BLOCK 13 WEEK 1

Question 1

TB Microorganisms

Answer 1

• Acid fast bacilli -
• Special staining is required, using the Zeihl-Neelsen stain, which turns them bright red against a blue background
• TB can be stained with Ziehl Nielsen (stains red), or auramine (fluorescent).

Question 2

TB Pathophysiology

Answer 2

The macrophages often migrate to regional lymph nodes, the lung lesion plus affected lymph nodes is referred to as a Ghon complex.

This leads to the formation of a granuloma which is a collection of epithelioid histiocytes.

There is the presence of caseous necrosis in the centre.

The inflammatory response is mediated by a TYPE 4 HYPERSENSITIVITY REACTION.

In healthy individuals the disease may be contained, in the immunocompromised disseminated (miliary TB) may occur.

Question 3

Answer 3

Multiple small calcifications in the lung can be due to miliary TB, which is associated with extrapulmonary TB.

Question 4

Answer 4

Question 5

Can TB be transmitted via breastmilk and harm the baby?

Answer 5

Yes TB can be transmitted via breastmilk and harm the baby

Question 6

Disease Progressision

Answer 6

Tuberculosis is mostly spread by inhaling saliva droplets from infected people. Once in the body, there are several possible outcomes:

-Immediate clearance of the bacteria (in most cases)

-Primary active tuberculosis (active infection after exposure)

-Latent tuberculosis (presence of the bacteria without being symptomatic or contagious)

-Secondary tuberculosis (reactivation of latent tuberculosis to active infection)

Question 7

LATENT TUBERCULOSIS

Answer 7

Latent tuberculosis is present when the immune system encapsulates the bacteria and stops the progression of the disease.

Patients with latent tuberculosis have no symptoms and cannot spread the bacteria.

Most otherwise healthy patients with latent tuberculosis never develop an active infection.

When latent tuberculosis reactivates, and an infection develops, usually due to immunosuppression, this is called secondary tuberculosis.

Question 8

Where do you get TB

Answer 8

The most common site for TB infection is in the lungs, where it gets plenty of oxygen. Extrapulmonary tuberculosis refers to disease in other areas:

-Lymph nodes
-Pleura
-Central nervous system
-Pericardium
-Gastrointestinal system
-Genitourinary system
-Bones and joints
-Skin (cutaneous tuberculosis)

Question 9

BCG VACCINE

Answer 9

The Bacillus Calmette–Guérin (BCG) vaccine involves an intradermal injection of live attenuated (weakened) Mycobacterium bovis bacteria (a close relative of M. tuberculosis that does not cause disease in humans).

This creates an immune response, providing lasting immunity against M. tuberculosis without causing infection.

The vaccine protects against severe and complicated TB but less against pulmonary TB.

Question 10

Before being given TB vaccine

Answer 10

MANTOUX TEST: Before vaccination, patients are tested with the Mantoux test and only given the vaccine if this test is negative. They are also assessed for the possibility of immunosuppression and HIV due to the risks related to a live vaccine.

The BCG vaccine is not part of the routine vaccination schedule. It is offered to patients at increased risk of TB, such as those from areas of high TB prevalence, with close contact with TB (e.g., family members) and healthcare workers

Question 11

SYMPTOMS

Answer 11

Cough
Haemoptysis (coughing up blood)
Lethargy
Fever or night sweats
Weight loss
Lymphadenopathy
Erythema nodosum (tender, red nodules on the shins caused by inflammation of the subcutaneous fat)
Spinal pain in spinal tuberculosis (also known as Pott’s disease of the spine)

Question 12

INVESTIGATONS

Answer 12

Investigations
Tuberculosis can be challenging to diagnose. The bacteria grow very slowly in a culture, cannot be stained with traditional gram stains and require specialist stains (e.g., Ziehl-Neelsen stain).

There are two tests for an immune response to tuberculosis caused by previous infection, latent TB or active TB:

1. Mantoux test
2. Interferon‑gamma release assay (IGRA)

In patients where active disease is suspected, investigations to support the diagnosis include:

-Chest x-ray
-Cultures

Question 13

MANTOUX TEST

Answer 13

The Mantoux test involves injecting tuberculin into the intradermal space on the forearm. Tuberculin is a collection of tuberculosis proteins isolated from the bacteria. It does not contain any live bacteria.

The infection creates a bleb under the skin. After 72 hours, the test is “read”. This involves measuring the induration of the skin at the injection site. An induration of 5mm or more is considered a positive result.

Question 14

Answer 14

Question 15

Answer 15

• To manage and diagnose active TB where we show symptoms we use the NAAT test
• To manage diagnose or manage potential latent TB we do the Mantoux test

Question 16

Answer 16

Question 17

Answer 17

Question 18

Erythema Nodosum

Answer 18

Question 19

Answer 19

Question 20

Interferon Gamma Release Assays

Answer 20

IGRA involves mixing a blood sample with antigens from the M. tuberculosis bacteria. After previous contact with M. tuberculosis, white blood cells become sensitised to the bacteria antigens and will release interferon-gamma on further contact. A positive result is when interferon-gamma is released during the test.

Question 21

CHEST X RAY TB

Answer 21

Primary tuberculosis may show patchy consolidation, pleural effusions and hilar lymphadenopathy.

Reactivated tuberculosis may show patchy or nodular consolidation with cavitation (gas-filled spaces), typically in the upper zones.

Disseminated miliary tuberculosis gives an appearance of millet seeds uniformly distributed across the lung fields.

Question 22

TB culture

Answer 22

Culture samples are ideally collected before starting treatment. This allows testing for drug resistance. However, cultures can take several months. Treatment is usually started while waiting for the culture results.

There are several ways to collect cultures:

-Sputum cultures (3 separate sputum samples are collected)

-Mycobacterium blood cultures (require special blood culture bottle)

• Lymph node aspiration or biopsy

Question 23

NAAT

Answer 23

Nucleic acid amplification tests (NAAT) assess for the genetic material of a pathogen. To detect tuberculosis DNA, NAAT is performed on a sample containing the bacteria (e.g., a sputum sample). It provides information about the bacteria faster than traditional culture, including drug resistance. NAAT is used for:

-Diagnosing tuberculosis in patients with HIV or aged under 16

-Risk factors for multidrug resistance (where the results would alter management)

Question 24

TREATMENT

Answer 24

Latent tuberculosis is treated with either:

Isoniazid and rifampicin for 3 months
Isoniazid for 6 months

The treatment for active tuberculosis can be remembered with the RIPE mnemonic:

R – Rifampicin for 6 months
I – Isoniazid for 6 months
P – Pyrazinamide for 2 months
E – Ethambutol for 2 months

Question 25

Question 26

TOM TIP

Answer 26

Remember that isoniazid causes peripheral neuropathy, and pyridoxine (vitamin B6) is co-prescribed to help prevent this. An exam question might say, “…are started on R, I, P and E. What else should be prescribed?” The answer would be pyridoxine or vitamin B6.

Question 27

HOW TO WE STOP SPREAD IN HOSPITALS

Answer 27

In hospitals, negative pressure rooms are used to prevent airborne spread. Negative pressure rooms have ventilation systems that actively remove air to prevent it from spreading onto the ward.

Question 28

SIDE EFFECTS OF TREATMENT

Answer 28

Side Effects of Treatment Rifampicin can cause red/orange discolouration of secretions, such as urine and tears. It is a potent inducer of the cytochrome P450 enzymes and reduces the effects of drugs metabolised by this system, such as the combined contraceptive pill. Isoniazid can cause peripheral neuropathy. Pyridoxine (vitamin B6) is co-prescribed to reduce the risk. Pyrazinamide can cause hyperuricaemia (high uric acid levels), resulting in gout and kidney stones. Ethambutol can cause colour blindness and reduced visual acuity. Rifampicin, isoniazid and pyrazinamide are all associated with hepatotoxicity. TOM TIP: A common exam question asks “…has recently started treatment for tuberculosis. They notice _____. Which medication is most likely to be implicated?” Numbness or unusual sensations in their feet implicates isoniazide (“I’m-so-numb-azid”). Difficulty recognising colours implicates ethambutol (“eye-thambutol”). Urine or tears that are orange or red implicates rifampicin (“red-I’m-pissin’”).

Question 29

LUNG CANCER

Answer 29

- Lung cancer is the third most common cancer in the UK behind breast and prostate cancer. - Lung cancer has the highest mortality rate. - Smoking is the biggest cause. - Around 80% of lung cancers are thought to be preventable.

Question 30

CARCINOGENS IN CIGARETTES

Answer 30

Question 31

CARCINOMA OF THE LUNGS - OTHER CAUSES

Answer 31

Question 32

Anatomy of the lungs

Answer 32

-The right lung has three lobes. -The left lung has two lobes. -The heart is on the left, leaving less room for an extra lobe. -Both lungs have an oblique fissure separating the lobes. The right lung also has a horizontal fissure.

Question 33

Pleura

Answer 33

There is a membrane that surrounds the lungs called the pleura. There are two layers of this membrane, with a small amount of fluid between them (less than 20mls). These layers separate the lungs from the chest wall. Lubrication between the two layers allows the lungs to expand and move without creating friction with the chest wall. Between the two layers, there is a potential space, called the pleural cavity. The two layers are usually touching each other, which is why it is only a potential space. There is negative pressure within the pleural cavity, pulling the two layers of the pleura together. As the chest wall expands, the negative pressure within the pleural cavity pulls the lungs outwards with the chest wall, causing them to expand.

Question 34

Pleural Effusion

Answer 34

- A pleural effusion is when the potential space of the pleural cavity fills with excess fluid. - This creates an inward pressure on the lungs, reducing the lung volume Symptoms - Dyspnoea (SOB) ( usually not suddenly could have a one month history of SOB for example) - Reduced exercise tolerance - Pleuritic chest pain (sharp chest pain when you breathe in)

Question 35

Causes of Pleural effusion

Answer 35

Causes of pleural effusions are mainly divided into: Exudative (protein content >35 g/l) Transudative (protein content <35 g/l) The history and clinical examination of the patient will usually be able to identify the most likely cause. It is important to differentiate whether there is a unilateral effusion or bilateral effusions. Note: transudative pleural effusions are more likely to be bilateral; exudative pleural effusions are more likely to be unilateral

Question 36

Answer 36

Question 37

Investigations Pleural Effusion

Answer 37

Blood Tests: FBC – may show a raised WCC suggestive of infection U&E – may show a raised creatinine suggestive of renal impairment LFTs – may show a low albumin and raised alanine aminotransferase (ALT)/aspartate aminotransferase (AST) suggestive of cirrhosis Imaging: Chest X-ray is the first-line imaging investigation in all patients with a suspected pleural effusion will reveal blunting of the costophrenic angle or white-out of lung (if large)

Question 38

Pleural Effusion Question

Answer 38

Question 39

Pleural Effusion question

Answer 39

Question 40

Rhesus disease go over

Answer 40

Question 41

MEIGS SYNDROME

Answer 41

Question 42

Pleural Effusion question

Question 43

Question 44

Answer 44

Question 45

Pleural Effusion Management

Answer 45

1. Oxygen therapy for breathlessness 2. Deal with underlying cause (eg. diuretics for heart failure or antibiotics for chest infections) 3. Ultrasound guided Pleural Aspiration 4. Pleuritic chest drain insertion - An intercostal drain – for large pleural effusions or empyemas (pus in pleuritic cavity) 5. Chemical pleurodesis - for recurrent or persistent pleural effusions This is injection of an irritant through a chest drain (usually sterile Talcum powder), which will cause a fibrotic reaction in the pleura aiming to seal the potential pleural space 6. Tunnelled indwelling pleural catheter – can be inserted to allow regular drainage of recurrent fluid This is especially helpful in palliative patients and reduces hospital stays

Question 46

Pleural Aspiration

Answer 46

Pleural Aspiration (Needle Thoracocentesis) is an invasive medical procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia.

Question 47

Pneumothorax

Answer 47

- A pneumothorax is when air gets into the pleural cavity. - which can be spontaneous or traumatic in origin. SYMPTOMs: - sudden onset of shortness of breath - pleuritic chest pain (sharp pain when your breathe in) Signs: - reduced chest expansion, - reduced or absent breath sounds on the affected side - hyper resonant on affected side

Question 48

Causes of pneumothorax

Answer 48

Causes can be classified into spontaneous and traumatic. Spontaneous causes can be further classified: - primary causes (no underlying lung pathology - typically tall thin young men) - secondary causes (underlying lung pathology). Secondary causes include connective tissue disease (such as Marfan's syndrome and Ehlers-Danlos syndrome), obstructive lung disease (such as asthma and COPD), infective lung disease (such as TB and pneumonia), fibrotic lung disease (such as cystic fibrosis and idiopathic pulmonary fibrosis), and neoplastic disease (such as bronchial carcinoma). Traumatic causes can be further classified into iatrogenic causes (such as insertion of a central line or positive pressure ventilation) and non-iatrogenic causes (either a penetrating trauma or blunt trauma with rib fracture).

Question 49

A large right sided pneumothorax.

Answer 49

On left hand side you can see grey haziness which is the lung - On the right hand side you can see black (all air) with a collapse lung on the side

Question 50

Another example

Question 51

TENSION PNEUMOTHORAX

Answer 51

A tension pneumothorax is a life-threatening emergency that: - occurs when there is an ongoing, one-way air leak into the pleural space as the pressure in this space increases, it will begin to displace the mediastinum, impeding venous return and cardiac output - this will eventually cause cardiovascular collapse and cardiac arrest - in a simple pneumothorax, air does not continue entering the pleural cavity in this way, so it does not cause tension

Question 52

Tension Pneumothorax pathophysiology

Answer 52

When there's damage to the pleura, either due to lung disease or trauma to the chest wall, air from the outside or from the lungs can flow freely into the pleural space, but cannot leave. The accumulated air in the pleural space puts positive pressure on the lung and prevents it from expanding properly, which causes respiratory distress. As the air continues to accumulate, the trachea and other structures of the chest can be pushed away from the pneumothorax, leading to increased difficulty breathing. Additionally, the increased pressure inside the chest can compress the heart and lead to a collapse of the blood vessels that drain to the heart, in turn decreasing venous return and cardiac output. If left untreated, tension pneumothorax can rapidly progress to cardiovascular collapse, which ultimately leads to cardiac arrest.

Question 53

Left sided tension pneumothorax

Answer 53

- The heart is being pushed to the right hand side

Question 54

Management of tension pneumothorax

Answer 54

A patient will therefore be in respiratory distress and in cardiogenic shock – tachycardic and hypotensive urgent treatment is required Initially the patient should be approached using the ABCDE algorithm give high-flow oxygen (15 litres/min) via a non-rebreather mask Emergency management is with chest decompression Use open thoracostomy followed by a chest drain if expertise is available. Otherwise a needle decompression can be used with a 16-gauge cannula, which is inserted at the second intercostal space, mid-clavicular line, on the affected side. The needle should be inserted just above the third rib, to avoid damaging the neurovascular bundle.

Question 55

Pneumothorax question

Answer 55

Question 56

Pneumothorax question

Answer 56

Question 57

Answer 57

Iatrogenic pneumothorax is a patient safety indicator (PSI) condition. It is a traumatic pneumothorax secondary to an invasive procedure or surgery.

Question 58

Histology of lung cancers

Answer 58

The histological types of lung cancer can be broadly divided into: - Small cell lung cancer (SCLC) (around 20%) - Non-small cell lung cancer (around 80%)

Question 59

Non - small lung cancer

Answer 59

Non-small cell lung cancer can be further divided into: -Adenocarcinoma (around 40% of total lung cancers) -Squamous cell carcinoma (around 20% of total lung cancers) -Large-cell carcinoma (around 10% of total lung cancers) -Other types (around 10% of total lung cancers) Small cell lung cancer: - Small cell lung cancer cells contain neurosecretory granules that can release neuroendocrine hormones. This makes SCLC responsible for multiple paraneoplastic syndromes.

Question 60

Question 61

Lung cancer presentation

Answer 61

-Shortness of breath -Cough -Haemoptysis (coughing up blood) -Finger clubbing -Recurrent pneumonia -Weight loss -Lymphadenopathy – often supraclavicular nodes are the first to be found on examination

Question 62

PANEOPLASTIC SYNDROME

Answer 62

- Paraneoplastic syndromes are a group of rare disorders that occur when the immune system has a reaction to a cancerous tumor known as a "neoplasm." - The immune system is very important in keeping you healthy.

Question 63

REFERRAL CRITERIIA

Answer 63

The NICE guidelines on suspected cancer (updated January 2021) recommend offering a chest x-ray, carried out within 2 weeks, to patients over 40 with: -Clubbing -Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes) -Recurrent or persistent chest infections -Raised platelet count (thrombocytosis) -Chest signs of lung cancer

Question 64

EXTRAPULOMARY MANIFESTATIONS

Answer 64

Lung cancer is associated with a lot of extrapulmonary manifestations and paraneoplastic syndromes. These are linked to different types and distributions of lung cancer. Exam questions commonly ask you to suggest the underlying cause of the paraneoplastic syndrome. Sometimes they can be the first evidence of lung cancer in an otherwise asymptomatic patient. Recurrent laryngeal nerve palsy presents with a hoarse voice. It is caused by a tumour pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum. Phrenic nerve palsy, due to nerve compression, causes diaphragm weakness and presents with shortness of breath. Superior vena cava obstruction is a complication of lung cancer. It is caused by direct compression of the tumour on the superior vena cava. It presents with facial swelling, difficulty breathing and distended veins in the neck and upper chest. “Pemberton’s sign” is where raising the hands over the head causes facial congestion and cyanosis. This is a medical emergency. Horner’s syndrome is a triad of partial ptosis, anhidrosis and miosis. It can be caused by a Pancoast tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion. Syndrome of inappropriate ADH (SIADH) can be caused by ectopic ADH secreted by a small cell lung cancer. It presents with hyponatraemia. Cushing’s syndrome can be caused by ectopic ACTH secretion by a small cell lung cancer. Hypercalcaemia can be caused by ectopic parathyroid hormone secreted by a squamous cell carcinoma. Limbic encephalitis is a paraneoplastic syndrome where small cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas. This causes symptoms such as short term memory impairment, hallucinations, confusion and seizures. It is associated with anti-Hu antibodies. Lambert-Eaton myasthenic syndrome can be caused by antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones. This leads to weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.

Question 65

INVESTIGATIONS IN LUNG CANCER

Answer 65

Chest x-ray is the first-line investigation in suspected lung cancer. Findings suggesting cancer include: -Hilar enlargement -Peripheral opacity – a visible lesion in the lung field -Pleural effusion – usually unilateral in cancer -Collapse

Question 66

INVESTIGATIONS

Answer 66

STAGING CT SCAN OF CHEST: abdomen and pelvis is used to assess the stage, lymph node involvement and presence of metastases. This should be contrast-enhanced, using an injected contrast to give more detailed information about different tissues. PET-CT (positron emission tomography) scans involve injecting a radioactive tracer (usually attached to glucose molecules) and taking images using a combination of a CT scanner and a gamma-ray detector to visualise how metabolically active various tissues are. They are useful in identifying areas that cancer has spread to by showing areas of increased metabolic activity. BRONCHOSCOPY WITH ENDOBRONCHIAL ULTRASOUND (EBUS) involves endoscopy with ultrasound equipment on the end of the scope. This allows detailed assessment of the tumour and ultrasound-guided biopsy. HISTOLOGICAL DIAGNOSIS requires a biopsy to check the type of cells in the tumour. This can be either by bronchoscopy or percutaneous biopsy (through the skin).

Question 67

TREATMENT for Non-small cell lung cancer

Answer 67

Surgery is offered first-line in non-small cell lung cancer to patients that have disease isolated to a single area. The intention is to remove the entire tumour and cure the cancer. See below for more detail on surgery. Radiotherapy can also be curative in non-small cell lung cancer when diagnosed early enough. Chemotherapy can be offered in addition to surgery or radiotherapy in certain patients to improve outcomes (“adjuvant chemotherapy”) or as palliative treatment to improve survival and quality of life in later stages of non-small cell lung cancer (“palliative chemotherapy“).

Question 68

TREATMENT for Small cell lung cancer

Answer 68

Treatment for small cell lung cancer is usually chemotherapy and radiotherapy. Prognosis is generally worse for small cell lung cancer compared with non-small cell lung cancer.

Question 69

Lung cancer surgery

Answer 69

There are several options for removing a lung tumour: Segmentectomy or wedge resection involves taking a segment or wedge of lung (a portion of one lobe) Lobectomy involves removing the entire lung lobe containing the tumour (the most common method) Pneumonectomy involves removing an entire lung The types of surgery that can be used are: Thoracotomy – open surgery with an incision and separation of the rib to access the thoracic cavity Video-assisted thoracoscopic surgery (VATS) – minimally invasive “keyhole” surgery Robotic surgery Minimally invasive surgery (i.e., VATS or robotic surgery) is generally preferred as it has a faster recovery and fewer complications.

Question 70

3 main thoracotomy incisions

Answer 70

- Anterolateral thoracotomy with an incision around the front and side - Axillary thoracotomy with an incision in the axilla (armpit) - Posterolateral thoracotomy with an incision around the back and side (the most common approach to the thorax)

Question 71

Mesothelioma

Answer 71

- Mesothelioma is a lung malignancy affecting the mesothelial cells of the pleura. - It is strongly linked to asbestos inhalation. - There is a huge latent period between exposure to asbestos and the development of mesothelioma of up to 45 years. - The prognosis is very poor. - Chemotherapy can improve survival, but it is essentially palliative.

Question 72

Mesothelioma

Answer 72

Question 73

Mesothelioma

Question 74

BREATHLESSNESS

Answer 74

Question 75

BREATHLESSNESS

Answer 75

Question 76

BREATHLESSNESS

Question 77

COUGH

Answer 77

Question 78

SPUTUM

Question 79

HAEMOPTYSIS

Answer 79

Question 81

WHEEZE

Question 82

ASTHMA

Answer 82

Asthma is a chronic inflammatory airway disease leading to variable airway obstruction. T The smooth muscle in the airways is hypersensitive and responds to stimuli by constricting and causing airflow obstruction. This bronchoconstriction is reversible with bronchodilators, such as inhaled salbutamol.

Question 83

ASTHMA SYMPTOMS

Answer 83

Typical symptoms are: Shortness of breath Chest tightness Dry cough Wheeze - Typically symptoms are worse at night - Symptoms should improve with bronchodilators. No response to bronchodilators reduces the likelihood of asthma. - Patients may have a history of other atopic conditions, such as eczema, hayfever and food allergies

Question 84

SPIROMETRY

Answer 84

Spirometry is the test used to establish objective measures of lung function. It involves different breathing exercises into a machine that measures volumes of air and flow rates and produces a report. A FEV1:FVC ratio of less than 70% suggests obstructive pathology (e.g., asthma or COPD).

Question 85

ACUTE ASTHMA EXACBERATIONS

Answer 85

Presenting features of an acute exacerbation are: Progressively shortness of breath Use of accessory muscles Raised respiratory rate (tachypnoea) Symmetrical expiratory wheeze on auscultation The chest can sound “tight” on auscultation, with reduced air entry throughout

Question 86

CHEST PAIN

Question 87

SIGNS

Answer 87

Question 88

Answer 88

Question 89

Answer 89

Question 90

Answer 90

Question 91

Answer 91

Question 92

Answer 92

Question 93

PNEUMONIA

Answer 93

Pneumonia is an infection of the lung tissue, causing inflammation in the alveolar space. Pneumonia can be seen as a consolidation on a chest x-ray.

Question 94

UPPER VS LOWER RESP TRACT INFECTIONS

Answer 94

Acute bronchitis refers to infection and inflammation in the bronchi and bronchioles. Both pneumonia and acute bronchitis are classed as lower respiratory tract infections. Upper respiratory tract infections (e.g., a common cold) are usually viral. As a general rule, the lower down the respiratory tract, the higher the probability of bacterial infection, as opposed to viral.

Question 95

CLASSIFFCATION OF PNEUMONIA

Answer 95

Community-acquired pneumonia (CAP) develops in the community Hospital-acquired pneumonia (HAP) develops after more than 48 hours in a hospital Ventilator-acquired pneumonia (VAP) develops in intubated patients in the intensive care unit Aspiration pneumonia is when the infection develops due to the aspiration of food or fluids, usually in patients with impaired swallowing

Question 96

4 Stages of Lobar Pneumonia

Answer 96

Question 97

Question 98

COMMUNITY ACQUIRED PNEUMONIA CAUSES

Question 99

BRONCHOPNEUMONIA

Question 100

Legionella pneumophila

Answer 100

Legionella pneumophila (Legionnaires’ disease) is typically caused by inhaling infected water from infected water systems, such as air conditioning units. It can cause a syndrome of inappropriate ADH (SIADH), resulting in hyponatraemia (low sodium). The typical exam patient has recently had a cheap hotel holiday and presents with pneumonia symptoms and hyponatraemia. A urine antigen test can be used as an initial screening test.

Question 101

MYCOPLASMA PNEUMONIA

Answer 101

Mycoplasma pneumoniae causes milder pneumonia and a rash called erythema multiforme, characterised by varying-sized “target lesions” formed by pink rings with pale centres. It can cause neurological symptoms in young patients.

Question 102

Presenting symptoms of pneumonia

Answer 102

Cough Sputum production Shortness of breath Fever Feeling generally unwell Haemoptysis (coughing up blood) Pleuritic chest pain (sharp chest pain, worse on inspiration) Delirium (acute confusion)

Question 103

SIGNS OF PNEUMONIA

Answer 103

Characteristic chest signs of pneumonia include: -Bronchial breath sounds (harsh inspiratory and expiratory breath sounds) due to consolidation around the airways -Focal coarse crackles caused by air passing through sputum in the airways -Dullness to percussion due to lung tissue filled with sputum or collapsed

Question 104

CURB-65 score

Answer 104

Question 105

CURB-65 score

Question 106

MAIN CAUSES OF PNEUMONIA

Answer 106

The top causes of typical bacterial pneumonia are: -Streptococcus pneumoniae (most common) - Haemophilus influenzae

Question 107

Other bacterial causes of pneumonia

Answer 107

Moraxella catarrhalis in immunocompromised patients or those with chronic pulmonary disease Pseudomonas aeruginosa in patients with cystic fibrosis or bronchiectasis Staphylococcus aureus in patients with cystic fibrosis Methicillin-resistant Staphylococcus aureus (MRSA) in hospital-acquired infections

Question 108

INVESTIGATIONS

Answer 108

Investigations Patients in the community with CRB 0 or 1 pneumonia do not necessarily need investigations. A point-of-care test for the CRP level can be used in primary care to help guide diagnosis and the use of antibiotics. Investigations for patients admitted to hospital include: -Chest x-ray -Full blood count (raised white cell count) -Renal profile (urea level for the CURB-65 score and acute kidney injury) -C-reactive protein (raised in inflammation and infection) Patients with moderate or severe infection will also have: -Sputum cultures -Blood cultures -Pneumococcal and Legionella urinary antigen tests White blood cells and CRP are raised roughly in proportion to the severity of the infection. The trend can help monitor the progress of the patient towards recovery. CRP starts rising 6 hours behind the onset of inflammation and peaks after 24-48 hours. It may initially be low before becoming very high a day or two later.

Question 109

PREVENTING PNEUMONIA

Question 110

COMMENSUALISM AND OPPORTUNISTIC INFECTION

Question 111

ACUTE BRONCHITIS

Answer 111

- Inflammation of the bronchi - Acute bronchitis may also be called a chest cold. - Most symptoms of acute bronchitis last for up to 2 weeks. The cough can last for up to 8 weeks in some people. - Chronic bronchitis lasts a long time. It is more common among smokers. - Usually caused by virus, but can be caused by bacteria or allergens

Question 112

Acute Bronchitis Symptoms

Answer 112

- Cough, first dry (non-productive), later, a lot of mucus is produced - Headache -Runny nose -Slight fever -Shortness of breath - Wheezing

Question 113

How is Acute Bronchitis diagnosed ?

Answer 113

- History and Physical Examination - Chest X-ray - Arterial blood gas - Pulse Oximetry - Cultures of nasal discharge and sputum

Question 114

How is acute bronchitis treated?

Answer 114

Acute bronchitis is usually mild and does not cause complications. The symptoms often resolve on their own and lung function goes back to normal. In most cases, antibiotics are not needed to treat acute bronchitis. That’s because most of the infections are caused by viruses. Antibiotics are not effective against viruses. If it has progressed to pneumonia, then antibiotics may be necessary.