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
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, patient’s condition became worse and she also complained of
lethargy. Patient went to emergency department yesterday and
temperature was documented at 37.5⁰ C. Patient was then warded to ward
5.
PAST MEDICAL HISTORY

This is the patient’s 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: 37.0˚C
 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 38⁰C
 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

(Day 1) White Blood Cell 17 ( ) 4- 11

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