Pneumonia

Question 1

Pneumonia is an infection of the lungs, which can lead to fluid and other components being draw into the lungs and filling the alveoli. What is the incidence of pneumonia?

1 - 50,000 / 100,000
2 - 5000 / 100,000
3 - 500 / 100,000
4 - 50 / 100,000

Answer 1

3 - 500 / 100,000

Question 2

Pneumonia is an infection of the lungs, which can lead to fluid and other components being draw into the lungs. What age does the cases of pneumonia at its peak?

1 - >35
2 - >45
3 - >60
4 - >75

Answer 2

4 - >75

Question 3

Pneumonia in children is the single largest contributor to childhood mortality worldwide, account for how many deaths per year in <5 year old children?

1 - 1000
2 - 10,000
3 - 100,000
4 - 1,000,000

Answer 3

4 - 1,000,000

Question 4

Pneumonia is an infection of the lungs, which can lead to fluid and other components being draw into the lungs. Are men or women affected more by pneumonia?

Answer 4

• equally affected

Question 5

The bodies innate immune system aims to reduce the risk of infection in a number of ways. Which of the following does this include?

1 - mucociliary escalator
2 - cough reflex
3 - macrophages
4 - all of the above

Answer 5

4 - all of the above

Question 6

Which of the following is NOT a risk factor for developing pneumonia?

1 - aged <5 or >65-years-old
2 - smoking
3 - recent viral RTI
4 - chronic respiratory diseases
5 - immunosuppressed (diabetes)
6 - gender
7 - neurological impairment
8 - IV drug users
9 - co-morbidities
10 - prolonged hospital stay

Answer 6

6 - gender

• patients at risk of aspiration include those with neurological diseases such as Parkinson’s disease or those with oesophageal obstruction

Question 7

Pneumonia can be caused by viruses, bacteria and fungi, but which is most common?

Answer 7

• bacteria

Question 8

The are a myriad of bacteria that can cause pneumonia, but which is most common?

1 - streptococcus pneumoniae
2 - haemophilus influenzae
3 - staphylococcus aureus
4 - legionella pneumophila

Answer 8

1 - streptococcus pneumoniae

All of these can cause pneumonia though

Question 9

The are a myriad of viruses that can cause pneumonia, but which is most common?

1 - Covid-19
2 - SARS
3 - influenza
4 - respiratory syncytial virus

Answer 9

3 - influenza

• respiratory syncytial virus is the most common cause of pneumonia in children

Question 10

Match the most common causes of pneumonia with the age of the child:

Newborn – organisms maternal genital tract: Group B strept, Gram neg orgs

Age
- Newborn
- Infants and young children
- >5 years old

Cause
- Viruses e.g RSV
- organisms maternal genital tract: Group B strept, Gram neg organisms
- Mycoplasma pn, Strept pn, Chlamydia pneumoniae

Answer 10

• Newborn = organisms maternal genital tract: Group B strept, Gram neg organisms
• Infants and young children = Viruses e.g RSV
• > 5 years old = Mycoplasma pn, Strept pn, Chlamydia pneumoniae

Question 11

Is pneumonia typically caused by an infection that begins in the upper (URT) or lower respiratory tract (LRT)?

Answer 11

• begins in the URT and then moves to the LRT

Question 12

Once an infection reaches the lower respiratory tract which of the following occurs?

1 - immune cells initiate and immune response
2 - immune cells secrete cytokines and an inflammatory response and induce fever
3 - fluid leaks into inflamed tissue and can cause pus accumulation
4 - gas exchange at the alveoli is impaired causing hypoxia
5 - all of the above, typically in this order

Answer 12

5 - all of the above, typically in this order

Question 13

Pneumonia can be classified on where it is acquired. Which of the following is the most common?

1 - community -acquired pneumonia
2 - hospital-acquired pneumonia
3 - ventilator associated pneumonia
4 - all equal

Answer 13

1 - community -acquired pneumonia
- patient becomes sick outside of a hospital setting

Question 14

Pneumonia can be classified on where it is acquired. Which of the following is the most aggressive and dangerous pneumonia?

1 - community -acquired pneumonia
2 - hospital-acquired pneumonia
3 - ventilator associated pneumonia
4 - all equal

Answer 14

2 - hospital-acquired pneumonia
- patient gets sick in whilst in hospital being treated for something else

Question 15

Are bacteria and viruses the only way patients can acquire pneumonia?

Answer 15

• no
• may acquire pneumonia by aspiration
• such as food, gastric contents

Question 16

Aspiration pneumonia can be caused by a myriad of things. Which of the following can increase the risk of an aspiration pneumonia?

1 - alcohol and drug abuse
2 - brain injuries
3 - swallowing dysfunction
4 - all of the above

Answer 16

4 - all of the above

Question 17

Pneumonia can be categorised based on where in the lungs the infection affects. One of these is bronchopneumonia. Which part of the lung is affected in bronchopneumonia?

1 - whole lobe only
2 - alveoli only
3 - bronchi only
4 - alveoli and bronchi

Answer 17

4 - alveoli and bronchi

Question 18

Pneumonia can be categorised based on where in the lungs the infection affects. One of these is lobar pneumonia. Which part of the lung is affected in lobar pneumonia?

1 - whole lobe only
2 - alveoli only
3 - bronchi only
4 - alveoli and bronchi

Answer 18

1 - whole lobe only
- commonly caused by streptococcus pneumoniae

Question 19

Pneumonia can be categorised based on where in the lungs the infection affects. One of these is atypical/interstitial pneumonia. Which part of the lung is affected in atypical/interstitial pneumonia?

1 - whole lobe only
2 - alveoli only
3 - interstitium around alveoli
4 - alveoli and bronchi

Answer 19

3 - interstitium around alveoli
- can typically cause less severe or sub acute pneumonia, termed ‘walking pneumonia’
- absence of lobar consolidation on chest x-ray
- not detectable on Gram stain
- lack of response to penicillin antibiotics

Question 20

When comparing a bacterial vs a viral cause of pneumonia, which is more likely to affect the whole of one lung or both lungs?

Answer 20

• viral

Bacterial causes of pneumonia are typically confined into one or 2 lobes

Question 21

Which is the most likely class of organism responsible for this acute presentation?

1 - Bacterial
2 - Fungal
3 - Rickettsial
4 - Tuberculous
5 - Viral

Answer 21

5 - Viral

Rickettsial and Tuberculous are typically more chronic conditions

Question 22

Does bacterial or viral pneumonia cause purulent sputum?

Answer 22

• bacterial

Question 23

Pneumonia can typically be broken down into 4 stages. What occurs at stage 1?

1 - resolution = exudate gets digested by enzymes, ingested by macrophages, or coughed up
2 - red hepatization = exudate, RBCs, neutrophils and fibrin fill airspace and lungs appear more solid
3 - congestion = blood vessels and alveoli start filling with excess fluid
4 - gray hepatization = lungs are firm but RBCs begin to break down

Answer 23

3 - congestion = blood vessels and alveoli start filling with excess fluid

• happens between 1 and 2 days

Question 24

Pneumonia can typically be broken down into 4 stages. What occurs at stage 2?

1 - resolution = exudate gets digested by enzymes, ingested by macrophages, or coughed up
2 - red hepatization = exudate, RBCs, neutrophils and fibrin fill airspace and lungs appear more solid
3 - congestion = blood vessels and alveoli start filling with excess fluid
4 - gray hepatization = lungs are firm but RBCs begin to break down

Answer 24

2 - red hepatization = exudate, RBCs, neutrophils and fibrin fill airspace and lungs appear more solid

• happens between 3 and 4 days

Question 25

Pneumonia can typically be broken down into 4 stages. What occurs at stage 3? 1 - resolution = exudate gets digested by enzymes, ingested by macrophages, or coughed up 2 - red hepatization = exudate, RBCs, neutrophils and fibrin fill airspace and lungs appear more solid 3 - congestion = blood vessels and alveoli start filling with excess fluid 4 - gray hepatization = lungs are firm but RBCs begin to break down

Answer 25

4 - gray hepatization = lungs are firm but RBCs begin to break down - happens between 5 and 7 days

Question 26

Pneumonia can typically be broken down into 4 stages. What occurs at stage 4? 1 - resolution = exudate gets digested by enzymes, ingested by macrophages, or coughed up 2 - red hepatization = exudate, RBCs, neutrophils and fibrin fill airspace and lungs appear more solid 3 - congestion = blood vessels and alveoli start filling with excess fluid 4 - gray hepatization = lungs are firm but RBCs begin to break down

Answer 26

1 - resolution = exudate gets digested by enzymes, ingested by macrophages, or coughed up - happens between 8 days to 3 weeks

Question 27

Pneumonia can cause respiratory and systemic symptoms. Which of the following is NOT a respiratory symptoms? 1 - Cough 2 - Dyspnoea 3 - Malaise 4 - Pleuritic chest pain

Answer 27

3 - Malaise - cough = productive or non-productive, with purulent sputum in bacterial pneumonia. - dyspnoea = mild to severe - pleuritic chest pain = sharp, localised pain, exacerbated by coughing or deep breathing, suggestive of pleural involvement

Question 28

Pneumonia can cause respiratory and systemic symptoms. Which of the following is NOT a systemic symptoms? 1 - fever and chills 2 - dyspnoea 3 - malaise 4 - anorexia and weight loss

Answer 28

2 - dyspnoea - fever and chills = high-grade (bacteria) or low grade (viral) fever - malaise, fatigue, and myalgias = common in both bacterial and viral pneumonia. - anorexia and weight loss = may occur due to decreased appetite and increased metabolic demands

Question 29

If examining a patient with pneumonia, which of the following are we likely to detect? 1 - tachypnoea 2 - tachycardia 3 - hypoxia: Indicative of respiratory compromise. 4 - basal crackles 5 - all of the above

Answer 29

5 - all of the above

Question 30

To diagnose a patient with pneumonia we can use a chest X-ray. Match the findings with the type of pneumonia: - lobar pneumonia, atypical/interstitial pneumonia and bronchopneumonia - lobular infiltrates with fluid - peri-hilar infiltrates - patchy areas of infiltration throughout

Answer 30

- lobar pneumonia = lobular infiltrates with fluid - atypical/interstitial pneumonia = peri-hilar infiltrates - bronchopneumonia = patchy areas of infiltration throughout

Question 31

In a patient with pneumonia, when we percuss the chest, would we expect there to be increased resonance or a decreased resonance with dullness with a consolidation, which is fluid in the lung tissue, that DOES NOT move with gravity?

Answer 31

- reduced resonance with dullness

Question 32

In a patient with pneumonia, would we expect to feel more or less tactile fremitus than in a normal lung?

Answer 32

- more Vibrations travel through fluid better so we feel them more than in a healthy lung

Question 33

In a patient with pneumonia, would we expect to hear vocal fremitus more or less than in a normal lung?

Answer 33

- more - vibrations travel through fluid better sop we feel them more than in a healthy lung

Question 34

In a patient with pneumonia, would we expect to hear late inspiratory crackles and bronchial breath sounds?

Answer 34

- yes

Question 35

Patients with suspected pneumonia are expected to be seen by their GPs. Which scoring system us used to assess the severity of patients pneumonia and mortality risk? 1 - Wells score 2 - Lights criteria 3 - Dukes criteria 4 - CURB65 score

Answer 35

4 - CURB65 score - C = new onset confusion (<8 on MMS) - U = urea (>7 mmol/L) (typically used in hospital only) - R = respiratory rate (>30/min) - B = BP (SBP <90 and DBP >60 mmHg) - 65 = patients aged >65

Question 36

The CURB65 score ranges from 0-4, increasing upon severity. - 0: low risk (less than 1% mortality risk) - 1 or 2: intermediate risk (1-10% mortality risk) - 3 or 4: high risk (more than 10% mortality risk) Patients that do not need hospital admission and are safe to be treated at home according to NICE typically have what score? 1 - 3-4 2 - 2-3 3 - 1-2 4 - 0-1

Answer 36

4 - 0-1 - also based on clinical insight Patients scoring >2 should be assessed in hospital Patients scoring >3 should be admitted to ICU

Question 37

In addition to a CRB65 score in primary care to assess the severity of patients pneumonia and risk of mortality, what other test is used to assess if a patient should be started on antibiotics according to NICE guidelines? 1 - WBC 2 - ESR 3 - CRP 4 - LFTs

Answer 37

3 - CRP All the others may also be performed though Blood and sputum cultures should also be performed

Question 38

CRP can be used to identify patients who may require antibiotics. What CRP level would mean that antibiotics should be started straight away? 1 - <20mg/mL 2 - 20-50mg/mL 3 - 20-100mg/mL 4 - >100mg/mL

Answer 38

4 - >100mg/mL CRP < 20 mg/L - do not routinely offer antibiotic therapy CRP 20 - 100 mg/L - consider a delayed antibiotic prescription CRP > 100 mg/L - offer antibiotic therapy

Question 39

It can be hard to differentiate between viral and bacterial causes of pneumonia. But typically, which is associated with the following: - high temperatures - high inflammatory markers (CRP) - systemically unwell child

Answer 39

- bacterial is more likely BUT diagnosis can only be confirmed using a blood and/or sputum culture

Question 40

In a patient with NKDA, which antibiotic should be the 1st line treatment for patients with low severity pneumonia? 1 - amoxicillin (penicillin) 2 - clarithromycin (macrolide) 3 - doxycycline (tetracycline) 4 - vancomyosin (glycopeptide)

Answer 40

1 - amoxicillin (penicillin) - 5 day course TDS - amoxicillin = penicillin binding protein that inhibits wall synthesis

Question 41

In a patient with an allergy to penicillin, which 2 of the following antibiotics should be the 1st line treatment for patients with low severity pneumonia? 1 - gentamicin (aminoglycosides) 2 - clarithromycin (macrolide) 3 - doxycycline (tetracycline) 4 - vancomyosin (glycopeptide)

Answer 41

2 - clarithromycin (macrolide) - binds 50s and inhibits protein synthesis 3 - doxycycline (tetracycline) - binds 30s and inhibits protein synthesis - 5 day course

Question 42

In patients with NKDA, and moderate to severe pneumonia (CURB65 score >3), they require dual antibiotic therapy for 7-10 days. Which 2 of the following should they be prescribed? 1 - co-amoxiclav (penicillin) 2 - clarithromycin (macrolide) 3 - doxycycline (tetracycline) 4 - vancomyosin (glycopeptide)

Answer 42

1 - co-amoxiclav (penicillin) 2 - clarithromycin (macrolide)

Question 43

Which of the following are pulmonary complications that can be caused by pneumonia? 1 - empyema (pus in pleural space) 2 - lung abscess (pus collection in lung parenchyme) 3 - pneumothorax 4 - acute respiratory distress syndrome 5 - pleural effusions 6 - all of the above

Answer 43

6 - all of the above

Question 44

Which of the following are extra-pulmonary complications that can be caused by pneumonia? 1 - bacteremia and sepsis 2 - metastatic infections 3 - pericarditis 4 - AKI 5 - all of the above

Answer 44

5 - all of the above

Question 45

NICE recommends that patients with pneumonia should NOT be discharged if they have certain criteria. Which of the following is NOT one of these? 1 - temperature >37.5°C 2 - RR >24 3 - HR >65 4 - SBP <90mmHg 5 - sats <90% on room air 6 - abnormal mental status 7 - inability to eat without assistance

Answer 45

3 - HR >65 heart rate over 100 beats per minute is part of the criteria

Question 46

A 72 year old man with background history of multiple myeloma presents to the emergency department with shortness of breath, sore throat runny node and a cough. He had chemotherapy 4 days previously. Observations: HR 118 bpm, BP 90/60 mmHg, temperature 38.2°C, respiratory rate 25 /min, O2 saturation 75% on air.. Blood results: Hb 96 g/L WBC 0.9 x109/L CRP 115 mg/L U&E: normal Urinalysis: 1+ blood and 1+ protein, nitrite -ve Chest X-ray shown in image. What is the most likely diagnosis? 1 - Aspiration pneumonia 2 - Neutropenic sepsis 3 - Lobar pneumonia 4 - Urinary tract infection 5 - Upper respiratory tract infection

Answer 46

2 - Neutropenic sepsis