EMQs in Clinical Medicine.pdf - Peshawar Medical College

38 Respiratory medicine
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Reduced expansion, dullness to percussion and increased tactile vocal
fremitus, in combination, suggest consolidation. Bronchial breathing is
also a feature of consolidation and results from transmission of airway
sounds through the consolidated lung to the periphery.
Strictly speaking, consolidation refers to the replacement of alveolar air by
fluid, cells, tissue or other material. The most common cause is pneumonia.
A 30-year-old farmer presents with repeated episodes of fever, rigors,
dry cough and shortness of breath with onset several hours after
starting work. On examination he is pyrexial with coarse endexpiratory
crackles. His chest radiograph shows mid-zone mottling.
This is a classic presentation of extrinsic allergic alveolitis (EAA), which
is a hypersensitivity reaction to inhaled antigens. In farmers, the antigen
often responsible is thermophilic actinomycetes in mouldy hay or
Aspergillus clavatus on germinating barley.
Lung function tests reveal a reversible restrictive defect. The cause of the
reaction may be determined by finding serum-precipitating antibodies. In
chronic EAA a honeycomb lung can sometimes be seen on the chest
radiograph. Acute cases may be treated with corticosteroids but allergen
avoidance is the key preventive measure.
12 Causes of pneumonia
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An 80-year-old man presents with bilateral cavitating bronchopneumonia
after an influenza infection.
Although not a common pathogen in community-acquired pneumonia,
Staphylococcus aureus may cause pneumonia in debilitated patients,
including elderly people and those recovering from influenza. It is also seen
in intravenous drug users (IVDUs) as a consequence of haematological
seeding from infected needles, often in association with staphylococcal
endocarditis of the tricuspid valve. Flucloxacillin is the treatment of
choice for staphylococcal infection.
A 24-year-old student presents with severe headache, fever, dry
cough and arthralgia. He has recently bought several parrots and was
previously fit and well.
Psittacosis is a rare cause of community-acquired pneumonia. It should
be suspected in any patient presenting with lower respiratory tract symptoms
and signs who has a history of exposure to birds. No acute diagnostic
tests are available and diagnosis is made in retrospect by
demonstrating a rising titre of complement-fixing antibody. As with
other atypical cases of pneumonia such as Legionella pneumophila