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174 Cards in this Set

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