Dr. Brignal said on test

Question 1

Influenza:

Pregnant Women

Answer 1

Pregnant women have high risk in influenza infection, up to 20% mortality from severe infection.

Question 2

Influenza Diagnosis

Answer 2

• In absence of a local outbreak, clinical sx positive predictive value ~0.
• WITH virus in community, 1 resp sx + fever >100.2F => over 80% sensitivity and specificity
• can confirm with rapid flu test, but likely unnecessary

Question 3

-most common cause of chronic cough in adults?

Answer 3

*Post nasal drip (PND)

Sinusitis and post nasal drip – Frequent sinus infections can cause post-nasal drip, (sometimes called “a tickle in the back of the throat”), and drainage can trigger chronic cough.

Question 4

-most common cause in children

Answer 4

Asthma

Question 5

Chronic Cough DDx (most common)

Answer 5

90% of non-smokers with a cough will either be PND, Asthma, or GERD

smoking 90% of cases=>Chronic Bronchitis

Question 6

smoking causes 90% of cases

Answer 6

Chronic Bronchitis

Question 7

Biopsies of Solitary Pulmonary Nodule (2)

Answer 7

a) Bronchoscopy
- less invasive, but often inconclusive especially with smaller lesions

b) Transthoracic needle aspiration
- more likely to get a definitive dx, but still frequently misses
- rate of pneumothorax is 25%

Question 8

Pulmonary Embolus->Indications of Shunting?

Answer 8

• Decreased VQ ratio (ventilation/perfusion) indicates shunting
• COPD, asthma, atelectasis, respiratory distress

Question 9

Arterial Blood Gases:
Metabolic vs Respiratory Acidosis/Alkalosis:

Is there alkalosis or acidosis-PH?

Answer 9

Is there alkalosis or acidosis? pH < 7.35= acidosis, pH > 7.45= alkalosis

Question 10

Respiratory - the pH and PaCO2 change in which direction?

Answer 10

Respiratory - the pH and PaCO2 change in opposite directions

• *Respiratory acidosis - pH is low, PaCO2 is high
• *Respiratory alkalosis - pH is high, PaCO2 is low

Question 11

Metabolic - the pH and HCO3- change in the which direction?

Answer 11

Metabolic - the pH and HCO3- change in the same direction

• *Metabolic acidosis - pH is low, HCO3- is low
• *Metabolic alkalosis - pH is high, HCO3- is high

Question 12

Respiratory Compromise occurs at what Hg PaO2?

Answer 12

Respiratory Compromise occurs at <60mmHg PaO2

Question 13

Restrictive lung diseases?

Answer 13

Restrictive lung diseases are a category of extrapulmonary, pleural, or parenchymal respiratory dz’s that restrict lung expansion equal:

1. Decreased lung volume,
2. Increased work of breathing,
3. Inadequate ventilation and/or oxygenation.

*Pulmonary function test demonstrates a decrease in the forced vital capacity.

Question 14

• Definitions of Intrinsic Restrictive vs Extrinsic Restrictive Dzs
• Causes of each

Answer 14

Restrictive lung dz’s mb d/t specific causes which can be intrinsic to the parenchyma of the lung, or extrinsic to it.

Intrinsic:

• TB
• Rheumatoid Arthritis
• Pneumoconiosis
• Radiation fibrosis
• Hypersensitivity pneumonitis
• Acute respiratory distress syndrome (ARDS)

Extrinsic:
Nonmuscular diseases of the upper thorax such as:
-kyphosis, 
-pectus carinatum 
-pectus excavatum

Diseases restricting lower thoracic/abdominal volume: -Obesity,

• Diaphragmatic hernia
• Presence of ascites
• Pleural thickening

Question 15

COPD-Malnutrition

Answer 15

-Warn patients to notify you if there is a change of >5 lbs in a week

Question 16

NAC in removing mucus side effect?

Answer 16

-gas and bloating

Question 17

Supplements for Exercise Induced Asthma (EIA)

Answer 17

-Vitamin C, Beta-carotene, Lycopene, Caffeine

Question 18

Spirometry obstructive vs restrictive lung disease

Answer 18

The FEV1 is decreased in obstructive lung diseases and normal or minimally decreased in restrictive lung diseases.

In obstructive lung disease, the FEV1 is reduced due to an obstruction of air escaping from the lungs. Thus, the FEV1/FVC ratio will be reduced. …

In restrictive lung disease, the FEV1 and FVC are equally reduced due to fibrosis or other lung pathology (not obstructive pathology).

Question 19

Lung Infections Pharmacology:

Pneumonia?

Answer 19

Pneumonia: beta-lactam (like amoxicillin 500 TID or 875 BID)
—–> Empiric therapy: should always treat bacterial pneumonia aggressively w/ antimicrobials
Treat early, treat most likely pathogens (Strep/HiB/Staph), consider atypical agents

Community acq. Pneumonia (CAP) empiric therapy:

• **Healthy outpatient  macrolide or doxycycline
• **Outpatient at risk (like COPD)  fluoroquinolone or beta lactam + macrolide

Question 20

Lung Infections Pharmacology:

Pseudomonas?

Answer 20

Tx: antipseudomonal beta lactam + cipro/levofloxacin

Question 21

Lung Infections Pharmacology:

MRSA

Answer 21

Tx: linezolid or Vancomycin

Question 22

Positive findings for pneumonia on PE

Answer 22

*Rales in lateral decubitus position is most predictive sign

Question 23

Pulmonary Imaging:

CXR views

Answer 23

PA: standard
LAT: see lesions behind heart & mediastinal structures
AP: only for those bedridden or in hospital
LD: to evaluate pleural effusion, pneumothorax, cavity lesions
EE: to see focal air trapping

Question 24

CXR Density?

Answer 24

• Air= black
• Fat & soft tissue= gray
• Bone & metal= white

Question 25

Wells PE scoring:

Answer 25

Clinical signs--->3
Alt. Dx Unlikely-->3
Hrt rate >100-->1.5
Immobilization prev. 4 days--->1.5
Prev. DVT/PE--->1.5
Hemoptysis--->1
Malignancy (tx last 6 mo)--->1
-------------------------------------------------------------------------------
PE less likely = less than 4 pts
PE likely = More than 4 pts

Question 26

Should pneumonia pt be admitted to hospital?

Predictive factors:

Answer 26

Predictive factors for hospitalization over 50, co-morbidity, abnormality in labs/visits.

Question 27

Should pneumonia pt be admitted to hospital?

PSI calculator

Answer 27

PSI calculator (<70 0 tx outpatient, >130 ICU dt 28% mortality)

Question 28

Should pneumonia pt be admitted to hospital?

CURB65

Answer 28

CURB65: 1pt ea - confusion, BUN>7 mmol/L, RR>30, BP<90/60, 65+; 2 pts: maybe inpat, 3+ def inpat.

Question 29

Acute vs. chronic cough

Answer 29

Less than 3 weeks = Acute

More than 3 Weeks = Chronic

Question 30

Action plan Asthma

Green, yellow, red

Answer 30

Green zone: breathing good, no early warning signs, PEF >80%, can play & seep  take recommended daily medication

Yellow zone: feel tired, chin or throat itches, cough, wheeze, tight chest, play interrupted, wake at night, PEF 50-80%

Red zone: very SOB, can’t do usual activities, medications not helping, PEF 50%

Question 31

Pleural effusion:

Normal vs Pathologic sign of effusion

Answer 31

Normal fluid amount is 10mL.

Pathologic sign of effusion is 100 mL.
Check for fluid in lateral decubitus position*