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66 Cards in this Set
- Front
- Back
Four hallmark symptoms of asthma |
Recurrent wheezing |
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Characteristic timing of symptoms that suggests asthma:
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Cough at night |
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A worsening of asthma symptoms may be seen after:
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Viral illness.
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What is necessary to make the diagnosis of asthma:
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Spirometry.
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When is peak flow metering done re: asthma?
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For monitoring, not for diagnosis.
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What is the cornerstone of asthma therapy?
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Inhaled Corticosteroids (ICS). This is the best choice for controller therapy and is needed for all but the mildest asthma.
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What are three classes of medications used in asthma for their anti-inflammatory properties?
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Inhaled corticosteroids (ICSs)
leukotriene antagonists (LTRAs) Mast Cell stabilizers |
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How much of an ICS dose is absorbed systemically?
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20%
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why is montelukast superior to zafirlukast?
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montelukast is not an CYP inhibitor. Zafirlukast is.
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What are three classes of medications used in asthma for their bronchodilating properties?
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Beta-2 agonists
Anticholinergics Theophylline |
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Mechanism of action of theophylline.
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Bronchodilator. Prevents the breakdown of cAMP (which causes bronchial relaxation) by phosphodiesterase. AKA phopsphodiesterase inhibitor. |
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What are two methylxanthine bronchodilators?
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theophylline (PO)
aminophylline (IV) |
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Facts to know about theophylline prescribing.
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Different preparations are NOT interchangeable mg to mg. |
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Clinical uses of anticholinergics (ipratropium and tiotropium)
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Maintenance therapy in COPD. |
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Clinical use of LABAs
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Not to be used as monotherapy. Can be used in combination with ICS for long-term control of asthma symptoms.
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Rationale for tapering corticosteroid dose:
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Long-term use causing adrenal insufficiency.
Expect cause of inflammation to return. |
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What type of gastric problem is caused by long term corticosteroid use?
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Gastric ulcer
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Is there evidence to support tapering PO CS dose after asthma flare?
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No
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Which of the following is not consistent with the diagnosis of asthma:
a) troublesome nocturnal cough b) cough or wheeze after exercise c) morning sputum production d) colds "go to my chest" or take more than 10 days to clear. |
c) morning sputum production
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How long does it take for clinical effects to be seen from ICS or LTRA therapy?
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1-2 weeks. |
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About prescribing omalizumab
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It can be used in asthma that is uncontrolled on optimized conventional therapy. Requires specialty consult.
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Assessment of asthma symptoms.
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Assess based on last 4 weeks. Severity is based on most bothersome symptom.
Inquire about: Symptom frequency SABA frequency nighttime symptom frequency |
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What is a normal FEV1/FVC?
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70-85%, depending on age. A decrease is seen with aging.
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What are criteria for well-controlled asthma or asthma that is intermittent and does not require controller therapy?
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Symptoms <=2 days/week
SABA use <=2 days/week nighttime awakenings <=2/month no interference with normal activity FEV1>80% predicted FEV1/FVC normal 0-1 exacerbation with oral CS/year |
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Outline asthma controller therapy.
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For intermittent asthma, none needed. |
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T/F: all patients with asthma should have a SABA inhaler.
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True.
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Name two LABAs
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salmeterol
formoterol |
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Name 3 SABAs.
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albuterol |
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Management of an asthma flare.
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Oral prednisone at 40-60 mg/day for 5-7 days.
Increased use of rescue therapy. |
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most common severity of asthma seen in clinical practice
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Moderate severe: daily symptoms, daily SABA use, nighttime symptoms >1/week but not nightly and about 2 exacerbations/year.
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Findings on exam during an acute asthma or COPD flare:
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Hyperresonance from air trapping
Decreased tactile fremitus Wheeze (expiratory leading to inspiratory) |
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What is PEF
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Peak Expiratory flow. This is measured by a peak flow meter and is used for monitoring.
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In well-controlled or intermittent asthma, PEF should be
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>80% normal.
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Most common reason for an asthma flare:
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URI. |
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Is asthma a reason to limit physical activity?
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No.
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What are the pulmonary symptoms characteristic of COPD?
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Shortness of breath |
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What are non-pharmacologic measured to be encouraged in all patients with COPD:
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SMOKING CESSATION
Avoidance of noxious agents, reduction of indoor pollution, reduction of occupational irritant exposure Influenza vaccine annually Pneumococcal vaccine as needed |
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What is considered diagnostic of COPD?
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FEV1/FVC<70% by spirometry.
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About FEV1 in diagnosing COPD.
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FEV1 is usually reduced as the disease progresses, but may be normal in early stages.
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What interventions are used for all severities of COPD?
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Risk reduction
Influenza Vaccination SABA inhalers for PRN use |
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Criteria for round-the clock treatment in COPD.
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Moderate COPD defined as:
FEV1/FVC<70% and FEV1=50-80% of predicted. |
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Initial round-the clock management of COPD:
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LABA, or an anticholinergic, or both
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Indication to add ICS to initial COPD management:
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More than 3 exacerbations in 3 years.
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ID this common trade name drug: Spiriva
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tiotropium, an anticholinergic inhaler used for COPD management.
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Identify this brand name medication used in COPD maintenance: Advair HFA
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LABA and ICS combo inhaler |
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Identify this brand name medication used in COPD maintenance: Symbacort
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LABA and ICS comb inhaler
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Identify this brand name medication used in COPD maintenance: Combivent
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ipratropium bromide and albuterol (anticholinergic + SABA)
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Ipratropium bromide, when used in COPD provides which therapeutic effect:
a) increased mucociliary clearnace b) reduced alveolar volume c) broncodilation d) mucolytic action |
c) bronchodilation
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COPD encompasses these two conditions
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Chronic bronchitis
Emphysema |
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How is chronic bronchitis diagnosed?
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Clinically by:
Excess mucus for 3 or more months/year for 2 consecutive years in the absence of other causes. |
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What is the pathophysiology of emphysema?
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Enlargement of airspaces distal to the terminal bronchiole.
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According to GOLD COPD guidelines, what medication is indicated for stages I to IV?
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A SABA inhaler for PRN use.
Note, Stage II is mild disease that does not require controller therapy |
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What is the most appropriate antibiotic therapy for COPD exacerbation in a patient that failed initial treatment?
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A respiratory fluroquinolone.
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What is the best ABX choice for a 52 year old man with an acute exacerbation of Stage II COPD?
a) azithromycin b) amoxicillin c) TMP/SMX d) levofloxacin |
a) azithromycin
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What are indications that antibiotic therapy may be needed in COPD flare?
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Change in purulence or quantity of sputum.
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Four components of the diagnosis of inhalation anthrax:
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Dry Cough
Fever Malaise Widened mediastinum on CXR |
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What is the goal of oxygen therapy in COPD?
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To ensure adequate oxygenation of vital organs as evidenced by SpO2 of >=90% or PaO2 >=60 mmHg.
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Instructions on using oxygen at home.
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Use for at least 15 hours/day, NOT just in response to dyspnea.
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Definition of an exacerbation of COPD.
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Change in a patient's baseline dyspnea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in management.
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Treatment of COPD exacerbation:
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Use SABA PRN. Add LABA and/or anticholniergic if needed.
Add oral prednisone if FEV1<50% predicted. Consider ICS in non-acidotic exacerbations. |
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Indications for CXR in COPD exacerbation:
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The presence of fever or low SpO2.
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Three most common bacterial agents in COPD exacerbation:
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S. pneumo
H. influenzae M. catarrhalis |
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Atypicals (M. and C. pneumo, legionella) are associated with what percentage of bacterial COPD flares?
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10%
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Best antibiotic choice for mild or moderate COPD flare:
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Doxycycline, which covers DRSP and atypicals.
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Best antibiotic choices for severe COPD flare:
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Azithromycin or Fluoroquinolone
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If a patient reports orthopnea as part of a pulm problem, what should you consider.
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90% of orthopnea is cardiac in origin.
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