Internal medicine

1. INTERNAL
MEDICINE
SGD CASE DISCUSSION OUTPUT

2. GROUP MEMBERS
• Thomas, Praise Shalom
• Uwimpuhwe, Angelique
• Vellore Rajendran, Vimal
• George, Praneet Samuel
• Jesudass Gandhi, Manoah
Gandhi
• Thengunattavila, Noel
Udayakumar
• Thilagaraju, Kathir
Nidarsan
• Babu, Guruprasad
• Chaklasiya, Jastin
Rameshbhai
• Shukla, Bhavin
Rashmikant
• Ravichandran Santosh
• Ahmed, Khalid Bashir
• Parupalli, Raja Rajeswari
• Ubakaram, Prasilla
• Elumalai, Sridhar

3. CASE
A 71-year-old woman is admitted because of fever and productive cough.
She claims feeling okay until about 4d PTA when she noted the onset of
cough. Initially nonproductive, the cough began to become productive of
yellowish sputum and was associated with left sided chest pain. Two days
PTA she noted feeling chills and had a temperature of 38.9 0 C. The fever,
cough and chest pain continued over the next 48 hrs so she came to the
Emergency Department. She denied hemoptysis, weight loss, sore throat,
sinusitis, back pain, diarrhea, rash, joint pain or headaches. She has a
history of congestive heart failure related to ischemic heart disease that has
been controlled with Lasix, an ACE- inhibitor, and Lopressor. She is a former
smoker but quit 3 months ago when her husband died of lung cancer. She
denies alcohol use, recent travel, domestic pets or any risk factors for HIV
exposure. She is a retired lawyer and she lives alone in the city.

4. PHYSICAL EXAM
• P.E. reveals a thin woman in mild respiratory distress.
• VITALS: T 39.4 0C; R 28; P 120; BP 128/84; O2 saturation is 89% on room
air.
• SKIN - normal but with decreased turgor;
• Neck - no palpable LAP or masses
• HEENT - sinuses nontender; TMs mildly red but no middle earfluid;
oropharynx is mildly red but no exudate.

5. • CHEST - remarkable for splinting to the left side on deep inspiration +
dullness to percussion ≈ 1/4 way up on left side; decreased breath sounds at
left base, but egophony and bronchial breath sounds are evident as one
listens more superiorly on the left side. The right chest is clear.
• CVS - distinct heart sounds, regular rate and rhythm, (-) murmurs or rubs.
• ABD - soft, nontender without hepatosplenomegaly
• GUT - (-) KPS, bilateral
• Extremities: (-) cyanosis of nailbeds, (-) edema
• NEURO – no focal abnormalities

6. LAB RESULTS
• CBC: WBC 18.0 (54 segs, 5 bands, 41 lymphs), Hb 13.8,
Hct 39.8 Platelet count 255K
• UA: clear, sp gr 1.020 1+ protein (-) cells or casts, (-)
RBC, (-) WBC Na 143 meq/l K 4.2 meq/l Cl 100 meq/l ,
HCO3 29 meq/l Cr 1.0 mg/dl
• FBS 150 mg/dl
• EKG: normal sinus rhythm, normal rate and intervals, no
ischemic changes

7. • CXR: normal heart size/left lower lobe infiltrate is
present that obscures the left heart border
• Sputum Gram’s stain: a few PMN, many epithelial
cells, and scattered
• Gram positive and Gram negative cocci and rods
are seen.

8. PERTINENT FINDINGS
• Age- 71 yrs old
• Occupation: Retired Lawyer
• Productive Cough
• Yellow sputum
• Fever with chills - 38.9 degrees Celsius
• Chest pain
• Congestive heart failure related to ischemic heart disease
controlled by Lasix, an ACE- inhibitor, and Lopressor

9. • Former smoker , quit 3 mos ago
• Lives alone in the City
• Temp.: 39.4 0 C
• RR: 28 breaths/min
• PR: 120 beats/min
• BP 128/84
• O2 saturation: 89% on room air
• General: Thin and in Mild respiratory distress

10. • Leukocytosis
• Elevated FBS result
• Proteinuria (transient)
• Sputum Gram stain few PMN, many epithelial
cells, and scattered Gram positive and Gram
negative cocci and rods are seen.

11. DIFFERENTIAL DIAGNOSES:
VIRAL PNEUMONIA
RULE IN RULE OUT
• Fever
• Productive cough
• Chills
• Chest pain
• History of smoking/smoker
• Tachypnea
• Tachycardic
• Dyspnea
• Dry cough
• Mucoid sputum
• Malaise
• Headache

12. TUBERCULOSIS
RULE IN RULE OUT
• Fever
• Productive cough
• Diurnal fever
• Night sweats due to weight loss or
anorexia
• General Malaise and weakness
• No hemoptysis
• No wasting
• Pallor
• finger clubbing
• Thrombocytopenia
• Mild anemia

13. PNEUMONIA
BASIS
• Fever (38.9 degrees Celsius)
• Productive cough( yellow sputum)
• Chills
• Chest Pain
• congestive heart failure related to ischemic heart disease
• Smoker
• History of husband dying of lung cancer

14. • Thin
• Tms mildly red
• Oropharynx mildly red
• Mild Respiratory distress- [Dyspnea ( O2 sat.- 89%)]
• Tachypnea (RR -28)
• Tachycardic (PR- 120)
• splinting to the left side on deep inspiration
• Dullness to percussion
• Consolidation in Superior left side
• Egophony
• Bronchial sound
• Leukocytosis

15. PATHOPHYSIOLOGY
Pneumonia 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 in several ways. The most common is by aspiration from
the oropharynx. Small-volume aspiration occurs frequently
during sleep (especially in the elderly) and in patients with
decreased levels of consciousness. Rarely, pneumonia occurs
via hematogenous spread (e.g., from tricuspid endocarditis) or
by contiguous extension from an infected pleural or mediastinal
space.

16. RISK FACTORS
• Old age
• Decreased level of consciousness
• Smoking
• Alcohol overuse
• Immunocompromised patients
• Lung diseases like COPD
• Kidney failure

17. TESTS TO BE DONE
• Gram stain and culture sputum
• Blood cultures
• Urinary antigen tests
• Polymerase chain reaction
• Serology
• Biomarkers like crp and procalcitonin

18. TREATMENT AND
MANAGEMENT
• Antibiotics is the mainstay for the treatment of pneumonia, should be initiated
as soon as a diagnosis of CAP is made.

19. Treatment algorithm

20. Based on the Clinical features presented in this case, the
patient is under Moderate risk Community Acquired
Pneumonia and should be hospitalized and monitored.
For moderate-risk CAP, a combination of an IV non-
pseudomonal β-lactam with either an extended macrolide
or a respiratory fluoroquinolone is recommended as initial
antimicrobial treatment

21. DOSAGE

22. SIGNS OF IMPROVEMENT
• In the absence of any unstable coexisting illness or other
life threatening complication, the patient may be
discharged once clinically stable and oral therapy is
initiated
• A repeat chest radiograph prior to hospital discharge is
not needed in a patient who is clinically improving
• A repeat chest radiograph is recommended during a
follow-up visit, approximately 4 to 6 weeks after hospital
discharge to establish a new radiographic baseline and to
exclude the possibility of malignancy associated with

23. PREVENTION
• Get the flu vaccine each year. People can develop bacterial pneumonia after a case
of the flu. You can reduce this risk by getting the yearly flu shot.
• Get the pneumococcal vaccine. This helps prevent pneumonia caused by
pneumococcal bacteria.
• Practice good hygiene. Wash your hands frequently with soap and water or an
alcohol-based hand sanitizer.
• Don’t smoke. Smoking damages your lungs and makes it harder for your body to
defend itself from germs and disease. If you smoke, talk to your family doctor about
quitting as soon as possible.
• Practice a healthy lifestyle. Eat a balanced diet full of fruits and vegetables. Exercise
regularly. Get plenty of sleep. These things help your immune system stay strong.
• Protect yourself when around sick patients. Being around people who are sick
increases your risk of catching what they have

24. THANK YOU