Test 3 Flashcards
If a cough in acute bronchitis lasts more than 14 days, then consider
pertussis
Usual duration of cough with acute bronchitis
1-3 weeks
s/s of acute bronchitis
cough with or without sputum, low grade fever, wheezes/rhonchi
Diagnostic for acute bronchitis
usually based on history and exam
This does not necessarily indicate a bacterial cause in acute bronchitis
purulent sputum
treatment for acute bronchitis
antitussive therapy for nighttime cough, NSAIDs, ipratropium inhaler
3 changes in asthma
bronchoconstriction, hyperresponsiveness, and inflammation
Restrictive disease is when
alveoli cannot be filled
obstructive disease is when
air cannot get out
factors that can exacerbate asthma
GERD, atopy
Exercise induced asthma is when symptoms begin
5-10 min after completing exercise and resolve in 1-4 horus
severe rhinorrhea, sneezing, N/V, and airway obstruction that occurs in those 20-30s.
aspirin-induced asthma
hallmark symptoms of asthma
wheezing, dyspnea, cough, and sputum production
Diagnosis for asthma is with
peak flow meters and spirometry
Between asthma attacks, sputum is usually ___; during an asthma attack, the sputum may be ____ even with an absence of infection
clear; yellow or green
Asthma is diagnosed with a FEV1 of ___ and a ____ FEV1/FVC ratio that improves with bronchodilator therapy.
less than 80%; reduced
In intermittent asthma, the symptoms occur ____; nighttime awakenings occur _____; SABA use is _______; and FEV1 is _____.
less than 2 days/week;
less than twice a month;
less than 2 days a week;
normal.
In mild persistent asthma, the symptoms occur ____; nighttime awakenings occur _____; SABA use is _______; and FEV1 is _____.
more than 2 days a week;
3-4 times a month;
more than 2 days a week but not daily;
Greater than 80%
In moderate persistent asthma, the symptoms occur ____; nighttime awakenings occur _____; SABA use is _______; and FEV1 is _____.
Daily;
More than once a week but not nightly;
Daily;
60-80%
In severe persistent asthma, the symptoms occur ____; nighttime awakenings occur _____; SABA use is _______; and FEV1 is _____.
throughout the day;
every night;
several times a day;
less than 60%
Normal FEV1/FVC is
70-80%
FVC is forced expiratory volume and can help indicate
restrictive disease if less than 80%
FEV1 is max volume expired in 1 second and can help indicate
obstructive disease if less than 70%
Step 1 of asthma approach
SABA PRN
Step 2 of asthma approach
low dose ICS + SABA PRN
Step 3 of asthma approach
low dose ICS + LABA + SABA PRN
Step 4 of asthma approach
medium dose ICS + LABA + SABA PRN
Step 5 of asthma approach
high dose ICS + LABA + SABA PRN
Step 6 of asthma approach
High dose ICS + LABA + oral steroid
SABA can be used up to ____ treatments at ____ minute intervals
3; 20
Use of SABA more than _____ days a week indicate inadequate control
2
common LABA
salmetrol and formoterol
Combined LABA + ICS drugs
fluticasone/salmeterol (Advair);
bedesonide/formoterol (Symbicort)
LABAs are usually only indicated for those older than
12
Can be used as alternatives to those with asthma who do not tolerate SABAs.
anticholinergics
short acting anticholinergic
ipratropium (Atrovent) 2-3 puffs every 6 hours
combined anticholinergic and beta 2 agonist
ipratropium/albuterol (Combivent)
For acute asthma exacerbations, you can tell the patient to continue SABA use to
every 3-4 hours for next 24-48 hours
used for prophylaxis for mild to moderate asthma
cromolyn
why theophylline has limited use
narrow therapeutic range, side effects same as caffeine
education for use of inhalers
slowly inhale, hold breath for 4-10 seconds, breath out through pursed lips. wait 1 min in between puffs.
This score in asthma control test means asthma is not well controlled
less than 19
f/u when stepping up or down in asthma therapy
in 4-6 weeks
improvement in occupational asthma after cessation of exposure is typically
gradual and reaches a plateau 2 years after
difference b/t cardiac and noncardiac chest pain characteristics
cardiac chest pain is pressure, noncardiac chest pain is stabbing and sharp
Chest pain that localizes to a small area of the chest suggests
pleural or chest wall involvement.
noncardiac chest pain has onset that is
abrupt
for those less than 40, this can r/o cardiac disease for chest pain
ECG
for those older than 40, this can be done r/o cardiac disease for chest pain
stress test, cardiac enzymes, heart cath
Musculoskeletal chest pain characteristics
persistent; aggravated by movement or breathing; can be reproduced by touch.
Pleuritic or pneumothorax chest pain characteristics
stabbing or shooting pain that is aggravated by breathing, coughing, sneezing
seen in young tall, thin men ages 30-40 who smoke and have no history of lung disease.
primary spontaneous pneumothorax
those with GERD related chest pain can be given
trial of twice daily high dose PPI for 1-2 months
acute cough lasts
less than 3 weeks
subacute cough lasts
3-8 weeks
chronic cough lasts
more than 8 weeks
most coughs are caused by
viral URI
common causes of subacute cough
asthma or sinusitis
postinfectious cough usually lasts
longer than 8 weeks after viral infection and resolves on its own
common causes of chronic cough
asthma, GERD
ACEI cough resolves in
1-4 weeks after cessation
characteristics of psychogenic cough
barking cough that doesn’t occur at night
First step in treating chronic cough
anithistamines, nasal steroids, Atrovent x 2 weeks
Second step in treating chronic cough
spirometry to check for asthma
Third step in treating chronic cough
Trial of high-dose PPI to treat for GERD
Fourth step in treating chronic cough
Chest xray
characterized as a dry, nocturnal cough and associated with a drop in morning peak flows
cough-variant asthma
methacholine test
bronchoconstrictor, incrementally given. Positive if there’s a 20% drop in FEV1.
COPD is categorized as
chronic bronchitis and emphysema
chronic bronchitis is characterized by a persistent cough for
3 consecutive months for 2 consecutive years.
destruction of the alveolar walls leading to expiratory airway collapse
emphysema
risk factors for COPD
smoking, recurrent respiratory infections, recurrent sinus infections, nasal polyps
COPD can cause this complication
cor pulmonale (right ventricular hypertrophy)
S/S of COPD
dyspnea on exertion, increase AP diameter of chest, prolonged expirations
With inspiration in those with COPD, there is a _____movement of the rib cage and _____ movement of the abd wall.
decreased; increased
Diagnosis of COPD
spirometry with FEV1/FVC
Stage I COPD
FEV1 > 80%
Stage II COPD
FEV1 50-80% with SOB on exertion
Stage III COPD
FEV1 30-50% with increased SOB and repeated exacerbations
Stage IV COPD
FEV1 less than 30% with impaired quality of life
Those with COPD may show this on labs
polycythemia d/t hypoxemia
standard Medicare criteria for home O2 is
PA02 less than 55 mg and o2 sat less than 88%
All patients with COPD should be prescribed with a
short acting bronchodilator as needed.
Those with Stage II-III COPD should have a
long acting bronchodilator (anticholinergic is preferred) + short acting bronchodilator
Those with Stage III-IV COPD should have a
long acting bronchodilator + ICS + short acting bronchodilator
Recommended first line therapy for COPD
ipratropium (atrovent) as needed + tiotropium (Spiriva) 1 inhalation daily
beclomethasone (QVAR)
inhaled corticosteroids
budesomide (Pulmicort)
inhaled corticosteroids
fluticasone propionate (Flovent)
inhaled corticosteroids
education about ICS
must be used regularly, rinse mouth after use
Inhaled bronchodilators relieve _____, and corticosteroids reduce ________.
bronchospasm; inflammation
if ICS is used in COPD, then recheck FEV1 in
3-4 weeks to see if the FEV1 improves
those with COPD should be educated about
pulmonary rehab, weight loss, smoking cessation
paradoxical breathing seen in severe dyspnea
chest wall rises and abd moves inward
Diagnostics for dyspnea
Chest xray, spirometry, V/Q scan to r/o PE, ECG/Echo, H&H to r/o anemia
most common causes of hemoptysis
bronchitis, lung cancer, PNA, TB
diagnostics for hemoptysis
sputum culture, CBC, coags, chest xray
hemoptysis from the GI tract is usually
coffee-ground, acidic
Urgent evaluation is needed if hemoptysis is more than
50 mL of blood loss in the past 24 hours
The most common causes of acute dyspnea
asthma, bronchitis, pneumothorax, PNA, PE
Repetitive upper airway narrowing or closure, which occurs during sleep
sleep apnea
diagnosis for sleep apnea
polysomnography (PSG)
s/s of sleep apnea
snoring, nocturnal gasping/choking, nocturia
There is evidence that untreated OSA is a cause
systolic hypertension.
most common signs of nicotine withdrawal
dysphoria and difficulty thinking
during precontemplation change of smoking cessation
advise patient to quit but do not pursue smoking cessation
when the patient shows awareness of smoking problem
contemplation
when the patient says they have to do something about their smoking
determination stage
important to provide intervention steps for smoking cessation during this stage
determination stage
when the patient actually stops smoking
action phase; make sure a f/u appt is set
Nicotine replacement therapy should be cautiously used in those with
cardiovascular disease
these types of nicotine replacements should be used for 8 weeks and gradually tapered
gum, patches, and nasal spray
buproprion for smoking cessation should NOT be prescribed in those with
eating or seizure disorders
most common side effect os buproprion
insomnia
dosing for buproprion
start with 150 mg daily x 3 days, then increase to bid;
start 1-2 weeks before quit date
Chantix can be started
1 week before quit date
common side effect of Chantix
nausea, high risk of hostile behavior
characterized by upper respiratory symptoms followed by lower respiratory infection with inflammation
bronchiolitis
bronchiolitis occurs in
children less than 2
most common cause of bronchiolitis
RSV
risk factors for bronchiolitis
prematurity, congenital heart disease
s/s of bronchiolitis
starts off with upper URI symptoms (runny nose) for 1-3 days, then fever & cough occur.
course of bronchiolitis
self-limited and resolves in 28 days
treatment for nonsevere bronchiolitis
bulb suction, fluids
NOT recommended for nonsevere bronchiolitis
bronchodilators, glucocorticoid
Cystic Fibrosis is a
autosomal recessive
usual presenting symptoms in cystic fibrosis
pulmonary infections, pancreatic insufficiency, elevated sweat chloride levels.
cystic fibrosis is caused by a mutation in the
CFTR protein
complications of CF in adulthood
spontaneous pneumothorax and hemoptysis
diagnosis of cystic fibrosis
newborn screening (IRT and DNA assay), if positive then diagnosis is confirmed with sweat chloride testing > 6 mmol/L
atbx recommended for those with CF
azithromycin
Many patients with CF show improvement with
bronchodilators
foreign body aspiration occurs in those
less than 3
commonly aspirated products
peanuts, nuts, seeds, popcorn, pieces of toys
Most aspirated foreign bodies are located in the
bronchi
S/S of bronchial foreign body aspiration
coughing/wheezing, hemoptysis, dyspnea, fever, decreased breath sounds
problem with choking episode is
it is usually self-limited followed by an asymptomatic period
complication of foreign body aspiration
pneumonia
why chest xray is not always diagnostic in foreign body aspiration
most objects are radiolucent and are not detected on xray
best diagnostic tool for foreign body aspiration
bronchoscopy
Hard and/or round foods should not be offered to children younger than
four years old
cause of croup
parainfluenza virus type 1
age group for croup
3 months to 3 years old
anatomic sign of croup seen on chest xray
steeple sign of the trachea
s/s of croup
initially starts with congestion;
progresses to fever, hoarsness, barking cough, stridor
diagnosis for croup
usually based on history and PE
trx for mild croup
humidity mist, fluids, antipyretics, dexamethasone
trx for moderate to severe croup
referral to ER
most common type of lung cancer
non-small cell lung cancer
most effective screening tool for lung cancer
low-dose helical CT
most common symptom of lung cancer
cough, hemoptysis
staging of non-small cell lung cancer
size of tumor, regional lymph node involvement, degree of metastasis
problem with lung cancer
already advanced to later stages by time of diagnosis.
total volume in the pleural space is
20 mL
Most common causes of pleural effusion
CHF, pneumonia, cancer
s/s of pleural effusion
pleuritic sharp, unilateral chest pain, nonproductive cough, dyspnea
physical findings in pleural effusion
dullness to percussion, absent tactile fremitus, egophony (E to A change), pleural friction rub
why chest xrays aren’t always diagnostic for pleural effusion
can only detect effusion greater than 500 mL
best diagnostic tool for pleural effusion
Chest US or CT
inflammation of the pleura
pleurisy
sharp or stabbing that is exacerbated by coughing, deep breathing, sneezing.
pleuritic chest pain
drugs associated with pleurisy
nitrofurantoin, methotrexate, amiodarone, beta blockers
may be described as a “stitch on the side”
pleurisy
physical exam with pleurisy
pt will lie on affected side, tenderness on palpation, pleural friction rub
pleural friction rub in pleurisy is only heard when
patient take a deep breath
treatment for pleurisy
thoracentesis, NSAIDs
typical pneumonia is caused by
streptococcus pneumonia
atypical pneumonia is caused by
influenza virus, mycoplasma pneumonia
more likely to acquire atypical pneumnoia
young adults
community acquired pneumonia is caused by
Streptococcus pneumoniae (gram +) and H. influenza (gram negative)
pneumonia in those with COPD, alcoholics, and diabetics is mostly caused by
Moraxella catarrhalis
outpatient trx of pneumonia
macrolide
outpatient trx of pneumonia in those with heart/lung disease, liver disease, or DM
fluoroquinolone + macrolide
not recommended for diagnosis of PNA in the outpatient setting
sputum culture; usually diagnosed through chest xray
s/s of pneumonia in elderly
lethargy, decreased appetitie, AMS
secondary pneumothorax is caused by
COPD, SLE, sarcoidosis, asthma
tension pneumothorax is caused by
mechanical ventilation or CPR
pneumothorax results when there is a loss of
negative pressure in the pleural space
s/s of pneumothorax
sudden sharp pain, dyspnea, cough
tension pneumothorax is a
medical emergency
diagnosis of pneumothorax
chest xray, ultrasound
treatment for asymptomatic pneumothorax
none, resolution in 7-14 days
treatment for primary pneumothorax
needle aspiration
treatment for secondary pneumothorax
chest tube
primary pneumothorax is
recurrent, refer to pulmonologist
pulmonary arterial hypertension results in
high pulmonary vascular resistance and right ventricular hypertrophy (cor pulmonale)
PAH is a PA pressure greater than
25 mmHg
common causes of PAH
hypoxia
s/s of PAH
asymptomatic until it becomes severe;
angina, cough, hemoptysis
usual time of onset of symptoms for PAH
insidious onset of 2 years
signs of right ventricular failure (JVD, hepatomegaly, ascites) is often seen with
PAH
diagnostic for PAH
doppler Echo, ECG
treatment for PAH
CCB, tadalafil;
oxygen;
CPAP
Multisystem, inflammatory, granulomatous disease of unknown origin that commonly affects young and middle-aged adults age 20-45
sarcoidosis
Presentation of sarcoidosis
asymptomatic with abnormal chest xray;
dry cough, dypsnea, chest pain, fever
other involvements with sarcoidosis
ocular and skin lesions
complication of sarcoidosis
pulmonary fibrosis
treatment for asymptomatic sarcoidosis
none; NSAIDs, steroids
treatment with stage III-IV sarcoidosis
immunosuppression, steroids
f/u with sarcoidosis
recurrence is common
sudden infant death syndrome occurs mostly in those less than
1 years of age
risk factors for SIDS
maternal smoking, low birth weight, preterm labor, prone sleeping, soft bedding, bed-sharing, overheating
protective measures for SIDS
pacifier, room-sharing, breastfeeding, fan use
multidrug resistance is growing for TB in these drugs
rifampin and isoniazid
TB infection occurs when the inhaled particles reach the
alveoli
Most cases of TB are
asymptomatic and identified through positive skin test
s/s of TB
fatigue, weight loss, night sweats, cough, hemoptysis, low grade fever
A person with TB will react positively to the skin test ____ after infection.
2-8 weeks
PPD skin test
induration is measured in 48-72 hours. Should be recorded by mm of induration
factors that cause false negative PPD result
age > 45, simultaneous live vaccination, infection
factors that can cause a false positive resolve
BCG vaccine
two step testing for TB
if negative, give second test 1-3 weeks later
Positive if induration in greater than 5 mm in those with
HIV, close contacts with TB
Positive if induration in greater than 10 mm in those with
immigrants, high risk facilities (prison, LTC, hospital, homeless), chronic disease (DM, renal failure, children less than 4)
Positive if induration in greater than 15 mm in those with
no known risk factor for TB
Must be done with every TB case
reported to local health department.
preventative therapy for those with latent TB
INH for 9 months
complication of INH
hepatitis
cause of Type 1 Diabetes
autoimmune destruction of beta cells in the pancreas resulting in insulinopenia
Type II diabetes causes
insulin resistance
s/s of type 2 diabetes
polyuria, polyphagia, polydipsia, blurred vision, fatigue
ADA criteria for diagnosis of diabetes
A1C > 6.5%;
FPG > 126 mg/dL;
2-hour OGTT with 75 g > 200 mg/dL;
random plasma glucose > 200 mg/dL
benefits of exercise in diabetes
increases glucose uptake in skeletal muscles and improves insulin sensitivity
Step 1 of DM management
lifestyle modifications, begin metformin
Step 2 of DM management
add either basal insulin (most effective) or sulfonyurea (least expensive)
Step 3 of DM management
if Hgb persists > 7%, increase insulin
goal of type 2 DM management is to keep
A1C
Early morning hyperglycemia is controlled by _____
basal insulin
post-meal glucose spikes are controlled by _____
prandial insulin.
onset of rapid acting insulin (Novolog, Humalog)
10-20 min
peak of rapid acting insulin (Novolog, Humalog)
1-3 hours
duration of rapid acting insulin (Novolog, Humalog)
3-5 hours
onset of short acting insulin (Regular & Humalin R)
30-60 min
peak of of short acting insulin (Regular & Humalin R)
2-4 hours
duration of short acting insulin (Regular & Humalin R)
5-8 hours
onset of intermediate acting insulin (NPH)
1-2 hours
peak of of intermediate acting insulin (NPH)
2-12 hours
duration of intermediate acting insulin (NPH)
24 hours
onset of long acting insulin (Levemir, Lantus)
90 min
duration of long acting insulin (Levemir, Lantus)
24 hours
Long acting insulin is
peakless
MOA of metformin
suppresses hepatic glucose production
Goal is to keep premeal insulin between
80-130 mg/dL
Pramlintide (Symlin)
SQ pen given before meals along with insulin
MOA of sulfonyurea
stimulate insulin secretion
education with sulfonyureas
take with meals
medication that can cause hypoglycemia
sulfonyureas
act in the small intestine, delaying the digestion of polysaccharides which leads to lower postprandial glucose levels.
alpha glucosidase inhibitors
with alpha glucosidase inhibitors, the med must be taken wtih
the first bite of a meal that contains carbs
f/u care for Diabetes
A1c every 3 months;
lipid panel annually;
urine microalbumin annually
thiazolidinediones (Actos) is contraindicated in
those with CHF as they cause edema
release insulin and decrease glucagon levels by slowing the inactivation of incretin hormones.
DPP4 inhibitors (Januvia)
hypoglycemia is blood sugar less than
70 mg/dL
hyperglycemia is blood sugar greater than
180 mg/dL
education on sick days with diabetics
check blood sugar every 4 hours;
drink 8 oz of sodium rich fluid every hour;
continue meds even if not eating
provides the earliest indication of renal damage from diabetes
microalbumin
Once microalbuminuria is confirmed in those with diabetes, then
start an ACEI or ARB
types of neuropathy with diabetes
peripheral, gastroparesis, neurogenic bladder, sexual dysfunction, orthostatic hypotension
All pregnant women are screened for GM at
24- 28 weeks
Diagnosis for GM is made if OGTT with 75 g is
fasting > 92;
1-hour > 180;
2-hour > 153
If lifestyle modifications fail, then this can be added for diabetes prevention
metformin
Meds that can be used during pregnancy
insulin, glyburide, metformin
complications of GM
macrosomnia, hypoglycemia, PIH, polyhdramnios, preterm labor
These types of insulin have a reduced risk of hypoglycemia
rapid acting and long acting insulin
these can mask the signs of hypoglycemia
alcohol and beta blockers
trx for mild to moderate hypoglycemia
15-20 g of carb/sugar
DKA is characterized as
hyperglycemia, ketonuria, and anion gap metabolic acidosis
s/s of DKA
abdominal pain, N/V, Kussmaul respirations, fruity odor
Labs in DKA
glucose less than 800 mg/dL;
high potassium;
elevated anion gap
a rapid urine dipstick that can determine serum ketone levels to explain the high anion gap in DKA
Nitroprusside
treatment for DKA
Isotonic fluids, correct K+ first, IV insulin
SQ insulin in DKA can be started when anion gap is
less than 12
HHNK is seen in
type 2 diabetics and elderly
DKA is seen in
type 1 diabetics and young
S/S of HHNK
gradual signs of polyuria and polydipsia, altered mental status
labs in HHNK
glucose > 1000 mg/dL; high osmolality; hyponatremia; NO ketones in urine; pH > 7.30
most common cause of HHNK and DKA
stopping insulin and dehydration
metabolic syndrome is characterized as
abdominal obesity, hyperglycemia, high triglycerides, low HDL, HTN, inflammatory state
labs values in metabolic syndrome
triglyceride > 150;
HDL 130/85;
fasting glucose > 100
risk factors for metabolic syndrome
family hx, obesity, abd fat, physical inactivity
Metabolic syndrome places the patient in a ____ state.
prothrombic
Diagnostic of metabolic syndrome
microalbuminuria;
fasting insulin > 10
acanthosis nigricans is seen in
metabolic syndrome
treatment for metabolic syndrome
antihypertensives, statins, ASA therapy, metformin
hemoptysis from the respiratory tract is
bright red/pink, frothy, alkaline pH
primary diagnostic tool for TB
sputum specimen
compared to albuterol, levalbuterol has ___ with a lower dose
greater bronchodilation
caution with prescribing this antibiotic with theophylline
macrolide
name a 3rd of 4th generation fluoroquinolone
levaquin
a short acting bronchodilator is effective for
4 hours
hyperresonnance on percussion is seen in those with
asthma
what pathogen is found in an acute exacerbation of chronic bronchitis
H. influenza
in cystic fibrosis, which vitamins are not well absorbed
fat soluble: A, D, E, K
GI problem in those with cystic fibrosis
meconium ileus
a problem seen after mechanical ventilation in a neonate
bronchopulmonary dysplasia (BPD)
symptoms of BPD resolve by
age 3
abtx for a 78 year old with community acquire PNA and COPD
amoxicillin and macrolide
a risk factor for pneumonia death
renal insufficiency
is someone with latent TB contagious?
No
s/s of somogyi effect
excessive hunger, weight gain, hyperglycemia
action to trx somogyi effect
decrease evening insulin, check blood sugar at 2 am
