INTERACTIVE CASE

DISCUSSION
HISTORY OF PRESENT ILLNESS
FM, 55y/o male executive
Confined due to stroke
7th hospital day fever and non-productive cough
PHYSICAL EXAM
BP: 110/70
RR: 26
Temp: 38.5 C
(+) rhonchi on right upper lung
PATIENTS
CXR
Normal Chest X-ray
RIGHT LUNG
LEFT LUNG
NORMAL PATIENT
DIFFERENTIAL DIAGNOSIS
CONSOLIDATION
ATELECTASIS
PLEURAL EFFUSION
CONSOLIDATION
Any pathologic process that fills the alveoli with fluid, pus, blood, cells
(including tumor cells) or other substances resulting in lobar, diffuse
or multifocal ill-defined opacities
Filling of the pulmonary tree with material that attenuates x-rays
more than the surrounding lung parenchyma
Pneumonia is the most common cause
CONSOLIDATION
RADIOGRAPHIC FINDINGS:
Homogenous opacification of the lung
Characterized by air bronchograms which are linear branching
lucencies representing the patent airways within consolidated lungs
No mediastinal and tracheal shift
No volume loss
CONSOLIDATION
ATELECTASIS
Lung collapse
Involves loss of volume in some or all of a lung with resultant
increased density of the involved lung
Caused by an airway obstruction(bronchus or bronchioles) or by
compression of the lung by pleural fluid or a pneumothorax
Obstructive or Non-obstructive
ATELECTASIS
Obstructive
larger bronchus lobar atelectasis
smaller bronchus segmental atelectasis
Non-obstructive
Loss of contact between the parietal and visceral pleura
Lung compression
Loss of surfactant (Adhesive)
Scarring or infiltrative disease of the lung (Circatricial)
ATELECTASIS (RUL)
RADIOGRAPHIC FINDINGS:
Triangular density or opacification without air bronchograms
Elevation of the horizontal fissure
Elevation of the right hilum
Crowding of the right sided ribs
Trachea may be shifted towards the opacification
Reverse S-sign of Golden
ATELECTASIS
PLEURAL EFFUSION
Collection of fluid within the pleural space or pleural cavity
Represents any pathological process which overwhelms the pleura's
ability to reabsorb fluid
Transudative or Exudative
Transudate - increase in hydrostatic pressure or a decrease in capillary
oncotic pressure
ex. Heart failure, cirrhosis, nephrotic syndrome
Exudate - increase in permeability in microcirculation or alteration in the
pleural space drainage to lymph nodes
ex. Pneumonia, TB, Bronchial CA
PLEURAL EFFUSION
RADIOGRAPHIC FINDINGS:
Blunting of the costophrenic angle
Blunting of the cardiophrenic angle
Contralateral mediastinal shift in massive effusions
MENISCUS SIGN
PLEURAL
EFFUSION
 CONSOLIDATION ATELECTASIS PLEURAL EFFUSION

Tracheal Deviation None Ipsilateral Shift Contralateral Shift

Minor Fissure Unchanged remains Elevated Bulging

at anatomical position
(4th anterior rib)

Radiologic Features Air Bronchograms Reverse S-sign of Meniscus Sign

Golden
CLINICAL IMPRESSION:
CONSOLIDATION OF THE RIGHT UPPER LOBE
SECONDARY TO BACTERIAL PNEUMONIA
PNEUMONIA
Infection of the lower respiratory tract that can be caused by bacteria,
fungi, viruses, protozoa, or parasites
Can develop after aspiration of oropharyngeal secretions, inhalation
of causative microorganisms, or when bacteria from an infection
elsewhere in the body spreads to the lungs
Development depends on the virulence of the microorganism and the
host's defense
Signs and symptoms
Fever
Tachypnea and dyspnea
Tachycardia
Pleuritic chest pain
Sputum production
Crackles
Increased tactile fremitus
Egophony
Dullness to percussion
TREATMEN: HAP
Infecting agents:
Early onset: S. pneumoniae, S. aureus, H. influenza
Late-onset: Escherichia, Pseudomonas, Klebsiella, MRSA, Anaerobes
Appropriate regimen depends upon:
Risk factors for MDR pathogens
Local pathogen susceptibility patterns
Prior microbiology data
TREATMENT: EMPIRIC THERAPY
Piperacillin-tazobactam 4.5 g IV every 6 hours
Cefepime 2 g IV every 8 hours
Levofloxacin 750 mg IV daily
Imipenem 500 mg IV every 6 hours
Meropenem 1 g IV every 8 hours
Ceftazidime 2 g IV every 8 hours
Vancomycin
Linezolid
THANK YOU!