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* PCP Pneumonia case from Archer CCS - solving steps
 #862971  
  mkusmle3 - 08/16/20 23:12
 
  Case of PCP pneumonia (from Archer CCS) - typically, it is a 10-min case.

Patient comes with known history of HIV, non-compliant, recent CD4 180. Dry cough, low-grade fever and dyspnea At admit, vitals temp : 100, RR 24, HR 110

10-MIN case. Needs to be fast. They are testing for really 3 to 4 very essential steps as mentioned below which are life saving.

Treatment should be initiated as soon as the diagnosis is suspected in a patient with risk factors for PCP ( as per Archer Review CCS , you DO NOT need confirmation of the diagnosis to initiate treatment. The confirmation should be obtained, where possible, only to make a decision regarding the continuation of treatment ). So once you know the risk profile, case history and after quick 4 to 5 min physical, you place orders.

stabilizing orders, monitoring pulse ox, CXR, CBC, CMP, U/A, blood cx if fever. Pulse ox comes back 88, stop clock --> place O2 protocol, ABGs. Advance clock 20 minutes to get to cxr-->

CXR shows bilateral infiltrates, diffuse, interstitial. ABGs come back Pa02 68. Stop clock --> Place treatment orders ( BACTRIM IV is a must right away and CONCURRENT CORTICOSTEROIDS if criteria met for steroids, bronchoscopy orders, LDH, sputum stain for pneumocystis -- your simulated time is being assessed and being scored here because it is a 10-min respiratory failure case.

They want you to act fast! You order tests to confirm PCP BUT YOU DO NOT WAIT for tests to return to manage presumptive PCP.
They want to see how soon you would place Rx as well as Steroids if ABG shows A-a > 35 or Pa02 < 70. See what ABG shows and act based on that whether or not pt needs steroids. As you know the report times for washings, cultures, etc take a lot of time to return.

For this reason, treatment is based on pre-test probability - an HIV patient, with low CD4 esply less than 200 or those on high dose steroids/ immunosuppressive therapy coming with dry cough, elevated LDH, bilateral cxr infiltraes - presumptive treatment for both PCP and Bacterial/atypical pneumonia is started right away after CXR findings. In HIV with low CD4, the disease can be indolent and may not even have a fever. But on CCS, you are often given fever, dry cough symptoms.

Either way, CXR diffuse bilateral interstitial infiltrates is classic in a patient profile mentioned above and should prompt you to initiate treatment ASAP. If someone has no such risk factors but comes with fever + diffuse bilateral CXR infiltrates, you do not suspect PCP, instead, you would suspect other types of pneumonia. So please note it is RISK FACTORS plus CXR typical infiltrates = presumptive suspicion of PCP!! You start treatment. You get an ABG on the initial screen because of resp symptoms and low sat.

The one that Archer CCS presents in 10-min is more serious with a high A-a gradient. If pA02 < 70 or A-a gradient is greater than or equal to 35, PROCEED to order ORAL PREDNISONE or IV Solumedrol ..CONCURRENT WITH BACTRIM!! WE WILL BE SCORED FOR THIS! Nothing else is needed in this 10-min cases, its all about these lifesaving orders...no screening on 2-mins and all that nonsense.

The reason for steroids, I am sure you are aware is that there is increased inflammation in the lungs as a reaction to killed pneumocystis particles following bactrim/abx. Corticosteroids given concurrently with anti‐PCP therapy helps to minimize this inflammatory process. So in some with respiratory failure already, there is no room for further deterioration ... So it is CRUCIAL to do steroids along with antiPCP therapy before more inflammation happens.

Here is a clipped side from Archer lectures: https://www.slideshare.net/usmlegalaxy/pulmonology-critical-care-archer-step3-...c=clipshare
 
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* Re:PCP Pneumonia case from Archer CCS - solving st
#3389863
  mkusmle3 - 08/24/20 22:36
 
  anyone have cystic fibrosis and pneumonia case approach?  
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