Transcription
post option so I'm gonna lose that ability soon and then restart. Thanks again, Michael, for being host.
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[Music] [Music] I'm seeing. Okay, I think we can begin now. Okay, of course, I'm going to interrupt you, um, during the presentation. Yeah, are they doing good? But are in between, so be prepared for interruptions in our presentation. I remember when we get knocked out on the same idea and password. You may proceed, Michael.
Okay, so, um, I'm gonna be starting off. This is Joven Chung with the history. So this is a history of patient WA. He's a 40-year-old accountant, um, of our King's 166 address. He's married and he's a Christian. So his presenting complaint is he has a four-day history of coughing, shortness of breath, and fever, and a two-day history of chest pain.
Next.
Okay, so now into the history of presenting complaints. Um, WA is a 40-year-old type 1 diabetic male patient who presented to the emergency department with a four-day history of worsening fever, a harsh, productive, um, a harsh cough productive of sputum that was clear at the time, and shortness of breath that was reportedly, that was reported. And this was exacerbated when he coughed and relieved when he rested. The report of the fever, he didn't have a thermometer, but there was a subjective reading from his wife who said he felt warm. He has no history of recent, he, he has no history of recent travel or ill contact. He states that he's been taking cough medicine, um, for the past four days, but these cough medicines haven't helped to, um, relieve his symptoms. Also, he reports that he's been waking up during the night, um, sweating heavily.
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So two days prior to presentation, his symptoms, um, have gotten worse and progressed. Um, his cough is not productive of a secular sputum with streaks of blood. He's also developed chest pain that worsens on inspiration and coughing. He denies, um, he denies having chills and rigors, but he did not, yeah, he, there's no headache or delirium, but he's feeling lethargic.
Next slide.
Um, before we go to the next slide, the, the chest pain in terms of our severity, you asked him. I know you're doing this thing virtually. Chest pain was eight out of ten. It didn't, it didn't radiate. Um, it was felt, it was felt, um, centrally. Well, no, not since we need yet, we need to ask that. And also relieving factor, relieving factors. Um, so when he rested, the pain was, was really worsened on coughing and really when you rested. Okay, great. You can continue.
So in terms of predisposing factors, he hasn't had any recent upper respiratory tract infections or influenza. He does not smoke, um, or having a history of lung disease.
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He isn't on any corticosteroid therapy or any diagnosed immuno, or she isn't, um, on any other known immunocompromised state apart from his, um, diabetes.
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Uh, uh, what more, more things, especially in this DNA, what you need to ask me? What's happening now? What happened worldwide? Oh, okay, that's true. Um, so we can ask him if he's been tested for COVID-19. No. If he has traveled recently. Oh, I got already. May not be in a COVID situation, but I've given you, you, he has traveled recently. Yeah, that was in the previous slide. No, no travel or I didn't get any ill contact. Right. Excellent. So I didn't hear that. My bad. I didn't hear that. Very good. So you need to ask about recent travel and contacts that are ill. Excellent. Continue.
So, next, next slide, please. In terms of his past medical history, I stated he, he's diabetic. He's, um, he's properly remembered. How many, how many years? He's type 1. So I'm gonna say, um, he was diagnosed at age 12. So that's, uh, 28 years. That's fine. You know what else you asked in the past medical history? I know you mentioned about immunocompromising. Ask if he's had any complications of these diabetes. Yeah. So, um,
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If he, if he has a nephropathy or a very good retinopathy or, um,
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You know, a neuropathy in his legs or so on, right? So you cannot specifically about diabetic complications, especially chronic kidney disease, that can predispose them to new owners. Yes. So I don't want to ask about, um, his diabetic, his control as well. Like if he, um, if he, like, how does he, if he has like a home blood, blood glucose glucometer that he takes regularly and, um, stuff like that. In the history, I said is well controlled. Okay. What, what are the immunocompromising conditions? HIV? Yes, but, um, he denies HIV. Other immunocompromised corticosteroids, like those who, yeah, those who use that. And what do you call it? People that take steroids. People like steroids. Um, people that take steroids. Oh, it could be asthmatic. Except for athletes. Asthmatics. Yeah. Corticosteroids. Someone to asthmatics. Conditions, right? Like, like, like what we have here. I think if it's like some people to bear at me might take it if they're one at me at me. No. Okay. Now scratch that. Yeah, scratch that. Uh-huh. Oh, people just look away. Psoriasis. Psoriasis. No, no, man. You wanted the dermatology. We're coming out for that line. Okay. All right. Well, in the interest at a time, we have to rush to, um, some critical conditions. Okay. So, so those aren't. Yeah, taking part across the U.S.
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No, no, no, no. What name is the sauna? We're coming off the right now. That you went and counted here in Germany. I'm not understanding the question. Cell disorders. Hemoglobin occurs. That's what I'm getting at to ask him. Oh, oh, oh, yeah, that's true. And if he has a history of, um, hypertension as well, right? I guess about disease. Important. So I should have put, but I just want the positive that he has diabetes. Right. Heart disease. Condition. Heart failure, right? That which he can't have his step on. Could have had seven in mind.
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Malignancies, any types, especially head and neck, right? Lung cancer. I think you mentioned asthma, COPD, heart failure. Name a few. All right. So you still need to ask. Yeah. All right. Sometimes, please let him tell you. No, no, no. But you can mention to, to, to run your audience that you did ask about these specific disorders. I should have mentioned those those negatives. Yes, sir. Continue.
In terms of his surgical history, um, he has no prior surgeries. His review system of non-contributory. No, about the drugs. Now the drugs. Drugs.
Next slide, please.
I mixed up the order. So in terms of medication, he's on insulin 35 units, um, daily. Aspirin 81 milligrams PO daily. And I was starting 20 milligrams PO daily. In terms of medication, he has no known drug allergies. And in terms of what, what else, um, would you ask about in terms of medication? In terms of medication, if he was taking any medication to treat his, um, the cough, like he's like treating, right? So we call that over-the-counter. Very good. Yeah. In the history, I didn't say he was taking cough medicine. You'd still put that in medication history. Medicine? No, you just stated, um, cough medicine. So maybe codeine, okay? Or you can see that they don't know. You know, coming out right down. White box. No name is the herbal manganese. Yeah, but they tend to know the herbs. And you need to add some about supplements, herbal supplements. So over-the-counter medication and herbal supplement that may interact with medication that you are planning to prescribe. True. All right. Continue.
So, his social history. Um, he's married with no kids. Denies smoking and drinks alcohol occasionally. The allergies? You mentioned allergies. Yeah, I didn't mention allergies. No known drug allergies or food allergies. Very good.
Go back one service.
Okay, so in terms of his family history, his father was a type 1 diabetic, has a history of heart, heart attack. That his mother has hypertension. So in summary, and he's only a child. Oh, wow. Yes, only child. All right. You're not ready for summer, right? But go back, please. Where we are now. Family history. So we're doing family. What else do we need to mention in the history? Yeah, the review of systems. Apart from regular systems, social. I think that I did say the social history. Social history said what? Because I mixed up the order. Where is it? Oh, yeah. Emotional history. Um, I said, next idea. I said he was married with no kids. Um, he denies smoking and drinks alcohol occasionally on the weekends. Yes, he has modern amenities. Yeah, garbage is collected twice per week. He has running water and he, he drinks. He has running water. Nice. Um, I know you're doing these things virtually, but, um, in every exam, you don't have to ask them about, um, support. They're talking, you know, psychological support or feel about the illness, financial. Yeah, he supports himself or he's dependent on Western Union dividends from abroad. Yeah. In the, in the demographics, I stated he was an accountant. Hello. That is true. They still have to mention in finance himself. They will want your exam. So basically, psychological and social issues, you need to mention in social. All right. Um, we don't like needles here, but we do ask about intravenous drug use. Yeah. So don't take it for granted that because we don't like needles, one and twelve was not shooting up heroin, you know, crap, hope, will, whatever, having a, yeah. So be more sorry with the social history. Yes, sir.
All right, go back now to review or the summary. The review of the systems. Oh, he was non-contributory. Don't do it. Residents that are our doctor Garrison with chick when she get tired. Style. Yeah, I can, I can do my review of assistance because I know what went on in HP Siana's neglect. But on a few occasions, the patients have helped me obviously about that. I guess the panda rush thinking corresponding with whatever happening, right? So what in the review of systems, you'd ask about? Well, um, I'd want to ask about mainly the two main systems. I would want to review would be would you, would be in there. Would have put in the HPS and said, yeah, already mentioned, but there are important things they need to tell us in review of assistance. Since he's diabetic, then a neurological review would be important. And we call it an endocrine review or endocrine. Um, so, so in fact, I would have asked that in the HBS with regards to polyurethane cell because the diabetes is unconscious. You're gonna lead to, um, infectious issues. From my understanding of, of the HPS, what, how is your doctor saying is that you should focus on what the patient complains about in the HPS and then in the review of systems again with everything else? No, this is how it went. Real life. I'm not talking about international tom. Okay. All right. Yo, you get the picture of a diabetic patient with with a pneumonia and it basically one assess, you know, well controlled. Accepting your own scenario. So to know well controlled, your, you'll be inaudible about pneumonias, urinary tract infection, cellulitis, you know, meningitis. Um, in the HPS and said, I can't go on and on. So we don't have to check in the HPS. I don't know who telling it is. And, um, in the HPS, their control that probably set them up, okay, for what you think is a pneumonia. All right. Heart conditions predisposed to pneumonia. And then, yes, he can have heart conditions. And having the diabetes is too long now. So, yeah, definitely, you know, go into the heart of it. Okay. You can probably mention one or two things. You can go back to the obvious systems for for things that are not too contributory and say that they mentioned motion HPS, but he also denied this, right? Okay. TBS. All right. We do ask about things like weight loss. All right. And you may want, depending on the story, you may want to put it in review of assistance or in the HPS. All right. So you ask double constitutional stuff too, but you can probably put it in review of assistance. All right. As to, as I said, not pop up with history too much. All right. So depending on what story you're getting, you may have to take all constitutional questions and put them up there. Okay. Okay. Right. Skin. You have to mention. It doesn't have to be in HPS, but it's not dimensional lesions. It has, you know, pneumonia, right? Due to staphylococcus activity. Skin region is a diabetic, right? If he's having GI symptoms, it may indicate a type of pneumonia like Legionella. I can't. What I'm saying, I can go on and on and on and on. So you don't need to still mention points in your review of systems. If you pick up a very important point in your real system, you may need to move it to your HPS to convince them of in a specific problem. All right. Monster ear can pioneer that can power the stain with your systems. Knowledge of our trousers, right? Giant swelling, right? So, yes, that can probably remain in your systems. Just don't, don't, don't fall at me. Ducks enough direct you. And you don't want that either. You can come across as not knowing what you're doing because mother day patients read Trang Google. I said, all right, this is the situation and I really need to go to the doc. And they may not tell you that they did reading got a test in your knowledge. So at the end of the day, they may ask, is this the problem, doc? Is this the diagnosis? And if it's not, you tell me why. All right. I have to know what you're doing. Yes, stuff. All right. So, so, so, yeah, the real system can be garrison style where, you know, I'm going to figure out what I'm going out. Everything happened at the HPS. I'm going to put rabius as a new contributor. All right. They, the way the things have to be standardized, just to follow the macros. After that, they can do it your way. Once you get information and treat them accurately forward again. Okay. So, summary. In summary, we have a 40-year-old type 1 diabetic patient, um, presents with a two-day history of forcing fever of dyspnea and a four-day history of worsening fever, cough, conditioning, and two-day history of chest pain on inspiration. And, um, he has no history of lung disease, no prior respiratory tract infection, or, um, any immunocompromised state with the exception of his type 1 diabetes, which is controlled. So we're on to examination now. Michael will take over.
All right, thank you. All right, examination. Yes, sir. So in the general exam, I saw a middle-aged man lying supine of normal body habitus in cardiopulmonary distress. So, um, temperature was, so as far as vitals, the temperature was 28.2 degrees Celsius, which is elevated. His blood pressure was 124 over 83, which is normal. And his respiratory rate was 30 breaths per minute. So he's stuck it. Neck. His heart rate was, um, 80 beats per minute, which is within normal range. And his STO2 was 95%, which is slightly below normal. And you need to put it, put it as the room air or supplemented oxygen too. Sometime in the ER, they make them comfortable, you know, for, you know, give your medical oxygen, set up a line, draw some lungs. So you need to let us know whether this was room air or oxygen. Yes, sir. Continue.
In the hand muscles, no clubbing, genuine lesions, also nose, splinter hemorrhage, gluconeocar, or nicolas, or nicotine staining. Um, mucous membranes were pink, dry, and, um, anecdotal. There was no central cyanosis and it was slightly decreased. I'm celebrating. Um, my call. Yes, micro. Sorry, sorry to disturb you. Being a host, I forgot to tell you because you guys sometimes like to to review, um, presentations. You're recording it? Recording your card in the session? Okay, great. Because I know sometimes you guys like to review, review, um, you know, sessions. So do record it and you can share a slide if you need to make, um, corrections for the slide. Is more accurate in its portrayal? No problem. Doing that. You know. All right, sorry for the for the interruption. Forward again. Right, so he's, um, a bit dehydrated, mild dehydration. He has, um, no scars and there was a right, there was an IV access, um, sighted in the, um, right. And to keep himself also. He, his respiratory exam, as I said, his respiratory rate was 30 breaths per minute. Um, his breathing was abdominal and there was some nasal flaring. You should be terric abdominal. You've been really not thirty, trust me. There was no chest wall deformities, no clubbing on the track here was. So the meeting is going to end in 10 minutes. No, no. Remember when I get knocked out, um, obviously I'm on the free version. We're going to work until, um, I can't work it no more. No, I was already. They take out a co-host in front of me. Um, so there was no clubbing. Um, central apex beats in the fifth intercostal space, mid-clavicular line. Chest expansion was equal bilaterally. And the tactile, tactile vocal parameters was increased bilaterally, and especially in the bases. And the percussion note was dull also, um, bilaterally. His, his breath sounds were bronchial and the vocal resonance was also enhanced. But where exactly, how was the for his cardiovascular exam was mostly normal. Palms pink and dry. The pants pink and dry would come in generally here. And the capillary fill.
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Collapsing pulse, radio, radio synchrony, no delay. Blood pressure was normal. Um, absent, um, JVP. No, the JVP, what would be the reading at the JVP? Five centimeters. Correct. So it's present. About that five. Uh-huh. Continue.
All right, um, apex beats. Yeah, I said this already. Mid-clavicular line. No, there was no pocket with V2, no paroxysmal heaves. S1, here, abnormal sounds. And his abdominal exam was non-contributory. For his, um, CNS, his higher mental function was normal. Um, he was alert and oriented in person, place, and time. His cranial nerves are normal. Sensory exam was normal. Motor exam was also normal. Well, it was four plus in the, in the upper limbs. And next, we have investigations. Good afternoon, everyone. So you have to know. So moving on to this investigation, starting off with the CBC. Hold on now. Hold on. Hold on. Before we move on, Michael, show me your slides. All right, respiratory, cardiovascular, the belly. Where's the belly again? Move me along now. After bill is one. No, not investigation. You mentioned anything about the skin? The skin? Here's nose and short. Did it mention that? Oh, ears, nose, and throat.
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Yeah, sorry about that. Um, yeah, but we do do ears and throat with respiratory tract issues. All right. Sinusitis, probably causing pneumonia. Skin lesions, bench, and stuff, right? Um, sometimes viral examples, you know, like, um, chickenpox can cause pneumonia, yeah. Musculoskeletal, septic arthritis, yeah. To put that in the scene here. The mo nita of trash, another things mentioned and don't mention all sorts, etc. No, no. I'm who is going to talk and we don't just go into investigations, you know. Who is the assessor? The assessment person. Um, who is the assessment person? That's Caesar. The diagnoser and and differential diagnoser. With that person, I hear a child have them doing this thing. In other words, they are, they, they're probably to tell them what's going on. Pneumonia is a possibility. And other possibilities are who? When whoever mentioned that to me. So the diagnosis, uh, what are saying? What they're saying, ducks in training, or you've got investigator, you don't know what to investigate. You don't put a list of things that may be problematic. Don't do it. The American way, way over from the back forward. So, so, wha, who are the possibilities to mention and why? Who have that list, please? And thanks. So his main diagnosis is, um, community-acquired pneumonia. Yes, sir. And other possibilities. And you should really tell us why. I think he's coming to acquire pneumonia apart from not having a recent, um, healthcare facility interaction. It really tells us, evidenced by, boom, boom, boom, boom. So, community-acquired pneumonia, as evidenced by his, um, history of coughing and respiratory symptoms. So the cough, the, um, the yellow sputum, um, um, and, um, this respiratory exam also, um, right. Exactly. That's what I want to hear. Say, convince you, you know, this is your number one because of these points. Very good. Right. Other, other things to continue. Other things to consider would be your other types of pneumonia. So your atypical pneumonias, which is, which are part of community-acquired pneumonias. Other conditions that would present similarly, yeah, could be asthmatic. And asthma, it could be, um, I won't call it bronchitis if you don't give up his job as, um, so, yeah, what else? Other guys gonna ask? Could we consider on other pulmonary conditions such as pulmonary abscess? Yeah. Um, what have I seen that he had? Who is this, by the way? Please. Antag. This is Melissa Charles. Okay, great. My list of. Continue. So, very good. All right. So it's concerning pulmonary abscess. And what about, um, pericarditis? Pericarditis. Yes. Um, yes. So, but you can, of course, discuss the points against them, right? Pulmonary embolism. Right. Wrong. Cactuses. But you'd have to discuss the points against them as to why, you know, they're not one or a minute to go. Let's get knocked off. So, so, so go through, go through all possibilities, but the points against them. All right. It's important. All right. In addition, you're gonna also mention his diabetic state and any other comorbidities he has in your assessment. Controlled or uncontrolled. Hello. You need to also mention apart from the differentials, you also need to mention his comorbidities and whether they're controlled or or uncontrolled. All right. Then you'll move on to, um, proving that it's pneumonia. And that's called investigations. With the investigations, we started off with the complete blood count and the values obtained reflected a mildly decreased hemoglobin. Perhaps, perhaps this is contributed by the hemoptysis, or maybe he already had a low hemoglobin before, but it's very, uh, insignificant. Okay. And we're going to work it up. Okay. Right. So next, the total of WBC is markedly elevated due to the presence of infection. Neutrophil count in particular, as these cells migrate directly to the site of infection, accumulating and so to control and clear the infection. And in light of the hemoptysis, the patient had bleeding parameters were done, and the results came out normal. Next slide, please.
All right, so for his urinalysis and electrolytes, um, his electrolytes listed here were normal. However, in specific pneumonia with Klebsiella or atypical bacteria, the sodium can be decreased, and often the urea is moderately elevated, while the creatinine is mildly elevated due to the amount of dehydration and hemoptysis. He has a significant dehydration here. So what gives it the normal range of two and it's 19. Okay. All right. So that's okay. Okay. Thank you. All right. Next time, please. No, you're dealing with patients virtually, but that's significant. Yeah, it was, it was a bit hard doing this part, but I tried my best. Okay. Okay. So on this slide, we can see other tests that were also done on the patient. His ESR has increased due to the inflammation, infection. However, it's known to stay under 100 in pneumonia. His CRP is elevated in both viral and bacterial infections. The CRP is elevated. However, in viral infections, the CRP can range from anywhere between 10 to about 50, but in bacteria, the value rises to between 50 and 200. His glycemic control is good, as he falls as a normal glucose range. And his ABG has normal parameters. However, the PAO2 is closer to the upper limit. And in conjunction with his 92% saturation on room air, this is suggestive that the patient has a minimal hypoxia like picture. Next slide, please.
So it's beautiful culture. Before we know, before we choose button culture, what other things would you do?
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I mean, we could do ABG. Did ABG? Glucose. Um, I, I didn't do the ABG. We did the HBA1C. I would do that. Okay. I'd still do that because HBA1C gives you, giving you, um, what's happening over three months. It could be 100. I understand. So, um, we still need a group. Make sure that I'm having DK. So yes, we need for him for this type of patient, your analysis, making sure he doesn't have ketones in, in quantity. Okay. You may have to do, um, lactate, right? If it is very, very ill. Okay. Okay. You can, you may.
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Um, CBC, you want these. RBG. HIV. You need to do HIV. Okay. HIV. I guess. Yes. And yes, you can do other things like LDH. Okay. And liver function. This is what's going on with your patients. But what I mentioned, um, is the bare essentials. Okay. Before you move on to sputum. Anyway, forward. No. Okay. Sure. And is PCT something that we do routinely here? Because I was reading anything. Something like PCT. PCT. PCT or procalcitonin. Yeah, I would love to do that routinely here. Okay. I forget you guys talking abbreviations. That was pretty natural. So, um, so, so, LOL to me is, um, you know, whatever I love. Anyway, okay. Just showing you that, yeah, sometimes I don't pick up an abbreviation as well. So, yes, I'd love to do that. What does procalcitonin help with? I'm not quite sure. All right. So it helps to differentiate between bacterial infections and not just humans, but bacterial infections, viral or fungal. You also use it to gauge your response. If you find that the, the, the levels are decreasing, that your empiric therapy is working, or or if you have culture-directed therapy that is working. To elaborate on our bacterial cell wall. So there's a H in say, a killing mode. All right. And under decreasing in quantities. So excellent to use, but we don't have it here. So, um, yes, thanks for mentioning it. Okay. All right. Um, next slide, please.
All right, so sputum culture is indicated in suspected respiratory tract infections. And this review, by the way, you guys start, you guys start at at time 130. So we have to wrap up in 150 here. Sure, sure. I'm almost over. So you don't call, you know, yeah. All right. So, um, we found S. pneumoniae on the sputum culture. And this bacteria was resist, sensitive to penicillin, absolutely, azithromycin, etcetera. Soon. The blood culture was also done at presentation to rule out sepsis. Next scientist.
All right, so an X-ray is indicated in all patients suspected of having a pneumonia. So this airplane film, PA X-ray of the chest showing an area of patchy opacification in the right lower lobe. And this appearance is characteristic of lobar consolidation caused by typical pneumonia. And just CT wasn't indicated because the X-ray was conclusive. Very good. However, if you have a complicated, um, pneumonia, even with a normal chest X-ray, you would do a CT. Very good. Right. And a bronchoscopy wasn't indicated either, as the X-ray was conclusive and there were evidence of a mass. And if the patient were developing a poor response to treatment, further in his management, then we would, um, proceed to do a chest CT or bronchoscopy. Yes. Next slide.
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All right, so good afternoon, everyone. I will be doing management. It's going through management. And this is, this, this is Melissa Charles. Yes. Okay. All right. Proceed, Miss Charles. Next slide, please. So the first thing that you want to determine is whether or not you want to admit this patient. So usually, what we do is we use the CURB-65 scoring system. You also have the PSI, um, but in this case, you can see these criticism. So it's based on confusion, urea, patient's respiratory rate, systolic blood pressure, and diastolic blood pressure, and the patient's age. So basically, history and examination and investigations that we would have received, we came up with a score of two, seeing the patient's respiratory rate was equal to two, um, beats per minute, and the patient's urea was elevated, and also the fact that he also has an underlying comorbidity. We want to have medications. Next five days. Okay. So the first thing that you do, your ABC approach, just, um, checking airway, breathing, and circulation. One thing that I forgot to mention is not here on this night, but it's important because the patient was slightly hypoxic. Um, we can probably give, when I probably will give, um, oxygen via nasal cannula. And also he was severely dehydrated, so we will have fluid resuscitation. It's important to ensure that he is, um, that his blood glucose levels are controlled. So he can do continuous blood glucose monitoring and ensure that he sticks his insulin as you met while in hospital for antibiotic therapy. We can give, um, ceftriaxone one gram IV every 24 hours. And, um, azithromycin 500 milligrams IV here for 24 hours. And we do this for a minimum of five days. So approximately five to seven days. Supportive therapy is also important. So chest physiotherapy and incentive spirometry. And, um, you continue to observe on, um, the clinical picture. Um, if there's no clinical improvement, we can repeat the blood culture, um, because he may see that he's diabetic and would be immunocompromised. Um, there can be other offending organisms. So we can repeat and see if it picks up something else. And we treat, um, pathogens specific. And we'll also repeat his ABG values for, um, the criteria for in discharge. So we repeat this checks like chest X-ray, um, ensuring that it's he's now clear. Um, ensure that he has been a febrile for three days before the show. They repeat that. You repeat chest X-ray. Um, it's not the most. Okay. Call it the worst name. Okay. All right. So we just repeat chest X-ray. If everything, everything in six weeks. All right. Okay. All right. So he has, will ensure that he has been in for a while for two to three hours before, two to three days, sorry, before being a shot. And show that he's here, another very stable glycemic control. And he would want us also to be greater than 90 on room air. And he can be discharged. And but I guess you just want to ensure that compensation counseling in terms of, um, continuing medication. And as you said, um, follow up within six weeks. Yeah. And that's it.
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For management. Yes, I would have to run up, up quickly. So, um, important to know that community-acquired pneumonia doesn't entail those bacterial pathogens. Okay, guest strep pneumonia will be hello. It doesn't only end. It doesn't only entertain, um, bacterial pathogens. It contains viral, fungal pathogens also, microbacterial pathogens. Bear that in mind. Okay. Of the bacteria pathogens, strep pneumonia is going to be number one worldwide. Okay. But as we vaccinate, probably stuff also take over as the number one bacterial pathogen. Other bacterial pathogens are you there from the gut? Because remember, for bacterial pneumonias, we tend to to aspirate, whether micro or macro. All right. So it's strep pneumonia, you know, the eclipse yellows from your goat, etcetera, etcetera. Bacteroides, yes, etcetera, etcetera. All right. For viral pathogens, as seen, what's happening with COVID? Coronavirus. All right. Cytosol V2. But the most important one for still will be influenza, as seasonal. All right. You have other pathogens like RSV that affect the immunocompromised host and the neonates. All right. So, low, um, the extremes of age. So they're very, very, very young. The premise. Okay. Remember, you have power influenza, adenovirus, human metapneumovirus, the list is done with a ver and varicella. Okay. Virus. So the list for viruses are very long. We can use molecular studies to diagnose them, PCRs. Okay. As you see with corona virus. Okay. Moving on to mycobacterial. TB, number one. Okay. You have other atypical bacteria that may mimic TB like Nocardia, that we see again in immunocompromised host. Okay. Moving on to fungal. What is popular here is PCP, Pneumocystis pneumoniae, in the HTAI patients. Gonna say that galore. All right. And it's gonna be the representing diagnosis of HIV is or one that's sending out taking their medications. Okay. He's the platinum that we're all exposed to. It's called chickens. I know we don't go into caves that much, right? To be exposed to to bat dung. Okay. To get histo. But histo can be a problem too, right? In terms of fungal pneumonias, Cryptococcus can cause pneumonia also. That's why it enters alone prior to going and disseminating into, um, other systems like the brain. Hello. Hearing me?
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Right now, basically, yeah, basically what I'm saying, community-acquired pneumonia is not just bacteria. All right. It incorporates everything in the community. All right. Healthcare, the healthcare-associated pneumonias tend to be bacterial. Okay. The synaptobacter, pseudomonas, auto-pseudomonas can become into acquired off, especially in the neutropenic patient. All right. And of course, viruses like coronavirus. Look what happens. Workers. All right. Viruses. Okay. No fungus really in the healthcare setting. All right. So it's mostly bacterial and viruses for healthcare-associated pneumonia. They should have had contact with the health care system, right? Um, up to three months prior to presentation. Okay. So we're still, um, as if until the regime, the pneumonias, you may be able to differentiate them on on imaging. Bacteria versus viral. Viral tends to cause a pneumonitis, so you see this reticular nuclear pattern versus bacterial where it tends to be lobar. All right. So that makes Chloe along with the procalcitonin that we mentioned that would be elevated in a bacterial pneumonia versus viral pneumonia. All right. Dispute. Very important. You can get to answer in in minutes by by smear for strep pneumonia. Melissa, who did investigations? Whether, um, gram-positive diplococci. Hello. Yes, I'm, I'm hearing the doctor person, right? Yeah. So you can confidently proceed and treat. And it's important that the sputum is appropriate for posing proteins that you'll have a lot of white cells and less than 25 square more epithelial per low power field. All right. That's the microbiologist will throw that away. All right. Um, I want you guys to prepare for for the other sessions. Okay. So, um, in a quick question, we'll have about two minutes before we sign on. None. All right. So just remember, just remember the other pathogens, okay? So not only bacterial, but fungal, viral, macrobacterial, and atypical. They typically include in your legionella, that to cancer in a healthcare setting or where you're exposed to, um, water misting, ACs, right? Chlamydia, that occurs primarily in the elderly. I guess you'll see that in the nursing home. Mycoplasma, that you'll see in a communal city like a university or school. All right.
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Yes, sir. Who is this?
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Huh? Very easily by examination. Very easily. I'll never forget X-ray for that. So for lobar pneumonias, right? You're gonna see, of course, technique. Okay. May use accessory muscles, decrease expansion on the affected side, increased vocal formative, vocal resonance, which is the same bronchial breath sounds, whispering pectoralis. So that's easy. Bronchopneumonia, basically harsh rest sounds. Okay. They may have, they may have signs of, um, consolidation that I just mentioned on. Okay. Ronkai, crackles. Crackles also occur with lobar pneumonia also. So fairly simple without even going to the X-rays. Remember, pneumonias can be also complicated by before we sign off, quickly, by by dissemination into other organs. Okay. So we're talking heart, we're talking brain, we're talking level. All right. So, so, so the patient maybe come back. This is bacterial pneumonia. Yeah, it can, it can disseminate as well as stay right in the territory causing lung abscesses. All right. And that's where cities will come in.
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That's it. Yeah. You guys have to prepare for your 130 class. So I won't, um, keep you. But, um, the crew from what firm three. Yes. Nothing. That's not sometimes, but taking the time out to present your people virtually. I know it's difficult to listen. Okay. You're not really dealing with real people. Config internet people or makeup stores, you know, but still, you know, I could follow it, right? So, um, so, so, so good, good presentation. You just need to be able to discuss your points, okay? So it's like the beating, not like the politicians. I'm very disappointed in them, actually. There's no convince for what they're doing for me yet, but, um, to debate a point, to say, yes, it is this because of X, Y, and Z. All right. And it's not that, although it can be, because they have points against it. All right. So you need to, you need to go through like that and discuss. Modern-day medicine, you don't want to say to the patient, you have pneumonia, and that's it. All right. Tell them why, exactly, and why not this. It's internet style. Another pulmonary embolism. All right. So you should be able to to discuss those points to one convenience. So, so brilliant to, uh, all right, signing on, folks. So next week, um, tell me what topics you want to discuss. Of course, I'll choose. I think I'm going to choose Thursday, not Friday, next week. So we'll be in touch. Crew, enjoy your evening. Enjoy your your weekend. Keep safe from COVID. If you haven't already gotten it. All right. You. Thank you, guys. Thank you. You're welcome. You're welcome. You.