RESPIRATORY EOR
flourescein staining
procedure in which a flourescein strip or drops are applied topically to the cornea to detect corneal abrasions and ulcers Application of florescent dye to the surface of the eye via eye drops or a strip applicator
WHICH ORGANISM LIKE TO AFFECT PATIENTS WITH CYSTIC FIBROSIS
pseudomonas pseudomonas aeruginosa becomes the major causative organism for infections
Initial diagnostic test for asthma?
pulmonary function tests
MOST COMMON CAUSE OF ACUTE BRONCHIOLITIS
respiratory syncytial virus
What organs are impacted in CF?
Sinuses, lungs, pancreas, intestines, liver, reproductive organs, and skin.
Diagnosis of an ocular foreign body?
Slit-lamp examination, usually with fluorescein staining with cobalt light illumination renders abrasions and nonmetallic foreign bodies more apparent. X-ray or CT of may be necessary if there is evidence of penetration of the globe.
Spirometry findings in asthma
Spirometry with pre and post-therapy (albuterol inhalation) readings Decreased FEV1/FVC (75-80%) > 10% increase of FEV1 with bronchodilator therapy FEV1 to FVC ratio < 80% (You would expect the amount of air exhaled during the first second (FEV1) to be the greatest amount. In asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio Peak flow is an inexpensive and easily available monitoring device once the diagnosis of asthma has been established.
Coccidioides treatment
fluconazole or itraconazole.
CFTR gene
folding and glycosylation failure seen in cystic fibrosis An autosomal recessive mutation in the CFTR gene Abnormally thick mucus, difficulty clearing mucus
Patient will present as → a 4-year-old boy with unilateral purulent, foul-smelling nasal discharge for three days. The child has no other respiratory symptoms
foreign body aspiration
Nasal flaring is a sign of _____ breathing.
inadequate
FEV1/FVC < 70%?
obstructive lung disease
Patient will present as → a 32-year-old male with dyspnea and a nonproductive cough. He is tachycardic, tachypneic and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia and his LDH is elevated
pcp pneumonia
A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment?
peak flow
A 27 year-old woman presents with one week of worsening productive cough, dyspnea, fever and malaise. Which of the following physical examination findings would support the diagnosis of lobar pneumonia?
Egophony
Which of the following is essential to make a diagnosis of cystic fibrosis?
Elevated sweat chloride
hyaline membrane disease pathogenesis
It is caused by a deficiency in surfactant resulting in poor lung compliance and atelectasis Infants less than 30 weeks gestation at birth
YOung people living in dorms, (+) cold agglutinins, bullous myringitis
Mycoplasma
What x-ray finding supports a diagnosis of croup?
"Steeple" sign on frontal CXR
Coccidioides
"Valley Fever" Look for this in a patient with non-remitting cough/bronchitis non-responsive to conventional treatments.
Patient will present as → a 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated.
(mycoplasma pneumonia)
Asthma exacerbation treatment
- first oxygen -then albuterol and ipratropium - then IV or oral corticosteroids Oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids
Croup treatment
- fresh cool air - steamy bathroom Supportive (air humidifier), antipyretics Severe: IV fluids and nebulized racemic epinephrine, steroids Treatment is antipyretics, hydration, humidified air (or oxygen), nebulized racemic epinephrine (only if signs of distress), and corticosteroids (dexamethasone)
VIRAL PNEUMONIA TREATMENT
- antipyretic - IV fluids - rest Tx: flu with Tamiflu (A and B) if sx's began < 48 hrs; symptomatic tx = beta 2 agonists, fluids, rest
bronchiolitis symptoms
-Cough -Tachypnea -Respiratory distress -Crackles/wheezes -Fever (1-2 days) -Rhinorrhea Rhinorrhea, wheezing/coughing that persists for months, low-grade fever, nasal flaring/retractions, nail bed cyanosis
CYSTIC FIBROSIS SYMPTOMS
-Cough with sputum -Decreased exercise tolerance -Hemoptysis -Steatorrhea and diarrhea -Malnourishment -Meconium ileus (thick clogged stool) -Recurrent lung infections (especially bronchiectasis) -Digital clubbing -Barrel chest -Hyperresonance to percusion -Apical crackles -Purulent nasal secretions Impaired digestion, fatty stool, distended abdomen, impaired growth, cyanosis, shortness of breath, chronic cough, barrel-shaped chest Presentation: Recurrent respiratory infections (especially pseudomonas), steatorrhea
Croup symptoms
-Prodrome of URI -Stridor -Barking cough -NO drooling Barking cough and stridor
BACTERIAL PNEUMONIA PHYSICAL EXAM FINDINGS
-tachycardia, tachypnea -diminished or adventitious breath sounds -dullness to percussion -decreased oxygen saturation (+) egophony - Transmission of vocal sounds through consolidation leads to the changes heard with egophony. (+) tactile fremitus - Consolidation would increase the transmission of vocal vibrations and manifest as increased tactile fremitus. (+) dullness to percussion fever, dyspnea, tachycardia, tachypnea, cough +/- sputum
3 main components to the pathophysiology of asthma?
1. Airway hyper-reactivity (IgE-mediated) 2. Bronchoconstriction (airway narrowing s/t smooth muscle constriction, mucus secretion, bronchial wall edema, airway remodeling, etc) 3. Inflammation (s/t cellular infiltration and cytokines)
List the classifications of asthma
1. Intermittent 2. Mild persistent 3. Moderate persistent 4. Severe persistent
Medication timeline for asthma (typically)?
1. SABA PRN (always; keep in all "steps")2. Add low-dose ICS3. Increase to med-dose ICS OR add LABA4. Add a LABA OR increase to med-dose ICS5. Increase to high-dose ICS6. Add PO steroids
What is the mainstay of treatment for CF patients in regard to their respiratory care?
1. Spirometry (monitoring trends/pulm status) 2. Supplemental oxygen as needed 3. Inhaled beta-agonists 4. Inhaled hypertonic solution (3% or 6%) 5. Chest physiotherapy (daily airway clearance) 6. Pulmozyme can be considered 7. Antibiotics when indicated 8. Trikafta
RSV prophylaxis
Palivizumab (Synagis) Palivizumab prophylaxis (once per month for five months beginning in November) for special populations (immunocompromised, premature infants, neuromuscular disorders)
ASTHMA
A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing. Asthma is a chronic, reversible inflammatory airway disease with recurrent attacks of breathlessness and wheezing' Asthma is a chronic, REVERSIBLE, inflammatory airway disease characterized by recurrent attacks of breathlessness and wheezing. lack of wheezing in an acute attack = emergency
cystic fibrosis
A genetic disorder that is present at birth and affects both the respiratory and digestive systems. Cystic fibrosis is an autosomal recessive disorder that results in the abnormal production of mucus by almost all exocrine glands, causing obstruction of those glands and ducts. Mucus plugging and chronic bacterial infection, accompanied by a pronounced inflammatory response, damage the airways, ultimately leading to bronchiectasis and respiratory insufficiency. Non-pulmonary - pancreatitis, and steatorrhea - patients will need supplementation of fat-soluble vitamins The course is characterized by episodic exacerbations with infection and progressive decline in pulmonary function. Although the lungs are generally histologically normal at birth, most patients develop pulmonary disease beginning in infancy or early childhood. Mucus plugging and chronic bacterial infection, accompanied by a pronounced inflammatory response, damage the airways, ultimately leading to bronchiectasis and respiratory insufficiency.
Patient will present as → a 9-month old infant presents with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C (101.4 F), and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Flaring of the alae nasi, use of accessory muscles, and subcostal and intercostal retractions are noted. Expiratory wheezes are present
ACUTE BRONCHIOLITIS
BACTERIAL PNEUMONIA SYMPTOMS
Acute onset, fever, chills, productive cough, shortness of breath, tachycardia AND CHEST PAIN fever, dyspnea, tachycardia, tachypnea, cough, +/- sputum
Patient will present as → a 5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged, expiratory wheezes.
ASTHMA
Name the abdominal complications of cystic fibrosis?
Abdominal complications of cystic fibrosis include pancreatic insufficiency, biliary cirrhosis, malabsorption, and liver disease.
hyaline membrane disease
Acute lung disease in premature infants; respiratory distress disease syndrome of the newborn. Hyaline membrane disease affects premature infants. It occurs when infants are born before the lungs are producing adequate amounts of surfactant. Surfactant helps to prevent the lungs from collapsing. As the airways collapse, infants will struggle more and more to breathe until they become acidotic and multisystem organ failure begins
A patient presents with occasional wheezing and chest tightness that occurs approximately once a week and at night only about once a month. Peak expiratory flow is 85% of predicted. Which of the following is the most appropriate initial treatment?
Albuterol (Proventil) inhaler
A 17 year-old male who is trying out for the track team notes excessive coughing with chest tightness when running. Which of the following is the most appropriate preventive agent for this patient?
Albuterol inhaler (Proventil)
What establishes the presence of airflow reversibility and diagnosis of asthma?
An increase in FEV1 of >12% with a minimum increase of 200 mL in FEV1 after bronchodilator use
What is an ocular Foreign body?
Any object embedded in or adhering to the conjunctiva or cornea An ocular foreign body is any object embedded in or adhering to the conjunctiva or cornea A foreign body trapped under the upper lid may cause one or more vertical corneal abrasions that worsen as a result of blinking
A 42 year-old male with unremarkable past medical history is admitted to the general medical ward with community-acquired pneumonia. He has a 20 pack-year history of cigarette smoking. He is empirically started on ceftriaxone (Rocephin). Which of the following antibiotics would be most appropriate to add to his empiric treatment regimen?
Azithromycin
Patient will present as → a 71-year-old male who was admitted to the acute care hospital two days following a massive CVA with a possible brainstem infarct. Because he was also experiencing secondary respiratory failure, he was intubated and placed on mechanical ventilation. He was subsequently transferred to the neurointensive care unit where he was stabilized. His present vital signs are: respiratory rate 14 (ventilator rate), temperature 100.4 F. His SpO2 is 95%. His rating on the Glasgow Coma Scale is 5.
BACTERIAL PNEUMONIA
A 22 year-old female with a history of asthma presents with complaints of increasing "asthma" attacks. The patient states she has been well controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals > 85% predicted value. Which of the following is the most appropriate intervention at this time?
Beclomethasone inhaler
What pneumococcal vaccines should CF patients get?
Both PCV13 and PPSV23
Bronchiolitis in babies is most commonly the result of what infection?
Bronchiolitis in babies is most commonly the result of the respiratory syncytial virus
What is bronchiolitis?
Bronchiolitis is inflammation of the bronchioles, the smallest air passages of the lungs which usually occurs in children < two years of age
What is bronchiolitis?
Bronchiolitis is inflammation of the bronchioles, the smallest air passages of the lungs which usually occurs in children less than two years of age
You suspect your patient has asthma, but they have normal spirometry results. What next?
Bronchoprovocation test (methacholine challenge)
Cryptococcus cause
Budding yeast found in soil contaminated with pigeon/bird droppings
Haemophilus influenzae:
COPD, smokers, postsplenectomy
What enzymes do CF patients need to replace?
CREON (pancrelipase; contains amylase, lipase, and protease)
FOREIGN BODY DIAGNOSIS
CXR (expiratory radiograph) may reveal regional hyperinflation of the affected side ABG - necessary for appropriately evaluating ventilation, may be useful for following the progression of respiratory failure when it is of concern
VIRAL PNEUMONIA X-RAY FINDINGS
CXR = bilateral interstitial infiltrates
CHEST X-RAY FINDINGS FOR CYSTIC FIBROSIS
CXR may reveal hyperinflation, mucus plugging, and focal atelectasis
hyaline membrane disease diagnosis
CXR will demonstrate diffuse bilateral atelectasis causing a "ground glass appearance" and air bronchograms
x-ray findings in hyaline membrane disease
CXR will demonstrate diffuse bilateral atelectasis causing a "ground glass appearance" and air bronchograms
Patient will present as → a 3-year-old girl with growth retardation has a long history of recurrent pneumonia and chronic diarrhea. Her mother states that he has 6-8 foul smelling stools per day. Physical exam reveals a low-grade fever, scattered rhonchi over both lung fields, crepitant rales at the left lung base and dullness to percussion. Other findings include mild hepatomegaly and slight pitting edema of the lower extremities. CXR reveals hyperinflation, mucus plugging, and focal atelectasis. Labs reveal an elevated quantitative sweat chloride test.
CYSTIC FIBROSIS
Coccidioides location
Caused by fungal inhalation in western states.
Cryptococcus
Caused by the fungus Cryptococcus neoformans, common in AIDS and immunocompromised states, is considered an AIDS-defining illness found in soil can disseminate and can cause meningitis
A 40 year-old alcoholic male presents with sudden onset of severe chills, fever, dyspnea and cough productive of red mucoid sticky sputum. He appears ill looking with cyanosis. Examination reveals vital signs: Temp - 102 degrees F; Pulse - 120 /minute and regular; 89 RR - 28/min; BP 90/62 mm Hg. Lungs reveal minimal rales and dullness in the right upper lobe with decreased breath sounds. Chest x-ray reveals right upper lobe consolidation with a bulging fissure. Gram stain reveals many white blood cells and many gram- negative rods. Which of the following is the most appropriate drug of choice?
Cefotaxime This patient most likely has pneumonia caused by Klebsiella. A third generation cephalosporin, such as cefotaxime, is the preferred antimicrobial therapy against Klebsiella pneumoniae. Alternative antibiotic choices may include a carbapenem, beta-lactam/beta- lactamase inhibitor or a fluoroquinolone.
CYSTIC FIBROSIS TREATMENT
Chest physiotherapy, high-fat diet, supplement fat-soluble vitamins (A, D, E, K) Clearing the airway of secretions - DNase and/or hypertonic saline and chest physiotherapy Reversing bronchoconstriction Treating respiratory infections (treat for pseudomonas) Replacement of pancreatic enzymes supplement fat-soluble vitamins (A, D, E, K) Nutritional and emotional support - high-fat diet
VIRAL PNEUMONIA DIAGNOSIS
Chest radiography usually demonstrates bilateral lung involvement, but none of the viral etiologies of pneumonia result in pathognomonic findings with CXR Rapid antigen testing for influenza RSV nasal swab Cold agglutinin titer that is negative
What are s/s of CF?
Chronic or persistent cough- Purulent/bloody sputum- Dyspnea- Wheezing- Meconium ileus- Steatorrhea- Malnutrition
Chlamydia pneumoniae
College kids, sore throat, long prodrome
Croup Age Prevalence
Common in children 6 mo-3 yrs, fall and early winter months (same time of year as bronchiolitis)
Symptoms of asthma?
Cough - Wheezing - Shortness of breath - Chest-tightness - May worsen at night
BACTERIAL PNEUMONIA DIAGNOSIS
Crackles in lungs and possible CXR History and Exam Findings Chest X-Ray infiltrate Elevated WBC count with left shift Atypical Presentation in Older Adult Less likely to have high fever, cough or extreme WBC elevation More likely to present with confusion or weakness patchy, segmental lobar, multilobar consolidation Blood cultures x 2, sputum gram stain
BACTERIAL PNEUMONIA DIAGNOSIS
Crackles in lungs and possible CXR CXR: patchy, segmental lobar, multilobar consolidation Blood cultures x 2, sputum gram stain
"Steeple" sign on CXR
Croup (parainfluenza virus)
What time of year is croup most common?
Croup can occur at any time of the year, but it is more common in the fall and winter months
What is croup?
Croup is a respiratory infection that is usually caused by a virus. It leads to swelling inside the windpipe, which interferes with normal breathing and produces the classic symptoms of "barking" cough, stridor, and a hoarse voice. Fever and runny nose may also be present. Often it starts or is worse at night.
Croup is a viral respiratory infection caused what virus?
Croup is a viral respiratory infection caused by Parainfluenza virus that involves a seal-like barking cough
Histoplasma capsulatum diagnosis
Culture is the gold standard for diagnosis but requires a lengthy incubation period
What is cystic fibrosis?
Cystic fibrosis is an autosomal recessive disorder that results in the abnormal production of mucus by almost all exocrine glands, causing obstruction of those glands and ducts.
What is an endocrinological manifestation in cystic fibrosis that results from destruction of pancreatic beta cells.
Diabetes mellitus is an endocrinological manifestation in cystic fibrosis that results from destruction of pancreatic beta cells.
Cryptococcus diagnosis
Diagnose with CSF and serum serology Lumbar puncture for meningitis
Pneumocystis Jiroveci diagnosis
Diagnose with bronchoalveolar lavage (PCR), labs, and an HIV test. Obtain a chest radiograph Chest x-ray characteristically shows diffuse, bilateral perihilar infiltrates A definitive diagnosis of PCP requires obtaining a respiratory tract specimen, either by tissue sample or by aspiration of secretions
RSV DIAGNOSIS
Diagnosed by nasal washing for RSV culture and antigen assay; CXR = normal
How is bronchiolitis diagnosed?
Diagnosed with nasal washing for RSV culture and antigen assay
ear foreign body diagnosis
Diagnosis is made by history and physical exam with visualization of foreign body
Patient will present as → an 18-month-old with ear pain and otorrhea. Otoscopic examination reveals a small insect impacted in the ear canal which is still moving. The tympanic membrane appears intact.
EAR FOREIGN BODY
A 2 month-old infant has been diagnosed with pneumonia due to Chlamydia trachomatis. Which of the following is the treatment of choice?
Erythromycin
Explain the pathophysiology of CF
Essentially w/o effective chloride channels, chloride stays in the cells, as well as sodium. Since water goes where Na+ goes, water will stay too. Cell secretions then will be gunky + goopy + thick (so can't be cleared from organ passages & impairs their function).
Most common cause of asthma?
Exposure to allergens (IgE mediated type I hypersensitivity)
What FEV1 findings on methacholine test are indicative of asthma?
FEV1 decreases by 20%
Management of ocular foreign body?
For surface foreign bodies, irrigation or removal with a damp, cotton-tipped swab or a small needle. For intraocular foreign bodies, surgical removal. Systemic and topical antimicrobials (effective against Bacillus cereus if the injury involved contamination with soil or vegetation) are indicated
Foreign body aspiration
Foreign body aspiration occurs when a foreign body enters the airways and causes choking. Objects can enter the esophagus through the mouth, or enter the trachea through the mouth or nose
Ocular Foreign Body diagnosis
Full inspection of lids, conjunctiva, and cornea - Slit-lamp examination will assist in identification and removal If you can't remove the foreign body easily then refer to the ophthalmologist X-ray or CT of may be necessary if there is evidence of penetration of the globe
DIAGNOSIS OF ASTHMA
GOLD STANDARD = PEAK EXPIRATORY FLOW RATE Spirometry with pre and post-therapy (albuterol inhalation) readings Decreased FEV1/FVC (75-80%) > 10% increase of FEV1 with bronchodilator therapy Diminished forced expiratory volume in 1 second (FEV1) you administer an inhaler and they will improve(FEV1) to Forced Vital Capacity (FVC) is < 80%
hyaline membrane disease treatment
Give antenatal steroid within 24-48 hours of birth - betamethasone IM x 2 Artificial surfactant can be given through the endotracheal tube Mechanical ventilation with positive pressure
Histoplasma capsulatum causes
Histoplasma is commonly transmitted by bird or bat (animal) droppings, and should always be borne in mind in spelunkers presenting with tuberculosis-like symptoms AIDS-defining illness - Highest risk is with a CD4+ cell count of < 150 cells/mm3
RSV TREATMENT
Hospitalization if O2 saturation < 95-96%, age <3 months, RR > 70, nasal flaring, retractions, or atelectasis on CXR Supportive ⇒ humidified O2, antipyretics, beta-agonist, nebulized racemic epinephrine, and steroids The only treatment demonstrated to improve bronchiolitis is oxygen Ribavirin is given if severe lung or heart disease and in immunocompromised patients Treatment is supportive with nasal suctioning, humidified O2, and antipyretics The only treatment demonstrated to improve bronchiolitis is oxygen Trial of inhaled bronchodilators, nebulized racemic epinephrine, corticosteroids if h/o underlying reactive airway disease - all are commonly used but do not have proof of efficacy
What is hyaline membrane disease (HMD)?
Hyaline membrane disease affects premature infants. It occurs when infants are born before the lungs are producing adequate amounts of surfactant. Surfactant helps to prevent the lungs from collapsing. As the airways collapse, infants will struggle more and more to breathe until they become acidotic and multisystem organ failure begins
what is the most common respiratory disease in a preterm infant
Hyaline membrane disease is the most common cause of respiratory disease in the preterm infant
Legionella pneumonia
Hyponatremia, GI symptoms, fever, and myalgias Usually from environmental water source habitat ***Test for antigen in urine, silver stain *** Air conditioning, aerosolized water, low NA+ (hyponatremia), GI symptoms (diarrhea) and high fever
A 24 year-old male presents in respiratory distress and appears quite ill. A Gram stain and culture of the sputum reveals gram-positive cocci in clumps and a chest x-ray reveals multiple patchy infiltrates with some cavitations. Which of the following is most likely to also be found in his medical history?
IV drug abuse
ocular foreign body treatment
If a corneal foreign body is detected, an attempt can be made to remove it by irrigation after the instillation of topical anesthetic. This is particularly helpful in the case of multiple superficial foreign bodies (eg, sand) An attempt can then be made to remove the foreign body with a swab, using direct visualization Intraocular foreign bodies require immediate surgical removal by an ophthalmologist If you can't remove the foreign body easily then refer to the ophthalmologist
Other than avoiding prematurity, what can be done to prevent newborn respiratory distress syndrome?
If the fetus is older than 32 weeks, administer betamethasone 48 to 72 hours before delivery to augment surfactant production.
If newborn hyaline membrane disease is present, what is the treatment for these patients?
In addition to intravenous surfactant, oxygen with or without nasal CPAP long term is indicated. This is done until the lung maturity has reached an acceptable level.
A 30 year-old male presents with sudden onset of chills, fever, chest pain and a cough productive of greenish-brown sputum. On examination his temperature is 102 degrees F. He appears acutely ill and his respirations are shallow. Chest x-ray demonstrates left lower lobe consolidation. Which of the following findings would most likely be present on examination of his left lower lung?
Increased tactile fremitus
indications for hospitalizations for bronchiolitis
Indications for hospitalization If SpO2 is < 95% on room air Toxic appearance, poor feeding, lethargy, or dehydration Moderate to severe respiratory distress: nasal flaring; intercostal, subcostal, or suprasternal retractions; respiratory rate >70 breaths per minute; dyspnea; or cyanosis Apnea Parents who are unable to care for them at home
Indications for hospitalization for bronchiolitis
Indications for hospitalization include moderate tachypnea with feeding difficulties, visible retractions, and oxygen desaturation Supportive measures include albuterol via nebulizer, antipyretics, and humidified oxygen Steroids (controversial) Symptoms resolve within five to seven days
RSV AGE POPULATION
Infants and young children
How do infants with bronchiolitis present?
Infants with bronchiolitis may present with fussiness, (low/high) low grade fever, coryza, congestion, and apnea, nasal flaring, and retractions
How does bronchiolitis present?
Infants with bronchiolitis may present with fussiness, low-grade fever, coryza, congestion, and apnea
Acute Bronchiolitis
Infection of the small airway, mostly viral, typically seen in children Bronchiolitis is inflammation of the bronchioles, the smallest air passages of the lungs which usually occurs in children less than two years of age
INFLUENZA TREATMENT
Influenza can be treated with oseltamivir (Tamiflu) Zanamivir and Oseltamivir (Tamiflu) both treat influenza A and B must be given within 48 hours Amantadine and Rimantadine treat only influenza A
A 4 year-old boy presents with pain and irritation of his left ear. Otoscopic examination reveals an insect in the left auditory canal. The tympanic membrane is not completely visualized. Which of the following is the most appropriate management of this patient?
Insertion of 2% lidocaine solution with suction or forceps removal
FOREIGN BODY PRESENTATION
Inspiratory stridor (if high in the airway) or wheezing and decreased breath sounds (if low in the airway)
Name a classical sign of croup
Inspiratory stridor is a classical sign of croup.
ASTHMA TREATMENT PROTOCOL
Intermittent: symptoms ≤2 days/week, nighttime awakenings ≤2×/month. short-acting β-agonist use ≤2 days/week, no interference with normal activity Mild persistent: symptoms >2 days/week but not daily, nighttime awakenings 3-4×/month, short-acting β-agonist use >2 days/week but not daily, minor limitations in normal activity Moderate persistent: daily symptoms, nighttime awakenings ≥1×/week but not nightly, daily use of short-acting β-agonist, some limitation in normal activity Severe persistent: symptoms throughout the day, nighttime awakenings often 7×/week, short-acting β-agonist use several times a day, extremely limited normal activity
EAR FOREIGN BODY PEARLS
Irrigation of the external ear can be uncomfortable for the child. Aggressive flushing can cause perforation of the tympanic membrane, so caution is advised while irrigating Aggressive flushing can cause perforation of the tympanic membrane, so caution is advised while irrigating After each flush, it is prudent to recheck the external canal for retained foreign body (FB) fragments, which can occur with an insect After irrigation, if the child is uncomfortable, consider treating with topical pain agents such as benzocaine-anti-pyrene Insects must be immobilized prior to removal. Drown insects with mineral oil or viscous lidocaine before attempting removal
What causes hyaline membrane disease?
It is caused by a deficiency in surfactant resulting in poor lung compliance and atelectasis
What causes hyaline membrane disease?
It is caused by a deficiency in surfactant resulting in poor lung compliance and atelectasis Hyaline membrane disease (also known as newborn respiratory distress syndrome or RDS) affects premature infants. It occurs when infants are born before the lungs are producing adequate amounts of surfactant Surfactant helps to prevent the lungs from collapsing. As the airways collapse, infants will struggle more and more to breathe until they become acidotic and multisystem organ failure begins Hyaline membrane disease/respiratory distress syndrome in preterm infants (RDS) is often due to young gestational age, immature type II alveolar cells, and lack of alveolar surfactant, resulting in inadequate alveolar surface tension during expansion, which results in atelectasis, reduced gas exchange, severe hypoxia, and acidosis.
Patient will present as → a 40-year-old alcoholic male with sudden onset of severe chills, fever, dyspnea, and cough productive of red mucoid sticky sputum. He appears ill-looking with cyanosis. Examination reveals vital signs: Temp - 102 degrees F; Pulse - 120 /minute and regular; 89 RR - 28/min; BP 90/62 mm Hg. Lungs reveal minimal rales and dullness in the right upper lobe with decreased breath sounds. Chest x-ray reveals right upper lobe consolidation with a bulging fissure. Gram stain reveals many white blood cells and many gram-negative rods.
KLEBISELLA PNEUMONIA
Currant jelly sputum, drinkers, aspiration
Klebsiella
currant jelly sputum
Klebsiella pneumoniae
Which of the following causes of pneumonia is most likely to be complicated by diarrhea?
Legionella
low NA+ (hyponatremia), GI symptoms (diarrhea) and high fever
Legionella
A 6 year-old boy is brought to the pediatric clinic by his mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing. Which of the following would be the most appropriate treatment for this patient?
Low dose inhaled corticosteroid
What is a gastrointestinal complication of cystic fibrosis, and presents as a neonate who fails to pass an initial stool?
Meconium ileus is a gastrointestinal complication of cystic fibrosis, and presents as a neonate who fails to pass an initial stool.
What is of particular concern with metallic foreign bodies?
Metallic foreign bodies may leave a rust ring
Histoplasma capsulatum location
Mississippi and Ohio River Valleys
RSV IS TYPICALLY SEEN IN WHICH SEASON
Most often caused by RSV - commonly in fall and winter months
WHERE DO MOST FOREIGN BODY OBJECTS LAND
Most often food and can be life-threatening. 80% in mainstem or lobar bronchus right > left Risk factors include institutionalization, advanced age, poor dentition, alcohol, sedative use
A 20 year-old male presents with 3 weeks of constitutional and upper respiratory symptoms, including malaise, sore throat, dry cough, and fever. Lung auscultation demonstrates diffuse crackles bilaterally. What is the most likely infectious agent involved?
Mycoplasma pneumoniae
Patient will present as → a 4-year-old boy with unilateral purulent, foul-smelling nasal discharge for three days. The child has no other respiratory symptoms.
NASAL FOREIGN BODY
WHICH MEDICATIONS CAN TRIGGER ASTHMA
NSAIDs and aspirin can precipitate an acute asthma attack
Narrowing of the upper trachea and subglottis leads to what characteristic finding on X-ray in patients with croup?
Narrowing of the upper trachea and subglottis leads to characteristic steeple sign on X-ray in patients with croup
Management of nasal foreign body?
Nasal foreign bodies can often be removed in the office with a nasal speculum and Hartmann nasal forceps Prior to removal, the provider may consider using oxymetazoline drops to shrink the mucous membrane
A 4 year-old boy presents with purulent, foul-smelling nasal discharge for three days. He has not had any other symptoms of respiratory illness, cough, wheeze, or fever. His activity level and appetite has been normal. On exam, he is afebrile. TM's have normal light reflex, canals are clear. Left nare is clear; there is considerable amount of purulent exudate from the right nare, and a bright reflection of light is noticed. Oropharynx is without inflammation or exudate. Neck is supple, without lymphadenopathy. Lungs are clear, with equal breath sounds and no wheezing. Heart has regular rhythm without murmurs. Which of the following is the most likely diagnosis?
Nasal foreign body
What are the indications for the administration of ribavirin in patients with bronchiolitis?
Nebulized or oral ribavirin, alone or in combination with other interventions, may be warranted for the treatment of documented RSV infection in immunocompromised patients
A 2 year-old presents to the emergency department in acute respiratory distress. The parents relate a history of a recent upper respiratory illness that was followed by a sudden onset of barking cough during the night, but this morning they noted increased difficulty breathing. The child is noted to have stridor at rest, but has no evidence of cyanosis. Which of the following is the most appropriate initial intervention?
Nebulized racemic epinephrine
A preterm infant is breathing rapidly and grunting. Intercostal retractions, nasal flaring, and cyanosis are noted. Auscultation shows decreased breath sounds and crackles. What is the diagnosis?
Newborn respiratory distress syndrome, also known as hyaline membrane disease.
How do you make the diagnosis of CF?
Newborn screening (immunoreactive trypsinogen will be high) + sweat chloride test + can do genotyping for most common CFTR mutations
rust ring
Occurs 6-8 hours after a metallic FB enters the cornea After removal of a foreign body containing iron, there is often a residual rust ring and reactive infiltrate. Patients with rust ring should be treated as patients with corneal abrasions. The rust ring itself is not harmful and will usually resorb gradually Metallic foreign bodies may leave a rust ring
Patient will present as → a 33- year-old complaining of right eye pain and irritation. He states that he wasn't wearing glasses, and while trimming his driveway with his weed trimmer, "something flew into my eye." Visual acuity is 20/20. Pupils are equal, round, reactive to light, and accommodation. Extraocular movements are intact. On physical examination, you note a tearing, red, and severely painful right eye.
Ocular Foreign body
A 22 month-old male infant presents with one day of barking cough preceded by three days of cold symptoms. On physical examination, his axillary temperature is 100.4°F and he has no stridor at rest. Inspiratory stridor is evident when he becomes agitated during the examination. There are no signs of respiratory distress or cyanosis. Which of the following is the most appropriate treatment for this patient?
Oral dexamethasone
BACTERIAL PNEUMONIA TREATMENT
Outpatient = doxy, macrolides; inpatient = ceftriaxone + azithromycin/respiratory FQs
BACTERIAL PNEUMONIA TREATMENT
Outpatient therapy (antibiotics) Doxycycline, Macrolides Inpatient (hospitalize if > 50 with comorbidities, altered mental status, poor fluid status) Ceftriaxone plus azithromycin, respiratory fluoroquinolones
A previously healthy 8-month-old boy is hospitalized for acute bronchiolitis. He has no known significant past medical or family history. On admission, he exhibits nasal flaring and retractions with a respiratory rate of 68, axillary temperature of 102.0 degrees F and O2 saturation of 86%. Which of the following medications is indicated?
Oxygen
What medication is used for respiratory syncytial virus prophylaxis for high-risk infants
Palivizumab (Synagis) is used for respiratory syncytial virus prophylaxis for high-risk infants
What may be given to special populations as immunoprophylaxis?
Palivizumab prophylaxis is a humanized monoclonal antibody against the RSV F glycoprotein. It is administered once per month for five months beginning in November for special populations (immunocompromised, premature infants, neuromuscular disorders) Palivizumab prophylaxis (once per month for five months beginning in November) for special populations (immunocompromised, premature infants, neuromuscular disorders)
What is a complication of cystic fibrosis that results in malabsorption, steatorrhea, and fat-soluble vitamin deficiencies?
Pancreatic insufficiency is a complication of cystic fibrosis that results in malabsorption, steatorrhea, and fat-soluble vitamin deficiencies.
An 18-month-old male presents with his parents who report symptoms of a barking cough and intermittent stridor that has worsened over the past 12 hours. They note improvement in symptoms when he was taken outdoors to the cool night air. Which of the following is the most likely organism causing this patient's symptoms
Parainfluenza virus
croup cause
Parainfluenza virus
What is the genetic defect in CF?
Patients inherit 2 defective copies of a gene on the long arm of chromosome 7. This gene codes for the cystic fibrosis transmembrane conductance regulator (CFTR).Explain the pathophysiology of CF
Best way to assess asthma exacerbation severity and patient response in ED?
Peak expiratory flow
Nasal foreign body
Persistent foul-smelling purulent unilateral nasal discharge in a young child without other respiratory symptoms should raise suspicion for a retained nasal foreign body, even without a history of witnessed foreign body insertion
NASAL FOREIGN BODY PRESENTATION
Persistent foul-smelling purulent unilateral nasal discharge in a young child without other respiratory symptoms should raise suspicion for a retained nasal foreign body, even without a history of witnessed foreign body insertion.
Patient will present as → a 32-year-old man with a two-week history of fever and dry, nonproductive cough. For the past five days, he has been having shortness of breath. There is no history of pleuritic chest pain or rigors. Past medical history is significant for HIV. His temperature is 100.4°F (38°C), the pulse is 92/min, O2 saturation is 92%, respirations are 18/min, and blood pressure is 120/70 mmHg. Purified protein derivative (PPD) is negative. CD4 cell count is 190. The chest exam reveals bibasal crackles. The chest radiograph shows interstitial infiltrates bilaterally. The patient's condition worsens on levofloxacin.
Pneumocystis Jiroveci
HIV positive patients are most at risk for development of this type of pneumonia
Pneumocystis jiroveci
Pneumocystis Jiroveci symptoms
Presents with a classic triad of symptoms - 1. dyspnea on exertion + 2. fever + 3. nonproductive cough
INFLUENZA PNEUMONIA SYMPTOMS
Primary influenza pneumonia manifests with a persistent cough, sore throat, headache, myalgia, and malaise for more than three to five days.
NASAL FOREIGN BODY TREATMENT
Prior to removal consider using oxymetazoline drops to shrink the mucous membrane Nasal foreign bodies can often be removed in the office with a nasal speculum and Hartmann nasal forceps
Ventilator associated pneumonia, patients become sick fast. Treat with 2 antibiotics
Pseudomonas
Ventilators, patients become sick fast - treat with 2 antibiotics
Pseudomonas
A 3 year-old male with cystic fibrosis develops pneumonia. Which of the following is the most likely etiology of the pneumonia?
Pseudomonas aeruginosa
Most prevalent organism in CF pulmonary infections?
Pseudomonas aeruginosa
ASTHMA DIAGNOSIS
Pulmonary Function Tests provide an objective method of evaluating the presence and degree of lung disease, as well as the response to therapy Allergy testing Mucous testing Etc. Diagnosis and monitor with peak flow GOLD STANDARD = PEAK EXPIRATORY FLOW RATE Spirometry with pre and post-therapy (albuterol inhalation) readings Decreased FEV1/FVC (75-80%) > 10% increase of FEV1 with bronchodilator therapy
A pediatric patient presents with a history of multiple recurrent respiratory infections associated with failure to thrive. A sweat chloride test is elevated. Which of the following is a common cause of death in patients with this condition?
Pulmonary infection
MOST COMMON CAUSE OF VIRAL PNEUMONIA IN KIDS
RSV
MOST COMMON VIRAL PNEUMONIA IN KIDS
RSV Respiratory syncytial virus (RSV) is the most frequent cause of lower respiratory tract infection in infants and children and the second most common viral cause of pneumonia in adults
VIRAL PNEUMONIA DIAGNOSIS
Rapid antigen testing for flu, RSV nasal swab, cold agglutinin titer negative
Coccidioides diagnosis
Serologic tests using enzyme-linked immunoassays (EIA) for IgM and IgG should be ordered first, if possible. If the EIA is positive, a confirmatory immunodiffusion test should be performed.
A blacksmith presents to your clinic after feeling like something went in his eye while he was grinding on a piece of metal. You stain the eye with Fluorescein and can visualize uptake with what appears like a deep abrasion. You are unable to visualize any foreign body with your indirect ophthalmoscope. Although he makes an attempt, he complains of some visual loss in that eye. His last Tetanus booster was 4 years ago. What is the most appropriate next step in the management of this patient?
Refer to ophthalmologist
ear foreign body treatment
Removal of foreign body which requires direct visualization prior to removal either via warm irrigation with a syringe, or instruments like an alligator forceps
FOREIGN BODY TREATMENT
Remove foreign body with a bronchoscope Rigid bronchoscopy preferred in children while flexible is diagnostic and therapeutic in adults
An infant born at 30 weeks' gestation begins to have respiratory difficulty shortly after birth. Examination reveals rapid, shallow respirations at 80 per minute with associated intercostal retractions, nasal flaring and progressive cyanosis. Chest x-ray reveals the presence of air bronchograms and diffuse bilateral atelectasis. Which of the following is the most likely diagnosis?
Respiratory distress syndrome Respiratory distress syndrome (hyaline membrane disease) is the most common cause of respiratory distress in a premature infant. This diagnosis is supported by the chest x-ray findings of air bronchograms and diffuse bilateral atelectasis, causing a ground-glass appearance
bronchiolitis cause
Respiratory syncytial virus (RSV)
Respiratory syncytial virus diagnosis?
Respiratory syncytial virus infection can be diagnosed by nasopharyngeal swab
Respiratory syncytial virus is the most common cause of what infection in infants?
Respiratory syncytial virus is the most common cause of bronchiolitis in infants.
RSV pneumonia treatment
Ribavirin is the only effective antiviral agent available to treat RSV pneumonia, but there are conflicting data regarding its efficacy.
Strep pneumoniae
Rust-colored sputum - common in patients with splenectomy
Salmon colored sputum, lobar, after influenza, MRSA treat with vancomycin
S. Aureus
Rust colored sputum - common in patients with splenectomy
S. Pneumoniae
Rust colored sputum, common in patients with splenectomy
S. Pneumoniae
Salmon colored sputum - MRSA treat with vancomycin
S. aureus
Long acting beta agonists?
Salmeterol Formoterol
salmon colored sputum
Staph aureus
Patients w/ CF are prone to colonization with what two bacteria?
Staph aureus and P. aeuroginosa
rust colored sputum
Strep pneumo
The most common pathogen identified in community acquired pneumonia (CAP) is
Streptococcus pneumoniae.
bronchiolitis treatment
Supportive measures include albuterol via nebulizer, antipyretics and humidified oxygen, steroids (controversial), resolves in 5-7 days Indications for hospitalization ⇒ tachypnea with feeding difficulties, visible retractions, oxygen desaturation < 95-96% Supportive measures include albuterol via nebulizer, antipyretics and humidified oxygen, steroids (controversial), resolves in 5-7 days
CYSTIC FIBROSIS DIAGNOSIS
Sweat chloride test An elevated quantitative sweat chloride test performed on two different days is diagnostic. ↑ NaCL > 60 mEq/L
Diagnosis of intermittent asthma?
Sxms: <2 d/wk Nighttime awakenings: <2/month SABA use for symptom control: <2d/wk Interference with activity: None Lung function: FEV1 >80% + FEV1/FVC normal
Diagnosis of mild persistent asthma?
Sxms: >2 d/wk (but NOT daily) Nighttime awakenings: 3-4/month SABA use for symptom control: >2d/wk Interference with activity: Minor Lung function: FEV1 >80% predicted + FEV1/FVC usu normal
Diagnosis of moderate persistent asthma?
Sxms: Daily Nighttime awakenings: >1 x wk (not daily) SABA use for symptom control: Daily Interference with activity: Some Lung function: FEV1 60-80% predicted and FEV1/FVC usu normal
Diagnosis of severe persistent asthma?
Sxms: Throughout the day Nighttime awakenings: Often 7x wk SABA use for sxm control: Several per day Interference with activity: Very limited Lung function: FEV1 <60% predicted and FEV1/FVC reduced >5%
Symptoms and signs of ocular foreign body?
Symptoms and signs of an ocular foreign body include foreign body sensation, tearing, redness, and occasionally discharge. Vision is rarely affected (other than by tearing).
What cells appear to play a rule in the activation of the inflammatory response in asthma?
TH2 cells (type of CD4 T cell)
Pneumocystis jiroveci
TMP-SMX (prophylaxis in AIDS patient) HIV CD4 <200, immunosuppressed
Asthma treatment
TREATMENT 1) MILD: Short-Acting Bronchodilator (Albuterol) 2) add: Low-Dose Inhaled Corticosteroid 3) MODERATE: add: Long-Acting Bronchodialator 4) SEVERE: Short-Acting Bronchodilator plus High-Dose Inhaled Corticosteroid plus Long-Acting Bronchodialator plus giving @ night, must rinse out mouth. Oral Corticosteroids (Prednizone) - rinse mouth Also: Begin using a spacer with current Inhalers Intermittent: Less than 2 times per week or ≤ 2 night symptoms per month Step 1: Short-acting beta2 agonist (SABA) PRN Mild Persistent: More than 2 times per week or 3-4 night symptoms per month Step 2: Low-Dose inhaled corticosteroids (ICS) daily Moderate Persistent: Daily symptoms or more than 1 nightly episode per week Step 3: Low-Dose ICS + Long-acting beta2 agonist (LABA) daily Step 4: Medium-Dose ICS +LABA daily Severe Persistent: Symptoms several times per day and nightly Step 5: High-Dose ICS +LABA daily Step 6: High-Dose ICS +LABA +oral steroids daily
The CFTR gene is located on the long arm of what chromosome?
The CFTR gene is located on the long arm of chromosome 7
What is the only treatment shown to improve bronchiolitis?
The only treatment demonstrated to improve bronchiolitis is oxygen
Pneumocystis Jiroveci x-ray findings
The radiograph shows diffuse interstitial or bilateral perihilar infiltrates DX: CXR is the cornerstone of diagnosis. The radiograph shows diffuse interstitial or bilateral perihilar infiltrates
Cryptococcus treatment
Treat with Amphotericin B + Flucytosine for 2 weeks followed by Fluconazole for 10 weeks
Histoplasma capsulatum treatment
Treat with itraconazole orally for weeks to months or Amphotericin B if severe or failed Itraconazole
What is the treatment of croup?
Treatment of croup may include humidified air and a single dose of dexamethasone Treatment is antipyretics, hydration, humidified air (or oxygen), nebulized racemic epinephrine (only if signs of distress), and corticosteroids (dexamethasone)
What is a new medication for CF patients that is actually VERY good?
Trikafta (elexacaftor/ivacaftor/tezacaftor)
What is the classic clinical presentation of an intranasal foreign body?
Unilateral purulent and foul-smelling nasal discharge in a young child strongly suggests the presence of a porous nasal FB
Patient will present as → a 45-year-old male with a one-week history of hacking, non-productive cough, low-grade fever, malaise, and myalgias. The chest x-ray reveals bilateral interstitial infiltrates and a cold agglutinin titer that is negative. Examination reveals scattered rhonchi and rales upon auscultation of the chest.
VIRAL PNEUMONIA
An elderly nursing home resident is admitted with methicillin-resistant Staphylococcus aureus pneumonia. Which of the following is the most appropriate treatment to initiate?
Vancomycin
Pseudomonas:
Ventilators, Cystic fibrosis, patients become sick fast - treat with 2 antibiotics
NASAL FOREIGN BODY DIAGNOSIS
Visualization of the foreign body (FB) establishes the diagnosis Rigid or flexible fiberoptic endoscopy may be necessary to identify some FB
Diagnosis of nasal foreign body?
Visualization of the foreign body (FB) establishes the diagnosis. Rigid or flexible fiberoptic endoscopy may be necessary to identify some FB. Plain radiographs can establish the presence of button batteries or magnets within the nasal cavity when suspected but are not necessary for the diagnosis of other types of intranasal FBs.
At what age is the preterm infant more likely to have hyaline membrane disease?
When the infant is around 26-28 weeks old
nasal flaring
Widening of the nostrils, indicating that there is an airway obstruction. Enlargement of nostrils with breathing (sign of respiratory distress)
A 32 year-old carpenter complains of right eye irritation all day after driving a metal stake into the ground with his hammer. He states that "something flew into my eye." Visual acuity is 20/20. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact. There is minimal right corneal injection. No foreign body is noted with lid eversion. Fluorescein stain reveals a tiny pinpoint uptake in the area of the corneal injection. Which of the following is the most appropriate diagnostic test at this stage?
X-ray orbits
What is seen on x-ray in hyaline membrane disease?
X-rays show diffuse atelectasis causing a "ground glass appearance" and air bronchograms
Pneumocystis Jiroveci
a fungus causing severe pneumonia Pneumocystis jirovecii is a yeast-like fungus of the genus Pneumocystis Common in HIV-infected patients with a low CD4 count of less than 200 Most common opportunistic infection in patients with HIV especially if CD4 count < 200
Patient will present as → a 5-month old infant with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C, and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Nasal flaring, use of accessory muscles, subcostal and intercostal retractions are noted. Expiratory wheezes and a cough are present.
acute bronchiolitis
Short acting beta agonists?
albuterol, levalbuterol, metaproterenol
croup
an acute respiratory syndrome in children and infants characterized by obstruction of the larynx, hoarseness, and a barking cough Croup refers to an infection of the upper airway, which obstructs breathing and causes a characteristic barking cough
peak flow meter
an inexpensive handheld device used to let patients with asthma measure air flowing out of the lungs, revealing any narrowing of the airways in advance of an asthma attack Peak flow is an inexpensive and easily available monitoring device once the diagnosis of asthma has been established.
Histoplasma capsulatum
caused by bat droppings -looks like sarcoidosis on CXR
bronchiolitis diagnosis
nasal swab Diagnosed with nasal washing, RSV antigen test; CXR can show diffuse infiltrates Nasopharyngeal secretions RSV antigen test CXR can show diffuse infiltrates
Lobar consolidation is seen in
community acquired pneumonia
Patient will present as → a 2-year-old boy who is brought to you by his father who is concerned about a "barking cough," mild fever, and a hoarse voice. He reports that he had a runny nose last week that has since resolved. Physical exam reveals inspiratory stridor.
croup
Klebsiella pneumoniae
currant jelly sputum, drinkers, aspiration
lack of wheezing in an acute asthma attack =
emergency
Mycoplasma pneumoniae SYMPTOMS
fever, fatigue, dry hacking cough Young people living in dorms, (+) cold agglutinins, bullous myringitis Young people living in dorms, (+) cold agglutinins, bullous myringitis, walking pneumonia, low temp
What is the only treatment demonstrated to improve bronchiolitis?
he only treatment demonstrated to improve bronchiolitis is oxygen
Patient will present with → a 21-year-old male presents with a cough and mild shortness of breath for three days. The cough is productive of yellowish mucus. He reports a low-grade fever with this episode but says that he has otherwise been healthy. He has spent the last month working in bat caves. He denies tobacco or alcohol use
histoplasmosis
A 3 month-old male presents with a hoarse cough and thick purulent rhinorrhea for the past 2 days. The mother noted that yesterday he appeared to get worse and seemed to have increasing problems breathing and trouble feeding. Examination reveals a temperature of 100.2 degrees F and respiratory rate of 80/minute with nasal flaring and retractions. Lung examination reveals a prolonged expiratory phase with inspiratory rales. He is tachycardic. Pulse oximetry reveals oxygen saturation of 89%. Chest x-ray reveals hyperinflation with diffuse interstitial infiltrates. Which of the following is the most appropriate intervention?
hospitalization
Patient will present as → a premature infant who is born at 30 weeks and after several hours develops rapid shallow respirations at 60/ min, grunting retractions, and duskiness of the skin. The chest X-ray reveals diffuse bilateral atelectasis, ground glass appearance, and air bronchograms
hyaline membrane disease
You are called to the nursery to see a male infant, born by uncomplicated vaginal delivery. He weighs 2,600 grams and has one deep crease on the anterior third of each foot. Respirations are 88 breaths/minute with expiratory grunting and intercostals retractions. He is cyanotic on room air and becomes pink when placed in 60% oxygen. Chest x-ray shows atelectasis with air bronchograms. Which of the following is the most likely diagnosis?
hyaline membrane disease Hyaline membrane disease is the most common cause of respiratory distress in the premature infant. The infant typically presents with tachypnea, cyanosis and expiratory grunting. A chest x-ray reveals hypoexpansion and air bronchograms.
Coccidioides (valley fever)
in dry states
MOST COMMON CAUSE OF VIRAL PNEUMONIA IN ADULTS
influenza
THE MOST COMMON VIRAL CAUSE OF PNEUMONIA IN ADULTS
influenza
A 25 year-old male with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist prn. He is presently using his short acting beta agonist on a daily basis. Which of the following is the most appropriate addition to this patient's regimen?
inhaled corticosteroid
A 10 year-old boy was playing with sparklers (magnesium sulfate) and got some of the "sparkle" in his right eye. Which of the following is the most appropriate initial treatment?
irrigate the eye for at least 20 minutes
Histoplasma capsulatum symptoms
is an opportunistic fungus that is known to cause systemic disease in HIV patients that involves low-grade fevers, cough, hepatosplenomegaly, and tongue ulceration
LEGIONELLA PNEUMONIA SYMPTOMS
low NA+ (hyponatremia), GI symptoms (diarrhea), and high fever
Which of the following is the most effective way for patients with persistent asthma to monitor the severity of their symptoms?
monitor peak flow
A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is
mycoplasma pneumonia
RSV SYMPTOMS
nasal discharge, cough, mild fever, dyspnea, nasal flaring, retractions, possible cyanosis Tachypnea, respiratory distress, wheezing
A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days, but symptoms worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 7 pounds, and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 100.8° F, pulse of 120 beats/minute, blood pressure within normal limits, and respiratory rate of 60 breaths/minute. The infant is well hydrated but appears ill. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical examination. Chest radiographs show patchy atelectasis and hyperinflation of the lungs.
respiratory syncytial virus (RSV)
MC cause of lower respiratory tract infection in children worldwide
rsv infection
Patient will present as → a 5-month old infant with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C, and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Nasal flaring, use of accessory muscles, subcostal and intercostal retractions are noted. Expiratory wheezes and a cough are present.
rsv infection
A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient?
spoken "ee" heard as "ay"
Pneumocystis Jiroveci treatment
trimethoprim/sulfamethoxazole
Apical infiltration is seen in
tuberculosis
intercostal retractions
use of intercostal muscles with breathing (indicates severe respiratory distress/work of breathing) - sunken intercostal muscles (can see ribs) sunken intercostal muscles (can see ribs)
A 15 year-old male presents with a 1 week history of hacking non-productive cough, low grade fever, malaise and myalgias. Examination is unremarkable except for a few scattered rhonchi and rales upon auscultation of the chest. The chest x-ray reveals interstitial infiltrates and a cold agglutinin titer was negative. Which of the following is the most likely diagnosis?
viral pneumonia
