Lecture 2: Pulmonary Infections Flashcards
Egophony
E –> A on auscultation due to solids. “Solids transmit sound better”
Bronchophony
Ask the patient to say “99” several times while auscultating the chest walls. Over consolidated areas “99” is understandable. This is because acoustic filtering is reduced in consolidated lung tissue, which allows better sound transmission.
Tactile Fremitis
tactile fremitus is a vibration that you can feel with the palm of your hands when someone says “blue moon” or “99”. increased fremitus is a sign of consolidation. decreased fremitus is a sign of pneumothorax or pleural effusion
Hemoptysis is usually this condition
viral bronchitis, due to irritation of airways producing hemoptysis
Conditions leading to solids in lungs
Pneumonia, abscess, blood, mass
Conditions causing hyperresonant
Empysema, COPD, pneumothorax, asthma attack
Pleuritic pain
Process involving the pleura leading to pain
Normal lung sounds
Resonant on percussion, Vesicular on periphery, No adventitious breath sounds, Symmetric tactile fremitus
Hypoinflation pulmonary findings
Bronchial sounds on periphery, Dull on percussion, Increased Tactile Fremitus, Egophony, Whispered pectoriloquoy, Rhonchi, crackles
Hyperinflation pulmonary findings
Hyper-resonant on percussion, decreased tactile fremitus, adventitious sounds like wheezing (asthma is hyperinflation)
CAP physical exam
fever, cough, sputum. If elderly may just be confused, lethargic, loss of appetite
TB physical exam
night sweats, fatigue, usually an immigrant/prisoner/HIV+
Bronchitis physical exam
normal
Pertussis physical exam
prolonged cough, coughing spells/paroxysms
Legionella physical exam
gram - bacteria, likes dirty water, cannot be passed person to person, AC units, hot tubs, epidemic needs to be reported. SOB, fever, cough, N/V/D, ask for travel history
PE physical exam
sudden, hypoxic, blood, NO fever
Pneumonia unlikely if
< 60 y/o with normal VS, normal physical exam, no comorbid conditions
Most common cause of pneumonia
Strep pneumoniae
Best initial test for pneumonia
Chest XRay – radiographic diagnosis. Will show infiltrates. If no infiltrates then it is not pneumonia, or too early to dx.
Why is a sputum stain and culture inappropriate to order in a r/o pneumonia case?
Only positive in 50% of patients (atypical bacteria cannot be stained – mycoplasma, chlamydia, legionella) You can obtain this in a hospitalized patient.
Why is a blood culture inappropriate to order in pneumonia?
Only 5% have invasive disease – pneumonia is not invasive
What will a CBC show with pneumonia?
Increased neutrophils/Polymorphic nuclear/bands –> all means bacteria. If viral –> + lymphocytes. Nonspecific.
Dehydration may cause this
A negative xray despite having pneumonia, why – it increases antidiuretic hormone leading to water reabsorption and a dilated Na
Negative Chest XRay but high suspicion of pneumonia then
Need a Chest CT Scan - will show a greater definition of abnormalities
BUN/Cr
Obtain only in a hospitalized patient to determine severity
When to admit to the hospital w pneumonia
Next step after dx is to assess for severity… SOB, confusion, hypotension, not perfusing, hyponatremia?
CURB-65
0-1 Go home, 2-4 go to hospital. Confusion. Uremia (BUN > 19) Resp distress (>30) BP low (systolic < 90), >65
CAP mgmt if no comorbidities, no previous antibiotics
Macrolides (azithromycin, clarithromycin, erythromycin) OR Doxy x 5 days ( can lead to QT prolongation) Do not stop until afebrile for 48 hours
CAP mgmt if comorbidities, treated with abx in 3 months
Respiratory FQ (levafloxacin 750mg. moxifloxacin, gemifloxacin) OR Beta-Lactam (high dose amox, augmentin, cefuroxime PLUS Macrolide
At intermediate risk for pneumonia get this vax
PPSV 23 those who are younger than 65 w/ these conditions: cigarettes, chronic heart disease, chronic lung disease, asthma, DM, chronic liver disease, alcoholism
At high risk for pneumonia get this vax
PCV 13 followed by PPSV23 > 65 with immunocompromise HIV, cancer, anatomic asplenia, CSF leak
Mycobacterium tuberculosis
aerobe, slow growing bacilli, inhaled through droplets. 3/100,000 people in the US get TB. Majority in foreign born individuals.
Who are at increased risk for contracting TB?
Recent < 5 years from developing countries. HIV+. Prisoners. Homeless. IV Drug users. Healthcare workers. Impaired cell immunity - DM, organ transplant, cancer
95% of people with TB have
Contained not infectious, but infected
5-10% Have
active disease –> transmission
Reactivation risk
10% in a lifetime
Latent TB granulomas can break and spread to
bones, brain, kidney, liver, lungs – from stress on immune system leading to reactivation
TB spread through
droplet like sneezing coming from the lungs
Best initial test to dx TB?
CXR is suggestive not diagnostic of TB
xray is + plus s/s of TB you need to do this
isolate, then get a sputum gram acid fast
sputum acid fast stain
not very sensttive or specific makes a PRESUMED dx and reflects high infectivity, initiate tx pending culture
sputum culture
gold standard, takes 4-6 weeks required for CONFIRMATION of TB and for drug suseptibility
PPD
Screening of asymptomatic individuals at risk only, not to diagnose
Treatment for TB
Need tx for 6 months. Isolate until 3 negaqtive acid fast cultures as it flares intermittently and can be missed on one. RIPE. Rifampin. Isoniazid. Pyraazinamide. Ethambutol –> all are hepatotoxic
Rifampin (RIF)
=R, Red color of body secretions
Isoniazid (INH)
=N neuro, peripheral neuropathy (give pyridoxine, B6)
Pyrazinamide (PZA)
hepatotoxic
ETM Ethambutol
e= eye, Optic neuritis/color vision
Who needs a PPD
Asympomatic at risk patients for latent TB. Immigrants (5 years recent), immunosuppressed, prisoners, health care workers, homeless, nursing home, alcoholics, close contact w tb patient
When is the PPD + at > 5mm
hiv, organ transplant, steroid users, close contact with an active tb patient
PPD+ at > 10mm
recent immigrants, prisoners, healthcare workers, homeless, nursing home, alcoholiics
> 15mm
no risk factors
+PPD next step?
CXR to confirm or r/o TB
+PPD and -XRay
dormant/latent TB –> treat brings risk from 10% to 1% to reactivate
+PPD and +Xray
active TB
dorment/latent TB treatment
Only INH for 9 months (esp if converted from negative to positive within 2 years) No need to repeat PPD in those with a positive PPD.
tb gold IGRA is indicated when
exposed to TB. Measures the bodys response to TB instead of a intradermal PPD this is blood work and can only determine exposure not active v latent. If + then CXRay to determine active or latent
PPD
Skin test, 2 visits, may cross react with BCG
IGRA TB Gold
Blood, one visit, Specific, no cross rxn w BCG, Not for kids < 5
