2.  What are the signs to diagnose severe pneumonia?  Enumerate 4 organisms for community acquired pneumonia

3. Symptoms (1) Cough(1) Absent early stage pneumonia, infants, sick elderly, stroke + alcoholism (2) Persistent dry cough in C pneumoniae + M pneumoniae (2) Chest pain ( pleuritic) Often present lobar pneumonia especially when associated with pleuritis (3) Confusion + unsteadiness among the elderly (4) Dyspnoea ( shortness of breath) (5) Fever with Rigors or night sweats> 4 days Fevers may be absent in infants + the elderly (6) Nausea or diarrhoea May be prominent symptoms

4. Signs ( 1)General examination: Fever >38 degrees C >4 days + systematically unwell (2) Inspection: Respiratory rates raised + significant shortness of breath (3) Percussion: Dullness (4) Ascultation: Localised crackles May be heard in (i)acute bronchitis, (ii) COPD +(iii) Heart failure Specificity crackles low (5) Ascultation : Bronchial breathing (6) Ascultation: Wheezes (i)a concomitant bronchitis(ii) a localised sign of narrowed bronchial branches or mucus plugs in the bronchial tree.

5.  Chest X ray  Microbiological testing  Blood tests: WCC, ESR,CRP

6.  Indicated : severely ill patient + diagnostic doubt  Unreliable : study shows 8 out of 26 pneumonias diagnosed with high resolution CTs were not diagnosed by CXR.  Follow up CXR after 6 weeks : patients with increased risk of lung cancer, smokers > 40 years

7.  Specimens: sputum or nasopharynx  Common causes of pneumonia : Streptococcus pneumonia ( pneumococci), Haemophilus influenzae, Mycoplasma pneumonia, Chlamydia pneumonia and Legionella pneumonia  PCR Analysis(1-2 days), IgM testing(1-2 days), Culture ( days)

8. Common aetiological agentsNotes (1) Streptococcus pneumonia( pneumococci ) Most common cause of CAP + hospitalised agents. Sudden onset with high fever. High mortality when not treated with antibiotics (2) Haemophilus influenzae Similar features to pneumococci infection. Most frequently infected are small children, elderly + COPD or Chronic patients (3) Mycoplasma pneumonia Outbreaks, Incubation period 2-3 weeks. Prominent fever, headache + cough. Minimal chest signs. Radiographic changes (4) Chlamydia pneumonia Similar features to mycoplasma infection. Not as frequently in epidemics (5) Legionella pneumonia Spread via water droplets. Diarrhoea, high fever + hyponatraemia. High mortality

9.  Elevated : ( usually ) pneumococcal pneumonia  Normal: (usually) pneumonias caused by viruses, M pneumonia and C pneumonia

10.  Elevated : all pneumonias regardless of aetiolo gy  A few days b4 value exceeds the reference range

11. CRP ValuesDiagnosis (1) <10 mg /dlAcute bronchitis and viral COPD causes Uncomplicated viral illnesses after 7- 10 days ( <10 mg/dl) (2) 10mg/dl to 100 mg /d lUncomplicated viral illnesses after 3-4 days of illness ( influenza may reach 100mg/dl) (3) >100mg /dlPneumonias ( persistently elevated value after 1 week of illness)

12.  Pneumonia severity index (PSI) US  CURB 65  CRB 65

13. PSI risk class l (lowest risk) Patient has none of the following: (1) Age >50 (2) History of (i) neoplastic disease (ii) congestive cardiac failure (iii) C erebrovascular (iv) renal (v) liver disease (3) Clinical signs (i) altered mental state (ii) pulse rate ≥125 bpm (iii) respiratory rate ≥30 breaths/min (iv) systolic blood pressure <90mmHg (v) temperature <35ºC or ≥40ºC.

14. PSI risk classes ll–V Patients with any of the above characteristics are classified according to their PSI score, calculated according to the table on the left.

15. (1) Factor: age + nursing home resident (2) Coexisting illness: (3) Signs on examination: (4) Results of investigation:

16. FactorPSI Score (i)Patient ageAge in years ( male) or age -10 ( female) (ii) Nursing home resident+10 Coexisting illnesses (i) Neoplastic disease+30 (ii) Liver disease+20 (iii) Cardiac failure+10 (iv) Cerebrovascular disease+10 (v) Renal disease+10

17. Signs on examinationPSI Score Respiratory rate >30 breaths/minute+20 Altered mental state+20 Systolic blood pressure <90 mm Hg+20 Temperature 40 degrees C +15 Pulse rate >125 beats per minute+10

18. Results of investigationsPSI Score Arterial ph<7.35+30 Serum urea level >11 mmol/l+20 Serum sodium level<130mmol/l+10 Serum glucose level >14 mmol/l+10 Haematocrit<30%+10 P a O2<60 mm Hg or O2 saturation <90% +10 Pleural effusion+10

19. ClassPSI Risk score II1-70 III71-90 IV91-130 V.130

20. Class I (low risk) or class II - treatment outside hospital (1) Amoxycillin 500-1000mg orally tds for seven days (if penicillin allergy, use cefuroxime 500mg orally bd for seven days) (2) AND if Mycoplasma or Chlamydia are suspected change to, or add, either: (i) Oral doxycycline 200mg orally for the first dose, followed by 100mg daily for five days or alternatively (ii) Roxithromycin 300mg orally daily for five days

21. Class III and IV* — treatment in hospital Should be managed as inpatients using (1) IV penicillins (or ceftriaxone/cefotaxime ) + oral agents such as doxycycline Or (2) clarithromycin or roxithromycin as per antibiotic guidelines

23. InfantsChildren Not feedingSigns of dehydration Family not able to provide observation or support Difficulty breathing Intermittent apnoeaGrunting Sa O2 < 92%, Cyanosis Respiratory rate > 70 / minuteRespiratory rate > 50 /minute