18. Respiratory Infections

Question 1

frontal, ethmoid, maxillary, sphenoid sinus, inflammation of the sinuses, also plugs the opening to the eustachian tube, farm ponds not draining properly, sinus pain, ear pain, ear pressure, ear pain, on exam nasal irritation, viral causes can be rhinovirus, influenza virus, and parainfluenza virus, bacterial causes are streptococcus pneumoniae, haemophilus influenzae, moraxella catarhallis neisseria, occasionally anaerobe, first 3 are the big 3, acute viral rhinosinusitis have some improvement in 7-10 days with usually no fever and if there is disappears in 24-48 hours, discolored nasal discharge is only a sign of nasal inflammation and is not a sign of bacterial versus viral, bacterial etiology will last longer than 10 days with biphasic pattern of illness, if lasting longer than 48 hours suggestive of bacterial infection, focal areas of infection suggest, if lasts longer than 7-10 days with no improvement suggests bacterial, if bacterial infection is suggested prescribe an antibiotic, treat with nasal steroid, netti pot rinses away the mucus to expose tissue and nasal steroid can penetrate better, if bacterial rhinosinusitis give 7-10 days since can resolve on its own, if the patient doesn’t follow up ***

Answer 1

rhinosinusitis/sinusitis

Question 2

amoxicillin and augmentin, clavulanate in the mixture causes diarrhea, consider penicillin allergies, give 3rd generation cephalosporins but need to be careful because causes c.diff with bloody diarrhea, if no improvement can give levoquin but causes torn achilles

Answer 2

medications to treat rhinosinusitis

Question 3

occcurs in patients 5-10, headache, nausea, occasionally vomiting, **beefy red throat with exudates, sometimes with red lacy rash **, most likely stretpococcal or viral, if you give amoxicillin you will cause rash, test with rapid antigen testing and throat culture, don’t test every patient because 1/5 people are common streptococcal carriers, testing would be positive even if no infection, have the age modified centor score available looking at tonsillar exudate, swollen tender anterior cervical nodes, absence of cough, history of fever or measured temperature **, score if 2-3 treat if positive, score of 4 test the patient and treat regardless, if patient has mild non-IgE mediated rash to penicillin give 2nd generation cephalosporin, if anaphylactic reaction to penicillin give macrolide but consider resistance, if IgE mediated allergic reaction with anaphylaxis, give **

Answer 3

streptococcal pharyngitis

Question 4

most likely viral, but think of other causes like GERD or squamous cell carcinoma

Answer 4

laryngitis

Question 5

rare in adults unless there is foreign body around the throat, think about other causes

Answer 5

tracheitis

Question 6

lower respriatory tract infection involving the large airways without evidence of pneumonia in the absence of COPD, cough productive or nonproductive, sputum color doesn’t matter, sometimes wheezing and rhonchi but sometimes clear, only 6% of patients are provably bacterial, majority outpatient is viral, pneumonia is an infection of the lung parenchyma, includes fever and cough, on exam signs on consolidation, assume cause is bacterial and treat with antibiotics, bronchiolitis is an inflammation of the airways doesn’t happen in adults very often

Answer 6

bronchitis/pneumonia/bronchiolitis

Question 7

if fever over 48 hours, no improvement after 7 days, biphasic pattern of worsening, wrong diagnosis and there is consolidation ***, treatment is similar to bacterial pneumonia, treatment of viral bronchitis with albuterol or predisone burst and taper for viral infection

Answer 7

bacterial bronchitis suspicions, treatment for viral bronchitis

Question 8

community acquired pneumonia vs nosocomial pneumonia, variance in history of cough with or without sputum, dyspnea, pleuritic chest pain, altered mental status in the elderly, physical exam can vary with fever, tachycardia, lung auscultation abnormalities like wheezing, crackles, rales, tactile fremitus, increased white blood cells, ultimately diagnosis of pneumonia depends on clinical suspicion and imaging, on chest x-ray will have findings, can be viral with influenza, rhinoviruses, parainfluenza, adenovirus, rhinovirus, coronavirus, MERS, SARS-CoV-2, human metapneumovirus, time to use tamiflu is important for board exams, typical bacteria are big 3, strep pneumo has a vaccination available, consider drug staph aureus if drug use, consider group A strep, aerobic gram negatives like klebsiella and ecoli, atypical bacteria include mycoplasma pneumonia, chlamydia pneumonia, chlamydia psitacci, mycobacterium tuberculosis, legionella, consider pneumocystis jirovecii if HIV aids, consider antibiotics

Answer 8

pneumonia

Question 9

if under 65 and healthy with no recent antibiotics give amoxicillin, if >65 with comorbidities and given recent antibiotics, give ***, be cognisant of allergies you are dealing with, consider history in your decisions, atypicals are killed nicely with azithromycin/erythromycin, but experts are disagreeing

Answer 9

discussion

Answer 10

Antibiotics are not appropriate

Question 11

not first line treatment for respiratory infections

Answer 11

fluroquinolones