Case 12- Pneumonia And TB

Question 1

Investigations for suspected pneumonia

Answer 1

Resp examination
Observations
Sputum culture and urinalysis (legionella, pneumococcal antigens)
FBC, UE (urea), LFT, CRP, blood cultures (2 sets at 2 different times, from 2 locations), blood gas for lactate (sepsis)
CURB 65 score
CXR

NB- diagnosis is X-RAY change and signs of LRTI . Must qualify what type eg. HAP/ CAP- read question info carefully (are they in hospital or are they in the community). 4-6 weeks repeat the CXR to make sure consolidation gone/ no neoplasm

Question 2

Atypical pneumonia organisms

Answer 2

Legionella pneumophilia- infected water supply/ air conditioning. Causes hyponatraemia via SIADH

Mycoplasma pneumoniae- young patients. Erythema multiforme rash. May cause neurological signs eg. GBS/encephalitis

Chlamydophilia pneumoniae- young child with wheeze

Coxiella burnetti (Q fever)- exposure to animals/ their bodily fluids (raised liver enzymes)

Chlamydia psittaci- infected birds eg. Parrots

Question 3

Patients shouldn’t be discharged if in last 24 hours they have had 2 of the following

Answer 3

Temp higher than 37.5
Resp rate above 24
Bpm above 100
02 under 90 on room air
Abnormal mental status
Inability to eat without assistance

Question 4

Causes of a transudative pleural effusion (less than 30mg protein)

Answer 4

Increased venous pressure- CCF, constrictive pericarditis, fluid overload

Hyponatraemia- cirrhosis, nephrotic syndrome, malabsorption

Hypothyroidism

Hypoalbuminaemia

Meigs syndrome- ovarian malignancy

NB- transudative more likely to be bilateral

Question 5

Causes of an exudative pleural effusion >30g/L)

Answer 5

Increased permeability of the pleural capillaries- pneumonia, TB, malignancy, pancreatitis, pulmonary infarction eg. PE, SLE

Question 6

Pneumonia

Answer 6

Must say whether HAP or CAP, never just pneumonia

Question 7

Sx of pneumonia

Answer 7

Fevers, rigors, malaise, dyspnoea, cough, sputum, haemoptysis, confusion, cyanosis, fever, pleuritic pain, tachycardia, tachypnoea, hypotension, bro chill breathing, reduced expansion, dull percussion, increased tactile fee it’s, increased vocal resonance

Question 8

Pneumonia differentials

Answer 8

Acute bronchitis, asthma exacerbation, TB, lung neoplasia, CHF

Question 9

Typical pneumonia organisms

Answer 9

Strep pneumoniae (causes reactivation of HSV- cold sores)
H influenzae
Klebsiella pneumoniae
Staph aureus
Moraxella catarrhalis

Question 10

TB Sputum

Answer 10

Grows acid fast bacilli that stain red with Ziegler’s Nielsen staining (mycobacterium tuberculosis)

Question 11

TB Sx

Answer 11

Cough, fever, weight loss, malaise, night sweats, pleuritic chest pain, erythema nodosum (painful red nodules over the pretibial region)

Question 12

TB differentials

Answer 12

CAP, lung cancer, sarcoidosis

Question 13

Suspected TB investigation and management

Answer 13

Isolate in hospital, appropriate PPE, test contacts for TB, test for other ID’s, then test appropriately as below;

Sputum culture- acid fast bacilli positive
Mantoux tuberculin test- 5mm or more requires further investigation
Bloods- FBC- increased WCC, anaemia, UE deranged (not eating perhaps), LFT- damage
CXR- fibronodular opacities
Interferon release gamma assays- meausre T cell response to TB antigens to diagnose prior exposure

RIPE treatment (also get given pyridoxine- 5 things)

Question 14

ABCDE Assessment

Answer 14

Never forget- acutely unwell patient you actually have to do this. Remember this in OSCE

Question 15

Acute respiratory distress syndrome

Answer 15

Non cardiogenic pulmonary oedema

Question 16

Causes of ARDS

Answer 16

Infection- sepsis or pneumonia
Blood transfusion
Trauma
Smoke inhalation
Acute pancreatitis
Cardio pulmonary bypass

Question 17

Clinical features of ARDS

Answer 17

Dyspnoea
Elevated respiratory rate
Bilateral lung crackles
Low oxygen saturations

Question 18

Criteria for ARDS

Answer 18

Acute onset (1 week of known risk factor)
Bilateral infiltrates on CXR
Non cariogenic (pulmonary artery wedge pressure is normal)
pO2/FiO <40 kPa

Question 19

Management of ARDS

Answer 19

Treat underlying condition
Oxygen
ITU support

Question 20

Allergic bronchopulmonary aspergillosis features

Answer 20

Bronchoconstriction- wheeze, cough, dyspnoea, previous asthma label
Bronchiectasis

Question 21

Investigations for ABPA

Answer 21

Eosinophilia
CXR changes
Positive RAST test to aspergillus
Positive IgG precipitins
Raised IgE

Question 22

Management of ABPA

Answer 22

Glucocorticoids- primary
Itraconazole- secondary

Question 23

Imaging features of ABPA

Answer 23

CXR- mass overlying the hilum, tram track opacities (bronchiectasis)
CT- branching lesion/ finger in glove (bronchocoele)

Question 24

What lobe is most commonly affected by aspiration

Answer 24

Right middle and lower lobes
Right bronchus is more vertical and has a larger calibre

Question 25

Atelectasis management

Answer 25

Position patient upright
Chest physiotherapy (breathing exercises)

NB- suspect 72 hours post op if patient has dyspnoea and hypoxaemia

Question 26

Klebsiella

Answer 26

Typically causes aspiration pneumonia and UTI’s
More common in alcoholics and diabetics
Red currant jelly sputum
Affects upper lobes
Causes lung abscesses and empyema

Question 27

Features of a pleural effusion

Answer 27

Dyspnoea
Non productive cough or chest pain
Dullness to percussion, reduced breath sounds, reduced chest expansion

Question 28

Differentiating exudative and transudative pleural effusions

Answer 28

> 30g/L- exudative
<30g/L- transudative

If protein level between 25-35- apply lights criteria

Question 29

Lights criteria

Answer 29

An exudative is likely if pleural fluid protein divided by serum protein is greater than 0.5

Question 30

Characteristic pleural fluid findings

Answer 30

Low glucose- TB, RA
Raised amylase- pancreatitis, oesophageal perforation
Blood staining- mesothelioma, PE, TB

Question 31

Pleural effusion and infection

Answer 31

If fluid purulent- chest drain inserted
If fluid clear but pH less than 7.2 in suspected infection- chest drain inserted

Question 32

Recurrent pleural effusion

Answer 32

Pleurodesis
Indwelling pleural catheter

Question 33

Mycoplasma pneumoniae

Answer 33

Autoimmune haemolytic anaemia
Erythema multiforme
CNS involvement eg. GBS/encephalitis

Question 34

Legionella

Answer 34

Hyponatraemia and lymphopenia

Question 35

CURB65

Answer 35

Confusion (AMT10 score 8/10)
Urea (>7)
Resp rate (>30)
BP (<90 or <60)
Aged 65+

Question 36

CURB65 Outcome

Answer 36

0- community
1- if sats above 92%, do CXR and if only one area of consolidation, manage in community
2- transfer to hospital

Question 37

Management of pneumonia

Answer 37

Low severity- 5 day amoxicillin course (macrolide eg. Clarithromycin if required)

Moderate or severe severity- 7-10 day course of amoxicillin and macrolide eg. Clarithromycin

Question 38

Symptom resolution in pneumonia

Answer 38

1 week- fever disappear
4 week- chest pain and sputum reduced
6 weeks- cough and breathlessness reduced
3 months- fatigue may still be present
6 months- most people back to normal

Question 39

Aspergillosis

Answer 39

Fungal infection of the lungs. It can take several forms;

-chronic pulmonary aspergillosis (CPA)
-aspergilloma
-allergic bronchopulmonary aspergillosis (ABPA)

Question 40

ABX for pneumonia

Answer 40

CAP- amox (doxy if allergy)

HAP- co-amox (48 hours+ in hospital)