Respiratory Am

Front 1

RESPIRATORY:
ADULT MED:
SMOKING CESSATION, COPD, ASTHMA, PNEUMONIA (LABS AND TESTS) TB, ACID-BASE, CARCINOMA

Back 1

RESPIRATORY:
ADULT MED:
SMOKING CESSATION, COPD, ASTHMA, PNEUMONIA (LABS AND TESTS) TB, ACID-BASE, CARCINOMA

Front 2

Define Dyspnea

Back 2

shortness of breath

Front 3

Define Cough

Back 3

physiologic mechanism that defends against respiratory pathogens and helps clear the tracheobronchial tree of mucus, foreign particles, and noxious aerosols

Front 4

Differentiate between acute and chronic cough

Back 4

Acute is a cough lasting no more than (< 3 weeks)

Chronic is a cough that lasts longer than (> 8 weeks)

Front 5

Define Hemoptysis

Back 5

expectoration of blood that originates below the vocal cords

Front 6

Know the nicotine withdrawal symptoms

Back 6

Withdrawal syndrome includes 4+ of the following: dysphoric or depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, or impatience, decreased heart rate, increased appetite or weight gain

Front 7

Know when to refer your smoker patient to formal treatment programs.

Back 7

when the pt is highly motivated to quit and willing to attend a treatment program. Pts with high level of nicotine dependence, previously failed to quit using self-help methods & pts with psychiatric co morbidity are most likely to benefit

Front 8

Describe the historical and physical symptoms and signs that would make you include COPD in your differential.

Back 8

Hx of cigarette smoking
Chronic cough & sputum production, Rhonchi, decreased breath sounds, & prolonged expiration on physical examination,
Airflow limitation on pulmonary function testing not fully reversible & progressive

Front 9

Define Chronic Bronchitis

Back 9

excessive secretion of bronchial mucus and is manifested by daily productive cough for 3 months or more in 2 consecutive years, Chronic cough and sputum production

Front 10

Define Emphysema

Back 10

abnormal permanent enlargement of air spaces distal to the terminal bronchiole, with destruction of their walls and without obvious fibrosis
dyspnea

Front 11

Define cor pulmonale

Back 11

hypertrophy of R ventricle resulting from disease of lungs: acute: dilation and failure of R. heart due to PE. Late: R sided cardiac failure.

Front 12

Give signs and symptoms of cor pulmonale

Back 12

chronic productive cough, exertional dyspnea, wheezing respirations, easy fatigability,weakness. Dependent edema, RUQ px may also appear. cyanosis, clubbing, distended neck veins, RV heave or gallop (or both), prominent lower sternal or epigastric pulsations, enlarged & tender liver

Front 13

Define hypercapnia (carbon dioxide retention)

Back 13

Abnormally increased arterial carbon dioxide tension

Front 14

Define Hypoxemia

Back 14

subnormal ixygenation of arterial blood, short of anoxia

Front 15

Give signs and symptoms of hypercapnia (carbon dioxide retention)

Back 15

Potent exposure: dyspnea. Weak exposure: hypoxemia

Front 16

Give signs and symptoms of hypoxemia

Back 16

dyspnea that may present as agitation

Front 17

Define asthma

Back 17

episodic or chronic symptoms of airflow obstruction, no productive cough

Front 18

Give Sx's, Hx, and Dx for asthma

Back 18

expiration wheezes - no inspirational wheeze, breathlessness, cough, wheezing, chest tightness

Front 19

Define bronchiectasis

Back 19

chronic dilation of bronchi or bronchioles as a sequel of inflammatory disease or obstrcution

Front 20

Give Sx's, Hx, and Dx for bronchiectasis

Back 20

chronic productive cough, dyspnea, wheezing, recurrent infections. Fam Hx cystic fibrosis & no smoking. Imaging: dilated, thickened airways and scattered irregular opacities

Front 21

Define cystic fibrosis

Back 21

congenital metabolic inherited autosomal disorder; secretions of exocrine glands are abnormal and produce excessive viscid mucus causing obstruction of passageways.

Front 22

Give Sx's, Hx and Dx for cystic fibrosis

Back 22

cough, sputum, dyspnea, wheezing, recurrent infections, pancreatic insufficiency Imaging: bronchiectasis, scarring on CXR Lab: sweat chloride

Front 23

Describe the typical picture of chronic bronchitis seen on CXR.

Back 23

peribronchial and perivascular markings.

Front 24

Describe the typical picture of emphysema seen on CXR.

Back 24

Plain radiographs for dx emphysema; hyperinflation with flat diaphragm or peripheral arterial deficiency in 1/2 cases. Parenchymal bullae in findings are diagnostic

Front 25

Describe a general plan for following and treating a patient with COPD as an outpatient, addressing issues of: pharmacologic therapy prevention of influenza and pneumococcal pneumonia

Back 25

IMMUNIAZTION TO PREVENT THE ABOVE DISEASES DURING THE APPROPRIATE SEASON-EVERY FALL FOR INFLUENZA AND EVERY SIX YEARS FOR PNEUMOCCAL

Front 26

Describe a general plan for following and treating a patient with COPD as an outpatient, addressing issues of: supplemental oxygen therapy

Back 26

comes in liquid oxygen systems (LOX), compressed gas cylinders, or oxygen concentrators. flow rate of 1–3 L achieves PaO2 > than 55 mm Hg. monthly cost: $300 -$500+ higher for liquid oxygen. Medicare covers 80%

Front 27

Describe a general plan for following and treating a patient with COPD as an outpatient, addressing issues of: nonpharmacologic therapy

Back 27

hydration, cough training, hand-held flutter device, postural drainage. Avoid cough suppressants, sedatives as routine measures

Front 28

Describe a general plan for following and treating a patient with COPD as an outpatient, addressing issues of: pulmonary rehabilitation

Back 28

aerobic physical exercise: walking 20 min 3X's daily, training inspiratory muscles to improve exercise tolerance, pursed-lip breathing to slow rate of breathing and abd breathing to relieve fatigue of accessory muscles

Front 29

Describe airway hyperresponsiveness and reversibility of airway obstruction as the key factors that set asthma apart from other disorders of airways obstruction (e.g., fixed airways obstruction).

Back 29

Hypertrophy of bronchial smooth muscle & mucous glands with plugging of sm airway with thick mucus. underlies disease chronicity & contributes to airway hyperresponsiveness, airflow limitation & resp sxs including wheezing, breathlessness, chest tightness, cough

Front 30

List several common precipitating factors for asthma attacks.

Back 30

exercise, URI, rhinitis, sinusitis, postnasal drip, aspiration, gastroesophageal reflux, changes in weather, stress. Exposure to environmental tobacco smoke, flying pigs and aliens

Front 31

Give symptoms of episodic or chronic asthma

Back 31

breathlessness, cough, wheezing and chest tightness. Worse night or early AM. Prolgoned expiration, limitation of airlfow on pulmonary fxn test or + bronchoprovacation challenge

Front 32

Identify several clinical disorders that can mimic bronchial asthma.

Back 32

(to many in each catagory to list) Upper and Lower airway disorders, Systemic vasculitides, Psychiatric

Front 33

Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: avoidance of environmental factors

Back 33

If it makes you sneeze or wheeze, aviod it - duh!

Front 34

Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: bronchodilators

Back 34

Short-acting inhaled clearly the most effective bronchodilators during exacerbations. Aadrenergic agonists used in all pts to treat acute sxs. agents relax airway smooth muscle, cause prompt increase in airflow & reduction of sxs.

Front 35

Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: corticosteroids (systemic and inhaled)

Back 35

Systemic: primary tx for moderate-severe exacerbations or don't respond promptly to inhaled 2-agonist therapy. Systemic: severe asthma. speed resolution of airflow obstruction & reduce rate of relapse.

Front 36

Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: Theophylline

Back 36

mild bronchodilation, anti-inflammatory properties, enhance mucociliary clearance, & strengthen diaphragmatic contractility. Sustained release: control nocturnal & reserved as adjuvant therapy for moderate, severe persistent asthma

Front 37

Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: cromolyn sodium

Back 37

long-term control medications that prevent asthma symptoms and improve airway function in pts with mild persistent asthma or exercise-induced asthma. modulate mast cell mediator release and eosinophil recruitment

Front 38

Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: leukotriene inhibitors

Back 38

Leukotrienes are potent biochemical mediators that contribute to airway obstruction & asthma sxs by contracting airway smooth muscle, increasing vascular permeability & mucus secretion, attracting & activating airway inflammatory cells

Front 39

Describe the airway pathology associated with “acute bronchitis”.

Back 39

Inflammation of the bronchi,
Cough with sputum, worse in A.M. Most common reason for abx abuse. No - low grade fever, Post nasal drip, Rhonchi that clears with cough

Front 40

Describe the pathogens associated with acute bronchitis.

Back 40

Rhinovirus, Adenovirus, RSV
Influenza, Parainfluenza
Human metapneumovirus
Coronavirus

Front 41

Given a patient with the appropriate symptoms be able to establish the diagnosis of “Acute Bronchitis” and formulate an appropriate treatment plan.

Back 41

Supportive care,
Cough Suppression at night if needed

Front 42

Identify common predisposing factors for pneumonia.

Back 42

Prior visit to the hospital,
Immunosuppression, Age
Smoking, irritation of the respiratory tract, Alcoholism

Front 43

Describe a reasonable work-up for the patient you suspect has pneumonia.

Back 43

CBC
Chem panel
Blood culture
Chest XR
ABGs
HIV for hospitalized patients

Front 44

Describe the classic clinical presentation and basics of treatment for a patient with community-acquired pneumonia.

Back 44

Acute, subacute onset of fever with or without sputum
Rigors, sweats, chills, chest discomfort, pleurisy, hemoptysis, Fatigue, myalgias, anorexia, HA, abd px, Bronchial breath sounds or rales with ascultation

Front 45

Describe how you might distinguish the following on clinical evaluation: upper from lower respiratory tract infection

Back 45

Infection below vocal cords=lower resp. infection
Infection above vocal cords=upper resp. infection

Front 46

Describe how you might distinguish the following on clinical evaluation: acute bronchitis from pneumonia

Back 46

Infiltrates, adventitious breath sounds with pneumonia
Fever, constitutional s/s with pneumonia

Front 47

Describe how you might distinguish the following on clinical evaluation: bacterial versus viral pneumonia

Back 47

bacterial: Consolidation with bacterial Hilar adenopathy & infiltrates with +gram stain Viral: Fever,cough,dyspnea with bacterial, URI prodrome, choryzia, wheezing or rales

Front 48

Describe how you might distinguish the following on clinical evaluation: community-acquired vs. nosocomial infection

Back 48

community: Strep pneumo
Occurs less than 48 hrs
nosocomial: Pseudomonas, must have 2: Fever, Cough, Leukocytosis, Purulent sputum
Occurs more than 48 hrs after admission

Front 49

Learn the association of host factors with particular pathogens. For example: Alcoholism is associated with a higher incidence of Streptococcus pneumoniae, Klebsiella pneumoniae and Staphylococcus aureus.

Back 49

IV drug use associated with higher incidence of Staphylococcus aureus etc.
Alcoholism associated with higher incidence of Streptococcus pneumoniae, Klebsiella pneumoniae and Staphylococcus aureus.

Front 50

Describe a general approach to antibiotic therapy for community-acquired pneumonia in the immunocompetent adult.

Back 50

Direct towards strep pneumo
Base effectiveness of therapy on clinical improvement, not culture results

Front 51

Describe aspects of pneumonia diagnosis and therapy that deserve special attention in patients with altered immunity.

Back 51

Chest XR is gold standard.
Think TB, pneumocystis, fungal, opportunistic pathogens

Front 52

Describe the clinical picture of respiratory infection caused by Mycoplasma pneumoniae and identify the lab tests available for diagnosis.

Back 52

Tracheobronchitis with gradual onset with low grade fever,chills, HA, malaise
not severe, referred to as "walking pneumonia"
Dx with Direct Coomb's (DAT) and cold agglutinins

Front 53

Identify Pneumocystis jiroveci as a frequent infection of AIDS patients, and the necessity of invasive techniques to obtain material for diagnosis.

Back 53

Dx must be proven due to toxic therapy
Bronchial lavage

Front 54

Define spirometry.

Back 54

Assessment of pulmonary function

Front 55

Describe the findings in the history and physical exam of a patient that would indicate that spirometry testing is needed.

Back 55

Evidence of lung dysfunction
Assessment of occupational hazard
Dyspnea and/or cough
Response of therapy
Pre-op assessment

Front 56

Define the following terms and be able to identify them on a spirogram: vital capacity

Back 56

Amount exhaled following maximum inhalation

Front 57

Define the following terms and be able to identify them on a spirogram: Forced Vital capacity

Back 57

(FVC) performed with a maximal forced expiratory effort

Front 58

Define the following terms and be able to identify them on a spirogram: FEV1

Back 58

Amount measured within first second of FVC

Front 59

Define the following terms and be able to identify them on a spirogram: FEF 25-75%(maximal mid-expiratory flow rate)

Back 59

Mean forced expiratory flow during the middle half of the FVC.
Assesses small airways

Front 60

Define obstructive lung disease in general terms and in terms of the spirogram.

Back 60

Obstructed to flow…
Decreased FEV1, FEF 25-75%
Increased expiratory phase
COPD, asthma

Front 61

Define restrictive lung disease in general terms and in terms of the spirogram.

Back 61

Restricted to volume
Spirometry. Decrease in lung volumes with normal flow rates. DLCO decreased (diffusion of CO test)
Pulmonary fibrosis, ILD, extrinsic cause (ankylososing spondylitits, obesity, prego), neuromuscular dx (myasthenia gravis, muscular dystrophy, phrenic nerve palsy…)

Front 62

Identify the different groups of disorders that can cause restrictive lung disease according to “Overview of pulmonary function testing” by Paul L Enright, MD (UpToDate).

Back 62

Intrinsic – inflammation or scarring of lung tissue
Extrinsic – disorders of chest wall or pleura that compress or limit expansion
Neuromuscular disorders – decrease the ability of the respiratory muscles to inflate or deflate the lungs

Front 63

Identify airborne transmission as the most common route of TB infection in humans.

Back 63

TB is spread via the air

Front 64

Describe the typical signs, symptoms and natural history of pulmonary tuberculosis in adults.

Back 64

Fever, Itsy bitsy Hemoptysis
Weight loss, Night sweats
Fatigue, Cough, Pulmonary infiltrates, usually apical
Natural history

Front 65

Describe primary TB

Back 65

Exposed, infection contained, but not erradicated

Front 66

Describe latent TB

Back 66

Exposed with no active disease, not transmissible

Front 67

Describe progressive primary TB

Back 67

Exposed and infected right away

Front 68

Identify high-risk groups for tuberculosis in the USA in whom screening and a careful diagnostic approach are justified.

Back 68

Immigrants
Homeless
Immunosuppressed
Healthcare workers

Front 69

Recognize that extrapulmonary tuberculosis occurs, and list several common sites. For example, recognize that pyuria (with a negative urine culture) and microscopic hematuria can be the presenting findings in renal tuberculosis.

Back 69

Bones (Pott's dx, Lymph nodes
Pleura, GI tract, Meninges
Peritoneum, Disseminated
Kidney

Front 70

Describe the appropriate work-up for a patient in whom you suspect may have tuberculosis.

Back 70

CXR, AFB stain and cultures
PPD with Mantoux Skin test
Gen-Probe PCR, Nucleic acid immunassay

Front 71

Describe an appropriate plan for the treatment of a patient with TB.

Back 71

Start 4 drug therapy regimen 6-9months. Proper isolation or masks used. Tell the health dept

Front 72

Describe aspects of a TB diagnosis and therapy that deserve special attention in patients with altered immunity
Additional considerations

Back 72

a.Longer therapy
b.Review for possible drug interactions

Front 73

Identify the body's most important buffer substance for hydrogen ions

Back 73

bicarbonate (HCO3-)

Front 74

Identify the most common type of cancer death in both men and women.

Back 74

lung cancer

Front 75

Describe the typical patient presentation or complaints on the history that might suggest lung cancer in your patient.

Back 75

New cough, Change in a chronic cough, Hemoptysis, Weight loss, Anorexia, Fatigue

Front 76

Describe or recognize classic signs of bronchogenic carcinoma on the chest x-ray.

Back 76

CXR shows pulmonary effusion.
Solitary pulmonary nodule, "Coin lesion"

Front 77

Describe small cell lung cancer and identify the most common sites of metastasis.

Back 77

Tumor of bronchial origin
Adenocarcinoma (35%)
Loc. In mid lung and periphery

Front 78

What areas of the body does lung CA frequently metastasize to?

Back 78

brain, liver, bone, and adrenals

Front 79

Describe squamous cell lung cancer and identify the most common sites of metastasis.

Back 79

Arises from bronchial epithelm

Front 80

Describe large cell lung cancer and identify the most common sites of metastasis.

Back 80

Heterogenous group of undifferentiated tumors
Don't fit in

Front 81

Describe Bronchioalveolar cell lung cancer and identify the most common sites of metastasis.

Back 81

Frequently loc. In the periphery. Any epi cell within or distal to the terminal bronchioles

Front 82

Describe the general significance of solitary pulmonary nodules (SPN; a.k.a.: coin lesions) on chest x-rays.

Back 82

•Most are asymmtomatic
•Most are an unexpected finding on CXR
•Higher risk of malignancy
•Most are infectious granulomas

Front 83

Briefly describe the types of therapy that might be afforded those patients with a diagnosis of Non-small cell cancer

Back 83

•Surgery
•Radiation
•Chemotherapy

Front 84

Briefly describe the types of therapy that might be afforded those patients with a diagnosis of small cell / oat cell cancer

Back 84

(tx depends on staging)
•Thoracic radiotherapy
•Chemotherapy
•Most virulent