HYHO URI + Pneumonia

Question 1

What is the classic cough pattern?

Answer 1

deep inspiration –>

attempted expiration against a closed glottis that suddenly opens –>

forceful exhalation of air, secretions, foreign debris

Question 2

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

Answer 2

Upper Airway Cough Syndrome

(includes allergic rhinitis, bacterial sinusitis)

Question 3

What is the most sensitive/specific test for GERD?

Answer 3

24 hr esophageal pH monitoring*

first line tx of GERD: 4 wk trial of PPI (dx and tx)

*not required to make dx

Question 4

When is an endoscopy useful for GERD?

Answer 4

no improvement on PPIs for 4 wk duration

Question 5

Pt reports they have a productive cough with green colored sputum. Should you be thinking bacterial or viral based on their presentation?

Answer 5

not enough info yet –> color of sputum is not diagnostic of presence of bacterial infection

Question 6

Should we give ABs with acute bronchitis?

Answer 6

they don’t provide major clinical benefit, and are not recommended routinely

only recommended for at risk pts, when clinical suspicion of CAP is high, or suspected B pertussis, mycoplasma or chlamydia infection

Question 7

when should you suspect bacterial URI?

Answer 7

after 7 days in an adult, 10 days in a kid

Question 8

What organisms are most commonly responsible for acute bacterial sinusitis?

Answer 8

adults: S pneumoniae and H. influenza
children: H. inf. and Moraxella catarrhalis

Question 9

The majority of pharyngitis cases are?

Answer 9

viral

Question 10

Modified CENTOR Criteria

Answer 10

• A guideline for diagnosing GAS without performing rapid Strep or throat culture.
• 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 is added if patient is b/t 3 and 14
• One point is deducted if patient is age 45+
• 0-1 points: recommend no further testing and no antibiotic indicated
• 2-3 points: perform rapid strep or throat culture and treat with antibiotic if positive
• 4+: consider empiric antibiotic treatment

Question 11

Pt. presents with acute cough <3 wks +/- sputum, what is your next move?

Answer 11

Question 12

What diagnostic testing is used to dx pneumonia?

Answer 12

• Leukocytosis with leftward shift or leukopenia.
• Elevated inflammatory markers (ESR, CRP, and procalcitonin).
• CXR
• CT (may be considered for immunocompromised patients)

Question 13

What lab abnormalities are seen with s. pneumoniae infections? how do we tx?

Answer 13

a. elevated LFT’s, hyponatremia, leukocytosis
b. penicillin, macrolides, fluoroquinolones

Question 14

What organism may cause empyema?

Answer 14

s. auerus

CA-MRSA

Question 15

If a pt presents with hx of ab use in the past 3 mo, and sx of pneumonia, what should you be worried about?

Answer 15

MRSA

also worry if hx includes recent hospitalization or IC staus

Question 16

What hx should indicate CA-MRSA?

Answer 16

Younger, healthier persons with h/o skin/soft tissue infections, contact sports, IV/IM drug use, crowded living conditions, men who have sex with men

can be assoc with: necrotizing and/or cavitary pneumonia, empyema, gross hemoptysis, septic shock, respiratory failure

Question 17

current jelly hemoptysis + alcoholic makes you think…

Answer 17

Klebsiella

Question 18

What typical cause of pneumonia is not a CAP?

Answer 18

Pseudomonas

risk in: ill pts, CF, elderly, hospitalized, ab use, severe COPD

Question 19

What pts get H. influenza?

Answer 19

elderly

sickle cell

IC

splenectomy

kids

*moraxella catarrhalis is similar, but typically indolent course

Question 20

What organisms cause atypical pneumonia?

Answer 20

legionella (GI sx, hyponatremia)

chlamydophilia (mimic legionella on CXR, but no GI sx)

mycoplasma (“no GI sx, walking pneumonia”, neuro sx)

viruses (most likely to cause pandemic)

Question 21

How do we tx pneumonia?

Answer 21

1. CAP uncomplicated outpatient tx:
   
   1. macrolide (azithromycin or clarithromycin)
   2. OR tetracycline (doxycycline)
2. CAP outpatient tx in patients with significant comorbidities/failed first-line treatment:
   
   1. macrolide + penicillin/lactamas
   2. OR fluoroquinolone (levofloxacin or moxifloxacin)

Question 22

What is CURB-65?

Answer 22

Confusion

Uremia > 7

Respiratory rate > 30

Blood pressure < 90 systolic or < 60 diastolic

age > 65

Question 23

How do we prevent CAP?

Answer 23

1. smoking cessation
2. influenza vaccination for all pts
3. pneumococcal vaccination for at risk pts

Question 24

What are the three goals of OMT in pneumonia pts?

Answer 24

1. Reduced parenchymal lung congestion
2. Reduced sympathetic hyper-reactivity to the parenchyma
3. Increased mechanical thoracic cage and diaphragmatic motion

Question 25

PNS, SNS, Motor levels utilized in pneumonia pts

Answer 25

• PNS - OA, AA, C2
  
  • inc tone –> thinning of secretions and relative bronchiole constriction
• SNS - T2-7
  
  • inc tone –> thickened secretions and bronchiole dilation
• Motor - C3-5
  
  • irritation caused by decreased excursion and overuse

Question 26

Chapman’s Pts for the Lungs

Answer 26