Diagnosis And Management Of Pneumonia In A 67-year-old Female With Cardiovascular Issues, Essay.

Types of Pneumonia

According to the given case scenario Ms. Jones is a 67-year-old female and currently experiencing cardiovascular issues such as elevated heart rate and excessive coughing. She has history of hypertension, COPD, hyperlipidemia and vitamin D deficiency. Considering current symptoms of Ms. Jones, she has been recommended for a diagnosis of pneumonia.  

X-ray study is considered a conventional laboratory method for diagnosing pneumonia. In this very specific aspect, radiologists usually look for white spots in the lungs, also known as infiltrates (Wootton & Feldman, 2014). Acording to current evidence, a pulmonary infiltrate is considered a substance denser than air for example, protein, pus or blood which significantly lingets within lungs’ parenchyma Kelly et al., (2016).  Pulmonary infiltrates are commonly associated with some transmissible diseases like tuberculosis and pneumonia. This radiological laboratory findings also help in determining pneumonia associated complications.

According to current evidences, pneumonia can be of two different types including community acquired pneumonia (CAP) and hospital acquired pneumonia (HAP)
(Tschernig, 2016). In this specific aspect CAP is usually defined as an acute infection of the pulmonary parenchyma in an individual who has specifically acquired the infection in the community, as differentiated from hospital-acquired (nosocomial) pneumonia (HAP). On the other hand, HAP is defined pneumonia that specifically takes place a minimum of 48 hours or more following hospital admission and not present at admission time (Tschernig, 2016). In case of Ms Jones, there is no evidence, that she has acquired the infection following her hospital admission.  Apart from that, considering the severity of the condition and the clinical signs and symptoms, Ms. Jones is currently experiencing, it can be stated that, she has been acquired the infection from her community setting.  

According to current evidence, it can be stated that both patients of CAP and HAP did not vary greatly in aspects of chronic comorbidities and age with exception of CAP (Tschernig, 2016). However, COPD is comparatively more common in patients with CAP.  According to relevant score assessment, it has been elicited that severity of both CAP and HAP is almost same.  In term of expression of plasma biomarkers, both CAP and HAP display activation of coagulation and systematic inflammation (Tschernig, 2016).  Apart from that, patients of both HAP and CAP elicited alterations that specifically indicated disturbance of vascular integration.  Differences, in this specific aspect can be defined as comparatively lower levels of MMP-8 and soluble E selection in HAP in comparison with CAP (Tschernig, 2016).  However, expression of protein C is found comparatively higher in case of HAP than CAP (Tschernig, 2016).  

Some evidence-based assessment tools are commonly utilized in order to determine the severity of infection (e.g., pneumonia) (Noguchi et al., 2017).  According to current report and status, CURB-65 and PORT scores are commonly recommended assessment tools for determining severity of pneumonia infection regarding care site, general management of infection and selection of antibiotics in patients with CAP in different countries (Nguyen et al., 2020).  The CURB-65 score that determines the occurrence of confusion, blood urea level more than 42.8 mg/dl, respiratory rate more than 30 per minute, blood pressure lower than 90/60 and age more than 65 years, is considered a common practical method for indicating the requirement for hospitalization in community-acquired pneumonia (Nguyen et al., 2020).  Considering the CURB-65 score, hospital admission of a patient is determined and pharmacological interventions are commenced (Ilg et al., 2019).

Radiological laboratory findings

In case of Ms. Jones, the CURB-65 score is to be assessed as she is currently experiencing clinical signs and symptoms of community-acquired pneumonia (CAP).  The level of blood urea nitrogen in case of the said patient is 17 mg/dL, which is comparatively lower than CURB-65 criteria and indicator for hospitalization.  Respiratory rate of the patient is also lower than 30 (e.g., 22 per minute). Blood pressure of the patient is 126/78 (higher than CURB-65 defined range for determining hospitalization for the patient).  Age of the patient is more than 65.  Therefore, only one criterion matches with CURB-65 risk assessment tool for pneumonia. As excluding age, all other determinants is below the range of the said risk assessment score, hospitalization is not required for the patient considering current vital signs and laboratory outputs. Anti-viral therapy can be commenced in residential setting in order to ensure gradual physiological development and wellbeing of the individual (Almeida et al., 2016) 

As pharmacological interventions for left-lower lobe pneumonia, Ms. Jones needs to follow bed rest and perform less daily life activities as it may result in breathing shortness and associated complications. Secondly, she is to drink plenty of fluids in order to maintain hydration status and loosening secretions. Then, antibiotic therapy is to be commenced to prevent further bacterial growth. In this specific aspect, as Ms. Jones is known to have allergic response to penicillin and penicillin group of drugs, then fluoroquinolone antibiotics for example, Levaquin would be an appropriate choice (Grief & Loza, 2018).

Airway restriction is a very common indicator of COPD. However, CAP increases further risk of airway restriction over COPD (Kainu et al., 2016). Gold standard is there to measure airflow restriction and/or airflow limitation in patients with COPD. According to current evidence, spirometry is considered the cornerstone of diagnosis of COPD and as per the guidelines of GOLD, persistent airflow restriction is defined as a post-bronchodilator proportion of FEV1 to Forced Vital Capacity (FEV1/FVC) of lower than 0.7⁴ (Kainu et al., 2016).

As per the given case study, Ms. Jones has mentioned intermittent pain in her bilateral legs specifically in time of walking and due to this reason, she needs to rest to stop the leg cramps/pain. Intermittent claudication would be the best choice for a potential diagnosis for this specific condition.

Intermittent claudication is also known as vascular claudication is a clinical sign and symptom that specifically explains muscle pain on mild exertion including cramp, ache, sense of fatigue or numbness, classically in muscle of calf, which specifically takes place in time of exercise, such as walking and is stopped by a short-period of rest (Patel & Surowiec, 2021). The diagnosis of the condition is specifically based on classic history of muscle cramping and pain that specifically takes place after the same extent of walking or exercise and quickly relieved after rest (Patel & Surowiec, 2021). As Ms. Jones has claimed about experiencing this complication, this specific choice of diagnosis needs to be prioritized and rest three are to be excluded from list.  

Severity of Pneumonia

According to current evidence, the most essential screening test and/or assessment for PAD/intermittent claudication is known as the ankle-brachial index (ABI). This test specifically utilizes ultrasound imaging in order to assess and compare arterial blood pressures at arm and ankle (Casey et al., 2019).

According to current evidence, differentials and/or differential diagnosis in medicine and/or health science is known as a list of possible diseases or conditions that could be causing clinical signs and symptoms of a patient. According to the given case study of Ms. Jones, she is currently experiencing intermittent pain/cramping specifically in her bilateral lower extremities in time of walking. She also has pain to left side of her back and pain in time of aspiration. In term of respiratory complications and/or respiratory distress, she has been coughing a lot lately, and complaints about some thick-brown-tinged sputum. Though she is feeling tired recently but not experiencing breathing shortness or associated complications.  Considering the symptoms of the patient, differentials are exacerbation of chronic obstructive pulmonary disease (COPD), Pulmonary embolism (e.g., common clinical signs and symptoms like irregular heart-beat, pain and muscle cramping specifically in calf of patients by a deep-vein thrombosis) and bronchiectasis (Lim, 2020).

Considering the diagnosis of the condition called pneumonia, patient education is to be given to both Ms. Jones and her daughter.  In case of treatment of transmissible diseases in residential setting, some special and additional precautions are to be followed in order to mitigate risk of further transmission and further deterioration in patient’s physiological health.  For example, the daughter of Ms. Jones, is to be advised to ensure proper wash of hands with soap and water and utilization of hand sanitizer after taking care of her mother. She and/or care-giver of Ms. Jones should be very careful specifically in time of sneezing and coughing and to prevent transmission of droplets, tissue is to be used or, in time of coughing and sneezing, nose and mouth are to be covered with sleeve or elbow (Grief & Loza, 2018). Apart from that, she also needs to ensure drinking of plenty of fluids as it significantly help in loosening secretions and bringing up phlegm. The daughter of Ms. Jones needs also to ensure sufficient ventilation and calm environment in room (e.g., free of noise that increases anxiety of patients that has negative influence on respiratory and cardiovascular health) (Grief & Loza, 2018). Lastly, she also needs to maintain appropriate hygiene (e.g., room free of dust, stimulants, use of soap, hand-sanitizer and hand towel). In time of providing care, care giver must wear mask and hand-gloves and the used products needs to be discarded in a safe place that will not result in further transmission and/or spread of infection in community (Grief & Loza, 2018).  

Considering the diagnosis of pneumonia of Ms. Jones, it has been asked whether a combined drug/ antibiotic therapy (e.g., amoxicillin/clavulanate and macrolide) would be effective for her or not. According to current evidence, amoxicillin and clavulanate potassium is considered a combination prescription antibiotic for pneumonia and some similar bacterial infection. Amoxicillin is a very common example of a penicillin antibiotic that effectively fights against bacteria like streptococcus pneumoniae (File et al., 2014). Some strains of the said bacteria are found to be resistant against amoxicillin. In order to ensure successful elimination of bacteria from host system, hence, clavulanate potassium is recommended to the patient as it helps in preventing bacterial strains which are amoxicillin resistant (File et al., 2014). Though this combination prescription acts efficiently in pneumonia patients, as Ms. Jones is allergic to penicillin and penicillin group of drugs, this recommendation would not be effective in case of her and may bring hypersensitive reaction that will further deteriorate health condition of the patient. Due to this specific reason, more precise planning for pharmacological intervention is to be drawn. 

Reference

Almeida, A., Almeida, A. R., Castelo Branco, S., Vesza, Z., & Pereira, R. (2016). CURB-65 and other markers of illness severity in community-acquired pneumonia among HIV-positive patients. International journal of STD & AIDS, 27(11), 998–1004. https://doi.org/10.1177

Casey, S., Lanting, S., Oldmeadow, C., & Chuter, V. (2019). The reliability of the ankle brachial index: a systematic review. Journal of foot and ankle research, 12, 39. https://doi.org/10.1186/s13047-019-0350-1

File, T. M., Jr, Lode, H., Kurz, H., Kozak, R., Xie, H., Berkowitz, E., & 600 Study Group (2014). Double-blind, randomized study of the efficacy and safety of oral pharmacokinetically enhanced amoxicillin-clavulanate (2,000/125 milligrams) versus those of amoxicillin-clavulanate (875/125 milligrams), both given twice daily for 7 days, in treatment of bacterial community-acquired pneumonia in adults. Antimicrobial agents and chemotherapy, 48(9), 3323–3331. https://doi.org/10.1128/AAC.48.9.3323-3331.2004

Grief, S. N., & Loza, J. K. (2018). Guidelines for the Evaluation and Treatment of Pneumonia. Primary care, 45(3), 485–503. https://doi.org/10.1016/j.pop.2018.04.001

Ilg, A., Moskowitz, A., Konanki, V., Patel, P. V., Chase, M., Grossestreuer, A. V., & Donnino, M. W. (2019). Performance of the CURB-65 Score in Predicting Critical Care Interventions in Patients Admitted With Community-Acquired Pneumonia. Annals of emergency medicine, 74(1), 60–68. https://doi.org/10.1016/j.annemergmed.2018.06.017 

Kainu, A., Timonen, K., Lindqvist, A., & Piirilä, P. (2016). GOLD criteria overestimate airflow limitation in one-third of cases in the general Finnish population. ERJ open research, 2(4), 00084-2015. https://doi.org/10.1183/23120541.00084-2015

Kelly, M. S., Crotty, E. J., Rattan, M. S., Wirth, K. E., Steenhoff, A. P., Cunningham, C. K., Arscott-Mills, T., Boiditswe, S., Chimfwembe, D., David, T., Finalle, R., Feemster, K. A., & Shah, S. S. (2016). Chest Radiographic Findings and Outcomes of Pneumonia Among Children in Botswana. The Pediatric infectious disease journal, 35(3), 257–262. https://doi.org/10.1097/INF.0000000000000990

Lim W. S. (2020). Pneumonia—Overview. Reference Module in Biomedical Sciences, B978-0-12-801238-3.11636-8. https://doi.org/10.1016/B978-0-12-801238-3.11636-8

Nguyen, Y., Corre, F., Honsel, V., Curac, S., Zarrouk, V., Fantin, B., & Galy, A. (2020). Applicability of the CURB-65 pneumonia severity score for outpatient treatment of COVID-19. The Journal of infection, 81(3), e96–e98. https://doi.org/10.1016/j.jinf.2020.05.049

Noguchi, S., Yatera, K., Kawanami, T., Fujino, Y., Moro, H., Aoki, N., Komiya, K., Kadota, J. I., Shime, N., Tsukada, H., Kohno, S., & Mukae, H. (2017). Pneumonia Severity Assessment Tools for Predicting Mortality in Patients with Healthcare-Associated Pneumonia: A Systematic Review and Meta-Analysis. Respiration; international review of thoracic diseases, 93(6), 441–450. https://doi.org/10.1159/000470915

Patel, S. K., & Surowiec, S. M. (2021). Intermittent Claudication. In StatPearls. StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28613529/

Tschernig T. (2016). Hospital-acquired pneumonia and community-acquired pneumonia: two guys?. Annals of translational medicine, 4(Suppl 1), S22. https://doi.org/10.21037/atm.2016.10.10

Wootton, D., & Feldman, C. (2014). The diagnosis of pneumonia requires a chest radiograph (x-ray)-yes, no or sometimes?. Pneumonia (Nathan Qld.), 5(Suppl 1), 1–7. https://doi.org/10.15172/pneu.2014.5/464