Osce Review: Pulmonary

Front 1

Chest X-ray
1. View
2. How/What to Analyze

Back 1

1. PA & lateral
2. top to bottom, in to out

Front 2

Chest X-ray
1. # of ribs
2. Trachea location
3. Mediastinum width
4. Heart
5. Lungs
6. Diaphragm
7. bones
8. Pleura

Back 2

1. 8-10 ribs
2. trachea midline
3. wide if >8cm @ aortic arch
4. Heart: border, curvature of aorta, width = 1/2 of rib cage
5. lungs: hilar/pulm vessels
6. sharp/clear costophrenic angles
7. bones intact
8. pleura to chest wall

Front 3

What is a silhouette sign

Back 3

*obscured heart border (RML or L lingua)

(lateral view RML consolidation on top of heart, RLL on bottom of heart)

Front 4

What do blunted costophrenic angles mean on an CXR?

Back 4

*pleural effusion

Front 5

What does it mean if lung markings are lost on one side in a CXR?

Back 5

*pneumothorax

Front 6

What does a mediastinal shift imply on a CXR?

Back 6

Tension pneumothorax

Front 7

What does it indicate if the diaphragm is elevated on one side on a CXR?

Back 7

Atelectasis (collapse/incomplete expansion)

Front 8

Acid-Base Chemistry
1. normal pH
2. pCO2
3. HCO3
4. pO2

Back 8

1. 7.35-7.45
2. 35-45
3. 22-26
4. 72-104

Front 9

Define the following:
1. FVC (forced vital capacity)
2. FEV1
3. TLC

Back 9

1. max inhale --> max exhale
2. air forced exhale in 1 second
(NOTE: FEV1/FVC >80%)
3. amount of air in lungs after max inspiration

Front 10

What would the following be in Obstructive Lung Disease:
1. FEV1
2. VC
3. FEV1/FVC
4. TLC

Back 10

1. decreased FEV1
2. nl or decreased VC
3. decreased ratio
4. nl or increased TLC

Front 11

What would the following show if Restrictive Lung Dz?
1. FEV1
2. VC
3. FEV1/VC ratio
4. TLC

Back 11

1. nl or decreased FEV1
2. decreased VC
3. nl or increased ratio
4. decreased TLC

Front 12

COPD
1. Describe
2. Sx

Back 12

1. irreversible, obstructive dz (chronic bronchitis, empysema, asthma)
2. cough (+/- productive), progressive, sputum production (>3mo for 2yrs), dyspnea

Front 13

COPD
1. Dx

Back 13

*Spirometry (decreased FEV1/VC)
*XR: flat diaphragm, retro-sternal air
*PExam: barrel chest (changes in AP diameter), hyperresonant (air trapping)

Front 14

General Tx guidelines for COPD

Back 14

*STOP smoking!
*don't use mucolytics, anti-tussive, Abx

Front 15

Tx for Mild (>80%) COPD

Back 15

*decrease RFs
*Immunize (flu/pneuomoccal)
*SABA (albuterol or Ipratropium) prn

Front 16

Doses for SABA for COPD

Back 16

*albuterol (Proventil) 2 puffs q2-6hrs prn [SABA]
*Iptratropium (Atrovent) 2 puffs QID [anticholinergic]

Front 17

Tx for Moderate (50-80%) COPD

Back 17

*immunize, SABA prn AND
*LABA (salmeterol, tiotropium)

Front 18

Doses for long acting inhalers for COPD

Back 18

*Salmeterol (seravent) 1 puff BID [LABA]
*Tiotropium (Spiriva) 1 capsule (18mcg) inhaled qd [Anticholinergic]

Front 19

Tx for Severe (30-50%) COPD

Back 19

*immunize, SABA, LABA +
*ICS (Fluiticasone)

Front 20

Doses for ICS for COPD

Back 20

*Fluticasone (Flovent) 2 puffs BID [44, 110, 220]

Front 21

Tx of very severe (<30% or >30% w/ chronic respiratory failure) COPD

Back 21

*O2 replace w/ respiratory failure
*Surgery

Front 22

Acute Exacerbation of Chronic Bronchitis
1. describe
2. MCC
3. Sx

Back 22

1. flare w/ existing chronic bronchitis
2. MCC = viral (20-50%), S. pneumo, H. flu, M. cat
3. Increased DOE, viscosity of sputum, increased volume

Front 23

Tx of AECB

Back 23

*don't smoke
*postural drainage
*Severe: increase dose/freq SABA, add anticholinergic, PO CS
*Abx:
-mild-mod: Amox, doxy, TMP/SMX
-severe: Augmentin, azithro, resp FQs

Front 24

Asthma
1. Define
2. Sx
3. Dx

Back 24

1. reversible inflammation of airway
2. accessory muscle use, tachycardia/tachypnea, wheeze, prolonged expiration
3. Spirometry >12%, >200ml change in FEV1

Front 25

Intermittent Asthma
1. Sx
2. Nighttime sx
3. SABA use
4. Activity impariment
5. FEV1
6. Tx Step

Back 25

1. <2x/wk
2. <2x/mo
3. <2x/wk
4. None
5. >80%
6. Step 1

Front 26

Mild Persistent Asthma
1. Sx
2. Nighttime sx
3. SABA use
4. Activity impariment
5. FEV1
6. Tx Step

Back 26

1. >2x/wk
2. 3-4x/mo
3. >2x/wk
4. minor
5 >80%
6. step 2

Front 27

Moderate Persistant Asthma
1. Sx
2. Nighttime sx
3. SABA use
4. Activity impariment
5. FEV1
6. Tx Step

Back 27

1. daily
2. >1x/wk
3. daily
4. some
5. 60-80%
6. step 3 or 4

Front 28

Severe Persistent Asthma
1. Sx
2. Nighttime sx
3. SABA use
4. Activity impariment
5. FEV1
6. Tx Step

Back 28

1. throughout day
2. >7x/wk
3. several times/day
4. extreme
5. <60%
6. step 5 or 6

Front 29

Stepwise Tx for Asthma:
1. step 1
2. Step 2
3. Step 3
4. Step 4
5. Step 5
6. Step 6

Back 29

1. SABA prn
2. low dose ICS
3. low dose ICS + LABA
4. med dose ICS + LABA
5. high dose ICS + LABA
6. high dose ICS + LABA + PO CS
(Prednisone (Sterapred) 5-60mg QD)

Front 30

What asthma meds are used to both prevent and tx sx?

Back 30

ICS

Front 31

When should you follow up for asthma?

Back 31

*F/U q2-6wks until controlled
*after control = q3-6mo

**Have Written Asthma Action Plan on file

Front 32

Influenza
1. Seasonal occurrence
2. Transmission
3. Incubation

Back 32

1. Fall/Winter
2. spread via large aerosol droplets
3. incubation 1-2d, virus shed 1wk

Front 33

Influenza
1. Onset
2. Sx
3. improves

Back 33

1. abrupt onset of F, HA, myalgia, malaise
2. F, non-productive cough, myalgia, ST, rhinitis
3. gradual improvement w/in 2-5d, post-influenza fatigue for few wks

Front 34

Influenza
1. Dx

Back 34

*Clinical: U/L RTI, signs of systemic infxn + no other cause
*Rapid antigen test (nasopharyngeal swab)
*Viral culture = gold std

-r/o strep & sepsis

Front 35

Who to tx for influenza

Back 35

*high risk & <48 hrs
*close contact of high risk
*>48hrs + persistent severe illness
*Pg 3rd tri or 2nd tri w/ comorbidities

Front 36

General tx for Influenza

Back 36

*rest, increase fluids, saline nasal drops, hand washing, OTC analgesics, cold/cough remedies

Front 37

Pharm Tx for Influenza

Back 37

*Zanamivir (type A/B): don't use in bronchospasm pt
*Oseltamivir (A/B)= tamaflu
*Amantadine/Rimantidine (A)
*prevent w/ vaccine

Front 38

Pertussis
1. Describe
2. Risks

Back 38

1. reportable, highly contagious bacterial infxn
2. <12mo, not immune, immunodeficient, school age

Front 39

Name & describe the 3 stages of pertussis

Back 39

1. Initial/catarrhal = rhinorrhea, F, dry cough (7d), URI worsens
2. Paroxysmal: longer coughing fits --> whooping sound, posttussive emesis ((1-6wks)
3. Convalescent: decrease cough, return to nl (2-3wks)

Front 40

Pertussis
1. Dx
2. Tx

Back 40

1. Nasopharyngeal swab + culture, leukocytosis + lymphocytosis
*clinical: cough >2wks + sx of stage 2
2. Macrolide: erythromycin
*immunize DTap (kids), Tdap (single booster >5yo)

Front 41

Acute Bronchitis
1. Seasonal occurrence
2. MCC
3. Sx

Back 41

1. Fall/spring
2. MCC = viral, atypical = bacterial (M. pneumo, B pertussis, S pneumo, C. pneumo)
3. productive cough, purulent sputum, F, myalgia, SOB, +/- rhinorrhea

Front 42

Acute Bronchitis
1. Dx
2. Tx

Back 42

1. PExam: usu remarkable, dx = exclusion
2. No Abx, avoid OTC meds (dry out), symptomatic tx (rest, fluids, anti-pyretics)

*If F/resp sx > 4-6d think bacterial cause & Abx

Front 43

CAP
1. Describe
2. Source of Infxn

Back 43

1. MC infectious COD
2. aspirate oropharyngeal contents, inhale aerosolized particles, seed in blood, extra-pulmonary infxn

Front 44

Causes of CAP
1. Typical
2. Atypical (MC young adults)

Back 44

1. S. pneumo, H. flu, virus
2. M. pneumo, Legionella, Chlamydia pneumo

Front 45

Sx of CAP
1. Typical
2. Walking

Back 45

1. S. peumo --> rust colored sputum, rapid onset, CXR consolidation, increase WBC, F, productive cough, SOB, fatigue
2. M. pneumo --> non-productive cough, F, slow course

Front 46

PExam of CAP

Back 46

*abnl (tachypnea, cyanosis, egophany (e-->a), increased tactile fremitus, rales/crackles, dull to percuss

Front 47

Dx CAP

Back 47

*CXR = consolidation
-if negative & suspicious --> CT
*sputum gram stain & cx

Front 48

Tx of CAP

Back 48

*healthy & no Abx in 3mo = Macrolide or doxycycline
*comorbidities/recent Abx/Abx resistance = Resp FQ or Macrolide + Beta-lactam inhibitor

Front 49

Tactile Fremitus, Auscultation, and percussion for:
1. Pneumonia
2. Pneumothorax
3. Effusion

Back 49

1. increased tactile fremitus, rales/crackles, dull to percuss
2. decreased tactile fremitus, decreased/no sounds, tympanic percussion
3. decreased tactile fremitus, decreased/no sounds, dull to percuss

*Note: nl auscultate = vesicular, nl percuss = resonant

Front 50

Pneumothorax
1. Describe
2. Sx
3. Dx
4. Tx

Back 50

1. collapsed lung, spontaneous (young/tall/thin/M), traumatic
2. SOB, unilateral CP
3. CXR = unilateral lucency (black), tracheal deviation (tension)
4. small = observe, lg = chest tube, tension = surgical emergency

Front 51

Pleural Effusion
1. Describe
2. Dx

Back 51

1. fluid b/t viscera & parietal pleura
2. CXR = blunted costophrenic angles
3. PEXam: decreased tactile fremitus, no/dec breath sounds, dull to percuss

Front 52

Pleuritis
1. Sx
2. Dx
3. Tx

Back 52

1. stabbing CP, follows virus
2. dx of exclusion
3. tx = NSAIDS

Front 53

TB
1. nl PPD/TST
2. dx

Back 53

1 nl pt = 15mm
2. AFB smear & sputum cx

Front 54

Pulmonary Embolism
1. Risk
2. sx

Back 54

1. Virchow's triad (hypercoagulable, stasis, intimal injury)
2. SOB, CP, tachy, hemoptysis, HoTN, cough

Front 55

Pulmonary Embolism (PE)
1. Dx
2. Tx

Back 55

1. gold std = pulmonary angiogram, CT, D-dimer, V-Q scan, EKG = S1Q3T3 pattern
2. admit, O2, supportive care, heparin + warfarin x 3mo

Front 56

Lung CA
1. Types
2. Sx
3. Dx
4. Tx

Back 56

1. non-small cell CA, small cell CA (more aggressive, central location, usu mets on dx)
2. cough (MC), hemoptysis, dyspnea, wheeze
3. CXR, bx= stage
4. chemo/rads, advanced = palliative

Front 57

Smoking Cessation
1. 5 A's

Back 57

*ask, advice, assess, assist, arrange

Front 58

Smoking Cessation Tx
1. Behavioral
2. Replacement

Back 58

1. supoort groups, QUIT plan
2. patch, gum, nasal spray, inhaler, lozenge

Front 59

Pharm Tx for Smoking Cessation

Back 59

1. Buproprion (Zyban), DA/NE reuptake inhibitor 150mg PO BID x 7-12wks (quit day 7), can combine w/ NRT, CI: sz, eating ds, MAOI
2. Varenicline (Chantix), AcH receptor agonist, 1mg BID, no combo w/ NRT, AE: increase SI/nightmares, ban w/ FAA traffic