week 3 resp. med in primary care

Question 1

Normal adult blood pressure rating?

Answer 1

Between 90/60 and 120/80

Question 2

High blood pressure =
Low blood pressure =

Answer 2

140/90mmHg
90/60mmHg

Question 3

What’s normal heart rate?

Answer 3

60-100 bpm

Question 4

What does ‘crepitations’ mean when referring to lung lobes?

Answer 4

Sound associated with subcutaneous emphysema, audible crackling noises

Question 5

Auscultation sounds and ‘base of lung’ meaning

Answer 5

Usually referring to the inferoposterior part of the inferior lobe

Question 6

Three air sounds of auscultating the lungs:

Answer 6

Air filled= resonant
Fluid filled= dull
Solid= flat

Question 7

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

Answer 7

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)

Question 8

How do we assess the severity of community acquired pneumonia?

Answer 8

Curb65

Question 9

What does CURB65 stand for

Answer 9

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

Question 10

Curb 65 score of 3 or more, vs 2

Answer 10

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.

Question 11

Typical organisms for community acquired pneumonia?

Answer 11

Hae. Influenzae
Streptococcus pneumoniae (most common)
Moraxella cattarhalis

Question 12

Antibiotic treatment for severe non serve CAP

Answer 12

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

Question 13

5 complications of pneumonia?

Answer 13

Bacteremia
Lung abscess
Pleural effusion
Empyrean
Pleurisy

Question 14

Would a ‘stony dullness to percuss’ be associated with large pleural effusion?

Answer 14

Yes

Question 15

Would increased breath sounds be a sign of pleural effusion?

Answer 15

No reduced

Question 16

Is reduced chest expansion a sign of pleural effusion?

Answer 16

Yes

Question 17

Tracheal deviation towards effusion is a sign of pleural effusion?

Answer 17

True

Question 18

Patient recovers from pneumonia. How soon should I follow him up at our patient clinic with a chest x-ray?

Answer 18

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

Question 19

different types of pneumonia

Answer 19

CAP
HAP/nosocomial
VAP as in ventilator associated
Aspiration (of sterile gastric contents)
Immunocompromised

Question 20

loss of heart border would likely make it middle or lower lobe pneumonia in a CXR

Answer 20

middle

Question 21

When should a CXR be performed in hospital?

Answer 21

In all patients with suspected pneumonia in hospital, within 4 hours

Question 22

Is pneumonia a radiological diagnosis?

Answer 22

yes.
Knowing this will help us not over-diagnose- what makes it different to lower resp. disease

Question 23

With the CURB-65, do you tend to over-diagnose or under-diagnose?

Answer 23

over-diagnose with the elderly, under-diagnose with young people

Question 24

CRB-65 is for secondary or primary care?

Answer 24

primary

Question 25

Treatment of moderate pneumonia in hospital?

Answer 25

amoxicillin plus clarithromycin (dual therapy) and supportive care, order microbiology testing

Question 26

CAP investigations: would you tend to test sputum, and blood cultures?

Answer 26

yes, but doesn’t make much of a difference unless you think atypical/severe and have no other reason to be pneumonia

Question 27

Carrying out gram stains for sputum in pneumonia: necessary?

Answer 27

unnecessary

Question 28

What is the most causative organism of CAP in hospitalised patients?

Answer 28

viral pathogens

(streptococcus pneumonia is most common bacteria)

Question 29

mycoplasma and legionella tend to be more of an outbreak pneumonia, yes or no

Answer 29

yes

mycoplasma = certain populations eg homeless, prisons
legionella= care homes etc

Question 30

How long should we be giving antibiotics for people with pneumonia?

Answer 30

BTS says 7 fays low- mod CAP
7-10 high severity

on average at least 5 days

Question 31

How frequently does pleural effusion occur in hospitalised patients?

Answer 31

60% of the time

in pleura is irritated, may produce fluid

Question 32

How can you tell the difference between empyema and pleural effusion in CXR?

Answer 32

You can’t really. You can tell a lung abscess tho

Question 33

Bedside ultrasound scan helps us look for fluid vs

Answer 33

stick needle in, what pH

Question 34

Is empyema a common complication of pneumonia

Answer 34

no, like 1-3%

Question 35

flu, staph aureus, cavities/abscesses

Question 36

what’s the evolution of empyema

Answer 36

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

Question 37

empyema definition

Answer 37

Grossly purulent in fluid in the pleural cavity, Fibrin deposition in pleura and formation of septation

Question 38

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?

Answer 38

1 week
4 weeks
3 months
6 months

Question 39

People over the age of what should have a follow-up CXR?

Answer 39

50

Question 40

47 year old with ongoing cough, should get follow-up cxr?

Answer 40

yes
‘ongoing’

Question 41

Mortality of hospital acquired pneumonia?

Answer 41

30-70%

needs to be 48-72 hours after being admitted

Question 42

HAP- more likely aetiology?

Answer 42

more likely to be gram negative, staph aureus

HAP: always microbiological investigation

Question 43

signet ring sign is a sign for what

Answer 43

bronchiectasis
if bronchiole is bigger than artery next to it

Question 44

vasculitis is

Answer 44

inflamamtion of the blood vessels,
in lungs tend to affect smaller

lots of symptoms for vasculitis

Question 45

Things you should always consider checking in patients with pneumonia

Answer 45

HIV status
Immunoglobulins
Vasculitis screen