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internal medicine mb step 2 > plum > Flashcards

plum Flashcards

1
Q

what is associated with asthma name 5 symptoms and signs

A 
nasal polyps 
worse at night 
sensitivity to aspirin 
eczema or atopic dermatitis 
increased expiratory phase
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2
Q

what is a the best initial test in acute Asthma excerabation

A

peak expiratory flow

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3
Q

what can Asthma exclusively present as

A

cough

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4
Q

what is most accurate test to diagnose Asthma in a patient and what parameter would you assess

A

PFT and diagnosis with
decrease FEV1/FVC
decrease FEV1
decrease FVC

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5
Q

asthma

if you patients PFT shows to be symptomatic what is next and how will it show to conclusive with asthma

A

normal pft
give patient metacholine
measures FEV1 decreases more than 20% diagnostic for asthma

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6
Q

asthma

if patient is symptomatic what diagnostic drug would administer and what will the PFT show

A

Albuterol increase 12% or 200 FEV1

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7
Q

what drug should never be used alone in asthma or cold

A

LABA must be with ics

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8
Q

asthma

define as intermittent mild, moderate, sever and explain the step up method of therapy

A

intermitten
s/s day <2x/week or Night <2x/mo FEV1 80%
- tx short acting beta albuterol as needed
Mild
s/s > 2x/week but <1x /day or Night < 1x/ week FEV1 80% SABA and ICS

moderate
s/s >1x/day or >1x/wk FEV1 61x/day or frequent FEV1< 60%
tx increase dose of drugs or increase only ICS

Refractory
oral steroids

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9
Q

best initial drug for long term control ASTHMA

A

ICS

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10
Q

what test best quantify asthma exacerbation

A 
PEF ( from patients normal PEF)
ABG for (A-a) gradient
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11
Q

First steps in managing Asthma Exacerbation

A

Oxgen
Albuterol -nebulizer
prednisone IV ( takes 4 hours to work)
ipratropium

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12
Q

SPO2 is kept at in Asthma

A

equal or greater than 90%

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13
Q

asthma

how to you quantify if the patient gets better
what is your next step

A

no wheezing
no increase O2 demand
PEF > 70%
Tx–> send home mediator dose Albuterol and oral steroids

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14
Q

Asthma patient no change after treatment for exacerbation what next step

A

send to wards
IV steroids
Mediator dose inhaler Albuterol

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15
Q

asthma

S/S of patient getting worse

A

increasing CO2 or normalizing CO2 patient should be hyperventilating blowing off CO2 –> shows patients is getting week and entering respiratory failure
decrease lung sounds–. Patient is tiring
PEF< 50%
increase 02 demand

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16
Q

salvage therapy asthma exacerbation

A

MG- relieve bronchospasm - pt not responses to albuterol while waiting for steroids

epinephrine last resort

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17
Q

what test helps to differentiate asthma and COPD

A

bronchodilator test

or metacholine challenge both positive in asthma

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18
Q

asthma

what is a the treatment for a patient not responding exacerbation treatment and is rapidly declining

A

TX send ICU, mechanical intubation and ventilation

IV steroid and continuous nebulizer albuterol

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19
Q

COPD chest x ray findings

A

increase AP diameter
flattened diaphragm
long narrow heart shadow

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20
Q

COPD

most accurate diagnostic test and findings

A

PFT
FEV1/FVC ration <70 %
decrease FEV1 and decrease FVC
increase TLC because of increase RV

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21
Q

DCLO in asthma and in COPD

A

asthma normal or increase

COPD decreased

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22
Q

S/S of COPD exacerbation

A

increase CO2
compensatory increase in HCO3
hypoxia

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23
Q

EKG for COPD

A

RV an RA hypertrophy

MAT and atrial fibrillation

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24
Q

what treatment improves mortality and delays progression

A

smoking cessation and

at home oxygen treatment

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25
Q

O2 indication COPD

A 
PO2< 55%
SAT<88%
OR 
PO2<66% or SAT ,90% with :
pulmonary HTN, high HCT, or cardiomyopathy, S/S right sided heart failure
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26
Q

what vaccination should both COPD and Asthma patients receive

A

influenzas

pneumoccal

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27
Q

best prognostic factor for COPD

A

FEV1

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28
Q

treatment method for COPD step up

all medical therapy fails

A
  1. SABA
    2 SABA + long acting muscarinic blocker (tioropium, ipratropium)
  2. SABA +LAMA+LABA
  3. SABA+LAMA+LABA+ICS
  4. SABA+LAMA+LABA+ICS+ THEOPHYLLINE
  5. SABA+LAMA+LABA+ICS+ THEOPHYLLINE+ ORAL CORTICOSTEROIDS
  6. lung transplant
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29
Q

Bactertia that cause pneumonia in COPD patients

A

strep.pneuo
H. influenza
M. cataorrhalis

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30
Q

COPD exacerbation drugs

02

A

Albuterol
ipratropium
steroids
antibiotics

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31
Q

antibiotic of choice COPD

A

macroclides: azithromycin, clarithromycin (warfirn)
cephalosporin: cefuroxime , cefixime, cefaclor
amoxicllin/calvuanlic acid
quinolones
Alternative
doxycycline

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32
Q

COPD exacerbation management AFTER TREATMENT
improving
no change
worsening +s/s

A
  1. improving –> send home PO steroids, MDI inhaler
  2. no change –> PO steroids nebulizer inhalers
  3. worse–> ICU increase CO2, decrease lung sounds
    IV steroids, continuous nebulizer, intubate
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33
Q

most common cause of bronchiectasis

A

cystic fibrosis

34
Q

COPD patient with catrostophic worsening of s/s

A

pneumothorax

35
Q

etiology bronchiectasis

A 
cystic fibrosis 
tb pneumonia 
immune deficiency + panhypogammaglobunemia
ABPA,  dyskinetic cilia syndrome
collagen vascular disease like Rh
36
Q

S/S of bronchiectasis

A 
high volume purulent sputum 
hemopytosis--> bc rupture of blood vessels can present as emergency - greatest complication
foul smelling sputum 
resistance to antibiotic treatment 
recurren persistant pneumonia
37
Q

bronchiectasis best initial test

most accurate and diagnostic test

A

chest x ray - dilated thickened bronchi not diagnostic

resolution ct most accurate and diagnostic

38
Q

BRONCHIECTASIS

treatment methods

A 
chest physiotherapy  (cupping clapping) +
postural drainage => dislodge  plugged up bronchi

treat each infections episode as they arise , same antibiotic as COPD
specific microbiologic diagnosis preferred- sputum culture

39
Q

signs of superimposed infection on bronchiectasis

A

fever, chest pain, changed in quality an quantity of sputum

40
Q

community acquired pneumonia

is defined as

A

pneumonia occurring before hospitalization or within 40 hours of hospitalization

41
Q

most common cause of CAP

A

strepococcus pneumonia

42
Q

best initial test for all pneumonia

A

chest x ray

43
Q

Tests for pneumonia in admitted patients triage

A
  1. chest x ray
  2. CBC and differentials, BUN, creatinine, glucose, electrolytes and ) O2 stat
  3. 2 pretreatment blood culture
  4. sputum gram stain (all patients) and culture of sputum (hospitalized pt)
  5. start antibiotics broad spectrum
44
Q

typical pneumonia causes and presentation

atypical pneumonia and presentation

A 
strep pneumo
kielbsella 
staph areus
anerobic,  gram negative rods
h. influenza
lobar consolidtion 
interstitial infiltrates 
mycoplasma 
CMV 
RSV
legionella 
coxeilla 
chlamydia pneumonia+ psitacci
45
Q

Pneumonia previously healthy no antibiotics for the last 3 months and no comorbities (outpatient

A

azithromycin or clarithromycin (warfin)

or doxycycline

46
Q

Pneumonia out patient comorbidities and antibiotics last 3 months

A

levofloxacin or moxifloxacin

47
Q

Pneumonia in patient treatment

A

levofloxacin or moxifloxacin (respiratory floroquinlones

or ceftatriaxone or azithromycin

48
Q

Pnemonia reasons to hospitlize

A

hypotension <90 mmhg
RR >30 or P02 <60 mmhg or pH< 7.35
pulse >125pm
confusion, comorbities COPD, CHF, renal failure , liver failure
temp >104
BUN >30 Na< 130 mml/L , glucose >250 mg/dl

49
Q

hospital aquired pneumonia

definiton

A

occurs 48 Hours after admission

or 90 days within hospitalization

50
Q

most common cause of HAP

A

gram negative bacteria

pseudomonas or e.coli

51
Q

HAP management

A

therapy centred around therapy for gam negative bacilli
antipseudomonal cephalosporins –>
1. cefepime, or ceftazidime
2. antipseudomonal penicillin : pipercillin/tazobactam
3. carbapenem: imipenem, meropenem, or doripenem

pipercillin and ticarcillin always used with betalactamase inhibitor

52
Q

ventilator associated pneumonia
pathophysiology
name 3 S/S

A 
no mucociliary clearance, no cough 
and postive peep prevents 
fever and or rising abc 
new filtrate on chest x ray 
purulent  secretions coming form the tracheal tube
53
Q

how to culture VAP pneumonia

A

BAL

bronchoaveolar lavage–> bronchoscope passed into lungs

54
Q

VAP Pneumonia drug treatment regimen

A 
3 drug combo
1.Cephalosporin (ceftazidime or cefepime) OR penicillin (piperacillin/tazobactam)
OR carbapenem (imipenem)
2. Aminoglycoside OR fluoroquinolone
3. Vancomycin OR linezolid

change initial therapy when identified

55
Q

which drug is inactivated by surfactant

A

daptomycin

56
Q

lung abscess etiology

A

patients with large volume of oral/pharyngeal content with poor dentation not adequately treated

stroke with loss of gag reflex
seizures
intoxication
endotracheal intubation

foul smelling sputum

57
Q

best initial test diagnosis of lung abscess with and finding on exam
most accurate test
test for specificitc microbiologic etiology

A

chest xray - cavity with air fluid level
chest CT most accurate

micro aetiology lung biopsy by bronchoscopy or transtracheal aspiration

58
Q

lung abscess drugs treatment

A

clindamycin (anaerobic)

or penicillin until cavity gone

59
Q

young Adult patient with chronic lung disease
couch sputum hemopytosis brochietasis
wheezing dyspnea , recurrent infections sinus pain nasal pain

A

cystic fibrosis in young adult

60
Q

pancreatitis in cystic fibrosis

A

beta cells spread

61
Q 
infertile man ( azoospermia) missing vas deferens
infertile female think cervical mucus altered menstral cycle
A

cystic fibrosis

62
Q

best diagnostic test and parameters for diagnosis

which test is not accurate

A

increased sweat chloride test
pilocarpine increase sweat
chloride levels > 60 meq/l diagnostic
not accurate CFTR is not accurate b.c to many mutations

63
Q

treatment cystic fibrosis

A

antibiotic in bronchiectasis - sputum culture is essential to guide therapy

  1. inhaled recombinant human deoxyribonucleauses
    breaks up clogged up air way secreted by neutrophils
  2. inhaled bronchodilators ( albuterol)
  3. pneumococcal vaccine
  4. lung transplant all other treatment failures sever disease
  5. ivacaftor increases the activity of CFTR in the 5% of patients who have a specific mutation
64
Q

asthmatic patient with recurrent episodes of brown flecked sputum and transient infiltrates on chest x ray

A

ABPA

65
Q

APBA
etiology
most commonly effected patients
signs and symptoms

A

hypersensitive reaction to fungal antigens colonize at bronchial tree

*asthma/atopy,

hempytosis, bronchiectasis, foul smelling sputum, recurrent chest infection

66
Q

APBA

diagnostic tests

A
  1. Peripheral eosinophilia
  2. Skin test reactivity to aspergillus antigens
  3. Precipitating antibodies to aspergillus on blood test
  4. Elevated serum IgE levels
  5. Pulmonary infiltrates on chest x-ray or CT
67
Q

ABPA chest x ray findings

A

lobar infiltrates- eosinophilic pneumonia

bronchiectatsis

68
Q

APBA

A

oral steroid prednisone sever cases
inhaled steroids not effective
itraconazole for recurrent episodes

69
Q

Pneumonia

  1. Hemophilus influenzae
  2. Staphylococcus aureus
  3. Klebsiella pneumoniae
  4. Anaerobes
  5. Mycoplasma pneumoniae
  6. Chlamydophila pneumoniae
  7. Legionella
  8. Chlamydia psittaci
  9. Coxiella burnetii
A
  1. COPD
  2. Recent viral infection (influenza)
  3. Alcoholism, diabetes
  4. Poor dentition, aspiration
  5. Young, healthy patients
  6. Hoarseness
  7. Contaminated water sources, air conditioning, ventilation systems
  8. Birds
  9. Animals at the time of giving
70
Q

Pleural effusion
thoracentsis anatomical location
maximum amount of fluid allowed to be removed

A

midaxillary line above the rib –> to avoid damage to intercostal artery, nerve, intercostal vein
2 interocostal spaces below level of fluid
remove max 1 Litre of fluid

71
Q

pneumonia dry not productive cough

A

atypical pneumonia

less sputum because infects interstial space not alveoli

72
Q

s/s that distinguish pneumonia from bronchitis

A

Dyspnea, high fever, and an abnormal chest x-ray are the main ways to distinguish pneumonia from bronchiti

bronchitis no fever,

73
Q

sputum gram stain “adequate” criteria

A

> 25 wbc and < less than 10 epithelial cells

74
Q

aspiration pneumonia anatomical location when lying flat

A

upper lobe

75
Q

stroke patient develops chronic infection with over several weeks with large volume sputum that is foul smelling. Also has several pounds during this time.

A

lung abscess

76
Q

aids patient with dry cough, dyspnea I exertion, fever, cd4 count <200 /ul

  1. what is best initial test and what will the lab finding show
  2. name 2 other test that can also be of diagnostic use
  3. what is the most accurate diagnostic taste
A

pneumocystis pneumonia P. Jiroveci
1. chest x ray–> will show bilateral interstitial infiltrates
2. A-a gradient can also be diagnostic alternative to chest x ray -> demonstrates hypoxia (increased A-) gradient
Decrease LDH most likely NOT P.J
LDH always increased in disease
3. most accurate testis BAL

77
Q

aids patient is diagnosed with pneumocystis pneumonia P. Jiroveci a chest x ray has been performed what is the next best step

A

sputum stain for pneumocystis pneumonia P. Jiroveci

78
Q

aid patient pneumocystis pneumonia P. Jiroveci is negative for sputum stain what is the next best step

A

negative sputum test then should be followed with a BAL

79
Q

pneumocystis pneumonia P. Jiroveci

  1. best initial therapy for treatment and prophylaxis
  2. if patient has toxicity to best treatment what is alternative
A
  1. TMP/SMX
  2. clindamycin and primaquine
    or
    Pentamidnine
80
Q
  1. define sever pneumocystis pneumonia P. Jiroveci
  2. what tx is required to decrease mortality
  3. how is mild PCP treated and defined
A
  1. pO2 below 70 or an A-a gradient above 35
  2. steroids added to tx
  3. atovaquone and defined as mild hypoxia
81
Q

patient diagnosed with pneumocystis pneumonia P. Jiroveci being treated with TMP/SMX demonstrate

A

G6PD bite cells

82
Q
  1. Klebsiella pneumoniae
  2. Anaerobes
  3. Mycoplasma pneumoniae
  4. Legionella
  5. Pneumocystis
A

1.

  1. Hemoptysis from necrotizing disease, “currant jelly” sputum
  2. Foul-smelling sputum, “rotten eggs”
  3. Dry cough, rarely severe, bullous myringitis 4.Gastrointestinal symptoms (abdominal pain, diarrhea) or CNS symptoms such as headache and confusion
  4. AIDS with <200 CD4 cells

internal medicine mb step 2 (7 decks)

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