Protacio, Najee Benvincent D.

Protacio
Group 17 Thursday Group Dra Te History # 5
General Data
Pt Aiza Castro, 25 years old, single, house wife, catholic, was born on December 15,
1988 in acolod !egros "ccidental, currently residing at 151 #uirino $ighway aesa
#uezon City, 1
st
time to see% consult in #uezon City &eneral $os'ital in "ut Patient
De'artment on (e't 11, 2)1*+
hie! o"plaint Cough
History o! Present illness#
2 wee%s P,C 't e-'erienced sudden 'roducti.e cough, 'legm is clear in color
describe as chest is tightness when coughing+ /t was Accom'anied with colds, which is
.iscous in consistency and clear in color+ ,he 'atient also e-'erienced headache and
dizziness with a 'ain scale of 8 out of 1), in the 'arietal area, the duration was whole day,
no medications ta%en but tries to relie.e by massage 'ain but it was not relie.e+ ac% 'ain
was also e-'erienced by the 'atient in the thoracic area, with a 'ain scale of 8 out of 1)
that radiates in the shoulder, e-'erienced whole day but aggra.ated during household
wor%+
1) days P,C consulted the barangay clinic due to cough yellowish in color and her
sym'toms still 'ersists+ CC done, which resulted to a decrease in 0C count and was
diagnose as Anemia+ ,he doctor didn1t 'rescribe any medications because currently the
'atient is breastfeeding+ /nstead the doctor 'rescribed 2errous (ulfate for her decrease
0C count+
3 days P,C cough is still 'resent with same 4uality and it was accom'anied by body
malaise and .omited the food she ate during lunch, bitter and yellowish in color+ (he
e-'erienced difficulty in breathing accom'anied by midsternal 'ain+ ,he 'atient also
e-'erienced 25'illow ortho'nea at night+
1 day P,C headache 'rogressed with a 'ain scale of 1) out of 1) that ga.e her
insomnia with low grade undocumented fe.er+ "ther conditions of cough, colds, and bac%
'ain were still 'resent that 'romted the 'atient to consult to #C&$+
Past $edical History
Pt has com'leted childhod .accines as .erbalized, $ad mum's, and 6easles+ "ther
adult disease was denied by the 't+ such as $y'ertension, Diabetes, and ,uberculosis+ !o
allergies to food, allergen+ !o history of blood transfusions+
%a"ily History
Pt is youngest in a breud of 2, 2ather and 6other and the rest the siblings are
a''arently healthy+ Presence of $eredofamilial Diseases were denied such as
$y'ertension, Cardio.ascular disorders, Diabetes, and Cancer
Personal and &ocial
7or%s before as a waitress for 1 year, $ouse 6aid for 5 years, urger (eller for 1
year, currently as a house wife+ $usband is a 6echanic that 'ro.ides the financial
concerns+ Pt non alcholic, nonsmo%er but was e-'osed to 2
nd
hand smo%er, Drin%s coffee
1 cu' 8 times a wee%+ (lee's 8 hours a day, 9at A .ariety of food more on .egetables+
$as no form of e-ercise+ (ource of water is nawasa and they drin% in the faucet if the
su''ly is runned out, $ouse is made of concrete and wood with 8 windows studio ty'e,
has a water 'ured comfort room, garbage is collected e.ery night+
'()Gyne History
$ad her menarche 11 y:o, flow is hea.y, last for 5 days, 5 na'%ins then regular flow,
!o other &yne Abnormality was noted+
"b (core &2'2 2))2
1. 2eb, 1*, 2)18 boy, nsd, 9ast A.enue, Doctor, fullterm
*. ;une28,2))8, female, nsd, 9ast A.enue, Doctor, fullterm

+evie, o! &yste"s
&eneral
- Poor .ppetite <5 = malaise, <5= fatigability, <5= weight change
$ead and !ec%
<5 = synco'e, <5 = di'lo'ia, <5 = 'hoto'hobia,
<5 = hearing loss, <5 = ear 'ain, <5 = discharge, <5 = tinnitus, <5 = .ertigo
0es'iratory
<5 = dys'nea, <5 = bac% 'ain <>= cough
Cardio.ascular
<5= chest 'ain, <5= 'al'itation, <5= dys'nea, <5= ortho'nea
&astro5intestinal
<5 = 'oor a'etite <5= flatulence
<5 =abdominal enlargement, <5 = steatorrhea,
<5= hematochezia <5= melena, <5= hematemesis
&enito5urinary
<5 = dribbling, <5 = incontinence, <5 = hematuria, <5 = 'olyuria
<5 = oliguria, <5 = 'assage of stone, <5 = discharge
<5= reast Pain
6usculos%eletal
<5= myalgia , <5 = swelling
<5 = bone deformity, <5 = atro'hy
<5 = restriction of motion
!eurologic
<5 = synco'e, <5 = seizures, <5 = wea%ness or 'aralysis
<5 = tremors, <5 = loss of memory,
9ndocrine
<5 = goiter, <5 = heat or cold intolerance
<5 = 'olyuria, <5 = 'olydy'sia, <5 = 'oly'hagia
<5 = abnormal growth
$ematologic
<5 = easy bruisability, <5 = easy fatigability, <5= Pallor
General &urvey
Pt is conscious, coherent, oriented to time, 'lace and 'erson, coo'erati.e, well5
nourished, symmetrical face, ambulatory, febrile, not in cardiac or res'iratory distress+
/ital &i0ns
,em' 83+? C, P@ 11):3), $0@ 88, 00@ 19
1nte0u"entary
(%in is brown, moist, no lesions+ !o $y'er5'igmentation, !o clubbing and swelling
of nail beds A with good s%in turgor+
H22NT
$air@ gray in color, abundant, well5distributed, smooth te-tureB scal' slightly mobile
along cranium, no masses or tenderness u'on 'al'ationB no lice, fla%ing or lesions were
noted
Cranium@ normoce'halic, symmetricalB tem'oral arteries .isible, with moderate
'ulsations
2ace@ o.al, symmetricalB no faciesB 't can mo.e facial muscles with ease
9yes@ eyebrows thin, blac%, well5distributed, symmetricalB eyelashes blac%, short,
oriented u'ward, eyelids is symmetrical, no 'tosis or edema, no lesionsB 'in%ish
conCuncti.ae, no lesions, iris is brown in colorB 'u'ils symmetrical, 258mm diameter, both
eyes ha.e D>E direct and consensual 'u'illary refle-es and normal accommodationB lens
are trans'arent
9ar@ triangular in sha'e, symmetrical, no lesions, no deformities or tenderness
!ose@ nose are symmetrical, no flaring of alae nasi, 'atent .estibule, mucosa 'in%ish
in color, no swelling, no lesions, with clear .iscous secretios and no bleedingB no nasal
se'tum in the midline, no 'erforations
6outh and ,hroat@ li's symmetrical, 'in%ish in color, moist, smooth, no lesionsB
buccal mucosa 'in% in color, no tongue de.iation on 'rotrusion, gingi.a is 'in%, tonsils
not swollen, u.ula midline+
!ec%@ s%in fair in color, no deformities, no masses, tra'ezius and sternocleidomastoid
muscles well5de.elo'ed, no tenderness, trachea in midline, no enlargement of cer.ical
lym'h nodes+
hest and 3un0s
(%in is fair in color, chest is symmetrical, no lagging and no widening of intercostals
s'aces D/C(E, no retractions on the chest wall, no noted su'erficial blood .esselsB
res'iratory rate at 19 breath cycles 'er minuteB with tenderness noted in the midsternumB
no masses were notedB e4ual chest e-'ansion, no lagging notedB wih an increase tactile
fremitus on anterior lung filedB all lung fields resonant on 'ercussionB ilateral 0onchi is
heard on the a'ices of the lungs more 'ronounce on the right, broncho'hony and
whis'ered 'ectrilo4uy was noted+
ardiovascular
Precordium is adynamic, without bulging or .isible 'ulsationsB Cugular .ein 'ulsation
noted ;FP was 3+5 cmB a'ical beat is at the 5
th
/C(, no tenderness, no masses, no hea.es,
no thrills and no lifts notedB heart rate at 88 beats 'er minuteB heart rhythm is noted to be
regularB no murmurs, no gallo's or e-tra heart sounds notedB carotid 'ulse is strong,
regular and e4ual, without bruitsB radial, brachial 'ulses are strong, regular and e4ual+
.(do"en
Abdominal circumference is 29, and it is flat, symmetrical, with in.erted umbilicus,
without bulging flan%s+ (%in is fair in color, no 'osto'erati.e scars or lesions were noted+
!o su'erficial blood .essels+ !o .isible mass or 'ulsations+ Patient has normoacti.e
bowel sounds of 3 'er minute+ !o friction rubs or bruits were heard o.er the abdominal
aorta+ Abdomen is soft all o.er, without muscle guarding or tenderness obser.ed+ Gi.er
and s'leen are not 'al'able+ Gi.er s'an is ? cm, All 4uadrants were tym'anitic u'on
'ercussion+ !o fluid wa.e 'ercei.ed, no shifting dullness u'on 'ercussion+
&pine and 24tre"ities
$ands, wrists and fingers# noted full range of motion D0"6E i+e+ fle-ion, e-tension and
adduction, of fingers and a''osition of thumbs for both handsB has no ulnar and radial
de.iation of wristsB no swelling, enlargement, nodes or tenderness of inter'halangeal and
metacar'o'halangeal Coints u'on 'al'ation of both handsB nail beds 'in%, nails
rectangularB no clubbing of nails, brittle nails, floating nails, nail fold inflammation or
ingrown nails
H''er arms@ bilateral full 0"6 i+e+ fle-ion, e-tension, 'ronation and su'inationB no
swelling, inflammation, nodes or tenderness u'on 'al'ation of olecranon bursa Delbow
CointEB no cre'itus or tenderness noted u'on 'al'ation of radius : ulna and muscles,
res'ecti.elyB muscles are symmetrical for both sides, with no atro'hy
(houlder Coints@ bilateral full 0"6 as to abduction, adduction, e-ternal and internal
rotationB 'atient is able to do circumduction without restriction
('ine# !o masses u'on 'al'ationB no asymmetry, 2ull 0"6 as to fle-ion, e-tension,
e-ternal and internal rotationB lower limbs are symmetrical, muscles showing no atro'hy
Inee Coints@ bilateral full 0"6 as to e-tension and fle-ionB no tenderness, cre'itus,
masses, lesions or nodules noted
An%le Coints and feet@ bilateral full 0"6 as to e.ersion, in.ersion, dorsifle-ion and
'lantar fle-ionB no swelling, enlargement, nodulations or tenderness u'on 'al'ation
,oes and (oles@ bilateral full 0"6 as to fle-ion, e-tension, abduction and adductionB no
lateral de.iation of big toeB no inflammation of nail foldsB 'edal arc 'resentB blac% nail
'olish noted on toenails
Neurolo0ic 24a"
Cerebrum : 6ental (tatus
Patient is conscious, coherent, alert, oriented to time, 'lace and 'erson, coo'erati.e,
and is able to follow sim'le commands+ /mmediate, recent and remote memory intact,
and can do sim'le math calculations, e-hibit abstract thin%ing and a''ro'riate moral
Cudgment+
Cerebellum
Patient has no intention tremors, and able to 'erform finger5to5nose test, ra'id
alternating mo.ements+
Cranial !er.es
C! /@ cant be detected due to colds
C! //@ able to read small characters from a distance of 1ft, no gross .isual defects
C! // A ///@ 'u'ils e4ually round and res'onds to direct and indirect light stimuli,
'u'il constricts to about 2mm
C! ///, /F A F/@ normal e-traocular muscle mo.ement
C! F@ can feel 'in'ric% : brushing sensation on her faceB no atro'hy or
fasciculations of mastication muscles and normotonicB muscle tension u'on teeth5
clenching symmetrical and e4ual
C! F A F//@ 'ositi.e corneal refle-
C! F//@ muscles of u''er and lower face show no atro'hy or fasciculations,
symmetrical and normotonicB muscle tension u'on closing of eyes is symmetrical
and e4ual
C! F///@ can fairly localize source of sound by rubbing fingersB can hear and
relay whis'ered words from both ears
C! /J A J@ u.ula midlineB 'haryngeal walls rise symmetrically u'on 'honation
and stimulation of the gag refle-B no hoarseness noted or .ocal anomalies
C! J/@ able to shrug shoulders e4uallyB able to rotate head against resistanceB no
atro'hy or fasciculations of muscles, muscles normotonic, muscle tension
symmetrical
C! J//@ tongue is midlineB no a''arent de.iation u'on 'rotrusionB no
fasciculation or atro'hy noted
6otor 9-am
6uscles are symmetrical in both u''er and lower e-tremities, without atro'hy or
fasciculations+ 6uscles normotonic ha.e a muscle strength inde- of 5:5+
(ensory 9-am
Patient has intact 'ain, crude touch, and 'osition sense on both u''er and lower
e-tremities+ Patient e-hibits stereognosia and gra'hestesia+
0efle-es
;oint refle-es intact, symmetrical, normorefle-i.e, with negati.e abins%i sign
6eningeal (igns
!egati.e Iernigs and rudzins%y signs were elicited+ Absent nuchal rigidity or 'ain
elicited u'on straight5leg test
Di!!erential Dia0nosis
1n!luen5a /iral %lu
asis@ (igns and sym'toms that were seen in the 't such as 2e.er, $eadache, with
'rogression to a 'roducti.e cough+ And also .iral fe.er are common now a days because
of rainy season in the country+ / rulled out this disease because it was already two wee%s
and usually .iral influenza are self limiting and also she has a''arent signs of bacterial
etiology such yellowish or greenish secretions+
/ncubation 'eriod @ 1 to * days+
,ransmission@ Aerosol 1 day before the onset of sym'toms or .ia asym'tomatic 'ersons
Firal shedding @ occurs at the onset of sym'toms or Cust before the onset of illness D)52*
hoursE and continues for 551) days
Gaboratory wor% u'+
asis of clinical criteria,
Com'lete blood count DGeu%o'enia and relati.e lym'ho'eniaE
9lectrolyte le.els+
,hroat (wab+ D enzyme in throat swabs, nasal swabs, or nasal washes+ 0esults within
8) minutesE
0,5PC0 testing D.iral culture of naso'haryngeal or throat secretionsE standard for
confirming influenza .irus infection+ Culture 2or 853 days+
PC0 9)K sensiti.e Dwithin 2* hoursE
Pre.ention
Faccines
1+E /nfluenza .irus .accine tri.alent DAfluria, 2luGa.al, 2luari-, 2lu.irin, 2luzone,
2luzone $igh5Dose, 2luzone /ntradermalE
2E /nfluenza .irus .accine 4uadri.alent D2luari- #uadri.alent, 2luzone #uadri.alent,
2luGa.al #uadri.alentE
+
,reatment
,he .iral fe.er of the 't is self limiting in 8 days for most cases+ D/ncrease 2luid
/nta%e and Fitamin C su''lementsE

Anti.iral Pharmacologic ,hera'y Dchemo'ro'hyla-is and treatmentE
"seltami.ir, Lanami.ir, Amantadine and 0imantadine
6pper +espiratory Tract 1n!ection
Basis# (igns and sym'toms that were seen in the 't such as 2e.er, $eadache, with
'rogression to a 'roducti.e cough+ ,his may be due to a .iral and bacterial infection 't
has colds that ma%es me consider it is an H0,/+ but / rulled out this disease because it
was more 'rominent in the large airways that was seen in the 'hysical e-am li%e ronchi
which is not commonly seen in H0,/+
6anifestations
Firal naso'haryngitis @
Patients with the common cold may ha.e a 'aucity of clinical findings des'ite notable
subCecti.e discomfort+, !asal mucosal erythema and edema are common
!asal discharge@ Profuse discharge is characteristic of .iral infections than bacterial
infectionsB initially clear secretions ty'ically become cloudy white, yellow, or green o.er
se.eral days+
&rou' A stre'tococcal 'haryngitis @
9rythema, swelling, or e-udates of the tonsils or 'haryn-
,em'erature of 88+8MC D1))+9M2E or higher
,ender anterior cer.ical nodes DN1 cmE
Absence of conCuncti.itis, cough, and rhinorrhea, which are sym'toms that may suggest
.iral illness
Acute bacterial rhinosinusitis @
Persistent nasal discharge Dany ty'eE or cough lasting 1) days or more without
im'ro.ement
7orsening course Dnew or worse nasal discharge, cough, fe.erE after initial im'ro.ement
/n older children and adults, sym'toms Deg, 'ain, 'ressureE tend to localize to the affected
sinus+
Gaboratory
lood count and cultures5 'atients with H0/s may ha.e an increased white blood cell
D7CE count with a left shift+ Aty'ical lym'hocytes, lym'hocytosis, or lym'ho'enia
may be seen in some .iral infectionsB lym'hocytosis may also be seen in 'ertussis+
Culturing of throat swabs, nasal swabs or washes, or nasal as'irates remains the standard
for confirming bacterial H0/ 'athogens+
2or confirming .iral naso'haryngeal infection, .iral cultures remain the standard+
0a'id tests for .iruses include .arious antigen, immunofluorescence, and PC0 assays+
,reatment
Antibiotics used in grou' A stre'tococcal infection are as follows@
Penicillin FI DPenicillin FE
Amo-icillin DAmo-il, 6o-atag, ,rimo-E
Penicillin & benzathine Dicillin GA, Perma'enE
Antibiotics used in e'iglottitis are as follows
Cefuro-ime DCeftinE
Ceftria-one D0oce'hinE
Cefota-ime DClaforanE
Antibiotics used in 'ertussis are as follows@
Clarithromycin Dia-inE
9rythromycin D956ycin, 9rythrocin, 9ryc, 9ry5,ab, 9+9+(+E
Azithromycin DLithroma-E
Antibiotics used in acute bacterial rhinosinusitis are as follows@
Amo-icillin:cla.ulanate
Do-ycycline
linical $ain Dia0nosis# 3o,er +espiratory Tract 1n!ection 7Bacterial Pneu"onia8
Basis#
$P/@ (udden 'roducti.e cough, 'legm is clear in color then yellowish, Accom'anied
with colds, which is .iscous and clear also e-'erienced headache and dizziness+ ac%
'ain in the thoracic area, radiates in the shoulder, also with malaise and .omiting (he
e-'erienced difficulty in breathing accom'anied by midsternal 'ain+ /n a 2 wee%s ,ime+
Personal (ocial@ 9-'osure to 2
nd
hand (mo%ing
Fital (igns@ 2ebrile 83+?
Chest and Gungs@ an increase tactile fremitus on anterior lung filedB all lung fields
resonant on 'ercussionB ilateral 0onchi is heard on the a'ices of the lungs more
'ronounce on the right, broncho'hony and whis'ered 'ectrilo4uy was noted+
.nalysis
,he 't may ha.e de.elo'ing 'neumonia that initially 'resents as a 'roducti.e cough
which is bacterial in origin+ ,he color changes of the s'utum of the 'atient from clear to
yellowish indicates a bacterial ty'e and not the .iral 'neumonia, which is in two wee%s
time time, if other res'iratory .irus are considered the disease itself must be in 8 to 5 days
self limiting com'ared to the 't case which is already in two wee%s time+ /t was followed
by non s'ecific sym'toms such headache, dizziness, bac% 'ain+ H'on Physical
e-amination ronchi were heard on both lung fields that indicates infiltrates in the large
airways and with broncho'ony and whis'ered 'ectorilo4uy+
9-'ected 2indings in Penuemonia
Patho'hysiology
,he causes for the de.elo'ment of 'neumonia are e-trinsic or intrinsic, and .arious
bacterial causes are noted+ 9-trinsic factors include e-'osure to a causati.e agent,
e-'osure to 'ulmonary irritants, or direct 'ulmonary inCury+ /ntrinsic factors are related to
the host+ Goss of 'rotecti.e u''er airway refle-es allows as'iration of contents from the
u''er airways into the lung+
acteria from the u''er airways or, less commonly, from hematogenous s'read, find
their way to the lung 'arenchyma+ "nce there, a combination of factors Dincluding
.irulence of the infecting organism, status of the local defenses, and o.erall health of the
'atientE may lead to bacterial 'neumonia+ ,he 'atient may be made more susce'tible to
infection because of an o.erall im'airment of the immune res'onse and:or dysfunction of
defense mechanisms Deg, smo%ing, chronic obstructi.e 'ulmonary disease, tumors,
inhaled to-ins, as'irationE+ Poor dentition or chronic 'eriodontitis is another 'redis'osing
factor+
,hus, during 'ulmonary infection, acute inflammation results in the migration of
neutro'hils out of ca'illaries and into the air s'aces, forming a marginated 'ool of
neutro'hils that is ready to res'ond when needed+ ,hese neutro'hils 'hagocytize
microbes and %ill them with reacti.e o-ygen s'ecies, antimicrobial 'roteins, and
degradati.e enzymesB they also e-trude a chromatin meshwor% containing antimicrobial
'roteins that tra' and %ill e-tracellular bacteria, %nown as neutro'hil e-tracellular tra's
D!9,sE+ Farious membrane rece'tors and ligands are in.ol.ed in the com'le- interaction
between microbes, cells of the lung 'arenchyma, and immune defense cells
(igns and sym'toms
Cough, 'articularly cough 'roducti.e of s'utum, is the most consistent 'resenting
sym'tom of bacterial 'neumonia and may suggest a 'articular 'athogen, as follows@
(igns of bacterial 'neumonia may include the following@
$y'erthermia Dfe.er, ty'ically O88MC, ,achy'nea, Hse of accessory res'iratory muscles,
,achycardia DO1)) b'mE, Central cyanosis
Physical findings may include the following@
Ad.entitious breath sounds, such as rales:crac%les, rhonchi, or wheezes, Decreased
intensity of breath sounds, 9go'hony, 7his'ering 'ectorilo4uy, Dullness to 'ercussion
!ons'ecific sym'toms such as fe.er, rigors or sha%ing chills, and malaise
CH05?5 is a scoring system de.elo'ed from a multi.ariate analysis of .arious factors
that a''eared to 'lay a role in 'atient mortality+
C onfusion P Altered mental status
H remia P lood urea nitrogen DH!E le.el greater than 2) mg:dG
0 es'iratory rate P8) breaths or more 'er minute
lood 'ressure P (ystolic 'ressure less than 9) mm $g or diastolic 'ressure less than ?)
mm $g
Age older than ?5 years
Pneumonia se.erity inde-5 ,he P(/ , is a 'rediction rule for mortality and se.erity based
on characteristics deri.ed from cohorts of 'atients+
Gaboratory
Arterial blood gas DA&E determination P $y'o-ia and res'iratory acidosis may be
'resent+
Fenous blood gas determination Dcentral .enous o-ygen saturationE
Com'lete blood cell DCCE Geu%ocytosis
(erum free cortisol .alue
(erum lactate le.el
C5reacti.e 'rotein DC0PE le.el may be 'redicti.e of more serious disease+
<
('utum &ram stain and culture should be 'erformed before initiating antibiotic thera'y
Dif a good54uality, contaminant5s'arse s'ecimen containing Q 1) s4uamous e'ithelial
cells 'er low5'ower field can be obtainedE+ ,he white blood cell D7CE count should be
more than 25 'er low5'ower field+
0adiogra'hically, lobar 'neumonia, or focal or nonsegmental 'neumonia, is manifested
as nonsegmental, homogeneous consolidation in.ol.ing one, or less commonly, multi'le
lobes+
( 'neumoniae infection is characterized by homogenous 'arenchymal lobar o'acities+
,reatment
"ut'atient 9m'iric Antibiotic ,hera'y@
"ral e-tended5s'ectrum macrolide or amo-icillin and cla.ulanate DAugmentinE to those
with mild, out'atient disease+
"ral fluoro4uinolone 'lus a macrolide+ may be substituted if a comorbidity+
Admitted 'atients should recei.e /F thera'y, a third5generation ce'halos'orin alone or
with a macrolide+ An alternati.e regimen would be /F fluoro4uinolones+
2or healthy 'atients with no e-'osure to antibiotics within the 're.ious 9) days, use a
macrolide or do-ycycline+
(u''orti.e measures include the following@
Analgesia and anti'yretics, Chest 'hysiothera'y, "-ygen su''lementation
0es'iratory thera'y, including treatment with bronchodilators and ! 5acetylcysteine
9-amination findings that may indicate a s'ecific etiology include the following@
radycardia@ 6ay indicate a Gegionella etiology
Periodontal disease@ 6ay suggest an anaerobic and:or 'olymicrobial infection
ullous myringitis@ 6ay indicate 6yco'lasma 'neumoniae infection
Cutaneous nodules@ 6ay suggest !ocardia infection
Decreased gag refle-@ (uggests ris% for as'iratio
(e.erity5of5illness scores or 'rognostic models, such as the CH05?5 criteria Dsee belowE
or the Pneumonia (e.erity /nde- DP(/E can be used to hel' identify 'atients that may be
candidates for out'atient treatment and those that may re4uire admission+ ,he /nfectious
Disease (ociety of America D/D(AE and American ,horacic (ociety DA,(E 'ro'osed
guidelines and criteria to determine the se.erity of community5ac4uired 'neumonia
DCAPE, which would affect whether in'atient treatment would occur on the ward or
re4uire /CH care+
<8)=
Although many of these 'redicti.e models were originally designed
for assessment of CAP, a retros'ecti.e cohort study showed that they can also be
a''licable to $CAP+
<81=
CURB-65
CH05?5 is a scoring system de.elo'ed from a multi.ariate analysis of 1)?8 'atients
that identified .arious factors that a''eared to 'lay a role in 'atient mortality+
<82=
"ne
'oint is gi.en for the 'resence of each of the following@

onfusion P Altered mental status

6 remia P lood urea nitrogen DH!E le.el greater than 2) mg:dG

+ es'iratory rate P8) breaths or more 'er minute

B lood 'ressure P (ystolic 'ressure less than 9) mm $g or diastolic 'ressure less than ?)
mm $g

Age older than 95 years

Current guidelines suggest that 'atients may be treated in an out'atient setting or may
re4uire hos'italization according to their CH05?5 score, as follows@

(core of )51 P "ut'atient treatment

(core of 2 P Admission to medical ward

(core of 8 or higher P Admission to intensi.e care unit D/CHE

,he 'ercentage of mortality at 8) days associated with the .arious CH05?5 scores
increases with higher scores+ ,he drastic increase in mortality between scores of 2 and 8
highlights the li%ely re4uirement for /CH admission in 'atients with a score of 8 or
higher, as shown below@

(core of ) P )+3K mortality

(core of 1 P 2+1K mortality

(core of 2 P 9+2K mortality

(core of 8 P 1*+5K mortality

(core of * P *)K mortality

(core of 5 P 53K mortality

Pneumonia severity index

,he P(/, also %nown as the P"0, score Dfor the study by which it was .alidatedE, is a
'rediction rule for mortality based on characteristics deri.ed from cohorts of 'atients
hos'italized with 'neumonia+
<88=
2or each of the .arious characteristics, a 'redetermined
.alue of 'oints is assigned+ /n a retros'ecti.e cohort com'arison of different 'redicti.e
models a''lied to $CAP, the P(/ had the highest sensiti.ity in 'redicting mortalityB
howe.er, alternati.e tools, including the /D(A:A,(, (CAP, and (6A0,5C"P
Dmentioned belowE, are considered easier to calculate+
<81=
Demogra'hic factors are scored as follows@

Age, men P (tarting 'oint .alue is age in years

Age, women P (tarting 'oint .alue is age in years minus 1) 'oints

!ursing home resident P Add 1) 'oints

Coe-isting illnesses are scored as follows@

!eo'lasia P Add 8) 'oints

Gi.er disease P Add 2) 'oints

Congesti.e heart failure, cerebro.ascular disease, renal disease P Add 1) 'oints for each

Physical e-amination findings are scored as follows@

Altered mental status P Add 2) 'oints

0es'iratory rate of 8) breaths or more 'er minute P Add 2) 'oints

(ystolic blood 'ressure less than 9) mm$g P Add 2) 'oints

,em'erature less than 85MC or that is *)MC or higher P Add 15 'oints

Pulse greater than 125 b'm P Add 1) 'oints

Gaboratory and radiogra'hic findings are scored as follows@

Arterial '$ less than 3+85 P Add 8) 'oints

H! .alue of 8) mg:dG or greater P Add 2) 'oints

(odium le.el less than 18) mmol:G P Add 2) 'oints

&lucose le.el of 25) mg:dG or greater P Add 1) 'oints

$ematocrit .alue less than 8)K P Add 1) 'oints

Partial arterial 'ressure DPa"2E less than ?) mm $g or 'eri'heral o-ygen saturation

D('"2E less than 9)K P Add 1) 'oints

Pleural effusion P Add 1) 'oints

,he combined total 'oints ma%e u' the ris% score, which stratifies 'atients into 5 P(/
mortality ris% classes, as follows@

)55) 'oints R Class / D)+1K mortalityE

5153) 'oints R Class // D)+?K mortalityE

3159) 'oints R Class /// D)+9K mortalityE

91518) 'oints R Class /F D9+8K mortalityE

6ore than 18) 'oints R Class F D23K mortalityE

Current guidelines suggest that 'atients may be treated in an out'atient setting or may
re4uire hos'italization de'ending on their P(/ ris% class, as follows@

Classes / and // P "ut'atient management

Class /// P Admission to an obser.ation unit or for short hos'ital stay

Classes /F and F P ,reatment in in'atient setting

,he Agency for $ealthcare 0esearch and #uality DA$0#E has 'ro.ided a P(/ calculator+
<8*=
/t is im'ortant to remember that obCecti.e criteria and scores should be used as guides
only and should always be su''lemented with 'hysician determination of the 'atientSs
thera'eutic needs+ ,he ris%s and benefits of hos'italization should be weighed carefully,
because hos'italization can 'ut 'atients at additional ris% Deg, thromboembolic e.ents,
nosocomial su'erinfectionE+ 7hen a 'neumonia is due to mi-ed etiologies, it is often
underestimated by se.erity score
G0,/ h. wheeze or ronchi5e-'iratory high 'itch
but H0,/ as stridor 5ins'iratory low 'itch sound
H0/@ acute infection in.ol.ing the u''er res'iratory tract, which includes the nose,
sinuses, 'haryn- or laryn-
G0 tract@ 'neumonia, lung abscess and acute bronchitis+
Signs and symptoms
Cough, 'articularly cough 'roducti.e of s'utum, is the most consistent 'resenting
sym'tom of bacterial 'neumonia and may suggest a 'articular 'athogen, as follows@

(tre'tococcus 'neumoniae@ 0ust5colored s'utum

Pseudomonas, $aemo'hilus, and 'neumococcal s'ecies@ 6ay 'roduce green s'utum

Ilebsiella s'ecies 'neumonia@ 0ed currant5Celly s'utum

Anaerobic infections@ "ften 'roduce foul5smelling or bad5tasting s'utum

A history of .arious e-'osures, such as tra.el, animals, occu'ational e-'osures, and
en.ironmental e-'osures, can be hel'ful in determining 'ossible etiologies and the
li%elihood of bacterial 'neumonia, as follows@

9-'osure to contaminated air5conditioning or water systems P Gegionellas'ecies

9-'osure to o.ercrowded institutions Deg, Cails, homeless sheltersE 5( 'neumoniae,

6ycobacteria, 6yco'lasma, Chlamydo'hila

9-'osure to .arious ty'es of animals 5 Cats, cattle, shee', goats DC burnetii,

anthracis <cattle hide=B tur%eys, chic%ens, duc%s, or other birds DC 'sittaciEBrabbits, rodents
D2 tularensis, T 'estis

(igns of bacterial 'neumonia may include the following@

$y'erthermia Dfe.er, ty'ically O88MCE

<29=
or hy'othermia DQ 85MCE

,achy'nea DO18 res'irations:minE

Hse of accessory res'iratory muscles

,achycardia DO1)) b'mE or bradycardia DQ ?) b'mE

Central cyanosis

Altered mental status

Physical findings may include the following@

Ad.entitious breath sounds, such as rales:crac%les, rhonchi, or wheezes

Decreased intensity of breath sounds

9go'hony

7his'ering 'ectorilo4uy

Dullness to 'ercussion

,racheal de.iation

Gym'hadeno'athy

Pleural friction rub

9-amination findings that may indicate a s'ecific etiology include the following@

radycardia@ 6ay indicate a Gegionella etiology

Periodontal disease@ 6ay suggest an anaerobic and:or 'olymicrobial infection

ullous myringitis@ 6ay indicate 6yco'lasma 'neumoniae infection

Cutaneous nodules@ 6ay suggest !ocardia infection

Decreased gag refle-@ (uggests ris% for as'iratio

Lobar pneumonia
2our stages of inflammatory res'onse are classically described, as follows@
1+ Congestion@ ,his stage is characterized by .ascular engorgement, intraal.eolar
fluid, and numerous bacteria+ ,he lung is hea.y, boggy, and red+
2+ 0ed he'atization@ /n this stage, massi.e confluent e-udation de.elo's, with red
blood cells, leu%ocytes, and fibrin filling the al.eolar s'aces+ ,he affected area
a''ears red, firm, and airless, with a li.erli%e consistency+
8+ &ray he'atization@ ,his stage is characterized by 'rogressi.e disintegration of red
blood cells and the 'ersistence of a fibrin e-udate+
*+ 0esolution@ ,he consolidated e-udate within the al.eolar s'aces undergoes
'rogressi.e enzymatic digestion to 'roduce debris that is later resorbed, ingested
by macro'hages, coughed u', or becomes organized by fibroblasts growing into
it+
Bronchopneumonia
roncho'neumonia ty'ically consists of foci of consolidation resulting from a
su''urati.e, leu%ocyte5rich e-udate that fills the bronchi, bronchioles, and adCacent
al.eolar s'aces+ /n terms of gross a''earance, well5de.elo'ed lesions may be 85* cm in
diameter, dry, granular, and grayish5red to yellow, with 'oorly demarcated margins+
Interstitia pneumonia
,he ty'ical lung inflammatory res'onse to the aty'ical bacteria results in an interstitial
'icture+ Al.eolar se'ta become widened and edematous and usually ha.e a mononuclear
inflammatory infiltrate of lym'hocytes, histiocytes, and 'lasma cells+ !eutro'hils may
also be 'resent in acute cases+ Pleuritis may result if the underlying inflammation e-tends
to the 'leural surface of the lung+