RESPIRATORY

PNEUMONIA

Introduction

5 min

Introduce yourself and the group

Provide rationale for the session and relevance to clinical practice

Outline learning objectives:

Be able to give a clear, thorough but short summary of a history and examination of someone with pneumonia
Present findings on a chest radiograph using a systematic approach
Be able to prescribe appropriate antibiotics to treat pneumonia based on severity
Decide whether a patient needs hospital admission for pneumonia and understand how that decision is made

Explain structure of session

Total time:

60 min

Number of students:

1-5

Grade of students:

3rd to 5th year medical students

Created by:

Dr Beth Brockbank

Uploaded:

13th September 2019

Last updated:

13th September 2019

Resources needed for this session:

Clerking and/or AMTS proforma, pen, paper, prescription chart

Students can scan the QR code opposite to view all investigation results on their phone as you work through the session.

Resources linked to this session:

None

Activity 1: History Taking and Examination

15 min

Ask the students to take a focussed history from a patient presenting with possible pneumonia. If more than one student, assign roles as follows:

Student 1: Take a focused history from a patient with pneumonia. Identify the patient’s symptoms, determine any risk factors for severe disease or unusual pathogens, ask about drug allergies (and their reaction).
Student 2: Perform an AMTS examination on the patient. Use the QR code opposite to link to an online AMTS calculator.
Student 3: Perform a focused respiratory examination and be prepared to present important positive and negative findings.
Student 4: Document the above in a clerking proforma.

Activity 2: Presentation Skills and Diagnostic Reasoning

15 min

Ask the student who took a history from the patient to present their history in two minutes maximum. Focus on a headline summary sentence, important positives and negatives.

Ask the student who examined the patient to present their examination findings in one minute maximum. Focus on headline summary sentence, important positives and negatives.

Ask the other student(s) to suggest differential diagnoses and suggest further investigations. If only one student, they can complete the full presentation as outlined above.

Suggested prompt questions for further discussion as time allows:

What are the causes of crackles on examination?
What are the important differential diagnoses in this case?
Why is it important to know about recent hospitalisations or if the patient lives in a care home?
What are common causative organisms of pneumonia? How might these differ if the patient has recently been admitted to hospital or has come from a care home?
What are the difference between typical and atypical organisms in pneumonia?

Activity 3: Initial Investigations

5 min

Review the patient’s blood results with the student(s). If none are available, use the example below. Students can scan the QR code to view results on their phone if required. Ask them to highlight the key abnormalities.

Consider:

Do they fit with the clinical picture? If not, does this change your most likely diagnosis?
What blood test results abnormalities may point towards certain atypical organisms?

Sodium 138

Potassium 4.1

Urea 8.1

Creatinine 127

eGFR 51

CRP 189

Bili 22

ALP 150

ALT 30

Alb 39

Hb 145

WCC 22.5

Neuts 21.8

Plt 240

Activity 5: Basic Imaging Interpretation

5 min

Ask students to review and present the chest radiograph of the patient. If none is available, use the example opposite. Students can scan the QR code to view the image on their phone.

Suggested structure:

Patient demographics/date/time
Type and technical quality of scan
Most obvious abnormality

For more junior students, or if further practice is needed, proceed with further interpretation of the chest radiograph as follows:

Airway (trachea)
Breathing (lung fields)
Circulation (heart size, borders)
Diaphragm
Review areas
Bones and soft tissue

Activity 6: Complications

5 min

Ask students to suggest five possible complications of pneumonia. Review the radiograph opposite. Students can scan the QR code to view on their phone if needed.

Consider:

What is the main abnormality on the radiograph opposite?
What is the management of this condition?

Activity 6: Prescribing

5 min

Ask the students to find and complete a sepsis proforma for this patient.

Using an online calculator, assess the patients prognosis using a validated tool (e.g. the CURB-65). The QR code opposite links to an online calculator. Consider:

What practical value does this scoring system have?

Ask students to find drug chart. Following the local antimicrobial policies, ask them to prescribe antibiotics for:

Mild pneumonia
Severe pneumonia
Penicillin allergy (anaphylaxis)

Discussion point

Which antibiotics are used to cover the atypical organisms and why? What is the mechanism of action of these antibiotics?

Activity 7: Further Discussion

Points for further discussion:

Does your patient need to be admitted to hospital?
What factors contribute to this decision? Consider medical and social issues.
Has your patient been screened for sepsis in ED? What does this mean in clinical practice?

Summary and Feedback

5 min

Questions

Identify and summarise key learning points (key three points if possible)

Feedback to student – highlight further learning needs

Feedback for teacher - ask students to provide feedback using the QR code opposite

References and Further Reading

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