pulm disorders

Question 1

cough red flags

Answer 1

-hemoptysis
- smoker >45 years with a new cough, change in cough, or voice disturbance
- older adults with 30 pack year history
- dyspnea
- hoarseness
- systemic symptoms (wt loss, fever, edema)
- dysphagia
- vomiting
- recurrent pneumonia

Question 2

chronic cough

Answer 2

> 8 weeks

Question 3

acute cough

Answer 3

<3 weeks

Question 4

subacute cough

Answer 4

3-8 weeks

Question 5

hemoptysis positioning

Answer 5

decubitus position with involved lung dependent

Question 6

solitary pulmonary nodule

Answer 6

asymptomatic, rounded lesion normally found on CXR

no atelectasis, no pleural effusion, no adenopathy

Question 7

solitary pulmonary nodule diagnostics

Answer 7

comprehensive history HPI to determine risk - wt loss, night sweats, smoking hx, hemoptysis, RA/sarcoidosis –>high risk

CT initially

<6mm in low-risk adults (<35)- no further follow up
<6mm high risk - follow up CT optional
6-8mm low risk - follow up CT in 6-12 mos, and 18-24 mo
6-8 mm high risk - follow up in 6-12 mos
>8mm high risk - refer for resection/biopsy

Question 8

influenza A treatment

Answer 8

hydration, NSAIDs

neuraminidase inhibitors within 48 h of symptom onset (recommended in hospitalized or high risk)

Baloxavir carboxyl (Xofluza)

Question 9

CAP pathogen

Answer 9

streptococcus pneumoniae

Question 10

how to decide if need to hospitalize for CAP

Answer 10

CURB-65 (confusion, urea, respiratory, BP, age)

pneumonia severity index (demographics, comorbidities, physical exam, lab/radiology)

Question 11

CAP diagnosis

Answer 11

usually based on symptoms

officially need opacities on CXR

no need for urine antigen, pro cal, BCx or sputum cultures

Question 12

CAP O/P treatment in pt w/o RF

Answer 12

amoxicillin OR
doxycycline OR
macrolide (azithromycin, clarithromycin) - if not resistant area

Question 13

CAP O/P treatment in pt w RF

Answer 13

car heart, liver, lung, or real disease; DM; ETOH, malignant, asplenia, immunosuppression, antimicrobials in past 3 mos

PO respiratory quinolone (levaquin)

OR combo therapy (augmentin OR cephalosporin AND macrolide OR doxy)

5 days

Question 14

CAP IP treatment (non-ICU)

Answer 14

IV resp fluoroquinolone

OR

IV beta lactam (cefotaxime, ceftriaxone, ceftaroline, ampicilllin-sulbactam)

PLUS

IV macrolide (azithromycin/clarithromycin)

Question 15

respiratory quinolones

Answer 15

gemifloxacin, levofloxacin, moxifloxacin

Question 16

CAP ICU treatment

Answer 16

IV beta lactam (ceftoxamine, ceftaroline, ceftriaxone, or zosyn)

PLUS IV resp fluoroquinolone
OR azithromycin

Question 17

CAP ICU treatment for psudomonas

Answer 17

B-lactam + macrolide

OR

B-lactam + resp fluoroquinolone

Question 18

CAP ICU treatment for MRSA

Answer 18

(or risk)

add vancomycin or linezolid

Question 19

RF for HAP and VAP

Answer 19

abx within 90 days
hospitalization >5 days
high frequency of abx resistance in community or hospital unit

these people get empiric abx

Question 20

HAP/VAP diagnostics

Answer 20

CXR - pulm opacities
sputum & BCx
abg
CBC, cmp
lactic acid

consider antigen testing for S. pneumoniae and legionalla, influenza testing, COVID test, pro cal

Question 21

recommendations of when to start abx in HAP/VAP

Answer 21

new infiltrates plus 2/3:

• fever>38
• leukocytosis or leukopenia
• purulent secretions

Question 22

CAP inpatient pathogens

Answer 22

strep pneumoniae
staph aureus

Question 23

VAP pathogens

Answer 23

gram - (pseudomonas, E coli, klebsiella)
staph aureus

Question 24

non-hospitalized COVID tx

Answer 24

symptom mgmt
remdesivir - high risk

Question 25

hospitalized COVID tx

Answer 25

high risk - remdesivir
on o2 - dexamethasone & remdesivir
rapidly progressing - baricitinib, tocilizumab

prophylactic heparin for everyone