primary care 1

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dheartrn
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127762
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primary care 1
Updated:
2012-02-27 00:11:35
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ENT colds pneumoni bronchitis asthma COPD
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meds, issues & tx
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  1. Some ototoxic medications such as ASA and ASA containing medication regardless of the amount oand duration of usage--when discontinued, result in complete recovery of hearing and cessation of assoicated symptoms such as tinnitus. true or false?
    True!
  2. what are the 5 signs of ototoxicity?
    • New onset tinnitus-noises in the ear(s)
    • Changes in existing tinnitus
    • Fullness or pressure in ear(s)
    • hearing loss or fluctuations in hearing
    • Vertigo
  3. name 6 common ototoxic medications
    • ASA & ASA containg products
    • NSAIDS

    Antbx: Aminoglycosides, Erythromycin. Vanco, Tobramysin, Amikacin, Netlmicin

    Loop Diuretics: Lasic Edecrin & Bumex

    Chemotherapeutic AGents: Cisplatin,k Nitrogen Mustard & Vincristine

    Quinine: Aralen, Atabrine, Legatrin, Q-Vel
  4. Toxic effects of NSAIDS are usually reversible (but not always) once NSAIDS are discontinued. True or False?
    True
  5. Aminoglycosides are most ototoxic when given IV, IM or PO?
    • IV
    • monitor theraputic levels to prevent harm
  6. Vanco is potentiall ototoxic when given IV, IM or PO?
    • IV
    • use caustion when patient also on aminoglycoside as potential for toxicity is increased.
  7. The ototoxic effects of quinine are similar to ASA and therefore the toxic effects are ALWAYS reversible. True or False?
    • False
    • although the ototoxic effects of quine are similar to ASA they are USUALLY reversible
  8. what is your dx?
    patient c/o sneezing, watery rhinorrhea, nasal congestion, itchy palate, itchy red & watery eyes.
    Allergic Rhinitis and Conjunctivitis
  9. you supect allergic rhinitis but it is not responsive to your tx so you do some blood work and find eosinophilia is your diagnosis confirmed?
    Yes, if neutrophilia had been found then it would be more likely an infectious cause rather than an allergic cause.
  10. In allergic rhinitis which antibodies are allergens activating?
    • IgE antibodies
    • treatment stratagies depend on modulation of immune response:

    interfere with the function of IgE antibodies

    interruption of the release of antigen-induced autocoids (histamine and eicosanoids) from IgE-sensitized cells

    inhibition of autacoid effect at receptor sites

    and the resolution of inflammation
  11. oral antihistamines do not treat which symptom of allergic rhinnitis?
    nasal congestion
  12. Allegra, Zyrtec, Claratin, Clarinex & Astelin are all what class of drugs?
    • second-gen antihistamines
    • they reduce, sneezing, itchy & runny nose by blocking H1 receptors and inhibiting autocoid release
  13. Beconase, Rhinocort, Flonase, Nasonex, Nasalide & Nasalcort of what class of drugs?
    • nasal corticosteroids
    • reduce sneezing, eye and nasopharyngeal itching, runny nose and congestion by inhibiting influx of inflammatory cells
  14. Montelukast (Singulair) is what class of drug?
    • Leukotriene-receptor antagonist
    • it reduces mucosal inflammation
  15. Ipratropium (Atrovent Nasal) is what class of med?
    Anticholenergic it reduces a non-stop runnynose
  16. Cromolyn (Nasalcrom) is what type of med?
    • mast-cell stabalizer
    • so it inhibits histimine release and reduces all the symptoms of rhinitis.
  17. There are some topical agents for ocular use to decrease the itchy watery inflammed conjuntivia associated with allergic rhinitis. True or False?
    • True
    • Mast-cell stablizers,, antihistamines and NSAD drugs have occular preperations
  18. Sudafed is what class of medication?
    a-Adrenergic agonist it vasoconstricts and relieves nasal congestion
  19. Prednisone, methylprednisolone and tramcinolone are what type of medications?
    oral corticosteroids that inhibit inflammatory cells. use only with cases unresponses to less agreessive tx.
  20. what is the recommendation for intial symptom relief of allergic rhinitis?
    nasal corticosteroids
  21. mast-cell stabalizers might be most effective as mono OTC therapy when used how?
    jsut before exposure, for exmaple when you are going to visit someone with a cat (and you are mildly allergic to cats)
  22. when would you combine a nasal corticosteroid with a second generation antihistamine?
    moderate to severe rhinitis with congestion.
  23. what is considered normal hearing (in decibles , dB)?
    0-25 dB
  24. what is considered severe hearing loss? (answer in dB, decibels)
    71-90 dB
  25. conductive hearing loss occurs when sound is inadequatley conducted through ...
    the external or middle ear to the inner ear
  26. Sensorineural hearing loss occurs when sound is carried normally through the external and middle but...
    there is a defect in the inner ear which results in sound distortion
  27. Sound waves enter the external auditory canal, travel to the middle ear (tympanic membrane and ossicles) and then into the inner ear coclea, where CN VIII carries the sound to the brain. This describes what type of hearing, conductive or sensoneuro?
    air conduction tested with Rhine test (tunign fork by ear)
  28. The large majority of adults with acute pharyngitis has a self-limited illness, fow which supportive care only is needed. what is that supportive care?
    analgesics and antipyretics OTC symptom abatement
  29. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria to determine the likelyhood of GABHS and the need for antibiotics. What are the 4 Centor criteria?
    history of fever, tonsillar exudates, no cough and tender anterior cervical lymphadenopathy (lymphadenitis).
  30. what is GABHS?
    Group A B-Hemolytic streptococcus, the causitive agent in approximately 10% of adult cases of pharyngitis. AKA "strep throat"
  31. How many of the 4 Centro criteria need to be present before you test or treat for GABHS (group A B-hemolytic streptococcus)
    • minimum of 2/4 for testing treat with positive quick test, or with all 4 criteria.
    • algorythm www.aafp.org/afp/2001/0415/p1557.html
  32. treatment for strep throat with what antbx?
    (GABHS pharyngitis)
    • penicillin or amoxicillin if penicillin allergy go to erythromycin
    • z-pack is expensive but effective, not ness. first line.
  33. a defect in the inner ear which results in sound distortions is called what kind of hearing loss?
    sensorineural or conductive?
    sensorineural
  34. fill in the blanks about air conductionsound transmission :
    Normally sound waves enter the external ______ _______, then trave to the middle ear's ______ _______ and ______ and then into the inner ears ______. The cochlear division of CN_____ carries the sound impulse to the brain.
    Normally sound waves enter the external auditory canal, then travel to the middle ear's Tympanic Membrane and Ossicles and then into the inner ears Cochlea.The cochlear division of CNVIII carries the sound impulse to the brain.
  35. is this a cause of conductive or sensorineural hearing loss

    impacted cerumen
    conductive
  36. Is this a cause of conductive or sensorineural hearing loss?

    Presbycusis, vascular changes or stiffening of the basilar membranes
    Sensorineural
  37. Is this a cause of conductive or sensorineural hearing loss?
    Noise exposure
    sensorineural
  38. When a person has a conductive hearing loss bone conduction is greater than air conduction. True or False?
    • True
    • so the Rhinne test will show little to no air conduction once bone conduction of the tuning fork stops.
  39. In sensorineural hearing loss, bone conduction and air conduction are both equally epreciated mainting the relative difference of bone and air conduction so in this case like in anormal ear AC is better than BC. True or False?
    True. However the sound may be heard much longer in the unafffected ear than the affected ear. So in the good ear AC 40sec and BC 10 sec. In the "bad ear" AC 25 seconds BC 5 seconds. AC is stil greater than BC but note the diffference.
  40. in a normal ear AC>BC
    true or false?
    true
  41. Is this a cause of conductive or sensorineural hearing loss?

    Otisis Media
    conductive hearing loss
  42. Is this a cause of conductive or sensorineural hearing loss?

    Eustachian tube dysfunction
    Conductive hearing loss
  43. Is this a cause of conductive or sensorineural hearing loss?

    Drug ototxicities
    sensorineural hearing loss
  44. Is this a cause of conductive or sensorineural hearing loss?

    Meniere's Disease
    sensorineural hearing loss
  45. Is this a cause of conductive or sensorineural hearing loss?

    Benign tumors of middle ear and
    Carcinoma of external auditory canal and/or middle ear
    conductive hearing loss
  46. Is this a cause of conductive or sensorineural hearing loss?

    Trauma
    sensorineural hearing loss
  47. Is this a cause of conductive or sensorineural hearing loss?

    endocrine disease, congenital occurance, viral illnessm basilar migraines, Paget's disease, collagen diseases and demyelinating processes
    sensorineural hearing loss
  48. Is this a cause of conductive or sensorineural hearing loss?

    Otosclerosis
    conductive hearing loss
  49. client presents with sensitivity to sound diminished but clarity unchanged. If volume is increased hearing is normal what type of hearing loss are you concerned with? What will the Rhinne and Weber show if you are right?
    • conductive hearing loss
    • Rhinne BC>AC in affected ear
    • Weber will be hear louder in the affected ear
  50. what is Otosclerosis and when should you suspect it as the culprit behind hearing loss?
    Otosclerosis abnorm growth of the bone of the middle ear. A slow progressive hearing loss usually beginning in the 20's or 30's.
  51. Is Otosclerosis a conductive or sensorineural hearing loss?
    conductive
  52. What is Presbyusis?
    age related hearing loss commonly caused by loss of the tiny hairs inside your ear that pick up sound waves and change them into nerve signals.
  53. 82 year old client complains that he notices that some sounds are overly loud, he can't hear well in noisy areas, some sounds are hard to distinguish like s and th, certain people's speech sounds mumbled or slurred, and he has some ringing in the ears, what is your suspition?
    Presbycusis
  54. client c/o changes in hearing what kinds of questions should you ask?
    • Onset: when did you first notice it? Location: unilateral bilateral
    • Duration: acute, chronic, progressive, fluctuating?
    • Character-associated symptoms, fever, ear pain, discharge, vertigo, tinnitus, neurologic disturbances (headache)
    • Agrrevating factors: What makes it worse? noise exposure, trauma, viral infections, medications
    • Relieving factors: what makes it better?
    • Timing and severity impact on ADL's
  55. c/o hearing loss or changes by patient what focused physical exams should you do?
    visual exam of TM and external auditory canl, pneumatic otoscopy to determine mobility of TM, clincial hearing test, whisper, Weber and Rinne, as ell as Complete head, neck and cranial nerve exam.
  56. You suspect a tumor or bony lesion is affecdting hearing loss in your patient what should you order?
    CT scan
  57. Vertigo and tinnitus are present with hearing loss what type of testing should you order?
    vestibular testing to determine the cause brain or inner ear.
  58. Refer to _____ for patients with acute hearing loss who do not have an apparent dx or in patients who do not improve with appropriate tx.
    ENT
  59. Refer to ___________ for patients with chronic deficits who may benefit from a hearing device
    audiologist
  60. refer to _________ for otosclerosis and congenital or acquired causes of conductive hearing loss.
    Surgeon
  61. an elderly industrial worker presents with ear pain , itching, a sensation of fullness in his ears and has condcutve hearing loss in one ear, that is new. What might you see on visual exam with otoscope that could be the problem?
    impacted cerumen (lots of ear wax!)
  62. what is a contraindication (relative) to ear lavage for excess ear wax affecting hearing?
    history of prior ear surgery potential for perforation, use caution.
  63. You see a lot of ear wax and the client is an elderly industrial worker with ear fullness, some pain and itching and some new hearing loss. what are 3 differntials to consider?
    foreign bodies, otitis media, otitis externa
  64. The ear wax is nto loosening with irrigation what can you order to go home with patient?
    Debrox/Murine 3-4gtts 3-4x daily. can loosen up the wax and it may fall out on it's own.
  65. client presents with ear pain. On exam you notice inflammation of the external auditory canal. This client swims and showers daily, uses q-tips after showers, has seasonal allergies and has a mild skin condition. What is the likely cause of this ear pain?
    • OE Otitis Externa
    • caused by bacteria or occasionally fungi
  66. what is this the clinical presentaion of?
    Ear pain- may begin gradually or suddenly
    pain increases with pressure on tragus, when pinna is moved &/or with jaw movement.
    ear feels full or blocked.
    purulent discharge and conductive hearling loss may occur.
    itching can occur with fungal invaders
    OE Otitis Externa
  67. how do you treat OE?
    • gently remove all exudative debris with gentle irrigation or suction
    • If swelling prevents the passage of topical meds, insert a cotton wick. drops should be placed on wick for first 2 days then remove the wick and place drops directly in the ear canal.
  68. what antbx are used to treat bacterial OE?
    • Polymyxin B Sulfate, Neomycin, Cortisportin Otic: 4 drops QID for 7 days
    • TobraDex 4 drops TID or QID for 7 days
    • Cipro HC Otic or Floxin Otic 3 drops TID for 7 days
  69. OE with a fungal presentation (often itchy) are treated with what medications?
    • Otic Domeboro 5 drops QID for 7 days
    • Vosol 5 drops QID for 7 days
    • Clotrimazole (Lotrimin) Solution 3 drops BID for 5-7 days
    • Severe cases may requiresystemic antibiotics Cipro or Augmentin
  70. with OE patients what care directives (education) instructions should you give?
    • keep water out of ear use cotton ball dipped in vasaine to plug ear in shower-no swimming
    • don't insert anything inthe ear to clean it
    • should resolve in 7 days.
    • moderate and severe cases should return to office in 2-3 days to check progress.
  71. Otitis Media an infection or inflammation of the middle ear. What type of OM is usually bacterial, with a rapid onset of signs and symptoms?
    Acute Otisits Media (AOM)
  72. how would you describe recurrent OM?
    3 or more cases in 6 months or 4 cases within one year
  73. Persistent inflammation manifested as asymptomatic middle ear fluid that follows AOM or arises without prior AOM is what type of ear infections?
    OME Otitis Media with effusion
  74. What causes Otitis Media?
    Eustachian tube dysfunction or anything that impedes flow of middle ear secretions (like infection or allergy which causes edema and congestion of the mucosa (breeding ground for germs)of the naopharynx, eustachian tube and middle ear.)
  75. what are the most common pathogens in otitis media?
    streptococcus pnuemoniae, haemiophilus influenzae, moraxella catarrhailis, and viruses
  76. Your patient has mild ear pain following a viral URI, he noticed some otorrhea, and changes in hearing in one ear (the one that is sore) and some vertigo at times. He thinks he had a fever last night, but not sure he still has one today. What dx are you contemplating?
    Otitis Media varify by visualizing typanic membrane looking for buldging or redness.
  77. with otitis media what kind of focused history questions do you need to ask?
    onset and duration of symptoms, specifically any fever, ear pain, hearing loss, tinnitus and dizziness. Any drainage from the ear, and associated sx like nasal congestion, headaches, sore throat and cough.
  78. You are assessing for what appears to be otitis media. what parts of the physical exam are you going to perform?
    • VS including temp
    • inspect nasal mucosa and pharynx for edema, boggyness, erethyma
    • palpate sinuses and lymph nodes
    • examine auricle and external auditory canal
    • Visualize the TM look at position, color, degree of translucency and mobility
    • And as always, heart and lung exam
  79. When a healthy adult has ear pain and the ear exam is norm be sure to do a more thorough exam of the head and nexk, examine mouth and teeth, assess function of TMJ, assess nose and pharynx, assess cranial nerves. What differntials are you ruling out?
    External otitits externa, mastoiditis, furnucle, TMJ, mumps, dental abscess, tonsillitis, foreign body and trauma.
  80. treatment of otitis media?
    • 1st line txAmoxicillian or Trimethopirm-Sulfamethoxazole
    • avoid analgesics like tylenol, antihistamines can thicken secretions and worsen the problems so avoid them and follow up in 2-3 weeks from intial visit to re-eval.
  81. when do you refer a client with otitis media?
    • when they have hearing loss bilaterally of 20dB or more
    • chroinic or persistent infection with evidence of mastoid involvement
    • recuurent infections
    • cholesteatoma formation or chronic perforation
  82. what should you find if a soputum culture is positive for strep? what will the report say that lets you know it is positive?
    more than 25PMN and <10 epithelial cells
  83. HCAP is associated with what kinds of organisms?
    • usually bacterial, aerobic gram neg bacilli
    • Pseudomonas aeruginosa
    • Escherichia coli
    • Klebsiella pneumoniae
    • Acinetobacter species
    • MRSA
    • use florquinolones (moxiflaxin)
  84. how do you treat bacterial pneumonia (CAP) out patient?
    doxycycline or Z-pack
  85. those at risk for CAP
    • smokers
    • ETOH
    • HIV
    • Auto immune compromise
  86. what are the criteria for HCAP dx?
    hint: 4 things
    • hospitalized >2 days
    • resident of skilled nursing facility
    • recieved IV antbx or chemo or wound care
    • on dialysis
  87. your preceptor tells you this patient has a less virlulent type of pneumonia and shows you a chest film with patchy diffuse infiltrates. What type of pneumonia is this?
    bronchiopneumonia
  88. what is the dx criteria for CAP?
    • at least 2/4 sx of acute infection
    • fever
    • cough
    • dyspnea
    • acute infiltrate on chect x-ray
    • remember must be aquired outside of hosp or extended care facility!
  89. antbx for hsopitalized pneumonia patient
    • moxiflaxin or levafloxin IV
    • if ICU pt will get cefuroxamine and azythromycin or moxifloxacin (with PCN allergy wil get moxifloxacin)
  90. antbx for pneumonia?
    • azythromycine
    • biaxin
    • erythromycin
    • doxycycline
    • if > 60 or with comorbid illness consider Quinolones
  91. what are the tx guidelines for CAP?
    • azithromax
    • erythromycin
    • if comorbid illness or PCN allergy go right to quinolone
  92. what are the 3 types of pneumonia?
    • CAP
    • HCAP
    • Hospital
  93. what finding is the key to dx pneumonia versus bronchitis or influenza or something else?
    • vital signs!
    • with pneumonia high HR, RR & high Fevers
  94. new onset confusion in elderly patient no other symptoms?
    consider infection and possibly pnemonia, get a chest x-ray!
  95. what is the cornerstone of dx for pneumonia?
    chest x-ray
  96. what antbx do you give for bronchitis?
    • cefuroximine (2nd generation bata lactam)
    • macrolide (like azythromycin)
    • bactrim (sulfa)
    • doxcycline (tetracycline)
  97. when do you give antbx for bronchitis?
    • COPD cefuroxime, bactrim macrolide or doxycycline
    • Chronid Illnees like liver, renal, CA, CHF or those without a spleen
  98. symptomatic treatment of bronchitis, what do you tell client?
    • bronchodialaor like albuterol
    • cough suppression with dextromethorphan or tussinex
    • keep well hydrated
    • stop smoking!
  99. describe the presentation of acute bronchitis.
    • acute onset of productive cough in pt with no hx of a cough or COPD
    • possibly a fever
    • bronchial breathsounds or wheezed over treachea
    • if lobular consolidation consider pneumonia-get a chest x-ray
  100. what are some differentials to consider with fever, cough and fatigue as the presentation?
    • URI
    • asthma
    • PE
    • COPD
    • Sinusitis
    • Pneumonia
    • Flu
    • Bropnchitis
  101. what componants of a focused physical exam should be done with a suspected bronchitis or pneumonia presentation?
    • general appearance
    • VS, including orthostatic
    • assess hydration:mucus membrane, skin turger & urine output
    • ENT & Neck
    • heart and lung (be thourough)
    • abd
    • menningeal signs
  102. what are the 4 questons to ask yourself when someone presents with acute cough?
    • 1. is the process limited to the trachea and bronchus or is there a pneumonia present?
    • 2. is a dx workup needed or can empiric tx be started?
    • 3. Are antibx indicated? is so which ones?
    • 4. Can the pt be tx safely as outpatient or should they be admitted?
  103. what can you recommend for a runny nose?
    • Topical stuff
    • nasal antihistamikne (patanase)
    • nasal anticholenergic (atrovent)
    • nasal decongestant (nasalcrom-but only us for 3 days max)
    • sudafed
    • Antihistamine (claratin/allegra)
    • Guiafenesin
  104. why would you recommend a nasal antihistamine like pantanase?
    for a runny nose
  105. why would you recommend someone take nasalcrom? And why for no more than 3 days at a time?
    drys up a runny nose but can lead to rhinnitis medicomentosa (addiction)
  106. client complains of URI with cough and purulent sputum, what is the tx?
    • symptom relief for the first 10-14 days.
    • vitamin C
    • Zinc
    • Echinacea (not for immunocompromised)
    • anti-inflammatory
    • antihistamine like sudaphed or atrovent
    • and rest
  107. rhinovirus give you what?
    common cold
  108. how do you prevent colds and flu?
    • frequent hand washing
    • get enough sleep
    • immune system drops 60% after just 3 days of poor sleep!
  109. if a client has purulent sputum and a cough are antibx needed? If so which ones?
    NO-none
  110. why recommend Vitamin C for a cold?
    • lymphocyte concentration 100x that of plasma, may prevent oxidative damage, enhance T lymphocyte proliferation and activity
    • oxidative damage can cause cellular damage.
  111. why recommend Zinc for a cold?
    • zinc is needed for neutorphil natural killer celss and T lymphocyte function
    • Ainc is capable of inhibiting viral replication so it may prevent virus from attaching and spreading shortening duration or severity of symptoms.
  112. Why should someone take ecinacea for a cold?
    • antibacterial and antiviral properties in vitro
    • possible immune system booster
    • incrased lymphocutes and granulocytes
    • use no more that 3 weeks b/c you build tolerance
    • CONTRAINDICATED IN CHRONIC STATES LIKE LUPUS, MS HIV
  113. An acute cough lasting less than 3 weeks is most like due to?
    • infection
    • common cold
    • rhinusistis
    • sinusitis
    • bronchitis
    • pneumonia
  114. a post infectious cough is common. How long can it last and why does it occur?
    healing epithelium of brunchus cause it and it can last fo up to 8 weeks!
  115. acute bronchitis hold the antibiotics and focus on symptom relief, but how?
    • cough suppression
    • adequate hydration
    • smoking cessation
  116. what is AECB?
    • acute exacerbation of chronic bronchitis
    • seen in patients with COPD
    • treated with cefuroxime or macrolide (Z-pac), bactrim or doxycycline
  117. finding of pleurisy, dyspnea hempptysis with high fever, tchypnea and or tachycardia suggestive of pneumonia or bronchitis?
    pneumonia
  118. high fever, HR & RR with finding of crackles, bronchial breath sounds, tactile fremitus, dullness to percussion, egophony, whispered pectoriloquoy suggest bronshitis or pneumonia?
    pneumonia
  119. you suspet pneumonia what diagnositcs should you consider ordering?
    • chest x-ray (number 1)
    • CBC,CMP, BNP-looking for CHF
    • sputum culture and gram stain
    • blood cultures for in pt or pre-admission
    • HIV status
  120. how is pneumonia classified?
    • location
    • lobar-aspiration usually virulent organism
    • bronchopneumonia-less virulent more common
    • Where it was acquired
    • Community (CAP)
    • Hospital
    • Health Care associated (nursinghome, dialysis, hopitalized more than 2 days in the past 3 months, recieving IV antibx, chemo or wound care)
  121. what are the goals of diagnosis and treatment for pneumonia?
    • determine who can stay home/need admit
    • provide empiric tx based on likely pathogens
  122. what can you use to test for Legionell and strep pneumoniae?
    urinary antigen assay-results are available immediately and they are not affected by antbx!
  123. why would you be checking procalictonin in someone suspected of having pneumonia?
    it is an inflammatory marker specifically increased in sepsis and bacterial infections so it will help in the decison to use antibiotics
  124. although clinical features do not accurately predict oganism type, how might a classical pneumococcal or staphyloccal pnemonia present?
    sudden chill followed by fever, pleuritic pain and procutive cough.
  125. Although clincial features do not preict organism type how might an atypical mycoplasma or chlamydia pneumonia present?
    begin with a sore throat and headache followed by a non-productive cough and dyspnea
  126. bacterial pathogens associated with pneumonia?
    hint: 6
    • 1. streptococcal (gm+ cocci in prs)
    • 2. Staph Aureus (gm + cocci in clusters)
    • 3. Haemophilus Influenza (gm- pleomorphic cocco-bacillus)
    • 4. Klebsiella (lg gm- rods)
    • 5. Moraxella Catarralis (gm- diplococcus)
    • 6. Legionnaire's Disease (gm- rod)
  127. what is the most common pneumonia pathogen (30-50% of all cases)
    strep pneumonia
  128. how does strep pneumoniae present?
    often with classic presentation: abrupt onset fever, cough with rusty sputum , and pleuritic chest pain.
  129. pt presesnt with abrupt onset of high fever, cough with rusty sputum and pleuritic chest pain, you suspect strep pneumoniae how do you test for this in the office?
    pneumococcal urinary antigen assay
  130. what might be associated with pneumonia, either making dx hard or complicating the course of the pneumonia.
    • bacteremia
    • pleural effusion
    • otitis media
    • empyema
    • meningitis
  131. what are the complications of strep pneumoniae?
    • bacteremia
    • meningitis
    • endocarditis
    • pericarditis
    • empyema
  132. Staph Aures is implicated in only about 10% of pneumonia. when would you consider it as the culprit of your clients sx?
    • follwoing a respiratory infection, especially influenza, and even more so in a young otherwise healthy person
    • common nosocomial infection
    • IV drug use is a risk
    • pt who becomes extremely ill can have lung necrosis or multiple small lung abcesses on films.
  133. what are some of the complications of staph aureus pneumonia?
    • bacteremia with metastatic seeding of distant sites (heart, bone, joint liver and meninges)
    • empyema
    • cavitation
    • residual pulmonary fibrosis following recovery
  134. What is a common cause of bronchitis in adults with chronic lung disease (COPD?Asthma)
    • haemophilus Influenza
    • treat with TMP-SMZ
  135. what is a typical bronchopneumia pattern?
    patchy diffuse infiltrates, may been seen with influenza
  136. influenza is a gm-coccobaccili is usually beta lactamase producing what should you treat with?
    • combo drug amoxicillian clavulanate
    • for PCN allergic patient cefuroximine axetil
  137. influenza can present with what comorbidities making it hard to dx?
    OM, sinusitis, bronchitis, epiglottitis, cululitis, arthritis, meningitis and endocarditis!
  138. what is the key to dx epiglottitis
    abrupt onset high fever, drooling c/o of severe sore throat despite and unimpressive exam
  139. what kind of pneumonia am I?
    Gram- bacilli, found in debilitate or ETOH atients, exray shos dense lobar onsolidation can cause tissue nerosis (hemoptysis) currant jelyy sputum and has a high incidence of abcess formation.
    • Klebsiellla Pneumonia
    • treat with cephalosporing if PCN allergy try TMP-SMZ (sulfa)
  140. Atypical pathogens caussing respiratory symptoms that mimic bronchitis and pneumonia include?
    • Influenza types A & B
    • varicella
    • CMV
    • Parainfluenza
    • Adenovirus
    • Respiratory syncytial virsu (RSV)
  141. Mycoplasma pneumonia often begins with headache, malaise, sore throat and progresses to non-productive cough. it is common late summer/early fall, spreads eassily has ear pain 30% of the time x-ray patchy broncho-pneumonia and skin may sow erythema, how would you treat?
    macrolide or tetracycline
  142. Chlamydia Pneumonia accounts for 10-20% of atypical pneumonias (TWAR) often confused with viral URI, and laryngitis, dry cough andparyngitis, chest x-ray with minimal patcy infiltrates how would you treat?
    tetracycline or macrolide
  143. This atypical pneumonia is found in clients with an underlying pulmonary disease. more common in winter sx are low grade fever and prductive cough. itis a gm-cocccus, what kind of pneumonia is this how do you treat it?
    • Moraxewella Catarrhalis Pneumonia
    • treat with cefuroximine, a fluoroquinolone (ciprofloxacin, moxifloxacin or levofloxacin)
  144. what risk factors increase contracting Legionella pneumona?
    • COPD
    • ETOH
    • smoking
    • immuno suppression
    • being male
    • +potable water and cooling system exposure
  145. what are the clinical features of legionella pneumonia?
    • intially : fever, no-productive cough, N/V, Myalgias,dyspnea and pleuritic chest pain
    • progressing to: chest pain, confusion, diarrhea & relative bradycardia
    • extrapulmonary finding: myocarditis, pericarditis, rhabdomylysis and renal dysfunction.
  146. patient ahs pleuritic chest pain, N/V, fever, non-productive cough and is getting worse. Blood work shows sodium<130, client has diarrhea and neurological symptoms, chest c-ray shows interstitial infiltrates what are you thinking?
    • Legionella pneumonia
    • sputum culture will have many PMN without bacteria (bugs)
  147. what does this constellation of sx suggest? high fever, hyponatremia, CNS manifestations, lactate dehydrogenase levels of >700
    • Legionella pneumonia
    • treat outpatients with erythromycin, azithromycin or fluroquinolones
  148. what type of pneumonia will be a middle lobe pneumonia?
    aspiration usually right middle lobe and mixed infection cause by normal flora of mouth.
  149. if signs of pnemonia plus headache what type of atypical pnemonia should you consider?
    • mycoplasma
    • treat with clarithromycin, azithromycin or doxycycline
  150. If signs of pneumonia and diarrhea what type of atypical pneumonia should you consider?
    • Legionnaires
    • trat with Azythromycin or fluroroquinolone
  151. sign of pneumonia and myalgias what atypical pneumonia should you consider?
    viruses, symptom support
  152. Sins of pneumonia and bullous myringitis (blistered and inflamed typanic membrane) what kind of pneumonia should you consider?
    • mycoplasma
    • treat with clarithromycin, azithromycin or doxycyline
  153. what is the empirical tx for pneumonia in out paitents <60 years old with no co-morbidityand moderate severity?
    • zithromax 500 mg QD
    • Biaxin 500mg BID
    • Erythomycin 500mg PO BID
    • Doxycycline 100mg PO BID
    • 3rd or 4th generation quinolone
  154. what is the empirical tx for suspected pneumonia in out patients with mild to moderate illness age > 60 or with comorbid ilneess?
    • rspiratory fluoroquinolone (moxifloxacin, gemifloxacin or levaquin)
    • beta lactam +macrolide
  155. with pneumonia and bronchitis what sx relief besides antibiotics can you offer a client?
    • adequate hydration water and humidificaton
    • expectorants to loosen sputum guaifenesin
    • aspirin or tylenol for fever
    • COUGH SUPPRESSION IS NOT RECOMMENDED
  156. admit or tx as out patient
    age >65 temp>101
    admit
  157. admit or treat as outpatient?
    BP <90, HR >120 RR >30
    admit
  158. admit or treat as outpatient?
    hypothermia age > 65 bilateral infilitrated, and pumonary edema
    admit
  159. hyponatremai PO2 < 60 on RA temp >101 vomiting
    admit (rational turns definitive on low PO2- other sx may be due to illness and vomiting alternig lab work but that would not affect PO2 to this degree)
  160. admit or treat as outpatient?
    pneumonia with comorbid illnees of CA, CHF, ESRD or cirrosis?
    admit
  161. you have been treating someone empirically for pneumonia and they return 2 days after starting antbx. They have fever of 100, myalgias, fatigue, cough, and stuffy nose. BP 90/60 HR 100 admit or keep as outpatients
    outpatient, assuming this is better than initial visist and they have help at home.
  162. what is the PSI (pneumonia severity index)
    • http://pda.ahrq.gov/clinic/psi/psicalc.asp
    • plug in findings.
  163. what are the CURB 65 criteria?
    • confusion
    • Uremia
    • Respiratory Rate
    • Blood Pressure
    • age > 65
    • 1 point for each if score >2 admit.
  164. outpatients with pneumonia should be re-evaluated when? and for what?
    • 48-72 hours
    • looking for decreased fever, respiratory rate and WBC stabalizing
  165. clients who are smokers, or x-smokers and post pneumonia need a chest x-ray. How long after symptoms subside should this be ordered and evaluated?
    2-3 months
  166. what can you do to prevent pneumonia?
    • get the vacine , it covers 90% of identified pathogens and is 80% effective!
    • influenza vaccine is yearly
    • stop smoking
    • proton pump inhibitor use is associated with increased incidence of CAP.
  167. whooping cough is most contangious in what stage?
    cvatarrhal stage
  168. what is the catarrhal stage of whooping cough?
    • it is similar to the common cold
    • nasal discharge,
    • sneezing
    • low grade fever
    • intermittent cough
    • highly infectious stage
  169. what is a paroxysmal stage of whooping cough (AKA pertussis)
    • nasal symptoms resolve
    • cough worsens spasms of quick, short coughs like a machine gun without breathing in between coughts, patients gag and gasp and often expel thick mucus, may be followed by vomiting and exhaustion
  170. what is the convalescent stage of whooping cough (AKA cough of 100 days)
    • gradual recovery
    • cough disappears over period of 2-3 weeks
    • classic cough may return with URI's over the next 6-12 months due to residual airway inflammation
  171. what is the best way to test for pertussis?
    isolation by culture (nasal swab?)
  172. how do you treat pertussis (whooping cough)
    macrolides like azythromycin
  173. what might you consider with chronic cough >3 weeks duration?
    • tabaccoa abuse & chronic bronchitis
    • GERD (75% of chronic cough with norm chest x-ray are from GERD)
    • allergic Rhinitis with postnasal drip
    • post infectious cough
    • habit cough
    • psychogenic
    • ACE Inhibitor side effect
  174. what really bad stuff should you rule out with the chronic cough presentation (duration >3weeks)
    • TB
    • HIV
    • Malignancy
    • CHF
    • Interstitial Lung disease
    • ACE Inhibitor
  175. influenza comes in 3 flavors A, B, C! which one only affects humans?
    • B & C
    • A affects humans, birds, pigs and ponies
  176. H1N1 is what kind of flu?
    Avian (Bird flu)
  177. describe antigenic drift
    • small chages in the virus that happens continually over time so that a new unrecognizable virus is formed and your immunity to the old virus won't work agains the new shifted virus.
    • virus Evolution
  178. Now describe antigenic shift
    shift between species creates a totaly new strain of the virus only occurs in type A
  179. which causes pandemic outbreaks antigenic shift or antigenic drift
    shift
  180. with season influenza how long between exposure and symptom expression?
    1-4 days
  181. when is the person infectious with seasonal influenza and for how long are they contagious (shedding virus)
    contagious 1 day before symptoms and for upt to 10 days after symptoms!
  182. what symptoms are associated with the flu?
    • sudden onset chills an fever (101-103)
    • sore throat, dry cough
    • fatigue, malaise
    • myalgia
    • diarrhea
    • headache
    • substernal soreness
    • photophobia
    • ocular problems
  183. what can the seasonal flu mimic? what are your differntials?
    • pneumonia
    • adenovirus
    • RSV
    • rhinovirus
    • parainfluenza virus (these viruses lead to Uppper and Lower respiratory infrections)
    • legionella
  184. of all the sx in common for cold and flu which are rarely seen with a cold?
    fever and headache (and extreme fatigue)
  185. which pneumonia is most common and which is most serious?
    • pneumococcal pneumonia is most common
    • staphylococcal pneumonia is most serious.
  186. what is the tx for the flu?
    • bedrest
    • analgesics
    • fluid
    • antiviral therapy with those at risk for complication-the earlier started the more effective
    • Oseltamivir=Tamiflu H1N1 resistant
    • Zanamivir
    • may need to add amantadine d/t resitance
  187. so if starting antivirals for flu when is soon enough?
    • within 12-24 hours of symptoms
    • remember H1N1 is resistant to Tamiflu (Oseltamivir)
  188. who should get antivirals for flu profalaxis
    • unvaccinated infants
    • adults >65
    • residents of nursing comes
    • comorbid conditions (respiratory, immunocompromised, renal, cardiopulmonary issues)
  189. when do you admit for flu?
    • persons with limited support (homeless/elderly)
    • pneumonia
    • changes in mental status
    • consider in pregnancy
  190. who gets which flu vaccine? traditional inactivated
    high dose inactived
    high dose attenuated (LAIV)
    • all are trivalent (covers 2 A & 1 B strain)
    • inactivated anyone
    • high dose inactived >65 yrs
    • high dose attenuated (LAIV) 5-49 flu mist
  191. who needs a flu vaccination
    • everyone >6 mon-5yr
    • pregnant women
    • people>50
    • those with chronic conditions
    • institutionalized
    • healthcare providers
    • household contacs of persons with chronic conditions
  192. who should not get a flu vaccine?
    • people with anaphylactic rx to egg
    • hx guillain-barre syndrome
    • persons with thrombocytopenia
    • persons VERY ill with fever (minor URI, mild fever, those on coumadin or corticosteroids it's okay they can have it)
  193. what is this the definition of?
    Chronic inflammatory disorder of the airways leading to airflow limitation.
    asthma
  194. With asthma airway inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough with an increase in symptoms when?
    night and early morning.
  195. Asthma is an obstuctive lung disease has what primary characteristic?
    • airway inflammation
    • characterized by hyperirritable airways=reversible airway obstuction
  196. hyperirritible airways that may produce reversible airway obstruction are found in what disorder?
    asthma
  197. which form of asthma occurs in adults and is not assoicaited with specific triggers?
    intrinsic or extrinsic
    intrinsic
  198. which is the allergic form of asthma?
    intrinsic or extrinsic?
    extrinsic (allergic) assiciated with specific inhaled substances.
  199. Pathological features associated with Asthma
    • airflow obstruction
    • bronshoconstriction & airway hyperreactivity
    • edema & airway inflammation
    • cough
    • mucous hypersecretion & impaired mucous clearance
  200. During asthma sx are caused by
    narrowed airway which causes what sx? tightened airway muscles causing what sx?
    inflammed thickened airway wall with increased mucous.
    • inflammed and thickened airway walls narrow airways and limit air flow.
    • tightened airway muscles, constrict airways
    • again limiting air flow
    • lastly these make it hard to clear mucous.
  201. what are the four components of asthma management?
    • Assessment and monitoring
    • 1. controlling factors contributing to asthma
    • 2. severity (smoking and allergen exposure)
    • 3. pharmacologic therapy
    • 4. education for a partnership in asthma care
  202. when intially diagnosing ashtma what are the steps (focal points).
    • detailed medical history
    • physical exam focus upper resp, chest and skin
    • spirometry to demonstrate revesibility
    • addtional diagnositc testing PRN to exclude other possible dx
  203. what key symptoms are assoicated with asthma dx or exerbation?
    • cough
    • recurrent wheeze
    • recurrent difficulty breathing
    • recurrent chest tightness
  204. True or false?
    asthma symptoms occur or worsen in the presence of:
    exercise
    viral infection
    inhalant allergens
    irritiants
    changes in weather
    strong emotional expression
    stress
    menstrual cycles
    true
  205. Name some key symptoms that suggest asthma
    • prominent nocturnal symptoms
    • symptoms occur in worsen in a seasonal pattern
    • patients has eczema, hay fever of family hx of ectopic diseasedssymptoms respond to anti-asthma therapy
    • patients colds go to the chest or take more than wo days to clear up.
  206. what are you looking for in the detailed medical history when working up a diagnoisis of asthma
    • sx and patterns of sx
    • family hx of asthma and allergy
    • severity of asthm-onset
    • sx frequency and severity
    • exercise tolerance
    • hopitalizations
    • current medications
    • look for identifying factors
    • resp ifnections
    • inhaleant allergens
    • tobacco smoke

    • Associated illnesses-atopic derm and allergic rhinitis
    • Use of oTC bronchodilator
  207. what sort of things tend to be exacerbating factors with asthma?
    • sinusitis
    • reflux esophagitis
    • viral URI
    • allergens
    • exposure to smoke, chemicals
  208. Asthma triggers:name at least 2 of each:
    indoor allergens
    outdoor allergens
    pharmacologic
    occupational allergens
    irritants
    miscellaneous
    • indoor allergens
    • animal dander
    • dust mites
    • cocroaches
    • mold
    • outdoor allergrens
    • chemicals
    • dust
    • fumes
    • Irritants
    • air pollution
    • tobacco smoke
    • fumes
    • Miscellaneous
    • cold
    • laughter
    • emotional upset
    • feed additives
    • GERD
    • sulfites
  209. what is the asthma triad?
    • mucosal swelling nose
    • increased nasal secretions
    • nasal polyps
  210. client has mucosal swelling in the nose, lots of nasal secretions and you notice nasal polyps what dx should you consider?
    asthma
  211. during an asthma attack which phase is prolonged, exhilation or inhalation?
    expiration
  212. what is the diagnostic clinical cinstellation that leads to the dx of asthma?
    • episodic sx of airflow obstruction
    • airflow obstuction is at least partialy reversible measured by spirometry
    • alternative dx have been excluded.
  213. what differntial dx should be considered when ruling in asthma?
    • COPD CHF
    • PE
    • COUGH 2nd to drugs
    • Mechanical obsturcftion
    • hypersensitivity rx
    • idiopathic hyperventilations
    • FBAO
    • cystic fibrosis
    • vocal cord dysfunction
  214. what is the gold standard for sx of asthma
    • spirometry
    • FEV1 <80% predicted for age and sex
    • FEV1/FVC< 0.65 or below the lower limit of normal
    • Flow volume lops
    • and it can show reversibility when FEV1 increase >12% after short-acting inhaled beta2-agonist
  215. FEV1 is what?
    forced expiratory volume in 1 second
  216. FVC is what?
    the total volume of air forcibily blown out after a deep inspriation.
  217. FEV1/FVC is usually reduced in obstuctive diseased like asthma and COPD
    true or false?
    true, usually only 75-80% of normal
  218. FEV1/FVC will be increased in restrictive lung diseases like pulmonary fibrosis, true or false?
    true
  219. name 4 tests that you can use to dx Asthma?
    • CBC-may show leukocytosis with increased eosinophils
    • chest x-ray
    • allergen testing
    • ABG
    • pulse oximetry
    • methacholine and cold-air challenge tests produce bronchoconstriction
    • biomarkers of inflammation (currently in the works)
  220. when do you use methacholine challenge test?
    if the patient has sx of asthma but has a normal spirometry test and no response to a bronchodilator, then oreder methacholine challenge.
  221. methacholine challenge test is negative does the person have asthma?
    no, negative rules out asthma!
  222. A patient comes up positive methacholine challenge test does she have asthma?
    maybe, but interpret this as asthma cautiously if the patient isn't experiencing symptoms.
  223. why would you do allergy testing on a suspected asthma patient ?
    b/c it can identify an allergic basis for the sx and it can evaluate the degree of sensitivity to a specific antigen.
  224. what are the 6 classes of medications for asthma and COPD?
    • short acting beta adrenergic agonisits.
    • long acting beta adrenergic agonists.
    • Methlzxanthines
    • Mast cell stablizers
    • corticosteroids both oral and inhaled
    • Leukotriene modifiers
  225. what asthma meds are common and work fast for quick relief?
    • short -acting beta 2 -agonist
    • anticholinergis
    • systemic corticosteroids
  226. what asthma meds are used daily: for long-term control?
    • Corticosteroids (inhaled and systemic)
    • mediator inhibitors/mast cell stabilizers (Cromolyn/nedocromil)
    • long-acting beta2 -agonisits
    • Leukotriene modifiers
    • Methylxanthines
  227. what's an MDI
    metered-dose inhaler
  228. whats a DPI?
    dry powder inhaler
  229. What are HFA's?
    hydrofluroalkanes , these replace the CFC's
  230. what meds are first line therapy for asthma and the most effective medication for relief of acute bronchospasm.
    • short-acting beta agonisit (SABA)
    • albuterol, levalbuterol (xopenex), pirbuterol, bitolten
  231. SABA's (short- acting beta agtonists like albuterol), do what?
    • relieve acute bronshospasm quickly
    • can be given as MDI or nebulizer
    • can be used for the prevention of exerice induced asthma
  232. If clients is going through more than 1 cansiter of albuterol what is going on?
    inadequate control.
  233. If you overuse albuterol what are the common side effects
    it may not be effective and may actually increase airway hyperresponsiveness
  234. client needs sx control of bronchospasm what will you give?
    albuterol (MDI or nebulizor)
  235. COPD is staged.
    Stage I = FEV1 >80% predicted
    Stage II = FEV1 <50% < 80% predicted
    Stage III = FEV1 <30% <50% predicted
    Stave IV = FEV1 <30%
    at which stage should you check ABG?
    Stage III (<50% predicted) or which signs of right sidedd HF
  236. common x-ray findings with COPD?
    flattening in the diaphram, irregular lung radiolucency reduction &/or absence of vasculature
  237. COPD is commonly misdiagnosed as asthma. what should you remember to not make this error?
    • COPD is not responsive to agrressive asthma therapy (ICS) inhaled corticolsteroid .
    • COPD dyspnea is with exertion, asthma is during attacks
    • COPD has expiratory and inspiratory wheezes, asthma only inspiratory
  238. medications can reduce COPD symptoms, increase exercise capacity, reduce the number and severity of exacerbations and improve helath status but can they modify the rate of decline in lung function?
    • NO!!!
    • only use inhaled or systemic glucocorticosteroids for symptomatic COPD with documented spirometric increase of 20% or more. treatments for subjective symptom management include bronchodilators (anticholenergic, beta adrenergics & theophylline)
  239. combination drugs, short acting anticholinergics and beta agonists produce a greater change in spirometry over 3 months than either one alone. name the combination drugs.
    Combivent albuterol and atrovent
  240. combining long acting beta agonist and tiotropium leads to few COPD exacerbations that either drug alone. name the combination drug
    tiotropium is spirivia (anticholinergic (like atrovent) so use also sometrol (saravent) with it.
  241. what can you add to an ICS (inhaled corticosteroid) to improve lung function than just the steroid alone in COPD patient?
    long acting beta 2 agonist like salmetrol, formotorol or arformoterol
  242. COPD with cardiac disease or co pulmonale you should consider adding which drug?
    • theophylline
    • start low and be aware of other factors that can screw up your dosing plan. you need a larger dose for patients using nicotine, phyention, carbamazapine INH and Ketoconazole. Lower the dose to achieve the same levels with liver, HF pneumonia, antibx, verapamil and nifedipine.
  243. with ICS treamtent like fluticasone/salmeterol monitor for what?
    • thrush and laryngeal
    • seek objective evidence of value in this therapy :improved dyspnea, reduced exacerbations, if no improvement 6 weeks -3 months take them off these meds.
  244. Steroid therapy in COPD discuss use and misuse breifly.
    • shor tburst for exacerbation tapered therapy
    • long term consider QOD dosing
    • immunosuppresion, osetoporaiss, diabetes are complications to consider when weight risk v benefit.
  245. To start O2 Therapy with COPD what are the criteria?
    PaO2 55 or O2 sat 88% with evidence of tissue hypoxia:which includes things like, polycythemia, altered mental status, cor pulmonale, or edema r/t RVF.
  246. what are the components of pulmonary rehab?
    • education about disease and medication use
    • upper and lower extremity strength training to prevent muscle weakness/wasting
    • endurance training
    • breathing retraiing including pursed lip and diaphragmatic breathing
    • pyscosocial support
  247. what medication improves survival in COPD?
    O2
  248. what is more improtant than medications in management of COPD?
    pulmonary rehab
  249. list the steps of care for managing COPD based on staging.
    • Stage 1 avoid risk factors (get flu shots)+ SABA's PRN
    • Stage II add to above 1 LABA and pulmonary rehab
    • Stage III add to above ICS if repeated exacerbations
    • Stage IV add to above O2 consider surgery.
  250. With COPD exacerbations are often responsible for decrements in funcitonal status and quality of life. on average they occur 2-3x yearly. name 2 co-morbid conditions wihcih complicate the assessmnet of an exacerbation of COPD.
    CHF and pneumonia
  251. patients experiencing COPD exacerbations with clinical signs of airway infections (increased color/volume of sputum &/or fever) may benefit from antibx tx. the most common pathogens are strep pneumonia, influenza & maraxalla catrarrhalis. (see it is improtant to get the flu shot). what antibx should you order?
    respiratory fluroquinolones Moxifloxacin, levofloxacin
  252. how long between treatment recommendation for COPD exacerbation management and reassessment?
    hours.
  253. what nonivasive intermittent therapy can you consider to avoid intubation in COPD patient with exacerbation?
    intermittent posistive pressure ventilation. it improves PH and blood gas.
  254. how would you check your COPD patient for malnutrition?
    labs, albumin, pre-albumin and transferrin.
  255. what is the primary cause of cor pulmonale?
    hypoxemia
  256. what do you see on exam with cor pulmonade
    • tricuspid valve insufficency
    • right atrial dilation,
    • dilated neck veins
    • hepatic congestion
    • pedal edema
  257. what is restrictive lung disease?
    inflammation as a result of insult or injury to alveoli leaving fibrosis with irreversible stiffening of the lung parenchyma.
  258. what causes interstitial lung disease (ILD)?
    • enviornmental inhalants
    • drugs
    • radiation
    • infection
    • malignancy
    • idopathic or auto immune diseases
  259. what does interstitial lung disease present as?
    • insidious onset of exertional dyspnea and cough non productive
    • fine late crackles in lung bases
    • "ground glass" on x-ray
  260. to tell restrictive disease from obstructive you need to look at what?
    FEV1/FVC ratio. in obstructive it is <70% and in restrictive it is greater than 70%

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