A case study presentation on pneumonia.

1. CASE STUDY PRESENTATION:
Pneumonia

2. A 33y/o female is brought to the hospital due
to severe cough with chest pain
• 3-4 episodes of vomitting per day
• headache
• fatigue

3. 01
c/c on admission
• Severe cough without sputum
• 3-4 vomitting episodes per day since
a week
• Headache
• Generalized weakness
03
Medication H/o:
• N/S
• OTC MEDS like PCM, Rantac, zifi-
200 for common cold
02
Medical H/O
• G3P3 3003
• No h/o abortions
• No significant allergies
• Frequent fever episodes in cold
season without medical intervention:
usually self treated
04
Family H/o
Significant for stroke and Angina/MI
SUBJECTIVE DATA
Name: APS Age: 33 Sex: F DOA: 3/9/19

4. P/E
• General: Moderate,WNL
• Vitals: BP 130/80 PR 84/min RR 18/min
• HEENT: N
• CVS: S1S2,no murmur
• CNS: Normocephalic
• RS: Normal breathing,mild dyspnea-crackles
• GIT: N
• PA: S/NT, non distended
• GU: N
• EXT: N-no clubbing, cyanosis, edema

5. BSL(R)– 72 mgs% (70–110 mgs%)
S.creatinine– 1.9mgs% (0.5-1.5mgs%)
Urea– 16mg/dL
D.bilirubin– 0.2
T.bilirubin– 0.8
T.protein– 6.9(6-7.8)
SGOT- 25 IU
SGOT- 19 IU
SaO2 - 95%
SERUM ELECTROLYTE:
S.Na– 138 mEq/L(135-145)
S.K– 3.4 mEq/L(3.5-5.5)
Ionised Ca– 1.16 mmol/L(1.12-1.32)
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ROUTINE ANALYSIS

6. CBC
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• WBC– 6.6x 10³/uL (4-11x10³/uL)
• LY%– 23.6% (25-45%)
• MO%– 3%(2-8%)
• NE%– 50%(35-75%)
• RBC– 4.3x106.
• Hgb–12.3g/dL (14-18g/dL)
• HCT– 38.7%(32-54%)
• MCV– 90 FL(79-101 FL)
• MCH– 26.2 pg(26-36 pg)
• MCHC- 29.1 g/dL(31-37 g/dL)
• RDV- 12.9% (11.5-14.5%)
• PLT– 290x10³/uL (150-450x10³/uL)
• PCT– 0.252% (0.130-0.280%)
• MPV- 8.7fl (9-17 fl)

7. ECG
Tachycardia
CXR
Loculated pleural effusion with calcification on right lobe with pleural thickening
S/O: chronic emphysema
LAB INVESTIGATION

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9. ASSESSMENT
Right Lobar Pneumonia
Final Diagnosis
Goals of therapy
Etiology
• To reduce morbidity & mortality
• Improve quality of life of patient,restore & preserve immune function
• To prevent complications and minimize adverse effects of the therapy
•
Community acquired:
air inhalation

10. 01 Inj. Pantop — 20 mg BD
• Generic– Pantoprazole
• MOA–It is a proton pump inhibitor,inhibits H,K ATPase enzyme which
secretes HCl in parietel cells of stomach
• Indications-Ulcers and reflux oesophagitis,GERD,Zollinger-Ellison
syndrome
• Contraindication- Hypersensitivity
• Side effects- Headache, diarrhea, dizziness
• Pregnancy–US FDA pregnancy category Not Assigned:This drug is
only recommended for use during pregnancy when there are no
alternatives and the benefit outweighs the risk.
• Warnings–Prolonged treatment (greater than 24-36 months) may
cause vitamin B12 deficiency.
• Std. Dose–20-80 mg/day

11. 02 Tb.ASPIRIN 150 mg OD
• Mode of action–Aspirin (acetylsalicylic acid) is a NSAID that inhibits
cyclooxygenase (COX) isoenzymes 1 and 2. The effect on COX isoenzymes
is dose-dependent with lower doses (60 to 150 mg) inhibiting platelet
synthesis while higher doses results in inhibition of both COX-1 and COX-2
blocking all prostaglandin production.
• Indications– Headache, fever, thrombosis, stroke, angina
• Contraindications– Haemorrhage, thrombocytopenia
• Adverse effects–dyspepsia, epigastric discomfort, heartburn, and nausea.
• Pregnancy–pregnancy category: C
• Warnings–Do not give this medication to a child or teenager with a fever,
flu symptoms, or chicken pox. Salicylates can cause Reye's syndrome,
• Std. Dose– Loading:150-325 mg Maintenance: 75-150mg

12. 03 Tb. CLOPITAB 75 mg OD
• Generic– Clopidogrel
• MOA–adenosine diphosphate (ADP) receptor antagonists (also called P2Y12
inhibitors).Its activity is thought to be due to its active thiol metabolite, which
inhibits the binding of adenosine diphosphate (ADP) to its platelet receptor which
indirectly inhibits platelet aggregation. This action is irreversible.
• Indications–used acutely in myocardial infarction, atrial fibrillation, following
coronary bypass, angioplasty and stenting. It is also used as prophylaxis to prevent
myocardial infarction and stroke.
• Contraindications– Haemophilia, Thalesemia, GI ulcers
• Adverse effects– chest pain, nosebleed, SOB,
• Pregnancy–Use is not recommended. When possible, discontinue this drug 5 to 7
days prior to labor
• Warnings–Do not stop taking clopidogrel without first talking to your doctor, even
if you have signs of bleeding. Stopping clopidogrel may increase your risk of a
heart attack or stroke.
• Std. Dose– 75-300 mg/day

13. 04 Tb. ATORAVAT 4 mg HS
• Generic– Atorvastatin
• MOA–Atorvastatin belongs to a group of drugs called HMG CoA
reductase inhibitors, or "statins."
• Indications–Atorvastatin is used to treat high cholesterol, and
to lower the risk of stroke, heart attack, or other heart
complications in people with type 2 diabetes, coronary heart
disease, or other risk factors.
• Contraindications–Allergy, liver disorder, pregnancy
• Adverse effects–hemorrhagic stroke, arthralgia, diarrhea
• Pregnancy–US FDA pregnancy category X
• Warnings–Minimize drinking alcohol. It can raise triglyceride
levels and may increase your risk of liver damage.
• Std. Dose– 10-20 mg ; max daily dose: 80mg/day

14. 05 MUCINAC GEL – TDS
• Generic–Acetylcysteine
• MOA–Acetylcysteine is a drug that breaks down mucus, the substance that lubricates
many parts of the body such as the mouth, throat, and lungs.exerts its mucolytic
action through its free sulfhydryl group, which reduces the disulfide bonds in the
mucus matrix and lowers mucus viscosity. This action increases with increasing pH
and is most significant at pH 7 to 9
• Indications–cystic fibrosis, emphysema, bronchitis, pneumonia,
tuberculosis,acetaminophen poisoning
• Contraindications–esophageal varices,Asthma Attack,decreased lung function
• Adverse effects–severe or ongoing vomiting, swelling of the eyes, face, or inside of
the nose,unusual tiredness or weakness
• Pregnancy–US FDA pregnancy category: B Animal studies did not show
teratogenicity.There are no controlled data in human pregnancy.
• Warnings–Volume of bronchial secretions may increase after administration
• Std. Dose–Recommended dosing: 1 to 2 mL of the 20% solution, or 2 to 4 mL of the
10% solution

15. 06 Syp. SORBITOL 10 ml OD
• MOA–Polyalcoholic sugar with hyperosmotic effects that induces
catharsis,hydrates, softens and eases stools by gently attracting water in the
colon through a process known as osmosis. The water increases stool volume
and stretches the wall of the bowel triggering the defecation reflex, so the
digestive system can be unblocked naturally.
• Indications– Constipation, hypoglycemia
• Contraindications– hypernatremia,Anuria, acute abdominal pain
• Adverse effects–Severe diarrhea, Shortness of breath, weight gain, or
swelling in the arms or legs,high blood sugar
• Pregnancy–Sorbitol has not been formally assigned to a pregnancy category
by the FDA. There are no controlled data in human pregnancy
• Warnings–A laxative may be habit forming and should be used only until your
bowel habits return to normal.
• Std. Dose–30-150 mL (70% solution)

16. 07 Tb. AMLO 2.5 mg OD
• Generic–Amlodipine
• MOA–Calcium channel blocking agents restrict the amount of calcium
entering cardiac and smooth muscle cells by blocking voltage-gated calcium
channels. This causes blood vessels to relax and widen (vasodilate), improves
oxygen supply to the heart, and lowers blood pressure. Some calcium channel
blockers also slow the heart rate.
• Indications–high blood pressure, angina, arrhythmias, and circulatory
disorders
• Contraindications– Hypocalcemia, anaphylaxis, hypoparathyroidism
• Adverse effects–edema. Other side effects include: fatigue, palpitations,
wheezing, dizziness
• Pregnancy–US FDA pregnancy category: C
• Warnings–Drinking alcohol can further lower your blood pressure and may
increase certain side effects of amlodipine.
• Std. Dose– 2.5 -10mg/day

17. 08 Tb. CITRAX 5 mg OD
• Generic– Cetirizine
• MOA–H1-antihistamine, a second generation antselectivel.Cetirizine is an
antihistamine that works selectively on peripheral histamine-1 (H-1)
receptors.Histamine is a chemical that is released by mast cells in response to an
allergen, and it is responsible for many of the symptoms of an allergic reaction
• Indications–perennial or seasonal allergic rhinitis (hay fever),allergic conjunctivitis,
insect bites, and other allergic skin disorders.
• Contraindications–severe hypertension, or severe coronary artery disease, and in
those who have shown hypersensitivity
• Adverse effects–Somnolence, fatigue, dry mouth. Insomnia reported with cetirizine
hydrochloride-pseudoephedrine hydrochloride fixed combination.
• Pregnancy–US FDA pregnancy category: Not formally assigned to a pregnancy
category.This drug should not be used during pregnancy unless the benefit outweighs
the risk to the fetus.
• Warnings–Caution should be exercised before driving or operating machinery
• Std. Dose–5 to 10 mg orally once a day
• -Maximum dose: 10 mg/day

18. 10 Inj.LEVOFLOX 500 mg iv OD
• Generic–Levofloxacin
• MOA–Levofloxacin is a broad-spectrum antibiotic that is active against both Gram-
positive and Gram-negative bacteria. Like all quinolones, it functions by inhibiting the
DNA gyrase (supercoiling of DNA) & topoisomerase IV(separate DNA that has been
replicated)
• Indications–acute bacterial sinusitis, pneumonia, urinary tract infections, chronic
prostatitis, gastroenteritis.along with other antibiotics it may be used to treat
tuberculosis, meningitis, pelvic inflammatory disease
• Contraindications–Myasthenia Gravis, epilepsy ,with NSAIDs
• Adverse effects– Arthralgia, tendinitis,QTP, diarrhea,dyspepsia, photosensitivity
• Pregnancy–US FDA pregnancy category C: Animal reproduction studies have shown
an adverse effect on the fetus and there are no adequate and well-controlled studies
in humans, but potential benefits may warrant use of the drug in pregnant women
despite potential risks.
• Warnings– Levofloxacin may cause swelling or tearing of a tendon (the fiber that
connects bones to muscles in the body), especially in the Achilles' tendon
• Std. Dose–500-750 mg orally or IV every 24 hours (500mg/100ml)

19. 09 Inj. PIPAMAX 500 mg iv OD
• Generic– Piperacillin and Tazobactam
• MOA–Piperacillin/tazobactam is a beta-lactam/beta-lactamase
inhibitor combination with a broad spectrum of antibacterial activity
encompassing most Gram-positive and Gram-negative aerobic
bacteria and anaerobic bacteria, including many pathogens
producing beta-lactamase
• Indications– peritonitis, UTI, septicemia, pneumonia and other
noscomical infections
• Contraindications–Hypersensitivity, seizures
• Adverse effects– thrombocytopenia,headache, diarrhea
• Pregnancy–US FDA pregnancy category B
• Warnings– Do not administer in case of hypersensitivity, cystic
fibrosis or with any vaccinations or immunization.
• Std. Dose– 0.5-4.5 g iv every 6 hours

20. 11 Tb. Pyridoxine 5 mg BD
• MOA–Vitamin B6 is a water soluble vitamin.Pyridoxine is involved in conversion of
tryptophan to niacin or serotonin, breakdown of glycogen to glucose-1-
phosphate,conversion of oxalate to glycine,synthesis of gamma aminobutyric acid
(GABA) within the CNS, and synthesis of heme.
• Indications– Anemias, high cholesterol,high homocysteine
• Contraindications–Allergy
• Adverse effects–Paresthesia, somnolence, Low serum folic acid levels
• Pregnancy–US FDA pregnancy category A: Adequate and well-controlled studies have
failed to demonstrate a risk to the fetus in the first trimester of pregnancy
• Warnings–Longer use can cause the bowels to stop functioning normally and might
cause dependence on laxatives.
• Long-term use can cause changes in blood electrolytes that can cause heart function
disorders, muscle weakness, liver damage, and other harmful effects.
• Std. Dose–oral multivitamin containing 2 to 5 mg pyridoxine daily for several weeks

21. 12 Tb. MTX 5 mg OD
• Generic–Methotrexate
• MOA–Methotrexate interferes with DNA synthesis. It has been shown to inhibit dihydrofolate
reductase (DHFR), an enzyme that participates in the folic acid synthesis. Folic acid is essential
in the synthesis of purines and pyrimidines, vital for protein, DNA, and RNA synthesis
• Indications–cancer of the breast, skin, head and neck, or lung. It is also used to treat severe
psoriasis, rheumatoid arthritis, abortions
• Contraindications– hypersensitivity, immune deficiency, pregnancy, Alcoholism
• Adverse effects–Mouth lesions, low blood counts, poor appetite, nausea and abdominal
discomfort are the most common side effects of methotrexate. Tiredness, dizziness, skin rash,
hair loss, and an increased susceptibility to infection have also been reported. Diarrhea and
ulcerative stomatitis. May cause bone marrow, liver, lung and kidney disease
• Pregnancy–US FDA pregnancy category X: Contraindicated
• Warnings–Methotrexate can cause serious or life-threatening side effects. Seek medical consult
on unusual bleeding or bruising
• Std. Dose–Single Dose: 10 to 25 mg/week orally, IM, IV, or subcutaneously until adequate
response is achieved
• Divided Dose: 2.5 mg orally every 12 hours for 3 doses once a week
• Maximum dose: 30 mg/week

24. PLANNING
Therapeutic monitoring
Discharge medications
• CBC:
1. plts.(aspirin, clopidogrel),MTX
2. Hb: MTX, pyridoxine
• S.Ca-Amlodipine
• Lipid Panel- Atorvastatin, pyridoxine
• BP, Ask the patient daily about the severity of cough and
dyspnea.
• SaO2 or RR.
Patient not discharged

25. POINT TO PATIENT
About the disease
About diet and lifestyle modifications
• Grapefruit and grapefruit juice may interact with atorvastatin and lead to potentially dangerous effects. Avoid drinking more than 1 liter per day of
grapefruit juice while taking this medicine.
• Caffeine may reduce the effectiveness of methotrexate in the treatment of arthritis. If you are receiving methotrexate for arthritis, you may want
to limit your intake of caffeine-containing foods and medications
• Hydration: loosening the mucus
• Green leafy vegetables and citrus fruits: antioxidants,protect against infection
• Turmeric,honey and ginger: mucolytic, anti inflammatory effects.
•
• About medications
Pneumonia is the infection of airways and lungs caused by bacteria, virus or fungi due to inhalation of microbe
• Take medications regularly as prescribed
• Do not skip doses, especially antibiotics as resistance may develop causing difficulties in treatment and increase duration and cost of therapy
• Report any side effects or changes seen immediately to your physician as it may be occuring due to medications prescribed to you.

26. POINT TO PHYSICIAN
• Present complaints of the patient include:
• Dyspnea,severe joint pain, chest pain-severe in morning
• Fluoroquinoline prescribed most likely causing arthralgia for which methotrexate is
prescribed
• Methotrexate induces pulmonary toxicity which is harmful to the patient since
pleural effusion with calcification is already evident on chest radiograph, although it
is given in lower dose
• Suitable alternative to fluoroquinoline (Levofloxacin) can reverse this issue
• Macrolide: Azithromycin or erythromycin according to the guidelines
• BP: not normotensive with amlodipine, increase dose of change drug with another
drug from same class or different drug from another class.
• Determine pulmonary arterial wedge pressure(PAWP)
• If pulmonary hypertension: drug of choice-PDE5i (slidenafil,tadafil)

27. POINT TO PHYSICIAN
• Culture sensitivity test recommended to determine the causative organism.
• Lipid panel advised to monitor effects and requirements of Atorvastatin
• The following major drug interactions found:
1. Medications like piperacillin, especially when given at high dosages for serious infections, can
sometimes increase the blood levels and effects of methotrexate, increased side effects such as
nausea, vomiting, mouth ulcers, and low blood cell counts, which can make you more likely to
develop anemia, bleeding problems, and infections
2. methotrexate and aspirin:This combination may increase the effects of methotrexate. This
combination may cause nausea, vomiting, diarrhea, sore throat, chills, fever, rash, unusual
bruising or bleeding, pale skin, dark urine, swelling of the extremities, or shortness of breath.
3. Atorvastatin and Pantoprazole: risk of complication of rhabdomyolysis
4. Levofloxacin may rarely cause central nervous system side effects such as tremors, involuntary
muscle movements, anxiety, confusion, depression, hallucinations or seizures, and combining it
with other medications that can also affect the central nervous system such as aspirin may
increase that risk

28. 1. Centers for Disease Control and Prevention. National Center for Health Statistics. Pneumonia.
http://www.cdc.gov/nchs/fastats/pneumonia.htm
2. https://journals.sagepub.com/doi/abs/10.1177/194589240501900413
3. https://www.plasticsurgery.theclinics.com/article/S0094-1298(05)00043-X/abstract
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1700000/
5. https://thorax.bmj.com/content/47/1/67.1
6. https://www.ncbi.nlm.nih.gov/pubmed/24049265/
7.
7.
REFERENCES

29. THANK YOU