Transcript Joanne and Arvin

Joanne and Arvin
Plans for Diagnosis
and Management
1. Immediate stabilization
Course in the
Ward
• Day 1 (01-26-10)
• Patient was hydrated and
placed under diet
– 1800 kcal/day, 270g CHO, 15g
CHON, 25g fats divided into 3
meals and 2 snacks.
Plans for Diagnosis
and Management
2. Complete History and Physical
Exam
3 of the following 5 criteria
(Acute Pyelonephritis):
1) clinical symptoms of APN
(chilling, nausea, vomiting,
flank pain)
2) CVA tenderness
3) leukocytosis (higher than
10,000/µL)
4) fever (higher than 38.5℃)
5) WBC count ≥5 cells/hpf on
centrifuged urine sediment
Reference: The Philippine Clinical Practice Guideline on the
Diagnosis and Management of Urinary Tract Infections: A
Quick Reference Guide for Clinicians* Report of the Task
Force on Urinary Tract Infections 1998
Course in the
Ward
Plans for Diagnosis
and Management
3. Patients presenting with
signs and symptoms of
pyelonephritis should have
a urine culture and blood
culture.
– The results of the urine
culture may not be
available for 48 hours
therefore a urinalysis
and CBC can be used to
support presumptive
diagnosis of
pyelonephritis.
Reference: The Philippine Clinical Practice Guideline on the
Diagnosis and Management of Urinary Tract Infections: A
Quick Reference Guide for Clinicians* Report of the Task
Force on Urinary Tract Infections 1998
Course in the
Ward
• CBC with platelet count:
– WBC of 35.5 predominantly
neutrophils.
• Urinalysis
– Yellow, slightly turbid, pH 6.5 sp
gr 1.005, albumin (-), sugar (-),
RBC 0-2/hpf, pus cell 8-12/hpf
and bacteria +++.
• Urine GS/CS and Blood C/S were
not done prior to antibiotic
therapy.
Plans for Diagnosis
and Management
4. Broad spectrum IV
antibiotics should be
started until the results
of the urine culture are
available and a more
selective antibiotic can
be identified.
5. Paracetamol
500mg/tab, 1 tab q4h
prn for fever
Course in the
Ward
• Ceftriaxone (2g/IV OD) and
Paracetamol (500mg/tab, 1 tab
q4h prn) were both started
Empiric Therapy
Reference: The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A
Quick Reference Guide for Clinicians* Report of the Task Force on Urinary Tract Infections 1998
Plans for Diagnosis and Management
• Empiric Therapy
– Sepsis secondary to acute pyelonephritis
• Parenteral regimen: ceftriaxone 1-2 g once a day;
ciprofloxacin 200-400 mg every 12 hours; ofloxacin 200400 mg every 12 hours; gentamicin 3-5 mg/kg once a
day or 1 mg/kg every 8 hours.
Reference: The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A
Quick Reference Guide for Clinicians* Report of the Task Force on Urinary Tract Infections 1998
Plans for Diagnosis
and Management
6. Request for chest x-ray and
sputum examination for acid-fast
bacilli.
Course in the
Ward
• Chest X-Ray was requested
• Negative AFB smear on day 1, 2
and 3 of hospital stay
Plans for Diagnosis and
Management
• A. PULMONARY TB DSSM Result:
– Smear (+)
• A patient with at least 2 sputum specimens positive
for AFB, with or without radiographic abnormalities
consistent with active TB.
• A patient with 1 sputum specimen positive for AFB
and with radiographic abnormalities consistent with
active pulmonary TB as determined by a physician
• A patient with 1 sputum specimen positive for AFB
and sputum culture positive for M. tuberculosis
Plans for Diagnosis and Management
• DSSM Result:
– Smear (-)
• A patient with at least 3 sputum specimens negative
for AFB with radiographic abnormalities consistent
with active TB, and there had been no response to a
course of antibiotics and/or TBDC to treat the patient
with a full course of anti-TB chemotherapy
Plans for Diagnosis and Management
• Types:
A. New – A patient who has never had treatment for
TB or who has taken anti-TB drugs for less than one
month.
B. Relapse – A patient previously treated for TB who
has been declared cured or treatment completed,
and is diagnosed with bacteriologically positive
(smear or culture) TB.
C. Failure – A patient who, while on treatment, is
sputum smear positive at five months or later during
the course of treatment.
Plans for Diagnosis and Management
D. Return after default (RAD) – A patient who
returns to treatment with positive bacteriology
(smear or culture), following interruption of
treatment for 2 months or more.
E. Transfer-in – A patient who has been transferred
from another facility with proper referral slip to
continue treatment.
Plans for Diagnosis and Management
F. Others – All cases that do not fit into any of the
above definitions. This group includes:
• a patient who is starting treatment again after
interrupting treatment for more than 2 months and has
remained or became smear-negative
• a sputum smear negative patient initially before starting
treatment and became sputum smear-positive during the
Rx.
Plans for Diagnosis and Management
• Category I (2 HRZE/ 4HR)
– New pulmonary smear (+) cases
– New seriously ill pulmonary smear (-) cases with extensive lung lesions on
CXR as assessed by TB Diagnostic Committee
– New extra-pulmonary TB
– Concomitant HIX infxn
– Intensive phase – HRZE for 2 months
– Maintenance phase – HR for 4 months
• Category II (2 HRZES/ 1HRZE/ 5HRE)
–
–
–
–
–
–
failure cases
relapse cases
return after default RAD (smear +)
other ( smear+ or -)
Intensive phase – HRZES for 2 months then HRZE for 1 month
Maintenance phase – HRE for 5 months
Plans for Diagnosis and Management
• Category III ( 2 HRZ(E) / 4HR)
– new smear (-) but with minimal PTB on CXR as
assessed by TB diagnostic committee
– ethambutol may be omitted for non-cavitary, smear
(-), fully susceptible cases
• Category IV
– chronic ( still smear (+) after supervised retreatment)
– refer to specialized facility or DOTS plus/ PMTM
Center
Plans for Diagnosis and Management
• Treatment regimen for category II:
– 2HRZES/HRZE/4HRE
– 30-37kg
•
•
•
•
Intensive phase – first 2 mon.
2 HRZE, 0.75g streptomycin
3rd mon. 2 HRZE.
Continuation phase – 2 HR, 1 E 400 mg
– 38-54 kg
•
•
•
•
Intensive phase – first 2 mon.
3 HRZE, 0.75g streptomycin
3rd mon. 3 HRZE
Continuation phase – 3 HR, 2 E 400 mg
Plans for Diagnosis and Management
• Treatment regimen for category II:
– 55-70kg
» Intensive phase – first 2 mon.
» 4 HRZE, 0.75g streptomycin
» 3rd mon. 4 HRZE
» Continuation phase – 4 HR, 3 E 400 mg
– >70kg
» Intensive phase – first 2 mon.
» 5 HRZE, 0.75g streptomycin
» 3rd mon. 5 HRZE
» Continuation phase – 5HR, 3 E 400 mg
• Follow-up: Category II - end of 3rd month and 5th month, start of
8th month
Insert CHEST X-RAY FINDINGS
and picture
Plans for Diagnosis
and Management
• Usual Dx and Mx plans for
pneumonia were
complicated by the CC. of
Pyelonephritis.
• Pneumonia Dx based on
clinical presentation and
confirmed by chest x-ray.
• Hydrate the patient
• CBC
• Gram stain and culture of the
sputum
• Sputum AFB smear to rule
out active TB
Course in the
Ward
• Patient was hydrated and
placed under diet
• CBC
• Urinalysis
• Chest X-Ray was requested
• Negative AFB smear on day
1, 2 and 3 of hospital stay
CAP
Philippine Community-Acquired Pneumonia (CAP)
Guidelines 2004
Any of the ff:
RR ≥30/min
PR ≥125/min
Temp ≥40 or ≤35°C
Suspected aspiration
Extrapulmonary evidence of
sepsis
Unstable comorbid conditions
CXR: multilobar, pleural
effusion, abscess, progression
of lesion to 75% in 24 hours
NO
YES
Any of the ff:
1. Shock or signs of
hypoperfusion,
hypotension,
altered mental
state, urine output
<30ml/hr
2. PaO2 < 60mmHg or
acute hypercapnea
(PaCO2 > 50mmHg)
at room air
NO
Low risk CAP
Moderate risk
CAP
Out-patient
In-patient
YES
High
risk
CAP
ICU
Plans for Diagnosis
and Management
• The course in the ward
for treating
Pyelonephritis and
Pneumonia are similar.
• Empirical regimen is
administered:
– Azithromycin 500 mg IV q
24 h plus β-lactam IV
(cefotaxime 1 to 2 g q 8 to
12 h; ceftriaxone 1 g q 24
h)
– Macrolides
Course in the
Ward
• Ceftriaxone (2g/IV OD)
and Paracetamol
(500mg/tab, 1 tab q4h
prn) were both started
• (In treating the
pyelonephritis, the
pneumonia also could
have been treated)
Plans for Diagnosis
and Management
• Routine urologic evaluation
(ultrasound or CT scan of the
kidney) and routine use of
imaging procedures are not
recommended.
• Radiologic evaluation should
be considered if the patient
remains febrile within 72
hours of treatment to rule out
the presence of
nephrolithiasis, renal or
perirenal abscesses, or other
complications of
pyelonephritis.
Reference: The Philippine Clinical Practice Guideline on the
Diagnosis and Management of Urinary Tract Infections: A
Quick Reference Guide for Clinicians* Report of the Task
Force on Urinary Tract Infections 1998
Course in the
Ward
Plans for Diagnosis
and Management
Course in the
Ward
• Day 2 (01-27-10)
• Spot sputum AFB stain still
showed no acid fast bacilli.
• Urine and blood specimen were
collected for urine GS and CS, and
blood culture
• There were still episodes of fever
and cough, with no dysuria
• Crackles were heard bilaterally on
both lung fields
• Ceftriaxone was continued and
Erdosteine (300mg/cap, 1 cap
BID) was started.
Day 2 (01-27-10)
• Serum sodium and potassium levels were
requested
– Hyponatremia and hypokalemia
• Kalium durule, 2 durules TID x 6 doses was
given and hydration with PNSS was continued.
• A repeat CBC showed WBC of 11.80. (35.5 in
Day 1)
• FBS was also requested showing normal value.
Day 3 (01-28-10)
• Spot sputum AFB stain still showed no acid fast bacilli.
• Patient was referred to DOTS for further evaluation and
management.
• Patient was afebrile, with stable vital signs, no dysuria
but still has cough and (+) bilateral crackles
• Ceftriaxone was shifted to Cefixime 200mg/cap, 1 cap
BID for 5 days (until Feb 1, 2010)
• Patient had stable vital signs. The rest of the hospital
stay was unremarkable. Patient was then discharged
improved and stable.
• Discharge Medications:
– Cefixime 200mg/cap, 1 cap BID for 5 days (until
Feb 1, 2010)
• Special Instructions
– Refer back to DOTS with X-ray and sputum AFB
results as outpatient, increase oral fluid intake
• Follow-up or Transfer Instruction
– To come back at Med OPD on Feb 11, 2010 (Thurs,
8am) with DOTS referral.
LABORATORY RESULTS
CBC
Date
Hgb (NV: 120-170 g/dl)
RBC (NV: 3.8-5.5x106/µL )
Hct (NV: 0.37-0.54)
MCV (NV: 78-101 fL)
MCH (NV: 27-31 pg)
MCHC (NV: 32-36 g/dl)
RDW (NV: 11.6-14.6)
MPV (NV: 7.4-10.4 fL)
Plt (NV: 150-450x109/L
WBC (NV: 4.5-10x109/L
Neutro (NV: 0.5-0.9)
Bands (NV: 0-0.05)
Segmenters (NV: 0.5-0.7)
Lym (NV: 0.20-0.40)
Mono (NV: 0-0.07)
Eos (NV: 0-0.01)
Baso (NV: 0-0.01)
Jan 26 2010
127
4.41
0.37
84.3
28.9
34.3
12.6
5.5
320
35.5
0.92
0.09
0.83
0.08
-
Jan 28 2010
113
3.98
0.33
83.7
28.3
33.8
12.9
5.3
298
11.8
0.63
0.63
0.34
0.02
0.01
-
Abnormal Findings
Hgb (NV: 120-170
g/dl)
Hct (NV: 0.37-0.54)
WBC
(NV: 4.5-10x109/L)
Neutro (NV: 0.5-0.9)
Segmenters
(NV: 0.5-0.7)
Jan 26
2010
127
Jan 28
2010
113
0.37
35.5
0.33
11.8
0.92
0.83
0.63
0.63
Blood Chemistry
Date
Jan 27, 2010
(Day 2)
Sodium (NV: 137-147 mmol/L)
133
Potassium (NV: 3.8-5 mmol/L)
3.3
FBS (NV: <100mg/dl)
87
Urinalysis
Date
Color
Transparency
pH
Specific Gravity
Albumin
Sugar
Hyaline casts
RBC
Pus cell
Squamous cell
Bacteria
Jan 26 2010
Yellow
Turbid
6.5
1.005
Negative
Negative
0-2/coverslip
0-2/hpf
8-12/hpf
++
+++
Urine GS/CS
• Urine culture showed no growth after 2 days
of incubation
• Urine gram stain showed no findings on
centrifuged and on uncentrifuged urine.
Blood Culture
• Blood culture showed no growth after 5 days
of incubation.