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116 Cards in this Set
- Front
- Back
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In the lungs you have pseudostratified ciliated epithelium to what point?
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Respiratory bronchioles
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In the lungs you have goblet cells until what point?
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Terminal bronchioles
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Where is a foreign object most likely going to be lodged if upright? If supine?
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Upright: Lower portion of R inferior lobe
Supine: upper portion of R inferior lobe |
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What structures perforate the diaphragm and at what vertebral levels?
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C8-IVC
C10: esophagus and vagus C12: aorta, thoracic duct, azygous vein |
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Innervation to lung
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Phrenic (C3-5)
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Muscles of inspiration/expiration during quiet breathing
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Inspiration: diaphragm
Expiration: passive |
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Muscles of inspiration/expiration during exercise
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Inspiration: diaphragm, external intercostals, scalene, SCM
Expiration: rectus abdominus, int/ext obliques, transversus abdominis, internal intercostals |
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Important lung products
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Surfactant
Prostaglandins Histamine Angiotensin converting enzyme Kallikrein |
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Surfactant
(a) source (b) composition (c) function |
(a) type II pneumocytes
(b) dipalmitoyl phophaticholine (c) decrease surface tension of alveoli; increases compliance and decreases work of breathing |
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Histamine effect on bronchi
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Bronchoconstriction
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Angiotensin convertin enzyme fct
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Converts angI to angII; also inactivates bradykinin
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Kallikrein fct
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Activates bradykinin
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Methemoglobin
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Oxidized HgB (ferric Fe3+) that does not bind O2 as readily. It has increased affinity for CN-
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Treatment for CN- poisoning (mechanism)
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Nitrites oxidize HgB to metHbB which binds to CN- and allows cytOxidase to fct; forms thiocyanate which is renally excreted
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Which gases are perfusion limited?
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O2 (in normal health), CO2, N2O
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Which gases are diffusion limited?
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O2 (pulmonary fibrosis) and CO
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Etiology of primary pulmonary HTN
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Inactivation in BMPR2 (normally inhibits vascular smooth muscle proliferation)
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Etiology of secondary pulmonary HTN (pathophys)
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(1) COPD (destruction of lung parenchyma)
(2) recurrent thromboemboli (decrease cross sectional area of pulmonary vascular bed) (3) mitral stenosis (increased resistance equals increased pressure) (4) autoimmune dz (inflammation leads to intimal fibrosis and medial hypertrophy) (5) L to R shunt (6) sleep apnea or living at high altitudes (hypoxic vasoconstriction) |
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Cor pulmonale
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Pulmonary HTN leads to RVH and eventual death from decompensation
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Hypoxemia
(a) definition (b) major causes (A-a gradient in each) |
(a) decrease in arterial P02
(b)(1) high altitude (normal A-a) (2) hypoventilation (normal A-a) (3) V/Q mismatch (increased A-a) (4) diffusion limitation (incr A-a) (4) R to L shunt (incr A-a) |
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Hypoxia
(a) definition (b) major causes |
(a) decreased oxygen delivery to tissue
(b) decreased cardiac output Hypoxemia Anemia Cyanide poisoning CO poisoning |
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Ischemia
(a) definition (b) causes |
(a) loss of blood flow
(b) reduced venous drainage |
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Shunt
(a) V/Q=? (b) effect of 100% O2 on PaO2 |
Shunt is airway obstruction V/Q=0
Giving 100% O2 will not improve oxygenation |
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Dead space
(a)V/Q=? (b) effect of 100% O2 on PaO2 |
Dead space is blood flow obstruction; V/Q approaches infinity; assuming <100% dead space, giving oxygen will improve PO2
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Response to high altitude
(a) acute ventilation (b) chronic ventilation (c) epo/hct/hgb (d) 2,3DPG (e) cellular changes (f) renal (g) pulmonary vasculature |
(a) acute incr in ventilation
(b) chronic increase in ventilation (c) incr Epo incr Hct and Hgb due to chronic hypoxia (d) Incr 2,3 DPG (binds Hgb so that it releases more O2) (e) increased mitochondria (f) incr renal exfretion of bicarb to compensate for resp alkalosis (g) chronic hypoxic pulmonary vasoconstriction results in RVH |
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Response to exercise
(a) CO2 production (b) O2 consumption (c) ventiltion (d) V/Q ratio in lung (e) pulmonary blood flow (f) pH (g) PaO2, PaCO2, venous CO2 content |
(a) incr CO2 production
(b) increased O2 consumption (c) incr ventilation rate to meet O2 demand (d) V/Q from apex to base becomes more uniform (e) incr pulmonary blood flow due to incr cardiac output (f) decr pH during strenuous exercise (secondary lactic acidosis) (g) no change in PaO2, PaCO2, but increase in venous CO2 content |
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Obstructive lung disease
(a) RV (b) FVC (c) FEV1 (d) FEV1/FVC |
Obstruction of flow results in air trapping in lungs. Airways close at prematurely high lung volumes resulting in:
(a) RV incr (b) FVC decr (c) FEV1 decr (--) (d) FEV1/FVC<80% |
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Restrictive lung disease
(a) lung volumes (b) FEV1/FVC ratio |
Restricted lung expansion causes:
(a) decreased (b) FEV1/FVC >80% |
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4 major types of obstructive lung disease (COPD)
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(1) Chronic Bronchitis
(2) Emphysema (3) Asthma (4) Bronchiectasis |
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2 general categories of restrictive lung disease
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Poor breathing mechanics (extrapulmonary, peripheral hypoventilation)
Interstitial lung disease (pulmonary, lowered diffusing capacity) |
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Reid index
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Gland depth/total thickness of bronchial wall
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Chronic bronchitis
(a) definition (b) findings (c) pathology |
Blue Bloater
(a) productive cough for >3 months in 2+ years; disease of small airways (b) wheezing, crackles, cyanosis (early onset hypoxemia due to shunting), late obset dyspnea (c) hypertrophy of mucus secreting glands in bronchioles; Red index>50% |
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Pink puffer
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Emphysema
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Barrel shaped chest
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Emphysema
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Emphysema (general)
(a) findings (b) pathophys |
(a) Increased elastase activity; exhale through pursed lips to increase airway pressure and prevent airway collapse; early onset dyspnea, decr breath sounds, rachycardia, late onest hypoxemia due to eventual loss of capiallary beds (occurs with loss of alveolar walls)
(b) Enlargement of airspaces and decreased recoil resulting from destruction of alveolar tissue |
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Cause of centriacinar emphysema
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Smoking
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Cause of panacinar emphysema
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Alpha 1 antitrypsin deficiency (also liver cirrhosis)
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Paraseptal emphysema associations and complications
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Assoc w/bullae; can rupture leading to spontaneous pneumothorax in young, otherwise healthy men
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Asthma
(a) pathology (b) findings |
(a) bronchial hyperresponsiveness causes reversible bronchoconstriction; smooth muscle hypertrophy and Curschmann's spirals (shed epithelium from mucous plugs)
(b) can be triggered; cough, wheezing, dyspnea, tachypnea, hypoxemia, decr I/E ratio, pulsus paradoxus, mucus plugs |
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Bronchiectasis
(a) pathology (b) associations (c) complication |
(a) chronic necrotizing infection of bronchi causing permanently dilated airways, purulent sputum, recurrent infection, and hemoptysis
(b) bronchial obstruction CF Poor ciliary motility Kartagener's syndrome (c) can develop aspergillosis |
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Types of restrictive lung disease due to poor breathing mechanics
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Polio, myasthenia gravis (poor muscular effort)
Scoliosis, morbid obesity (poor structural apparatus) |
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Types of interstitial (restrictive) lung diseases
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ARDS
Hyaline membrane disease Pneumoconioses (coal miner's, silicosis, asbestosis) Sarcoidosis Idiopathic pulmonary fibrosis (repeated cycles of lung injury and wound healing with increased collagen) Goodpasture's syndrome Wegener's granulomatosus Eosinophilic granuloma (histiocytosis X) Drug toxicity (bleomycin, busulfan, amiodarone) |
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Neonatal respiratory distress syndrome
(a) cause (b) lecithin to sphinomyelin ratio (c) possible sequelae of persistently low O2 tension (d) risk factors (e) treatment |
(a) surfactant deficiency
(b) <1.5 in amniotic fluid (2 is normal) (c) PDA (d) prematurity, maternal diabetes (elevated insulin), cesarean delivery (decr release of fetal glucocorticoids) (e) maternal steroids before birth; artificial surfactant for infant |
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Acute respiratory distress syndrome
(a) causes (b) pathophys |
(a) trauma, sepsis, shock, gastric aspiration, uremia, acute pancreatitis, amniotic fluid embolism
(b) diffuse alveolar damage incr capillary permeability allowing protein rich leakage into alveoli resulting in formation of intralveolar hyaline membranes; initial damage due to neutrophilic substances, activation of coag cascade or oxygen free radicals |
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Definition of sleep apnea
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Personal stops breathing for at least 10s repeatedly during sleep
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Central sleep apnea
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No sleep effort
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Obstructive sleep apnea
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Respiratory effort against airway obstruction
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Associations w/ sleep apnea (causal and result)
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Obesity, loud snoring, systemic/pulmonary HTN, arrhythmias, and possible sudden death; may result in chronic fatigue
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Treatment of sleep apnea
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Wt loss, CPAP, surgery
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Asbestosis
(a) define (b) increased risk for? (c) findings (d) location in lung |
(a) diffuse pulmonary interstitial fibrosis due to inhaled asbestos fibers
(b) pleural mesothelioma and bronchogenic carcinoma (c) long latency; ferruginous bodies in lung (asbestos coated with hemosiderin); ivory white pleural plaques (d) mainly affects lower lobes |
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What is the relationship b/w smoking and asbestosis with bronchogenic carcinoma and mesothelioma?
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No additive risk for mesothelioma
Greatly increased risk for bronchogenic carcinoma |
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Where do most pneumocioses have their effect in the lung?
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Upper lobes (not asbestosis)
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Bronchial obstruction findings:
(a) breath sounds (b) resonance (c) fremitus (d) tracheal deviation |
(a) absent or decr over affected area
(b) decr resonance (c) decr fremitus (d) tracheal deviation towards side of lesion |
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Pleural effusion
(a) breath sounds (b) resonance (c) fremitus (d) tracheal deviation |
(a) decr over effusion
(b) dullness (c) decr fremitus (d) n/a |
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Pneumonia
(a) breath sounds (b) resonance (c) fremitus (d) tracheal deviation |
(a) may have bronchial breath sounds over lesion
(b) dullness to percussion (c) increased fremitus (d) n/a |
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Tension pneumothorax
(a) breath sounds (b) resonance (c) fremitus (d) tracheal deviation |
(a) decreased breath sounds
(b) hyperresonant (c) absent fremitus (d) away from side of lesion |
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General presentation of lung cancer
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Cough, hemoptysis, bronchial obstruction, wheezing, pneumonic "coin" lesion on x ray film
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Most common tumor in lung
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Metastasis to lung most common cancer
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Primary vs Metastatic lung cancer presentation
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Met: dyspnea
Primary: cough |
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SCC of lung
(a) location (b) risk factors (c) description (d) histology |
(a) central
(b) smoking (c) hilar mass from bronchus; cavitation; parathyroid like activity due to PTHrP (d) keratin pearls and intracellular bridges |
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Adenocarcinoma: bronchial
(a) location (b) risk factors (c) description (d) histology |
(a) peripheral lung
(b) n/a -most common lung cancer in nonsmokers and females (c) develops in site of prior pulmonary inflammation or injury (d) clara cells transformed into type II pneumocytes;multiple densities on x ray of chest |
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Adenocarcinoma of lung: broncioloalveolar
(a) location (b) risk factors (c) description (d) histology |
(a) peripheral lung;
(b) NOT linked to smoking (c) grows along airways; can present like pneumonia (d) clara cells transformed into type II pneumocytes; multiple densities on CXR |
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Small cell (oat cell) carcinoma
(a) location (b) risk factors (c) description (d) histology (e) treatment |
(a) central
(b) n/a (c) Undifferentiated and very aggressive; often assoc w/ ectopic production of ACTH or ADH; may lead to Lambert Eaton syndrome. (d) neoplasm of neuroendocrine Kulchitsky cells (small dark blue cells) (e) responsive to chemo |
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Lambert Eaton syndrome
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Autoantibodies against calcium channels
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Large cell carcinoma
(a) location (b) description (c) histology (d) treatment |
(a) peripheral
(b) highly anaplastic undifferentiated tumor; poor prognosis; less responsive to chemo (c) pleomorphic giant cells w/leukocyte frags in cytoplasm (d) surgery (less responsive to chemo) |
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Carcinoid tumor presentation
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Secretes serotonin; causes car cinoid syndrome (flushing, diarrhea, wheezing, salivation)
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Metastases to lung characteristics of most common
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Brain (epilepsy)
Bone (pathologic fracture) Liver (jaundice, hepatomegaly) |
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Pancoast's tumor
(a) description (b) clinical presentation |
(a) occurs in apex of lung
(b) may affect cervical sympathetic plexus causing Horner's |
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Lobar pneumonia
(a) most frequent organism(s) (b) characteristics |
(a) pneumococcus
(b) intraalveolar exudate leading to consolidation; may involve entire lung |
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Bronchopneumonia
(a) most frequent organism (b) characteristics |
(a) S aureus, H flue, Klebsiella, S pyo
(b) acute inflammatory infiltrates from bronchioles into adjacent alveoli; patchy distribution involving more than 1 lobe |
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Interstitial/atypical pneumonia
(a) most frequent organism(s) (b) characteristics |
(a) viruses (RSV, adeno), mycoplasma, legionella, chlamydia
(b) diffuse patchy inflammation localized to interstitial areas at alveolar wallsl generally involves more than 1 lobe; more indolent course than bronchopneumnia |
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Lung abscess
(a) definition (b) organisms |
(a) Collection of pus within parenchyma usually resulting from bronchial obstruction (e.g. cancer) or aspiration of oropharyngeal contents (esp patients predisposed to LOC -alcoholics, epileptics)
(b) S aureus or anaerobes |
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Pleural effusion: transudative
(a) describe composition (b) major causes |
(a) decr protein content
(b) CHF, nephrotic syndrome, hepatic cirrhosis |
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Pleural effusion: exudate
(a) composition/description (b) major causes (c) course of action |
(a) increased protein content, cloudy
(b) malignancy, pneumonia, collagen vascular disease, trauma (basically anything that can increase vascular permeability) (c) must drain in light of risk of infection |
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Lymphatic pleural effusion
(a) composition/description (b) cause |
(a) milky fluid
(b) increased triglycerides |
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H1 blocker action
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Reversible inhibitors of H1 histamine receptors
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1st generation H1 blockers
(a) common names (b) clinical uses (c) toxicities |
(a) diphenydramine, dimenhydrinate, chlorpheniramine
(b) allergy, motion sickness, sleep aid (c) sedation, antimuscarinic, anti alpha adrenergic |
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2nd generation H1 blockers
(a) common names (b) clinical uses (c) toxicity |
(a) loratadine, fexofenadine, desloratadine, cetirizine
(b) allergy (c) far less sedating than 1st generation b/c of decr entry into CNS |
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Major classes of asthma drugs
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Beta agonists
Beta 2 agonists Methylxanthines Muscarinic antagonists Cromolyn Corticosteroids Antileukotrienes |
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Asthma drugs: non specific beta agonists
(a) major drug (s) (b) mode of action/use (c) adverse effect |
(a) isoproterenol
(b) relaxes bronchial smooth muscle (beta 2) (c) tachycardia (beta 1) |
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Beta 2 agonists
(a) major drug (s) (b) mode of action/use (c) adverse effect |
(a) albuterol, salmeterol
(b) albuterol: relaxes bronchial smooth muscle (beta2) Salmeterol: long acting agent for prophylaxis (c) tremor and arrhythmia |
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Methylxanthines
(a) major drug (s) (b) mode of action/use (c) adverse effect |
(a) theophylline
(b) likely causes bronchodilation by inhibiting phosphodiesterase decr cAMP hydrolysis (c) usage limited b/c of narrow therapeutic index (cardiotoxicity, neurotoxicity); metaolized by p450 |
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Muscarinic antagonists
(a) major drug (s) (b) mode of action/use (c) adverse effect |
(a) ipratropium
(b) competitive block of muscarinic receptors preventing bronchoconstriction; also used for COPD (c) n/a |
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Cromolyn
(a) mode of action (b) adverse effect/use |
(a) prevents release of mediators from mast cells; useful only for prophylaxis nor for acute attach
(b) toxicity rare |
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Corticosteroids
(a) major drug(s) (b) mode of action/use |
(a) beclomethasone, prednisone
(b) inhibit synth of virtually all cytokines; inactivate NF kappa B (TF that induces production of TNF alpha etc). 1st line therapy for chronic asthma |
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Antileukotriences
(a) major drug (s) (b) mode of action/use (c) adverse effect |
(a) Zileuton; Zafirlukast, Montelukast
(b) Zileuton: 5-lipooxygenase pathway inhibitor; blocks conversion of arachidonic acid to leukotrienes Zafr and Monte: block leukotrience receptors; esp good for aspirin induced asthma) |
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Guaifenesin (robitussin) MOA
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Removes excess sputum but large doses necessary; does not suppress cough reflex
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N acetylcysteine
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Mucolytic-->can loosen mucous plugs in CF patients. Also used as an antidote for acetaminophen overdose
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Sinus pain; low grade fever (sinusitis)
(a) MCC (b) pathogenesis (c) treatment |
(a) MCC: strep pneumo, H, flu, morzella catarrhalis
(b) pathogenesis S pneumo: capsule, IgA protease H flu: capsule, IgA protease, endotoxin Moraxella: beta lactamase (c) S pneumo: penicillin H flu: amoxicillin Moraxella catarrhalis: ceftriaxone |
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Sore mouth w/thick white coat that can be scraped off easily to reveal painful red base
(a) MCC (b) pathogenesis (c) treatment |
(a) MCC: candida albicans
(b) pathogenesis: overgrowth of normal flora, IC, overuse of antibiotics (c) treatment: nystatin |
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Inflammed tonsils/pharynx, abscesses, cervical lymphadenopathy, fever, stomach upset, sandpaper rash
(a) MCC (b) pathogenesis (c) treatment |
(a) MCC: GAS
(b) pathogenesis: exotoxin A (c) treatment: penicillin |
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White papules w/red baseon posterior palate and pharynx, fever: MCC?
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Coxsackie A; no treatment
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Pharyngitis w/severe fatigue, lymphadenopathy, fever +/- rash
(a) MCC (b) pathogenesis (c) treatment |
EBV; infect B lymphocytes by attachment of CD21; cause incr CTL's; supportive treatmen
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Low grade fever w/1-2d onset of membranous nasopharyngitis and/or obstructive laryngotreacheitis; abnormal ECG unvaccinated; bull beck from lymphadenopathy
(a) MCC (b) pathogenesis (c) treatment |
Corynebacterium diptheriae; diptheria toxin inactivates EF2 in heart, nerves, epithelium; pseudomembrane can cause airway obstruction; treat w/penicillin/antitoxin
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Rhinitis, sneezing, coughing; seasonal peaks: MCC(s)?
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Rhinovirus (summer/fall)
Coronovirus (winter/spring) |
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Red, bulging tympanic membrane; fever
(a) MCC (b) pathogenesis (c) treatment |
S pneumo/capsule, IgA protease/penicillin
H flu/capsule, IgA protease, endotoxin/amoxicillin Moraella catarrhalis/beta lactamase/ceftraixone |
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Ear pain w/otitis externa
(a) MCC (b) pathogenesis (c) treatment |
S aureus/normal flora enter abrasions/beta lactamase resistance penicillin
Candida albicans/normal flora enter abrasians/nystatin Proteus Pseudomonas/water source |
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Malignant otitis externa/severe ear pain in diabetic/life threatening
(a) MCC (b) pathogenesis |
Pseudomonas/capsule
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Inflamed epiglottitis; often 2-3 yrs old and unvaccinated
(a) MCC (b) pathogenesis (c) treatment |
H flu, capsule, IgA protease, ceftriaxone
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Infant w/fever, sharp barking cough, inspiratory stridor, hoarse phonation
(a) MCC (b) pathogenesis (c) treatment |
Parainfluenza (croup)/viral cytolysis w/multinucl giant cells; ribavirin
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Bronchitis; wheezy; infant or less than 5YO
(a) MCC (b) pathogenesis (c) treatment |
RSV; fusion protein creates syncitia/ribavirin
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Bronchitis greater than 5YO
(a) MCC (b) treatment |
Mycoplasma, viruses
Treat symptomatically |
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Typical lobar pneumonia: adults (incl alcoholics) w/rusty sputum
(a) MCC (b) pathogenesis (c) treatment |
S pneumo/capsule, IgA, third gen ceph or azithromycin
Hflu/capsule, IgA protease/3rd gen ceph, azithromycin |
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Typical pneumonia: neutropenic patients, burn patients, CGD, CF: MCC?
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Pseudomonas
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Typical pneumonia: foul smelling, aspiration possible: MCC
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Anaerobes/mixed infection
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Typical pneumonia: alcoholic, abscess, aspiration, capsuled organism, currant jelly sputum: MCC and pathogenesis?
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Klebsiella; capsule
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Atypical pnuemonia: poorly nourished, unvaccinated baby/child; giant cell pneumonia w/rash
MCC, pathogenesis, treatment? |
Measles, cytolysis in LN, skin, mucosa; supportive treatment
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Atypical pneumonia: teens/young adults; dry cough "walking pneumonia"
MCC; pathogenesis; treatment? |
Mycoplasma; adhesins to adhesion to mucus; O2 radical cause necrosis of epithelium; tetracyclin/erythromycin
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Atypical pneumonia: air conditioning; common showers esp >50YO, heavy smoker/drinker
MCC; pathogenesis; treatment? |
Legionella; intecellular in macs; erythromycin
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Atypical pneumonia: bird exposure +/- hepatitis
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Chlamydia; obligate intracellular; tetraceclin/erythromycin
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Atypical pneumonia: AIDs patients w/staccato cough; "ground glass" x ray; premature infants
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Pneumocystis jiroveci; attaches to type I pneumocytes, causes excess replication of type II pneumocytes; TMPSMX, pentamidine
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Acute pneumonia: >55YO, HIV+, or immigrants from developing country w/B symptoms: MCC
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MTB
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Acute pneumonia w/chronic cough, B symptoms, dusty environment w/bird or bat fecal contamination (missouri, ohio river valley): MCC, pathogenesis, treatment
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Histoplasma, facultative intracellular, ampB
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Acute pneumo w/chronic cough, wt loss, night sweats desert sand SW US
MCC, diagnosis, treatment |
Cocci, endospores in spherules, ampB
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Acute pneumonia: rotting, contaminated wood, east coast: MCC, treatment
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Blasto, ketoconazole
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Sudden acute respiratory syndromes: "four corners"
MCC, treatment |
Hantavirus, ribavirin
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