Grand Round B3 (Group 4)

1. Grand Round B3 (Group 4) Ali Alhashli: History Dana Aljalahma: Physical Examination Abdulaziz Jamal: Investigations Sara Alhadi: Differential Diagnosis Abdulla Al-Jadaan: Management Haifa Abdulqader: Pneumonia ShahdAlali: Poster

2. History

3. Demographic Data

4. Chief Complaint (CC): • Fever and cough for 1 week prior to admission. • History of Present Illness: • Short story of events: the patient developed fever and cough 1 week before he was admitted to SMC. The symptoms did not improve within 3 days so he went to Muharraq Local Health Center where he was prescribed panadol and antibiotics. The fever improved for 2 days after which he relapsed again. Therefore, he presented to A/E in SMC where chest x-ray was done and he was diagnosed as having chest infection. • The fever was measured with a thermometer from the axilla and It was fluctuating between 37-40 C. It was intermittent and raising every 2 hours. The fever was associated with sweating, chills and rigors. It was relieved when taking panadolbut comes back whenever the effect of treatment disappears.

5. History of Present Illness (continued): • Patient also had cough which he noticed that it increased and became significant as he was admitted to the hospital. The cough was productive with greenish sputum. It was intermittent and not increasing at a specific time of the day or aggravated by a specific factor/trigger. There is no shortness of breath neither chest pain. No sounds from the chest were heard by the patient and there was no hemoptysis. • In addition, the patient had vomiting and diarrhea for 3 days prior to admission. He was vomiting 4 times/ day. He vomited nearly a cup of gastric contents and food. It was non-projectile and there was no hematemesis. The patients also experienced diarrhea for 4 times/ day. Stool had the normal brownish color and it was semi-solid. There was some mucus in the stool but no blood or association with abdominal pain. He doesn’t have loss of appetite neither reduced activity. • There is no history of contact with sick people or previous admission for the same reason.

6. Past Medical History: • Gout: which he was diagnosed with 6 years ago in SMC when he had pain and swelling of his right big toe. He was prescribed (Allopurinol) which he doesn’t take and instead takes painkillers whenever needed. • He has no other chronic medical conditions (such as diabetes, hypertension…). • In addition, he has no inherited disorders (such as sickle cell disease, G6PD deficiency or thalassemia). • Past surgical/ hospitalization history: • No history of previous hospitalizations or surgical procedures. • No history of accidents/ injuries. • No history of blood transfusion. • Immunizations: • All immunizations are up-to-date • Medications: • Patient does not take any medications regularly. • Allergy: • No known allergies to medication or food.

7. Family History: • Patient is not married. His father is 60 years old and his mother is 58 years old. Both of his parents have diabetes and hypertension but no other medical conditions. • He has one older sister and two younger brothers. They don’t have any medical conditions except for his youngest brother who has depression and is taking anti-depressants.

8. Social History: • Patient is living in a house with his parents and youngest brother. He has good relationships with his family members. He works in Ministry of Justice and Islamic Affairs and has a good income. He does not smoke and does not consume alcohol. There are no pets at home. There is history of recent travel to Dammam before he got sick.

9. Systemic Review

10. Differential Diagnosis List • COPD • Acute bronchitis • Asthma exacerbation • Pneumonia • TB • Pulmonary edema due to heart failure • Pulmonary embolism • ARDS • Meningitis • UTI • Sepsis • SLE

11. Physical Examination

12. General Appearance • An adult male, conscious, alert, well nourished, • Lying in a 45 degree position, • Not in pain, • Had tachypnea and tachycardia, • Not pale not cyanosed or jaundice, • Patient is connected to simple face mask, IV fluid and pulse oxymetry • Showed normal facial expression, good hygiene and normal odor.

13. Vital Signs

17. Respiratory

18. Cardiovascular

19. Abdomen

20. Case Summary

21. Case Summary • A.H.O is a 27 years old Bahraini male (known case of gout) who presented to A&E department in SMC on the 4th, February 2017 with history of fever and cough for 1 week duration. • Fever with a mean of 38.5 C which was intermittent. Cough was productive with greenish sputum. • Physical examination revealed slightly reduced chest expansion, increased tactile fremitus (especially on the right side of the chest) and bilateral crackles heard on the lower lobes of both lungs.

22. Differential Diagnosis(Rule-In / Rule-Out)

29. Investigations

30. Complete Blood Count (CBC) Comment: CBC is not significant for this patient

31. WBC Differential Comment: Neutrophils are markedly elevated, suggesting a bacterial infection

32. Electrolytes and LFT Comments: All values are within normal range except LDH ( increased)

33. Microbiology & urinalysis Comment: - Elevated CRP & ESR suggesting an inflammatory process - Insignificant urinalysis except for mild ketonuria

34. CXR Comments: shows bilateral infiltrates more in the right lung. The pattern is suggestive of bronchopneumonia.

35. ABG Comment: A normal ABG Low PO2 CT-angio was Negative ( Rule out PE)

36. Differential Diagnosis and Final Diagnosis

37. Normal WBC count Normal creatinine Normal urine output

38. Normal urinalysis results (no proteinuria, no casts) Normal creatinine No anemia, leukopenia, throbocytopenia

39. Increased neutrophils Chest x-ray Culture (S.epidermidis)

40. CT Angio for PE  Negative

41. Final Diagnosis:Bilateral Bronchopneumonia

42. Management

43. Management • Physical Examination: • Altered mental status. • Respiratory Rate (RR) < 30 breaths/ minute. • Systolic blood pressure > 90 mmHg • Temperature > 35C or < 40C • Heart rate < 125 beats/ minute

44. Management • Laboratory and radiographic findings: • Partial pressure of oxygen > 60 mmHg. • Oxygen saturation > 90% • Chest x-ray: showing involvement of more than one lobe.

45. Management • First, patient must be stabilized through the following: • IV fluid replacement therapy: especially in our patient who had a history of vomiting and diarrhea of 3 days duration (prior to admission). Therefore, he was assessed clinically and assumed to have mild dehydration (5%). After starting therapy, patient urine output must be monitored. In addition, electrolytes and kidney function should be re-checked. • The patient also had to be supplemented with oxygen as his saturation was 89% on room air. In this patient, oxygen was given through simple face mask and monitored with pulse oximetry. Notice that oxygen saturation must be monitored above 96%.

46. Management • If there is pleurisy (inflammation of the lining around the lungs which is associated with sharp chest pain upon breathing) → analgesics can be provided such as (Perfalgan: IV paracetamol). • A possible complication of pneumonia is pleural effusion. If it occurs → it is managed with drainage (especially if it is symptomatic). Fluid is best removed slowly (0.5-1.5 L/ 24 hours). It may be aspirated in the same way as a diagnostic tap or using an intercostal drain. • To treat the infection in this patient → 3rd generation cephalosporin (ceftriaxone IV) must be given (due to its good spectrum of covering most of common bacterial organisms). A macrolide (such as azithromycin) might also be combined with the cephalosporin to cover organisms that cause atypical pneumonia.

47. Pneumonia

48. Atypical VAP HCAP Typical HAP

49. Community-Acquired Pneumonia (CAP) • Occurs in the community or within 48 hours of hospital admission. • Most common bacterial pathogen is streptococcus pneumoniea.

50. Diagnostic Tests • PA and lateral CXR. • Sputum gram stain and culture. • Special stains (acid-fast stain, silver stain). • Urinary antigen assay. • Blood culture.