Pneumonia

Question 1

Definition

Answer 1

Infection of the lung(s) that usually occurs in defined lobar patterns, but might also be diffuse

Question 2

Common causes
neonates (0-6wks)

Answer 2

Group B Strep
E. coli

Question 3

Common Causes
Children (6wks-18yrs)

Answer 3

RSV (<1 yr)
Parainfluenza (2-5yrs)
Mycoplasma
Chlamydia pneumoniae
Streptococcus pneumoniae

Question 4

Common Causes
Adults 18-40

Answer 4

Mycoplasma
C. pneumo
S. Pneumo

Question 5

Common Causes
Adults 40-65

Answer 5

Mycoplasma
S. pneumo
Haemophilus influenzae
Anaerobes
Viruses

Question 6

Common Causes
Elderly > 65

Answer 6

S. pneumo
viruses
Anaerobes
H. flu
Gram(+) rods

Question 7

Recurrent Pneumonia

Answer 7

chronic obstruction i.e. foreign object aspiration, classically right middle or lower lobe pneumonia
Bronchogenic carcinoma
Lymphoma
Immumodeficiency
Wegener’s granulomatosis; carriers of unusual organisms; Nocardia, Coxiella, Aspergillus (leads to fungal balls), Pseudomonas (CF patients ,difficult to treat definitively)

Question 8

Characteristics and History with Atypical Presentation

Answer 8

Mycoplasma
Legionella
Chlamydia

Question 9

Characteristics and History with Hospital Acquired Pneumonia

Answer 9

Staph
Gram(+) rods
Anaerobes
Gram(-) rods

Question 10

Characteristics and History with Immunocompromised hosts

Answer 10

Staph
Gram + rods
Fungi
Viruses

Question 11

Characteristics and History with HIV Patients

Answer 11

Pneumocystis carinii (jiroveci) - however, S. pneumoniae remains the most common
causative bacterial pathogen overall in HIV+ patients
CMV

Question 12

Characteristics and History with Aspiration Pneumonia

Answer 12

Anaerobes
Usually occurs in intubated patients or those with speech/ swallow pathology

Question 13

Characteristics and History with Air Conditioning in closed quarters or aerosolized water

Answer 13

Legionella

Question 14

Characteristics and History with Alcoholics/IV drug users

Answer 14

Klebsiella
Current jelly sputum
S. pneumo
Staph. aureus

Question 15

Characteristics and History with Bird Droppings

Answer 15

Chlamydia Psittaci or Histoplasma spp

Question 16

Characteristics and History with Recent Immigrant

Answer 16

Tuberculosis

Question 17

Characteristics and History with CF patients

Answer 17

Pseudomonas ; breath smells like grapes
S. Aureus

Question 18

Characteristics and History with COPD

Answer 18

H.Flu
Moraxella Catarrhalis
S.pneumo

Question 19

Characteristics and History with known TB

Answer 19

Aspergillus (in pulmonary cavitation)

Question 20

Characteristics and History with Postviral

Answer 20

S. aureus - may cause necrotizing pneumonia
H. flu

Question 21

Symptoms

Answer 21

Classically presents with sudden-onset
Fever
Productive cough
Purulent yellow-green
Hemoptysis
Dyspnea
Night sweats
Pleuritic chest pain

Atypical presentations are gradual in onset and flu-like
Dry cough
Headaches
Myalgias
Sore throat

Question 22

Physical Exam

Answer 22

Auscultation of the lungs reveals
Decreased or bronchial breath sounds
Crackles/rales
Wheezing
A-to-e egophany

Percussion reveals
Dullness over affected lobe(s)
Tactile fremitus

Elderly and patients with chronic lung disease, diabetes, or immunocompromised status may minimal exam findings

Question 23

Evaluation
CXR

Answer 23

May show lung consolidation in affected lobe(s)
Establishes diagnosis in combination with Gram stain or culture

Question 24

Evaluation
CBC

Answer 24

Elevated WBC with pathogen-dependent shift

Question 25

Sputum Gram stain and cultures

Answer 25

Identify pathogen Directs medical treatment

Question 26

Evaluation ABGs

Answer 26

Characterizes respiratory status and compromise Hypoxia may cause increased respiratory rate, resulting in respiratory alkalosis

Question 27

Evaluation Specific Pathogens

Answer 27

Legionella Urine Legionella antigen test Sputum staining with direct fluorescent antibody Culture Chlamydia pneumoniae Serologic testing Culture PCR Mycoplasma Diagnosis is usually made clinically Serum cold agglutinins Serum Mycoplasma antigen

Question 28

Differential

Answer 28

Common cold, influenza, pulmonary effusion, tuberculosis, acute respiratory distress

Question 29

Treatment Non-Operative

Answer 29

Outpatient oral antibiotics in uncomplicated cases; Medications directed at sensitivity of known pathogens and/or additional broad coverage In-hospital IV antibiotics recommended in patients >65 yrs and/or with multilobar pneumonia May be necessary in patients with significant comorbidities including Alcoholics COPD Malnutrition Diabetes Immunocompromised Altered mental status Required in unstable patients or those in respiratory failure

Question 30

Treatment Operative

Answer 30

Interventional treatments are rare in cases of pneumonia Usually indicated to treat secondary pathology Recurrent pleural effusions Fungal ball removal Intubation

Question 31

Prognosis

Answer 31

Highly depends on patient comorbities and type of pneumonia Usually resolve without complications in otherwise healthy patients

Question 32

Prevention

Answer 32

Safe medical practice (i.e. handwashing) can prevent spread of nosocomial disease Carefully monitor intubated patients and those with speech/swallow pathology Incentive spirometry and deep breathing post-operatively can prevent atelectasis anresultant pneumonia

Question 33

Complications

Answer 33

If left untreated, can lead to respiratory failure, sepsis, shock, and/or death