Ambulatory 2

Question 1

Possible causes of cough that’re ass’d w/ other symptoms?

Answer 1

• URI (most common cause of acute cough)
• Pulmonary disease: pneumonia, COPD, pulmonary fibrosis, lung cancer, asthma, lung abscess, TB
• CHF w/ pulmonary edema

Question 2

Duration of time that defines acute vs. chronic cough?

Answer 2

3 weeks is the duration that separates them.

Usually acute & self-resolving, but if lasts > 1 month, further investigation is appropriate

Question 3

Possible causes of postnasal drip?

Answer 3

• URIs (viral infections)
• Rhinitis (allergic or non-allergic)
• Chronic sinusitis
• Airborne irritants

Question 4

Likely cause of isolated cough in patients w/ normal CXR…

– nocturnal cough?

Answer 4

GERD

Question 5

Possible causes of isolated cough in patients w/ normal CXR?

Answer 5

• Smoking
• Postnasal drip
• GERD
• Asthma
• ACE inhibitors

Question 6

Causes of chronic cough in adults?

Answer 6

• Smoking
• Postnasal drip
• GERD
• Asthma

Question 7

Cough – when is CXR indicated

Answer 7

• If acute & a pulmonary cause is suspected
• If acute & p/w hemoptysis
• if chronic
• sometimes in a long-term smoker in whom COPD or lung cancer is a possibility

Question 8

Cough – when is CBC indicated?

Answer 8

If infection is suspected

Question 9

Cough – when are PFTs indicated?

Answer 9

• if asthma is suspected

- if cause is unclear in a pt w/ chronic cough

Question 10

Cough – when is Bronchoscopy indicated?

Answer 10

If there’s no dx after CXR, CBC, & PFTs

– to look for tumor, foreign body, or tracheal web

Question 11

Postnasal drip – Tx?

Answer 11

• 1st gen anti-histamine/decongestant
• if sinusitis also present, consider ABX

For Allergic rhinitis, consider non-sedating long-acting oral anti-histamine (loratadine)

Question 12

Allergic Rhinitis – Tx?

Answer 12

Loratadine

MOA = long-acting, oral anti-histamine

Question 13

Nonspecific antitussive meds for cough symptoms?

Answer 13

• Codeine
• Dextromethorphan
• Benzonate (Tessalon Perles) capsule

(“expectorants” such as Guaifenesin & water improve effectiveness of meds)

Question 14

Common features of viral URI?

Answer 14

Rhinorrhea, Myalgias, Headache, Fever, Cough

yellow sputum + F/C = bacterial

Question 15

Common features of bacterial URI?

Answer 15

Fever, Cough, Yellow Sputum

rhinorrhea, myalgias, headache + F/C = viral

Question 16

Acute Bronchitis – _____ account for the majority of cases.

Answer 16

Viruses

Question 17

Acute Bronchitis – workup?

Answer 17

• CXR if suspect pneumonia (presence of fever, tachypnea, crackles, egophony on auscultation, or dullness to percussion)
• • infiltrate or consolidation NOT present in acute bronchitis
• Lab tests are not indicated

Question 18

Acute Bronchitis – what features might suggest pneumonia?

Answer 18

Presence of fever, tachypnea, crackles, egophony on auscultation, or dullness to percussion

• • if present, get CXR
• • acute bronchitis does not have infiltrate or consolidation

Question 19

Acute Bronchitis – clinical features?

Answer 19

1. Cough (w/ or w/out sputum) for 1-2 wks
   - in some pts, may last > 1 month
2. Chest discomfort or SOB may be present
3. Fever may or may not be present

Question 20

Acute Bronchitis – Tx?

Answer 20

Symptomatic – cough suppressants &/or bronchodilators

ABX usually not necessary – most cases are viral

Question 21

Most common URI?

Answer 21

Common cold

Question 22

Common cold – most common causes?

Answer 22

• Rhinovirus (> 100 serotypes w/ no cross-immunity between them)
• Coronavirus
• Parainfluenza virus (types A, B, C)
• Adenovirus
• Coxsackie virus
• RSV

Question 23

Common cold – most common route of transmission?

Answer 23

Hand-to-hand transmission

Question 24

Common cold – possible complications?

Answer 24

Secondary bacterial infection – bacterial sinusitis or pneumonia

** these are VERY rare

Question 25

Is fever typically part of the Common Cold?

Answer 25

Not in adults (suggest bacterial complication or influenza) Not unusual in children

Question 26

Common Cold -- clinical features?

Answer 26

Rhinorrhea, sore throat, malaise, nonproductive cough, nasal congestion

Question 27

Common cold is synonymous with ______

Answer 27

Acute Rhinosinusitis | -- inflammation & congestion of mucous membranes of nasal & sinus passages

Question 28

Common causes of Sinusitis?

Answer 28

- Acute bacterial -- Strep pneumoniae, H. influenzae, or anaerobes - Other types -- viral, fungal, allergic

Question 29

Most common sinuses involved in Sinusitis?

Answer 29

Maxillary sinuses

Question 30

Sinusitis -- Tx to promote drainage?

Answer 30

- Saline nasal spray | - Decongestants (Pseudoephedrine or Oxymetazoline)

Question 31

Sinusitis -- Antihistamines you could use? Why do you not want to overuse these?

Answer 31

* Loratadine (Claritin), fexofenadine (Allegra), chlorpheniramine (ChlorTrimeton) * Reserve for pts w/ allergies bc of “drying effect”

Question 32

Acute purulent sinusitis -- ABX Tx?

Answer 32

Amoxicillin, amoxicillin-clavulanate, TMP/SMX, levofloxacin, moxifloxacin, and Cefuroxime are all good choices

Question 33

Sore throat -- likely cause(s)? Most concerning cause(s)?

Answer 33

Viruses -- most likely Concern = group A β-hemolytic strep due to possibility for rheumatic fever Others: - - Chlamydia, mycoplasma - - Gonococci (oral sex) - - Corynebacterium diphtheriae—pseudomembrane covering pharynx - - Candida albicans (if immunosuppressed, on ABX, or severely ill)

Question 34

Sore throat -- Tx?

Answer 34

Viral (most likely) -- symptomatic (ibuprofen or acetaminophen, gargling warm salt water, use humidifier) Strep throat -- penicillin x 10 days (erythromycin if PCN allergy) Mononucleosis -- advise rest & ibuprofen/acetaminophen for Sx

Question 35

Sore throat -- Dx tests?

Answer 35

- Rapid strep -- results in < 1hr but only gives +/- for strep - Throat culture = best test but takes 24 hrs - Monospot test -- if Mono is suspected

Question 36

UTI -- ABX Tx?

Answer 36

TMP/SMX (3 days), Nitrofurantoin (7 days), Cephalexin, Ciprofloxacin (3 days), Amoxicillin

Question 37

Pyelonephritis -- ABX Tx?

Answer 37

- TMP/SMX or Fluoroquinolone for gram-negative rods - Amoxicillin effective for most gram-positive cocci (enterococcus, S. saprophyticus) - Single dose of Ceftriaxone or Gentamicin often given initially before starting oral Tx

Question 38

Acute Prostatitis -- ABX Tx?

Answer 38

Ampicillin & Gentamicin

Question 39

Community acquired pneumonia -- ABX Tx?

Answer 39

As outpatient: Azithro, Clarithromycin, or doxycycline (if existing comorbidities/previous antibiotics, give Levofloxacin) As inpatient: Levo or moxifloxacin or Ceftriaxone + azithromycin

Question 40

Lung Abscess -- ABX Tx?

Answer 40

Clindamycin or Penicillin | usually due to aspiration thus cover for anaerobes

Question 41

Impetigo -- ABX Tx?

Answer 41

(Impetigo = staph and strep) Mild -- Topical mupirocin or bacitracin or Repatamulin Severe - Oral doxycycline or clindamycin or Trim/sulfa

Question 42

Erysipelas or cellulitis -- ABX Tx?

Answer 42

Erysipelas: (strep > staph) Cellulitis: (staph>strep) Mild -- oral dicloxacillin or cephalexin or if allergic, macrolide or clindamycin Severe -- IV oxacillin or nafcillin or cefazolin or if allergic, clindamycin

Question 43

Spontaneous bacterial peritonitis -- ABX Tx?

Answer 43

Cefotaxime

Question 44

Postpartum Endometritis -- ABX Tx?

Answer 44

Clindamycin + gentamicin

Question 45

Endocarditis -- ABX Tx?

Answer 45

Vancomycin + gentamicin

Question 46

PID -- ABX Tx?

Answer 46

Exclude pregnancy first and give Ceftriaxone+doxycycline (outpatient) or if inpatient, cefotetan + doxycycline If pregnant, substitute doxycycline with azithromycin or amoxycillin or erythromycin