Genmed Exam Ii

Front 1

R lobes vs L lobes
Each lobe = %fxn
Each lung ___ segments
Gas xchange @___ branches
Alveolar ducts @___ branches
Sacs @ ____ branches

Back 1

- Right = 3 lobes (55%)
- Left = 2 lobes (45%)
- Each lobe = 20% lung fnx
- Each lung = 10 segments
- gas exchange starts @ 17 branches
- alveolar duct @ 20 branches
- sacs @23 branches = most gas exchange

Front 2

4 types of cells in the lungs

Back 2

type 1- Gas exchange alveolar cells
tyep 2- produce surfactant
Primary cells- macrophages
associated endothelial cells

Front 3

A/a gradient

Back 3

A-a Gradient: Alveolus : arteriole
- Capacity of lungs to oxygenate blood – difference btwn alveolar and arterial O2.
Higher A-a gradient = worse Px. Normal gradient is 7-14.

Front 4

Understand how change in atmosphere or CO2 will change the PaO2 equation

Back 4

Decreased atmospheric pressure drops it
increased CO2 in lungs will drop it (its a ratio, when CO2 goes up O2 HAS to go down.

Front 5

V/Q

Back 5

Volume of Air to a section
Flow of blood to a section
ideal is 1 but higher vent at top and higher Q at bottom makes natural inequality
High = lots of air - little blood (PE possibly)
Low = Little air- lots of blood (leads to SHUNT)

Front 6

Blood pH evaluations

Back 6

- Low pH= Acidosis – caused by High PaCO2, lactic acidosis, Kidney dz, toxins
- High pH = Alkalosis – caused by Low PaCo2, met alkalosis, hyperventilation

Front 7

define
FVC
FEV1

Back 7

- FVC: forced VC (expired)
- FEV1: forced expired in 1sec
FEV1/FVC: <70 = obstruction
- low in Obstructive lung dz.

Front 8

Lung Volume and associated diseases indicators

Back 8

Lung Volumes
- high: emphysema
- normal/high: asthma/CB
- low: restrictive lung dz

Front 9

Diffusing Capacity and diseases

Back 9

Diffusing capacity – how well O2 getting into blood
(↓ in emphysema; fibrotic lung dz)
- Low: emphysema; restrictive lung dzs
- normal: asthma/CB

Front 10

Obstructive lung disease Pulmonary Function tests:

Back 10

low Fev1/FVC <70%
High volume
Low diffusing Capacity
Asthma has >12% bronchodilation response

Front 11

Restrictive lung disease Pulmonary Function tests

Back 11

Normal to increased FEV1/FVC
Low volume
Low difusing capacity

Front 12

What are the Obstructive lung disease?
Restrictive?

Back 12

Asthma, COPD, CF
Pulm Fibrosis, Sarcoidosis, Neromm dz, Pulmonary Edema

Front 13

Effects of surgery on lung function

Back 13

- More risk = ab/thoracic surgery: sig effects post op
- less risk = surgery on limbs: not ass w/ Δ in lung fnx, but may predispose to other pulm complications
- ↓ lung vol; poor cough due to sedation/pain meds; immobility; post op infxns; COPD exacerbation: gets worse (death 5% - not uncom)

Front 14

considering VQ inequality what is a Zero Q? What is a Zero V?

Back 14

Q is called dead space- O2 supplement will help
V is called Shung- O2 will not help.

Front 15

What are the 4 mechanisms of hypoxia?

Back 15

COPD or Asthma (V/Q inequality)
ARDS or Aspiration
Hypoventilation (decreased central dirve or ability to ventilate)
Pulmonary Fibrosis (diffusion defects)

Front 16

Diffuse interstitial lung disease clinical

Back 16

SX: SOB w normal activity, NonProdCough
CXR: diffuse linear or Nodular scarring prominent @bases
PFT: Dec Vol, Diffusing Capacity, FEV1/FEV is Normal
TX:

Front 17

Sarcoidosis Lung disease Clinical

Back 17

SX: 20-40yo, US-black, SOB, Cough, Rash, Iritis, noncaseating granulomas on multiple organs (liver, bone, heart, erythema nodosum
CXR: Hilar LN enlargement w/ no-caseating Gran.
PFT: Dec Vol, Diffusing Capacity, FEV1/FEV is Normal
TX: Corticosteroids, Methotrexate (diabetics who can't tolerate corticosteroids)

Front 18

Idiopathic Pulmonary Fibrosis Clinical

Back 18

SX: 60-70yo Only lungs involved, Crackles, Clubbing of digits, cough
CXR: Honeycombing, bronchiectasis, reticular opacities
biopsy shows normal tissue next to abnormal w/o transition
PFT:
TX: "no proven therapy," Transplant

Front 19

What is the most common cause of decrease in lung volume with no change in diffusion capcaity?

Back 19

Obesitay!

Front 20

What neuromuscular diseases can cause Restrictive lung diseases/

Back 20

ALS
Myasthenia Gravis

Front 21

What are the two features of Asthma and the appropriate Tx?

Back 21

1- airway bronchospasm (hyperactivity >12%): Bronchodilators
2- Airway inflammation and mucus: corticosteroids

Front 22

What are the sings of poor control in an asthmatic?

Back 22

Signs of Poor Control: *RULE OF 2s
- must use “rescue” meds >2x/week
- nighttime awakening due to breathing >2x/month
- do NOT do elective surgery if poor control

Front 23

Define Status Asthmaticus

Back 23

Status Asthmaticus: severe asthmatic episode that is NOT responsive to repeated tx w/ usual inhaled medications (probably due to mucus) (if doesn’t improve w/ 2nd admin of meds w/ 5 min btwn admin – seek medical help)

Front 24

Treatment for SEVERE asthma

Back 24

Severe:
-1st inhaled corticosteroids (Flovent/Pulmacort)
*when above doesn’t control, use combo:
-2nd inhaled long acting bronchodilator (don’t use by themselves)
- Leukotriene receptor antagonist (Singulaire)
- Anti Ig E tx (Zolaire) – injxn 2/week – serious
- oral steroids (prednisone)

Front 25

What is the most important way to prevent the onset of progression of COPD?

Back 25

Smokin Cessation

Front 26

compare Sx of CB and Emphysema

Back 26

CB is an inflammatory problem around the airways
Emphysema is actual destruction of the lung tissue without inflammation or cough (remember the antitrypsin thingy bob)

Front 27

COPD Severity is indicated by Spirometry (FEV in particular), What are the 5 stages?
-Remember that to have any Obstructive dusease has to have a FEV1/FEV ration of?

Back 27

Ratio will always be <70%
0- FEV is normal = at risk of COPD
1- Mild: FEV >80
2- Mod: FEV 50-80
3- Sev: FEV 30-50
4- Very bad: FEV <30 or Pao2 hypoxic w FEV < 50

Front 28

what are the factors influencing survival in COPD?

Back 28

BODE (doesn't bode well for them)
B-BMI
O- degree of obstruction (FEV1)
D- dyspnea level: how SOB
E- Exercise capacity (6min walk-how far can you go?)

Front 29

Drugs used in COPD:

Back 29

(BAD!)
Brochodilators
- B2 agonists (albuterol, salmeterol (long acting))
-Anticholinergic (Ipratroprium, Tiotroprium (LA))
-Methylxanthine (theophyline)
Anti Inflammatories
-Inhaled Steroids: Fluticasone, Budesonide
Dual Action Tx:
-Albut + Ipratrop
-Bude + Form
-Flut + Salm

Front 30

What is the step-wise approach to tx of COPD?

Back 30

Bronchodilators O2 tx  exercise training/Rehab
- Dyspnea ↓ & exercise tolerance ↑
*Smoking cessation is KEY; reg use of inhaled meds; flu & pneumonia vaccines; reg exercise; good nutrition/ wt control; rapid tx of exacerbations

Front 31

Tell me about CysticFibrosis

Back 31

genetic dz (m/c fatal auto recessive among caucasion pops (1 in 2000-3000 live births)
*Usual sxs: (mainly found in childhood)

Front 32

Sx of Cystic Fibrosis

Back 32

Mainly found in childhood, Persistent Pulmonary infection (pseudomonas), Pancreatic insufficiency, Elevated sweat chlroine test
Pulmonary:
-Persistent productive cough
-Airflow obstruction
-bronchiectasis
Physical finding:
-wheezing
-clubbing
Other Sx:
-Sinus dz (sinusitis or polyps)
-Pancreatif insufficiency with malabsorption
-Infertility

Front 33

Tx of Cystic Fibrosis Lung disorders

Back 33

- tx & prevention of respiratory infxns
- reg respiratory therapy to clear airway secretions
- lung transplant for severe lung dz

Front 34

Common Cold

Back 34

SX: not localized, fever, malaise w/o lymphadenopathy, mild sore throat
TX: Tylenol, Cepastat/Benadryl for sore throat

Front 35

Influenza

Back 35

SX: Prominent Fever, Malaise, myalgia everywhere, non-specific runny eyes/nose, scratchy throat, seasonal
Dx: Nasopharyngeal swab
Tx: in first 2 days- Tamiflu 75mg BIDx 5 days
-post 2 days sx releif

Front 36

Acute Pharyngitis

Back 36

SX: Beefy Red pharynx w/ purulence, Fever, Anterior Cervical Lymphadenopathy
Dx: Usually Strep- Rapid strep test, ASO titer
TX: Amoxicillin or Ampicillin

Front 37

Mono

Back 37

SX: Dull white grey exudate, possible hepatosplenomeg, POST cervical adenopathy
Dx: monospot/CBC (atypical lymphs)
TX: Amoxicillin Ampicillin
- if causes rash- give corticosteroids

Front 38

Sinusitis

Back 38

SX: Facial pain due to Sinus ostial obstruction
Acute: <4wks
-following URI (opportunistic Pathogens)
-Noninfectious: Polyps, irritants, tumor, (any obstruction)
TX: Empric: Narrow spectrum antibiotics (Amox, TMP, SMX)
- if >7days w/ purulence give Ampicillin/sulbactim or augmentin or oxyquinolone.
-if narrow is uneffective give Levoflox

Front 39

otitis Externa

Back 39

Swimmer's ear: Crusty goodness
Cause- usually pseudomonas, sometimes staph
TX: Ciprofloxacin drops w/debridement

Front 40

Otitis Media

Back 40

Usually Bacterial infx following viral URI
Tx: Amox or no Amox w/ tylenol

Front 41

Recurrent Otitis Media

Back 41

> 4 in 1 yr or
3 in 6 months
Tx: bata lactam antibiotics
- possibly maintenance w/ TMP/SMX; possible myrinotomy tube
- 1 dose daily of TMP

Front 42

Serous Otitis Media

Back 42

Serous otitis media:
Usually goes away on its own but slowly
consider antibiotics and/or myringotyomy tubes if sig hearing loss/effusion > 3 mo – conductive

Front 43

Chronic Otitis Media

Back 43

Chronic otitis media:
-recurrent purulent drainage w/ a chronic TM perforation; usually requires mastoidectomy & tympanoplasty
- usually pseudomonas – resistant to many txs

Front 44

Laryngitis:

Back 44

inflammation of the larynx
nearly always viral
Tx: Don't talk

Front 45

Epiglottitis

Back 45

Epiglottitis: potentially fatal
- usually H. influenza
- pools of saliva around epiglottis; narrowed opening – intense wheezing (stridor)
- lateral neck films; cherry red epiglottis w/ fiberoptic rhino-laryngoscopy (visualize thru nose)

Hospitalization/ICU possible tracheostomy
Tx: Ampicillin/sulbactam or (2nd/3rd generation cephalosporin
- Hib vaccine – prophylaxis
- (↓ incidence)

Front 46

Acute Bronchitis

Back 46

SX: cough w/ sputum production- purulent or foamy, no fever, occasional rhoncus
Dx: absence of abnormality on CXR
TX: quinalone (especially in pt with COPD)

Front 47

Sever Bronchitis

Back 47

Acute with
1- increased amount of sputum
2- change in color of sputum
3- increased SOB
4- FEVER
TX: Z-pac with possible tx of bronchospasm

Front 48

Pleurisy

Back 48

*inflammation involving surface of lung
- 1⁰ sxs: chest pain, worse w/ inspiration
-lasts about a month
- usually viral
- tx: sxs – DOC = NSAIDs; narcotics in severe cases
- Terrible terrible = corticosteroids

Front 49

What are the general sx of pneumonia?

Back 49

Cough
Fever/Chills
dyspnea
Malaise/sepsis
Confusion in elderly

Front 50

What are the general physical findings of Pneumonia?

Back 50

Fever and Tachycardia
Tachypnea
Crackles, sometimes wheezes or absent breath sounds
Fremitus/egophony w/ consolidaiton

Front 51

What are the 5 causes of pneumonia

Back 51

Bacterial +: Strep Pneumonia, -: Klebsiella, Psuedomonas
Fungal: Cocci, Histoplasmosis, Blastomycosis, Aspergillis
Mycobacterium: TB, Avium intercellulare
Viral: RSV, Adeno, Flu
Atypical: Chlamydia, mycoplasma

Front 52

Community Acquired Pneumonia 2 types

Back 52

Previously healthy outpatient- Gram+, Atypical, Viral, Fungal w/ low mortality
Older (>65) or w/ cardiopulm dz: add G-, aspiration, higher mortality

Front 53

Hospital Acquired Pneumonias severity types

Back 53

Floor: most common is S. Pnuemonia with mortality of 5-20%
ICU: S. Pneumonia w/ MRSA. Mortality of 25-30%
- add in Pneumocystis in unsuspected HIV patient

Front 54

Pathogens in Immunocompromised Pt

Back 54

Bact: Pseudomonas, Nocardia
Fungal: coccidiomycosis, Aspergillis,
Mycobacterium
Viral (CMV)
Protozoal
--- all have a poor prognosis

Front 55

Clinical signs of severe pneumonia

Back 55

hypoxia w/ SOB, SaO2<92%
Tachycardia
Hypotension (indicates septic shock)

Front 56

Walking pneumonia that lasts a long time is mainly caused by

Back 56

any atypical pathogen

Front 57

TX for more severely ill Pneumonia Pt

Back 57

Initial empiric coverage w/ mutliple antibiotics for a variety of pathogens
-Ceftriaxone 2gIV daily w/ Levoflox 750mg orally

Front 58

Tx for mildly ill Pneumonia Pt
Moderately?

Back 58

Empiric Macrolide - Erythromycin
Quinolone

Front 59

Pt comes in with mild non productive cough, cxr reveals infiltrates in RUL. What is the suspicion?
What is the Tx?

Back 59

First- pneumonia, second cocci, 3rd maybe TB or Viral. So while you are waiting for all your cultures to come back what do you treat him with?” Azythromycin: covers typical and atypicals- place to start.

Front 60

Latent TB definition
Dx?
Tx?

Back 60

Not active disease aquired previously -NOT infx
DX: manitoux intradermal injection of PPD +=+
TX: DOC is Isoniazid and B6 50mg for 9 mo
-Isoniazid resistant: Rifampin 300mg for 4 mo

Front 61

Increased risk for TB?

Back 61

prisoners, nursing home, hospital/health workers; Indian reserve
- rate of hospital workers as high as 50%

Front 62

Define Active TB
Dx?
Tx?

Back 62

evidence of TB most often multiplying in lungs or extrapulm site- INFXous
DX: Sptutum AFB smear and culture x3, occasional bronchoscopy
TX: 4drug combo: Isoniazid +b6, Rifampin, Pyrazinamide, Ethambutol for 2 months
-then Isoniazid, B6 and Rifampin for 4 months
NOTE: Need to report to state: skin test all contacts

Front 63

Primary TB

Back 63

first exposure- Not INFXous
SX: cough, minor sx for 2-4wks
DX: Central infiltrates on CXR
TX: prevent

Front 64

Secondary TB

Back 64

"Reactivated"- INFXous
SX: Cough w/ hemoptysis, fever and Nightsweats, Fatigue
DX: peripheral and apical CXR infiltrates, Hilar adenopathy
Ghon's complex

Front 65

Secondary TB course of infection

Back 65

Infection -> granuloma -> m/o remains viable, but sequestered -> dz may “reactivate” & begin growing
- may experience complications of pneumonia and tubercles in organs: Kindeys, Brains, Bones's

Front 66

what is a key source of false + TB tests?

Back 66

Pt who received CBG vaccine

Front 67

PE risk factors

Back 67

• recent surgery (knee/hip); trauma; immobilization (also travel, prego, obesity) anything that leads to stasis of blood.
• cancer (hypercoagulability state – also Estrogen (birth control), prego, obesity, genetic/acquired thombophilia – ATIII/Protein C/S def; Factor V Leiden; SLE)
• Prior hx of DVT or PE
• smoking; air embolism (air in IV needle); amniotic fluid embolism, placenta previa (placenta separates before baby is born)

Front 68

3 primary presentations of PE:

Back 68

1. Pleuritic pain – esp w/ deep breath; abrupt – infarcts part of lung – see wedge on CXR; /hemoptysis – (generally after acute event) = 65%
2. isolated dyspnea = 22%
3. Circulatory collapse – SOB = 8%

Front 69

DX of DVT

Back 69

*US of LE*; spiral CT; d-dimer

Front 70

PE prophylactic TX

Back 70

• prophylactic tx w/ lose dose heparin in high risk pts: low dose hep post op, then 4-6 weeks of Coumadin following arthroplasty

Front 71

EKG signs of PE

Back 71

• EKG: cor pulmonle w/ RAD; increased p wave amplitude in lead II; large S wave in lead I; ST depression in lead II; large W wave w/ t wave inversion in III

Front 72

What is the most useful test in DX PE?

Back 72

D Dimer

Front 73

PE treatment course

Back 73

• Initial tx = Heparin
• If unstable pt – consider thrombolytic therapy (TPA) or surgical embolectomy, someone who is hemodynamically really compromised.
• Long term tx = Warfarin (Coumadin) – 1st episode: 6 months of therapy; 2nd episode: Lifelong therapy; if pt has predisposing factor: Lifelong therapy
• Filter in subclavian vein to IVC to catch clot

Front 74

Risks for Lung Cancers

Back 74

Risk- 90% - smokers/ex
- women- 15-20% nonsmokers
- ↑ risk w/ Carcinogens (asbestos/air pollution); 2nd hand smoke, fam hx of lung cancer

Front 75

Signs of possible lung cancer

Back 75

- Cough m/c sx; Hemoptysis (centrally located m/c); wheeze, SOB, dysphagia (compression of esophagus); wt loss (unexplained);
chest discomfort (impinge bvs - 2⁰ to growth);
- **signs of metastatic dz (liver, bone, brain, adrenal glands, could mimic CVA/seizure) – lung cancer is usually aggressive & met is common

Front 76

5 common types of lung cancer

Back 76

Adenocarcinoma- m/c peripheral
SCC- Smoker Central Cancer
Small Cell Carcinoma- Agressive, rarely tx w/ surgery, smoker
Large Cell Carcinoma- less common, peripheral
BAC- NOT related to smoking, slow, looks like infiltrate pneumonia, multifocal

Front 77

Lung Cancer Tumor Staging

Back 77

Staging: (*3 & 4 m/c dx since we usually “catch” these lung cancers late – no surgery is usually performed do to LN involvement & metastasis)
1 – small (3 cm) No involvement of LN (N0)
2 – larger, possible hilar LN involvement (N1)- can be resected
3 – mediastinal LN involvement (N2)- no longer resectable
4 – Metastatic dz

Front 78

Lung cancer Dx, TX, Px?

Back 78

DX: • Routine CT scans in select grps w/ cig smoking hx may ↓ mortality ;
• screening bronchoscopy w/ autoaluorescence (blue light will show up brown where neoplastic cells are located)
TX: • for NON-small cell lung cancers – surgery is the only tx that offers significant chance @ long term survival (<5yrs)
• Surgery @ stages 1 & 2, but many not be able to do if pt has comorbitity – COPD, etc.; not recommended @ stage 3.
PX: • even in Stage 1 – 1/3 pts still die w/in 5 yrs (relapse even w/ surgery);
• survival in stage 4: <2 yrs