Pulmonology
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| Urine Ag test for: | S pneumo or Legionella pneumophila PNA
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| PNA empiric tx | resp FQs, macrolides, 2G or 3G cephs x5-21days = TxOC; kids HD amox or Aug
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| Nosocomial PNA tx | Antipseudomonal PCNs + aminoglycosides or cephs ± vanc; Early onset: CTX or resp FQ (IV), Unasyn or ertapenem; Late onset (poss MDR): antipseudomonal ceph + antispeudo FQ; aminoglycoside + vanc
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| PNA Mgmt guides (acronyms) | PORT, CURB-65 (consciousness impaired, urea>7, RR>30, SBP<90, >65yo
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| Nosocomial PNA bugs | GN: E coli, PA, klebs, acinetobacter; SA, SP, H flu
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| Pos PPD tx | INH 300mg daily for 6-12 months; monitor LFTs
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| Aspergillus tx | itraconazole, voriconazole; resection
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| Flu incubation | 1-4 days post-exposure
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| Flu presentation in kids | croup, bronchiolitis, GI upset, conjunctivitis, OM; sore throat, nasal congestion, conjunctivitis, nonproductive cough
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| Flu: comps | Pneumonia; Myositis; Myocarditis, pericarditis; Aseptic meningitis; Encephalitis; Reye syndrome; Guillain-Barre syndrome
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| Flu: dx | Epidemiologic; Virus isolation or antigen detection; Serologic
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| Most common clinical manifestation of acute upper airway obstruction: | croup
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| Croup presentation | stridor, barking seal; worse at night; winter; 6 mos-3 yo; males; Parainfluenza; high RR, rales, rhonchi, retractions; steeple sx
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| Prolonged expiratory phase, hyper-resonance to percussion, & wheezing = | bronchiolitis
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| Bronchiolitis presentation | <2 yo (peak 6 mos); M>F; winter; if cardiopulmonary dz / immunodeficiency: more severe dz; concurrent URI; low fever
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| Bronchiolitis agent | RSV or HMPV (also poss PIV, flu or adeno)
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| Premature infants w/bronchiolitis often have: | apneic spells as presenting symptom
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| Bronchiolitis: X-ray may show: | hyperinflation, atelectasis and infiltrates
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| Croup/bronchiolitis tx | supportive; cool mist humidification; pulse ox, O2 if hypoxemia; poss bronchodilators
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| Pneumonia RFs | CHD/ lung dz; CF; asthma; SCD; immunodeficiency syndromes
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| Pneumonia: viral causes | more common in kids <5 yo; RSV, PIVs, Influenza, Adenovirus
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| Pneumonia: viral causes in neonates: | consider CMV, Herpes, rubella
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| Pneumonia: bac causes if <1 month old | GBS, SA, gram neg enteric bacilli; T. pallidum; Listeria
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| Pneumonia: bac causes for 1 month-5 yo | SP (most common); H flu; GAS; SA (&MRSA); M. pneumo; C. pneumoniae
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| Pneumonia: bac causes for >5 yo | M pneumo most common; SP, C pneumo; TB
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| Less common bac causes of pneumonia | C trachomatis (afebrile pneumo in 2 wks-3 mos); pertussis, PCP
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| Pneumonia: dx | CXR = segmental infiltrates, atelectasis, pleural effusions; poss empyema; blood cx pos in 10-30% of bac
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| Viral pneumonia s/s | tachypnea, retractions, nasal flaring & use of accessory mx; diffuse rales, wheezing; CXR diffuse interstitial infiltrates & hyperinflation
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| M pneumo findings | CXR interstitial or bronchopneumonic infiltrates, frequently in the middle or lower lobes; Fever, cough, HA, malaise; sore throat / OM
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| No. 1 cause of death from infectious disease in the US | pneumonia
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| HAP = sx onset >___ hours after hospital admission | 48
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| Most common cause of bacterial pneumonia (70%) | Streptococcus pneumoniae
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| May have associated non-respiratory syndromes (CNS, immune hemolytic anemia) | Mycoplasma pneumoniae
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| may cause necrotizing infiltrates or pneumatoceles | Staphylococcal pneumonia; GN; aspiration pna
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| Inhalation of oropharyngeal or gastric contents (volume-dependent) | aspiration pneumonia
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| RF for infection with drug resistant pneumococci | recent beta lactam therapy (within 3 months); >65 yo
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| Risk factor that increases the risk for gram negative respiratory infection | residence at nursing home
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| RF for pseudomonas aeruginosa PNA | Corticosteroid therapy (> 10 mg/d of prednisone); Structural lung disease (bronchiectasis); Broad-spectrum antibiotics (>7 d in past month)
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| Apical/posterior infiltrates of upper lobes, F, C, dry cough | TB
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| Pediatric with barking cough, stridor | viral croup (laryngotracheobronchitis); Tx w/ racemic epi and glucocorticosteroids if stridor at rest.
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| Fever (80%), cough, rusty sputum. RR often >24. Crackles/rales, decreased breath sounds, dullness to percussion, +egophony, pectoriloquy. CXR infiltrates/ consolidation | Pneumonia
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| Pt >35 yo with PNA. Rusty colored or yellow-green sputum. Acute onset, F/C. Bug = | Strep pneumoniae
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| Pt <35 yo, college students. Fever, cough, +/- sputum, chills, muscle aches. PNA bug = | Mycoplasma pneumonia
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| PNA w/ Smokers, COPD: bugs = | H. influenza; M cat (COPD)
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| PNA w/ DM, immunocompromised, EtOH. Currant color sputum. Bug = | Klebsiella
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| PNA w/ Water, late summer, construction site. Diarrhea, toxic looking; males, high fevers, multilobar dz | Legionella
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| PNA from Nursing homes, chronic care facility. Purulent sputum. Bug = | Staphylococcus aureus
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| PNA & HIV+, AIDS, Immunocompromised, sxs out of proportion to exam; diffuse interstitial/alveolar infiltrates. Bug = | Pneumocystis jerovecii (tx of choice: TMP-SMX)
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| PNA & decreased mental status, poor dental hygiene, dentures, foul smelling sputum, bronchiectasis. Patchy infiltrates in dependant lung zones | Aspiration PNA
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| Cystic fibrosis w/ PNA. Bug = | Pseudomonas aeruginosa
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| PNA: lancet-shaped gram-positive diplococci | Strep pneumo
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| PNA: patchy lower lung consolidations. Bug = | Pseudo aeruginosa
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| Gram negative PNA organisms (2) seen in EtOH/COPD: | Klebsiella, Legionella
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| Lancet shaped gram positive cocci in pairs = | Streptococcus pneumoniae
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| TB infection is spread person to person via: | respiratory droplets in air (cough)
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| Positive PPD Zone Size >= __ mm if no risk factors: | 15
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| Positive PPD Zone Size >= __ mm if co-morbid RFs: DM, CKD, ca, IVDA, congregate setting, foreign born/immigrant <5yrs from endemic area (Asia, Africa, Latin America), Mycobacteriology lab tech, gastrectomy | 10
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| Positive PPD Zone Size >= __ mm if HIV+, contact of TB+ person, organ transplant / immuno-suppression, fibrotic CXR, on 15 mg prednison/day, or TNF alpha inhibitor | 5
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| Positive PPD Zone Size >10 if comorbid RFs = | DM, CKD, ca, IVDA, congregate setting, foreign born/immigrant <5yrs from endemic area (Asia, Africa, Latin America), Mycobacteriology lab tech, gastrectomy
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| Positive PPD Zone Size >5 if: | HIV+, contact of TB+ person, organ transplant / immunosuppression, fibrotic CXR, on 15 mg prednisone/day, or TNF alpha inhibitor
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| Substance used for control in PPD test: | Candida albicans antigen
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| The inability to react to TB skin tests because of a weakened immune system = | anergy
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| More specific test for LTBI & can help exclude BCG or Mycobacterium (non-TB) reactions = | Interferon Gamma Release Assay
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| Macrophages: Activated phagocytic cells are common in: | fungal, acid-fast & some atypical bacterial infections
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| Influenza has an incubation period of ___ days | 1-4
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| Fever, myalgia, headache, malaise, nonproductive cough, sore throat, rhinitis are all symptoms of: | influenza
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| Flu resolves in ___ days; cough/ malaise can persist for 2 weeks | 3-7
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| Children with influenza may present with: | otitis media, nausea, vomiting
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| Viral cultures are optimal from ______ specimens and require specific viral culture media | nasopharyngeal
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| Only _______ are effective against both Influenza A and B | ostelmavir and zanamivir
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| Who needs annual influenza vaccinations? | LT aspirin tx. PG. Chronic medical conditions (pulmo, cardiac, metabolic, renal, neuro, immunodef, hemoglobinopathy). SNF residents. Age 6 mos-18 yrs or >50 yo
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| Who needs annual influenza vaccinations? | Chronic medical conditions (pulmonary, cardiac, metabolic, renal, neurologic, immunodeficiency, hemoglobinopathy)
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| Cough, weight loss, fever, night sweats, hemoptysis, fatigue, decreased appetite, chest pain can be: | reactivated TB
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| In bacterial pneumonia, blood cx is positive how often: | in 10-30%
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| frank pus located in pleural space = | empyema
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| Pulmonary defense mechanisms = | mucociliary lining of lung, phagocytes (alveolar macrophages, neutrophils), surfactant, IgG, chemotactic agents (C5a, IL-8)
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| Serum antibody titer (IgG, IgM, Legionella) can be helpful to dx: | Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella
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| Respiratory anthrax tx | Cipro or doxy
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| Respiratory (pneumonic) plague tx | streptomycin or doxy
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| Respiratory tularemia (F tularensis) tx | streptomycin
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| Bronchitis vs pneumonia | Bronchitis: prior URI; cough, low fever, clear lungs or ronchi, normal CXR. PNA: acute cough, fever, tachypnea, CP, WBCs, pulmonary infiltrate on CXR
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| ‘Discovered’ in 1976; found in aquatic environments | Legionella pneumophilia
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| 50% of 20 yo have serologic evidence of past infxn; assoc w/ chronic inflammatory dz (atherosclerosis) | Chlamydia pneumonia
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| pneumococcus colonizes ____% of healthy adults | 5-10
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| Risk factor for enteric gram negative respiratory infection | underlying cardiopulmonary disease
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| Influenza rate has doubled in past decade, possibly due to: | aging population and/or change in predominating viral strains (H3N2)
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| Influenza sees resolution in ___ days, though cough and malaise can persist for over 2 weeks | 3-7
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| lower respiratory tract is normally sterile if | directly sampled
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| Acceptable sputum specimen has fewer than ___ squamous epithelial cells per low power field | 10
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| vaccine against tuberculosis | Bacille Calmette-Guérin (BCG)
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| Short-term cough, producing mucoid sputum, persistent cough after 5 days of URI, usually viral in etiology | acute bronchitis
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| Lower respiratory tract starts below what anatomic structure? | vocal chords
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| Tx of latent TB | INH x9 months (or RIF x4 months; or RIF + PZA x2 months in resistant pts)
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| Tx of active TB | Quad therapy x8 weeks (INH/vit B6, RIF, ethambutol, PZA), followed by INH/RIF x4 months
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| Tx of TB in immunocompromised pt | HIV: Quad tx x1 year. Pt on chemo: 6-9 months
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| TB tx if converted neg to pos | INH 6-12 months
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| TB tx of family members of index case | INH x1 year as Ppx
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| Side effects of ethambutol | optic neuritis, red/green color blindness
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| Side effects of rifampin | liver dysfunction, rash, flu, turn orange
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| Side effects of INH | hepatitis, peripheral neuropathy (give vit B6 with INH)
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| Side effects of pyrazinamide (PZA) | increased uric acid, hepatitis
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