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173 Cards in this Set

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1. 70 y old acute shaking chills, increased fatigue, rust sputum, shortness of breath, O2 82%, BP 160/86, what is going on?
strep pneumo
1. 70 y old acute shaking chills, increased fatigue, rust sputum, shortness of breath, O2 82%, BP 160/86, what would the gram stain look like
gram positive diplococci
1. 70 y old acute shaking chills, increased fatigue, rust sputum, shortness of breath, O2 82%, BP 160/86, what antibiotic would you use?
Beta Lactam (penicillin, cephalosporins
what do beta lactams do?
affect the cell wall.... this will destroy strep pneumo
red currant jelly sputum

Gram stain?
gram negative rod
red currant jelly sputum

bacteria
Klebsiella pneumoniae?
red currant jelly sputum

virulence
large polysaccharide capsule
What tidal volume do you give on ventilation?
6-8ml/kg
what formula is used to meausre efficiency of o2 diffusion btw her lungs and pulmonary circulation?
A-a gradient
cystic fibrosis on vent for a week

gram stain? oxidase?
gram negative rod

positve
cystic fibrosis on vent for a week

bacteria?
pseudomonas
heroin addict recovering from flu

bacteria?
Staph Aureus
underlying causes of cystic fibrosis
Na channel dysfunciton
oxidase of pseudomonas?
positive
if you had dental decay and inhaled it what would likely be the bacterial cause of pnuemonia
anaerobes
what do you order to evaluate VTE?

(2) what is the gold standard? [probably not on test]
Pulmonary angiogram-Gold standard

d-dimer
what are the 3 risk factors for VTE
stasis
hypercoaguability
injury

Virchows triad
acquired hypercoagualbility? 4

inherited? 3
Acquired: lupus, nephrotic syndrome, HIT, cancer

inherited: Factor Leiden V, protein C/S deficiency, antithrombin II deficiency
have DVT

secondary to immobilization surgery or trauma

therapy time?
3 months
have DVT

first time

therapy time?
6 months
have DVT

recurrent, cancer, hypercoagable state

therapy time?
lifetime coumadin
despite serveral boluses of IV normal saline, she is not maintaining adequate perfusion. which pressures do you base the need for vasopressors on?

Diastolic, Systolic, or Mean Arterial?

what does it have to be less than?
mean arterial

<60mmHg
what 2 bacterial pneumonias are common in kids
mycoplasma

chlamydia
does mycoplasma have a cell wall?
NO

can't use beta lactam
what lab diagnosis you need for mycoplasma?
cold agglutinins
DOC for mycoplasma infection?
doxycycline or erythromycin
if you have a similar infection to mycoplasma with obligate intracellular parasites what do you have
chlamydia
what is the serotype of chalmydia pneumonia?
TWAR
know the bacterial vs Viral chart

onset
rigor
cough
temp
WBC
CXR
Onset- B: sudden V: gradual
Rigors- B:seen here V: not so much
Cough B: productive V: non
Temp B: higher V: lowar
WBC- B: higher V: lower
CXR B: lobar consolidation V: more diffuse
6 year old native american boy with flu like symptoms and short of breath. x ray with evidence of pulmonary edema
hantavirus (remember mice)
anthrax gram stain
large gram positive rod
DOC for anthrax?
ciprofloxin

doxy

penicillin
if you see widened mediastinum what should you think
ANTHRAX
To recognize for xray
interstitial lung disease
alveolar lung disease
silhouette sign
air bronchogram
lung segments/fissures
COPD findings
why does an antibiotic fail?
resistance
acquired drug resistance mechanism? 3..which is major
Altered DNA via:

--transduction: DNA of one bacteria introduced into another
--transformation: DNA uptake from lysed bacteria
Conjucation: gene transfer cell to cell plasmids, major mechanism
what is the post antibiotic effect?
suppression despite drug levels below MIC
viral URT infections most common causes?
rhinovirus

adenovirus

coronovirus
most common cause of common cold?
rhinovirus
what is the most common misuse of antibiotics?
rhinovirus..common cold
how is rhinovirus spread?
resp droplit...esp hand to mouth (nose)
besides rhinovirus what causes common cold
adenovirus
LRT disese in children can be caused by what?
adenovirus
what is antigenic shift
large change
what is antigenic drift
small change, mutation
what is the importance of the individual lobes within the right or left lung?

*****
each get a single tertiatry bronchi and their own blood supply

so if someone gets pneumonia, you can just remove one segment!
at what passage way in the respiratory tract do you start to see respiratory epithelium?
nasal cavity
when do you start to see goblet cells in the resp tract?
nasal cavity
when do you stop seeing respiratory epithellium in the resp tract?
Terminal bronchioles
when do you stop seeing goblet cells in the resp tract?
large bronchioles
when do you start seeing clara cells in the resp tract?
large bronchioles
when do you stop seeing clara cells in the resp tract?
respiratory broncioles
when do you stop seeing smooth muscle in the resp tract?
alveoli (so alveolar ducts is last place)
when do you start seeing type 1 and 2 pneuomocytes in the resp tract?
respiratory bronchioles
what are the muscles usually involved during inspiration (5)
Diaphragm

External intercostals

Internal intercostals
(parasternal portion)

Scalene muscles

Levator costarum (minor role)
what supplies blood to the respiratory tissues? (maintaining each segment)
bronchial arteries

(blood from the right ventricle does not supply the respiratory tissues themselves)
what are the sympathetic innervations of the lung? (levels)
T2-T7
please list the rib borders of the inferior portion of the lung....


also list the rib boarders for the line of pleural reflection

what is this good for?
Inferior border of lungs
Anterior = 6th costal cartilage
Lateral = 8th rib
Posterior = 10th rib

Line of pleural reflection
Anterior = 8th costal cartilage
Lateral = 10th rib
Posterior = 12th rib

use this info to know where to do a thoracocentisis so you don't puncture the lungs
Starting with the Nares and ending with the Alveoli, please list the order of the airways
Nares
Vestibule
Nasal Cavity
Nasopharynx
Oropharynx
Larynx
Trachea
1-3 Bronchi
Large Bronchioles
Terminal Bronchioles
Respiratory Bronchioles
Alveolar Ducts
Alveoli
what is respiratory epithelium?
pseudostratified ciliated columnar epithelium
what is the most common cause of lower respiratory tract infection?
Influenza virus
what causes LRTI in children/newborns (most commonly)
Respiratory Syncytial virus
what is the only virus that actually invade the alveoli and cause alveolitis?
Hantavirus
what spreads parainfluenza leading to croup?
Respiratory droplets
What is preventative against infections in newborns and children?
IgA antibodies

Secretory can be given in breast milk!
what are the types of strains of Respiratory Syncytial Virus? (RSV)

What population do these affect most? ****
A and B

The major lower respiratory tract
pathogen of infants worldwide (especially premature infants)
What type of process is inspiration, what is necessary for it?

****
It is an active process (energy is required) because muscles are contracting
why type of process is expiration? what is necessary for it?

****
It is a passive process (energy is not required) because muscles are not contracting. Expiration only requires energy during strenuous exercise.
describe how spriometry works?

what is it dependent on?

what can it determine?

what cant it determine *****
Air flow measurements via forced exhalation

(note: this is patient dependent, it can vary with their effort)

used to determine presence or absence of airway obstruction

can suggest restriction***** but not diagnose it!!
what is forced vital capacity?

**
maximal amount of air that can be forcibly exhaled
FEV1/FVC ratio of <70% suggests?
obstruction
FEV1/FVC ratio of 70-80% suggests?
normal
FEV1/FVC ratio of >80% suggests?
restriction
flow limitation is encountered during forced expiration, when the pleural pressure becomes positive relative to airway pressure, and the effect of any obstructive lesion in this region is accentuated...what flow volume loop does this describe

*****
Variable Intrathoracic
if you suspect asthma, but spirometry comes up normal, what test should you try?

****
methacholine challenge

look for "The PC20 was reached"
Spirmoetry alone cannot diagnose _______

****
restrictive lung diseases
what test measures ventilated and unventilated segments of the lung?

What is this good for?

****
Plethesmography

good for showing COPD (versus restrictive)
Chemotherapeutic drug

***
Any chemical used in the treatment, relief, or prophylaxis of a disease
Prophylaxis

***
Use of a drug to prevent imminent infection of a person at risk
Narrow spectrum

***
Antimicrobials effective against a limited array of microbial types. Targets a specific cell component found only in certain microbes – for example, a drug effective mainly on gram-positive bacteria
Broad spectrum

***
Antimicrobials effective against a wide variety of microbial types. Targets cell components common to most pathogens – for example, a drug effective against both gram-positive and gram-negative bacteria
Post antibiotic effect (PAE) is ?
Persistent inhibition of bacterial growth following exposure to an ABX
meaning that growth is inhibited even though drug levels have dropped below the MIC
when do you want to use a bactericidal agent?
when the immune system is depressed
what are 3 general mechanisms of drug resistance?
The drug does not reach its target: (decreased uptake OR increased efflux)

The drug is not active:
-increased rate of inactivation
-limited formation of active form of drug

The target is altered:
-target deleted
-target modified
-acquisition of a resistant form of native, susceptible target
what is vertical acquired resistance?
Mutation and selective pressure (vertical)

Mutation and ABX selection of a resistant mutant are the molecular basis of resistance to:
streptomycin
--ribosomal mutation

quinolones
--gyrase or topoisomerase gene mutation

linezolid
--ribosomal RNA mutation
what is horizontal acquired resistance?
Gene Transfer (horizontal)

Transduction
-DNA of one bacteria introduced into another ... phage mediated ... same species
-Important in the transfer of resistance among strains of S. aureus
what is Conjugation?
Gene transfer through direct cell-to-cell contact

a form of horizontal acquired resistance
what is the major mechanism of resistance transfer?
Conjugation: Gene transfer through direct cell-to-cell contact
there are 3 general therapies with antibiotics... what are they?
empirical therapy:
-organism not yet identified
-broad spectrum agent used

definitive therapy
-organism and susceptibilities known
-narrow spectrum agent used

prophylactic therapy
-prevent initial or recurrent infection
-spectrum of agent depends on situation
What is a superinfection and what causes it? What gives you a greater chance of getting a superinfection
drug resistant microorganisms may emerge

Superinfection is due to removal of normal microflora

The broader the spectrum of drug and the longer the period of treatment, the greater the chance for superinfection
LRT in children is most often caused by
adenovirus
Infantile gastroenteritis is most often caused by?
adenovirus
what are the 2 pneumonia virus vaccines and what populations are they used in
Pneumovax: Adults/post hospital stay

Prevnar: kids
6. Which generation of H1 antagonist has longest duration
2nd generation
Which generation of H1 antagonist has largest sedation effect?
1st generation
8. Which generation of H1 antagonists have strongest anti-emetic/anti-muscarinic
1st
9. Most common viral LRT infection?
influenza
10. Most serious sequalae of flu?
a. 2ndary bacterial pneumonia
11. Most common LRT infection in newborns?
a. Respiratory syncytial virus (RSV)
12. 3 year old boy with inspiratory stridor and barking cough could have what two major things?
Epiglottitis

Laryngotrachobronchitis (CROUP
Cause of Epiglottitis?
1. Haemophilus influenza type B
prevention for Epiglottitis?
Hib vaccine
cause of Laryngotrachobronchitis (CROUP)
1. Parainfluenza virus
if you see the Steeple sign what should you think? 2
epiglottitis, or CROUP
a. Cause of strep pharyngitis?
i. Strep pyogenes (group a beta hemolytic streptococci)
b. Sequalae of strep infection
i. Rheumatic Fever ---> glomerulonephritis
c. Treatment failure of strep pharyngitis? 2
i. Non-compliance
ii. Beta lactamase producing bacterial flora
if you see Toxin mediated, pseudomembrane you think?
a. Corynebacterium diphteriae
16. Paraoxysmal cough
a. Bordetella pertussis
b. Whooping cough
Bordetella pertussis
why is whooping cough on the rise?
i. People aren’t getting vaccinated
17. 45 year old poor immigrant, night sweats, weight loss, dyspnesa, released from 3 months immigration detention…you think what?
TB
18. Organism of TB? important characteristic of wall
a. Mycobacterium tuberculosis
b. Acid fast bacteria
19. What is the lesion associated with TB
a. Ghon complex
20. Immunocompromised patients develop what with TB? what does this do
a. Miliary TB
i. Hematogeonuos spread to other organisms
21. Positive PPD?
a. 10mm induration>48
b. Will immunocompromised have positive PPD?
nope

think miliary
this TB drug is a potent CYP450 inducer
b. Rifampin
this TB drug turns your urine red
b. Rifampin
this TB drug causes hepatitis, CNS toxicity, and peripheral neuropathy
c. Isonizade
this TB drug causes Hepatotoxicity, hyperuricemia
d. Pyrazinamide
Optic neuritis, impaired red-green vision, hyperuricemia are all side effects of what TB drug
e. Ethambutol
23. Why use 4 TB drugs
a. Resistance
24. what do you use for the treatement of Latent infections of TB?
a. Isoniazid or rifampin
25. 12 year old with cough associated with wheezing and fatigue, for several weeks, no fever or chills, CXR shows hyperinflation, flattened diaphragms, what does he have
a. Asthma
b. Will a pt with asthma have a bronchodilator response?
yes
c. FEV1/FVC ratio for asthma? what kind of disease is this?
Less than 70

obstructive
26. FEV1/FVC Ratio for restrictive disease
>80
27. 3 components of asthma
a. Chronoic inflammation of the airways
b. Hypersecretion of mucus glands
c. Airway smooth muscle hyperresponsiveness
28. Status asthmaticus?
a. Persistent attack despite nebulizer, 02 and steroid therapy
29. Maintenance meds for asthma? 6
a. Inhaled steroid
b. Long acting beta agonists
c. Cromolyn
d. Leukotriene modifiers
e. Omalizumab
f. Methylxanthines
30. Asthma exacerbation meds? 3
a. Short acting beta agonist
b. IV: steroids (systemic)
c. Anticholinergics
if you see:

Red hepatization

you should think...
a. Early bacterial pneumonia
if you see:

Hemosiderin laden macrophages

you should think...
a. Pulmonary congestion
if you see:

Curschman’s spirals

you should think...
a. Bronchial asthma
if you see:

Charcot-leyden crystals

you should think...
a. Bronchial asthma
if you see:

Granular PAS positive material

you should think...
a. Alveolar proteinosis
READ: clinical findings of hospital acquired pneumonia according to Leech
i. Terminally ill patients
ii. Acquired in the course of a hospital stay
iii. Patients already ill from another disease process; Patients with severe underlying disease, immunosuppression, prolonged antibiotic therapy, or invasive access devices (catheter)
iv. Patients on mechanical ventilation are at a particularly high risk
v. Bronchiolitis
i. Patchy (non-continuous) consolidation of the lung centered around bronchi or bronchioles (terminal and respiratory bronchioles) is associated with what?
hospital acquired pneumonia (bronchopneumonia)
most common organisms causing hospital acquired pneumonia?
gram negative rods (ex. Pseudomonas) and S.aureus; Klebsiella
when your immune system is down, what normal flora is increased?
gram negative bacteria (these are mostly anerobic)

this can lead to aspiration pneumonia
i. Acute bacterial infection resulting in fibrinosuppurative consolidation usually producing virtually total lobar consolidation
ii. Uniform consolidation

this describes?
lobar pneumonia
what is the main difference between lobar and hospital acquired pneumonia ?
lobar: uniform consolidation

HAP: patchy consolidation
iii. Most common causative agent of lobar pneumonia
Streptococcus pneumonia
what are the 4 stages of inflammation seen in lobar pneumonia
Congestion
Red Hepatization
Grey Hepatization
Resolution
1. Characterized by massive confluent exudation with neutrophils, red cells, and fibrin filling the alveolar spaces; extensive neutrophil exudation into the alveoli
2. Grossly, the lobe appears distinctly red, firm, and airless, with a liver-like consistency

this describes what stage of what disease
Red Hepatization

lobar pneumonia
1. Lung is heavy, boggy, and red
2. Characterized by vascular engorgement, intra-alveolar fluid with few neutrophils, and often the presence of numerous bacteria

this describes what stage of what disease
Congestion

lobar pneumonia
1. Progessive disintegration of red cells and the persistence of a fibrinosuppurative exudate
2. Transformation of exudates to fibromyxoid masses/macrophages and fibroblasts
3. Gross appearance is grayish brown, dry surface

this describes what stage of what disease
Grey hepatization

lobar pneumonia
1. Consolidated exudates within the alveolar spaces undergoes progressive enzymatic digestion to produce granular, semi-fluid debris that is resorbed, ingested by macrophages, expectorated, or organized by fibroblasts growing into it

this describes what stage of what disease
iv. Resolution (final stage)


lobar pneumonia
describe pneumonia in the immuno-compromised patient
chronic pneumonia that can expand over the lung

can make a caseous center and irregular cavity that is poorly walled off by fibrous tissue
how do you get miliary tuberculosis? what happens with this
TB when you are immunocompromised

can spread throughout lymphatics to multiple organs
what is the current theory for development of chronic obstructive pulmonary disease
Protease-antiprotease theory

Aided by oxidant-antioxidant imbalance
Theory – alveolar wall destruction due to imbalance between proteases (mainly elastase) and antiproteases/in the lung

too much destruction of elastic tissue (done by elastase) leading to alveolar collapse
if you see golden-brown rods with a translucent center in the lung what are you looking at?
asbestos bodies
Diffuse pulmonary interstitial fibrosis due to a previous exposure to a pathogen is a typical finding of what?
asbestosis
what are the 2 forms of asbestosis?
1. Serpentine: curly, flexible fibers
2. Amphibole: straight, stiff, brittle fibers
what is the most common manifestation of asbestos exposure? located where?
Pleural plaques

iii. Most frequently on anterior and posterolateral aspects of the parietal pleura and over the domes of the diaphragm
if you see i. Elevated eosinophil count in the peripheral blood
ii. Eosinophils, Curschmann spirals, and Charcot-Leyden crystals in the sputum
iii. Mucus plug

what should you think
asthma
a. Most prevalent occupational disease in the world?
acute silicosis
d. Accumulation of lipoproteinaceous material within alveoli is associated with?
acute silicosis
c. Intra-alveolar, granular, pink precipitate; alveoli filled with a smooth, floccular, pink material is a microscopic finding of what?
pulmonary congestion/edema
a. Early ambulation in postoperative and post partum patients
b. Elastic stockings; graduated compression stockings for bedridden patients
c. Anticoagulation for high-risk individuals

are used to prevent what?
PE
insertion of a filter (“umbrella”) into the inferior vena cava is a possible preventative treatment of what?
PE
primary pulmonary hypertension is b. Most frequently secondary to ______
structural cardiopulmonary conditions
discuss the genetics of primary pulmonary HT
e. Less than 10% has genetic component
b. Loss of bilateral costophrenic angle on CXR is due to?
bilateral pleural effusion
_____ is characterized by loculated, yellow-green, creamy pus composed of masses of neutrophils admixed with other leukocytes
Empyema
Empyema is an example of what type of plueral effusion?

this card sucks. just read it.
purulent (infalmmatory pleural effusion)
iii. Exudate =
inflammatory extravascular fluid

1. High protein content/concentration
2. Cellular debris
3. Specific gravity >1.020
if you see tumor cells or sanguineous inflammatory exudates what should you be thinking?
iv. Hemorrhagic pleuritis
i. Transudate =
fluid with low protein content (mostly albumin); specific gravity < 1.012
iv. Chylothorax
lymph fluid inbetween pleura

usually on the left side
hemothorax?
blood caused

due to 1. Aortic aneurysm
2. Vascular trauma
3. Can be fatal