pulm

Question 1

S and S of asthma

Answer 1

respiratory distress at rest
diaphoresis
RR over 28
pulse >110
pulsus paradoxus >12- unique feature of asthma 
hyperressonance

Question 2

astuma ominous signs

Answer 2

fatigue
paradoxical chest or ab movment
absent breath sounds
can be recumbant
cyanosis

Question 3

asthma labs

Answer 3

slight wbc elevation withh eosinophilla
initially resp acidosis with mild hypoxemia on ABG
HYPERCAPNEA IS AN OMINOUS FINDING
A PC02 >45MMMHG INDICATES AN EMERGENCY
A NORMAL PCO2 (35-45) IS A VERY SICK PATIENT
chest x-ray is only useful to rule out other conditions

would show hyperinflation

Question 4

asthma PFT

Answer 4

hospitilazation with initial FEV-1 is <30% predicted or dose not increase by at least 40% after one hour of vigorous therapy
hospialization is reccomended if peak flow is <60L/min ainitiallly and doesn to improve to >50% predicted after 1 hour of treatment.

general improvment in FVC or FEV1 of 15% or FEF 25-75 of 25% after inhailed bronchodialator

Question 5

outpatient management of asthma -

Answer 5

short acting B2 adrenergic agonist (albuterol, for symptom releife before exercise

Question 6

Short acting B2 adrenergic agonist

Answer 6

albuteral or proventil step one

Question 7

step 2 daily maintenance with inhaled corticosteroids

Answer 7

budesonide (pulmicort) triacinolone (amacort

Question 8

side effects of step 2 inhaled corticosteroids

Answer 8

(rinse mouth) candidal infection of oropharynx, dry mouth, sore throat,

Question 9

step 3 asthma

Answer 9

short acting b2 adrenergic agonist - albuterol, proventil for symptom breakthrough

Question 10

if symptoms persist beyond step 3 then

Answer 10

increase corticosteroid dose or add LONG acting b2 adrenergic agonist (salmeterol (servent) or ipratropium bro- arovent -good for lots of secretions

Question 11

useful for chronic asthma

Answer 11

antileukotryines- singulair

Question 12

Inpatient managment of asthma

Answer 12

02 at 2-3 L
mild to mod- abg not necessary, if sa02 is over 90%
abg for less than 90%
hydration oral or IV

Question 13

inhaled sympathomimetics

Answer 13

alupent (0.3cc in 5% soutions) in 2.2 ml nss q 30-60mins
proventil,
proventil or ventolin inhaled

corticosteroids
methlprednisolone 60-125mg IV x1 and then 20mg q 4or 6 untill attack is broken

can use parenteral sympathomimetics in pts who cant do po
can also use anticholonergic (atrovent

Question 14

black box on leukotryins and LABA

Answer 14

dont take in acute attack singular or salmeterol

Question 15

Status asthmaticus def

Answer 15

severe acute asthma presenting in an unremitting, poorly responsive, life thereatening manner,

Question 16

status asthmaticus management

Answer 16

02
D51/2 ns
inhaled and pareneral sympathomimetics- alupent or proventil or ventolin
methylpred-60-125IV or hydroortisone 300iv now
consider atrovent- 2-6puffs q4-6 anticholinergic
continous pulse ox
freq ABG
tube if necessary

Question 17

Chronic bronchitis

Answer 17

characterized by excessive bronchial mucous and is manifested by productive cough for 3months or more in at least tow consecutive years

Question 18

Emphysema

Answer 18

abnormal, permanent enlargement of the alveoli

Question 19

emphysema symptoms

Answer 19

progressive constant dyspnea
onset of symptms after 50 
min clear sputum
thin
increase in chest AP diameter
hyperressonant precussion
normal hematocrit
increased total lung capacity

Question 20

chronic bronchitis symptoms

Answer 20

intermittant mild to mod dypsnea
symptoms onset after age 35
COPIUS PURULENT SPUTEM PRODUCTION
stocky body habitus
normal chest AP diameter
bulla blebs on cxr
hyperinfation on cxr
HEMATOCRIT INCREASED
hypercapnea hypoxia on ABG

Question 21

COPD fev and volume stuff

Answer 21

FEV is down but TLC< FRC and RV may be up

Question 22

COPD management outpatint

Answer 22

stop smoking
aovind irritants
postural drainage
INHALED IPRATROPIUM BROMIDE (ATROVENT) OR SYMPATHOMIMETICS (PROVENTIL, VENTOLIN)MAINSTAY OF THERAPY

Question 23

COPD inpatient

Answer 23

02 at 1-2L per min or 24-28% on venti mask
pharmacologic progression as with asthma
purluent sputem gets abx for 7-10 days

Question 24

copd inpaitient ABX

Answer 24

ampicilin or amox- 500mg four times per day
doxy 100mg bid or
bactrim DS 1 tab BID

Question 25

TB def

Answer 25

systemic disease caused by M Tuberculosis. Pulm disease, is the most common clinical presentation, othe sites of involvment include lymphatics, denitourinary, bone, meningies, perotoneum and heart

Question 26

TB most at risk

Answer 26

crowded living conditions, the institutionalized, HIV +, those with DM, chronic renal players, malignancy, malnutrition and the immunosuppressed.

Question 27

TB s and S

Answer 27

``` most are asymptomatic fatigue, annorhexia dry cough, progressign to wet with some blood weight loss and low grade fever night sweats ```

Question 28

TB labs

Answer 28

DEFINITIVE DIAGNOSIS BY CULTURE OF M TUBERCULOSIS X 3 AFB ssmear are presumptive evidence of active TB small momogenious infiltrate in Upper lobes on CR PPD shows exposure but is not diagnositic for active disease

Question 29

TB managemnt

Answer 29

local helath department, must be notified | hospitilization is not required

Question 30

TB meds

Answer 30

Isoniazid 300mg, rifampin 600mg, pyrazinamide 1.5-2.0 gm and ethambutol 15mg per kg per day initially if the isolate is succeptable tto INH and RIF than you can drop ethambutol 3 drugs for 2 months, and 4 months of INH and RIF daily

Question 31

TB meds INH

Answer 31

nephro toxic

Question 32

TB meds consideration

Answer 32

persons iwth HIV should be treated for 9 months | depot injections are available

Question 33

Pulm tb patient monitoring

Answer 33

weekly sputum smears and cultures for 6 weeks, and then monthly untill negative cultures, persistant symptoms or cultures should raise suspicion for resistance

Question 34

baseline before TB therapy

Answer 34

liver labs, and watch for red-green color acuity in efambutol

Question 35

Chemoprophylaxis and PPD

Answer 35

positive PPD of 5mm for an HIV +, contact with a known positive or chest film typical of TB 10mm for immagrants or health care workers 15mm for no in high prevelance groups

Question 36

Pneumonia def

Answer 36

lower respirartoy infection, strep pneumonia is the most common etilolgical agent of CAP

Question 37

Pneumonia s and s

Answer 37

fever, shaking chills, lung consolidaiton on physical exam, malise and fremitus

Question 38

Pneumonia labs

Answer 38

``` elevated WBC's infiltrates on CXR GS and culture if indicated ABG for respiratory faiure CXR and consider 3 blood cultures ```

Question 39

CAP in previously healthy pt abx

Answer 39

macrolide (mycins) or tetracycline (clclines)

Question 40

CAP in comorbid patints abx

Answer 40

``` floriquinolone (oxacins) + Amoxicillin/clavulanic acid# Imipenem/cilastatin# Imipenem/cilastatin/relebactam. Ampicillin/flucloxacillin. Ampicillin/sulbactam (Sultamicillin) Ceftazidime/avibactam. Piperacillin/tazobactam. Ceftolozane/tazobactam ```

Question 41

Non ICU CAP

Answer 41

oxacins or beta lactam + macrolide or tetracycline

Question 42

ICU CAP if P aeruginosa suspected

Answer 42

pip/tazo or meropenem or cefepime _ AMG/azithromycin add vanco if MRSA pnu is suspected

Question 43

ICU PNU - viral

Answer 43

still gets abx for secondary bacterial infetion- tamflu if in the first 48 hrs

Question 44

abx for PCN allergy patients

Answer 44

aztreonam

Question 45

for pseudomonas PNU use

Answer 45

zosyn plus cipro

Question 46

HAP definition

Answer 46

pneumona that occurs 48hours or more after aadmission whih was not incubation the time of admission includs VA and HCAP, most common is Staphylcoccus aureus or streptococcus

Question 47

VAP definition

Answer 47

pneumona that arisis more than 48-72 hours after endotracheal intubation pseudomonas is most common orginization

Question 48

Penumothorax -

Answer 48

gas in the pleural space that raises pleural pressures and can impair respiration, resulting in a "collapsed lung"

Question 49

S and S of pneumothorax

Answer 49

chest pain, dypsnea, cough HYPERROSONANCE ON THE AFFECTED SIDE diminshed breaht sounds and fremitice on the affected side mediastinal shift towards the unnafected side in the case of tension hypotension

Question 50

Pneumothorax labs

Answer 50

CHEST X RAY IS DIAGNOSTIC | abg my be indicated

Question 51

pneumothorax management

Answer 51

<20% pneumothorax in asymptomatic patinents requires no intervention chest tube first if available, needle throcostomy

Question 52

needle thoracostomy site

Answer 52

2nd intercostal space mid clavicular line

Question 53

chest tube placement site

Answer 53

4th or 5th ics Mid axillary

Question 54

PE definition

Answer 54

leading cause of inhospital death leads to faillure of left ventricle.

Question 55

PE S AND S

Answer 55

usually occur abruptly unexplained dyspnea and taccy are most common chest pain, retrosternal or lateralized and pleuritic

Question 56

PE diagnosis

Answer 56

spiral CT vq scan in all clinicallly stable patients reflexive hyperventilation causes hypercapnea pulmonary angiography when clinical data and vq scan contradictory or those at great risk from anticoagulation with high probability VQ scan.

Question 57

PE managemtn

Answer 57

supplamental 02 IV fluids, for hypotension and reduced Cardiac output tube for change in mental status heparin 80u/kg bolus followed by 18u/kg to ptt of 1.5-2x normal, coumadin simultaneus to inr of 2-3

Question 58

finrinolytic therapy for PE

Answer 58

for those withh hemodynamic compromise or shock before starting hepairn, PT and PT myst be <2x normal

Question 59

ARDS- management

Answer 59

TV 5-7 or 6-8 ml/kg ideal body weight, | peep of 10

Question 60

ARDS

Answer 60

refractroy hypoxemia

Question 61

assist control

Answer 61

pt can trigger and gets set volume

Question 62

SIMV

Answer 62

preset numebr of breaths at preset volume, can take own breath at whatever volume they want

Question 63

FVC

Answer 63

volume of gas forcefully expelle from lungs after max inspiration

Question 64

FEV1

Answer 64

expelled over 1 second

Question 65

pleural effusion serum protien

Answer 65

one or more of the following equals exudate pleural fluid protein to serim protein ration is >0.5 pleural fluid LDH to serum LDH ration is >0.6 Pleural fluid LDH is greter than 2-3 the upper limit of normal serum LDH (140-280u/L) transudates have none of these features

Question 66

RML think

Answer 66

aspiration PNU