LTRI in Adults

Question 1

Symptoms of Pneumonia

Answer 1

Malaise 
Myalgia (muscle pain)
Fever 
Chest pain (pleuritic)
Cough 
Purulent sputum 
Dyspnoea

Question 2

Signs of Pneumonia

Answer 2

Pyrexia
Tachypnoea (rapid breathing)
Central cyanosis (hypoxia)
Dullness to percuss on affected lobes
Bronchial breath sounds (due to consolidation)
Inspiratory crepitations
Increased vocal resonance (consolidation)

Question 3

Pneumonia investigations

Answer 3

CXR (consolidation)
U+Es 
LFT 
CRP (raised in pneumonia)
FBC (raised WBC, especially neutrophils)
Blood or sputum culture 
Urinary legionella antigen 
Throat swab (for atypical pathogens)
HIV test

Question 4

When a patient produces rusty coloured sputum what could this indicate?

Answer 4

Pneumonia caused by streptococcus pneumonia

Question 5

5 bacterias that cause Pneumonia

Answer 5

Strep Pneumonia (commonest)
Haem. Influenzae 
Legionella 
Staph aureus 
Mycoplasma pneumoniae

Question 6

What can be used to score the severity of pneumonia?

Answer 6

CURB 65

C - confusion 
U - blood urea > 7 
R - Respiratory rate > 30 
B - diastolic BP < 60 
65 - age > 65yrs

Question 7

If a patient scores a CURB 65 of 0-1 what antibiotics should they be treated with?

Answer 7

Low risk and could be treated in community

Amoxycillin or clarithromycin / doxycycline

Question 8

If a patient scores a CURB 65 of 2 what antibiotics should they be treated with?

Answer 8

Hospital treatment usually required (1-2)

Amoxycillin and clarithromycin or levofloxacin

Question 9

If a patient scores a CURB 65 of 3-5 what antibiotics should they be treated with?

Answer 9

High risk of death and need for ITU

Co-amoxyclav and clarithromycin or levofloxacin (if penicillin allergic)

Question 10

Other treatments for Pneumonia other than antibiotics?

Answer 10

Oxygen
IV fluids
CPAP (continuous positive airflow pressure)
Intubation and ventilation

Question 11

Complications with Pneumonia

Answer 11

Septicaemia - if bacteria enters blood 
Acute kidney injury 
Empyema (pus in pleural cavity) 
Lung abscess
Metastatic infection 
ARDS

Question 12

Differential diagnosis

Answer 12

TB 
Lung cancer 
Pul embolism 
Pul oedema 
Pul vasculitis

Question 13

Aetiology of Empyema

Answer 13

Secondary to Pneumonia
Streptococcus
Staph. aureus
Anaerobes

Question 14

Symptom and sign of empyema

Answer 14

Chest pain (pleuritic) and swinging pyrexia

Question 15

Investigation and diagnosis for empyema

Answer 15

CT thorax and pleural ultrasound (shows fluid) to investigate and diagnosed by pleural aspiration (pH < 7.2)

Question 16

Treatment of empyema

Answer 16

Chest drain and IV antibiotics
Sometime intrapleural t-PA/DNase
Surgery if no improvement

Question 17

Aetiology of lung abscesses

Answer 17

Secondary to pneumonia - certain organisms more likely to result in caveatting pneumonia; staph aureus, pseudomonas, anaerobes

Question 18

Symptoms of lung abscess

Answer 18

Non-specific - lethargy, weigh loss, high swinging pyrexia

Question 19

Lung abscess investigation

Answer 19

CT thorax 
Sputum culture (including TB microscopy and culture)

Question 20

What is bronchiectasis?

Answer 20

Dilation of the bronchi due to scarring and thickened airway wall (mucus build up)

Question 21

Aetiology of bronchiectasis

Answer 21

Idiopathic
Immotile cilia syndrome (mucus build up)
Cystic fibrosis
Childhood infection - measles
Hypogammaglobulinaemia (less antibodies to fight infection)
Allergic bronchopulmonary aspergillosis (ABPA) - hypersensitivity to aspergillosis

Question 22

Symptoms of bronchiectasis

Answer 22

Chronic cough
Sputum production
Sometimes - wheeze, dyspnoea, fatigue, flitting chest pain, haemoptysis (vessel dilation causes rupture)

Question 23

Signs of Bronchiectasis

Answer 23

Finger clubbing

Course inspiratory crepitations (auscultation)

Question 24

Investigation on bronchiectasis

Answer 24

HRCT thorax (CT)
Sputum culture (for H influence, staph aureus, pseudomonas aeruginosa)
Serum immunoglobulins
Total IgE (for ABPA) and aspergillum precipitins
CF genotyping

Question 25

Treatment of bronchiectasis

Answer 25

Chest physiotherapy
Antibiotics
May require inhaled therapy including beta 2 agonist and inhaled corticosteroid (for those SOB and wheezy)

Question 26

Aetiological classifications of pneumonia

Answer 26

Community acquired 
Hospital acquired (nosocomial)
In the immunocompromised 
Atypical 
Aspiration 
Recurrent

Question 27

Patterns of pneumonia

Answer 27

Bornchopneumonia
Segemental
Lobar

Hypostatic
Aspiration
Obstructive, retention, endogenous lipid

Question 28

What is the basis of anatomical classification of pneumonia: bronchi vs lobar?

Answer 28

Pneumonia is alveolar inflammation caused by infection. It can affect alveoli uniformly from one or more lobes of the lung (lobar) or spread from the terminal bronchioles to the alveoli in a more patchy distribution (bronchopneumonia)

Question 29

What are the causative organisms of Pneumonia in the Immunocompromised and what drugs do you give?

Answer 29

Viruses
Legionella- Clarithromycin (tetracycline or macrolide)
Staphylococcus - Flucloxacillin
Streptococcus pneumoniae - Amoxicillin

Question 30

What are the causative organisms of Pneumonia in the Community and what drugs do you give?

Answer 30

Streptococcus pneumoniae - Amoxicillin
Mycoplasma pneumoniae- Clarithromycin (tetracycline or macrolide)
Chlamydophila pneumoniae- Clarithromycin (tetracycline or macrolide)
Haemophilus influenzae - Amoxicillin/Co-amoxiclav

Question 31

What are the causative organisms of Pneumonia in the Hospital and what drugs do you give?

Answer 31

Gram negative bacteria - Amoxicillin
MRSA - Vancomycin + Rifampin
Streptococcus pneumoniae - Amoxicillin

Question 32

What are the causative organisms of Atypical Pneumonia and what drugs do you give?

Answer 32

Mycoplasma pneumoniae- Clarithromycin/Tetracycline
Legionella- Clarithromycin/Tetracycline
Chlamydia- Clarithromycin/Tetracycline
Coxiella burnetii - Clarithromycin/Tetracycline