A 65 year old man has been admitted to your Intensive Care Unit with a presumptive diagnosis of community acquired pneumonia. He is sedated, intubated and ventilated, and is haemodynamically stable.
(a) What specific historical information would you attempt to obtain? Discuss why.
(a) What specific historical information would you attempt to obtain? Discuss why.
Specificity of typical or atypical in nature is poor; rapidity of onset (? Prognostic). Factors that might alter aetiology: recent or current hospitalisation, nursing home etc (more nosocomial like, including Gram negatives); areas associated with outbreaks (e.g. legionella); exposure to specific scenarios eg. Birds (psittacosis); exposure to communities with specific resistance patterns (eg. Drug resistant pneumococcus), risk for pseudomonas (structural lung disease e.g. bronchiectasis, corticosteroids, previous broad spectrum antibiotic use, undiagnosed HIV), visits to tropical areas (e.g. Burkholderia pseudomallei). Risk factors for poor prognosis: include age > 65, co-morbidities (eg. Diabetes, renal failure, neoplastic disease, alcoholism, immunosuppression). Usual historical data regarding other major illnesses/comorbities, drugs, allergies, etc. Information regarding specific immunosuppression may also allow better coverage of potential organisms: consider T cell dysfunction (e.g. AIDS, immunosuppressive therapy and risks of Pneumocystis and TB), neutropaenia (e.g Pseudomonas, Fungi), previous splenectomy etc.
The first part of this question (the history of a pneumonia patient) closely resembles Question 26 from the first paper of 2006.
Contrary to custom, I will reproduce the answer here:
Patient's medical history of prognostic importance
Recent history of aetiological importance
Presenting history
Mandell, Lionel A., et al. "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults." Clinical infectious diseases 44.Supplement 2 (2007): S27-S72.