PANCE Blueprint Pulmonary (12%)

Bacterial pneumonia (ReelDx)

REEL-DX-ENHANCED-PAID-MEMBERS-ONLY

Pneumonia Patient will present with →  a 71-year-old male who was admitted to the acute care hospital two days following a massive CVA with possible brainstem infarct. Because he was also experiencing secondary respiratory failure, he was intubated and placed on mechanical ventilation. He was subsequently transferred to the neurointensive care unit where he was stabilized. His present vital signs are: respiratory rate 14 (ventilator rate), temperature 100.4 F. His SpO2 is 95%. His rating on the Glasgow Coma Scale is 5.

What do you hear on auscultation? Click here to reveal the answer

Patients will present with fever, dyspnea, tachycardia, tachypnea, cough +/- sputum

Presentation and risk factors depends on etiology

  • S. Pneumoniae: Rust colored sputum, common in patients with splenectomy
  • S. Aureus: Salmon colored sputum, lobar, after influenza, MRSA treat with vancomycin
  • Pseudomonas: Ventilators, Cystic fibrosis, patients become sick fast - treat with 2 antibiotics
  • Legionella: Air conditioning, aerosolized water, low NA+ (hyponatremia), GI symptoms (diarrhea) and high fever
  • Mycoplasma: Young people living in dorms, (+) cold agglutinins, bullous myringitis, walking pneumonia, low temp
  • Klebsiella: Alcohol abuse, currant jelly sputum, aspiration
  • Pneumocystis jiroveci HIV CD4 <200, immunosuppressed
  • Haemophilus influenzae: COPD, smokers, postsplenectomy
  • Histoplasma capsulatum caused by bat droppings -looks like sarcoidosis on CXR
  • Coccidioides (valley fever) in dry states
  • Chlamydia pneumoniae: College kids, sore throat, long prodrome
  • Poor dental hygiene is associated with pneumonia caused by anaerobes
  • Influenza pneumonia is characterized by a more precipitous onset and fulminant course
  • The indolent course suggests an atypical pneumonia and Mycoplasma is the most common atypical agent
  • Lobar consolidation is seen in community-acquired pneumonia
  • Apical infiltration is seen in tuberculosis

Patients with pneumonia will have physical exam finding of

  • (+) egophony - Transmission of vocal sounds through consolidation leads to the changes heard with egophony.
  • (+) tactile fremitus - Consolidation would increase the transmission of vocal vibrations and manifest as increased tactile fremitus.
  • (+) dullness to percussion

CXR: patchy, segmental lobar, multilobar consolidation

  • Blood cultures x 2, sputum gram stain

Outpatient therapy (antibiotics)

  • Doxycycline, Macrolides

Inpatient (hospitalize if > 50 with comorbidities, altered mental status, poor fluid status)

  • Ceftriaxone plus azithromycin, respiratory fluoroquinolones

A chest X-ray showing a very prominent wedge-shape area of airspace consolidation in the right lung characteristic of bacterial pneumonia.

A chest X-ray showing a very prominent wedge-shape area of airspace consolidation in the right lung characteristic of bacterial pneumonia.

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Question 1

A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient?

A
spoken "ee" heard as "ay"
B
hyperresonant percussion note
Hint:
Consolidation from bacterial pneumonia causes findings of dullness to percussion, late inspiratory crackles and bronchial breath sounds over the involved area.
C
wheezes over the involved area
Hint:
See explanation B.
D
vesicular breath sounds over involved area
Hint:
See explanation B.
Question 1 Explanation: 
This patient most likely has a bacterial pneumonia with consolidation, which would produce egophony, where a spoken "ee" is heard as "ay."
Question 2
A 42 year-old male with unremarkable past medical history is admitted to the general medical ward with community-acquired pneumonia. He has a 20 pack-year history of cigarette smoking. He is empirically started on ceftriaxone (Rocephin). Which of the following antibiotics would be most appropriate to add to his empiric treatment regimen?
A
Piperacillin
Hint:
Antipseudomonal penicillins, such as piperacillin, added to an aminoglycoside or fluoroquinolone are indicated for empiric treatment of nosocomial pneumonia.
B
Vancomycin
Hint:
Use of vancomycin should be restricted to cases where there is a high index of suspicion of involvement of methicillin resistant Staphylococcus aureus (MRSA).
C
Clindamycin
Hint:
Clindamycin is indicated in cases of suspected anaerobe involvement.
D
Azithromycin
Question 2 Explanation: 
Patients with community-acquired pneumonia who require hospitalization on the general medical ward are treated with an extended-spectrum beta-lactam antibiotic, such as ceftriaxone, with a macrolide, such as azithromycin. Addition of a macrolide is also recommended due to the patient's smoking history and possible involvement of Haemophilus influenzae.
Question 3
A 40 year-old alcoholic male presents with sudden onset of severe chills, fever, dyspnea and cough productive of red mucoid sticky sputum. He appears ill looking with cyanosis. Examination reveals vital signs: Temp - 102 degrees F; Pulse - 120 /minute and regular; 89 RR - 28/min; BP 90/62 mm Hg. Lungs reveal minimal rales and dullness in the right upper lobe with decreased breath sounds. Chest x-ray reveals right upper lobe consolidation with a bulging fissure. Gram stain reveals many white blood cells and many gram- negative rods. Which of the following is the most appropriate drug of choice?
A
Ticarcillin
Hint:
Infections caused by Klebsiella organisms are resistant to both ticarcillin and ampicillin.
B
Cefotaxime
C
Doxycycline
Hint:
See B for explanation.
D
Clindamycin
Hint:
See B for explanation.
Question 3 Explanation: 
This patient most likely has pneumonia caused by Klebsiella. A third generation cephalosporin, such as cefotaxime, is the preferred antimicrobial therapy against Klebsiella pneumoniae. Alternative antibiotic choices may include a carbapenem, beta-lactam/beta- lactamase inhibitor or a fluoroquinolone.
Question 4
A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is
A
tuberculosis.
Hint:
Most children with pulmonary tuberculosis are asymptomatic with few physical examination findings. The results of the diagnostic studies do not support tuberculosis as the most likely diagnosis.
B
mycoplasma pneumonia.
C
pneumococcal pneumonia.
Hint:
The clinical presentation of bacterial pneumonias in children is variable, but usually involves fever of acute onset. The WBC count is also usually elevated, making this a less likely diagnosis.
D
staphylococcal pneumonia.
Hint:
See C for explanation.
Question 4 Explanation: 
The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely.
Question 5
An elderly patient with poorly-controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, and rales at the left base. Pulse oximetry is 90%. Which of the following is the next appropriate step in the management of this patient?
A
Administer nebulized corticosteroids
Hint:
Inhaled corticosteroids are not utilized in the management of community-acquired pneumonia.
B
Admit to the hospital
C
Oral antimicrobial therapy
Hint:
Due to the age of the patient, comorbid diseases, and current signs of respiratory distress, intravenous not oral antimicrobial therapy is indicated.
D
Endotracheal intubation
Hint:
Endotracheal intubation is indicated for respiratory failure unresponsive to conservative management.
Question 5 Explanation: 
Community acquired pneumonia is the most deadly infectious disease in the U.S. Important risk factors for increased morbidity and mortality include advanced age, alcoholism, comorbid medical conditions, altered mental status, respiratory rate greater than 30 breaths/min, hypotension, and a BUN greater than 30.
Question 6
The most common pathogen identified in community acquired pneumonia (CAP) is
A
Mycoplasma pneumoniae.
Hint:
M. pneumoniae, S. aureus, Legionella pneumophila are common pathogens for CAP, but do not account for a majority of the cases.
B
Staphylococcus aureus.
Hint:
See A for explanation.
C
Legionella pneumophila.
Hint:
See A for explanation.
D
Streptococcus pneumoniae.
Question 6 Explanation: 
S. pneumoniae accounts for a majority of cases of community acquired pneumonia.
Question 7
Which of the following is an indication for a pediatric patient to receive the 23-valent polysaccharide vaccine (Pneumovax)?
A
Children at any age with a history of asthma
Hint:
Pediatric patients with cystic fibrosis, not asthma, are included in the indications for vaccination with Pneumovax, however they must be at least 2 years old.
B
All children at 2,4,6 and 12-18 months of age
Hint:
The 7-valent pneumococcal conjugate vaccine (Prevnar) is currently recommended to be given to children under the age of two on the schedule outlined.
C
All children at 12-23 months of age in a two dose series
Hint:
While a two dose series is recommended for appropriate pediatric patients that receive Pneumovax, the recommended timing between doses is 3-5 years.
D
Children age 24-59 months at high risk for invasive pneumococcal disease
Question 7 Explanation: 
Pneumovax is licensed for use in children over the age of 23 months and is indicated for all pediatric patients at increased risk for pneumococcal disease.
Question 8
A 2 month-old infant has been diagnosed with pneumonia due to Chlamydia trachomatis. Which of the following is the treatment of choice?
A
Ceftriaxone (Rocephin
Hint:
Ceftriaxone is a third-generation cephalosporin that may be safely used in children, however is not indicated for the treatment of Chlamydial pneumonia.
B
Doxycycline
Hint:
Doxycycline is a tetracycline and is contraindicated in children under eight years of age secondary to damaging effects on bone and teeth enamel.
C
Levofloxacin (Levaquin)
Hint:
Levofloxacin is a fluoroquinolone and is contraindicated for use in children under 18 years of age secondary to damaging effects that may occur with growing cartilage.
D
Erythromycin
Question 8 Explanation: 
Erythromycin or sulfisoxazole is the treatment of choice for an infant with Chlamydial pneumonia.
Question 9
Which of the following is a physical examination finding that is consistent with a diagnosis of lobar pneumonia?
A
Resonant to percussion
Hint:
Physical examination findings that are consistent with a diagnosis of lobar pneumonia include dullness to percussion, increased tactile fremitus and a trachea that is midline.
B
Late inspiratory crackles
C
Decreased tactile fremitus
Hint:
Physical examination findings that are consistent with a diagnosis of lobar pneumonia include dullness to percussion, increased tactile fremitus and a trachea that is midline.
D
Tracheal shift toward uninvolved side
Hint:
Physical examination findings that are consistent with a diagnosis of lobar pneumonia include dullness to percussion, increased tactile fremitus and a trachea that is midline.
Question 9 Explanation: 
Late inspiratory crackles are a physical examination finding that is consistent with lobar pneumonia.
Question 10
An elderly nursing home resident is admitted with methicillin-resistant Staphylococcus aureus pneumonia. Which of the following is the most appropriate treatment to initiate?
A
Nafcillin
Hint:
Nafcillin is classified as a penicillinase-resistant penicillin, however would not be effective against methicillin- resistant strains of Staphylococcus aureus.
B
Vancomycin
C
Clindamycin
Hint:
Clindamycin is primarily utilized in treatment of severe anaerobic infections, but is not indicated for the treatment of methicillin-resistant Staphylococcus aureus.
D
Doxycycline
Hint:
Doxycycline is a tetracycline and is only utilized to treat respiratory infections that are susceptible to tetracycline, such as Mycoplasma or Chlamydial pneumonias.
Question 10 Explanation: 
Vancomycin with or without the addition of gentamicin or rifampin and linezolid is the treatment of choice for methicillin-resistant Staphylococcus aureus.
Question 11
Which of the following findings confirm the adequacy of a sputum specimen for Gram stain and culture?
A
Decreased red blood cells
Hint:
The presence or absence of red blood cells is not a criterion for determining the adequacy of a sputum sample.
B
Decreased bronchial epithelial cells
Hint:
The presence of bronchial epithelial cells confirms the sample came from the lower respiratory tract.
C
Increased Gram positive cocci
Hint:
The presence of Gram positive cocci has no bearing on the adequacy of the sputum sample.
D
Increased polymorphonuclear leukocytes
Question 11 Explanation: 
The presence of increased polymorphonuclear leukocytes and the absence of squamous epithelial cells are the criteria utilized to evaluate the adequacy of a sputum sample.
Question 12
A 24 year-old male presents in respiratory distress and appears quite ill. A Gram stain and culture of the sputum reveals gram-positive cocci in clumps and a chest x-ray reveals multiple patchy infiltrates with some cavitations. Which of the following is most likely to also be found in his medical history?
A
IV drug abuse
B
Alcohol abuse
Hint:
A history of alcohol abuse is commonly seen with pneumonia caused by Klebsiella pneumoniae.
C
Poor dental hygiene
Hint:
Poor dental hygiene is associated with pneumonia caused by anaerobes.
D
HIV positive patient
Hint:
HIV positive patients are most at risk for development of pneumonia caused by Pneumocystis jiroveci.
Question 12 Explanation: 
This patient has pneumonia caused by Staphylococcus aureus which is commonly associated with a history of intravenous drug use, influenza epidemics and the hospital setting.
Question 13
A 20 year-old male presents with 3 weeks of constitutional and upper respiratory symptoms, including malaise, sore throat, dry cough, and fever. Lung auscultation demonstrates diffuse crackles bilaterally. What is the most likely infectious agent involved?
A
Respiratory syncytial virus
Hint:
RSV is characterized by wheezing on auscultation and the course is typically 3-7 days.
B
Influenza virus
Hint:
Influenza pneumonia is characterized by a more precipitous onset and fulminant course.
C
Mycoplasma pneumoniae
D
Streptococcus pneumoniae
Hint:
Pneumococcal pneumonia is typically characterized by a more severe illness and more fulminant course.
Question 13 Explanation: 
The indolent course suggests an atypical pneumonia and Mycoplasma is the most common atypical agent.
Question 14
Which of the following chest x-ray abnormalities would most likely be seen in a patient with hypersensitivity pneumonitis?
A
Lobar consolidation
Hint:
Lobar consolidation is seen in community-acquired pneumonia.
B
Apical infiltration
Hint:
Apical infiltration is seen in tuberculosis.
C
Granulomatous inflammation
Hint:
Granulomatous inflammation is seen in sarcoidosis.
D
Diffuse nodular densities
Question 14 Explanation: 
Diffuse nodular densities are seen in hypersensitivity pneumonitis.
Question 15
A 27 year-old woman presents with one week of worsening productive cough, dyspnea, fever and malaise. Which of the following physical examination findings would support the diagnosis of lobar pneumonia?
A
Decreased tactile fremitus
Hint:
Consolidation would increase the transmission of vocal vibrations and manifest as increased tactile fremitus.
B
Egophony
C
Hyperresonance to percussion
Hint:
Dullness, not hyperresonance, would be expected with consolidation.
D
Wheeze
Hint:
Wheezing is associated with narrowing of the small airways as seen in asthma.
Question 15 Explanation: 
Transmission of vocal sounds through consolidation leads to the changes heard with egophony.
Question 16
Which of the following causes of pneumonia is most likely to be complicated by diarrhea?
A
Legionella
B
Chlamydophila
Hint:
Chlamydophila pneumonia is associated with dry cough, low-grade fever, and hoarseness.
C
Mycoplasma
Hint:
Mycoplasma pneumonia is most likely complicated by bullous myringitis, hoarseness, rash, and chronic cough.
D
Pneumococcal
Hint:
Pneumococcal pneumonia presents with a single rigor, rust-colored sputum, and productive cough. There is no diarrhea as part of its infection.
Question 16 Explanation: 
Legionella is a water-borne pathogen that can cause diarrhea as a complication of its infection.
Question 17
A 30 year-old male presents with sudden onset of chills, fever, chest pain and a cough productive of greenish-brown sputum. On examination his temperature is 102 degrees F. He appears acutely ill and his respirations are shallow. Chest x-ray demonstrates left lower lobe consolidation. Which of the following findings would most likely be present on examination of his left lower lung?
A
Hyperresonance
Hint:
Hyperresonance is an abnormal sound as a result of air trapping as in COPD.
B
Vesicular breath sounds
Hint:
Vesicular breath sounds are the description of normal lung sounds.
C
Increased tactile fremitus
D
Wheezing
Hint:
Wheezing is a musical noise sounding like a squeak caused by high velocity air flow through a narrow or obstructed airway.
Question 17 Explanation: 
Increased tactile fremitus occurs in the presence of fluid or a lung consolidation such as lobar pneumonia.
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