General adult internal med Flashcards
bronchodilator responsiveness defn
[NEJM resp medicine today Apr 2024]
10+ % increased FEV1 or FVC
within 10-15 mins rapid acting bronchodilator
asthma vs copd for bronchodilator responsiveness
No difference in large cohort study
Short-acting bronchodilator respons does not predict response to LONG-acting B-D
resp pathogens causing CAP
name at least 3 in:
gram pos
gram neg
atypical
Gram pos:
- Strep pneumo
- MSSA
- Strep pyogenes
- other strep
Gram neg
- H influenzae
- Moraxella catarrhalis
- ENTERO-bacteriaceae (Klebsiella pneumoniae, E coli)
Atypical
- Legionella pneumophila
- Mycoplasma
- Chlamydophila
- Q fever
how to bacteria cause CAP
microaspirations esp during sleep
inhalation (eg of particles)
why are ‘typical’ and ‘atypical’ terms not encouraged when describing pneumonia
clinical exam and/or xr are NOT sens or spec for determining cause
…but they say later in article to consider micro testing if clinical features consistent…
ddx for non-resolving pneumonia
- complication eg empyema
- underlying bronchogenic carcinoma (with airway obstruction)
- non-covered organism (eg TB)
- inflammatory pneumonia (eg vasculitis, organising pneumonia)
amoxy vs macrolide in CAP
strep pneumo - increasingly resistant to macrolides, so use amoxy
for atypicals, macrolide effective, and almost as common as typicals
still just use amoxy
CAP in older adults is associated with what
CVD. check lipids, BP, etc
which CXR get 6 week follow up in pneumonia
those that had abnormalities. for ?ca.
if abnormal or persisting, refer
asthma rx safe to use in pregnancy?
pretty much all of them
salbutamol - A
Ipra - B1
Salmeterol - B3 (but benefits > risks)
risk of not -> preterm, LBW, congenital malformations
public health factors that have contributed to reduction in bronchiectasis prevalence
childhood vaccines
improved living conditions
abx
…still common in underserved & migrant communities
pathophys of bronchiectasis
infection/inflammation –> neuts, macroph, lymps attacking elastin and lung structures -> dilation of bronchi
mucosa + muscular walls replaced by scarring and oedema, weaker cartilage, and cilial clearance weakened
self perpetuating cycle: recurrent infection, mucus, colonisation airway damage
screening tests for cause of non-CF bronchiectasis
FBC, immunoglob levels (M, A, G), Aspergillus serology, Aspergillus specific IgE testing
Consider
- HIV, HTLV1
- Vit D (correlates disease severity)
- alpha-1 anti-trypsin
- autoimmune serology (ACCP, RF, ANA, ENA, ANCA)
If young + upperlobe predominant disease, sweat testing
triad sx bronchiectasis
SOB
sputum
cough
also includes: haemoptysis, chest pain, wheeze, indigestions, recurrent chest infx
% idiopathic bronchiectasis
~ 50%
but probably they have some underlying immune defect we can’t test
why send sputum mcs in bronchiect
check colonisers. includes M avium and M abscessus - need 3 for these.
further ix is fungal + mycobacterial culture
can do yearly
most common PFT pattern in bronchiect
obstructive > 50%
can help if concurrent bronchodilator/COPD/asthma present.
do at baseline, don’t need to rpt yrly unless specialist OPD
what specialist tests can be considered for bronchiect
bronchscopy - sputum samples, check for tumours/other endobronchial obstruction, opportunisitic infections in a pt who can’t cough up
extended PFTs, other genetic disorder testing (sweat tests, ciliary dyskinesia)
CPPD stands for?
calcium pyro phosphate disease
when to suspect CPPD - over what age?
> 55 yrs PLUS syndromes
when to suspect CPPD - what syndromes in > 55 yrs
- sub/acute arthritis attacks, esp KNEE
- arthritis like RA or OA, but atypical features
- CPPD on XR (chondrocalcinosis, etc)
- severe acute or recurrent axial neck pain, or neck/shoulder girdle stiffness
hence ddx PMR
how to dx CPPD
hard -
the calcium crystals on joint aspirate if you can
DECT = dual energy CT
USS if you can
XR - chrondrocalcinosis.
like to XR both knees, pelvix AP, wrists
potential triggers for CPPD
trauma
surgery
severe medical illness
how does CPPD differ in CF from gout
tends to affect knees & wrists more
lasts longer if untreated, 1-3 weeks (vs 1-2)
tends to be less fulminant in onset (gout max pain in 12 hrs, vs slower onset)
