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level: Level 1

Questions and Answers List

level questions: Level 1

QuestionAnswer
LTBI What is the risk of progression and in who?5-10% to active disease, 50% in the first 2 years: Risk of progression highest in: Children < 5, Immunocomprimised, Low BMI, Exposure to Active TB, CKD on dialysis, CXR changes, DM, ETOH, IVDU, Homeless, Smoker, Transplant recipient, Meds: TNF Remicaid.
What is Primary TB infectionLower lobe disease seen in immunocomprimized: 90% goes to LTBI, 10% go to active TB and 5% stays in the lung or disseminates. (military TB)
What is Secondary TB?Reactivation or new exposure. Upper lobe disease. Presents with constitutional sx: fever, night sweats, wt. loss, cough, pleuritic CP, and hemoptysis. Seen in immunocomprimized.
Where does extra pulmonary TB manifest?Lymph nodes: 35% supraclavicular and post. cervial, painless and contender. GU: Uriary sx and cx neg pyuria, infertility due to genital organ involvement, Bone: Vertebral column (pott's dz), GI: ileum and cecum, Heart: constrictive pericarditis.
Who do you screen for TB?Close contacts, HIV, Healthcare workers, Homeless,Immigrants < 5 yr, IVDU, prisoners and residents of NH.
How do you screen for TBPPD: > 5 induration for HIV, Fibrotic changes on CXR, Recent contact with active case or immunocompromised. > 15 if no risk factors, and > 10 for all others and IGRA ( Interferron Gamma Release Assay) or Quantiferon TB Gold and TSPOT. Use this assay for pt who will not show for f/u. and for hx of BCG vaccine.
What is the next step in evaluation a + PPD?Sputum x 3 ( 8-24 hours apart including am sample) for AFB smears and culture on each. NAAT done through Washington State Public Health Lab. or Expert testing on sputum X 2. ( this also give you rifampin resistance and done in few hours) Also check labs: baseline LFT, HIV, Hep panel. CXR with AP view.
How do you treat LTBI4 I's ( Isolation: at night and children < 4), ( intensive case finding-look for contacts), Immunization ( BCG), INH (90% effective) Qd or bid x 9-12 mo., 6 mo is 60% effective, or INH Rifampin once a week DOT x 3 mo 60% effective.
How do you screen close contacts of active cases?Check PPD and again in 10 wks.
How do you treat active TBNever begin treatment until active disease is r/o. Anything other than 7 days/ wk should by DOT by healthcare provider. DOT RIPE: Rifampin, INH, PZA, and Ethambutol x 2 mo, then INH and Rifampin x 4 mo. Repeat CXR at the end of treatment. If clear, then completely treated.
How do you monitor treatment?Monitor monthly for clinical eval, culture and smears and side effects of medication., sx: anorexia n/v, dark urine, icterus, rash, parenthesis, fatigue, weakness, fever and RUQ pain, monthly LFT and CBC,
What are the side effects of Rifampin?Hepatitis, thrombocytopenia, drug to drug interaction, colors secretions red. Stop treatment if LFT > 3x normal and symptomatic or > 5x normal and asymptomatic.
What are the side effects of INH?Hepatitis, peripheral neuropathy prevented by taking B6 pyridoxine.
What are the side effects of PZA?High UA levels with possible gout exacerbation
What are the side effects of ethambutol?Optic neuritis.
How do you dx active TB?CXR, 3 sputum samples for NAA, AFB and smear and cx.. If active TB confirmed, susceptibility testing for first line drugs should be done.
CAP Diagnostic criteriaNew infiltrate on CXR, Temp > 38, WBC > 10 or bands > 15%. Sx of cough , dyspnea, RR> 30, hypoxia w/ sat < 90 and ascultatory findings.
CURB 65 management of CAPConfusion, BUN > 20, RR > 30, BP < 90/60, Age >65
CAP no comorbidities treatmentAzithromycin or Doxycycline
cap with comorbidities treatmentHigh dose Amox or Augmentin +Azithromycin or Doxy OR respiratory FQ ( levaquin or moxifloxacin) Treat for 5-10 days