Teaching Clinic: 4 patients with cough & fever Flashcards
Patient 1
CC: Fever with cough x 5 days
HPI :
7 d – malaise & myalgia
5 d – fever, cough, with scanty sputum not responding to amoxicillin given by GP
2 d – fever & cough continued, some purulent sputum – abdominal discomfort with nausea and diarrhoea .
PH : ex-smoker, non-alcoholic known diabetes x 15 yrs with good control by oral drugs
What are causative agents associated with diarrhoea?
- Influenza
- Legionella
Sputum may indicate lower respiratory tract infection
Myalgia and malaise is more common with URTI, viral (influenza)
LRTI is more associated with bacterial infection / pyogenic infection
Patient 1
Patients did not respond antibiotics and developed further symptoms. Why?
- Pathogen may be responding to antibiotics due to resistance or it is not a bacteria
- Could be atypical in origin
- Non-compliance to medication
- GI S/S may be due to amoxicillin or part of the picture of this LRTI organism = Diarrhoea (S/E from antibiotics)
- ‘Flu-like’ S/S, not respond to amoxicillin
If viral in origin, there may be abdominal discomfort to begin with (i.e. coronavirus can cause abdominal discomfort first before respiratory Sx)
Patient 1
What RF does this patient have to infection?
Elderly, ex-smoker, DM
Extreme age (children & elderly)
Patient 1
PE: General : temp 40°C central cyanosis +ve mild mental confusion
What may account for these symptoms?
There is fever, may have infection
Central cyanosis means hypoxia
* Mild mental confusions:
◦ Can mean severe (Feature of infection)
◦ Severe hypoxia can lead to confusion
◦ CNS involvement
◦ Electrolyte imbalance
◦ Hypoglycemia due to pre-existing DM (glycaemic disturbance due to infection = sepsis)
◦ High fever may lead to confusion (in children, febrile convulsion)
Patient 1
RS :
* mildly stressed with RR 28/min
* trachea central RUZ – ↓ chest expansion, dull percussion except apex
* bronchial breath sounds with insp crackles
RSV interpretations:
- Tachypnoic
- Respiratory distress;
- Consolidations in RUZ
- Decreased movement in RUZ
Pulmonary consolidation compatible with patient with LRTI (pneumonia)
Patient 1
CVS: PR 110/min, regular
BP 125/80
Abdomen: mild diffuse tenderness, no rebound, no mass felt bowel sound normal
CNS : normal
Pulse Oximetry: SaO2 90% (on nasal cannula 3L O2/min flow)
- CVS: Sinus tachycardia with normal BP
- Soft; Mild diffuse tenderness (no signs of acute abdomen);NO Peritoneal signs
- CNS presentations is normal: NOT associated focal neurological deficits (meningism [Kernig & Brudzinski sign] = implies no meningitis and encephalitis)
- Patient has hypoxia
Patient 1
What is strange about the WBC here?
WBC is abnormally normal!
When WBC is single digit, likely normal (4-11)
- Elderly
- Atypical pneumonia
- Immunocompromised
- Partially treated pneumonia
Patient 1
Why does patient have hypoNa?
- SIADH complicating pneumonia (serum urine osmolality)
- Diarrhoea: usually lose more K than Na
- Malnutrition: Poor oral intake
Patient 1
Why may ALT and AST (parenchymal enzymes) be elevated?
- Drug reaction (liver has to process drugs)
- Reaction to infection (liver doesn’t have to wait for organisms to go to them, they just mount the immunological reaction from the liver)
- Reaction to hypoxia
- Underlying fatty liver disease
Patient 1
What is normal range of PaO2?
PaO2 10-14 kP on room air
PaCO2 4.5-6 kP (CO2 is normal)
Type I hypoxic respiratory failure
- The patient is on oxygen to achieve a PaO2 9.8 kP
- Hypoxemia (not enough oxygen in blood = means that we have measured it from ABG!)
- Hypoxia (not enough oxygen)
Patient 1
What is seen here?
Patchy infiltrates: heterogenecity
Consolidation:
- Dense: solid
- Patchy: heterogenous (areas of aeration / radiolucency)
Patient 1
Why is culture -ve? What other test should we use?
Culture may be negative because:
- Partially treated
- Viral in origin
- Poor technique of patient: saliva only
Urine antigen test: specific, sensitivity, rapid, cheap
- +ve from day 3: several weeks; not affected by Ab
Patient 1
Why does this patient have atypical pneumonia? What are some atypical pathogens?
CNS manifestaions is atypical due to mental confusion.
Atypical:
◦ Chlamydia
◦ Legionella
◦ Mycoplasma
◦ !!! Younger patient sexually active:
◦ Chlamydia, Mycoplasma
Deeper sample: BAL, NPA:
‣ TB PCR
Patient 1
What are the investigations for Legionella pneumonia?
Serum antibody: 4 fold rise in titre
Mycoplasma and chlamydia can be detected by PCR with swap
Legionella is a notifiable disease
Patient 1
Why is patient confused clinically?
High fever
Hypoxemia
Feature of L pneumonia
SIADH with hyponatremia
Exclude: DM related, hypo/hyperglycemia, minor stroke
Patient 1
What are the common organisms for community acquired pneumonia in HK?
TB usually present with chronic lung changes, seldom presents acutely (except for in TB meningitis!!!)
Patient 1
What are the mode of transmission (Legionnaire’s disease)?
Patient 1
When must we be alerted to Legionella pneumonia?
Treated with azithromycin and meropenem