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1、番茄花园-PneumoniaStillwatersrundeep.流静水深流静水深,人静心深人静心深Wherethereislife,thereishope。有生命必有希望。有生命必有希望Definition Pneumonia is an acute infection of the parenchyma of the lung(肺实质肺实质), caused by bacteria, fungi(真菌）真菌）, virus, parasite（寄生虫）（寄生虫） etc. Pneumonia may also be caused by other factors including X-r
2、ay, chemical, allergen EpidemiologywThe morbidity and mortality of pneumonia are high especially in old people. EtiologywThere are two factors involved in the formation of pneumonia , including pathogens and host defenses. ClassificationwClassification of anatomywClassification of pathogenwClassific
3、ation of acquired environment.Classification by pathogen Pathogen classification is the most useful to treat the patients by choosing effective antimicrobial agentsBacterial pneumonia(1) Aerobic Gram-positive bacteria,such as streptococcus pneumoniae, staphy- lococcus aureus, Group A hemolytic strep
4、tococci(2) Aerobic Gram-negative bacteria, such as klebsiella pneumoniae, Hemophilus influenzae, Escherichia coli(3) Anaerobic bacteria Atypical pneumonia Including Legionnaies pneumonia ,Mycoplasmal pneumonia ,chlamydia pneumonia.Fungal pneumonia Fungal pneumonia is commonly caused by candida(念珠菌念珠
5、菌) and aspergilosis(曲菌曲菌). pneumocystis jiroveci（肺孢子虫）（肺孢子虫）Viral pneumonia Viral pneumonia may be caused by adenoviruses, respiratory syncytial virus, influenza, cytomegalovirus, herpes simplexPneumonia caused by other pathogen Rickettsias (a fever rickettsia), (立克次体）立克次体） parasites(寄生虫寄生虫) protozo
6、a（原虫）（原虫） .Classification by anatomy1. Lobar（大大叶叶性性）: Involvement of an entire lobe2. Lobular（小小叶叶性性）: Involvement of parts of the lobe only, segmental or of alveoli contiguous to bronchi (bronchopneumonia).3. Interstitial（间质性）（间质性）Lobar pneumoniaLobular pneumoniaInterstitial pneumoniaClassification
7、 by acquired environmentuCommunity acquired pneumonia，CAPu（社区获得性肺炎）uHospital acquired pneumonia，HAP ，NPu（医院获得性肺炎）uNursing home acquired pneumonia,NHAPu (护理院获得性肺炎）uImmunocompromised host pneumonia,(ICAP)u(免疫宿主低下肺炎）Diagnosis（诊断步骤）wGive a definite diagnosis of pneumoniawTo evaluate the degree of the pn
8、eumoniawTo definite the pathogen of the pneumoniaDiagnosispHistory and physical examination(5W)pX-ray examinationpPathogen identificationDifferentiationwPulmonary tuberculosiswLung cancerwAcute lung abecesswPulmonary embolismwNoninfectious pulmonary infiltrationPathogen identificationwSputum: More t
9、han 25 white blood cells (WBCs) and less than 10 epithelial cells.wNasotracheal suctioningwBAL, ETA, PSB, LAwBlood culture or pleural effusion culturewSerologic testing (immunological testing)wMolecular TechniquesThe principal of therapywSelect antibioticswAccording to guideline TherapywThe therapy
10、should always follow confirmation of the diagnosis of pneumonia and should always be accompanied by a diligent effort to identify an etiologic agent.wEmpiric therapy,(4-8h)wCombined empiric therapy to target therapyIt is important to evaluate the severity degree of pneumoniawThe critical management
11、decision is whether the patient will require hospital admission. It is based on patient characteristics, comorbid illness, physical examinations, and basic laboratory findings.The diagnostic standard of sever pneumoniawAltered mental statuswPa0260mmHg. PaO2/FiO230/minw Blood pressure90/60mmHgwChest
12、X-ray shows that bilateral infiltration, multilobar infiltration and the infiltrations enlarge more than 50% within 48h.wRenal function: U20ml/h, and 80ml/4h CAP (社区获得性肺炎）wCAP refers to pneumonia acquired outside of hospitals or extended-care facilities .wStreptococcus pneumoniae remains the most co
13、mmonly identified pathogen. wOther pathogens include Haemophilus influenzae, mycoplasma pneumoniae, Chlamydophilia pneumoniae, Moraxella catarrhalis and ects.wDrug resistance streptococcus pneumoniae(DRSP)Clinical manifestationwThe onset is accutewRespiratory symptomswExtrapulmonary symptomssignswCo
14、nsolidation signswMoist raleswRespiratory rate or heart rateLaboratory examinationwWBCwX-ray featuresDiagnosiswClinical diagnosiswPathogen diagnosiswEvaluate the severity degree of pneumoniaTherapywAntiinfectious therapy(Combined empiric therapy to target therapy)wSupportive therapyEmpiric therapy (
15、1)wOutpatient65 years old or having comorbid diseases or antibiotic therapy within last 3 monthswCommon pathogens: S pneumoniae(drug-resistant), M pneumoniae, C pneumoniae, H pneumoniae, H influenzae, Viruses, Gram-negative bacilli and S aureuswA fluoroquinolonewA beta-lactam / beta-lactamase inhibi
16、torwThe second generation cephalosporin or combination of a macrolideEmpiric therapy (3)wInpatient : Not severely ill.wCommon pathogen:S pneumoniae, H influenzae, polymicrobial, Anaerobes, S aureus, C pneumoniae, Gram-negative bacilli.wThe second or third generation cephalosporin plus A macrolidewA
17、beta-lactam/betalactamase inhibitor.wA newer fluoroquinoloneEmpiric therapy (4)wInpatient severely illwCommon pathogens:S pneumoniae, Gram-negative bacilli, M pneumoniae, S aureus and viruseswThe second or third generation cephalosporin plus A macrolidewA beta-lactam/betalactamase inhibitor.wA newer
18、 fluoroquinolonewVancomycinEmpiric therapy (5)wPatients in ICU without Pneudomonas aeruginosa infectionwThe second or third generation cephalosporin plus A macrolidewA beta-lactam/betalactamase inhibitor.wA newer fluoroquinolonewVancomycinEmpiric therapy (6)wPatients in ICU with Pneudomonas aerugino
19、sa infectionwA antipneudomonas aeruginosa beta-lactam/betalactamase inhibitor plus fluoroquinoloneprognosispreventiveHAP（医院获得性肺炎）wHAP refers to pneumonia acquired in the hospital setting.wEnteric Gram-negative organisms, S. aureus, Pneudomonas aeruginosa, ects.The pathogen of HAP Gram-negative bacte
20、ria (GNB) account for 55% to 85% of HAP infections gram-positive cocci account for 20% to 30% and some other pathogens. EPIDEMIOLOGYwGeneral risk factors for developing HAP include age more than 70 years, serious comorbidities, malnutrition, impaired consciousness, prolonged hospitalization, and chr
21、onic obstructive pulmonary diseases. EPIDEMIOLOGYwHAP is the most common infection occurring in patients requiring care in an intensive care unit (ICU), with incidence rates ranging from 6% up to 52%, much higher than the 0.5% to 2% incidence reported for hospitalized patients as a whole. This incre
22、ased incidence is due to the fact that patients located in an ICU often require mechanical ventilation, and mechanically ventilated patients are 6 to 21 times more likely to develop HAP than are nonventilated patients. Mechanical ventilation is associated PATHOGENESISw Aspiration :Microaspiration of
23、 contaminated oropharyngeal secretions seems to be the most important of these factors, as it is the most common cause of HAP. wInhalationwContaminationClinical manifestationswThe onset is acute or insidiouswRespiratory symptomswPhysical signsLaboratory examinationswChest X-raydiagnosiswClinical dia
24、gnosiswPathogen diagnosiswEvaluate the severity degree of pneumoniaTreatment (1)wAntibiotic therapy: antimicrobial therapy begin promptly because delays in administration of antibiotics have been associated with worse outcomes. wThe initial selection of an antimicrobial agent is almost always made o
25、n an empiric basis and is based on factors such as severity of infection, patient-specific risk factors, and total number of days in hospital before onset. Treatment (2)wAll empiric treatment regimens should include coverage for a group of core organisms that includes aerobic gram negative bacilli (
26、Enterobacter spp, Escherichia coli, Klebsiella spp, Proteus spp, Serratia marcescens, and Hemophilus influenzae) and gram-positive organisms such as Streptococcus pneumoniae and Staphylococcus aureus.Treatment (3)wIn patients with mild or moderate infections and no specific risk factors for resistan
27、t or unusual pathogens, monotherapy with a second-generation cephalosporin such as cefuroxime; a nonpseudomonal third-generation cephalosporin such as ceftriaxone; or a beta-lactam/beta-lactamase inhibitor such as ampicillin/sulbactam, ticarcillin/clavulanate, or piperacillin/tazobactam may be appro
28、priate. wFor patients in this low-risk category who have an allergy to penicillin, it is appropriate to initially use a fluoroquinoloneTreatment (4)w Patients with severe infections with specific risk factors should have broadened empiric coverage.wCombination therapy should be employed in these cas
29、es because of the high rate of acquired resistance among these organisms. wAppropriate combinations for this group of patients include an aminoglycoside or ciprofloxacin in addition to a beta-lactam with antipseudomonal coverage. wAdditionally, vancomycin should be considered if the patient has risk
30、 factors that suggest methicillin-resistant Staphylococcus aureus could be a pathogen. PreventionwRelease aspirationwWashing handswvaccinationICHP (免疫低下宿主肺炎)wPneumonia in an immunocompromised host describes a lung infection that occurs in a person whose ability to fight infection is greatly impaired
31、. (Non-HIV-ICH)Causes, incidence, and risk factors wImmunosuppression can be caused by HIV infection, leukemia, organ transplantation, bone marrow transplant, and medications to treat cancer.wMicroorganisms include all kinds of bacteria and virus(CMV), candida(念珠菌念珠菌) and aspergilosis(曲菌曲菌). pneumoc
32、ystis carinii（PCP,卡氏肺孢子虫）卡氏肺孢子虫）Symptoms wThe onset is incidous , but clinical Symptoms are severe.wFeverwNonproductive (dry) cough or cough with mucus-like, greenish, or pus-like sputumwPCPwFungal infectionDiagnosiswEarlier finding and diagnosisw Pathogen diagnosis Chest x-ray Sputum gram stain, ot
33、her special stains, and culture Arterial blood gases Bronchoscopy Chest CT scan,wTissue diagnosisTreatmentwAntimicroorganism therapywThe goal of treatment is to get rid of the infection with antibiotics or antifungal agents. The specific drug used will depend on what kind of organism is causing the
34、problem. One drug may kill one type of organism, but not another.wRespiratory treatments (to remove fluid and mucus) and oxygen therapy are often needed.Pneumococcal pneumoniaAbstraction Pneumococcal pneumonia is produced by streptococcal pneumoniae It is the most commonly occurring bacterial pneumo
35、nia Etiology Streptococcus pneumonia are encapsulated, gram-positive cocci that occur in chains or pairs The capsule which is a complex polysaccharide has specific antigenicity Type 3 is the most virulent, usually causing severe pneumonia in adults, but type 6,14,19 and 23 are virulents is children
36、Bacteria are introduced into the lungs by the four routeswSource Route Response Outcomewcolonization aspirationwAir inhalationwNon-pulmonary blood lung pneu.winfection stream defenseswContiguous directw infection extentionpathogenesiswPneumococci usually reach the lungs by inhalation or aspiration.
37、They lodge in the bronchioles, proliferation and initiate an inflammatory process. PathologyCongestionred hepatizationgrey hepatizationresolution) PathologyRed hepatilization All of the four main stages of the inflammatory reaction described above may be present at the same time In most cases, recov
38、ery is complete with restoration of normal pulmonary anatomy Clinical manifestations Clinical manifestations (1) Many patients have had an upper respiratory infection for several days before the onset of pneumonia Onset usually is sudden, half cases with a shaking chill The temperature rises during
39、the first few hours to 39-40 Clinical manifestations (2)Typically, patients have the symptoms of high fever , shaking chill, sharp chest pain, cough, dyspnea and blood-flecked sputum. But in some cases, especially those at age extremes symptoms may be more insidious. The pulse accelerates Sharp pain
40、 in the involved hemi thorax The cough is initially dry with pinkish or blood-flecked sputum Gastrointestinal symptoms such as, anorexia, nausea, vomiting abdominal pain, diarrhea may be mistaken as acute abdominal inflammationClinical manifestations (3)Signs 1 The acutely ill patient is tachypneic,
41、 and may be observed to use accessory muscles for respiration, and even to exhibit nasal flaring Fever and tachycardia are present, frank shock is unusual, except in the later stages of infection or DIC Signs 2 Auscultation of the chest reveals bronchovesicular or tubular breath sounds and wet rales
42、 over the involved lung A consolidation occurs, vocal and tactile fremitus are increasedLaboratory examinations Laboratory examinations (1) The peripheral white blood cell (WBC) count Before using antibiotic, the culture of blood and of expectorated purulent sputum between 24-48 hours can be used to
43、 identify pneumococci Colony counts of bacteria from bronchoalveolar lavage washings obtained during endoscopy are seldom available early in the course of illness Use of the PCR may amplify pneumococcal DNA and improve potential for detectionX-ray examination Chest radiographs is more sensitive than
44、 physical examination PA and lateral chest radiographs are invaluable to detect pneumoniaX-ray examination Usually lobar or segmental consolidation suggests a bacterial cause for pneumonia If blunting of the costophrenic angle is noted, pleural effusion may be exist. The features of CTAir-bronchogra
45、m signComplications In 5% to 10% of patients, infection may extend into the pleural space and result in an empyema （脓胸）（脓胸） In 15% to 20% of patients, bacteria may enter the blood stream (bacteremia) via the lymphatics and thoracic dust. Invasion of the blood stream by pneumococci may lead to seriou
46、s metastatic disease at a number of extra pulmonary sites (meningitis, arthritis, pericarditis, endocarditis, peritonitis, ostitis media etc).Complications sepsis （脓毒性休克）（脓毒性休克） lung abscess（肺脓疡）（肺脓疡） or empyema pleural effusion（胸腔积液）（胸腔积液） pleuritis ARDS（急性呼吸窘迫综合征）（急性呼吸窘迫综合征） ARF（急性呼吸衰竭）（急性呼吸衰竭） pn
47、eumothorax（气胸）（气胸） Extrapulmonary infectionsDiagnosis According to history, the clinical signs , physical examinations, laboratory examinations and radiographic features it is not difficult to make the diagnosis Differential diagnosis pulmonary tuberculosis Other microbial pneumonias: klebsiella pne
48、umonia, staphylococal pneumonia, pneumonias due to G (-) bacilli, viral and mycoplasmal Acute lung abscess Bronchogenic carcinoma Pulmomary infarctionTreatmentswAntibioticswSupport therapywTherapy of complicationsAntibiotic therapy (1) All patients with suspected pneumococcal pneumonia should be tre
49、ated as promptly as possible with penicillin G The dose and route of delivery may have to be on the basis of patients status adverse rea- ction or complication that occur For patients who are believed to be allergic to penicillin, one may select the first or second generation cephalosporin or advanc
50、ed macrolide+ -lactam or respiratory fluoroquinolone alone.For patients with PRSP, one may select the second and third generation cephalosporin or advanced macrolide+ -lactam or respiratory fluoroquinolone alone.In some cases, vancomycin may be used.Antibiotic therapy (2)Antibiotic therapy Treatment
51、 with any effective agent should be given for at least 5 to 7 day or after the patients have been afebrile for 2-3 days Supportive measurewSupportive measure are generally used inwthe initial management of acute pneumo-wcoccal pneumonia, such measures include w Bed rest Monitoring vital signs and ur
52、ine output Administering an occasional analgesic to relieve pleuritic pain Replacing fluids, if the patient is dehydrated Correcting electrolytes Oxygen therapy Treatment of complications Empyema develops in appoximately 5% of patients with pneumococcal pneumonia, although pleural effusion commonly
53、develop in 10%- 20% patients Chest X-ray with lateral decubitus films are often useful in the early recognition of pleural effusion, pleural fluid that is removed should be subjected to routing examination If pneumococcal bacteremia occurs, extra pulmonary complications such as arthritis, endocardit
54、is must be excluded, because the therapy requires higher dosages Treatment of infections shockPrognosisPrognosis is much better Any of the following factors makes the prognosis less favorable and convalescence more prolonged elderly: involvement of 2 or more lobes underlying chronic diseases (heart
55、lung kidney) normal temperature and WBC count 5000 immunodeficiency with severe complicationPrevention The most important preventive tool available is using a poly valent pneumococcal vaccine in those with chronic lung diseases, chronic liver diseases, splenectomy, diabetes mellitus and aged Staphyl
56、ococcus pneumonia Staphylococcal pneumonia is usually caused by staphylococcus aureus It is often a complication of influenza, but may be primary, particularly in infants and the aged It occurs in immunocompromissed patients such as diabetes mellitus hematologic disease ( leukemia, lymphoma, leukope
57、nia ) AIDS, liver disease, malnutrition, alcoholism Staphylococcal bacteremia complicating infections at other sites (furuncles, carbuncles) may cause hematogenous pulmonary involvement (due to blood spread) Some or all of the symptoms of pneumococcal pneumonia (high fever, shaking chill, pleural pa
58、in, productive cough) may be present, sputum may be copious and salmon-colored Prostration is often marked According the symptoms, signs of pneumonia, leukocytosis and a positive sputum or blood culture, the diagnosis can be made Gram stain of the sputum provides earliest diagnostic clue Chest X-ray
59、 early in the disease shows many small round areas of densities that enlarge and coalesce to from abscess, and leave evidence of multiple cavities Until the sensitivity results are know, a penicillinaseresistant penicillin or a cephalosporin should be given Therapy is continued for 2 weeks after the
60、 patient has become afebrile and the lungs have shown signs of clearing Vancomycin is the drug of choice for patients allergic to penicillin and cepha- losporin and for those not responding to other antistaphylococcal drugs, mainly used in MRSA.Pneumonia caused by klebsiellaKlebsiella pneumonia ( al
61、so named Friedlanderpneumonia) is an acute lung infection, caused by Klebsiella pneumoniae 1, it occurs much more inaged, malnutrition, chronic alcoholism, and inwhom with bronchial pulmonary disease This pneumonia is most likely to be found in man with middle age, onset usually is sudden, with high
62、 fever, cough, pleuritic pain, abundant sputum, cyanosis, tachycardia my be present, half cases with a shaking chill Shock appears in early stage Clinical manifestations are similar to sever pneumococcal pneumonia The sputum is viscid and “ropy”, and may be “brick red” in color Chest X-ray shows a d
63、ownward curve of the horizontal interlobar fissure, if the right upper lobe is involved Areas of increased radiance whithin dense consolidation suggest cavitation It constitutes 2% of bacterial pneumonia, but mortality may be as high as 30% When an elderly patient suffered from acute pneumonia with
64、sever toxic symptom, viscid and “brick red”, sputum must consider this disease The diagnosis is determined by bacterial examination of sputum Early using antimicrobial therapy is im- portant for patients with survivable ill- illnesses, aminoglycoside (Kanamycin, Amikacin, Gentamycin ) and the third
65、generation cephalosporin are often used. Mycoplasmal pneumonia Mycoplasmal pneumonia is caused by Mycoplasmal pneumoniae Mycoplasmal pneumoniae is one of the smallest organisms 125-150 m capable of replication in cell-free media Infection is spread form person to person by respiratory secretions exp
66、elled during bouts of coughing, causing epidemic or sporadic occurance It commonly occurs in children, adolescent, mainly in fall and winter It constitutes more than 1/3 of non bacterial pneumonias, or 10% of pneumonias from all cause Cellular infiltrate around bronchioles, and in alveolar interstit
67、ium, consists mostly of mono- nuclear elementsClinical findings The illness begins insidiously with constitutional symptomatology: malaise, sore throat, cough, fever, myalgia Half of cases have no symptom Chest X-rayChest X-ray findings are manifold Most patients have unilateral lower lobe segmental
68、 abnormalities The earliest signs are an interstitial accentuation of marking with subsequent patch air space consolidation and thickened bronchial shadows The pneumonia may persist for 3-4 weeks a slight leukocytosis is seen, with a normal differential count The diagnosis is generally proved by a s
69、ingle antibody titer of 1:32 or greater, a titer of cold agglutinins of 1:32 or greater a single Ig M determination The most promising in terms of speed, sensitivity and specificity is PCR although cost and lack of general availability limit its routine useTherapy A definite clinical response is see
70、n to erythromycin and some other newer macrolideLegionnaies Pneumonia Legionella can be an opportunistic pathogen. Patients with immunosuppression are at increased risk for infection. But sometimes outbreaks do occur in previously healthy individuals.Legionellae are small, gram-negative, obligately
71、aerobic baclli.Legionnaires disease is acquried by inhaling aerosolized water containing Legionella organisms or possibly by pulmonary aspiration of contaminated water.The contaminated water are derived from humidifiers, shower heads, respiratory therapy equipment, industrail cooling water.Because o
72、f the frequently use of air conditioner, Legionnaies pneumonia is also seen in CAPClinical manifestationswThe onset of L.pneumonia is sometimes severe.wHigh fever, rigors, and significant hypoxemia are usually seen in patients with L.pneumonia.wFailure to rapidly appropriate therapy in these cases i
73、s likely to result in a poor outcome.wCommon signs include cough, dyspnea, pleuritic chest pain, gastrointestinal symptoms, especially diarrhea or localized abdominal pain, nausea, vomitting are a prominent finding in 20% to 40% of patients with L.pneumonia.Physical examinationwPhysical finding are
74、often similar to other pneumonias.wRales are usually present over involved areaswPulse rate is not coincide to the body temperate.Chest X-raywNo diagnostic features on the chest X-ray distinguish it from other pneumoniawInfiltrates can be unilateral, bilateral, patchy, or dense, and can spread very
75、quickly to involve the entire lung, pleural effusion, usually small in volume occurswRoutine laboratory tests also are nonspecific.Laboratory examinationwSerologic testing is the most often used for establishing a diagnosis.wA fourfold or greater rise in antibody is considered definitively exist for
76、 Legionella.DiagnosiswAccording to history, clinical signs, X-ray features and serologic testing, we can diagnose it.TherapywErythromycin is considered the drug of choice.It should be given until clinical improvement is seen.It usually lasts 2-3 weeks.CandidiasisCandidiasis is an opportunistic disea
77、se, it is caused by candida.Clinical signswRespiratory signs: fever,cough, sputum production, dyspnea.wX-ray shows no specific.It is similar to acute pneumonia.diagnosiswMainly according to sputum culture or biopsy of lung.TherapywNystatin or various azole drugsAspergillosiswAspergillosis refers to
78、infection with any of species of the genus AspergillusClinical signswThe disease generally occurs in immunosuppressed and anticancer therapy patients.wThere are four types of pulmonary aspergillosis.Clinical signs of Pulmonary aspergillosiswPresents as chronic productive cough, hemoptysis, dyspnea,
79、weight loss, fatigue, chest pain, or feverwSometimes patients with pulmonary aspergillosis accompany with prior chronic lung disease.wTypical picture of an aspergilloma is a fungus ball in a cavity in an upper lobewThe sputum culture is positive in most patients.DiagnosiswThe repeated isolation of A
80、spergillus from sputum or the demonstration of hyphae in sputum or BALF suggests endobronchial infection. TreatmentwWith intravenous amphotericin B (1.0 to 1.5 mg/kg daily)wPatients with severe hemoptysis due to fungus ball of lung may benefit from lobectomy Therapy to Infectious ShockwTreatment in
81、intensive care units cardiac rhythm, blood pressure, cardiac performance, oxygen delivery, and metabolic derangements can be monitoredwAdequate oxygenation and ventilatory support (sometimes mechanical ventilation)wEffective antibiotic therapywMaintain blood pressure, including maintain circulation
82、blood volume, use of dopamineSummaryw1.肺炎的定义w2.肺炎的分类w3.CAP和HAP的定义和常见的病原体w4.肺炎球菌肺炎的典型的临床表现和影象特点及其治疗原则w5.各种病原体肺炎的治疗原则w6.感染性休克的治疗原则Questionsw1.What is the differences between CAP and HAP?w2.What is the standard of sever pneumonia?w3.what are the principals of antibiotic therapy of various of pneumonias
83、?Case reportw患者,男性,32岁w主诉:发热伴咳嗽6天w现病史:患者于6天前劳累后出现发热,体温最高达39,稍有畏寒,自服退热药后热退,之后体温又上升,达38,伴有咳嗽,痰为白色黏液样,偶呈黄脓性,遂于我院就诊,胸部X线显示:左下肺片状高密度影,外周血白细胞6.0*109 /L,N66.2%,在门诊予与亚星和左克抗感染3天,体温不退,行胸部CT检查示:左下肺片状密度增高影。故收入院进一步诊治。入院体检w神清，一般可，T：38，P90次/分，R18次/分，BP110/70mmHg，口唇无紫绀，全身浅表淋巴结未及肿大，颈软，两肺呼吸音粗，未及干湿罗音，腹软，无压痛，双下肢无浮肿，NS(
84、-)辅助检查w血支原体抗体IgM：160w胸片w胸部CT胸片胸部CTcase2w患者，男性，50岁w主诉:咳嗽伴咳黄痰二十余天w现病史:患者于入院前二十余天开始无明显诱因下出现咳嗽,咳黄脓痰,量中,无咯血,胸痛和呼吸困难等其他呼吸系统症状。四天后出现发热一次，体温未测，自服安乃近后热平，但一直有夜间出汗较多伴乏力，遂于当地医院就诊，胸片示两肺多发阴影，拟肺炎后于次日来我院行CT（见CT结果），为进一步诊治入院。w追问病史患者于入院约半年前确诊天疱仓，遂开始服用强地松片30mg/d,后因病情反复增加用量，并于入院前月加用硫唑嘌呤片d入院体检、辅助检查w体检无特殊阳性体征w胸部检查 How do
85、we diagnose?选择题w1男性，58 岁，有慢性咳嗽、咯痰史 15 年，1 周来高热、咯红砖色胶冻样痰，伴气急紫绀，谵妄，本 例可能性最大的诊断是：BwA、肺炎球菌肺炎 wB、克雷白杆菌肺炎 wC、浸润型肺结核 wD、病毒性肺炎 wE、支原体肺炎w2男性，35 岁，发热、寒颤 3 天，体温 39 度，胸片示右上肺大片阴影，痰涂片见较多革兰氏阳性成对 或短链状球菌，这时治疗首选 ？CwA、头孢唑啉 wB、丁胺卡那霉素 wC、青霉素 wD、氟哌酸 wE、红霉素w3肺炎球菌肺炎在病变消散后肺组织结构：EwA、纤维组织增生 wB、有小空洞残留 wC、肺泡壁水肿 wD、局部支气管扩张 wE、肺泡
86、壁无损坏w4男，20 岁，低热咽痛，咳嗽半月入院，咳嗽甚剧，为刺激性干咳，体检：T37.8 度，咽充血，心肺无 阳性体征，化验：WBC：8109/L，中性 70，X 线胸片示右下肺间质性炎变，间有小片状阴影，以下哪 项检查对明确诊断意义较大？EwA、痰细菌培养 wB、咽拭子细菌培养 wC、痰查抗酸杆菌 wD、结核菌素试验 wE、冷凝集试验w5患者，25 岁，女性，咽痛，咳嗽，乏力，四肢肌肉疼痛，中等发热，双肺呼吸音稍粗，未闻罗音，白 细胞 9.6109/L，中性 86，胸片示：左下肺部斑片状浸润阴影，血清冷凝集试验：1：64 阳性，最好 应选择的治疗药物是：EwA、抗结核药 wB、青霉素 wC
87、、头孢菌素 wD、氨基甙类抗生素 wE、红霉素w6.军团菌肺炎首选的抗生素是:AwA.红霉素wB.青霉素wC.头孢菌素wD.丁胺卡那霉素wE.氯霉素w7肺炎球菌致病力的主要因素是 EwA肺炎球菌内毒素wB肺炎球菌外毒素wC肺炎球菌菌体蛋白质wD. 肺炎球菌迅速繁殖wE肺炎球菌含高分子多糖体荚膜对组织的侵袭力w8治疗肺炎球菌肺炎首选抗生素是BwA 红霉素 wB青霉素wC丁胺卡那霉素wD氯霉素wE羧苄青霉素w9男性，25岁，因受凉后突起畏寒、发热(39.2度)。左w侧胸痛伴咳嗽，咯少量铁锈色痰，胸部X线摄片见左下肺野大片淡薄阴影。其最可能的诊断是：CwA.金黄色葡萄球菌肺炎wB结核性胸膜炎wC肺炎球菌肺炎wD原发性支气管肺癌合并阻塞性肺炎wE急性原发性肺脓疡w9肺炎球菌肺炎患者在抗生素治疗下体温接近正常后反又升高，白细胞增高，首先考虑：EwA细菌产生耐药wB抗生素用量不足wC药物热wD加用退热药wE出现并发症w10.肺炎球菌肺炎的炎症发展最高峰是：AwA.灰色肝样变期 wB.消散期wC.红色肝样变期 wD.病变组织的机化wE.充血期
