pneumonia

Question 1

contexts of pneumonia

Answer 1

ventilator aquired
community acquired
nursing home acquired
hospital aquired

Question 2

agents responsible for community acquired

Answer 2

streptococcus
haemophilus
moraxella
respiratory viruses
atypical organisms
mycopalsma

Question 3

nursing home and hosppital aqcuired organisms

Answer 3

staph/MRSA
pseudomonas
gram negatives

Question 4

patient risk factors

Answer 4

alcohol
diabetes
immunosuppressed
high dose inhaled steroids - patients with COPD and asthma
aspiration risk
travel

Question 5

occupational and other exposures

Answer 5

mulch
psittacine birds
farming
vets and veterinary nurses
air conditioning systems (legionella pneumophila)

Question 6

typically presentation of community acquired pneumonia

Answer 6

viral URTI prodrome
cough
fever - sweats/shivers
headache common
extreme lassitude
can be quick onset
pleuritic chest pain
rusty sputum - blood tinged (not common)

Question 7

on examination of community aquired pneumonia

Answer 7

unwell in pain
pale sweaty
fever
hypotension/respiratory distress if very sick
crackles commonest locaal sign on ausultation
dull
might hear bronchial breathing
might hear a pleural rub
might have a pleural effusion - dull, reduced/absent BS

Question 8

lower lobe pneumonia may present with

Answer 8

acute upper abdominal pain due to lower lobe irritating pneumonia
may present with abdo pain and guarding

Question 9

frail elderly people may present with

Answer 9

delirium and little fever

Question 10

immunosuppressed may present with

Answer 10

fever and no localising features

Question 11

diabetic patients may present with

Answer 11

DKA/hyperosmolar hyperglycaemic states - consider pneumonia as a trigger

Question 12

blood tests

Answer 12

FBC - especially white cell count
UEC
CRP - usually in the hundreds
LFTs - usually mildly deranged
blood cultures - may identify causative organism
BSL/HbA1C
serology for viruses /mycoplasma
throab swab - viral PCR
urine - pneumococcal and legionella antigen
CXR - no need for CT in straightforward case
may need ABGs depedning upon severity of illness

Question 13

CURB65

Answer 13

C - confusion
U - urea > 7
R - resp rate > 30
Blood pressure - either systolic under 90 or diastolic under 60
Age > 65

Question 14

CURB 65 scores

Answer 14

0 or 1 - low mortaality
2 - mortality intermediate
3 or more - mortality high

Question 15

manageemnt of community. acquired pneumonia

Answer 15

oxygen if sats < 94%
analgesia if chest pain present
antibiotics according to local guidelines
oral for ambulant patient, IV for sicker patient
10-14 days usually

Question 16

fluids

Answer 16

IV resus for sick septic patient
oral for ambulant patient

Question 17

if the patient is hypotensive

Answer 17

call ICU

Question 18

follow up

Answer 18

no need for repeat CXR in hosspital if patient is improving
follow up 4-6 weeks is. good as radiological improvement lags
full recovery may take 6-8 weeks

Question 19

watch for complications

Answer 19

failure to improve/persistant fever/persistant neutrophilia

could the antibiotics be wrong/diagnosis wrong
paragnuemonic effusion

Question 20

parapneumonic effusion

Answer 20

common
extremely important not to miss
repeat chest x-ray and respiratory US
- drain any effusion which is not trivial in size
- monitor small effusions
never let the sun set on a parapneumonic effusion