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NEUMOLOGA
PRIMERA CLASE
TBC-NAC-NIH
PLEURA-IRA-ASMA
PATOGENIA
INFECCION:
Por va inhalatoria (M. tuberculosis). Raramente
por ingestin de leche de vaca contaminada (M.
bovis). Lo ms frecuente es que se necesiten
varios meses de convivencia con un enfermo
bacilfero para que se produzca la transmisin. La
primoinfeccin suele ser asintomtica. 5% TBC
primaria.
ENFERMEDAD TUBERCULOSA:
Primaria (nios <4).
<15% infectados se enferman y ser en los 2.
10% de infectados dan TBC secundaria
(reactivacin). 50% en VIH.
TBC
ETIOLOGIA
Prevalencia de la infeccin: ms
de un tercio de la poblacin
mundial (1 800 millones de
personas). Mortalidad: 2
millones de personas al ao.
Declaracin obligatoria.
VIH principal factor de riesgo.
No se relaciona con
hipogammaglobulinemia ni
mucoviscidosis.
M.tuberculosis:
bacilo
aerobio estricto, inmvil.
Lpidos de su pared celular
le dan ciertas propiedades.
Latentes.
Multiplican resisten
TCD4 Th1 (Ifg, IL-2)
Granuloma
muramildipeptido.
Ziehl-Neelsen,
Fluorescencia
Lwenstein.
No es cromgeno.
96
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FORMAS CLNICAS
PRIMOINFECCION:
Nios, asintomtica, no contagia.
Algunos: fiebre + neumnico + tos seca. Autolimitado.
Eritema nodoso.
MANTOUX a las 2 a 10s. Solo para infeccin. VSG
elevada.
CLINICA PRIMOINFECCION:
1. Infiltrado lobular + adenopata. 95% curan.
2. Derrame pleural TBC: ruptura foco subpleural,
exudado, jvenes, hipersensbilidad, sintomtico, Rx
Torax. TORACOCENTESIS. Mantoux 2/3. BIOPSIA
PLEURAL. Cultivo negativo. Bk negativo. TRATAR.
3. TBC miliar: ancianos. Puede ser primaria o
reactivacin. Fiebre + anemia + HEM + perdida peso
+ linfadenopatias. Rx Torax a los 4s de clnica.
Mantoux 50%. Bk negativo. Salvo orina y
secreciones. BX HEPATICA, MO. CULTIVO MO. Fondo
de ojo.
ENFERMEDAD TUBERCULOSA:
5% de primoinfectados (con FR)
Reactivacion = forma mas frecuente. 10% infectados.
CLINICA CRONICA DE FEBRICULA+PESO+SUDORACION.
Pulmonar en pices. Solo 15% son extrapulmonar (VIH
50%).
1. TBC PUMONAR.
2. TBC EXTRAPULMONAR.
3. TBC Y VIH
MEDICINA
EXTRAPUL.
PULMONAR
Sntoma ms frecuente:
tos. Esputo no purulento,
fiebre, malestar general,
astenia, anorexia, prdida
peso,
sudoracin
nocturna.
Hemoptisis
si
hay
cavernas. Rx: infiltrado
infraclavivular
con
broncograma areo y
tendencia a la cavitacin.
Baciloscopa y cultivo en
esputo suelen ser (+).
Mortalidad TB no tratada:
60% en 2,5 aos.
Aspergilomas
en
cavidades tuberculosas.
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Laringitis tuberculosa
Tuberculosis sea
Tuberculosis
genitourinaria
Meningitis tuberculosa
Pericarditis tuberculosa
Uvetis.
Coriorretinitis
tuberculosa
Peritonitis tuberculosa
Iletis tuberculosa
Insuficiencia suprarrenal
Tuberculosis cutnea
TBC y silicosis.
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METODOS AUX.
RADIOLOGA.
Rx trax: ++ S.
Patrones en la primo
infeccin: complejo Ghon,
linfadenopatia
hiliar,
parenquimatoso,
derrame, miliar.
Enfermedad tuberculosa
pulmonar: multinodular +
cavitacin
apical
posterior.
CERTEZA: CULTIVO
PROBABILIDAD: BAAR,
CLINICA, RX.
MANTOUX
Sospecha clnica. Contactos recientes. Rx
anormal. FR para TBC. VIH. Grupos.
Intradermica 2U PPD. Leer 48-72h INDURACIN.
Hipersensibilidad tipo IV, demora 2-10s.
Detecta INFECCION. >=10mm (5mm)(0 mm).
F(+): infeccin por otras micobacterias ,
vacunacin con BCG.
F(-): infeccin reciente, TB miliar, derrame
pleural, SIDA, inmunodeprimidos.
BACILOSCOPA
Mtodo rpido y especfico. 3
muestras, maana.
Se necesita 50 mil-100 mil
bacilos/ml para que sea (+).
CULTIVO
Obtencin
de
muestras:
broncoscopa
con
biopsia
transbronquial y BAL.
Medio de cultivo: Lwenstein.
Tarda
2-8
sem.
Mtodo
diagnstico de seguridad. Se
necesita 10 bacilos/ml para que
sea (+).
PATOLOGA
Anatoma patolgica: granulomas
caseificantes. til en derrame
pleural (80% son +) y biopsia
heptica. Cobaya.
HEMOPTISIS
Airway disease: Acute or chronic bronchitis - Airway trauma Bronchiectasis - Bronchovascular fistulae - Dieulafoy's disease Foreign bodies Neoplasms. Pulmonary parenchymal disease : Genetic defect in connective tissue (Ehlers-Danlos vascular
type) - Infection (especially tuberculosis, pneumonia, mycetoma, or lung abscess) - Inflammatory or immune disorders.
Pulmonary vascular disorders : Left atrial hypertension (eg, mitral valve disease, poor left ventricular performance) Pulmonary arteriovenous malformations - Pulmonary thromboembolism. Miscellaneous : Bevacizumab treatment - Catamenial
hemoptisis Coagulopathy - Cocaine use Cryptogenic - Iatrogenic
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PROFILAXIS
Profilaxis primaria y secundaria.
Otros factores de riesgo: silicosis,
hemodilisis (IRC), DM,
corticoterapia prolongada, Ca. de
cabeza y cuello,
linfoma de Hodgkin, hemofilia,
alcoholismo, malnutricin,
fumador
importante. Vacunacin BCG.
Drug
PPD, mm
5a
10
10
Low-risk personsc
15
Table 165-6 Revised Drug Regimens for Treatment of Latent Tuberculosis Infection (LTBI) in Adults
Interval and
Commentsa
HIV- HIV +
Duration
Daily for 9
monthsd,e
A (II)
A (II)
B (II)
B (II)
Daily for 6
monthse
Regimen is not indicated for HIV-infected persons, those with fibrotic lesions on chest
radiographs, or children.
B (I)
C (I)
B (II)
C (I)
B (II)
B (III)
D (II)
D (II)
Regimen generally should not be offered for treatment of LTBI in either HIV-infected or HIVnegative persons.
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D (III) D (III)
Dosage
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Drug
Daily Dose
3 POR SEMANA
Isoniazid
Rifampin
Pyrazinamide
25 mg/kg, max 2 g
35 mg/kg, max 3 g
Ethambutold
15 mg/kg
30 mg/kg
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Continuation Phase
Indication
MESES
DROGAS
MESES
DROGAS
HRZEa,b
HRa,c,d
HRZEa
HRa
Pregnancy
HREe
HR
HRZESf
HRE
Failuresg
(6)
RZEh
(1218)
HZEQi
Resistance to H + R
Minimo
20
Minimo
20
Intolerance to Z
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HRE
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HR
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<=2 NO
3-4 ESTUDIAR
5-6 TRATAR
>=7 CERTERO
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VA DE
INFECCION
DEFINICION
FACTORES DE RIESGO
CLINICA
OBSTETRICIA
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NAC
ETIOLOGA
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Factor
Possible Pathogen(s)
Alcoholism
Lung abscess
Histoplasma capsulatum
Legionella spp.
H. capsulatum
Exposure to birds
Chlamydia psittaci
Exposure to rabbits
Francisella tularensis
Coxiella burnetii
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EX. AUXILIARES
RADIOGRAFA DE TRAX: PA-L
GRAM-CULTIVO DE ESPUTO
BRONCOFIBROSCOPA (CP, LBA)
IFI, ELISA o FIJACIN
COMPLEMENTO - TEST
URINARIO HEMOCULTIVO HEMOGRAMA
GLUCOSA UREA - CREATININA
ELECTROLITOS- AGA
INFILTRADO
ALVEOLAR: LOBAR: Gram+, Mycoplasma MULTILOBAR: gram -, St neumoniae
INTERSTICIAL: Mycoplasma, legionella, chlamydia, P.
carinii, CMV, VHZ, sarampin.
CAVITADA: anaerobio, Sf.aureus, St penumoniae
serotipo III, BGN, TBC, hongos.
SEVERIDAD
CURB-65
PNEUMONIA SEVERITY INDEX (PSI)
CRITERIOS DE INGRESO A UCI
COMPLICACIONES
ATELECTASIA
DERRAME PARANEUMNICO
EMPIEMA
ABSCESO PULMONAR
BRONQUIECTASIA
OBSTETRICIA
Class
Points
Mortality, %
No predictors
0.1
II
<70
0.6
III
71-90
0.9
IV
91-130
9.3
>130
27.0
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TRATAMIENTO
ANTIBIOTICOTERAPIA
HIDRATACIN ADECUADA
ANTIPIRTICOS
/
ANALGSICOS
OXIGENOTERAPIA
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SEPSIS
Description
Systemic
>=2: temperature >38.5C or <35.0C; heart rate of >90 beats/min; respiratory rate of
>20 breaths/min or PaCO2 of <32 mm Hg; and WBC count of >12,000 cells/mL, <4000
inflammatory
cells/mL, or >10 percent immature (band) forms
response syndrome
Sepsis
Severe sepsis
Septic shock
Refractory septic
shock
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Organism
Streptococcus pneumoniae
Preferred antimicrobial(s)
Penicillin nonresistant;
Penicillin G, amoxicillin
MIC <2 microgram/mL
Beta-lactamase
producing
M. pneumoniae/C.
pneumoniae
Legionella species
Chlamydophila psittaci
Coxiella burnetii
Francisella tularensis
Yersinia pestis
Bacillus anthracis
(inhalation)
Alternative antimicrobial(s)
Macrolide, cephalosporins (oral cefuroxime, cefdinir] or
parenteral ceftriaxone, clindamycin, doxycyline, respiratory
fluoroquinolone*
Vancomycin, linezolid, high-dose amoxicillin (3 g/day with
penicillin MIC 4 microgram/mL)
Macrolide, a tetracycline
Fluoroquinolone
Fluoroquinolone, azithromycin
A tetracycline
A tetracycline
Doxycycline
Streptomycin, gentamicin
Ciprofloxacin, levofloxacin, doxycycline
(usually with second agent)
Doxycyline
Macrolide
Macrolide
Gentamicin, streptomycin
Doxycyline, fluoroquinolone
Other fluoroquinolones; beta-lactam, if susceptible;
rifampin; clindamycin; chloramphenicol
Beta-lactam/beta-lactamase inhibitor,
fluoroquinolone
Enterobacteriaceae
Pseudomonas
aeruginosa
Acinetobacter species
Carbapenem
Staphylococcus aureus
Methicillin susceptible
Methicillin resistant
Bordetella pertussis
Anaerobe (aspiration)
Influenza virus
Coccidioides species
Histoplasmosis
Blastomycosis
CURB65
Low severity (eg, CURB65 =
0-1 <3 percent mortality)
Low severity + comorbilidad
o problema social.
Antistaphylococcal penicillin
Cefazolin, clindamycin
Vancomycin or linezolid
TMP-SMX
Macrolide
TMP-SMX
Treatment
site
Preferred treatment
Home
Hospital
Hospital
Alternative treatment
Doxycycline 200 mg carga - 100 mg VO c/24h or clarithromycin 500
mg VO c/12h
Doxycycline 200 mg carga - 100 mg VO c/24h or clarithromycin 500
mg VO c/12h
Amoxicillin 500 mg IV c/8h or Doxycycine 200 mg carga + 100 mg orally or levofloxacin 500 mg Vo
c/24h or moxifloxacin 400 mg VO c/24h
benzylpenicillin (penicillin G) 1.2
grams IV c/6h plus clarithromycin
500 mg IV c/12h
Antibiotics given as soon as
Benzylpenicillin (penicillin G) 1.2 grams IV c/6h plus either
possible
levofloxacin 500 mg IV c/12h or ciprofloxacin 400 mg IV c/12h
Hospital
Co-amoxiclav 1.2 grams IV c/8h*
High severity (eg, CURB65 =
OR
(consider
plus clarithromycin 500 mg IV
3-5, 15-40 percent
critical care
Cefuroxime 1.5 grams IV c/8h or cefotaxime 1 gram IV c/8h or
c/12h*
mortality)
review)
ceftriaxone 2 grams IV c/24h, plus clarithromycin 500 mg IV c/12h
(If Legionella strongly suspected,
(If Legionella strongly suspected, consider adding levofloxacin)
consider
adding levofloxacin)
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Outpatient treatment
1. Previously healthy and no use of antimicrobials within the previous 3 months:
A macrolide (azithromycin, clarithromycin, or erythromycin) OR Doxycyline*
2. Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus;
alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs;
or use of antimicrobials within the previous 3 months (in which case an alternative from a different class
should be selected):
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR A beta-lactam
(first-line agents: high-dose amoxicillin, amoxicillin-clavulanate; alternative agents: ceftriaxone,
cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*
3. In regions with a high rate (>25 percent) of infection with high-level (MIC 16 g/mL) macrolide-resistant
Streptococcus pneumoniae, consider use of alternative agents listed in (2) above.
Inpatients, non-ICU treatment
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR
An antipneumococcal beta-lactam (preferred agents: cefotaxime, ceftriaxone, or ampicillin-sulbactam; or
ertapenem for selected patients) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*
Inpatients, ICU treatment
An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin OR
An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory
fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR For penicillin-allergic patients, a
respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) PLUS aztreonam
Special concerns
If Pseudomonas is a consideration:
An antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or
meropenem) PLUS either ciprofloxacin or levofloxacin (750 mg) OR The above beta-lactam PLUS an
aminoglycoside PLUS azithromycin OR The above beta-lactam PLUS an aminoglycoside PLUS a
respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]); for penicillin-allergic
patients, substitute aztreonam for above beta-lactam
If CA-MRSA is a consideration:
Add vancomycin or linezolid
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FACTORES DE
RIESGO
DEFINICION
NIH
TABAQUISMO
ALCOHOLISMO
ADULTO MAYOR
EXPOSICIN PREVIA A ATB
UREMIA
INTUBACIN ENDOTRAQUEAL
USO DE SNG
COMA
CIRUGA MAYOR
DESNUTRICIN
FALLA MULTIORGNICA
NEUTROPENIA
USO DE ANTI H2/IBP
OBSTETRICIA
ETIOLOGA
VIA DE
INFECCION
COLONIZACIN DE
OROFARINGE DE PACIENTE
HOSPITALIZADO
ASPIRACIN DE
SECRECIONES
OROFARINGEAS
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NIH
Definicin.
Tto de pseudomona
Temperature
36.5 or 38.4 = 0 point - 38.5 or 38.9 = 1 point - 39 or <36.5 = 2
points
Blood leukocytes, microL
4000 or 11,000 = 0 points - <4000 or >11,000 = 1 point - Band forms
50 percent = add 1 point
Tracheal secretions
Absence of tracheal secretions = 0 point
Presence of non-purulent tracheal secretions = 1 point
Presence of purulent tracheal secretions = 2 points
Oxygenation
PaO2/FIO2, mmHg >240 or ARDS (defined as PaO2/FIO2 200, PAWP
18 mmHg and acute bilateral infiltrates) = 0 points
PaO2/FIO2 240 and no ARDS = 2 points
Pulmonary radiography
No infiltrate = 0 point
Diffuse (patchy) infiltrate = 1 point
Localized infiltrate = 2 points
Progression of pulmonary infiltrate
No radiographic progression = 0 point
Radiographic progression (after HF and ARDS excluded) = 2 points
Culture of tracheal aspirate
Pathogenic bacteria cultured in rare or few quantities or no growth =
0 point
Pathogenic bacteria cultured in moderate or heavy quantity = 1 point
Same pathogenic bacteria seen on Gram's stain, add 1 point
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Table 257-6 Pathogenic Mechanisms and Corresponding Prevention Strategies for Ventilator-Associated
Pneumonia
Pathogenic Mechanism
Prevention Strategy
Oropharyngeal colonization with pathogenic bacteria
Elimination of normal flora
Large-volume
oropharyngeal aspiration
around time of intubation
Gastroesophageal reflux
Bacterial overgrowth of
stomach
Hand washing, especially with alcohol-based hand rub; intensive infection control
educationa; isolation; proper cleaning of reusable equipment
Large-volume aspiration
Endotracheal intubation
Noninvasive ventilationa
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Ampicillin/sulbactam (3 g IV q6h) or
Ertapenem (1 g IV q24h)
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PLEURA
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Disease
Empyema
Malignancy
Positive cytology
Lupus pleuritis
Severo
exudado
linfocitos
pseudoquilotorax
ph menor de 7.2
glucosa menor de 50 mg/dl
ADA mayor de 45 UI/L
TBC
varon
moderado
exudado
linfocitos
pseudoquilotorax
ph menor de 7.2
glucosa menor de 15 mg/dl
AR
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Esophageal rupture
Fungal pleurisy
Chylothorax
Hemothorax
Urinothorax
Peritoneal dialysis
Extravascular
migration of central
venous catheter
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Comment
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EMPIEMA
Bacteriology
Minimal, <10 mm
y Bx
decbito lateral
Small to moderate
A1
y B0
<1/2 hemithorax.
Large, free flowing
B1
(1/2 hemithorax),
A2
OR
loculated ,thickened
B2
parietal pleura
A0
Quimica
Cat Mal Px
Dre
unknown
Negativo
C0 pH 7.20
Cultivo o
gram +
pus
2 Low
No
3 Moderate Yes
OR C1 pH <7.20
4 High
Yes
CULTIVO O GRAM
POSITIVO
ASPECTO
PURULENTO
TUBO DE
DRENAJE
GLUCOSA LP
< 50 mg/dl
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Ph < 7.2
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HEMOTORAX
CAUSAS
TRAUMA TORACICO
METASTASIS
TEP
DISECCION AORTICA
DX
HTO 50% SP
TTO
TUBO DE DRENAJE
TORACOTOMA
CAUSAS
QUILOTORAX
LINFOMAS - TRAUMA
DX
TTO
shunt pleuroperitoneal
MESOTELIOMA
DERRAME VIRAL
PNEUMOTHORAX
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CASOS % CASOS %
Nontraumatic
Malignant
Lymphomatous
Nonlymphomatous (primary
pulmonary, mediastinal, metastatic
extrathoracic malignancies)
Nonmalignant
Idiopathic
Miscellaneous (benign tumors,
lymphangioleiomyomatosis, intestinal
lymphangiectasis, protein-losing enteropathy,
regional ileitis, reticular hyperplasia, pleuritis,
cirrhosis, thoracic aortic aneurysm, lupus,
tuberculosis, sarcoidosis, amyloidosis, venous
thrombosis, mitral stenosis, nephrosis, thyroid
goiter, tuberous sclerosis, filariasis, heart
failure, Down syndrome, Noonan syndrome)
Traumatic
Etiology
138 (72)
87 (45)
70 (37)
34 (46)
13 (18)
9 (12)
17 (9)
4 (5)
51 (27)
26 (14)
21 (28)
7 (9)
15 (8)
14 (19)
53 (28)
40 (54)
48 (25)
40 (54)
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OXIHEMOGLOBINA
DESOXIHEMOGLOBINA
METAHEMOGLOBINA
CARBOXIHEMOGLOBINA
CARBAMINOHEMOGLOBINA.
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FISIOPATOLOGIA
TIPOS
HIPOXEMIA
PaO2 < 80 mmHg
Insuficiencia respiratoria
PaO2 < 60 mmHg
DEFINICION
IRA
CLINICA
OBSTETRICIA
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IRA
ETIOLOGIA
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IRA
TTO ESPECIFICO
OXIGENOTERAPIA
BAJO FLUJO
1. CANULA BINASAL
2. MASCARILLA SIMPLE
3. MASCARILLA RESERVORIO
ALTO FLUJO
1. MASCARILLA SISTEMA VENTURI
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BRONCODILATADORES
ANTIBIOTICOS
CORTICOIDES
VENTILACION
MECANICA
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ETIOLOGIA
SDRA
DEFINICION
TRATAMIENTO
Soporte ventilatorio:
intubacin y ventilacin
mecnica, administrando
altas cocnentraciones de
oxigeno con una presin
positiva al final de la
espiracin (PEEP) alta.
DIAGNOSTICO
Patologia desencadenante.
IRA: tf, cianosis central, m.
accesorios.
Infiltrado alveololar difuso.
D/C EAP o P enclavamiento
<=18mmHg.
PAO2/FiO2 <= 200 (<=300
dao pulmonar agudo)
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ASMA
BRONQUIAL
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Environmental Factors
Genetic predisposition
Indoor allergens
Atopy
Outdoor allergens
Airway hyperresponsiveness
Occupational sensitizers
Gender
Passive smoking
Ethnicity?
Respiratory infections
Obesity?
Early viral infections?
Triggers
Allergens
Upper respiratory tract viral
infections
Exercise and hyperventilation
Cold air
Sulfur
gases
Stress
Irritants (household
paint fumes)
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PEF
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Mild
Breathlessness
While walking
Talks in
Alertness
Respiratory rate
Increased
Use of accessory
muscles;
suprasternal
Usually not
Moderate
Severe
Symptoms
While at rest (infant While at rest (infant softer, shorter cry,
stops feeding)
difficulty feeding)
Prefers sitting
Sits upright
Phrases
Words
Usually agitated
Usually agitated
Signs
Increased
Often >30/minute
Guide to rates of breathing in awake children:
Age
Normal rate
<2 months
<60/minute
2-12 months
<50/minute
1-5 years
<40/minute
6-8 years
<30/minute
Commonly
Usually
Subset: respiratory
arrest imminent
Drowsy or confused
Paradoxical
thoracoabdominal
movement
Wheeze
Pulse/minute
<100
Pulsus
paradoxus
PEF percent
predicted or
percent
personal best
70 percent
Usually loud;
throughout inhalation
and exhalation
100-120
>120
Guide to normal pulse rates in children:
Age
Normal rate
2-12 months
<160/minute
1-2 years
<120/minute
2-8 years
<110/minute
Often present
May be present
>25 mmHg (adult)
10-25 mmHg
20-40 mmHg (child)
Functional assessment
Loud; throughout
exhalation
Absence of wheeze
Bradycardia
Absence suggests
respiratory muscle
fatigue
<25 percent
<40 percent
Impairm
ent
Normal
FEV1/FVC:
8-19a 85 %
Moderate
Severe
Daily
2 days/week
Nighttime awakenings
2x/month
3-4x/month
Often 7x/week
2 days/week
Daily
None
Minor limitation
Some limitation
Extremely limited
FEV1/FVC reduced 5
percent
FEV1/FVC reduced
>5 percent
60-80a 70 %
Risk
Mild
>2 days/week but not
dayl
Symptoms
20-39a 80 %
40-59a 75 %
Exacerbations requiring
oral systemic
corticosteroids
MEDICINA INTERNA
FEV1 80 percent
predicted
FEV1/FVC normal
FEV1/FVC normal
0-1/year (see footnote)
2/year (see footnote)
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time for patients in any severity category
Relative annual risk of exacerbations may be related to FEV1
Step 3
Step 4 or 5
Step 1
Step 2
And consider short course of GCO
In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.
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Impai
rment
Risk
Symptoms
Nighttime awakenings
Interference with
normal activity
Short-acting beta2agonist use for
symptom control
FEV1 or peak flow
ATAQ
ACQ
ACT
Exacerbations requiring
oral systemic
corticosteroids
Progressive loss of lung
function
Treatment-related
adverse effects
Recommended action for
treatment
MEDICINA
INTERNA
Some limitation
Extremely limited
2 days/week
>2 days/week
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MEDICINA INTERNA
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PEF
MEDICINA INTERNA
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Varn
de
25
aos,
con
diagnostico de asma bronquial
presenta sntomas en forma
diaria, con un VEF entre 60 y
80% de valor previsto. El
diagnostico es:
1. Estado asmtico
2. Asma intermitente
3. Asma persistente severo
4. Asma persistente moderado
5. Crisis asmtica
Escolar de 8 aos, presenta
agitacin,
tos,
sibilancias
durante las noches hasta dos
veces
por
semana.
La
espirometria
establece
una
disminucin del flujo espiratorio
mximo inferior al 20%. En el
tratamiento de control se
considera el uso de:
1.
2.
3.
4.
5.
Antileucotrienos
Corticoides inhalados
Corticoides inhalados y salbutamol
Bromuro de ipratropio
Salbutamol a demanda
Cual no es criterio de
gravedad en la crisis
asmtica?
1. Trastorno de conciencia
2. Presencia de sibilancias
diseminadas
3. Cianosis
4. Acidosis hipercapnica
5. Presencia
de
pulso
paradojal
1.
2.
3.
4.
5.
Paciente de 4 aos, es
llevado a emergencia por tos
y polipnea. Antecedente de
SOBA a repeticin, rinitis y
urticaria. Al examen fsico FR
64, FC 150, presenta tiraje,
sibilancias
y
estertores
Cul seria su presuncin
diagnostica?
1. Fibrosis qustica
2. Bronquiolitis
3. ICC
4. Asma
5. Reflujo gastroesofagico
Aleteo nasal
Taquipnea
Tirajes intercosatales
Cianosis
Sibilancias en dos tiempos
En la reaccin asmtica
aguda intervienen los
siguientes mediadores,
excepto:
1. Leucotrienos
2. Oxido ntrico
3. Neuropeptidos
4. Histamina
5. Protaglandina E2
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
Cortiocoterapia EV
Aminofilina EV
Dextrosa 5%
Adrenalina EV
Oxigeno humedo
agente
etiolgico
mas
frecuente del NAC en adulto?
1. Hemophylus influenzae
2. Neumococo
3. Moraxella sp
4. Mycoplasma pneumoniae
5. Chlamydia pneumoniae
Cules
son
las
caractersticas del esputo
observado al microscopio
ptico al 10% para que pueda
ser considerado valido para
el diagnostico?
1.
2.
3.
4.
5.
Tratamiento
de
eleccin en caso de
neumona
por
micoplasma es:
1.
2.
3.
4.
5.
Amikacina
Penicilina G sodica
Eritromicina
Amoxicilina
Ceftriaxona
Hemophylus influenzae
Neumococo
Klebsiella pneumoniae
Mycoplasma pneumoniae
Staphylococo aureus
Ceftriaxona
Dicloxacilina
Lincomicina
Teicoplanina
Azitromicina
Tratamiento de eleccin en
NAC
1.
2.
3.
4.
5.
Hemophylus influenzae
Pseudomona aeriginosa
Klebsiella pneumoniae
Mycoplasma pneumoniae
Staphylococo aureus
Son agentes
excepto:
1.
2.
3.
4.
5.
patgenos
de
NAC
Hemophylus influenzae
Neumococo
Legionella pneumophylla
Mycoplasma pneumoniae
Pseudomona aeriginosa
MEDICINA INTERNA
Carcinoma
Linfoma
Yatrogenia quirrgica
Trauma torcico
Congnita
Pleural
Parenquimal
Obstructivp
Restrictivo
Mediastinal
3.
4.
5.
MEDICINA INTERNA
El
compromiso
mas
frecuente en la TBC
genital en varones es:
1. Testiculo
2. Epididimo
3. Capa vaginal testicular
4. Prostata
5. Conducto deferente
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En el peru durante
el ao 2005, segn
MINSA, la tasa de
incidencia de TBC
pulmonar BK +
fue:
1. 67.1 x 100 000.
2. 68.8
3. 66.4
4. 105.4
5. 161.1
De los farmacos
antituberculosos
Cul se asocia a
la
neuritis
retrobulbar?
1. Isoniazida
2. Rifampicina
3. Etambutol
4. Estreptomicina
5. Pirazinamida
En el tto de TBC
Qu farmaco NO
es de 1 linea?
1. Cicloserina
2. Estreptomicina
3. Pirazinamida
4. Rifampicina
5.
Etambutol
MEDICINA
INTERNA
En el tratamiento
antituberculoso,
el
farmaco que actua
como bacteriostatico
en bacilos en reposo
y como bactericida
en
fase
de
mutliplicacion rapida
es:
1. Etionamida
2. Etambutol
3. Pirazinamida
4. Isoniazida
5. estreptomicina
El
farmaco
antituberculoso que
actua
mejor
en
lesiones caseosas es:
1. Gentamicina
2. INH
3. Ciprofloxacino
4. Levofloxacino
5. Rifampicina
En nuestro medio
Cul es la causa mas
fcte de hemoptisis?
1. Paragonimos
2. Aspergilosis
3. Cancer pulmn
4. Bronquiectasia
secuela de TBC
5. Hidatidosis
pulmonar
Varon de 57 aos,
diagnostico de TBC
antes de iniciar tto que
examen
preferencial
debe solicitar:
1. BK en orina y jugo
gastrico
2. Bilirrubina
y
transaminasas
3. Hemograma y cr
4. Dosaje de gases
arteriales
5. Sodio y potasio
El esquema de eleccion
para el tratamiento de la
tuberculosis pulmonar
en el adulto no tratado
previamente es:
1. 2HRSE/4R2H2
2. 2RHRZSE/4R2H2E2
3. 2HRZ/4R2H2
4. 2HRZE/4R2H2
5. 2HRZE/7R2H2
MEDICINA INTERNA
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3 CRITERIOS DE LIGHT:
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CALCULE EL CONTENIDO DE O2 EN
SANGRE SI EL PACIENTE SATURA 80%:
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