week 3 resp. med in primary care Flashcards
Normal adult blood pressure rating?
Between 90/60 and 120/80
High blood pressure =
Low blood pressure =
140/90mmHg
90/60mmHg
What’s normal heart rate?
60-100 bpm
What does ‘crepitations’ mean when referring to lung lobes?
Sound associated with subcutaneous emphysema, audible crackling noises
Auscultation sounds and ‘base of lung’ meaning
Usually referring to the inferoposterior part of the inferior lobe
Three air sounds of auscultating the lungs:
Air filled= resonant
Fluid filled= dull
Solid= flat
Patient with pneumonia signs. Crepitations over left lower lobe. Amoxicillin for two days, not worked. Cough, 4 days of sob, two days of abdominal pain and vomiting. Smoker. Sats- 87 on air, heart rate- 120,
BP 100/50mmHg, dehydrated.
What do you do first
Give him oxygen.
IV fluids- hypotensive and is clinically dehydrated, so needs IV fluids. TAKE bloods- incl. cultures.
Then chest x-ray- find out if it’s pneumonia/investigate crepitations. Do this as early as possible, but stabilise patient first.
Finally take arterial blood gases (pH to exclude acidosis and lactate as part of sepsis 6 bundle plus PO2 and PCO2)
How do we assess the severity of community acquired pneumonia?
Curb65
What does CURB65 stand for
Confusion (new onset)
Urea > 7mmol/l
Resp. Rate less than or equal to 30/min
BP < 90 systolic or <60 diastolic
Age 65 or over
Curb 65 score of 3 or more, vs 2
3= high risk of death, get senior clinician. If 4/5 consider critical care
2= moderate risk of death. Short stay inpatient treatment or hospital-supervised outpatient treatment.
Typical organisms for community acquired pneumonia?
Hae. Influenzae
Streptococcus pneumoniae (most common)
Moraxella cattarhalis
Antibiotic treatment for severe non serve CAP
Non severe = amoxicillin
Or if atypical or penicillin allergy, do clarithromycin
Duration 5 days, 10 days atypical
Severe = add flucloxacillin to CAP treatment for 14-21 days
If true penicillin allergy, add linezolid for 14 days
5 complications of pneumonia?
Bacteremia
Lung abscess
Pleural effusion
Empyrean
Pleurisy
Would a ‘stony dullness to percuss’ be associated with large pleural effusion?
Yes
Would increased breath sounds be a sign of pleural effusion?
No reduced
Is reduced chest expansion a sign of pleural effusion?
Yes
Tracheal deviation towards effusion is a sign of pleural effusion?
True
Patient recovers from pneumonia. How soon should I follow him up at our patient clinic with a chest x-ray?
6-8 weeks
Why?
It can take up to that long for full radiological resolution of pneumonia. Also because what about co existing abnormalities/pathology eg proximal lung cancer, bronchial obstruction eg aspirated food
different types of pneumonia
CAP
HAP/nosocomial
VAP as in ventilator associated
Aspiration (of sterile gastric contents)
Immunocompromised
loss of heart border would likely make it middle or lower lobe pneumonia in a CXR
middle
When should a CXR be performed in hospital?
In all patients with suspected pneumonia in hospital, within 4 hours
Is pneumonia a radiological diagnosis?
yes.
Knowing this will help us not over-diagnose- what makes it different to lower resp. disease
With the CURB-65, do you tend to over-diagnose or under-diagnose?
over-diagnose with the elderly, under-diagnose with young people
CRB-65 is for secondary or primary care?
primary
Treatment of moderate pneumonia in hospital?
amoxicillin plus clarithromycin (dual therapy) and supportive care, order microbiology testing
CAP investigations: would you tend to test sputum, and blood cultures?
yes, but doesn’t make much of a difference unless you think atypical/severe and have no other reason to be pneumonia
Carrying out gram stains for sputum in pneumonia: necessary?
unnecessary
What is the most causative organism of CAP in hospitalised patients?
viral pathogens
(streptococcus pneumonia is most common bacteria)
mycoplasma and legionella tend to be more of an outbreak pneumonia, yes or no
yes
mycoplasma = certain populations eg homeless, prisons
legionella= care homes etc
How long should we be giving antibiotics for people with pneumonia?
BTS says 7 fays low- mod CAP
7-10 high severity
on average at least 5 days
How frequently does pleural effusion occur in hospitalised patients?
60% of the time
in pleura is irritated, may produce fluid
How can you tell the difference between empyema and pleural effusion in CXR?
You can’t really. You can tell a lung abscess tho
Bedside ultrasound scan helps us look for fluid vs
stick needle in, what pH
Is empyema a common complication of pneumonia
no, like 1-3%
flu, staph aureus, cavities/abscesses
what’s the evolution of empyema
inflammation of pleura
exudative stage (simple parapneumonic effusion)
becomes complicated when:
deposition of fibrin, septation and loculation, INCREASE in wbc
may then have fibroblast infiltration, and the heavy sediment prevents lung expansion
empyema definition
Grossly purulent in fluid in the pleural cavity, Fibrin deposition in pleura and formation of septation
Pneumonia timeline, how quickly would a fever resolve, and how quickly would chest pain and sputum be reduced?
After how long may fatigue still be present, and how many months before back to normal?
1 week
4 weeks
3 months
6 months
People over the age of what should have a follow-up CXR?
50
47 year old with ongoing cough, should get follow-up cxr?
yes
‘ongoing’
Mortality of hospital acquired pneumonia?
30-70%
needs to be 48-72 hours after being admitted
HAP- more likely aetiology?
more likely to be gram negative, staph aureus
HAP: always microbiological investigation
signet ring sign is a sign for what
bronchiectasis
if bronchiole is bigger than artery next to it
vasculitis is
inflamamtion of the blood vessels,
in lungs tend to affect smaller
lots of symptoms for vasculitis
Things you should always consider checking in patients with pneumonia
HIV status
Immunoglobulins
Vasculitis screen
