Gen Med- Respiratory problems Flashcards
Common Cold
- Rhinovirus (2% complicated by bacterial infection
- Symptoms not localized
- treat symptoms (stuffy head, tender sinuses, clear purulence)
-NO ABX unless complicated by bacterial infection
Influenza
- Viral
- more prominent constitutional symptoms
- -Fever, malaise, myalgias
- -seasonal
- Rapid test available; nasopharyngeal swab
First 2 days → treat w/ Oseltamvir (2x day 5 days)
Prophylaxis → Oseltamvir & Flu shot (1x day 6 days)
Acute Pharyngitis
- usually Viral
- 15% due to Strep Pyogenes
- -exudate w/ fever and ANTERIOR cervical adenopathy
- -strep screen test
–Tx: Penicillin or Erythromycin
Mononucleosis
- Viral (EBV)
- POSTERIOR cervical adenopathy
- dull white exudate
- Monospot test, ATL on CBC
- RASH if given Amoxicillin
- Tx w/ steroids
Acute Sinusitis
- usually caused by sinus ostial (opening) obstruction
- usually viral or bacterial
- <4 weeks
- -(Strep. pneumonia, H. influenza, M. Catarrhalis)
- can be noninfectious (allergies, polyps, irritants, tumor)
Narrow Spectrum:
-Amoxicillin or TMP/SMX
7+ days and purulence
-Ampicillin / Sulbactam, Oxyquinolone
Chronic Sinusitis
-results from sinus ostial obstruction
>12 weeks
-usually bacterial or fungal
-Sinus CT scan to see extent
- Culture guided treatment w/ nasal saline lavage
- and/or nasal steroids
Otitis externa
-P. aeruginosa & occasionally S. Aureus
- *Ciprofloxacin
- HC drops, debridement
- avoid Q tips
Otitis media
- Red TM, post. cervical adenopathy, fever
- Children t drain well
- Usually bacterial, following URI
- *Strep Pneumoniae, H. influenza, M. Catarrhalis
- *Amoxicillin (1/3 resistant)
- -treatment debatable
Recurrent otitis media
-Red TM, post. cervical adenopathy, fever
>4 in 1 year OR 3 in <6 months
TX:
- beta-lactams (amoxicillin?)
- TMP/SMX maintenance
- Myringotomy tubes
Serous otitis media
- someone who has a cold and then flies
- almost always self-limited
-Abx and/or myringotomy tubes if significant hearing lost and effusion >3 months
Chronic otitis media
- Recurrent purulent drainage w/ chronic TM perforation
- Mastoidectomy and typanoplasty
Laryngitis
nearly always viral
Acute epiglottitis
- H. influenza ?
- potentially fatal
DX: lateral neck films
-cherry red epiglottis (rhino-larygoscopy)
RX: Ampicillin / sulbactam
- -hospitalization and IV abx
- Hib vaccine
Acute Bronchitis
- inflammation of the AIRWAYS
- usually viral
- cough w/ sputum production
- absence of abnormalities on CXR differentiates from Pneumonia
SEVERE Bronchitis:
- ↑ AMOUNT of sputum
- change in COLOR of sputum
- ↑ shortness of breath
- Abx (esp w/ lung disease i.e. COPD)
- -Azithromycin or Levofloxacin
- may need to treat bronchospasm (albuterol, steroids)
Pleurisy
- inflammation of lung SURFACE
- chest pain; worse w/ INSPIRATION
-usually viral
TX symptomatically- NSAIDs, narcotics if severe
Pneumonia: Previously healthy outpatient (Group 1)
- S. pneumonia, H. influenza
- Mycoplasma, Chlamydia (atypical pneumonia/walking)
- Viral (RSV, adenovirus, influenza?)
- Coccidiodmycosis
- Uncommon: Legionella, Mycobacterium
-1% mortality
Pneumonia: Outpatient, Older (65+) or w/ cardiopulmonary disease (Group 2)
- S. pneumonia
- Pseudomonas, Klebsiella sp., E. coli
- Aspiration pneumonia (anaerobes)
-5% mortality
Pneumonia: Hospitalized Patients (Group 3)
- S. pneumonia
- Pseudomonas, Klebsiella
- Aspiration pneumonia (anaerobes)
- *Staph. Aureus
-5-20% mortality
Severe Pneumonia- ICU (Group 4)
- S. pneumonia
- Klebsiella, Pseudomonas (E. coli?)
- Staph. Aureus *(MRSA)
- *Legionella
- *Unusual pathogen (Pneumocystis) in unsuspected HIV
-25-30% mortality
Pneumonia in Immuno-Suppressed patient
- Bacterial Pathogen
- Pseudomonas, Nocardia
- Fungal: Coccidioidomycosis, Aspergillus
- Mycobacterial: TB, atypical mycobacteria
- Viral: CMV
- Protozoal: Pneumocystis
Pneumonia treatment & symptoms: severely ill patient
At risk patients for SEVERE pneumonia: -w/ Lung disease (COPD, asthma, ILD) -*history of alcohol/drug abuse -*Immunocompromised (-*Older age & ↑ *risk of aspiration) * are normal predisposing factors)
-Ceftriaxone w/ Levofloxacin (quinolone)
SIGNS:
- Hypoxemia (SaO2 < 92%)
- Hypotension
- Tachycardia
- Altered mental status: obtundation or confusion
Pneumonia treatment: immuno-suppressed patient
-brochoscopy w. lavage to look for atypical pathogens
Pneumonia treatment: usual outpatient
- Mild symptoms:
- -Azithromycin (empiric macrolide)
- Moderate symptoms
- -Levofloxacin (quinolone)
- Severe: Ceftriaxone w/ Levofloxacin
- Nutrition very important
Coccidioidomycosis
- presents as community acquired
- dust exposure
- causes cavity in lung
- sever constitutional symptoms
- blood test can indicated recent infection
- Eosinophilia w/ pneumonia
- Fluconazole
- Amphotericin B (sever cases)
Treatment of Latent TB
- Isoniazid w/ vit. B6 for 9 months (first line drug)
- -caution w/ liver disease/ alcohol use
- -impairs B6 absorption
- Rifampin for 4 months
- -potentially hepatotoxic
-MONITOR LFT
Treatment of Active TB
For 2 months: -Isoniazide w/ B6 \+Rifampin \+Pyrazinamide \+Ethambutol
then Isoniazid & Rifampin for 4 months
-MONITOR LFT
3 primary presentation of PE
1) Pleuritic pain or hemoptysis
2) Isolated dyspnea
3) Circulatory collapse
-Dyspnea not present in 1/4 of cases
Major risk factors of PE
- Recent surgery
- trauma to LE
- cancer
- prior history of DVT or PE
- -stasis
- -smoking
- -coagulopathy
- -hormone replacement therapy
Treatment of PE
Initial therapy: Heparin
Long term therapy: Warfarin
–1st episode → 6 months
–2nd episode → lifelong
5 mechanism of reduced oxygenation
1) V/Q inequality (↓ ventilation or perfusion)
2) Shunt (V/Q = O b/c ventilation = O)
3) Hypoventilation (causes ↑ CO2 which displaces O2)
- -advanced COPD/Asthma, ALS, Parkinsons
4) Diffusion defect: thick alveolus
- -Interstitial lung disease
5) ↓ oxygen in inspired air (FIO2): altitude effect
PaO2 → measures OXYGENATION
paCO2 → measure VENTILATION
–directly proportional
Obstructive lung disease PFTs
Spirometry:
- low FEV1/FVC (<0.7)
- -**asthma shows improvement w/ bronchodilator
Lung Volumes: (TLC)
- -HIGH in emphysema
- -Normal / slightly elevated: chronic bronchitis & asthma
Diffusing Capacity: (DLCO)
- **LOW in emphysema
- Normal in chronic bronchitis & asthma
Restrictive lung disease PFTs
Spirometry:
-normal or increased FEV1/FVC
Lung volumes: (TLC)
-DECREASED
Diffusing Capacity: (DLCO)
-usually decreased (IPF)
Asthma
FEV1/FVC < .70
- FEV1 **(improves w/ dilator)
- TLC & DLCO normal
Airway *BRONCHOSPASM & INFLAMMATION
- Inflammation→ ↑ responsiveness→ *spasm→ symptoms
- Bronchospasm: triggered & usually worse at night
Symptoms: (worse at night & awakening)
- episodic shortness of breath
- wheezing (↓ breath sounds on exam)
- sensitive to specific triggers
- signs of sinusitis/rhinitis
Made worse by:
-β-Blockers, Aspirin, IV contrast
Poor control:
- rescue meds 2x/week
- nighttime awakening due to breathing 2x/month
Asthma treatment
- Mild → avoid triggers
- Short-acting inhaler as needed
- Inhaled corticosteroids / long-acting bronchodilator
- Leukotriene receptor antagonist
- Anti-IgE therapy, oral steroids
COPD drug therapy
BRONCHODILATORS
- Short acting
- -β2-agonist: Albuterol
- -Anti-ACh: Ipra-tropium, Oxi-tropium* (not in US)
- Long acting
- -β2-agoinist: Salmeterol, Formoterol
- -Anti-ACh: Tio-tropium
- -Theophylline (Methylxantine)
ANTI-INFLAMMATORY
-Inhaled steroids: Fluticasone & Budesonide
(Bronchodilators → O2 therapy → Exercise training)
Factors Increasing preoperative pulmonary risk
- Obesity (obstructive sleep apnea)
- Cigarette smoking w/in 8 wks of surgery
- Productive cough w/in 5 days of surgery
- Diffuse wheezing w/in 5 days of surgery
- -current URI
- FEV1/FV 45 mmHg (↓ ventilation)
- Age >70yrs
- poor general health
Known Causes off ILD
DRUGS
- chemotherapeutic agents (years later)
- Amiodarone (cardiac patients)
- Methotrexate (arthritis patients)
- Nitrofurantoin (UTI)
DUSTS/OCCUPATIONAL
- asbestos (construction, military, ships)
- silica (miners, metal/glass worker, sand-blasting)
HYPERSENSITIVITY:
- moldy hay, cotton dust, sugar cane (Agriculture)
- Birds (Animals)
- moldy humidifier/hot tub (others)
ARDS
CAUSES:
-Direct lung injury: severe pneumonia, gastric aspiration, smoke inhalation, lung contusion
-Systemic Injury: Shock/Trauma, sepsis, drug OD, pancreatitis, burn injury
↑ permeability of alveoli → fill w/ fluid → collapse → SHUNT (V = O)
Characteristic feature:
-Low oxygen that does NOT respond to supplemental O2. (A-a gradient >200)
Treatment:
- Endotracheal tube, mask
- Positive Pressure throughout ventilation
- Positive end-expiratory pressure:
- -opens alveoli, ↓ shunt
- -low lung volumes to prevent over-expansion
Death usually related to infectious complications
-High PEEP may complicate; pneumothorax w/ atelectasis
Causes of Hypercapnic Respiratory Failure
- Advanced COPD → respiratory muscles fatigue
- Sever asthma → Status asthmaticus
- Neuromuscular disease
- Hypoventilation → traume, stroke, drug-effect, over sedation
Most common sites of Lung cancer & Mesothelioma metastasis
LUNG CANCER
- Bone
- Brain
- Liver
- Adrenal glands
(TB: Brain, bone, kidney)
MESOTHELIOMA
- lungs
- breast
- colon
- kidney
- Melanoma
