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CCFP 2 > Respi > Flashcards

Respi Flashcards

1
Q

Diagnostic criteria of Chronic Fatigue Syndrome

A

Clinically evaluated, unexplained fatigue > 6 mo, NOT alleviated by rest, impacts lifestyle
AND > 4 of the following
1) impair short term memory/concentration = Dec function
2) New H/A
3) sore throat
4) tender cervical/ axillary lymph node
5) muscle pain
6) multi-joint pain with NO swelling/ erythema
7) unrefreshing sleep
8) post exertional malaise > 24 hr

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2
Q

DDx of Fatigue

A 
SO FATIGUE-D
S - substance abuse 
O - obstructive sleep apnea 
F - Failure (CHF)
A - anemia 
T - tumor 
I - infection 
G - GI malabsorption 
U - uremia 
E - endocrine (DM, hypothyroid) 
D - depression
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3
Q

Initial assessment of Fatigue

A

Hx: review meds (Amiodarone and others), EtOH, sleep habits, associated symptoms, sex, eating, bowels, exercise

PE: lymphadenopathy - Abdo (liver, spleen size) - Neuro(reflexes)

Lab: 
CBC, CRE, extended lytes 
Ferritin 
LFTs, TSH, FBG 
CK, ESR 
Urine (protein, blood, glucose)
Urine pregnancy test (Female)
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4
Q

blood test to diagnose celiac disease

A

IgA
anti-TTG
anti-EMA
Biopsy

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5
Q

Diagnostic criteria of RA

A

At least 4 of the following

1) morning stiffness around joints for > 1 hr
2) arthritis >= 3 joint areas (soft tissue swelling)
3) arthritis of hand joints (wrist, MCP, PIP)
4) symmetric arthritis, bilateral involvement PIP, MCP, or MTP joints
5) Rheumatoid nodules
6) serum rheumatoid factor elevated
7) radiographic changes on hands and wrist views (erosions, decalcification)

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6
Q

Shingle vaccines options

A

Zostavax® II (LZV) Shingrix® (RZV)
Schedule 1 dose 2 doses, 2-6 months apart
Route Subcutaneous lntramuscular
Dose 0.65 mL 0.5 mL

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7
Q

What is the painful complication of herpes zoster that can be prevented by vaccines?

A

decrease post herpetic neuralgia 2/3

also decrease shingles by 51%

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8
Q

COPD diagnosis criteria

A

Spirometry - fixed post bronchodilator FEV1/FVC < 0.7 or FEV1/FVC < lower limits of normal values
(repeat in few months if FEV1/FVC 0.6-0.8)

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9
Q

What are the indications to check alpha-1 antitrypsin when diagnosing COPD?

A

1) If < 65 y/o with COPD OR

2) with a smoking history of < 20 pack years

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10
Q

What is the management for alpha-1 anti-trypsin deficiency (AATD)?

A

1) treat COPD
2) consider exogenous AAT in non-smoker/ex-smoker
3) vaccination with Hep A/B, pneumococcal & influenza

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11
Q

How to prevent AECOPD? (***single most effective intervention)

A
  • *** smoking cessation
  • annual influenza + pneumococcal (+booster @5 yrs) vaccine
  • review puffer technique + action plan
  • negative repercussions of inactivity **ESOB not life threatening
  • stay indoors when air quality is poor
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12
Q

Symptoms of “Mild” COPD

A
  • SOB w/ hurried walk
  • recurrent chest infection
  • FEV1 > 80%
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13
Q

Symptoms of Moderate COPD

A
  • SOB requiring resting ~ 100m (few mins)
  • limits in daily activities
  • exacerbations requiring corticosteroids +/- abx
  • FEV1 50-79%
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14
Q

Symptoms of Severe COPD

A
  • breathless after dressing
  • Resp/cardiac failure
  • FEV1 30-49%
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15
Q

What are the common causes of AECOPD?

A 
- Infection (50%)
  >>> H. influenza, S. pneumonia, Moraxella catarrhalis
- CHF 
- irritants 
- PE 
- MI
- anemia
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16
Q

Management of AECOPD

A
  • Use Ventolin (SABD) + LAAC (long-acting anticholinergic, Spiriva)
  • *** moderate to severe AECOPD: 30-40mg prednisone/d x 5 d, no taper
  • increased purulence (or mod to severe symptoms): abx (CRP <40 likely does NOT need abx)
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17
Q

What are the risk factors of pseudomonas with AECOPD?

What is the treatment?

A

FEV1 < 35% predicted
chronic steroids
constant purulent sputum

Ciprofloxacin 500-750mg BID

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18
Q

What is the pharmacotherapy approach to mild COPD?

A

Mild: SABD prn only
(SABA short acting beta2 agonist - Salbutamol [Ventolin] 1-2 puffs QID prn, Terbutaline (Bricanyl) OR
SAMA muscarinic antagonist - Ipratropium [Atrovent] 2 puff QID prn)

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19
Q

pharmacotherapy for Moderate/Severe COPD with low risk of AECOPD (CAT >10, mMRC>2, <=1 mod AECOPD in past 12 months)

A

1) LAMA (preferred) or LABA
&raquo_space; Tiotropium (Spiriva) 1 cap/ 2 puffs inhaled QD
2) LAMA/LABA
&raquo_space;
3) LAMA/LABA/ICS (inhaled corticosteroid)

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20
Q

Goal of Oxygen therapy for COPD

A

The goal of oxygen therapy is to maintain

PaO2 ≥ 60 mmHg or SpO2 ≥ 90% at rest, on exertion and during sleep

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21
Q

Etiology of Atrial fibrillation

A 
Cardiac
 > HTN
 > valvular disease 
 > coronary artery disease (CAD) 
 > congestive heart failure (CHF) 
 > cardiomyopathy 
 > pericarditis 
 > myocarditis
 > sick sinus syndrome 
NON-Cardiac 
 > Thyrotoxicosis 
 > infection (e.g. pneumonia)  
 > COPD 
 > OSA 
 > PE
 > Obesity 
 > Diabetes 
 > GERD 
 > stress 
Substance
 > Alcohol 
 > cocaine 
 > NO association with caffeine
22
Q

How to diagnose new Atrial fibrillation?

A

ECG
CBC (anemia/infection), INR, Cr, lytes, LFTs, TSH, A1C, (glucose, lipids)
Echo
Consider Holter 24hr to 30d
Stress test, CXR, sleep study, six minute walk test

23
Q

What are the symptoms of unstable Afib at ER

A

Rapid A-fib with hypotension
ACS
Pulmonary edema

24
Q

How to manage unstable A-fib at Emergency

A

1) Urgent rate control (IV Diltiazem, metoprolol, verapamil, digoxin)
2) Immediate OAC (NOAC/heparin) then Cardioversion
3) after cardioversion, anticoagulation for 4 weeks, consider long-term anticoagulation based on CHADS-65

25
Q

Indications of A-fib rate control vs. rhythm control

A

*** No difference in mortality
First-line: Rate control (< 100bpm)
&raquo_space; Exception (Rhythm control first):
- highly symptomatic
- multiple recurrences
- extreme impairment in QOL
- arrhythmia induced cardiomyopathy

  >> Early AFib (<=12 months) with risk factors: 
  ( elderly, TIA, HF, HTN, DM, severe CAD, CKD
26
Q

s/e of amiodarone

A

pulmonary fibrosis
need periodic LFTs
need monitor TSH

27
Q

First line meds for rate control of A-fib

A
  • beta-blocker: atenolol 50-150mg QD; Bisoprolol 2.5-10mg daily; metoprolol 25-200mg BID
  • Non-dihydropyridine CCB (NOT in CHF): Diltiazem, verapamil
28
Q

What is CHADS-65 rule?

A

People with paroxysmal or persistent A-fib needs to start OAC if

1) Age >=65 OR
2) CHADS2 >=1

29
Q

What are included in CHADSS-65?

A

CHADS2: 1 point for each

  • CHF
  • HTN
  • Age > 75 y/o
  • DM
  • Stroke/TIA - get 2 points
30
Q

when do the people with (paroxysmal or persistent) A-fib need to take ASA?

A

Age < 65 y/o
AND CHADS=0
AND has CAD or vascular disease

31
Q

When should we choose Warfarin instead of NOAC for A-fib patients?

A

Valvular A-Fib (mechanical prosthetic valve, rheumatic mitral stenosis, moderate-severe non-rheumatic mitral stenosis)

32
Q

What can increase INR of the patients on warfarin?

A

1) diarrhea
2) worsening heart failure
3) fever
4) impaired liver function

33
Q

Asthma diagnosis criteria for children > 6 years old

A

1) patient + Family history
2) MUST have spirometry and in its absence, a positive methacholine or exercise challenge test or sufficient peal expiratory flow variability

Spirometry (preferred)
&raquo_space; decreased FEV1/FVA < 0.8-0.9
&raquo_space; Increase FEV1 12% with bronchodilator

PEF - peak expiratory flow (alternative)
&raquo_space; increase >=20 % with bronchodilator

Methacholine
&raquo_space; PC20 < 4mg/mL ( 4-16 borderline, > 16 negative)

Exercise
&raquo_space; decrease FEV1 >= 10-15% post exercise

**for accuracy, discontinue ICS +/- LABA 24 hr prior to spirometry

34
Q

Diagnosis criteria of Adult asthma

A

1) Patient + Family history
2) Must have spirometry/positive methacholine/exercise challenge test/ sufficient peak expiratory flow (PEF) variability

Spirometry (preferred)
&raquo_space; decreased FEV1/FVA < 0.75 - 0.8
&raquo_space; Increase FEV1 12% with bronchodilator

PEF - peak expiratory flow (alternative)
&raquo_space; increase 60L/min (min 20 %) with bronchodilator
&raquo_space; diurnal variation > 8% if measured BID

Methacholine
&raquo_space; PC20 < 4mg/mL ( 4-16 borderline, > 16 negative)

Exercise
&raquo_space; decrease FEV1 >= 10-15% post exercise

**for accuracy, discontinue ICS +/- LABA 24 hr prior to spirometry

35
Q

Diagnosis criteria of Asthma in children < 6 years old

A 
Require all three of the following during >= 2 episodes 
# Documentation of airflow obstruction: (cough/dyspnea/wheeze) by M.D. or parents  
# Documentation of reversibility of airflow obstructions by M.D. or parents 
# No clinical evidence of an alternative diagnosis
36
Q

What is the management of asthma attack in children < 6 years old ?

A

1) mild symptoms: 4 puffs salbutamol, reassess 30min
2) moderate symptoms:
&raquo_space; 4 puff salbutamol, can repeat 2-3 doses, reassess in 60 min
&raquo_space; Oral steroid (dexamethasone 0.15-0.6mg/kg max 50mg) 1 dose, reassess in 3-4 hours

37
Q

pathogen of AECOPD

A
  • H. Influenza
  • S. Pneumoniae
  • M. Catarrhalis

Complicated COPD (gram negative)

  • Klebsiella
  • pseudomonas
38
Q

causes of AECOPD

A
  • infection (50%)
  • CHF
  • irritant
  • PE
  • MI
  • anemia
39
Q

management of AECOPD

A
  • mild: Ventolin (SABA) + Spiriva (LAMA antimuscarinic antagonist)
  • mod to severe: 30-40mg prednisone/d x 5d, no taper
  • Triple therapy: SABA only –> LAMA –> LAMA/LABA –> LAMA/LABA/ICS –> oral therapy (macrolide, Roflumilast)
40
Q

when to add Abx for AECOPD

A 
2-3 of Winnipeg criteria 
- sputum purulence 
- sputum volume 
- dyspnea 
OR CRP > 40
41
Q

management of Asthma COPD overlap

A

ICS/LABA +/- LAMA

42
Q

prevention strategy of AECOPD

A
  • smoking cessation - single most effective
  • vaccination: annual influenza + pneumococcal (booster q5yr) vaccine
  • review puffer technique + written action plan
  • Negative repercussion of inactivity (?) / pulmonary rehabilitation/ exercise therapy
  • stay indoor when air quality is poor
43
Q

DDx of COPD

A
  • asthma
  • CHF
  • GERD
  • TB
  • Bronchiolitis (obliterative + diffuse panbronchiolitis)
  • alpha-1 antitrypsin deficiency
44
Q

features of complicated /high risk COPD

A
  • FEV1 < 50%
  • = or > 4 exacerbations/yr
  • cardiac disease

Abx: Amoxicillin/Clavulanate, Levofloxacin, Moxifloxacin

45
Q

AECOPD at risk of pseudomonas

A
  • FEV1 < 35% predicted
  • chronic steroid use
  • constant purulent sputum

Abx: Ciprofloxacin

46
Q

treatment for dyspnea in COPD

A
  • O2 supplement: goal sat > 90%, no benefit in mortality
  • acupuncture
  • active mind-body therapy
  • Yoga
  • Tai chi
  • opioid (palliative)
47
Q

dysphagia + cough triggered by eating/ drinking

A

Eosinophilic esophagitis

48
Q

chronic wet cough, clubbing, FTT, recurrent pneumonia, onset in infancy

A

bronchiectasis, cystic fibrosis

49
Q

diagnostic test of cystic fibrosis

A
  • Sweat (chloride) test

- genetic test : mutations in the CFTR gene

50
Q

Asthma maintenance management

A

Always ICS as 1st -line management, Do not use SABA as regular monotherapy, always with ICS
(Except for children 1-5 y/o: SABA +/- ICS)

For > 12 y/o : can use ICS/LABA (Symbicort) as reliever

51
Q

Lung cancer screening criteria for smokers/ ex-smokers

A

NO chest x-ray for screening

1) Age 55-74
2) 30 pk/yr smoker, current or quit < 15 yrs ago

Annual low-dose chest CT up to 3 times

CCFP 2 (21 decks)

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