Kimberly Moriarty
Community Acquired Pneumonia and Allergic Rhinitis Case studies
1. Differentiate CAP as to typical and atypical, including causative agent. (6 points)
CAP indicated pneumonia on someone not hospitalized or living in as nursing home 14
days before onset of symptoms.
Atypical: usually caused by Legionella pneumophila, Mycoplasma pneumoniae,
and Chlamydophila pneumonia. Usually affects younger people, also called walking
pneumonia. Passed easily in dorms, military groups. Can be caused by dirty air
conditioner filters, smoking or exposure to smoke, and immunocompromised people.
Symptoms include; fever, chills, fatigue, cough, headache, decreased appetite, shortness
of breath. Symptoms are less severe on onset but can last for weeks.
Typical: Usually affects older individuals with underlying heart and lung
conditions. Caused by Streptococcus pneumoniae, Haemophilus influenzae or Klebsiella
pneumonia. Symptoms are similar to atypical, including, pleuritic chest pain, tachycardia.
This is generally more severe and usually requires hospitalization.
2. Identify 5 risk factors for the development of CAP. (5 points)
The five risk factors include: Age (very old or very young), Co morbities/chronic
illnesses (HIV, emphysema, lung heart diseases), smoking and/or alcohol abuse,
dorm/communal living, contact with environmental factors (dust, fumes, etc)
3. Describe the most common clinical presentation of CAP. (5 points)
Commonly, CAP would present as a person; Shortness of breath, may or may not
have sputum production, fever, chills, rapid breathing, and stabbing chest pains. May also
have nausea, vomiting, fatigue, headaches, loss of appetite, muscle aches. This patient
will “look sick”. They will be tachy, tachypnic, hypotensive. Rales on auscultation.
4. Is a chest x-ray required for diagnosis? Why or why not? (2 points)
Chest x ray is indicated. This will show areas of consolidation in the lungs. Most
helpful is there is a previous one to compare it to. This will confirm the diagnosis and
rule out complications. Can have a false negative in the cases of dehydration.
5. Is a gram stain required for diagnosis? Why or why not? (2 points)
No. The use is controversial. It can be helpful in some cases, but getting a good
sample proves most difficult. Plus most have varying degrees of specificity and
sensitivity. In most cases, the gram stain is not indicated as beneficial to treatment.
6. What are the indications for outpatient vs. inpatient management of CAP? (4 points)
There is a pneumonia severity index to help clinicians guide their thinking about
hospitalization. Anyone who looks really sick should be. After that, those with severe
abnormalities in their vitals, altered mental status, low pulse ox, severe electrolyte
imbalances, failure to respond to outpatient therapy, and those with severe co existing
conditions should be hospitalized. There are many internet references to help guide
thinking, but clinical judgment is the most important.
7. Assuming your causative agent is the most common cause of CAP, what is your
Management plan. If you are prescribing medications, be specific as to
medication/dose/duration. (6 points)
Management of a “routine” CAP would include the following; Antibiotic education,
follow up in 24-48 hours, education of increasing fluids, using Tylenol, regular use of
flu/pneumonia vaccine if indicated, maintaining a healthy diet, exercise, and education
about minimizing risk factors. I would then prescribe doxycycline 200mg po bid for 14
days.
Allergic Rhinitis (40 points)
1. What additional information would you like to know? (5 points)
Additional information to ask: any sick contacts, any smokers in house, any shortness
of breath, waking up in the middle of the night, cough, fever, chills, diarrhea, any
medications help/hinder, animals in house, any family history of allergies (or asthma,
eczema) the meaning of persistent (how long, how often etc), and how great the
interference is.
2. While the symptoms lead you strongly to a diagnosis of allergic rhinitis, what
physical exam signs might you find that also support this diagnosis? (5 points)
Physical exam signs would include; obvious congestion/inflammation in nose, mouth
breathing, pale to purple mucous membranes, thin watery discharge, allergic salute,
sneezing, post nasal drip, dark circles around eyes, and hoarseness.
3. Does he need to be referred to an allergist for testing, why or why not? What are
the indications for referral? (3 points)
No. I think at this point he should try to identify his trigger and work around that.
There are many things we could try before sending him to a specialist including
medications and eliminating possible triggers. Indications for a referral include;
inability to avoid trigger, symptoms present for 6 months, and symptoms not
controlled by medications and allergy exposure control.
With spring allergies, triggered with outdoor exposure, he is probably allergic to tree
pollens. Fall allergies are more likely due to ragweed.
4. What are your treatment options (hint, there are 6, five are drug classes). Identify
the six, and discuss the benefits and limitations of each treatment option.
Antihistamines: available over the counter, can cause daytime sleepiness, 2nd
generation ones available without the sleepiness, come in pills, sprays. Best
results when used before an exposure.
Corticosteroids: a nose spray, best used year round, safe, may take several weeks
to achieve full affects. Now considered best first line treatment for allergic
rhinitis. Need prescription.
Decongestants: should not be used more than 3 days consistently. Some may
worsen symptoms. Available over the counter. Help to mask symptoms.
Leukotriene inhibitor: used for allergy/asthma combo. Need a prescription. Helps
to control symptoms.
Allergy shots (immunotherapy): painful, expensive. Need to have them twice a
week for months, the every 2-4 weeks for years. Can have a life threatening
reaction to shot.
Also have nasal cromolyn, less effective than nasal steroids.
Allergy avoidance: the biggest thing a person can do for treatment, but the most
time consuming and annoying…..Wash all linens weekly in hot water, eliminate
stuffed animals, regularly wash curtains, dust frequently, use a HIPA filter to
vacuum, remove carpeting, eliminate smoke, change and shower upon entering
the home, get rid of animals
Given the six you have identified, develop a specific treatment plan for this boy. If you
prescribe medications, be specific on the drug, dose and instructions for use. (6 points)
He should be showering and changing clothes upon coming home, and his mother
should be washing his linens frequently. Since his exposure is in the environment,
possibly suggesting a change in sports (although unlikely) is his symptoms are that
severe. I would then start him on Flonase 50mcg/spray 2 puffs daily. I would also
recommend the use of an antihistamine (Benadryl 25mg po Qhs) at night to help him get
some relief and some sleep. He would need to be taught how to use the nasal spray. He
needs to be inhaling through the nostril he is spraying while the mist is coming out. He
can also use some vasoline on the tip if his turbinate is dry. He must have his head tipped
slightly forward, close on nostril, and sniff as he dispenses the medication. I would warn
them to not use the Benadryl during the day to prevent drowsiness. I would not
recommend decongestants, as these can cause rebound congestion.
Talk about the rash he describes. Is it sweat related? Any management suggestions? (3
points)
The rash he is describing sounds like eczema. I’d ask more about how, much how
often, does it itch etc. It is most likely sweat related. This rash would be expected to be
seen in someone with underlying allergies. In older children it seems to go to the knees
and elbows (young children face, scalp, and trunk). Management suggestions are to keep
the area clean and moisturized. Some hydrocortisone cream may help with the itching
and redness.