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pneumonia
RPM II
73
Medical
05/13/2010

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Term
what is the first thing to consider when diagnosing a pt with pneumonia?
Definition
determine where the pneumonia was contracted
Term
what is the likely pathogen if the pneumonia was contracted outside by an other wise healthy pt?
Definition
diplococci, haemophilus
Term
what is the likely pathogen if the pneumonia was contracted by a smoker?
Definition
mycoplasma (esp in young adults), viral or legionella, (if truly sick)
Term
what is the likely pathogen if the pneumonia was contracted in NYC? what is the common clinical presentation?
Definition
pneumocystis (PCP) due to high HIV rates, drug use population. this will appear as diffuse inflitrate.
Term
what is the likely pathogen if the pneumonia was contracted in a hospital (nosocomial)?
Definition
HAP (haemophilus), staph and pseudomonas (the later 2 have some resistance to antibx)
Term
what is the likely pathogen if the pneumonia was contracted by a pt with CF?
Definition
staph and pseudomonas, which thrive in bronchiectasis, or destruction of the bronchial treee
Term
what is the importance of the hx in pts w/pneumonia?
Definition
the correct antibx need to be administered, and sometimes the cx can take longer than the pt has to come back
Term
what does an abruptness of pneumonia onset point to in terms of pathogens?
Definition
gram positive cocci
Term
what do chills tell you about a pt w/pneumonia?
Definition
the pt has likely become bacteremic and a blood cx needs to be performed/antibx need to be administered
Term
what does pain upon breathing tell you about a pt w/pneumonia?
Definition
pleuritis (stabbing pain w/breaths), which is commonly caused by the coxsackie virus in young women in the winter - known as bohr-holmes syndrome
Term
what does a dry cough in a pnuemonia pt indicate?
Definition
*viral cause or legionella/mycoplasma*
Term
what does a yellow sputum mean if coughed up by a pneumonia pt?
Definition
bacterial pneumonia
Term
what does dyspnea/CXR with whited-out lungs indicate in a pneumonia pt?
Definition
non-bacterial pneumonia, b/c a bacterial infection of that magnitude would be fatal
Term
what needs to be r/o in a possible pneumonia pt?
Definition
PE, sarcoid, CHF, ARDs, and noxious gasses
Term
can animals pass on pneumonia?
Definition
yes
Term
how might a pt contract pneumonia due to histoplasmosis?
Definition
histoplasmosis is a fungus growing on feces of chickens, bats, etc - may be seen in pts traveling to developing countries
Term
what needs to be done for every pneumonia pt?
Definition
a sputum analysis - needs to be performed by the dr
Term
what is seen in a sputum analysis of pneumonia pts?
Definition
WBCs w/morphologically similar organisms (all gram + or -) and bronchial epithelial cells - should NOT see squamous cells (indicative of oral contamination)
Term
what is a luteins tube?
Definition
a suction device used for sputum analysis that attaches to the bronchoscope
Term
what is likely if a sputum analysis shows both gram + and -?
Definition
most likely mixed gram +/- is from elderly pts via aspiration
Term
how is a sputum analysis performed?
Definition
make sure the inside of the tube is sterile, have the pt expectorate into it, and take it directly to the lab (otherwise too many other organisms will grow)
Term
how does sputum appear histologically?
Definition
gram + diplococci being chewed apart by WBCs OR gram negative bacteria (larger, such as haemophilus) which are accompanied by many more WBCs
Term
who are coccobacilli (such as diplococci haemophilus) common in?
Definition
smokers
Term
what pts are neisseria (m catarrhalis) common in?
Definition
bronchitis pts
Term
beyond a pt expectorating, what are other methods for getting a sputum sample?
Definition
catheter to the cricothyroid membrane to suck out fluid (danger to thyroidema artery), and needle bx (danger in spreading infection) - but the best way is w/a clean & sterile bronchoscope
Term
what are the 2 types of pneumonia patterns?
Definition
alveolar (fluid surrounds alveolus, get rales) and interstitial (looks like congestive failure)
Term
what is lobar pneumonia?
Definition
when the infection surrounds an airway
Term
what is seen in necrotizing pneumonia?
Definition
cavitations and abscesses
Term
what is general management of pneumonia?
Definition
good bronchiodilatortherapy, *miller pump (done by family), O2 (if pt has high CO2, such as in COPD - helps pts breathe)
Term
who needs to be monitored the most in terms of dehydration?
Definition
the elderly and children
Term
how does empyema present? how is empyema treated?
Definition
empyema presents as high WBC count as it is an infection between visceral and parietal pleura that needs to be tested with a 22 gauge needle and if pus, then followed by a chest tube
Term
do viruses such as influenza commonly cause pneumonia?
Definition
yes
Term
what pneumonia-causing bug are many elderly pts subject to? why? how is this treated?
Definition
bordetella pertussis - b/c the vaccine wears off. this is treated with antibx effectively, but needs to be confirmed via a cx
Term
what makes strep bacteria (gram positive) so lethal to humans?
Definition
they have developed a mucopolyssachride capsule which inhibits WBCs - which is what PCN targets
Term
what is the most common of all community acquired pneumonias?
Definition
strep pneumoniae, which spreads in the lobar region to the pleural surface (can effuse)
Term
what WBCs levels are consistent with a strep infection?
Definition
~20,000 - which if high enough and sustained = deranged liver and hypoxemia
Term
what can result if breaks in the pleural surface are not treated?
Definition
empyema, which often occurs w/delayed therapy
Term
can strep pneumonia lead to meningitis, endocarditis, and pericarditis?
Definition
yes
Term
what occurs if strep pneumonia isn't treated?
Definition
ARDS
Term
what is the best treatment of strep pneumonia?
Definition
prevention - recommend polyvalent pneumococcal vaccine (particularly if have predisposing condition)
Term
what is the most concerning of the streptococci in terms of pneumonia?
Definition
strep pyogenes - which is common w/influenza, increases ASO (anti-streptolysin O), affects the kidneys and causes empyema
Term
do most antibx work on strep?
Definition
yes
Term
what is the main issue with staph infections?
Definition
staph has become resistant to PCN, methicillin, only vancomycin is left
Term
what do staph infections do to the lungs?
Definition
eats them, causes empyema, affects heart valves (IVDA), can cause a hematocoele (hole in lung wall)
Term
how will pts with staph infections present?
Definition
mild leukocytosis, hypoxemia, +blood cx 25% of the time, empyema, spontaneous pneumothorax, and heart effects
Term
are gram negative pneumonia infections a large problem? when are they seen?
Definition
yes, particularly pseudomonas - infections by gram negative bacteria are seen often in pts w/tracheal tubes
Term
how does gram negative pneumonia present? what is the clinical resolution rate?
Definition
as an acute toxic illness, even though the onset is insidious. if disease is only caught at acute stage: 80% mortality, if caught in insidious onset stage: 50-80% mortality. the clinical resolution rate is slow.
Term
what is the most common cause of nosocomial pneumonia?
Definition
pseudomonas - infections often due to broad spectrum antibx
Term
what kind of pneumonia-causing pathogen is common in smokers?
Definition
haemophilus - growth of bug favored with nicotine
Term
how does haemophilus appear microscopically?
Definition
as a pleomorphic rod w/a capsule
Term
who does haemophilus generally affect?
Definition
the elderly, pts with COPD, chronic alcoholics, smokers
Term
is viral infection a common antecedent for haemophilus infection?
Definition
yes
Term
what does haemophilus only grow on?
Definition
chocolate agar
Term
what is the virulence factor for klebsiella?
Definition
its capsule keeps phagocytes from consuming it
Term
what pt populations commonly get klebsiella?
Definition
diabetics, alcoholics and hospitalized pts
Term
what characterizes a klebsiella pneumonia?
Definition
a lot of sputum, mainly from the upper lobes. often there is a "bulging fissure" sign in the upper lobe, accompanied by leukopenia, cavitation, empyema, respiratory failure and shock
Term
what pt population is most likely to get pneumonia due to pseudomonas?
Definition
immunocompromised pts, those w/DM, the elderly and HIV pts
Term
how are pts infected with pseudomonas?
Definition
inhalation and colonization of the oropharynx (50% of hospital workers have pseudomonas in their body)
Term
how is pneumonia due to e coli generally contracted? what part of the lungs are usually affected by e coli?
Definition
instrumentation in the GI tract, pneumonia due to e coli is seen post cystoscopcy etc. this is more common in the lower lobes
Term
why is mycoplasmic pneumonia so drug resistant?
Definition
b/c mycoplasma doesn’t have cell wall but a triple membrane - need to kill the ribosomes with quinolones and macrolide (no penicillin because no cell wall)
Term
what are the symptoms of pneumonia due to mycoplasm?
Definition
sparse (dry) sputum (the only other causes of this are viral and legionella), lymphadenopathy, eruptions, increased in LFTs, and mild, scattered bronchopneumonia
Term
when does mycoplasma affect philadelphia?
Definition
between thanksgiving and easter, so do the lab test for it then!
Term
what is the cause of most anerobic pneumonias?
Definition
pts with poor dentition (large amounts of thick fluid in mouth) aspirating anerobic bacteria such as bacteroides/fusiform from the mouth. colonization is slow at first, but is followed by dyspnea and lung abscesses in 20% of affected pts
Term
what is the best tx for viral pneumonia?
Definition
prevention: influenza shot - esp healthcare workers. treatment: tamiflu/relenza
Term
what are the symptoms of viral pneumonia?
Definition
dry, unproductive cough, non-elevated WBC count
Term
what are 2 important quesions to ask pts (life&death) suspected of pneumocystis carnii?
Definition
do you use drugs? are you gay?
Term
how do legionella pneumonia pts present?
Definition
dry, non-productive cough, flu, overwhelming pneumonia, absent URI, high fever (106+), shaking, and chills
Term
who does legionella commonly cause pneumonia in?
Definition
immunocompromised pts, COPD pts, diabetics, alcoholics, and workers at excavation sites commonly get pneumonia due to legionella
Term
what is the diagnosis of legionella presumptive until?
Definition
tissue bx
Term
what do you treat legionella w?
Definition
zithromax and cephalosporins, need to target ribosomes.
Term
*Young medical student comes in with good health, no HIV, nonsmoker, what bugs do you think would infect?* (exam question)
Definition
*strep, diplococci, maybe mycoplasm -> all of which are responsive to the same antibx*
Term
*80 year old lady in ICU, has infiltrating pneumonia what do you worry about?* (exam question)
Definition
*nosocomial gram negatives, staph, pseudomonas -> all of which are responsive to the same antibx*
Term
how can you test if a pt probably aspirated something?
Definition
if the pt gags when a tongue blade is stuck in their mouth aspiration is not likely, however if they don't gag - aspiration needs to be investigated