Question

2. A 48-year-old known hypertensive man is brought to the hospital with 3day history of fever and a productive cough. There is positive history of headache and is increasingly confused. Drug history include hydrochlorothiazide and lisinopril for hypertension. Patient is allergic to amoxicillin. On examination, the temperature was 38.7°C [101.7°F]), blood pressure 90/54 mmHg, respiratory rate 36/min, and pulse 110/min. there was no signs of meningeal irritation but oriented only to person. A chest x-ray shows a left lower lung consolidation. A CT scan is not contributory

a. what is your working diagnosis and 2 differential diagnoses? b. what’s drug (s) of choice? Why c. what counselling wil you provide to the patient? d. write a summary on your diagnosis

Answer 1

Answer a

My working diagnosis is -

1. Community-acquired pneumonia
   1. Explanation:
      1. The patient has fever and cough
      2. He confusion
      3. chest Xray shows the presence of left lower lung consolidation
2. Acute respiratory failure
   1. Explanation:
      1. This patient has pneumonia
      2. HIs is confused
      3. His respiratory rate is 36 / min
      4. The increase respiratory rate could be due to
         1. pneumonia - leading to ventilation-perfusion mismatch
         2. Due to compensation for metabolic acidosis. Pneumonia must have caused sepsis and sepsis must have lead to metabolic acidosis
3. Septic shock
   1. Explanation
      1. This patient pneumonia
      2. But this condition is complicated.
      3. His is hypertensive yet his blood pressure is low.
      4. this low blood pressure seems to be unlikely due to anti-hypertensive overdose and more likely due to sepsis

Answer b

The drug of choice for this patient is:

As per the official clinical practice guidelines of the American Thoracic society and infectious disease society of America

The drug of choice of a patient with comorbidities and who is allergic to amoxicillin = Monotherapy with fluoroquinolones - intravenous levofloxacin 750 mg one time per day .

The reasons for the selecting of this drug

1. Recommended by the American Thoracic Society and infectious disease society of America
2. Has a good gram-positive coverage ( pathogens causing community-acquired pneumonia are gram-positive)
3. This drug is available in both intravenous and oral forms.
   1. This is important in this case because the patient condition is critical
   2. Pneumonia in his case is complicated with acute respiratory failure and sepsis
   3. In such a patient, intravenous preparation is preferred. (as shock shunt blood away from the splanchnic circulation)
   4. Once the patient is able to tolerate oral feeds, the oral formulation can be used.
4. The patient is allergic to amoxicillin

Answer c

I will counsel the patient regarding the following

1. I will advise the patient to get hospitalizes as his blood pressure is low and he has comorbidity of hypertension.
2. He needs to temporarily stop taking his anti-hypertensive medication as his blood pressure is low.
3. He needs to inform whenever he gets a fever spike so that it can be measured and charted.
4. He needs to follow a salt-restricted diet.

Answer d)

A 48-year-old man has a fever, productive cough, and headache for 3 days. He is a known case of systemic hypertension and on lisinopril and hydrochlorothiazide. On examination, he looked confused and oriented in person. he has hypotension and is breathless. A chest X-ray was done suggestive of left lower lobe consolidation. With the working diagnosis of left-sided community-acquired pneumonia with acute respiratory failure and septic shock, the patient was admitted. He is started on I.v. levofloxacin (750 mg) once a day. His mental condition and fever will be monitored during the stay. Xray will be performed on the 7 th day to look for resolution of pneumonia. If there is no improvement in the fever by the 3rd day, a change in the antibiotic may be considered