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Pneumonia

Clinical Discipline(s)/Organ System(s)
Geriatric Medicine, Infectious Diseases, Microbiology, Respiratory Medicine
Progress Test Topic(s)
Respiratory
Description
You visit an 80 year old NZ European woman with the GP you are shadowing. She has a fever and is coughing up purulent sputum. She is in a private hospital because of advanced dementia and has been a resident for the past 3 years. A mobile chest X-ray taken in the private hospital shows 'confluent shadowing in the left lower lobe and a left-sided pleural effusion'. The GP sends her to the local Emergency Department and contacts her family. The patient has an advance directive stating that if she becomes very unwell she should not be 'kept going by machines', although her family is not comfortable with letting her die at present.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Anatomy and function of the respiratory tract
   - Pulmonary mechanics, gas exchange
   - Lung defence mechanisms including cellular and immunologic mechanisms; mucociliary clearance; consequences of impairment
   - Microbiology of the upper respiratory tract (in institutionalised patients)
   - Pathology and microbiology of pneumonia
   - Causes and investigation of pleural fluid
   - Pathogenesis and microbiology of aspiration pneumonia, parapneumonic effusion and empyema
   - Diagnosis of pneumonia (microbiologic, molecular), including sputum analysis
   - Pharmacology of penicillins, extended spectrum penicillins (e.g. amoxicillin), clavulanic acid (amoxicillin and clavulanic acid), tetracyclines (e.g. doxycycline), macrolides (e.g. erythromycin, roxithromycin and azithromycin)
Clinical and Communication Skills 
   - Elicit a history from a patient with purulent sputum; screen for risk factors for pneumonia; obtain supporting history from relatives and caregivers where possible if patient unable to provide accurate history
   - Examination of the respiratory system
   - Classification of pneumonia and assessment of severity using CURB-65 and other criteria
   - Interpret chest X-ray, full blood count, sputum culture, sputum cytology, arterial blood gas, urinary antigens, sputum culture, serological testing
   - Differential diagnosis of fever in an older patient
   - Differential diagnosis and investigation of pleural effusion
   - Indications for CT chest and bronchoscopy
   - Indications for pleural aspiration and intercostal tube insertion
   - Diagnostic testing for tuberculosis
   - Management of pneumonia: pharmacological and non-pharmacological
   - Outline the management of parapneumonic effusion/empyema
   - Prognosis and complications of pneumonia (in an older patient)
Personal and Professional Skills 
   - Communication with family/carers regarding management of a terminal illness
   - Death and dying; role of palliative care and advance care planning
   - Competence and consent issues including enduring power of attorney
   - Protection of Personal and Property Rights Act
   - Documentation of resuscitation orders and withholding of medical treatment in appropriate situations
Hauora Māori 
   - Consideration of access to cultural/spiritual support for patient and whānau
   - Ensure a culturally safe environment in life-changing scenarios
   - Understand the role of kaupapa Māori health policies, services and research in reducing inequalities
Population Health 
   - Infection control and prevention of transmission of respiratory pathogens
   - Adult immunisation programme
   - Epidemiology of pneumonia
   - Epidemiology of dementia
   - Social care structure for dementia
   - Antibiotic stewardship
Conditions to be considered relating to this scenario
Common
community acquired / nosocomial pneumonia, aspiration pneumonia, chronic obstructive pulmonary disease, bronchiectasis
Less common but 'important not to miss'
tuberculosis, lung cancer, parapneumonic effusion/empyema, lung abscess