Reply to this discussion and provide recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples.

HH is a 68 yo M who has been admitted to the medical ward with community-acquired pneumonia for the past 3 days. His PMH is significant for COPD, HTN, hyperlipidemia, and diabetes. He remains on empiric antibiotics, which include ceftriaxone 1 g IV qday (day 3) and azithromycin 500 mg IV daily (day 3). Since admission, his clinical status has improved, with decreased oxygen requirements.

Ht: 5’8″ Wt: 89 kg

Allergies: Penicillin (rash)

Introduction

Pneumonia is an infection of the lung or pulmonary parenchyma by definition. Unfortunately, community-acquired pneumonia (CAP) is a prevalent illness often misdiagnosed and improperly managed. Although it often manifests as a very minor condition, it remains a significant source of morbidity and death. It is estimated that about 5 million instances of pneumonia occur annually in the United States, with over 1 million hospitalizations and 60,000 fatalities (Mandell L. A.2015). Depending on the host pathogen, the severity of the sickness might range from moderate to lethal. The average patient has a high body temperature and heart rate, as well as chills, cough, and shortness of breath. Chest discomfort may result from coughing or pleuritic involvement. As in the case of HH, a 68-year-old man, up to 20% of CAP patients may develop gastrointestinal symptoms such as nausea, vomiting, or diarrhea.

Streptococcus pneumoniae, Mycoplasma pneumoniae, and Hemophilus influenzae are the common bacterial infections that may cause CAP.  pneumoniae and Viral Respiratory Infections (Marrie T, 2014). In the case of HH, there is no known pathogen information; however, according to the case study, he is on the third day of empiric antibiotic treatment with Ceftriaxone 1 g IV/q day and Zithromax 500 mg/IV/q day, which is improving his respiratory condition, as evidenced by decreased oxygen requirements.

Patients with a confirmed or suspected illness, but for whom the culprit organism(s) or germs have not been identified often get empiric antibiotic treatment. (Empiric Antibiotic Selection – Infectious Disease and Antimicrobial Agents, not long ago)

Current Medical Demands

Respiration and oxygenation. Community-acquired pneumonia (CAP) is present in Mr. HH, a risk factor, who has a history of COPD. His blood pressure requires stabilization and management. Due to nausea and vomiting, his diabetes mellitus should be managed along with water and nourishment.

Mr. HH has a history of COPD and CAP. Comorbidities such as chronic obstructive pulmonary disease (COPD), asthma, and heart failure are risk factors for CAP. Variable CAP symptoms include productive cough, dyspnea, pleuritic discomfort, and abnormal vital signs. The infection causes the air sacs (alveoli) of the lungs to become inflamed and to fill with fluid or pus, resulting in shortness of breath and low oxygen saturation. Oxygen saturation levels should be maintained above 90 percent but not so high as to impair respiratory drive in COPD patients. (Mandell L. A. (2015).

Treatment Regimen and Pharmacotherapeutics

Inhaled corticosteroids (ICS) are essential for lowering the frequency of exacerbations associated with chronic obstructive pulmonary disease (COPD). (Crim et al.,2009) Inhaled corticosteroids (ICS) are anti-inflammatory drugs routinely recommended as respiratory therapy for the majority of people with Chronic Obstructive Pulmonary Disease (COPD), while Long-Acting Beta 2 agonists are Bronchodilators often used to treat COPD and pneumonia ( Sibila et al., 2015)

I will continue ceftriaxone 1 g IV QD and azithromycin 500 mg IV QD. Ceftriaxone is a parenteral cephalosporin of the third generation with a long elimination half-life that facilitates once-daily delivery. It is effective against Streptococcus pneumonia, staphylococci sensitive to methicillin, and Haemophilus influenza. In addition, Ceftriaxone has a significant position in treating invasive pneumococcal infections, either alone or as part of a combination regimen, due to its potent action against S. pneumoniae ( Lamb et al., 2015). When the source of the disease is identified, IV antibiotics may be discontinued and replaced with oral antibiotics, such as broad-spectrum Azithromycin. Need cultural and sensitivity report.

Check vital signs every four hours. Continue taking home blood pressure meds as indicated. Amlodipine) Norvasc 10 mg daily may be recommended for the treatment of hypertension.

Monitor glucose levels before meals and before bed. In diabetics, illness and steroid usage may destabilize blood glucose levels. Therefore, I will continue diabetes meds at home. In addition, since the patient cannot tolerate a P.O. diet at this time, the patient’s risk for unstable blood sugars is enhanced.

Maintain D51/2 NS Intravenous Fluids daily at 25-30 cc/kg. Since the patient’s nausea and vomiting are likely due to the IV antibiotics, I would prescribe 8 mg of Zofran every 8 hours as required for nausea and vomiting.

Patients’ education is an integral component of any therapy strategy. Included in a plan’s components are coughing and deep breathing. Signs and symptoms to report to the nurse, as well as education on the medicine’s harmful side effects. Since the patient is taking inhaled corticosteroids, I believe it is essential to address his persistent sensitivity to respiratory infection. Finally, as the patient will be discharged with oral antibiotics, teaching about their correct usage and administration must be performed.

Reply to this discussion:

The clinical vignette, describes a 68years old man, with multiple comorbidities, such as COPD, Hypertension, hyperlipidemia, and diabetes, being managed for community-acquired pneumonia for the past 3 days, with difficulty tolerating food, probably due to nausea and vomiting. Consequently, potential challenges in this patient would include;

1) Possible electrolyte derangements due to inability to feed and to vomit, especially, Na, Cl, K, and H from gastric juice loss, thus predisposing this patient to hyponatremia, and hypokalemia, metabolic alkalosis, and hypochloremia(Shrimanker & Bhattarai, 2022).

2) This diabetic and hypertensive patient is likely to have stopped his antihypertensive medications, his anti-lipid medications, and his oral antidiabetic drugs, due to nausea/vomiting, except he was on insulin for his diabetes, as most routine antihypertensives/anti-lipid medications are usually taken orally. This inadvertently could result in elevated blood pressure, blood glucose, and lipid levels.

3) This patient could become very lethargic as a result of increased metabolism due to his pneumonia as well as the heavy antibiotics he’s currently taking without any supporting nutrients from food or intravenous fluids.   

Based on the above, this patient clearly requires intravenous fluids, parenteral anti-emetics, and possible conversion to parenteral antihypertensive/insulin for his diabetes, until he is stable enough to commence oral medications. Consequently, I would recommend the following:

1. The immediate commencement of intravenous infusion such as IVF Full strength Darrows (FSD) 500mls 8hly until vomiting subsides. This is because, FSD has a great concentration of K, Na, and Cl, which could replace those lost to vomiting and would not aggravate the patient’s hypertensive status, due to its isotonic sodium, level. In addition, FSD does not contain glucose, thus making it safe for this diabetic patient(Epstein & Waseem, 2022).
2. Intravenous administration of promethazine at 25mg daily or intravenous metoclopramide at 10mg daily could be administered either as a stat dose or as a once-daily dose until nausea/vomiting subsides(Hurault-Delarue et al., 2022).
3. Ceftriaxone, a widely used 3rd generation cephalosporin with a broad spectrum of activity against gram-positive and negative organisms, is also very notorious for causing nausea and vomiting in certain groups of individuals, to which this patient could belong. As a result, I would discontinue the intravenous ceftriaxone by day 5, since he has appreciably improved, and replace it with another 3rd generation cephalosporin like Cefpodoxime, once this patient begins to take orally, at 200mg twice daily for 1week(Poiată et al., 2022).
4. This Patients serum electrolyte would be monitored closely, to ensure they are within normal ranges, with appropriate corrections instituted when the need arises.
5. This patient’s blood pressure will also be monitored closely, with interventions, made with intravenous hydralazine at 5-20mg slowly over 10-15minutes or intravenous labetalol at 50mg 8hrly depending on blood pressure levels until he begins to take it orally. Also, blood glucose levels will be monitored closely and interventions made with insulin in cases of hyperglycemia or correcting with 20mls of 50% dextrose at 1:1 dilution in cases of hypoglycemia. (Lipari, M & Moser, L. R. 2016)(Mathew & Thoppil, 2022).

My education strategy: This involves educating the patient about the need for him to exercise regularly, ensuring regular checkups with his healthcare provider as well as strict compliance with his medications. In addition, I will explain the concept of the DASH diet to this patient, as he clearly meets the requirements for this care. This was initially formulated for the management of hypertension but has found tremendous use in the management of diabetes, lipid disorders, and obesity (metabolic syndrome). DASH diet includes; 1) About 5servings per day of vegetables 2) About 5meals per day of fruits 3) 2 servings per day of low-fat dairy products 4) 2 or fewer servings per day of lean meat 5) 2 to 3 times per week of nuts and seeds 6) intake of complex carbohydrates, such as those containing cellulose and starches. The human body does not digest cellulose and its fiber function helps in excretion and weight loss. Examples of complex carbohydrate products include millet oat, cracked wheat (whole grains), legumes like beans, etc(Challa et al., 2022).

Virtual World is a computer-based online community environment that is designed and shared by individuals so that they can interact in a custom-built, simulated world. If I ever woke up to the virtual world, it would be a very difficult for me. I can imagine the world with no outside physical contact with other people that will be lonely and very depressing. Human face to face is also very important. Face to face interaction will allows you to communicate other people in many different ways that is so impossible to do on-line. Feeling, emotions, physical expressions can also be highly evaluated through face to face interaction. I really do believe that Facebook, Skype, Twitter, Instagram is a awesome thing because it allows you to reach out to your family members and friends that are very far away from you. Somehow, I really doesn’t believe that the virtual world change our personalities. We are who we are. The virtual world allows you to have the opportunities to alter our identities or possible other identity that is not completely true. An example of misconception when people make up these fake profiles claiming to be honest with you, hardworking, respectful knowledgeable plumber but actually he is a scam con-artist out there waiting to rob you, or get into you home. Technology is great thing that is some of the time used for bad or wrong doing. Somehow i don’t think that a total ban on Technology is very much needed. We just really just need to to education our youth on the importance of being careful while on-line, but important Face to face interaction is.