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84 Cards in this Set

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RESPIRATORY:
ADULT MED:
SMOKING CESSATION, COPD, ASTHMA, PNEUMONIA (LABS AND TESTS) TB, ACID-BASE, CARCINOMA
RESPIRATORY:
ADULT MED:
SMOKING CESSATION, COPD, ASTHMA, PNEUMONIA (LABS AND TESTS) TB, ACID-BASE, CARCINOMA
Define Dyspnea
shortness of breath
Define Cough
physiologic mechanism that defends against respiratory pathogens and helps clear the tracheobronchial tree of mucus, foreign particles, and noxious aerosols
Differentiate between acute and chronic cough
Acute is a cough lasting no more than (< 3 weeks)

Chronic is a cough that lasts longer than (> 8 weeks)
Define Hemoptysis
expectoration of blood that originates below the vocal cords
Know the nicotine withdrawal symptoms
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
Know when to refer your smoker patient to formal treatment programs.
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
Describe the historical and physical symptoms and signs that would make you include COPD in your differential.
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
Define Chronic Bronchitis
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
Define Emphysema
abnormal permanent enlargement of air spaces distal to the terminal bronchiole, with destruction of their walls and without obvious fibrosis
dyspnea
Define cor pulmonale
hypertrophy of R ventricle resulting from disease of lungs: acute: dilation and failure of R. heart due to PE. Late: R sided cardiac failure.
Give signs and symptoms of cor pulmonale
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
Define hypercapnia (carbon dioxide retention)
Abnormally increased arterial carbon dioxide tension
Define Hypoxemia
subnormal ixygenation of arterial blood, short of anoxia
Give signs and symptoms of hypercapnia (carbon dioxide retention)
Potent exposure: dyspnea. Weak exposure: hypoxemia
Give signs and symptoms of hypoxemia
dyspnea that may present as agitation
Define asthma
episodic or chronic symptoms of airflow obstruction, no productive cough
Give Sx's, Hx, and Dx for asthma
expiration wheezes - no inspirational wheeze, breathlessness, cough, wheezing, chest tightness
Define bronchiectasis
chronic dilation of bronchi or bronchioles as a sequel of inflammatory disease or obstrcution
Give Sx's, Hx, and Dx for bronchiectasis
chronic productive cough, dyspnea, wheezing, recurrent infections. Fam Hx cystic fibrosis & no smoking. Imaging: dilated, thickened airways and scattered irregular opacities
Define cystic fibrosis
congenital metabolic inherited autosomal disorder; secretions of exocrine glands are abnormal and produce excessive viscid mucus causing obstruction of passageways.
Give Sx's, Hx and Dx for cystic fibrosis
cough, sputum, dyspnea, wheezing, recurrent infections, pancreatic insufficiency Imaging: bronchiectasis, scarring on CXR Lab: sweat chloride
Describe the typical picture of chronic bronchitis seen on CXR.
peribronchial and perivascular markings.
Describe the typical picture of emphysema seen on CXR.
Plain radiographs for dx emphysema; hyperinflation with flat diaphragm or peripheral arterial deficiency in 1/2 cases. Parenchymal bullae in findings are diagnostic
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
IMMUNIAZTION TO PREVENT THE ABOVE DISEASES DURING THE APPROPRIATE SEASON-EVERY FALL FOR INFLUENZA AND EVERY SIX YEARS FOR PNEUMOCCAL
Describe a general plan for following and treating a patient with COPD as an outpatient, addressing issues of: supplemental oxygen therapy
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%
Describe a general plan for following and treating a patient with COPD as an outpatient, addressing issues of: nonpharmacologic therapy
hydration, cough training, hand-held flutter device, postural drainage. Avoid cough suppressants, sedatives as routine measures
Describe a general plan for following and treating a patient with COPD as an outpatient, addressing issues of: pulmonary rehabilitation
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
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).
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
List several common precipitating factors for asthma attacks.
exercise, URI, rhinitis, sinusitis, postnasal drip, aspiration, gastroesophageal reflux, changes in weather, stress. Exposure to environmental tobacco smoke, flying pigs and aliens
Give symptoms of episodic or chronic asthma
breathlessness, cough, wheezing and chest tightness. Worse night or early AM. Prolgoned expiration, limitation of airlfow on pulmonary fxn test or + bronchoprovacation challenge
Identify several clinical disorders that can mimic bronchial asthma.
(to many in each catagory to list) Upper and Lower airway disorders, Systemic vasculitides, Psychiatric
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
If it makes you sneeze or wheeze, aviod it - duh!
Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: bronchodilators
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.
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)
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.
Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: Theophylline
mild bronchodilation, anti-inflammatory properties, enhance mucociliary clearance, & strengthen diaphragmatic contractility. Sustained release: control nocturnal & reserved as adjuvant therapy for moderate, severe persistent asthma
Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: cromolyn sodium
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
Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: leukotriene inhibitors
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
Describe the airway pathology associated with “acute bronchitis”.
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
Describe the pathogens associated with acute bronchitis.
Rhinovirus, Adenovirus, RSV
Influenza, Parainfluenza
Human metapneumovirus
Coronavirus
Given a patient with the appropriate symptoms be able to establish the diagnosis of “Acute Bronchitis” and formulate an appropriate treatment plan.
Supportive care,
Cough Suppression at night if needed
Identify common predisposing factors for pneumonia.
Prior visit to the hospital,
Immunosuppression, Age
Smoking, irritation of the respiratory tract, Alcoholism
Describe a reasonable work-up for the patient you suspect has pneumonia.
CBC
Chem panel
Blood culture
Chest XR
ABGs
HIV for hospitalized patients
Describe the classic clinical presentation and basics of treatment for a patient with community-acquired pneumonia.
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
Describe how you might distinguish the following on clinical evaluation: upper from lower respiratory tract infection
Infection below vocal cords=lower resp. infection
Infection above vocal cords=upper resp. infection
Describe how you might distinguish the following on clinical evaluation: acute bronchitis from pneumonia
Infiltrates, adventitious breath sounds with pneumonia
Fever, constitutional s/s with pneumonia
Describe how you might distinguish the following on clinical evaluation: bacterial versus viral pneumonia
bacterial: Consolidation with bacterial Hilar adenopathy & infiltrates with +gram stain Viral: Fever,cough,dyspnea with bacterial, URI prodrome, choryzia, wheezing or rales
Describe how you might distinguish the following on clinical evaluation: community-acquired vs. nosocomial infection
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
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.
IV drug use associated with higher incidence of Staphylococcus aureus etc.
Alcoholism associated with higher incidence of Streptococcus pneumoniae, Klebsiella pneumoniae and Staphylococcus aureus.
Describe a general approach to antibiotic therapy for community-acquired pneumonia in the immunocompetent adult.
Direct towards strep pneumo
Base effectiveness of therapy on clinical improvement, not culture results
Describe aspects of pneumonia diagnosis and therapy that deserve special attention in patients with altered immunity.
Chest XR is gold standard.
Think TB, pneumocystis, fungal, opportunistic pathogens
Describe the clinical picture of respiratory infection caused by Mycoplasma pneumoniae and identify the lab tests available for diagnosis.
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
Identify Pneumocystis jiroveci as a frequent infection of AIDS patients, and the necessity of invasive techniques to obtain material for diagnosis.
Dx must be proven due to toxic therapy
Bronchial lavage
Define spirometry.
Assessment of pulmonary function
Describe the findings in the history and physical exam of a patient that would indicate that spirometry testing is needed.
Evidence of lung dysfunction
Assessment of occupational hazard
Dyspnea and/or cough
Response of therapy
Pre-op assessment
Define the following terms and be able to identify them on a spirogram: vital capacity
Amount exhaled following maximum inhalation
Define the following terms and be able to identify them on a spirogram: Forced Vital capacity
(FVC) performed with a maximal forced expiratory effort
Define the following terms and be able to identify them on a spirogram: FEV1
Amount measured within first second of FVC
Define the following terms and be able to identify them on a spirogram: FEF 25-75%(maximal mid-expiratory flow rate)
Mean forced expiratory flow during the middle half of the FVC.
Assesses small airways
Define obstructive lung disease in general terms and in terms of the spirogram.
Obstructed to flow…
Decreased FEV1, FEF 25-75%
Increased expiratory phase
COPD, asthma
Define restrictive lung disease in general terms and in terms of the spirogram.
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…)
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).
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
Identify airborne transmission as the most common route of TB infection in humans.
TB is spread via the air
Describe the typical signs, symptoms and natural history of pulmonary tuberculosis in adults.
Fever, Itsy bitsy Hemoptysis
Weight loss, Night sweats
Fatigue, Cough, Pulmonary infiltrates, usually apical
Natural history
Describe primary TB
Exposed, infection contained, but not erradicated
Describe latent TB
Exposed with no active disease, not transmissible
Describe progressive primary TB
Exposed and infected right away
Identify high-risk groups for tuberculosis in the USA in whom screening and a careful diagnostic approach are justified.
Immigrants
Homeless
Immunosuppressed
Healthcare workers
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.
Bones (Pott's dx, Lymph nodes
Pleura, GI tract, Meninges
Peritoneum, Disseminated
Kidney
Describe the appropriate work-up for a patient in whom you suspect may have tuberculosis.
CXR, AFB stain and cultures
PPD with Mantoux Skin test
Gen-Probe PCR, Nucleic acid immunassay
Describe an appropriate plan for the treatment of a patient with TB.
Start 4 drug therapy regimen 6-9months. Proper isolation or masks used. Tell the health dept
Describe aspects of a TB diagnosis and therapy that deserve special attention in patients with altered immunity
Additional considerations
a.Longer therapy
b.Review for possible drug interactions
Identify the body's most important buffer substance for hydrogen ions
bicarbonate (HCO3-)
Identify the most common type of cancer death in both men and women.
lung cancer
Describe the typical patient presentation or complaints on the history that might suggest lung cancer in your patient.
New cough, Change in a chronic cough, Hemoptysis, Weight loss, Anorexia, Fatigue
Describe or recognize classic signs of bronchogenic carcinoma on the chest x-ray.
CXR shows pulmonary effusion.
Solitary pulmonary nodule, "Coin lesion"
Describe small cell lung cancer and identify the most common sites of metastasis.
Tumor of bronchial origin
Adenocarcinoma (35%)
Loc. In mid lung and periphery
What areas of the body does lung CA frequently metastasize to?
brain, liver, bone, and adrenals
Describe squamous cell lung cancer and identify the most common sites of metastasis.
Arises from bronchial epithelm
Describe large cell lung cancer and identify the most common sites of metastasis.
Heterogenous group of undifferentiated tumors
Don't fit in
Describe Bronchioalveolar cell lung cancer and identify the most common sites of metastasis.
Frequently loc. In the periphery. Any epi cell within or distal to the terminal bronchioles
Describe the general significance of solitary pulmonary nodules (SPN; a.k.a.: coin lesions) on chest x-rays.
•Most are asymmtomatic
•Most are an unexpected finding on CXR
•Higher risk of malignancy
•Most are infectious granulomas
Briefly describe the types of therapy that might be afforded those patients with a diagnosis of Non-small cell cancer
•Surgery
•Radiation
•Chemotherapy
Briefly describe the types of therapy that might be afforded those patients with a diagnosis of small cell / oat cell cancer
(tx depends on staging)
•Thoracic radiotherapy
•Chemotherapy
•Most virulent