FINAL Flashcards
1
Q
you see bulging fissure on CXR …
A
klebsiella (typical)
tx: Carbapenems
2
Q
MCC of Typical pneumonia =
A
Strep pneumo
3
Q
MCC of ATYPICAL pneumonia
walking pneumonia
A
Mycoplasma pneumoniae
4
Q
Treatment drug choice for ATYPICAL pneumonia
A
Macrolides – Azithryomycin
5
Q
Chest XRAY shoes interstial pattern, patient appears fine …
A
ATYPICAL Pneumonia
6
Q
Atypical Pneumonia
Patient was recently in contact with birds, + Splenomegaly
DX?
A
Psittacosis
TX with MACROLIDES
7
Q
Patient presents with muscle aches, diarrhea, and ataxia
Labs: Hyponatremia
Lives in the city and has been using his AC…
A
Legionella
TX: Macrolide/Floroquinolone
8
Q
Patient has been in the hospital 48+ hours, has a normal CXR but has purulent bronchitits
What is the MCC of this pneumonia?
A
HAP = pseudomonas followed by S. aureus
9
Q
Treatment of CAP
outpatient with no previous lung disease or risk factors …
A
azithromycin or clarithromycin or doxycycline
10
Q
treatment of CAP
Outpatient WITH lung disease/risk factors
A
Beta lactam (Penicillin/cephalosporin) + Azithromycin or fluroquinolone
11
Q
Treatment of CAP
INpatient with NO lung dz/risk factors
A
IV azithromycin or IV Fluroquinolone
12
Q
Treatment of CAP
INpatient with comorbidities
A
Beta lactam + Azithromycin or Macrolide or DOXy
13
Q
Piperacillin-Tazobactam can be used as treatment towards what pathogen?
A
HAP – Pseudomonas aeruginosa
14
Q
Treating ACTIVE Tb
- Start on all 4 drugs: RIPE
A
Rifampin
Isoniazid
Pyrazinadmide
Ethambutol
2. Once pansensitive D/C E, after 2 mo D/C , use I/R for 6 mo total
15
Q
What is the solution to TB drug resistance?
A
DOT = directly observed therapy
16
Q
chronic airflow obstruction d/t chronic bronchitis and or pulm epmhysema
A
COPD
17
Q
GOLD 1 = MILD
What is the FEV1 predicted
A
> 80 %
18
Q
50% < FEV 1 < 80%
A
GOLD 2 = MODERATE
19
Q
30% < FEV1 < 50%
A
GOLD 3 Severe
GOLD 4 = VErY SEVERE <30%
20
Q
Treatment for MILD COPD
A
SABA
21
Q
Treatment for GOLD 2
Moderate
A
LABA
22
Q
treatment for GOLD 3
A
ICS
23
Q
reduce incidence of community-acquired pneumonia
A
PPSV23
Patients <65 yo, FEV1 <40% predicted, with comorbidities
24
Q
reduces pneumococcal disease in adults > 65
A
PCV13
25
fever, night sweats, hemoptysis
TB
26
TB immunity is mediated by
TH1 cells
27
A positive PPD is evidence of what type of immune response
Cell-mediated (Type IV) hypersensitivity
28
**caseating granulomas** ..,.
TB
29
combo of **parenchymal lung lesion and nodal involvement** is referred to as the ...
Ghon Complex
30
**sulfur granules
formation of multiple abscesses**
draining sinus tracts
Actinomycosis
| TB look alike
31
borad based budding
Blastomycosis
32
patient was recently in **San Joaquin valley** and presents with **erthyema nodusum**
Coccidiomycosis
| Thick-walled, non-budding spherules
filled with endospores
33
**2** **bacterial** TB look alikes =
Nocardia and Actinomcyetes
34
**Carcinoid tumors arise** from what type of organs or cells
neuroendocrine
35
most **carcinoid tumors** are found where?
GI tract
| tracheobronchil tree/lungs
36
# macroscopic pattern
masses that grow **within the lumen of the bronchus**
**covered by intact mucosa**
**3-4**cm
Central Tumors
| Peripheral -- **outside** the bronchioles **collar button lesions**
37
# What type of carcinoid
**organoid nests, rosettes, or a trabecular growth** pattern of uniform cells -- **seperated by delicate fibrovascular stroma**
Micropscopic morphology of TYPICAL carcinoids
38
"salt and pepper" appearance
| nucleir with finely granular chromatin
Bronchial Carcinoid Tumors
39
systemic release of serotonin and other vasoactive substances
| sx; **flushing, diarrhea, bronchospasm**
Carcinoid syndrome
40
growth of **secondary tumors via lymphatic or hematogeneous dissemination**
Metastatic Lung Tumors
41
# preferential site for hematogenous metastsais
Non-small cell lung cx (**NSCLC**)
**bone**, adrenal glands, **brain** and liver
42
# preferential site for hematogenous metastsais
Small cell lung canver (SCLC)
**Bone, brain** and liver
43
what **symptoms** should you be on the lookout for **metastatic disease**?
Mental/Neuro changes
Hepatomegaly
Bone pain/fractures
44
# **Solitary Fibrous Pleural Tumor**
Pathogenesis:** Inversion of chromosome 12** and the subsequent **fusing of two genes**:
**NAB2 and STAT6**
drives pleural tumor growth
45
# **Solitary Fibrous Pleural Tumor**
Morphology: rare, well-localized, round-oblong tumors with whorled appearances that arise from the pleura & are often attached to it by a?
pedicle
46
rare, **malignant tumor** of the thoracic cage affecting **both layers of pleura**
| d/t **exposure of ASBESTOS**
Mesothelioma
47
Pathogenesis: homozygous **deletion** of **tumor suppressor gene**,
**CDKN2A** on chromosome 9
47
Pathogenesis: homozygous **deletion** of **tumor suppressor gene**,
**CDKN2A** on chromosome 9
48
What types of **diets** are recomennded for patients with **asthma**?
Anti Inflam Diet
* **INC omega 3 fatty acids / DEC omega 6**
Mediterranean diet
| omega 3 -- **salmon, walnuts, chia seeds, sardines/flax**
49
obesity is associated to:
while malnutrition is associated to:
Obesity -- ASTHMA
Malnutrition -- COPD
50
Vitamin and mineral supplement to compensate for inadequare oral intake:
VIT D, Ca2+, and antioxidants
51
What can indicate **fluid deficit/fluid overload**?
HYPERnatremia -- fluid deficit
HYPOnatremia -- fluid overload
52
What **diet recomenddation** do you give for a patient with **COPD**?
High Calorie / High Protein Diet
53
**Individuals with CF** also have **difficulties absorbing** what kind of vitamins?
ADEK
54
What **nutritional** intervention should be given to those with **CF**
INC Calorie and FAT intake
Maintain lean body mass
55
Intake of what vitamin may lead to reduction in the incidence of pneumonia?
VIT C
56
**Hypermetabolism** has an **increased** **reliance** on?
Gluconeogenesis
| INC catbolism of muscle tissue
57
What is the best measure of energy requirements for the critcally ill?
Indirect Calorimetry
| heat release calculated indirectly by measuring consumption of O2 a
58
**enteral nutrition** should be started within how many hours of admission of the critcally ill patient who is unable to eat?
24-48 hours
| maintains normal gut pH/flora, inhibits opp bacterial overgrowth
59
What type of **nutrition therapy is approtiate for patients with ARDS or acute lung injury**?
Enteral nutrition
60
If pt is on **propofol** (which provides ??? kcal/ml), deduct those calories from energy requirements.
1.1
61
When to use **exlcusive PN and supplemental PN**?
exclusive -- within 7 days (High nut. risk)
Supplmental -- after 7-10 days
62
What is the **second** most common lung cancer which carries the **best prognosis**?
squamous cell carcinoma
63
What is an **effective treatment** for **squamous cell carcinoma**?
Bevacizumab
64
**squamous cell carcinoma** is associated to **hyperarathyroidism and hypercalcemia** which is associated to what syndrome?
Paraneoplastic syndrome
65
The **most common lung cancer (60%)** ...
Adenocarcinomas
| affects bronchioles and alveoli -- more distal airways
66
What **two common mutations** are associated with **adenocarcinomas**?
EGFR and Kras
67
this mutation is a **proto-oncogene** which possibly is a **cysteine receptor to turn gene off** ...
KRAS
68
What type of carcinoma has a **strong association to smoking history**, **cannot be resected** and has the **worst prognosis**?
Small Cell Carcinoma
| arises in the proximal airways
69
**Small cell carcinoma** arises in the **proximal airways** from what type of cells? Associated with **deletion on chrom 3**
K-cells (Kulchistsky)
70
**Small cell carcinoma secretes ectopic ACTH/ADH** which is associated with which syndrome?
**Paraneoplastic syndrome**
ADH --> SIADH (too much ADH causes water retention/hypo-osmolarity)
ACTH -- prod. excess glucocorticoids --> abdnormal fat deposition, HTN)
71
What **biomarkers** allow targeted therapies or immune checkpoints, **without the use of cytotoxic chemo**
EGFR, ALK, ROS, BRAF, NTRK
72
what **increasses toxicity** in squamous cell cancer
bevacizumab
73
Which **two biomarkers respond to crizontinib**?
EGFR TKI, EML4-ALK
74
an **apical lung tumor** -- damages nerves going up to the face, resulting in **horners syndrome**
Pancoast tumor
| compression of sympathetic ganglion
75
what is the **triad of symptoms in horners syndrome**?
**Ptosis** (eyelid drop) , **Misosis** (Constricted pupil) , **anhidrosis**
76
**most common benign primary lung tumor**
CXR = **coin lesions**
Pulmonary hamartoma
77
**TTF-1** is a specific IHC marker and helpful for diagnosis of ...
| also shows intracytoplasmic **mucin**
adenocarcinomas
| histology shows gland formation
78
Which cell carcinoma expresses neuroendocrine markers **chromogranin, synaptophysin**, and CD56
Small Cell Carcinoma
| releases hormones --> paraneoplastic syndromes
79
**Superior vena cava syndrome and Pancoast syndrome** are most common with ?
Small Cell Lung Carcinoma
80
# Tuberculum impar
cell proliferation in medial tongue bud
| No Tx needed, can use anti fungal wash
Median Rhomboid Glossitis
81
cyst/swelling of the **minor salivary glands**
| self resolves, crytotherapy
Mucocele
82
retention cyst of **sublingual** gland duct
| Tx: Marsupialization (puncture/drain)
RANULA
83
caused by nervous biting
white, exophytic, hyperkeratotic, **CANT be scraped OFF**
Smoking, EtOH --> Sq. cell CA (pre malignant)
Leukoplakia
84
**Torus mandibularis = bony overgrowth** of manible
What can this impinge?
Whartons Duct
| at the base of the lingual frenulum
85
**acute necrotizing ginivits** = trench mouth is caused by?
| Treated with penicillin
Borella vincentii
86
**Aphthous stomatitis = canker sores** usually occur where?
| Tx: Anti-inflammatories/steroids
non-keratinized tissue
| buccal mucosa, floor of mouth
87
**Herpe stomatitis = cold sores** are due to **HSV-1** and occur on what surfaces?
| Tx: Acyclovir
Keratinized tissue
| lips, gums
88
**Herpangina** is most commonly caused by:
| Canker like sores inside of mouth
Coxsackie virus A
| Tx; Symptom relief
89
Most common cause of **ACUTE tonsillitis**
viruses, group A Strep, H. Flu
EBV - hairy leukoplakia
| Tx: bacterial -- penicillin, augmentin/cephalosporins
90
**Tonsillolith** is due to what?
stones of food getting stuck within the crypts of tonsils causing bad breath
91
# Ludwig Angina
**invasion of mylohyoid muscle** causing swelling where?
| Sx; Pain, drooling, dysphagia, tongue protrusion
under the chin
| Treat with IV antibiotic, steroids, tracheostomy
92
3-5-7 Rule for tonsillectomy
3 infections/yr
5/2 years
7/3 years
93
90% of oral cancer is ....
**Squamous Cell**
| Most commonly found on the **LOWER LIP**
94
**Basal Cell Cancer** is most commonly found where?
Upper Lip
95
**Tongue cancer** is most commonly located
Anterior 2/3
| likely to metastasize to posterior head/neck lymph nodes
96
**Buccal mucosa carcinoma** is MC in **Asia/Africa** due to **consumption** of what?
BETEL NUT
| spreads to floor of mouth
97
**Posterior cricothyroarytenoid** muscle function =
**AB**duction
98
**Interarytenoid** and **Thyroarytenoid** muscle functions =
ADduction
99
**Thryoglossal duct cyst** is a **remnant of foramen cecum** which is found where?
MIDLINE -- near pyramidal lobe of thyroid
| moves with swallowing and tongue protrusion
100
**Goiters** can occur due to WHAT?
Hypo or Hyperthyroidism
101
**Reinke's edema** presents as **hoarseness** due to what?
Overuse of smoking
102
**superior laryngeal nerve damage** will cause
cricothyroid weakness
103
**Recurrent laryngeal nerve damage** will cause
inter-laryngeal ab/adductor weakness
104
if there is **uneven elevation of uvula**, what CN is damaged?
| deviates AWAY from side of lesion
CN X
105
**eustachian tube drains** mucus into
nasopharynx
106
Why do children get ear infections?
Eustachian tube = more horizontal -- drainage impaired
107
If tympanometry shoes pressure less than -200,
Hearing Test shows **conductive hearing loss** or air-bone gap
You would suspect disease in what part of the ear?
Middle Ear Disease
108
**Medical management of acute otitis media** includes:
Antibiotics: Amox/Ampicillin +/- clavulanic acid for B-lactamase coverage
Erythromycin, TMP/SMX, Cefamine
Nasal decongestants
Analgesics
109
What surgical procedure will **ventilate middle ear**, used in **CHRONIC OM**
Tympanostomy
110
What **surgical procedure** could be recomended for a child that has **chronic or recurrent infections**?
Adenoidectomy
111
**obliteration of the postauricular crease** is a symptom most commonly seen in what **middle ear** disease?
Acute mastoiditis
| IV antibiotics for 24-48 hrs, then oral abx for 2 weeks
112
**squamous cell growth** where its not supposed to be, in middle ear =
| Chronic OM -> poor ventilation -> INC neg press -> pocket/cyst w/squamou
Cholesteatoma
| results in erosion of ossicles and destruction of mastoid cavity
113
**MCC of acute localized otitis externa** (furnucle) =
Staph Aureus
114
**MCC of acute diffuse otitis externa** (Swimmers Ear) =
Pseudomona aeruginosa
115
**LOW protein, LDH, and cholesterorl** is inidcative of what type of pleural fluid?
| HIGH Glucose, BASIC pH
TRANSUDATIVE
| CHF, Liver cirrhosis, nephrotic syndrome
116
Sleep is measured via what?
Polysomnography
117
What waves do you see when someone is **ALERT** or when they are **DROWSY**?
Alert = Beta Waves
Drowsy = Alpha Waves
118
What waves are seen during NREM sleep?
Theta Waves (N1-N2)
Delta Waves (N3 = deeper sleep)
119
What stage of sleep shows **K-complexes and sleep spindles**?
N2 along with theta waves
120
**SAWTOOTH** waves are indicative of what sleep stage?
REM sleep
121
What type of **neurotransmitters** promote **wakefulness and alertness**
Monoamines
| norepinephrine, histamine, serotonin and dopamine
122
what NT comes from the **Locus coeruleus nucleus and regulates wakefulness**?
Norepinephrine
123
what **NT promotes REM sleep** and wakefulness
Acetylcholine
| promotes fast EEG rhytmns
124
What **regulates switching between wakefulness and sleep**?
Orexin and Hypocretin
125
What group promotes Sleep
Somnogens
| Adenosine, cytokines, prostaglandin
126
lookout for **ascending paralysis**, and **rapid onset of muscle weakness following an infection/illness** ....
Guillain Barre Syndrome
| peripheral neuropathy to cause resp failure
127
# Guillain Barre Syndrome
cross-reactive immune attack on peripheral muelin sheaths due to **molecular mimicry**
typically caused by a **GI infection** by what?
campylobacter jejuni
| muelin mimics capsular bacterial LPS
128
How do you diagnose Guillain Barre Syndrome?
**sural nerve biopsy** with segmental demylineation present
129
What diagnostic tests can be used to diagnose **myasthenia gravis**?
| associated with **thyomas**
**Edrophonium test** -- INC Ach at NMJ
**Ice pack test** -- cooling improves neuromusclar tranmssion
130
**picornaviridae infection of motor cells (anterior horn) of spinal cord**
Poliomyelitis
| flaccid paralysis, unvaccinated, travel to endemic area
131
**irreversible, progressive neurodegenerative disease of motor neurons with significant paralysis** and a poor prognosis of 2-5 years
Amyotrophic Lateral Sclerosis
132
treatment for ALS
palliative care
Riluzole -- extends life by 3-6 mo -- inhibits glutamatergic transmission
133
Most common pathogen of CAP in OUTPATIENTs
1. Mycoplasma pneumoniae
2. Resp viruses
3. Strep pneumo
134
Most common pathogen of CAP in INPATIENTs
1. Strep pneumo
2. Resp Viruses
3. Mycoplasma pneumo
135
Most common pathogens of CAP in INPATIENT
1. Strep pneumo
2. Legionella
3. Gram Neg bacilli
136
CURB 65
confusion
BUN > 20
RR > 30
BP < 90 / < 60
65 yo
137
CURB 65 score of 0-1
treat as outpatient
| 30 day mortality = 0.7-2.1
138
CURB Score of 2
treat as inpatient
| 30 day mortality = 9.2
139
CURB 65 score of 3+
ICU
| 30 mortality rate 15-40
140
1st choice treatment of CAP
healthy pt with no co morbities
Amoxicilin
| doxy
141
1st drug choice to treat CAP in patient with comorbities
amox/clavulanate plus doxy
142
primary requirement for noninvasive ventilation
spontaneous breathing
| least invasive = face mask / most = tracheal trube
143
What is the ideal position for intubation
SNIFFING position
Extension at c1-c2
Flecion at C6-7
144
in obese patients, the sniffing position is not good, instead you want external auditory meatus is in line with ?
sternal notch
145
# name the technique
posterior pressure applied to the cricoid cartilage to occlude esophagus
Sellevk maneuver
146
# ventilation w/simple nasal mask
provides a single set pressure throughout sleep
only forces air in (inspiration only)
CPAP
147
# ventilation with simple nasal mask
as two distinct pressure settings for inhalation and exhalation
BIPAP
148
PT home exercise
bronchial drainage
draining with saline to decrease mucous and infections
149
6 min walk test
desaturating during the test may occur in ....
interstital lung disease
PULM HTN
severe obstructive lung disease
150
Resp Failure Type 1 vs Type 2
Type 1 = **Hypoxemic**
Type 2 = **Hypercapnic**/Ventilatory
150
Resp Failure Type 1 vs Type 2
Type 1 = **Hypoxemic**
Type 2 = **Hypercapnic**/Ventilatory
151
How to Calculate Anion Gap
(Na+ + K+) -- (HCO3- + Cl-)
| Normal = less than 12, abnormal = greater than 12
152
# is there compensation by the lungs
Winters Formula
PaCO2 = 1.5 X [ HCO3] + 8, plus or minus 2
153
# NON-ANION Gap Metabolic acidosis
USEDCRAP
Ureteric Diversion
Sigmoid Fistula
Excess Saline
Diarrhoea
Carbonic Anhydryase inhibitors
Addisons
Renal Tubular Acidosis
Pancreatic Fistula
154
# causes of high anion gap metabollic acidosis
CAT MUDPILES
CO
Aminoglycosidse
Teophylline
Methanol
Uremia
Diabetic ketoacidosis
Paractetamol
Iron
Lactic Acidosis
Ethanol
Saliclyci acid
155
What **non cardiac thoracic procedure** would you suggest for a patient with **severe COPD** and poor resp mechanics?
| FEV1 < 35%, end stage emphysema, able to do rehab
Lung Volume Reduction Surgery
| EXCLUDE; Age > 75, FEV1 < 20%, on high dose steroids, hypercapnic
156
# Indications
Absolute: Enlarged Mediastinal LN
Relative: T2/3 Tumor
adeno/large cell CA
Stage 1 small cell
Vocal cord paralysis
Large Tumor Resection
157
Most common mediastinal teratoma =
mediatstinal germ cell tumor
| Three Types: Mature, Immature, Malignant
158
post-op FEV1 value is estimated using Split Lung Function Test
| pt. undergoes spirometry test and perfusion scan
Post-op FEV1 (predicted) = (pre-op FEV1) X (%perfusion)
| Low Post op = HIGH Risk , High Post Op = LOW Risk
159
**H1** antihistamine drugs work via what pathway?
| smooth muscle, endothelium
IP3-DAG pathway
| hydrophobic -- can cross BBB -- sedation
160
What antagonist part of antihistamines INCREASES appetite
Serotonin antagonist
| ACh blocks -- DEC level of awareness
161
# use of antihistamines
seasonal allergies
first gen H1
diphenhydramine
162
# use of antihistmines
allergic reactions
2nd gen HI = cetrizine, loratidine
163
# use of antihistamines
Promethazine, Cyclizine, Meclizine
MOTION sickness
164
antihistamine toxicity can cause
| espceically with CYP450 inhibitors like macrolides/azoles
QT prolongation --> Cardiac arrythimias
| WORST = astemizole/terfenadine
165
What drug is sometimes called **OTC hypnotic**
diphenhydramine
166
what antihistamine has some **dopamine anatgonistic effects**
Promethazine
167
What antihistamine has dual action mechanism
Blocks H1 receptors/Blocks mast cell release of histamine
AZELASTINE
168
Which antihistamine is
Long Acting, LESS QT Prolongation
Desloratadine
169
What antihistamine can be given with CYP450 inhibitors without QT prolongation
Fexofenadine
170
What antihistmaine is more sefating, approved for infants < 6 mo
Cetirizine
171
what antihistmaine drug antagonizes serotonin receptors
| useful in Cushing syndrome, vasc. headache, and anorexia
Cyproheptadine
| can treat anorgasmy = imparired sexual function
172
Anterior vs. Posterior Epitaxis
Which is more common
Which is most server
MC = Anterior
Most servere = POSTERIOR
173
During an **anterior** epistaxis, bleeding is from
Kiesselbach's Plexus
174
**Posterior Epistaxis**, bleeding is from
Woodruff's plexus
175
arteries associated with **kiesselbach's plexus**
Anterior ethmoidal,
Posterior ethmoidal
Sphenopalatine
Greater palatine
Superior labial branch of facial artery
176
arteries in Woodruffs plexus
sphenopalatine
ascedning pharyngeal
internal msxillary veins
177
Classic Triad of Osler-Weber-Rendu Disease
Epistaxis + Mucocutaneous telangiectasia + family Hx
178
# adjuvant compressive therapy
anterior epistaxis treatment
Step 1 Part B = Meds
| Part A = Compressive therapy (10-15 min)
Oxymetazoline nasal spray
Epinephrine
| vasoconstriction via alpha receptors
179
# 2nd Step
if compressive therepay failed in anterior epistaxis management, what can you do
CAUTERY
180
What is the 3rd Step in anterior epistaxis management
Anterior Nasal Packing
Gauze, baloon, tampon for **48 hours**
181
Final step of anterior epistaxis management
Pack affected nares and contralateral nares
182
# Posterior Epistaxis Management
1st Step = Posterior Nasal Packing
Balloon catheter, foley catheter, or rubber catheter with cotton packing
| 2nd step = admit to hospital for ENT
