Transcript PATHOLOGY - powerpoint world

TAKE MY BREATH
AWAY…...
Ali Hasan
May Harker
Anna Harrison-Murray
Amer Ullah
MB
• A 62 year old Caucasian woman
breathing quickly, who arrived in
England from Australia three weeks
ago
• Complained of feeling “lousy”
SYMPTOMS
•One episode of haemoptysis
•A tight chest affecting breathing - RR 20 on
admission
• 3/7 before attending A+E – first
presentation of illness was aching
knee and ankle joints.
• Left shoulder pain later emerged
ALSO …
• Anorexia, nausea, and vomiting
• Dizziness, with one marked episode
of confusion and loss of balance
• Hot and cold flushes
• Feeling very tired
PAST MEDICAL HISTORY
• Previous episode of pneumonia, age
31.
• Hot and cold flushes – previously well
controlled by HRT.
• Hallux rigidus
• High cholesterol – 7.5
(normal 4 - <6).
AND …
• Occasional headaches when
overworked.
• Neurodermatitis which has not
recurred for years.
SURGICAL HISTORY
• Removal of fibroadenoma in the right
breast
• Tubal ligation
CURRENT MEDICATION
• Remifem, an OTC HRT “replacement”
ALLERGIES
• An adverse reaction to voltarol which
caused paraesthesia in her foot.
FAMILY HISTORY
• No illnesses mentioned in daughters
• Mother had a cholesterol problem, for
which she had an endarterectomy –
and subsequently suffered a stroke
which left her senile.
• Maternal grandmother died of
rheumatic heart disease.
SOCIAL HISTORY
• An English woman who lives in
Australia
• Migrated to Australia, age 17
• Lives with her husband, a cattle farmer,
two daughters
• Smoked for 12 pack years, age 18-35
SYSTEMS REVIEW
CVS:
• No palpitations, swelling, or previous
history of SOB
SYSTEMS REVIEW
CONT.
Respiratory system:
• No cough
• No wheezing
• Occasional “nasal drip”
SYSTEMS REVIEW CONT
GU System:
• Increased thirst
• Went to the toilet 5x/24h
• No urinary urgency, and usually
one episode of nocturia per night
• Two past urinary infections
SYSTEMS REVIEW CONT
GI System:
• Patient has not eaten, and there were no
bowel motions since presentation 3/7 ago.
• Patient suffered from “plenty of wind”.
• No tenderness or pain.
VITAL SIGNS
BP
135/69
RR
20
Temp. 38.6
O2 Sat 91% (air)
Pulse 100 reg
GCS 15
CLINICAL EXAMINATION
CVS
Resp
GI
° abnormalities detected
XX
XX
° abnormalities detected
INVESTIGATIONS
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ECG
Blood Analysis
Chest Radiography
CT Scan
Microbiology
BLOOD ANALYSIS
9
WCC
24.4
x10
/L
FBC
Plat 232 x109/L
Neut 23.4 x109L
INR
0.9
Blood
APTT-R 1.31
coag.
TT
11
Na+ 130 mmol/L Cardiac CK
123iu/L
K+
4.0 mmol/L enzymes Trop T <0.01
Ca2+ 1.14 mmol/L
Cl95 mmol/L
Urea 4.7 mmol/L
Creat 87 µmol/L
pH
Blood
pCO2
Gases
pO2
Oximetry sO2
Hb
U and E
7.471
4.95 kPa
5.31 kPa
82.4%
10.8 g/dL
ECG
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Tachycardic sinus rhythm
CHEST RADIOGRAPHY
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Patchy consolidation left lung
Slight left pleural effusion
CT SCAN
MICROBIOLOGY
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Blood Cultures
Blood and Sputum Gram Stains
Antibiotic Sensitivity Tests
Legionella Titre
FOLLOW UP
3/7 later
• Patient appeared visibly better
• IV antibiotics and fluid had been
stopped – antibiotics were now oral
• Nausea stopped 2/7 after admission
FOLLOW UP CONT
• Chest no longer “tight”. Breaths
deeper but still some pain on left side
when taking very deep breaths
• An intermittent dry unproductive
cough appeared 2/7 after admission.
No further sputum production or
haemoptysis - referred to physio
MORE FOLLOW UP
• Patient now eating small meals and
resumed bowel movements
• No further dizziness, but still the
occasional flush
AND FINALLY…
• Some lethargy.
• Vital signs good. Pulse around 76, temp
36.6, resp rate around 15.
• Discharge planned 3/7 after.
PATHOLOGY
• DEFINITION
Inflammation of the lung
parenchyma - exudative
solidification (consolidation)
• CAUSES
Bacterial (most common)
Other
EPIDEMIOLOGY
• Incidence
of CAP - 12 per 1000 adults
• CAP accounts for 5-12 % of all LRTI’s
• Approximately 10% require hospitalisation
EPIDEMIOLOGY CONT
• Mortality reduced by effective use of
antibiotics but remains dangerous
condition and a major cause of death in
over 70’s
- Mx community < 1%
- Mx in hospital Approximately 10%
CLASSIFICATION (1)
• COMMUNITY AQCUIRED (CAP)
- Primary or secondary
- Mainly Gram +ve bacteria
• HOSPITAL ACQUIRED
- Acquired > 48hrs after admission
- Mostly caused by Gram -ve bacteria
- Problem with antibiotic resistance
CLASSIFICATION (2)
BY SITE
• LOCALISED
(LOBAR)
• DIFFUSE
(LOBULAR)
- involvement of large
portion / entire lobe
- patchy consolidation
- infrequent due to
antibiotic effectiveness
- extension of preexisting disease
- extremely common
esp. infancy and old
age
CLASSIFICATION (3)
• BY AETIOLOGY
COMMON ORGANISMS
- Streptococcus Pneumoniae (60-75%)
- Mycoplasma Pneumoniae (5-18%)
- Influenza A (usually with bacterial)
- Haemophilus influenzae
- Staphylococcus aureus
- Legionella species
- Chlamydia psittaci
CLINICAL FEATURES
• Vary according to immune system and infecting agent
• Symptoms
• Signs
- Malaise
- fever
- high temp (up to 39.5)
- cyanosis
- pleuritic pain
- confusion
- dyspnoea
- tachypnoea
- cough
- tachycardia
- purulent / rusty
sputum
- consolidation signs
- pleural rub
COMPLICATIONS
• Respiratory failure
• Hypotension
• Atrial fibrilation
• Pleural effusion
• Empyema
• Lung abscess
• Organisation of exudate
• Bacteremic dissemintion
MANAGEMENT 1
Mild community acquired
Nonsmoking
adults < 60 yrs
Erythromycin 500 mg X
3 or Clarithromycin 250
mg x 2
Smoking adults
& > 60 yrs
Cefaclor 500
mg x3
MANAGEMENT 2
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Patients with severe pneumonia best
managed on an intensive care unit
Severe community acquired
i.v. 6 h Cefuroxime 1.5 g
& Clarithromycin 500 mg
12 h
MANAGEMENT OF MB
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Severe community acquired pneumonia
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No causative organism identified but L.
pneumophilia Ag test (urine) negative
DRUGS 1
Regular
CEFOTAXIME (broad spectrum
antibiotic) 1g i.v. tds
ERYTHROMYCIN 500 mg oral qds
PARACETAMOL 1g oral qds
METOCLOPRAMIDE 10mg i.v. tds (for
nausea - side-effect of antibiotics)
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DRUGS 2
As Required
DIHYDROCODEINE 30 mg oral (for
pleuritic chest pain)
CYCLIZINE (for nausea/vomiting) 50
mg oral
Saline
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OTHER
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O2 therapy for hypoxaemia
Fluids encouraged to avoid dehydration
Seen by chest physiotherapist due to
inability to expectorate
Antibiotics shifted to oral route after 3
days of i.v.