Unit 2 Flashcards
CURB-65
helps guide CAP admission/triage
5 predictors to calculate a 30-day predicted mortality rate
Confusion Urea (BUN >20) RR >30 BP < 90/60 >65 y/o
0 - outpt tx safe
1 - 2: admit
3-4: ICU, urgent referral
CROUP diagnosis
- doesn’t require CXR (but if get will see steeple sign)
Pertussis: Catarrhal
stage 1
7-10 days, up to 3 weeks
coryza (runny nose)
low grade fever
mild occasional cough
resembled mild URI
Amylase INCREASE
- pancreatitis (degree of elevation may not correlate with severity of pancreatic injury - about 10% of time, amylase is WNL when pt has pancreatitis)
- chronic renal failure
- follow up with evaluation for perforated peptic ulcer
Alkaline Phosphatase (ALP)
A family of enzymes found in nearly all body tissues. Produced by liver and bones (children’s level is 2x-4x that of adult due to bone growth). Function unknown.
lung sounds over suprasternal notch
tracheal/bronchial (louder higher pitched, hollow quality, louder on expiration)
kids CAP treatment
- supportive
- hospitalized <3 m/o, apnea, hypoxemia, poor feeding, effusion of CXR, respiratory distress, clinical deterioration w/ treatment
- if treat output follow up in 12hr-5days
bacterial: amoxicillin (alternative = cephalosporin or macrolide)
viral: RSV - supportive / Flu - oseltamvir or zanamivir (>5y/o)
Bacterial Tracheitis key symptoms
(severe life-threatening form of larynotracheobronchitis)
- severe upper airway obstruction
- fever
- viral co-infection (viral primary croup)
- sniffing dog/tripod position
- high fever
- dysphagia
- drooling
- muffled voice
- inspiratory retractions
- cyanosis
- soft stridor
localized mucosal invasion of bacteria in primary viral croup —- inflammatory edema, purulent secretions, pseudomembranes
Sodium INCREASE
(called hypernatremia)
- excess ingestion
- inadequate water intake
- aldosteronism
pediatric bacterial CAP tx
amoxicillin 5-10 days aimed at S. pneumoniae
lung sounds over periphery
vesicular (gentle rusting inspiration, fades in expiration)
early sign of pneumococcal pneumonia
bronchial breath sounds
Blood Urea Nitrogen
8-26
The chief product of protein metabolism, urea is formed by the liver from ammonia and is excreted in the urine.
Uremia is a toxic condition associated with renal insufficiency and produced by retention in blood of nitrogenous substances.
Anaerobic pneumonia key symptoms that isn’t with other diseases
cough w/ foul smelling sputum
CAP CXR
bacterial vs viral findings
cannot reliably distinguish viral from bacterial
bacterial: lobar infiltrates, pleural effusions, abscess, “round” pneumonias
viral: perihilar streaking, increased interstitial markings, patchy bronchopneumonia, hyperinflation
Alkaline Phosphatase (ALP) INCREASE
- Commonly occurs with obstructed bile ducts (so conjugated or direct bili also goes up)
- New bone formation as in children and in Paget’s disease (thickening and hypertrophy of long bones and deformity of flat bones - condition affects elderly)
a patient presents with unilateral volume loss on the right side when inspecting their CXR film. Why could be the cause?
pleural effusion
atelectasis
empyema
Bilirubin DECREASE
*insignificant
CROUP/EPIGLOTTITIS/RSV:
breathing
C: retractions
E: tripod position
RSV: apnea or tachypnea
Albumin USE
- evaluating edema
- liver disease
- suspected malnutrition
Thyroid-Stimulating Hormone (TSH) or Thyrotropin: DECREASE
- hyperthyroidism
- excess levothyroxine intake
- pituitary failure (see note above) (may need to do a T3 and T4 uptake and TRH stimulation test)
- hypothalamic failure (see note above) (same follow up tests as above)
Monocytes
· 2-6% of total WBC.
· Secondline of defense.
· Stronger and longer lived than neutrophils
· Respond to viral infections and chronic bacterial infections and inflammation
“common cold” causes
rhinovirus (color months) adenovirus (all season, epidemics common) RSV parainfluenza human metapneumovirus influenza (epidemics late fall-winter) enterovirus (Summer cold)
average incubation period for: RSV influenza adenovirus pertussis
RSV: 5 days
Influenza: 1-4 days
Adenovirus: 4-9 days
Pertussis: 7-17 days
Pleuritis treatment
treat pain and control cough
Serum Creatinine INCREASE
- renal impairment
* athletes may have nonpathological elevation due to increased muscle mass
Potassium INCREASE
- renal disorders
- meds
- abnormal intake
- burns or crushing injuries
- MI
- DKA
- most common cause is hemolyzed specimen (so when in doubt, always repeat test before ordering other work-ups)
In hyperkalemia, an EKG reveals a prolonged PR interval, wide QRS complex, ST-segment depression, and tall, tented T waves.
Bronchiolitis key symptoms
** most common serious acute respiratory illness in kids**
<2 y/o, begins as URI (fever, rhinorrhea, cough)
- meniscus or layering fluid of lateral decubitus CXR
Adult CP s/s
PTA or win 48 hours admission: fever (may be low in elderly) cough w/ or w/o sputum dyspnea/tachypnea (sensitive in elderly) mental status change (elderly) rales bronchial breath sounds inspiratory crackles **parenchymal opacity on CXR**
CROUP causative agents
*PARAINFLUENZA VIRUS* RSV rhinovirus adenovirus influenza A/B M. pneumonia
CROUP/EPIGLOTTITIS/RSV:
other symptoms
C: improves outside in cool air
E: drooling, painful swallowing
RSV: hypoxemia
Prostate-Specific Antigen (PSA) INCREASE
- benign prostatic hyperplasia (BPH)
- prostate cancer
- following prostate massage (may double - wait 2 wks after prostate manipulation to perform a PSA assay)
- prostate biopsy (may show 50 fold increase)
Bacterial Tracheitis treatment
debridement, ETT, IV Abx
CROUP/EPIGLOTTITIS/RSV:
onset
C: gradual at night
E: rapid
RSV: gradual
Adult CAP causes
usually bacterial S. pneumoniae
- M. pneumoniae, C. pneumoniae
viral causes: #1 = influenza, RSV, adenovirus, parainfluenza
Potassium DECREASE
(hypokalemia) - can develop rapidly
* renal disorders
* meds
* excess licorice ingestion (due to aldosterone-like effect of glycyyrhizic acid)
In hypokalemia, an EKG shows a flattened T wave, ST-segment depression, and U wave elevation. In severe cases, ventricular fibrillation, respiratory paralysis, and cardiac arrest can occur.
Aminotransferases: alanine or ALT (aka SGPT), aspartate or AST (aka SGOT)
Enzymes primarily located in hepatocytes (liver cells). When the liver is injured, these 2 enzymes leak from the hepatocytes. Generally, the blood level of aminotransferase reflects the severity of hepatic injury.
ALT is fairly specific for the liver (think “L” for liver)
AST also goes up after injury to cardiac or skeletal muscle (think “S” for skeleton and cardiac)
So if both ALT and AST are elevated, hepatic problems are likely and the ALT is higher except in alcoholic hepatitis when the AST is higher.
patient presents w/ lower pitched popping sounds heard on auscultation. this sound is longer in duration. what do you suspect? what is most often the cause?
care crackles
CHF, pneumonia
“common cold” treatment
symptomatic: po antihistamines, decongestants, cough suppressant
* *NO ANTIBIOTICS**
imaging or paralysis of diaphragm
fluoroscopy or US
most valuable examination finding in older pediatric population with pneumonia
unilateral crackles
Amylase (AML)
- Enzyme that digests starch and glucose
- Produced by pancreas, salivary glands, and lung tumors
- The small amount absorbed in the circulation is excreted by the kidneys
Blood Urea Nitrogen INCREASE
(called azotemia)
- renal insufficiency
- increased dietary intake if protein
- decreased water intake
- deceased urine flow (as in CHF)
- blood in GI tract
- inhibition of anabolism by corticosteroid drugs
- hyperthyroidism
- increased protein catabolism (as occurs in burns)
CROUP/EPIGLOTTITIS/RSV:
AGE
C: <3 y/o
E: 3-6 y/o
RSV: <2 y/o
transmission source for legionnaires
contaminated water
Potassium
3.5-5.3
- K+ is the major intracellular cation (positive ion).
- Kidneys responsible for extracellular regulation.
- K+ is essential for maintaining electrical conduction within the cardiac and skeletal muscles.
- K+ and Na+ balance by going in opposite directions (example - when K+ goes up, Na+ goes down)
Epiglottitis diagnosis
definitive = cherry red and swollen epiglottis and swollen arytenoids upon direct inspection of epiglottis by airway specialist
determine by presentative (don’t delay care to obtain CXR)
- lateral CXR will show thumbprint sign
Bacterial Tracheitis causative agents
S. aureus
- H. influenzae
- group A streptococcus pyogenes
- Neisseria species
- M. cat
imaging for pulmonary vascular bed
pulmonary angiography
Chloride INCREASE
- nephritis
- eclampsia
- anemia
- cardiac disease
- dehydration from diarrhea (diarrhea induced metabolic acidosis causes body to blow off CO2 so the Cl- increases)
who can and cannot get LAIV4
CAN: 1-49 y/o
CANNOT: pregnancy, <18y/o w/ ASA use, healthcare personnel, close contact w/ high risk groups, ASTHMA, immunocompromised, use of antiviral in last 48 hrs
Alkaline Phosphatase (ALP) USE
*detect biliary obstructing hepatic lesions
*supplement info from other liver function studies (like aminotransferase)
Explanation: with biliary obstruction, ALP and conjugated bili increase while in viral hepatitis, ALP is WNL or mildly elevated but the aminotransferases, ALT and AST as well as conjugated bili, increase)
*assess response to vit D tx of rickets
*detect osteoblastic skeletal disease such as Paget’s (note ALP not usually up after bone fractures)
*alcohol ingestion will cause increase if pt already has cirrhosis or hepatitis (otherwise usually not)
Acid phosphatase is a test generally used to detect prostate cancer; the more widespread, the more likely an increase
CROUP/EPIGLOTTITIS/RSV:
fever
C: low grade
E: high grade
RSV: low grade
wheezes
narrowed airway — obstructive lung disease
Bacterial Tracheitis diagnosis
viral croup progresses and unresponsive to treatment
- elevated WBC w/ left shift
- paternal neck shows normal epiglottis w/ sever subglottic and tracheal narrowing
- irregularity of contour of proximal tracheal mucosa
BRONCHOSCOPY
viral causes of CAP in kids
most common cause in kids (vs. bacterial)
RSV
parainfluenza
influenza A/B
human metapneumonvirus
Sodium
- The major extracellular cation.
- Affects body water distribution, maintains osmotic pressure of extracellular fluid, helps promote neuromuscular function and helps maintain acid-base balance.
Aminotransferases: alanine or ALT (aka SGPT), aspartate or AST (aka SGOT) USE
- diagnosing and monitoring liver disease
* screening tests in patients on meds that can produce liver damage
Pleural Transudate
usually r/t heart failure
suggests absence of local pleural disease
glucose = serum glucose
pH 7.4-7.55
<10,000 WBC predominance of mononuclear cells
Albumin INCREASE
Most common cause is dehydration
Neutrophils
50-70% of total WBC.
· First line of defense against bacteria and inflammation
key factor to distinguish adenovirus vs flu
adenovirus - year round
flu has a season
EPIGLOTTITIS causative agents
H. influenzae
N. meningitis
streptococcus species
FEV1/FVC ratio in obstructive dysfunction
both decreased (reduced airflow rates seen in asthma, COPD, bronchiectasis, bronchiolitis, upper airway obstruction, CF)
imaging for foreign body
forced expiratory radiographs
Serum Creatinine
Male 0.8-1.2, Female 0.6-0.9
The end product of creatine metabolism. It is a nonprotein nitrogen compound prevalent in muscles in the form of phosphocreatine. The more muscle mass the more creatinine in the serum. A better measure of renal damage than BUN because renal impairment is about the only cause of creatinine elevation (therefore the test could be said to be specific for renal impairment). A rising creatinine indicates a falling glomerular filtration rate (GFR).
The specificity of this test is good (not much besides poor renal function increases the level).
The sensitivity of this test is not good. Early stage moderately severe damage may cause only a 1mg/dl rise per day. People with poor muscle mass (sometimes elderly) may have kidney damage without elevation.
Epiglottitis treatment
emergent ETT by airway expert for 1-2 days (rapid resolution)
ceftriaxone (cephalosporin): 2-3 days IV then 10 days po
Pleural Effusion diagnostic
CXR
thoracentesis
Bronchiolitis causes
viral #1 is RSV
- parainfluenza
- influenza
- adenovirus
- human metapneumovirus
- severe bacterial less common
Sodium USE
- evaluate heart failure
- liver disease
- chronic renal failure
- evaluate edematous states
- evaluate F and E and acid-base balance
- evaluate neuromuscular functions
- use of lithium (can lead to nephrogenic diabetes insipidus)
Chloride DECREASE
- fever
- diabetes
- pneumonia
- GI loss (vomiting or gastric suction)
- CHF (dilutional hypochloremia)
- thiazide diuretic
Basophils
· 1-3% of total WBC.
· Similar to neutrophils. Play a role in preventing blood clotting, are elevated in allergic reactions and in hypothyroidism
pleuritis key symptoms
localized pain, sharp, fleeting, worse w/ cough, sneeze, deep breath, or movement
diaphragmatic involvement = referred ipsilateral shoulder pain
(young healthy adults w/ viral respiratory infection or pneumonia, simple rib fracture)
Bilirubin (Direct and Indirect) INCREASE
unconjugated or indirect - this indicates hepatic damage or a severe overload as would occur in hemolytic disease of newborn or even in a sickle cell crisis. If hemolysis continues, both direct and indirect may rise.
direct or conjugated - direct bili overflows into the bloodstream because it is somehow blocked from its normal pathway from the liver into the biliary tree. If obstruction continues, both direct and indirect may rise due to hepatic damage.
partial upper airway foreign body aspiration key findings
drooling, strider, ability to vocalize
complete upper airway foreign body aspiration key findings
abrupt onset of:
inability to vocalize or cough
cyanosis w/ marked distress
(w/ hx of running w/ food in mouth or playing w/ small object)
most common bacterial cause of CAP in kids
S. pneumoniae
others include: chlamydia (newborns - 12 weeks) C. pneumoniae C. pittaci B. pertussis M. pneumoniae (kids >5yr, aka atypical) Legionella
who gets RIV4 vaccine
egg allergy who required epi
obstructive sleep apnea can only be diagnosed by ?
polysomnogram (PSG)
Other Thyroid Tests
Thyroxine (T4) is the principal hormone secreted by the thyroid gland in response to TSH. The half life is about 6 days.
Triiodothyronine (T3) is more potent than T4. Most of it is probably derived from T4 in a process that takes place in the liver and kidneys. It is present only in minute quantities and has a half life of 1 day.
Tests:
- radioactive-iodine (RAI)
- T3 uptake
- total T4
- free T4
- In thyrotoxicosis, all the above are elevated in thyrotoxicosis (TSH is down)
- In myxedema, all are decreased (TSH is up)
- In subacute thyroiditis, initially RAI is low and T4 high, then low T4 and high TSH
in a patient w/ restrictive lung dysfunction what results would be reflected after obtaining a spirometry test?
reduced FVC
Prostate-Specific Antigen (PSA) DECREASE
insignificant
Legionnaires treatment
macrolides or fluoroquinolone for 10-14 days (no erythromycin)
imaging for bronchial anatomical abnormalities
MRI
Serum Creatinine DECREASE
not significant
Pertussis: Paroxysmal
stage 2
1-6 weeks, up to 10 weeks
paroxysms of numerous rapid coughs thick mucus long inspiratory effort (whoop) cyanosis vomiting and exhaustion attacks more frequent at night attacks worsen for weeks 1-2 then same for 2-3 weeks then gradually lessen
class of drug for acute relief of symptoms r/t bronchospasm
SABA
Amylase DECREASE
usually insignificant
- chronic pancreatitis
- pancreatic cancer
- liver disease
- toxemia of pregnancy
CROUP treatment
based on symptoms
Mild:
- 1 dose of IM dexamethasone
- supportive - oral hydration
- DC if improves in 3 hours
Severe:
- humidified O2
- neb racemic epi
- 1 dose of IM dexamethasone
- admit if recurrent epi tx needed
RSV key symptoms
<2 y/o following URI
diffuse wheezing, variable fever, cough, tachypnea, feeding difficulty
crackles, prolonged expiration, retractions
epidemics late fall- early spring (Jan-Feb peak)
hyperinflation on CXR
lasts 3-7 days (fever lasts 2-4 days)
PFT indications
assess type/extent of lung dysfunction dx cause of dyspnea and cough detect early evidence of lung dysfunction followup response to therapy preop assessment disability evaluation
early coarse crackles
pneumonia or HF
Total protein
About 50% of this is albumin.
Anaerobic Pneumonia treatment
IV clindamycin q8h (po with improvement) OR augmenting q12h
alternative: amoxicillin OR PCN G + metronidazole
Pertussis lab tests
PCR (rapid antigen) - nasal swab best in first 3 weeks of cough
culture - best done first 2 weeks of cough, may takes up to 7 days for result
serologic assays - only through state health departments if outbreaks
Pertussis stages
- Catarrhal (7-10 days, up to 3 weeks)
- Paroxysmal (1-6 weeks, up to 10 weeks)
- Convalescent (7-10 days, up to 3 weeks)
gold standard for foreign body aspiration
Bronchoscopy
Serum Calcium
- 9-10.1 adult
- 6 child (rapid growth)
Controlled by the parathyroid hormone (PTH), calcitonin (a hormone produced by the thyroid), and adrenal steroids.
Since about half of total Ca+ is bound to albumin, decreased serum albumin leads to decreased total Ca+.
Ca helps regulate and promote neuromuscular activity, skeletal development and blood coagulation. Absorbed from GI tract if sufficient vit D present. Excreted in urine and feces.
Eosinophils
· 0-3% of WBC.
· Elevated in Allergies, parasite infections, and drug reactions
Pertussis treatment
work best in early disease before onset of paroxysmal cough - begin before test results
azithromycin (<1m/o)
clarithromcin (>1m/o)
erythromycin (>1 m/o but not preferred)
Bactrim alternative to macrolides >2m/o
imaging for swallowing dysfunction
fluoroscopic studies ( upper Gi series, etc)
CROUP/EPIGLOTTITIS/RSV:
occurrence
C: common
E: rare
RSV: common
Pleural Effusion key symptoms
chest pain + pleuritis
dyspnea, dullness to percussion, absent/decreased breath sounds
Bronchiolitis testing/treatment
AAP does NOT recommend: RSV swab CXR Albuterol or steroids antibiotics
if severely ill use aerosol ribavirin antiviral
Recommended:
supportive measure
usually can be treated outpatient
Bronchiolitis risk factors
< 12 weeks
hx of prematurity (<35 weeks)
underlying cardiopulmonary disease
immunodeficiency
Total protein INCREASE
*multiple myeloma (to further evaluate for this, do immunologic typing)
Bilirubin
adult:1.1 or less neonate: 1-10
As RBCs degrade, bili attaches to blood albumin (at this point, it is called indirect or unconjugated or prehepatic bili) and is carried to the liver where it is combined or conjugated with glucuronide to become conjugated or direct or posthepatic bili. The resulting compound is excreted in bile, some leaving the body thru the intestines (gives stool its characteristic color - thus stools are pale when bile duct is obstructed) and a little thru the urine. Some is also reabsorbed in the blood.
Hyperbilirubinemia can be caused by excess indirect (unconjugated or prehepatic) bili or by excess direct (conjugated or posthepatic) bili or the cause can be mixed.
When total bili is above 3, jaundice is usually visible.
what must be done with new pleural effusion and no clinically apparent cause?
diagnostic thoracentesis
what is the most common bacterial organism responsible for secondary bacterial infection in a patient with influenza?
pneumococcal pneumonia (staph pneumonia = most serious)
Prostate-Specific Antigen (PSA)
PSA is produced by normal, hyperplastic, and cancerous prostate tissue.
Immature granulocytes (Bands):
· 0-5% of total WBC.
· Immature or early stage neutrophils. These are elevated when the body is first launching a response to a bacterial or viral infection and are a sign of acute infection
imaging for congenital lung lesions, pleural disease, mediastinum, pulmonary masses/nodules
chest CT
RSV disgnosis
rapid RSV antigen
pulmonary secretions by fluorescent antibody staining
ELISA
diffuse hyperinflation and peribronchiolar thickening on CXR
WBC differential reference ranges
Total leukocytes (WBCs): 4.00-11.0 x 109/L
Neutrophils: 2.5–7.5 x 109/L
Lymphocytes: 1.5–3.5 x 109/L
Monocytes: 0.2–0.8 x 109/L
Eosinophils: 0.04-0.4 x 109/L
Basophils: 0.01-0.1 x 109/L
most common adenovirus disease?
pharyngitis
what inherited disorder presents as a risk factor for a PE?
factor V leiden
Children and WBC differential
2 wks to 12 yrs - have inverse neutro:lymph relationship
Neutros: 29-47%
Lymph: 38-63%
CROUP/EPIGLOTTITIS/RSV:
sounds
C: barking cough
E: inspiratory stridor
RSV: staccato cough, rales, expiratory wheezing
key finding in legionnaires disease vs other pneumonia
hyponatremia
Potassium USE
- monitor renal function
- diuretic (thiazide or loop) use to monitor for depletion
- arrhythmias
- c/o weakness, muscle cramps, parathesias
- detect origin of arrhythmias
abnormalities on physical exam: shift in trachea position
pneumothorax or significant atelectasis
RSV treatment
NO VACCINE
NO: antibiotics, decongestants, expectorants, albuterol, systemic corticosteroids
Give ribavirin aerosolization in infants w/ significant anatomic, immunologic, cardiac defects
a patient presents to clinic w/ blunted ventilatory drive and compensates by voluntarily hyperventilating to maintain PO2/PCO2 levels. this condition co-exists with OSA. What is your diagnosis?
Obesity-hypoventilation syndrome
complications of pneumococcal pneumonia
pleural effusion
empyema
pericarditis
Parainfluenza
most common cause of croup in kids
type 1 & 2 cause croup <5 y/o in fall
type 3 <3y/o bronchiolitis and pneumonia
type 4 year round alternates years w type 3
Prostate-Specific Antigen (PSA) USE
detect prostate diseases
-benign prostatic hyperplasia (BPH); level remains <10
- cancer
- stage patient with prostate cancer (PSA increases with increased staging)
- confirm response to cancer therapy
Screening of asymptomatic men: increases detection of cancer but it has not been proven to save lives (treatment controversial)
The American Cancer Society and the American Urological Association currently recommend that decisions to use PSA screening should be made on an individual basis between the patient and provider after discussing risks and benefits of screening.
most common individuals that contract adenovirus
infants, young kids, military recruits
if bacteria causes pneumonia in a kid, what is the most likely organism
s. pneumoniae
Blood Urea Nitrogen DECREASE
- nephrosis (possible)
- liver failure or hepatitis
- late pregnancy
- overhydration
Adult CAP risk factors
older
hx ETOH, tobacco abuse
asthma/COPD
immunocompromised
abnormalities on physical exam: tactile fremitus
restrictive lung disease (precursor to lung failure)
Bilirubin USE
- evaluate liver function
- aid dx of biliary obstruction
- aid dx of hemolytic anemia
- aid differential dx of jaundice
- monitor progress of jaundice
- determine whether phototherapy or transfusion needed for neonate (unconjugated bili can accumulate in brain causing brain damage - exchange needed at total bili of 18)
- aid dx of hemolytic anemia
abnormalities on physical exam: wheezing or prolonged expiratory time
intrathoracic airway obstruction
WBC differential: Shift to the left
increase in bands. Means acute infection. Up in some leukemia and pernicious anemia
Blood Urea Nitrogen USE
- evaluate renal function
* aid assessment of hydration
CROUP/EPIGLOTTITIS/RSV:
infection
C: viral
E: HiB (bacterial)
RSV: viral
Thyroid-Stimulating Hormone (TSH) or Thyrotropin: USE
*diagnose hypothyroidism
*newer test can also dx hyperthyroidism
*monitor drug therapy in patients taking levothyroxine (Synthroid)
Patients are usually considered euthyroid when the TSH falls to normal
what age group is most at risk for RSV?
<5y/o and >65y/o
fine late inspiratory crackles
pulmonary fibrosis
imaging for vascular malformations and PEs
ventilation-perfusion scans
imaging for croup vs epiglottis
lateral neck (Epiglottitis has thumbprint sign)
most important cause of lower respiratory tract illness in young children
RSV
rhonchi
excessive secretions and abnormal airway collapse, clear after cough
Serum Calcium INCREASE
- hyperparathyroidism *overuse of antacids
- parathyroid tumor *excess ingestion
- Paget’s disease *adrenal insufficiency
- metastatic cancer
- prolonged immobility
- renal disease (decreased excretion)
- diuretic (HCTZ may be used in pts with hypercalciuria to prevent Ca+ being lost in urine)
Chloride
95-105
- The major extracellular anion (negative ion). - Present in blood and stomach.
- Blood level controlled by renal excretion. - Chloride is absorbed from the intestines and excreted by the kidneys.
- Serum concentrations are regulated by aldosterone secondarily to regulation of sodium.
Primary cause of abnormal chloride is response to shift in CO2.
- if CO2 decreases, the Cl- will increase
- if CO2 increased, the Cl- will decrease
lower airway foreign body aspiration key findings
sudden onset of coughing, wheezing, respiratory distress, asymmetrical breath sounds (decreased), localized wheezing, asymmetrical CXR (esp. w/ forced expiratory view) [CXR may be normal]
must suspect in kids w/ chronic cough, persistent wheezing, or recurrent pneumonia in 1 location
Serum Calcium DECREASE
- hypoparathyroidism
- malabsorption
- Cushing’s syndrome
Total protein USE
*suspected hepatic disease (as when jaundice seen)
*suspected protein deficiency
Serum protein electrophoresis reveals more info about individual proteins
Amylase USE
*diagnose acute pancreatitis
After onset of acute pancreatitis, serum amylase beings to rise in 2 hrs, peak at 12 to 48 hrs, and return to normal in 3-4 days.
*diff dx of abd pain
*evaluate pancreatic injury caused by abd trauma or surgery
*following perforation of peptic ulcer to r/o pancreatic subsequent pancreatic damage (gastric juices cause chemical pancreatitis)
Serum lipase is another test to confirm pancreatitis (high levels last up to 14 days). Lipase also increases with high intestinal obstruction or renal disease
CROUP key symptoms
5 m/o - 5 yr
- recent URI
- fall, early winter
- barking seal cough
- edema in subglottic space
- usually improves in a few days
late signs: restrictions, air hunger, cyanosis, stridor at rest
usually don’t see fever or drooling
treatment for pneumococcal pneumonia
amoxicillin (monitor for resistance)
PFT contraindications
acute severe asthma respiratory distress angina aggravated by testing pneumothorax ongoing hemoptysis active TB
Serum Creatinine USE
screening for patients at risk of renal injury (HTN or diabetes)
Total protein DECREASE
- pregnancy
- cytotoxic drugs
- dietary deficiency
Pleural Exudate
usually r/t bacterial pneumonia/cancer
ratio of pleural fluid protein to serum protein > 0.5
Thyroid-Stimulating Hormone (TSH) or Thyrotropin: INCREASE
- hypothyroidism
- thyroiditis
- inadequate hormone therapy (levothyroxine or Synthroid)
Most of the time an elevated TSH indicates primary hypothyroidism (due to thyroid gland failure). Patients with secondary (pituitary failure) or tertiary (hypothalamic) hypothyroidism have low or normal TSH.
There is no correlation between extremity of TSH elevation and severity of hypothyroidism or symptomatology
Thyroid-Stimulating Hormone (TSH) or Thyrotropin:
TSH is secreted by the anterior pituitary and is responsible for increasing triiodothyronine (T3) and thyroxine (T4) secretion by the thyroid gland.
what 2 symptoms could a patient >4y/o present w/ during flu season and you suspect flu?
fever > 38.2 and cough
Lymphocytes
· 25-35% of total WBC.
· Increase in chronic or viral infection or in leukemia
Serum Calcium USE
- aid dx of neuromuscular, skeletal, and endocrine disorders
- aid dx of arrhythmias
- blood clotting problems
- acid-base imbalance
- assess muscle cramping, tetany
Albumin DECREASE
- malnutrition
- liver disorder
- chronic diseases
- burns
- nephrotic syndrome or chronic renal failure
- Hodgkin’s disease
Pertussis: Convalescent
stage 3
7-10 days, up to 3 weeks
paroxysms gradually lessen
gradual recovery
what are some causes of digital clubbing that you may encounter in the outpatient setting
lung absces empyema bronchiectasis CF cirrhosis Graves disease
imaging for ILD or bronchiectasis
high resolution CT
Albumin
- The blood’s main protein
- it is produced by the liver
- It is largely responsible for oncotic pressure (maintains blood volume and pressure by preventing capillaries from leaking serum)
- Unclear how albumin is lost from body - small amounts lost thru urine and GI tract.
Aminotransferases: alanine or ALT (aka SGPT), aspartate or AST (aka SGOT) DECREASE
*advanced cirrhosis or hepatitis (few hepatocytes remain to leak enzymes)
EPIGLOTTITIS key symptoms
- usually unvaccinated (HiB)
- sniffing dog position/tripod sign (neck hyperextended w/ chin stretched forward)
- high fever
- dysphagia
- drooling
- muffled voice
- inspiratory retractions
- cyanosis
- soft stridor
Sodium DECREASE
(hyponatremia)
- heart failure
- cirrhosis
- nephrotic syndrome
- diarrhea or vomiting
- chronic renal insufficiency
- diuretic therapy
In the first three, body water is up but circulating volume down, so ADH is stimulated and water retained and Na+ is diluted
XR for pleural fluid
lateral decubitus
what must be used to deliver inhaled medications to kids <4 m/o
pMDI or similar spacer
CAP CBC
bacterial vs viral findings
bacterial: WBC elevated w/ left shift, low WBC can mean overwhelming infection
viral: WBC normal or slightly elevated
CROUP/EPIGLOTTITIS/RSV:
voice
C: hoarseness
E: muffled
RSV: n/a
Aminotransferases: alanine or ALT (aka SGPT), aspartate or AST (aka SGOT) INCREASE
- ALT and AST with liver injury
* AST with skeletal muscle and cardiac injury
pneumococcal pneumonia is more common cause of CAP or HAP?
CAP
WBC differential: shift to the right
increase in mature neutrophils. Seen in diseases of liver
Adult CAP diagnosis
required = pulmonary opacity on CXR
POC tests for causative organisms:
sputum gram stain
urinary antigen (s.pneumonia, legionella)
rapid flu antigen
abnormalities on physical exam: unilateral crackles in the older patient
valuable finding in pneumonia
abnormalities on physical exam: tachypnea w/ equal insp vs exp time
decreased lung compliance
Adult CAP treatment
healthy, no recent Abx: macrolides (clarithromycin, azithromycin) x5 days OR doxycycline x5 days NO fluroquinolones
cormordibities, Abx <90 days, >65 y/o, immunosuppressed, daycare kid:
respiratory fluoroquinolone
OR
macrolide + b-lactam (Amoxil/Augmentin preferred to cefpodoxie/cefuroxime)
aspiration of a FB can mimic the symptoms of what?
croup
