Osce Flashcards
ASTHMA
- reversible obstructive lung disease
- IgE mast cell mediated response —> lead to broncho-constriction, inflammation, bronchial hypersensitivity
Risk factors:
- male gender
- atopy ( including rhinitis + eczema)
- family history
- exposure to air pollution/ second hand smoke
Clinical:
- wheezing ( particularly when expiring)
- cough ( worst at night)
- dyspnea ( SOB)
* GET THESE after exposure to allergen, exercise, cold air, cat hair
* symptoms come & go ( episodic)
Physical exam: (seen with asthma exacerbation)
- prolonged expiration with wheezing
- hyper-resonance on percussion —> (air trapping lead to hyper-inflated lungs)
- use of accessory muscle to help them breath
- extra-pulmonary findings:
1. pale, swollen membrane of nasal cavity
2. Nasal polyps ( samter’s traid: asthma + chronic rhino-sinusitis with nasal polyp + Aspirin ( or NSAID) sensitivity)
3. Atopic dermatitis ( elbow, knee…)
Diagnosis:
- if not in acute exacerbation, patient can be normal
- use pulmonary function test ( PFT) —> spirometry
1. Decrease FEV1/ FVC ( indicates obstructive disease of the airway)
- confirm with (bronchodilator test)
1. Administer albuterol ( findings: > 12 % increase in FEV1 = positive test)
- if patient is fulfilling asthma criteria, but with normal PFT —> use Broncho-provocation testing ( Methacholine challenge) —> this induces asthma
- Methacholine inhaled ( induces broncho-constriction= mimic asthma attack)
- > 20% decrease in FEV1 ( positive test)
Treatment:
- SABA ( Short acting beta 2 agonist)
- albuterol, levalbuterol
- first line for acute exacerbation
- broncho-dilators
- Inhaled corticosteroids
- triamcinolone, beclomethasone, budesonide
- first line for chronic maintenance + daily controller therapy
- reduce frequency of symptoms - LABA: (long-acting beta 2 agonist)
- Salmeterol, formoterol
- used in maintenance to prevent symptoms
- broncho-dilator (as long as 12 hours)
- Never use monotherapy —> always combine with Inhaled corticosteroid - Monotelukast
Treatment guideline: (NAEPP)
- Intermittent/ step 1:
- daytime symptoms < 2 times/ week + nocturnal symptoms < 2 times/ months
- normal FEV1 (80%)
- tx: SABA ( albuterol only) - Mild persistence/ step 2:
- daytime symptoms > 2,but < 7 days/week + nocturnal awakening 3-4 time/months
- normal FEV1 (80%)
- tx: SABA + inhaled corticosteroid (ICS) - Moderate persistence/ step 3:
- daily symptoms + nocturnal awakening > 8 time/month
- FEV1 (60-80 % )
- tx: LABA + ICS ( low dose) - Severe persistence/ step 4:
- daily symptoms + nightly nocturnal awakening
- FEV1 ( less than 60%)
- TX: LABA + ICS (medium dose) - Refractory Step 5/6:
- Tx: increase strength of ICS + LAMA (tiotropium) + biologics)
Syncope (+ dizzy + lightheaded + blackout +faint)
Syncope differential diagnosis:
- Neurologic dysfunction
- stroke
- seizure (look for tongue biting, mental status change/orientation)
- psychological:
1. conversion disorder
2. pseudo-seizure
3. sleep disorder: narcolepsy
- Carotid ( control beta-receptor reflex) (stimulate carotid artery = stimulate parasympathetic response) ( cause heart to slow down —> reduce CO —> reduce blood flow to brain —> syncope)
- vasovagal syncope
- Chronic cough = increase intrathoracic pressure
- Chronic constipation = increase straining
- BPH or prostate cancer = difficult passing urine
- carotid hypersensitivity
- Child hug a grandfather —> grandfather collapse
- Bottom a shirt tightly on neck
- Shaving neck
- vasovagal syncope
- Heart
- CAD (blood vessels)
- chest pain ( + S3 audible)
- Heart failure ( chambers)
- low ejection fraction
- Valvular heart disease (valves)
- aortic stenosis ( ejection systolic murmur)
- young patient
1. MVP: mid-systolic click followed by late systolic
murmur; lead to MR: pan-systolic murmur
2. HOCM: ejection systolic murmur similar to aortic
stenosis, however differ in maneuvers,
intense murmur when patient is standing
or valsalva—> increase preload
improves murmur when squaring) - Atrial myoxoma (tumor)—>( block mitral valve,
prevent blood flow to ventricle)
- Arrhythmia
- atrial fibrillation
- atrial flutter
- SVT
- CAD (blood vessels)
- Dehydration:
- have you been feeling well lately
- have you been not eating or drinking properly- have you had diarrhea ? ( cause orthostatic hypotension —> syncope—> give IV fluid)
- Pulmonary Embolism:
-- - - -
Note: All left sided murmur: increase in intensity, if increased preload
History of stroke
Any neurological symptoms suggestive of stroke ?
- Any Dysphasia ?
- Any Slurred speech?
- Any Limb weakness ?
History of seizure
Any neurological symptoms suggestive of seizure ?
- Did you have any form of tonic-clonic seizure that lead to LOC?
- How did it happen?
- What caused you to have syncope?
- Did you have some form of aura prior to the happening of seizure ?
- Aura = temporal lobe firing
- Has it been witnessed by somebody?
- Did you pass urine or stool on yourself?
- Did you have tongue biting ?
- Were you confused after the episode or did you gain conscious ? (Potictal phase ?)
Causes of hemoptysis (BATTLE CAMP)
BATTLE CAMP: (confirm with Bronchoscopy)
- Bronchitis, bronchiectasis
- Aspergilloma
- Tumor
- Tuberculosis
- Lung abscess
- Emboli (pulmonary)
- Coagulopathy
- Autoimmune disorder, AV malformation, Alveolar hemorrhage
- Mitral stenosis
- Pneumonia
DIAGNOSIS:
- Massive Hemoptysis: (> 100ml in 24 hours)
——> tumor/ bronchiectasis, Lung abscess, AV malformation - Non-massive hemoptysis: (CT or Chest x-ray)
- Normal: ( Hematemesis, epistaxis, bronchitis)
- Diffused abnormality: ( CHF, bronchiectasis, pulmonary vasculitis)
- Focal abnormality:
- Infection: ( bacterial, viral, TB, fungal)
- Malignancy
- Pulmonary vasculitis: ( SLE, Goodpasture’s, Granulomatosis with polyangitis/ Wegener’s)
- Vascular: ( PE, AV malformation)
Investigation:
- CBC, Coagulation parameter, biochemistry
- Pulse oximetry & ABG ( to determine the impact of hemoptysis on oxygenation & ventilation)
- Spirometry: once bleeding is controlled, spirometry is used to determine the patient’s respiratory function.
- EEG: particularly if heart disease or Pulmonary thromboembolism is suspected.
- Transthoracic echocardiogram (TTE): to detect endocarditis, mitral valve stenosis, congenital heart disease, signs of pulmonary HTN or presence of shunt due to AV malformation
- Cytological study & sputum microbiology
- Mantoux in patients with suspected TB, blood culture or serologies if infectious disease is suspected
Diagnosis:
1. Bronchoscopy
Treatment:
1. Lateral decubitus bed rest
2. Monitor of vital signs
3. Supplement oxygen
4. Administer of antitussives to control coughing
5. Empiric antibiotics
6. Total fasting to avoid bronchaspiration
7.
Syncope history:
5 Ps:
- Prodrome:
- lightheadedness, dizziness, blurred vision —> vasovagal, orthostatic hypotension
- Nausea, sweating, abdominal pain —> vasovagal
- none —> vasovagal in elderly, cardiac syncope - Precipitating associated conditions:
- warms, crowded environment, pain, emotion distress, fear, exercise, dehydration, coughing, laughing, micturition, eating ———> vasovagal, orthostatic hypotension, situational
- head movement, tight collars, shaving —> carotid sinus syndrome
- during exercise or no obvious precipitant—> arrhythmia, or structural hear disease
- Position:
- prolonged standing —> vasovagal, orthostatic hypotension
- sudden change in posture—> orthostatic hypotension
- supine —> arrhythmia, structural heart disease - Palpitation:
- palpitation —> arrhythmia
Post-event phenomena
- immediate complete recovery —> common in arrhythmia
- N/V, fatigue —> vasovagal
- pallor, sweating —> syncope
- blue —> seizure
Movement
- minor twitching, but floppy when unconscious ( myoclonic jerks) —> syncope
- rhythmic jerking preceded by rigidity or abnormal posture—> seizure
Eyes:
- open —> seizure or syncope
- closed —> pseudo-seizure, psychogenic syncope
Mental state:
- prolonged confusion, retrograde amnesia —> seizure
- transient disorientation —> neurally mediated syncope
- amnesia concerning LOC —> neurally mediated syncope in elderly
Diagnosis
PE:
- Vital signs, including orthostatic BP measurement
- Carotid artery auscultation & palpitation
- Detailed cardiopulmonary, abdominal & neurologic exam
- Carotid sinus massage (only when pt. On telemetry) —> contraindicated if recent MI, or cerebral ischemia, or if carotid bruits present…./…patient > 40, & initial syncope workout is negative
Acute chest pain
History:
1. Onset, course & duration, position, quality, radiation, severity & triggers, relation to position & breathing
- Associated symptoms
- heart
- N/V, Sweating/Fatigue, SOB, dizziness/LOC, ankle/leg swelling, leg pain after walking, erectile dysfunction
- lung: cough, sputum, chest tightness, wheeze, recent fever, flu like symptoms
- stomach: difficulty swallowing, heart burn, GERD, history of peptic ulcer disease
- rib cage: chest wall trauma, rash, blisters
-Flight: long flights, leg pain, swelling
- history of panic attack, sudden fear, psychiatric
Risk factors:
- CAD: HTN, diabetes, high cholesterol, family history of heart attack at age less than 50, obesity, lack of exercise, stress
- pericarditis:
Community acquired pneumonia
common organisms:
1. Strep. Pneumonia
2. Staph aureus
3. H. Influenza
4. Moraxella
symptoms:
1. Fever
2. Blood-streaked sputum
3. Cough with purulent sputum
4. Dyspnea
Differential diagnosis:
1. Nosocomial pneumonia
- Aspiration pneumonia
- Asthma
- episodic dyspnea, cough, wheezing, chest tightness - Lung cancer
- weight loss, progressive dyspnea + hemoptysis - TB
- Pulmonary embolism
- sudden dyspnea + chest pain + tachycardia + no consolidation on x-ray
- PE lead to pleural effusion ( exudative, small, bloody) - CHF
Treatment:
1. Macrolide, doxycycline, fluoroquinolone (as outpatient)
2.
Asthma
(Episodic dyspnea, cough, wheezing, chest tightness)
Exposure to possible triggers:
1. Exercise
2. NSAIDs
3. Allergen
4. Cigarette smoke
Differential diagnosis:
1. Foreign body aspiration
2. Chronic bronchitis
3. Bronchiectasis
4. Tracheal stenosis
5. Cystic fibrosis
TB
( B-symptoms: fever, night sweat, weight loss+ Malaise, anorexia, chronic cough, blood-streaked sputum)
- risk factors:
1. Recent contact with Tb
2. Incarceration
3. Homeless
4. HIV
5. Overcrowded houses
6. Immunosuppressive therapy
PE:
1. Decrease breath sound
2. Pleural effusion
3. Miliary TB —> disseminated hematological & lymphatic
Lab:
1. AFB smear & culture ( order 3 time, one every 2 hours)
2. Tuberculin-skin test (PPD)
Differential diagnosis
1. Pneumonia
2. Sarcoidosis
3. Coccidioidomycosis (fungus; valley fever; Arizona, California; Mexico; central/south America)
3. Blastomycosis (new York to MN)
3. Histoplasmosis ( New York to MN + Florida)
4. Lung cancer
Pulmonary Embolism
( sudden onset dyspnea + pleuritic chest pain + tachypnea + tachycardia + hypoxia + fever + anxiety + hemoptysis)
Diagnosis:
1.chest x-ray ( westermark sign+ Hamptom hump)
2. ABG ( respiratory alkalosis + hypoxia + increase A-a gradient)
3. D-dimer
4. V/Q scan (pregnant), pulmonary angiography (stable), TTE (unstable)
4. Adjunctive venous Duplex ultrasound
……
Treatment:
1. Heparin (immediately)
2. Bridge with warfarin ( INR 2-3)
3. Thrombolysis (atlepase) ( if severe clot or PE with hemodynamically unstable)
4. Thrombectomy
5. IVC filter (if HIT or anticoagulation is contraindicated)
Differential diagnosis:
1. MI
2. Angina
3. Pericarditis
4. Pneumonia
4. COPD
5. Asthma
6. CHF
7. Pneumothorax
8. Costochondritis
9. Anxiety
Interstitial lung disease
( progressive dyspnea + nonproductive cough)
- Occupational or environmental exposure:
- Asbestos + silicosis + berylliosis - History of granulomatous lung disease:
- sarcoidosis + fungal + TB - Past or current medication:
- amiodarone+ sulfa + methotrexate … - History of connective tissue disorder:
- SLE + wegner granulomatosis + Rheumatoid arthritis + GoodPasture syndrome + dermatomyositis
