22 hours ago

Casey Hoffman 

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Patient HH is a 68-year-old male who is admitted to the medical-surgical floor with community-acquired pneumonia. His vital signs upon admission include temp of 102.7, BP 138/72, HR 124, RR 34, & O2 sat 90% on 4L NC. His initial WBC count was 18.2. His x-ray showed right lower lobe infiltrates and blood cultures have no growth to date for two days. The bronchial lavage culture showed gram-positive cocci in pairs, 34 WBCs, and heavy Streptococcus pneumoniae growth. The patient was admitted to the medical-surgical unit and placed on IV antibiotics including ceftriaxone 1g qday and azithromycin 500 mg qday. He is currently on day 3 of antibiotic therapy and his overall condition has improved, including decreased oxygen demand (now RA down from 4L NC) and a WBC count of 14.6. His current vitals include temp 100.9, BP 136/70, HR 88, RR 20, & O2 sat 92% on RA. The patient is currently not tolerating anything by mouth and complains of nausea and vomiting. 

The patient’s other medical history includes COPD, HTN, hyperlipidemia, and diabetes. He has an allergy to Penicillin (rash). According to the antibiotic sensitivities chart that was provided, the patient is currently on the appropriate antibiotics. I would keep the patient’s current antibiotics the same because he is responding appropriately to the current treatment. The Streptococcus pneumoniae bacterium is one of the most common organisms causing upper and lower respiratory infections in adults (Kaplan & Mason, 2008). Penicillin is generally the antibiotic of choice to treat Streptococcus infection (CITATION). Patient HH, however, is allergic to penicillin. Once a patient displays hemodynamic stability and their overall condition improves oral antibiotics can be started and IV antibiotics can be discontinued (Kaplan & Mason, 2008). According to the authors Kaplan & Mason (2008), once a patient has been afebrile for 48 hours, remains free of supplemental oxygen, maintains a RR less than 20, maintains a HR of less than 100, and maintains a SBP greater than 90 they can be transitioned to oral antibiotics. HH’s nausea and vomiting need to be treated and controlled prior to initiating oral antibiotic treatment. I would treat HH’s nausea and vomiting with a selective serotonin antagonist. Selective serotonin antagonists inhibit the action of serotonin at the 5-HT3 receptor in the small bowel, vagus nerve, and chemoreceptor trigger zone (Stewart, Crawford, & Taylor, 2000). This action then causes a decrease in the stimulation of the medullary vomiting center. Selective serotonin antagonists are the primary treatment for many of the causes of nausea. I would begin HH on ondansetron 4 mg IV q6h PRN for nausea. I would also start HH on maintenance IV fluid due to his inability to hydrate by mouth. HH will be started on NS at 75ml/hr until he is tolerating PO hydration. 

Regarding the patient’s transition to oral antibiotics (once nausea and vomiting are controlled), I would prescribe 500 mg Azithromycin PO daily for seven days. Current clinical guidelines indicate that patients suffering from community-acquired pneumonia should be treated for 5-7 with an oral antibiotic after IV antibiotic therapy is complete (Kaplan & Mason, 2008). 

Regard patient education for HH, it is important for him to understand that his medical history of COPD, HTN, and diabetes put him at a higher risk for developing community-acquired pneumonia. I would highly recommend that HH receive the pneumonia vaccine because he is over 65 years of age and has a significant medical history. 

Flake, Z. A., Scalley, R. D., & Baily, A. G. (2004). Practical Selection of Antiemetics. American

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Kaplan, S. L., & Mason, E. O., Jr. (2008). Management of Infections Due to Antibiotic-Resistant

Streptococcus pneumoniae. Clinical microbiology reviews11(4), 628-644.

Stewart, L., Crawford, S. M., & Taylor, P. A. (2000). The comparative effectiveness of ondansetron

and granisetron in a once daily dosage in the prevention of nausea and vomiting caused by

cisplatin: a double-blind clinical trial. The pharmaceutical journal265(7104), 59-62.


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