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Ambulatory Pulmonary Medicine

Cough
O Causes and Clinical ClassiIications:
4 cute Cough less than 3 weeks duration.
&55er Res5iratory Tract InIections most common cause oI acute cough.
ower Res5iratory Tract InIections.
4 Chronic Cough more than 3 weeks duration.
!ost-Nasal Dri5 most common cause oI chronic
dulthood sthma.
Chronic Obstructive ung Diseases.
Interstitial ung Diseases.
Congestive Heart Failure.
astroeso5hageal ReIlux Disease.
Drug-Induced CE inhibitors.
Tobacco smoke.
O Diagnostics:
4 No worku5 is required Ior acute cough.
4 Indications Ior a CXR include a) chronic cough, b) hemo5tysis, c) 5ulmonary sym5toms and
d) tobacco use.
O Treatment/Management:
4 ddress underlying causes.
4 !harmacothera5y ntitussive Thera5y:
Indications include a) when the cause (and resulting thera5y) is unknown, and/or b)
there is dry, 5ur5oseless coughing.
Codeine and Dextromethro5han combination is indicated Ior the treatment oI acute
cough.

cute Bronchitis
O Microbial Etiology:
4 'iral InIection most common microbial etiology.
4 Bacterial InIection 2
nd
most common microbial etiology.
O Clinical !resentation oI 'iral Bronchitis:
4 Fever may or may not be 5resent.
4 Rhinorrhea and dry cough.
4 Dysa5nea and 5leuritic 5ain may be 5resent (secondary to recurrent coughing).
4 Constitutional Sym5toms Iatigue, malaise and myalgia.
O Clinical !resentation oI Bacterial Bronchitis:
4 Fever
4 !roductive cough with s5utum.
4 Dysa5nea and 5leuritic 5ain may be 5resent (secondary to recurrent coughing).
4 Constitutional Sym5toms Iatigue, malaise and myalgia.
O Diagnostics:
4 Chest X-Ray indicated iI 5neumonia is sus5ected.
O Treatment/Management:
4 !harmacothera5y antitussive thera5y is indicated, while antibiotics are not indicated unless
bacterial inIection is sus5ected.

The Common Cold
O E5idemiology:
4 Most common ty5e oI u55er res5iratory tract inIection.
4 Higher incidence in children.
O Microbial Etiology:
4 'iruses most common microbial etiology; Rhinovirus is the most common agent.
O Clinical Characteristics:
4 Transmission is through hand-to-hand contact.
O Clinical !resentation:
4 Rhinorrhea and nasal congestion (sneezing).
4 Sore throat and dry cough.
4 Constitutional Sym5toms Iatigue, malaise, myalgia and headache.
O Treatment/Management:
4 Su55ortive Measures:
Increased Iluid intake and adequate hydration.
Rest
4 !harmacothera5y:
!henyle5hrine/5seudoe5hedrine indicated Ior treatment oI nasal congestion.

st
ntihistamines indicated Ior treatment oI rhinorrhea.
ntitussive Thera5y indicated Ior treatment oI cough.
NSIDs/as5irin indicated Ior treatment oI headache, Iacial 5ain and myalgia.

Sinusitis
O Causes:
4 Bacterial InIection most common microbial etiology.
4 llergies
O Microbial Etiology:
4 Bacterial InIection:
Streptococcus pneumoniae most common agent.
aemophilus influen:ae 2
nd
most common agent.
Staphylococcus aureus more common with chronic sinusitis.
O Clinical ClassiIications:
4 cute or Chronic.
O Clinical Characteristics:
4 Ty5ically involves the maxillary sinus.
O Clinical !resentation:
4 cute InIectious Sinusitis:
Sym5toms and clinical signs 5resent Ior longer than 8 to days
Fever
Nasal congestion and 5urulent nasal discharge.
Sinus 5ain maxillary sinusitis may mimic dental caries.
4 llergic Sinusitis:
Nasal congestion and clear nasal discharge.
Sinus 5ain.
4 Chronic InIectious Sinusitis:
Sym5toms and clinical signs 5resent Ior at least 2-3 months.
Nasal congestion and 5ost-nasal dri5.
O !athologies/Com5lications:
4 Mucocele and Nasal !oly5s.
4 Orbital Cellulitis.
4 Facial Osteomyelitis.
4 Cavernous Sinus Syndrome.
4 Rarely, contiguous s5read to the CNS e5idural abscess, subdural em5yema, meningitis and
brain abscess.
O Diagnostics:
4 cute sinusitis is based on clinical sus5icion and Iindings.
O Treatment/Management:
4 !harmacothera5y Decongestants:
!seudoe5hedrine indicated Ior the treatment oI nasal congestion.
4 !harmacothera5y ntibiotic Thera5y:
moxicillin
st
line treatment Ior Stre5tococcal inIection.
Bactrim
st
line treatment Ior Haemo5hilus inIection.
4 !harmacothera5y ntihistamines:
Indicated Ior the treatment oI allergic sinusitis.
oratidine
st
line treatment.

Sore-Throat (aryngo5haryngitis)
O Causes:
4 'iral InIection most common microbial etiology.
4 Bacterial InIection 2
nd
most common microbial etiology
O Microbial Etiology:
4 Bacterial InIection:
Streptococcus pyogenes most common bacterial agent.
aemophilus influen:ae 2
nd
most common bacterial agent.
orynebacterium diphtheria.
oraxella catarrhalis.
4 'iral InIection:
E5stein Barr 'irus (EB').
Her5es Sim5lex 'irus (HS'-).
O Clinical !resentation oI 'iral InIection:
4 Rhinorrhea and dry cough.
O Clinical !resentation oI Bacterial InIection:
4 Fever
4 !haryngeal exudates.
O !athologies/Com5lications
4 Rheumatic Fever (S. pyogenes).
4 Di5htheria (. diphtheriae).
4 Mononucleosis (EB').
O Diagnostics:
4 Throat Culture nalysis gold-standard.
O Treatment:/Management:
4 Su55ortive Measures:
Increased Iluid intake and adequate hydration.
Rest
nalgesia with acetamino5hen or ibu5roIen.
4 Treatment oI Stre5t Throat 5enicillin is
st
line 5ro5hylaxis.
4 Treatment oI 'iral InIection 5urely su55ortive and sym5tomatic relieI.