LOCSIN, MA. PATRICIA ALYSSA L.

FMCH

COMMON PULMONARY DISEASES

CASE: A friend who is a nursing student texted one day asking for your medical advice
regarding her sick relative who is a 40 year old female, who has been experiencing fever
(>38°C) and a productive cough with yellow to greenish sputum of 1 week duration, associated
with difficulty of breathing. She told you that she already took the patient’s vital signs since she
knows how to do it. The blood pressure was 130/90mmHg, heart rate of 90bpm, respiratory rate
of 20 cpm. She wants to know what the condition of the patient might be, since they are afraid
to go directly to the hospital.

 Complete history is important especially with these kinds of symptoms. During

this time of pandemic, it is specifically important to know the travel history of the
patient to rule out COVID-19.
 It would be hard to totally rule out the above-mentioned symptoms without
physical examination, especially auscultation of the lung fields. Chest x-ray would
also be helpful in arriving at a diagnosis.  
 Due to presence of fever and productive cough and difficulty of breathing in an
elderly female with co-morbids, I would consider the patient having community
acquired pneumonia.

IMPRESSION: COMMUNITY ACQUIRED PNEUMONIA

DIFFERENTIAL DIAGNOSES:
 acute upper respiratory infection
 bronchial asthma
 bronchitis
 COVID-19 pneumonia

ADVISED MANAGEMENT AND TREATMENT

Although I have seen a lot of this case before during my hospital rotations, I can only
advise and give medication to her symptoms.

 Get plenty of rest. Rest is vital for cellular repair in the body. A person with
pneumonia may benefit from keeping physical exertion to a minimum.
 Eat nutritious foods.
 Consume lots of liquids and electrolytes. This can help prevent dehydration.
Drinking cool beverages or eating homemade ice popsicles may help hydrate the
body and cool it down.
 Mucus in the throat and chest can trigger more coughing and irritation. A warm
saltwater gargle may help eliminate mucus or germs in the throat, which may
provide some relief.
 Inhaling warm, damp air may ease breathing and keep the throat from tightening.
Breathing in the steam from a shower or breathing over a warm cup of tea may
help.
  Antipyretics such as paracetamol 500mg every 4 hours if temperature exceeds
37.8°C may also be taken to manage the fever
 Self-isolate for 14 days as a precautionary measure, to protect other members of
the family.
 DOH recommends calling 24/7 Telemedicine Hotline for those who wish to
consult health professionals.
 I would also tell the patient to seek the advice of a licensed physician for a
thorough examination and assessment if symptoms persist, following this
algorithm from WHO on patient triaging and referral for resource-limited settings
during community transmission:

. 
DISCUSSION

Community-acquired pneumonia (CAP)

Risk factors of CAP

 Chronic obstructive pulmonary disease 

 Diabetes 
 Alcoholism
 Smoking 
 Malnutrition
 Immunodeficiency
 Cardiovascular and renal comorbidities 

Etiologies of CAP: 

(i) Typical Pathogens 

 Streptococcus pneumoniae
 Haemophilus influenzae
 (ii) Atypical Pathogens 
Legionella pneumophila
Mycoplasma pneumoniae
Chlamydia pneumoniae
(iii) Viruses 
 Adenovirus
Respiratory syncytial virus
human parainfluenza virus

Symptoms and Signs

Symptoms include malaise, chills, rigor, fever, cough, dyspnea, and chest pain. Cough typically
is productive in older children and adults and dry in infants, young children, and the elderly.
Dyspnea usually is mild and exertional and is rarely present at rest. Chest pain is pleuritic and is
adjacent to the infected area. Pneumonia may manifest as upper abdominal pain when lower
lobe infection irritates the diaphragm. GI symptoms (nausea, vomiting, diarrhea) are also
common. Symptoms become variable at the extremes of age. Infection in infants may manifest
as nonspecific irritability and restlessness; in the elderly, manifestation may be as confusion and
obtundation.

Diagnostics

 Chest x-ray
 Consideration of alternative diagnoses (eg, heart failure, pulmonary embolism)
 Sometimes identification of pathogen

Diagnosis is suspected on the basis of clinical presentation and infiltrate seen on chest x-ray.
When there is high clinical suspicion of pneumonia and the chest x-ray does not reveal an
infiltrate, doing computed tomography (CT) or repeating the chest x-ray in 24 to 48 hours is
recommended.
Chest x-ray findings generally cannot distinguish one type of infection from another, although
the following findings are suggestive:

 Multilobar infiltrates suggest S. pneumoniae or Legionella pneumophila infection.

 Interstitial pneumonia (on chest x-ray, appearing as increased interstitial markings and
subpleural reticular opacities that increase from the apex to the bases of the lungs)
suggests viral or mycoplasmal etiology.
 Cavitating pneumonia suggests S. aureus or a fungal or mycobacterial etiology.

 
Treatment

 For low-risk CAP without comorbid illness, AMOXICILLIN remains the standard drug
of choice. Use of extended macrolides may also be considered 
 For low-risk CAP with stable comorbid illness, β-lactam with β-lactamase inhibitor
combinations (BLIC) or second generation cephalosporins with or without extended
macrolides are recommended. For patients who have completed first-line treatment
(BLIC or 2nd generation cephalosporin) with no response, an extensive work up should
be done to identify the factors for failure of response. Work-up may include doing
sputum Gram stain and culture.
 For moderate-risk CAP, a combination of an IV non antipseudomonal β-lactam (BLIC,
cephalosporin) with either an extended macrolide or a respiratory fluoroquinolone is
recommended as initial antimicrobial treatment.
 For high-risk CAP without risk for Pseudomonas aeruginosa, a combination of an IV
non-antipseudomonal β-lactam (BLIC, cephalosporin or carbapenem) with either an IV
extended macrolide or an IV respiratory fluoroquinolone is recommended as an initial
antimicrobial treatment.
 For high-risk CAP with risk for P. aeruginosa, a combination of an IV
antipneumococcal, antipseudomonal β-lactam (BLIC, cephalosporin or carbapenem)
with an extended macrolide and aminoglycoside OR a combination of an IV
antipneumococcal, antipseudomonal β-lactam (BLIC, cephalosporin or carbapenem) and
an IV ciprofloxacin or high dose IV levofloxacin.