Updated: 2/13/2018

Pneumonia

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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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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.PL.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? Review Topic

QID: 100827
1

Green color of sputum

75%

(3/4)

2

Cough

0%

(0/4)

3

Rust-tinged sputum

25%

(1/4)

4

Fever

0%

(0/4)

5

Shortness of breath

0%

(0/4)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M1.PL.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 x-ray is shown in Figure A. Which of the following is the most likely etiology of his illness? Review Topic

QID: 100102
FIGURES:
1

Long-distance travel

8%

(1/13)

2

Impaired cough reflex

38%

(5/13)

3

Hypertrophic cardiomyopathy

23%

(3/13)

4

Valvular disease

15%

(2/13)

5

Close living quarters

15%

(2/13)

M1

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PREFERRED RESPONSE 2

(M1.PL.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? Review Topic

QID: 100939
1

Eosinophilia in the alveolar septa

6%

(5/85)

2

Vascular dilation and noncaseating granulomas

7%

(6/85)

3

Fragmented erythrocytes

8%

(7/85)

4

Alveolar exudate containing neutrophils, erythrocytes, and fibrin

72%

(61/85)

5

Collagen whorls

2%

(2/85)

M1

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PREFERRED RESPONSE 4
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