Week Two - Case Two Flashcards

1
Q

what is pneumonia and what is it characterised by

A

a common lower respiratory tract infection and is characterised by inflammation of the lung tissue.

it is almost always an acute infection, and almost always is caused by bacteria.

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2
Q

what is diagnosis of pneumonia usually confirmed by

A

chest x-ray

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3
Q

what is the most fatal hospital acquired infection

A

pneumonia

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4
Q

what percentage of pneumonia cases at pneumococcal in cause and what are the rest

A

75% of cases are pneumococcal in cause, and 20% atypical. The remaining 5% may be caused by aspiration of vomit, radiotherapy and allergic mechanisms.

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5
Q

what is hospital acquired pneumonia defined as

A

pneumonia that develops 48hrs after admission

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6
Q

what is the prognosis for hospital acquired pneumonia

A

generally poor, due to co-morbidities, older age range of patients, and resistance of organisms

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7
Q

what are the common organisms in hospital acquired pneumonia

A

gram negative bacilli, staphylococcus aureus

drug resistant organisms are more common and are more dangerous

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8
Q

what is the prognosis for community acquired pneumonia

A

generally good, especially for younger patients

S. pneumoniae and viral pneumonias are still fatal in older patients

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9
Q

what are the common organisms in community acquired pneumonia

A

streptococcus pneumoniae, haemophilius influenzae

anaerobes are rare

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10
Q

what does step pneumoniae infection often follow

A

often follows viral infection with influenza or parainfluenza

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11
Q

what is hospital acquired infection often with

A

gram negative organisms

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12
Q

what are the symptoms of pneumonia

A

Typically the same for hospital acquired / non-hopsital acquired cases

Shortness of breath

Cough
May be productive in adolescents and adults – Purulent sputum possible
Often dry in infants and the elderly

Fever

Rigors

Vomiting

Headache

Loss of appetite

Very occasionally – haemoptysis

Pleuritic chest pain – which may on occasion radiate to the shoulder (if diaphragm is involved) or the anterior abdominal wall
Pleuritic chest pain – a sharp shooting or stabbing pain, usually in the side, that is most painful on inspiration, but can also be felt on expiration, or even whilst talking.

Upper abdominal tenderness in some patients with lower lobe pneumonia

Signs of consolidation – both on examination and CXR

Dyspnoea

Tachypnoea

Tachycardia

Increased secretions – noticeable in ventilated patient in hospital acquired cases

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13
Q

what are the signs seen in strep pneumoniae

A

rapid shallow breathing and pleural rub

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14
Q

what may be the only sign in elderly patients

A

confusion

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15
Q

what oxygen saturation is usually worrying

A

<92%

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16
Q

what would a CXR look like

A
  • evidence of infiltrate in the form of consolidation
  • changes may not appear for up to 48hrs after symptoms, however, after effective treatment, consolidation may still be seen on CXR for up to 6 weeks
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17
Q

what is not routine in community acquired infection of pneumonia

A

blood cultures to assess the identity of the causatory organism

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18
Q

what would a FBC show

A
  • elevated WCC
  • elevated ESR (>100mm/h) and increased CRP
  • possible anaemia (sign of abscess)
  • blood cultures - check for septicaemia
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19
Q

why would one take a urine sample in suspected pneumonia

A

in severe cases of pneumonia, where legionella is suspected, urine testing for legionella antigen may be indicated

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20
Q

what is pleural fluid aspiration test used for

A

to assess for organisms.

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21
Q

what is the CURB-65 score and what is it used for

A

used to assess the severity of community acquired pneumonia. it predicts the risk of mortality. (CURB score 0 = <1% risk, CURB score 5= 60% risk). Each factor of the score is worth 1 point

C – Confusion – use the abbreviated mental test (score ≤8)

U – Urea – >7mmol/L

Respiratory rate – ≥30/min

Blood Pressure <90 systolic, or <60 diastolic

65 – age >65 years
A score ≥3 is severe pneumonia. ≥2 requires hospitalisation

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22
Q

what are the differentials for pneumonia

A

PE - patient is not usually scenically unwell. shortness of breath is more likely to be of a sudden onset

pulmonary/pleural TB

pulmonary oedema

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23
Q

what is the treatment for pneumonia if not vomiting and CURB65 score is < or equal to 2

A

use oral antibiotics, if severe and/or vomiting IV antibiotics are required

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24
Q

what should oxygen saturation be kept at

A

> 92%

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25
Q

what is used to prevent dehydration and shock

A

fluids

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26
Q

what is the most common complication of pneumonia

A

respiratory failure

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27
Q

what is respiratory failure defined as

A

PaO2 <8kPa.

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28
Q

what is respiratory failure treated with

A

60% oxygen (high flow)

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29
Q

what should you aim to keep stats at when on oxygen

A

90-94%

30
Q

what may be given if atrial fibrillation occurs

A

this is the most common complication in the elderly. it usually resolves but digoxin may be given to reduce the HR as short term therapy

31
Q

what is empyema

A

the infection of the pleural fluid

32
Q

what is lobar collapse most commonly the result of

A

sputum retention

33
Q

what is a late complication of pneumonia

A

lung abscess - this is a cavitating lesion containing pus within the lung

34
Q

what can septicaemia result in

A

infective endocarditis and meningitis

35
Q

what is the most common type of pneumonia

A

strep-pneumonia

very commonly preceded by viral infection

36
Q

what happens in cases of strep pneumoniae

A

the patient will rapidly become febrile, with a temp of up to 39.5, pleuritic pain and dry cough

may be pleural rub and rust coloured sputum

37
Q

what strains are common in the young, but rare in the elderly

A

Mycoplasma pneumoniae, Chlamydia pneumoniae

38
Q

what stains are common in the elderly but not in young people

A

Haemophilus influenzae

39
Q

if someone smoked 5 cigarettes per day for 60 years what is their smoking history in pack years

A

5 cigarettes per day = 1/4 pack

60 x 1/4 = 15 pack years

40
Q

what is myalgia

A

muscle aches and pain

41
Q

what is anosmia

A

partial or full loss of smell

42
Q

what does a CURB65 score of greater than 3 mean

A

urgent admission to hospital

43
Q

what initial investigations should u order when querying pneumonia

A
  • ABG
  • blood cultures
  • CRP
  • CXR
  • ECG
  • FBC
  • Lactate
  • LFTs
  • U+E
44
Q

what is the initial management of a patient with potential pneumonia

A
  • start oxygen
  • monitor urine output
  • start antibiotics
  • start IV fluids
45
Q

what is an elevated lactate level indicative of

A

sepsis

46
Q

what samples would you send to the microbiology labs if querying CAP

A
  • sputum cultures
  • blood cultures
  • HIV test
  • respiratory virus screen
  • urine pneumococcal and legionella antigen
46
Q

what are the common clinical presentations of someone with pneumonia

A

cough: may be dry or productive. Sputum in pneumococcal pneumonia is characteristically rust coloured.

breathlessness: alveoli become filled with pus which impairs gas exchange, the patient will complain of feeling breathless, not able to lie down and reduction in oxygen saturations

fever: this can be up to 39.5 to 40 degrees

chest pains: commonly pleuritic in nature and worse when coughing

47
Q

what is a sign of effusion

A

Dullness on percussion

48
Q

what in particular do we want to look at in the FBC

A

white cell count

haemoglobin

platelets

49
Q

what is bacterial pneumonia characterised by

A

acute inflammation of the lung parenchyma

this is associated with neutrophil inflitration

50
Q

what test should patients presenting with pneumonia be offered

A

a HIV test

51
Q

what kind of bacteria is streptococcus pneumoniae

A

gram positive coccus

52
Q

what is the key information of streptococcus pneumoniae

A

Commonest cause of CAP, up to 80% of infections.

Can be detected from blood culture (in 30% of cases) or via urinary antigen.

Vaccine available for babies and >65 year olds, for immunosuppressed and asplenic patients and those with long term conditions.

Rates of infection have fallen due to immunisation.

53
Q

what type of bacteria is haemophilus influenzae

A

gram negative bacillus

54
Q

what is the key information about haemophilus influenzae

A

Rates of infection have fallen as children now immunised.

Note: vaccine does not cover for all serotypes and is not particularly efficient in adults

Around 20% of UK strains now resistant to penicillins.

55
Q

what type of bacteria is Klebsiella pneumoniae

A

gram negative bacteria

56
Q

what is the key information about Klebsiella pneumoniae

A

Commensal organism of the GI tract.

Elderly patients and people with comorbidities at increased risk, alcohol excess also risk factor

Clinically tends to affect upper lobes

Inherently resistant to penicillins, cephalosporins recommended, penicillin combined with a beta-lactamase inhibitor may be an option.

57
Q

what type of bacteria is staphylococcus aureus

A

gram positive coccus

58
Q

what is the key information about staphylococcus aureus

A

Chronic lung pathology also a risk factor, i.e., cystic fibrosis and bronchiectasis

Flucloxacillin mainstay of therapy but important to consider MRSA if not improving

59
Q

what are the atypical causes of pneumonia

A

mycoplasma pneumoniae

legionella pneumonophilia

chlamydia pneumoniae

Chlamydia psittaci

60
Q

what is the key information about mycoplasma pneumoniae

A

Can be associated with epidemics and tends to affect younger patients.

Dry cough Patchy consolidation on CXR

Cannot be cultured in routine laboratories, diagnosis by PCR or serology

Treat with macrolide

61
Q

what is the key information about legionella pneumophilia

A

Occasionally sporadic cases but often occur in outbreaks, associated with air conditioning systems.

Think of this in patients who have recently been on holiday.

Tends to affect males (2:1 ratio) and smokers.

Prodromal syndrome of high fevers before a dry cough develops

Can be diagnosed with urinary antigen testing.

Treat with macrolides.

5-10% of CAP.

Occurs in outbreaks in families and institutions

62
Q

what is the key information about chlamydia pneumoniae

A

Young adults and extremes of age vulnerable

Diagnosis made on acute and convalescent serology or PCR Treat with macrolide or doxycycline.

Around 3% of CAP

63
Q

what is the key information about Chlamydia psittaci

A

Classically associated with contact with birds esp. parrots and pigeons

Can occasionally cause hepatosplenomegaly

Diagnosis made on acute and convalescent serology or PCR Treat with macrolide or doxycycline.

64
Q

what is meant by typical and atypical pneumonia

A

Pneumonia is classically divided into typical and atypical organisms based on historical laboratory techniques: typical organisms can be cultured in the laboratory whereas atypical organisms are intracellular pathogens and cannot be cultured using standard methods and alternative diagnostic tools are needed. This division is clinically relevant as atypical organisms need to be treated with antibiotics which get into intracellular space (e.g. macrolides). Also, atypical organisms do not possess a cell wall on which penicillins or cephalosporins can act.

65
Q

what is common in pneumonia and complicates around 50% of cases

A

pleural effusion

66
Q

what is empyema

A

collection of pus in the pleural space

67
Q

what antibiotics should be started for case patients pneumonia

A

Co-amoxiclav 500/125mg tds clarithromycin 500mg bd for 5/7

As per CURB65 guidelines, this prescription offers broad spectrum cover of potential microbial causes of pneumonia.

68
Q

why do we prescribe clarithromycin

A

In severe pneumonia, we add additional antibiotic treatment (typically with clarithromycin) to broaden antibiotic spectrum and cover atypical bacterial causes of pneumonia.

69
Q

what should happen to all pneumonia patients after 6 weeks

A

have a follow up CXR in 6 weeks because

chest radiograph should be arranged after about 6 weeks for patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy (especially smokers and those aged >50 years. The vast majority of patients (98%) who are diagnosed with CAP have a significant risk factor for underlying malignancy. Follow-up CXR screens for malignancy after the acute infiltrate has cleared.

70
Q
A