CFPC 2027 - Pneumo

In a presentation of pharyngitis, look for _________

mono

Dangerous conditions with dysphagia

• Submandibular space infections (Ludwig's angina - woody induration, crepitus)

• Primary HIV (mucocutaneous ulcerations)

• Peritonsillar abscess (trismus)

• Epiglottitis (out of proportion to findings on exam)

• Retropharyngeal space infection

CENTOR strep test

Strep throat tx

Seasonal influenza tx

oseltamivir (Tamiflu) 75mg PO BID x 5d

efficient if < 48h of illness

Bacterial sinusitis sx

• Symptômes persistants (de 10 à 14 jours) sans amélioration

• Aggravation des symptômes après 5 à 7 jours suivant une amélioration initiale (infection biphasique)

Bacterial sinusitis tx

Chronic rhinosinusitis def

Inflammation in paranasal sinuses and nasal passages >12 weeks despite medical treatment

Chronic rhinosinusitis tx

• Prednisone 20mg PO BID x 5d, then 20mg daily x 5 days (total 10 days)

• Amoxicillin-clavulanate 875mg PO BID or Clindamycin 450 mg PO TID

• Topical glucocorticoid spray and intranasal saline irrigation or sprays

In pediatric patients with a persistent (or recurrent) cough, generate a broad differential diagnosis

gastroesophageal reflux disease [GERD], asthma, rhinitis, presence of a foreign body, pertussis

For chronic cough, if CXR N, no ACE-i, no exposure to irritants, what dx to consider

UACS (upper airway cough syndrome, aka post nasal drip)

Asthma

GERD

For chronic cough, if all failed what other management to consider

speech pathology treatment

Neuromodulating medication

• Gabapentin (300-1800mg daily x 10w), Pregabalin 300mg PO daily x4w

CT scan if suspect lung cancer, bronchiectasis or ILD

Referral to specialty

In patients with a persistent (e.g., for weeks) cough, consider non-pulmonary causes

GERD, congestive heart failure, rhinitis

In patients presenting with an acute cough, include serious causes

pneumothorax, pulmonary embolism

Regardless of where you assess the patient who presents with shortness of breath (e.g., office, home visit) consider life-threatening conditions

pulmonary embolus, foreign body aspiration in a child, anaphylaxis, myocardial infarction

When a patient with a diagnosed cause of dyspnea presents with worsening symptoms or treatment failure, what factors to consider

new pets, environmental factors, medication technique/adherence, dietary changes

Asbestosis imagery findings

RXP: atteinte des bases, plaques pleurales.

CT thorax: honeycombing

Sarcoidose sx

fever, polyarthralgia, erythema nodosum, dry cough, dyspnoea, fatigue and weight loss

Sarcoidose tests (important one)

-Hypercalcémie

-RXP: bilateral hilar lymphadenopathy

-Bx: non caseating granuloma

-Lavage boncho-alveolaire: raised lymphocytes

Sarcoidosis tx

1. CS

2. Immunosuppressants

3. Agents biologiques

Ddx hemoptysie

Maladie interstitielle pulmonaire étiologies

-FPI

-Pneumonite hypersensitivité (poumon du fermier)

-Sarcoidose (granulomes non caseux)

-Asbestosis

-Autres: infx, rx (amiodarone), radiotx, rhumato

SAHS (STOP BANG)

Snore

Tired

Observed stop breathing

HTA
BMI > 35

Age > 50

Neck circumference > 40

Gender (M)

PNTX tx

Tension: décompression par aiguille ou drain.

Embolie pulmonaire tx

Anticoagulation (HBPM ou ACOD) + O2

Massive EP: thrombolyse (alteplase IV)

Long terme: x 3 mois (provoqué), > 3-6 mois (non provoqué)

HT pulmonaire def et test gold standard

Pulmonary arterial pressure over 25mmHg

GS: Right heart catheterisation

Sx cutané de tuberculose

Érythème noueux

qSOFA criteria

AMS (GCS <15)

RR >22

Hypotension (<100 systolic)

CURB-65 criteria

Confusion

Urea >7

Respiratory Rate >30

Blood pressure (<100 systolic / <60 diastolic)

>65 y.o.

Treatment for croup

Viral infx so nebulised corticosteroids

Barking cough in child dx?

Croup (viral infx)

LIGHT criteria for exsudate vs transsudate

⅔ indicates exsudat:
1- Pleural LDH/ serum LDH >0.6
2- Pleural/Serum protein >0.5
3- Pleural LDH> 2/3 higher normal value of Serum LDH

**bonus: si ph < 7.2 = infx

COPD dx

Spirometry FEV1/FVC <0.70 post-bronchodilator 

Grade

• Mild = FEV1>80% predicted

• Moderate = 50-80%

• Severe = 30 to <50%

• Very Severe <30%

screen alpha-1 antitrypsin deficiency (1 x in life)

COPD treatments by group and classification

Group A: Low Sx and No hospitalisations → LABA or LAMA

B: High Sx but no Hospit → LABA + LAMA

E: Hospitalised ≥1 time → LABA + LAMA + ICS (if Eos>300, ≥ 2 COPDE/yr, asthma)

Non pharmaco COPD tx

Pulmonary rehab (refer respiratory technician or pulmonary rehabilitation personnel)

O2 therapy (PaO2 <55mmHg, SaO2<88%)

CPAP if chronic hypercapnia or OSA

Vaccine (flu + pneumocoque)

Action plan

Smoking cessation

COPDE tx

Non invasive ventilation

SABA (eg. 4-8 puffs inhaled q20mins up to 4h then q1-4h PRN) +/- LAMA

Atbx

• Simple: azithro 500 day 1 then 250 × 4d (or amox 500 tid x 7d)

• Complicated (> 3 COPDE/yr, comorbidities, etc): moxifoloxacin 400 × 5d

Pred 40 die x 5d

Severe: Magnesium sulfate 2g IV over 20 minutes

When treating patients with COPDE what is important to rule out?

MI, CHF, systemic infections, anemia

What is a secondary effect of amiodarone?

Pulmonary fibrosis

Asthma diagnosis in adults

FEV1/FVC (<0.75-0.8 in adults and <0.9 for children) AND Post-bronchodilator reversiblity increase in FEV1 >12% (minimum of 200mL in adults) 

Asthma diagnosis in children (1-5)

1. Documentation of airflow obstruction (eg. wheezing or other symptom)

2. Documentation of reversibility of airflow obstruction (eg. improved with SABA  ± oral corticosteroids)

3. No clinical evidence of an alternative diagnosis

Signs of poor asthma control

• Daytime sx > 2/week

• Night-time waking due to asthma

• Reliever use >2/week

• Activity limitation due to asthma

Uncontrolled if 3-4

Treatments for Asthma in adults

Tx of asthma in children < 12

Non pharmaco for asthma tx or control

• Smoking cessation

• Healthy diet

• Weight reduction

• Breathing exercises

• Dealing with emotional stress

• Swimming in young people with asthma

• Vaccinations (influenza)

• Avoid indoor/outdoor allergens

• Avoid occupational exposures/allergens 

• Caution with medications that could worsen asthma (NSAIDs, BB)

Management asthma exacerbation in primary care

Treatments for Embolism/DVT

1- Observe → Si stable et PESI 0 → ACOD/warfarin et congé

2- If unstable → Oxygen >90% + HBPM SC > HNF > ACOD Xa

3- tPA si Embolie massive, peu fréquent

4- Anticoagulation long terme

Long term anticoagulation

Latent TB tx

Three months of isoniazid, pyridoxine and rifampicin

Six months of isoniazid and pyridoxine

Pneumonia pathogens

PAC: s. pneumoniae, m. catarrhalis, h. influenza.

Atypique: legionella, mycoplasma pneumoniae.

Nosocomiale (>48 hours after admission): p. aeruginosa, s. aureus

What are unusual pneumonia infx risk factors?

history of tuberculosis, exposure to birds, travel, HIV infection, aspiration

What are significant findings for bacterial pneumonia?

Acute onset + age > 65

Ways to prevent pneumonia

flu vaccine, Pneumovax, ribavarine

Pneumonia tx

Pneumocystis Pneumonia (PCP) def

Fungal infx Pneumocystis Jirovecii that affects immunocompromised patients

PCP tests

Gaz arteriel (sévérité)

culture expecto: silver staining (mexican hat), r/o TB

FSC, CRP, VIH

RXP: infiltrats hilaires bilat.

CT PRN

LBA, broncho si culture -

PCP tx

TMP SMX ± CS si sévère (gr. A-a < 70)

DDx des maladies interstitielles?