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174 Cards in this Set
- Front
- Back
What do "rales" sound like?
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crackles
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What are "rhonci"?
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coarse breath sounds
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What does a "wheeze" sound like?
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melodic whistle/sigh
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Seal-like barking cough. Diagnosis?
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Croup
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Inspiratory brassy wheeze. What is this called?
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Stridor
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What is sub-cutaneous emphysema?
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SCE is a kind of crepitis from air in subQ tissue usually from trauma
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Describe "grunting" in a child with respiratory problems? Indicates what?
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involuntary whimper-like sound which indicates increased work of breathing
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What will crepitis usually indicate on Step 2?
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fracture or joint disease
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ABCF mnemonic for causes of Obstructive Lung Diseases.
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Asthma
Bronchiectasis COPD Cystic Fibrosis Foreign object |
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2 Bronchial smooth muscle defects in Asthma.
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Hypertrophy and Hyperreactivity
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What time of day is Asthma worst normally?
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night
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Most common diagnosis: wheeze under 1 y/o and wheeze over 2 y/o
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under 1: RSV bronchiolitis
over 2: Asthma |
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Normalizing PCO2 in an Asthma attack means what?
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diaphragm fatigue/impending resp. failure
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Child that gets SOB every time he gets a URI. Diagnosis?
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Asthma
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Primary respiratory disease which can cause eosinophilia.
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Asthma
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Increased risidual volume of the obstructive lung disease Asthma will show up how on CXR?
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hyperinflation
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FEV/FVC in Asthma?
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decreased; think expiratory wheeze so longer expiration so decreased FEV1
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FEV/FVC is decreased in Obstructive Lung Diseases. How to remember?
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ObstrUcTive so think difficulty breathing OUT, so longer expiration, so much smaller FEV1
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PFTs are normal, but clinically looks like Asthma. What test?
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Methacholine challenge
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Why can FEV/FVC become elevated as Restrictive Lung Disease worsens?
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RestrIctive: think difficulty breathing enough volume In, so all lung volumes will be Restricted (FVC decreased)
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Barrel Chested means what about Residual Lung Volume?
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Obstructive: RV Over normal
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Usual FEV/FVC result in Restrictive Lung Disease
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both FEV and FVC are restricted, so normal ratio
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Difference between Salmeterol and Albuterol (both beta agonists).
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Salmeterol is long-acting
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5 steps in Chronic Asthma treatment
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1) PRN short acting beta agonist
2) add low dose inhaled corticosteroids (ICS) 3) add long acting beta agonist 4) change ICS to high-dose 5) add oral steroids |
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ASTHMA mnemonic for treatment of acute Asthma exacerbations.
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Albuterol
Steroids T-rarely used (theophylline) Humidified Oxygen Mg (for severe attacks) Anticholinergic: Ipatropium |
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4 types (stages) of Chronic Asthma.
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Mild Intermittent
Mild Persistent Moderate Persistent Severe Persistent |
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Symptom frequency in Mild Intermittent Asthma.
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less than 2 days per week
less than 2 nights per month |
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Symptom frequency in Mild Persistent Asthma.
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more than 2 days per week
less than 1 per day |
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Symptom frequency in Moderate Persistent Intermittent Asthma.
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Daily
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Symptom frequency in Severe Persistent Asthma.
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continual or sx refractory to meds
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Treatment for Mild Intermittent Asthma (sx 2 days/week)
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PRN Albuterol (step 1)
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Treatment for Mild Persistent Asthma (sx over 2 days/week). (2)
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Step 2:
PRN Albuterol Inhaled Corticosteroids (ICS) |
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Treatment for Moderate Persistent Intermittent Asthma (Daily sx) (2)
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Step 3:
Inhaled Corticosteroids (ICS) Long Acting Beta Agonist (LABA) |
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Treatment for Severe Persistent Asthma. (2)
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Step 4:
High Dose ICS Long Acting Beta Agonist (LABA) |
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Treatment for Severe Persistent Asthma refractory to normal Asthma meds (2)
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Step 5:
PO steroids (Prednisone) +/- anti IgE (Cromolyn) - only for prophylaxis, not for acute |
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Why is Theophylline not often used in Asthma?
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cardio and neuro toxicity
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When to consider adding Montelukast in Asthma regimine.
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If sx over 2 days/week (mod persis asthma) and ICS not controlling
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cycles of infection lead to permanent fibrosis, remodeling, and dilation of the bronchi. What is the disease?
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bronchiectasis
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What are Tram Lines on CXR? Diagnosis?
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Parrallel outlines of dilated bronchi which indicates Bronchiectasis
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Treatment for severe Bronchiecasis.
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lobectomy or transplant
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2 types of COPD
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Chronic Bronchitis
Emphysema |
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Criteria for dx of Chronic Bronchitis. (3)
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chronic Productive Cough
for over 3 months per year for 2 years in a row |
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Emphysema in patient who has never smoked. Diagnosis?
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Alpha1Antitrypsin Deficiency
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Patient with mild Asthma hardly ever uses Beta Blocker. He asks if he should be on inhaled steroids like he's read about. When to initiate ICS?
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1st line for chronic control: start if sx over 2 days/week (mod persis asthma)
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Blue Bloater. What disease?
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Chronic Bronchitis
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Pink Puffer. What disease?
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Emphysema
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Cachectic man comes in with SOB which has developed over the last 2 years. Diagnosis?
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Emphysema
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Increased risidual volume of the obstructive lung disease COPD will show up how on CXR?
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hyperinflation
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Diaphragm appearance on CXR in COPD.
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flat
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Parenchymal Bullae Pathognomonic for what disease?
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Emphysema
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Decreased FEV/FVC in a smoker. Diagnosis?
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COPD
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COPD patient quits smoking. What to tell him about prognosis?
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won't cure permanent damage, but will cut decline rate in half
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What is Cor-Pulmonale?
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Right Ventricle dilation due to Pulmonary Hypertension
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50 y/o male diagnosed with COPD. When to give pneumococcal vaccine?
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1x at diagnosis
1x at 65 (since over 5 years from last dose) |
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61 y/o male diagnosed with COPD. When to give pneumococcal vaccine?
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1x at diagnosis; will not need dose at 65 y/o because it is within 5 years of last dose
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How often to give flu vaccine in patient with COPD.
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yearly
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Pure Emphysematous patients characteristic history.
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few reactive airway episodes except during acute exacerbations
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Productive Cough. What type of COPD?
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Chronic Bronchitis
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dry cough. What type of COPD?
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Emphysema
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When to obtain a blood culture in patient with COPD exacerbation?
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if febrile
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1st test to order in patient with exacerbation of known COPD.
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CXR
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When to get a gram stain/sputum culture in patient with COPD exacerbation? (2)
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if productive cough or
if CXR shows infiltrate |
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Most important assessment for follow up on a patient with COPD.
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oxygen saturation
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Most important advice for a patient with COPD.
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smoking cessation
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Patient with h/o COPD found to have a HCT of over 55. What to do?
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start oxygen supplementation at home
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If patient with COPD is found to have pulmonary hypertension or cor-pulmonale, what to add to the tx regimen?
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start oxygen supplementation at home
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4 part treatment for acute COPD exacerbation
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oxygen
albuterol ipatropium corticosteroids |
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What other medication does a patient with COPD exacerbation often get (besides oxygen, albuterol, ipatropium, and corticosteroids).
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antibiotics
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decreased lung compliance. Restricitve or Obstructive?
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Restrictive
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A primary inflammatory cause of restrictive lung disease.
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Sarcoid
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Common risk factor for restrictive lung disease in reproductive aged woman.
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Pregnancy :)
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decrease lung expansion from anatomic defect (name 3)
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Scoliosis
Ankylosing Spondylitis Obesity |
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Why give the lowest FiO2 (with ventilation) as possible?
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Interstitial lung disease (restrictive) can be caused by prolonged high concentrations of O2
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noncaseating granulomas in the lungs, liver, eyes, skin, heart, and/or kidney. What is the disease?
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Sarcoidosis
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3 most common symptoms in Sarcoidosis for Step 2
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Cough and Arthritis and Fatigue
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When to treat a patient with Sarcoid (with corticosteroids)?
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if symptomatic
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Electrolyte abnormality common in Sarcoid that indicates treatment with corticosteroids.
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Hypercalcemia
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moldy hay: what classic Pneumonitis?
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Farmer's Lung
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feathers: what classic Pneumonitis?
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Bird Fancier's Lung
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actinomycete spores from compost: what classic Pneumonitis?
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Muchroom worker's Lung
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aspergillus clavatus spores in grain: what classic Pneumonitis?
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Malt Worker's Lung
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grain weevil dust: what classic Pneumonitis?
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Grain Handler's Lung
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actinomycete spores in sugarcane what classic Pneumonitis?
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Bagassosis
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actinomycete spores from air conditioning: what classic Pneumonitis?
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Air conditioner lung
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Treatment of Pneumonitis? (2)
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1) avoid trigger (often involves change in occupation)
2) corticosteroids |
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calcified pleural plaques on CXR. Diagnosis?
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Asbestosis
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cancer associated with asbestosis?
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mesothelioma
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Eggshell calcifications on CXR. Diagnosis?
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Silicosis
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Pneumoconiosis associated with high-technology fields (aerospace, power plants, ceramics, plating facilities, dental material, dyes).
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Berylliosis
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Confirmational test for interstitial pneumonia (pulmonary fibrosis)?
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surgical biopsy
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Prognosis for Usual Interstitial Pneumonia (Idiopathic Pulmonary Fibrosis)?
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death within 5-10 years
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Diagnosistic findings of Eosinophilic Pulmonary Syndromes (allergic aspergillosis, lofflers syndrome, eosinophilic pna)
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CBC showing Eosinophilia with CXR showing pulmonary infiltrates.
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Pulse Oximetry shows decreased HbO2 saturation (hypoxemia). First 2 tests to order.
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CXR and ABG
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Another name for respiratory acidosis?
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hypercapnia
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Diagnostic test to confirm hypoventilation as the cause of hypoxemia.
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PaCO2 will be increased with hypoventilation
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Why use HCO3 from BMP instead of from ABG in acid-base work-up?
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HCO3 in ABG is calculated but it is measured in BMP
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PaCO2 is elevated (hypoventilation). How to r/o another contributing mechansim to the hypoxemia?
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If Aa gradient is also increased, there is another mechanism as well as the hypoventilation
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Patient hypoxic on ventilator. What to adjust first?
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Increase FiO2 (up to 0.5)
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Patient hypoxic on ventilator despite increasing FiO2. What to adjust next?
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Increase PEEP
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Patient on ventilator develops hypercapnea (respiratory acidosis). What to adjust?
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increase Minute Ventilation
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How to diagnose a V/Q mismatch
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Increased Aa Gradient
PO2 corrects with O2 |
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How to diagnose a Shunt as cause of hypoxemia.
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Increased Aa Gradient
PO2 does not correct with O2 |
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Hypoxemia with Normal Aa gradient and normal PaCO2. Diagnosis?
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Low FiO2 (e.g. Altitude)
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CXR in ARDS.
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diffuse bilateral infiltration sparing costophrenic angles
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How to differentiate between Acute Lung Injury (ALI) and ARDS.
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PaO2:FiO2 less than 300 = ALI
PaO2:FiO2 less than 200 = ARDS |
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ARDS diagnostic mnemonic for ARDS.
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Acute Onset
Ratio PaO2:FiO2 less than 200 Diffuse infiltration on CXR Swan-Ganz wedge pressure less than 18 |
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Pulmonary Capillary Wedge Pressure in ARDS (which rules out cardiac origin)
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less than 18
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Mortality rate for ARDS.
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30%
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Pulmonary Capillary Wedge Pressure (PCWP) elevation means what?
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elevated left atrial pressure
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How to adjust on ventilator to help recruit collapsed Alveoli (e.g. ARDS).
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increase PEEP
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PFT pattern for most pneumoconiosis.
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restrictive
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Of the 4 phases of ARDS, when do you find infiltrates on CXR?
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phase 3
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Ventilation adjustment in ARDS to minimize iatrogenic damage.
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low tidal volumes
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What is phase 4 of ARDS
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severe hypoxemia, shunt, and mixed acidosis
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Which valve disease commonly causes pulmonary hypertension?
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mitral
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VSD, ASD, PSD which develop left-to-right shunts need to be corrected in order to avoid this.
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pulmonary hypertension
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COPD causes pulmonary hypertension by what mechanism.
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hypoxic vasoconstriction
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How does left sided heart failure cause right sided heart failure
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pulmonary hypertension
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How to make an incidental diagnosis of pulmonary hypertension. (2)
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CXR shows enlarged arteries
ECG shows RVH |
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Confirmatory test for pulmonary hypertension.
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Echo +/- catheterization
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If Pulmonary Embolism is causing pulmonary hypertension and right heart failure, what additional treatment?
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thrombolysis
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95% of Pulmonary Emboli are from where?
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DVT from deep leg vein
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3 etiologies of Pulmonary Embolism besides DVT.
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1) amniotic fluid emboli
2) fat emboli (e.g. femoral fx) 3) air emboli (e.g. cardiac surgery) |
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VIRchow's mnemonic for the triad of venous thrombosis risk.
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Vascular trauma
Increased coagulability Reduced blood flow (stasis) |
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ECG in Pulmonary Embolism (the uncommon classic triad)
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S1Q3T3:
S in I Q in III T inverted in III |
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sudden SOB and tachycardia in a bedridden patient. Diagnosis?
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PE
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Pleuritic Chest pain plus hypoxia. Diagnosis?
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PE
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Confirmatory test of choice for PE.
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CT with IV contrast
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Confirmatory test of choice for PE in pregant woman or otherwise contrast contraindicated?
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V/Q scan
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Anticoagulation regimen in PE
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Heparin bridge to Coumadin
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How long to extend anticoagulation past the regular 6 months post PE if patient has Factor V Leiden?
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life-long
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What DVT prophylaxis to give immobile patients?
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lovenox (enoxaparin); early ambulation most effective when possible
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Follow up test after incidental lung nodule found on CXR.
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CT scan
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URI sx in recent immigrant found to have lung nodule. Diagnosis?
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TB
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URI sx in Patient from Arizona found to have lung nodule. Diagnosis?
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Coccidioidomycosis
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URI sx in Patient from Ohio found to have lung nodule. Diagnosis?
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Histoplasmosis
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CXR follow schedule for low risk lung nodule.
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q3 months for 1 year
then q6 months for another year |
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URI sx in Patient from Great Lakes Region. Consider what endemic infection?
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Blastomycosis
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Carcinoma lung nodule: characteristic calcification description
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NOT calcified or
IRREGULAR calcification |
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What is the threshold for biopsy in work-up of incidental lung nodule?
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over 2 cm gets biopsy
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This type of lung cancer is the most common type and is not associated with smoking.
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Adenocarcinoma
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These 2 types of lung cancer is highly associated with smoking.
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Ssssquamous and Ssssmall cell cancers are associated with Ssssmoking
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What 2 cancers to suspect if a centrally located lesion.
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Ssssquamous and Ssssmall cell cancers are usually Ssssentral in location
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Lung cancer that most commonly metastasizes (usually by the time of presentation).
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Small cell lung cancer
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Paraneoplastic SIADH. What type of cancer
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Small cell lung cancer
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Paraneoplastic Eaton-Lambert Syndrome. What type of cancer?
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Small cell lung cancer
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a rare type of lung cancer that has the worst prognosis.
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Large Cell/Neuroendocrine Carcinoma
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Where is the classic lesion located in Lung Adenocarcinoma?
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Peripherally
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Pancoast's tumor (at the apex of the lung) can cause this syndrome.
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Horner's (miosis, ptosis, anhidrosis)
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Which nerve is involved in the hoarsness created by obstructing lung cancer?
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recurrent laryngeal nerve
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Supraclavicular venous engorgement. What is this called? (e.g. in patient with obstructing lung cancer.)
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Superior Vena Cava Syndrome
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Hypercoagulability as a paraneoplastic syndrome. What type of lung cancer?
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Adenocarcinoma
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Treatment for Small Cell Lung Cancer?
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Chemo to prolong life
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4 most common sites of metastasis from lung cancer (BLAB mnemonic)
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Bone
Liver Adrenals Brain |
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Treatment for NSCLC (Adeno-, Squamous Cell, or Large Cell Carcinoma) of the lung,.
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surgical resection if possible, then radiation and chemo
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Treatment of Brain metastasis from lung cancer. (2 options based on number of mets)
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1 met = surgery
more = whole brain (palliative) radiation |
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Where do you see pleural effusions?
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costophrenic angle
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Pleural effusion due to elevated PCWP or decreased oncotic pressure.
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Transudate
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Pleural effusion due to vascular permiability.
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Exudate
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When to get thorocentesis of Pleural Effusion?
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if over 1 cm
and if unilateral |
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3 causes of Transudative Pleural Effusion (memorize these: the others are Exudative!)
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CHF
Cirrhosis Nephrotic Syndrome |
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Effusion found to contain puss. What is this called?
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Empyema
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4 independent criteria to classify parapnemonic effusion as complicated.
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positive gram stain
pH under 7.2 glucose under 60 pus (empyema) |
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Treatment for Complicated Parapneumonic Effusion.
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Chest tube drainage in addition to Antibiotics
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Lights Criteria that classifies Effusion as Exudative (1 or more of 3)
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Pl-Protein/S-Protein less than 0.5
Pl-LDH/S-LDH less than 0.6 Pl-LDH over 2/3rds of upper limit of normal S-LDH |
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Tracheal Deviation. What type of pneumothorax?
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Tension Pneumothorax
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Treatment of Tension Pneumothorax?
|
emergent needle compression followed by chest tube
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Treatment for Flail Chest?
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Positive Pressure Ventilation
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Treatment of large pneumothorax?
|
chest tube
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Treatment of small pneumothorax?
|
supportive (O2)
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Positive Pressure Ventilated patient suddenly gets pleuritic chest pain and reduced breath sounds on one side. Diagnosis?
|
Tension Pneumothorax
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2 most common causes of tension pneumothorax.
|
penetrating trauma
infection |
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No fremitus (vibration with vocal cords) palpated on one side of chest. Diagnosis?
|
pneumothorax
|
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Spontaneous Pneumonthorax more common in this type of patient.
|
Tall, thin, young male
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