Foundations Exam 3 Flashcards by Jessica Valdez

Influenza strain type associated with pandemics?

Influenza type A

(Type A subtypes:
Hemagglutinins H1, H2, H3
Neuraminidases N1, N2)

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Incubation period, transmission, and infectious period - Influenza

incubation 2-3 days
transmission is via respiratory droplets/direct contact

pt infectious usually a day before sxs start and will last up to a week

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Name general sxs of Flu

Fever
Aches (myalgias) 
Chills ( cough - non-productive)
Tiredness 
Sudden onset

HA, ocular sxs, sore throat

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How is Influenza virus testing performed?

Testing options?

Nasopharyngeal swabs

RAT - rapid antigen test, results in <15 mins, not a perfect test
Culture, result in 3-10 days
RT-PCR - more accurate, but $$, test time 1-8 hrs

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High risk groups that Flu Rx treatment is indicated for..

Extremes of ages
Chronic illnesses (cardiac, pulm, renal, DM) 
Immunosuppression 
Pregnancy/post partum (2wks)
Children <19yo on chronic ASA therapy 
Native Americans
Morbidly obese (BMI>40)
Residents in nursing homes

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WHEN should Influenza treatment be initiated?

First 24-48hrs

Rx may take ~1-3 days off course and severity of sxs

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Antiviral Flu medication options

Neuraminidase Inhibitors:

Oseltamivir (Tamiflu) most common
Zanamivir (Relenza)
Peramivir (Rapivab) IV med only

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ADEs of Oseltamivir (Tamiflu)

n/v 10% most common side effect

in peds, possible agitation, hallucinations, SI (should discuss w parents)

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ADEs of Zanamivir (Relenza)

Bronchospasm - shouldn’t give to asthmatic pts or those w airway compromise

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Complications of Influenza

PNA**
Sinusitis 
Otitis Media 
Myositis/Rhabdomyolysis 
CNS involvement 
Cardiac complications

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Flu prevention- who gets vaccinated?

everyone >6 months of age

annually ~Oct becomes available

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Peds pt (6 months - 8yrs) first season of Flu vaccination- schedule ?

2 doses, > 4 weeks apart

1st dose primes their immune system- 2nd dose at or after 4 wk mark, okay for it to be different vaccine

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Flu vaccine considerations for adults 65+

-higher dose vaccine
(believed elderly have harder time mounting immune response so high dose given)

-adjuvanted seasonal vaccine for adults 65+

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Acute bronchitis clinical presentation

Cough >5 days (~1-3 weeks)
\+/- productive 
Usually afebrile
chest wall tenderness 
Wheezing 
Mild dyspnea

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Acute bronchitis etiology

VIRAL - most common

(even if pt presents with purulent sputum - could just be viral)

Bacterial - pathogens: mycoplasma, c pneumoniae, bordetella pertussis* (only one that should be given Abx tx)

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Acute bronchitis PE findings

Wheezing
Rhonchi (clears with coughing)
Negative for rales and signs of consolidation

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Incubation and contagious time for Pertussis

Incubation 7-17 days

Contagious for 2 wks after onset of mild cough (during catarrhal stage)

Stages of Pertussis

Catarrhal 1-2 wks
(malaise, rhinorrhea, mild cough, milder fever)

Paroxysmal lasts 2-3 months
(paroxysmal cough - whooping cough, +/- post-tussive syncope or emesis)

Covalescent 1-2 wks
(gradual reduction in freq and severity of cough)

1st line Tx for Pertussis

Macrolides
*Azithromycin 500mg day 1, 250mg day 2-5

Clarithromycin 500mg BID x 7 days

Erythromycin 500mg QID x 7 days

TMP-SMX 160-800mg BID x 7 days

When should pregnant women receive Tdap?

b/w 27-36 weeks gestation, or immediately postpartum

all infants - Dtap
11-18yo Tdap booster
All adults single Tdap dose
Pregnant women - with each pregnancy

How is PNA transmitted?

Aspiration from oropharynx
Inhalation of contaminated droplets
Hematogenous (blood) spread
Extension from infected pleural or mediastinal space

(don’t catch PNA from someone- might get their URI - but generally PNA occurs b/c of aspiration of organisms)

PNA- pathogen and classic presentation

S pneumoniae

sudden onset of chills
rust colored sputum

most common of CAP 2/3 cases

PNA- pathogen and classic presentation

M pneumoniae

historically children and adolescents
may be asymptomatic or mild
CXR - reticulonodular pattern/patchy areas of consolidation
Bullae on TM

PNA- pathogen and classic presentation

Legionella

GI disorders (watery diarrhea) 
Confusion or encephalopathy 
outbreaks usu from contaminated water sources

PNA- pathogen and classic presentation MRSA

- cavitary infiltrate or necrosis - gross hemoptysis - rapidly increasing pleural effusions

PNA- pathogen and classic presentation Klebsiella pneumoniae

- comorbidities usu ETOH abuse, DM, severe COPD | - "currant jelly" sputum (thick, mucoid, blood tinged)

What are the atypical PNA pathogens?

Mycoplasma pneumoniae Chlamydophilia pneumoniae Legionella C psittaci atypical a historical term, does not mean uncommon - means unresponsive to beta lactams

PNA severity index vs | CURB-65

index scores to assess whether pt should be treated inpatient or outpatient PSI - pts > 50yo, w pre-existing conditions and PE abnormalities then stratified on add'l risk factors CURB 65 - shorter list, pts >65yo ``` Confusion Urea >7 or BUN >20 (modified version omits) RR >30breath/mins BP (SBP <90, DBP <60) 65 - age + ``` Score 1-2 consider hosp Score 3-4 urgent hosp +/- ICU

CAP Tx outpatient

Macrolide or Doxycycline if risk factors for macrolide resistance or Abx last 3 months Respiratory fluoroquinolone or Beta lactam (high dose Amoxicillin or Augmentin) PLUS macrolide duration Abx at least 5 days

CAP inpatient (non-ICU) Tx

Respiratory fluoroquinolone or Beta lactam PLUS macrolide

CAP ICU inpatient Tx

anti-pneumococcal beta-lactam PLUS azithromycin or anti-pneumococcal beta-lactam PLUS a respiratory fluoroquinolone If PCN allergic: respiratory fluoroquinolone PLUS aztreonam

CAP ICU for pseudomonas risk Tx

Antipneumococcal, antipseudomonal beta lactam (Cefipime) PLUS either ciprofloxacin or levofloxacin or above beta lactam PLUS aminoglycoside PLUS azithromycin (or respiratory fluoroquinolone) FULL duration 14 day treatment (14-21 days)**

CAP ICI Tx for MRSA

If MRSA risk: | Add vancomycin or linezolid

Duration of Tx for HAP, VAP PNA

duration of Tx 14-21 days if pt responds to initial tx may limit to 7 days **if Pseudomonas aeruginosa needs to be full duration 14 days minimum

Top 3 most common causes of ARDS?

``` #1 Diffuse PNA #2 Sepsis #3 Aspiration ```

What is the Berlin definition?

All 4 criteria must be met to Dx ARSD 1. acute onset w/in 1 wk of known clinical insult 2. bilateral pulmonary infiltrates 3. respiratory failure not explained by HF or volume overload 4. mod-severe O2 impairment (ABGs <300mmHg)

Spontaneous pneumothorax, clinical presentation, 1st line diagnostics, and treatment ?

Usu tall, thin, young men 20-40yo, smokers Dyspnea, pleuritic CP unilateral and sharp 1st line CXR (best in lateral decubitus view) and CT chest, U/S if emergent at bedside Tx 100% O2 Small pneumothorax - observe Large - needle aspiration Unstable- chest tube

Describe a tension pneumothorax

medical emergency, 1-2% of primary spontaneous pneumothorax pt looks really sick! distended neck veins, hypotension, tracheal deviation, worsening dyspnea CXR mediastinal shift and tracheal deviation contralateral side, flattening or inversion diaphragm ispsilateral side pt needs chest tube

Cause and treatment of secondary spontaneous pneumothorax?

occurs as complication of underlying lung dz more severe than PSP pts should be hospitalized, most will req chest tube

P-HTN | Group 1, etiology

Pulmonary arterial hypertension (PAH) secondary to various disorders.. ``` idiopathic portal HTN Drugs/toxins (appetite suppressants, SSRIs) HIV Schistosomiasis CT d/o congenital heart dz ```

P-HTN | Group 2, etiology

Pulmonary venous hypertension secondary to left heart disease

P-HTN | Group 3 etiology

secondary to lung disease or hypoxemia #1 COPD ILD OSA high altitudes