65 Year Old Female with Pneumonia

A 65-year-old female with pneumonia
CHIEF COMPLAINT: A 3-day long fever accompanied by a persistent cough
HISTORY: The patient's name is Mrs. Alcot, a sixty-five-year-old woman with a complaint of persistent fever and cough. The patient stated that the illness started three days ago after waking up. A feverish feeling and the ejection of yellowish-green phlegm from the mouth during coughing fits were the symptoms reported at the onset of illness. The symptoms of the illness have since worsened as time passed. A notification was also given a recurring pain in the right chest whenever a deep breath is taken. The patient's husband was reported by the patient to have been ill with similar but milder symptoms a week ago.
PHYSICAL EXAMINATION:
Vital Signs: BP 128/86, HR 101 (regular), RR 18, T 37.4°C
GEN: Slight increase in breathing speed; no discomfort is expressed
Working Diagnosis:
Community-acquired pneumonia (CAP)
Tobacco use disorder
Pathophysiology:
Community-acquired pneumonia (CAP) is considered to be the most common type of pneumonia. In approximately 85% of CAP cases, the causative agent is one of the three pathogens: Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis. CAP is contracted by assimilating the pathogen into the body through inhalation. The pathogen inhaled is transmitted through the respiratory system to a lung segment or lobe. The elderly and individuals with compromised immune systems bear high risks of contracting CAP, with CAP's mortality rate being particularly higher among such vulnerable infected (Cacciatore et al., 2017).
Treatment Plan:
The patient's low CURB-65 score led to the decision to treat the patient as an outpatient. The Pneumonia Severity Index (PSI) was not calculated for the patient as no Arterial Blood Gases (ABGs) were available.
Pharmacologic basic concepts:
- Antibiotics are to be used for the patient's treatment for at least five days.
- The antibiotic treatment should not be stopped until the patient's fever subsides and does not return for at least 48 to 72 hours.
- The most widespread causative agents of CAP are the pathogens, S. pneumonia, Mycoplasma pneumonia, and H. influenza.
- A change of treatment plan may be required if the patient's history, clinical findings, and epidemiology necessitates it.
Nonpharmacologic:
- The patients should stay hydrated by drinking fluids.
- The patient should take deep breaths and cough hourly.
- Humidifiers should be used to moisten the air.
- The patient should get plenty of rest.
- Acetaminophen, ibuprofen, or naproxen is to be taken to relieve pain and fever.
Education/Counselling
- The importance of the completion of the antibiotic prescription is to be impressed upon the patient. The application of the antibiotics should not cease even if the symptoms disappear.
- The patient is informed to report back if new symptoms develop or extant symptoms worsen. The worsening symptoms can manifest as shortness of breath, growing chest pain, or blood-tinged mucus' expulsion.
- The patient is to have a repeat chest x-ray in 6 months to determine if the pneumonia is caused by underlying mass. The risk of an underlying mass exists as the patient has a history of smoking.
SOAP Note
S: The patient, Mrs. Alcot, is a 65-year-old female reporting a fever and persistent cough, which causes the expulsion of yellowish-green sputum. The patient indicated that the symptoms appeared three days prior and have worsened since then. The patient denied any other symptoms such as shortness of breath (SOB), palpitations, dyspnea on exertion (DOE), lightheadedness, nausea, vomiting, diarrhea, abdominal pain, and headaches. The patient reports experiencing pain in the right chest whenever a deep breath is taken. The patient can consume fluids with no difficulty, but the patient suffers from a lack of appetite. The patient is a smoker and smokes a pack of cigarettes daily. The patient does not consume alcohol. The patient reported similar, albeit milder symptoms in the husband a week prior; the symptoms were reported to subside without treatment. The patient has not used any antibiotics in recent years. The patient's medical record is significant for arthritis and hypertension (HTN). The patient received an influenza vaccine earlier this year but received no pneumococcal vaccine.
O: Vital Signs: T 37.4°C, BP 128/86, RR 18, HR 101 (regular), pulse oximetry 98%
GEN: Exhibits mild tachypnea, but no discomfort is reported
Skin: Warm, dry, and firm
HEENT (Heart, eyes, ears, nose, and throat): No tenderness of the sinus. PERRLA, EOMs intact. Normal fundoscopic exam. TMS normal, slight reddening of the turbinates, but no discharge. No exudation from the pharynx, cobblestoning, or enlargement. Neck: Supple, no enlargement of the thyroid, JVD (jugular vein distention), or carotid bruits. No lymphadenopathy.
Cardiovascular (CV): Regular rate and rhythm (RRR) without murmurs, rubs, or gallops.
Resp: No difficulty in breathing, lowered audible breath, dullness to percussion, and increased tactile fremitus in the right lower lobe (RLL). Mild crackles in the RLL without wheezes or egophony.
Abdomen: Soft, non-tender, good bowel sounds, no organomegaly.
Extremities: DP and PT pulses +2, trace pedal edema.
Mental Status: Awake and oriented x 3
Labs: CBC (WBC = 14,900, neutrophils = 87%, platelets =310,000/uL, Hgb = 16, Het = 48) BMP (Na = 137, K= 4.1, BUN = 15, Cr= 1.0, BG = 148)
CXR: Consolidation of the right mid lobe. No pleural effusion noted CURB-65 Pneumonia Severity Score = 1 point (age) low risk
A: CAP: Clinically stable
HTN: At JNC (Joint National Committee) 8 goals
Tobacco use: No desire to desist from use is expressed.
P: CAP: Azithromycin 500 mg daily x 3 days. Explained the need to complete usage of the prescription even if symptoms disappear. Drink fluids, rest, take deep breaths and cough hourly, use a humidifier. May use acetaminophen for fever or pain. A pneumococcal vaccine was administered to the patient today.
Rationale
The occurrence of community-acquired pneumonia (CAP) is elevated in persons over 65 years of age, with the infected cases ranging between 25 to 35 per 1000 inhabitants/year in the population. CAP bears a considerable risk to life, and an infection can necessitate emergency medical care and admission to a hospital. The risk of CAP infection to the elderly is attributed to the series of physiological changes resulting from the aging process.
The complexities introduced by the advanced age of elderly subjects increases the amount of medical attention required. There is a greater number of complementary tests needed. There is a greater possibility of complication during treatment, the hospital stay may be prolonged, and the likelihood of hospital admission is higher than that of the younger subjects (Linares et al., 2014). In 2010, 878,000 adults 45 and over were hospitalized with a primary diagnosis of CAP. 71% of the hospitalized adults were 65 years or older, and admission to the intensive care unit (ICU) was required for 10 to 20% of admitted elderly patients. Infections due to pneumococcal pneumonia alone accounted for 866,000 outpatient visits in the year 2004. An annual cost of $10.6 to $17 billion is spent providing CAP-associated health care in the United States. These numbers are anticipated to grow in subsequent years as the number of elderly increases (Kaysin & Viera, 2016).
Key concepts and viewpoints
Antibiotics are usually recommended to treat bacterial pneumonia, while viral pneumonia is treated with antiviral medicine. As a supplement to medication, a patient might receive pain relief, fluids, oxygen, or medical support prescribed by a doctor. To determine if a patient is to be hospitalized, the following criteria are considered:
1. If the patient possesses high-risk features
- Respiratory rate > 30
- Pulse rate > 90
- Temperature < 35.6°C or > 38.1°C
- Oxygen saturation ? 92% breathing room air
- Feeding tube present (unless prior directive on the end of life pneumonia)
2. If the patient cannot be afforded adequate medical care at the place of residence. This could be due to financial, physical, or social incapability to receive appropriate medical treatment (Linares et al., 2014).
If any doubt exists about a patient's success if treated as an outpatient, it is usually prudent to admit the patient. In securing a better patient outcome, early recognition of patients' symptoms is significantly advantageous for providing early treatment. The first-line therapy recommended for patients may vary due to management, be it a nursing home, the hospital, or the patient's place of residence. The treatment for severe cases is the same for patients regardless of the management site (Linares et al., 2014).
Soundness of research
The elderly are highly susceptible to pneumonia, with a high rate of morbidity and mortality. The difficulty of diagnosis of pneumonia in the elderly is serious as the symptoms exhibited might be atypical. Early recognition and highly reliable laboratory and clinical findings will improve the outcome of pneumonia treatment in the elder and reduce morbidity and mortality.
A history of dyspnea suggests CAP's diagnosis, cough, pleuritic pain, acute functional or cognitive decline with irregular vital signs (e.g., fever, fast breathing), and abnormal lung examination findings. Chest radiography and ultrasonography are two ways of confirming a CAP diagnosis. A patient's Pneumonia Severity Index (PSI) score indicates the most suitable treatment therapy, either outpatient or inpatient therapy.
Patients undergoing outpatient therapy for CAP do not require microbiological testing of sputum or blood and can be treated with macrolide, doxycycline, or a respiratory fluoroquinolone. Hospitalized patients (inpatient therapy) should receive fluoroquinolone or a combination of beta-lactam plus macrolide antibiotics. Patients admitted into the intensive care unit due to severe infection should be treated with dual antibiotic therapy with a third-generation cephalosporin and a macrolide alone or in combination with a respiratory fluoroquinolone.
The treatment for Pseudomonas species infections requires the administration of an antipseudomonal antibiotic and an aminoglycoside, plus azithromycin or a fluoroquinolone. Methicillin-resistant Staphylococcus aureus infections should be treated with an administration of vancomycin or linezolid, or ceftaroline should be used for resistant cases. Corticosteroids are to be administered to a patient with severe CAP within 36 hours of admission to lessen adult respiratory distress syndrome risk. This early administration also lessens the time of treatment. The vaccinations recommended for adults 65 years, and above are 23-valent pneumococcal polysaccharide and 13-valent pneumococcal conjugate vaccinations. These two vaccinations lower the risk of contracting an invasive pneumococcal disease such as pneumonia (Kaysin & Viera, 2016).
Pneumonia evidence-based guidelines and diagnosis
Evidence-based guidelines (EBG) have been implemented to assist health care workers in diagnostic procedures, medical treatment, and general management. Developed by a systematic review of scientific evidence and best practice, EBGs are designed to help health workers make the best decisions for CAP patients' treatment and care by translating scientific evidence into daily practice (Eekholm et al., 2020). These guidelines were used to determine Mrs. Alcot's treatment plan.
The complexities involved in diagnosing elderly patients due to comorbidities, the immune system's weakness, and the atypical symptoms manifesting often result in difficult diagnoses. In recent times, lung ultrasound (LUS) is becoming the preferred method for diagnosing pneumonia in the elderly. The limitations of traditional plain chest radiography characterized by long delays and a large radiation dose make lung ultrasound more suitable. The lung ultrasound eliminates the need for a chest computed tomography (CT) to generate a definite diagnosis. The safety of LUS and the application of LUS in the differential diagnosis of pneumonia makes it ideal for diagnosing frail, bedridden patients. The LUS is the choice tool in management sites that do not have CT scans available for outpatients and patients in the ICU.
References
Kaysin, A., & Viera, A. J. (2016). Community-acquired pneumonia in adults: diagnosis and management. American Family Physician, 94(9), 698-706.
Llinares, P., Menéndez, R., Mujal, A., Navas, E., & Barberán, J. (2014). Guidelines for the management of community-acquired pneumonia in the elderly patient. Rev Esp Quimioter, 27(1), 69-86.
Cacciatore, F., Gaudiosi, C., Mazzella, F., Scognamiglio, A., Mattucci, I., Carone, M., ... & Abete, P. (2017). Pneumonia and hospitalizations in the elderly. Geriatric Care, 3(1).
Eekholm, S., Ahlström, G., Kristensson, J., & Lindhardt, T. (2020). Gaps between current clinical practice and evidence-based guidelines for treating older patients with Community-Acquired Pneumonia: a descriptive cross-sectional study. BMC infectious diseases, 20(1), 73.
Thanavaro J. L. (n.d) Chapter 3: Common respiratory diseases disorders in primary care. Joanes & bartlett Learning, LLC.