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FM18 Family Medicine
Differential Diagnosis of Bronchitis
• URTI
• Asthma
• Acute exacerbation of chronic bronchitis
• Sinusitis
• Pneumonia
• Bronchiolitis
• Pertussis
• Environmental/occupational exposures
• Post-nasal drip
• Others: GERD, CHF, cancer, aspiration
syndromes, CF, foreign body
How to Tell if Viral or Bacterial?
Bacterial infections tend to give a higher fever, excessive amounts of purulent sputum production, and may be associated with concomitant COPD
Risk Factors for CAD
Major
• Smoking
• Diabetes
• HTN
• Hyperlipidemia
• Family history of early CAD in first
degree relative (males <55 yr,
females <65 yr)
• Untreated obstructive sleep apnea • Chronic kidney disease
Minor
• Obesity
• Sedentary lifestyle • Age
Red Flags
• Severe pain
• Pain for >20 min
• New onset pain at rest • Severe SOB
• Loss of consciousness • Hypotension
• Tachycardia
• Bradycardia
• Cyanosis
Ruling out Coronary Artery Disease in Primary Care
CMAJ 2010;182(12):1295-1300
Components of the prediction rule used to determine the presence or absence of CAD in patients with chest pain in primary care:
• Age/sex (female ≥65, male ≥55): 1 pt
• Known clinical vascular disease (coronary
artery disease, occlusive vascular disease, or
cerebrovascular disease): 1 pt
• Pain worse during exercise: 1 pt
• Pain not reproducible by palpation: 1 pt
• Patient assumes pain is of cardiac origin: 1 pt Positive result: 3-5 pts; negative result: ≤2 pts (sensitivity: 87.1%, specificity: 80%)
Common Presenting Problems Toronto Notes 2019 Bronchitis (Acute)
Definition
• acuteinfectionofthetracheobronchialtreecausinginflammationleadingtobronchialedemaand mucus formation
Epidemiology
• 5thmostcommondiagnosisinfamilymedicine,mostcommonisURTI
Etiology
• 80%viral:rhinovirus,coronavirus,adenovirus,influenza,parainfluenza,respiratorysyncytialvirus (RSV)
• 20%bacterial:M.pneumoniae,C.pneumoniae,S.pneumoniae
Investigations
• acutebronchitisistypicallyaclinicaldiagnosis
• sputumculture/Gramstainisnotuseful
• CXRifsuspectpneumonia(cough>3wk,abnormalvitalsigns,localizedchestfindings)orCHF • PFTwithmethacholinechallengeifsuspectasthma
Management
• primaryprevention:frequenthandwashing,smokingcessation,avoidirritantexposure
• symptomaticrelief:rest,fluids(3-4L/dwhenfebrile),humidity,analgesicsandantitussivesasrequired • bronchodilators may offer improvement of symptoms (e.g. salbutamol)
• currentliteraturedoesnotsupportroutineantibiotictreatmentforthemanagementofacutebronchitis
because it is most likely to be caused by a viral infection
■ antibiotics may be useful if elderly, comorbidities, suspected pneumonia, or if the patient is toxic
(see Antimicrobial Quick Reference, FM49) ■ antibiotics in children show no benefit
Chest Pain
• see Cardiology and Cardiac Surgery, C4 and Emergency Medicine, ER21 Differential Diagnosis
Table 11. Differential Diagnosis of Chest Pain
Diagnosis
Acute Myocardial Infarction
Chest Wall Pain
Gastroesophageal Reflux Disease
Panic Disorder/Anxiety State
Pericarditis
Pneumonia
Heart Failure
Pulmonary Embolism
Acute Thoracic Aortic Dissection
Clinical Findings
Chest pain radiates to both arms
Third heart sound on auscultation
Hypotension
>2 of: localized muscle tension; stinging pain; pain reproducible by palpation; absence of cough
Burning retrosternal pain, acid regurgitation, sour or bitter taste in the mouth; one-week trial of high-dose proton pump inhibitor relieves symptoms
Single question: In the past four weeks, have you had an anxiety attack (suddenly feeling fear or panic)?
Clinical triad of pleuritic chest pain (increases with inspiration or when reclining, and is lessened by leaning forward), pericardial friction rub, and electrocardiographic changes (diffuse ST segment elevation and PR interval depression without T wave inversion)
Egophony
Dullness to percussion
Fever
Clinical impression
Pulmonary edema on chest radiography
Clinical impression/judgment
History of heart failure
History of acute myocardial infarction
High pretest probability based on Wells criteria
Moderate pretest probability based on Wells criteria
Low pretest probability based on Wells criteria
Acute chest or back pain and a pulse differential in the upper extremities
LR+ LR–
7.1 0.67 3.2 0.88 3.1 0.96 3.0 0.47
3.1 0.30 4.2 0.09 N/A N/A
8.6 0.96 4.3 0.79 2.1 0.71 2.0 0.24 11.0 0.48 9.9 0.65 5.8 0.45 3.1 0.69 6.8 1.8 1.3 0.7 0.1 7.6 5.3 N/A
Adapted from: McConaghy J, Rupal S. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013 Feb 1; 87(3): 177.182