3 Pneumonia, Pleural Effusion, and Hiccups

Question 1

Other term of hiccups

Answer 1

Singultus

Question 2

persistent vs intractable hiccups

Answer 2

persistent: >48 hours
intractable: >1 month

Question 3

physical maneuvers to treat hiccups

Answer 3

Foreign body removal
Ice water, sip
Quickly drink water
Sugar, swallow a teaspoon

Many of these physical maneuvers are based on the concept that stimulating the pharynx will block the vagal portion of the reflex arc and abolish the hiccups

Question 4

Cyanosis is usually visible when deoxygenated Hgb exceeds

Answer 4

50 g/L
| 5 g/dL

Question 5

at least ____ of pleural fluid in the hemithorax exists if seen on upright CXR

Answer 5

150-200 cc

Question 6

criteria to determine pleural exudate

Answer 6

LIGHT CRITERIA: 1 or more of the ff:
PF/serum protein ratio >0.5
PF/serum LDH ratio >0.6
PF LDH >2/3 of UL for serum LDH

Question 7

Remarks on pleural fluid analysis

Answer 7

Neutrophil predominance: parapneumonic, PE, pancreatitis

Lymphocytic predominance: CA, TB, postcardiac surgery

Low glucose: parapneumonic, CA, TB, RA

Question 8

how to determine pleural fluid that may be empyematous

Answer 8

normal pH is around 7.64
In parapneumonic effusions, a pleural fluid ~pH <7.10~ predicts development of empyema or persistence and indicates need for thoracostomy tube drainage

Question 9

therapeutic thoracentesis is indicated if

Answer 9

patient has dyspnea at rest

acute drainaige of volumes larger than 1-1.5 L is associated with reexpansion pulmonary edema, so large-volume drainage is to be avoided

Question 10

remarks on pleural effusion in heart failure

Answer 10

To confirm exudative etiology in heart failure patients undergoing diuretic therapy, determine serum to pleural fluid albumin gradiant (SPAG)
>12 g/L (1.2 g/dL) means exudative

optimization of medical therapy typicaly resolves >80% of effusions d/t heart failure

Question 11

remarks on acute bronchitis

Answer 11

naproxen reduces coughing in patients with acute bronchitis

Question 12

For intractable coughing paroxysms in the ED, some patients respond to

Answer 12

4 mL of 1-2% preservative-free lidocaine (40-80 mg) by nebulization

This will cause transient suprression of the gag reflex due to posterior pharyngeal anesthesia

Question 13

remarks on kelbsiella pneumoniae pneumonia

Answer 13

usually in alcoholics or nursing home patients
bulging fissure sign with abscess formation on CXR

Question 14

pneumonia agent in elderly and COPD

Answer 14

Haemophilus influenzae

COPD: also Moraxella catarrhalis

Question 15

considered the initial and most effective treatment of massive and recurrent hemoptysis

Answer 15

bronchial artery embolization followed by bronchoscopy

Question 16

2 organisms that account for the most severe CAP in otherwise healthy adults

Answer 16

Streptococcus pneumoniae and Legionella

Question 17

Still the most common pathogen causing pneumonia in alcoholics

Answer 17

S. pneumoniae
but Klebsiella and Haemphilus are also important agents of infection

Question 18

most common infection in the elderly

Answer 18

pneumonia

Question 19

most comon serious viral infection in the elderly

Answer 19

Influenza

Question 20

Most common cause of bacterial pneumonia in patients with HIV

Answer 20

S pneumoniae

Question 21

CURB 65

Answer 21

Confusion
Urea >7 mmol/L (>19 mg/dL)
RR ≥30
BP ≤90/60
≥65 years of age

Question 22

dyspnea in the upright position

Answer 22

platypnea
results from
-loss of abdominal wall muscular tone
-R-to-L intracardiac shunting (patent foramen ovale)

Question 23

dyspnea when lying on one side but not on the other side

Answer 23

TREPOPNEA
the patient lies on the side of the more affected lung where gravity increases blood flow to the worse lung and reduces it to the better lung
patients with trepopnea prefer to lie and sleep on the opposite side of the diseased lung, as the gravitation increases perfusion of the lower lung

Question 24

remarks on hiccups

Answer 24

afferent arm: phrenic and vagus nerves, thoracic sympathetic chain

in most cases in which a specific cause can be assigned, hiccups appear to result from stimulation, inflammation, or injury to one of the nerves of the reflex arc

Question 25

acute (benign, self-limited) causes of hiccups

Answer 25

Alcohol intoxication
Gastric distention
Abrupt change in env temperature
Psychogenic
Excessive smoking

Question 26

chronic (persistent, intractable) causes of hiccups

Answer 26

CNS structural lesions
vagal or phrenic nerve irritation
metabolic: uremia, hyperglycemia

general anethesia
surgical procedures
foreign body in ear touching tympanic membrane (especially hair)