Transcript Approach to a Patient with Cough and Fever

Approach to a Patient with
Cough and Fever
Subsection B4
Facilitator: Remedios F. Coronel, M.D.
December 7, 2009
Objectives
• To present a case of a patient with cough and
fever
• To discuss the pathogenesis of the signs and
symptoms of the patient
• To interpret the laboratory and ancillary
procedures appropriate for a patient with
cough and fever
• To plan an effective management for a patient
with cough and fever
2
General Data
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Name: RM
Age: 60
Sex: Male
Status: Married
Address: Quiapo, Manila
Religion: Roman Catholic
Race: Filipino
Occupation: Vendor
3
History of Present Illness
Chief Complaint:
Productive Cough and Fever
1 week PTA
1 day PTA
November 23,
2009
• Cough with whitish sputum
• Easy fatigability
• Low grade fever – relieved by Paracetamol
500mg/tab
• (-) Accompanying symptoms
•
•
•
•
Persistent cough with yellowish sputum
Dyspnea
Fever recurred
(-) Drug intake
• Admission
4
Past Medical History
• HPN (2005) - Highest BP 200/160; Usual BP – 120/80
– Nifedipine, - unrecalled dosage; “Amcor” from a Chinese store
– Non-compliant
• LVH (2005)
• “ Food poisoning” (unrecalled cause) – UST Hospital (2005)
• External Hemorrhoids (2005) - resolved
• Claims to have complete childhood immunizations
• No history of surgery
• (-) DM
• (-) Bronchial asthma
• (-) PTB
• (-) Blood transfusion
• (-) Allergies
• (-) Trauma/ accident
5
Family History
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(+) HPN – parents and siblings
(+) Heart disease – parents and siblings
(+) DM - sister
(-) Cancer
(-) Allergy
(-) Asthma
(-) PTB
(-) Thyroid diseases
6
Personal/Social History
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Drinks a lot of soft drinks (approximately 1L/ meal)
(+) Smoking - 25 years (1969-1994); 2 pack/year
Drinks alcoholic beverages occasionally
Mixed diet, preference to salty foods
Used to work for customs as a “checker” for 2O years
and retired in 2009
Currently sells candles candles in Quiapo church with
his wife
Married with eight children
Currently lives with his 20-year old son in a small
apartment located in Abad Santos - no ventilation and
sunlight coming in
Running as a form of exercise
7
Review of Systems
• (-) anorexia, (+) weight loss (2 inches in waistline in the past
month)
• (-) itchiness
• (-) headache, (-) blurring of vision
• (+) dizziness
• (-) colds
• (-) chest pain, (-) palpitations
• (-) abdominal pain
• (-) vomiting, (-) diarrhea, (-) constipation
• (-) hematuria, (-)flank pain
8
Review of Systems
• (-) dysuria, (+) paroxysmal nocturia every 2
hours, 4 times/night for the past 2-3 months,
(+) polydipsia (1.5 L/night)
• (-) bleeding, (-) easy bruisability
• (-) heat/cold intolerance
• (-) muscle pain
• (-) edema
9
Physical Examination
Upon Admission (November 23, 2009)
Upon Interview (November 27, 2009)
• Conscious, coherent, ambulatory, not in
CP distress
• BP: 160/100mmHg, PR: 92bpm, regular,
RR: 21cpm, regular, T: 37.5 °C
• Ht=160 cm Wt=45 kg BMI=18
• Warm dry skin, no active dermatoses
• Pale palpebral conjunctivae, anicteric
sclera, pupils 2-3mm ERTL
• Septum midline, no nasoaural discharge
• No tragal tenderness, non-hyperemic,
no pain on mastoid area
• Conscious, coherent, ambulatory, not in
CP distress
• BP: 120/80 mmHg, PR: 89bpm, RR:
20cpm, T: 36°C
• Ht=160 cm Wt=45 kg BMI=18
• Warm dry skin, no active dermatoses
• Pale palpebral conjunctivae, anicteric
sclera, pupils 2-3mm ERTL
• Septum midline, no nasoaural discharge
• No tragal tenderness, non-hyperemic,
no pain on mastoid area
10
Physical Examination
Upon Admission (November 23, 2009)
Upon Interview (November 27, 2009)
• Neck not rigid, no palpable cervical
lymphadenopathy
• No chest wall deformity, symmetric chest
expansion, no retractions, equal vocal and
tactile fremiti, clear breath sounds
• Adynamic precordium, AB at 6th LICS AAL,
(-) parasternal heave, (-) thrills, base: S2>S1,
loud P2, apex: S1>S2 and (+) S3, carotid
artery: rapid upstroke, gradual downstroke,
JVP 3 cm at 30° angle
• Flat abdomen, NABS, soft, no mass, no
tenderness, 8 cm liver MCL, Traube’s space
not obliterated, (-) hepatojugular reflux
• No palpable inguinal nodes, no CVA
tenderness
• Pulses full and equal, (-) cyanosis
• Neck not rigid, no palpable cervical
lymphadenopathy
• No chest wall deformity, symmetric chest
expansion, no retractions, resonant both
lungs, equal vocal and tactile fremiti, clear
breath sounds
• Adynamic precordium, AB at 6th LICS AAL,
(-) heave, (-) thrills, base: S2>S1, apex: S1>S2
and (+) S3, carotid artery: rapid upstroke,
gradual downstroke, JVP 3cm at 30° angle
• Flat abdomen, NABS, soft, no mass, no
tenderness, 8 cm liver span MCL, Traube’s
space not obliterated, (-) hepatojugular
reflux
• No palpable inguinal nodes, no CVA
tenderness
• Pulses full and equal, (-) cyanosis
11
Physical Examination
Upon Admission (November 23, 2009)
Upon Interview (November 27, 2009)
• Conscious, coherent, oriented to three
spheres, GCS 15
• Sense of smell intact
• Isocoric pupils: 2-3mm ERTL, no visual
field cuts
• Fundoscopy: (+) ROR, no papilledema,
no hemorrhages, clear disc margins
• EOMs full and equal, (+) conjugate eye
movements
• Intact V1-V3
• Can clench teeth, raise eyebrows, frown,
no gross facial asymmetry
• Gross hearing intact, (-) lateralization on
Weber’s test
• Uvula midline on phonation
• Conscious, coherent, oriented to three
spheres GCS 15
• Sense of smell intact
• Isocoric pupils: 2-3mm ERTL, no visual
field cuts
• Fundoscopy: (+) ROR, no papilledema,
no hemorrhages, clear disc margins
• EOMs full and equal, (+) conjugate eye
movements
• Intact V1-V3
• Can clench teeth, raise eyebrows, frown,
no gross facial asymmetry
• Gross hearing intact, (-) lateralization on
Weber’s test
• Uvula midline on phonation
12
Physical Examination
Upon Admission (November 23, 2009)
Upon Interview (November 27, 2009)
• Can shrug shoulders, turn head side
to side against resistance
• Tongue midline on protrusion
• MMT: 5/5 on all extremities
• No sensory deficits
• No atrophy, no fasciculations, no
spasticity
• Cerebellar functions intact
• DTRs: (++) on all limbs
• No Babinski, no Chaddocks, no
Oppenheims
• No nuchal rigidity, no Brudzinski, no
Kernigs
• Can shrug shoulders, turn head side
to side against resistance
• Tongue midline on protrusion
• MMT: 5/5 on all extremities
• No sensory deficits
• No atrophy, no fasciculations, no
spasticity
• Cerebellar functions intact
• DTRs: (++) on all limbs
• No Babinski, no Chaddocks, no
Oppenheims
• No nuchal rigidity, no Brudzinski, no
Kernigs
13
Salient Subjective Features
Pertinent Positives
• 60 years old
• Male
• Productive cough with whitish 
yellowish sputum (1 week)
• Easy fatigability
• Fever
• Dyspnea
• Known HPN (2005)
• LVH (2005)
• (+) Smoking 2 pack/year
• Occasional alcohol drinker
• Currently sells candles
• Currently lives in a small apartment
• (+) weight loss
• (+) dizziness
Pertinent Negatives
• (-) colds
• (-) orthopnea and PND
• (-) Bronchial asthma
• (-) PTB
• (-) Allergies
• (-) edema
14
Salient Objective Features
Pertinent Positives
• Conscious, coherent, ambulatory, not in
CP distress
• BP: 160/100mmHg, PR: 92bpm, regular
RR: 21cpm, regular T: 37.5 °C
• BMI 18
• Pale palpebral conjunctivae
• Adynamic precordium
• AB at 6th LICS AAL
• (+) S3 at apex
• 8 cm liver span MCL
Pertinent Negatives
• Septum midline
• (-) nasoaural discharge
• (-) palpable cervical lymphadenopathy
• S2>S1 at base,S1>S2 at apex
• No chest wall deformity
• Symmetric chest expansion
• No retractions
• Resonant both lungs
• Equal vocal and tactile fremiti
• Clear breath sounds
• (-) parasternal heave, (-) thrills
• JVP 3cm at 30° angle
• (-) hepatojugular reflux
• Traube’s space not obliterated
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Cough and
Fever
NonInfectious
Infectious
Pulmonary
Extra Pulmonary
Lung
Abscess
Pericarditis
URTI
Pleuritis
LRTI
Pneumonia - CAP
Tuberculosis
Pulmonary Vasculitis
CHF
• (-) orthopnea, PND
• normal JVP
• AB at 6th LICS AAL
• S3 at apex
• (-) hepatojugular reflux
• (-) edema
• Dyspnea
• 8 cm liver span MCL
• Weight
loss
• No
musculoskeletal
Manifestation
• No Dermatomal
• Cough
is not sudden
in onset
manifestation
(Rash)
Connective
Tissue
Disease
• No varicosities
• Not in RDS
• No history of cramping
• No history of trauma
• Unremarkable
Pulmonary
EmbolismPulmonary PE
• No history of allergen
• Cough did not spontaneously resolve
Allergy • No wheezes on PE
COPD
• Unremarkable Pulmonary findings
• No dyspnea on exertion
• No expiratory wheeze
Neoplasm
• Cough is not chronic
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Cough and
Fever
Infectious
Pulmonary
Lung Abscess
URTI
LRTI
Extra Pulmonary
Pericarditis
Pleuritis
• No chest pain
• No pleuritic chest pain
• No pain in movement
• No multisystem
Pulmonary Vasculitis
manifestations
• No hemoptysis
• No purpura or petechiae
Pneumonia - CAP
Tuberculosis
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Differential Diagnosis
Cough with
Fever
Lung
Abscess
• (-) pleuritic
chest pain
URTI
• (-) colds
• Septum midline
• (-) nasoaural
discharge
• (-) palpable
cervical
lymphadenopathy
LRTI
•(-) wheezes
Tuberculosis
• Weight loss (+)
• Productive cough
• Fever
• Dyspnea
• Unremarkable lung
findings
• AFB not performed
Pneumonia
- CAP
• Fever
• Cough
• Dyspnea
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Clinical Impression
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Community-Acquired Pneumonia
Tuberculosis suspect
Hypertensive Cardiovascular Disease
Left Ventricular Hypertrophy, NYHA Functional
Class I Stage B
• DM suspect
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Philippine Clinical Practice Guidelines
• Diagnosis of Community Acquired Pneumonia
– Cough
– Abnormal vital signs: tachypnea, tachycardia, fever
– At least one abnormal chest finding: diminished breath
sounds, rhonchi, crackles, wheezes
• Radiographic chest examination- new infiltrates with no clear
alternative cause- required to confirm diagnosis (Grade A)
The Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and
Prevention of Community-Acquired Pneumonia in Immunocompetent Adults
20
European Clinical Practice Guidelines
• To differentiate pneumonia from other LRTIs, the patient
should have the following clinical findings:
– Acute onset of cough
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Dyspnea
New focal chest signs
Tachypnea
Fever of four days duration
Presence of an infiltrate on a chest radiograph
European Respiratory Journal by Woodhed et. Al
European Respiratory Society
European Society of Clinical Microbiology and Infectious Diseases
21
Chest X-Ray Findings
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Midline alignment
of trachea: normal
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Sharp costophrenic
angle: no pleural
effusion
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Silhouette Sign:
obliterated right
cardiac base –
consolidation at right
lung base
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Laboratory Procedures
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Complete Blood Count
Hgb
RBC
Hct
MCV
MCH
MCHC
RDW
Platelet
WBC
Neutrophils
Segmenters
Bands
Metamyelocytes
Lymphocytes
Monocytes
Eosinophils
Basophils
Myelocytes
11/23/09
96
2.93
0.28
94.3
32.6
34.6
13.40
481
17.70
0.75
0.74
0.01
0.24
11/28/09
118
3.73
0.35
94.60
31.50
33.30
14.10
830
15.39
0.75
0.72
0.01
0.01
0.23
0.01
0.02
Unit
g/L
X10^12/L
U^3
pg
g/dL
X10^9/L
X10^9/L
NV
120-170
4.0-6.0
0.37-0.54
87 + -5
29 + -2
34 + -2
11.6 – 14.6
150-450
4.5-10.0
0.50-0.70
0.50-0.70
0-0.05
0.20-0.40
0.00-0.07
0.00-0.05
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Biochemical Blood Test
SGPT-ALT
SGOT-AST
Creatinine
Sodium
Potassium
11/23/09
37.8
55.3
5.2
130
5.4
11/28/09
3.5
Unit
U/L
U/L
mgl/dL
mmol/L
mmol/L
N.V.
0-31
0-38
0.5-1.2
137-147
3.8 - 5
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ECG
• Sinus rhythm
• Left ventricular hypertrophy
– Pathological reaction to cardiovascular disease, or high
blood pressure
– Increase afterload that the heart has to contract against
– Causes of increased afterload that can cause LVH include
aortic stenosis, aortic insufficiency, and hypertension
• Peak T-waves
– Due to hyperkalemia
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Other Laboratory Exams
Test
Rationale for Requesting
Expected Result
iCa
Decreased
iPO
Increased
Asses for kidney injury
BUN
Increased
Uric acid
Increased
Lipid Profile
ABG
U/S of
KUBP
Asses risk of heart disease
Determination of pH, partial pressure of carbon
dioxide and oxygen, and the bicarbonate level
Metabolic
acidosis
Assess the size, location, and shape of the kidneys and
related structures such as the ureters bladder, and
prostate
Sputum GS,
culture
Identify certain pathogens by their characteristic
appearance
Sputum AFB
Screening for TB
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Pneumonia
• An infection of the pulmonary parenchyma
• Categorized as either community-acquired pneumonia (CAP)
or health care–associated pneumonia (HCAP)
• Results from the proliferation of microbial pathogens at the
alveolar level and the host's response to those pathogens
• Microorganisms gain access to the lower respiratory tract
most commonly by aspiration from the oropharynx
• Clinical manifestation when the capacity of mechanical
barriers fail and the capacity of alveolar macrophages to
ingest or kill the microorganisms is exceeded
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Respiratory Tract
Defense Mechanisms
• Mechanical factors: hairs and turbinates of the nares,
branching of tracheobronchial tree, gag reflex, cough
mechanism, normal flora
• Resident alveolar macrophages, local proteins with
intrinsic opsonizing or antibacterial/antiviral activity
• Initiation of host inflammatory response to bolster
lower respiratory tract defenses
• Host inflammatory response, rather than the
proliferation of microorganisms, triggers the clinical
syndrome of pneumonia
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Pneumonia: Pathophysiology
Inflammatory mediators: interleukin (IL) 1 and tumor
necrosis factor (TNF) fever
Chemokines: IL-8 and granulocyte colony-stimulating
factor release of neutrophils producing peripheral
leukocytosis and increased purulent secretions
Inflammatory mediators released by macrophages and
the newly recruited neutrophils create an alveolar
capillary leak radiographic infiltrate and rales
detectable on auscultation
Alveolar filling hypoxemia
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Pneumonia: Pathology
Initial phase: edema, presence of a proteinaceous exudate—and often of bacteria—in the
alveoli; rarely evident in clinical or autopsy specimens
Red hepatization: presence of erythrocytes in the cellular intraalveolar exudate,
neutrophils, and bacteria
Gray hepatization: no new erythrocytes are extravasating, and those already present
have been lysed and degraded, neutrophil is the predominant cell, fibrin deposition is
abundant, bacteria have disappeared; corresponds with successful containment of the
infection and improvement in gas exchange
Resolution: macrophage is the dominant cell type in the alveolar space, debris of
neutrophils, bacteria, and fibrin has been cleared
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Pneumonia: Etiology
Countries
#1
#2
#3
#4
#5
Philippines
S. pneumoniae
M. tuberculosis
Chlamydia spp.
L. pneumophila
M. pneumoniae
USA
S. pneumoniae
H. influenzae
L. pneumophila
Chlamydia spp.
G (-) bacilli
Canada
M. pneumoniae
C. psitacci
Influenza virus
Coxiella burnetti
Australia
S. pneumoniae
Viruses
H. influenzae
G (-) bacilli
M. pneumoniae
The Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and
Prevention of Community-Acquired Pneumonia in Immunocompetent Adults
35
Pneumonia: Clinical Manifestations
•
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•
•
Febrile
Tachycardia
Chills and/or sweats
Cough (non-productive
or productive of
mucoid, purulent, or
blood-tinged sputum)
• Dyspnea
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•
•
•
•
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Pleuritic chest pain
Nausea
Vomiting
Diarrhea
Fatigue
Headache
Myalgia
36
Pneumonia: Prognosis
• Age, co-morbidities, site of treatment
(inpatient or outpatient)
• Complicated course: age > 65 years old, comorbid illness, temperature > 38.3 °C,
immunosuppressive therapy, high-risk etiology
• Young patients without co-morbidities: full
recovery in about two weeks
• Overall mortality rate (outpatient group): <1%
• Overall mortality rate (inpatient group): 10%
37
Co-morbidities Present in the
Patient
• Hypertension- non-compliant with medications
– Major co-morbid condition associated with a complicated course of
pneumonia
– Risk factors for pneumonia in the elderly by Koivula I, Sten M, Makela
P in The American Journal of Medicine. 2000; 96(4):313-320
• Acute kidney injury- laboratory findings suggestive of
declining kidney function
– Systemic hypertension
– Probable infection
– Probable diabetes
•
Warrants further examination
38
Management
39
Management
• Stabilize patient (address hypertension, cardiorespiratory distress, etc. if present)
• Empiric antibiotic therapy must be started
– Based on the most likely etiology of pneumonia
– Elderly patients with co-morbid conditions S.
pneumoniae, Legionella sp., Gram negative bacilli including
anaerobes
– Parenteral beta-lactams with anaerobic coverage (coamoxyclav, ampicillin/sulbactam, cefoxitin and other 2nd
generation cephalosporins; erythromycin if Legionella is
suspected)
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Course in the Wards
• Hospital Day 1: Admission Day
– Requested to be started on:
• Ceftriaxone 2g/IV OD
• Azithromycin 500mg/tab 1tab OD for 3 days
• Erdosteine 300mg/cap 1cap BID
• Paracetamol 500mg/tab 1tab q4 prn for T > 38 °C
• Amlodipine 5mg/tab 1tab OD
Note: Medications were not started due to financial
constraints
• Furosemide 40mg/IV 1dose and Salbutamol
nebulization q4 were requested
41
Course in the Wards
• Hospital Day 2
– Patient was hypertensive at 180/100 mmHg
• Given Amlodipine 10mg/tab
– Ceftriaxone was started
42
Course in the Wards
• Hospital Day 3
– Salbutamol was shifted to combivalent
nebulization q12, with gentle chest physiotherapy
after each nebulization
– Patient had a BP of 140/90mmHg
• Started on Metoprolol 50mg/tab 1tab BID
43
Course in the Wards
• Hospital Day 4
– Ceftriaxone was shifted to Cefuroxime 500mg/tab
1tab BID to complete 7days
– Was not done due to financial constraints
• Hospital Day 5
– Azithromycin, FeSO4 + FA, Metoprolol, as
previously ordered, were started
44
Course in the Wards
• Hospital Day 6
– Cefuroxime, as previously ordered, was started
• Hospital Day 7
– Condition of the patient improved and was stable
• Approved for discharge
45
Discharge Plans
• Azithromycin
– MOA: blocks transpeptidation by binding to 50s ribosomal
subunit of susceptible organisms and disrupting RNAdependent protein synthesis at the chain elongation step
– AE: Mild to moderate nausea, vomiting, abdominal pain,
dyspepsia, flatulence, diarrhea, cramping, angioedema,
cholestatic jaundice, dizziness, headache, vertigo,
somnolence, transient elevations of liver enzyme values
– Dosage: 500 mg/tab 1 tablet OD for 3 days
– SRP: Php 150.00
46
Discharge Plans
• Cefuroxime
– MOA: binds to one or more of the penicillin-binding proteins (PBPs)
which inhibits the final transpeptidation step of peptidoglycan
synthesis in bacterial cell wall, thus inhibiting biosynthesis and
arresting cell wall assembly resulting in bacterial cell death
– AE: large doses- cerebral irritation and convulsions, nausea, vomiting,
diarrhea, GI disturbances, erythema multiforme, Stevens-Johnson
syndrome, epidermal necrolysis, anaphylaxis, nephrotoxicity,
pseudomembranous colitis
– Dosage: 500mg/tab 1 tablet BID for 7 days
– SRP: Php 75.00
47
Discharge Plans
• Amlodipine
– MOA: relaxes peripheral and coronary vascular smooth muscle;
produces coronary vasodilation by inhibiting the entry of calcium ions
into the voltage-sensitive channels of the vascular smooth muscle and
myocardium during depolarization; increases myocardial O2 delivery in
patients with vasospastic angina
– AE: headache, peripheral edema, fatigue, somnolence, nausea,
abdominal pain, flushing, dyspepsia, palpitations, dizziness; rarely:
pruritus, rash, dyspnea, asthenia, muscle cramps; potentially fatal:
hypotension, bradycardia, conductive system delay
– Dosage: 10mg/tab 1 tablet BID
– SRP: Php 22.00
48
Discharge Plans
• Metoprolol
– MOA: selectively inhibits β-adrenergic receptors but has little or no
effect on β2-receptors except in high doses; has no membranestabilizing nor intrinsic sympathomimetic activity
– AE: bradycardia, hypotension, arterial insufficiency, chest pain, CHF,
edema, palpitation, syncope, gangrene, dizziness, fatigue, depression,
confusion, headache, insomnia, short-term memory loss, nightmares,
somnolence, pruritus, rash, increased psoriasis, reversible alopecia,
heart failure, heart block, bronchospasm
– Dosage: 50mg/tab 1 tablet BID
– SRP: Php 4.00
49
Discharge Plans
• Erdosteine
– MOA: contains two sulfhydryl groups, which are freed
after metabolic transformation in the liver; the liberated
sulfhydryl groups break the disulphide bonds, which hold
the glycoprotein fibers of mucus together; makes the
bronchial secretions more fluid and enhances elimination
– AE: epigastralgia, nausea, vomiting, loose stools,
spasmodic colitis, headache
– Dosage: 300mg/cap 1 capsule BID
– SRP: Php 19.00
50
Discharge Plans
• Ferrous Sulfate + FA
– MOA: facilitates O2 transport via hemoglobin; used as iron
source as it replaces iron found in hemoglobin, myoglobin
and other enzymes
– AE: GI irritation, abdominal pain and cramps, nausea,
vomiting, constipation, diarrhea, dark stool and
discoloration of urine, heartburn
– Dosage: 500mg/tablet 1tablet BID
– SRP: Php 20.00
51
Discharge Plans
• Getting plenty of rest and drinking lots of fluids
• Active lifestyle
• Lifestyle interventions:
– Reduction of dietary salt intake (<6g NaCl/day)
– Moderate alcohol consumption
• Men: </= 2 drinks per day
• Women: </= 1 drink per day
– Adapt DASH dietary plan
• Diet high in fruits and low-fat dairy products, reduced saturated
and total fat
– Physical activity
• Regular aerobic activity (e.g. brisk walking for 30 mins/day)
52
Discharge Plans
• Return to UST Hospital for check-up after one
week or immediately when condition worsens
53
Prevention
• Vaccination effective for high-risk populations
– Age > 65 years old
– Presence of chronic illness: cardiovascular disease,
diabetes, liver disease
– Functional or anatomic asplenia
– Smokers
– Living in nursing homes or chronic use of health care
facilities
– Immunocompromised
The Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and
Prevention of Community-Acquired Pneumonia in Immunocompetent Adults
54
Prevention
• Efficacy of Pneumococcal Vaccination in Adults: A Metaanalysis
– Huss A, Scott P, Stuck AE, Trotter C, Egger M Canadian Medical
Association Journal. 2009;180:48-58
• Pneumonia in the Elderly: A Review of the Epidemiology,
Pathogenesis, Microbiology, and Clinical Features
– Chong CP, Street PR Southern Medical Journal . 2008; 101:1141-1145
55
References
• Basic and Clinical Pharmacology 10th edtion by Katzung
• Harrison’s Principles of Internal Medicine 17th edition by Fauci, Braunwald,
Kasper, Hauser, Longo, Jameson, and Loscalzo
• The Philippine Clinical Practice Guidelines on the Diagnosis, Empiric
Management and Prevention of Community Acquired Pneumonia in
Immunocompetent Adults
• Journals:
–
–
–
–
Efficacy of Pneumococcal Vaccination in Adults: A Meta-analysis by Huss A, Scott P, Stuck AE, Trotter
C, Egger M in the Canadian Medical Association Journal. 2009;180:48-58
Guidelines for the diagnoses and treatment of adult lower respiratory tract infections: a true
‘‘European cooperative effort’’ by Restrepo MI and Anzueto A in European Respiratory Journal. 2005;
26: 979–981
Pneumonia in the Elderly: A Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical
Features by Chong CP, Street PR in the Southern Medical Journal . 2008; 101:1141-1145
Risk factors for pneumonia in the elderly by Koivula I, Sten M, Makela P in The American Journal of
Medicine. 2000; 96(4):313-320
56
Thank You
57