How is care managed to a patient admitted as a emergency to an acute medical ward with a diagnoisis of pneumonia two days ago. The condition has deterionated since admission.?

Answer 1

Care Management needs to take five directions: * Palliative measures * identification of the pneumonia * treatment of the pneumonia * underlying causal factors and their treatment * overall patient condition. After two days I assume you've run sputum and blood cultures as well as a CBC, etc., and started a course of levofloxacin and/or gentamycin, and found the results to be less than sterling. I will also assume you're tested negative for LRE. So, I'm guessing you're assuming a viral cause, or something cryptic, related to an underlying cause we haven't discussed here (perhaps a compromised immune system). You might consider daptomycin (note that testing on daptomycin implies that it works best on Gram pos -- this isn't necessarily the only beneficial effect -- read ALL the data) or zyvox if you consider it to be a resistant bacterium, some of the antivirals, or something to attack any underlying issues (such as that immune condition I keep suspecting). Bear in mind that in America, we are occasionally seeing strains of various bacteria that are no longer sensitive to many penicillin variants. Depending on how sharp your lab is and your relations with them, you might want to mention this. From a management standpoint, palliative methods, breathing and O2 Sat foremost, should be the focus until a treatment plan is developed. I'd also plan for potential contagion, as airborne variants are a possibility. Warning -- this is in no way to be construed to be Medical Advice, nor am I a doctor.

Overall, I agree with cjonb's excellent answer. I might, however, bring up a couple other points of concern/for thought.

About the history:

* How old is the patient? As far as epidemiological information goes, this is right up there on the list of importance. A young and an old patient have very different pathophysiologies of disease for pneumonia. * Where do they live? What part of the world/country? Do they live at home or in a nursing home? This also plays a HUGE role. Many diseases are more commonly seen in certain areas of the world, and not at all seen in others. If they live in a nursing home, they are much more likely to have an aspiration pneumonia or a pneumonia with a resistant organism. * What other medical problems do they have? This can factor into what we treat the person with, or may give a clue to what to look for. * Have they been treated with any antibiotic in the last month or two? Makes you much more likely to have a resistant organism. * Have they been hospitalized recently? More likely to see strange or resistant organisms * Any strange exposures? Could it be anthrax (farmers, tanners, etc), or other strange cause? * Any travel? Kind of fits in with where they live... * Are we sure this is pneumonia? Could this be a mass? Many masses will masquerade as a pneumonia, or cause an obstructive atelectasis or effusion that can look like pneumonia. If it is not getting better, might consider a CT to make sure there is no mass, especially if the patient is a smoker. * What is their HIV status? No one likes to talk about it, but many problems are more likely to be out in left field if the patient is HIV positive, especially if their CD4 count is very low. Now we're talking about things like Pneumocystis carinii (jirovekii) pneumonia, Mycobacterium avium, some weird fungal infections, etc...

About the current situation:

* In what way have they deteriorated? * Are they breathing adequately? Are they controlling their secretions? If not, may need to be intubated and mechanically ventilated.

* What are the vital signs?

* Are they febrile? Continued fevers, or recurrent spiking fevers may mean another organism has taken over, or the pneumonia may have turned into an abscess or infected effusion that needs to be drained.

* Are they hypotensive? If hypotensive, they need to be resuscitated and possibly started on pressors. Sepsis and shock are very serious, and need to be treated adequately or the mortality is quite high. Need to consider corticosteroids and follow lactic acid levels if septic, although steroids are falling out of favor this month, they may be back in next month :)

* What are the cultures showing? Although, at 2 days, you will not likely have an exact identification of the organism, there should be a basic morphology and gram stain available by now. This can point you in a direction as far as antibiotics.

* What antibiotics have they been on? If they are really this sick, should be on broad spectrum antibiotics, probably cefepime if concerned for pseudomonas, and vancomycin. If there is worsening, should also cover for viral infection, and if immunosuppression or fungal infection is on the table, with an antifungal of choice. May want to consider a bronchoscopy and bronchoalveolar lavage to get a good sample of the lung fluid for culture. Coughed up sputum samples are about worthless for culture.

* Could there be a co-morbid MI occurring? This is a not-uncommon cause of acute worsening, especially in the proper age- and risk group.

* Could there be a co-morbid infection? Also, not altogether uncommon. C. diff diarrhea is a growing problem, especially in ICUs, but all floors are feeling the pain. Other places that could be infected, could be the urine (especially if there is a foley in place), the gallbladder (if that sick, acalculous cholecystitis should be considered), an infected effusion (parapneumonic effusions are very common). If ventilated, there may be a concurrent ventilator associated pneumonia on top of the already present pneumonia.

* Could this be ARDS? Any very sick person, especially one on mechanical ventilation, but ANY sick person, can develop acute respiratory distress syndrome (ARDS). This is a very serious complication of severe illness where the lungs become very permeable to fluid, and essentially fill up like balloons so that oxygenation cannot occur. This has a high mortality rate, although it is manageable, if caught early.

About future management:

* Does the patient need to be transferred to a higher level of care? If this patient is not in the ICU already, perhaps they should be. If they are not improving in the ICU, do they need to be transferred to a regional center for care and access to specialists not available at the current facility?

* What is the patient's desires regarding intubation and mechanical ventilation? * Would they desire CPR? * Would they desire to live in a nursing home, if they do not already?

All these need to be addressed in order to make heads or tails of the situation. I can imagine a very very sick individual here. But then again, I usually look on the darker side of things, so maybe I'm over-reacting.