Exam 1 Acute_Chronic

Acute Pulmonary Conditions Acute Bronchitis (Ch 84, pg 540, TB pg36) ● Clinical presentation of ● HPI ○ cough w/ or w/out sputum ○ may have pain with inspiration ○ Nasal/pharyngeal symptoms present early in course of illness ● Physical findings: ○ wheezes, rhonchi, course rales may be present ○ Reduced FEV1 ○ Normal VD, maybe a low-grade fever ○ Xray findings look normal, no signs of consolidation. (Consolidation=pneumonia) ● Diagnostics ○ Typically not indicated uncles concern for community-acquired pneumonia ■ Labs- leukocytosis and elevated CRP more likely CAP ■ Procalcitonin <0.25ng/mL is likely viral ● Treatment ○ only 5-10% are bacterial, so NO ABX ○ High risk with Flu should be treated ■ Antiviral therapy: ozeltamivir or zanamivir ○ Treatment for focused symptoms ■ Antitussives (for cough) ● dextromethorphan ● benzonatate ■ Bronchodilators if wheezing ■ hydration and humidifier use - Mild alteration in lung tissue compliance - Is the characteristic of obstructive bronchitis and not emphysema -Chronic bronchitis inflames the bronchi and has fluctuating symptoms: excessive mucus production, cough, and fever. -Emphysema gradually destroys the alveoli and almost exclusively causes shortness of breath. -Empyema is the medical term for pockets of pus that have collected inside a body cavity . They can form if a bacterial infection is left untreated, or if it fails to fully respond to treatment. The term empyema is most commonly used to refer to pus-filled pockets that develop in the pleural space. COVID-19 ● Symptom management and supportive care ● HPI ○ risk factors for severe disease ○ timing of symptom onset

○ vaccine status ○ viral symptoms ● Physical findings ○ can vary ○ useful to help r/o other causes of symptoms ● Antigen testing (rapid) or PCR (NAAT) ○ pcr can have false negative, if concerned=repeat ● TX: ○ symptomatic unvaccinated >50 yo or any patient >65 or patients with risks for severe disease ■ Paxlovid- GI upset and potential for rebound ■ Remdesivir ■ Dexamethasone ● 6mg once a day for up to 10 days, for patients that are hypoxia to decrease inflammation ■ Brochodilators/Inhaled corticosteroids ■ Aspirin ● Education: ○ 5 day isolation ○ warning signs to go to ER ● Complication ○ increased risk for PE and CVA- hypercoagulability ○ secondary bacterial infection ○ long COVID Pneumonia (Ch 93, pg 602, TB pg46) ● 60-70% caused by S. Pneumoniae ● Atypical pneumonia is caused by mycoplasma- presents with HA and sore throat ● HPI ○ fever, chills, malaise, cough w/ o w/out sputum, dyspnea, pleuritic chest pain ○ recent use of abx, hx of underlying lung disease, smoking ○ older adults may lack typical six, more likely tachypneic, fatigue, weakness/falls, altered mental ○ HA and sore throat more atypical pneumonia ● Physical findings: ○ rates that don’t clear with cough ○ dullness to percussion ○ bronchial breath sounds ● Diagnostics ○ Bronchoscopy if pt is not getting better after 2 wks abx, and hospitalization ○ Chest X-ray ○ could do CT- for smaller pneumonia ○ pulse ox ○ sputum culture & gram stain ○ Labs

● Diagnostic testing ○ culture or aspirate ○ PCR ○ serology (blood test) ● Tx ○ early is best 1-2 wks ○ Hx of, at risk for complications, routine contact - give tx ○ ABX ■ Macrolide (Azithromycin, Erythromycin, Clarithromycin) ■ Trimethoprim-Sulfamethozasole (bactrim) ● Vaccination ○ Every pregnant woman in 3rd trimester should get. In each pregnancy TB ● Causes by bacteria; mycobacterium TB ● usually attacks lungs, but also lymph nodes, joints, brain and other organs ● cured w/ proper tx ● 13 million pp in the US have latent TB ○ 5-10% of these will develop active TB infection during lifetime ● Clinical presentation ○ Latent ■ asymptomatic ■ can not spread ○ TB disease ■ s/s; cough >3wks, hemoptysis (coughing up blood), night sweats, fatigue, weight loss ■ contagious ○ Risk factors ■ living in a region with high rates ■ immunocompromised (HIV, DM, Transplant, meds) ■ homeless, incarcerated, nursing home, substance or working with these populations ● Diagnostic ○ Mantoux skin test ■ Positive test = >5mm to 10mm ■ Positive test with chronic diseases = >10mm ○ blood test ■ 2 FDA approved tests on market ● quantiferon-tb Gold plus (gold standard) ● T-spot ○ Positive results require Chest X-ray or sputum smear or culture to determine if latent or active ● TX ○ range from 3-9 months

○ CDC recommends shorter regimens for compliance Pulmonary Embolism (blood clot) (ch 95, pg , TB 49) ● Blockage of one or more pulmonary arteries or branches. Most commonly from a thrombus/blood clot ● 3rd most common cause of CV death ● Complication of an underlying issue ○ Stasis (stagnation or cessation of flow) ○ Vascular damage ○ Hypercoagulability ● DVT is greatest risk factor for developing PE ○ HPI ■ risk factors ● Stasis- prolonged immobility (travel, injury, illness), PVD, long bone fracture, paralysis, HF ● Vascular Damage- trauma, surgery, central venous instrumentation ● Hypercoagulability- Malignancy, pregnancy/postpartum, estrogen use, family hx blood clotting, personal hx, stroke, smoking ■ sxs ● Dyspnea, tachypnea, tachycardia, orthopnea ● pleuritic chest pain, hemoptysis ● Calf/thigh pain and/or swelling ● malaise, dizzy, syncope ○ Physical findings ■ May be fairly unremarkable ■ Concerning ● unilateral swelling- DVT ● Tachycardia ● Tachypnea ● Abnormal lung sounds ■ ER- hypotension , hypoxia, moderate-severe respiratory distress, cyanosis, JVD ● shows signs of cardiovascular collapse ● Hypotensions in a patient with PE has a high correlation with acute right ventricular failure and subsequent death ○ Diagnostic testing ■ CTA chest ■ venous doppler ■ Echocardiogram ■ Labs: D-dimer, CBC, BMP or CMP, others suspected differential ○ TX ■ ED ■ Anticoagulation meds for minimum 3 months

■ decreased lung sounds ■ absent tactile or vocal fermitus ■ hyperresonant precussion ■ subcutaneous emphysema ■ RED FLAG SIGNS: tracheal deviation, tachypnea, tachycardia, hypotension, hypoxia —> ER ○ Diagnostic ■ Chest x-ray ■ Ct is more sensitive but less common due to delay time ■ Ultrasound ■ Labs: ABG for hypoxia, CBC, CMP ○ TX; ■ small >2-3cm is stable without underlying lung disease and can be managed outpatient ■ any signs of hemodynamic compromise ->ED ■ invasive treatment ● needle aspiration, small bore catheter, chest tube ■ Pulmonary consult ○ Education ■ Avoid scuba diving and air travel ■ smoking cessation Pleural Effusion (Ch 92, pg , TB 45) ● Abnormal amount of fluid in pleural cavity ● In developed countries most commonly caused by ○ CHF ■ Distended neck veins being a significant finding of CHF ○ Malignancy ■ Breast cancer ○ Bronchiectasis ○ Pneumonia ○ PE ● Transudative Effusion (CHF) ○ Usually bilateral ○ caused by disrupted absorption of pleural fluid ● Exudative effusion ○ Caused by pleural/lungs inflammation (infection/virus) ○ OR impaired lymph drainage of pleural space ● HIP ○ HX ■ prior exposures (TB, asbestos) ■ alcohol abuse ○ ROS ■ Dyspnea, worse with recumbent position to activity

■ cough ■ Pleuritic pain ■ ask about pertinent to look for s/s infection (fever, URI six), malignancy (night sweats, weight loss) ● Physical Findings ○ Decreased or absent breath sounds over effusion ○ dullness to percussion ○ small may have normal exam ○ other exam findings r/t underlying cause ● Diagnostic testing ○ CT and chest US are more reliable for detection and location of effusion ○ US is best at detecting septations in effusion** ○ Thoracentesis ■ performed by surgeon, pulmonologist or interventional radiology ■ send pleural fluid for analysis (cell counts, culture, pathology) ■ if large volume taken, may need IV albumin to help with fluid shift ○ Bronchoscopy (if mass identifies) ○ Thoracoscopy ● TX ○ Thoracentesis ■ to remove fluid and improve symptoms ○ To based on underlying cause ■ Diuretics (CHF), abx (pneumonia), chemo/radiation Chronic Pulmonary Conditions FINISH Asthma (Ch 85, tb 37) ● Most common disorder among all age groups ● Chronic inflammatory d/o of the airways ● episodic and recurrent characterized by wheezing, shortness of breath, chest tightness and cough ● Likely a combo of genetics and environment ● IgE Mediated hypersensitivity is one of the strongest predisposing factors ○ Sx ■ more than 1 of the following: wheezing, cough, shortness of breath, chest tightness ■ worsen at night or early in the morning ■ vary over time and in intensity ■ has triggers ○ Physical findings ■ widespread musical wheezes (may or may not be present) ■ Rhinitis and dermatitis may be present ○ Diagnostics

○ if do suspected, spirometry (pre and post) ■ Improvement on post spirometry after a bronchodilator means they have copd ○ later stages ■ increased A-P diameter (barrel chest) ■ Clubbing of fingernails ○ Diminished breath sounds ○ wheezes ● Diagnostic ○ FEV1/FVC of less than 0.70 and FEV1 of less than 80% ○ Chest x-ray ■ If they have COPD and are worried about them having pneumonia ○ CT scan ○ EKG ○ Labs: CBC, Alpha1-antitrpsin, ABG ● Treatment ○ patient diagnosed with chronic obstructive pulmonary disease reports daily symptoms of dyspnea and cough. Which medication will the primary health care provider prescribe? ■ Ipratropium bromide (atrovent) ■ This is a bronchodilator to treat spasms ■ Give corticosteroids ■ can also do azithromycin ● Education: ○ Treatment options ○ Spirometry Lung Cancer ● Encompasses malignancies involving lungs or airways ○ non-small cell lung cancer (80-85%) ■ adenocarcinoma (most common in non-smokers) ■ squamous cell carcinoma ○ Small cell lung cancer ● 5 year survival rate as a whole is <20% ● Smoking accounts for 80-90% of cases ● Pathophysiology of development not fully understood ○ genetics and environment important ● HPI ○ HX ○ smoker ○ eviornmental exposures ● ROS ○ Cough ○ weight loss

○ hemoptysis ○ dyspnea ○ fatigue ● Physical findings ○ lymphadenopathy ○ metastatic signs ■ bone tenderness ■ focal deficits ● Diagnostic ○ Annual low dose CT screening for adults 50-80 years ago with 20 pack year hx are are still smoking or quit less than 15 yrs ago ○ Biopsy ■ determine histology and staging of this cancer ○ PET scan ○ Labs ● A patient with limited stage small cell lung cancer (SCLC) has undergone chemotherapy with a good initial response to therapy. What will the provider tell this patient about the prognosis for treating this disease? ○ That relapse is likely with a 2-year overall survival of 50%. ○ Although SCLC often responds Nv Ue R ry Sw Ie N ll Gin TiB tia. ll C yO to Mchemotherapy, the majority of patients will relapse and the 2-year survival rates are approximately 50% ● Metastatic Signs ○ Headache ○ Diagnostically confirmed low hematocrit ○ Existence of lymph nodes greater than 1 cm Chest Pain ● Esophageal pain ○ Sharp, stabbing, and present for several weeks. Pain is worse after eating. ● GERD - pt gets prescribed a proton pump inhibitor. After 2 months the sxs improve. ○ Wean patient from proton pump inhibitor ● High school athlete reports chest pain that is aggravated by deep breathing and lifting. EKG is normal. Notes localized pain near the sternum that increases with pressure. ○ NSAIDS are recommended Dyspnea (Ch 89, pg, TB 42) ● Young adult patient without previous hx of lung disease has an increased respiratory rate and report a feeling of “not getting enough air” Ausculation is clear and no signs of increased respiratory effort. Which diagnostic tests will the provider preform initially? ○ CBC- would evaluate for anemia, which is more common cause of hypoxia in otherwise healthy adults

Sarcoidosis ● is an inflammatory disease in which the immune system overreacts, causing groups of cells to form clusters of inflamed tissue called "granulomas" in one or more organs of the body ● Stage 0- normal chest x-ray ● Stage I- BHL ○ prescribed a nonsteroidal anti-inflammatory medication to treat joint discomfort ● Stage II- BHL with pulmonary infiltrates ● Stage III- Pulmonary infiltrates without BHL ● Stage IV- Pulmonary fibrosis -Which diagnostic test is most useful when monitoring the progression of sarcoidosis over along period of time? - Pulmonary foundation test TX: ● Oral Corticosteroids are begun when pulmonary symptoms develop. ● Antimalarial agents are used to treat chronic skin lesions. Immunosuppressants are used when corticosteroids are no longer effective or when the disease progresses HEENT Allergic Rhinitis- seasonal allergies ● IgE mediated ● Commonly seen in allergic conjunctivitis ● A patient has recurrent sneezing, alterations in taste and smell, watery, itchy eyes, and thin nasal secretions. Puffiness around the eyes, vitals WNL = allergic rhinitis ● Allergy testing reveals sensitivity to various trees and grasses, what is first-line therapy - intranasal steroids ● Patient is concerned about frequent nasal stuffiness and congestion that begins shortly after getting out of bed in the morning. Patient denies itching and sneezing. A physical exam shows erythematous nasal mucosa with scant discharge. What treatment ○ Daily intransal steroids (vasomotor or idiopathic rhinitis) ● sx- sneezing, purities (general itching), nasal congestion, rhinorrhea, mucosal swelling, post-nasal drip, palate itchiness often present ● tx- 1st avoid triggers , pharmacotherapy ○ pharmacotherapy ■ intranasal steroids-(1st line after avoid triggers) : reduce inflammatory response. Can cause rebound congestion after multiple day use- d/c if occurs. Example: Flonase, nasarelle. Nasal spray can take up to a week to be effective ■ Antihistamines

● lipophilic- Benadryl- cross blood brain barrier, caution with elderly for fatigue and CNS sx ● hydrophilic- Allegra, Zyrtec- does not cross blood/brain, safer ■ Decongestants- careful, can cause HTN due to alpha adrenergic ■ OTC nasal decongestion is afarn ■ Nasal irrigation does not cause nose bleeds. It hydrates nasal pathways ● FACT- Tylenol PM has 50mg of Benadryl in each capsule Types of cold medicine ● Antihistamines- relieve stuffiness ● Vasoconstrictors= pseudoephedrine (dries up) sudafed ● Calming coughs= dextromethorphan ● relieves body aches= acetaminophen Allergic Conjunctivitis ● Sx: stringy/white discharge, itching/ tearing, no photophobia , slight to moderate redness of the eye, usually bilateral. With chronic allergies nasal mucosa appears swollen, boggy, pale and gray ● TX: cold compress, artificial tears , mast stabilizers (alocril, patanol, zaditor), NSAID (acular), antihistamine (livostin eye drop), systemic antihistamine ● Viral conjunctivitis - Cold + conjunctivitis. Erythema of one eye with profuse, watery discharge and enlarged anterior cervical lymph nodes, along with a fever ○ Artificial tears and cold compress ● Allergic conjunctivitis and prescribed a topical antihistamine-vasocontrictor reports worsening symptoms. ○ Determine the duration of tx with this med Bacterial Conjunctivitis ● Sx: mucopurulent discharge, starts unilateral, discomfort/aching, swelling of eyelids, eyelids stick together after sleep, diffuse hyperemia, usually no photophobia. ● Tx: cold compress, watch and wait, topical abx (sulamyd 10% 2 drops every 3 hrs while awake), Quinolone (ocuflox, quinine, zymar), aminoglycosides (tobrex/tobradex, garamycin) Acute Bacterial Rhino-sinusitis (acute sinusitis) ● Symptoms lasting for up to 10 days is a tell ● Airways start at the top of your sinuses and end at your bronchioles ● usually precedes viral URI but allergies, dental infection, trauma may precede along it ● Common pathogens- steptrococcus pneumoniae, H influenza (think smokers, college students) MCAT Moraxella catarrhalis ○ sx; present from 2-12 wks, facial pain- if marked lid edema is present pt needs to go to ER for IV abx, persistent URI where they got better and then got bad again,

● Wich are potential complications of chronic or recurrent sinusitis? ○ Meningitis, orbital infection, osteomyelitis Epistaxis (nose bleed) ● Initial intervention- assess airway safety and vital signs ● Nasal packing- unilateral epistaxis that continues to bleed after 15 min of pressure on the anterior septum and application of topical nasal decongestant ● Can use silver nitrate as treatment ● Rihno rocket- tampon for the nose ● Recurrent epistaxis labs - CBC with type and cross, PT and PTT, PT/INR ● Chronic nasal obstruction and recurrent epitaxis - squamous cell carcinoma nasal mass ● Patient reports chronic nasal obstruction and difficulty distinguishing smells. Grapelike lesions in both nostrils - what are patients cause of symptoms - nasal polyps Nasal trauma ● Child hit with a baseball bat - important intervention - immobilizing the child’s head and neck and call 911 ● Blusih mass against the nasal septum - Urgent drainage of the mass ○ Indicated a septal hematoma and must be drained urgently for cosmetic purposes to precent loss of nasal cartilage caused by loss of blood supply to this area ● 12 month old in ED that fell into a coffee table. Palpates instability and point tenderness of the nasal septum. Orbital structures appear intact. - Involvement of social services ● Ulceration of the nasal septum - referring to a specialist Aphthous/stomatitis (canker sores) ● Superficial ulcerations on musouc membranes or lips, cheek, tongue, floor of mouth, palate, and gingiva ● buring 1-48 hours before vesicles appear ● painful ● lesion heal within 7-10 days ● TX: symptomatic ○ viscous xylocaine ○ benadryl 5mg.ml mixed with equal kaopectate Dental abscess - tooth pain ● Tooth pain in a lower molar and notes mobile tooth with erythema and edema or the surrounding tissues without discharge - prescribe amoxicillin and refer to dentist in 2-3 days ● Dental abscess - follow-up with edema of the eyelids and conjunctivae - hospitalize the patient for an endodontist consultation

● Ludwig’s Angina ○ needs drains to drain infection and possible surgery ○ serious condition that needs IV abx and drains Salivary Glands ● Sialolithiasis ○ Sx: painful swelling in the mouth with increased pain at mealtimes. Examination shows a mass in the salivary gland region. ○ Noninfectious salivary gland disorder characterized by pain at mealtimes caused by blockage of the salivary duct by stones. ● Patient has chronic swelling of the parotid gland that is unresponsive to antibiotics and which has not increased in size. ○ Fine-needle aspiration is needed for testing ● Actinomycosis ○ IV penicillin followed by oral penicillin for several months is the treatment Cervical Adenitis ● Acute infection of the cervical lymph node ● usually secondary to URI or dental infection or cat scratch ● s. Aureus or s. Pyogenes ● common sites are submandibular and anterior cervical areas ● usually symptomatic tx unless severe pain Epiglottitis ● LIFE-THREATENING, abrupt onset ● Child sitting in the tripod position and notes stridor, drooling and anxiety. ○ Obtain an immediate consult with an otolaryngologist ○ admitted to ER immediately ● Diagnostic test - confirm diagnosis or epiglottitis ○ Fiberoptic nasopharyngoscopy ● Epiglottitis secondary to a chemical burn. Which medication will be given to prevent complications? ○ Dexamethasone (to decrease the inflammation) ● Oral lesions 3 days after feeling pain and tingling in the mouth. Vesicles and ulcerative lesions on the buccal mucosa. What is the cause? ○ HSV ● Gingival inflammation needs a physical examination ● Several white, verrucous lesions in clusters throughout the mouth - surgical excision needed Peritonsillar abscess ● Patient with fever, chills, and a severe sore throat. Foul-smelling breath and a muffled voice with marked edema and erythema of the peritonsillar tissue

Group A strep(GABHS) ● Winter and spring ● incubation is 2-4 days followed by abrupt onset of sore throat, malaise, fever, and HA. Mild stiff neck and GI Sx, cough hoarseness and rhinorrhea are NOT usually present with strep throat ● Rheumatic fever is a concern. This happens in a small percentage of pts ○ If it lands in the kidneys ■ Glomerular nephritis ● You as them Any recent URI? Centor Criteria ● Can be used for group A strep suspicion ● Go to bottom on document Chronic tonsillitis ● More than 6 sore throats in 1 year or 3 of more episodes in 2 years ● chronically enlarged, cryptic tonsils ● periodic tender lymph nodes Infectious Mononucleosis ● Mono is a sister to strep so you want to do a throat culture to rule out strep ● Epstein-Barr virus ● teens and young adults, college kids (kissing disease) ● characterized by clinical triad: S/T, fever, and lymphadenopathy (anterior and posterior cervical) ● 1-2 month incubation period ● illness lasts 3-4 wks ● Labs: monospot, throat c/s, EBV (IgM/IgG) ● tx: rest, avoid contact sports for 6 wks bc of spleen concern , pain medication, warm saline gargles, lozenges. Steroid use. Still need to move around Acute otitis media ● Fluid in the middle ear, 6-15 months peak, congestion impedes flow of middle ear secretions ● sx: otalgia (ear pain), otorrhea, hearing loss, vertigo, fever, irritability, n/v/ diarrhea. Associated with URI/allergy ● exam: bulging of Tempanic membrane, limited or absent mobility of tempanic membrane, air-fluid level behind the tempanic membrane, loss of landmarks, otorrhea, tenderness over mastoid bone ● common pathogens ○ strep pneumonia, h flu, moracella catarrhalis ● TX: watchful waiting for 24-48 hours. Viral 30-60%

● Examiner is unable to visualize the T/M in the right ear bc of cerumen in the ear canal. The left tympanic membrane is dull gray with fluid levels present ○ Remove the cerumen and visualize the tympanic membrane ● Symptomatic treatment with 24 hour follow up ○ 36 month old with fever, mild otalgia, and red, non-bulging T/M ● Parent-reported scoring system ○ Appetite, difficulty sleeping, tugging on ears Serous otitis media (otitis media with effusion) ● Accumulation of fluid in ear > 2-3 months without s/s of acute infection ● s/s: feeling of fullness in ear, popping (crackling) sensation, decreased hearing, vertigo, itchy. Failure of the tympanic membrane to move on pneumatic otoscopy, visible air-fluid level behind the tympanic membrane, bubbles behind the T-M. ● Tx: 50% of middle ear effusions are culture-positive ○ abx, topical decongestants, topical steroid nasal sprays ○ re-evaluate after 4-6 weeks ○ hearing evaluation ○ most cases spontaneously resolve without abx ○ may need to refer to ENT for tubes Otitis externa (swimmers ear) ● Pt reports feeling of fullness and pain in both ears and the provider elicits exquisite pain when manipulating the external ear structures = acute otitis externa ● Inflammation/cellulitis of the external auditory canal ● swimming or aggressive cleaning of canal ● S/s ○ pruritis (itchy), pain, drainage, hearing impairment ○ ear pain may be gradual or sudden ○ tragus pressure/pinna movement creates pain ○ sensation of fullness ○ purulent discharge may occur ● tx: ○ removal of all infected debris with curette or irrigation ○ Cipro HC - covers both pathogens that could cause this and contains a corticosteroid for inflammation ● Risk factors: underlying DM, use of ear plugs and hearing aids, vigorous external canal hygiene Shiny, irregular, painless lesion on the top of one ear auricle and suspects skin cancer A biopsy should be performed Painless, hard lesions on a patient’s external ears that expel a white crystalline substance when pressed Uric acid chemical profile needs to be done