Pulm 4 Flashcards
A 75 yo male presents with a cough, dyspnea, fever, sweats, chest pain, and fatigue. On exam you notice tachypnea, tachycardia, increased tactile fremitus, egophony, and altered breath sounds over the RML. He had the flu 2 weeks ago, but for the past few days up until today he felt fine. He has a 25 pack year history of tobacco use which was discontinued 5 years ago. On his CXR you see patchy airspace infiltrates in the right lung and a lobar consolidation in the RML, consistent with your PE findings. What is the most likely etiologic agent? What disease does the pt most likely have?
Typical community acquired pneumonia (Typical CAP)
Most likely s. pneumonia or s. aureus because he recently had the flu
S. pneumonia is the MC cause of typical CAP
A 53 yo male presents with a fever, dyspnea, chest pain, fatigue, headache, and a productive cough. He is worried because his sputum is red and jelly-like. On exam you find that he has a fever, tachypnea, hypoxia, increased tactile fremitus, egophony, and altered breath sounds over the LLL. CXR shows a lobar consolidation and a small pleural effusion over the LLL. What is the most likely etiologic agent? How do you treat this pt if he has not received Abx in the past 3 months?
Typical CAP
Most likely klebsiella (could also be s. pneumonia)
Treat with a macrolide (Biaxin or Z-pack) or doxycycline
In this pt you can be pretty certain it’s klebsiella so you don’t need to test for the pathogen, instead you can just start empiric therapy
A 23 yo female comes in to your clinic because she has had severe fatigue all day with some muscle pain. She has a low-grade fever, but otherwise she appears fine. On exam you note RUL increased tactile fremitus and egophony. What do you suspect the pt has? What is the most likely underlying etiologic agent?
Atypical CAP
Most likely caused by mycoplasma pneumonia (could also be chlamydia pneumonia)
A 68 yo pt presents with an acute onset cough, dyspnea, fever, chest pain, scant hemoptysis, and a stomach ache. On exam you find his BP is 105/50, his RR is 40, and he has increased tactile fremitus, egophony, and altered breath sounds in the LUL. CXR shows patchy airspace infiltrate in the left lung and a lobar consolidation in the LUL. What treatment do you recommend for this pt?
Typical CAP
This pt should be admitted since he scored a 3 on the CURB-65 criteria (RR, BP, & >65yo)
Since he is an in-pt you have to test for the pathogen via pre-Abx sputum cultures or blood cultures
Start empiric therapy of fluoroquinolone (PO or IV or, a B-lactam (amoxicillin, augmentin) with a macrolide (biaxin, z-pack). Make sure he is hydrated and that the room O2 > 90%
Once you get back the culture results you can tailor the Abx treatment based on the pathogen
A pt presents with a cough, dyspnea, fever, chills, sweats, and fatigue. On exam you find increased tactile fremitus, egophony, and abnormal breath sounds over the LUL. CXR shows a LUL lobar consolidation and left lung patchy airpace infiltarate. The pt tells you that 2 months ago she was treated for strep with an antibiotic, and she wants to know if this could be her strep coming back. What do you tell the pt? What treatment do you recommend?
She has typical CAP which is unrelated to her strep
Treat the pt with fluoroquinolone or a B-lactam (amoxicillin, augmentin) with a macrolide (Biaxin, Z-pack)
What is the most likely pathogen for typical CAP in children > 2 yo? In children < 1 yo?
> 2 yo: Parainfluenza
< 1 yo: RSV
Your pt has had COPD for 8 years, but some new symptoms make you concerned that he might have pneumonia. What is the most likely pathogen for PNA in this pt? How would you treat it?
H. influenza, Moraxella catarrhalis, s. pneumonia
Treat with fluoroquinolones or a B-lactam (amoxicillin, augmentin) with a macrolide (biaxin, z-pack)
A pt presents to you with a fever, recent unintentional weight loss, and a cough that’s producing a foul smelling, purulent sputum. Last week your pt was in the ER and had a NG tube placed because she was having trouble breathing. What disease does she most likely have? What is the most likely pathogen?
Anaerobic pneumonia
Prevotella melaninogenica, peptostreptococcus, fusobacterium nucleatum, or bacteriodes sp.
A pt comes in because he hasn’t been feeling well recently. He looks pretty under the weather and has a fever and a cough that’s producing foul smelling, white/yellow sputum. You notice he has numerous cavities. What is the best treatment for this pt?
Anaerobic PNA
Treat with clindamycin, amoxicillin-clavunate, or PCN with metronidazole
An 85 yo man presents with a cough, fever, chills, chest pain, and dyspnea. He tells you a few other people in his nursing home have had the same symptoms recently, but he doesn’t know what was wrong with them. What is the most likely diagnosis? How do you treat him?
Health care associated pneumonia (HCAP)
You have to do a gram stain or sputum culture because you will start empirical therapy for a s. pneumonia infection (MC cause of HCAP), but you need to tailor the therapy based on the culture results
A pt on your rounds has recently developed a cough, fever, chills, sweats, and dyspnea. She has been in the hospital for the past 3 days, but these symptoms are new and unrelated to the reason she is in the ICU. What is the most likely pathogen causing her new symptoms? How will you treat her?
Hospital acquired pneumonia (HAP)
Most likely caused by p. aeruginosa (bad prognosis)
Treat her with empiric therapy for p. aeruginosa, but take a sputum culture so that you can tailor her therapy when the culture results come back
A pt in the hospital has recently developed a fever, increased respiratory secretions, tachypnea, tachycardia, increased minute ventilation, and cyanosis around his lips. He was intubated 3 days ago. What disease are you most concerned this pt might have?
Ventilator associated PNA
A pt presents with a cough, fever, and shortness of breath. He has recently lost 10 lbs unintentionally, and you notice that the corners of his mouth have a blue tinge. You did a sputum culture, and the results came in that it is pneumocystis pneumonia (PCP). What diseases does this pt have? How are you going to treat him?
HIV-related PNA and HIV
Treat with bactrim (TMP/SMX/trimethoprim/sulfamethoxazole) and with steroids (because he is hypoxic)
A 63 yo woman presents to your office. In her social history you learn that she is a recent immigrant from Russia. She tells you that she has a cough that won’t seem to go away, loss of appetite, weight loss, and night sweats that have slowly been getting worse. She appears unusually thin and doesn’t look well. What disease do you think she might have? What is the most likely pathogen? What tests might you do to help determine if your diagnosis is correct?
Tuberculosis pneumonia
Mycobacterium tuberculosis
Diagnose with a PPD
Do a CXR and look for infiltrates, atelectasis, lymph enlargement, and Ghon or Ranke
Two days ago you saw a pt with a chronic cough, hemoptysis, unintentional weight loss, fever, and night sweats. He appeared malnourished, so you recommended a PPD just to rule out TB. When he comes in today the PPD is positive. What treatment options are you going to recommend for this pt?
TB PNA
Treat with 2 months of Ethambutol, isoniazid, rifampin, and pyrazinamine then 4 months of isoniazid and rifampin
