-
DD's for acute cough.
- Acute Resp Infection (Bronchitis, sinusitis, PND)
- COPD exacerbation
- asthma
- pna
- pulmonary embolism
-
DDs for chronic cough (>8 weeks).
- Asthma (2nd common cause)
- GERD (1st, 2nd, or 3rd)
- Infection: Pertussis, atypical pna
- ACEI (dry cough 1-3 wks after starting)
- chronic bronchitis (smokers)
- bronchiectasis (chronic cough, viscid sputum, bronchial wall thickening on CT)
-
3 most common bugs in CAP.
- S.pneumoniae (rust-colored sputum)
- M.pneumoniae
- Chlamydia pneumoniae
-
Most common cause of death from pna.
S.pneumoniae
-
Low grade fever, cough, chills, HA, malaise, rash, joint aches, arrythmias.
- Atypical pna
- (young, otherwise healthy, non-smokers, community outbreak)
-
Most pts with CAP shoud be treated with a _______ or ________.
-
If DRSP is suspected in pna, what do you Rx?
- Quinolone (Levofloxacin, Moxi, Gemi)
- PCN or Ceph + macrolide or doxy
-
Who whould receive the PPSV23 vaccine?
- adults 19-64 yo who are at increased risk
- (asthma, COPD, CV, etc)
-
Who should receive PPSV13 and then 23 in one year?
- All adults 65 or older
- 19-64 yo with asplenia, immunocompromising conditions, CSF leaks, cochlear implants
-
Key indicators of COPD.
- DYSPNEA that worsens esp w/ activity, and is persistent
- CHRONIC COUGH - intially intermittent, unproductive, then present every day
- CHRONIC SPUTUM PRODUCTION 3 or more months in 2 consecutive years
-
DD for SOB, chronic cough, chronic sputum.
- COPD
- HF (pulmonary edema on CXR)
- Asthma (sx worse in early am or eve/night)
- TB (any age, infiltrate on CXR)
-
What is needed to confirm TB?
sputum
-
GOLD 1 for COPD.
- Mild
- FEV1 80% or greater predicted
-
GOLD 4 for COPD.
- Very Severe
- FEV1 < 30% predicted
-
What 3 things do anticholinergics cause?
- a little bronchodilation
- may cause constipation
- may cause increased IOP
-
When should you use a steroid plus a LABA for COPD?
When FEV1 < 60% predicted
-
What is the first thing you should Rx for COPD?
- short-acting anticholinergic (ipatropium) PRN or
- SABA PRN
-
How do LABAs work?
By reducing inflammation
-
If ipatropium or Albuterol is not working for COPD, what is next?
- Long acting anticholinergic OR LABA
- plus rescue med
-
If Long acting anticholinergic OR LABA plus rescue med is not working for COPD, then what?
ICS + LABA or LA anticholinergic + rescue med
-
If ICS + LABA or LA anticholinergic + rescue med not working for COPD, then what?
- add LABA OR LA anticholinergic or
- change from LABA to LA anticholinergic or from LA anticholinergic to LABA
-
Preferred meds for intermittent asthma.
SABA prn
-
Preferred meds for persistent asthma.
- Low dose ICS
- Low dose ICS + LABA, OR med dose ICS
- Med dose ICS + LABA
-
Follow up appointment should be scheduled __________ while gaining control for asthma.
every 2-6 weeks
-
Follow up appointment should be scheduled __________ to monitor control for asthma.
every 1-6 months
-
Follow up appointment should be scheduled __________ if step down is anticipated for asthma.
3 months
-
____________ is often a marker of inadequate asthma control.
exercise-induced bronchoconstriction
-
What's the most important reason to decrease asthma exacerbations?
to prevent progressive loss of lung fxn (can -> COPD)
-
Tx for pt < 65 yo, otherwise healthy, dx with CAP.
- *Macrolide or Doxy
- (Azithromycin 500mg day 1, 250 mg days 2-5)
-
What 3 things should you consider hospital admission for an adult pt who has pna?
- confusion since onset
- high RR (like 30)
- Narrow pulse pressure (like BP 80/50)
-
Recommended tx for COPD exacerbation.
prednisone 40mg po qd x 5 days
-
SABA is used for _________ in asthma, not to prevent ________.
-
Intermittent asthma: symptoms _______ days/week; nighttime awakenings _______ x month; Use of SABA for symptom control _______ days/week; FEV1 _______% of predicted; exacerbations requiring po steroids ________ per year.
- 2 or less
- 2 or less
- 2 or less
- 80
- 0-1
-
Most common SE of long term ICS?
cataracts & osteopenia
-
Three reasons most people become anemic.
- Blood loss (melena, hematemesis, trauma)
- BM not making enough RBCs
- Increased destruction of RBCs
-
What should cause an alarm if a pt has decreased H&H?
if the pt also has COPD! (b/c it should be increased)
-
What are some reasons the BM would not make RBCs and cause a pt to be anemic?
- lack of nutrients (Fe, folate, B12)
- aplastic anemia, myelodysplastic syndromes
- BM suppression (chemo)
- CRF = decreased EPO
- malignancy, ACD (inflammation)
-
What are some reasonsfor increased destruction of RBCs that would cause a pt to be anemic?
- sickle cell, thalassemia
- malaria
- hemolytic anemia (G6PD deficiency)
-
How would this effect H&H? COPD
increased (b/c O2 deprivation & increased RBCs)
-
How would this effect H&H? CKD?
decreased (no EPO = no RBCs = ACD)
-
How would this effect H&H? DM with A1c 13.8
decreased (thick, sticky blood, RBCs die young = ACD)
-
How would this effect H&H? Testosterone use
increased
-
How would this effect H&H? 84 yrs old
decreased
-
With what two types of anemia should you do a peripheral blood smear?
- microcytic, hypochromic
- macrocytic, normochromic
-
If the iron count is high, what should the TIBC be?
What if iron count is low?
- low
- high
- (more iron = decreased binding capacity)
-
Two common causes of microcytic anemias.
-
How may older adults present with anemia?
exacerbation of co-morbid conditions (angina, worsening dementia)
-
Suppemental replacement for iron when deficient.
- 150-200mg/d ELEMENTAL IRON
- 4-6 months
-
When is Ferrous gluconate given?
usually in pregnancy to prevent IDA
-
What is the best choice to Rx for elemental iron? Why?
- Ferrous fumarate 325mg bid (=106mg elemental)
- b/c Ferrous sulfate 325mg is needed tid (65mg elemental)
-
What is the hallmark of thalassemia?
insufficient synthesis of alpha or beta chains of hgb
-
ACD is usually _____cytic, _______chromic; if longstanding, can be ______cytic, ______chromic.
-
What can cause macrocytosis? (B12 and/or folate deficiency)
- EtOH abuse
- **malabsorption (celiac, IBD)
- Meds (methotrexate, trimethoprim, phenytoin)
- malignancy
- pregnancy & lactation
-
When working up for B12 or folate deficiency, what is the diagnosis if MMA and homocysteine levels are normal?
unlikely B12 or folate deficiency
-
When working up for B12 or folate deficiency, what is the diagnosis if MMA is normal and homocysteine is elevated?
likely folate deficiency
-
When working up for B12 or folate deficiency, what is the diagnosis if MMA and homocysteine levels are elevated?
- B12 deficiency
- maybe folate deficiency
-
What is tx for B12 deficiency anemia?
- B12 IM qd x 1week, then
- weekly x 1 month, then
- monthly for life
-
When can neuro symptoms be expected to improve with B12 replacement?
5-10 days
-
How long should you treat folate deficiency?
- 1-4 months or
- until hematologic recovery
-
What usually causes petechiae?
thrombocytopenia (plt <150,000)
-
Causes of thrombocytopenia
- recent viral or bacterial infection
- drug-induced
- SLE
- antiphospholipid syndrome
- leukemia
-
What will be signifcant with neutrophils (polys or segs) and lymphocytes with a viral infection?
close in number
-
What will be signifcant with neutrophils (polys or segs) and lymphocytes with a bacterial infection?
wide apart in number
-
What does it mean if monocytes are high?
Infection started > 24 hrs ago
-
When do monocytes show up?
after 24 hours
-
If a pt has long-standing IDA for > 1 year, what would his RDWs likely be?
much less than 15%
-
Two most common presenting symptoms of brain tumor in adults.
-
Red flags in history of HA:
First or worst HA: ________
Focal neuro symptoms:_________
Fever: ________
- SAH
- hemorrhage, infection
- infection
-
With HA, don't forget to check what? (esp when PE normal)
- BP, pulse
- palpate head, neck, shoulders, spine
- Bruits (AVM)
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