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Chapter 3

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Common Respiratory Disorders in Primary Care © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION

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Joanne L. Thanavaro © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Chapter Outline

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D. Guidelines to direct care: Global Initiative for Asthma 2015 and National Heart Lung and Blood Institute (NHLBI) GuideA. History and Physical Exam (EPR-3) © Jones & Bartlett Learning, LLClines for the Diagnosis and Management © Jonesof&Asthma Bartlett Learning, LLC B. Recommended Lab/Diagnostics E. Treatment Plan NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION C. Pathophysiology D. Guidelines to direct care: Prevention and control of seasonal Case 4 - Chronic Obstructive Pulmonary influenza with vaccines: recommendation of the Advisory Disease (COPD) Committee on Immunization Practices (ACIP) © Jones & Bartlett Learning, LLC A. History © andJones Physical Exam E. Treatment Plan& Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION B. Recommended abs/Diagnostics C. Pathophysiology Case 2 - Acute Bronchitis D. Guidelines to direct care: Global Initiative for Chronic A. History and Physical Exam Obstructive Lung Disease (2015) Recommended Labs/Diagnostics © Jones &B.Bartlett Learning, LLC © Jones & Bartlett E. Treatment Plan Learning, LLC C. Pathophysiology NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION D. Guidelines to direct care: Chronic Cough Due to Acute Case 5 - Community-Acquired Pneumonia (CAP) Bronchitis: American College of Chest Physicians (ACCP) A. History and Physical Exam Evidence-Based Clinical Practice Guidelines B. Recommended Labs/Diagnostics E. Treatment Plan © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC C. Pathophysiology NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION D. Guidelines to direct care: Infectious Diseases Society of Case 3 - Asthma America/American Thoracic Society Consensus Guidelines A. History and Physical Exam on the Management of Community-Acquired Pneumonia B. Recommended Labs/Diagnostics in Adults © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC C. Pathophysiology E. Treatment Plan

Case 1 - Influenza

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CHAPTER 3

| Common Respiratory Disorders in Primary Care

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Learning Objectives

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3. State pathophysiology of common pulmonary disorders. 4. Document a clear, concise SOAP note for patients with com1. Identify key history and physical examination parameters for © Jones & Bartlett Learning, LLCmon pulmonary disorders. © Jones & Bartlett Learning, LLC common pulmonary disorders seen in primary care includFOR SALE DISTRIBUTION NOT FOR SALE OR ing influenza, acute bronchitis, asthma, COPD, andDISTRIBUTION CAP. 5. Identify relevant educationNOT and counseling strategiesOR for patients with common pulmonary disorders. 2. Summarize recommended laboratory and diagnostic studies indicated for the evaluation of common pulmonary disorders 6. Develop a treatment plan for common pulmonary disorders seen in primary care. utilizing current evidence-based guidelines.

Using a case-based approach, the learner will be able to:

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Case 1 Mrs. Cleaver is a 48-year-old female who comes to the office accomRunny nose © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC panied by her husband. She’s complaining of fatigue, fever, and chills Nasal congestion NOT FORforSALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the last 2 days. She recently returned home from California where

Muscle or body aches she was taking care of her three grandchildren for the last 3 weeks. She Headaches reports that the kids all had “colds” but got better without treatment. Fatigue Her past medical history (PMH) is remarkable for idiopathic cardioVomiting and diarrhea (more common in children) myopathy, diabetes mellitus 2, and & hypertension. is a non©type Jones BartlettShe Learning, LLC © Jones & Bartlett Learning, LLC smoker and nondrinker. She has not been able to exercise since she NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Physical Exam returned home because of her extreme tiredness. Her medications For patients with comorbid conditions, be sure to evaluate for any include: carvedilol 6.25 BID, lisinopril 20 mg, and aldactone 25 mg worsening of underlying conditions. In this patient, it is important daily. She planned to get her influenza vaccine sometime next week. not only to rule out pneumonia but also to evaluate for heart failPhysical Exam ure and uncontrolled diabetes.

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VitalNOT Signs:FOR Blood SALE pressure (BP) heart rate (HR) 65, OR 126/76, DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Routine Labs/Diagnostics respiratory rate (RR) 12, temperature (T) 99.8. General (GEN): No acute distress Ñ The Centers for Disease Control and Prevention (CDC), World Health organization (WHO), and Infectious Disease Eyes, ears, nose, and throat (EENT): Pharyngeal redness without exuSociety of America recommend that healthcare providers didates. Tympanic membranes (TMs) without bulging or fluid lines influenza clinically. © Jones &Heart: Bartlett LLC © Jonesagnose & Bartlett Learning, LLC S1 and Learning, S2 regular rate and rhythm (RRR) with pansystolic Testing is recommended for: Ñ murmur along the left sternal border NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ñ Hospitalized patients with influenza-like illnesses Lungs: Clear to auscultation Ñ Patients who died of an influenza-like illness (to clarify Abdomen: Soft, nontender with good bowel sounds etiology) What additional assessments/diagnostics do you need? Ñ Patients for whom decisions about infection control and ©diagnoses Jones list? & Bartlett Learning, LLC treatment of close contacts © isJones &1–3Bartlett Learning, LLC What is the differential a concern NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION What is your working NOT diagnosis? tests are approximately Ñ Sensitivities of rapid diagnostic 50–70% when compared with viral culture or reverse tranAdditional Assessments/Diagnostics scription polymerase chain reaction (RT-PCR); specificities of rapid diagnostic tests for influenza are appropriately Needed 90–95%. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Ñ False-positive (and true-negative) results occur more freReview of Systems NOT FOR SALE (ROS) OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION quently when disease prevalence in the community is low, Ask about common signs and symptoms of influenza, including: usually at the beginning and end of the flu season. Fever/chills Ñ False-negative (and true-positive) results occur more freCough quently when disease prevalence is high in the community, throat Learning, LLC is usually atLearning, the height of the flu season.4 © Jones &Sore Bartlett © Joneswhich & Bartlett LLC

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Case 1

© Jones & Bartlett Learning, LLC Differential Diagnoses List NOT FOR SALE OR DISTRIBUTION Upper respiratory tract infection Influenza

© Jones & Bartlett Learning, LLC Ñ Can lessen symptoms and reduce duration of symptoms NOT FOR SALE OR DISTRIBUTION Ñ

Ñ Working Diagnosis—Influenza © Jones & Bartlett Learning, LLC

by 1–2 days Can prevent serious flu-related complications for people with high-risk health conditions Side effects include nausea, vomiting, diarrhea, dizziness, cough, and headache6 © Jones & Bartlett Learning,

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Pathophysiology

35

Nonpharmacologic

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Influenza is a contagious respiratory illness caused by the inÑ Drink plenty of liquids—choose water, juice, and warm fluenza viruses that infect the nose, throat, and lungs. Viruses soups to prevent dehydration. Drink enough liquid so that spread mainly by droplets when people cough, sneeze, or talk. your urine is pale yellow or clear. © Jonesof & Bartlett Learning, © Jones & Bartlett Learning, LLC Contagiousness influenza occurs 1 day beforeLLC symptoms to Ñ Rest. 5–7 days afterFOR illness.SALE These viruses are unpredictable, and their NOT OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ñ Consider pain relievers such as Tylenol (acetaminophen) or severity can vary widely from season to season. Older people; ibuprofen to help with body aches.7 children; pregnant women; people with asthma, chronic obstructive pulmonary disease (COPD), diabetes, or heart, kidney, Education/Counseling or neurologic disease; and people with weakened immune sys© Jones & Bartlett Learning, LLC steroid use) are at greater © Jones & best Bartlett Learning, tems (HIV, AIDS, cancer, or chronic way to prevent influenzaLLC is to get a flu vaccine every Ñ The for serious Complications of flu include bacseason. NOT FORrisk SALE ORcomplications. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION terial pneumonia, sinus infections, dehydration, worsening of Ñ Yearly flu vaccination is ideally by October. chronic medical conditions, and death.5 Ñ It takes 2 weeks after vaccination for antibodies to develop that protect against infection. older should get a flu vaccine Ñ Everyone 6 months of age and © Jones Plan? & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC What Is Your Treatment every year. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ñ Reinforce that you can’t get the flu from a flu shot. Pharmacologic Ñ Side effects that can occur include soreness, redness, or swellÑ Annual flu vaccines ing at the injection site, low-grade fever, and body aches. Lifethreatening allergic reactions are very rare and may include Ñ Trivalent flu vaccine—protects against two influenza A vibreathing hoarseness, wheezing, hives, tachycar© Jones & Bartlett Learning, LLC B virus. © problems, Jones & Bartlett Learning, LLC ruses (an H1N1 and an H3N2) and an influenza dia, or dizziness. These reactions occur among persons with a Available vaccines include:OR DISTRIBUTION NOT FOR SALE NOT FOR SALE OR DISTRIBUTION severe allergy to eggs and usually occur within a few minutes Ñ Standard-dose trivalent shots (IIV3) that are manufacto a few hours after administration.7 tured using virus grown in eggs Ñ Intradermal trivalent shot—approved for people 18 SOAP Note through 64 years of age © Jones & Bartlett Learning, LLC © Jones & Cleaver Bartlett Learning, S: Mrs. presents today with aLLC 2-day history of fatigue, feÑ High-dose trivalent shot—approved for people 65 years ver, SALE and chills.OR She DISTRIBUTION recently returned home from babysitting NOT FOR SALE NOT FOR andOR olderDISTRIBUTION her grandchildren, who all had “colds.” She has a sore throat, Ñ Trivalent shot containing virus grown in cell culture— nasal congestion, and a mild headache. She denies cough, approved for people 18 years and older vomiting, diarrhea, chest pain, shortness of breath (SOB), Ñ Recombinant trivalent shot that is egg free—approved for ankle swelling, or lightheadedness. Her blood sugars have people 18 years and © older Jones & Bartlett Learning, LLCbeen slightly elevated from©herJones & Bartlett Learning, LLC normal fasting blood sugar against two influenza Ñ Quadrivalent flu vaccine—protects NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (FBS) range of 130–140, and she continues to eat and drink A viruses and two influenza B viruses. Available vaccines without difficulty. She has continued all her regular medicainclude: tions. She has not had her annual flu vaccine yet. Ñ Quadrivalent flu shot O: Vital Signs: BP 126/76, HR 65, RR 12, T 99.8 Ñ Quadrivalent nasal spray—approved for people 2 through GEN: No acute distress & Bartlett Learning, LLC © 49 Jones © Jones years of& ageBartlett Learning, LLC EENT: No redness or crusting of eyes. TMs without bulging or NOT FOR NOT FOR SALE OR DISTRIBUTION drugs SALE OR DISTRIBUTION Ñ Antiviral fluid lines in bilateral ears. Pharyngeal redness without exuÑ Two antiviral drugs recommended by the CDC dates. No thyromegaly or carotid bruits Ü Oseltamivir (Tamiflu) and Zanamir (Relenza) Heart: S1 and S2 RRR with pansystolic murmur along the left Ñ If used, should be started within 2 days of initial symptoms sternal border unchanged from previous exam. Point of maxiand taken for at least 5 days (PMI)Learning, minimally displaced © Jones & Bartlett Learning, LLC © Jonesmal&impact Bartlett LLC laterally

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Lungs: Clear to auscultation. No crackles, fremitus, or egophDrink plenty OR of fluids. Tylenol (acetaminophen) for muscle NOT FOR SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

ony. No dullness to palpation aches. Monitor blood sugars daily. Continue all other medications as before. Call back if symptoms don’t gradually improve Abdomen: Soft, nontender with good bowel sounds over the next week or if she develops SOB or chest pain or is Extremities: Full range of motion of all extremities. No leg edema. unable to eat or drink. Dorsalis pedis and posterior tibialis pulses +2. No open lesions © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC on feet Health Promotion Issues NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Neuro: Alert and oriented × 3 Recent Labs (1 month ago): Blood urea nitrogen (BUN) 10, Ñ Annual influenza vaccination creatinine (Cr) 0.8, potassium (K) 4.0, hemoglobin A1c 6.0 A: Likely influenza: Day 2 Guidelines to Direct Care Cardiomyopathy: Stable © Jones & Bartlett Learning, LLC Jones for & Bartlett Learning, LLC Advisory © Committee Immunization Practices (ACIP). Diabetes mellitus 2: Controlled NOT FORtype SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ACIP vaccine recommendations. http://www.cdc.gov/ Hypertension (HTN): At Eighth Joint National Committee vaccines/hcp/acip-recs/. Accessed September 16, 2015. ( JNC 8) goals Grohskopf LA, Olsen SJ, Sokolow LZ, et al. Prevention and P: Discussed rationale for use of antivirals, given her PMH control of seasonal influenza with vaccines: recommendaof cardiomyopathy and diabetes mellitus (DM). Oseltamivir tions of the Advisory Committee on Immunization Practices © Jones & Bartlett LLC influenza vaccine today for © Jones(ACIP)—United & Bartlett Learning, 75 mg BIDLearning, × 5 days. Quadrivalent States, 2014–15LLC influenza season. MMWR. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION both patient and husband. Reviewed possible side effects of 2014;63(32):691–697. http://www.cdc.gov/mmwr/preview/ antiviral drug and influenza vaccine. Discussed measures to mmwrhtml/mm6332a3.htm. Accessed September 16, 2015. prevent spread of virus (hand washing, covering sneezes).

Case 2

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Mr. Gretsky is a 60-year-old engineer who comes to the clinic stating he has been feeling terrible for the last 4 days. He reports Jones & Bartlett LLC having©cold symptoms, including aLearning, sore throat, runny nose, body aches,NOT and fatigue. coughOR was initially dry, but now he has FORHis SALE DISTRIBUTION some yellowish sputum. His cough is making it difficult for him to speak and is interfering with his ability to work. Last evening he developed pain in the left side of his chest when he coughs. His PMH is significant only for hypertension. He takes lisinopril 20 mg daily. HeLearning, denies alcohol LLC use and quit smoking 20 years ago. & Bartlett ©

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clinically. Sputum cytology may be helpful if the cough is persistent. Chest X-ray (CXR) should be performed only in patients © examination Jones &isBartlett Learning, whose physical suggestive of pneumonia. LLC NOT FOR SALE OR DISTRIBUTION Differential Diagnosis:

Acute bronchitis Allergic rhinitis Asthma Jones & Bartlett Learning, LLC COPD SALE OR DISTRIBUTION NOT FOR SALE Common cold OR DISTRIBUTION Physical Exam Influenza Vital Signs: BP 140/88, HR 88, RR 14, T 98.1 Congestive heart failure exacerbation HEENT: Mild pharyngeal erythema Gastroesophageal reflux disease Heart: S1 and S2 RRR without gallops, or rubs © Jones &murmurs, Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Occupational exposures Lungs: Clear to auscultation. No dullness to percussion Malignancy NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Abdomen: Soft, nontender with good bowel sounds (BS) What additional assessments/diagnostics do you need? What is the differential diagnoses list? What your working diagnosis? © is Jones & Bartlett Learning, LLC

Working Diagnosis—Acute bronchitis Pathophysiology

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Cough is the most common symptom compelling patients to NOT FOR SALE OR DISTRIBUTION come to the office for treatment. Acute bronchitis is an acute reAdditional Assessments/Diagnostics spiratory infection with a normal chest radiograph that is maniNeeded fested by cough with or without phlegm production that lasts for Acute bronchitis may be suspected in patients with an acute reup to 3 weeks. Because many illnesses also present with a cough, spiratory infection with cough, and the diagnosis can be made this diagnosis can be difficult to distinguish & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC from other illnesses.

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Case 2

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The evaluation of adults with an acute cough illness, or with preÑ Consider a delayed “wait-and-see prescription” for antibiNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

sumptive diagnosis of uncomplicated acute bronchitis, should otics. Instruct patients to not fill prescription until at least focus on ruling out pneumonia. 7–10 days, when symptoms are likely to subside without Chronic bronchitis is defined by a productive cough that treatment. lasts at least 3 months per year for at least 2 consecutive years. Ñ Provide information sheets for symptom management, The presence of purulent sputum is¬ predictiveLearning, of bacte- LLC viral infections and antibiotics, © Jones Bartlett © Jones & Bartlett Learning, LLC and ensuring close follow9 rial infection. Gastroesophageal refluxSALE diseaseOR also DISTRIBUTION causes a up by phone or a scheduled follow-up NOT FORvisit. SALE OR DISTRIBUTION NOT FOR cough but is usually associated with increased symptoms at night, heartburn, and a sour taste in the mouth. More than SOAP Note 90% of cases of acute cough illness are nonbacterial. Viral etiS: Mr. Gretsky is a 60-year-old patient who reports having cold ologies include influenza, parainfluenza, respiratory syncytial symptoms, including a sore throat, runny nose, body aches, virus © (RSV), and adenovirus; agents include Jones & Bartlettbacterial Learning, LLC Borde© Jones & Bartlett Learning, LLC and fatigue for the last 4 days. He developed a cough, which tella, NOT pertussis, Mycoplasma pneumoniae, and Chlamydophila FOR SALE OR DISTRIBUTION NOT FOR SALEof OR DISTRIBUTION now is occasionally productive yellowish sputum. Cough is pneumonia.8 his worse symptom, and it’s making it difficult for him to work. His cough was initially dry, but now he has some yellowish What Is Your Treatment Plan? sputum. He also has left-sided chest pain when he coughs. He Treatment of acute bronchitis is divided into prescribing antibiothad his flu vaccine 1 month ago at his work health clinic. ics Bartlett and symptom management.LLC © Jones & Learning, © Jones & Bartlett Learning, LLC O: Vital Signs: BP 140/88, HR 88, RR 14, T 98.1 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION GEN: No acute distress. Coughing frequently with occasional Pharmacologic 9 yellowish sputum. Antibiotics: EENT: Eyes without redness or crusting. Ears no redness, TMs Ñ Not routinely indicated and should be avoided to minimize normal without bulging or fluid line. Nasal turbinates mildly antibiotic resistance © andJones Clostridium infection. & difficile Bartlett Learning, LLCred with serous drainage. Pharynx © Jones & Bartlett Learning, LLC red with +1 tonsils withtrial of an antitussive medication (such Ñ Guidelines suggest aNOT out exudates. NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION as codeine, dextromethorphan, or hydrocodone) (American Heart: S1 and S2 RRR without murmurs, gallops, or rubs College of Chest Physician [ACCP] Guidelines).10 Lungs: Clear to auscultation. No egophony or fremitus. No dullÑ Although commonly used, expectorants and inhaler medicaness to percussion. No wheezing tions are not recommended for routine use. Abdomen: Soft, nontender with good bowel sounds © Jones inhalers & Bartlett © Jones & Bartlett Learning, LLC may beLearning, beneficial forLLC patients with Ñ Beta-agonist Extremities: No edema wheezing. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A: Acute bronchitis There are no data to support the use of oral corticosteroids. Ñ HTN: At JNC 8 guideline goals Ñ Pelargonium (also known as kalwerbossie, South African Prior smoker geranium, or rabassam) was shown to improve return to P: Discussed the nature of acute bronchitis. Explained that antiwork in patients (2 days earlier) compared to those taking 11 © Jones & Bartlett LLC © Jonesbiotics & Bartlett Learning, LLC even with discolored are not indicated for bronchitis placebo.10,Learning, sputum. GivenOR CDC patient handout on avoidance of antibiNOT FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION Nonpharmacologic otics for viral conditions. Drink plenty of fluids and rest. Tylenol for chest wall pain. Try dark honey for symptom relief. Ñ Drink plenty of fluids Pelargonium may also be used. Congratulate patient for his Ñ Dark honey for symptom relief continued smoking cessation. Given anticipatory guidance © Jones & Bartlett Learning, LLCregarding likelihood of cough © lasting Jones Bartlett Learning, LLC for & another 7–10 days. Education/Counseling FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Call back if symptoms don’tNOT gradually decrease. Ñ Many healthcare providers are reluctant to not prescribe anHealth Promotion Issues tibiotics because it is difficult convincing patients that antibiotics are usually ineffective against acute bronchitis. Ñ Discuss importance of annual influenza vaccine. Ñ Methods for managing patient expectations for medication frequently and practice good hygiene. Ñ Wash hands ©treat Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to acute bronchitis include: NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Guidelines to Direct Care Ñ Define the illness as a “chest cold” or “viral upper respiratory infection.” Braman SS. Chronic cough due to acute bronchitis: ACCP Ñ Instruct patients that symptoms may last about 3 weeks. evidence-based clinical practice guidelines. Chest. 2006; Ñ Explain that antibiotics don’t reduce duration of symp129(1 suppl):95S–103S. http://journal.publications.chestnet toms and may cause side effects or antibiotic resistance. © Jones & Bartlett Learning, LLC © Jones.org/data/Journals/CHEST/22039/95S.pdf & Bartlett Learning, LLC

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Centers for Disease Control and Prevention. Acute cough illness print-materials/hcp/adult-acute-cough-illness.html. Accessed NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (acute bronchitis) physician information sheet (adults). http:// www.cdc.gov/getsmart/community/materials-references/

Case 3

September 16, 2015. http://www.cdc.gov/getsmart/campaignmaterials/info-sheets/adult-acute-cough-illness.pdf

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Jennifer is a 27-year-old slender white female who presents today Ñ Symptoms occur or worsen in the presence of exercise, viral with a complaint of a chronic cough of more than 2 months and infection, animals with fur or hair, house dust mites (in mat© Jones Bartlett © Jones Bartlett Learning, LLC shortness of breath.& Sometimes theLearning, cough producesLLC clear phlegm. tresses, pillows, etc.), & mold, smoke (tobacco/wood), pollen, Her episodes of SOB SALE are occurring often, up to several times changesNOT in weather, strong emotional expression (laughing NOT FOR ORmore DISTRIBUTION FOR SALE OR DISTRIBUTION a week, and it seems to take longer for her to recover. She has difor crying), airborne chemicals or dusts, menstrual cycles ficulty breathing at night and can sometimes hear a “wheezing Ñ Symptoms occur or worsen at night, awakening the patient sound.” It occasionally feels like there is “a band around my chest Classify asthma severity. See Table 3-1.12 and it’s frightening.” She has also been very tired lately and has a © Jones & Bartlett Learning, LLC2 packs of cigarettes a day, © decreased appetite. Jennifer smokes a Jones & Bartlett Learning, LLC Physical NOT FORhabit SALE ORatDISTRIBUTION NOT FOR SALEExam OR DISTRIBUTION she began 15 years of age. Physical exam (PE) given is adequate to start dx list and treatment (tx) plan

Physical Exam

Routine Labs/Diagnostics Needed Vital Signs: BP 104/64, HR 94 (regular), RR 20, T 97.6 Jones movements & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC EENT: Visual fields and©extraocular (EOMs) intact. done after bronchodilation Ñ Pulmonary function test was TMs translucent, gray, light FOR reflex and landmarks no NOT FOR SALE OR DISTRIBUTION NOT SALE OR visible, DISTRIBUTION with albuterol fluid. Nose: Mucosa pink, clear discharge, no polyps. Mouth: Ratio of forced expiratory volume in 1 second to forced vital No pharyngeal edema, exudates, or lymphadenopathy. No capacity (FEV1/FVC) <70% of predicted frontal/maxillary sinus tenderness. Negative transillumination FEV1 56% of predicted Lungs: Resonant to percussion, lung expansion equal. No inAllergy tests—used specific allergens suggested Ñ © Jones & Bartlett(AP)/lateral Learning, LLC Diffuse © Jonesto&document Bartlett Learning, LLC crease in anteroposterior diameter. by clinical history or to reinforce need for environmental NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION expiratory wheezes bilaterally. No voice sounds or tactile control (not done in this patient) fremitus CV: S1, S2 RRR, no murmurs, rubs, or gallops Differential Diagnoses List Abdomen: Nontender, no masses or guarding. BS+ No tremors, strengthLLC 5/5. Tender paracervical muscles COPD © Jones &Neuro: Bartlett Learning, © Jones & Bartlett Learning, LLC to palpation Asthma NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Extremities: No edema, pulses 2+ CHF Pulmonary embolism What additional assessments/diagnostics do you need? Mechanical obstruction of the airways (benign and malignant What is the differential diagnoses list? tumors) What is your working © diagnosis? Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Pulmonary infiltration with eosinophilia NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Cough secondary to drugs Additional Assessments/Diagnostics Needed Vocal cord dysfunction ROS ROS that focuses on the following key indicators for a diagnosis (dx) © Jones & Bartlett Learning, LLC of asthma:

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Ñ Wheezing Ñ History of any of the following: cough, worse particularly at night, recurrent wheeze, recurrent difficulty in breathing, recurrent chest tightness

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Working Diagnosis

© Jones & Moderate persistent asthma

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Pathophysiology

Asthma is a chronic inflammatory disorder of the airways that involves the interaction of airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation. The interaction of these

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Case 3

© Jones & Bartlett Learning, LLC 3-1 DISTRIBUTION Classification of Asthma Severity NOT FORTABLE SALE OR

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Classification of Asthma Severity (patients age 12 years or older) Persistent Components of Severity Impairment Normal FEV1/ FVC: 8–9 y 85%, 20–39 y 80%, 40–59 y 75%, 60–80 y 70%

Intermittent

Mild

© Jones &<2Bartlett Learning, LLC days/week >2 days/week NOT FOR SALE OR DISTRIBUTION but not daily

Symptoms

Moderate Daily

Severe

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Nighttime awakenings

≤2 times/month

3–4 times/month

>1 time/week, but not Often 7 times/week nightly

SABA use

≤2 days/week

>2 days/week,

Daily

Several times per day

Interference with normal activity

None

Minor limitation

Some limitation

Extreme limitation

Lung function

Normal FEV1

FEV1 >60% but <80% FEV1 <60% of FEV1 >80% of © Jones & Bartlett Learning, LLC predicted of predicted predicted FEVNOT FEV1/FVC 5% FEV1/FVC reduced >5% FOR SALE ORreduced DISTRIBUTION 1/FVC normal

symptomLearning, LLC but not daily and © Jones &for Bartlett control NOT FOR SALE OR DISTRIBUTION not >1 time/day

© Jones & Bartlett Learning, LLC between NOT FOR SALE OR DISTRIBUTIONexacerbations

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>2/ya Exacerbations 0–1/ya requiring Consider severity and interval since last exacerbation. oral systemic Frequency and severity may fluctuate over time for patients in any severity corticosteroids © Jones &category. Bartlett Learning, LLC © Jones & Bartlett Relative annual risks of exacerbations may be related to FEV1.

Risk

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features determines the clinical presentation and the severity of the disease, including variable and recurring symptoms such as cough12, 13 ing, wheezing, shortness of breath, and chest tightness. © Jones & Bartlett Learning, LLC Although usually presents in children, it is common NOT asthma FOR SALE OR DISTRIBUTION among persons over the age of 65 and is an important cause of illness and death among older adults. When asthma does occur in advanced age, the symptoms are similar to those of young adults. However, asthma can be more dangerous in older adults because they are more likely to developLearning, respiratory failure even with mild attacks.12–14 © & Bartlett LLC

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Step 4: Preferred: Medium-dose ICS and LABA Alternative: Medium-dose ICS and LTRA or theophylline or zilueton© Jones & Bartlett Learning, LLC Step 5: Preferred: High-dose ICS and and oral corticoNOT FOR SALE ORLABA DISTRIBUTION steroid and consider omalizumab for patients who have allergies Step 6: Preferred: High-dose ICS and LABA and oral corticosteroid and consider omalizumab for patients who have Jonesallergies & Bartlett Learning, LLC

NOT FOR SALE OR DISTRIBUTION An important component of this stepwise treatment strategy is reevaluation of treatment within 2 to 6 weeks of diagnosis so medications can be adjusted.

After you determine disease severity, the National Asthma Educa© Jones Bartlett Learning, LLCNonpharmacologic © Jones & Bartlett Learning, LLC tion and Prevention Program (NAEPP)&guidelines recommend a stepwise approach to theNOT pharmacologic management asthma treatment based NOTaction FOR SALEplan OR DISTRIBUTION FOR SALE OR ofDISTRIBUTION Ñ Follow up in 1 month to develop for ages 12 and older.12 on peak flow measurements15 Ñ Evaluate symptom control on routine follow-up using one of Step 1: Preferred: Short-acting beta-2-agonist (SABA) prn the following: Step 2: Preferred: Low-dose inhaled corticosteroids (ICS) Ñ Asthma Therapy Assessment Questionnaire (http:// Alternative: Cromolyn, leukotriene receptor antagonists © Jones & Bartlett Learning, LLC (LTRA), © Jones & Bartlett Learning, LLC ev idencebasedpractice.osumc.edu/Documents/ nedocromil, or theophylline NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR) DISTRIBUTION Guidelines/ATAQChecklist.pdf Step 3: Preferred: Low-dose ICS and long-acting beta-2-agonist Ñ Asthma Control Questionnaire (http://aafa.org/pdfs/ (LABA) or medium-dose ICS SWP%20final%20questionnaire.pdf) Alternative: Low-dose ICS and either LTRA, theophylline, or Ñ Asthma Control Test (http://www.asthmacontrol.com) zileuton

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© Jones & Bartlett Learning, LLC A: Moderate persistent asthma NOT FOR SALE OR DISTRIBUTION

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Tobacco use Ñ Discuss and demonstrate correct device technique. P: Discussed etiology and pathophysiology of asthma, signs of Ñ Discuss importance of annual influenza vaccine. deterioration, and when to contact healthcare provider. DisÑ Provide peak flow meter and instructions to take peak flow cussed the purpose of inhaled SABA, LABA, and inhaled cortimeasurement daily ש1 month. Jones & Bartlett Learning, LLCcosteroid. Start albuterol 1–2©puffs Jones Bartlett Learning, LLC prn for& SOB and wheezing strong recommendation to quit, Ñ Smoking cessation: Make NOT FOR SALE OR DISTRIBUTION NOTa FOR SALE OR DISTRIBUTION and 100/50 fluticasone propionate/salmeterol diskus, 1 puff discuss motivation to attempt smoking cessation, and offer twice daily. Demonstrated use of inhalers; returned demonstrategies for smoking cessation.12 stration without difficulty. Emphasized importance of rinsing mouth after inhaler use to minimize chance of developing SOAP Note candidiasis. Recommended having cat sleep in another room, © Jones & Bartlett Learning, LLC © isJones Learning, which she reluctant&to Bartlett do. Described how smokingLLC affects S: Jennifer presents today with a complaint of a chronic cough NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION asthma. She would like to try to titrate her cigarette smoking of more than 2 months and shortness of breath. She has daily down gradually. Plan is to decrease daily cigarettes down to 15 symptoms and awakens with nighttime symptoms 2–3 times daily within the next month. She is strongly motivated to stop a week. Sometimes the cough produces clear phlegm. She smoking because symptoms are interfering with sleep and abilreports wheezing and chest tightness that worsen when she ity to exercise. Ordered and demonstrated proper use of peak goes to the gym. She has stopped going to the gym because © Jones & Bartlett Learning, LLC © Jones & meter. Bartlett LLC flow Take Learning, daily measurement for 1 month and bring of the SOB. She is trying to cut down her smoking habit; now NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION these values to 1-month follow-up visit. Evaluate symptoms down to 1 pack daily. No other environmental exposures exand develop asthma action plan at that time. cept her pet cat, which she has slept with nightly for the last 4 years. She reports her cousin has asthma. Health Promotion Issues O: Vital Signs: BP 104/64, HR 94 (regular), RR 20, T 97.6 Ñ Annual influenza vaccine © Jones & Bartlett Learning, LLC EENT: Visual fields and EOM intact. TMs translucent, gray, © Jones & Bartlett Learning, LLC light reflex and landmarks visible, no fluid. Nose: Mucosa drugs (NSAIDs) sparÑ Use nonsteroidal anti-inflammatory NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION pink, clear discharge, no polyps. Mouth: No pharyngeal ingly because they may exacerbate symptoms edema, exudates, or lymphadenopathy. No frontal/maxillary sinus tenderness. Negative transillumination. Guidelines to Direct Care Lungs: Resonant to percussion, lung expansion equal. No inGlobal Initiative for Asthma. Pocket Guide for Asthma Management crease in AP/lateral diameter. Diffuse expiratory © Jones & Bartlett Learning, LLC wheezes © Jones & Bartlett Learning, LLC and Prevention. http://www.ginasthma.org/local/uploads/files/ bilaterally. No voice sounds or tactile fremitus. GINA_Pocket_April20_1.pdf. Accessed September 16, 2015. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION CV: S1, S2 RRR, no murmurs, rubs, or gallops National Heart, Lung, and Blood Institute. Expert Panel Report Abdomen: Nontender, no masses or guarding. BS+ 3: guidelines for the diagnosis and management of asthma. PFTs taken 10 minutes after 2 puffs of albuterol: FEV1/FVC http://www.nhlbi.nih.gov/health-pro/guidelines/current/ <70% of predicted; FEV1 56% of predicted asthma-guidelines. Accessed September 16, 2015.

Case 4 Mr. Lucas is a 65-year-old © manJones complaining of increasingLearning, shortness Lungs: No evidence of consolidation or focal&abnormality, & Bartlett LLC © Jones Bartlettfairly Learning, LLC of breath over the last few NOT months.FOR He reports that he is used to bediffuse mild end-expiratory wheezing. Breathing through NOT FOR SALE OR DISTRIBUTION SALE OR DISTRIBUTION ing SOB with physical exertion but has started to feel SOB when pursed lips and has a prolonged expiratory phase during performing basic daily activities. He denies fever, sick contact, or quiet breathing. weight loss. He does report a chronic cough that is occasionally proCV: S1 and S2 RRR, faint heart sounds with no murmurs ductive of whitish sputum but has not noticed any recent change in Abdomen: Soft, nontender with good bowel sounds. No bruits © Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC the frequency or character of his cough. He doesn’t LLC take any regular Extremities: Full range of motion of all extremities. No cyanosis medication. has a SALE 65-pack-year of cigarette smoking. NOTHe FOR ORhistory DISTRIBUTION NOT FOR SALE OR DISTRIBUTION or edema

Physical Exam Vital Signs: BP 138/88, HR 88 (regular), RR 18, T 98.8 Thin and mildly dyspneic &GEN: Bartlett Learning, LLC

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What additional assessments/diagnostics do you need? What is the differential diagnoses list? What&isBartlett your working diagnosis? LLC Jones Learning,

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Case 4

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Description (based on postbronchodilator FEV1) Additional Assessments/Diagnostics Needed NOT FOR SALEFindings OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

0 At risk for COPD—risk factors and chronic symptoms but normal spirometry 1 Mild COPD Key indicators for considering a COPD diagnosis include: FEV1/FVC ratio <0.70 © Jones & Bartlett Learning, LLCFEV ≥80% of predicted value © Jones & Bartlett Learning, LLC Ñ Chronic cough 1 Chronic sputum production NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ñ 0 Moderate COPD Ñ Repeated episodes of acute bronchitis FEV1/FVC ratio <0.70 Ñ Dyspnea that is progressive, persistent, worse on exercise, FEV1 50% to <80% of predicted value and worse with respiratory infections May have chronic symptoms of exposure to risk factors, including tobacco Ñ History © Jones & Bartlett Learning, LLC smoke, © Jones 0 Severe COPD & Bartlett Learning, LLC occupational dust and chemicals, smoke from home cooking NOT FOR SALE OR DISTRIBUTION NOT <70% SALE OR DISTRIBUTION FEV1/FVC ratioFOR and heating fuels FEV1 <30% of predicted value Ñ Three tools helpful for assessing COPD include: May have chronic symptoms Ñ COPD Assessment Test (CAT): Measures health status im0 Very severe COPD 16 pairment in COPD FEV /FVC ratio <70% © Jones & Bartlett Learning, LLC © Jones & 1Bartlett Learning, LLC Ñ Clinical COPD Questionnaire (CCQ): Measures clinical 17 <30% of predicted value OR FEV NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1 control in COPD FEV <50% of predicted value plus severe chronic symptoms 1 Ñ Modified British Medical Research Council (MMRC) dys2. Chest X-ray—pulmonary hyperinflation, flattening of the pnea scale: Measures health status and predicts future diaphragm, and increased retrosternal clear space on the later mortality risk18 view are all classic findings for COPD. Valuable to exclude exacerbations, the history of exacÑ To assess for risk of© Jones & use Bartlett Learning, LLCalternative diagnoses © Jones & Bartlett Learning, LLC erbations and spirometry. High-risk patients are those with NOTscreening FOR SALE ORantiDISTRIBUTION NOT FOR SALE OR DISTRIBUTION 3. Alpha-1 antitrypsin deficiency for alpha-1 two or more exacerbations within the last year, those with an trypsin deficiency, which is a rare autosomal cause of emFEV1 <50% of predicted values, or patients with one or more 19 physema in young patients with no smoking history. Not hospitalizations for COPD indicated for this patient. Perform when COPD develops in Ñ Assess for comorbid conditions—these may influence patients of Caucasian descent younger than the age of 45 or mortality and&hospitalizations and shouldLLC be evaluated © Jones Bartlett Learning, © Jones & Bartlett Learning, LLC with a strong family history of COPD routinely: NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 4. Complete blood count (CBC) to evaluate for elevated hemoÑ Cardiovascular diseases globin and hematocrit (H&H) (common in COPD) and for Ñ Osteoporosis elevated white blood cell count due to infection Ñ Respiratory infections 5. Pulse oximetry to evaluate for oxygen saturation and need for Ñ Anxiety and depression oxygen therapy LLC © Jones & Bartlett Learning, LLC © Jonessupplemental & Bartlett Learning, Ñ Diabetes 6. Electrocardiogram (ECG) to evaluate for right ventricular NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION hypertrophy Ñ Lung cancer Ñ Bronchiectasis Arterial blood gases are not indicated in the primary care setting.

ROS

Differential Diagnoses List

Physical Exam

© Jones & Bartlett Learning, LLC This patient has some classic findings, including expiratory Asthma NOT FOR SALE OR DISTRIBUTION wheezing, pursed-lip breathing, and a prolonged expiratory phase. Other notable findings to look for include an increased anteroposterior (AP) diameter, use of accessory muscles of respiration, hyperresonace to percussion, hypoxemia, cyanosis, and signs of right heart © failure in advanced cases. Learning, LLC Jones & Bartlett

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Routine Labs/Diagnostics

1. Spirometry is required to establish the diagnosis and severity of disease Gold Staging System for COPD Severity19

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Congestive heart failure Bronchiectasis Tuberculosis Diffuse panbronchiolitis

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© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Working Diagnosis COPD Pathophysiology

COPD is a common preventable and treatable disease. COPD is the third leading cause of death in the United States and has

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC continued to increase in incidence. The burden of this disease Nonpharmacologic NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

will likely increase in the future because of continued exposure to Ñ Oxygen therapy: Long-term administration of oxygen (>15 COPD risk factors and the aging population. hours daily) has been shown to increase survival in patients COPD is characterized by persistent airflow limitation involvwith severe resting hypoxemia. ing both small airway disease and parenchymal destruction. In of noninvasive ventilation Ñ Ventilatory support: A combination the small airways, flow limitation is due airway inflammation, © Jones & toBartlett Learning, LLC © Jones & Bartlett Learning, LLC with long-term oxygen therapy may be helpful in patients airway fibrosis, luminal NOT plugs, and increased airway resistance. NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION with pronounced daytime hypercapnia. Parenchymal destruction occurs because of loss of alveolar attachÑ Surgery: Surgical treatment options include lung volume ments and a decrease in elastic recoil.19–21 reduction surgery and lung transplantation in appropriately selected patients.19 What Is Your Treatment Plan?

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Education/Counseling

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Education and counseling are important to help prevent exacerbations. Exacerbations negatively affect quality of life, accelerate the rate of decline of lung function, are associated with significant mortality, and have a high socioeconomic cost.19

Bronchodilators:

Ñ Principal agents include beta-2 agonists, anticholinergics, theophylline, or combination therapy May be prescribed as needed or on a schedule to prevent or Ñ © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Ñ Smoking cessation has the greatest capacity to influence the reduce symptoms NOT FOR SALE OR DISTRIBUTION NOT FOR SALEofOR DISTRIBUTION progression COPD. Encourage all patients who smoke to Ñ Long-acting agents reduce exacerbations and hospitalization quit. Pharmacotherapy and nicotine replacement increase and improve symptoms long-term smoking abstinence. Use the 5 A’s and 5 R’s. Ñ Combining bronchodilators from different pharmacologic Ñ Encourage regular physical activity. Recommend pulmonary classes instead of increasing the dose of a single agent may 19 Jones Learning, LLCrehabilitation program. © Jones & Bartlett Learning, improve efficacy and©decrease the& riskBartlett of side effects

SOAP Note Inhaled corticosteroids: NOT FOR SALE OR DISTRIBUTION

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S: Mr. Lucas is a 65-year-old man complaining of increasing shortness of breath over the last few months. He recently has noticed increasing SOB while performing basic daily activities. In the past he has had dyspnea exertion (DOE). He has aLLC chronic © Jones & on Bartlett Learning, cough that is occasionally productive of whitish sputum; no reNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Combination therapy: cent change in the character of his cough. He takes no regular medication. Significant 65-pack-year smoking history. Ñ Combining a long-acting beta-2 agonist with an inhaled corO: Vital Signs: BP 142/86, HR 76, RR 18, afebrile. O2 saturaticosteroid is more effective in improving lung function and tion 94% reducing exacerbations in patients with moderate to very severe COPD. GEN:&Thin, mildly dyspneic © Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC Adding a third agent (anticholinergic) to the drug regimen Ñ HEENT: PERRLA, intact. Normal fundoscopic exam. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OREOMs DISTRIBUTION appears to provide additional benefit. No sinus tenderness on palpation. TMs normal, turbinates without redness or bogginess, pharynx without exudates. Ñ Phosphodiesterase-4 inhibitors are indicated for patients in Neck: Supple, no lymphadenopathy, thyroid enlargement, GOLD 3 and GOLD 4 stages to reduce exacerbations.19 jugular vein distention ( JVD), or carotid bruits Theophylline: © Jones & Bartlett Learning, LLC Jones & Bartlett Learning, LLC Cardiovascular (CV): S1 and S2© regular rate and rhythm without well tolerated than inhaled long-acting Ñ Less effective and lessNOT FOR SALE OR DISTRIBUTION murmurs, gallops, or rubs NOT FOR SALE OR DISTRIBUTION bronchodilators; not recommended if those drugs are availResp: No labored breathing. Lungs: Increased AP diameter, no able and affordable. dullness to palpation, decreased breath sounds throughout Ñ Low-dose theophylline reduces exacerbations but doesn’t with mild expiratory wheezing improve postbronchodilator lung function.19 Abdomen: Soft, nontender, bowel sounds, no organomegaly © Jones & Bartlett Learning, LLC © Jones & good Bartlett Learning, LLC Antibiotics: Extremities:NOT Dorsalis pedis (DP) OR and posterior tibial (PT) NOT FOR SALE OR DISTRIBUTION FOR SALE DISTRIBUTION pulses +2, trace pedal edema Ñ Only should be used for treating infectious exacerbations of CXR: Pulmonary hyperinflation, flattening of the diaphragm COPD and other bacterial infections. Pulmonary function test (after bronchodilation with 2 puffs alÑ Chronic treatment with systemic corticosteroids should be buterol) FEV1/FVC ratio 0.60; FEV1 60% of predicted value avoided because of an unfavorable benefit-to-risk ratio.19 Ñ Scheduled treatment with these medications improves symptoms, lung function, and quality of life and reduces frequency of exacerbations in patients with an FEV1 <60% of predicted. © Jones & Bartlett LLC drugs may increase riskLearning, of pneumonia.19 Ñ These

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CAT test = 25 Health Promotion Issues MRRC score = 3 Ñ Influenza vaccines yearly Clinical COPD questionnaire—deferred until after therapy is initiated Ñ Pneumococcal polysaccharide vaccine is recommended for © Jones & Bartlett Learning, LLCCOPD patients 65 years and © older Jones Learning, LLC and & for Bartlett COPD patients A: COPD (moderate, stage 2) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION younger than age 65 with an FEV1 <40% of predicted Tobacco use disorder P: Discussed the nature of COPD. Albuterol, 1–2 puffs q 4–6 hours as needed for shortness of breath. Fluticasone propioGuidelines to Direct Care nate/salmeterol inhaled 250/50, 1 puff inhaled every 12 hours. Global Initiative for Chronic Obstructive Lung Disease. Demonstrated proper use of inhalers. Returned demonstra© Jones & Bartlett Learning, LLC © Jones & Bartlett http://www.goldcopd.org/. AccessedLearning, September 16,LLC 2015. tion without difficulty. Referral for pulmonary rehabilitation NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Centers for Disease Control and Prevention. Prevention and exercise program. Discussed importance of risk reduction, control of seasonal influenza with vaccines: recommendaincluding smoking cessation, and offered medication to assist tions of the Advisory Committee on Immunization Practices with smoking cessation. Declines at this time but has strong (ACIP)—United States, 2014–15 influenza season. MMWR. motivation to quit. Wants to try slow taper of cigarettes. Avoid 2014;63(32):691–697. http://www.cdc.gov/mmwr/preview/ vigorous outdoor exertionLLC or stay inside on high-pollution © Jones & Bartlett Learning, © Jonesmmwrhtml/mm6332a3.htm. & Bartlett Learning, LLC Accessed September 16, 2015. days. Will for home oxygen on a routine basis. DisNOT FOR SALE ORevaluate DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cussed strategies for minimizing dyspnea, including pursed-lip breathing. Influenza and pneumococcal vaccine today.

Case 5

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Mr. Roos is a 57-year-old man who comes to the office complaining use of immunosuppressing drugs; use of antimicrobials within the of fever and a cough. He states that he felt completely healthy 4 days previous 3 months (in which case an alternative from a different ago, but on the following day started feeling feverish and coughed class should be selected); or other risks for drug-resistant Strepto© Jones & Bartlett LLC have © Jones Bartlett Learning, LLC up yellowish-green phlegm the nextLearning, morning. His symptoms coccus pneumoniae (DRSP)&infection. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION progressively worsened. He also mentions that his chest hurts on Physical Exam the right side when he takes a deep breath. He reports that his wife was sick with milder but similar symptoms a week or two ago. Ñ The physical exam should include a respiratory, cardiovascuPMH: Includes hypertension and arthritis. His medications inlar, abdominal, skin, and mental health assessment clude metoprolol and celecoxib. He smokes roughly a pack exam for this patient revealed decreased breath Ñ Physical © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC of cigarettes per day but does not drink alcohol or use other sounds, dullness to percussion, and increased tactile fremitus NOT FOR SALE DISTRIBUTION NOT FOR SALE ORlobe. DISTRIBUTION drugs. OR No drug allergies. in the right lower All other systems were within normal limits Physical Exam Ñ Assess for criteria for clinical stability including:22 Vital Signs: BP 128/86, HR 101 (regular), RR 18, T 37.4°C Ñ Temp ≤37.8°C GEN: Appears mildly tachypneic, not in distress © Jonesbut&isBartlett Learning, LLCÑ HR ≤100 bpm © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION Ñ RR ≤24 breaths/min What additional assessments/diagnostics do OR you need? Ñ Systolic blood pressure (SBP) ≥90 mm Hg What is the differential diagnoses list? Ñ Arterial oxygen sat ≥90% What is your working diagnosis? Ñ Ability to maintain oral intake Additional Ñ Normal mental status © Jones &Assessments/Diagnostics Bartlett Learning, LLCNeeded © Jones & Bartlett Learning, LLC severity of illness Ñ Assess for NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ROS Ñ CURB-65 criteria help determine hospital admission Evaluate for presence of comorbidities (to direct antibiotic tx), decision (confusion, uremia, respiratory rate, low blood including chronic heart, lung, liver, or renal disease; DM; alcoholpressure, age 65 or greater) (Curb-65 Pneumonia Severity ism; malignancies; asplenia; immunosuppressing conditions or Score).23

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Ñ Pneumonia Severity Index (PSI) can be used to identify ClassSALE 5: PointsOR >130: Mortality 29.2% (high risk) NOT 5. FOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION patients with CAP who may be candidates for outpatient treatment versus inpatient treatment (Pneumonia Severity Index Calculator).24

General

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Interpretation 1. Classes 1–2: Outpatient management 2. Class 3: Consider short observation hospital stay LLC © Jones & Bartlett 3. Classes 4–5: Inpatient management

Learning, LLC

The information below (general, PMH,SALE physicalOR exam,DISTRIBUTION and lab NOT FOR SALE OR DISTRIBUTION NOT FOR and radiology findings) all relate to the pneumonia severity index. Additional Diagnostics Needed 1. Age in years: Add 1 point per year CBC (WBC = 14,900, neutrophils = 87%, platelets = 310,000/ 2. Gender: Subtract 10 points for women uL, Hgb = 16, Hct = 48) 3. Nursing home resident: Add 10 points Basic metabolic panel (BMP) (Na = 137, K = 4.1, BUN = 15, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Cr = 1.0, BG = 148) NOTMedical FOR SALE NOT FOR SALE OR DISTRIBUTION Past HistoryOR DISTRIBUTION Pulse oximetry (98%) 1. Cancer: Add 30 points Chest X-ray (consolidation of right midlobe. No pleural effu2. Liver disease: Add 20 points sion noted) 3. CHF: Add 10 points Pulmonary function tests (PFTs) (not really helpful in this situ© Jones & Bartlett Learning, LLC © Jonesation, & Bartlett Learning, LLC i.e., we expect them to be abnormal) 4. CVA: Add 10 points NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Sputum/blood cultures: The overall yield and infrequent posi5. Chronic kidney disease: Add 10 points tive impact on clinical care argue against the routine use of blood and sputum cultures. Therefore, the guidelines suggest Examination Findings empirical treatment for patients in the outpatient setting (as 1. Altered level of consciousness: Add 20 points © Jones & Bartlett Learning, LLClong as you have risk stratified © appropriately). Jones & Bartlett Learning, LLC 2. Breathing rate >30 rpm: Add 20 points NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 3. Systolic BP <90 mm Hg: Add 20 points Differential Diagnoses List 4. Temperature not 95–104°F (35–40°C): Add 15 points Community-acquired pneumonia (CAP) 5. Heart rate >125 bpm: Add 10 points COPD Lung abscess © Jones & Bartlett Learning, LLC Pulmonary embolism NOT FOR SALE OR DISTRIBUTION Congestive heart failure (CHF) Neoplasms Sarcoidosis

Labs © Jones & Bartlett Learning, LLC Arterial bloodFOR gas (ABG): NOT SALE

OR DISTRIBUTION

1. Arterial pH <7.35: Add 30 points 2. PaO2 <60 mm Hg (<90% O2 sat): Add 10 points Keep in mind that arterial blood gases (ABGs) are not usually

© Jones & Bartlett Learning, LLC © JonesWorking & Bartlett Learning, LLC ordered in the primary care setting. This parameter limits the abilDiagnosis ity to use this scoring system in the office. However, its use is helpNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Community-acquired pneumonia ful for patients presenting to the emergency department (ED) where an ABG can be obtained. Labs: Serum chemistry: 1. 2. 3. 4. 5.

1. 2. 3. 4.

Tobacco use disorder

Pathophysiology

Serum sodium <130© mEq/L: Add& 20 Bartlett points CAP is one of the most common© infectious Streptococcus Jones Learning, LLC Jonesdiseases. & Bartlett Learning, LLC Blood urea nitrogen NOT (BUN) FOR >64 mg/dL: Add 20 points pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis NOT FOR SALE OR are DISTRIBUTION SALE OR DISTRIBUTION the pathogens that account for approximately 85% of CAP. CAP Serum glucose >250 mg/dL: Add 10 points usually occurs as a result of inhalation or aspiration of the pathoBlood count—hematocrit <30%: Add 10 points gen into a lung segment or lobe; it may also occur from a distant Chest X-ray—pleural effusion: Add 10 points source or from bacteremia. Morbidity and mortality are highest in elderly patients and immunocompromised hosts.25 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Scoring

NOT1: FOR OR DISTRIBUTION Class Points 0:SALE Mortality 0.1% (low risk) Class 2: Points <70: Mortality 0.6% (low risk) Class 3: Points 71–90: Mortality 2.8% (low risk) Class 4: Points 91–130: Mortality 8.2% (moderate risk)

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What Is Your Treatment Plan?

CURB-65 score indicates that this patient can be treated in the outpatient setting. PSI score was not calculated because of unavailability of ABGs.

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© Jones & Bartlett Learning, LLC smokers, OR patients must have repeat CXR in 6 months to Ñ For SALE NOT FOR DISTRIBUTION 25 verify that pneumonia was not caused by underlying mass.

SOAP Note Ñ Patients with pneumonia should be treated with antibiotics for at least 5 days. S: Mr. Roos is a 57-year-old man who reports fever and productive stopped&until the patient has been LLCsputum, which began 3 days© © be Jones Bartlett Learning, Jones & Bartlett Learning, LLC Ñ Antibiotics should not ago. His symptoms have progresafebrile for at least 48NOT to 72 hours. sively worsened. He deniesNOT SOB, FOR DOE, palpitations, lightSALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION headedness, or headaches. He reports that his chest hurts on the The most common causes of CAP in outpatients are S. pneuÑ right side when he takes a deep breath. He is currently able to moniae, Mycoplasma pneumoniae, and H. influenzae; patient drink fluids without difficulty, but his appetite is poor. He denies history, clinical findings, and epidemiology may suggest a nausea, vomiting, diarrhea, or abdominal pain. His wife was sick cause that could alter therapy. See Table 3-2. © Jones & Bartlett Learning, LLC © Jones Bartlett LLC with milder symptoms&a week or two Learning, ago but got better withNonpharmacologic out treatment. smokes 1 packOR of cigarettes daily but does NOT FOR SALE OR DISTRIBUTION NOTHe FOR SALE DISTRIBUTION not drink alcohol. He has not taken any antibiotics for the last Ñ Drink fluids to avoid dehydration. several years. PMH is significant for HTN and arthritis. Had inÑ Take deep breaths and cough hourly. fluenza vaccine this year but never got pneumococcal vaccine. Ñ Use a humidifier to make air warm and moist. O: Vital Signs: T 37.4°C, BP 128/86, RR 18, HR 101 (regular), Rest. © Jones &ÑBartlett Learning, LLC © Jonespulse & Bartlett Learning, LLC oximetry 98% 25 Take acetaminophen, ibuprofen, or naproxen for fever or pain.NOT NOT FOR Ñ SALE OR DISTRIBUTION FOR SALE OR GEN: Appears mildly DISTRIBUTION tachypneic, but is not in distress Skin: Warm and dry, good skin turgor Education/Counseling HEENT: No sinus tenderness. PERRLA, EOMs intact. Normal Ñ Emphasize importance of taking the antibiotic until gone, fundoscopic exam. TMs normal, turbinates mildly reddened, even if symptoms improve. without exudate, cobblestoning, © Jones & Bartlett Learning, LLCbut no discharge. Pharynx © Jones & Bartlett Learning, LLC Ñ Call back if you develop new or worsening shortness of or enlargement. Neck: Supple, no thyroid enlargement, JVD, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION breath, chest pain, or confusion or cough up bloody or rustor carotid bruits. No lymphadenopathy colored mucus. TABLE 3-2 Clinical Characteristics and Possible Antibiotic Choices

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Patient Characteristics

Previously healthy; no risk factors for drug-resistant S. pneumoniae

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© Jones & Bartlett Learning, LLC Outpatient Oral Antibiotic Regimen NOT FOR SALE OR DISTRIBUTION

Macrolide • Azithromycin • Clarithromycin • Erythromycin OR Learning, LLC © Jones & Bartlett • Doxycycline NOT FOR SALE OR DISTRIBUTION

Comorbidity or risk factor for drug-resistant S. pneumoniae, including: • Use of a broad spectrum antibiotic in the previous 3 months • Age older than 65 years • Alcoholism © Jones & Bartlett Learning, LLC • Chronic disease (e.g., heart, lung, liver, or kidney disease; diabetes) NOT FOR SALE OR DISTRIBUTION • Cancer • Asplenia • Exposure to a child in day care • Immunosuppression

© IfJones & Bartlett Learning, LLC Note: the patient has received an antibiotic within the previous 3 months, anSALE option from a different class. NOT pick FOR OR DISTRIBUTION

Lives in a region with >25% or higher rate of infection with high-level (MIC ≥16 mcg/mL) macrolide-resistant S. pneumoniae

Macrolide PLUS beta-lactam: • High-dose amoxicillin • Alternative to macrolide-doxycycline Alternative to oral beta-lactams: © Jones & Bartlett Learning, LLC • PO cefpodoxime or cefuroxime NOT FOR SALE OR DISTRIBUTION IM ceftriaxone OR • Respiratory fluoroquinolone: • Moxifloxacin • Levofloxacin © Jones & Bartlett Learning, LLC • Gemifloxacin NOT FOR SALE OR DISTRIBUTION As above

Source: Courtesy of Prescriber’s Letter.

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CHAPTER 3

| Common Respiratory Disorders in Primary Care

© Jones & Bartlett Learning, LLC CV: HR RRR without murmurs, gallops, or rubs NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC HTN: Continue metoprolol. Encouraged heart healthy lifestyle. NOT FOR SALE OR DISTRIBUTION

Resp: No labored breathing. Decreased breath sounds, dullness Tobacco use: Advised regarding the importance of smoking cesto percussion, and increased tactile fremitus in the right sation. Stressed that smoking may contribute to development lower lobe (RLL). Mild crackles in the RLL without wheezes of pneumonia. Patient is willing to discuss smoking cessation or egophony strategies at follow-up visit. Handouts provided on possible © Jones &sounds, Bartlett Learning, LLCsmoking cessation interventions. © Jones & Bartlett Learning, LLC Abdomen: Soft, nontender, good bowel no organomegaly NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Extremities: DP and PT pulses +2, trace pedal edema Health Promotion Issues Mental Status: Awake and oriented × 3 Ñ Recommend yearly influenza vaccine. Labs: CBC (WBC = 14,900, neutrophils = 87%, platelets = Ñ Recommend pneumococcal vaccine now. 310,000/uL, Hgb = 16, Hct = 48) Ñ Wash hands frequently and practice good hygiene. BMP = 137, & K =Bartlett 4.1, BUN =Learning, 15, Cr = 1.0, BG = 148) ©(Na Jones LLC © Jones & Bartlett Learning, LLC recommend smoking cessation and offer treatment Ñ StronglyNOT CXR: Consolidation of right midlobe. No pleural effusion noted NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION options. CURB-65 Pneumonia Severity Score = 1 point (age) low risk A: CAP: Clinically stable Guidelines to Direct Care HTN: At JNC 8 goals Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases use: Poor motivationLLC to try quit attempt at this time © Jones © Jones &Tobacco Bartlett Learning, Learning, LLC Society& of Bartlett America/American Thoracic Society Consensus guideP: CAP: Azithromycin 500 mg daily × 3 days. Discussed imporNOT FOR SALE OR DISTRIBUTION NOTlines FOR SALE OR DISTRIBUTION on the management of community-acquired pneumonia in tance of taking antibiotic until gone. Drink fluids, rest, take adults. Clin Infect Dis. 2007;44:S27–72. deep breaths and cough hourly, use humidifier. May use acetaminophen for fever or pain. Pneumococcal vaccine today.

REFERENCES

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1. World Health Organization. WHO recommendations on the use 10. Braman SS. Chronic cough due to acute bronchitis: ACCP eviof rapid testing for influenza diagnosis. http://www.who.int/ dence-based clinical practice guidelines. Chest. 2006;129(I suppl): influenza/resources/documents/RapidTestInfluenza_WebVersion 95S–103S. http://www.ncbi.nlm.nih.gov/pubmed/16428698 © Accessed JonesSeptember & Bartlett © Eisebitt Jones & Bartlett LLC .pdf. 4, 2014.Learning, LLC 11. Matthys H, R, Seith B, Heger M.Learning, Efficacy and safety of an 2. Harper BradleySALE JS, Englund et al. Expert Panel of the Infecextract ofNOT Pelargonium sidoides (EPs 7630) adults with acute bronNOTSA,FOR ORJA,DISTRIBUTION FOR SALE ORinDISTRIBUTION tious Diseases Society of America: Seasonal influenza in adults and chitis. A randomized, double-blind, place-controlled trial. Phytomedchildren—diagnosis, treatment, chemoprophylaxis and institutional icine. 2003;10(suppl 4):7–17. outbreak management: clinical practice guideline. Clin Infect Dis. 12. National Heart, Lung, and Blood Institute. Guidelines for the diag2009;48(8):1003–1032. Accessed September 4, 2014. nosis and management of asthma (EPR-3). http://www.nhlbi.nih 3. Centers for Disease Control and Prevention. Guidance for clini.gov/health-pro/guidelines/current/asthma-guidelines. Accessed © Jones & Bartlett LLC diagnostic tests. http://www © Jones & Bartlett cians on theLearning, use of rapid influenza September 4, 2014. Learning, LLC .cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm. US Census Bureau. national population projections: percent NOT FOR SALE OR DISTRIBUTION NOT13. FOR SALE OR2008 DISTRIBUTION Accessed September 4, 2014. distribution of the projected population by selected age groups and 4. Lab Tests Online. Influenza tests. http://labtestsonline.org/ sex for the United States: 2010 to 2050. http://www.census.gov/ understanding/analytes/flu/. Accessed September 4, 2014. population/projections/data/national/2008/summarytables.html. 5. Erlikh IV, Abraham S, Kondamudi VK. Management of influenza. Accessed September 4, 2014. Am Fam Physician. 2010;82(9):1087–1095. 14. Older–Adults and Asthma © http://www.aafa.org/display.cfm?id= © Jones & Bartlett Learning, LLC Jones & Bartlett Learning, LLC 6. Centers for Disease Control and Prevention. Vaccine recommenda8&sub=17&cont=173. Accessed September 30, 2015. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tions of the ACIP. http://www.cdc.gov/vaccines/hcp/acip-recs/ 15. National Heart, Lung, and Blood Institute. Asthma action plan. recs-by-date.html. Accessed September 4, 2014. http://www.nhlbi.nih.gov/health/resources/lung/asthma-action7. Centers for Disease Control and Prevention. Flu treatment and what plan-html. Accessed September 4, 2014. to do if you get sick. http://www.cdc.gov/flu/faq/what-to-do.htm. 16. COPD Assessment Test. COPD assessment test. http://catestonline Accessed September 4, 2014. .org. Accessed September 4, 2014. © Jones & AA. Bartlett Learning,bronchitis. LLC N Engl J © Jones & Bartletthttp://www.ccq.nl. Learning, LLC 8. Wenzel RP, Fowler Clinical practice—acute 17. CCQ. Clinical COPD questionnaire. Accessed Med. 2006;355(20):2125–2130. September 4, 2014. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9. Albert RH. Diagnosis and treatment of acute bronchitis. Am Fam 18. Spiromics. Modified Medical Research Council dyspnea scale Physician. 2010;82(11):1345–1350. (mMRC questionnaire). http://www.cscc.unc.edu/spir/public/

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC on the management of community-acquired pneumonia in adults. UNLICOMMMRCModifiedMedicalResearchCouncilDyspnea NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Clin Infect Dis. 2007;44(suppl 2):S27–72. http://www.thoracic.org/ Scale08252011.pdf. Accessed September 4, 2014.

statements/resources/mtpi/idsaats-cap.pdf. Accessed September 4, 19. Global Initiative for Chronic Obstructive Lung Disease. Home page. 2014. http://www.goldcopd.org. Accessed September 4, 2014. 23. Medscape. CURB-65 pneumonia severity score. http://reference 20. Miniño AM, Xu J, Kochanek KD; Division of Vital Statistics. Deaths: .medscape.com/calculator/curb-65-pneumonia-severity-score. preliminary data for 2008. Natl Vital Stat Rep. 2010;59(2):1–52. © Jones & Bartlett Learning, LLCAccessed September 4, 2014. © Jones & Bartlett Learning, LLC http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_02.pdf. SALEPneumonia OR DISTRIBUTION 24. The Ohio State University NOT College FOR of Medicine. Accessed September 4,NOT 2014. FOR SALE OR DISTRIBUTION Severity Index (PSI) calculator. http://internalmedicine.osu.edu/ 21. Murphy SL, Xu J, Kochanek KD; Division of Vital Statistics. Deaths: pulmonary/cap/10849.cfm. Accessed September 4, 2014. preliminary data for 2010. Natl Vital Stat Rep. 2012;60(4):1–51. 25. Cunha BA. Community-acquired pneumonia. Medscape. 2014. http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf. http://emedicine.medscape.com/article/234240-overview#a1. Accessed September 4, 2014. Accessed © September 4, 2014. 22. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious © Jones & Bartlett Learning, LLC Diseases Jones & Bartlett Learning, LLC Society of America/American Thoracic Society consensus guidelines

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