Anaemia And Pneumonia Flashcards

Question

How do the symptoms of pneumonia occur?

Answer 1

Systemic cytokine release leads to dysregulation of the hypothalamic thermoregulation leading to fever and chills or rigors In lobar pneumonia, accumulation of neutrophils and plasma exudate from capillaries into alveoli of specific area of the lung or lobes. This leads to irritation and attempted clearance of the airways, the fluid infiltrates are inside the alveoli, airway clearance leads to phlegm production and this leads to a productive cough. The accumulation into specific lobes also leads to fluid build up and this does not allow the X rays to pass through so there is white opacity on plain film at the site of the fluid build up. This shows as a consolidation on chest x ray The accumulation of fluid in the lobes also lead to blockage of the alveolar sacs and this decreases exchange of CO2 and O2. This leads to hypoxemia and this triggers peripheral and central chemoreceptors to increase respiratory drive hence leading to dyspnea In interstitial pneumonia, there is accumulation of infiltrates( inflamed cellular debris) in the alveolar walls (that is, space between the alveolar spaces and bloodstream) This leads to thickening of the alveolar walls and increased diffusion distance between the alveoli and capillaries this decreases exchange of CO2 and O2. This leads to hypoxemia and this triggers peripheral and central chemoreceptors to increase respiratory drive hence leading to dyspnea Accusation of infiltrates also lead to irritated alveolar walls and triggers a cough reflex Since fluid infiltrates are not in the alveoli, attempts to Empty the alveoli by coughing doesn’t lead to production of fluid so there’s a dry cough

Answer 2

History Physical exam Stage severity Risk factors Investigations Identify sequelae Pulmonary signs and symptoms : Cough with or without sputum production, dyspnea, pleuritic chest pain Tachypnea,increased work of breathing, adventitious breath sound such as rales or crackles and Rhonchi Increased tactile fremitus and dullness on percussion Systemic signs and symptoms: Fever chills fatigue malaise chest pain anorexia

Answer 3

Lobar pneumonia: Homogenous consolidation, silhouette sign, air bronchogram, sharply marginated fissure Organism- Strept pneumoniae Bronchopneumonia: Poorly defined Heterogenous patchy infiltrates scattered throughout the lungs, air bronchogram Organisms: Staph aureus leading to multi lobar, cavitation, pneumatocoeles , abscess Interstitial pneumonia: Bilateral diffuse fine reticular opacity Organism: pneumocystis jiroveci pneumonia (PCP) Aspiration: Airspace opacification in a lobar or segmental distribution Gravity dependent predilection Organism: stroke , seizure

Answer 4

Pulse oximetry- low arterial oxygen saturation FBC-leucocytosis WBC more than 12 x 10 /L indicates bacterial aetiology CRP-elevated level more than 100 mg/L Makes pneumonia more likely Microbiology-sputum culture and gram staining, blood culture, pleural fluid analysis ,COVID-19 testing BUE and Cr-usually normal but urea may be elevated Liver function test:usually normal, good for baseline measurement Maybe abnormal in severed disease and sepsis Arterial blood gas- low arterial oxygen saturation Other imaging test: chest ct scan, chest ultrasound Others: lactate(In patients with severe pneumonia, tissue organ effective blood volume reduction, which further exacerbates tissue hypoxia and increases anaerobic metabolism. Blood lactic acid is a product of the anaerobic glycolysis of glucose, and can directly reflect the tissue hypoperfusion and hypoxia conditions. ) , “procalcitonin (The final step in the synthesis of calcitonin is inhibited by cytokines and endotoxin released during bacterial infections; therefore, procalcitonin levels are selectively elevated in patients with bacterial infections.. Procalcitonin has good discriminatory value for distinguishing between viral and bacterial infections, and results can be obtained in hours or less. In patients with community-acquired pneumonia, procalcitonin is about 65 to 70 percent accurate in distinguishing bacterial from viral pathogen) , INR(An elevated international normalized ratio (INR) has been associated with more severe illness. This finding may herald the development of disseminated intravascular coagulation), blood sugar (Infection causes a stress response in the body by increasing the amount of certain hormones such as cortisol and adrenaline. These hormones work against the action of insulin and, as a result, the body's production of glucose increases, which results in high blood sugar levels.)

Answer 5

Altered mental status Hypotension requiring fluid support Temperature less that 36 degrees Respiratory rate more than or equal to 30cpm Arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2) ratio Less than or equal to 250 Blood urea nitrogen more than or equal to 20mg/dL(7mmol/L) Leukocyte count less than 4000cells per Microlitre Platelet count less than 100,000/mL Multilobar infiltrates

Answer 6

Amoxicillin 1g 8 hourly or Amoxicillin + Clavulanic acid 625mg 8hrly Plus or minus Azithromycin 500mg daily Treat for 5-7 days Those with comorbidities, Amoxicillin + Clavulanic acid 1g 12hrly Or Cefuroxime 500mg 12hrly Plus Azithromycin 500mg daily

Answer 7

Combination therapy with IV beta-lactam plus a macrolide (Macrolides are a class of drugs used to manage and treat various bacterial infections. Azithromycin, clarithromycin, and erythromycin . macrolide antibiotics are active mainly against Gram‐positive bacteria and have only limited activity against Gram‐negative bacteria. Azithromycin is the macrolide with the best Gram-negative activity of the group and is effective against Shigella and Salmonella species. ) example IV amoxiclav plus Azithromycin /clarithromycin You may consider a respiratory fluoroquinolone mono therapy Start treatment within 4 hours of presentation If patient has sepsis, start treatment within one hour presentation Treat for 5-7days unless lab results indicate a longer course or patient isn’t clinically stable

Answer 8

Beta-lactam antibiotics include penicillins, cephalosporins and related compounds. As a group, these drugs are active against many gram-positive, gram-negative and anaerobic organisms β-lactam antibiotics are antibiotics that contain a beta-lactam ring in their chemical structure. This includes penicillin derivatives, cephalosporins and cephamycins, monobactams, carbapenems and carbacephems

Answer 9

Switch to pathogen specific target antibiotic therapy Oxygen therapy -prescribe oxygen if saturation is less than 94% and maintain a target range -a lower target range of 88-92% is appropriate if patient is at risk of being hypercapneic respiratory failure example COPD PATIENTS -monitor ABGs Fluid resuscitation -assess all patients for volume depletion and give IV fluids if required if required Vasopressors -start if patient is hypotensive during or after fluid resuscitation to maintain MAP more than or equal to 65mmHg Venous thromboembolism (VTE) prophylaxis -consider low molecular weight unfractionated heparin for patients who are not fully mobile Nutritional support -arrange nutritional support ( example via nasogastric feeding ) for all patients Analgesia -give simple analgesia for chest pain

Answer 10

Pulse is less than 100 bpm Resolution of tachypnea Clinically hydrated and taking oral fluids Resolution of fever for more than 24hours Resolution of hypotension Absence of hypoxia Imrpoving WBC count Lack of bacteremia

Answer 11

When a Chnage in empirical antibiotic therapy is considered necessary, a macrolide should be substituted for or added to the treatment for those with low severity pneumonia treated with amoxicillin mono therapy in the community or hospitals For those with moderately severe pneumonia in hospital on combination therapy, changin to doxycycline or a fluoroquinolone with effective pneumococcal cover are alternative options Adding a fluoroquinolone is an option for those with high severity pneumonia not responding to beta lactam / macrolide combination antibiotic regimen Consider referral to higher CENTRE with details of management until time of referral

Answer 12

Progression of initial infection-sepsis , overwhelming infections Development of comorbidities and complications (PE,ACS,ARDS) Pneumothorax A non resolving infection -delayed clinical response : extend the treatment to 8-14 days -loculated infection( this will require drainage ) -incorrect initial diagnosis( consider TB, malignancy, inflammatory lung disease )? - ineffective antibiotics(example poor absorption or inadequate dose ) - improvement expected too soon Acronym SLAPHER S-septicaemia L-lung abscess A-ARDS P-para pneumonic effusion(A parapneumonic effusion refers to the accumulation of fluid in the pleural space in the setting of an adjacent pneumonia. ) H-hypotension E-empyema (Empyema is defined by purulent fluid collection in the pleural space, which is most commonly caused by pneumonia. A lung abscess, on the other hand, is a parenchymal necrosis with confined cavitation that results from a pulmonary infection.) R-respiratort failure or renak failure treptococcus pneumonia is a common etiology of pneumonia with sepsis and, in its acute stage, can increase the risk of AKI. Sepsis-mediated hypoperfusion and hypoxemia may result in peritubular hypoxia and then cause AKI

Answer 13

-out patients generally have good prognosis -mortality ranges from five to ten percent in people admitted to the medical ward Mortality rises to 20-50% in patients in the ICU Risk factors associated with increased 30day mortality: -bacteremia -admission to the ICU -comorbidities -infection with multi drug resistant pathogen Readmission rates ranges from 7-12%

Answer 14

Mild-fever , symptoms of upper respiratory tract infections SPO2 more than or equal to 97% on room air Modern- Symptoms of pneumonia with respiratory rate more than ir equal to 24 cpm SPO2 less than or equal to 94% on room air Severe Respiratory distress requiring Mechanical ventilation( non invasive or invasive ) SPO2 less than or equal to 90% on room air

Answer 15

Mild- Home isolation Monitoring Symptom management and supportive care Antipyretic and analgesic Moderate: Home isolation Monitoring Symptom management and supportive care Antipyretic and analgesic Antibiotic Monoclonal antibody Antibiral medication example remdesivir Severe: Hospital/ICU admissions Consider oxygen therapy Venous thromboembolism prophylaxis Symptom management and supportive care Antipyretic and analgesic Antibiotic Corticosteroids Monoclonal antibody Antibiral medication example remdesivir Others: IL-6 inhibitor, JAK inhibitor

Answer 16

The severity of the illness is a key factor in the decision for admission, and the choice of first or second-line treatment. — Pneumonia — C-confusion U- blood urea nitrogen R respiratory rate B- BP 65 patients more than or equal to age 65 Box 8-1: Severity score for community acquired pneumonia (CURB-65) Severity score may be based on the following, assigning one point to each of the following factors (maximum 5 points); y Confusion, restlessness, or excessive drowsiness y Blood Urea Nitrogen ( > 7 mmol/L) y Respiratory rate ( ≥ 30 per minute in adults, and ≥ 50 in children) y Low BP (Systolic BP < 90 and/or diastolic BP < 60 mmHg) y Patients at the extremes of age, (< 5yr or ≥ 65yr) Interpretation 0-1; consider home treatment 2-3; consider short inpatient hospitalisation > 3; admit and consider intensive care In the presence any of the following additional factors, all cases of pneumonia would warrant hospitalisation. Additional factors y Coexisting diseases such as chronic lung disease, heart failure or renal dis- ease y Extensive disease, multiple lobes involved y Low oxygen saturation SpO2, < 92% on room air y Severe tachycardia

Answer 17

Life threatening organ dysfunction caused by a dysregulated host response to infection It is a clinical syndrome that has biological, physiologic and biochemical abnormalities caused by a dysregulated host response to an infection Sepsis and the inflammatory response that ensues can lead to multiple organ dysfunction syndrome and death Sepsis exists on a continuum of severity ranging from infection to septic shock which can lead to multiple organ dysfunction syndrome and death

Answer 18

Using the QSOFA score The SOFA score The adapted NEWS tool QSOFA- Quick sequential organ failure assessment score Low blood pressure less than or equal to 100mmHg Respiratory rate more than or equal to 22cpm Altered mental (GCS less than or equal to 14) Each point is 1 2-3 points means high risk 0-1 point means not high risk SOFA- PaO2/FiO2 ratio:0-PaO2/FiO2 more than 400 and a SPO2/FiO2 more than 302 1-PaO2/FiO2 less than 400 and a SPO2/FiO2 less than 302 2-PaO2/FiO2 less than 300 and a SPO2/FiO2 less than 221 3-PaO2/FiO2 Less than 200 and a SPO2/FiO2 Less than 142 4-PaO2/FiO2 Less than 100 and a SPO2/FiO2 Less than 67 Bilirubin(mg/dL): (0) less than 1.2,(1) 1.2-1.9, (2) 2.0-5.9, (3) 6.0-11.9, (4) more than 12 Platelet count(for coagulation. Platelets x10 to the power 3 /mm to the power 3): (0) more than or equal to 150, (1)les than 150, (2) less than 100, (3) less than 50 , (4) less than 20 Serum creatinine or urine output(for renal mg/dL) : (0) less than 1.2, (1)1.2-1.9, (2) 2.0-3.4, (3) 3.5-4.9, (4) more than 5.0 Mean arterial pressure (MAP)( doses in mcg/kg/min , Administration of vasopressors and dose rate ,cardiovascular): (0) MAP more than or equal to 70mmHg, (1) MAP more than or equal to 70mmHg, (2) dopamine less than or equal to 5 or any dobutamine, (3) dopamine more than 5..norepinephrine less than or equal to 0.1…phenylephrine less than or equal to 0.8 (4) dopamine more than 15…norepinephrine more than 0.1…phenylephrine more than 0.8 (Neurological)Glasgow Coma Scale (GCS) score: (0) 15, (1) 13-14, (2) 10-12, (3)6-9, (4) less than 6 MAP = DP + 1/3(SP – DP)

Answer 19

Bacteremia advance age more than or equal to 65 Immunosuppression Diabetes and obesity Cancer Previous hospitalization Community acquired pneumonia ICU admission

Answer 20

Warm flushed skin is present in the early phases of sepsis As sepsis progresses to shock, the skin may become cool due to redirection of blood flow to core organs Decreased capillary refill or peripheral cyanosis may indicate shock Additional signs of hypo perfusion include altered mental status, obtundation or restlessness, oliguria and Anuria Ileus or absent bowel sounds are often an end stage sign of hypo perfusion

Answer 21

Leukocytosis (WBC more than 12 x 10 to the power 9 /L or leukopenia ( WBC less than 4 x 10 to the power 9/L Normal WBC count with greater than 10 percent immature forms ( left shift) Hyperglycemia ( plasma glucose more than 140mg/dL or 7.7mmol/L ) in the absence of diabetes Plasma C reactive protein elevation Acute oliguria ( urine output less than 0.5mls/kg/hr for at least 2 hours despite adequate fluid resuscitation) Creatinine increase more than 0.5mg/dL or 44.2 micromol/L

Answer 22

Stabilize respiration Venous access Fluid resuscitation ( start within 1 hour) IV antibiotics(start within one hour)

Answer 23

Clinical response ( resolution of confusion , obtundation) Respiratory improvement (by normalization of RR) Haemodynamic response (BP resolution, urine output improvement) Lab parameter response (WBC,CRP , lactate) Microbiology response (example urinalysis improvement in leukocytes and proteins)

Answer 24

Blood product infusion Nutrition Stress ulcer prophylaxis Venous thromboembolism Insulin therapy External cooling or antipyretics Mechanical ventilation

Answer 25

Finger clubbing is the swelling and widening of the fingers and nails, which results from changes in the tissues beneath the nails. While the exact mechanism behind finger clubbing is not yet fully understood, several theories have been proposed. One of the most widely accepted theories suggests that finger clubbing occurs due to reduced oxygen levels in the blood. When there is a lack of oxygen in the blood, the body's tissues may release chemicals that promote the growth of blood vessels in the fingers and nails. These new blood vessels can cause the tissues beneath the nails to expand, leading to the characteristic appearance of clubbed fingers. Another theory suggests that finger clubbing is caused by an increase in the levels of a hormone-like substance called prostaglandin E. Prostaglandin E is involved in inflammation and is produced in response to tissue damage or infections. It may also promote the growth of blood vessels and contribute to the development of finger clubbing. Various medical conditions can cause finger clubbing. These conditions include lung diseases such as cystic fibrosis, lung cancer, and bronchiectasis. Heart disorders, such as congenital heart disease and endocarditis, can also cause finger clubbing. Additionally, gastrointestinal conditions such as inflammatory bowel disease and liver cirrhosis have been linked to finger clubbing. In summary, finger clubbing is a complex process that involves changes in the tissues beneath the nails, which can occur due to reduced oxygen levels in the blood, an increase in prostaglandin E levels, or various underlying medical conditions.