Respiratory

Question 1

Danger Signals

(5)

Answer 1

COVID-19

Lung Cancer

Acute Carbon Monoxide Poisoning

Pulmonary Emboli

Impending Respiratory Failure (Asthmatic Exacerbation)

Question 2

COVID-19

Infection is caused by the SARS-CoV-2 virus

• Symptoms appear __ to __ days after exposure and may include?
• For some, the presenting symptom is the sudden loss of t____ and/or s____. Some have cold-like symptoms such as sore ___, nasal _____, and rh_____.
• Persons with ______ medical conditions such as heart or lung disease or diabetes are at higher risk of developing more serious ______.
• Most people have mild illness and are able to recover at ____. Advise patient to call their primary care provider for testing instructions and treatment.
• Close contacts need to self-quarantine for a __-day duration. Patients with serious disease (e.g., trouble breathing, confusion) will need ______.

Answer 2

• Symptoms appear 2 to 14 days after exposure and may include?
• For some, the presenting symptom is the sudden loss of taste and/or smell. Some have cold-like symptoms such as sore throat, nasal congestion, and rhinitis.
• Persons with underlying medical conditions such as heart or lung disease or diabetes are at higher risk of developing more serious complications.
• Most people have mild illness and are able to recover at home. Advise patient to call their primary care provider for testing instructions and treatment.
• Close contacts need to self-quarantine for a 14-day duration. Patients with serious disease (e.g., trouble breathing, confusion) will need hospitalization.

Question 3

Lung Cancer

Symptoms depend on location(s) and tumor metastases.

• Majority of patients already have ad_____ disease on presentation.
• _____ (50%–75%) in a smoker or former smoker that persists should raise suspicion.
• _____tysis and dys____ may accompany cough.
• Some have ____ pain, which is described as a d___, a___, persistent pain; some have shoulder and/or b____ pain.
• Recurrent _____ on the same lobe might be a sign of local tumor obstruction.
• Can present with ____ loss, an_____, fa___, and f____.
• ______ syndrome (pupil constriction with ptosis) is present in some patients.

Answer 3

Symptoms depend on location(s) and tumor metastases.

• Majority of patients already have advanced disease on presentation.
• Cough (50%–75%) in a smoker or former smoker that persists should raise suspicion.
• Hemoptysis and dyspnea may accompany cough.
• Some have chest pain, which is described as a dull, achy, persistent pain; some have shoulder and/or bone pain.
• Recurrent pneumonia on the same lobe might be a sign of local tumor obstruction.
• Can present with weight loss, anorexia, fatigue, and fever.
• Horner syndrome (pupil constriction with ptosis) is present in some patients.

Question 4

Lung Cancer

• (1)* most common type of lung cancer (85%).
• Screening test for lung cancer is (1)*?
• The test is recommended for adults age __ to __ years who are chronic ____ (or quit smoking ).

Answer 4

• Non–small-cell lung cancer is the most common type (85%).
• Screening test for lung cancer is an annual low-dose computed tomography (LDCT) of the lung.
• The test is recommended for adults age 55 to 80 years who are chronic smokers (or quit smoking <15 years previously).

Question 5

ACUTE CARBON MONOXIDE POISONING

• Mild-to-moderate cases of carbon monoxide poisoning can present with (1), the most common symptom.
• It can be accompanied by nausea, malaise, and dizziness. In some cases, it may resemble a viral (1) infection (URI).
• Symptoms are variable and can range from mild con____ to co__. There may be a cherry-___appearance of the skin and lips, but it is considered an “insensitive sign.”
• Severe toxicity can present with se____, syncope, or coma.
• Diagnosis is based on history and physical examination in conjunction with elevated carboxyhemoglobin level measured by __oximetry of an ____ blood gas sample. A venous sample can be used, but it is less accurate.

Answer 5

• Mild-to-moderate cases of carbon monoxide poisoning can present with headache, the most common symptom.
• It can be accompanied by nausea, malaise, and dizziness. In some cases, it may resemble a viral upper respiratory infection (URI).
• Symptoms are variable and can range from mild confusion to coma. There may be a cherry-red appearance of the skin and lips, but it is considered an “insensitive sign.”
• Severe toxicity can present with seizures, syncope, or coma.
• Diagnosis is based on history and physical examination in conjunction with elevated carboxyhemoglobin level measured by cooximetry of an arterial blood gas sample. A venous sample can be used, but it is less accurate.

Question 6

PULMONARY EMBOLI

• An older adult complains of _____ onset of dyspnea and coughing. Cough may be productive of ___-tinged f____ sputum.
• Other symptoms are ____cardia, pallor, and feelings of impending ____.
• Any condition that increases risk of blood ____ will increase risk of pulmonary embolism (PE).
• These patients have a history of atrial _____, es_____ therapy, sm____, surgery, cancer, pr_____, long bone ______, and prolonged in_____.

Answer 6

• An older adult complains of sudden onset of dyspnea and coughing. Cough may be productive of pink-tinged frothy sputum.
• Other symptoms are tachycardia, pallor, and feelings of impending doom.
• Any condition that increases risk of blood clots will increase risk of pulmonary embolism (PE).
• These patients have a history of atrial fibrillation, estrogen therapy, smoking, surgery, cancer, pregnancy, long bone fractures, and prolonged inactivity.

Question 7

IMPENDING RESPIRATORY FAILURE (ASTHMATIC EXACERBATION)

• An asthmatic patient presents with tachypnea (>20 breaths/min), tachycardia or bradycardia, c_____, and anxiety.
• The patient appears exhausted, fatigued, and diaphoretic and uses ______muscles to help with breathing.
• Physical exam reveals cyanosis and “_____” lungs with no wheezing or breath sounds audible.
• When speaking, the patient may speak only ___ or two words (cannot form complete sentence because needs to breathe).

Answer 7

• An asthmatic patient presents with tachypnea (>20 breaths/min), tachycardia or bradycardia, cyanosis, and anxiety.
• The patient appears exhausted, fatigued, and diaphoretic and uses accessory muscles to help with breathing.
• Physical exam reveals cyanosis and “quiet” lungs with no wheezing or breath sounds audible.
• When speaking, the patient may speak only one or two words (cannot form complete sentence because needs to breathe).

Question 8

IMPENDING RESPIRATORY FAILURE (ASTHMATIC EXACERBATION)

Treatment Plan

(1) injection stat.

Call (1).

Oxygen at __ to __ L/min;

(1) nebulizer treatments

parenteral (1)

antihistamines (1)

H2 antagonist (1).

After treatment, what is a good sign?

What is the patient then discharged with?

Answer 8

Adrenaline injection stat.

Call 911.

Oxygen at 4 to 5 L/min;

albuterol nebulizer treatments

parenteral steroids

antihistamines (diphenhydramine)

H2 antagonist (cimetidine).

After treatment, a good sign is if breath sounds and wheezing are present (a sign that bronchi are opening).

Usually discharged with oral steroids for several days (e.g., Medrol Dose Pack).

Question 9

Normal Breath Sounds

• Lower lobes:* ______ breath sounds (soft and low)
• Upper lobes:* ______ breath sounds (louder)

Answer 9

• Lower lobes:* Vesicular breath sounds (soft and low)
• Upper lobes:* Bronchial breath sounds (louder)

Question 10

Normal Respiratory Rate

=

• Women tend to have slightly ____ rates than men.
• A very small increase in partial pressure of carbon dioxide (PaCO2) will affect the respiratory rate. But high levels of carbon dioxide (>70–80 mmHg) can _____ respiration and cause head_____, restlessness, un______, and d_____.

Answer 10

In adults is 14 to 18 breaths/min.

• Women tend to have slightly higher rates than men.
• A very small increase in partial pressure of carbon dioxide (PaCO2) will affect the respiratory rate. But high levels of carbon dioxide (>70–80 mmHg) can depress respiration and cause headaches, restlessness, unconsciousness, and death.

Question 11

Normal Findings: Tachypnea

Increased respiratory rate has many causes, including increased oxygen _____, hyp____, and increased Pa_____.

Many conditions can cause tachypnea, such as p___, fe__, fev___, physical ex____, as____, pn______, P_, and h____thyroidism.

Answer 11

Increased respiratory rate has many causes, including increased oxygen demand, hypoxia, and increased PaCO2.

Many conditions can cause tachypnea, such as pain, fear, fever, physical exertion, asthma, pneumonia, PE, and hyperthyroidism.

Question 12

Egophony

• Normal =*
• Abnormal =*

Answer 12

• Normal =* Will hear “eee” clearly instead of “bah.” The “eee” sound is louder over the large bronchi because larger airways are better at transmitting sounds; lower lobes have a softer-sounding “eee.”
• Abnormal =* Will hear “bah” sound.

Question 13

Tactile Fremitus

How to test for tactile fremitus?

• Normal =*
• Abnormal =*

Answer 13

Instruct patient to say “99” or “one, two, three”; use finger pads to palpate lungs and feel for vibrations.

• Normal =* Stronger vibrations are palpable on the upper lobes and softer vibrations on lower lobes.
• Abnormal =* The findings are reversed; may palpate stronger vibrations on one lower lobe (i.e., consolidation); asymmetric findings are always abnormal.

Question 14

Whispered Pectoriloquy

How to test for this?

• Normal =*
• Abnormal =*

Answer 14

Instruct patient to whisper “99” or “one, two, three.” Compare both lungs. If there is lung consolidation, the whispered words are easily heard on the lower lobes of the lungs.

• Normal:* Voice louder and easy to understand in the upper lobes. Voice sounds are muffled on the lower lobes.
• Abnormal:* Clear voice sounds in the lower lobes or muffled sounds on the upper lobes.

Question 15

Percussion

How to percuss?

What sound is heard over normal lung tissue?

What sound is heard with chronic obstructive pulmonary disease (COPD), emphysema (overinflating). If empty, the stomach area may be?

What sound is heard with Bacterial pneumonia with lobar consolidation, pleural effusion (fluid or tumor). A solid organ, such as the liver?

Answer 15

Use middle or index finger as the pleximeter finger on one hand. The finger on the other hand is the hammer.

• Resonance* = Normal
• Tympany or Hyperresonance*
• Dull Tone*

Question 16

Pulmonary Function Test

Gold Standard test for (2) (pre- and post-bronchodilator)

Measures ob_____ vs. r_____ dysfunction

Answer 16

Gold Standard test for Asthma and COPD (pre- and post-bronchodilator)

Measures obstructive vs. restrictive dysfunction

Question 17

Pulmonary Function Testing Terms

• (1) =* Amount of air that a person can forcefully exhale in 1 second.
  (1) = Total amount of air that can be exhaled during the FEV1 test.
  (1) = Proportion of a person’s vital capacity that the person is able to expire in 1 second.

Answer 17

Forced expiratory volume in 1 second (FEV1): Amount of air that a person can forcefully exhale in 1 second.

Forced vital capacity (FVC): Total amount of air that can be exhaled during the FEV1 test.

FEV1/FVC ratio: Proportion of a person’s vital capacity that the person is able to expire in 1 second.

Question 18

FEV1/FVC Ratio

Normal > ___%

COPD < ___%

Answer 18

Normal > 75%

COPD < 70% (0.7)

Question 19

Obstructive vs. Restrictive Dysfunction

Classify these conditions as obstructive or restrictive dysfunction

Obstructive definition =

Restrictive definition =

1. Asthma
2. COPD (chronic bronchitis and emphysema)
3. Pulmonary Fibrosis
4. Diaphragm obstruction
5. Bronchiectasis
6. Pleural disease

Answer 19

Obstructive = reduction in airflow rates

Restrictive = reduction of lung volume due to decreased lung compliance

1. Obstructive
2. Obstructive
3. Restrictive
4. Restrictive
5. Obstructive
6. Restrictive

Question 20

Chronic Obstructive Pulmonary Disease

Definition + Permanent loss of (1)

Most characteristic symptom of COPD (1)

FEV1/FVC < ____

Most common cause? Highest incidence in what gender, what age?

Answer 20

Chronic obstructive pulmonary disease (COPD) is a chronic lung disease characterized by the permanent loss of elastic recoil of the lungs, alveolar damage, airflow limitation, chronic inflammation, and changes in the pulmonary vasculature.

Chronic and progressive dyspnea

FEV1/FVC < 0.7 (<70% lung function)

Chronic cigarette smoking, men >40 yo

Question 21

COPD

Most patients have a mixture of (2)

May have (1) component that overlaps with COPD known as (ACOS)

Pulmonary hypertension aka (1) may develop in later stages

COPD now ___ leading cause of death in US

Answer 21

Most patients have a mixture of emphysema and chronic bronchitis

May have asthma component that overlaps with COPD known as (ACOS-asthma COPD overlap syndrome)

Pulmonary hypertension aka cor pulmonale may develop in later stages

COPD now 4th leading cause of death in US

Question 22

Chronic Bronchitis

=

Answer 22

This is defined as coughing with excessive mucus production for at least 3 or more months for a minimum of 2 or more consecutive years. There is airway hypersecretion and inflammation.

Question 23

Emphysema

=

Answer 23

Irreversible enlargement and alveolar damage with loss of elastic recoil result in chronic hyperinflation of the lungs. Expiratory respiratory phase is markedly prolonged.

Question 24

Asthma

=

Answer 24

Airway inflammation resulting in hyperreactivity. The contribution of each disease (chronic bronchitis, emphysema, asthma) varies in each individual.

Question 25

Asthma Risk Factors * **(1)** (etiology in up to 90% of cases of COPD), older age (\>40 years). * **(1) exposure** (e.g., coal dust, grain dust) is responsible for about 10% to 20% of cases. * **(1) (AATD)**; patients have severe lung damage at earlier ages; alpha-1 trypsin protects lungs from oxidative and environmental damage**. The World Health Organization (WHO) recommends all patients with a diagnosis of COPD should be?.**

Answer 25

* **Chronic smoking** (etiology in up to 90% of cases of COPD), older age (\>40 years). * **Occupational exposure (**e.g., coal dust, grain dust) is responsible for about 10% to 20% of cases. * **Alpha-1 anti-trypsin deficiency (AATD)**; patients have severe lung damage at earlier ages; alpha-1 trypsin protects lungs from oxidative and environmental damage. The **World Health Organization (WHO) recommends all patients with a diagnosis of COPD should be screened at least once.**

Question 26

Classic Case of COPD A \_\_\_\_\_-aged to older adult ____ with a history of many years of _____ smoking presents with history of a viral \_\_\_\_, which has exacerbated his COPD symptoms. Complains of worsening d\_\_\_\_\_, which is accompanied by a chronic _____ that is productive of large amounts of ______ sputum. Walking up the stairs or physical exertion ____ the dyspnea.

Answer 26

A middle-aged to older adult male with a history of many years of cigarette smoking presents with history of a viral URI, which has exacerbated his COPD symptoms. Complains of worsening dyspnea, which is accompanied by a chronic cough that is productive of large amounts of tenacious sputum. Walking up the stairs or physical exertion worsens the dyspnea.

Question 27

Chronic Bronchitis vs. Emphysema **“Blue Bloater” =** * Patient with a bluish tinge to their skin due to chronic \_\_\_oxia and \_\_\_capnia **“Pink Puffer” =** * Patient with pink skin color (\_\_\_\_\_ oxygen saturation), th\_\_\_, tachypneic and uses ______ muscles to breath and \_\_\_-lip breathing, many have _____ chest

Answer 27

**“Blue Bloater” = Chronic Bronchitis** Patient with a bluish tinge to their skin due to chronic hypoxia and hypercapnia **“Pink Puffer” = Emphysema** Patient with pink skin color (adequate oxygen saturation), thin, tachypneic and uses accessory muscles to breath and pursed-lip breathing, many have barrel chest

Question 28

Chronic Bronchitis or Emphysema ## Footnote * (1) component:* Increased anterior–posterior diameter, decreased breath and heart sounds, use of accessory muscles to breathe, pursed-lip breathing, and weight loss * (1) component:* Chronic cough productive of large amounts of sputum; lung auscultation will reveal expiratory wheezing, rhonchi, and coarse crackle

Answer 28

* Emphysema component:* Increased anterior–posterior diameter, decreased breath and heart sounds, use of accessory muscles to breathe, pursed-lip breathing, and weight loss * Chronic bronchitis component:* Chronic cough productive of large amounts of sputum; lung auscultation will reveal expiratory wheezing, rhonchi, and coarse crackle

Question 29

COPD Objective Findings * Percussion =* * Tactile fremitus and egophony =* * Chest x-ray (CXR) =*

Answer 29

* Percussion =* Hyperresonance * Tactile fremitus and egophony =* Decreased * Chest x-ray (CXR) =* Flattened diaphragms with hyperinflation; bullae sometimes present

Question 30

COPD GOLD Treatment Guidelines GOLD (Global Initiative for Chronic Obstructive Lung Disease) Each patient classified into **(4) groups + definitions**

Answer 30

**Group A** = Minimally symptomatic COPD (low risk of exacerbations) ## Footnote **Group B** = More symptomatic (low risk of exacerbations) **Group C** = Minimally symptomatic (but high risk of future exacerbations) **Group D =** More symptomatic (high risk of future exacerbations)

Question 31

COPD GOLD Group A Treatment Minimally symptomatic COPD (low risk of exacerbations =

Answer 31

SABA alone or in combination with SAMA/anticholinergic; combination therapy preferred (more effective) but monotherapy is acceptable

Question 32

COPD GOLD Group B Treatment More symptomatic (low risk of exacerbations) =

Answer 32

LAMA or LABA or SABA for symptom relief PRN

Question 33

COPD GOLD Group C Treatment Minimally symptomatic (but high risk for future exacerbations) =

Answer 33

LAMA is first line; SABA for symptom relief PRN

Question 34

COPD GOLD Group D Treatment More symptomatic (high risk of future exacerbations) =

Answer 34

High risk; refer to pulmonologist

Question 35

COPD Pharmacologic Treatment * **Rx (1)** now recommended for all patients with COPD, to be used for intermittent increases in dyspnea PRN. * If patient has poor symptom relief with a short-acting anticholinergic/short-acting muscarinic antagonist (SAMA; ipratropium [Atrovent]), then add a **Rx (1)** (Group A)

Answer 35

* **Short acting beta2 agonist (SABA)** now recommended for all patients with COPD, to be used for intermittent increases in dyspnea PRN. * If patient has poor symptom relief with a short-acting anticholinergic/short-acting muscarinic antagonist (SAMA; ipratropium [Atrovent]), then add a **SABA** (Group A)

Question 36

Classes of Bronchodilators **(1)** Albuterol, levalbuterol (Xopenex), pirbuterol (Maxair) **(1)** Salmeterol, formoterol, vilanterol **(1)** ipratropium (Atrovent) **(1)** Tiotropium bromide (Spiriva), umeclidinium powder (Ellipta), glycopyrrolate (Seebri Neohaler). Available as combination LAMA plus LABA formulations.

Answer 36

**SABA** Albuterol, levalbuterol (Xopenex), pirbuterol (Maxair) **LABA** Salmeterol, formoterol, vilanterol **SAMA** ipratropium (Atrovent) **LAMA** Tiotropium bromide (Spiriva), umeclidinium powder (Ellipta), glycopyrrolate (Seebri Neohaler). Available as combination LAMA plus LABA formulations.

Question 37

*Corticosteroids and phosphodiesterase-4 inhibitors in COPD* * **Long**-**term** monotherapy with oral **corticosteroids** is? * **Selective phosphodiesterase-4 inhibitor roflumilast (Daliresp**) indicated to reduce risk of COPD ______ in patients with _____ COPD. It is not a bronchodilator. * Contraindicated in moderate-to-severe \_\_\_\_\_bimpairment. * Associated with increase in ______ adverse reactions such as insomnia, depression, suicidal ideation, and weight loss

Answer 37

* **Long-term** monotherapy with oral **corticosteroids** is **not recommended**. * **Selective phosphodiesterase-4 inhibitor** **roflumilast (Daliresp)** indicated to reduce risk of COPD exacerbations in patients with **severe COPD**. It is not a bronchodilator. * Contraindicated in moderate-to-severe liver impairment. * Associated with increase in psychiatric adverse reactions such as insomnia, depression, suicidal ideation, and weight loss

Question 38

Oxygen Therapy in COPD * Long term oxygen therapy is recommended for chronic (1) * PaO2 _\<_ ____ mmHg or PaO2 _\<_ \_\_\_% * Titrate oxygen so that PaO2 is ____ - \_\_\_\_% * Con\_\_\_\_\_\_ oxygen therapy preferred for COPD patients with chronic severe hypoxemia * Improved survival with _____ oxygen use compared with _____ oxygen use

Answer 38

* Long term oxygen therapy is recommended for chronic hypoxemia * PaO2 _\<_ 55 mmHg or PaO2 _\<_ 88% * Titrate oxygen so that PaO2 is 88- 92% * Continuous oxygen therapy preferred for COPD patients with chronic severe hypoxemia * Improved survival with continuous oxygen use compared with nocturnal oxygen use

Question 39

Air Travel in COPD Some patients with COPD may become ______ during air travel so (1) may be needed

Answer 39

Some patients with COPD may become hypoxemic during air travel so oxygen may be needed

Question 40

Supplementation with Antioxidants in COPD Vitamins (2) Z\_\_\_\_ Sel\_\_\_\_\_\_ shown to improve (1) among patients with COPD

Answer 40

Vitamin C and E Zinc Selenium shown to improve muscle strength among patients with COPD

Question 41

SABAs Adverse Effects (*albuterol, levalbuterol, metaproternol)* Cardiac SE (2) Cautious if patient has \_\_\_\_tension, ang\_\_\_\_, and/or \_\_\_\_thyroidism Avoid combining with _______ drinks

Answer 41

Palpitations, Tachycardia Cautious if patient has hypertension, angina, and/or hyperthyroidism Avoid combining with caffeinated drinks

Question 42

Anticholinergics SE (*Ipratropium (Atrovent) SAMA, tiotropium (Spiriva) LAMA)* Avoid is patient has narrow angle \_\_\_\_\_, prostate (1), bladder neck \_\_\_\_\_\_\_

Answer 42

Avoid is patient has narrow angle glaucoma, BPH, bladder neck obstruction

Question 43

General Treatment for COPD ## Footnote **(1) Cessation - how?** **(3) Vaccinations** **Pulmonary hygiene (1) or Pulmonary Re\_\_\_\_\_\_\_** **How to treat lung infections?**

Answer 43

**Smoking Cessation =** nicotine patches/gum, buproprion (Zyban) or Varenicline (Chantix), patient education, behavioral counseling ## Footnote **Annual Influenca, Pneumococcal (PCV13 (prevnar) now PCV15 + PPSV23 (pneumovax)) 12 months apart** **Pulmonary hygiene (postural drainage) or Pulmonary Rehabilitation** **Treat lung infections aggressively**

Question 44

*Management of Stable Chronic Obstructive Pulmonary Disease* Once COPD has been diagnosed, effective management should be based on an individualized assessment of current symptoms and future risks * Re\_\_\_\_\_ symptoms * Re\_\_\_\_\_ symptoms * Improve _____ tolerance * Improve health status *and* prevent disease \_\_\_\_\_\_, prevent and treat ex\_\_\_\_\_\_, and reduce mor\_\_\_\_\_\_

Answer 44

* Reduce symptoms * Relieve symptoms * Improve exercise tolerance * Improve health status *and* prevent disease progression, prevent and treat exacerbations, and reduce mortality

Question 45

Nonpharm Treatment for COPD Nonpharmacologic management of COPD should be in accordance with the individualized assessment of symptoms and exacerbation risk: * (1) cessation (can include pharmacologic treatment) * Physical (1) * (1) vaccination annually * (1) vaccination * Pulmonary (1)

Answer 45

* Smoking cessation (can include pharmacologic treatment) * Physical activity * Influenza vaccination annually * Pneumococcal vaccination * Pulmonary rehabilitation

Question 46

COPD Management of Exacerbations Exacerbation of COPD is defined as an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication. 1. First assess (1) VS 2. Patients with characteristics of mod-severe exacerbation (increased dyspnea, increased sputum/viscosity, increased sputum purulence should be (1) as they are higher risk of death 3. Rx (1) = mainstay therapy for acute exacerbation 4. SABA can be combined with Rx (1) 5. Tell them to use what with inhaler 6. Rx (1) can be added PRN

Answer 46

1. First assess pulse oxygen saturation 2. Patients with characteristics of mod-severe exacerbation (increased dyspnea, increased sputum/viscosity, increased sputum purulence should be hospitalized as they are higher risk of death 3. SABA = mainstay therapy for acute exacerbation 4. SABA can be combined with SAMA 5. Tell them to use a spacer with inhaler 6. Oral glucocorticoids (prednisone 40mg daily for 5 days) can be added PRN

Question 47

COPD Management of Exacerbations * Most common cause of exacerbations? * Diagnostic imaging (1) to exclude alternative diagnoses (PNA, PE, Pneumothorax) * Diagnostics (2) useful to diagnose coexisting cardiac problems * (1) tests not recommended during an exacerbation because can be difficult to perform and measurements not accurate enough * Hospitalized patients increased risk for D\_\_\_ and P\_\_ → enhance \_\_\_\_prophlyactic measures and strongly enforce measures against active cigarette smoking

Answer 47

* Respiratory tract infections (viral or bacterial) * Chest x-ray to exclude alternative diagnoses (PNA, PE, Pneumothorax) * EKG and cardiac troponins useful to diagnose coexisting cardiac problems * Spirometry tests not recommended during an exacerbation because can be difficult to perform and measurements not accurate enough * Hospitalized patients increased risk for DVT and PE→ enhance thromboprophylactic measures and strongly enforce measures against active cigarette smoking

Question 48

COPD Management of Exacerbations * Suspect secondary bacterial infection if acute onset of fever, purulent sputum, increased wheezing and dyspnea = at high risk for **(1) pneumonia** * *Treatment options* 1. Drug Class (1) (azithromycin, clarithromycin) or 2. Drug Class (1) (cefuroxime, cefdinir, cefpodoxime) for __ - __ days 3. **Rx (1) or (1)** if at risk for ***Pseudomonas*** (with sputum for culture and sensitivity)

Answer 48

* Suspect secondary bacterial infection if acute onset of fever, purulent sputum, increased wheezing and dyspnea = at high risk for ***Haemophilus influenzae*** **pneumonia** * *Treatment options* 1. Drug Class **Macrolides** (azithromycin, clarithromycin) or 2. Drug Class **2nd Generation Cephalosporin** (cefuroxime, cefdinir, cefpodoxime) for **3-5 days** 3. **Ciprofloxacin or Levofloxacin** if at risk for ***Pseudomonas*** (with sputum for culture and sensitivity)

Question 49

When do you refer for COPD? * \_\_\_\_\_-to-\_\_\_\_COPD * Severe _____ or rapid \_\_\_\_\_ * Age * _____ loss

Answer 49

* Moderate-to-severe COPD * Severe exacerbations or rapid progression * Age \<40 years * Weight loss

Question 50

Exam Tips on COPD First line treatment for mild COPD = If short acting bronchodilators not controlling symptoms, next step is to add? (1) is a short acting anticholinergic or SAMA Do not use (1) (salmeterol, formoterol) for rescue treatment

Answer 50

First-line treatment for mild COPD (Group A) is either a SABA or a short-acting anticholinergic (or SAMA). If poor relief on single agent, add a second agent. If on SABA, add short-acting anticholinergic (Atrovent If short acting bronchodilators not controlling symptoms, next step is to add LABA or LAMA, and continue SABA PRN Ipratropium (Atrovent) is a short acting anticholinergic or SAMA Do not use LABAs (salmeterol, formoterol) for rescue treatment

Question 51

Clinical Pearls COPD Low ____ is associated with worse outcomes in patients with COPD. Consider \_\_\_\_\_\_supplementation (e.g., \_\_\_\_\_) in underweight patients. When you are treating a COPD patient, pick an antibiotic that has coverage against **both (1) (gram negative) and (1) (gram positive).**

Answer 51

Low BMI is associated with worse outcomes in patients with COPD. Consider nutritional supplementation (e.g., Ensure) in underweight patients. When you are treating a COPD patient, pick an antibiotic that has coverage against **both** ***H. influenzae*** **(gram negative) and** ***Streptococcus pneumoniae*** **(gram positive).**

Question 52

What common lung infection does this describe? **No.1 cause?** Acute onset. High fever and chills. Productive cough and large amount of green to rust-colored sputum. Pleuritic chest pain with cough. Crackles; decreased breath sounds, dull. CBC: leukocytosis; elevated neutrophils. Band forms may be seen.

Answer 52

Community Acquired Pneumonia (CAP) No.1 cause = *Streptococcus pneumoniae* (gram +)

Question 53

What Common Lung Infection is described? **No. 1 cause =** CXR reveals lobar infiltrates. Gradual onset. Low-grade fever. Headache, sore throat, cough, wheezing, rash (sometimes). CXR: interstitial to patchy infiltrates.

Answer 53

Atypical Pneumonia **No.1 Cause =** ***Mycoplasma Pneumoniae***

Question 54

What Common Lung Infection is Described? Fever, cough, pleurisy, shortness of breath. Scanty sputum production. Myalgias. Breath sounds: decreased breath sounds, rales.

Answer 54

Viral Pneumonia influenza, RSV

Question 55

What Common Lung Infection is described? Paroxysms of dry and severe cough that interrupts sleep. Cough: dry to productive. Light-colored sputum. Can last up to 4–6 weeks. No antibiotics. Treat symptoms.

Answer 55

Acute Bronchitis

Question 56

What Common Lung Infection is described? Cough lasting 3 weeks or longer. Pleuritic chest pain. Hemoptysis with fatigue, weight loss, anorexia, fever/chills, night sweats.

Answer 56

Tuberculosis (TB)

Question 57

What Common Lung Infection is described? Intermittent cough that becomes more severe with inspiratory whoop; may be followed by posttussive vomiting. Cough worse at night; persists for 2–6 weeks or longer. Infants do not “whoop”; minimal cough followed by vomiting; apnea more common.

Answer 57

Pertussis (Whooping Cough)

Question 58

Community Acquired Pneumonia in Adults Most common cause of focal _____ on a CXR (lobar pneumonia) _Most common pathogens_ 1. (1) gram positive 2. (1) gram negative 1. More common in smokers, COPD 3. (1) gram negative 1. #1 bacteria in cystic fibrosis 4. (1) Atypical bacteria 5. (3) Respiratory viruses

Answer 58

Most common cause of focal infiltrate on a CXR (lobar pneumonia) _Most common pathogens_ 1. *S.pneumoniae* gram positive 2. *H.influenzae* gram negative 1. More common in smokers, COPD 3. *Pseudomonas aeruginosa* gram negative 1. #1 bacteria in cystic fibrosis 4. *Mycoplasma pneuoniae* Atypical bacteria 5. Influenza, parainfluenza, RSV = Respiratory viruses

Question 59

Classic Case of CAP An older adult presents with sudden onset of a high fever (\>100.4°F) with chills, anorexia, and fatigue that is accompanied by a _____ cough with \_\_\_\_\_sputum (\_\_\_\_-colored sputum seen with streptococcal pneumonia). The patient complains of sharp stabbing chest pain (\_\_\_\_\_chest pain) with coughing and dyspnea. \_\_\_\_\_pneic. Elderly patients may have atypical symptoms (e.g., afebrile or low-grade fever, no cough or mild cough, weakness, con\_\_\_\_\_\_).

Answer 59

An older adult presents with sudden onset of a high fever (\>100.4°F) with chills, anorexia, and fatigue that is accompanied by a productive cough with purulent sputum (rust-colored sputum seen with streptococcal pneumonia). The patient complains of sharp stabbing chest pain (pleuritic chest pain) with coughing and dyspnea. Tachypneic. Elderly patients may have atypical symptoms (e.g., afebrile or low-grade fever, no cough or mild cough, weakness, confusion).

Question 60

CAP Objective Findings * Auscultation =* * Percussion =* * Tactile fremitus and egophony =* Abnormal whispered pectoriloquy =

Answer 60

* Auscultation:* Rhonchi, crackles, and wheezing * Percussion:* Dullness over affected lobe * Tactile fremitus and egophony:* Increased Abnormal whispered pectoriloquy (whispered words louder)

Question 61

CAP Diagnostics **Gold Standard =** Repeat when to document clearing? (1) +(1) is **not** gold standard * Order CBC =* what might it show?

Answer 61

**CXR gold standard** (shows lobar consolidation in classic bacterial pneumonia) Repeat CXR in 6 weeks to ensure clearing of infection Sputum C&S + gram stain NOT recommended (but are option for outpatient with severe cases of CAP) *CBC* = may show leukocytosis (\>10.5 x10^9/L) with possible “shift to the left” (increased band forms)

Question 62

CAP Treatment **NO COMORBIDITY** (previously healthy with no risk factors for respiratory isolation of methicillin-resistant *Staphylococcus aureus* (MRSA) or *Pseudomonas aeruginosa* or hospitalization with receipt of parenteral antibiotics within past 90 days) **First line agents (2)** **Alternative (2)**

Answer 62

**_First line agents_** Amoxicillin 1 g PO TID *or* Doxycycline 100 mg PO BID **_Alternative_** (*macrolide, do not use if pneumococcal resistance \>25%)* Azithromycin 500 mg PO on first day, then 250 mg PO daily *or* Clarithromycin 500 mg PO BID or extended-release 1,000 mg PO daily

Question 63

CAP Treatment **WITH COMORBIDITY** e.g., alcoholism; congestive heart failure [CHF]; chronic heart, lung, liver, or kidney disease; diabetes; splenectomy/asplenia; antibiotics in previous 3 months) or high rates (\>25%) of local pneumococcal resistance: **COMBINATION THERAPY (1)****(3)****+ (1)****(3)** OR **MONOTHERAPY (1)****(3)**

Answer 63

*Combination therapy (beta-lactam plus macrolide or doxycycline):* – Amoxicillin–clavulanate 500/125 mg PO TID, 875/125 mg PO BID, or 2,000/125 mg PO BID *or* – Cefpodoxime 200 mg PO BID *or* – Cefuroxime 500 mg PO BID ***PLUS*** – Azithromycin 500 mg PO on first day, then 250 mg PO daily *or* – Clarithromycin 500 mg PO BID or extended-release 1,000 mg PO daily *or* – Doxycycline 100 mg PO BID *Monotherapy (respiratory fluoroquinolone):* – Levofloxacin 750 mg PO daily *or* – Moxifloxacin 400 mg PO daily *or* – Gemifloxacin 320 mg PO daily

Question 64

CAP Treatment **WITH COMORBIDITY** *Poor prognosis (refer for hospitalization):* * Elderly: Age ___ years or older, acute _____ status changes, C\_ \_ * \_\_\_\_\_\_lobar involvement * Acute \_\_\_\_\_status change * Al\_\_\_\_\_\_ (aspiration pneumonia)

Answer 64

* Elderly: Age 60 years or older, acute mental status changes, CHF * Multiple lobar involvement * Acute mental status change * Alcoholics (aspiration pneumonia)

Question 65

CURB-65 Tool to assess whether patient with CAP needs hospitalization Score \> __ = should be hospitalized **C** **U** **R** **B** Age ___ years or older

Answer 65

Score \> 1 = should be hospitalized ## Footnote **C** (*c*onfusion) **U** (blood *u*rea nitrogen \>19.6 mg/dL) **R** (*r*espiration \>30 breaths/min) **B** (*b*lood pressure \<90/60 mmHg) Age **65** years or older

Question 66

CAP Prevention ## Footnote **(1)** vaccine for all persons \>50 years or if in contact with persons who are at higher risk of death from pneumonia, who are healthcare workers, others. **(1)** if \>65 years or with high-risk condition. Can use at younger ages if high risk of death from pneumonia.

Answer 66

**Influenza vaccine** for all persons \>50 years or if in contact with persons who are at higher risk of death from pneumonia, who are healthcare workers, others. **Pneumococcal polysaccharide vaccine (Pneumovax)** if \>65 years or with high-risk condition. Can use at younger ages if high risk of death from pneumonia.

Question 67

Pneumococcal Vaccines (Adults) ## Footnote **(1)** recommended for all children \<2 years or \>2 years with certain medical conditions. Adults aged ≥65 years can use the vaccine (discuss and decide with their clinician). Space at least __ year apart from PPSV23. **(1)** Pneumovax 23, Pnu-Imune 23) recommended.

Answer 67

**PCV13 (pneumococcal conjugate vaccine: Prevnar 13)** recommended for all children \<2 years or \>2 years with certain medical conditions. Adults aged ≥65 years can use the vaccine (discuss and decide with their clinician). Space at least 1 year apart from PPSV23. **PPSV23 (pneumococcal polysaccharide vaccine: Pneumovax 23**, Pnu-Imune 23) recommended.

Question 68

Pneumococcal Vaccines (Adults Aged 65 Years or Older) ## Footnote Administer (1) first. Shared decision-making with (1) If patient wants to be vaccinated with PCV13 (Prevnar), give at least __ year apart from last PPSV23. If PPSV23 administered prior to age 65, administer another dose of PPSV23 at least __ years apart.

Answer 68

Administer PPSV23 (Pneumovax) first. Shared decision-making with PCV13. If patient wants to be vaccinated with PCV13 (Prevnar), give at least 1 year apart from last PPSV23. If PPSV23 administered prior to age 65, administer another dose of PPSV23 at least 5 years apart.

Question 69

Pneumococcal Vaccines (Adults Aged 65 Years or Older) **Healthy Patients** * **Single dose of \_\_\_\_\_\_** is usually sufficient at age 65 years (lifetime). * 60% to 70% effective in preventing invasive disease caused by serotypes in the vaccine. **Underlying Disease** * \_\_\_% effective **Severely Immunocompromised** * Only \_\_% effective

Answer 69

Healthy Patients * Single dose of PPSV23 is usually sufficient at age 65 years (lifetime). * 60% to 70% effective in preventing invasive disease caused by serotypes in the vaccine. Underlying Disease * 50% effective Severely Immunocompromised * Only 10% effective

Question 70

Pneumonia Vaccine Special Situations Can give to persons as young as age **_19 yo_** for **Impaired \_\_\_\_\_\_** * Splenectomy, asplenia, or diseased spleen * Alcoholics/cirrhosis of the liver * HIV infection * Chronic renal failure **Preexisting ____ and _____ disease** * Asthma, congenital heart disease, emphysema, others **\_\_\_\_\_ disorders** * Sickle cell anemia * Hodgkin’s lymphoma, multiple myeloma

Answer 70

**Impaired immunity** * Splenectomy, asplenia, or diseased spleen * Alcoholics/cirrhosis of the liver * HIV infection * Chronic renal failure **Preexisting heart and lung disease** * Asthma, congenital heart disease, emphysema, others **Blood disorders** * Sickle cell anemia * Hodgkin’s lymphoma, multiple myeloma

Question 71

Pneumonia Vaccine High Risk Patients Repeat vaccine in \_\_\_-\_\_\_ years (boosts antibodies) * If first dose was given ____ age of 65 years * Asp\_\_\_\_, chronic ____ failure (give at \_\_years of age) * Imm\_\_\_\_\_\_\_\_ states * *\_\_\_\_\_ cancers:* Lymphoma, Hodgkin’s disease, leukemia

Answer 71

Repeat vaccine in 5-7 years (boosts antibodies) * If first dose was given before age of 65 years * Asplenia, chronic renal failure (give at 19 years of age) * Immunocompromised states * *Blood cancers:* Lymphoma, Hodgkin’s disease, leukemia

Question 72

An infection of the lungs by atypical bacteria. More common in children and young adults. Seasonal outbreaks (summer/fall). Highly contagious. Also known as *walking pneumonia*.

Answer 72

Atypical Pneumonia

Question 73

Atypical Pneumonia Causative Organisms *(4)*

Answer 73

* Mycoplasma Pneumoniae\** * Chlamydophila Pneumoniae\** * Legionella Pneumoniae* * Chlamydia Psittaci*

Question 74

*Mycoplasma Pneumoniae* (most common cause of atypical pneumonia) * Nonpulmonary complications may occur = hemolytic \_\_\_\_\_, meningo-\_\_\_\_\_\_, urt\_\_\_\_\_ * Gold standard for diagnosis =

Answer 74

* Nonpulmonary complications may occur = hemolytic anemia, meningo-encephalitis, urticaria * Gold standard for diagnosis = PCR of sputum or oropharyngeal swab

Question 75

Causes of Atypical Pneumonia ## Footnote * (1):* More common in school-age children; usually develops into bronchitis or mild pneumonia. * (1)* Not as common; a zoonotic infection from infected pet birds (e.g., parrots, parakeets) and poultry (e.g., turkeys, ducks).

Answer 75

* Chlamydophila pneumoniae:* More common in school-age children; usually develops into bronchitis or mild pneumonia. * Chlamydia psittaci:* Not as common; a zoonotic infection from infected pet birds (e.g., parrots, parakeets) and poultry (e.g., turkeys, ducks).

Question 76

*Legionella pneumoniae:* (cause of atypical pneumonia) * Found in areas with ______ such as those that are air conditioned (hospitalize, more severe with ____ mortality). * Causes a severe type of pneumonia called \_\_\_\_\_\_\_’ disease. Case fatality rate 10% (up to 25% fatality for healthcare-associated infections). * Risk factors * Age ≥\_\_\_years * sm\_\_\_\_\_ * chronic lung disease such as \_\_\_\_; * \_\_\_\_system disorders * _____ illness such as diabetes, renal failure, or hepatic failure.

Answer 76

* Found in areas with moisture such as those that are air conditioned (hospitalize, more severe with higher mortality). * Causes a severe type of pneumonia called Legionnaires’ disease. Case fatality rate 10% (up to 25% fatality for healthcare-associated infections). * Risk factors * Age ≥50 years * smoking * chronic lung disease such as COPD; * immune system disorders * underlying illness such as diabetes, renal failure, or hepatic failure.

Question 77

Classic Case of Atypical Pneumonia\* A _____ adult complains of several weeks of fatigue, accompanied by coughing that is mostly \_\_\_productive. May be accompanied by headache and low-grade fever. _____ onset of symptoms. Reports history of a **\_\_\_\_** before onset of **bronchitis** (sore \_\_\_\_, clear \_\_\_\_, and \_\_\_\_-grade fever). Older patient may have more severe disease.

Answer 77

A young adult complains of several weeks of fatigue, accompanied by coughing that is mostly nonproductive. May be accompanied by headache and low-grade fever. Gradual onset of symptoms. Reports history of a cold before onset of **bronchitis** (sore throat, clear rhinitis, and low-grade fever). Older patient may have more severe disease.

Question 78

Atypical Pneumonia Objective Findings ## Footnote * Auscultation:* * Nose:* * Throat:* * CXR:* ____ inter\_\_\_\_ infiltrates (up to 20% have pleural effusion) * CBC:* May have _____ results If suspect infection with Legionella, order a _____ antigen test for *L. pneumophilia* Consider testing for _____ if patient fails outpatient therapy for CAP, has severe pneumonia, or travels

Answer 78

* Auscultation:* Wheezing and diffused crackles/rales * Nose:* Clear mucus (may have rhinitis of clear mucus) * Throat:* Erythematous without pus or exudate * CXR:* Diffuse interstitial infiltrates (up to 20% have pleural effusion) * CBC:* May have normal results If suspect infection with Legionella, order a urinary antigen test for *L. pneumophilia* Consider testing for Legionella if patient fails outpatient therapy for CAP, has severe pneumonia, or travels

Question 79

Atypical Pneumonia Treatment Plan **Rx (2)** **Alternative Rx (2)** Antitussives (3) PRN Increase fl\_\_\_\_ and r\_\_\_\_

Answer 79

**Azithromycin (Z-Pack) × 5 days** **Levofloxacin (Levaquin) 750 mg PO × 5 to 7 days** _Alternatives_ **Doxycycline 100 mg PO BID × 7 to 10 days** **Clarithromycin (Biaxin) 500 mg PO BID × 7 to 10 days** Antitussives (dextromethorphan, Tessalon Perles, honey) PRN Increase fluids and rest

Question 80

(1) Acute viral (sometimes bacterial) infection of the bronchi causes inflammatory changes in the trachea, bronchi, and bronchioles, which result in increased reactivity of the upper airways. Usually self-limited.

Answer 80

Acute Bronchitis Also known as *tracheobronchitis*.

Question 81

Causes of Acute Bronchitis Viruses like?

Answer 81

Denovirus, influenza (winter/spring), coronavirus, respiratory syncytial virus, parainfluenza, and human metapneumovirus.

Question 82

Classic Case of Acute Bronchitis A ____ adult male complains of a ____ that is keeping him ____ at night. Cough is mainly d\_\_ but can be productive of either purulent or nonpurulent sputum. The patient may have frequent paroxysms of coughing; may have \_\_\_-grade fever and/or chest ____ with cough. May have wh\_\_\_\_\_ and rh\_\_\_\_\_\_ (clears with coughing). Median duration of cough is ___ days (range of 1–3 weeks). May report history of a ____ before onset of bronchitis symptoms.

Answer 82

A young adult male complains of a cough that is keeping him awake at night. Cough is mainly dry but can be productive of either purulent or nonpurulent sputum. The patient may have frequent paroxysms of coughing; may have low-grade fever and/or chest pain with cough. May have wheezing and rhonchi (clears with coughing). Median duration of cough is 18 days (range of 1–3 weeks). May report history of a cold before onset of bronchitis symptoms.

Question 83

Acute Bronchitis Objective Findings ## Footnote * Lungs:* Ranges from ____ to severe _____ (prolonged expiratory phase), rh\_\_\_\_ * Percussion:* \_\_\_\_\_\_\_ * CXR (to rule out pneumonia):* \_\_\_\_\_\_ Afebrile to \_\_\_-grade fever

Answer 83

* Lungs:* Ranges from clear to severe wheezing (prolonged expiratory phase), rhonchi * Percussion:* Resonant * CXR (to rule out pneumonia):* Normal Afebrile to low-grade fever

Question 84

Acute Bronchitis Treatment Plan Treatment is mainly? What can you give for as an antitussive? (2) What can you give as an expectorant/mucolytic? (1) What can you give for wheezing? For severe wheezing, consider short term?

Answer 84

Treatment is mainly **SYMPTOMATIC, increase fluids and rest, stop smoking** Dextromethorphan BID-QID, Tessalon Perles (benzonatate) TID PRN (antitussives) Guaifenesin PRN (expectorant/mucolytic) Albuterol inhaler (Ventolin) QID or nebulized PRN for wheezing Short term oral steroid for severe wheezing

Question 85

Acute Bronchitis Complications Exacerbation of (1) → Increased risk of status \_\_\_\_\_\_ (1) secondary from bacterial infection (pneumococcus, mycoplasma, others)

Answer 85

Exacerbation of asthma → Increased risk of status asthmaticus Pneumonia secondary from bacterial infection (pneumococcus, mycoplasma, others)

Question 86

Pertussis AKA **\_\_\_\_ Cough** Caused by **(1)** bacteria (gram negative) * A coughing illness of at least __ days’ duration with one of the following findings: * par\_\_\_\_\_\_ coughing, inspiratory whooping (or posttussive vomiting) without apparent cause. * Illness can last from a few ____ to \_\_\_\_. * \_\_\_vaccinated children and adults with expired vaccinations are at risk for pertussis. * Neonates and infants are at highest risk of \_\_\_\_\_.

Answer 86

AKA **Whooping Cough** Caused by **Bordetella Pertsussis** bacteria (gram negative) * A coughing illness of at least 14 days’ duration with one of the following findings: * paroxysmal coughing, inspiratory whooping (or posttussive vomiting) without apparent cause. * Illness can last from a few weeks to months. * Unvaccinated children and adults with expired vaccinations are at risk for pertussis. * Neonates and infants are at highest risk of death.

Question 87

3 Stages of Pertussis (1) Stage (lasts 1-2 weeks) * if treated at this stage, can _____ disease course (it treated within 3 weeks of onset) (1) Stage (lasts 2-4 weeks) * treatment has _____ influence on disease but is useful to prevent disease \_\_\_\_\_ (1) Stage (lasts 1-2 weeks) * treatment goal is to eradicate _____ state/disease \_\_\_\_\_. Antibiotic will ___ shorten illness at this stage

Answer 87

Catarrhal Stage (lasts 1-2 weeks) * if treated at this stage, can shorten disease course (it treated within 3 weeks of onset) Paroxysmal Coughing Stage (lasts 2-4 weeks) * treatment has little influence on disease but is useful to prevent disease spread Convalescent Stage (lasts 1-2 weeks) * treatment goal is to eradicate carriage state/disease spread. Antibiotic will not shorten illness at this stage

Question 88

Classic Case of Pertussis Suspect pertussis in previously “\_\_\_\_\_” patient with a severe \_\_\_\_cough of \>\_\_ weeks’ duration. Initial symptoms are low-grade fever and rhinorrhea with a mild cough (\_\_\_\_\_ stage). Cough becomes severe with \_\_piratory “\_\_\_\_” sound. The patient may _____ afterward. Cough is worse at night. ____ have atypical presentation, no whoop with minimal to no cough. \_\_nea is more common in infants.

Answer 88

Suspect pertussis in previously “healthy” patient with a severe hacking cough of \>2 weeks’ duration. Initial symptoms are low-grade fever and rhinorrhea with a mild cough (catarrhal stage). Cough becomes severe with inspiratory “whooping” sound. The patient may vomit afterward. Cough is worse at night. Infants have atypical presentation, no whoop with minimal to no cough. Apnea is more common in infants.

Question 89

Pertussis Labs (1) swab for culture (best time to collect is 0-2 weeks following \_\_\_\_\_) (1) may provide accurate results up to 4 weeks Pertussis ______ by (1) CBC = CXR =

Answer 89

Nasopharyngeal swab for culture (best time to collect is 0-2 weeks following cough) PCR may provide accurate results up to 4 weeks Pertussis antibodies by ELISA CBC = elevated WBC, marked lymphocytosis (up to 80% lymphocytes in differential) CXR = should be negative, if positive, is due to secondary bacterial infection

Question 90

Pertussis Close Contacts Should you treat close contacts? If so, within when? Isolation precautions? Is there a difference between treatment and chemoprophylaxis for close contacts?

Answer 90

Yes, chemoprophylaxis for close contacts within 3 weeks of exposure Respiratory Droplet Precautions Treatment and chemoprophylaxis use the same doses and antibiotics

Question 91

Pertussis Antibiotic Treatment First line drug class = * (1) 500 mg on day 1, then 250 mg daily from days 2 to 5 (drug of choice of very young infants) * (1) 500 mg QID × 14 days * (1) (Biaxin) BID × 7 days

Answer 91

**Macrolides** * Azithromycin (Z-Pack) 500 mg on day 1, then 250 mg daily from days 2 to 5 (drug of choice of very young infants) * Erythromycin 500 mg QID × 14 days * Clarithromycin (Biaxin) BID × 7 days

Question 92

Pertussis Antibiotic Treatment * Macrolides given to infants \<1 month of age:* Monitor for infantile hyper\_\_\_\_ ______ (IHPS) and other adverse events. For persons ≥2 months of age, an alternative to macrolides is Rx (1). * Alternative:* **(1) Rx** PO BID × 14 days (infants \>1 month of age given × 7-day duration and dosed by weight) Other treatment measures = Anti\_\_\_\_\_, m\_\_\_\_lytics, r\_\_\_\_, and hy\_\_\_\_\_; frequent small m\_\_\_\_.

Answer 92

* Macrolides given to infants \<1 month of age:* Monitor for infantile hyperpyloric stenosis (IHPS) and other adverse events. For persons ≥2 months of age, an alternative to macrolides is trimethoprim–sulfamethoxazole. * Alternative:* Trimethoprim–sulfamethoxazole (Bactrim DS) PO BID × 14 days (infants \>1 month of age given × 7-day duration and dosed by weight) Other treatment measures = Antitussives, mucolytics, rest, and hydration; frequent small meals.

Question 93

Pertussis Prevention and Complications ## Footnote * Aged 11 to 18 years (and 18 years to adulthood):* Centers for Disease Control and Prevention (CDC) recommends using (1) vaccine over (1) vaccine. * Complications:* S\_\_\_itis, otitis \_\_\_\_, pn\_\_\_\_\_, fainting, rib fr\_\_\_\_\_, and others

Answer 93

* Aged 11 to 18 years (and 18 years to adulthood):* Centers for Disease Control and Prevention (CDC) recommends using tetanus, diphtheria, acellular pertussis (Tdap; instead of tetanus diphtheria [Td]). * Complications:* Sinusitis, otitis media, pneumonia, fainting, rib fractures, and others

Question 94

Differential Diagnosis for Cough Match the condition to the signs and symptoms **(1)** Fever, tachypnea, or tachycardia, productive cough. CXR shows lobar consolidation. May have pleuritic chest pain with cough **(1)** Ticklish sensation in back of the throat, clearing throat often, cough worsens when supine. May have rhinosinusitis with purulent PND. **(1)** Shortness of breath or dyspnea, wheezing, dry cough; symptoms respond to albuterol or SABA. **(1)** Heartburn after large or fatty meals or with empty stomach; worsens when supine. Cough may be present.

Answer 94

**Bacterial Pneumonia =** Fever, tachypnea, or tachycardia, productive cough. CXR shows lobar consolidation. May have pleuritic chest pain with cough **Postnasal drip =** Ticklish sensation in back of the throat, clearing throat often, cough worsens when supine. May have rhinosinusitis with purulent PND. **Asthma** Shortness of breath or dyspnea, wheezing, dry cough; symptoms respond to albuterol or SABA. **Gastroesophageal Reflux** Heartburn after large or fatty meals or with empty stomach; worsens when supine. Cough may be present.

Question 95

Differential Diagnosis for Cough Match the condition to the signs and symptoms **(1)** Shortness of breath/dyspnea that worsens with exertion or physical activity, pitting edema, and dry cough. Physical exam may show S3, elevated JVD. **(1)** New onset of dyspnea, hemoptysis, pleuritic chest pain. Vital signs with tachycardia, tachypnea. May have signs of DVT. **(1)** Cough in a person with risk factors such as long-term cigarette smoking (≥30-pack-year history). Weight loss. **(1)** Nonproductive cough in a person with hypertension, diabetes, or CKD. Can start within 1 week of starting medication.

Answer 95

**Heart Failure =** Shortness of breath/dyspnea that worsens with exertion or physical activity, pitting edema, and dry cough. Physical exam may show S3, elevated JVD. **Pulmonary Embolism =** New onset of dyspnea, hemoptysis, pleuritic chest pain. Vital signs with tachycardia, tachypnea. May have signs of DVT. **Lung Cancer =** Cough in a person with risk factors such as long-term cigarette smoking (≥30-pack-year history). Weight loss. **ACE-Inhibitor use =** Nonproductive cough in a person with hypertension, diabetes, or CKD. Can start within 1 week of starting medication.

Question 96

Exam Tips * Recognize presentation of bacterial pneumonia versus atypical pneumonia. * The top two bacteria in CAP are: **(2)** * The top two bacteria in atypical pneumonia are: **(2)**

Answer 96

* Recognize presentation of bacterial pneumonia versus atypical pneumonia. * The top two bacteria in CAP are: * **S. pneumoniae** * **H. influenzae** * The top two bacteria in atypical pneumonia are: * **M. pneumoniae** * **Chlamydia pneumoniae**

Question 97

Exam Tips * \_\_\_\_-colored or \_\_\_\_\_-tinged sputum means *S. pneumoniae* more likely. * *COPD/smoker with pneumonia:* More likely to have *(1)* bacteria. * Know presentation and treatment of _____ (whooping cough). * _______ treatment for acute bronchitis. Do not pick antibiotics to treat acute bronchitis. * *Outpatient CAP:* Diagnosis is based on presentation, signs and symptoms, and (1). Do not order(1) ; instead, order (1). CBC is not required for diagnosis

Answer 97

* Rust-colored or blood-tinged sputum means *S. pneumoniae* more likely. * *COPD/smoker with pneumonia:* More likely to have *H. influenzae* bacteria. * Know presentation and treatment of pertussis (whooping cough). * Symptomatic treatment for acute bronchitis. Do not pick antibiotics to treat acute bronchitis. * *Outpatient CAP:* Diagnosis is based on presentation, signs and symptoms, and CXR. Do not order sputum for C&S; instead, order CXR. CBC is not required for diagnosis

Question 98

Clinical Pearls * If you suspect CAP based on clinical signs and symptoms but patient has a negative CXR/radiograph, obtain a **(1)** of the chest. Consider if patient is \_\_\_\_\_\_compromised and unable to mount strong inflammatory response. * Macrolides given to infants \<1 month of age at risk for developing **(1)**. * Suspect **(1)** in a “healthy” adult with no fever who has been coughing for \>2 to 3 weeks, especially if previously treated with an antibiotic (that was not a macrolide) and is getting worse (rule out pneumonia first).

Answer 98

* If you suspect CAP based on clinical signs and symptoms but patient has a negative CXR/radiograph, obtain a CT of the chest. Consider if patient is immunocompromised and unable to mount strong inflammatory response. * Macrolides given to infants \<1 month of age at risk for developing **IHPS (infant hyperpyloric stenosis)** * Suspect pertussis in a “healthy” adult with no fever who has been coughing for \>2 to 3 weeks, especially if previously treated with an antibiotic (that was not a macrolide) and is getting worse (rule out pneumonia first).

Question 99

Clinical Pearls * Emphasize importance of adequate ____ intake (best mucolytic, thins out mucus). * Lung cancer can present as recurrent ______ (due to mass blocking bronchioles). * If *S. pneumoniae* macrolide resistance \>\_\_%, do not use macrolide monotherapy. See CAP treatment guidelines notes.

Answer 99

* Emphasize importance of adequate fluid intake (best mucolytic, thins out mucus). * Lung cancer can present as recurrent pneumonia (due to mass blocking bronchioles). * If *S. pneumoniae* macrolide resistance \>25%, do not use macrolide monotherapy. See CAP treatment guidelines notes.

Question 100

Self-limiting infection (range of 4–10 days). Most contagious from days 2 to 3. More common in crowded areas and in small children. Transmission is by respiratory droplets and fomites. Highly contagious. Most cases occur in the winter months.

Answer 100

Common Cold (Viral Upper Respiratory Infection)

Question 101

Classic Case of the Common Cold Patient has acute onset of \_\_\_\_, \_\_\_throat, frequent sn\_\_\_\_\_ in early phase accompanied by nasal c\_\_\_\_\_, runny eyes, and rh\_\_\_\_\_\_ of clear mucus (coryza). The patient may complain of headache. Sp\_\_\_\_\_\_ resolution expected within __ to __ days.

Answer 101

Patient has acute onset of fever, sore throat, frequent sneezing in early phase accompanied by nasal congestion, runny eyes, and rhinorrhea of clear mucus (coryza). The patient may complain of headache. Spontaneous resolution expected within 4 to 10 days.

Question 102

Common Cold Objective Findings ## Footnote * Nasal turbinates =* * Anterior pharynx =* * Cervical nodes =* * Lungs =*

Answer 102

* Nasal turbinates:* Swollen with clear mucus (may also have blocked tympanic membrane) * Anterior pharynx:* Reddened * Cervical nodes:* Smooth, mobile, and small or “shotty” nodes (≤0.5 cm) in the submandibular and anterior cervical chain * Lungs:* Clear

Question 103

Common Cold Treatment Plan **Treat \_\_\_\_\_\_**; increase fl\_\_\_\_ and r\_\_\_\_; ____ hands frequently **Analgesics** Rx (1) or nonsteroidal anti-inflammatory drugs (NSAIDs; Rx (1)) for fever and aches PRN **Oral decongestants** e.g Rx (1) PRN **Topical nasal decongestants** (e.g., Rx (1) can be used BID up to __ days PRN only; do not use for \>3 days due to risk of re\_\_\_\_\_\_nasal congestion (rhinitis medicamentosa) **Antitussives** (e.g., Rx (1)) PRN **Antihistamines** (e.g., Rx (1)) for nasal congestion PRN

Answer 103

**Treat symptoms**; increase fluids and rest; wash hands frequently ## Footnote **Analgesics** (acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs; ibuprofen) for fever and aches PRN **Oral decongestants** (e.g., pseudoephedrine [Sudafed]) PRN **Topical nasal decongestants** (e.g., Afrin) can be used BID up to 3 days PRN only; do not use for \>3 days due to risk of rebound nasal congestion (rhinitis medicamentosa) **Antitussives** (e.g., dextromethorphan [Robitussin]) PRN **Antihistamines** (e.g., diphenhydramine [Benadryl]) for nasal congestion PRN

Question 104

Complications of Common Cold (2)

Answer 104

Acute Sinusitis Acute Otitis Media

Question 105

Tuberculosis An infection caused by ***(1)*** bacteria. Most common site of infection is the _____ (85%). Other sites include the pl\_\_\_\_, k\_\_\_\_, br\_\_\_, lymph nodes, ad\_\_\_\_, and b\_\_\_\_. Most contagious forms are p\_\_\_\_\_ TB, pl\_\_\_\_ TB, and lar\_\_\_\_\_ TB (coughing spreads aerosol \_\_\_\_\_\_). CXR (reactivated TB) will show cav\_\_\_\_\_ and adenopathy and gr\_\_\_\_\_\_ on the hila of the lungs.

Answer 105

An infection caused by ***Mycobacterium tuberculosis*** bacteria. Most common site of infection is the lungs (85%). Other sites include the pleurae, kidneys, brain, lymph nodes, adrenals, and bone. Most contagious forms are pulmonary TB, pleural TB, and laryngeal TB (coughing spreads aerosol droplets). CXR (reactivated TB) will show cavitations and adenopathy and granulomas on the hila of the lungs.

Question 106

Tuberculosis High-Risk Populations * Imm\_\_\_\_\_ (from high-prevalence countries) * Migrant f\_\_\_\_ workers * Illegal d\_\_\_\_users * \_\_\_\_less * In\_\_\_\_\_ of jails * N\_\_\_\_\_ home and adult living facility residents * H\_\_\_-infected, \_\_\_\_\_compromised.

Answer 106

* Immigrants (from high-prevalence countries) * Migrant farm workers * Illegal drug users * Homeless * Inmates of jails * Nursing home and adult living facility residents * HIV-infected, immunocompromised.

Question 107

What type of TB infection does this describe? An intact immune system causes macrophages to sequester the bacteria in the lymph nodes (mediastinum) in the form of granulomas. Not infectious.

Answer 107

*Latent TB Infection (LTBI)*

Question 108

What type of TB Infection does this describe? Also known as *disseminated TB disease*. Infects **multiple organ systems**. More common in younger children (\<5 years) and the elderly. CXR will show classic “**milia seed” pattern.**

Answer 108

*Military TB*

Question 109

*Multidrug-resistant TB (MDR TB) or extensively drug-resistant TB:* Bacteria resistant to at least two of the best anti-TB drugs—**(2)**

Answer 109

Bacteria resistant to at least two of the best anti-TB drugs—**isoniazid (INH) and rifampin (considered first-line drugs).**

Question 110

*Reactivated TB infection or active TB Disease (infectious):* Latent bacteria become reactivated due to? Most TB cases (80%) of active disease in the United States are reactivated infections.

Answer 110

Latent bacteria become reactivated due to **depressed immune system.** Most TB cases (80%) of active disease in the United States are reactivated infections.

Question 111

What vaccine may cause false positive reactions to the TB skin test? If patients have had this vaccine, what is the preferred way of screening?

Answer 111

*Prior Bacillus Calmette-Guérin (BCG) vaccine:* TB blood tests are preferred method of testing for people who received the BCG vaccine. Use QuantiFERON-TB Gold in-tube test (QFT-GIT), T-Spot TB test.

Question 112

Classic Case of Tuberculosis An adult patient (from \_\_\_\_-risk population) complains of fever, anorexia, f\_\_\_\_, and night ____ along with a mild nonproductive cough (\_\_\_\_phase). Aggressive infections (\_\_\_\_\_sign) will have productive cough with \_\_\_\_\_-stained sputum (hemoptysis) along with \_\_\_\_\_loss (late sign).

Answer 112

An adult patient (from high-risk population) complains of fever, anorexia, fatigue, and night sweats along with a mild nonproductive cough (early phase). Aggressive infections (later sign) will have productive cough with blood-stained sputum (hemoptysis) along with weight loss (late sign).

Question 113

Tuberculosis Treatment Plan ## Footnote TB is a ________ disease. Report TB to local health department for contact ____ as soon as possible. All active TB patients should be tested for H\_\_\_ infection. When TB bacteria are _____ replicating and damaging the body, it is called TB \_\_\_\_\_. Symptoms of pulmonary/pleural TB include cough productive of \_\_\_\_\_-tinged sputum, ____ sweats, and ____ loss.

Answer 113

TB is a reportable disease. Report TB to local health department for contact tracing as soon as possible. All active TB patients should be tested for HIV infection. When TB bacteria are actively replicating and damaging the body, it is called TB disease. Symptoms of pulmonary/pleural TB include cough productive of blood-tinged sputum, night sweats, and weight loss.

Question 114

Tuberculosis Treatment Plan (4) Rx = Initial regimen for suspected TB disease before C&S results are available **(1) - (1) months =** Duration of treatment for active TB disease * Treatment depends on whether the patient has drug-re\_\_\_\_\_TB or drug-sus\_\_\_\_\_\_ TB. * MDR TB is resistant to more than ____ anti-TB drug and at least to (2). Refer patient to TB ex\_\_\_\_\_.

Answer 114

**Isoniazid (INH), Rifampin (RIF), Ethambutol (ETH), and Pyrazinamide (PZA).** **6-9 months =** Duration of treatment for active TB disease * Treatment depends on whether the patient has drug-resistant TB or drug-susceptible TB. * MDR TB is resistant to more than one anti-TB drug and at least to isoniazid (INH) and rifampin (RIF). Refer patient to TB expert. Several treatment regimens are available. Consult CDC TB website

Question 115

(1) Mandatory for noncompliant patients. Success for treatment of TB disease is dependent on medication compliance. How is this done?

Answer 115

* Directly Observed Treatment* * How:* Patient is observed by a nurse when they take the medications. Mouth, cheek, and area under the tongue are checked to make sure the pill was swallowed adequately.

Question 116

TB Drug Adverse Effects ## Footnote * (1):* Give with pyridoxine (vitamin B6) to decrease risk of peripheral neuritis, neuropathy, hepatitis, seizures. * (1):* Optic neuritis, rash. Avoid if patient has eye problems. Eye exam at baseline. * (1):* Hepatitis, hyperuricemia, arthralgias, rash * (1):* Hepatitis; thrombocytopenia; orange-colored tears, saliva, and urine; drug interactions

Answer 116

* Isoniazid (INH):* Give with pyridoxine (vitamin B6) to decrease risk of peripheral neuritis, neuropathy, hepatitis, seizures. * Ethambutol (ETH):* Optic neuritis, rash. Avoid if patient has eye problems. Eye exam at baseline. - *E for Eye* * Pyrazinamide (PZA):* Hepatitis, hyperuricemia, arthralgias, rash * Rifampin (RIF):* Hepatitis; thrombocytopenia; orange-colored tears, saliva, and urine; drug interactions

Question 117

Purified Protein Derivative Converters and Chemoprophylaxis for Latent Tuberculosis Infection TB Mantoux Test * Recent purified protein derivative (PPD) converter is defined as a person with history of _____ PPD results who then converts to a \_\_\_\_\_\_PPD. * Higher risk of active TB disease (up to 10%) within first __ to __ years after seroconversion. * Treatment reduces the risk that latent tuberculosis infection (LTBI) will progress to TB disease. * ______ duration (\_–\_ months) rifamycin-based treatment for LTBI is now preferred over _____ duration treatment (\_–\_ months).

Answer 117

* Recent purified protein derivative (PPD) converter is defined as a person with history of negative PPD results who then converts to a positive PPD. * Higher risk of active TB disease (up to 10%) within first 1 to 2 years after seroconversion. * Treatment reduces the risk that latent tuberculosis infection (LTBI) will progress to TB disease. * Shorter duration (3–4 months) rifamycin-based treatment for LTBI is now preferred over longer duration treatment (6–9 months).

Question 118

Identifying Latent TB * Assess for signs and symptoms of TB (c\_\_\_\_\_, night \_\_\_\_\_, weight \_\_\_\_). If symptoms present, the patient has _____ TB disease. * Do people with latent TB have symptoms? Are they infectious? * Order (1) (make sure patient has no upper lobe cavitations and mediastinal adenopathy). * Check baseline _____ function tests and monitor. Check alcohol use if on Rx (1) - *risk for hepatitis*. * Consultation with TB expert is advised if known source of TB infection has drug-\_\_\_\_\_TB.

Answer 118

* Assess for signs and symptoms of TB (cough, night sweats, weight loss). If symptoms present, the patient has active TB disease. * People with LTBI do not have symptoms and cannot spread the infection to others. * Order CXR (make sure patient has no upper lobe cavitations and mediastinal adenopathy). * Check baseline liver function tests and monitor. Check alcohol use if on INH. * Consultation with TB expert is advised if known source of TB infection has drug-resistant TB.

Question 119

*Short Course Regimens* for Latent TB 1. Rx (2) every (1) for ___ months 2. Rx (1) every (1) for ___ months (preferred for HIV-negative adults/children) 3. Rx (2) every (1) for ___ months

Answer 119

1. **Isoniazid + Rifampin** every week for 3 months 2. **Rifampin** every day for 4 months (preferred for HIV-negative adults/children) 3. **Isoniazid + Rifampin** every day for 3 months

Question 120

Preventative Treatment of Latent TB ## Footnote \<35 yo = \>35 yo =

Answer 120

Generally, preventive treatment for LTBI is encouraged for those \<35 years of age. After 35 years of age, much higher risk of liver damage from INH chemoprophylaxis. Assess risk versus benefits and discuss with the patient.

Question 121

Tuberculosis Skin Test (Mantoux Test) What are you looking for? What does it feel like? What sign not significant?

Answer 121

Look for an induration (feels harder). The red color is not as important. If a PPD result is a bright-red color but is not indurated (skin feels soft), it is a negative result.

Question 122

Induration _\>_ 5mm Positive result in what populations? (4)

Answer 122

1. HIV-infected persons 2. Recent contact with infectious TB cases 3. CXR with fibrotic changes consistent with previous TB disease (cavitations on the upper lobes) 4. Immunocompromised (e.g., organ transplant, bone marrow transplant, renal failure, patients on biologic drugs)

Question 123

Induration of ≥10 mm Positive result in which populations? (4)

Answer 123

1. Recent immigrants (within the past 5 years) from high-prevalence countries (Latin America, Asia [except Japan], Africa, India, Pacific islands) 2. Child \<4 years of age or children/adolescents exposed to high-risk adult 3. Injection drug user, healthcare worker, homeless 4. Employees or residents from high-risk congregate settings (jails, nursing homes)

Question 124

Induration of ≥15 mm Positive in what population? (1)

Answer 124

Persons with no known risk factors for TB

Question 125

Tuberculosis Skin Test Mantoux test/TB skin test (TST) Inject ____ mL of 5TU-PPD sub\_\_\_\_\_\_\_\_. Do not use the tine test (has not been used for many years).

Answer 125

Inject 0.1 mL of 5TU-PPD subdermally. Do not use the tine test (has not been used for many years).

Question 126

Blood Tests for Tuberculosis ## Footnote ***(1)**-TB Gold in-tube test or the T-SPOT TB test* (also known as (1): Blood tests that measure gamma-interferon (from lymphocytes). *IGRA test results:* Available within ___ hours (only one visit required). If history of previous ____ vaccination, IGRA blood tests preferred.

Answer 126

* QuantiFERON-TB Gold in-tube test or the T-SPOT TB test* (also known as interferon-gamma release assays [IGRAs]): Blood tests that measure gamma-interferon (from lymphocytes). * IGRA test results:* Available within 24 hours (only one visit required). If history of previous BCG vaccination, IGRA blood tests preferred.

Question 127

Sputum Tests for Tuberculosis * Early morning deep cough specimen; collect for __ consecutive days. * Sputum nucleic acid amplification test (NAAT) is a _____ test (1–3 days). * Sputum for **(1) is gold standard** for diagnosing pulmonary TB infection; can take up to 8 weeks to grow. * *(1) (AFB) =* Positive AFB is not ______ , but it is ______ of TB infection. It is a rapid test, and results can be obtained 1 to 2 days. It helps to strengthen diagnosis of TB before sputum C&S results are available (takes up to 8 weeks for result). * Order sputum for **(3)** smear if you suspect active TB infection.

Answer 127

* Early morning deep cough specimen; collect for 3 consecutive days. * **Sputum nucleic acid amplification test (NAAT)** is a rapid test (1–3 days). * Sputum for **C&S is gold standard** for diagnosing pulmonary TB infection; can take up to 8 weeks to grow. * ***Acid-fast bacilli (AFB) smear**:* Positive AFB is not diagnostic, but it is suggestive of TB infection. It is a rapid test, and results can be obtained 1 to 2 days. It helps to strengthen diagnosis of TB before sputum C&S results are available (takes up to 8 weeks for result). * Order sputum for **NAAT, C&S, and AFB** smear if you suspect active TB infection.

Question 128

Booster Phenomenon =

Answer 128

A person with LTBI can have a false-negative reaction to the tuberculin skin test (TST) or the PPD if they have not been tested for many years. ## Footnote **Two-step** tuberculin skin testing is recommended by the CDC. Explanation: When the TST/PPD is done the first time, if there is no reaction, it may be a false negative. Repeat the PPD (1–3 weeks later). Positive reaction means that the patient has a LTBI (booster phenomenon). Follow up with CXR and inquire about signs/symptoms of TB infection. If no symptoms of active TB disease and negative CXR, offer LTBI prophylaxis. If the second PPD is negative, it means the person has a true negative test result (does not have a TB infection).

Question 129

Exam Tips ## Footnote A PPD result may be listed as 9.5 mm. If the patient falls under the 10-mm group, then it is \_\_\_\_\_\_(by definition) unless the patient has the signs/\_\_\_\_\_ and/or \_\_\_\_findings suggestive of TB. Memorize the criteria for the \_\_*-*mm and \_\_-mm results. You may be asked to identify a _____ of a CXR (radiography) of a patient with pulmonary TB or bacterial pneumonia. Memorize the appearance of a posterior–anterior (PA) CXR of a person with **healed pulmonary TB**. The classic findings are pulmonary nodules and/or cavitations (round black holes) on the upper lobes with or without fibrotic changes (scars). With right middle-lobe pneumonia, look for consolidation (white-colored area) on the right middle lobe, which is located at about the same level as the right breast on the front of the chest.

Answer 129

A PPD result may be listed as 9.5 mm. If the patient falls under the 10-mm group, then it is negative (by definition) unless the patient has the signs/symptoms and/or CXR findings suggestive of TB. Memorize the criteria for the 5-mm and 10-mm results. You may be asked to identify a photograph of a CXR (radiography) of a patient with pulmonary TB or bacterial pneumonia. Memorize the appearance of a posterior–anterior (PA) CXR of a person with healed pulmonary TB. The classic findings are pulmonary nodules and/or cavitations (round black holes) on the upper lobes with or without fibrotic changes (scars). With right middle-lobe pneumonia, look for consolidation (white-colored area) on the right middle lobe, which is located at about the same level as the right breast on the front of the chest.

Question 130

Clinical Pearls ## Footnote The QuantiFERON-TB Gold in-tube and the T-SPOT TB tests are available at public health clinics. Never treat TB with fewer than _____ drugs. According to the CDC, on the average, about ___ contacts are listed for each index person with infectious TB. Persons with HIV infection with CD4 \<500 or patients who are taking tumor necrosis factor antagonists (or biologics) are at very high risk for active TB disease after initial exposure (primary TB). The tuberculin skin test is considered both valid and safe to use throughout pr\_\_\_\_\_\_\_. \_\_\_\_\_ children are more likely than _____ children to develop life-threatening forms of TB disease.

Answer 130

The QuantiFERON-TB Gold in-tube and the T-SPOT TB tests are available at public health clinics. Never treat TB with fewer than three drugs. According to the CDC, on the average, about 10 contacts are listed for each index person with infectious TB. Persons with HIV infection with CD4 \<500 or patients who are taking tumor necrosis factor antagonists (or biologics) are at very high risk for active TB disease after initial exposure (primary TB). The tuberculin skin test is considered both valid and safe to use throughout pregnancy. Younger children are more likely than older children to develop life-threatening forms of TB disease.

Question 131

A disease characterized by chronic airway inflammation. Defined by the history of respiratory symptoms that vary over time (wheezing, shortness of breath, chest tightness, cough) accompanied by variable expiratory airflow limitation. **Reversible airway obstruction and increased responsiveness to stimuli (internal or external).**

Answer 131

Asthma

Question 132

Asthma ## Footnote Genetic predisposition with positive family history of? (2) Exacerbations can be \_\_\_\_-threatening. Rule out allergic asthma (refer for allergy \_\_\_\_\_), (1) disease, r\_\_\_itis, s\_\_\_itis, and stress. Asthma does not appear to be a strong risk factor for acquiring COVID-19.

Answer 132

Genetic predisposition with positive family history of allergies, eczema, and allergic rhinitis (atopy or atopic history). Exacerbations can be life-threatening. Rule out allergic asthma (refer for allergy testing), gastroesophageal reflux disease (GERD), rhinitis, sinusitis, and stress. Asthma does not appear to be a strong risk factor for acquiring COVID-19.

Question 133

Treatment Goals (All Asthmatics) 1. Any school, sports, or work limitations? 2. Pr\_\_\_\_\_\_ exacerbation 3. Minimal use of _____ medicine ( 4. Avoid ___ visits/hos\_\_\_\_\_\_\_\_ 5. Maintain near-normal pulmonary function (reduce permanent lung d\_\_\_\_\_\_); prevent loss of lung f\_\_\_\_\_\_(or, for children, prevent reduced lung growth)

Answer 133

1. Can perform usual “normal” activities with no limitations (e.g., attend school full time, play “normally,” work full time, no job absence due to asthmatic symptoms) 2. Prevent exacerbation 3. Minimal use of rescue medicine (\<2 days a week albuterol use) 4. Avoid ED visits/hospitalization 5. Maintain near-normal pulmonary function (reduce permanent lung damage); prevent loss of lung function (or, for children, prevent reduced lung growth)

Question 134

Classic Case of Asthma A young-adult patient with asthma complains of worsening symptoms after a recent bout of a U\_\_. The patient is using an albuterol inhaler more than normal (≥\_\_ times/day) to treat the symptoms. Complains of ______ of breath, w\_\_\_\_\_\_, and chest \_\_\_\_\_\_\_ness that is sometimes accompanied by a dry cough at ____ and early morning (e.g., 3 a.m.) that interrupts sleep.

Answer 134

A young-adult patient with asthma complains of worsening symptoms after a recent bout of a URI. The patient is using an albuterol inhaler more than normal (≥three times/day) to treat the symptoms. Complains of shortness of breath, wheezing, and chest tightness that is sometimes accompanied by a dry cough at night and early morning (e.g., 3 a.m.) that interrupts sleep.

Question 135

Objective Findings of Asthma ## Footnote * Lungs:* (1)\* with ______ expiratory phase. As asthma worsens, the wheezing occurs during both ______ and expiration. With severe bronchocon\_\_\_\_\_\_, breath sounds are f\_\_\_\_\_ or inaudible. * Cardiovascular:* \_\_\_\_\_\_cardia, rapid pulse.

Answer 135

* Lungs:* Wheezing with prolonged expiratory phase. As asthma worsens, the wheezing occurs during both inspiration and expiration. With severe bronchoconstriction, breath sounds are faint or inaudible. * Cardiovascular:* Tachycardia, rapid pulse.

Question 136

Trigger Factors for Asthma * Airborne allergens:* Dust m\_\_\_\_, mo\_\_, cock\_\_\_\_\_\_ * \_\_\_\_\_ allergies:* Sulfites, red and yellow dye, seafood * Viral U\_\_\_\_, airborne allergens * _____ air or cold weather and fumes from chemicals or sm\_\_\_\_\_ * Emotional st\_\_\_\_\_ and _______ (exercise-induced asthma) * G\_\_\_\_\_ (reflux of acidic gastric contents irritates airways)

Answer 136

* Airborne allergens:* Dust mites, mold, cockroaches * Food allergies:* Sulfites, red and yellow dye, seafood * Viral URIs, airborne allergens * Cold air or cold weather and fumes from chemicals or smoke * Emotional stress and exercise (exercise-induced asthma) * GERD (reflux of acidic gastric contents irritates airways)

Question 137

Trigger Factors for Asthma * (1) acid (ASA) or N\_\_\_\_\_\_ (patients with nasal polyps are more sensitive to ASA and NSAIDs) * Sm\_\_\_\_, illicit drug use (coc\_\_\_\_ and her\_\_\_\_), gen\_\_\_\_\_, at\_\_\_\_ **Major risk factors for fatal asthma:** * Previous hospitalization requiring int\_\_\_\_\_\_ or ___ admission * E\_ visits in the past year * Recent history of p\_\_\_\_\_\_ controlled asthma

Answer 137

* Acetylsalicylic acid (ASA) or NSAIDs (patients with nasal polyps are more sensitive to ASA and NSAIDs) * Smoking, illicit drug use (cocaine and heroin), genetics, atopy **Major risk factors for fatal asthma:** * Previous hospitalization requiring intubation or ICU admission * ED visits in the past year * Recent history of poorly controlled asthma

Question 138

Asthma Treatment Plan ## Footnote ***Initial visit:*** Assess asthma c\_\_\_\_\_ to determine if therapy should be ad\_\_\_\_\_\_. At each visit, assess asthma control, proper medication tech\_\_\_\_, patient ad\_\_\_\_\_\_, and patient concerns. ***Nebulizer treatments:*** Give up to ____ albuterol treatments every __ minutes as needed. Alternative is albuterol metered-dose inhaler (MDI) used with a ___ (equivalent to nebulizer). Short course of oral _______ may be needed for exacerbations. If low-dose _____ corticosteroids (ICSs), add \_\_ABAs (or increase dose to medium-dose ICSs only).

Answer 138

***Initial visit**:* Assess asthma control to determine if therapy should be adjusted. At each visit, assess asthma control, proper medication technique, patient adherence, and patient concerns. ***Nebulizer treatments**:* Give up to three albuterol treatments every 20 minutes as needed. Alternative is albuterol metered-dose inhaler (MDI) used with a spacer (equivalent to nebulizer). Short course of oral corticosteroids may be needed for exacerbations. If low-dose inhaled corticosteroids (ICSs), add LABAs (or increase dose to medium-dose ICSs only).

Question 139

“Rescue” or “Reliever” Medications (1) is the only drug class used for rescue (traditional strategy). Under the **_Global Initiative for Asthma (GINA) 2020_**, the preferred reliever is (1), with SABA as an \_\_\_\_\_\_\_.

Answer 139

SABA is the only drug class used for rescue (traditional strategy). Under the **_Global Initiative for Asthma (GINA) 2020_**, the preferred reliever is Combination ICS-Formoterol (LABA), with **SABA as an alternative**.

Question 140

SABAs MDI, MDI with spacer, or by nebulizer * (1) (Ventolin HFA) or (1) (Maxair):* Two inhalations every 4 to 6 hours as needed * (1) (Xopenex HFA):* Two inhalations every 4 to 6 hours as needed; less likely to cause cardiac stimulation (fewer palpitations, less tachycardia)

Answer 140

MDI, MDI with spacer, or by nebulizer ## Footnote * Albuterol (Ventolin HFA) or pirbuterol (Maxair):* Two inhalations every 4 to 6 hours as needed * Levalbuterol (Xopenex HFA):* Two inhalations every 4 to 6 hours as needed; less likely to cause cardiac stimulation (fewer palpitations, less tachycardia)

Question 141

SABAs Quick onset (\_\_–\_\_ minutes) and lasts about __ to __ hours * Used for quick relief (of \_\_\_\_\_) but does not treat underlying \_\_\_\_\_\_ * With nebulizer, give up to ____ treatments every **minutes as needed; short course of oral** ____ may be needed for exacerbations (\_\_\_\_\_ Dose Pack) * Used for treatment of \_\_\_\_\_\_-induced asthma

Answer 141

Quick onset (15–30 minutes) and lasts about 4 to 6 hours * Used for quick relief (of wheezing) but does not treat underlying inflammation * With nebulizer, give up to three treatments every 20 minutes as needed; short course of oral corticosteroids may be needed for exacerbations (Medrol Dose Pack) * Used for treatment of exercise-induced asthma

Question 142

Long-Term Control Medications LABAs (used alone) increase the risk of ____ from asthma. Combination of LABA and ICS is \_\_\_\_\_. Example: Fluticasone with _____ (Advair), budesonide with ______ (Symbicort)

Answer 142

LABAs (used alone) increase the risk of death from asthma. Combination of LABA and ICS is safer. Example: Fluticasone with salmeterol (Advair), budesonide with formoterol (Symbicort)

Question 143

Sustained-Release Theophylline (Theo-24) * Drug class*: (1). Used as an ad\_\_\_\_\_ drug. Acts as a \_\_\_\_\_\_\_\_. * Monitor levels to reduce risk of \_\_\_\_\_\_. The drug has multiple drug interactions, including: * Mac\_\_\_\_\_, quin\_\_\_\_\_ * Cim\_\_\_\_\_ * Anti\_\_\_\_\_\_ such as phenytoin, carbamazepine (Tigerton) * Check blood levels: Normal is __ to __ mg/dL

Answer 143

* Drug class*: Methylxanthine. Used as an adjunct drug. Acts as a bronchodilator. * Monitor levels to reduce risk of toxicity. The drug has multiple drug interactions, including: * Macrolides, quinolones * Cimetidine * Anticonvulsants such as phenytoin, carbamazepine (Tigerton) * Check blood levels: Normal is 12 to 15 mg/dL

Question 144

Spacer or Chambers =

Answer 144

Use of a “spacer” or “chamber” (AeroChamber) is encouraged. It will increase delivery of the aerosolized drug to the lungs and minimize oral thrush (for inhaled steroids).

Question 145

Asthma: Long Term Control Medications (9)

Answer 145

Inhaled Corticosteroids Long-acting beta 2 agonists Combination of ICS with LABA Leukotriene receptor antagonists/inhibitors Mast cell stabilizers (cromoglycates) Methylaxanthines Immunomodulators Anti-immunoglobulin E antibodies Systemic Oral Corticosteroids

Question 146

(1) Triamcinolone (Azmacort) BID Budesonide (Pulmicort) BID Fluticasone (Flovent) BID

Answer 146

Inhaled Corticosteroids

Question 147

(1) Salmeterol (Serevent) BID Formoterol (Foradil) BID

Answer 147

Long-acting beta2-agonists

Question 148

(1) Salmeterol–fluticasone (Advair HFA, Advair Diskus) BID Budesonide–formoterol (Symbicort) Mometasone–formoterol (Dulera)

Answer 148

Combination of ICS with LABA

Question 149

(1) Montelukast (Singulair) daily Zafirlukast (Accolate) BID Zileuton (Zyflo) daily

Answer 149

Leukotriene receptor antagonists/inhibitors

Question 150

(1) Cromolyn sodium (Intal) QID Nedocromil sodium (Tilade) QID

Answer 150

Mast cell stabilizers (cromoglycates)

Question 151

(1) Theophylline (not used often) daily; starting dose 300 mg/day BID

Answer 151

Methylxanthines

Question 152

(1) Omalizumab (Xolair)

Answer 152

Immunomodulators

Question 153

(1) Dupilumab (Dupixent)

Answer 153

Anti-immunoglobulin E antibodies

Question 154

(1) Prednisone Prednisolone Methylprednisolone

Answer 154

Systemic Oral Corticosteroids

Question 155

Inhaled Corticosteroids (Triamcinolone (Azmacort) BID, Budesonide (Pulmicort) BID, Fluticasone (Flovent) BID) **Side/Adverse Effects** **Oral \_\_\_\_** (g\_\_\_\_\_ or drink water after use); use with \_\_\_\_; H\_\_ axis suppression, gl\_\_\_\_\_\_, others.

Answer 155

**Oral thrush** (gargle or drink water after use); use with spacer; HPA axis suppression, glaucoma, others.

Question 156

LABA (Salmeterol (Serevent) BID, Formoterol (Foradil) BID) **Side/Adverse Effects** Warn patients of increased risk of asthma \_\_\_\_\_; not to be used as _____ drug. Do not use ____ with asthmatics, use as?

Answer 156

Warn patients of increased risk of asthma death; not to be used as rescue drug. Do not use alone with asthmatics, use as LABA + ICS combinations

Question 157

Combination of ICS with LABA (Salmeterol–fluticasone (Advair HFA, Advair Diskus) BID, Budesonide–formoterol , (Symbicort), Mometasone–formoterol (Dulera)) **Side/Adverse Effects** Preferred **_GINA 2020_** =

Answer 157

Preferred **_GINA 2020_** medication is ICS–formoterol for reliever (rescue drug) or daily as treatment (Steps 1, 2, 3).

Question 158

Leukotriene Receptor Antagonists/Inhibitors (Montelukast (Singulair) daily, Zafirlukast (Accolate) BID, Zileuton (Zyflo) daily) **Side/Adverse Effects** N\_\_\_\_\_\_\_\_ effects (agitation, aggression, depression, others). Monitor ____ function tests (zileuton).

Answer 158

Neuropsychological effects (agitation, aggression, depression, others). Monitor liver function tests (zileuton).

Question 159

Mast cell stabilizers (cromoglycates) (Cromolyn sodium (Intal) QID, Nedocromil sodium (Tilade) QID) **Side/Adverse Effects** Cromolyn (Intal) and nedocromil (Tilade) _____ have been ______ in the United States; cromolyn for ______ still available.

Answer 159

Cromolyn (Intal) and nedocromil (Tilade) inhalers have been discontinued in the United States; cromolyn for nebulization still available.

Question 160

Methylxanthines Theophylline (not used often) daily; starting dose 300 mg/day BID **Side/Adverse Effects** \_\_\_\_\_\_mimetic. Avoid with seizures, hypertension, stroke. Several drug \_\_\_\_\_; monitor drug \_\_\_\_.

Answer 160

Sympathomimetic. Avoid with seizures, hypertension, stroke. Several drug interactions; monitor drug levels.

Question 161

Immunomodulators Omalizumbab (Xolair) **Side/Adverse Effects** \_\_\_\_\_\_\_\_ can occur with first dose or after long-term use.

Answer 161

Anaphylaxis can occur with first dose or after long-term use.

Question 162

Anti-immunoglobulin E antibodies Dupilumab (Dupixent) **Side/Adverse Effects** Be equipped and prepared to treat an\_\_\_\_\_\_\_\_ when starting this drug. Higher risk of TIA, CVA, MI, em\_\_\_\_\_.

Answer 162

Be equipped and prepared to treat anaphylaxis when starting this drug. Higher risk of TIA, CVA, MI, emboli.

Question 163

Systemic oral corticosteroids (Prednisone, Prednisolone, Methylprednisolone) **Side/Adverse Effects** Short course for \_\_–\_\_ days. If used \>\_ days, requires \_\_\_\_\_. Used for \_\_\_\_\_\_\_.

Answer 163

Short course for 3–4 days. If used \>4 days, requires weaning. Used for exacerbations.

Question 164

Asthma Classification (Age 12 Years or Older)

Answer 164

Question 165

Stepwise Approach (GINA, 2020) **Global Initiative for Asthma Management and Prevention (2020)** **Step 1** 1. Symptoms how often in a month? 2. Rx = **Step 2** 1. Symptoms how often in a month? 2. Rx = **Step 3** 1. Symptoms how often? 2. Rx = **Step 4** 1. Symptoms most \_\_\_\_\_, or \_\_\_\_\_with asthma once a week or more (\_\_\_lung function) 2. \_\_\_\_\_\_-dose ICS–LABA \_\_\_\_\_; _____ for expert advice **Step 5** 1. Symptoms most \_\_\_\_, or ______ with asthma once a week or more (\_\_\_\_lung function) 2. Refer for ph\_\_\_\_\_\_ assessment; add anti-\_\_\_

Answer 165

**Step 1** 1. Symptoms less than two times a month 2. Low-dose ICS with formoterol PRN (alternative is SABA with low-dose ICS) **Step 2** 1. Symptoms two times a month or more, but less than daily 2. Low-dose ICS daily or low-dose ICS with formoterol PRN **Step 3** 1. Symptoms most days, or waking with asthma once a week or more 2. Low-dose ICS–LABA daily or medium-dose ICS or low-dose ICS + leukotriene receptor antagonist (LTRA) **Step 4** 1. Symptoms most days, or waking with asthma once a week or more (low lung function) 2. Medium-dose ICS–LABA daily; refer for expert advice **Step 5** 1. Symptoms most days, or waking with asthma once a week or more (low lung function) 2. Refer for phenotypic assessment; add anti-IgE

Question 166

Asthma Treatment Recommendations (2007)

Answer 166

Question 167

Asthma Treatment Summary Every asthma patient should be on a (1) PRN according to 2007 guidelines Starting in Step 2, add (1) In Step 3, add (1) to low-dose ICS (use combination medications Advair, Symbicort) Continue using SABA as ____ drug.

Answer 167

Every asthma patient should be on a SABA (albuterol) PRN according to 2007 guidelines Starting in Step 2, add low-dose ICS In Step 3, add LABA to low-dose ICS (use combination medications Advair, Symbicort) Continue using SABA as PRN drug.

Question 168

Asthma Treatment Summary For GINA 2020 * Preferred reliever/rescue med is (1). * Role Albuterol or SABA monotherapy? * Role or ICS–LABA * GINA preferred ICS (1) * GINA preferred LABA (1)

Answer 168

* Preferred reliever/rescue med is ICS–formoterol or ICS–LABA * Albuterol or SABA monotherapy is discouraged, but it can be used as an alternative rescue drug. GINA does not advise against their use as an add-on reliever/rescue drug. * ICS–LABA can be used as both maintenance (daily) treatment and a rescue inhaler. Extra inhalations can be used for breakthrough asthma symptoms. For severe persistent asthma, refer to asthma specialist. * Preferred ICS = budesonide or beclomethasone * Preferred LABA = formoterol * Symbicort = budesinide + formoterol

Question 169

Asthma Patient Education * Review inhaler _____ (use _____ if patient has problems). * T\_\_\_\_\_ about rescue medications and long-term controller medications. * Develop a written asthma _____ plan; partner with patient and f\_\_\_\_\_\_. * Control and limit exposure to _____ if allergic asthma; consider ________ with allergist. * Teach how to use \_\_\_\_\_\_\_; recognize worsening.

Answer 169

* Review inhaler technique (use spacer if patient has problems). * Teach about rescue medications and long-term controller medications. * Develop a written asthma action plan; partner with patient and family. * Control and limit exposure to allergens if allergic asthma; consider immunotherapy with allergist. * Teach how to use spirometer; recognize worsening.

Question 170

Exercise-Induced Bronchoconstriction (Exercise-Induced Asthma) Acute bronchoconstriction occurring during or immediately after exercise. * Up to \_\_% of asthmatics may have exercise-induced bronchoconstriction (EIB). * Leuk\_\_\_\_\_, hist\_\_\_\_\_, and \_\_\_\_leukin levels are increased. * What should they do before exercise?

Answer 170

* Up to 90% of asthmatics may have exercise-induced bronchoconstriction (EIB). * Leukotrienes, histamine, and interleukin levels are increased. * Premedicate 5 to 20 minutes before exercise with two puffs of a SABA (albuterol [Ventolin], levalbuterol [Xopenex], pirbuterol [Maxair]). Effect will last up to 4 hours.

Question 171

Asthmatic Exacerbation * ***Respiratory distress:*** \_\_\_\_\_pnea, using _____ muscles (intercostals, abdominal) to breathe, talks in br\_\_\_\_/fragmented sentences, severe diaph\_\_\_\_, fatigue, agitation. * ***Lungs:*** Minimal to no breath _____ audible during lung auscultation. Peak expiratory flow (PEF)

Answer 171

* ***Respiratory distress:*** Tachypnea, using accessory muscles (intercostals, abdominal) to breathe, talks in brief/fragmented sentences, severe diaphoresis, fatigue, agitation. * ***Lungs:*** Minimal to no breath sounds audible during lung auscultation. Peak expiratory flow (PEF) \<40%. Lips/skin is blue tinged (cyanosis). Check O 2 saturation. Use supplemental oxygen.

Question 172

Asthma Exacerbation * *Give nebulizer treatment:* ______ 0.5% solution by nebulizer every ___ to 30 minutes up to _____ doses. If unable to use inhaled bronchodilators, give _______ 1:1,000 solution intramuscularly (IM). * *After nebulizer treatment(s):* Listen for breath sounds. If inspiratory and expiratory wheezing is present, this is a \_\_\_\_\_sign (signals opening up of airways). If there is a ____ of breath sounds or wheezing after a nebulizer treatment, this is a bad sign (patient is not responding). Call \_\_\_.

Answer 172

* *Give nebulizer treatment:* Albuterol 0.5% solution by nebulizer every 20 to 30 minutes up to three doses. If unable to use inhaled bronchodilators, give epinephrine 1:1,000 solution intramuscularly (IM). * *After nebulizer treatment(s):* Listen for breath sounds. If inspiratory and expiratory wheezing is present, this is a good sign (signals opening up of airways). If there is a lack of breath sounds or wheezing after a nebulizer treatment, this is a bad sign (patient is not responding). Call 911.

Question 173

Asthma Exacerbation * *Discharge:* For moderate-to-severe exacerbations, _____ Dose Pack or prednisone tabs __ mg/day × days (no \_\_\_\_necessary if 4 days or less and not steroid dependent). Continue medications and increase dose (or add another controller drug). * *Refer to \_\_\_\_:* * If poor to no response to nebulizer treatment (PEF * If no response to nebulizer treatment, impending respiratory arrest, give \_\_\_\_Pen *stat.* Call \_\_\_.

Answer 173

* *Discharge:* For moderate-to-severe exacerbations, Medrol Dose Pack or prednisone tabs 40 mg/day × 4 days (no weaning necessary if 4 days or less and not steroid dependent). Continue medications and increase dose (or add another controller drug). * *Refer to ED:* * If poor to no response to nebulizer treatment (PEF \<40% of expected), call 911. * If no response to nebulizer treatment, impending respiratory arrest, give Epi-Pen *stat.* Call 911.

Question 174

Peak Expiratory Flow Rate HAG = * What do you tell the patient to do? * What does the PEF tell you?

Answer 174

PEF is based on height (H), age (A), and gender (G), or HAG * During expiration, patient is instructed to blow hard using the spirometer (three times). The highest value is recorded (personal best). * Measures effectiveness of treatment, worsening symptoms, and exacerbations.

Question 175

Spirometry Parameters Asthma action plan forms are available online for free. * *Green Zone:* \_\_% to \_\_\_% of expected volume * No wheeze or cough. Sleeps through the night. Can work and play. Continue daily controller medications. * *Yellow Zone:* \_\_\_% to \_\_\_% of expected volume * Mild wheeze, tight chest, coughing at \_\_\_\_\_\_. Exposure to known trigger or first signs of a cold, continue with green zone medicines and add or increase dose. * *Red Zone:* * Breathing hard and fast, nasal fl\_\_\_\_\_, trouble speaking. In children, ribs show from using _____ muscles. Administer oxygen. First-line treatment is ______ by MDI with spacer or nebulizer. Onset of action \<5 minutes. If not effective, call \_\_\_.

Answer 175

* *Green Zone:* 80% to 100% of expected volume * No wheeze or cough. Sleeps through the night. Can work and play. Continue daily controller medications. * *Yellow Zone:* 50% to 80% of expected volume * Mild wheeze, tight chest, coughing at night. Exposure to known trigger or fi rst signs of a cold, continue with green zone medicines and add or increase dose. * *Red Zone:* \<50% of expected * Breathing hard and fast, nasal fl aring, trouble speaking. In children, ribs show from using accessory muscles. Administer oxygen. First-line treatment is albuterol by MDI with spacer or nebulizer. Onset of action \<5 minutes. If not effective, call 911.

Question 176

Clinical Pearls of Asthma * Pulse oximetry oxygen saturation of ≤90% is indicative of ______ asthmatic episode and severe hy\_\_\_\_\_. Call 911. * A near-normal pulse oximetry may be present in a patient with impending respiratory failure due to hyper\_\_\_\_\_\_ (bedside capnometry may be better method to monitor).

Answer 176

* Pulse oximetry oxygen saturation of ≤90% is indicative of severe asthmatic episode and severe hypoxemia. Call 911. * A near-normal pulse oximetry may be present in a patient with impending respiratory failure due to hypercapnia (bedside capnometry may be better method to monitor).

Question 177

Chest X-Ray Interpretation You may see **one plain CXR film on the exam**. Here are some basics. * “X-rays” are ______ (gamma rays) that pass through the human body and hit a metal target (the film cassette). Depending on the type of tissue density, they are absorbed differently. * The darker the color, the _____ the tissue density (e.g., air on lungs). * X-rays can be plain or con\_\_\_\_\_\_\_. * A systematic approach of reading chest films should be followed every time. Compare the present film with the ____ films (if available). 1. In the ___ view the x-ray goes through the back to the front, The _____ column is more visible at this view. 2. For the ___ view the x-ray goes through the front of the chest toward the back 3. ______ view is the view from the side of the chest.

Answer 177

* “X-rays” are radiation (gamma rays) that pass through the human body and hit a metal target (the film cassette). Depending on the type of tissue density, they are absorbed differently. * The darker the color, the lower the tissue density (e.g., air on lungs). * X-rays can be plain or contrasted. * In the PA view the x-ray goes through the back to the front, The spinal column is more visible at this view. 1. For the anterior–posterior (AP) view the x-ray goes through the front of the chest toward the back 2. Lateral view is the view from the side of the chest. 3. A systematic approach of reading chest films should be followed every time. Compare the present film with the old films (if available).

Question 178

Chest X-Ray Appearance ## Footnote * Air:* Appears as ____ color (low density so less absorption) over lung field * Bones:* Appear as ____ to gray * Metals:* ____ white (high absorption) * Tissue:* Different \_\_\_ish shades (medium absorption) * Fluid:* \_\_\_\_ish to \_\_\_ish * Tissues visible:* Trachea, bronchus, aorta, heart, lungs, pulmonary arteries, diaphragm, gastric bubble, ribs

Answer 178

* Air:* Appears as black color (low density so less absorption) over lung field * Bones:* Appear as white to gray * Metals:* Bright white (high absorption) * Tissue:* Different grayish shades (medium absorption) * Fluid:* Grayish to whitish * Tissues visible:* Trachea, bronchus, aorta, heart, lungs, pulmonary arteries, diaphragm, gastric bubble, ribs

Question 179

Chest X-Ray of Abnormal Conditions ## Footnote * (1):* Black color in the hilum (above the clavicles), a lot of black color in hyperinflated lungs, blunted costovertebral angle (CVA; diaphragm flat instead of dome shaped). * (1)* Grayish to white areas on a lobe or lobes of lung (consolidation) from purulent fluid. * (1):* Upper lobe with cavitation (black round holes), fibrosis (scarring), and pulmonary infiltrates (fluid) in active TB disease.

Answer 179

* Emphysema:* Black color in the hilum (above the clavicles), a lot of black color in hyperinflated lungs, blunted costovertebral angle (CVA; diaphragm flat instead of dome shaped). * Lobar pneumonia/bacterial pneumonia:* Grayish to white areas on a lobe or lobes of lung (consolidation) from purulent fluid. * TB:* Upper lobe with cavitation (black round holes), fibrosis (scarring), and pulmonary infiltrates (fluid) in active TB disease.

Question 180

Chest X-Ray of Abnormal Conditions ## Footnote * (1)*: Heart occupies more than 50% of the chest diameter; it is enlarged. * (1) sign:* Displacement of the normal silhouette in the chest film. For example, displacement of the para-aortic line can be caused by an aortic aneurysm or dissection/rupture.

Answer 180

* Left ventricular hypertrophy (LVH)/cardiomyopathy:* Heart occupies more than 50% of the chest diameter; it is enlarged. * Silhouette sign:* Displacement of the normal silhouette in the chest film. For example, displacement of the para-aortic line can be caused by an aortic aneurysm or dissection/rupture.

Question 181

Exam Tips * Expect questions about asthma (diagnosis, treatment). Memorize an asthma stage because you may get “numbers” and have to figure out the asthma severity of a patient. Suggest memorizing **Step 3** **(e.g., FEV1 of \_\_-\_\_%).** * **If FEV1 is \>80%**, it is either (1) or (1) asthma. * Check **night awakenings.** If they occur * If patient on low-dose ICS and has poor control (Step 2), add a **\_\_\_\_.**

Answer 181

* Expect questions about asthma (diagnosis, treatment). Memorize an asthma stage because you may get “numbers” and have to figure out the asthma severity of a patient. Suggest **memorizing Step 3 (e.g., FEV1 of 60%–80%).** * If **FEV1 is \>80%**, it is either **intermittent or mild persistent asthma.** * Check night awakenings. If they occur * If patient on low-dose ICS and has poor control (Step 2), add a **LABA**.

Question 182

Exam Tips * Memorize factors needed to figure out PEF = **which mneumonic?** * There is only one rescue drug class; it is the **(1)**. All asthmatics need a SABA for as _____ use. * First-line drugs for asthma are **(1)**; they treat lung **inflammation**.

Answer 182

* Memorize factors needed to figure out PEF = **HAG mnemonic (height, age, gender)** * There is **only one rescue drug class; it is the SABAs**. All asthmatics need a SABA for as needed use. * **First-line drugs for asthma are ICSs;** they treat lung **inflammation**.

Question 183

Exam Tips * Chronic use of high-dose inhaled steroids can cause ost\_\_\_\_, g\_\_\_\_\_ failure in children, gl\_\_\_\_\_, cat\_\_\_\_\_, i\_\_\_\_\_ suppression, hypothalamic–pituitary–ad\_\_\_\_\_ suppression, and other effects. * Recognize respiratory failure. Severe respiratory distress: \_\_\_\_pnea, dis\_\_\_\_\_\_ of or lack of wheezing, \_\_\_\_\_\_muscle use, dia\_\_\_\_\_, and exhaustion.

Answer 183

* Chronic use of high-dose inhaled steroids can cause osteoporosis, growth failure in children, glaucoma, cataracts, immune suppression, hypothalamic–pituitary–adrenal suppression, and other effects. * Recognize respiratory failure. Severe respiratory distress: Tachypnea, disappearance of or lack of wheezing, accessory muscle use, diaphoresis, and exhaustion.

Question 184

Clinical Pearls ## Footnote During a severe asthmatic exacerbation, is it hard to hear breath sounds? After administering albuterol what is a sign that the patient's airways are opening? Always ask frequency of albuterol (SABA) inhaler, how many times a week means a person has poorly controlled asthma or having an exacerbation? If you suspect allergic asthma, check what? then refer to who for what?

Answer 184

During a severe asthmatic exacerbation, it is hard to hear breath sounds, and you may not hear any wheezing. Administer albuterol nebulizer treatment and listen for **wheezing, which means patient’s airways are opening.** Ask asthmatic patient how many times they use their albuterol (SABA) inhaler. If using **more than twice per week**, has poorly controlled asthma or having an exacerbation. If you suspect allergic asthma, check **serum immunoglobulin G allergy panels** (e.g., mold allergy, grass allergy panels). Refer to **allergist for scratch testing** (more sensitive than blood allergy panels) and treatment.

Question 185

Exam Tips First-line treatment for mild COPD (Group A) is either a (1) or (1) If poor relief on single agent, add a second agent. If on SABA, add short-acting ______ (Atrovent). If short-acting bronchodilators are not controlling symptoms, next step is to start patient on a (1) or (1) based on patient preference. Continue using SABA as needed. \_\_\_\_\_\_\_ (Atrovent) is a short-acting anticholinergic or SAMA. Do not use ____ (salmeterol, formoterol) for rescue treatment.

Answer 185

First-line treatment for mild COPD (Group A) is either a SABA or a short-acting anticholinergic (or SAMA). If poor relief on single agent, add a second agent. If on SABA, add short-acting anticholinergic (Atrovent). If short-acting bronchodilators are not controlling symptoms, next step is to start patient on a long-acting bronchodilator (LAMA or LABA) based on patient preference. Continue using SABA as needed. Ipratropium (Atrovent) is a short-acting anticholinergic or SAMA. Do not use LABAs (salmeterol, formoterol) for rescue treatment.

Question 186

Clinical Pearls ## Footnote Low ____ is associated with worse outcomes in patients with COPD. Consider _______ supplementation (e.g., \_\_\_\_) in underweight patients. When you are treating a COPD patient, pick an antibiotic that has coverage against both *(1)* (gram negative) and *(1)* (gram positive).

Answer 186

Low BMI is associated with worse outcomes in patients with COPD. Consider nutritional supplementation (e.g., Ensure) in underweight patients. When you are treating a COPD patient, pick an antibiotic that has coverage against both *H. influenzae* (gram negative) and *Streptococcus pneumoniae* (gram positive).

Question 187

Exam Tips Recognize presentation of bacterial pneumonia versus atypical pneumonia. The top two bacteria in CAP are *(2)* The top two bacteria in atypical pneumonia are *(2)* Rust-colored or blood-tinged sputum means *(1)* more likely. COPD/smoker with pneumonia: More likely to have *(1)* bacteria.

Answer 187

The top two bacteria in CAP are: * *S. pneumoniae* * *H. influenzae* The top two bacteria in atypical pneumonia are: * M. pneumoniae * Chlamydia pneumoniae **Rust-colored or blood-tinged sputum** means *S. pneumoniae* more likely. **COPD/smoker with pneumonia:** More likely to have *H. influenzae* bacteria.

Question 188

Exam Tips ## Footnote Know presentation and treatment of _____ (whooping cough). \_\_\_\_\_\_\_ treatment for acute bronchitis. Do not pick antibiotics to treat acute bronchitis. *Outpatient CAP:* Diagnosis is based on presentation, signs and symptoms, and CXR. Do not order (1); instead, order (1). CBC is ___ required for diagnosis.

Answer 188

Know presentation and treatment of pertussis (whooping cough). Symptomatic treatment for acute bronchitis. Do not pick antibiotics to treat acute bronchitis. *Outpatient CAP:* Diagnosis is based on presentation, signs and symptoms, and CXR. Do not order sputum for C&S; instead, order CXR. CBC is not required for diagnosis.

Question 189

Clinical Pearls ## Footnote If you suspect CAP based on clinical signs and symptoms but patient has a negative CXR/radiograph, obtain a \_\_\_of the chest. Consider if patient is \_\_\_\_\_\_compromised and unable to mount strong inflammatory response. Macrolides given to infants \<1 month of age at risk for developing \_\_\_\_. Suspect _____ in a “healthy” adult with no fever who has been coughing for \>2 to 3 weeks, especially if previously treated with an antibiotic (that was not a macrolide) and is getting worse (rule out pneumonia first). Emphasize importance of adequate _____ intake (best mucolytic, thins out mucus). Lung cancer can present as recurrent _____ (due to mass blocking bronchioles). If *S. pneumoniae* macrolide resistance \>\_\_%, do not use _____ monotherapy. See CAP treatment guidelines notes.

Answer 189

If you suspect CAP based on clinical signs and symptoms but patient has a negative CXR/radiograph, obtain a CT of the chest. Consider if patient is immunocompromised and unable to mount strong inflammatory response. Macrolides given to infants \<1 month of age at risk for developing IHPS. Suspect pertussis in a “healthy” adult with no fever who has been coughing for \>2 to 3 weeks, especially if previously treated with an antibiotic (that was not a macrolide) and is getting worse (rule out pneumonia first). Emphasize importance of adequate fluid intake (best mucolytic, thins out mucus). Lung cancer can present as recurrent pneumonia (due to mass blocking bronchioles). If *S. pneumoniae* macrolide resistance \>25%, do not use macrolide monotherapy. See CAP treatment guidelines notes.