Case 2: Sub Acute Breathlessness Flashcards
(100 cards)
1
Q
what are the common histological features of asthma?
A
mucus plugs
no ciliated epithelium
thickened basal membrane
hypertrophy/hyperplasia of the smooth muscle
2
Q
what common questions do we ask about a cough?
A
how long have you had the cough? is it there all the time?
does anything make the cough better or worse? is it worse at any particular time of the day e.g. when you lie down at night or does it wake you up at night?
is it a dry cough or are you producing sputum?
what is the colour/volume/tenacity of the sputum?
are there any red flag symptoms, e.g. haemoptysis?
how is the cough impacting your day-to-day life?
3
Q
what tests can be conducted for asthma?
A
exhaled NO
peak flow diary
spirometry
peak flow
a higher than normal level of NO means that there is inflammation in the lining of the airways or it could mean that you have allergic asthma. inflammation responds well to corticosteroid therapy.
4
Q
what is the normal range for peak flow?
A
400-700 litres per min
5
Q
what does use of an ICS inhaler increase the chance of?
A
oral candiases - unless you clean your mouth out after inhalation
6
Q
what is salbutamol?
A
beta 2 agonist
it is a short acting bronchodilator and is classed as a reliever medication. it works quickly to relax the airway muscles and has an immediate effect
7
Q
what is QVAR?
A
beclomethasone dipropionate
this is an inhaled corticosteroid which acts to reduce inflammation in the airways. it is classed as a preventer medication as it doesn’t have an immediate effect and may take weeks to work and is used to prevent ongoing asthma symptoms, by reducing airway inflammation and thereby bronchial hyper-reactivity to stimuli like cold air.
8
Q
what are some common SABA medications?
A
albuterol
levalbuterol
pirbuterol
salbutamol
tetrabutaline
9
Q
what are some common LABA medications?
A
salmeterol
formoterol
10
Q
what are some common ICS (inhaled corticosteroid) medications?
A
beclomethasone (QVAR)
Budesonide (Pulmicort Flexhaler, Pulmicort Respules)Ciclesonide (Alvesco)Fluticasone (Flovent HFA)Mometasone (Asmanex Twisthaler, Asmanex HFA)
Ciclesodine
Budesonide
11
Q
which health conditions are commonly associated with a wheeze?
A
COPD
obstructive pulmonary disease
cardiac failure
eosinophilic lung disease
asthma
12
Q
what are the reccommendations for someone with asthma participating in sport?
A
exercise is not always a trigger for asthma. even those with exercise-induced asthma can safely partake in sport. such patients should be advised to carry their bronchodilator inhaler (SABA - blue) with them and then take an additional dose in advance if physical activity is known to precipitate an attack
13
Q
why is it important to have the flu vaccination if you have asthma?
A
flu can be more serious for people with asthma, even if their asthma is mild or their symptoms are well-controlled by medication. This is because people with asthma have swollen and sensitive airways and lungs and flu can cause further inflammation of this. flu infection in the lungs can trigger asthma attacks and a worsening of asthma symptoms. it also can lead to pneumonia and other acute respiratory diseases.
asthma that requires continuous or repeated use of inhaled/systemic steroids or with previous exacerbations requiring hospital admission should therefore be offered the flu vaccination and be up to date with the government covid vaccination policies
14
Q
what is PEFR?
A
the PEFR is the rate of maximal volume of air that a person can exhale during a short maximal expiratory effort after a full inspiration.
predicted peak flow rates are calculated using the patient’s sex and height. normal values can be found on charts, online and on handy calculation wheels sometimes handed out by pharmaceutical companies.
15
Q
how do you record serial readings of PEFR and for how long?
A
for diagnosis 2-4 weeks, twice daily
for occupational asthma it may require 2-4 hourly reading over several weeks
16
Q
what is the link between bruising and steroid use?
A
you can get bruising as a result of steroid use - although this is very unlikely at inhaled doses
17
Q
what are some possible differential diagnoses for bruising?
A
bruising due to steroid use
bruising due to self-harming behaviour
domestic violence
sports-related trauma
18
Q
if a patient is having an asthma crisis and waiting for an ambulance, what treatment should you initiate whilst waiting?
A
using a salbutamol metred dose inhaler with a spacer has been shown to be as effective as jet nebuliser therapy. different treatment regimens can be used, from one puff every five minutes to six puffs in the spacer at once.
inhaled SABA (short acting beta 2 agonists) such as salbutamol, terbutaline, levalbuterol or perbuterol are the treatment of choice for treating acute symptoms of asthma and exacerbations.
Inhaled ipratropium bromide combined with an inhaled beta 2 agonist provide significantly greater bronchodilation than treatment with a beta 2 agonist alone, leading to a faster recovery and shorter duration of admission in severe or life threatening asthma
19
Q
what is respiratory acidosis?
A
this is a drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of CO2
20
Q
what is respiratory alkalosis
A
a rise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2
21
Q
what is metabolic acidosis?
A
this is a decrease in pH in blood and body tissues as a result in upset metabolism
22
Q
what is metabolic alkalosis?
A
high pH, high HCO3
23
Q
what is mixed metabolic and respiratory acidosis?
A
CO2 rises
HCO3 falls
low pH
24
Q
what is mixed metabolic and respiratory alkalosis?
A
a pathological condition which there is an elevated pH, a low pCO2 and an elevated HCO3 level, which occurs when there i both a respiratory and metabolic cause present at the same time - very RARE
25
What is the effect of pregnancy on asthma?
asthma symptoms can improve, stay the same, or worsen in pregnancy. most women will have a normal outcome but severe asthma can cause complications
women with asthma should be closely monitored and it is particularly important that asthma is well controlled to reduce risk of complications
women should be counselled about the importance and safety of taking their asthma medication during pregnancy to maintain good control. women who smoke should be advised about the dangers to themselves and to their baby and be offered appropriate support to stop smoking.
SABA, LABA, oral/inhaled corticosteroids, sodium cromoglicate and nedocromil sodium and oral IV theophylline can be used as normal during pregnancy.
having twins can push on the diaphragm and thus reducing lung expansions as you enter the third trimester which causes increased breathlessness in healthy women
26
what is the link between anaesthesia and asthma?
although a spinal anaesthetic is commonly used in a planned C-section, sometimes a general anaesthetic is required in an emergency or if there are contraindications to spinal anaesthesia.
One of the main criteria for choosing the type of anaesthesia is the ease of postoperative recovery, including control of postoperative pain, nausea and vomiting, and urinary retention. These side effects may delay hospital discharge or result in unplanned readmission. Spinal anaesthesia is a simple and reliable technique with a success rate of over 90%. However, general anaesthesia is commonly preferred because of its faster onset of action. Spinal anaesthesia is also associated with a better control of postoperative nausea and vomiting and a higher possibility of early discharge.
A history of asthma has several implications in the perioperative setting. The patient may present for an anaesthetic poorly optimized, particularly in the setting of urgent or emergent surgery. Because of airway hyperreactivity, bronchospasm may readily be precipitated by instrumentation, a variety of drugs, and perioperative complications such as aspiration, infection, or trauma. Emergence from anaesthesia presents a constant risk of laryngospasm and bronchospasm. Pain, fluid shifts, and delayed mobilization can contribute to an increased risk of postoperative pulmonary complications in these patients. These risks are exacerbated by the co-existence of chronic obstructive pulmonary disease (COPD) or active smoking.
27
what is LTRA? how does it work?
leukotriene receptor antagonist
it blocks the effects of leukotrienes which contrict the bronchi in the airway and thus results in bronchodilation
they also reduce the eosinophils which travel to the airways thus reducing inflammation and hyper-reactivity of the airways
28
what are the dangers of smoking in pregnancy?
miscarriage- stillbirth (baby dying in womb or shortly after giving birth)- ectopic pregnancy (pregnancy growing outside of womb)- birth defects in babies- premature birth (before 37 weeks of pregnancy)- low birth weight- sudden infant death syndrome, or cot death- increased risk of infant mortality
29
what are some smoking alternatives during pregnancy?
Nicotine replacement therapy (NRT) delivers nicotine into the blood stream without the toxic component of cigarette smoking. NRT alleviates cravings for tobacco and is an effective and safe smoking cessation tool and can be used in pregnancy.E-cigarettes can also provide a form of nicotine replacement but they have not been licensed or controlled and their safety in pregnancy is unclear. There is not as much evidence for e-cigarettes being a useful and safe aid to quitting smoking as there is for licensed and well established stop smoking medications. However some women have stopped smoking completely using an e-cigaretteThe patient should be offered referral to the smoking cessation services and offered nicotine replacement therapy.
3/5ths of all asthma is hereditary
30
what is the atopic triad?
asthma
allergic rhinitis
atopic dermatitis
31
What is the link between COPD and asthma?
patients that have symptoms consistent with both COPD and asthma may have some improvement in symptoms with use of bronchodilators but not as much as asthmatics experience.
there are a cohort of patients who have symptoms of chronic breathlessness on exertion, daily cough productive of sputum and features of COPD on radiology imaging such as hyperinflation. their lung function may show a reduced FEV1 in line with COPD and also reversibility on spirometry in response to salbutamol or diurnal variation.
this is termed as asthma/COPD overlap.
32
what is the definition of asthma?
asthma is a reversible airflow limitation caused by inflammation in the airways characteristically described as a Th2 airway inflammation.
33
what is foreign body aspiration?
this is sudden onset of airway obstruction caused by aspiration of a foreign object.
it is the most likely explanation of both unilateral silent chest and wheeze as the foreign body is completely occluding some airways and partially occluding others
34
what are some of the features of severe acute asthma?
peak flow 33-50% of best or predicted PEFR
respiratory rate > 25 pm
heart rate > 110 bmp
inability to complete sentences in one breath
35
pneumocystis jiroveci
a fungus causing severe pneumonia
36
aspergillosis
a respiratory disease caused by the fungus aspergillus
37
Haemophilus influenzae
Haemophilus influenzae is a Gram-negative, coccobacillary, facultatively anaerobic capnophilic pathogenic bacterium of the family Pasteurellaceae. The bacterium was argued by some to be the cause of influenza
38
moxarella catarrhalis
Moraxella catarrhalis is a fastidious, nonmotile, Gram-negative, aerobic, oxidase-positive diplococcus that can cause infections of the respiratory system, middle ear, eye, central nervous system, and joints of humans
39
cocci bacteria
any bacteria that is rounded, circular.
can be found almost anywhere and many good types are found in humans
it may cause skin irritations and sometimes serious diseases
40
diplococci
spherical bacteria that grow in pairs and cause diseases such as pneumonia
41
c difficile
this is a bacterium which is spread by spores in feces that are difficult to kill, it causes symptoms such as diarrhosea and nausea and can lead to serious inflammation of the colon
it is gram positive
42
what is a pack year?
it is the number of packs per day multiplies by the number of years the patient has smoked
43
what is pleurisy?
chest pain worse on inspiration
44
what is acute pericarditis?
chest pain better leaning forward, ST elevation everywhere, PR depression
45
what is myalgia?
muscle pain
46
what is endocarditis?
inflammation of the inner lining of the heart
47
what is green sputum?
stagnant sputum, gram negative bacteria (bronchiectasis, pseudomonas)
48
what is subacute breathlessness?
subacute dyspnea developing over hours to days could indicate acute asthma, exacerbation of COPD, pulmonary oedema, myocarditis, superior vena cava syndrome, eosinophilic pneumonia or cardiac tamponade
superior vena cava syndrome (SVCS) is a group of symptoms that happen when something blocks or compresses your superior vena cava. its often associated with cancer, but may involve an infection, blood clot or implanted medical device. severe cases can be life-threatening, especially in children
49
what is cardiac tamponade?
acute compression of the heart caused by fluid accumulation in the pericardial cavity
50
what are the characteristic signs of pneumonia?
fever, cough productive of green sputum, raised rr, raised temp, coarse inspiratory crackles, dullness to percussion
51
what is the CRB-65 score?
this is a score used for pneumonia, it may help us with making a decision on referring adults. the score is determined by awarding one point for each of the following features:
confusion - recent
RR - 30 bm or higher
BP - systolic 90mmHg or less or diastolic 60mmHg or less
age - 65 or older
52
what do the following CRB-65 scores mean?
3 or more
1 or 2
0
urgent admission
hospital assessment should be considered
treatment at home should be considered, depending on clinical judgement and social circumstances
53
what is the NEWS score?
it is used for adults over 16y who are not pregnant or suffering from spinal cord injury
it uses pulse, bp, rr, pO2, temp and consciousness to identify risk of serious underlying illness as well as deterioration
54
what is the GP sepsis screening tool?
if there are any of the flags from the sepsis tool then you do the sepsis 6 pathway to treat (search the image up)
unwell?
infection?
red flags present?
amber flags present?
55
what are the red flags for sepsis?
unresponsive
acute confusion
hypotension
tachycardia
high RR
low pO2
non-blanching rash
not passed urine in the last 18 hours
high lactate
56
what are sepsis 6 criteria management?
blood culture
urine output
fluids
antibiotics
lactate
oxygen
BUFALO
57
what are the cardinal features of pneumonia?
cough - may be dry or produce sputum which is characteristically rust/red coloured. there may also be haemoptysis
breathlessness - alveoli become filled with pus which impairs gas exchange, the patient will complain of feeling breathless, not able to lie down and have reduced pO2
fever - this can be very high up to 39.5 or 40
chest pains - commonly pleuritic in nature and become worse when coughing
58
what initial investigations would you undertake in someone with suspected pneumonia?
ABG
blood cultures
CRP
CXR
ECG
FBC
Lactate
LFT
U+E
59
what does a low platelet count mean?
increased risk of bruising and bleeding
60
what is CRP?
this is an acute phase protein produced by the liver in response to infection or trauma. CRP typically rises with any inflammation but to a much higher degree in patients with severe bacterial infections. CRP has been described as a test for pneumococcal pneumonia. very high levels are more indicative of infection whereas lower levels are seen in inflammatory conditions and malignancies.
61
what is the definition of CAP?
signs of lower respiratory tract infection (fever, cough, phlegm, crepitations or bronchial breathing) + CXR changes
62
how does pneumonia present in the frail/compromised?
the symptoms may be less pronounced. fever/cough may be absent.
in patients with underlying chest disease or heart failure, clinical signs are easily over-interpreted.
63
what are some non-pulmonary signs of pneumonia?
confusion, abdominal pain, diarrhoea, vomiting.
myalgia and arthralgia
pneumonia may also develop into sepsis
64
what can be seen on examination with pneumonia?
if there is a large area of consolidation, chest expansion can be reduced on the side of the infection.
dullness to percussion over the affected area can occur and 'stony dullness' is a sign of effusion.
on auscultation, creptitations or bronchial breathing may be heard over the affected area.
this can sometimes be accompanied with a pleural rub.
65
in pneumonia what are the FBC results of:
white cell count
Hb
Platelets
total white cell count increases in acute infection, neutrophil rise would indicate bacterial infection and neutropenia can indicate viral infection
low Hb anaemia can complicate pneumonia
high or low platelets can be indicative of an inflammatory process which would be in keeping with an infection diagnosis
66
in pneumonia what are the FBC results of:
U+E
LFT
CRP
Lactate
urea and creatine show acute kidney injury and could be a sign of sepsis
if LFT are abnormal it could be a reflection of reduced liver perfusion associated with sepsis
CRP is an acute phase protein produced by the liver in response to infection or trauma. CRP typically rises with any inflammation but to a much higher degree in patients with severe bacterial infections. CRP has been described as a test for pneumococcal pneumonia and was named after its ability to precipitate the C-polysaccharide of Strep. pneumoniae. Very high levels (>100) are more indicative of infection whereas lower levels are seen in inflammatory conditions and malignancies.
lactate is produced as a product of anaerobic respiration and increases in sepsis and shock. it is a marker of illness severity
67
what is the cellular pathophysiology of bacterial pneumonia?
it is characterised by acute inflammation of the lung parenchyma. this is associated with cellular infilatration, inflammatory exudate in the interstitium, alveolar oedema and haemorrhage. the alveolar spaces are filled with the inflammatory exudate resulting in consolidation of the alveoli.
68
what is CAP?
community acquired pneumonia infers that infection has been acquired without any contact with healthcare services
69
what is meant by typical and atypical pneumonia?
pneumonia is classically divided into typical and atypical organisms based on historical laboratory techniques: typical organism can be cultured in the laboratory whereas atypical organisms are intracellular pathogens and cannot be cultured using standard methods.
the division is clinically relevant as atypical organisms need to be treated with antibiotics which get into intracellular space and attack the cell wall
70
what are some typical bacterial causes of CAP?
streptococcus pneumonia
haemophilus influenzae
klebsiella pneumoniae
staphylococcus aureus
see onemed for a LOT more detail - needed
71
what are some atypical bacterial causes of CAP?
mycoplasma pneumoniae
legionella pneumophilia
chlamydia pneumoniae
chalmudia psittac
72
what is pleural effusion?
pleural effusion is common in pneumonia and complicates around 50% of cases. The majority are simply exudate however some can become empyema.
empyema is a collection of pus in the pleural space, signs of this can be swinging fevers and continued high inflammatory markers in the presence of appropriate antimicrobials. it is essential to sample this fluid and if empyema diagnosed the fluid drained as antimicrobial penetration into pus is poor.
pneumonia can also be complicated by sepsis.
73
what is empyema?
pus in pleural cavity
74
what is CURB-65?
1. Confusion
2. Uremia <7mmol
3. Respiratory distress <30RR
4. BP low
5. Age >65
75
When is CURB not helpful?
Primarily in patients under the age of 65 as they cannot score as highly as older patients; and as you remember from your Years 1 and 2 physiology, younger people tend to compensate so a 30 year old with a respiratory rate of 28 and a systolic blood pressure of 92mmHg would not score on CURB.
Conversely, patients with chronic renal impairment with a normal urea of around 7 may score an extra point for a raised urea but in reality it may be their baseline, it is always important to review current renal function in comparison to older results.
76
why should CAP patients have a CXR follow up?
a chest radiograph should be arranged after about 6 weeka for patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy (Espcially smokers and those ages >50). 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.
77
what are coarse crackles?
long duration, discontinuous, low pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa; evident with inspiration. COPD, heart failure, and pneumonia.
78
what is the sepsis 6?
within 1 hour:
take blood cultures
take urine output measurements
take serum lactate and FBC
give high flow O2
give antibiotics
give IV fluids
79
what tests do you need to do before starting antibiotics?
FBC, blood cultures, sputum, U+E, lactate, HIV
80
what are the common organisms when dealing with hospital acquired pneumonia?
staphylococci (inc MRSA)
enterococci
gram negative bacilli (E-coli or pseudomonas)
mixed flora (if aspiration pneumonia)
81
why does aspiration pneumonia usually involve the right lower lobe?
the right main bronchus is straighter from the trachea compared to the left main bronchus, so aspiration usually occurs in the right main bronchus. as the lower lobe is the straight continuation of the right main bronchus, aspiration follows the straighter path
82
What is aspiration pneumonia?
can occur when a foreign substance, such as vomit, is inhaled into the lungs
the right lower lung lobe is the most common site of infiltrate formation due to the larger caliber and more vertical orientation of the right mainstem bronchus
83
describe HAP
hospital acquired pneumonia is defined as new onset of symptoms along with a compatible x-ray developing more than 48 hours after the patient's admission into hospital. it occurs in around 1% of in-patients and its consequences can range from extending the patients hospital stay to increased mortality
HAP can be early or late onset. early onset occurs within 4-5 days of admission and is usually caused by antibiotic sensitive community organism.
late onset occurs after 5 day and is more likely to be caused by antibiotic resistant hospital pathogen
84
describe VAP
ventilator associated pneumonia is HAP occurring in patients on mechanical ventilation. the mortality rate from AP can reach 50% or higher.
85
what are the specimen types for CAP and VAP
sputum - some patients have difficulty in expectorating a sample. even when they do, the result may not reflect the organism at the site of infection e.g. upper respiratory tract flora may contaminate the sample
broncho-alveolar lavage - in ventilated patients, direct sampling of deep respiratory secretions is possible and produces good quality results
86
what are the risk factors for CAP and VAP?
ICU stay, mechanical ventilation
prolonged hospital or ICU stay (with increasing risk of multi-drug resistant organisms)
severe underlying illness, multiple co-morbidities
underlying respiratory disease (e.g. COPD, asthma)
abdominal surgery, vomiting/aspiration
87
Bacterial causes of late onset HAP
Enterobacteria: E. coli, Klebsiella sp., Enterobacter sp., Serratia sp.
Gram negative bacilli
GI tract commensals
Translocate to respiratory tract in hospitalised patients with multiple underlying morbidities
May be multi-drug resistant
Staphylococcus aureus (including MRSA)
Gram positive coccus
Upper respiratory tract commensal
Aspiration of upper respiratory secretions into lower respiratory tract can result in pneumonia
Pseudomonas sp.
Gram negative bacillus
Innately resistant to many antibiotics
Can colonise moist areas (both in patients and in the environment). Immunosuppressed or those previously exposed to antibiotics particularly at risk.
Environmental gram negatives: Acinetobacter sp., Stenotrophomonas maltophilia
Multi-drug resistant and difficult to treat
Usually cause infection in significantly immunosuppressed or ventilated patients
88
how would you differentiate between an effusion and consolidation radiologically?
they both produce opacification of the lung field
in consolidation, the margins of opacification are not as clear as compared to effusions
in effusions the opacification is dense and there are no markings visible in the lung field. in consolidation, you can see air bronchograms, so the opacification is not dense
the diaphragm/costo-phrenic and cardio-phrenic angles are not visible in effusions
while these may still be visible in consolidation depending on area of lung affected
89
describe viral pneumonia
The commonest viruses to cause pneumonia in adults are influenza A and B. However, adenovirus, para-influenza and respiratory syncytial viruses can also cause pneumonia. Coronaviruses should also be considered. Although SARS-CoV-2 is the most famous coronavirus, there are other important coronaviruses to be aware of, namely Middle East respiratory syndrome-related coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome coronavirus (SARS-CoV). Diagnosis of these viruses can be made using PCR based techniques: taking a viral nasopharyngeal or throat swab for influenza or respiratory viruses is recommended and is a quick and effective test. Pneumonia due to influenza is often complicated with a post viral superinfection with bacteria or in severe cases with fungi like Aspergillus
90
what are some respiratory symptoms of covid?
hypoxia
breathlessness
cough
91
what is the main cause of fungal pneumonia?
In the UK, Pneumocystis jirovecii is the most common cause of fungal pneumonia. It is mainly seen in patients with altered cell-mediated immunity (immunodeficiency incl. HIV, immunosuppression e.g. after transplantation) but can also occur in patients with a severe underlying respiratory condition (COPD, Cystic Fibrosis)
92
what is aspergillus?
Aspergillus is an environmental mold that can also cause lung disease. The type of disease is dependent on the host immune response. This can range from invasive aspergillosis in extremely immunocompromised patients, to chronic pulmonary aspergillosis in patients with relatively normal immune function but structural lung disease, to allergic bronchopulmonary aspergillosis (ABPA) in patients suffering from an exaggerated allergic immune response to aspergillus.
93
what organism causes TB?
Mycobacterium tuberculosisOther mycobacterium and non-tuberculous mycobacterium (NTM) species are increasingly recognised as a cause of pulmonary infection. These are slow growing bacteria with a lipid rich cell wall, they can survive in the environment and in the human body for years.
94
describe TB
Following exposure, the alveolar macrophages engulph the mycobacterium to eliminate the infection. However, the mycobacterium can evade the immune system and replicate within the macrophages, they are contained by lymphocytes forming a granuloma. This is latent TB, and the patient will be asymptomatic.5-10% of latent TB becomes active TB, this can happen at any time. The risk of active TB is higher in those with compromised or suppressed immune systems (HIV, malnutrition, diabetes, immunosuppressants).
95
what are some common symptoms of TB?
Common symptoms of active lung TB are productive cough, hemoptysis, chest pains, weakness, weight loss, fever, and night sweats, all lasting more than 2-3 weeks. Tuberculosis can spread via bloodstream to cause extrapulmonary manifestations (such as brain, joints, lymph nodes). This is seen particularly in immunocompromised patients. Disseminated TB (milliary TB) has high mortality despite treatment.
96
how do we diagnose TB?
Diagnosis is made from sputum samples sent for direct microscopy (specific acid-fast staining) and PCR. A sample should also be sent for TB culture for speciation and sensitivity testing as antibiotic resistance is common. A chest X-ray can show apical fibrosis, cavitation and paratracheal hilar lymphadenopathy. Multiple small nodules may be present (milliary TB). Past infection sometimes shows as calcification.
97
what is the treatment of TB?
While TB is a serious condition that can be fatal if left untreated, deaths are rare if treatment is completed. Active pulmonary TB requires a 6-month course of a combination of antibiotics. The standard treatment is 2 antibiotics (isoniazid and rifampicin) for 6 months and 2 additional antibiotics (pyrazinamide and ethambutol) for the first 2 months. It may take several weeks before the patient starts to feel better. Most patients become staining negative and non-infectious in 2 weeks.
98
A 67 year old man is admitted to A&E with a one week history of cough, productive of rust-coloured sputum, fever and anorexia. He is on no other medications and is otherwise well. On examination he is alert. His pulse is 110 bts/min, BP 95/65 mmHg, heart sounds normal. He has a respiratory rate of 35 bths per minute and crackles in left lower lobe. His temperature is 39 degrees Celsius. His blood tests come back showing a CRP 100 (normal < 10), WCC 12.6 and Urea 6 mmol/l. His CXR shows consolidation in the left lower lobe. With regard to the patient's CURB-65 score, what is the risk of mortality for this patient?
The CURB65 is 2. Using MD Calc 30 day mortality is predicted as 6.8% and 3-15% in the NICE guidelines.
99
A 20 year old man is admitted to A&E with a one week history of cough, productive of rust-coloured sputum, fever and anorexia. He is on no other medications and is otherwise well. On examination he is confused. His pulse is 130 bts/min, BP 80/50 mmHg, heart sounds normal. He has a respiratory rate of 40 bths per minute and crackles in left lower lobe. His temperature is 39 degrees Celsius. His blood tests come back showing a CRP 260 (normal < 10), WCC 12.6 and Urea 8 mmol/l. His CXR shows consolidation in the left lower lobe. With regard to the patient's CURB-65 score, which of the following is the single best course of action?
The CURB65 is 4 and the patient is hemodynamically compromised. The patient should be admitted to a high dependency unit for iv antibiotics and monitoring.
100
A 35 year old man presents to the GP with a cough productive of a small amount of green sputum. He looks unwell and has a high fever. He has been unable go to work and has spent most of the weekend in bed with fevers and generalised aches. He is managing fluids, even though he has lost his appetite, and is usually very fit and well. He has some crackles on left when you auscultate his lungs with your stethoscope. His blood pressure is normal and his respiratory rate is not raised. What is the most appropriate next step in management for the GP?
This gentleman has symptoms and signs consistent with pneumonia so antibiotics should be started without delay. He is young, has a normal blood pressure and respiratory rate and is not confused so could be treated at home with oral antibiotics with advice to ring GP urgently if he becomes short of breath, confused or dizzy and lightheaded.
