Setting: ED
CC: “Cough, shortness of breath, and chest pain”
VS: BP: 108/72 mm Hg; P: 112 beats/minute; T: 102.8°F; R: 26 breaths/minute
HPI: A 68-year-old man with several days of increasing cough, discolored sputum production, and chest pain arrives at the ED. The pain is sharp, right sided, and worsens when he takes a deep breath. He has had a fever of 102°F at home. The dyspnea markedly worsened today, and that is what made him come to the hospital.
PMHX:
Tobacco smoking in past; quit 15 years ago
Medications:
Vitamins
On CCS, for dyspnea, order oxygen, oximeter, and chest x-ray.
For routine fever evaluation, how much testing should you order just because of the presence of a fever?
a. Chest x-ray
b. Chest x-ray, urinalysis (UA)
c. Chest x-ray, UA, blood culture
d. Chest x-ray, UA, blood culture, stool culture
e. Chest x-ray, UA, blood culture, stool culture, urine culture
Answer c. Chest x-ray, urinalysis (UA), blood culture
These are the tests of fever evaluation just for a person with no other localizing symptoms. You can order this on CCS for any fever.
Initial Orders:
Oximeter, chest x-ray, oxygen
Blood cultures, UA
PE:
General: fatigued, tired
Chest: right-sided crackles in lung field
Abdomen: nontender, no organomegaly
Cardiovascular: no murmurs, no gallops
Which of the following is the greatest determinant of the need for hospital admission?
a. Hypoxia and hypotension
b. Number of lobes involved
c. Age and medication use
d. Organism type and previous intubation
e. Number of previous episodes of pneumonia
Answer a. Hypoxia and hypotension
Admission to the hospital is based on the severity of the disease. The severity of pneumonia is based on the presence of hypoxia, hypotension, altered mental status, and renal failure.
All the other features, such as age, the number of previous illnesses, and the number of lobes involved, are important, but not nearly so important as hypoxia and hypotension. If you have only one lobe involved in a young person, but the patient is hypotensive (systolic blood pressure [SBP] <90 mm Hg) or hypoxic, then the young patient needs to be admitted.
Mycoplasma pneumonia involves five lobes, but it is mild and does not cause hypoxia or hypotension. The same is true of Chlamydia pneumonia. So admission is not based on etiology, it is based on the severity.
Move the clock forward to the minute you need to get the results of the oximeter.
Because you ordered the oxygen and oximeter at the same time, the oximeter reading will not reflect the oxygen administration. Tests ordered at the same time as treatments do not reflect the treatments.
Results:
Oximeter: 91% saturation on room air
Saturation <92% = PO2 at least <70 mm Hg = Severe pneumonia
Pneumococcus
• Most common community-acquired pneumonia (CAP)
• Environmental source or reservoir unknown
You can repeat the oximeter reading now that the patient is on oxygen. It will reflect the use of oxygen now that you have moved the clock forward.
In pneumonia, it is key to
Assess oxygenation and blood pressure (BP) immediately.
Get x-ray results and start antibiotics within 30 minutes of the patient’s arrival in the ED.
Advance the clock 10 to 20 minutes to get x-ray results.
Orders:
ABG
ABG helps answer the question, “Ward or ICU?”
Hypotension + Severe Hypoxia (PO2 <60 mm Hg) = ICU
Report:
Chest x-ray: right middle and right lower lobe infiltrates; effusion on right
UA: no white blood cells (WBCs), no protein
ABG: pH 7.46; PCO2 34 mm Hg; PO2 65 mm Hg
Hyperventilation should mean respiratory alkalosis.
PCO2 down 10 mm Hg = pH up 0.08
What test should you use first to detect pleural effusion?
a. x-ray
b. Computed tomography (CT)
c. Ultrasound
d. Thoracentesis
Answer a. X-ray
All detect a pleural effusion. Start with the x-ray.
Decubitus x-ray detects pleural effusion.
Effusions Move = Layer Out
Orders:
Ceftriaxone IV
Azithromycin IV
Decubitus x-ray
Transfer patient to hospital floor
What difference does it make if there is an effusion?
a. No difference in treatment
b. Placement of patient in ICU
c. Need for thoracentesis
d. Difference in antibiotic choice
Answer c. Need for thoracentesis
Thoracentesis is needed if there is an effusion to see if there is empyema. Empyema means an infection in the pleural space, not just that there is fluid transudatively moving into the pleural space. An empyema is infected exudate. If there is empyema, drainage with a chest tube is needed because it will act like an abscess. In addition, undrained empyema can also slow scar formation and tighten the lungs and destroy lung function.
The patient is moved to the hospital ward. All orders for decubitus films, oxygen, azithromycin, and ceftriaxone go with the patient. Move the clock forward to get results of the films.
Ceftriaxone inhibits cell wall production.
Azithromycin inhibits ribosomal production of protein.
Report:
Decubitus x-ray: layering out of effusion seen
Orders:
Thoracentesis under sonographic guidance
Pulmonary consultation
Which quality of pleural fluid is the strongest indication for chest tube drainage?
a. Lactate dehydrogenase (LDH) >60% of serum
b. pH <7.2
c. Protein >50% of serum
d. WBC count 500/μL
Answer b. pH <7.2
Unquestionably, the strongest indication for chest tube drainage is a low pleural fluid pH. This is the greatest indicator of severe infection. LDH >60% of serum and protein >50% of serum indicate an exudative effusion, but not clearly an infection. WBC count in pleural fluid is strangely not as accurate an indicator of infection as it is in urine, cerebrospinal fluid (CSF), and ascites.
Normal pleural fluid pH is 7.6.
Pleural Fluid Report:
pH: 7.5
Protein and LDH: slightly elevated
WBCs: 486/mm3
The patient is on oxygen and antibiotics. Repeat the oximeter on oxygen to ensure adequate oxygenation. As soon as hypoxia, fever, and hypotension improve, the patient can be safely discharged home on oral azithromycin. The same criteria for admission (CURB)—Confusion, Uremia, Respiratory distress, BP low—are the same as for discharge. In the absence of CURB, the patient can leave.
Pneumonia vaccine should be given to prevent infection with other serotypes.