Day 6 - Pulm1 Tonsils, Sinusitis, PNA

Question 1

Cause, Dx feat, & Txof peritonsilar abscess

Answer 1

Bn tonsilar and pharyngeal constrictors; Caused by S. pyogenes, S. aureus, or Bacteroides; Severe sore throat, fever, muffled hot potato voice; Abscess on tonsil or deflection of uvula to opposite side; Trismus, drooling; Tx: Needle aspiration or I & D

Question 2

Distinguish acute bacterial sinusitis from rhinosinusitis (or common cold)

Answer 2

Last 7+ days and Any of following: Purulent nasal discharge, Maxillary tooth or facial pain, Worsening sx after initial improvement; No need for imaging confirmation (CT of sinuses can r/o sinusitis)

Question 3

Tx acute bacterial sinusitis

Answer 3

Observation & sx relief (if fever

Question 4

Tx chronic bacterial sinusitis

Answer 4

(3 mo. of sx); Oral steroids if tolerable or 3-6 wks of antibx; Intranasal saline; Intranasal steroids indefinitely; If allergic, tx allergies; If nasal polyps and refractory to steroids, debulking surgery; If allergic fungal sinusitis, then sinus surgery & prolonged steroids

Question 5

Complications of sinusitis

Answer 5

Meningitis; Abscess; Orbital infx; Osteomyelitis

Question 6

Allergic fungal sinusitis p/w & dx

Answer 6

Chronic rhinosinusitis, thick allergic mucin; Seen on CT scan, typically confirmed on sinus surgery

Question 7

Most common cause of PNA & empiric antibx tx in children aged: Newborn - Mo. 1

Answer 7

GBS, Gram (-) like E. coli, Listeria; C. trachomatis; Ampicillin & Gentamycin; If suspect MRSA, consider vancomycin; If Chlamydia, erythromycin

Question 8

Most common cause of PNA & empiric antibx tx in children aged: After first mo. - 4 mo.

Answer 8

RSV; C. trachomatis (if not already dx), Parainfluenza, Bordetella, S. pneumo, S. aureus; Macrolides (Azithromycin or erythromycin) w or w/o Ceftaxime

Question 9

Most common cause of PNA & empiric antibx tx in children aged: 4 mo. - 4 yr.

Answer 9

RSV and other viruses (influenza, parainfluenza, coronavirus, adenovirus); S. pneumo, H. flu, Mycoplasma; Amoxicillin or Ampicillin

Question 10

Most common cause of PNA & empiric antibx tx in children aged: 5- 15 yr.

Answer 10

Strep pneumo; Mycoplasma; Chlamydia; Options: (1) Amoxicillin + Clarithromycin (2) Azithromycin, or (3) Amoxicillin + Doxycycline

Question 11

Indications for pneumococcal vaccination in adults

Answer 11

(1) Age 65+ (2) Serious long-term health problems (Hear disease, SCD, alcoholism, CSF leaks, Lung disease not including asthma, DM, Liver cirrhosis) (3) Resistance to infx lowered (Hodgkin disease, Multiple myeloma, cancer tx, long-term steroid use, bone marrow tx, kidney failure) (4) Certain Alaskan native or American indian populations at higher risk

Question 12

Antibx tx pseudomonas PNA

Answer 12

Antipseudomonal beta-lactam (piperacillin, tazobactam, cefipime, meropenem, imipenem, aztreonam) must be added to one of following for at least 2 weeks for added coverage: (1) Antipseudomonal quinolone (2) Aminoglycoside + Azithromycin (3) Aminoglycoside + Antipseudomonal quinolone

Question 13

XR and lab findings suspicious for PCP as cause of respiratory distress

Answer 13

CXR: diffuse b/l (usually not b/l in other PNA) interstitial infiltrates; CD4 220 (unique to PCP); Rising LDH despite tx portends a poor prognosis

Question 14

Tx PCP

Answer 14

21 days of antibx, choices include: (1) TMP-SMX (first-line) (2) Pentamidine (first-line alternative); (3) Trimetrexate w/ leucovorin (4) Primequin plus clindamycin; If mod-severe, hospitalized & given steroids

Question 15

Ddx for ground glass opacity or infiltrates

Answer 15

DDx: Interstital PNA; PCP PNA; Pulmonary edema; Pulmonary hemorrhage; Hypersensitivity pneumonitis

Question 16

Common cause of PNA: immunocompromised pts

Answer 16

PCP

Question 17

Common cause of PNA: atypical walking PNA

Answer 17

Mycoplasma pneumoniae

Question 18

Common cause of PNA: alcoholics

Answer 18

Klebsiella

Question 19

Common cause of PNA: interstitial PNA in bird handlers

Answer 19

C. psittaci

Question 20

Common cause of PNA: pt w/ hx of bats/bat droppings

Answer 20

Histoplasma caspulatum

Question 21

Common cause of PNA: recently visited CA, south Texas, New mexico

Answer 21

Coccioides imitis

Question 22

Common cause of PNA: currant jelly sputum

Answer 22

Klebsiella

Question 23

Common cause of PNA: Q fever (interstitial fever in livestock handler)

Answer 23

Coxiella burnetti

Question 24

Common cause of PNA: air conditioners

Answer 24

Legionella pneumophila

Question 25

Common cause of PNA: 1 year of age and younger

Answer 25

RSV

Question 26

Common cause of PNA: neonates

Answer 26

GBS

Question 27

Common cause of PNA: children and young adults

Answer 27

Mycoplasma pneumoniae

Question 28

Common cause of PNA: other health problems

Answer 28

Klebsiella

Question 29

Common cause of PNA: viral pneumoniae

Answer 29

(1) RSV (2) Influenza

Question 30

Common cause of PNA: life-threatening wool sorters diease

Answer 30

Bacillus anthracis

Question 31

Common cause of PNA: COPD exacerbation

Answer 31

Haemophilus influenza

Question 32

Common cause of PNA: ventilator patients w/ CF

Answer 32

Pseudomonas aeruginosa

Question 33

Common cause of PNA: Pontiac fever (flu-like sx)

Answer 33

Legionella pneumophila

Question 34

PNA based on lab signs: gram (+) cocci in clusters

Answer 34

S. aureus

Question 35

PNA based on lab signs: gram (+) cocci in pairs

Answer 35

S. pneumo

Question 36

PNA based on lab signs: gram (-) rods in 80 yo

Answer 36

E. coli

Question 37

PNA based on lab signs: gram (+) rods in neonate

Answer 37

GBS

Question 38

PNA based on lab signs: gram (-) rods in neonate

Answer 38

E. Coli