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UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER

Medicine II Preceptorial
Dr. Ramos

2017A
Group A8: De Asis, De Guzman, D., De Guzman F., De Leon, De Ramos, De Vega, Del Prado, Dela
Cruz, A , Dela Cruz J., Dela Cruz, K., Dela Cruz, M., Dela Cruz P.
Date of admission: November 4, 2015
Date of Interview: November 6, 2015

Identifying Data:
CN is a 64 year old male, Filipino, Roman Catholic, married, born on February 26, 1951, from
Pangasinan but currently resides in Bacood, Sta. Mesa. Patient is a known hypertensive, already
bedridden with left-sided hemiparesis. This is his 5th hospitalization in this institution.
CN is a 64 year old male, Filipino, Roman Catholic, married, born on February 26, 1951, from
Pangasinan but currently resides in Bacood, Sta. Mesa. Patient is already bedridden with left-sided
hemiparesis.He is a known hypertensive, post-stroke (2012), post stroke seizure (2012), s/p
craniectomy (2012), s/p tracheostomy (2012). This is his 5th hospitalization in our institution.
Source and Reliability:
Patients wife and son, good reliability
Chief Complaint:
Intermittent high-grade fever of 2weeks duration
History of Present Illness:
Patient is a 64 year old male, known hypertensive, post-stroke (2012), post-stroke seizure
(2012), s/p craniectomy (2012), s/p tracheostomy (2012) admitted for the 5th time in our
institution. *ask for prior weight, rishs nya for hypertension.
2 weeks PTA, patient was noted to be feverish accompanied by cough and colds, with
phlegm described as clear to white in color. Fever, which lasted for a day, was intermittent and only
falls on 37.7 C. He was given Paracetamol (500mg) and tepid sponge baths which afforded him
some relief. Patient was also noted to be irritable. The cough and colds persisted with no
consultation done until
1 week PTA, patient had one seizure episode, which lasted for 45 minutes and was described
as involuntary movement of all extremities but was more prominent on the right side extremities
with midline blank stare. Cough and colds still persisted with no changes in character of phlegm
noted. No other associated signs and symptoms noted. No consult was done until..
4 days PTA, cough and colds still persisted with no changes in character of the phlegm.
Patient was feverish, noted as 37.3C. Fever was relieved by tepid sponge bath and lasted for less
than a day. No other associated signs and symptoms noted. No medications were given. No
consultation was done. Cough and colds persisted until..
7 hours PTA, cough and colds still persisted with no changes in character of the phlegm.
Patient experienced intermittent fever, 4 to 5 hours apart with the highest temperature recorded as

39oC. Patient was again given Paracetamol (500mg) and tepid sponge baths but did not provide
relief. This prompted consult and subsequent admission in UERMMMCI Hospital.
Pertinent positives: cough, colds, seizures, intermittent fever
Pertinent negatives: muscle/joint pain, hemoptysis, night sweats, chills
Past Medical History:
Patient had measles, mumps and varicella during childhood.
Stroke:

2000 - 1st stroke due to hypertension (BP:200/110 mmHg)

2012 (January) - 2nd stroke, accompanied by seizures

2015 (May) - 3rd stroke


Pneumonia:

2011 (July)

2012 (July)

2012 (March)

2015 (May)
Seizures:

2012- 1st seizure described as: tumitirik yung mata niya sa taas tapos yung right side ng
katawan niya gumagalaw, tapos biglang lahat na

2015 (November)- 5 seizure episodes last week, lasting 45 seconds per episode, relieved by
massage
Surgeries:

2012- Craniectomy for seizure

2012- Tracheostomy. Patient had mechanical ventilator via endotracheal tube for 2 weeks
then converted to tracheosptomy as per doctors advise then weaned off from ventilator
No PTB exposure. No accidents, and the patients allergies were undocumented.
Family History:
Mother passed away at age 51 due to HPN.
Father passed away at age 76 due to lung disease.
Patient has 8 siblings, all with HPN (4 living, 4 passed
away due to HPN).
No family history of DM and Cancer.

Social History:
Patient is married and had 5 children. One of his child died due to measles with heart complications
at age 3. He is a high school graduate and used to work as a supervisor at a laundry to-go until
2012. He currently lives in his own house located in Bacood, Sta. Mesa together with his wife, his
two youngest children and his 3 grandchildren. Surrounding area was described as not congested
and with access to potable water, electricity and with regular garbage collection.
Patient NS is already bedridden with hobbies such as watching television and listening to music. He
has a good appetite. His regular diet includes mostly vegetables and bread. Nevertheless, patient
has no food preference as long as the food is cut into small pieces. He sleeps from 1AM to 10AM
with no interruption. His son assists him daily for his regular passive exercise. He has 61 pack year

smoking history. After craniotomy in year 2012, patient stopped smoking. He is an alcoholic drinker
who drinks every 2 weeks and can finish 1 beer per sitting. He drinks 2 cups of coffee in a day. His
current medications include Centrum Silver (OD), Losartan (50mg, OD), Phenobarbital (90mg, OD),
Aspirin (100mg, OD). Financial assistance for patients hospital care and other expenses is provided
by his children
Review of Systems
GENERAL

(+) Weakness

SKIN

Unremarkable
No changes in color, texture, and in hair and nails noted. No itchiness or
rashes.

EYES

Unremarkable
No redness, tearing, pain, double vision, discharge and trauma. (+) cataract
on both eyes

EARS

Unremarkable

NOSE, THROAT,
MOUTH

(-) Pain, (-) tinnitus No discharges.


No trauma, nose bleeding; changes in olfaction not assessed
With dental carries, facial pain, sinus disorder, gum bleeding

RESPIRATORY

No wheezing,
(+) PTB exposure

CARDIOVASCULAR

Unremarkable
No palpitations, syncope, chest pain and orthopnea.

GASTROINTESTINA
L

(+) Decreased appetite (3 meals/day 1 meal/day); occasional constipation

URINARY

Unremarkable
No retention, hematuria, nocturia, polyuria, stones, infection, urgency,
dribbling, change in color

GENITOREPRODUC
TIVE

Not assessed

HEMATOPOIETIC

Unremarkable
No excessive bleeding or bruising, pallor or pica.

NERVOUS SYSTEM

(+) Seizure; last seizure episode was Nvember 3, 2015

PSYCHIATRIC

Not assessed

MUSCULOSKELETA
L

(+) Muscle weakness

ENDOCRINE
SYSTEM

Unremarkable

TEMPORAL PROFILE:

PHYSICAL EXAM:
General Survery:
Patient is awake, alert, uncooperative. He is bedridden, non ambulatory, thin and looks
chronically ill. He was well-groomed. He has a moderate in height and build.
GCS; E4, V2(trachestomy), M4
Vital Signs:
BP: 110/70mmHg (interview); 140/67mmHg (chart data)
RR: 20
PR: 86
Temp: 36.7C
Skin:
Skin is tan and warm to touch, with no pallor, no cyanosis, no jaundice and good skin turgor. CRT <
2secs. Clubbing of the nails which is more prominent on Left fingernails
HEENT:
Head: Depression on Right Fronto-temporal Area due to Craniectomy.
Eyes: Lids are symmetrical, (-) ptosis, (-) periorbital edema, (+) pale conjunctiva, anicteric sclera,
(+) cataract on both eyes. Opthalmoscopy not done, cant follow instructions and irritable
Ears: Normoset ears, color same as facial skin, mobile, pinna recoils when folded; (-)masses,
(-)gross deformities, (-) discharge
Nose: Symmetrical nasolabial fold, septum in midline, (-) discharge, both nares patent
Mouth: Pale lips, (-) cracks and lesions, pinkish mucosa, moist (-) lesions, tongue and uvula in
midline, pinkish gums, (+)missing dentition, (+) cavities, Gag reflex not assessed.
Throat: Pale and dry lips, (-) lesions, pinkish gums, with missing dentition
Neck: Trachea is in midline with tracheostomy tube intact and patent. No cervical
lymphadenopathies. (-) tenderness, thyroid non-palpable, (-) enlargement, (-) Neck vein
engorgement, (-) masses, symmetric carotid pulse with no bruit.
Chest and Lungs:
Chest is symmetric, equal chest expansion, tactile fremitus not assessed, (+) crackles on Right
Middle Lung, decreased breath sounds on Right Lower Lung, clear breath sounds on rest
of lung fields, no wheezing. No lesions, no deformities.

Cardiovascular:
Adynamic precordium, no heaves, distinct S1 and S2, no murmurs, no thrills. 4cm jugular vein
pressure with bed at 30 degrees. Normal heart rate regular rhythm; PMI at 5th ICS LMCL.
Presence of edema of both lower extremities (Grade 1; bipedal edema; non pitting)
Abdomen:
Flat with normoactive bowel sounds, no masses, no bruits, no abdominal tenderness, no distention
Musculoskeletal:
Very limited ROM; Hemiparetic Left Upper and lower extremity; weak right upper and
lower extremities, (+) muscle wasting on all extremities and temporalis. No swelling, no
tenderness

Extremities:
Full equal pulses, CRT <2 seconds, no cyanosis, (+) Grade 1 non-pitting bipedal edema, patient
flexes right arm and both lower extremities.
Neurologic Exam:
MSE: Patient is awake, unable to follow directions. Orientation to time and place not assessed.
CEREBELLAR EXAM
Coordination: was not assessed since patient can no longer follow instructions.
Gait and balance were not assessed due to patients inability to stand.
CRANIAL NERVES
I

Patient unable to respond not elicited

II

Pupils are directly and consensually reactive to light, accommodation not tested because
patient doesnt follow instructions. All visual fields are intact. Visual acuity not tested
patient cant speak what he reads; with cataract on both eyes

III, IV,
VI

EOMs intact as observed with spontaneous eye movements but doesnt follow insruction;
no nystagmus; primary gaze is midline.

Patient unable to verbalize perception of light sensation and pin prick on forehead,
cheek, and jaw; equal contraction of masseter, temporalis, pterygoid, and lateral
pterygoid observed while eating. Test needing instructions not done.

VII

Patient unable to respond. Observed as able to close eyes, suck from bottle, frown, raise
eyebrows.No facial asymmetry or involuntary facial movements; can raise eyebrows,
close both eyes and open them against resistance; can smile, frown, puff cheeks out
symmetrically.

VIII

Able to react to wifes voice, but not to interviewers gross hearing on both sides intact.

IX,X,
XI

Patient unable to respond. Observed tongue at midline with no atrophy, able to swallow
solid food, gag reflex not checked, moves only the Right shoulder with poor muscle bulk.

and
XII

tongue midline on rest; can move tongue when chewing; no atrophy or fasciculations.

STRENGTH
Upper Extremities

RIGHT

LEFT

Lower Extremities

RIGHT

LEFT

Proximal

3/5

0/5

Proximal

3/5

2/5

Distal

3/5

0/5

Distal

3/5

2/5

REFLEXES
RIGHT

LEFT

Biceps

Patient rigidly Flexes his arm

Triceps

Patient rigidly Flexes his arm

Brachioradialis

Patient rigidly Flexes his arm

1+

Knee

Patient rigidly Flexes his leg

Patient rigidly Flexes his leg

Ankle

1+

1+

Babinski

SENSORY EXAMINATIONS
Right

Left

unable to assess, patient


doesnt communicate

unable to assess, patient doesnt


communicate

Light
touch

Arms

Pain/Prick

Arms

withraws extremity with pain

doesnt move

Leg

withraws extremity with pain

withraws extremity with pain

Arms

unable to assess, patient


doesnt communicate

unable to assess, patient doesnt


communicate

unable to assess, patient


doesnt communicate

unable to assess, patient doesnt


communicate

Hot/Cold

Leg

Leg
Proprioce
ption

Arms
Leg

PROBLEM LIST:
1. Productive cough, colds, fever, food aspiration
2. Hypertension, stroke and seizures

PROBLEM 1: Productive cough, colds, fever, food aspiration


SUBJECTIVE
OBJECTIVE
Patient is a 64 year-old male presented with
- Crackles on right middle lung
productive cough (with clear to white secretions)
- Decreased breath sounds on the right
and colds two weeks PTA, emergence of fever on
lower lung
the day of admission, history of food aspiration
Recurrent history of Pneumonia:

2011 (July)

2012 (July)

2012 (March)

2015 (May)

ASSESSMENT:
Patient presented with productive cough with clear, whitish secretions and subsequently developed
fever. He also had decreased breath sounds on the right lower lung on physical examination. He has
bout of recurrent pneumonias for the past 4 years.
Community-Acquired Pneumonia will be the first impression. This was considered due to the
immunocompromised state of the patient, given that he is already bedridden, with numerous
comorbidities. In the elderly, factors such as decreased cough and gag reflexes as well as reduced
antibody and Toll-like receptors increase the likelihood of pneumonia. Moreover, pneumoococcal
infections occur with increased frequency in patients with underlying chronic diseases such as
COPD, CHF or diabetes.
Pneumonia results from the proliferation of microbial pathogens at the alveolar level and the hosts
response to those pathogens. Once the pathogens lodge in the alveoli, resident alveolar
macrophages are extremely efficient at clearing and killing pathogens. Only when the the capacity
of the alveolar macrophages to ingest or kill the microorganisms is exceeded does clinical
pneumonia manifest. In that situation, the alveolar macrophages initiate the inflammatory response
to bolster lower respiratory tract defenses. Fever ensues, and neutrophils migrate to the lungs,
producing both peripheral leukocytosis and increased purulent secretion. Inflammatory mediators
released by macrophages create an alveolar leak equivalent resulting to radiographic infiltrate and
rales detectable on auscultation. Hypoxemia results from alveolar filling. Increased respiratory drive
in the systemic inflammatory response syndrome leads to respiratory alkalosis. Decreased
compliance due to capillary leak, hypoxemia, increased respiratory drive, increased secretions and
infection-related bronchospasm can all lead to dyspnea. Considering the pathophysiology of
pneumonia, patients present with fever, cough and colds. A strong suspicion can be raised due to
the current condition of the patient.
Patient previously had 3 stroke attacks, the most recent of which happened on May 2015. Up to
one-third of stroke patients suffer from pneumonia, causing the highest attributable mortality of all
medical complications following stroke. Most available data suggests post-stroke pneumonia
attributed to aspiration. Pneumonia accounts for an estimated one-third of nosocomial infections in
critical care units as per the national nosocomial infection surveillance system. Ill hospitalized
patients routinely aspirate and patients with an impaired swallowing mechanism due to
neurological injury are at especially high risk, which is the case in our patient.

In 2012, he underwent tracheostomy from being hooked to mechanical ventilator via endotracheal
tube for 2 weeks as per doctors advise then he was weaned off from ventilator. The application of
ventilator support carries its own independent risk of pneumonia. Respiratory failure due to stroke
leads to intubation in up to 6% of patients suffering from ischemic stroke and 30% with a
hemorrhagic stroke. Pneumonia in stroke is often from aspiration which usually affects the
dependent portions of the lungs. The superior segments of the lower lobes are actually also
posterior, such that aspirated material or secretions would drain there first in the supine patient.
This often occurs on the right side more than the left as the right main stem bronchus is more
directly aligned with the trachea. However, patients are routinely rotated and repositioned such
that any location is possible. Patient had crackles on Right Middle Lung, decreased Breath sounds
on Right Lower Lung, clear breath sounds on rest of lung fields. Other Symptoms of impaired
swallow mechanism include cough, fever, and breathlessness.
Working Diagnosis: Aspiration Pneumonia
PROBLEM 2: HYPERTENSION, STROKE and SEIZURES
SUBJECTIVE
OBJECTIVE
Average BP of 160/100, highest BP of 200/110,
- BP on admission: 140/67mmHg.
history of stroke in years 2000, 2012 and 2015.
- On PE, cannot follow instructions,
irritable, not oriented to time and place
CN has strong family history of hypertension as
his mother and all 8 of his siblings have the
- Left-sided hemiparesis
condition.
He is maintained on Losartan 50mg
Stroke History:

2000- 1st stroke due to hypertension


(BP:200/110 mmHg)

2012 (January)- 2nd stroke, accompanied


by seizures

2015 (May)- 3rd stroke


Seizure: Started in 2012 until the present. Most
recent attacks occurred 5 times in a week,
lasting 45 seconds per episode.
s/p craniectomy

ASSESSMENT:
Patient is a known hypertensive maintained on Losartan 50mg, with recurrent history of stroke for
the past 5 years. On admission, his BP was found to be 140/67mmHg.
The pathogenesis of essential hypertension is multifactorial and highly complex. Factors include
humoral mediators, blood vessel elasticity, circulating blood volume, vascular caliber, blood
viscosity, vardiac output and neural stimulation. Other predisposing factors include genetic
predispositiion, excess dietary salt intake, and adrenergic tone. Besides increasing the risk of stroke
and atherosclerotic coronary heart disease, hypertension can lead to cardiac hypertrophy and heart

failure, aortic dissection, and renal failure. Age and other illnesses, such as diabetes also contribute
to the development of hypertension. However, most cases are found to be idiopathic in nature.
(essential hypertension).
Patient was noted to have chronic hypertension which puts him at risk to cerebrovascular accidents.
One of which is stroke. Among all the neurologic diseases of adult life, stroke ranks first in
frequency and importance. The common mode of expression of stroke is a relatively sudden
occurrence of a focal neurologic deficit. Strokes are broadly categorized as ischemic or
hemorrhagic. Ischemic stroke is due to occlusion of a cerebral blood vessel and causes cerebral
infarction. One of three main processes is usually operative: atherosclerosis with superimposed
thrombosis affecting large cerebral or extracerebral blood vessels, cerebral embolism, and
occlusion of small cerebral vessels within the parenchyma of the brain. Hypertension is also the
most readily recognized factor in the genesis of primary intracerebral hemorrhage. Hemorrhage
occurs either within the substance of the brain, intracerebral hemorrhage, or contained within the
subarachnoid spaces and ventricular system, subarachnoid hemorrhage.
Hemiplegia stands as the most typical sign of cerebrovascular diseases, whether in the cerebral
hemisphere or brainstem, but there are many other manifestations, occurring in recognizable
combinations. These include paralysis, numbness, and sensory deficits of many types on one side
of the body, aphasia, visual field defects, diplopia, dizziness, dysarthria, and so forth. In our patient,
following bouts of strokes in the past 5 years, he has grown bedridden and now has left sided
hemiparesis.
Another complication of possible intracranial hemorrhage is the development of seizures. A first
solitary or brief outburst of seizures may occur during the course of many medical illnesses. It
indicates that the cerebral cortex has been affected by disease, either primarily or secondarily.
Recurrent attack of seizures with most of the attacks being similar in type, can be due to an
inactive lesion that remains as a scar in the cerebral cortex. This is highly probable that the initial
cause of the patients seizure was due to a hemorrhage due to chronic hypertension, which is an
irritative lesion in the cortex that can produce seizure. He then underwent craniotomy which left a
probable inactive lesion that could trigger subsequent seizures. Patient presented with generalized
seizures tonic-clonic type. This type of seizure is the common primary type of seizure, that starts
with little or no warning.
Impression: CAP / Aspiration pneumonia
Comorbids: CVA / HTN / Seizures
Differentials:
1. Pulmonary Embolism

Rule in due to presence of atypical symptoms: Fever, Productive cough, Shortness of breath,
also presents with seizures, history of stroke and paralysis, history of smoking, Tachypnea
(RR >16/min)
Rule out: Non-display of classic presentation of this problem, abrupt onset of pleuritic chest
pain, hypoxia, and shortness of breath, various atypical symptoms (i.e. abdominal pain,
syncope, wheezing, decreasing levels of consciousness, delirium), physical signs which are
highly seen in these cases such as: Rales (58%), Accentuated heart sound (53%),
Tachycardia, S3 or S4 gallop.
o In our patient, cough and colds started 2 weeks PTA progressing to fever 1 day PTA
without signs of chest pain and hypoxia (classic signs of Pulmonary embolism)

o Patient have unremarkable heart sounds and CV PE.


Patients with pulmonary embolism may present with atypical symptoms. In such cases,
strong suspicion of pulmonary embolism based on the presence of risk factors can lead to
consideration of pulmonary embolism in the differential diagnosis. These symptoms include
the following:
Seizures
Syncope
Abdominal pain
Fever
Productive cough
Wheezing
Decreasing level of consciousness
New onset of atrial fibrillation
Flank pain
Delirium (in elderly patients)
o In our case, seizure, fever, and cough are risk factors to consider Pulmonary
embolism.
Etiology:
o incidence of venous thromboembolic events in the older population is greater among
men than women.
o Pulmonary embolism is increasingly prevalent among elderly patients, yet the
diagnosis is missed more often in these patients than in younger ones because
respiratory symptoms often are dismissed as being chronic
o Multifactorial in origin:
Venous stasis
Hypercoagulable states
Immobilization
Surgery and trauma
Pregnancy
Oral contraceptives and estrogen replacement
Malignancy
Hereditary factors
Acute medical illness

2. Aspiration Pneumonia
Patient previously had 3 stroke attacks, the most recent of which happened on May 2015. Up to
one-third of stroke patients suffer from pneumonia, causing the highest attributable mortality of all
medical complications following stroke. Most available data suggests post-stroke pneumonia
attributed to aspiration. Pneumonia accounts for an estimated one-third of nosocomial infections in
critical care units as per the national nosocomial infection surveillance system. Ill hospitalized
patients routinely aspirate and patients with an impaired swallowing mechanism due to
neurological injury are at especially high risk, which is the case in our patient. In 2012, she
underwent tracheostomy from being hooked to mechanical ventilator via endotracheal tube for 2
weeks as per doctors advice then she was weaned off from ventilator. The application of ventilator
support carries its own independent risk of pneumonia. Respiratory failure due to stroke leads to
intubation in up to 6% of patients suffering from ischemic stroke and 30% with a hemorrhagic
stroke. Pneumonia in stroke is often from aspiration which usually affects the dependent portions of
the lungs. The superior segments of the lower lobes are actually also posterior, such that aspirated
material or secretions would drain there first in the supine patient. This often occurs on the right
side more than the left as the right main stem bronchus is more directly aligned with the trachea.
However, patients are routinely rotated and repositioned such that any location is possible. Patient
had crackles on Right Middle Lung, decreased Breath sounds on Right Lower Lung, clear breath

sounds on rest of lung fields. Other Symptoms of impaired swallow mechanism include cough,
fever, and breathlessness.

PLAN:
Diagnostics
1) The following laboratory tests may not be useful for diagnostic purposes but are useful for
classifying illness severity and site-of-care/admission decisions:

Serum chemistry panel (sodium, potassium, bicarbonate, blood urea nitrogen [BUN],
creatinine, glucose)

Arterial blood gas (ABG) determination (serum pH, arterial oxygen saturation, arterial
partial pressure of oxygen and carbon dioxide) Hypoxia and respiratory acidosis may be
present.

Venous blood gas determination (central venous oxygen saturation)

Complete blood cell (CBC) count with differential

Serum free cortisol value

Serum lactate level

2) CBC

Leukocytosis with a left shift may be observed in any bacterial infection. However, its
absence, particularly in patients who are elderly, should not cause the clinician to discount
the possibility of a bacterial infection.

Leukopenia (usually defined as a WBC count < 5000 cells/L) may be an ominous clinical
sign of impending sepsis.

3) Coagulation studies

An elevated international normalized ratio (INR) has been associated with more severe
illness. This finding may herald the development of disseminated intravascular coagulation.

*INR can go down w/ drugs, liver failure too

4) Blood cultures

Blood cultures should be obtained before the administration of antibiotics. These cultures
require 24 hours (minimum) to incubate. When blood cultures are positive, they correlate
well with the microbiologic agent causing the pneumonia.

Unfortunately, blood cultures show poor sensitivity in pneumonia; findings are positive in
approximately 40% of cases. Even in pneumococcal pneumonia, the results are often
negative. Their yield may be higher in patients with more severe pneumonia/infection.

5) Sputum evaluation

Sputum Gram stain and culture should be performed before initiating antibiotic therapy (if a
good-quality, contaminant-sparse specimen containing < 10 squamous epithelial cells per
low-power field can be obtained*if >10 laway lang). The white blood cell (WBC) count should
be more than 25 per low-power field in non-immunosuppressed patients.

6) Chest radiography

The presence of an infiltrate is required for the diagnosis.

7) Brain MRI/ head CT scan

May show structural abnormalities that could be the cause of a seizure.

8) EEG
9) Chest CT> *check for tumor causing recurrent pneumonia
Treatment Plan

Admit patient. Monitor vital signs. Do suctioning of tracheostomy tube when patient is
having difficulty breathing.
Pneumonia:
Initiate treatment of the following:
o IV non-antipseudomonal -lactam (BLIC, cephalosporin or carbapenem) PiperacillinTazobactam 4.5 IV q8 or Ceftriaxone 1-3 g IV q12-24 or Meropenem 0.5g IV q8
o With extended macrolide (Azithromycin 500mg/d IV for at least 2 days then switch to
oral)
o OR with respiratory fluoroquinolone (Ciprofloxacin 400mg IV q8-12
Hypertension
o Goal BP is <150/90 for ages >60 y.o. (JNC 8) *lower
o Continue Losartan 50 mg OD. Add Diuretic (Furosemide 40mg BID)
Seizure disorder
o Continue Phenobarbital 90 mg*can be due to the craniectomy SCAR

Follow up instructions/Home care


Clinical follow-up All patients who are treated for CAP at home should have a follow-up
visit or communication with a healthcare provider within several days after being diagnosed
to determine whether they are feeling better and assess whether any complications of
pneumonia have developed.
Follow-up chest radiograph - Some authorities recommend a follow-up chest radiograph
at 7 to 12 weeks after treatment for selected patients who are over age 40 years or are
smokers to document resolution of the pneumonia and exclude underlying diseases, such as
malignancy
Vaccination Patients with CAP should be appropriately vaccinated for influenza and
pneumococcal infection. *eg. Pneumococcal

*AFibrillation>irregularly irregular>
PT rehab< ted stokings
Precortisl>for adrenal insufficiency due to infection>n gonorrhea
Pneumonia >resistant>
PEG insertion> for nutrition