 Welcome back to Pneumonia Part 2. In this part, we'll discuss how to diagnose a pneumonia and how to treat it. The diagnosis can consist of labs and imaging. Of the two, imaging is the most helpful. We do often do labs in these patients. In patients with pneumonia, we expect their wipelous cell count to go up, together with their neutrophils. We also expect their platelet to go up as part of an acute phase reaction. In terms of their electrolytes, sicker patients might have nebulatremia. They may also be acidotic. They might have impaired renal function. Sometimes an ABG is done in patient with respiratory failure. In the well-looking patients, an ABG is not necessary. Imaging is key for diagnosis of pneumonia. The imaging of choice here is a chest x-ray. If the patient is too sick to leave the department, we can just start with a portable chest x-ray. If they're well enough to leave, then we do two views of the chest. Let's look at what an x-ray would look like in the patient with pneumonia. In this patient with a portable chest x-ray, could you tell where the infiltrate is? The infiltrate is on the right side of the lung, in the right upper lobe. This is typical of a right upper lobe pneumonia. What about this chest x-ray? Can you see where the infiltrate is? It's also on the right side, but this time it's on the right middle lobe. This is a right middle lobe pneumonia. If you're interested in learning how to read chest x-ray, I've included a resource on the blog. Let's move on to treatment. As with all emergency department patients, we would like to start with ABC. Then we'll delve into specific treatment for pneumonia. And then we'll decide who can go home and who need to stay in the hospital. First, ABC. If the patient is not protecting their airway or if they're in significant respiratory distress, we may have to intubate them. For B, what if the patient is hypoxic? We will give them supplemental oxygen. What about for circulation? What if the patient is hypotensive or tachycardic? We need to give them IV fluids. Crystalloids such as neuronal saline and ringers lactates are both good choices. Once the patient is more stabilized, we can move on to more specific therapy. In this case, antibiotics. In the previous video, we discussed that the organism responsible for the pneumonia has to depend on both the patient and the setting that they get their pneumonia from. We will follow that classification when we discuss the antibiotic choices. Keep in mind that the choice of antibiotics will depend on what your local prevalence and resistance organisms are. And therefore, even though we'll be discussing some specific antibiotics, it is best to check with your local consultants. First, the healthy patient who has a community-acquired pneumonia. Or CAP for short. In the healthy patient, a macrolide or doxycycline are good choices. We can also consider IV antibiotics for the patients who are sicker. Either IV septraxone and a macrolide. IV fluoroquinolone is also a good choice. What about the community-acquired pneumonia patient with a comorbidity? If their comorbidity is general immunosuppression, then the IV form of antibiotics that we just talked about, i.e. fluoroquinolones or septraxone plus macrolides, will be good choices. In the patients with COPD, the same regimen would also work. In patients with HIV that were worried about PCP pneumonia, tri-methoprim salvamethalsazole is a good choice. In patients who have an aspiration pneumonia, we want to target anaerobes. Clendamycin is often used. In those who have had a healthcare or hospital-acquired pneumonia, since they can have much more different bacteria, we need to go broader and stronger in terms of antibiotics coverage. Suitable regimen include again septraxone, fluoroquinolones, and vancomycin if we're suspecting methicillin-resistant staph aureus. These are just examples of regimen you may choose to use here. Depending on your institution, you may be choosing different drugs. For viral pneumonia, it is often in the context of a pandemic. You should refer to the local guidelines at that time to see whether you should be using antivirals or not. The next part is risk gratification. That is, who should be admitted, who can go home, and who should be admitted in the ICU. There are two very helpful tools that help us decide. The first one is called CURP65, and the other one is called the Pneumonia Severity Index. On the blog, under other resources, you see both of these discussed in details by other sites. We'll first talk about CURP65. This score used five risk factors to see the overall risk of death of 30 days. The more number of risk factors, the higher the risk. It stands for confusion, urea more than 7 millimoles per liter. The R stands for respiratory rate more than 30 per minute. B stands for blood pressure, either a systolic less than 90 or a diastolic less than 60. 65 stands for age greater or equal to 65 years old. Each score is given one point. The higher the number of points, the higher the risk of mortality at 30 days. Patients with the score of 5 has an almost 60% chance of death at 30 days. For patients with a score of 0 to 1, they're usually treated as an outpatient. A patient with a score of 4 to 5 needs hospitalization. They might need the ICU. For those with a score of 2 to 3, they can consider a very short stay in the hospital unless they have very close follow-up as an outpatient. Another rule is known as the Pneumonia Severity Index or the PORT score. Again, this is also a brisk stratification tool to decide for mortality morbidity in the patients with Pneumonia. It uses a lot of data points to calculate the overall score, including their age, gender, whether they're from a nursing home, comorbidities such as cancer, liver disease, congestive heart failure, or history of cerebral vascular disease. On the physical examination, it looks for altermental status, increased heart rate, increased breast rate, hypertension, and a high or low temperature. It also draws in multiple lab and radiological findings. Similar to the Curve 65 score, the higher the number, the higher the 30-day mortality. We won't go through each single item here, but I will refer you back to the blog for the other resources that discussed this tool. In summary, we discussed the diagnosis and treatment of Pneumonia. We know that the diagnosis hinges on a chest x-ray. For treatment, we always start with ABC for the emergency patient. Once the patient is stabilized, we will also give them antibiotics. The choice of the antibiotics will depend on who the patient is and where the setting that they'll require their Pneumonia from. Lastly, we also discussed two brisk stratification tools. They'll help us decide whether the patient can be treated as an outpatient or should be admitted. We hope you find this useful. Thank you for watching.