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.

[Click here to toggle visibility of the answers]

College Answer

(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.

Discussion

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

  • smoking
  • COPD
  • heart disease, including CCF and pulmonary hypertension
  • exercise tolerance
  • immunesuppression, eg. corticosteroids
  • malignancy
  • vaccination history
  • history of exposure to TB, country of origin
  • end-stage organ failure, eg. cirrhosis or dialysis-dependent renal failure

Recent history of aetiological importance

  • swallowing difficulty, history of stroke
  • alcohol binges
  • haemoptysis
  • recent travel
  • recent gardening (Legionella)
  • recent bushwalking
  • exposure to birds or pets
  • recent chemotherapy
  • recent hospital stay
  • recent antibiotic use

Presenting history

  • rapidity of onset
  • associated symptoms eg. copious amounts of sputum, flu-like symptoms, hemoptysis, pleuritic chest pain, and so forth

References

References

 

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.