PNEUMONIA

LEARNING OBJECTIVES :

KNOWLEDGE - Students should be able to describe:

1. Define and describe the epidemiology, pathophysiology, symptoms, signs, and typical clinical course of community-acquired, nosocomial, and aspiration pneumonia and pneumonia in the immunocompromised host.
2. Define and describe the conceptualization of "typical" and "atypical" pneumonia and its limitations.
3. Define and describe common pneumonia pathogens (viral, bacterial, mycobacterial, and fungal) in immunocompetent and immunocompromised hosts.
4. Define and identify patients who are at risk for impaired immunity.
5. Define and describeindications for hospitalization and ICU admission of patients with pneumonia.
6. Define and describe the antimicrobial treatments (e.g. antiviral, antibacterial, antimycobacterial, and antifungal) for community-acquired, nosocomial, and aspiration pneumonia, and pneumonia in the immunocompromised host.
7. Define and describe the implications of antimicrobial resistance.
8. Define and describe the pathogenesis, symptoms, and signs of the complications of acute bacterial pneumonia including: bacteremia, sepsis, parapneumonic effusion, empyema, meningitis, and metastatic microabscesses.
9. Define and describe the indications for and efficacy of influenza and pneumococcal vaccinations.
10. Define and describe the Centers for Medicine and Medicaid Services (CMS) and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) quality measures for community-acquried pneumonia treatment.
11. Recognize bronchial breath sounds, rales (crackles), rhonchi and wheezes, signs of pulmonary consolidation, and pleural effusion on physical exam.
12. Recommend when to order diagnostic laboratory tests--including complete blood counts, sputum gram stain and culture, blood cultures, pleural effusion alanysis, and arterial blood gases--how to interpret those tests, and how to recommend treatment based on these interpretations.

SKILLS - Students should be able to:

1. History:   ascertain the pertinent history, including exposure, occupation, TB, travel and pets; determine if the patient is immunocompromised or at risk for TB or PCP - in order to initiate respiratory isolation in the ER; and rule out non-infectious mimics of pneumonia .
2. Physical examination: perform the lung examination; differentiate consolidation from pleural effusion.
3. Differential diagnosis : distinguish the various etiologies of community acquired and nosocomial pneumonia; and distinguish pneumonia from its non-infectious mimics.
4. Laboratory :   know the sensitivity and specificity of sputum culture and the proper way of obtaining sputum for gram stain and culture.   Students should be aware of the correlation of positive blood and pleural fluid cultures with lung pathogens.
5. Communication : communicate optimism and encourage risk reduction, including smoking cessation.
6. Procedures :   obtain sputum for gram stain and observe the gram stain performed in the microbiology lab; perform the gram stain, blood cultures and thoracentesis with assistance.
7. Management :   choose the appropriate antibiotics and make changes based on culture results. Students should be aware that the patient will improve before the x-ray does; and know when to order a follow-up x-ray; and encourage patients to have a pneumovax (if not given previously).
8. Be familiar with LUMC protocols regarding stratification and treatment of community-acquired pneumonia .

ATTITUDES AND PROFESSIONAL BEHAVIORS:

• Students should understand the patient's fear and uncertainty, and be able to deal with the occasional difficult patient.

RECOMMENDED READINGS :

1. Bartlett JG et al., Practice Guidelines for the Management of Community Acquired Pneumonia in Adults.   Clinical Infectious Diseases, 2000; 31: 347-82.
2. Halm, EA   Management of Community-Acquired Pneumonia .   NEJM   Dec 19, 2002.   Vol 347;2039-45.   Number 25