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Family Medicine EOR > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

What is the presentation of asthma?

A

most often young patients with wheezing and dyspnea often associated with illness, exercise and allergic triggers
-airway inflammation, hyper responsiveness, and reversible airflow obstruction

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2
Q

How is asthma diagnosed?

A

monitor with peak flow, PFT’s, greater than 12% increase in FEV1 after bronchodilator therapy

  • FEV1 to FVC ratio <80% (you would expect the amount of air exhaled during the first second (FEV1) to be the greatest amount
  • in asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio
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3
Q

What are the treatment guidelines for mild intermittent?

A

less than 2 times per week or 3-night symptoms per month

-step 1: short-acting beta2 agonist (SABA) prn

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4
Q

What are the treatment guidelines for mild persistent?

A

more than 2 times per week or 3-4 night symptoms per month

-step 2: low-dose inhaled corticosteroids (ICS) daily

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5
Q

What are the treatment guidelines for moderate persistent?

A

daily symptoms or more than 1 nightly episode per week

  • step 3: low-dose ICS + long acting beta2 agonist (LABA) daily
  • step 4: medium-dose ICS + LABA daily
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6
Q

What are the treatment guidelines for severe persistent?

A

symptoms several times per day and nightly

  • step 5: high-dose ICS + LABA daily
  • step 6: high-doe ICS + LABA + oral steroids daily
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7
Q

What is acute treatment?

A

oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids

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8
Q

Making sense of forced vital capacity

A
  • forced expiratory volume (FEV) measures how much air a person can exhale during a forced breath
  • the amount of air exhaled may be measured during the first (FEV1), second (FEV2), and/or third seconds (FEV3) of the forced breath
  • forced vital capacity (FVC) is the total amount of air exhaled during the FEV test
  • you would expect the amount of air exhaled during the first second to be the greatest amount
  • in asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio
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9
Q

What is bronchitis?

A

cough > 5 days with or without sputum production, lasts 2-3 weeks

  • chest discomfort
  • shortness of breath
  • +/- fever
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10
Q

What is the etiology of bronchitis?

A

viruses (most common)

-cannot distinguish acute bronchitis from URTI in the first few days

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11
Q

Are labs indicated for bronchitis?

A

labs are not indicated, unless pneumonia suspected (HR> 100, RR>24, T>38, rales, hypoxemia, mental confusion, or systemic illness) = CXR

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12
Q

What is the tx of bronchitis?

A

antibiotics not recommended - mostly viral

  • symptomatic -based treatments NSAIDs, ASA< Tylenol, and/or ipratropium
  • cough suppressants - codeine-containing cough meds
  • bronchodilators (albuterol)
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13
Q

What is chronic bronchitis?

A

defined as a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause

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14
Q

What are the characteristics of chronic bronchitis?

A
  • excess mucus production narrows airways - productive cough
  • scarring and inflammation - enlargement of glands - smooth muscle hyperplasia = obstruction
  • blue bloaters (2nd to chronic hypoxia)
  • common in smokers (80% of COPD patients)
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15
Q

What are the symptoms of chronic bronchitis?

A

cough, sputum production, and dyspnea (on exertion or at rest)

  • prolonged forced expiratory time (takes longer to get all air out)
  • during auscultation: end-expiratory wheezes on forced expiration, decreased breath sounds, inspiratory crackles
  • tachypnea, tachycardia
  • cyanosis
  • use of accessory muscles
  • hyperresonance on percussion
  • increase pulmonary hypertension with RVH, distended neck veins, hepatomegaly
  • signs of corn pulmonate
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16
Q

How is chronic bronchitis diagnosed?

A
  • clinical diagnosis: chronic cough, productive sputum > 3 months, at least 2 consecutive years
  • PETs: FEV1/FVC ratio of less than 0.7
  • CXR - low sensitivity, useful in an acute exacerbation to r/o pneumonia or pneumothorax
  • peribronchial and perivascular markings
  • increase HGB and increase HCT are common because of the chronic hypoxic state
  • alpha-antitrypsin levels - FH premature emphysema?
  • ABG - chronic pCO2 retention, decreased pO2
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17
Q

What is the treatment for chronic bronchitis?

A
  • short-acting bronchodilators for mild disease
  • long-acting bronchodilators +/- inhaled corticosteroids for moderate to severe disease
  • ipratropium bromide is inhaled of choice for COPD
  • smoking cessation and supplemental O2 (O2 is single most important medication in the long term)
  • antibiotics for acute exacerbations
  • flu and pneumococcal vaccines are a must
  • surgery: lung resection vs transplant
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18
Q

What is emphysema?

A

a consequence of the destruction of alveolar space = pink puffers = the body’s natural response to decrease lung function is chronic hyperventilation

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19
Q

What are the characteristics of emphysema?

A
  • elastase (protease) excess and overinflation (“pink puffers,” barrel chest, pursed lips)
  • elastase - released from PMNs and macrophages, ingesting lung tissue (normally inhibited by alpha 1 antitrypsin)
  • tobacco smoke - increase PMNs and macrophages, inhibits antitrypsin, and increases oxidative stress on the lung
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20
Q

What are the symptoms of emphysema?

A

minimal cough, quiet lungs, thin, barrel chest

  • acute chest tightness
  • worse in the morning
  • clear to white sputum
  • 50 y/o typical
  • dyspnea (MC)
  • wheezing
  • tachypnea
  • dyspnea with mild exertion
  • cyanosis
  • JVD
  • atrophy of limb musculature
  • peripheral edema
  • “barrel chest” (2:1 anterior: posterior diameter)
  • diffuse or focal wheezing
  • diminished breath sounds
  • hyperresonance to percussion
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21
Q

How is emphysema diagnosed?

A

pathologic diagnosis: permanent enlargement of airspaces distal to bronchioles due to the destruction of alveolar walls

  • decreased DLCO
  • PETs (spirometry): diagnostic FEV1/FVC <0.75
  • FEV1 decreased
  • total lung capacity (TLC), residual volume, FRC increased (indicates air trapping)
  • vital capacity decreased - extra air that does come in is not useful - becomes residual volume (dead space)
  • chest x-ray will reveal flattened diaphragm , hyperinflation, and small, thin appearing heart
  • parenchymal bullae (sub pleural blebs) are pathognomonic
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22
Q

What is the tx of emphysema?

A

smoking cessation and home O2 are only interventions shown to lower mortality

  • give steroids and antibiotics for acute exacerbations: increased sputum production or change in character or worsening SOB
  • not responsive to bronchodilators
  • IV methylprednisolone if hospitalized
  • azithromycin or levofloxacin
  • O2 >90%, nasal cannula
  • NPPV: BiPAP or CPAP
  • can lead to acute respiratory distress syndrome (ARDS)
  • look for nocturnal hypoxemia; give CPAP or O2 as needed
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23
Q

What is the criteria for continuous or intermittent long-term O2?

A
  • pao2 55 mmHg
  • O2 saturation <88% (pulse oximetry) either at rest or during exercise
  • Pao2 55 59 mm Hg + polycythemia or for pulomale
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24
Q

What are the characteristics of small cell lung cancer?

A

(15% of cases) (central mass) - 99% smokers, does not respond to surgery and metastases at presentation

  • presents as recurrent pneumonia
  • constitutional SX (advanced disease): anorexia, weight loss, weakness, cough
  • location: central, very aggressive
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25
Q

What is small cell lung cancer associated with?

A
  • superior vena cava syndrome (SCLC): obstruction of SVC by a mediastinal tumor, facial fullness, facial and arm edema, dilated veins over the anterior chest, arms, face; JVD
  • phrenic nerve palsy - hemidiaphragmatic paralysis
  • recurrent laryngeal nerve palsy - hoarseness
  • horner syndrome: invasion of the cervial sympathetic change by apical tumor - unilateral facial anhidrosis (no sweating), ptosis, miosis
  • malignant pleural effusion
  • Eaton-Lambert syndrome (most common in SCLC): similar to myasthenia gravis (proximal muscle weakness/fatigue, diminished DTRs, paresthesias (lower extremity)
  • digital clubbing
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26
Q

How is small cell lung cancer dx?

A
  • CXR is most important for DX, but not used for screening
  • CT chest with IV contrast (used for staging)
  • tissue biopsy - determine the histology type (definitive)
  • cytologic examination of sputum - DX central tumors, not peripheral lesions
  • fiber-optic bronchoscopy - DX central tumors, not peripheral lesions PET scan
  • transthoracic needle biopsy - suspicious masses, highly accurate for peripheral lesions
  • mediastinoscopy - advanced disease
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27
Q

What is the tx of small cell lung cancer?

A

combination chemotherapy needed

  • prognosis: limited: 10-13% 5-y survival
    extensive: 1-3% 5-y survival
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28
Q

What are the types of non-small lung cancer?

A
  • squamous cell
  • large cell
  • adenocarcinoma
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29
Q

What are the characteristics of squamous cell lung cancer?

A 
(central mass) with hemoptysis 
25-30% of lung cancer cases 
-location: central 
-may cause hemoptysis 
-paraneoplastic syndrome: hypercalcemia 
-elevated PTHrp
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30
Q

What are the characteristics of large cell lung cancer?

A

fasting doubling rates - responds to surgery rare (only 5%)

  • location: periphery 60%
  • paraneoplastic syndrome: gynecomastia
31
Q

What are the characteristics of adenocarcinoma lung cancer?

A

most common (peripheral mass) 35-40% of cases of lung cancer

  • most common
  • associated with smoking and asbestos exposure
  • location: periphery
  • paraneoplastic syndrome: thrombophlebitis
32
Q

What is the tx of non-small cell lung cancer?

A
  • can be treated with surgery
  • treatment depends on staging
  • stage 1-2 surgery
  • stage 3 chemo then surgery
  • stage 4 palliative
33
Q

What is the tx of small cell lung cancer?

A

can not be treated with surgery will need chemotherapy

34
Q

What are the associated manifestations with lung cancer?

A
  • superior vena cava syndrome (facial/arm edema and swollen chest wall veins)
  • pancoast tumor (shoulder pain, Horner’s syndrome, brachial plexus compression)
  • Horner’s syndrome (unilateral miosis, ptosis, and anhidrosis)
  • carcinoid syndrome (flushing, diarrhea, and telangiectasia)
35
Q

What is community-acquired pneumonia?

A

(pneumococcal pneumonia) - immunocompetent
-occurs outside of the hospital or within 48 hour of hospital admission in a patient not residing in a long-term care facility
MCC: S. pneumonia (2/3), haemophilus influenza, mycoplasma pneumonia, S. aureus, N. meningitides, M. catarrhalis, K. pneumonia, other GNR
-viruses: influenza, RSV, adenovirus, parainfluenza virus

36
Q

What are the risk factors for pneumonia?

A

advanced age, alcoholism, tobacco use, comorbid medical conditions (asthma, COPD)

  • acute or subacute onset of fever
  • gradual onset cough with or without sputum production
  • shortness of breath on exertion
  • others: sweats, chills, rigors, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia , headache, abdominal pain
  • signs: fever or hypothermia, tachypnea, tachycardia, O2 desaturation, inspiratory crackles, and bronchial breath sounds, dullness to percussion
37
Q

How is pneumonia dx?

A
  • CXR: patchy airspace opacities to lobar consolidation with air bronchograms to diffuse alveolar or interstitial opacities
  • not necessary in outpatient because empiric therapy is effective
  • recommended if unusual presentation, history, or inpatient
  • CT chest is more sensitive or specific
38
Q

What are the labs for pneumonia?

A
  • sputum gram statin and sensitivity - not sensitive or specific for S. pneumonia
  • Urinary Ag test for S. pneumoniae and legionella is as sensitive/specific as gram stain and is readily available
  • rapid Ag test for flu is sensitive, not specific
  • pre-antibiotic sputum and blood cultures two sticks at separate sites
  • CBC and CMP, LFTs, bilirubin
  • ABG in hypoxemic patients
  • HIV testing in at risk patients
  • HIV testing in at-risk patients
  • procalcitonin - released by bacterial toxins and inhibited by viral infections
39
Q

How can pneumonia be prevented?

A
  • pneumovax 23
  • prevnar 13
  • 65+ and immunocompromised give both, or any chronic illness with increased risk of CAP
  • immunocompromised patents at high risk should get single revaccination of 23 6-y after the first dose, regardless of age
  • immunocompetent and 65+ y get the second dose of 23 if first received vaccine 6+ y ago (<65)
  • influenza: age 65+, residents of LTCF, pulmonary or CV disease, chronic metabolic disorder, or health care worker
40
Q

What are the characteristics of Nosocomial pneumonia?

A

Pathogens: S. aureus, K. pneumoniae, E.coli, Pseudomonas aeruginosa

  • required at least 2 of the following: Fever Leukocytosis Purulent sputum
  • CXR: new or progressive parenchymal opacity
  • blood cultures x 2 CBC and CMP
  • sputum culture an gram stain
  • ABG, thoracentesis if there is an effusion
  • procalcitonin
41
Q

What is outpatient tx of community-acquired pneumonia?

A

duration of treatment: 5 day minimum or until afebrile x 48-72 hours

  • macrolide clarithromycin 500 mg PO BID or azithromycin 500 mg PO first dose, then 250 mg PO daily x 4 day
  • doxycycline 100 mg PO BID
42
Q

What are the pathogens that cause community-acquired pneumonia?

A

S. pneumoniae, M. pneumoniae, C. pneumoniae, respiratory viruses: flu

43
Q

What is the tx of community-acquired pneumonia for a pt that is at risk for resistance: Abx last 90 days, age >65, immunosuppression, comorbid illness?

A

Respiratory FQ: moxifloxacin 400 mg PO daily, levofloxacin 750 mg PO daily
-macrolide plus beta lactam (HD amoxicillin 1 g PO TID or augmentin 2 g PO BID)

44
Q

What is the tx of community-acquired pneumonia for smokers?

A

cefdinir

45
Q

What are the pathogens that cause inpatient, non-ICU community-acquired pneumonia?

A

S. pneumonia, Legionella, H. influenzae, Enterobacteriaceae, S. aureus, pseudomonas

46
Q

What is the tx of community-acquired pneumonia for inpatient, non-ICU pts?

A

respiratory FQ: IV levofloxacin 750 mg daily or IV ciprofloxacin 400 mg q 8-12 hours

47
Q

What is the tx of community-acquired pneumonia for inpatient, non-ICU pts that are at risk for resistance: Abx last 90 days, age >65, immunosuppression, comorbid illness?

A

At risk for pseudomonas:
IV macrolide plus IV beta-lactam
(HD ampicillin 1-2 g q 4-6 h or cefotaxime 1-2 g q 4-12 h or ceftriaxone 1-2 g q 12-24 h)

48
Q

What are the pathogens that cause community-acquired pneumonia that are hospitalized or ICU pts?

A

S. pneumoniae, legionella, H. influenzae, Enterobacteriaceae, S. aureus, pseudomonas

49
Q

What is the tx of community-acquired pneumonia for pts that are hospitalized or ICU pts?

A

duration 5-day minimum or until afebrile x 48-72 h
-azithromycin or respiratory FQ (moxifloxacin, levofloxacin) plus anti-pneumococcal beta-lactam: cefotazime, caftriaxone, UNASYN

50
Q

What is the tx of community-acquired pneumonia for pts that are hospitalized or ICU pts that are at risk for resistance: Abx last 90 days, age >65, immunosuppression, comorbid illness?

A

-antipneumococcal and antipseudomonal beta-lactam: zosyn, cefepime, imipenem or meropenem plus ciprofloxacin or levofloxacin
or
-antipneumococcal beta-lactam (cefotazime, ceftriaxone, UNASYN) plus aminoglycoside (gentamicin, tobramycin, amikacin) plus azithromycin or respiratory FQ)
-if at risk for MRSA: add vancomycin or linezolid 600 mg BID

51
Q

What are the pathogens that cause nosocomial pneumonia?

A

S. aureus, K. pneumoniae, E. coli, Pseudomonas aeruginosa

52
Q

What is the tx of nosocomial pneumonia?

A

one of the following

  • ceftriaxone 1-2 g IV q 12-24 h
  • moxifloxacin 400 mg PO or IV
  • levofloxacin 750 mg PO or IV
  • ciprofloxacin 400 mg IV q 8-12 h
  • UNASYN 1.5-3 g IV q 6 h
  • Zosyn 3.375-4 mg IV q 6 h
  • Ertapenem 1 g IV daily
53
Q

What is the tx of nosocomial pneumonia for pts that are at risk for resistance: Abx last 90 days, age >65, immunosuppression, comorbid illness?

A

One agent from each:
Antipseudomonal
-cefepime 1-2 g IV BID or ceftazidime 1-2 g IV q 8 h
-imipenem 0.5 - 1 g IV q 6-8 h or meropenem 1 g IV q 8 h
-Zosyn 3.375-4.5 g IV q 6 h
-PCN allergy: aztreonam 1-2 g IV q 6-12 h
Second antipseudomonal
-levofloxacin 750 mg IV daily or ciprofloxacin 400 mg IV q 8-12 h
-IV gentamicin, tobramycin, amikacin
MRSA coverage
-IV vancomycin
-linezolid

54
Q

What are the characteristics of obstructive sleep apnea?

A

irregular breathing and snoring patters which

  • occurs at night due to reduced tone in muscles around the airway making them unable to support the weight of the parapharyngeal tissue
  • obesity is the leading risk factor for obstructive sleep apnea
  • aggravated by ingestion of ETOH or sedatives before sleeping, nasal obstruction (eg, cold)
  • can occur in children due to adenotonsillar hypertrophy
55
Q

What are the signs and symptoms of obstructive sleep apnea?

A

Hx of loud snoring -witnessed cyclical snoring, restlessness, thrashing of extremities during sleep

  • apnea - cessation of breathing
  • fatigue, interrupted sleep, and excessive daytime sleepiness
  • nocturia + insomnia
  • personality changes, poor judgment, memory impairment, inability to concentrate
  • other: depression, hypertension, headaches worse in AM, impotence
  • signs: appears sleepy narrow oropharynx, excessive soft tissue folds, large tonsils, pendulous uvula, large tongue deviated nasal septum “bull neck” appearance
56
Q

How is obstructive sleep apnea dx?

A

polysomnography

Five or more predominantly obstructive respiratory events per hours of sleep (for polysmnography) or recording time (for HSAT) in a patient with one or more of the following

  • sleepiness, non restorative sleep, fatigue, or insomnia symptoms
  • waking up with breath-holding, gasping, or choking
  • habitual snoring, breathing interruptions, or both noted by a bed partner or other observer
  • hypertension, mood disorder, cognitive dysfunction, coronary artery disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or type 2 diabetes mellitus
  • fifteen or more predominantly obstructive respiratory events per hour of sleep (for polysomnopgraphy) or recording time (for OCST), regardless of the presence of associated symptoms or comorbidities
57
Q

What is the treatment for obstructive sleep apnea?

A

Weight loss and continuous positive airway pressure devices (CPAP)

  • alternative treatments include positional therapy, mandibular advancement devices, and surgical interventions
  • only 75% use after 1 year
  • if O2<90% switch to BiPAP (higher pressure during inspiration, lower pressure during expiration)
  • if both ineffective, add O2 therapy UPPP - works in 50%
58
Q

What are the characteristics of tobacco use/dependence?

A
  • cigarette smoking causes transitional cell carcinoma of the bladder
  • a heavy smoker who smokes 2 packs per day for 20 years will lose 14 years of life
  • binds nicotinic receptor in CNS causing the release of dopamine (reward - increase pleasure, attention, mental processing, and working memory), acetylcholine, and glutamate
  • inhibits GABA inhibition - increase GABA
  • increase BP, HR, cardiac contractility, GI tract activity, and decreases muscle tone
  • metabolized by the liver, the half-life of nicotine 1-2 hours so must smoke every 1-2 hours
59
Q

What is the tx of tobacco use/dependence?

A

Smoking cessation
-70% want to quit, 50% try to quit, and only 5% do quit
-withdrawal begins within 2 hours and peaks with 1-2 days may feel awful for months after the last cigarette
First-line
-varenicline (chantix) - best efficacy
-bupropion SR (Wellbutrin, zyban)
-nicotine replacement therapy (NRT) - recommended for inpatient use
-support
Second-line
-nortriptyline and clonidine
-cognitive-behavioral therapy for every patient
-most relapses occur within the first 3 mo of quitting 35-40% relapse between 1-5 y after quitting
-recommend follow up after starting medication in 1-2 wk to monitor for adverse effects and provide reinforcement

60
Q

What are the characteristics of the patch?

A

starting on quit day

  • if >10 cigarettes/day use the highest dose (21 mg/d) x 6 wk, then 14 mg/d x 2 wk, then 7 mg/d x 2 wk
  • apply new patch each morning to non hairy skin site, remove and replace next morning
  • rotate daily to avoid skin irritation
  • remove at bedtime to avoid vivid dreams and insomnia, if experienced
61
Q

What are the characteristics of gum (nicorette)?

A
  • 4 mg dose recommended for 25+ cigarette/day smokers
  • chew the gum whenever an urge to smoke arises
  • one piece of gum every 1+/- 2h x 6 wk, for 3 mo total duration
  • avoid acidic beverages before and during use (coffee, carbonated beverages) - lowers oral pH causing nicotine to ionize and reducing nicotine absorption
  • side effects related to vigorous chewing (excess nicotine release)
62
Q

What are the characteristics of lozenges?

A
  • resembles a “tic-tac”, dissolves rapidly and delivers nicotine more rapidly
  • 4 mg dose for smokers who smoke within 30 min of waking up; 2 mg for all other smokers
  • similar dosing schedule to gum, maximum 5 lozenges every 6 h or 20/d
  • place in mouth and dissolves over 30 min, no chewing necessary
63
Q

What are the characteristics of chantix?

A

partial agonist at alpha4beta2 subunit of the nicotinic acetylcholine receptor

  • binds to and produces partial stimulation of the alpha4beta2 nicotinic receptor, reducing symptoms of withdrawal
  • binds to alpha4beta2 subunit with high affinity, blocking nicotine in tobacco smoke from binding to the receptor, reducing the reward aspects of cigarette smoking
64
Q

What is the administration of Chantix?

A
  • quit smoking 1 wk after starting medciation (stable blood levels achieved)
  • 0.5 mg daily x 3 d, then 0.5 mg BID x 4 d, then 1 mg BID up to 12 wks
  • risk of nauses minimized by taking with food and a full glass of water, or by increasing dose
  • abnormal dreams can be reduced by taking the evening dose of Chantix earlier in the day, lowering the dose or skipping evening dose
65
Q

What are the characteristics of Bupropion?

A

enhanes central nervous system nonadrenergic and dopaminergic release

  • safe for use in patients with stable CVD or COPD
  • good choice for patients concerned about post-cessation weight gain or with comorbid depression
  • approved for use in pregnancy (first or second-line)
  • safe for adolescents (not the first line, limited data)
66
Q

What is the administration of Bupropion?

A
  • takes 5-7 d to reach steady-state blood levels
  • start one week prior to quit-date
  • 150 mg/d x 3 d, 150 mg BID thereafter at least 12 wks
67
Q

What is tuberculosis?

A

a disease caused by bacteria called Mycobacterium tuberculosis (acid-fast bacilli)

  • presentation: fatigue, productive cough, night sweats, weight loss, post - tussive rales
  • RF: endemic area, immunocompromised (HIV), recent immigrants (<5 y/o), prisoners, healthcare workers
  • transmission: inhalation of aerosolized droplets
68
Q

What is the screening of tuberculosis?

A

screening with tuberculin skin test (TST) or interferon-gamma release assays IGRAs

69
Q

What are the Mantoux test rules?

A

test if positive if induration

  • > 5 mm at high risk, fibrotic changes on CXR, immunocompromised HIV/drugs, steroids/TNF antagonists daily, or close contact with pt with infectious TB
  • > 10 mm in patients age <4 or some risk factors = hospitals and other healthcare facilities, IVDU, recent immigrants from high prevalence area, renal insufficiency, prison, homeless shelter, diabetes, head/neck cancer, gastrectomy/jejunoileal bypass surgery
  • > 15 mm if there are no risk factors
70
Q

How is tuberculosis dx?

A

with sputum for AFB smears and mycobacterium tuberculosis cultures - have to be 3 AFB negative

  • NAAT helps diagnosis better and sooner
  • CXR: cavitary lesions, infiltrates, goon complexes in the apex of the lungs
  • biopsy = caveating granulomas
  • military TB = spread outside lungs = vertebral column: Pott disease; scrofula (TB to cervical lymph nodes)
71
Q

What is the tx of tuberculosis?

A

start empiric treatment in those who likely have it

  • PPD positive + CXR negative: latent TB = isoniazid for 9 months (+B6 to prevent neuropathy)
  • PPD positive + CXR positive: active TB = Quad therapy (RIPE): rifampin, isoniazid, pyrazinamide, ethambutol - all are hepatotoxic

Four drugs x 8 weeks (RIPE) then two drugs x 16 week (RI)

  • rifampin - red-orange urine, hepatitis
  • isoniazid - peripheral neuropathy (B6 = pyridoxine 25-50 mg/day)
  • pyrazinamide - hyperuricemia (gout)
  • ethambutol - optic neuritis (eye changes), red-green blindness
72
Q

What is needed for therapy cessation of tuberculosis?

A

patients with active TB will need two negative AFB smears and cultures in a row negative for therapy cessation

  • prophylaxis for household members = isoniazid for 1 year
  • D/C therapy if transaminases > 3-4 x ULN
  • Pt’s on INH should take supplemental Vitamin B6 (pyridoxine 25-50 mg/day) to prevent neuropathy
73
Q

What should you monitor during tuberculosis tx?

A

monitor serum creatinine, take meds on empty stomach since food can reduce absorption, watch for hepatotoxicity, aware of drug interactions especially with HIV meds

Family Medicine EOR (14 decks)

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