Station 1.13: Abdominal and Respiratory

Question 1

Clinical signs

What are the clinical signs of Pneumonia?

Pneumonia

This patient has been acutely unwell for 3 days, with shortness of breath and a productive cough.
Please examine his chest.

Answer 1

• Tachypnoea, O2 mask, sputum pot (rusty sputum associated with pneumococcus)
• Reduced expansion
• Dull percussion note
• Focal coarse crackles, increased vocal resonance and bronchial breathing
• Ask for the temperature chart
• If dull percussion note with absent tactile vocal fremitus, think parapneumonic effusion/empyema

Question 2

Discussion - investigation

What are the investigations of Pneumonia?

Pneumonia

This patient has been acutely unwell for 3 days, with shortness of breath and a productive cough.
Please examine his chest.

Answer 2

• CXR: consolidation (air bronchogram), abscess and effusion
• Bloods: WCC, CRP, urea, atypical serology (on admission and at day 10) and
  immunoglobulins
• Blood (25% positive) and sputum cultures
• Urine:
  ⚬ Legionella antigen (in severe cases)
  ⚬ Pneumococcal antigen
  ⚬ Haemoglobinuria (mycoplasma causes cold agglutinins → haemolysis)

Question 3

Discussion - Community acquired pneumonia (CAP)

Describe Community acquired pneumonia (CAP)?

Pneumonia

This patient has been acutely unwell for 3 days, with shortness of breath and a productive cough.
Please examine his chest.

Answer 3

• Common organisms:
  ⚬ Streptococcus pneumoniae 50%
  ⚬ Mycoplasma pneumoniae 6%
  ⚬ Haemophilus influenzae (especially if COPD)
  ⚬ Chlamydia pneumoniae.
• Antibiotics:
  ⚬ 1st line: penicillin or cephalosporin + macrolide

Question 4

Discussion - Special considerations

Describe Special considerations for Pneumonia?

Pneumonia

This patient has been acutely unwell for 3 days, with shortness of breath and a productive cough.
Please examine his chest.

Answer 4

• Immunosuppressed:
  ⚬ Fungal ————————————– Rx Amphotericin
  ⚬ Multi‐resistant mycobacteria
  ⚬ Pneumocystis carinii ——————- Rx Cotrimoxazole/Pentamidine
  ⚬ CMV —————————————– RxGanciclovir
• Aspiration (commonly posterior segment of right lower lobe):
  ⚬ Anaerobes ——————————– Rx + Metronidazole
• Post‐influenza:
  ⚬ Staph. aureus —————————- Rx + Flucloxacillin

Question 5

Discussion - Severity score for pneumonia: CURB‐65 (2/5 is severe)

Describe the Severity score for pneumonia: CURB‐65 (2/5 is severe) for Pneumonia?

Pneumonia

This patient has been acutely unwell for 3 days, with shortness of breath and a productive cough.
Please examine his chest.

Answer 5

• Confusion
• Urea >7
• Respiratory rate >30
• BP systolic <90mm Hg or diastolic <60mm Hg
• Age >65

Severe CAP should receive high‐dose IV antibiotics initially plus level 2 care (HDU/ITU)

Question 6

Discussion - Prevention

Describe the prevention for Pneumonia?

Pneumonia

This patient has been acutely unwell for 3 days, with shortness of breath and a productive cough.
Please examine his chest.

Answer 6

Pneumovax II® to high‐risk groups, e.g. chronic disease (especially nephrotic and asplenic
patients) and the elderly

Question 7

Discussion - Complications

Describe the complications for Pneumonia?

Pneumonia

This patient has been acutely unwell for 3 days, with shortness of breath and a productive cough.
Please examine his chest.

Answer 7

• Lung abscess (Staph. aureus, Klebsiella, anaerobes)
• Para‐pneumonic effusion/empyema
• Haemoptysis
• Septic shock and multi‐organ failure