Community Acquired PNA

Question 1

Because this occurs often in the elderly (community-acquired PNA): it’s important to note the differences in how they would present. Same symptoms - dyspnea, tachypnea, inspiratory crackles. What additional symptoms or change in timing would be seen? 
SELECT ALL THAT APPLY
A: cough with or without sputum
B: low temperature
C: subacute onset of symptoms
D: acute change in mental status

Answer 1

B: low temperature

D: acute change in mental status

Answer: B, D (fever is often low in the elderly, mental status change)

Question 2

What is the MOST sensitive sign in the elderly presenting with pneumonia?

A: tachypnea
B: low-grade fever
C: mental status change
D: inspiratory crackles

Answer 2

Answer: A - Tachypnea

Question 3

A 65yr old patient presents with CAP. What is the most likely cause?
A: bacterial
B: viral
C: fungal
D: trauma

Answer 3

Answer: A: bacterial

Question 4

What is the MOST common bacteria that causes CAP in adults?
A: S pneumoniae
B: M pneumoniae
C: H pneumoniae
D: C pneumoniae

Answer 4

Answer - A: S pneumoniae

Question 5

If the adult patient had CAP caused by a virus - what is the MOST common viral organism?
A: RSV
B: adenovirus
C: parainfluenza virus
D: influenza

Answer 5

D: influenza

Question 6

55 yr. old patient presents to your clinic with dyspnea, fever, and inspiratory crackles heard on auscultation. You suspect CAP. Your
next intervention would be?
A: Order blood work, EKG, CXR
B: Order PFTs
C: Order spirometry test with PRN bronchodilator
D: Order PO antibiotics

Answer 6

D: Order PO antibiotics

Answer: D (only hospitalized patients require diagnostic testing; if the patient is treated outpatient – empiric abx is almost always effective in this population without the need for diagnostic tests)

Question 7

The FNP wishes to confirm the presence of S. pneumoniae as the causative organism for the patients' CAP. What lab test could be employed to confirm?
A: rapid nasal antigen swab
B: sputum gram stain
C: urinary antigen test
D: sputum culture

Answer 7

C: urinary antigen test

Answer: C (a specific and rapid result of S. pneumoniae; pneumococcal urine antigen test (UAT) is an assay commonly used to identify
pneumococcal antigens excreted into the urine to increase the rate of specific microbiological diagnosis over conventional culture methods)

Question 8

During your initial work-up for patient with CAP, you order a rapid nasal swab to detect Influenza. Your patient questions why this is necessary. Your response is?
A: Most often, influenza is the cause
B: A positive test will determine treatment
C: Influenza could complicate CAP disease progression
D: I need to obtain this test to report to Health Department

Answer 8

B: A positive test will determine treatment

Answer: B (positive flu result will reduce unnecessary antibiotic use)

Question 9

If you were to obtain a CXR on a patient suspected to have CAP, what findings would be present and confirm your suspicion of this diagnosis?
A: pleural fluid accumulation in dependent zones
B: Infiltrates in dependent zones with multiple cavitation
C: pulmonary opacities
D: deep sulcus sign

Answer 9

C: pulmonary opacities

Answer: C pulmonary opacity on chest x-ray (clearing of opacities can take 6wks or longer; quicker in young, non-smokers with 1 lobe involved)

Question 10

T or F: CXR cannot identify causative organism or distinguish bacterial from viral pneumonia

Answer 10

True

Question 11

A patient’s chest x-ray shows SIGNIFICANT pleural fluid collections. What do you anticipate concerning the patient’s condition and what should be your intervention?

Answer 11

Answer: anticipate impending airway compromise; REFER! may require thoracentesis

Question 12

Patients chest x-ray shows cavitary opacities. What do you suspect and what is your intervention?

Answer 12

Answer: suspect TB; REFER TO ED IMMEDIATELY – requires airborne isolation and TB work-up

Question 13

A 65-yr. old, previously healthy patient reports to your clinic and is diagnosed with CAP. You check the eMAR and determine this patient has received no abx within the last 90 days. What is the recommended outpatient abx choice?
A: clarithromycin
B: amoxicillin
C: clindamycin
D: levaquin

Answer 13

A: clarithromycin

Answer: A (macrolides)

Question 14

A 35-yr. old patient with hx of recent corticosteroid use reports to your clinic and is diagnosed with CAP. You check the eMAR and determine this patient has received azithromycin 4 wks ago. What is the recommended outpatient abx choice?
A: clarithromycin
B: amoxicillin
C: clindamycin
D: levaquin

Answer 14

D: levaquin

Answer: D any patient w/ risk of drug resistance receives a respiratory fluoroquinolone or a macrolide + b-lactam (Drug resistance factors = abx <90 days, >65yr old, comorbid illness, immunosuppression, exposed to a child in daycare)

Question 15

What is the typical antibiotic treatment duration for adults with CAP?
A: 3-5 days
B: 7-10 days
C: 3 days of IV abx
D: 5 days

Answer 15

D: 5 days

Answer: D (a minimum of 5 days of therapy and continue abx until pt. is afebrile for 48-72hr)

Question 16

A patient schedules an appointment with you regarding a persistent cough for 3 weeks. You look in the medical record and see his last visit was the diagnosis of CAP. What is your intervention for this patient?
A: Order a repeat CXR to evaluate current treatment
B: Order repeat labs to evaluate for persistent infection
C: Schedule an appointment 4 weeks from today
D: Perform a rapid flu swab to evaluate for flu

Answer 16

C: Schedule an appointment 4 weeks from today

Answer: C (cough and fatigue may last up to 4 weeks; routine CXR not needed if patient is improving)

Question 17

What is the MOST important prevention technique for pneumonia?

Answer 17

Answer: pneumonia vaccine

Question 18

What patient would you vaccinate with PCV13?
A: asthma
B: diabetes
C: sickle cell
D: alcoholic

Answer 18

C: sickle cell

Answer: C (PCV13 = immunocompromised, renal failure, HIV, cochlear implants, CSF leaks, sickle cell, cancer, organ transplant – immunocompromised or blood disorders (inc. cancer); PPSV23: these are people that did stuff in their life to get the diagnoses they have
(smokers, chronic heart / lung / liver disease, asthma, DM, alcoholic, any one in long-term care facility)

Question 19

What clinical prediction rule can help guide the decisions concerning whether to admit or treat a patient with CAP outpatient?
A: Pneumonia Severity Index
B: Modified Wells Score
C: CURB-65
D: CIWA score

Answer 19

C: CURB-65

Answer: C (Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment; pneumonia severity index (PSI) is a clinical prediction rule often used to predict the need for hospitalization in people with pneumonia)

Question 20

Utilizing CURB-65, what does each letter represent?

Answer 20

Answer:
C-confusion to person, place, time – confused elderly
U-urea (BUN) >7 – dehydration secondary to pneumonia (high BUN level is one of the components of both the CURB-65 score and PSI. BUN
levels show a decrease in renal perfusion and indirectly predict the severity of pneumonia. The patients who have pneumonia are usually
dehydrated that results from increase of BUN excretion from the kidneys.)
R-resp rate >30min - tachypneic
B-blood pressure <90/60 – hypotensive (impending shock)
A-age >65yr – old, same age as vaccination of pneumonia

Question 21

A score of “0” using the CURB-65 calculator means what?

Answer 21

Answer: Outpatient tx with close follow-up

Question 22

A score of “3+” using the CURB-65 calculator means what?

Answer 22

Answer: ICU Admit

Question 23

A score of “1-2” using the CURB-65 means what?

Answer 23

Answer: Admit to hospital, but no ICU is needed

Question 24

A patient presents with pneumonia. What would you expect to see on CXR?

Answer 24

Answer: Infiltrates and lung consolidation

Question 25

A 60-yr. old patient presents with fatigue, SOB, high fever, and purulent sputum. He is not a smoker. On physical exam, his lungs DO NOT clear after coughing several times. What is the MOST likely diagnosis?

Answer 25

Answer: Pneumonia

Question 26

A patient with recent PNA asks, “When will I get rid of this cough?” The appropriate response by the NP is?

Answer 26

Answer: Cough and fatigue may last up to 4 weeks

Question 27

CAP: For all patients, we treat until the patient has been afebrile and clinically stable for at least 48 hours and for a minimum of five days. How to treat mild vs severe infection?

Answer 27

Patients with mild infection generally require five to seven days of therapy.

Patients with severe infection or chronic comorbidities generally require 7 to 10 days of therapy.

Question 28

CAP vs. pneumococcal pneumonia: Treating patients with a macrolide will USUALLY cover s. pneumonia, the most common cause, but will also cover mycoplasma, another common cause.

Answer 28

Macrolide - for patient living in a non-resistant region

Question 29

CAP vs pneumococcall pneumonia cont:

There are some strains of s. pneumonia that are resistant to macrolides, and if you are treating a patient in a region where there is known high resistance to macrolides, then EMPIRIC treatment is what?

Answer 29

Patients living in a resistant region

treatment is with a fluoroquinolone OR a macrolide PLUS a beta-lactum (such as high dose amoxicillin) is recommended

Question 30

Pediatric Outpatient TX of CAP:

Answer 30

for a child under 5, Amoxil is first line.

It is also first line in > 5yr, unless you suspect Mycoplasma