Pneumonia & ARDS flashcards
23 high-yield MRCP Part 1 cards from the Intellect Medicos Respiratory Medicine course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.
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What is the most common cause of community-acquired pneumonia?
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Streptococcus pneumoniae.
Why? Classic features: sudden fever, pleuritic pain, rust-coloured sputum, lobar consolidation, sometimes with cold sores (HSV reactivation).
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What does CURB-65 stand for?
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Confusion; Urea > 7 mmol/L; Respiratory rate ≥ 30/min; Blood pressure (systolic < 90 or diastolic ≤ 60 mmHg); age ≥ 65.
Why? One point each; it predicts 30-day mortality and guides place of care and antibiotic choice. CRB-65 (no urea) is used in the community.
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In hospital, which CURB-65 score range means HIGH risk of death from community-acquired pneumonia (NICE)?
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3–5 (mortality risk more than 15%); NICE: consider inpatient care with referral to critical care if appropriate.
Why? 0–1 is low risk (< 3%) and 2 is intermediate (3–15%). NICE grades severity using clinical judgement together with the score.
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What is the first-line antibiotic for LOW-severity community-acquired pneumonia in adults (NICE)?
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Oral amoxicillin 500 mg three times a day for 5 days.
Why? Pneumococcus is the main target. Penicillin allergy: doxycycline or clarithromycin (erythromycin in pregnancy).
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What is the first-line antibiotic regimen for HIGH-severity community-acquired pneumonia (NICE)?
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Co-amoxiclav plus clarithromycin (erythromycin in pregnancy), for 5 days.
Why? The macrolide adds atypical cover (Legionella, Mycoplasma).
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Under the 2025 NICE pneumonia guideline, which adjunct should be considered for HIGH-severity CAP in hospital?
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Corticosteroids, preferably IV hydrocortisone, for 4–7 days (or until discharge if sooner), alongside antibiotics.
Why? Steroids reduce mortality and treatment failure in severe CAP. Dexamethasone is an alternative if hydrocortisone is unsuitable.
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What serious adverse effects are fluoroquinolones such as levofloxacin known for (MHRA)?
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Tendinitis and tendon rupture; also aortic aneurysm/dissection and long-lasting, disabling neuromuscular and psychiatric effects.
Why? Risk of tendon damage is higher in people over 60, renal impairment, solid-organ transplant and with corticosteroids. Since January 2024 the MHRA says systemic fluoroquinolones must only be used when other commonly recommended antibiotics are inappropriate.
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In adults admitted with pneumonia, within how long of presentation should antibiotics be started (NICE)?
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Within 4 hours.
Why? Early antibiotics improve outcomes. Stop after 5 days unless results or clinical state justify a longer course.
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Who should have a follow-up chest X-ray about 6 weeks after pneumonia (NICE)?
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People at risk of lung cancer or other lung disease (e.g. smokers or over 50), or with persisting symptoms or unexplained weight loss.
Why? Persistent shadowing may be an underlying tumour causing post-obstructive pneumonia.
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A 58-year-old man returns from a hotel holiday with high fever, dry cough, diarrhoea and confusion. Sodium is 126 mmol/L and ALT is raised. He has not improved on amoxicillin. What is the most useful rapid investigation?
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Legionella urinary antigen test.
Why? Legionella pneumophila is spread by inhaling contaminated water aerosols (air-conditioning, showers, hot tubs) — not person to person. Hyponatraemia (SIADH), deranged LFTs and poor response to penicillins are classic.
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What is the first-line antibiotic class for Legionella pneumonia (course notes)?
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A macrolide (clarithromycin or azithromycin).
Why? Legionella is intracellular, so beta-lactams do not work. Alternatives: doxycycline or levofloxacin.
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Name two extrapulmonary complications of Mycoplasma pneumoniae infection.
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Any two of: cold autoimmune haemolytic anaemia (IgM), erythema multiforme/SJS, bullous myringitis, myocarditis, aseptic meningitis, Guillain–Barré syndrome.
Why? Mycoplasma typically affects young adults in crowded settings; the CXR often looks worse than the patient. Diagnosis by serology or PCR; treat with a macrolide.
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Which organism causes pneumonia in alcoholics with "redcurrant jelly" sputum and upper-lobe cavitation?
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Klebsiella pneumoniae.
Why? Klebsiella is associated with alcohol excess, diabetes and aspiration, and forms cavities.
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A patient deteriorates with cavitating pneumonia a week after influenza. What is the likely organism?
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Staphylococcus aureus.
Why? Post-influenza staphylococcal pneumonia is severe; Panton–Valentine leucocidin (PVL)-producing strains carry high mortality.
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A parrot owner has pneumonia with severe headache, relative bradycardia, splenomegaly and raised ALT. What is the likely organism?
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Chlamydia psittaci (psittacosis).
Why? It is caught from infected birds (parrots, pigeons) and treated with a tetracycline such as doxycycline.
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What antibiotic is suggested for SEVERE hospital-acquired pneumonia (or high risk of resistance) in the course notes?
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IV piperacillin–tazobactam (alternatives: ceftazidime or ceftriaxone); add vancomycin, teicoplanin or linezolid if MRSA is suspected.
Why? Late HAP is often due to Pseudomonas, Enterobacteriaceae and MRSA. Non-severe early HAP can be treated with co-amoxiclav for 5 days.
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What is the gold-standard investigation for Pneumocystis jirovecii pneumonia (PJP)?
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Bronchoalveolar lavage (BAL) with silver staining (or PCR) showing the organism.
Why? Clues: immunosuppression (HIV, transplant, steroids), hypoxia out of proportion to signs, exercise desaturation, raised LDH and beta-D-glucan; CXR may be normal early.
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What is the first-line treatment for PJP, and when are corticosteroids added?
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High-dose co-trimoxazole for 21 days; add steroids if PaO2 < 9.3 kPa (moderate–severe disease).
Why? Steroids reduce the inflammatory response to dying organisms and lower mortality in hypoxic patients.
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At what CD4 count is PJP prophylaxis started in HIV, and with which drug?
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CD4 < 200 cells/mm³; low-dose co-trimoxazole.
Why? The risk of PJP rises sharply below this CD4 threshold.
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Which oxygenation criterion is part of the Berlin definition of ARDS?
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PaO2/FiO2 ratio ≤ 300 mmHg (≤ 40 kPa) with PEEP or CPAP ≥ 5 cmH2O.
Why? Other criteria: onset within 1 week of an insult, bilateral opacities not explained by effusion/collapse/nodules, and not fully explained by heart failure or fluid overload.
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Lung-protective ventilation in ARDS uses a tidal volume of ______ and a plateau pressure below 30 cmH2O.
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6 mL/kg predicted body weight
Why? Low volumes and pressures prevent ventilator-induced lung injury; permissive hypercapnia is accepted.
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Lung-protective ventilation in ARDS uses a tidal volume of 6 mL/kg predicted body weight and a plateau pressure below ______.
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30 cmH2O
Why? Low volumes and pressures prevent ventilator-induced lung injury; permissive hypercapnia is accepted.
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Which positioning strategy reduces mortality in severe ARDS?
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Prone positioning.
Why? It improves V/Q matching and oxygenation. Other measures: higher PEEP, conservative fluids, ECMO as rescue.