Pneumonia
Pneumonia
Pneumonia
2022-2023
History
Demographics
Initials: T.M
MRN: ZH00156226
Room number: 235
Age: 55-year-old
Gender: male
Nationality: Egyptian
Marital status: married
Occupation: employed (accountant)
Source of history: patient
Chief complaint
55 years old Egyptian male patient with known type 2 diabetes mellitus for past 4 years
presents with Severe body pain since 3 days, fever, headache and cough since two days.
Review of systems
Constitutional: Generalized fatigue, fever, no weight loss, insomnia
Neurological: headache, hearing difficulty in the left side(old) , dizziness
Cardiovascular: No palpitations, chest pain or chest tightness
Respiratory: No shortness of breath, no Hemoptysis, no Chest pain, cough
Gastrointestinal: No nausea and vomiting, no diarrhea, no constipation
Genitourinary: urinary frequency, urgency, dysuria
Musculoskeletal: No Muscle wasting, no Morning stiffness, normal gait
Endocrinological: Polyuria , Polydipsia, Dry mouth
Past medical and surgical history
Patient was diagnosed with type 2 diabetes mellitus since 4 years and he is on oral
hypoglycaemic medication and the patient is non-compliant with medications, Hence
diabetic status was uncontrolled when he was admitted in the hospital.
Cataract surgery was done in the right eye in February 2022.
Patient have dyslipidaemia and he’s on statins
Family history
No family history of similar complaint
Family history is non-contributory
Social history
He is living with his family
Patient does not smoke or consume alcohol
His diet is home cooked meals.
Patient does not exercise
Physical examination
Vitals signs
Temperature: 38 ̊C
Pulse: 102bpm
BP: 122/69
RR: 20 breaths/min
spO2: 96% on room air
Measurements
Weight: 84 kg
Height: 175 cm
BMI: 27.43 kg/m2
General examination
Patient was lying in bed and not in distress. Patient looks fatigue. No cyanosis,
muscle wasting, speech abnormalities, nail clubbing, tar stain, asterixis and signs of
dehydration noted. He was connected to an IV line and was conscious, alert and
oriented.
Focused examination
On examination:
Respiratory:
- Equal air entry bilaterally with normal vesicular breath sounds and no wheezing
bilaterally
- Normal abdominothoracic respiration pattern
- All lung fields resonant on percussion with normal tactile fremitus
Abdominal:
- The abdomen was soft and nontender
- No masses felt on light and deep palpation
- no hepatomegaly or splenomegaly
- negative rebound test and negative Murphey’s punch test
- no abdominal bruit detected
Cardio:
- chest looks symmetrical no scars and no deformities or abnormal shape.
- Normal location of apex beat with normal character.
- Normal heart sounds (S1 and S2) no murmurs or add sounds.
Neuro:
- Normal gait and there is no neurological deficits.
- Normal tone, power, and reflexes.
- No loss of sensation in periphery and normal cranial nerves examination.
Differential diagnosis
Acute pharyngitis
acute bronchitis
pneumonia.
Allergic rhinitis
Investigations
Lab investigations
CBC
Investigation Value
WBC 14520/cumm ( high)
RBC 5.88 million/cm (high)
Hgb 16.6
Hct 49.1%
MCV 83.5%
RDW 12.4%
Platelet 187000/cumm
Neutrophils% 76.4% (high)
Lymphocytes% 12.4%
ABG:
Investigation Value
PH 7.443
PCO2 37.6mmHg
PO2 41.4mmHg
HCO3 25.2mmol/L
Investigation Findings
Influenza A antigen Negative
Influenza B Negative
antigen
Infection markers
- CRP : 79.90 mg/L
Urinalysis
Investigation Value
Urine color Pale Yellow
Urine appearance Clear
Urine PH 5.0
Glucose urine 1000mg/dl
Bilirubin urine Negative
Ketones urine 150mg/dl
Blood urine Negative
Protein urine Negative
Nitrite Urine Negative
Leukocytes urine Negative
Electrolytes
Investigation Value
Sodium 136.0mmol/L
Potassium 4.38mmoL/L
Calcium 2.41 mmol/L
Chloride 99.1mmol/L
Chloride:Sodium Ratio 0.729mmol/L
Imaging
Chest x-ray
- Prominent bronchovascular markings bilaterally
- Left lower lung zone showing consolidation
- Normal thoracic cage
- Clear costophrenic angles
CT scan of the chest
- Subtle patchy areas of ground glass attenuation.
Interpretation
- Elevated WBCs (neutrophilis specifically) along with the increased CRP, the
Prominent bronchovascular markings bilaterally and consolidation in the left lower
lung zone indicates an infective/inflammatory state in the lung.
The ketone bodies and high glucose level seen in urine analysis is due to uncontrolled
type 2 diabetes mellitus and it suggest Diabetic ketosis without acidosis.
Negative sputum and throat swab culture maybe because they started the antibiotic
course before taking the swab.
Influenza A and B rapid test result was negative because the clinical presentation and
the imaging suggest atypical pneumonia.
Provisional diagnosis
- atypical pneumonia with CURB-65 score of 0
- Diabetic ketosis without acidosis due to uncontrolled type 2 diabetes mellitus.
Management plan
My plan
- Give normal saline IV because the patient looks dehydrated.
Order blood workup (CBC, CRP, PCT, and ABG), urinalysis, HbA1c, sputum culture ,
chest x-ray, urine culture, urinary Legionella antigen , molecular diagnosis of
Mycoplasma pneumoniae or Chlamydophila pneumoniae, serology for atypical
pathogens
- Give the patient IV paracetamol to relieve the body pain, headache and fever.
- Pneumonia:
o Amoxicillin-clavulanate + azithromycin
- dysuria:
o advice the patient to drink more water
o uristat oral
- Cough:
o Guaifenesin
- Diabetes mellitus type 2:
o Consult endocrinologist to prescribe the needed medication.
Hospital Plan
- Admit patient
- Treat the uncontrolled diabetes with insulin as blood sugar was very high and ketone
was positive in the urine, but the ABG was normal
- Antibiotic intravenous started
- Blood investigation was sent
- X-ray, CT scan was advised
- Intravenous fluid to maintain the hydration and correct the ketosis
Follow up
Subjective: Patient feels better, and the fever subsided after 3 days
Objective: Vitals are stable and afebrile. The patient looks well and not in pain. CRP
decreased to the normal range. Ketones in the urine reduced from 150 to 50.
Assessment: chest x-ray and CT-scan confirm that the patient has pneumonitis. Sputum
culture and throat swab results suggested that the given antibiotics works very well to treat
the infection.
Plan: repeat x ray chest will be done on OPD once the patient come for follow up,
discharged the patient on antibiotics and insulin.
Learning points
- The irritants that first induce pneumonitis are frequently never discovered.
- Many additional lung illnesses including pneumonitis share same symptoms. As a result, it
may take several tests before a definitive diagnosis is made because the doctor must first
rule out these other possibilities.
Literature review
The COVID-19 vaccine helps lower the risk of COVID-19 and offers protection against serious
illness, even in those who become infected after receiving the vaccine. ' Although extensive
research has revealed positive safety profiles for COVID-19 vaccinations, the long-term
safety and infrequent adverse responses are unknown. It has been documented that
interstitial pneumonitis is a rare side effect of vaccination against other bacteria. However,
the initial COVID-19 vaccine trial did not include it. Here, we present data on three cases of
interstitial pneumonitis following COVID-19 vaccination (Pfizer). All three patients met the
suggested criteria for drug-related pneumonitis, which also included the exclusion of other
possible causes and the presence of newly detected lung parenchymal opacities on chest CT
with a bilateral non-segmental distribution. After vaccination, all patients had an unusually
"prolonged" fever, tiredness, or dyspnea (4-15 days). Variable CT findings included air-space
consolidation with linear opacities, ground-glass opacities, and reticulation with subpleural
sparing or predominance.
Shimizu, T., Watanabe, S., Yoneda, T., Kinoshita, M., Terada, N., Kobayashi, T., Gohara, K.,
Tsuji, T., Nakatsumi, H., Tambo, Y., Ohkura, N., Abo, M., Hara, J., Sone, T., Kimura,
H., & Kasahara, K. (2022). Interstitial pneumonitis after COVID-19 vaccination: A
report of three cases. Allergology International, 71(2), 251–253.
https://doi.org/10.1016/j.alit.2021.10.003