Patients Past Medical History - Case Study Example

Case Study Patient History The patient is a 64-year-old man with productive cough. The cough is also associated with fever and chills. The patient denies any recent weight loss, night sweats, and previous exposure to tuberculosis. Patient’s Past Medical History The patient is undergoing a treatment for hypertension, increased cholesterol and ischemic heart disease and sees his doctor periodically. His current medication includes: Captopril 6.25 mg BD Betaloc 50 mg BD Anginine prn. Patients’ Social History The patient has a history of alcohol abuse and has been smoking pack-a-day for 20 years. Five days ago, the patient developed a cough productive of yellow sputum. Physical Examination The physical examination of the patient revealed respiratory distress and he could only talk in short sentences. His clinical observations are: GCS 15/15 Respiratory rate 34 breaths/min. Heart rate 110/min BP 150/80mmHg Temperature 38.5C SpO2 (room air) 92% Crackles were audible on auscultation Percussion of the chest revealed dullness over the right lower chest Blood work revealed normal serum electrolyte values Normal hematocrit and platelet count White blood cell count elevated A chest radiograph showed a right pleural effusion and alveolar infiltrate involving the right middle and lower lobes. Blood and expectorated sputum were obtained for gram-stain and culture, results of blood culture negative The patient continued to have difficulty breathing and arterial blood gases were taken. Arterial blood gas count was: pH 7.29 PaCO2 55 mmHg HCO3- 23 mmol/L PaO2 47 mmHg SaO2 86% Following analysis of the blood gas results the patient was commenced on supplemental oxygen at a FiO2 of .50. Additional clinical assessment revealed: Pale, cool, dry skin Dry, cracked lips Decreased urine output (voided once in 8 hours – volume 150 mls) History of poor food/fluid intake over the past 5 days BSL 9.0 mmol/L Although not diagnostic of a particular causative agent, the characteristics of the sputum produced suggested the presence of Streptococus pneumoniae, common bacteria that causes acute pneumonia in adults. Further Observations Sputum grew Streptococus pneumoniae which was sensitive to penicillin and appropriate changes to antibiotic therapy were made. The symptoms are indicative of either bacterial pneumonia or pulmonary tuberculosis. In addition, the patient was already on a dose of Captopril for treating high blood pressure. Though, Captopril generally is well tolerated, and side effects are usually mild and transient. Continual use of the medicine commonly causes a dry, persistent cough. . The concerned patient’s productive cough could have been a side effect of this medicine. Further, a major side effect of the medicine could be kidney failure and increased levels of potassium in the blood. The patient showed symptoms of renal complications as his urination was considerably reduced. (Gennis P et al) Case Analysis The early symptoms of the patient that included productive cough along with fever and chills, indicated a probable case of pulmonary tuberculosis or acute pneumonia. Symptoms of pulmonary tuberculosis include chest pain, coughing up blood, and a productive, prolonged cough for more than three weeks. Systemic symptoms include fever, chills, night sweats, appetite loss, weight loss, pallor, and often a tendency to fatigue very easily. Since the patient already has a history of high cholesterol and had pale, cool, dry skin, dry, cracked lips and decreased urine output indicative of kidney dysfunction, the practitioner could have wrongly diagnosed the patient of pulmonary tuberculosis. However, advanced check ups and tests revealed an elevated white blood cell count and Streptococus pneumoniae in patient’s sputum. In case of pulmonary tuberculosis, the white blood cell count decreases considerably. Moreover, in case of tuberculosis, the bacteria responsible is Mycobacterium tuberculosis where as the most common bacteria that causes pneumonia is the Streptococcus pneumoniae (pneumococcus) bacteria. Since the patient’s sputum showed presence of this bacteria, he was diagnosed and treated for acute bacterial pneumonia. This type of pneumonia usually begins with flu like symptoms that include chills and fever. However, this type of pneumonia can be very critical as it directly impacts lungs and kidneys. To confirm the case of bacterial pneumonia, several advanced tests were conducted. The patient was subjected to pulse oximetry, and the lower oxygen level than expected, again indicated towards pneumonia. Further, since the patient suffered shortness of breath, a chest radiograph was conducted. The radiograph indicated a right pleural effusion and alveolar infiltrate involving the right middle and lower lobes. Also, abnormal fluid collections reflected in the radiograph also can help diagnose pneumonia. In addition, arterial blood samples were tested to gauge an exact measurement of the exchange of oxygen and carbon dioxide in the patient’s body. This test, called an arterial blood gas is extremely important to check the exact level of various gases in the blood stream. The patient’s ABG test revealed the following readings: pH 7.29 PaCO2 55 mmHg HCO3- 23 mmol/L PaO2 47 mmHg SaO2 86% The readings indicated lower level of oxygen owing to improper functioning of lungs. Following this analysis of the blood gas results the patient was commenced on supplemental oxygen at a FiO2 of .50. This was done to facilitate easy breathing for the patient and gradually raise the oxygen levels to normal. Further, to identify sputum stains, a sputum culture was conducted. The stains contained in the sputum enable the doctor to determine which specific bacterium is causing the pneumonia. The sputum culture may yield the following observations: Presence of Pneumococci may produce bloody or rust-colored sputum. Presence of Pseudomonas, Haemophilus, and pneumococcal species may produce green sputum. Presence of Anaerobic infections may produce foul-smelling sputum. Presence of Klebsiella and type 3 pneumococci may produce sputum resembling currant jelly. The patient’s sputum indicated the presence of Streptococus pneumoniae and was also sensitive to penicillin. (Agarwal G et al, 2004) Consequently the patient was diagnosed of bacterial pneumonia and the patient was put on an immediate dose of Erythromycin. Erythromycin is commonly used for patients who show sensitivity towards penicillin. Pneumonia Causes Causes for the development of pneumonia can be extrinsic or intrinsic, and various bacterial causes exist. Extrinsic factors include exposure to a causative agent, pulmonary irritants, or a pulmonary injury. Pneumococcal agents like Klebsiella, Haemophilus influenzae, gram-negative organisms, Staphylococcus, and Legionella species, and aspirated materials are the common tigers for pneumonia. Further, since the patient has smoking history of a pack a day, his immunity to such infections was considerably reduced. In addition, complications that arise due to extensive smoking also increase the risk of pneumonia. Different bacteria, viruses and fungal infections can be the cause of pneumonia. However, Pneumococcal pneumonia is commonly caused by Streptococcus pneumoniae. Pneumonia caused by this bacteria is the most common form of pneumonia in the U.S. Also, pneumococcus infection is responsible for over 6,000 deaths per year in the U.S. This is the highest casualty rate for a disease for which a curable vaccine exists. Moreover, if pneumonia gets critical, it can lead to, pneumococcal meningitis, which is again associated with a particularly high fatality rate. (Feldman C et al, 1991) Pneumonia can be triggered in different ways. The micro-organisms that commonly cause pneumonia may remain inside the patient’s body for some time before the symptoms of pneumonia actually show up. Inhaling infected substances like chemicals, vomit or a smoke can also cause pneumonia. If a person shows symptoms of pneumonia, he should be subjected to immediate medical examination for a proper diagnose. Fever with chills or sometimes low body temperature, increased respiratory rate, low blood pressure, high heart rate, or low oxygen amount in the blood are common symptoms gauged in a physical examination of a patient indicative of pneumonia. Also, if physical examination reveals acute difficulty in breathing, mental confusion and cyanosis (blue-tinged skin), the pateint must immediately be put under suitable medication (Mufson, MA, 1996). The patient in this case showed signs of fever accompanied by chill, had high heart rate, low oxygen count and extreme difficulty in breathing. In patients with symptoms of pneumonia, conducting a detailed examination of lungs and kidneys is also important. Also, sometimes though the physical examination of the lungs may seem normal, yet it may indicate a decreased expansion of chest on the affected side, stressed breathing on auscultation and audible crackles over the affected area during inspiration. In the case of this patient, crackles were audible on auscultation and percussion of the chest revealed dullness over the right lower chest. While these signs are relevant, they are insufficient to either diagnose or rule out pneumonia. Moreover, due to similarity in symptoms, pneumonia has often been diagnosed as tuberculosis or vice a versa (emedicine.com). To further consolidate diagnose of bacterial pneumonia, the patient was subjected to chest X-rays. Now, different chest situations as indicated in an x-ray are a critical test for pneumonia. Though chest x-rays can reveal areas of opacity which represent consolidation, yet it is not always possible to detect pneumonia on x-rays. A probable cause for this could e the initial stage of the disease or its impact on an area which s not detectable by x-ray. Further, x-rays can be misleading, because other problems, like lung scarring and congestive heart failure, can mimic pneumonia on x-ray. Additionally, chest x-rays are also used to evaluate the complications of pneumonia. The chest radiography of the patient concerned revealed, right pleural effusion and alveolar infiltrate involving the right middle and lower lobes indicative of increased complications in lungs due to pneumonia (http://www.medicinenet.com/pneumonia/article.htm). To do away with any doubts about diagnose of pneumonia, the patient’s sputum culture may be conducted. Apart from determining the presence of the kind of bacteria present in the patient body, sputum cultures are also used to confirm whether the infection is sensitive to an antibiotic that has already been started. A blood sample may similarly be cultured to look for bacteria in the blood. In the case of the concerned patient, the sputum culture confirmed the presence of the Streptococcus pneumoniae and showed sensitivity towards penicillin. Several methods can be used for obtaining patient’s sputum. These include, Early morning sputum Random sputum 24 hour collection Saline inhalation induced sputum Gastric lavage Bronchoscopy In case a patient denies any expectoration, the medical practitioner can induce it. The same can be done by making the patient inhale heated 7% saline solution by a nebulizer, which irritates the respiratory tract and generates secretions that are suitable for studies (Wipf JE et al, 1999) In addition, bronchoscopy can be conducted to obtain respiratory secretions for testing the sputum. Moreover, gastric lavage for collection of overnight respiratory secretions can be used to collect sputum if the patient has a tendency to swallow the sputum. The ABG count for the patient concerned gave the following results: pH 7.29 PaCO2 55 mmHg HCO3- 23 mmol/L PaO2 47 mmHg SaO2 86% Considering these results, the patient was commenced on supplemental oxygen at a FiO2 of .50 Medical practitioners may also request a blood culture to confirm the diagnosis as well as check for complications induced by suspected pneumonia. A complete blood count in the patient concerned showed a high white blood cell count, indicating the presence of an infection or inflammation. Further, since the patient had considerably low intake of fluids in the past five days and reduced urination, the blood tests was also used to evaluate kidney function. After several tests and observations, the patient showed the following symptoms that indicated towards an acute case of bacterial Pneumonia: 1. High fever with chills 2. Cough productive with sputum that has a rusty color 3. Though the patient did not complain of a chest pain , he suffered from extremely shallow breathing 4. The patient had shortness of breath and could barely speak. 5. The patient had increased white blood cell count. 6. The oxygen level in the blood was below the normal. 7. Along with heart and lungs, the pneumonia has also impacted kidneys of the patient resulting in reduced urination. Pneumonia Trends and Complications According to the U.S. Centers for Disease Control and Prevention (CDC), certain groups of people are at a higher risk of catching pneumococcus infection due to exterior factors described above. These groups include: People aged 60 and above People over age two years of age who have problems with their lungs, heart, liver, or kidneys People over age two years of age with health problems like diabetes, sickle cell disease, alcoholism, or HIV/AIDS Persons over two years of age who are taking any treatments that weaken the body's immune system According to various studies, 50 percent of pneumonia cases are triggered by some kind of bacterial infection. The streptococcus bacterium, known as pneumococcus, is the main cause of the most typical pneumonia. Further, people aged 60 and above, who develop the pneumococcus infection, are more likely to develop the following complications: A build-up of fluid around the patient’s lungs. This is called a pleural effusion and it results in severe breathing difficulties. The same was observed in the patient concerned. The patient’s kidneys may be impacted resulting in reduced urination and a lower intake of fluid. This may result in an increased blood urea level, further putting the patient at a risk of developing renal complications. Suggested Medication Several studies have revealed that almost 10% of the general patients test allergic towards penicillin, and therefore require alternative antibiotics that can control bacterial growth significantly. It is imperative to test the properly for any sensitivity towards penicillin as allergy towards penicillin can induce further complications in patients. Patient’s complete medical history along with extensive tests may reveal his sensitivity towards penicillin and accordingly the most suitable alternative medication may be suggested (emedicine.com). In the case of the given patient, his allergy towards penicillin was indicated in the sputum culture. Therefore, the patient was put on a dosage of Erythromycin. Erythromycin is an antibiotic used for people who have an allergy to penicillin. Since the patient had infection in respiratory tract as indicated by shortness of breath and a right pleural effusion with alveolar infiltrate involving the right middle and lower lobes, Erythromycin was a suitable medication as it has proven essentially effective for mycoplasma and Legionellosis. Using the antibiotic erythromycin for treating pneumonia in most patients aged 60 and above is a popular medication and is highly cost effective as well. The drug is also recommended from the American Thoracic Society (ATS), which recommends erythromycin or other agents for those intolerant or allergic to penicillin. Further, since the patient tested positive for gram stain, and the infection was touted to be life threatening, he was put on a medication of Vancomycin. Vancomycin is effective for the treatment of serious, life-threatening infections by Gram-positive bacteria which are unresponsive to other less toxic antibiotics. Vancomycin works by killing bacteria and thwarting their reproduction. Given through a vein, Vancomycin is also used by medical practitioners to treat people who are hospitalized with severe infections that do not respond to other antibiotics. These Infections of the blood or bone; lower respiratory tract, such as pneumonia or complications of flu; and endocarditis are commonly treated by Vancomycin. Vancomycin typically has a high cure rate for pneumonia. For people in the hospital, cure rates are 73% to 96%; outside of the hospital, cure rates are generally above 80%. Further, Vancomycin is significantly effective against Streptococcus pneumoniae, Staphylococcus, and Listeria monocytogenes, among other bacteria (WHO (1999). "Pneumococcal vaccines”). Therefore, the medication prescribed to the patient concerned was apt and was in complete accordance to the indications given by different clinical examinations. References: 1. Agarwal G, Awasthi S, Kabra SK, Kaul A, Singhi S, Walter SD; ISCAP Study Group. (2004). "Three day versus five day treatment with amoxicillin for non-severe pneumonia in young children: a multicentre randomised controlled trial". BMJ 328: 791–4. doi:10.1136/bmj.38049.490255.DE. PMID 15070633. 2. Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV, Facklam RR (October 1993). "Pneumococcal polysaccharide vaccine efficacy. An evaluation of current recommendations". JAMA 270 (15): 1826–31. doi:10.1001/jama.270.15.1826. PMID 8411526. 3. Clinical efficacy of 3 days versus 5 days of oral amoxicillin for treatment of childhood pneumonia: a multicentre double-blind trial". Lancet 360: 835–41. doi:10.1016/S0140-6736(02)09994-4. PMID 12243918. 4. Combes A, Luyt CE, Fagon JY, et al (October 2004). "Impact of methicillin resistance on outcome of Staphylococcus aureus ventilator-associated pneumonia". Am. J. Respir. Crit. Care Med. 170 (7): 786–92. doi:10.1164/rccm.200403-346OC. PMID 15242840. 5. Emerman CL, Dawson N, Speroff T, et al (1991). "Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients". Annals of emergency medicine 20 (11): 1215–9. doi:10.1016/S0196-0644(05)81474-X. PMID 1952308. 6. Feldman C, Kallenbach JM, Levy H, Thorburn JR, Hurwitz MD, Koornhof HJ (1991). "Comparison of bacteraemic community-acquired lobar pneumonia due to Streptococcus pneumoniae and Klebsiella pneumoniae in an intensive care unit". Respiration 58 (5-6): 265–70. doi:10.1159/000195943. PMID 1792415. 7. Fine MJ, Auble TE, Yealy DM, et al (January 1997). "A prediction rule to identify low-risk patients with community-acquired pneumonia". N. Engl. J. Med. 336 (4): 243–50. doi:10.1056/NEJM199701233360402. PMID 8995086. http://content.nejm.org/cgi/pmidlookup?view=short&pmid=8995086&promo=ONFLNS19. 8. Garenne M, Ronsmans C, Campbell H (1992). "The magnitude of mortality from acute respiratory infections in children under 5 years in developing countries". World Health Stat Q 45 (2-3): 180–91. PMID 1462653. 9. Gennis P, Gallagher J, Falvo C, Baker S, Than W (1989). "Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department". The Journal of emergency medicine 7 (3): 263–8. doi:10.1016/0736-4679(89)90358-2. PMID 2745948. 10. Hayden FG, Atmar RL, Schilling M, et al (October 1999). "Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza". N. Engl. J. Med. 341 (18): 1336–43. doi:10.1056/NEJM199910283411802. PMID 10536125. http://content.nejm.org/cgi/pmidlookup?view=short&pmid=10536125&promo=ONFLNS19. 11. Heckerling PS, Tape TG, Wigton RS, et al (1990). "Clinical prediction rule for pulmonary infiltrates". Ann. Intern. Med. 113 (9): 664–70. PMID 2221647. 12. Hoare Z, Lim WS (2006 pages=1077–79). "Pneumonia: update on diagnosis and management". BMJ 332: 1077. doi:10.1136/bmj.332.7549.1077. PMID 16675815. http://www.bmj.com/cgi/content/full/332/7549/1077. 13. http://www.healthlinkbc.ca/kbase/topic/detail/drug/uf4975/detail.htm 14. http://www.medicinenet.com/pneumonia/article.htm 15. http://www.wrongdiagnosis.com/t/tuberculosis/intro.htm#whatis 16. Infections: Pneumonia - kidshealth.com 17. Jefferson T, Deeks JJ, Demicheli V, Rivetti D, Rudin M (2004). "Amantadine and rimantadine for preventing and treating influenza A in adults". Cochrane Database Syst Rev (3): CD001169. doi:10.1002/14651858.CD001169.pub2. PMID 15266442. 18. Lim WS, van der Eerden MM, Laing R, et al (2003). "Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study". Thorax 58 (5): 377–82. doi:10.1136/thorax.58.5.377. PMID 12728155. 19. Metlay JP, Kapoor WN, Fine MJ (November 1997). "Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination" (PDF). JAMA 278 (17): 1440–5. doi:10.1001/jama.278.17.1440. PMID 9356004. http://jama.ama-assn.org/cgi/reprint/278/17/1440. 20. Moussaoui R, de Borgie CA, van den Broek P, Hustinx WN, Bresser P, van den Berk GE, Poley JW, van den Berg B, Krouwels FH, Bonten MJ, Weenink C, Bossuyt PM, Speelman P, Opmeer BC, Prins JM. (2006). "Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study". BMJ 332: 1355–58. doi:10.1136/bmj.332.7554.1355. PMID 16763247. 21. Mufson, MA; RJ Stanek (1999-07-26). "Bacteremic pneumococcal pneumonia in one American City: a 20-year longitudinal study, 1978–1997". Am J Med (Department of Medicine, Marshall University School of Medicine) 107 (1A): 34S–43S. doi:10.1016/S0002-9343(99)00098-4. PMID 10451007. 22. pneumonia at Dorland's Medical Dictionary 23. Pneumonia Guideline - Synopsis" (PDF). iv5. http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/MACAP2001gline.pdf. 24. Pneumonia, Bacterial - emedicine.com, specifically, "The chest radiograph usually clears within 4 weeks in patients younger than 50 years without underlying pulmonary disease". Symptoms are often resolved within 1–2 weeks.] 25. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP)". MMWR Recomm Rep 48 (RR-4): 1–28. April 1999. PMID 10366138. http://www.cdc.gov/mmwr/preview/mmwrhtml/00057028.htm. 26. Stedman's Medical Dictionary, "pneumonia". Accessed on: November 24, 2007. 27. Syrjälä H, Broas M, Suramo I, Ojala A, Lähde S (August 1998). "High-resolution computed tomography for the diagnosis of community-acquired pneumonia" (PDF). Clin. Infect. Dis. 27 (2): 358–63. doi:10.1086/514675. PMID 9709887. http://www.journals.uchicago.edu/doi/pdf/10.1086/514675. 28. Table 13-7 in: Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson (2007). Robbins Basic Pathology. Philadelphia: Saunders. ISBN 1-4160-2973-7. 8th edition. 29. WHO (1999). "Pneumococcal vaccines. WHO position paper". Wkly. Epidemiol. Rec. 74 (23): 177–83. PMID 10437429. 30. Wipf JE, Lipsky BA, Hirschmann JV, et al (May 1999). "Diagnosing pneumonia by physical examination: relevant or relic?". Arch. Intern. Med. 159 (10): 1082–7. doi:10.1001/archinte.159.10.1082. PMID 10335685. http://archinte.ama-assn.org/cgi/content/full/159/10/1082. Read More