PNA, Tuberculosis Flashcards
Most common cause of Typical PNA
Strep PNA
Atypical causes of PNA
Mycoplasma PNA, Chlamydophila PNA, Legionella, Viral
Sx of Typical PNA
Fever
Productive cough
Pleuritic CP
Dyspnea
Severe chills with violent shaking is assoc w: STREP PNA (the most common type)
Sx of Atypical PNA
low grade fever
dry cough
extrapulm sx: muscle ache, n/v/d, pharyngitis
H. influenza
Klebsiella
Staph aureus are all types of
Typical PNA
PE of Typical PNA (classic)
Tachypnea, tachycardic
Consolidation: bronchial breath sounds, dull to percussion, increased tactile fremitus, egophony, rales
PE of Atypical PNA
often normal!! may have crackles/rales
Keep in mind when taking PE of a Diabetic, Immunocomp, or old pt in which you suspect PNA
Physical exam may be normal
With an effusion, PNX, or obstructive pattern..
what will Fremitus and Breath sounds be like?
Decreased
H flu
Klebsiella
Staph
and STREP PNA
Typical PNA
Most common cause of CAP
Chills and violent Rigor
Blood rusty sputum
gram + diplococci
Strep PNA
Extremes of Age: SUPER YOUNG or SUPER OLD
immunocomp
underlying pulm dz
H. influenzae
Superimposed infection AFTER a VIRAL infection
or Hospital acquired
CXR: bilateral, multi-lobar, abscesses- cavitary lesions YIKES
Staph Aureus
Severe alcoholism
super sick pt, chronic illness- DM
Purple colored sputum!!! (currant jelly)
CXR cavitary lesions hallmark (not specific)
Klebsiella
Which two types of Typical PNA can show cavitary lesions on CXR?
Staph Aureus
Klebsiella
Most common cause of Atypical “walking” PNA
Mycoplasma PNA
what Pap had!!!
Mycoplasma PNA (atypical) sx
HA, fatigue, fever then —-> dry cough
Complication of Mycoplasma PNA
Cold Autoimmune hemolytic ANEMIA
Dx of Mycoplasma PNA
CXR: Reticulonodular, diffuse, patchy, interstitial infiltrates
PCR: cold agglutinins
Tx for PNA
Z pack most common- Azithromycin (a macrolide)
or
Doxy
Tx for PNA
Azithromycin “Z pack” or
Doxy
Legionella PNA
atypical
assoc with WATER sources
not spread person to person
fever, chills, sob, DRY cough, and GI SX !!! this is unique- watery diarrhea
other complications: Low NA, increased LFT, Neuro sx (HA, confusion)
Tx: Azithromycin or FluoroQ (Levofloxacin)
Legionella unique traits
Water
no person to person spread
GI SX!!- diarrhea
Hyponatremia, Liver fx test, Neuro sx
Treat with Azithro or FluoroQ (Levofloxacin)
What is the cutoff of someone going into hospital to determine if its Community Acquired “CAP” or Hospital Acquired?
CAP: outside of hospital or within 48 hrs
HAP: after 48 hrs of being in hospital
If hospital acquired, what are common organisms?
Pseudomonas and MRSA
Most common pathogens causing diff types of PNA
Typical: Strep
Atypical: Mycoplasma
Hospital: Pseudomonas, MRSA
Beta lactams
PCNS
Cephalosporins
Beta lactam used to treat PNA
Ceftriaxone (Rocephin)
Anti-pseudomonal beta lactams used to treat PNA
remember pseudomonas is a common cause of Hospital acquired PNA
Need Anti pseudomonal beta lactam
+
Aminoglycoside or FluoroQ
Example of tx for Hospital acquired PNA
with anti-pseudomonal coverage
Piperacillin/Tazobactam (anti-pseud beta lactam)
+
Levofloxacin (fluoroQ)
Anti-pseudomonal Beta lactams
Piperacillin/Tazobactam
Ceftazadime
Cefepime
Aminoglycosides
Amikacin
Gentamicin
Tobramycin
CURB65 criteria- when deciding whether to admit a PNA patient or not
Confusion Uremia >30 Resp rate >30 BP low, systolic <90 or diastolic <60 Age >65
If at least 2 are present, ADMIT!!!
Histoplasmosis (caused by oval yeast) tx
Itraconazole (mild-mod dz) or Amphotericin B (severe)
Pneumococcal vaccines
PCV13 and PPSV23
PCV13: part of 4 dose series–> 2, 4, 6, and 12 mo
PPSV23: all adults 65 and older, and younger pts with inc risk
If you are over the age of 65, which Pneumococcal vaccine should you receive?
PPSV23
SOB on exertion (and O2 sat drops)
Dry cough
Fever
Most common HIV opportunistic infection
PCP
Pneumocystis PNA
Tx of PCP
Bactrim x 21 days
if HIV+, can add Prednisone if pt is hypoxic
Primarily Rapidly progressive TB (tuberculosis)
often Children
Contagious
Clinical progression
Chronic- Latent infection
not contagious
Secondary Reactivation of TB
waning immune defenses
Old, HIV, Steroid use, CA
Localize in Apex/upper lobes with Cavitary lesions
CONTAGIOUS
Clinical sx of TB
cough, fever, night sweats, CP, HEMOPTYSIS
Extrapulm (can affect any organ): Scrofula (irritated and inflamed lymph nodes), Pott’s dz (Tb of spine, arthritis), pericarditis, adrenal gland
CXR of Primary TB
middle/lower lobe consolidation
CXR of Reactivated TB
upper lobe (apical) fibrocavitary dz
Tx of TB
“RIPE!”
Rifampin
Isoniazid
Pyrazinamide
Ethambutol for 2 months
followed by 4 mo continued Rifampin and Isoniazid
How long total is tx for Active TB?
6 months
2 mo with the 4 drugs
4 mo with the 2 drugs (Rifampin and Isoniazid)
What 2 drugs do you continue for the last four mo of TB treatment?
Rifampin
Isoniazid
Tx of Latent TB
Isoniazid and Pyridoxine x 9 months
SE of Rifampin
Orange colored secretions
Classic Primary TB on CXR
Lower lobe consolidation
Classic Reactivation TB on CXR
Infiltrates and cavitation in upper lobe/apices
Most common cause of Acute Bronchitis
VIRAL
Often ppl with Acute Viral Bronchitis
appear better than they feel
really feel like crap (cough, no fever, chest wall tender, wheezing, mild dyspnea)
When to get CXR if pt is coming in with Bronchitis like sx?
if any are present:
- fever
- tachy x2
- consolidation on chest exam
OR
cough >3 weeks
Symptomatic tx for Acute Viral Bronchitis
Hydrate and rest
- NSAIDs
- Ipratropium “Atrovent” (SAMA)
- Antitussive
- Albuterol inhaler
- OTC stuff like cough drops, hot tea, honey
Pertussis WHOOPING cough is an example of when Bronchitis is bacterial
URI 1-2 wks
WHOOP cough 2-6 wks, posttussive emesis
cough gradually resolves, up to 6 wks
Pertussis “whooping cough” tx is NOT TO IMPROVE PTS CONDITION, but rather decrease transmission
(make sure pt knows this)
Azithromycin “Z pack”
or
Bactrim
Complicated CAP
Beta lactam (Amox-Clav “Augmentin”)
+
Macrolide (Azithro “Z pack”)
OR
FluoroQ (Levofloxacin)
PCP tx
Bactrim
and Prophylaxis Bactrim recommended in HIV pts with CD4 count <200
Aspiration will likely be seen in what lobe?
Right LOWER lobe d/t leaking down from R main bronchus
Tx for Aspiration PNA
Piperacillin/Tazobactam
Lung Anatomy
Trachea Primary bronchi Secondary bronchi Tertiary bronchi Bronchioles
Solitary Pulmonary Nodule
Small <3 cm
“coin lesion”
most are benign, smooth, well defined edges
4 Main types of Lung CA
Small cell
-Oat cell
Non-small cell
- Adeno
- Squamous cell
- Large cell
Small cell Lung CA
“Oat cell”
Oat Cell is Highly Aggressive
Central airway
Large hilar mass with BULKY mediastinal adenopathy
cough, SOB, weight loss
HIGHLY AGGRESSIVE- often METS
Large hilar mass w bulky adenopathy
Compression on central airway
HIGHLY AGGRESSIVE
Small/ Oat cell
If Non-small cell Lung CA, what type is the most common?
Adenocarcinoma
Arise frm Mucous glands or any Epithelial cell in/distal to terminal bronchioles
Mets to distant organs
Squamous cell carcinoma
Central or Main bronchus
more likely to cause HEMOPTYSIS (bloody cough)
Mets to REGIONAL lymph nodes
can cavitate
Large cell lung CA
Mets to distant organs
AGGRESSIVE w rapid doubling times
CA a/w:
SVC syndrome and Paraneoplastic syndrome? (SIADH, Cushings, Eaton-lambert)
Small Cell lung CA/ Oat cell
pushing on the central stuff
highly aggressive
Adenocarcinoma
peripherally
distant METS
Thrombophlebitis, clubbing
Squamous cell
SLOW GROWING
CENTRAL BRONCHI
Hemoptysis (blooody cough)
SLOWER growing
May cavitate
Large cell
Aggressive, fast growing
dx of exclusion
Sx of Lung CA
Cough Weight loss SOB CP Hemoptysis (squamous cell)
Sx that Lung CA has spread Intrathoracically
Pleural effusion
Pericardial effusion
Hoarseness to voice
SVC syndrome
SVC syndrome- compression of the vena cava
Small/Oat cell
SOB Facial swelling Head fullness Dilated neck veins Prominent vein pattern on chest Dysphagia
Gold standard to diagnose SVC syndrome
Superior veno cavogram
Pancoast syndrome
Tumor in superior sulcus
compressing Brachial plexus and Cervical sympathetic nerves
Shoulder > forearm, scapula, and finger pain
SAME SIDE of tumor
Horner’s syndrome
Injury of sympathetic nerves of face
Miosis-pupil constriction
Anhidrosis- lack sweating
Ptosis-droopy
Pancoast syndrome
shoulder
Rib destruction
Atrophy of hand muscles
Pain in C8, T1, T2 nerve roots
Paraneoplastic syndrome
side effect of having CA
Altered immune response to the tumor
- bood
- endocrine
- neuro
Blood effects of Paraneoplastic syndrome
HyperCa2+ (bone destruction) Anemia Leukocytosis (too much) Thrombocytosis (too much) Hypercoag
Endocrine effects of Paraneoplastic syndrome
HyperCa2+
Excess HCG production (gynecomastia, milky nipple discharge)
SIADH
often w small/oat cell
Hyponatremia
Irritable, restless, personality change, confusion, coma, seizure, respiratory arrest
Cushing’s syndrome
often w small/oat cell
Muscle weakness, weight loss, HTN, Hirsutism, oseoporosis
Neuro effects of Paraneoplastic syndrome
Eaton Lambert
Immune mediated at the NMJ
defective release of Ach, muscle weakness, decreased DTRs
Most common site of Lung CA METS
Liver #1
Bone
Adrenal glands
Brain
TMN staging system
T- primary tumor
N- node involvement
M- distant mets
Tx of Small cell/Oat cell lung CA
Chemo regardless of stage
relapse is common
Non-small cell lung CA
SURGERY until get to Stage 4, then need to consider Palliative radiation or Combo chemo
Who to screen for Lung CA
Low density Chest CT
- Current smoker age 55-74 with 30 pack yr hx
- quit within 15 yr
- 20 pack yr hx and 1 additional risk factor
Rx drugs for Smoking cessation
Zyban (wellbutrin)
Chantix (varenicline)
Nicotine replacement
OTC nicotine (gum)
