Treatments Flashcards
Asthma step 1
SABA
Asthma step 2
SABA and low-dose ICS
Asthma step 3
SABA + low-dose ICS + LABA or med-dose ICS
Asthma step 4
Med-dose ICS + LABA
Asthma step 5
High-dose ICS + LABA
Asthma step 6
High-dose ICS + LABA + PO CS
Mild exacerbation of asthma
SABA
Moderate exacerbation of asthma
Correction of hypoxemia with supplemental oxygen
Reversal of airflow obstruction with SABA and early administration of systemic corticosteroids
Severe exacerbation of asthma
Immediate oxygen, high dose of SABA and systemic corticosteroid (IV magnesium sulfate produces a detectable improvement in airflow)
Acute bronchitis
Supportive (encourage hydration, expectorants, anti-tussives, B2 agonists)
Chronic bronchitis
1st line- bronchodilators (anticholinergics): LAA (Tiotroprium-Spiriva) + SABA + ICS
Mucolytics, prevention (vaccines), pulmonary rehab
Acute exacerbation of chronic bronchitis
1st line: 2nd gen cephalosporin
2nd line: macrolide or Bactrim
Abx indicated for elderly, IC, cough > 7 days and pt with underlying cardiopulmonary disease
Complicated acute exacerbation of chronic bronchitis
FQ (Moxifloxacin or Levofloxacin, Gemifloxacin)
Augmentin
Emphysema
Stop smoking Anticholinergic inhalers > B2 agonists SABA for acute exacerbations Abx and CS for acute exacerbations Vaccinations: pneumonia and influenza Supplemental oxygen Encourage physical activity- pulmonary rehab
Sarcoidosis
Modest maintenance dose of corticosteroids
NSAIDs for athralgias and rheumatic complaints
Refractory: Methotrexate, azathioprine, inflixamab, lung transplant
Outpatient management of bacterial pneumonia (CAP)
No recent abx: macrolide (clarithromycin or azithromycine) or doxycycline
Comorbidities, risk for drug resistance or recent abx use: respiratory FQ (moxi, gemi, levo) or a macrolide + beta-lactam (Amox HD or augmentin)
Regions of high resistance: Respiratory FQ (Moxi, gemi, levo) or macrolide + beta-lactam
Hospital acquired pneumonia
Low-risk of MRSA or MDR pathogens: Cefepime, piperacillin-tazobactam, meropenem, Levofloxacin
More severe: Vancomycin + (Cefepime or Piperacilin-tazobactam or Meropenem)
If legionella suspected, add Levo or Azithromycin
If pseudomonas, high mortality, or MDR gm-neg suspected: add Cipro, levo, or tobramycin or amikacin
Pleural effusion
Treat the underlying disease Thoracentesis Chest tube drainage Tunneled pleural catheter placement Surgical drainage Pleurodesis
Pneumothorax
If small, stable spontaneous primary pneumothorax, observe
Supplemental oxygen
Simple aspiration drainage if large or progressive primary pneumothorax
Serial CXRs every 24 hrs
With secondary, large, tension pneumo- chest tube placement
Avoid exposure to high altitudes, flying in an unpressurized aircraft and scuba diving
ARDS
Identify and treat underlying conditions
Supportive care for severe respiratory dysfunction (intubation with positive pressure ventilation and low level PEEP)
Hyaline membrane disease
Mechanical ventilation
Adminstration of exogenous surfactant
Hordeolum
External: warm compresses only
Internal: Dicloxicillin (250-500 mg q6h) + warm compresses
If CA-MRSA: TMP/SMX DS (2 tablets BID)
Macular degeneration
Refer to ophthalmology
Neovascular: photodynamic therapy, VEGF inhibitors
Atrophic: Magnifying glasses and visual aids help
Antioxidants (Vit C and E), zinc, copper, carotenoids
Optic neuritis
Referral to ophthalmology and neurology
Admit- IV methylprednisolone 250 mg QID x 3 days with oral steroid taper
Plasma exchange
Orbital cellulitis
Admit! Consults! Monitor vision status and CNS change. Broad-spectrum IV abx for GP, GN, and anaerobic organisms
Vancomycin 15-30 mg/kg IV q8-12h + ceftriaxone 2 gm IV q24h + metronidazole 1 gm IV q12h
Piperacillin/tazobactam 4.5 gm IV q8h
Pterygium
No tx for inflammation- artificial tears only
May use topical NSAIDs or weak CS (fluoromethalone or lotepredonal) BUT MD
Surgery indicated for growth that threatens the visual axis, marked induced astigmatism, or severe irritation
Blepharitis
Proper hygiene, warm dry compresses, baby shampoo scrubs, artificial tears (for dry eyes)
(S. aureus) 1st line: bacitracin or erythromycin 0.5% ointment
2nd line: FQ solution
Cataract
No medication to treat or slow cataracts
Refer to surgery if affecting ADLs
Chalazion
Small chalazia often resolve without intervention, warm compresses help larger chalazia
Allergic conjunctivitis
Washes, PO antihistamines, artificial tears
Chlamydial conjunctivitis
Azithromycin 1 g once
Bacterial conjunctivitis
FQ solution: Cipro
Gonococcal conjunctivitis
Ceftriaxone 1 gm IM (adult)
Corneal abrasion
Heal with time
Prophylaxis abx given in contact lens wearers- FQ drops
Moxifloxacin drops
Contact lens wearers: Cipro drops or Levofloxacin drops
Dacryoadenitis
Viral (self-limiting, supportive, warm compresses, PO NSAIDs) Bacterial (1st gen cephalosporins- cephalexin 500 mg QID)
Referral for ENT, ophthalmology, and ID
Acute angle closure glaucoma
Requires surgical tx; IOP reduction within 6 hr
IOP reduction: start carbonic anhydrase inhibitor (acetazolamide orally and topical BB)
Surgical iridectomy
Primary open-angle glaucoma
Prostaglandin analogues: latanoprost B-adrenergic antagonist: timolol (Avoid with asthma/COPD)
Acetylcholinesterase inhibitor: Pilocarpine 1-4%
Erythema multiforme
Largely symptomatic: antihistamines, analgesics, skin care, topical steroids. For serious cases, hospitalization focus on much the same care as severe burns: fluid replacement, wound care, pain management
Cimetidine: H2 blocker
Dapsone
Scabies
Immunocompetent Permethrin 5% cream. Apply to entire skin from chin down to and including toes Leave on for 8-14 hrs Repeat in 1-2 wks Safe for children age > 2 mos Reapply to hands after handwashing Norwegian or crusted scabies in IC pts: Ivermectin on days 1, 2, 8, 9, and 15 + Permethrin 5% cream daily X 7 days
Basal cell carcinoma
Surgical removal
Topical 5% imiquimod, 5-fluorouracil, or Interferon cream
Radiation if not surgical candidate
Pityriasis rosea
For pruritis sx: topical steroids, PO antihistamines, oatmeal baths
Avoidance of water, sweat and soap
Topical zinc oxide and calamine lotion for itching
UV radiation therapy
In severe, persistent cases, topical steroid (e.g., triamcinolone) or oral corticosteroid (e.g., prednisone)
Psoriasis
Topical steroids (high strength)
Tar-based
Anthralin
Vit D analogs (calcipotriene) and retinoids (vit A analogs)
Biologic immune agents: Methotrexate, cyclosporine A, alefacept
Kenalog intralesional injections
Melanoma
Full surgical excision is the standard of care
Squamous cell carcinoma
Low risk cutaneous SCC: electrodessication and currettage
Invasion cutaneous SCC: surgical excision and Mohs micrographic surgery
Chemoradiation therapy
Reserved for high-risk metastatic cases or for pts who are unable to undergo surgical excision
Atopic dermatitis
High strength topical steroids and antihistamines for itching; calcineurin inhibitors (ex: Tacrolimus)
Acute lesions: wet dressings, topical or systemic abx (cephalexin, dicloxacillin)
Chronic lesions: daily hydration with unscented bath oils. PO antihistamines used for itching
Paronychia
Warm soaks Hygiene! Stop nail biting, wash hands Bacterial: I and D; culture TMP-SMX DS 1-2 tab PO BID while waiting for culture result Fungal: Topical amphotericin B, clotrimazole, econazole, miconazole, or nystatin tid/qid x 7-14 days Viral: Acyclovir 400 mg PO TID x 10 days Famciclovir 250 mg PO TID x 7-10 days Valacyclovir 1000 mg PO BID x 7-10 days
Molluscum contagiosum
Wash hands!
Retin A- apply daily
LN2 tx
Podophyllin- wash off in 1-2 hrs, repeat Q2 weeks prn
Direct lesion trauma agents: Tetinoin, salicylic acid, potassium hydroxide, cantharidin, silver nitrate, phenol, and tricholoroacetic acid
Immune response stimulation: Imiquimod cream, intralesional interferon alfa, streptococcal antigen injection
Antiviral therapy: Ritonavir, Cidofovir, Zidovudine
Varicella zoster
Chickenpox: In otherwise healthy pts, symptomatic therapy only
IV acyclovir recommended for immunosuppressed or IC pts
Calamine lotion, oral antihistamines may be used as antipruritic agents
Shingles: Calamine lotion, NSAIDs
For difficult/sever/IC cases
Oral corticosteroids (prednisone)
Antivirals (acyclovir, valacyclovir)
Opioid pain control (e.g., oxycodone)
Cellulitis
Hygiene
LE cellulitis inpt: Pcn, cephalosporin (IV allergy), vanc/linezolid (I allergy)
LE cellulitis outpt: PEN VK, amoxicillin, cephalosporin, macrolide
MSSA outpt: Dicloxicillin, doxycyline, Bactrim (last two are second line)
MSSA inpt: Naficillin, Oxacillin, Vanc
Dog/cat bite tx with augmentin
Infectious esophagitis
Candida: PO fluconazole
CMV: ganciclovir
HSV: acyclovir
Eosinophilic esophagitis
Remove foods that incite allergic response, inhaled steroids
Pill-induced esophagitis
Drink pills with greater than or equal to 4 oz water, avoid recumbency 30-60 mins afterwards
Caustic esophagitis
Supportive, pain meds, IV fluids
Mallory-Weiss tear
Supportive if no active bleed, hemodynamic stabilization if yes
GERD
Lifestyle modifications, H2RA (mild), PPI (severe)
Barrett’s esophagitis
Lifetime PPI, screen every 3-5 yrs
Esophageal cancer
Esophagectomy (S0-2A), chemotherapy + radiation
Achalasia
Botox, nitrates, CCBs, pneumatic dilation of LES, esophagomyomectomy
Nutcracker esophagus
CCBs, nitrates, botox, sildenafil
Esophageal varices
Octreotide in acute bleed and endoscopic band, BBs for prevention
H. pylori infection
Clarithro + amoxicillin + PPI (metro if PCN allergic)
NSAID/acute gastritis
Tx H. pylori if present, remove causative factor, PPI/H2RA
Acute pericarditis
Most cases are self-limited and resolve in 2-6 wks
Treat the underlying cause
NSAIDs are the mainstay of tx (Colchicine is often used)
Glucocorticoids may be tried if pain does not respond to NSAIDs (avoid if at all possible)
Admit if fever, leukocytosis, large pericardial effusion, hx of warfarin tx, elevated troponins, or IC state
Pericardial effusion
Pericardiocentesis is not indicated unless there is evidence of tamponade, if small and clinically insignificant, repeat echo in 1-2 wks
Cardiac tamponade
Non-hemorrhagic: If hemodynamically unstable, monitor closely (echo, CXR, ECG), if known renal failure, HD is more helpful than pericardiocentesis
Hemorrhagic: If bleeding is unlikely to stop on its own, emergent surgery
Pericardiocentesis is only temporizing measure and is not definitive ts. Surgery should NOT be delayed to perform pericardiocentesis
Giant cell myocarditis
Supportive tx for CHF and arrhythmias (medications and pacemaker or AICD), heart transplant, immunosuppressive drugs (cyclosporin, azathioprine, prednisone)
Endocarditis
Native valve endocarditis: Vanc + Ceftriaxone
Vanc + Gentamicin
Prosthetic valve endocarditis: Vanc + Gentamicin + Rifampin
IVDU: Nafcillin + Gentamicin (for MSSA) or Vanc + Gentamicin (MRSA)
+/- Rifampin (for prosthetic valve)
