cardio/pulm Flashcards
What are 4 main triggers for asthma?
Weather change
Aspirin
Beta blockers
Viral URI
How many children will outgrow mild asthma ?
60%
What is the trend in asthma mortality?
Mortality of asthma is increasing!
Is asthma more common in boys or girls?
More common in boys until puberty - but later it is equal in boys and girls
What are the 3 clinical descriptions associated with mild intermittent asthma?
Symptoms less then 2x weekly
Night symptoms less then 2x monthly
No pulmonary function abnormalities
What are the 3 clinical descriptions associated with mild persistent asthma ?
Normal PFTs
Symptoms more than 2x per week
Night symptoms more than 2x per month
What is the treatment for mild persistent asthma?
Low dose inhaled steroids
2nd line - leukotriene inhibitor
What is the treatment for moderate persistent asthma?
Low to medium dose steroid + laba
When do you classify a child as having moderate persistent asthma?
When a child requires bronchodilators more than twice per week
What is the definition of mild exacerbation of asthma ?
Decreased pulmonary function but still >50% of predicted
When is levalbuterol indicated instead of albuterol?
Only in patients with tachycardia, tremors or irritability
When is chest PT and mucolytics indicated for asthma?
Never
What are 5 side effects of beta adrenergic agonists?
Tremors Tachycardia Hypokalemia Hyperglycemia Hypomagnesemia
What does high or low CO2 indicate in the setting of acute asthma?
High pCO2 indicates CO2 retention and fatigue with respiratory failure
Low pCO2 reflects tachypnea
What are 5 signs of hypercapnia?
Agitation Flushing Altered mental status Headache Tachycardia
What is the most common cause of chronic nighttime cough?
Reactive airway disease
What are 4 main causes of infant wheezing, other than asthma?
Aspiration
Bronchopulmonary dysplasia
Foreign body
Vascular rings
What is the definition of exercise induced asthma?
Coughing and wheezing 5 minutes after exercising with improvement within 15 minutes of rest
What diagnosis should you consider in a patient with a “respiratory infection that is not clearing”?
Foreign body
What are the 4 main causes of poor exercise tolerance ?
Cardiac disease
Anemia
Muscle weakness
Psychological factors
What medication may be indicated for exercise induced asthma?
Leukotriene inhibitor (montelukast)
What are the 4 risk factors for persistent asthma ?
Onset before age 3
IgE elevated
Maternal hx asthma
Eosinophilia
What diagnosis must be considered in a patient with unlabored breathing but sudden onset of intermittent productive cough and wheezing?
Foreign body aspiration
What diagnosis corresponds with blunted inspiratory loop on spirometry?
Vocal cord paralysis
What is the safest and most effective way to confirm foreign body aspiration?
Airway fluoroscopy
What is the treatment for a swallowing dysfunction ?
Thickened formula and upright feeding position
What are 3 signs of respiratory failure ?
Tachypnea
Retractions
Pulsus paradoxus
What is pulsus paradoxus?
When the difference in blood pressure during inspiration and expiration is >10mmHg
What is the first thing to do when deciding whether to intubate a patient ?
Assess respiratory effort
What is the best way to assess for the severity of respiratory distress ?
Sweating / fast heart rate
What is the proper way to administer oxygen in a patient with chronic lung disease and why?
At the lowest concentration needed to maintain sats above 90 …rapid correction of hypoxia can lead to respiratory arrest because respiratory drive is driven by hypoxia
What are 3 initial screening tests for a chronic cough?
Sweat choride test
Tb skin test
Cxr
What value indicates an abnormal sweat chloride test?
> 60
How is cystic fibrosis inherited?
Autosomal recessive (carriers show no signs of disease)
What is the most effective test for confirming cystic fibrosis?
Sweat chloride
What disease should you suspect in an infant with hypochloremic alkalosis ?
Cystic fibrosis
If a sibling of someone with CF marries someone in the general population, what are the odds of them having a child with CF?
1 in 150
If two carriers of CF are married, what is the risk they will have a child with Cf?
1 in 4
What is the carrier rate of CF in the general population ?
1 in 25
What are the odds of a healthy sibling of someone with CF being a carrier?
2/3
What vitamin may be deficient in patients with CF? What should be done about this deficiency ?
Vitamin E (supplements should be started prior to age 5)
What lab study if abnormal in patients with vitamin K malabsorption?
Prolonged PT
What are 3 common GI manifestations of CF in the neonatal period?
Meconium ileus
Meconium peritonitis
Unconjugated hyperbilirubinemia
What are the X-ray findings of meconium peritonitis?
Pseudocyst (calcified meconium)
What is the abdominal film appearance with meconium ileus?
Ground glass appearance due to decreased bowel gas
What is the antibiotic treatment of an acute exacerbation of CF?
Aminoglycoside and piperacillin (for pseudomonas coverage )
What diagnosis should you consider in a patient with lower body edema, hepatomegaly, gallop heart rhythm and clubbing of fingers?
Cor pulmonale
What causing flushing and agitation as well as headaches due to cerebral vasodilation?
Hypercarbia
How is apnea of prematurity treated?
Caffeine
What are 4 main causes of central apnea which must be ruled out before the diagnosis “apnea of prematurity” is given?
Sepsis
Medication
Anemia
Electrolyte abnormalities
What is the likely cause of a patient in acute respiratory distress who is post-op tonsillectomy due to history of obstructive apnea?
Pulmonary edema
What is the definition of apnea?
Cessation on breathing >20 seconds or <20 seconds if associated w bradycardia or cyanosis
What is the diagnosis in a patient with pleural fluid that has >110 triglycerides, high lymphocytes and protein >3?
Chylothorax
When is pleural effusion likely to be an “exudate”?
With pneumonia, Cancer, inflammation or trauma
What will the fluid LDH and protein levels be in an exudative pleural effusion?
LDH 3x the serum LDH
Protein >3 grams
What are 3 causes of transudative pleural effusion?
Cirrhosis
Nephrotic syndrome
CHF
What is the triglyceride level in transudative pleural fluid?
<50
What is the diagnosis and treatment for a patient with tachypnea, tachycardia, low BP and tracheal deviation ?
Tension PTX - needle or chest tube ASAP
What are 3 causes of respiratory deterioration in an intubated patient?
Tension PTX
Incorrect tube positioning
Equipment failure
What are 6 main risk factors for SIDS ?
Sleeping on tummy Co sleeping Low income Smoking Cold weather Young parents
What are 6 possible causes of ALTE in an infant?
Neurological abnormality Abuse/trauma Lung infection / apnea Sepsis Hypoglycemia Gerd / aspiration
When can an infant with ALTE be discharged home from the ER?
First episode that is brief and presents with an explanation (uri or reflux)
What is the initial step when presented with an infant with noisy breathing?
Birth history and observe breathing in different positions
What is the only way to correlate pulse oximetry and pulmonary lung function?
ABG (CBG is unreliable)
What diagnosis should you consider in a patient with chocolate colored blood and cyanosis despite normal pulse ox?
Methemoglobin
What are 3 conditions in which pulse oximetry is unreliable?
Carboxyhemoglobin
Methemoglobin
Impaired perfusion (septic shock)
What are the 4 common causes of stridor in a neonate?
Choanal atresia
Vascular ring
Laryngeal web/stenosis
Vocal cord paralysis
What is the most common cause of stridor in a 1 month old infant?
Laryngomalacia/tracheomalacia
What are 3 causes of stridor in a child age 1-4 years old?
Croup
Epiglotitis
Foreign body aspiration
What is the likely cause of stridor in a child older than 5 years old?
vocal cord dysfunction
Peritonsillar abscess
Anaphylaxis
What are classic X-ray findings with bronchiolitis?
Hyperinflation and patchy infiltrates
How can bronchiolitis be distinguished from chlamydia pneumonia ?
Chlamydia typically presents at 1-3 weeks of age with staccato cough and no fever or wheezing
What is the most common cause of bronchiectasis?
Cystic fibrosis
What is a permanent dilation of small airway segments?
Bronchiectasis
How is bronchiectasis diagnosed?
CT of the chest
What diagnosis should you consider in a patient with repeat lower respiratory tract infections with consistent right middle love atelectasis and cough that is worse after lying down?
Bronchiectasis
Other than CF, what are 6 causes of bronchiectasis ?
Dyskinesia (primary ciliary dyskinesia) Immunodeficiency Lobar pneumonia Aspergillosis TB Extrinsic compression (Lymph nodes)
What syndrome presents with chronic sinusitis, situs inversus and male infertility?
Kartagener
What diagnosis should be considered in an infant with recurrent wheezing that is worse with feeding ? How would you diagnose this?
Tracheal or esophageal compression (vascular ring, double aortic arch)
Diagnose with barium swallow
What is the hyperinflation of one or more lobes of the lung which presents as respiratory distress or airway obstruction in newborns?
Congenital lobar emphysema
What is the malformation of dysplastic lung tissue that presents as recurrent pneumonia ?
Congenital cystic adenomatoid malformation
What incidental finding presents with consistent airway compression ?
Bronchogenic cysts
What is the name of lung tissue that is supplies by systemic instead of pulmonary arterial supply?
Pulmonary sequestration
What is the appropriate treatment for a patient with positive PPD but negative chest X-ray for TB?
Isoniazid x 9 months
What diagnosis should you consider in a patient with low grade fever an cough for one month and a cxr that shows hilar adenopathy?
How would you treat?
TB -
2months rifampin, INH and pyrazinamide followed by 4 months of INH and rifampin OR
9 months INH and rifampin
What are 4 presentations of extrapulmonary TB?
Meningitis
Adenitis
Pleuritis
Disseminated (miliary)
How is TB meningitis treated differently than regular pulmonary TB?
Add streptomycin and steroids
What is the appropriate initial step in a patient with flail chest after chest wall trauma?
Intubation and pain management
What is the most important procedure to perform following blunt trauma to the chest?
Physical exam
What is the cause of death in a patient with ARDS?
Multiorgan failure
What is the best method of temperature control following a near drowning?
External rewarding of the head and neck
What are 4 likely causes of hemoptysis in children?
Infection
Cystic fibrosis
Foreign body aspiration
Hemosiderosis
What is the best course of action when presented with a patient with acute hemoptysis?
PH of aspirate to determine if acidic (from stomach) or alkaline (from lungs)
CBC and coags
What are the 4 most common causes of pneumonia in the patient age 3 weeks to 3 months?
Chlamydia
RSV
Parainfluenza
Pertussis
What are the 3 most common causes of pneumonia in a patient from 3 months to 4 years of age?
Viral
Strep pneumo
Mycoplasma
What abx are used to treat necrotizing pneumonia?
Vanco or clinda
What is the best diagnostic study to confirm the diagnosis in a patient with pneumonia that has been confirmed on chest X-ray?
Blood culture (sputum or nasopharyngeal culture are not the correct answer )
What is the goal of treatment in a patient with CHF due to left to right shunting?
Reducing volume overload with diuretics
When is verapamil contraindicated as treatment for CHF?
In a child less than 1 year old
What is the goal of treatment in an infant with coarctation of the aorta?
Maintain patent PDA with prostaglandin
What are 5 causes of cyanotic congenital heart disease ?
Truncus arteriosis Transposition of great arteries Tricuspid atresia Tetralogy of fallot Total anomalous pulmonary venous return
What is the only cyanotic heart disease that presents in the first few hours of life?
Transposition of the great vessels
What is the treatment of methemoglobinemia?
Methylene blue
What is the possible diagnosis in a patient whose mother mixes the formula with well water and presents with cyanosis but no respiratory distress ?
Methemoglobinemia
Why does methemoglobin cause cyanosis ?
Defective hemoglobin molecule can not carry oxygen to tissues
What are 3 causes of CVA in infants ?
Cyanotic heart disease
Polycythemia
Iron deficiency anemia
What is appropriate workup for a patient with blue hands and feet on a off since births in an otherwise normal baby?
Reassurance
What must occur in order for total anomalous venous return to be compatible with life?
PFO or ASD which connects right and left atrium
What is the pathology of total anomalous pulmonary venous return?
None of the 4 veins that drain blood from the lungs to the heart is attached to the left atrium therefore oxygenated blood returns to the right atrium
What are the 4 components of tetralogy of fallot?
Pulmonary stenosis
Overriding aorta
VSD
RVH
What abnormal heart sounds will be heart in a patient with total anomalous venous return?
Fixed split S2 and short systolic murmur
What cxr findings are consistent with total anomalous pulmonary venous return?
Pulmonary congestion (due to increased venous return) and normal to small heart size
What ABG abnormalities are consistent with total anomalous pulmonary venous return ?
Hypoxia
Hypercarbia
What is the treatment for a patient who was normal until the 2nd day of life when he became cyanotic with tachypnea and normal cxr ?
Prostaglandin to maintain patent PDA
What is the first line treatment for pulmonary hypertension?
Nitric oxide
What are 4 factors that correlate with cognitive prognosis in patients with cyanotic heart disease ?
Neurological baseline before surgery
Seizures after surgery
Coexisting problems
Duration of circulatory arrest intraoperatively
What diagnosis presents with a boot shaped heart on CXR?
Tetralogy of fallot
What is the treatment of an acute TET spell ?
Place child in squatting position to increase PVR + morphine, phenylephrine, propranolol and IVF
What is the pathology behind a TET spell?
Dehydration or anemia cause increased right to left shunting and therefore a hypercyanotic hypoxic episode
What are the symptoms of an acute TET spell?
Agitated infant with absent heart murmur
When do patients with tetralogy of fallot typically present?
Age 3-5 months
What cardiac defect presents with an egg shaped heart and increased pulmonary vascularity?
Transposition of the great vessels
A 10 day old newborn presents with tachypnea, thready pulses and large liver as well as EKG findings of aortic stenosis. What therapy should be started immediately?
Prostaglandin- this baby is in cardiogenic shock and ductus needs to be reopened
What atypical heart sound is present in both tetralogy of fallot and transposition?
Single 2nd heart sound
What are olser nodes?
Tender nodules on fingers and toes
What are janeway lesions?
Non tender red nodules on palms and soles
What diagnosis should you consider in a patient with generalized facial swelling, fatigue, weight loss and dusky color?
Superior Vena Cava syndrome
What is persistent fetal circulation?
Pulmonary vascular resistance greater than systemic resistance causes right to left shunting
What is the best test to confirm endocarditis?
Blood culture (not an ECHO)
What diagnosis should you consider in a patient with two weeks of fever and lethargy as well as new murmur, petechiae and splenomegaly on physical exam?
Endocarditis
What is the likely pathogenic organism in a patient with subacute bacterial endocarditis?
Strep viridans
What are the 3 most common bacterial causes of acute bacterial endocarditis?
Strep viridans
Strep bovis
Staph aureus
What are the 5 HACEK bacteria?
Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella
What is the appropriate antibiotic prophylaxis against endocarditis ?
Amoxicillin 30-60 minutes prior to procedure
When is antibiotic prophylaxis recommended prior to dental procedure?
Incompletely repaired cyanotic heart dz
Heart disease corrected w hardware within past 6 months
Defect near prosthetic cardiac device
What is the most common bacterial cause of pericarditis?
Staph aureus
What are the 2 most common causes of pericarditis?
Viral infection
Collagen vascular disease
What classic EKG finding is associated with pericarditis?
Diffuse ST elevation
What 3 physical exam findings are associated with pericarditis ?
Muffled heart sounds
Pericardial friction rub
Jugular venous distention
What is the most important study to order when pericarditis is suspected?
CXR
What is the pathological cause of a pansystolic murmur best heard at the left lower sternal border?
VSD
What cardiac defect is associated with maternal use of lithium ?
Epstein anomaly
What cardiac defect is associated with maternal use of alcohol?
VSD and ASD
What cardiac abnormality should you consider in a patient with split loud S2 and hyperdynamic precordium?
VSD
What malformation is associated with bounding carotid pulses and decreased peripheral pulses?
Cranial bruit associated with AV malformation of the brain
What should you do if you hear a 3rd heart sound on physical exam?
Sit the child up and the sound should disappear - if the sound is present while sitting up, further workup is needed
What diagnosis should you expect in a patient with exercise intolerance and fixed split 2 heart sound on exam?
ASD
What cardiac abnormality presents with systolic click and normal S2?
Pulmonary stenosis
What cardiac abnormality presents with systolic click and murmur at right upper sternal border that radiates to the neck?
Aortic stenosis
What activities should be avoided in a patient with Marfan syndrome and why?
Weight lifting and contact sports - risk for aortic enlargement and dissection
What EKG finding would be present in coarctation of the aorta?
RVH
What EKG finding would be present in a patient with aortic stenosis?
LVH
When are PACs on EKG abnormal?
Children on digoxin or children less than 1 year old due to risk of atrial flutter
What syndrome should you be concerned about in a patient with short PR interval and delta wave on EKG?
Wolff Parkinson white
What syndrome must be ruled out in a patient who presents with sudden onset of syncope after vigorous exercise or emotional stress?
Prolonged QT
What is the likely diagnosis in a patient with recurrent episodes of syncope with prolonged standing but no family hx of sudden cardiac death?
Neurocardiogenic syncope
What is the first thing to do in a stable patient with HR 225?
12 lead EKG
What first thing should you do with a child with HR 230 in SVT and hemodynamic instability? What if cardiac failure?
Vasovagal maneuvers then adenosine or cardioversion–if cardiac failure, adenosine is first line!!
What is the risk in a patient with AV block and prolonged QRS complex?
Compromised blood flow to the brain causing seizure and syncope
What medication is contraindicated in a child with WPW?
Digoxin
What type of chest pain would raise suspicion for cardiac origin?
Radiation to neck/back/shoulders
Pain is constant, dull and pressure-like
