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Clin Med Exam 2 (Lauren) > Upper Respiratory Infections > Flashcards

Upper Respiratory Infections Flashcards

1
Q

What is the main cause of the common cold?

A

Rhinovirus 30-50%

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2
Q

What are the most common symptoms of the common cold?

A

Rhinorrhea

Nasal congestion

Sore throat

Cough

Malaise

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3
Q

What would you see if you looked in the nose of someone with the common cold?

A

Mucosal swelling

Discharge that may be clear or purulent

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4
Q

What is the treatment for the common cold?

A

NOT antibiotics

NSAIDS, Tylenol

Antihistamine/decongestant combo

Expectorants/antitussives

Topical analgesics for sore throat

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5
Q

Who is at high risk of influenza?

A

Adults >65 yo

Children <5 and especially under 2 yo

Chronically ill (DM, COPD, cardiac, renal/liver)

Pregnant women

Healthcare workers

Nursing home residents

Native Americans (top 10 cause of death)

BMI 40+

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6
Q

Why do people die from the flu?

A

Secondary bacterial pneumonia

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7
Q

How does influenza present?

A

Abrupt onset- “I felt fine this morning and now i feel like i got hit by a truck”

Fever- may be very high

Myalgia

Sore throat- may be severely sore, but will not look like anything on exam

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8
Q

Who should be tested for influenza during flu season?

***

A

Healthy people with flu symptoms after a hospital admission, REGARDLESS of time of illness onset

healthy but high risk patients presenting WITHIN 5 DAYS of illness onset

Immunocompromised patients with acute febrile respiratory illness REGARDLESS of time of illness onset

ANY patient currently admitted to hospital who has acute febrile respiratory illness regardless of time of illness onset

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9
Q

Who should be tested for influenza even when it’s not flu season?

A

Healthcare workers, residents, or visitors in an institution experiencing a flu outbreak

Individuals who may have been exposed to the flu either in travel or on a cruise ship

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10
Q

When should any type of flu testing be done?

A

Within first 3-4 days of illness

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11
Q

What two types of flu tests are just screening tests?

A

Rapid antigen test (RAT)-takes 15 min

Immunofluorescence- takes 1-4 hrs

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12
Q

What is the MOST sensitive and specific flu test?

A

RT-PCR

Tells you influenza type and subtype

Takes 1-8 hrs

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13
Q

What is the gold standard flu test for lab diagnosis?

A

Viral cultures

Takes 3-10 days, so this is not for initial clinical management, but to confirm screening

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14
Q

When should you order RT-PCR or viral culture for influenza testing?

A

Negative RAT or immunofluorescence, and community flu rates are high

Positive RAT or immunofluorescence and community flu rates are low

Patient has recent exposure to pigs/poultry and there is worry for novel influenza A virus

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15
Q

Who should receive antiviral treatment for the flu?

A

People at high risk for complications**

Illness requiring hospitalization

Severe/complicated illness

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16
Q

When should antiviral treatment be given for the flu?

A

Within 24-30 hours from onset of symptoms.

Little benefit if given after 30 hrs

(Typically shortens course by 1-2 days)

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17
Q

What are the neuraminidase inhibitors for influenza?

A

Oseltamivir (Tamiflu) 75mg bid x 5 days

Zanamivir (Relenza) 10mg (2 inhalations) bid x 5 days

Peramivir (Rapivab) 600mg IV once

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18
Q

What influenza treatment is contraindicated in patients with asthma/chronic respiratory conditions?

A

Zanamavir (inhaled antiviral)

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19
Q

Can you give neurominidase inhibitors for flu treatment to pregnant women?

A

They are category C, but you should give them if you confirm or suspect influenza A

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20
Q

How long does it take after getting a flu shot for antibodies to develop?

A

2 weeks

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21
Q

How much protection does the flu shot provide against the flu

A

50-80% protection if its a close match

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22
Q

When is the best time to get the flu shot?

A

In October

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23
Q

Is the flu shot recommended for pregnant women?

A

Yes

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24
Q

What are the contraindications to getting a flu shot?

A

Current mod-severe illness

Hx of GUillain-barre within 6wks of previous flu shot

Hx of allergic reaction to flu shot

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25
Q

What is the most common etiology of pharyngitis?

A

Viral

Rhinovirus, adenovirus, parainfluenza, influenza

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26
Q

Which is more likely to cause pharyngeal exudate: viral or bacterial pharyngitis?

A

Bacterial

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27
Q

What viral cause of pharyngitis will be very painful and cause vesicles on an erythematous base?

A

HSV1 and HSV2

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28
Q

What viral cause of pharyngitis will cause tonsillar exudates, enlarged cervical nodes, and splenomegaly in 50 % of the time?

A

Mononucleosis (EBV)

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29
Q

What viral cause of pharyngitis will present with acute gingivitis, painful oropharyngeal ulceration, febrile illness, painless lymphadenopathy, and no tonsillar enlargement or exudates?

A

Acute Retroviral syndrome (HIV infection)

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30
Q

What should you consider testing for if pharyngitis symptoms are not improving in 5-7 days and your patient has risky behaviors

A

HIV testing

This might be acute retroviral syndrome and is often the first presentation of HIV

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31
Q

What is the treatment for viral pharyngitis?

A
  • supportive care/magic mouthwash
  • If caused by HSV- acyclovir, famciclovir
  • If HIV, refer to infectious disease for retrovirals
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32
Q

Which bacteria most commonly causes bacterial pharyngitis?

A

Group A Strep (GAS)

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33
Q

Which bacteria are associated with bacterial pharyngitis from oral sex?

A

C. Trachomatis

N. Gonorrhea

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34
Q

Which bacteria causes pharyngitis with a gray exudate that is tightly adherent to the throat and nasal passageway?

A

C. Diphtheriae

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35
Q

Which bacteria commonly causes bacterial pharyngitis in kids?

A

H. Influenza

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36
Q

How will someone with streptococcal pharyngitis present?

A

Nausea**

Palatial petechiae** CLASSIC

Purulent exudate**

Painful swallowing

Fever, malaise

Swollen glands

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37
Q

What are the Centor Criteria?*

A
  • tonsillar exudates
  • tender anterior cervical adenopathy
  • fever by history
  • absence of cough

Patients with 3/4 of these should be tested for Group A Strep (GAS)

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38
Q

What are the 2 types of tests we can use to determine the cause of pharyngitis?

A

-Rapid antigen detection (Group A Strep) 70-80% sensitivity

-Throat culture- gold standard
Can order bacterial and viral

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39
Q

What diagnostic test is the gold standard for determining the cause of pharyngitis?

A

Throat culture

90-95% sensitive
95-99% specific

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40
Q

Which bacteria will the Rapid Antigen Detection Test (RADT) test for?

A

Group A Strep

41
Q

What should you do if a patient meets 3/4 of the Centor Criteria, but their Rapid Antigen Detection Test came back negative for Group A Strep?

A

Treat them empirically for GAS while awaiting culture results.**

(RADT is only 70-90% sensitive)

42
Q

What is the first line treatment for streptococcal pharyngitis?

A

Penicillin V 500mg P.O. TID x 10 days

Amoxicillin 500mg BID x 10 days

Penicillin G benzathine (bicillin) 1.2 mil units IM single dose

Cephalexin 500mg P.O. BID x 10 days

43
Q

How do you treat streptococcal pharyngitis if someone has a penicillin allergy?

A

Azithromyin 500mg P.O. day 1 followed by 250 mg days 2-5

Clindamycin 300mg po x 10 days

Clarithromycin 250mg bid x 10 days

44
Q

What kind of supportive care can you offer to patients with streptococcal pharyngitis in addition to antibiotics?

A

Lozenges, NSAIDS, Tylenol

45
Q

What is scarlet fever?

A

A complication of streptococcal pharyngitis caused by a reaction to a toxin from the bacteria. 10% of patients will experience it. Will go away after abx treatment, but can predispose for acute rheumatic fever.

46
Q

What are the symptoms of scarlet fever?**

A

Rash

Desquamation

Pastia’s lines (in AC fossa)**

Facial flushing with circumoral pallor**

Strawberry tongue**

47
Q

What is the concern with scarlet fever?

A

Can predispose for acute rheumatic fever

48
Q

What do you think it is:

  • Pastia’s lines in AC fossa
  • Strawberry tongue
  • flushed face with circumoral pallor
  • rash
  • desquamation
A

Scarlet fever

49
Q

How long after starting antibiotics will someone with streptococcal pharyngitis be contagious?

A

No longer contagious after 24 hours. Can return to school/work

50
Q

How long will it take for streptococcal pharyngitis symptoms to improve after starting abx?

A

3-4 days

BUT no longer contagious after 24hrs

51
Q

What is the most common deep neck infection in children and adolescents?

A

Peritonsillar abscess

52
Q

What are the main differences between peritonsillar abscess and cellulitis?

A

Cellulitis:
No pus. Infection of tissue between palatine tonsils and pharyngeal muscles

Abscess: Collection of pus between tonsil and pharyngeal muscles. Usually a progression of cellulitis

53
Q

WHat are the predominant bacteria that cause peritonsillar abscess?

A

GAS

Staph (including MRSA)

Mixed respiratory anaerobes

H.influenzae

54
Q 
What do you think it is:
Unilateral sore throat 
Drooling
Trismus
Fever
Neck pain/swelling
Uvula deviation*
Palpable fluctuance of soft palate*
Hot Potato voice*
A

Peritonsillar abscess

55
Q

When would you do imaging if you suspected a peritonsillar abscess?

A

To r/o spread to parapharyngeal space or if you can’t do the exam due to trismus.
Distinguishes cellulitis from abscess

56
Q

If you did order imaging for suspected peritonsillar abscess, what imaging would you order?N

A

CT with IV contrast (soft tissue!)

57
Q

Is imaging necessary in order to diagnose peritonsillar abscess?

A

No,

you can draw labs, do a throat culture, and do a culture and gram stain of aspirated abscess fluid

58
Q

What is one of the main concerns with peritonsillar absecsS?

A

Airway obstruction

59
Q

What is some of the supportive care you need to give to patients with peritonsillar abscess?

A

FLUIDS (super sore throat, probably haven’t been drinking)

Pain control

60
Q

What antibiotics do you prescribe for peritonsillar abscess?

A

Parenteral:
Ampicillin-sulbactam
Clindamycin

Oral:
Augmentin
Clindamycin

61
Q

What bacteria typically causes epiglottitis?

A

H influenzae

62
Q

Is epiglottitis an emergency?

A

YES

Need hospitalization, intubation, and antibiotics

63
Q 
What do you suspect:
Drooling
Stridor
Severe sore throat
No cough
Toxic appearance
Unvaccinated child or older adult
A

Epiglottitis

64
Q

What would you see on a lateral X-ray on someone with epiglottitis?

A

“Thumb sign”

65
Q

What can cause retropharyngeal abscess/cellulitis?

A 
Trauma (chicken bone)
Recent instrumentation (tonsillectomy)
66
Q

What do you suspect:
Very stiff neck
Minimal peritonsillar findings
No trismus

A

Retropharyngeal abscess or cellulitis

67
Q

What is Ludwig’s Angina?

A

Submandibular space infection

68
Q

What can cause Ludwig’s angina?

A

Tooth infection

69
Q 
What is it:
Stiff neck
Drooling
Unable to speak
“Woody” hardened submandibular area
Crepitus of submandibular area
No trismus
Elevated, tender oropharynx
A

Ludwig’s angina (submandibular space infection)

70
Q

What is the most common cause of infectious laryngitis?

A

Viruses (associated with URI)

71
Q

What are non-infectious causes of laryngitis?

A 
Vocal abuse
Smoke inhalation
Radiation
GERD
Vocal cord nodules
Laryngeal nodules
Cancer of vocal cords
Neurologic dysfunction
72
Q

What is the KEY symptom of laryngitis?

A

Hoarseness

73
Q

When would you refer to ENT for laryngitis/

A

Hoarseness for more than 2 weeks in the absence of URI infection. Especially with hx of alcohol or tobacco.

74
Q

What is treatment for laryngitis/

A 
Treat underlying cause
Voice rest
Humidifier
Hydration
Stop smoking
No antibiotics unless bacterial
75
Q

What are the symptoms of all types of rhinosinusitis?

A

Purulent nasal drainage
AND
Nasal obstruction

And/or:
Facial pain
Pressure/fullness

76
Q

What is the difference between acute, subacute and chronic rhinosinusitis/.

A

Acute <4 weeks

Subacute 4-12 weeks

Chronic >12 weeks

77
Q

What is Recurrent acute rhinosinusitis?

A

4 or more episodes of acute rhinosinusitis per year

78
Q

What is the most common etiology of acute rhinosinusitis?

A

Viral.
(“Acute viral rhinosinusitis” AVRS)

Rhinovirus
Influenza
Parainfluenza

79
Q

What is the difference between AVRS and ABRS?

A

Acute viral rhinosinusitis

Acute Bacterial rhinosinusitis

Signs/symptom severity varies based on which one you have

80
Q

What are some of the signs/symptoms of acute rhinosinusitis?

A 
Low fever
Nasal congestion
Facial pain
Fatigue
Cough
Maxillary tooth discomfort*
Ear pressure
Headache
Purulent nose drainage
Nasal mucosa swelling
Edema over cheekbone/periorbital
Tenderness to percussion of upper teeth
Sinus tender to palpating
Transillumination of frontal/maxillary sinuses may show opacity, unreliable

(Common cold would only share rhinorrhea, nasal congestion, low fever, nasal mucosal swelling, cough)

81
Q

Should we do radiographs, cultures or sinus films to diagnose AVRS?

A

No

Sinus films won’t really help because we cant see ethmoid sinus and we are unable to distinguish polyps from fluid/edema

82
Q

What is the treatment for AVRS/

A 
Supportive- 
Analgesics
Neti pot
Mucolytics
Intranasal decongestants 
Intranasal glucocorticoids
83
Q

Where do most cases of Acute BACTERIAL rhinosinusitis come from?

A

A viral infection followed by a secondary bacterial infection

(The mucosal edema and inflammation leads to trapped bacteria)

84
Q

What are the three cases where you would want to give antibiotics for ABRS?

A
  1. Persistent symptoms lasting more than 10 days with no improvement
  2. Onset with severe symptoms (<102 fever, purulent nasal discharge, facial pain lasting 3-4 consecutive days at onset)
  3. Viral URI that lasted 5-6 days and started to improve, followed by severe symptoms “double worsening”
85
Q

What makes a patient at high risk for antibiotic resistance? **

A

65 or older

Severe infection, fever 102+

Hospitalized in last 5 days

Immunocompromised

Comorbidities (DM, cardiac)

Antibiotic use in the last month (no matter what for)

86
Q

What is the first line antibiotic treatment for ABRS for a patient not at high risk for antibiotic resistance, and without a penicillin allergy?

A

Augmentin 500mg TID or 875mg BID

5-7 days**

87
Q

What is the first line antibiotic treatment for ABRS in a pt who is not at high risk for antibiotic resistance but DOES have a penicillin allergy?

A

Doxycycline 100mg BID
Levofloxacin 500mg QD
Moxifloxacin 400mg QD

All for 5-7 days**

88
Q

What is the antibiotic treatment for ABRS for a patient that is at risk for antibiotic resistance or for whom the first treament (Augmentin 500mg TID or 875mg BID x 5-7 days) did not work?

A

Augmentin 2000mg BID for 7-10 days

89
Q

What is the antibiotic treatment for ABRS for a pt who is at high risk for antibiotic resistance or for whom the first treatment (levofloxacin 500mg, Doxycycline 100mg, or moxifloxacin 400mg x 5-7days)
Did not work AND they have a penicillin allergy?

A

Levofloxacin 500mg qd
Doxycycline 100mg bid
Moxifloxacin 400mg qd
x7-10 days

Same drugs and dosages, but now you do it longer! 7-10 days**

90
Q

What is Complicated acute bacterial rhinosinusitis?

A

Spread of infection to the CNS, orbit, or surrounding tissues

91
Q

What are some of the presentations of complicated ABRS?

A

Osteomyelitis- infection in bone after frontal sinus infection

Meningitis, brain abscess, epidural abscess

Periorbital/preseptal cellulitis

92
Q

How do you diagnose complicated ABRS**

2 methods, which is gold standard?

A

CT scan With contrast**

Sinus Aspirate culture is Gold Standard (ENT will do this though)

93
Q

How do you manage complicated ABRS?

A

Admit to hospital

URGENT ENT/ID CONSULT

94
Q

What are the 4 cardinal symptoms of chronic rhinosinusitis in adults?

A

Mucopurulent nasal drainage

Nasal obstruction/congestion

Facial pain/pressure/fullness

Reduced sense of smell

95
Q

What are the 4 cardinal symptoms of chronic rhinosinusitis in childern?

A

Mucopurulent nasal drainage

Nasal obstruction/congestion

Facial pain/pressure/fullness

Cough

(In adults the 4th one is loss of smell, not cough)

96
Q

What are the diagnostic criteria for chronic rhinosinusitis?

A

The presence of at least 2 of the 4 cardinal symptoms of CRS lasting over 12 weeks with medical management,
PLUS either:
-Sinus mucosal disease with imaging showing mucosal thickening or pacification of the paranasal sinuses
OR
-direct visualization of mucosal inflammation, polyps in nasal cavity, and/or purulent mucus and edema

97
Q

What, other than Chronic rhinosinusitis can cause loss of smell?

A

Facial/head trauma

Sinus surgery

Zinc supplements

98
Q

When would you order a NON-contrast CT for rhinosinusitis?

A

When rhinosinusitis is recurrent or treatment resistant, and you want to look at the bony structures to see if there’s something causing that chronic rhinosinusitis

Clin Med Exam 2 (Lauren) (6 decks)

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