Updated: 2/13/2018

Pneumonia

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https://upload.medbullets.com/topic/117037/images/pneumonias.jpg
https://upload.medbullets.com/topic/117037/images/pneumonia.jpg
Snap Shot
  • A 77-year-old man is brought in by EMS after waking up in the middle of the night covered in sweat, with a high fever, and a coughing up yellow sputum. A chest xray is shown.
Introduction
  • Definition 
    • infection of lung parenchyma that usually occurs in defined lobar patterns, though may also present more diffusely
    • Clinically defined as fever, cough and new infiltrate on CXR
  • Pathophysiology
    • See Microbiology of Pneumonia topic 
  • Risk factors
    • impaired cough reflex 
    • damage to respiratory cilia
    • mucus plugs
Classification
  • Classic patterns include
    • lobar
      • intra-alveolar exudate which consolidates
      • may involve entire lung or be confined to 1 lobe
      • 4 stages  
    • brochopnuemonia
      • acute inflammatory infiltrates from bronchioles into adjacent alveoli
      • patchy distribution
      • involves ≥ 1 lobes
    • interstitial
      • diffuse patchy inflammation localized to interstitial areas of alveolar walls
      • distribution involving ≥ 1 lobes
      • generally less severe than lobar or bronchopneumonia
Presentation
  • Symptoms
    • classically presents with sudden-onset of
      • 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
  • Physical exam
    • auscultation of the lungs reveals
      • decreased or bronchial breath sounds
      • crackles/rales
      • wheezing
      • E-to-A egophany
        • with consolidation
    • percussion reveals
      • dullness over affected lobe(s)
      • tactile fremitus
        • increased with consolidation
        • decreased with pleural effusion
Evaluation
  • CXR
    • may show lung opacification/consolidation in affected lobe(s)
    • establishes diagnosis in combination with Gram stain or culture
  • CBC
    • elevated WBC count
  • Sputum Gram stain and cultures
    • identify pathogen
    • directs antimicrobial therapy
Treatment
  • Pharmacologic
    • empiric antibiotics directed at most likely pathogens (depends on clinical scenario)
    • organism-specific antibiotics if organism identified
 

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(M1.PL.15.24) Myeloperoxidase (MPO) is a heme-containing molecule that is found in the azurophilic granules of neutrophils. Upon release, the enzyme catalyzes hypochlorous acid production during the phagocytic response. In the setting of pneumonia, which of the following is the end result and clinical significance of this reaction? Tested Concept

QID: 100827
1

Green color of sputum

60%

(26/43)

2

Cough

0%

(0/43)

3

Rust-tinged sputum

35%

(15/43)

4

Fever

2%

(1/43)

5

Shortness of breath

2%

(1/43)

M 1 E

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(M1.PL.13.37) A 21-year-old college student with a history of hypertrophic cardiomyopathy and a systolic murmur heard best at the left sternal border presents to the emergency room with a temperature of 102.3 F, worsening shortness of breath, chest pain and productive cough. He states that two days ago upon returning from Spring Break in Australia he drank a significant amount of alcohol and had an episode of vomiting. He recalls little about the evening. His electrocardiogram displays a regular sinus rhythm and his chest radiograph is shown in Figure A. Which of the following is the most likely etiology of his illness? Tested Concept

QID: 100102
FIGURES:
1

Long distance travel

9%

(4/45)

2

Impaired cough reflex

53%

(24/45)

3

Hypertrophic cardiomyopathy

9%

(4/45)

4

Valvular disease

9%

(4/45)

5

Close living quarters

20%

(9/45)

M 2 E

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(M1.PL.13.136) A 48-year-old male dies in the intensive care unit following a severe Streptococcus pneumonia pneumonia and septic shock. Autopsy of the lung reveals a red, firm left lower lobe. What would you most likely find on microscopic examination of the lung specimen? Tested Concept

QID: 100939
1

Eosinophilia in the alveolar septa

5%

(6/127)

2

Vascular dilation and noncaseating granulomas

7%

(9/127)

3

Fragmented erythrocytes

7%

(9/127)

4

Alveolar exudate containing neutrophils, erythrocytes, and fibrin

76%

(96/127)

5

Collagen whorls

2%

(3/127)

M 2 D

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