Comps Review: WHNP Primary Care.
Questions and Answers.
Sinusitis Presentation -
\Caused by viral or bacterial infections and allergies.
Usually involves maxillary and ethmoid sinuses
Chronic sinusitis occurs with episodes of prolonged infection that resist tx.
Acute sinusitis: nasal congestion, facial pain, toothache, headache, fever, yellow/green
nasal drainage; increased pain with bending over or sudden head movement; common
cold and allergic rhinitis may precede infection; "double sickening" URI symptoms with
initial improvement followed by increasing nasal symptoms
Chronic sinusitis: nasal congestion, discharge, cough that last longer than 30 days; dull
ache or pressure across forehead and/or midface, constant postnasal drip and chronic
cough
Afebrile or low-grade fever
Mucopurulent nasal discharge; postnasal discharge
Nasal mucosa swollen, pale, red to gray
Pain on firm palpation over sinus area
Sinusitis Diagnostic Method -
\1. None for typical presentation
2. Sinus radiography: confirmed by mucosal thickening, sinus opacity, air-fluid levels;
Normal sinus radiography to exclude maxillary and frontal disease; ethmoid involvement
more difficult to exclude
3. CT scan: reserved for complicated disease and search for ethmoidal disease in
patients with refractory symptoms and negative conventional radiographs
Sinusitis 1st Line Treatment -
\Nonpharmacologic:
saline nasal spray
steam inhalation
warm compressees
hydration 2-3L daily
Pharmacologic:
ABX for acute otitis media if s/sx are present >10d after onset of uppper respiratory
symptoms, or if worsening (Amoxicillin)
Decongestants
Nasal steroids - to reduce mucosal inflammation
,Antihistimines not recommended unless patient has allergies
Pain mgmt with tylenol, NSAIDS, or opiods
Education:
Avoid allergens, smoking
Keep hydrated
Sinusitis when to consult -
\Refer for severe facial pain, periorbital swelling
Failure to respond to two courses of ABx
Suspected anatomic abnormality
Chronic sinusitis or more than 3 episodes of acute sinusitis per year
Bronchitis Presentation -
\....
Bronchitis Diagnostic Method -
\...
Bronchitis 1st Line Treatment -
\...
Bronchitis when to consult -
\...
Asthma Definition -
\A chronic inflammatory disorder of the airways in which many cells and cellular
elements play a role, in particular, mast cells, eosinophils, T lymphocytes, neutrophils
and epithelial cells in suspected individuals. This inflammation causes recurrent
episodes of wheezing, breathlessness, chest tightness and cough, especially at night
and the early morning. These episodes are associated with airflow obstruction that is
often reversible; the inflammation also causes an associated increase in existing
bronchial hyperresponsiveness to a variety of stimuli.
Asthma Diagnostic Method -
\1. Pulmonary function tests/spirometry to establish airway obstruction
FEV1 (forced expiratory volume in 1 second) less than 80% of predicted; FEV1/FVC
(forced vital capacity) less than 65% or below normal limit
Spirometry and peak flow rates improve with bronchodilator challenge, FEV1 increases
12% and at least 200mL after use of inhaled short acting B2-agonist
2. If normal spirometry, assess, diurnal variation of PEF (peak expiratory flow); 20%
difference between two measures/PEF variability supports diagnosis of asthma
,3. Broncoprovocation with methacholine, histamine, or exercise if diagnosis in question;
negative test helps exclude diagnosis of asthma
4. Chest radiograph if infection, large airway lesions, heart disease, or foreign body
obstruction suspected.
Asthma 1st Line Treatment -
\Goals: minimize symptoms, normalize daily activity; maintain near-normal pulmonary
function, minimal use of short acting B2-agonist
Nonpharmacological: peak flow monitoring - establish a personal best and an asthma
action plan, a drop in peak flow below 80% indicates an acute exacerbation, and need
to contact clinician for medication adjustment, a drop in peak flow below 50% indicates
need for emergency treatment
Avoid known allergens, adequate hydration and humidity, annual influenza vaccine and
pneumococcal vaccine.
Asthma when to consult -
\Failure to respond to emergency treatment; arrange for emergency room treatment if
signs of severe obstruction present - peak flow reduced by 50%, pulsus paradoxus, use
of accessory muscles for respiration
Difficulty controlling asthma or if step 4 is required
Pneumonia Presentation -
\May be masked or absent in very young, elderly, immunosupressed, coexisting chronic
disease
fevers, chills, sweats, cough with/without sputum production
dyspnea, pleuritic chest pain
associated symptoms - lethargy, headache, anorexia, nausea, vomiting.
Physical findings: tachypnea, dyspnea, tachycardia
Percussion - often normal in early disease, dullness over area of consolidation
Auscultation - course rhonchi may clear or shift with cough, nonclearing rales,
diminished breath sounds over consolidation
Fever w/ chills, high spikes (102.2), especially if bacterial etiology
Small areas of pneumonia cannot always be detected by physical examination.
Pneumonia Diagnostic Method -
\Chest radiograph - establishes diagnosis by revealing an infiltrate, helps distinguish
pneumonia from acute bronchitis; demonstrates the presence of complications such as
pleural effusion and multilobular disease
Value of sputum collection for Gram's stain and culture is controversial
CBC w/ diff - WBC elevated with shift to the left, bandemia, neutrophilia, especially if
bacterial etiology
Pneumonia 1st Line Treatment -
, \Non-pharmacologic
Oral hydration and humidification
Improve oxygen
Pharmacology
Empiric antimicrobial therapy for patients without comorbidity and less than 60 years
old...
azythromycin or clarithromycin
Patients with comobidity or over 60 years old...
Levofloxacin
Pneumonia when to call -
\Base decision to hospitalize based on age, comorbid illness, physical examination, and
laboratory findings
No improvement in 24-36 hours
Fever over 102, pallor, or cyanosis, nasal flaring
Mental confusion
Asthma Classification -
\Intermittent - Step 1
Symptoms 2x/week or less; nocturnal symptoms 2x/month or less
PEF/FEV1 >80% of predicted value; variability <20%
Normal between exacerbations
Mild Persistant - Step 2
Symptoms 3-6x/week; nocturnal symptoms 3-4x/month
PEF/FEV1 >80% of predicted value, variability 20-30%
Moderate persistent - Step 3
Daily symptoms; nocturnal symptoms more than 1x/week but not nightly
PEF/FEV1 >60% but less than 80%; variability >30%
Severe persistent - Step 4
Continual daily symptoms; frequent nocturnal symptoms
PEF/FEV1 <60%; variability >30%
Asthma etiology -
\Allergic triggers: airborne pollens, molds, dust mites, cockroaches, animal dander, food
additives or preservatives, feather pillows
Nonallergic triggers: smoke and other pollutants, viral respiratory infections, medications
(ASA, NSAIDS, Beta blockers), exercise, GERD, emotional factors, menses/pregnancy
Strong history of atopy
Questions and Answers.
Sinusitis Presentation -
\Caused by viral or bacterial infections and allergies.
Usually involves maxillary and ethmoid sinuses
Chronic sinusitis occurs with episodes of prolonged infection that resist tx.
Acute sinusitis: nasal congestion, facial pain, toothache, headache, fever, yellow/green
nasal drainage; increased pain with bending over or sudden head movement; common
cold and allergic rhinitis may precede infection; "double sickening" URI symptoms with
initial improvement followed by increasing nasal symptoms
Chronic sinusitis: nasal congestion, discharge, cough that last longer than 30 days; dull
ache or pressure across forehead and/or midface, constant postnasal drip and chronic
cough
Afebrile or low-grade fever
Mucopurulent nasal discharge; postnasal discharge
Nasal mucosa swollen, pale, red to gray
Pain on firm palpation over sinus area
Sinusitis Diagnostic Method -
\1. None for typical presentation
2. Sinus radiography: confirmed by mucosal thickening, sinus opacity, air-fluid levels;
Normal sinus radiography to exclude maxillary and frontal disease; ethmoid involvement
more difficult to exclude
3. CT scan: reserved for complicated disease and search for ethmoidal disease in
patients with refractory symptoms and negative conventional radiographs
Sinusitis 1st Line Treatment -
\Nonpharmacologic:
saline nasal spray
steam inhalation
warm compressees
hydration 2-3L daily
Pharmacologic:
ABX for acute otitis media if s/sx are present >10d after onset of uppper respiratory
symptoms, or if worsening (Amoxicillin)
Decongestants
Nasal steroids - to reduce mucosal inflammation
,Antihistimines not recommended unless patient has allergies
Pain mgmt with tylenol, NSAIDS, or opiods
Education:
Avoid allergens, smoking
Keep hydrated
Sinusitis when to consult -
\Refer for severe facial pain, periorbital swelling
Failure to respond to two courses of ABx
Suspected anatomic abnormality
Chronic sinusitis or more than 3 episodes of acute sinusitis per year
Bronchitis Presentation -
\....
Bronchitis Diagnostic Method -
\...
Bronchitis 1st Line Treatment -
\...
Bronchitis when to consult -
\...
Asthma Definition -
\A chronic inflammatory disorder of the airways in which many cells and cellular
elements play a role, in particular, mast cells, eosinophils, T lymphocytes, neutrophils
and epithelial cells in suspected individuals. This inflammation causes recurrent
episodes of wheezing, breathlessness, chest tightness and cough, especially at night
and the early morning. These episodes are associated with airflow obstruction that is
often reversible; the inflammation also causes an associated increase in existing
bronchial hyperresponsiveness to a variety of stimuli.
Asthma Diagnostic Method -
\1. Pulmonary function tests/spirometry to establish airway obstruction
FEV1 (forced expiratory volume in 1 second) less than 80% of predicted; FEV1/FVC
(forced vital capacity) less than 65% or below normal limit
Spirometry and peak flow rates improve with bronchodilator challenge, FEV1 increases
12% and at least 200mL after use of inhaled short acting B2-agonist
2. If normal spirometry, assess, diurnal variation of PEF (peak expiratory flow); 20%
difference between two measures/PEF variability supports diagnosis of asthma
,3. Broncoprovocation with methacholine, histamine, or exercise if diagnosis in question;
negative test helps exclude diagnosis of asthma
4. Chest radiograph if infection, large airway lesions, heart disease, or foreign body
obstruction suspected.
Asthma 1st Line Treatment -
\Goals: minimize symptoms, normalize daily activity; maintain near-normal pulmonary
function, minimal use of short acting B2-agonist
Nonpharmacological: peak flow monitoring - establish a personal best and an asthma
action plan, a drop in peak flow below 80% indicates an acute exacerbation, and need
to contact clinician for medication adjustment, a drop in peak flow below 50% indicates
need for emergency treatment
Avoid known allergens, adequate hydration and humidity, annual influenza vaccine and
pneumococcal vaccine.
Asthma when to consult -
\Failure to respond to emergency treatment; arrange for emergency room treatment if
signs of severe obstruction present - peak flow reduced by 50%, pulsus paradoxus, use
of accessory muscles for respiration
Difficulty controlling asthma or if step 4 is required
Pneumonia Presentation -
\May be masked or absent in very young, elderly, immunosupressed, coexisting chronic
disease
fevers, chills, sweats, cough with/without sputum production
dyspnea, pleuritic chest pain
associated symptoms - lethargy, headache, anorexia, nausea, vomiting.
Physical findings: tachypnea, dyspnea, tachycardia
Percussion - often normal in early disease, dullness over area of consolidation
Auscultation - course rhonchi may clear or shift with cough, nonclearing rales,
diminished breath sounds over consolidation
Fever w/ chills, high spikes (102.2), especially if bacterial etiology
Small areas of pneumonia cannot always be detected by physical examination.
Pneumonia Diagnostic Method -
\Chest radiograph - establishes diagnosis by revealing an infiltrate, helps distinguish
pneumonia from acute bronchitis; demonstrates the presence of complications such as
pleural effusion and multilobular disease
Value of sputum collection for Gram's stain and culture is controversial
CBC w/ diff - WBC elevated with shift to the left, bandemia, neutrophilia, especially if
bacterial etiology
Pneumonia 1st Line Treatment -
, \Non-pharmacologic
Oral hydration and humidification
Improve oxygen
Pharmacology
Empiric antimicrobial therapy for patients without comorbidity and less than 60 years
old...
azythromycin or clarithromycin
Patients with comobidity or over 60 years old...
Levofloxacin
Pneumonia when to call -
\Base decision to hospitalize based on age, comorbid illness, physical examination, and
laboratory findings
No improvement in 24-36 hours
Fever over 102, pallor, or cyanosis, nasal flaring
Mental confusion
Asthma Classification -
\Intermittent - Step 1
Symptoms 2x/week or less; nocturnal symptoms 2x/month or less
PEF/FEV1 >80% of predicted value; variability <20%
Normal between exacerbations
Mild Persistant - Step 2
Symptoms 3-6x/week; nocturnal symptoms 3-4x/month
PEF/FEV1 >80% of predicted value, variability 20-30%
Moderate persistent - Step 3
Daily symptoms; nocturnal symptoms more than 1x/week but not nightly
PEF/FEV1 >60% but less than 80%; variability >30%
Severe persistent - Step 4
Continual daily symptoms; frequent nocturnal symptoms
PEF/FEV1 <60%; variability >30%
Asthma etiology -
\Allergic triggers: airborne pollens, molds, dust mites, cockroaches, animal dander, food
additives or preservatives, feather pillows
Nonallergic triggers: smoke and other pollutants, viral respiratory infections, medications
(ASA, NSAIDS, Beta blockers), exercise, GERD, emotional factors, menses/pregnancy
Strong history of atopy
