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335 Cards in this Set

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What is a white blood cell count and differential?
Total number of white blood cells (leukocytes) in 1mm^3 of peripheral blood.

Differential measures the percent of each type of leukocyte present.
What are white blood cells involved in?
The immune response.
What is a normal range for WBC count?
From 5000-10000
How do you express CBC in bar form?
Left-WBC
Right-PT
Upper-Hgb
Lower-HcT
What is leukocytosis?
Abnormal condition characterized by an increase in WBCs. They are >10000cells/mm^3.
If your pt's lab results show leukocytosis what might you suspect as the cause?
Infection
Inflammation
Tissue necrosis
Leukemic neoplasia
They can increase with trauma or stress.
What is leukopenia?
A deficiency of WBCs with a count of <4000cells/mm^3
What might leukopenia indicate?
Bone marrow failure- for some reason not enough cells are being created.
Besides a WBC count what is another test that can also detect inflammation?
C reactive protein
If the WBC count is >50000 cells what can be a possible cause?
Leukemoid rxn - when a normal person is responding to an illness and just produces too many WBCs - you might also consider leukemia.
What is the general differential count of WBCs (percentages)?
Neutrophils - 60s
Lymphocytes - 30
Monocytes - 6
Eosinophils -3
Basophils - 1
What white blood cells are considered granulocytes and why?
Neutrophils
Eosinophils
Basophils
These are multibed nuclei,polymorphonuclear leukocytes. (Poly's or PMNs)
What white blood cells are considered nongranulocytes?
Lymphocytes
Monocytes
What is a "shift to the left"?
This is seen with ongoing bacterial infections and there are many early immature Neutrophils called Bands present.
Usually >80% of the WBCs will be neutrophils.
What are basophils also known as?
Mast cells
What are basophils and eosinophils effected by?
Allergic rxns
Parasitic infections
Collagen vascular disease
What are basophils and eosinophils usually not affected by?
Bacterial or viral infections.
What is basophilia?
Increased number of basophils. >100
What is eosinophilia?
Increased number of eosinophils? >500
What are lymphocytes?
A type of leukocytes. T and B cells that fight chronic bacterial and acute viral infections.
What are monocytes?
A type of leukocyte that fights bacterial infection.
Where are red blood cells produced?
In the bone marrow by erythoid elements (Erythropoietin).
What is the RBC count?
The number of circulating RBCs in the blood.
What is the hemoglobin count?
Total amount of hemoglobin in the blood. Hemoglobin carries oxygen and CO2. This value helps to determine the number of RBCs in the blood.
What is the hematocrit (Hct)?
% of total blood volume made up by RBC's. Normally 3x the amount of hemoglobin.
What might cause the hemoglobin to be decreased?
Sickle cell disease
Hgb C disease
What might decrease the hematocrit level?
Anemia and increased erythrocytosis.
What is the difference btwn hemoglobin and hematocrit?
Hemoglobin (Hgb) is the iron-containing protein that bonds with oxygen, allowing the red blood cells to transport oxygen throughout the body. Hematocrit (HCT, sometimes called Packed cell Volume, or PVC) measures the portion of blood volume made up by red blood cells. These two blood tests are not the same but they both reflect the red blood cell count.
How are red blood cells described?
1)Size
2)Weight
3)Hgb concentration
What is red blood cell size indicated with?
MCV (Mean corpuscular volume) and RDW (Red blood cell distribution width)
What indicates red blood cell weight?
MCH (Mean corpuscular hemoglobin).
What indicates red blood cell concentration?
MCHC (Mean corpuscular hemoglobin concentration)
What are the 3 levels of variation when looking at red blood cell size?
Normocytic
Microcytic (decreased MCV)
Macrocytic (increased MCV)
What are the 3 levels of RBC concentration, i.e. hemoglobin content?
Normochromic (normal color)
Hypochromic (decreased MCHC <32%)
Hyperchromic (increased MCHC)
What is a platelet count?
A count of the number of platelets per cubic mm of blood.
What are platelets essential for?
Blood clotting.
What are values for normal, increased, and decreased platelet count?
Normal 150000-400000/mm3
Thrombocytosis >400000/mm3
Thrombocytopenia <100000/mm3
What might 6 causes be for thrombocytopenia?
1)Reduced production
2)Sequestration of platelets
3)Accelerated destruction
4)Consumption of platelets
5)Platelet loss from hemorrhage
6)Dilution with large volumes of blood transfusion
When is a blood culture obtained?
When you want to detect bacteria in the blood.

"Bacteremia" - usually accompanies fever chills
How are blood cultures obtained?
2 cultures at 2 different sites
Best to draw prior to antibiotic administration
Requires 24-48 hours to grow
(Can be contaminated by poor technique)
What is the difference between the 2 tubes taken during a blood culture?
One tube is anaerobic and one is aerobic.
What do pulmonary function tests measure (PFTs)?
How well the lungs take in and exhale air and how efficiently they transfer oxygen into the blood.
What 5 tests (if all can be done) are during a pulmonary function test?
1)Spirometry
2)Flow volume loops
3)Lung volume measurement- both static and dynamic
4)Diffusion capacity of CO
5)Arterial blood gas
What does spirometry provide information about?
Obstruction or restriction of airflow.
FVC, FEV1, and FEV1/FVC ratio
Which test amoung the PFTs require more advanced equipment?
Diffusion capacity of CO
Arterial blood gas
What does a measurement of diffusion capacity of CO tell you about?
Interstitial lung disease
When measuring lung volumes which measurements occur during normal breathing and which require special testing?
Dynamic- during normal breathing
Static- special testing
What are 7 reasons PFTs are performed?
1)Diagnose lung disease
2)Determine strength and fxn of chest muscles
3)Follow disease progression
4)Assess respiratory response to treatment
5)Assess baseline prior to prescribing drugs
6)Preoperative risk assessment
7)Worker's compensation/disability evaluation following exposure
When using a PFT to diagnose disease, what is needed as well?
Hx and physical exam - PFT can't be used alone
With what patients are PFTs more reliable?
Those with risk factors:
1)>45yo and current or former smoker
2)Prolonged cough or sputum production
3)Hx of exposure to lung irritants
Give an example of a condition where PFTs are used to assess respiratory response to treatment.
Asthma- bronchodilators
What are 2 medications given that can cause terrible respiratory compromise over time?
Amiodarone
Bleomycin
How is the patient prepared for PFT testing?
1)Explain procedure-office based
2)Avoid analgesics
3)Withhold bronchodilators
4)Instruct pt to void, loosen restrictive clothing,remove dentures,and avoid heavy meals.
5)No smoking for 4-6 hrs prior to test
Why would you want to avoid analgesics prior to PFT testing?
It might depress respiratory function.
What are the rules about withholding bronchodilators as far as PFT testing?
Short acting beta2 agonists 4-6 hrs before
Long acting beta2 agonists (Cromolyn,Iatropium)12 hrs before
Long acting theophylline 24 hrs before
How will the PFT test feel?
1)Nose clip and breathing will occur through a mouthpiece
2)Procedure takes about 20 min
3)Pt cooperation is crucial
(Poor seal around mouthpiece is critical)
4)Pt is standing!
What are the risks of PFT testing?
They are minimal-
Pneumothorax in pts with emphysema and this is contraindicated in those with recent MI or unstable angina
What is tidal volume and its normal value?
Volume of a single normal breath (usually at rest).
500cc
What is vital capacity?
The maximum volume that can be ventilated in a single breath. IRV+TV+ERV
What is IRV?
Inspiratory reserve volume-volume of air that can be inspired beyond a restful inspiration. 3100cc
What is ERV?
Expiratory reserve volume -volume of air that can be expired beyond a restful expiration. 1200cc
What is residual volume?
volume remaining in the lungs after a forced expiration- keeps alveoli inflated.1200cc
In what type of disorders is vital capacity reduced?
Restrictive
What is forced vital capacity?
Amount of air that can be forcefully expelled from a maximally inflated lung position.
Normal=80-120% of predicted value
what is force expiratory volume in 1 second?
FEV1 - Volume of air expelled during the first second of the forced vital capacity (FVC).
Normal=80-120% of predicted value
What is normal FEV1 to FVC ratio?
>75% of predicted
What is forced expiratory small airway flow (FEF25-75)?
The airflow rate of expired air between 25% and 75% of the flow during FVC.
What are normal spirometry screening values based upon?
Age
Height
Weight
Ethnicity
Gender
(expressed as percentage)
What 3 values will you be given during PFT?
Value found
Predicted %
Predicted value
What are the criteria for FEV1/FVC ratio?
>75% in pts younger than 60yo
>70% in pts older than 60yo
How many trials do you perform during one PFT test?
3
What might abnormal PFT results mean?
Lung disease
Obstructive:Asthma,COPD,Bronchiectasis,Cystic Fibrosis

Restrictive(Parenchyma):Sarcoidosis,Pulm Fibrosis,Pneumoconiosis

Restrictive(Extraparenchymal):Neuromuscular, Chest wall
What is the hallmark PFT change for obstructive lung disease - and value changes?
Decreased expiratory flow rates.
FEV1<80%
FVC normal or <80%
FEV1/FVC ratio <75%
Total lung volumes generally increased.

The flow volume loop as a concavity in the expiration portion.
What is the severity scale for FEV1 when testing pts with obstructive lung disease?
FEV1>80% Normal
FEV1 70-79% Mild obstructive
FEV1 50-69% Moderate obstructive
FEV1 <50% Severe obstructive
What is the hallmark PFT change for restrictive lung disease - and value changes?
Decreased lung volumes (esp TLC and VC).
FEV1 normal or <80%
FVC is decreased
FEV1/FVC ratio <75% (usually normal or increased)

The flow volume loop has less volume underneath it.
What is the severity scale for FVC when testing pts with restrictive lung disease?
FVC over 80%: Normal
FVC over 60%: Mild restrictive lung disease
FVC over 50-60%: Moderate restrictive lung disease
FVC under 50%: Severe restrictive lung disease
During spirometry, how will forced vital capacity be changed in patients with obstructive or restrictive lung disease?
O - Normal or decreased
R - DECREASED
During spirometry, how will forced expiratory volume in one second (FEV1) be changed in patients with obstructive or restrictive lung disease?
O - DECREASED
R - Normal or decreased
During spirometry, how will FEV1/FVC ratio be changed in patients with obstructive or restrictive lung disease?
O - decreased
R - Normal or increased
During spirometry, how will FEF 25-75% be changed in patients with obstructive or restrictive lung disease?
O - decreased
R - Normal or increased
During spirometry, how will Total lung capacity be changed in patients with obstructive or restrictive lung disease?
O - Normal or increased
R - decreased
During spirometry, how will Functional residual capacity (FRC) be changed in patients with obstructive or restrictive lung disease?
O - increased
R - decreased
During spirometry, how will Residual volume be changed in patients with obstructive or restrictive lung disease?
O - Normal or increased
R - decreased
What is the systematic method for reading the PFT?
Step 1. Look at the forced vital capacity (FVC) to see if it is within normal limits.

Step 2. Look at the forced expiratory volume in one second (FEV1) and determine if it is within normal limits.

Step 3. If both FVC and FEV1 are normal, then you do not have to go any further - the patient has a normal PFT test.

Step 4. If FVC and/or FEV1 are low, then the presence of disease is highly likely.

Step 5. If Step 4 indicates that there is disease then you need to go to the %predicted for FEV1/FVC. If the %predicted for FEV1/FVC is 88%-90% or higher, then the patient may have a restricted lung disease. If the %predicted for FEV1/FVC < 70%, then the patient has an obstructed lung disease.
If your patient is diagnosed with an airflow obstruction pattern,how would you proceed with PFT testing?
Give the pt an inhaled bronchodilator and repeat spirometry in 10-20 minutes.
(cost of test increases a great deal!)
History
58 year old female
25 pack years of smoking
Shortness of breath on walking one block for 5 years
Wheezing while short of breath
Family history of Asthma
Had Asthma during childhood

Predicted Value
Observed Pre
% Predicted
FVC Liters3.29,1.66,50
FEV1 Liters2.61,1.25,47
FEV1/FVC %76,75,98
FEF25-75 L/S2.55,1.14,44

Diagnosis for patient?
From the number you might think restrictive lung disease, so now you need to look at actual volumes.
Which PFT measurements do you look at to determine whether there is a response to an administered bronchodilator?
FVC (you want at least 200ml increase)
FEV1 (you want to see increase of at least 12%)
What criteria do you use to classify a response during the PFT after bronchodilator administration?
FVC
FEV1
Significant: 2 of 3 indices show significant change
Moderate: 1 of 3 indices show significantchange
No response: None of 3 show significant change
What is the significance of a bronchodilator response?
Significant response: we can assume pt has asthma (restrictive airway dz)

Borderline response: seen in COPD pts

Lack of response: doesn't r/o asthma. pt could have been already on maximal bronchodilator therapy or refractory at time of bronchodilator admin
What pts are given bronchodilators?
All who are obstructed irrespective of the results from PFT study.
If you suspect musculoskeletal problems after a PFT test what test might you give?
MVV - because these pts wear out over time. big deep breaths over 6 seconds and then extrapolate the data to 1 minute.
What is oximetry?
Non invasive method of monitoring arterial blood oxygen saturation.
How do you measure a pts O2 level using oximetry?
Spectrophotometer probe that is connected to the pts finger, nose, or ear.
How does the oximeter obtain oxygen data?
The probe emits a red infared light that passed thorugh the body part and calculates how much light is absorbed by the hemoglobin.
What is SaO2 and what is the normal value in adults for this?
Ratio of arterial hemoglobin saturated with oxygen. This value is expressed as a percentage.

Normal:95-100%
Newborn-40-92%
When you combine SaO2 and the patients physiologic status what can be obtained? When is this info helpful?
A close estimate of the partial pressure of oxygen (PaO2).

When used between ABG determinations to reduce cost and number of blood draws.
How do alkalotic and acidotic states shift the oxygen-hemoglobin dissociation curve(%Saturation of oxyhemoglobin as a function of PO2)?
Alkalotic-to the left(heme less likely to give up O2)

Acidotic-to the right(heme more likely to give up O2)
Advantages of oximetry?
Quick,
noninvasive,
continuous,
results immediatly available,
can detect variations that might not be noted with ABG, alarms can be set for downward trends.
What are some disadvantages of oximetry?
1.Only provides O2 (1 determinant of ABG-no bicarb or pH)
2.Reading is probe placement dependent
3.Bright light around probe=difficult reading
4.False elevation if dyshemoglobins are present(CO) or in amemic pts.
5. Falsely low values for a # of reasons
What is an ABG?
Arterial blood gas allows assessment of:
1.Ventilation(pts respiratory status)
2.Metabolic(renal) acid/base and electrolye balance
3.Adequacy of O2
When would an ABG be indicated?
1.Any condition where you are concerned about respiratory distress.
2.Monitor pts on ventilators.
3.Monitor critically ill,non-ventilator pts.
4.Establish pre-op baseline values.
5.Clinical judgement
What test do you need to perform prior to obtaining an ABG?
Allen test -ensures collateral circulation(and know pt's temp)
What is important about the handling of the ABG sample once drawn?
Must be taken to lab very quickly becausee gases are still transferring.
3 risk of ABG draw?
1.Prolonged bleeding
2.Hematoma
3.Infection or nerve damage near puncture site
What type of pts would an ABG be contraindicated for?
1.Those with bleeding disorders
2.Pts on anticoagulation
3.Pts needing repeated measurements (you might place an arterial line in that case)
A man goes to the doctor and says to the doctor:
"It hurts when I press here" (pressing his side)
"And when I press here" (pressing the other side)
"And here" (his leg)
"And here, here and here" (his other leg, and both arms)

Your diagnosis?
So the doctor examined him all over and finally discovered what was wrong... "You've got a broken finger!
5 ABG values obtained from a sample and thier normals?
1.pH (7.35-7.45)
2.PaCO2 (35-45mmHg)
3.HCO3 (22-26mmHg)
4.PaO2 (80-100mg- really want 100)
5.SaO2 (95-100%)
Most important buffer in the blood?

FYI:A buffering agent adjusts the pH of a solution.Can be basic or acidic, in this case its basic!
Bicarbonate
What are 4 primary acid base disturbances?
1.Respiratory acidosis
2.Respiratory alkalosis
3.Metabolic acidosis
4.Metabolic alkalosis
Define respiratory acidosis and the usual lab values.
Increase in CO2 (which is an acid)
pH < 7.35
pCO2 >45 mm Hg
HCO3 Normal
What are the most common causes of respiratory acidosis, S/S,Treatment?
Most common causes:
hypoventilation,
retention of CO2 (COPD),
muscular weakness

Signs & Symptoms
decreased ventilation, altered sensorium, tachycardia, arrhythmias

Treatment:
Stimulation to increase ventilations by aggressive pulmonary toilet or by intubation (controlling the patient’s airway).
Define respiratory alkalosis and the usual lab values.
Decrease in CO2 (which is loss of an acid)

pH > 7.45
pCO2 < 35
HCO3 Normal
What are the most common causes of respiratory alkalosis, S/S,Treatment?
Most Common Causes
Hyperventilation
Emotions, pain
Brain trauma
Ventilator overventilation

Signs & Symptoms:
Tachypnea

Treatment:
Sedation
Voluntary breathing control
Tip of the day:
If lost in the wilderness. Take viagra and an iron supplement. This will turn you into a perfect compass.
Define metabolic acidosis and the normal lab values for this condition.
Loss of HCO3 - or addition of H+

pH < 7.35
pCO2 Normal
HCO3 < 21
What are the most common causes of metabolic acidosis, S/S,Treatment?
Most Common Causes:
Ketoacidosis – seen in diabetics (DKA)
Starvation (eating disorders)
lactic acidosis
severe diarrhea
renal failure

Signs & symptoms:
Headache, nausea, vomiting, diarrhea, sensorium changes, tremors, convulsions

Treatment:
Treat underlying disease (insulin, dialysis, IV HCO3)
When you see Metabolic acidosis what are you immediatly supposed to think to check?!
Anion gap
[Na + K] - [Cl + HCO3]
What is a tolerable anion gap?
10
What are causes of high or positive anion gap?
M - methanol/metformin
U - uremia
D - diabetic ketoacidosis
P - paraldehyde/propylene glycol
I -Infection/ischemia/ isoniazid
L - lactate
E - ethylene glycol/ ethanol
S - salicylates/starvation
Define metabolic alkalosis and the normal lab values for this condition.
Loss of [H+] or addition of [HCO3-]

pH > 7.45
pCO2 Normal
HCO3 > 26
What are the most common causes of metabolic alkalosis, S/S,Treatment?
Most Common Causes:
chronic vomiting
gastric suction
hypokalemia hypochloremia
Overuse of antacids

Signs & Symptoms:
Nausea, vomiting, diarrhea, sensorium changes, tremors, convulsions

Treatment:
Replace fluid losses, especially potassium (K+) and chloride (CL-)
What type of anion gap would a pt with chronic diarrhea have?
Within normal range
Which organ is faster at compensating for a respiratory or metabolic disturbance, lung or kidney?
Lungs are much faster - minutes to hours

Kidneys- hours to days
If you have a primary metabolic problem what type of compensation should be present?
Respiratory
If you have a primary respiratory problem what type of compensation should be present?
Metabolic
When compensation is taking place do the pCO2 and HCO3 move in the same or opposite direction (with respect to the H model.
Same
With compensation, what system is the one primarily affected on the H model?
The one with the greatest deviation from the midline.
When a patient is experiencing partial compensation which values are abnormal (pH,PCO2,PHCO3)
all of them
4 Compensatory Acid-Base disturbances?
1.“Partially compensated” Respiratory acidosis
2.“Partially compensated” Respiratory alkalosis
3.“Partially compensated” Metabolic acidosis
4.“Partially compensated” Metabolic alkalosis
When full compensation has taken place during an acid/base disturbance, what are the general values found on ABG?
Normal pH!
Abnl PaCO2 and HCO3
What is a mixed acid/base disorder?
When two or more primary acid base abnormalites coexist.(on the H model the pH line would cross the midline unlike other disorders)
While making his rounds, a doctor points out an x-ray to a group of medical students.

“As you can see,” he says, “the patient limps because his left fibula and tibia are radically arched.”

The doctor turns to one of the students and asks, “What would you do in a case like this?”
“Well,” ponders the student, “I suppose I’d limp, too.”
What are 4 factors that may interfere with interpreation of ABG?
1.Carbon Monoxide-alters O2 Sat
2.Sedative hypnotics or narcotics-inhibits respiration
3.Delays in analyzing samples
4.Failure to note the patient’s temperature(bc machine won't calibrate)
When concerned about the presence of anaerobic metabolism what lab value do you want to obtain?
Lactate -this is a sensitive and reliable indicator of tissue hypoxia
What are the intrinsic normal rates of the different foci levels in the heart?
SA: 60-100 bpm
Atrial foci: 60-80 bpm
Junctional foci: 40-60 bpm
Ventricular foci: 20-40 bpm
What does irregularly irregular most often refer to?
Atrial fibrillation
Sinus Arrhythmia

Irregular rhythm that varies with respiration.
P wave are identical.
Normal variant.
What rhythm is shown. Characterize why you pick your answer.
What are 6 examples of supraventricular arrhythmias?
1.Premature atrial complexes
2.Premature junctional complexes
3. Atrial fibrillation
4.Atrial flutter
5.Paroxysmal supraventricular tachycardia
6.Junctional rhythms and tachycardia
What are some causes of irritable atrial or junctional foci that can lead to supraventricular arrhythmias?
1.Sympathetic stimulation (E and NE)
2.Caffeine, cocaine, amphetamines, etc
3.Excess digoxin, alcohol, etc
4.Hyperthyroidism
5.Stretch
6.Hypoxia (more an issue with ventricular beats)
What are 6 examples of ventricular arrhythmias?
1.Premature ventricular complexes (PVCs)
2.Aberrancy vs. ventricular ectopy
3.Ventricular tachycardia
4.Differential diagnosis of wide QRS tachy
5.Accelerated ventricular rhythms
6.Idioventricular rhythms
What can lead to ventricular arrhythmias?
1.****Hypoxia: coronary artery disease, lung disease, high altitude, shock, etc
2.Hypokalemia
3.MVP, stretch, myocarditis
What is Wolf Parkinson White?
Accessory conduction bundle from atrium to ventricle (Bundle of Kent)
Speeds conduction to area in ventricle causing “delta” wave.
Associated with rapid ventricular response to SVT, AF, A Fib
Source of PSVT
Circus (re-entry) tachycardia
What is included in the primary survey of an xray?
Scan for:
Bony abnormalities
Soft tissue abnormalities
Other obvious problems
What is included in the secondary survey of a chest xray?
Scan for:
Identify film
Quality (RIP)
Heart
Air shadows
Water shadows
Bone shadows
Funny looking things
When looking a chest film's rotation what do you compare?
Orientation of clavicles with respect to spinous processes.
How do you assess for adequate inspiration on a chest film?
Count the ribs
8-acceptable
10-ideal
How do you determine proper penetration on a chest film?
You want to see more bony prominences higher up and the lower areas are more radiolucent. The penetration can either be over or under-penetrated.
What are 3 general considerations concerning the lateral chest film?
1.The diaphragm shadows should be clear
2.The shadow of upper vertebrae is whiter than that of lower vertebrae
3.The retrosternal and retrocardiac spaces should both be the same “color” and are normally dark.
Amount of fluid that would begin to blunt the costophrenic angles on a PA film?
300ml
Amount of fluid that would begin to blunt the costophrenic angles on a lateral film?
75ml
What markings do you follow to the edge of the lungs to ensure there is not a pneumothorax present?
Hilar markings
What are some major causes of an opacified air or water shadow on a chest film?
1.Pneumothorax
2.Atelectasis
3.Pleural Effusion
4.Pneumonia
5.Pneumonectomy
6.Congestive Heart Failure & pulmonary edema
How do you differentiate btwn a simple and tension pneumothorax?
Tension pneumothorax will affect the mediastinum.
What is the best way to see small pneumothoraces on a chest film?
Expiratory film or lateral decubitus.
What is the best method for estimating the size of a pneumothorax?
CT scan
What are 3 examples of 'BILL' that might be confused with a pneumothorax?
1.Bullae
2.Skin folds
3.Medial border of scapula
What are some S/S of a tension pneumothorax?
Hypotension, distended neck veins, decreased or absent breath sounds, hyperresonance to percussion, tracheal deviation away from affected side.
What is really the finding that is sufficient to diagnose a tension pneumothorax - because you should know before taking an xray.
No lung sounds.- xray of tension pneumothorax is bad medicine
How would an asthma or COPD pts lungs appear on xray?
Abnormal hyperinflation
Flattened diaphragm on x-ray.
Darker and larger appearance of lungs
What are the 3 types of atelectasis and characteristics of each?
1.Subsegmental atelectasis:
Occurs most commonly in post-op pts. Unable to take deep breaths.Common in bases appears as linear densities parallel with diaphragm in bases.
2.Compressive atelectasis-due to obstructing lesion.Lungs re-expand when abnormality removed like effusion or pneumothorax
3.Obstructive atelectasis-
Occurs distal to an occluding lesionCauses lung collapse with parietal and visceral pleural line remaining intact.
Which way would the heart and trachea shift if atelectasis is present?
Toward the side of atelectasis.
What would occur on xray with a right lung effusion?
Right effusions push trachea, heart, to the left and the right hemidiaphragm (BILL) disappears.
What would occur on xray with a left lung effusion?
Left effusions push trachea, heart to the right and the left hemidiaphragm (BILL) disappears.
About how much fluid could a left lateral decubitus chest film discern?
15-20ml
4 important characteristics of a chest film showing pneumonia?
1.More opaque than surrounding normal lung
2.Margins may be fluffy and indistinct except around the fissures where they will be sharp
3.May contain air bronchograms.
4.Not associated with a shift of mobile structures like atelectasis or effusion
How would CHF appear on an xray?
Usually presents with thickening of interlobular septa(Kerly B lines), peribronchial cuffing, fluid in fissures, and effusions.

Also cephalization of blood flow is associated.
What do Kerly-B lines indicate?
Congestion
What is peribronchial cuffing?
Doughnuts around the hilum - where fluid has extravastated itself from the vessel and outlined it more clearly. Can be seen with CHF
What is the most common finding on a chest xray of a pt with a pulmonary embolism (PE)?
Normal film -nothing.
What are a couple non specific finding that might point toward a PE?
Elevated diaphragm (on the PE side) and pleural effusion.
What is a mass <3cm on a chest film referred to?
Nodule
What size mass on a chest film is most likely going to indicate CA?
>5cm
What is Westermark's sign?
This is the "pruned tree" appearance of altered blood flow present in a pulmonary embolus.
What are 5 potential problems that arise in(or most often in) the anterior mediastium?
1. Masses
2. Thyroid
3. Lymphoma
4. Thymoma
5.Teratoma
Where does thoracic lymphadenopathy usually occur (within mediastinum)?
Middle
Which mediastinal region do uncommon disease processes originate?
Posterior
When scanning bones/soft tissue on a chest film, what are some important points of interest?
1. Look at all major chest bones (Clavicles, ribs, sternum, scapulae)
2. Follow the outline of each bone, making sure the cortex is smooth.
3. Breaks in cortex suggest a fracture.
What important anomaly can be seen in soft tissue?
Subcutaneous air
What type of fracture is commonly missed on a chest film?
Rib fractures.
If you suspect a rib fracture, what type of film do you order?
Rib series
How would you confirm rib fractures not evident on a chest film?
CT, bone scan, or wait 2 weeks and repeat the chest film(you should see new bone formation)
What ribs are very uncommonly fractured and why?
Ribs 1-3 because they are much more dense than the lower ribs.
If isolated rib fractures are present what future disease process might you be concerned about?
Atelectasis because the pt does not want to move or is not breathing as deeply as they should.
When would a 'flail chest' be present?
If at least 5 ribs are fractured or if 3 ribs are fractured in 2 different places.
What is a very important assumption if ribs 1,2,or 3 are fractured?
That there is underlying injury.
What is a flail chest?
When the chest wall moves in the opposite direction to the rest of the chest during breathing (paradoxical).
As far as "funny looking things" on chest films what might you see?
Tubes (ETT,chest tubes)
Lines
Pacers and leads(automated implantable defibrillators)
Foreign bodies
How far above the carina should an endotracheal tube end?
3 cm
What are 6 normal findings on a chest film?
1. Right hemidiaphragm is 1-2 cm higher than the left
2. Diaphragm should never be paper thin
3. Costophrenic angles should be sharp and clear
4. Cardiac diameter should be less than 1/2 chest wall diameter
5. Hilar vessels are more prominent in the lower lobes(in erect pt, upright film)
6. Lung markings should be visable to lung periphery
Characterize lobar pneumonia.
1. Fluffy infiltrates confined to one lobe
2.Almost always contains air bronchograms
3. Almost always causes BILL to disappear
What is the prototype bug causing lobar pneumonia?
pneumococcal pneumonia-Streptococcus pneumonia
Characterize segmental pneumonia.
(Bronchopneumonia)
1.Fluffy infiltrates involving several lung segments
2. Exudate fills bronchi so NO air bronchograms are present
3. May be associated with atelectasis
What is the prototype bug causing segmental pneumonia?
Staphylococcus aureus or pseudomonas
When you see bronchograms, think - what type of pneumonia?
Lobar
Interstitial pneumonia involves?
The airway walls and alveolar septa.
Characterize interstitial pneumonia.
1. Fine reticular pattern in the lungs(network of lines) not confined to one lobe
What is the prototype bug causing interstitial pneumonia?
Mycoplasma pneumonia and viral pneumonia
What type of pneumonia can be mistaken for a mass or nodule?
Round pneumonia
(Would be differentiated from the mass by symptoms)
Characterize round pneumonia.
1. Common in children
2. Almost always posterior in lungs and in lower lobes
What are the prototype bugs that cause round pneumonia?
Haemophilus influenzae, Streptococcus, and pneumococcus
What are the two physiologic causes of pleural effusions?
1. Increased fluid formation in pleural space
2. Decreased rate of fluid resorption from pleural space
What are some causes of increased fluid formation in the pleural space?
1. ↑ hydrostatic pressure-L sided CHF
2. ↓ colloid osmotic pressure-hypoproteinemia
3.↑ capillary permeability-membrane disruption with pneumonia or hypersensitivity reactions
What are some causes of decrease resorption of fluid from the pleural space?
1. ↓ rate of lymphatic absorption
2. ↓ pressure in pleural space as in atelectasis due to bronchial obstruction
When do transudates form?
When there is increased capillary hydrostatic pressure or decreased osmotic pressure.
As in:
CHF, cirrhosis, nephrotic syndrome, & hypoproteinemia
What do exudates generally have more of?
Cells, protein, solid material.
As in: an infectious, inflammatory, or neoplastic condition.
What are the indications for thoracentesis with pleural effusion?
Therapy: Relieve pain, dyspnea, other sx, better radiographic veiw, fluid cannot be loculated and lateral decub must show ~10mm of fluid layered

Diagnostic - to determine transudate or exudate
What are 3 contraindications for thoracentesis?
1. Hx of bleeding disorders or use of anticoagulants
2. Fluid loculation (seen on chest xray)
3. Platelet/PT count - should be reviewed for thromocytopenia.
What are 5 important preprocedural notes for thoracentesis?
1. Explain procedure to pt
2. Obtain informed consent
3. No fasting or sedation necessary - just using local anesthetic
4. Movement/coughing should be avoided
5.U/S or fluoroscopy may be helpful
What approach is preferred for thoracentesis and why(3)?
Posterior because:
1.Interspaces are wider
2.Neurovascular bundle is closer to the inferior margin of the rib posteriorly (so go above)
3. Scary for pt to see needle enter chest
What are the 5 steps for thoracentesis?
1.Position pt
2.Locate scapula
3.Drape pt
4.Anesthetize the site (1% Lidocaine)
5.Perform thoracentesis
Where do you want to insert the needle for thoracentesis?
Posterior lateral aspect of back superior to the diaphram but inferior to top of fluid level.

Never below 8th intercostal space.
How do you confirm the site of entry during thoracentesis?
Count ribs on chest xray and percussion.
Where is the inferior angle of the scapula located?
Horizontally at the 7th rib or 7ICS
What is the major potential complication of thoracentesis?
Pneumothorax
What is the best chest film to take if a small pneumothorax is suspected?
Upright, PA film with pt exhaling
What is a complication of a small pneumothorax?
Tension pneumothorax
What do you need to evaluate for after thoracentesis to ensure there is no pneumothorax?
Dyspnea, tachypnea, and lack of lung sounds on affected side.
After a thoracentesis, what do most physician consider ordering?
Hb and Hct, Chest xray, vital signs, bed rest
What are the tests that should be run on the thoracentesis specimen?
(Extras?)
1. LDH
2.Protein
3.WBC count with diff
4.glucose
5.pH
6.Triglyceride
7.Amylase
8.Concomitant serum LDH and protein
EXTRAS:Supplement with other reasonably requested analyses of cytology, cultures (Mycobacterium tuberculosis and fungus), CEA(cancer), rheumatoid factor, ANA(autoimmune disease)
What is the gross normal appearance of pleural fluid?
Clear, serous, light yellow - straw colored
Exudative effusions must meet one of the following criteria?
1.Total Protein levels > 3g/dl
2.Fluid/serum protein ratio > 0.5
3.Fluid/serum LDH ratio > 0.6
4.WBC > 1000/ mm3
What might a decreased glucose level in your pleural fluid sample indicate?
TB or malignancy, very low in RA and empyema
What might an increased amylase level in your pleural fluid sample indicate?
Malignant effusion - very high in pancreatitis or esophageal rupture
What might increased triglyceride levels in your pleural fluid sample indicate?
Chylous effusion (>110mg/dL)
What does a gram stain & culture on your pleural fluid sample r/o and when would you perform this test?
Bacterial pneumonia and empyema. Perform this test prior to antibiotics administration.
Most common causes of malignancy seen with cytology testing of pleural fluid?
Breast and lung
When would the CEA antigen be elevated in a pleural fluid sample?
Malignancy (Carcinoembryonic antigen)
What is a pH <7.2 for your pleural fluid sample consistent with?
One with a pH of 7.2-7.4?
Empyema
7.2-7.4 =Malignancy
What might contraindicate surgery on cancer that has caused a pleural effusion?
If that effusion is malignant.
2 Types of bronchoscopies?
Rigid or flexible
With a rigid bronchoscopy is general anesthesia used and in what situation might this type of bronchoscopy be used?
General anesthesia is used. This is used less often to retrieve a larger specimen- you do not go down as far.
With a flexible bronchoscopy is general anesthesia used and in what situation might this type of bronchoscopy be used?
General anesthesia is not used (just anxiolytic). This method is used more often to obtain biopsies and bronchial washings.
Indications for bronchoscopy?
Big chart in notes:)
What type of CA tumors are usually found at the periphery of the lungs?
Large cell and adenocarcinomas
What type of CA tumors are found centrally on the lungs?
Small cell or oat cell.
What are 5 contraindications to performing bronchoscopy on a pt?
1.Uncooperative patient
2.Patients with hypercapnia and severe shortness of breath
3.Severe tracheal stenosis
4.Uncorrected bleeding disorder
5.Recent myocardial infarction
Why would you not want to perform a bronchoscopy on a pt who has suffered from a recent MI?
You worry about arrhythmias
When doing a bronchoscopy on a pt with severe SOB, what additional breathing support is provided?
You insert a mechanical ventilator - give them an airway.
How do you prepare a pt for a bronchoscopy?
1.Explain procedure to the patient
2.Informed consent required
3.Pt must be NPO 4-8 hours prior to test
4.Remove dentures, glasses, contact lenses
5.Premedicate
6.Local anesthetic is applied to throat
What medication is given prior to a procedure to reduce the vasovagal response?
Atropine
How is the pt positioned during bronchoscopy?
Supine
Where is the tube inserted and passed during a bronchoscopy?
Through the nose or mouth into pharynx down into trachea,bronchi, and bronchioles.
What is the approximate timing of a bronchoscopy?
30 minutes
What are 7 potential complications of bronchoscopy?
1.Fever-common
2.Hypoxemia
3.Laryngospasm
4.Bronchospasm
5.Pneumothorax
6.Aspiration
7.Hemorrhage (after biopsy)
7 Post procedure instructions/observations for bronchoscopy?
1.NPO- until gag response has returned
2.Elevate the head of the bed 15 degrees
3.Observe sputum for blood
4.Observe for laryngospasm
5.Fever not uncommon
6.Warm saline gargles and lozenges help if sore throat occurs post-procedure.
A lung biopsy is classified as either ___ or ____?
Open or closed.
If your patient, following bronchoscopy develops dyspnea, tachypnea, diaphoresis, no breath sounds on one side - what do you suspect and what is the next step?
Pneumothorax - obtain a chest xray
What can lung biopsy diagnose?(5)
Carcinomas, granulomas, infections, sarcoidosis, infection.
What are 5 contraindications of lung biopsy?
1.Patients with bullae or cysts of lung
2.Suspected vascular anomalies
3.Bleeding disorders
4.Pulmonary hypertension
5.Respiratory insufficiency
What are 3 potential complications of taking a lung biopsy?
1. Pneumothorax
2. Pulmonary hemmorrhage
3. Empyema
Is informed consent required for lung biopsy?
yes
How long should a pt be NPO before lung biospy?
Nothing by mouth after midnight the night before
What are 3 lung biopsy methods that could obtain a lesion located centrally in the lung?
1. Transbronchial
2. Transbronchial needle aspiration
3. Transbronchial brushing
What are 3 lung biospy mehtods that could obtain a lesion located in the distal lung?
1. Percutaneous lung biopsy (CT guided perhaps)
2.Open lung biopsy
3. Thorascopic lung biopsy
Following a lung biopsy, what do you want to observe?
1. Vitals
2. Assess breath sounds
3. Obtain chest xray if possible pneumothorax
4. check for biopsy 24-48 hrs
What is a V/Q scan?
Pulmonary ventilation/perfusion scan where nuclear material is inhaled and injected to measure breathing and circulation in all areas of lungs.
What is an important measurement determined by a V/Q scan?
V/Q mismatch
What are 3 indications for a V/Q scan?
1. Detection of pulmonary emboli
2. Assessment of regional lung function (often performed before surgery)
In what situation could you say a V/Q scan is nearly perfectly specific and sensitive for PE?
If the chest xray is negative.
In what patients are V/Q scans contraindicated?
Pregnancy and unstable angina.
What are some factors that would interfere with V/Q scan results?
Various pulmonary parenchymal problems like: Pneumonia, Emphysema, Pleural effusion, and Tumor.
What is very important to obtain prior to performing a V/Q scan on a pt?
CHEST XRAY, obtain informed consent, remove jewelry around chest - no fasting required.
What would normal finding be verbalized as on a V/Q scan?
Diffuse homogeneous uptake of nuclear material by the lungs.
When would you have to order another test following a V/Q scan to confirm a PE diagnosis?
If the scan falls within low, moderate, or even high probability you would then order a CT or pulmonary angiography.

The high probability finding might be sufficient alone if other physical evidence exists for PE.(Long flight, birth control, smoker)
What is the gold standard to diagnose PE?
Pulmonary angiography
What is pulmonary angiography being largely replaced with?
CT angiogram
What is a disadvantage to a CT angiogram as compared to Pulm. Angiography?
The CT might not pick up the small emboli.
What is pulmonary angiography?
Injection of iodine-containing solution into pulmonary artery to allow for outline of that artery as it divides and passes into the lungs.
What are 3 contraindications for pulmonary angiography?
1. Pts with allergies to shellfish or iodinated dye
2. Pregnancy
3. Bleeding disorders
Some important bits of information to obtain from patient before pulmonary angiography?
1. Informed consent
2. Any allergies to shellfish or iodine
3. Does pt have any arrhythmias
4. Inform pt about warm flush they will feel when dye is injected.
5. NPO after midnight
6. Premedicate with atropine and demerol
Where is the catheter placed for pulmonary angiography?
The femoral vein.
After pulmonary angiography what are important post procedure assessements?
1. Observe catheter site for inflammation, hematoma,hemmorrahage
2. Assess vitals
3. Coughing is common
4. Bedrest 24-48 hrs after test
How is CT Angiography performed?
With a helical scanner, the pt is injected with dye and asked to hold thier breath. Thin, contigious CT slices are obtained and reconstructed to produce a 3-D image.
What does contiguous mean?:)
Touching, in contact.
From where should a sputum sample be obtained?
It should be a deep bronchial sample.
What is a panculture?
When a culture is taken of the sputum, urine, and blood.
Why is a sputum culture and sensitivity performed?
Diagnose and treat pathogenic organisms (bact, fungus, atypical organisms). Diagnose abnormal cytology.
What are the indications for ordering the C&S based on?
Clinical condition (bacterial, viral, fungal-for yeasts and molds)
What populations might you see fungal results on C&S of sputum?
Immunocompromised pts
About how much sputum do you need for the sputum C&S?
5ml/1tsp
When can you obtain the best specimen for sputum C&S?
In the early morning, after rising from sleep prior to eating or drinking. Rinse mouth first to decrease contamination from oropharynx.
How should the pt go about collecting the sample for sputum C&S?
After several rapid deep breaths, cough.

You might have to induce sputum with nebulized hypertonic saline or distilled water (moisten airway), chest percussion and postural drainage, or nasotracheal suction.
Why is gram staining your sputum sample first important?
This will allow you to tailor your empirical treatment for either a gram + or gram - bug.
What are the criteria for an ideal sputum sample for culture?
1.Under 10 squamous
epithelial cell per low power field
2.Many Neutrophils present (>5 per high power field)
3.Bronchial epithelial cells present
4.Alveolar Macrophages may be present
What would an inadequate sputum sample contain?
Over 25 squamous epithelial cells/LPM - this would be considered contaminated.
What stain is used for fungal organisms? Some organisms?
Methenamine silver staining - histoplasmosis, coccidioidiomycosis, aspergillus
What type of bacteria are pseudomonas, klebsiella, proteus?
Gram (-) rods
What type of bacteria would clostridium be?
Gram (+) rod
What type of bacteria would strep and staph be?
Gram (+) cocci
Pneumonia is commonly caused by a?
Virus
How is a viral culture obtained?
Sputum is mixed with commercially prepared animal cells in a test tube. The characteristic change to the cells caused by the virus helps to ID it. - can take days to weeks for growth.
How is a fungal culture obtained?
A sample is spread on a special culture plates that encourage growth of mold and yeast. Different biochemical tests and stains are used to ID molds and yeast. Can take weeks.
What is the bacteria that causes TB- and how long does it take to grow on a conventional culture?
Mycobacterium Tuberculosis - 4-6wks
If TB is suspected how is the sputum culture obtained?
Sputum is collected in a negative pressure room in the early morning. You need 3-5 specimen(all of which need to be positive). This sample can be obtained with bronchoscopy and bronchial lavage.
How is a TB sputum sample stained?
Acid-fast mycobacteria with Ziehl-Neelsen Stain(red against a blue background).
Does a Ziehl-Neelsen Stain confirm TB diagnosis?
No, some nonTB mycobacteria may colonize the airway. You still need a positive culture or DNA/RNA amplification studies.
What is a new culture method for TB that is much faster than Ziehl-Neelsen Stain?
BACTEC method (CO2 detected and quantified, quicker than culture).
Polymerase chain reaction culture (PCR-Amplification of genomes detected by DNA probe)
Advantages:
1.Allows identification in 36-48 hours
2.Allows treatment to begin sooner
3.Reduces transmission of the disease
What does a negative sputum culture exhibit?
No harmful bacteria or fungi.
What does a positive sputum culture represent?
Bacteria, Viral, Fungus, Atypical infections.
What are 5 factors that can interfere with your sputum C&S?
1.Recent use of antibiotics, which may prevent the growth of bacteria or fungi in the culture.
2.Contamination of the sputum sample.
3.An inadequate sputum sample.
4.Waiting too long to deliver the sample to the laboratory.
5.Use of mouthwash before collecting a sputum sample.
How is antibiotic sensitivity tested for with a sputum sample?
Kirby-Bauer disk diffusion antibiotic susceptibility testing or MIC(minimum inhibitory concentration) E-test.
What do positive and negative tests results for sputum cytology indicate?
Positive - malignant cells (indicates lung tumor)
Negative- nothing! could be either
What has ordering a sputum for cytology largely been replaced by? - so why would sputum for cytology remain useful?
Bronchoscopy and percutaneous lung biopsy.

Sputum for cytology remains useful in a couple of situations:
1.Abnormal CXR+ productive cough+ negative bronchoscope
2.Monitoring smokers who already have atypical changes in respiratory tract.
Are ciliated columnar cells normal in a sputum sample?
yes
What is the purpose of nose and throat cultures?
To isolate particular pathogens. - for example Beta-hemolytic strep which can lead to rheumatic heart dz or glomerulonephritis.
For whom is a rapid streptococcal screening indicated for?
Children 3-15 yo with sore throat, fever
Adults:Severe recurrent sore throat+fever+palpable lymphadenopathy+tonsillar exudates
How is a rapid streptococcal test obtained?
Tongue is depressed with any area of inflammation or ulceration on posterior throat are swabbed.
If the Rapid Streptococcal test is positive does that mean? Negative?
Positive- The pt has Group A strep
Negative-they still could have strep, send for culture if you are suspicious
(Test is very specific, but sensitivity varies)
Other names for Alpha1-antitrypsin?
A1AT,
AAT,
Alpha1-antitrypsin phenotyping
Why is Alpha1-antitrypsin tested?
Deficient or absent serum levels of this
enzyme are found in some patients with
EARLY onset emphysema.
What would indicate an Alpha1-antitrypsin test?
Fm Hx is emphysema
Is fasting required for Alpha1-antitrypsin testing?
No
What are 2 interfering factors with Alpha1-antitrypsin testing?
1.Serum levels increase in pregnancy
2.Oral contraceptives falsely increase levels
If there are abnormally decreased levels of Alpha1-antitrypsin how do you advise the pt?
1.Avoid smoking, infection, inhaled irritants
2.Proper nutrition
3.Adequate hydration
4.Educate about the disease process of Emphysema.
What is the sweat electrolyte test used for and what do results indicate?
Relatively non-invasive test used in pediatric population to diagnose or screen for CF
Pts.

With CF have increased sweat sodium(>90mEq/L) & chloride(>60meQ/L) - most have 2-5x normal values
(Sensitive & specific for CF)
Does the sweat electrolye test indicate severity of CF?
No, only that the disease is present.
What two wide QRS tachycardias can be difficult to distinguish btwn?
Ventricular Tachycardia, Supraventricular Tachycardia (Abberancy, BBB)
Characteristics of Accelerated Idioventricular Rhythm? (HR,Rhythm,Pwave,PR int,QRS)
HR:40-100
Rhythm:Regular
Pwave:Absent or not related
PR int:N/A
QRS:> or equal to .12
Characteristics of Idioventricular Rhythm? (HR,Rhythm,Pwave,PR int,QRS)
HR:20-40
Rhythm:Regular
Pwave:Absent or not related
PR int:N/A
QRS:> or equal to .12
Characteristics of Ventricular Fibrillation? (HR,Rhythm,Pwave,PR int,QRS)
HR:300-600
Rhythm:Very -irregular
Pwave:Absent
PR int:N/A
QRS: Fibrillatory baseline
Characteristics of Ventricular Asystole? (HR,Rhythm,Pwave,PR int,QRS)
HR:Absent
Rhythm:Absent
Pwave:Absent or present
PR int:N/A
QRS: Absent
What type of pacemaker cannot typically change the rate of the heart?
The single chamber pacemaker
Which type of pacemaker would allow a more active lifestyle for a pt?
Dual chamber pacemaker - the pacemaker senses the P wave and then fires
Important characteristic of 1st degree AV block?
PR interval >.20sec
What are type I and II Mobitz referred to as?
I- Wenckebach
II-Mobitz
Where is a Wenckebach block located and what is this rhythm characterized by?
In the AV node and is characterized by increasing PR intervals that eventually do not conduct a beat through to the ventricles.
Where is a Mobitz block located?
Below the AV node.
What is the difference btwn thePR and QRS intervals with a Type I and II second degree heart block?
I- Long PR and normal QRS
II- Normal PR and wide QRS
Which, Wenckebach or Mobitz, do vagal maneuvers have more of an influence over?
Wenckebach
What are some causes of First degree heart block?
Drugs, ischemia, degenerative disease conduction system, infiltrative dz(like sarcoidosis), increase vagal tone.
What are some causes of Wenckebach heart block?
Drugs, ischemia, increased vagal tone
What are some causes of Mobitz (Type II) second degree heart block?
Acute MI, (more diffuse), severe LV disease
What are some causes of third degree heart block?
More diffuse disease of LV/conduction system.
In third degree heart block how is the P related to the QRS complex?
It is normal but not related at all.
When dealing with heart block what is important to note with respect to atrial and ventricular beats?
The ratio of conducted to blocked beats.