CR4

Question 1

1. What is the difference between community-acquired pneumonia and hospital-acquired pneumonia? (2 mark)

Answer 1

Community-acquired pneumonia is contracted outside of hospital (1 mark)
Hospital-acquired pneumonia occurs 48 h or more after hospital admission (1 mark)

Question 2

2. Define the acronyms CB65 in the diagnostic algorithm CRB65? (3 marks)

Answer 2

C: Confusion (1 mark); 65: 65 years of age or older (1 mark);
B: Blood pressure (1/2 mark): SBP< 90 mm Hg OR DBP greater than 60mmHg (1/2 mark, need to include correct units)v

Question 3

3. List two clinical investigations carried out in hospital for a patient suspected with community-acquired pneumonia? (2 marks)

Answer 3

X-ray
Blood culture
Sputum culture
Full blood count
Liver function tests (1 mark for each)

Urea and electrolytes to inform severity assessment
C-reactive protein to aid diagnosis and as a baseline measure (1/2 mark for each)

Question 4

4. What is the minimum number of days a patient with pneumonia may receive antibiotics? (1 mark)

Answer 4

Minimum duration of 5 days (1 mark)

Question 5

5. Why was Mrs Sinclair prescribed controlled oxygen therapy and what range of SpO2 should be maintained in a patient with asthma on controlled oxygen therapy? (2 marks)

Answer 5

To treat her hypoxaemia (i.e. low blood oxygen saturation levels, spO2 below 94%) (1 mark)
Maintain SpO2 between 94–98% (1 mark; 1/2 mark if range not cited)

Question 6

Asthma is a common chronic inflammatory condition of the lung airways whose cause
is incompletely understood. It has which three characteristics? [3]

Answer 6

a) airflow limitation
b) airway hyper-responsiveness
c) inflammation of the bronchi with eosinophils, T-lymphocytes and mast cells

Question 7

Describe the pathophsyiology of asthma [4]

Answer 7

i. Allergen picked up by dendritic cells and presented by MHC Class II molecules
ii. CD4 cells activate the TH-2 lymphocytes through the release of IL4, IL5, IL13.
iII. IL 4 leads to the production of IgE antibodies: coat mast cells and stimulate degranulation and the release histamines, leukotrienes and prostaglandins
iv. IL-5 activates eosinophils: causes more cytokine & leukotrienes release
v IL-9 = mast cell proliferation

Question 8

Describe the difference in IL-5 and IL-9 in asthma pathophysiology [2]

Answer 8

1. IL-5 = Eosinophil activation
2. IL-9 = mast cell proliferation

Question 9

Describe the acute effects of an asthma attack [3]

Answer 9

1. smooth muscle around bronchiole to spasm: bronchoconstriction
2. increased mucus production
3. increase in vascular permeability

Question 10

Describe the chronic effects of asthma [4]

Answer 10

Chronic effects: causes airway remodelling
1. Oedema
2. Fibrosis of airways
3. Thickening of epithelial basement membrane
4. mucous gland hyperplasia and hypersecretion

Question 11

Describe the symptoms of asthma [5]

Answer 11

Episodic symptoms:

ii. Diurnal variability. Typically worse at night.
iii. Dry cough with wheeze and shortness of breath
iv. A history of other atopic conditions such as eczema, hayfever and food allergies
vi. Bilateral widespread “polyphonic” wheeze heard by a healthcare professional. BUT: neither sensitive nor specific for asthma
vii. Prolonged expiratory phase (respiratory and expiratory phases should be equal)

Question 12

Describe lung function test results in asthmatic patients:

FVC [1]
FEV1 [1]
FEV1/FVC [1]
PEF (with treatment) [1]

Answer 12

FVC: may be normal in Asthma Ptx
FEV1: reduced
Bronchodilator reversibility test: FEV1 improvement >12% / 200ml is a positive test in adults & > 12% in children
FEV1/FVC: <70%
Peak expiratory flow: Treatment brings a reduction in variability of airflow

Question 13

Describe asthma treatment pathway

Answer 13

Reliever medication: Short acting beta 2 agonists (SABAs)
1. Adrenalin acts on the smooth muscles of the airways to cause relaxation.
2. This results in dilatation of the bronchioles and improves the bronchoconstriction present in asthma

First line therapy:
* Low dose inhaled ICS (if need, may required higher doses)

Add on therapy:
* ICS + inhaled long acting beta 2 agonists (LABA) or long acting anti muscarinic (LAMA)

Add on therapy:
ICS + LAMA / LABA + specialist therapies

Question 14

What is MART / SMART therapies? [1]

Answer 14

is a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required.

Question 15

ICS causes a reduction in why three pro-inflammatory mediators in asthma? [3]

Answer 15

IL-6, TNF-a & CXCL8

Question 16

British thoracic society Guidelines state that Life threatening asthma is
present in a patient with any of which factors?

Answer 16

Question 17

Two leading causes of pneumonia? [2]

Answer 17

2. Streptococcus pneumoniae (50%)
3. Haemophilus influenzae (20%)

Question 18

Why can pneumonia lead to sepsis? [1]

Answer 18

1. Loss of barrier function between alveoli and capillaries may lead to spread of infection (sepsis)

Question 19

Describe the management for mild, moderate and severe pneumonia [3]

Answer 19

i. Mild CAP: 5 day course of oral antibiotics: amoxicillin or a macrolide (azithromycin)
ii. Moderate to severe CAP: 7-10 day course of dual antibiotics (amoxicillin AND macrolide (azithromycin)
iII Severe Benzylpenicillin if blood culture tells you something different

Question 20

g. Patient should be reviewed 24 hrs before discharge
i. Should not have two more of those
1. Temp above []
2. HR > [] bpm
3. RR > [] per min

Answer 20

1. Temp above 37.8
2. HR > 100 bpm
3. RR > 24 per min

Question 21

What is ‘silent chest’ in life threatening asthma? [1]

Answer 21

• No wheeze. This occurs when the airways are so tight that there is no air entry at all. This is ominously described as a “silent chest”.

Question 22

What are the PEFRs for:

Moderate
Severe
Life-threatening asthma

Answer 22

Moderate: 50-75% predicted

Severe: 33-50% predicted

Life-threatening asthma: < 33%

Question 23

Acute asthma management? [5]

Answer 23

O! SHIT!

Oxygen
Salbutamol - (? in cardiac patients with presenting tachy, monitor potassium!)

Hydrocortisone - (or any steroid)

Ipratropium Bromide - (acetylcholine antagonist via blockade of muscarinic cholinergic receptors)

Tube (intubation) - (only if VVV severe)

Magnesium (calcium channel blockade)

Question 24

First line investigations for asthma diagnosis? [2]

Second line? [2]

Answer 24

First line
* Fractional exhaled nitric oxide
* Spirometry with bronchodilator reversibility

Second line
* Peak flow variability measured by keeping a diary of peak flow measurements several times per day for 2 to 4 weeks
* Direct bronchial challenge test with histamine or methacholine

Question 25

Characteristic chest signs of pneumonia? [3]

Answer 25

Bronchial breath sounds. These are harsh breath sounds equally loud on inspiration and expiration. These are caused by
consolidation of the lung tissue around the airway.

Focal coarse crackles. These are air passing through sputum in the airways similar to using a straw to blow in to a drink.

Dullness to percussion due to lung tissue collapse and/or consolidation.

Question 26

Describe the MoA of amoxicillin [1]

Answer 26

Amoxicillin competitively inhibit penicillin binding proteins, leading to up-regulation of autolytic enzymes and inhibition of cell wall synthesis.

Question 27

Describe the MoA of Macrolides [2]

Answer 27

Macrolides inhibit bacterial protein synthesis.

The mechanism of action of macrolides revolves around their ability to bind the bacterial 50S ribosomal subunit causing the cessation of bacterial protein synthesis.

Question 28

Name an ICS used to treat asthma [1]

Answer 28

Beclomethasone