Primary Care Airway Obstruction

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    Primary Care:Primary Care:

    Respiratory TractRespiratory TractInfections andInfections and

    AsthmaAsthma

    Tamra N. Fortenberry, MD

    Department of Ob/Gyn

    The University of Tennessee

    Memphis, TN

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    Objectives - Respiratory

    Tract Infections1. List the differential diagnosis for

    respiratory tract infection.

    2. Obtain a pertinent history in a patientwith a suspected respiratory tract

    infection.

    3. Describe the usual symptoms and signs

    of respiratory tract infection.4. Perform a targeted physical

    examination to confirm the diagnosis of

    respiratory tract infection.

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    Objectives Respiratory

    Tract Infections5. Interpret selected tests to diagnose

    respiratory tract infection:

    a. Chest X-ray

    b. Sputum Gram stain and culture

    c. Tuberculin skin test

    d. Serologic tests for viral orbacterial infection

    e. Pulse Oximetry

    6. Treat uncomplicated respiratory tractinfections.

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    DifferentialDiagnosis

    for Respiratory TractInfections Upper respiratory infection (URI)

    Viral Rhinitis (Common cold)

    Sinusitis Pharyngitis

    Influenza

    Pneumonia

    Bronchitis Tuberculosis

    Asthma

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    The Common Cold An estimated 2 of every 5

    Americans are affected each year

    Some experience multipleepisodes in 1 year

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    The Common Cold Rhinoviruses are the most

    common viral agents

    Over 100 serotypes have beenimplicated

    Other viruses implicated included

    coronaviruses, influenza C,

    parainfluenza virus, adenoviruses,

    and respiratory syncytial virus

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    The Common Cold No specific virus can be identified

    in 50% of the cases

    Highly contagious, respiratorydroplets spread by sneezing,

    coughing, or hand contact with the

    nose, eyes, or face

    75% of patients infected with

    rhinovirus will have symptoms

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    The Common Cold Is not caused by a change in

    weather, loss of sleep, going

    outside with wet hair, or fatigue Risks for contracting a cold are

    due to exposure to the causative

    viruses through personal contact

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    The Common ColdSigns and symptoms

    Has an incubation period of 2 4

    days

    Thereafter, sneezing, coughing,

    malaise may last from 6 10 days

    or possibly up to 3 weeks after

    incubation period

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    The Common ColdSigns and symptoms

    Patient may complain of

    headache, nasal congestion, andscratchy throat

    Subsequently, may complain of

    sneezing and clear, watery

    rhinorrhea in association with nasal

    obstruction with general malaise

    but no fever

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    The Common ColdSigns and Symptoms

    After 2 3 days, nasal discharge

    becomes thicker, cloudy, andyellowish in color as systemic

    symptoms improve

    Hoarseness, cough, and sore

    throat may last up to 7 10 days

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    The Common ColdDiagnosis

    Made on clinical grounds pt symptoms,

    nasal exam showing reddened,edematous mucosa, narrowed nasal

    passages, and watery discharge

    Laboratory and/or imaging only indicated

    if other conditions are strongly suspected

    Viral isolation/culture is not practical

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    The Common ColdManagement/Treatment

    No curative treatment

    Supportive therapy 10

    treatment Fluids, rest, humidification, and

    decongestants

    Analgesics, cough suppressants,mucolytics, and antihistamines are also

    helpful Short term use of zinc lozenges (zinc

    gluconate 10-15 mg q 2 hrs) shown toreduce duration of subjective symptomsif begun early in course of disease

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    The Common Cold Inappropriate prescribing of antibiotics is

    common

    Due to patient beliefs/misinformation of

    cold being bacterial in origin

    Rural location

    Female gender

    Patients with purulent secretions

    Antibiotics should be considered ifsymptoms last longer than 10-14 days,due to an 80% chance of a secondaryinfection occurring

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    S

    inusitis Over 35 million people in the US

    are affected each year

    Causative agents are usuallynormal inhabitants of therespiratory tract

    Hemophilus influenzae and

    Streptococcus pneumoniae are themost common causes

    Viral and fungal agents are rare

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    Sinusitis

    Signs and symptoms

    Patient may complain of a feeling of

    fullness and pressure over the involvedsinuses, nasal congestion, and purulent

    nasal discharge

    Other associated symptoms include sore

    throat, malaise, low grade fever,

    headache, toothache, cough >1 weeks

    duration

    Symptoms may last 10 14 days

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    Sinusitis

    As part of the history, the physician

    may inquire about the following:

    Are symptoms exacerbated bypositional changes, preceded by

    air travel, URI, or seasonal

    allergies?

    Exposure to tobacco smoke, coldor damp weather, pollution?

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    SinusitisDiagnosis

    Based on clinical signs and symptoms

    Physical exam may reveal patient

    described symptoms palpate oversinuses, observe for structuralabnormalities such a deviated nasalseptum

    Sinus radiographs may reveal cloudiness

    and air fluid levels Limited coronal CT are more sensitive to

    inflammatory changes and bonedestruction

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    Sinusitis

    Management/Treatment

    2/3 of untreated patients will improvesymptomatically within 2 weeks

    Antibiotics may be appropriate in certainpatients

    Amoxicillin (500mg TID) or Trimethoprim-sulfamethoxazole (1 double strengthtablet BID) for 10 days, or up to 21 days

    Alternative antibiotic therapy shouldinclude drugs with activity against betalactamase-producing bacteria

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    Sinusitis

    Supportive therapy such as

    humidification, antihistamines,

    analgesics, and/or vasoconstrictorsmay relieve congestion and

    fullness

    OTC decongestant sprays for use

    of more than 5 days durationshould be discouraged

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    Pharyngitis

    Fewer than 25% of patients with a

    sore throat have true pharyngitis

    Primarily seen in 5 18 year oldpopulation, it is common in adult

    women

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    Pharyngitis

    May be of bacterial or viral origin

    Most common cause is viral; most

    common agent is rhinovirus Self-limiting; usually lasts 3-4 days

    Group A, beta-hemolytic strep is the

    primary bacterial pathogen, in 1/3 cases

    - early detection reduces incidence of

    acute rheumatic fever and post

    streptococcal pharyngitis

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    Pharyngitis

    Signs and symptoms

    Inflammation of the pharynx andlymphoid tissue results in fever, sorethroat, malaise, and rhinorrhea

    There is usually a lack of cough

    Classic triad of findings for Group A streppharyngitis include:

    High fever Tonsillar exudates

    Anterior cervical adenopathy (in absenceof significant cough)

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    Pharyngitis

    Diagnosis

    On PE: observe throat for tonsillar

    exudates; obtain throat swab Rapid streptococcal identification

    tests are most commonly used;there is a sensitivity of 80% and a

    specificity of 95% Throat cultures may be collected if

    rapid strep screen is negative

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    Pharyngitis

    Management/Treatment

    Symptomatic treatment includes salt-water gargles, acetaminophen, cool-misthumidification, and throat lozenges

    Antibiotics treatment is necessary totreat proven strep infections

    Benzathine penicillin G 1.2 million unitsas a single dose, is optimal therapy

    For pen allergic pts, erythromycin500mg po QID x 10 days or Azithromycin500mg once daily x 3 days.

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