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