 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.
DIAGNOSIS
1. DIFFERRENTIAL DIAGNOSIS :
- PNEUMONIA
- BRONCHIECTASIS
- TB

2. WORKING DIAGNOSIS :
- Pneumonia
 INVESTIGATION

SPECIFIC :
BASIC :
Full Blood Count Sputum FEME, C&S, AFB
Blood Urea and Blood C&S
Serum Electrolytes Pleural aspiration
(BUSE) Bronchoscopy
Serology (Mycoplasma,
Creatinine
Chlamydia,Legionella)
Arterial Blood Gases Immunoflourosence or
(ABG) Giemsa stain for PCP
Chest X-Ray
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 38C
IV Augmetin 1.2 g TDS
To review all investigations results
 FOLLOW UP 24th 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 Blood Pressure Temperature

(x/minute) (mmHg) (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 Result Normal range
White Blood 17 ( ) 4- 11
(Day 1)
Cell
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
Thank you