Pleuritic chest pain is a very common presentation to both GP and A&E test if you know your pneumonias from your pulmonary embolisms!
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Pleuritic chest pain
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Stem 1, question 1 of 5
Deborah, a 67 year old female, presents to her GP with a productive cough, fever, dyspnoea and pleuritic chest pain. Her husband says she has received her flu vaccination for the season.
What is the most likely diagnosis?
Hospital acquired pneumonia
Community acquired pneumonia
Question 1 Explanation:
Pneumonia is an important differential to consider in any person presenting with pleuritic chest pain. Remember that older patients are often afebrile and may present with confusion and worsening underlying disease.
Stem 1, question 2 of 5Which of the following is not a risk factor for community acquired pneumonia?
Exposure of cigarette smoking
Use of Anti-diabetic drugs
Contact with children
Acute severe asthma
Question 2 Explanation:
Community acquired pneumonia (CAP) has a number of risk factors: greater than age 65, residence in a healthcare setting, COPD, exposure to cigarette smoking, alcohol abuse, poor oral hygiene, use of acid reducing drugs (corticosteroids, antipsychotics, anti-diabetic drugs), contact with children and HIV infection. Acute severe asthma is a risk factor for a pneumothorax.
Stem 1, question 3 of 5
The GP takes the following observations: heart rate 112, respiratory rate 26, blood pressure of 86/64.
What is the most appropriate management for Deborah?
Analgesics, oral fluids and rest
Book appointment for tomorrow to re-examine
Oral antibiotics in the community
Admission to hospital for short stay
Admission to hospital with consideration of critical care input
Question 3 Explanation:
This is a bit of a harder one as it is a second order question. The observations are given to you so you can work out the CURB-65 score. C-confusion or new onset AMTS of 8 or less, U- urea greater than 7 mol/L, R-respiratory rate of 30 or higher, B- blood pressure of less than 90 systolic or diastolic less than 60. The 65 refers to age 65 or older. Deborah scores a point for her blood pressure and a point for her age, so scores 2/5. The CURB-65 score influences the management of these patients. 0-1 are managed as outpatients in the community, 2- a short stay in hospital is recommend or very close monitoring in the community, a score of 3-5 recommends admission to hospital with consideration of intensive care input.
Stem 1, question 4 of 5Macrolides are used to treat pneumonia, what is the mechanism of action of macrolides?
Inhibition of bacterial DNA gyrase
Inhibition of bacterial protein synthesis
Inhibition of bacterial cell wall synthesis
Inhibition of dihydrofolate reductase
Inhibition of cell wall synthesis in gram positive bacteria
Question 4 Explanation:
Macrolides such as eythromycin and azithromycin act by inhibiting bacterial protein synthesis. Remember to ask what drugs a patient takes as macrolides interact with digoxin, theophylline and statins!
Stem 1, question 5 of 5Which of the following is a causative agent of community acquired pneumonia?
Question 5 Explanation:
Streptococcus pneumoniae is the most common causative agent of community acquired pneumonia. The other answer options are all causative agents of hospital acquired pneumonia.
Stem 2, question 1 of 5
Shaun, a 31 year old man, is admitted to hospital following a road traffic accident. He is dyspnoeic with pleuritic chest pain with clear seatbelt bruising and diminished breath sounds on the right.
What is the most likely diagnosis?
Question 6 Explanation:
Hopefully this question wasn't too bad. A history of chest trauma with signs of seatbelt bruising combined with dyspnoea, pleuritic chest pain and diminished breath sounds should point you to a pneumothorax. A tension pneumothorax is more serious and requires immediate decompression the signs of this are distressed, rapid and laboured respiration, cyanosis, profuse diaphoresis and tachycardia.
Stem 2, question 2 of 5
2 weeks later after being discharged following a fixation of a tibial fracture, Shaun becomes increasingly breathless with pleuritic chest pain and becomes very faint despite being on bed rest.
What is the most likely cause of his pleuritic pain?
Continuing resolution of the pneumothorax
Question 7 Explanation:
There are a number of risk factors for a pulmonary embolism in the question stem: Recent trauma, surgery in the last 2 months and prolonged period of immobility. Although the other answer options are important causes of pleuritic chest pain, they do not fit the entire clinical picture for this case.
Stem 2, question 3 of 5Which investigation is the gold standard to diagnose a pulmonary embolism?
CT- pulmonary angiography (CTPA)
Question 8 Explanation:
A CTPA is the preferred diagnostic test for a pulmonary embolism, it allows for the direct visualisation of a thrombus in the pulmonary vasculature. An echo can be used in haemodynamically unstable patients but a CTPA is still preferred. D-dimers and Wells score can help to ascertain the likelihood or more usefully can be used for their negative value.
Stem 2, question 4 of 5Shaun is diagnosed with a pulmonary embolism and is started on apixaban. What is the mechanism of apixaban?
Inhibition of thromboxane synthesis
Inhibition of factor IXa
Inhibition of factor Xa
Inactivation of thrombin and factor Xa by complexing antithrombin III
Activation of plasminogen
Question 9 Explanation:
Apixaban is a direct oral anticoagulant (DOAC) and so is a direct factor Xa inhibitor. DOACs are increasingly preferred due to their predictable therapeutic effects and no requirement for frequent INR monitoring.
Stem 2, question 5 of 5While recovering from his pulmonary embolism, Shaun is seen by the physiotherapists to prevent him from developing an hospital acquired pneumonia. What is the definition of a hospital acquired pneumonia?
Acute lower respiratory tract infection after at least 24 hours of admission to hospital
Acute lower respiratory tract infection after at least 48 hours of admission to hospital and is not incubating at time of admission
Acute lower respiratory tract infection after at least 72 hours of admission to hospital
A bacterial lower respiratory tract infection after mechanical ventilation
Acute lower respiratory tract infection after at least 48 hours of admission to hospital, following intubation and ventilation
Question 10 Explanation:
Hospital acquired pneumonias (HAP) are a serious infection often caused by dangerous pathogens such as pseudomonas aeruginosa amongst others. A HAP is an acute lower respiratory tract infection after 48 hours in hospital and the individual was not incubating the infection at time of admission. Risk factors include poor infection control and intubation and mechanical ventilation.
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