Intern Survival Series Lecture #6 Most Common Medical Diagnosis: - - PowerPoint PPT Presentation

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Intern Survival Series Lecture #6

Most Common Medical Diagnosis: Pneumonia and CHF

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Objectives

– Be familiar with the most common primary and secondary diagnosis encountered in medicine – Be able to appropriately work up and treat various types of pneumonia – Be able to identify and appropriately treat CHF

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A Brief Note

• This lecture series is not meant to be all inclusive
• r totally comprehensive to all of medicine
• It is not meant to supersede clinical judgment
• It is not meant to replace daily reading or bedside

teaching

• It is meant to act as a starting point for which to

grow from as new primary care physicians

• It is a tool to help you survive the your new job

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Most Frequent Primary Care, Inpatient Diagnosis

• 1)Pneumonia
• 2)Congestive Heart Failure
• 3)Osteoarthritis
• 4)Coronary Artery Disease
• 5)Septicemia
• 6)Cardiac Dysrhythmias
• 7)Chronic Obstructive Pulmonary Disease

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Fastest Growing Inpatient Diagnosis in Medicine

• 1)Acute Renal Failure
• 2)Anemia
• 3)Diabetes Mellitus
• 4)Malaise and Fatigue
• 5)Pulmonary Heart Disease

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Most Common Secondary Diagnosis

• 1)Hypertension
• 2)Hyperlipidemia
• 3)Fluid and electrolyte disorders
• 4)Coronary Atherosclerosis
• 5)Diabetes Mellitus
• 6)Anemia
• 7)Cardiac Dysrhythmias
• 8)Esophageal Disorders

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Pneumonia

• 2 Broad Categories

– Community Acquired Pneumonia – Health Care Acquired/HA Pneumonia

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Community Acquired Pneumonia

• Common and potentially serious illness
• associated with considerable morbidity

and mortality – particularly in elderly patients and those with significant comorbidities

• There is seasonal variation
• Prevalence is greater during the winter months.
• Rates of pneumonia are higher for men than

for women

• Bacterial vs Viral
• Streptococcus pneumoniae is the most

common cause of pneumonia worldwide

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Community Acquired Pneumonia

• Diagnostic Approach

– clinical evaluation

• Cough
• Fever
• Pleuritic chest pain
• Dyspnea
• Sputum production

– chest radiograph – +/- microbiologic testing

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Community Acquired Pneumonia

• RADIOLOGIC EVALUATION

– The presence of an infiltrate on plain chest radiograph is considered the gold standard – A chest radiograph should be obtained in patients with suspected pneumonia when possible – demonstrable infiltrate by chest radiograph or other imaging technique is required for the diagnosis of pneumonia

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Community Acquired Pneumonia

• Radiologic Evidence

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CAP

• If the clinical evaluation does not support pneumonia

in a patient with an abnormal chest x-ray, other causes for the radiographic abnormalities must be considered

– Malignancy – Hemorrhage – Pulmonary edema – Pulmonary embolism – Inflammation secondary to noninfectious causes

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Community Acquired Pneumonia

• Obtaining Microbial Evidence
• For outpatients with CAP, routine diagnostic tests are
• ptional
• Hospitalized patients with specific indications should have

blood cultures and sputum Gram stain and culture

• Patients with severe CAP requiring ICU admission should

have blood cultures, Legionella/pneumococcus urinary antigen tests, and sputum culture

– +/- viral panels (rapid infuenza a&b)

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Community Acquired Pneumonia

Initial Treatment of non hospitalized patients with out any significant comorbidities

– Empiric treatment is the normal – North American Guidelines Recommend macrolides or doxycylcline

• azithromycin 500mg PO x 1 day then 250mg PO x 4 days
• clarithromycin 500mg PO BID x 5-10 days
• doxycycline 100mg PO BID x 5-10 days

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Community Acquired Pneumonia

For non-hospitalized patients with comorbidities

• r recent antibiotic use

– fluoroquinolone as monotherapy – combination therapy with a beta-lactam plus a macrolide or doxycycline

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Community Acquired Pneumonia

For hospitalized patients not requiring intensive care unit admission

• Monotherapy with a respiratory fluoroquinolone
• Levaquin most commonly used
• Combination Tx w/ an anti-pneumococcal beta-lactam + macrolide

– Cetriaxone, cefotamime, unasyn – PLUS – azithromycin, clarithromycin

• Coverage for drug-resistant pathogens, such as Pseudomonas or

methicillin-resistant Staphylococcus aureus (MRSA), should be included in patients with risk factors

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Community Acquired Pneumonia

Hospitalized patients requiring ICU care

– combination therapy with an anti-pneumococcal beta-lactam – plus either IV azithromycin or a respiratory fluoroquinolone – plus, if MRSA is suspected, linezolid or vancomycin

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Healthcare-associated pneumonia (HCAP)

• Pneumonia that occurs in a non-hospitalized patient with

extensive healthcare contact: – Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days – Residence in a nursing home or other long-term care facility – Hospitalization in an acute care hospital for two or more days within the prior 90 days – Attendance at a hospital or hemodialysis clinic within the prior 30 days

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Hospital Acquired Pneumonia

• Pneumonia that occurs 48 hours or more after

admission

• did not appear to be incubating at the time of

admission.

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HCAP/HAP

• Workup

– Very Similar to CAP

• Clinical Picture
• Radiographic evidence
• Blood Culture
• Urinary Antigens

– Pneumococcal and legionella

• CBC, RFP, virus panels, etc

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HCAP/HAP

Treatment

• Antimicrobial selection should be based upon

risk factors for multidrug-resistant (MDR) pathogens

– recent antibiotic therapy (if any) – the resident flora in the hospital – the presence of underlying diseases – available culture data

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HCAP/HAP

• For patients with risk factors for multi drug

resistant pathogens, empiric broad-spectrum, multidrug therapy is recommended.

• Once the results of pre-therapy cultures are

available, therapy should be narrowed based upon the susceptibility pattern of the pathogens identified

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HCAP/HAP

• Commonly Used Intravenous antibiotic regimens

– levofloxacin 750mg IV daily – piperacillin/tazobactam 4.5 g IV q 6 hrs

• If severely PCN allergic, Aztreonam often substituted

– vancomycin 15-20mg/kg IV q 12

• Can use linezolid in place of vanco if needed

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Duration of therapy

• De-escalation of therapy should be considered

after 48 to 72 hours

• De-escalation should be based upon the

results of initial cultures and the clinical response of the patient

• A short duration of therapy (7 days) is

sufficient for most patients with uncomplicated HAP/HCAP who have had a good clinical response

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CHF: A Brief Overview

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NYHA CHF Classification

• The New York Heart Association (NYHA).
• This system assigns patients to one of four

functional classes Class I — symptoms of HF only at activity levels that would limit normal individuals Class II — symptoms of HF with ordinary exertion Class III — symptoms of HF with less than ordinary exertion Class IV — symptoms of HF at rest

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Evolution of CHF (ACC/AHA)

• Stage A — High risk for

HF, without structural heart disease or symptoms

• Stage B — Heart

disease with asymptomatic left ventricular dysfunction

• Stage C — Prior or

current symptoms of HF

• Stage D — Refractory

end stage HF

Stages in the development of HF

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Etiology

• Systolic dysfunction

– Most common causes: – coronary (ischemic) heart disease – idiopathic dilated cardiomyopathy (DCM) – hypertension – valvular disease

• Diastolic dysfunction

– Most common causes: – Hypertension – ischemic heart disease – hypertrophic obstructive cardiomyopathy – restrictive cardiomyopathy

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Initial Testing

#1: H&P for Clinical Signs & Symptoms, followed by…….

• EKG:

– Identify evidence of previous MI, structural heart disease – Identifies any underlying arrhythmias

• CXR

– Look for cardiomegally, pulmonary congestion, pleural effusions

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Initial Testing

• BNP

– useful in distinguishing HF due to systolic/ diastolic dysfunction from

• ther causes of dyspnea

– Most dyspneic patients with HF have values above 400 pg/mL, while values below 100 pg/mL have a very high negative predictive value – Can also be elevated in pulmonary embolism, A-fib, LV dysfunction without exacerbation, and cor pulmonale – http://www.nejm.org/doi/full/10.1056/NEJMoa031681

• RFP, CBC, LFTs
• Echo

– Appropriate in patients with symptoms or when additional studies point towards cardiac disease

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ACEI Treatment

ACE INHIBITORS

• CONSENSUS TRIAL (1987)

– First trial to demonstrate a mortality benefit of ACEI in CHF. – All pts were Class IV & ½ were on spironlactone at time of enrollment. – http://www.nejm.org/doi/full/10.1056/NEJM1987060431 62301

• SOLVD Trial (1991)

– 16% reduction of risk of death in pts w/ EF<35% – http://www.nejm.org/doi/full/10.1056/NEJM1991080132 50501

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BB Treatment

Beta Blockers

• U.S. Carvedilol Heart Failure Study(1996)

– 1st trial to demonstrate a mortality benefit with betablockade in treatment of CHF – Treatment with Carvedilol led to 65% lower risk of death compared w/ placebo. – http://www.nejm.org/doi/full/10.1056/NEJM199 605233342101

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Diuretic Treatment

DIURESIS STATEGY

• DOSE(2011): Study designed to compare intermittent high dose bolus vs

continuous infusion of diuretics. Study found no significant difference.

• Did illustrate TX strategies commonly used in acute CHF(initial 2x patients

normal PO dose at home. If unsuccessful w/ intermittent bolus, change patients to continuous infusion)

• http://www.nejm.org/doi/full/10.1056/NEJMoa1005419

Aldosterone Blockers

• RALES (1999)

Showed mortality benefit in patients with stage III/VI CHF – Of note severe hyperkalemia occured in only 2% of patients – http://www.nejm.org/doi/full/10.1056/NEJM199909023411001

• EMPHASIS-HF (2010)

– Demonstrates a 34% risk reduction in the risk of death in patients w CV causes in patients with NYHA Class II – http://www.nejm.org/doi/full/10.1056/NEJMoa1009492

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ICD Treatment

ICD Implantation:

• MADIT Trial (1996)/MADIT II(2002)

– I)Showed mortality benefit w ICDs vs medical Tx – II)Showed pts w/ prior MI(>3months) & LVEF<30%, should receive an ICD to reduce mortality.

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Common Treatments of CHF

• Beta Blockers

– carvedilol – metoprolol

• ACE Inhibitors

– lisinopril – enalapril

• Diuretics

– Lasix (furosemide), demadex (torsemide) – spironolactone

• ICD Implantation

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• Questions?