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PCM EXAM II Somi > HYHO SPE 3-2 URI and Pneumonia > Flashcards

HYHO SPE 3-2 URI and Pneumonia Flashcards

1
Q

Physical exam findings of URI/pneumonia

A
    • inc work of breathing (retractions)
    • adventitious breath sounds (crackles, rhonchi, wheezing)
    • positive special testing (tactile fremitus, egophony, dullness to percussion, bronchophony)
    • hypoxemia
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2
Q

Differential diagnosis of noninfectious causes of cough (x9)

A
  1. Upper Airway Cough Syndrome (UACS)
    - - most common cause of chronic cough in HEALTHY, NON-SMOKERS with a normal CXR
  2. Asthma/COPD
    - - second most common cause of chronic cough
  3. Gastroesophageal reflux (GERD)
  4. Postnasal drip
  5. Medication side effect (e.g. ACE inhibitors)
  6. Congestive Heart Failure (CHF)
  7. Malignancy
  8. Smoking
  9. Pollution
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3
Q

What is the most sensitive and specific test for diagnosis of reflux disease (i.e. GERD)

A

24-hour esophageal pH monitoring

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4
Q

What is the most common cause of a chronic cough in healthy, nonsmokers with a normal CXR?

A

Upper airway cough syndrome (UACS)

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5
Q

First line of treatment for GERD

A

4 week trial of PPI (proton pump inhibitor) – is both diagnostic and therapeutic

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6
Q

Differential diagnosis of infectious causes of cough and congestion (x6)

A
  1. Common cold/URI/Viral syndrome
  2. Pharyngitis
  3. Sinusitis
  4. Bronchitis
  5. Influenza
  6. Pneumonia
    a) CAP (community-acquired pneumonia)
    b) Aspiration pneumonia
    c) TB
    d) Opportunistic organisms (e.g. PCP = pneumocystis pneumonia)
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7
Q

Most common etiology of URI is?

A

Viral – influenza, parainfluenza, adenovirus, coronavirus, rhinovirus

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8
Q

Bacterial causes of URI?

A
  1. Mycoplasma pneumoniae
  2. Chlamydia pneumoniae
  3. Bordetella pertussis
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9
Q

What are the two phases of URI?

A
  1. Initial Phase – cough and systemic symptoms secondary to infection/inflammation; fever absent or low grade
  2. Protracted phase – evidence of reactive airway disease in patient’s w/o prior pulmonary disease; in some patients, cough persists secondary to bronchial hyperresponsiveness and lasts >/= 2-4 weeks
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10
Q

Things to monitor/take into consideration during a physical exam for URI

A
  1. Monitor for abnormal vitals (e.g. fever, BP, tachycardia, tachypnea)
  2. Consider high risk patients (e.g. hx of heart or lung dz, severity of symptoms, low oxygen sat on pulse ox)
  3. Lung findings (e.g. rales, rhonchi, wheezes)
    * * in most cases PE is unremarkable and often normal**
  4. Conjunctivitis and adenopathy suggest adenovirus infection (this finding is not specific)
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11
Q

Is the color of the suptum diagnostic of a bacterial URI?

A

NO! Color of sputum is NOT diagnostic of the presence of a bacterial infection

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12
Q

For treatment of bronchitis do you use antibiotics? If so, in what circumstances?

A

Antibiotics are NOT recommended routinely.

Use only in high risk patients (those with heart, lung, kidney disease or immunosuppression)

or when suspicion for CAP is high despite normal CXR

or in suspected cases of B pertussis, Mycoplasma, or Chlamydia infection

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13
Q

What condition presents with inflammation/infection of nasal mucosa and of one or more paranasal sinuses?

A

Rhinosinusitis

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14
Q

Sinusitis can be subdivided into acute, subacute, and chronic. What are the durations of each?

A

Acute: s/s lasting < 4 wks
Subacute: s/s lasting 4 - 12 wks
Chronic: s/s lasting > 12 wks

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15
Q

Definition of recurrent acute rhinosinusitis

A

4 or more episodes of acute rhinosinusitis per year with interim resolution of symptoms

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16
Q

Most viral URI’s improve in 7-10 days. If symptoms don’t improve, what should you consider?

A

Consider case of BACTERIAL rhinosinusitis after 7 days in adults, and 10 days in children

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17
Q

Most common organisms causing acute bacterial sinusitis in adults vs children

A

Adults: S. pneumoniae & H. influenza
Children: Moraxella catarrhalis & H. influenza

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18
Q

Criteria for diagnosis of Rhinosinusitis

A
  1. Presence of purulent nasal discharge
  2. Maxillary dental or facial pain
  3. Unilateral maxiallary sinus tenderness
  4. Worsening symptoms after initial improvement
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19
Q

First-line treatment for rhinosinusitis

A

Amoxicillin & trimethoprim-sulfamethoxazole

10 -1 4 days

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20
Q

Second-line treatment for rhinosinusitis

A

– use of initial treatment fails or if patient has severe, recurrent disease

Treatments include:
– Amoxillin-clavulanic acid

– 2nd or 3rd-generation cephalosporins (cefuroxime, cefaclor, cefprozil)

– fluoroquinolones or 2nd-gen macrolides (clarithromycin, azithromycin)

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21
Q

In suspected cases of pharyngitis, what must be ruled out?

A

R/O more severe causes of throat pain (e.g., epiglottis, retropharyngeal abscess, paritonsillar abscess, and group A beta hemolytic strep (GAS)

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22
Q

Incidence of pharyngitis is most common in what populations? What is the etiology in these groups?

A

Most common in PEDIATRIC populations (peak between 4 - 7 years)

30% of all pediatric cases d/t GAS (group A strep)

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23
Q

Modified CENTOR criteria for diagnosis of GAS without performing rapid strep test or throat culture

A

A point is given for each of the following criteria:

    • absence of cough
    • enlarged/tender anterior cervical adenopathy
    • fever of 100.4 F or higher
    • tonsillar swelling/exudates
    • one additional point added if patient is btwn 3 - 14 yo or one point is deducted if pt is age 45 or older

0-1 points = recommend no further testing and NO antibiotic indicated

2-3 points = perform rapid strep or throat culture and treat w/ Abs if positive

4 or more points = consider empiric antibiotic treatment

24
Q

What is the gold standard for diagnosing GAS?

A

~Throat culture~

diagnosis can also be made by rapid antigen testing (rapid Strep)

25
Q

What is the treatment of choice for GAS pharyngitis? What if the patient has an allergy to this treatment?

A

Penicillin is antibiotic of choice for GAST pharyngitis (10 day course of penicillin V or intramuscular pen G benzathine)

If pt has penicillin allergy –> can treat w/ cephalasporins and macrolides

26
Q

What condition is part of a DDx of nearly all respiratory illnesses?

A

Community acquired pneumonia (CAP)

27
Q

Define CAP

A

Community-acquired pneumonia –> acute infection of pulmonary parenchyma OUTSIDE of health care setting (e.g. nursing home, hemodialysis centers, recently hospitalized)

28
Q

Define nosocomial pneumonia

A

Nosocomial pneumonia –> acute infection of the pulmonary parenchyma acquired INSIDE health care setting (hospital-acquired pneumonia [HAP], and ventilator-associated pneumonia [VAP])

29
Q

Criteria for HAP and VAP

A

HAP (hospital-acquired penumonia) = pneumonia acquired > 48 hours after hospital admission

VAP (ventilator-associated pneumonia) = acquired > 48 hours after endotracheal intubation

30
Q

Most common pathogens causing CAP

A
  1. S. pneumoniae

2. Legionella

31
Q

Diagnostic markers for CAP (x4)

A
  1. Leukocytosis w/leftward shift or leukopenia
  2. Elevated inflammatory markers (ESR, CRP, procalcitonin)
  3. Chest imaging (presence of infiltrate)
  4. CT for immunocompromised patients (they can’t mount a typical inflammatory response and thus have a negative chest x-ray)
32
Q

DDxs (non-infectious illnesses that mimic CAP or co-occur and present with pulmonary infiltrate and cough)

A
  1. CHF w/pulmonary edema
  2. Pulmonary emoblism
  3. Pulmonary hemorrhage
  4. Atelectasis
  5. Aspiration or chemical pneumonitis
  6. Drug reactions
  7. Lung cancer
  8. Collagen vascular diseases
  9. Vasculitis
  10. Acute exacerbations of bronchiectasis
  11. Interstitial lung diseases (e.g., sarcoidosis, asbestosis, hypersensitivity pneumonitis, cryptogenic organizing pneumonia)
33
Q

Streptococcus pneumonia – typical organism causing pneumonia

    • Who does it target
    • S/S
    • Classic lab abnormalities
    • Medications
A

Who: classically targets elderly, young, and immunocompromised people (e.g., HIV, Sickle cell, transplant recipient)

S/S: sudden on set of rigors, sputum, pain, fevers, and classic lobar infiltrates

Labs: elevated LFTs, hyponatremia, leukocytosis

Meds: responds to penicillins, macrolides, and fluoroquinolones to varying degrees

34
Q

What bacterial pneumonia-causing agent may cause empyema and extensive infiltrates on CXR?

A

Staph aureus

35
Q

What bacterial pneumonia-causing agent is related to recent antibiotic use (esp. fluoroquinolones) w/in past 3 months; recent hospitalization and immunosuppression

A

Methicillin resistant staph aureus (MRSA)

36
Q

What bacterial pneumonia-causing agent presents with the following characteristics:

    • affects younger, healthier persons, men who have sex with men, in crowded living conditions,
    • patients have hx of skin/soft tissue infections
    • IV/IM drug users
    • those who play contact sports
    • can be severe, assoc w/ necrotizing & cavitary pneumonia, empyema, gross hemoptysis, spetic shock, and resp failure
A

Community acquired methicillin resistant staph aureus (CA-MRSA)

37
Q

What bacterial pneumonia-causing agent has the following characteristics:

    • classically in alcoholics and aspiration
    • lobar infiltrates, rigors, abscess
A

Klebsiella

** currant jelly hemoptysis is KEY

38
Q

What bacterial pneumonia-causing agent has the following characteristics:

    • ill patients, CF, elderly, recently hospitalized, assoc w/antibiotic use, severe COPD
    • causes severe disease, multiple infiltrates, systemic illness (cyanotic, confused, fever)
    • NOT a CAP
    • antibiotic resistance is common
A

Pseudomonas

39
Q

What bacterial pneumonia-causing agent has the following characteristics:

    • elderly, sickle cell, immunocompromised, splenectomy
    • are in children (d/t HIB vaccine)
    • chest pain, effusions, multilobar disease
A

Haemophilus influenza

40
Q

What bacterial pneumonia-causing agent has the following characteristics:

    • similar to H. inf
    • typically indolent course w/cough, prod sputum, pleuritic CP w/infiltrate usually diffuse on CXR
A

Moraxella catarrhalis

41
Q

What are the four main agents causing atypical pneumonias

A
  1. Legionella
  2. Chlamydophilia
  3. Mycoplasma
  4. Viruses
42
Q

Characteristics of legionella caused atypical pneumonia

    • who does it affect
    • s/s
    • when does it occur
    • associated conditions
    • CXR finding
A

Who: elderly, smokers, immunosuppressed

S/S: GI symptoms, hyponatremia, broad spectrum pulm symptoms

When does it occur: commonly seen throughout year, some decrease in summer

Associated conditions: “itis” (e.g., sinusitis, pancreatitis, myocarditis, pyelonephritis)

CXR findings: patchy infiltrate, hilar adenopathy, pleural effusions

43
Q

Big difference between legionella and chlamydophilia caused atypical pneumonias

A

Chlamydophilia may mimic legionella on CXR but does NOT have GI symptoms

Also chlamydophilia causes a milder illness, sore throat, fever, np cough, rhonchi/rales

44
Q

What atypical pneumonia-causing agent has the following characteristics:

    • “walking pneumonia”, sore throat, headache
    • occurs in cycles (every 4-8 years)
    • lacks GI symptoms
    • rashes, neuro symptoms, arthralgias
    • chest pain, bullous myringitis
A

Mycoplasma

45
Q

Treatment of CAP uncomplicated outpatient

A

Macrolide (azithromycin or clarithromycin)

OR

Tetracycline (doxycycline)

46
Q

Treatment of CAP outpatient in pts with significant comorbidities/failed first-line treatment

A

Macrolide + Penicillin/lactamase

OR

Fluoroquinolone (levofloxacin or moxifloxacin)

47
Q

What is a PSI/PORT score

A

Pneumonia Severity Index (PSI) assigns patients to 5 risk categories based upon age and mesurable derangements with:

groups 1-3 = outpatient candidates
groups 4-5 = inpatients (generally ICU)

48
Q

What is CURB-65

A

score for pneumonia severity that measures

Confusion
Uremia > 7 
Respiratory rate > 30
Blood pressure < 90 systolic or < 60 diastolic 
Age > 65
49
Q

Three primary pillars for prevention of CAP

A
  1. Smoking cessation
  2. Influenza vaccination for all patients
  3. Pneumococcal vaccination for at risk patients
50
Q

Three main goals for manipulative treatment in pneumonia

A
  1. Reduce parenchymal lung congestion
  2. Reduce sympathetic hyper-reactivity to the parenchyma of the lung
  3. Increase mechanical thoracic cage and diaphragmatic motion
51
Q

What are the respiratory system affects of increased parasympathetic tone (think about secretions and bronchioles)

A

Parasympathetics (OA, AA, C2)

Increased tone = thinning of secretions and relative bronchiole constriction

52
Q

What are the respiratory system affects of increased sympathetic tone (think about secretions and bronchioles)

A

Sympathetics (T2 - T 7)

Increased tone = thickened secretions and bronchiole dilation

53
Q

Chapman’s points for bronchi

A

Anterior: Intercostal space between 2nd & 3rd ribs at sternocostal junction

Posterior: T2 midway between SP & tip of TP

54
Q

Chapman’s points for upper lungs

A

Anterior: Intercostal space btwn 3rd & 4th ribs at sternocostal junction

Posterior: Space btwn TPs of T3 & T4, midway btwn the SP & tip of the TP

55
Q

Chapman’s points for lower lungs

A

Anterior: intercostal space btwn 4th & 5th ribs at sternocostal junction

Posterior: space btwn TPs of T4 & T5, midway btwn SP & tip of TP

PCM EXAM II Somi (3 decks)

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