Common Outpatient conditions

Question 1

treatment for acute bronchitis

Answer 1

• cough suppressants such as codeine or dextromethophan
• short acting beta-agnoists (controls symptoms - bronchospasm, wheeze, dyspnea and cough)
• PO NSAIDS- Improves the associated contitutional sxs
• antibiotics not recommended (acute bronchitis caused by pertussis infection is only indication)
• decongestants (toopical & oral) - effective for nasal congestion

Question 2

prevention of acute bronchitis?

Answer 2

• influenza vaccine
• zinc
• pneumococcal vaccine indicated for chronic bronchitis

Question 3

• cough for up to 3 weeks
• most commonly 2nd to common cold
• but first step is to determine etiology

Answer 3

Acute cough

Question 4

• cough for more than 8 weeks
• differential large, but also not emergency
• most common etiologies: upper airway cough syndrome, asthma, and gastroesophogeal reflux disease

Answer 4

chronic cough

Question 5

Top 4 chronic cough causes?

Answer 5

Upper airway cough syndrome
asthma
GERD
ACE inhibitors

Question 6

• # 1 cause of chronic cough in nonsmoking immunocompotent pt w/ normal CXR
• dx: based on H&P
• PE: draining posterior pharynx, nasal discharge, throat clearing, oropharyngeal cobblestoning
• TX: PO or topical decongestant, 1st gen antihistamine, +/- SABA inhaler

Answer 6

upper airway cough syndrome

Question 7

• acid reflux stimulates the afferent limb of cough refelx or esophageal-brochial cough reflex
• though sxs could be silent
• therapy: oral PPI recommended
• if poor respose to therapy- 24hr esophageal monitoring

Answer 7

GERD

Question 8

• cause cough in 5-20% of patients on these medications
• women more often than men
• not dose related
• cough starts 1-6 weeks after initiation
• tx: D/C medication, start ARB

Answer 8

ACE inhibitor

Question 9

• constantly occuring/ localized outbreaks
• these are small changes in the virus that happen continually over time. Antigenic drift produces new virus strains that may not be reconized by the body’s immune system
• ex. pts was infected with a particular flu viral, develops antibodies and gets infected with a new virus and antibody doesn’t recognize new virus
• one of the main reason why you can get the flu multiple times

Answer 9

antigenic drift

Question 10

• occasionaly occurs/ more widespread
• abrupt, major change in a virus, resulting in new hemagluttinin and/or new hemagglutinin and neuraminidase proteisn in viruses that infect hums
• Results in a new virus subtype or a virus with a hemag. or hemagglutinin and neuramindase combo that has emerged from an animal pop. that is different from the subtype in humans
• people have little or no protectin against the new virus

Answer 10

anteginc shift

Question 11

High risk population for influenza

Answer 11

• residents of nursing homes and chronic care facilites
• adults >65 years of age
• pregnant women and women up to two weeks postpartum. the risk of complicated influenza increased by trimester
• individuals with chronic medical conditions
• native americans and alaska natives
• morbidly obese individuals

Question 12

how do people infected with the influenza present?

Answer 12

• abrupt onset of fever, HA, myalgia and malaise
• accompanied by: URI, non-productive cough, ST, PND and rhinorrhea
• febrile, oropharyngeal hyperemia, cervical adenopathy(more prominent in younger patients), chest exam unremarkable
• sxs last, on average 2-5 days, possible a week or more
• complications: #1 pneumonia (strep pneumo is most common but staph is #2

Question 13

Influenza antiviral treatment

Answer 13

Neuraminidase inhibitors

• < 1% resistanace found
• reduces sxs by 1 day

Adamantines

• due to high level of resistance- not used to treat influenza 2013

These medication should not be used to treat other respiratory viruses

Question 14

• MOA: interfere with the release of these new influenza virsues from infected cells. Which prevents new round of infection from starting
• Medications: oseltamivir (tamiflu), Zanamivir
• ADRS: GI (N/V) and rash, rare neuropsych effects (delirium, hallucinations, confusion)

Answer 14

Neuraminidase inhibitors

Question 15

• MOA: prevents viral replication by blocking the viral M2 protein ion channel, preventing fusion of the virus and host-cell membranes (prevents the uncoating of the viruse proceeding its entry into cells)
• class is active only for influenza A, but high rate of viral resistance to this class

Answer 15

Influenza antiviral treatment

Question 16

• Route: IM or intradermal

recommended for

• All individuals > 50y/o
• healthy pregnant adults up to 49 y/o
• immunocompromised hosts
• pts with chronic neurologic disease (MS)

Does no interfere with immune response to IIVS or lAIVs
Side effects: injection site pain and slight increased risk of Guillain-Barre

Answer 16

Inactivated influenza vaccines

Question 17

Route: intranasal

Recommended for:

• Healthy non-pregnant adults to 49 y/o
• C/I in immunocompromised

Administer simultaneously with other LAIVs or wait 4 weeks between

Side effects: intranasal- rhinorrhea, congestion, HA and sore throat

Answer 17

Live attenuated influenza vaccine

Question 18

• can be used to prevent influenza in high risk children not fully immunized
• can be administerd simultaneously with IIV to cover till immune response
• should not be given for 14 days after LAIV given
• can be given for pre and post-exposure prophylaxis

Answer 18

chemoprophylaxis

Question 19

• viral infection of the upper respiratory system, including the nose, throat, sinuses, eustachian tubes, trachea, larynx and bronchial tubes
• 30-50% are caused by a group known as rhinoviruses
• almos all clear up in less than two weeks without complications
• sept-april with highest incidence in children 3-10 y/o
• incubation period: 24-72hrs
• frequent trigger for asthma and COPD exacerbations

Answer 19

Viral URI

Question 20

what are physical exam findings of the common cold?

Answer 20

• conjunctival injection
• nasal mucosal edema
• nasal congestion
• pharyngeal erythema
• +/- adenopathy
  clear lung exam

Question 21

treatment of the common cold?

Answer 21

• mainstay- symptomatic therapy
• reassure and advise that it could take upt ot 14 days to fully resovle

Question 22

pharmacologic treatment options for common cold?

Answer 22

• Ipratroprium bromide NS (atrovent) QID: for symptoms of sneezing and rhinorrhea relief, no affect on nasal congestion
• cromolyn sodium NS: mild improvement in rhinorrhea, throat pain and cough
• PO antihistamines: significant improvement in sneezing and rhinorrhea
• antitussives: mroe beneficial for chronic cough, not acute URI sxs
• decongestants: effective for nasal congestion

Question 23

• Characterized by self-limited inflammation of the bronchi and clinically expressed as cough, which may include sputum production
• generally caused by a virus
• PE: diffuse wheezing due to bronchospasm, ronchi on auscultation (clears after cough), rhinorrhea, conjunctivitis, +/- adenopathy

Answer 23

Acute Bronchitis