Management Of Community Acquired Pneumonia

## Diagnostic Tests

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* CBCD, electrolytes, glucose, BUN, Cr
* ABG on RA
* blood cultures (draw 2 before treatment, at least 10 min. apart)
* sputum gram stain and culture
* CXR (PA and lateral)
* acid fast stain of sputum if cough > 1 month or suspicious CXR for TB
* thoracocentesis if pleural effusions present
* stain, culture, pH, leukocyte count, differential

## General Management

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* analgesics/antipyretics
* ensure adequate hydration
* oxygen therapy to O2 sat ≥ 90%
* consult RT, PT, OT, speech language pathologist, dietician as needed

## Hospitalization

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* When to admit
* Age >65 yrs
* Decreased immunity (cancer, diabetes, AIDS, splenectomy)
* Mental status changes
* Increased A-a gradient
* Two or more lobes involved
* No home
* Organ failure (↑Cr, bone marrow suppression, severe hypotension, liver failure)
* WBC > 30,000/mm3 or < 4000/mm3 (sepsis)

## Treatment

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* if no pathogen identified, empirically treat
* NO COMORBIDITIES: po macrolide or doxycycline
* WITH COMORBIDITIES: po beta-lactam plus macrolide, or fluoroquinolone, quinolones (levofloxacin)
* if suspect ASPIRATION: amoxicillin-clavulanate or levofloxacin and metronidazole
* treat empirically until pathogen identified by sputum or blood culture, then use specific therapy

* OUTPATIENT: treat for 10 - 14 days
* Followup with GP, CXR in 8-12 weeks

* INPATIENT: treatment length based on response to therapy, comorbid illnesses, complications
* usually treat bacterial infections until patient is afebrile for >72 hours
* resolution of respiratory symptoms, fever, PaO2 level, WBC, and findings on serial CXR

* give influenza and pneumococcal vaccine on day of discharge
* smoke cessation

### Poor prognostic factors

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* age, men, nursing home
* comorbidities: cancer, liver, CHF, CVDTV

, renal

* O/E: LOC, RR, BP, pulse, temperature
* labs: pH, pO2, ↓hematocrit, ↑BUN, ↓Na, ↑glucose, pleural effusion

## Other OSCE modules

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* v
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Objective structured clinical examination

Acute Confusion \- Acute Coronary Syndrome Orders \- Anemia \- Arterial Blood Gasses \- Asthma \- Blood Pressure \- Chest pain \- Chest XRay \- CHF \- Coma \- COPD \- Cranial Nerves \- Diabetic History \- Diabetic Foot \- Dysphagia \- EKGs \- Gallbladder and Liver \- Liver Disease \- Gait and Balance \- Headache \- Hematemesis \- Hypertension \- Jugular Venous Pulses \- Knee Exam \- Lymph Nodes \- Community Acquired Pneumonia \- Parkinson Disease \- Peripheral Arterial Insufficiency \- Pneumonia Examination \- Precordial Exam \- STD's \- Spleen \- Swollen Leg Exam \- Thyroid Exam \- Upper vs Lower Motor Neuron Lesions \- Urinary Incontinence
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