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Respiratory Medicine Made Simple : Pneumonia : Clinical Examination, Investigations and Management

 Pneumococcal pneumonia presents classically as lobar or segmental consolidation.

Multiple , non-contiguous and sometimes bilateral segments may be affected with multilobar involvement being a poor prognostic factor.

The absence of an air bronchogram within an area of consolidation suggests exudate or pus filling the conducting airways aside from Streptococcus pneumonia , organisms commonly responsible for this appearance include Staphylococcus and Gram negative organisms.

Early cavitation in an area of consolidation is typical ofstaphylococcal infection but consider Gram negative organism such as Klebsiella and donot forget Tuberculosis.

Also consider Aspiration pneumonia or proximal bronchial obstruction eg due to carcinoma or a foreign body.

A variety of Radiographic patterns are described in Mycoplasma pneumonia & in Lgionnaire”s disease.

The presence of pleural fluid is suggestive of bacterial aetiology and a diagnostic tap should be performed if this is anything more than trivial in size.

In pneumococcal pneumonia the radiograph maybe normal at presentation even in the presence of a classical history and signs of consolidation on examination only to become abnormal over the next few hours.

Routine blood tests :

Full blood count

Anemia will compound impared tissue oxygen delivery and white cell count is likely to be elevated.

However a patient with overwhelming sepsis may have a normal white cell count.

Electrolytes and Renal function

Uremia is a bad prognostic sign in pneumonia

Hyponatremia is another non-specific marker of severity of infection and is also a particular feature of Legionaires disease.

Liver function Tests :

Derangement of liver enzymes maybe seen in any severe sepsis but transient hepatitis is seen as a part of multisystem involvement in atypical infections such as Legionairres disease.

Also inflammatory markers such as CRP is a more sensitive marker of severity of pneumonia than an increased temperature or a white cell count.

Microbiological Tests :

Sputum microscopy and culture

If sputum is obtainable,it is important to send early in infection

And do a sputum for AFB test / Acid fast bacilli

Blood cultures

Urinary assays of specific antigens : pneumococcal antigen and Legionella antigen

Serological testing : Send acute and convalescent titres for atypical serology

Pleural fluid if there is significant effusion.

Management

General management and resuscitation if needed.

CURB -65 score

Assessment using CURB-65 is vital as a prognostic indicator

Confusion

Mini mental scale Examination < 8

Or new disorientation in person , place and time

Urea > 7 mmol/l

Respiratory rate > 30 / minute

BP systolic < 90 mm Hg or

Diastolic < 60 mmHg

Age > 65 yrs

Score 1 point for each feature present.

A score of 3 – 5 suggests severe pneumonia,

Antibiotics :

Antibiotics should be given without delay with the choice guarded by the BTS guidelines

And / or local knowledge of of the pathogens commonly implicated.

Always consult local prescribing policies in addition to obtaining microbiological advice as necessary.

CURB-65 score 1 or 2 in the moderately sick patient ,oral amoxicillin and a macrolide should be given.

In those patients allergic to penicillin, a fluoroquinolone should be given ie levofloxacin

CURB 65 score 3 or more

In the more severely ill patient , co-amoxiclav or a third generation cephalosporin should be given intravenously in conjunction with a macrolide.

In patients who are penicillin allergic, an intravenous fluoroquinolone in addition to a macrolide shoukd be considered.

If Legionaires disease is considered, then intravenous Erythromycin 1 Gram every 6 hours should be considered.

If there is any suggestion of preceding influenza , consider adding a specific antistaphylococcal antibiotic eg Fluclocloxacillin.

If Gram negative infection or aspiration is suspected , then a 3rd Generation Cephalosporin is the antibiotic of choice.

Respiratory Medicine Made Simple : Pneumonia : Definition , Causes and History

 

Pneumonia refers to infection &  inflammation of the lung tissue / parenchyma.

Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing.

A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia.

 

Pneumonia can range in seriousness from mild to life-threatening.

It is most serious for infants and young children, people older than age 65, and people with health problems or weakened immune systems.

Symptoms

The signs and symptoms of pneumonia vary from mild to severe, depending on factors such as the type of germ causing the infection, and your age and overall health.

Mild signs and symptoms often are similar to those of a cold or flu, but they last longer.

 

Signs and symptoms of pneumonia may include:

Chest pain when you breathe or cough

Confusion or changes in mental awareness (in adults age 65 and older)

Cough, which may produce phlegm

Fatigue

Fever, sweating and shaking chills

Lower than normal body temperature (in adults older than age 65 and people with weak immune systems)

Nausea, vomiting or diarrhea

Shortness of breath

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Clinical features of pneumonia

Fever

Cough

Shortness of breath

Malaise

Breathlessness

Confusion

Fever : is usually high grade upto 38.5 C

Breathlessness is a characteristic feature of pneumonia.

It indicates a ventilation perfusion mis match as seen in pneumonic consolidation.

Cough :

Does the patient have a cough?

If yes,is it dry , productive or purulent?

Does the patient normally have a cough and produce sputum?

In a patient with Normal lungs, a dry cough is suggestive of pneumonia of any sort.

A purulent cough is suggestive of an underlying bacterial infection.

A brownish red / rusty colored cough is suggestive of pneumococcal infection.

Chest pain could be due to soreness from coughing or it may be pleuritic due to which is more common in bacterial than non-bacterial infection.

When did the illness start ?

Bacterial pneumonias have a small prodrome as compared to non-bacterial infections

Eg Mycoplasma will have a longer prodromal phase.

Presence of confusion indicates the pneumonia is severe.

But note that classic symptoms and signs of pneumonia are less likely in the elderly and hence confusion may be the main presenting symptoms and only diagnostic clue.

Are there any other likely Diagnosis ?

Other common causes of acute presentation with breathlessness include :

Pulmonary oedema

Pulmonary embolism

Are there any clinical features that suggest these as possible cause ?

Patients with atypical pneumonias may have GI symptoms.

Relevant Past Medical history

A detailed Past Medical history is required

But particular emphasis should be on the following ;

Ask if the patient has a previous history of

COPD / Chronic Obstructive Pulmonary Disease

Bronchiectasis or a long standing lung problem

Smoking history

Alcohol History

Alcoholism can lead to recurrent Aspiration Pneumonias as well as pneumococcal and Gram negative and atypical infections.

Also determine if the patient has suffered from Alcohol withdrawal  if admitted to the hospital.

Pets : are there any parrots or budgies at home of patient ?

Is the patient immunosuppressed ?

HYPONATREMIA : RISK FACTORS , CAUSES, INVESTIGATIONS ,COMPLICATIONS & MANAGEMENT

HYPONATREMIA : RISK FACTORS , CAUSES, INVESTIGATIONS ,COMPLICATIONS & MANAGEMENT

RISK FACTORS OF HYPONATREMIA

The following factors may increase your risk of hyponatremia:

Age. Older adults may have more contributing factors for hyponatremia, including age-related changes, taking certain medications and a greater likelihood of developing a chronic disease that alters the body's sodium balance.

Certain drugs. Medications that increase your risk of hyponatremia include thiazide diuretics as well as some antidepressants and pain medications. In addition, the recreational drug Ecstasy has been linked to fatal cases of hyponatremia.

Conditions that decrease your body's water excretion. Medical conditions that may increase your risk of hyponatremia include kidney disease, syndrome of inappropriate anti-diuretic hormone (SIADH) and heart failure, among others.

Intensive physical activities. People who drink too much water while taking part in marathons, ultramarathons, triathlons and other long-distance, high-intensity activities are at an increased risk of hyponatremia.

SIADH

SYNDROME OF INAPPROPRIATE ADH SECRETION

Syndrome of inappropriate antidiuretic hormone secretion occurs when excessive levels of antidiuretic hormones (hormones that help the kidneys, and body, conserve the correct amount of water) are produced. The syndrome causes the body to retain water and certain levels of electrolytes in the blood to fall (such as sodium).

CAUSES OF SIADH

SYNDROME OF INAPPROPRIATE ADH SECRETION

SIADH tends to occur in people with heart failure or people with a diseased hypothalamus (the part of the brain that works directly with the pituitary gland to produce hormones). In other cases, a certain cancer (elsewhere in the body) may produce the antidiuretic hormone, especially certain lung cancers. Other causes may include the following:

Meningitis (inflammation of the meninges, the membranes that cover the brain and spinal cord)

CAUSES OF SIADH

SYNDROME OF INAPPROPRIATE ADH SECRETION

Encephalitis (inflammation of the brain)

Brain tumors

Psychosis

Lung diseases

Head trauma

Guillain-Barré syndrome (a reversible condition that affects the nerves in the body. GBS can result in muscle weakness, pain, and even temporary paralysis of the facial, chest, and leg muscles. Paralysis of the chest muscles can lead to breathing problems.)

Certain medications

Damage to the hypothalamus or pituitary gland during surgery

Thyroid or parathyroid hormone deficiencies

HIV

Hereditary causes

INVESTIGATIONS FOR DETECTING CAUSE OF HYPONATREMIA

URINARY SODIUM CONCENTRATION is useful for disinguishing between renal and extrarenal hypovolemic hyponatremia and hypervolemic hyponatremia.

PAIRED URINE AND PLASMA OSMOLALITIES  should be sent to exclude possibilty of SIADH.

CT Head to exclude any sub dural haematoma / head injury to exclude SIADH as a cause of hyponatremia.

COMPLICATIONS OF HYPONATREMIA

In chronic hyponatremia, sodium levels drop gradually over 48 hours or longer — and symptoms and complications are typically more moderate.

In acute hyponatremia, sodium levels drop rapidly — resulting in potentially dangerous effects, such as rapid brain swelling, which can result in a coma and death.

Premenopausal women appear to be at the greatest risk of hyponatremia-related brain damage. This may be related to the effect of women's sex hormones on the body's ability to balance sodium levels.

PREVENTION OF HYPONATREMIA

Treat associated conditions. Getting treatment for conditions that contribute to hyponatremia, such as adrenal gland insufficiency, can help prevent low blood sodium.

Educate yourself. If you have a medical condition that increases your risk of hyponatremia or you take diuretic medications, be aware of the signs and symptoms of low blood sodium. Always talk with your doctor about the risks of a new medication.

Take precautions during high-intensity activities. Athletes should drink only as much fluid as they lose due to sweating during a race. Thirst is generally a good guide to how much water or other fluids you need.

MANAGEMENT OF HYPONATREMIA

Hyponatremia treatment is aimed at addressing the underlying cause, if possible.

If you have moderate, chronic hyponatremia due to your diet, diuretics or drinking too much water, your doctor may recommend temporarily cutting back on fluids. He or she may also suggest adjusting your diuretic use to increase the level of sodium in your blood.

If you have severe, acute hyponatremia, you'll need more-aggressive treatment. Options include:

TREATMENT OF HYPONATREMIA

Intravenous fluids. Your doctor may recommend IV sodium solution to slowly raise the sodium levels in your blood. This requires a stay in the hospital for frequent monitoring of sodium levels as too rapid of a correction is dangerous.

Medications. You may take medications to manage the signs and symptoms of hyponatremia, such as headaches, nausea and seizures.

1.8 % saline infused at rate of ( 1.7 * patients weight in Kg) ml/hr or 3% saline infused at rate of (1.0 * pts weight in Kg )/ml/hr will increase serum sodium concentration by 1 mmol/hour.

Aim in early phases is to increase serum sodium concentration by  1 mmol/hour  but no more than  15 – 20 mmol/hour over 48 hour.

TREATMENT OF SIADH

Specific treatment for SIADH will be determined by your doctor based on:

Your age, overall health, and medical history

Extent of the disease

Your tolerance for specific medications, procedures, or therapies

Expectations for the course of the disease

The most commonly prescribed treatment for SIADH is fluid and water restriction. If the condition is chronic, fluid restriction may need to be permanent. Treatment may also include:

Certain medications that inhibit the action of ADH (also called vasopressin)

Surgical removal of a tumor that is producing ADH

Other medicines to help regulate body fluid volume

METABOLIC MEDICINE MADE SIMPLE : HYPONATREMIA : CAUSES , PATHOPHYSIOLOGY & CLINICAL FEATURES

HYPONATREMIA  : CAUSES , PATHOPHYSIOLOGY & CLINICAL FEATURES

HYPONATREMIA

DEFINITION

Hyponatremia is a low sodium concentration in the blood. 

It is generally defined as a sodium concentration of less than 135 mmol/L (135 mEq/L), with severe hyponatremia being below 120 mEq/L. 

Symptoms can be absent, mild or severe. Mild symptoms include a decreased ability to think, headaches, nausea, and poor balance.

CAUSES OF HYPONATREMIA

HYPOVOLEMIC VOLUME STATUS

Total body water is lower than normal status

Diuretics

Sodium losing Disorders

Mineralocorticoid Deficiency

Vomiting

Diarrhea

Gastroenteritis

Burns

EUVOLEMIC

Total body water is in its normal range

SIADH

Glucocorticoid Deficiency

Hypothyroidism

HYPERVOLEMIC

Total body water is more than its normal range

Cardiac Failure

Hepatic Failure

Nephrotic Syndrome

PATHOPHYSIOLOGY

Gradual and longterm lowering of sodium concentration is mich well tolerated than a rapid acute fall of sodium levels.

Patients with mild hyponatremia are usually asymptomatic ( 125 – 135 mmol/l of sodium levels.)

Patients with moderate hyponatremia ( sodium 115 – 125 mmol/l) may have nausea , lethargy ,headache and dosorientation.

Patients with severe hyponatremia ( sodium of less than 115 mmol/L) can suffer from seizures ,coma and even death

CLINICAL FEATURES OF HYPONATREMIA

Hyponatremia signs and symptoms may include:

Nausea and vomiting

Headache

Confusion

Loss of energy, drowsiness and fatigue

Restlessness and irritability

Muscle weakness, spasms or cramps

Seizures

Coma

Neurology Made Simple : Coma : Clinical Examination and Management

COMA : CLINICAL EXAMINATION AND MANAGEMENT:

CLINICAL EXAMINATION IN COMA

NEUROLOGICAL EXAM :

Pupillary size and reaction : Bilateral fixed and dilated pupils indicates severe damage and are a sign of poor prognosis.

A unilateral fixed dialted pupil indicates 3rd cranial nerve lesion commonly due to uncalherniation.

Unlateral Horner”s syndrome indicates damage to the hypothalamus or lateral medullary syndrome.

Bilateral small pupils is suggestive of opiodoverdose or pontine damage.

INVESTIGATIONS

Laboratory tests

Blood samples will be taken to check for:

Complete blood count

Electrolytes, glucose, thyroid, kidney and liver function

Carbon monoxide poisoning

Drug or alcohol overdose

A spinal tap (lumbar puncture) can check for signs of infections in the nervous system. During a spinal tap, a doctor or specialist inserts a needle into the spinal canal and collects a small amount of fluid for analysis.

Brain scans

Imaging tests help doctors pinpoint areas of brain injury. Tests may include:

Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of the brain. A CT scan can show a brain hemorrhage, tumors, strokes and other conditions. This test is often used to diagnose and determine the cause of a coma.

Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of the brain. An MRI can detect brain tissue damaged by an ischemic stroke, brain hemorrhages and other conditions. MRI scans are particularly useful for examining the brainstem and deep brain structures.

Electroencephalography (EEG). An EEG measures the electrical activity inside the brain. Doctors attach small electrodes to the scalp. Doctors send a low electrical current through the electrodes. The brain's electrical impulses are then recorded. This test can determine if seizures may be the cause of a coma.

MANAGEMENT OF COMA

A coma is a medical emergency.

Doctors will first check the affected person's airway and help maintain breathing (respiration) and circulation. Doctors may give breathing assistance and High flow oxygen, blood transfusions and other supportive care.

Establish iv access and monitor Oxygen saturations.

In case of hypoglycemia , if fingerprick glucose is less than 2.5 mmol/l give 50 ml of 50 % glucose iv.

In suspected opioid toxicity ,if pupils are small and respiratory rate is low ,give naloxone 400 mcg stat and repeated to a total of 1.2 mg .

Treatment varies, depending on the cause of the coma. A procedure or medications to relieve pressure on the brain due to brain swelling may be needed.

If the coma is the result of drug overdose, doctors will give medications to treat the condition. If the coma is due to seizures, doctors will administer medications to control seizures.

Other treatments may focus on medications or therapies to address an underlying disease, such as diabetes or liver disease.

Sometimes the cause of a coma can be completely reversed and the affected person will regain normal function. But if the affected person has suffered severe brain damage, he or she may sustain permanent disabilities or may never regain consciousness. The person may enter a persistent vegetative state or become brain dead.

COMA : CLINICAL FEATURES , CAUSES , CLINICAL FEATURES AND APPROACH TO DIAGNOSIS

COMA : CLINICAL FEATURES , CAUSES , CLINICAL FEATURES AND APPROACH TO DIAGNOSIS

COMA

A coma is a prolonged state of unconsciousness. 

During a coma, a person is unresponsive to his or her environment. 

The person is alive and looks like he or she is sleeping. However, unlike in a deep sleep, the person cannot be awakened by any stimulation, including pain.

Comas can be derived by natural causes, or can be medically induced.

CLINICAL FEATURES OF COMA

Patient fails to respond normally to painful stimuli, light, or sound; lacks a normal wake-sleep cycle; and does not initiate voluntary actions.

Coma patients exhibit a complete absence of wakefulness and are unable to consciously feel, speak or move.

Clinically, a coma can be defined as the inability to consistently follow a one-step command.

 It can also be defined as a score of ≤ 8 on the Glasgow Coma Scale (GCS) lasting ≥ 6 hours. 

A coma is a medical emergency. Swift action is needed to preserve life and brain function. Doctors normally order a battery of blood tests and a brain CT scan to try to determine what's causing the coma so that proper treatment can begin.

CAUSES OF COMA

Coma can be caused by a variety of causes  including  traumatic head injury, stroke, brain tumor, drug or alcohol intoxication, or even an underlying illness, such as diabetes or an infection to  name a few.

Traumatic brain injuries. Traumatic brain injuries, often caused by traffic collisions or acts of violence, are common causes of comas.

Stroke. Reduced or interrupted blood supply to the brain (stroke), which may be caused by blocked arteries or a burst blood vessel, can result in a coma.

Opiod toxicity , Post ictal , Subrachnoid haemorrhage / SAH

Tumors. Tumors in the brain or brainstem can cause a coma.

Diabetes. In people with diabetes, blood sugar levels that become too high (hyperglycemia) or too low (hypoglycemia) can cause a coma.

Lack of oxygen. People who have been rescued from drowning or those who have been resuscitated after a heart attack may not awaken due to lack of oxygen to the brain.

Infections. Infections such as encephalitis and meningitis cause swelling (inflammation) of the brain, spinal cord or the tissues that surround the brain. Severe cases of these infections can result in brain damage or a coma.

Seizures. Ongoing seizures may lead to a coma.

Toxins. Exposure to toxins, such as carbon monoxide or lead, can cause brain damage and a coma.

Drugs and alcohol. Overdosing on drugs or alcohol can result in a coma.

CLINICAL APPROACH TO DIAGNOSIS

Because people in a coma can't express themselves, doctors must rely on physical clues and information provided by families and friends. 

Be prepared to provide information about the affected person, including:

Events leading up to the coma, such as vomiting or headaches

Details about how the affected person lost consciousness, including whether it occurred suddenly or over time

Any noticeable signs or symptoms prior to losing consciousness

The affected person's medical history, including other conditions he or she may have had in the past, such as a stroke or transient ischemic attacks

Recent changes in the affected person's health or behavior

The affected person's drug use, including prescription and over-the-counter medications as well as unapproved medications or illegal, recreational drugs

PHYSICAL EXAMINATION

In a physical exam, doctors will check the affected person's movements and reflexes, response to painful stimuli, and pupil size. 

A head to toe screen is performed looking at general condition of the patient including hygiene/ nutrition status which if inadequate can indicae alcohol or drug abuse.

Look for signs of drug abuse such as needle track marks

Doctors will observe breathing patterns to help diagnose the cause of the coma. Doctors also may check the skin for signs of any bruises due to trauma.

To determine the affected person's level of consciousness, doctors may speak loudly or press on the angle of the jaw or nail bed. Doctors will watch for signs of arousal, such as vocal noises, eyes opening or movement.

Doctors will test reflexive eye movements. These tests can help determine the cause of the coma and the location of brain damage.

Doctors also may squirt ice-cold or warm water into the affected person's ear canals and observe eye reactions.

Look for any signs of chronic liver disease which suggests Alcohol abuse.

Observe any signs of trauma and bruising on head or other parts of the body.

Observe the respiratory pattern : Cheynes stokes respiration indicates bilateral cortical damage , hyperventilation suggest Metabolic acidosis oor brainstem pathology.