Pulmonary

Question 1

Viral URI - Tx

Answer 1

• Nasal steroids: Proven benefit w/ allergic rhinitis
• Decongestants ONLY if Eustachian tube dysfunction
• Macrolide ABX have no effect on URI s/s
• Zinc: inhibits rhinovirus replication

Question 2

Acute Bacterial Rhinosinusitis

Answer 2

• Persistent s/s of ARS >10d with NO improvement
• Onset with severe Sx (temp >102 and purulent nasal discharge or facial pain) lasting 3+ days
• Onset with worsening symptoms following a viral URI that lasted 5+ days and was initially improving

Question 3

Who to refer to ENT?

Answer 3

1) Multiple recurrent episodes of ABRS (3+/year)
2) Chronic rhinosinusitis (w/ or w/o polyps or asthma) with recurrent exacerbations
3) Patients with allergic rhinitis who may be candidates for immunotherapy

Question 4

Acute Bronchitis

Answer 4

• Cough generally persists 2-3wk; airway hyperreactivity may last 5-6wk
• Only “need” ABX if pertussis
• CXR after wk of coughing
• NSAIDs and ipratropium inhaled
• No ASA if suspecting influenza
• Evidence equivocal re/OTC cough meds and codeine

Question 5

ABX in Bronchitis

Answer 5

• reductions in cough in 0.6d

- Azithromycin no better than low-dose Vc

Question 6

Antibiotic abuse

Answer 6

• 25% of pt’s have self-treated URI with “Left-over” ABX from previous illness
• ABX therapy causes long-term resistance in gut flora

Question 7

Pneumonia: Facts

Answer 7

• Disease of lung parenchyma
• Caused by mmicroaspiration of oropharyngeal contents
• Follow-up CXR in patients >40yr
• Healthcare-associated PNA: If hospitalized w/in 3mo; Cover pseudomonas and/or MRSA
• CXR may be negative in dehydrated patient
• Review CURB-65

Question 8

Pneumovax

Answer 8

• > 65yr
• 2-64 w/chronic illnesses, smoking, and asplenia
• 1x @ 65yr

Question 9

Pulmonary Embolus

Answer 9

• 30% mortality
• Massive: die within 1-2hr (cardiogenic shock)
• Submassive: saddle, no hypotension, 5% mortality
• Come in multiples
• Common complication of DVT (>50%)

Question 10

PE: Assessment

Answer 10

• PESI Score (+1 for each):
• > 80 yo
• Hx of Ca
• Chronic cardiopulmonary Dz
• HR >110
• SBP >100
• SaO2 <90%
• 0=low risk; 1+=high risk

Question 11

PE: Treatment

Answer 11

• No significant differences in outcome when treated out- vs. inpatient
• Low risk = class I or II
• Treat with Lovenox 1mg/kg SC BID and warfarin 5mg q pm
• Check INR in 3-4d (Goal 2-3)
• Also BLE duplex ultrasound

Question 12

Pneumothorax

Answer 12

• Nasal O2
• Observe for 6hr and repeat CXR
• Assess for hypotension (tension pneumo)
• ED for pneumocath or chest tube if clinically unstable or size >2-3cm or >30%
• Smoking cessation
• No flying for 2wk

Question 14

Mechanisms of Asthma

Answer 14

• Airway smooth muscle constriction
• Airway edema from inflammatory cells
• Mucous hypersecretion
• Airway hyper-responsiveness - an exaggerated bronchoconstrictor response to stimuli

Question 15

See Charts

Answer 15

on Slides

Question 16

4 Essentials of Asthma Care (EPR-3)

Answer 16

1) Assessment and monitoring asthma severity and asthma control
2) Education for a partnership in care
3) Control of factors contributing to asthma severity
4) pharmacologic treatment

Question 17

Asthma: Assessment & Monitoring

Answer 17

• For periodic monitoring of asthma control to guide decisions for maintaining or adjusting therapy:
• Patients should monitor control in ongoing manner and be taught how to recognize inadequate control
• Either symptoms or peak flows; benefits similar
• Daily peak flows for moderate or severe persistent asthma, or Hx of severe exacerbations or poor perception of airway obstruction or worsening asthma

Question 18

Asthma: Assessing the level of control

Answer 18

• Asthma better or worse since last visit
• Has your asthma awakened you in night or early morning?
• Have you needed or used more albuterol than usual?
• Have you had any urgent medical care recently?
• Are you able to do activities without cough, chest tightness, or SOB?
• What is your peak flow, personal best, vs. predictive?
• Access to meds daycare/school/work?