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Number one cause of mortality from infectious disease
pneumonia
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M/C cause of acute bronchitis
viral (influenza, rhinovirus, adenovirus, coronavirus, parainfluenza, RSV)
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Bacterial cause of acute bronchitis
mycoplasma, chlamydia
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Dx of bronchitis
- constitutional sx
- wheezing, rhonchi on lung exam
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Bronchitis tx
- supportive
- bronchodilators
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CXR in acute bronchiolitis
hyperinflation, peribronchial cuffing
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Tx of acute bronchiolitis
- supportive
- oxygen
- bronchodilators
- fluids
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Bronchiolitis prophylaxis
ribavirin
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direct laryngoscopy reveals "cherry red" epiglottis
acute epiglottitis
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Tx of acute epiglottitis adults
- 2-3G ceph
- B-lactam/B-lactamase inhibitor
- PCN allergy: Bactrim, clinda
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Tx of acute epiglottitis children
- stabilize airway
- abx
- dexamethasone
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When is eradication of HIB carrier warranted?
If child is < 4yo and not vaccinated, give Rifampin to all family members x4days to eradicate carriage of HiB
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laryngotracheobronchitis
croup
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m/c cause of croup
parainfluenza
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seal like barking cough
croup
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differentiate croup from epiglottitis
presence of cough, lack of drooling
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tx of croup
- mild: supportive, hydrate, do not agitate
- moderate WITH stridor: nebulized racemin epinephrine, oxygen if desaturating. Dexamethasone IM x 1
- Admit to hospital: requires multiple racemic epi treatments, desaturating, in respiratory distress
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cause of influenza
orthomixovirus
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Type A influenza affects
humans, swine, horses
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Type B influenza affects
humans
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Type C influenza affects
humans
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Dx of influenza
- throat saw or nasal wash for rapid ELISA
- HOWEVEr poor Sn, cannot distinguish b/w A and B
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Tx of influenza
- supportive care
- antivirals if: active malignancy, nursing home resident, those requiring hospitalization, at high risk
- Relenza > 7 yo
- Tamiflu > 1 yo
- Both above if sx present < 48 hours
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Reye syndrome
fatty liver plus encephalopathy in children with Type B influenza
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Influenza vaccine CI
hypersensitivity to eggs, current illness, hx of GBS, hx of allergy to vaccines
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Mortality from influenze m/c due to what
secondary bacterial pneumonia
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Gram negative pleomorphic bacillus
pertussis
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pertussis reservoir
humans only
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catarrhal stage of pertussis
insidious onset of sneezing, coryza, loss of appetite, hacking cough most prominent at night
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stage of pertussis that is contagious
catarrhal
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paroxysmal stage of pertussis
spasms of rapid coughing fits followed by high pitched inspiration.
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Convalescent stage of pertussis
decrease in frequency and severity of paroxysms, stage is usually 4 weeks after onset of cough
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Dx of pertussis
nasopharyngeal culture
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Tx of pertussis
- erythromycin
- alternatives: clarithromycin, Bactrim, azithromycin
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m/c cause of viral pneumonia
influenza a and b
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cause of viral pneumonia in ilitary, colleges
adenovirus
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cxr in viral pneumonia
interstitial infiltrates
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tx of viral pneumonia
supportive
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m/c causes of HAP
pseudomonas, klebsiella, e coli, acinetobacter, staph
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Sx of legionella pneumonia
N/V/D
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sx of mycoplasma pneumonia
bullous myringitis, rash, hemolytic anemia
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sx of chalmydia pneumonia
sore throat, hoarseness
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labs for mycoplasma pneumonia
IgG, IgM on top of nl
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Tx of HAP
- cefepime
- zosyn
- cabrapenem
- vanco/zyvox if MRSA suspected
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pneumococcal vaccines
- PCV < 4 yo
- PPV > 65, > 2 yo with chronic illness that predisposes them to CAP
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m/c mycosis occuring in the US
Histoplasmosis
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found predominately in the Ohio and Mississippi River valley
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tx of histoplasmosis
- amphotericin for life threatening disease
- itraconazole for all other cases
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where is aspergillus found
in soil and moist environments (compost, hay, grain, gardens)
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tx of aspergillus
amphotericin
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found in desert soil of southwest UA
coccidiomycoses
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San Joaquin Valley Fever
coccidiomycoses
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CXR findings in coccidiomycoses
single infiltrate or multilobar involvement
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tx of coccidiomycoses
- immunocompetent: no tx
- severe infection: azole, amphotericin
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Primary TB
Occurs after initial infection, may be asx or presnt with fever, pleuritic CP
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Latent TB
- bacterium is contained, person is asx and not infectious
- Tb reactivated in setting of immune compromise
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hallmark of TB
bx demonstrating caseating granulomas
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TB dx
+AFB smear (3 consecutive mornings)
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ghon complex
calcified primary focus in TB
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ranke complex:
calcified primary focus and calcified hilar LN
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miliary TB
millet seed appearance diffusely throughout lungs (hematogenous spread)
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TB Tx
- RIPE
- Rifampin, Isoniazid, Pyrazinamide, Ethambutol
- Tx regular person 6-9 months
- Tx HIV postive 1 year
- Tx previously neg pts with positive PPD 6-9 months
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Side effects of INH
hepatitis, peripheral neuropathy
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Side effects of rifampin
hepatitis, orange urine, flu-like sx
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Side effects of ethambutol
optic neuritis
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SCC CXR findings
bronchial in origin, centrally located, sessile mass, more likely to present with hemoptysis
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Adenocarcinoma CXR findings
arises from mucous glands, usually in periphery of lung
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m/c type of bronchogenic carcinoma
adenocarcinoma
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large cell carcinoma CXR findings
central or peripheral masses
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small cell carcinoma
tumor of bronchial origin, begins centrally, may cause bronchus obstruction
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Paraneoplastic syndrome
- Endocrine: cushings, SIADH, hypercalcemia, gynecomastia
- Neuromuscular: peripheral neuropathy, Eaton-Lambert
- Hematologic: anemia
- Cutaneous: acanthosis nigricans
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overall 5 year survival rate for lung ca:
15%
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Pancoast's tumor
- tumor of lung apex, causes Horner's and shoulder pain
- associated with bronchogenic carcinoma
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carcinoid tumors
- well differentiated neuroendocrine tumores that are considered to be low-grade malignant neoplasms
- grow slowly and rarely met
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bronchial gland tumors
carcinoid tumors
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bronchoscopy reveals pink or purple lesion that is well vascularized
carcinoid tumor
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tx of carcinoid tumor
surgical excision, lesions are RESISTANT to XRT and chemo
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Where can lung ca met to?
- adrenal glands
- liver
- brain
- bone
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coin lesion
solitary pulm nodule < 3 cm
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etiologies of coin lesions
- old or active TB
- fungal infection
- FB reaction
- malignancy
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Benign coin lesions vs malignant lesions
- benign: smooth, well defined edge, dense calcifications
- malignant: rapidly progressive, rarely calcified, usually >2 cm in diameter, indistinct margins, spiculated peripheral halo
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Dx of asthma
- < FEV/FVC ratio < 70%
- Improvement in FEV1 and FVC after administration of B2 agonist
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Tx of mild intermittent asthma
no daily meds, just SABA
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tx of mild persistant asthma
daily low dose inhaled corticosteroid or cromolyn
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tx of moderate persistant asthma
daily inhaled medium dose steroid or low-dose inhaled steroid + LABA (Advair)
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Tx of severe persistent asthma
daily inhaled high dose steroid and long acting B2 AND PO steroids
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bronchectasis
abnl, permanent dilation of bronchi and destruction of bronchial walls
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clinical manifestations of bronchiectasis
clubbing, lung crackles
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CXR findings in bronchiectasis
tram-track lung markings, honeycombing, atelectasis
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Tx of bronchiectasis
- Bronchodilators, chest PT
- ABX for acute sx: bactrim, tetracycline, augmentin
- Suppressive therapy
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CF cause
abnl in membrane chloride channel
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median survival with CF
31
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CF puts pts at risk for what other dz
GI tract malignancies, malnutrtion and arthropathies, and pancreatic insufficiency
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Chronic bronchitis def
productive cough >3 months for two consecutive years
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emphysema def
permanent enlargement of air spaces distal to terminal bronchiole, no obvious fibrosis
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PFTs in COPD
FEV1/FVC < 70% of predicted, > RV, > TLC, > FRC
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CXR in COPD
hyperinflated with flat diaphragms, parenchymal blebs
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ABG in COPD
hypoxemia, chronic respiratory acidosis in advanced disease
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TX of COPD
- First line: SABAs (anticholinergics over BA, ie atrovent over albuterol)
- Second line: LABA + inhaled steroid +/- long acting anticholinergic (Spiriva)
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m/c cause of transudative pleural effusion
CHF
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exudative pleural effusion
abnl capillary permeability
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transudative pleural effusion
d/t increased hydrostatic or decreased oncotic pressure
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causes of exudative pleural effusions
- parapneumonic effusion
- Ca
- fungal infection
- CT dz
- TB
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Causes of transudative pleural effusion
CHF, cirrhosis, nephrotic syndrome
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Lung PE findings in pleural effusion
- dullness to percussion
- decreased to absent lung sounds
- no air bronchograms
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CXR findings in pleural effusion
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blunting of costophrenic angle
mediastinum shifted away from effusion
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Light's criteria
- An effusion is likely exudative if at least one of the following exist:
- Pleural protein to serum protein ratio > 0.5
- Pleural LDH to serum LDH ratio > 0.6
- Pleural LDH to serum LDH ratio > 0.6
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tx of transudative pleural effusion
therapy directed at underlying condition, chest tube rarely indicated
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tx of malignant pleural effusions
drainage through repeat thoracentesis, chest tube, pleurodesis
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Tx of parapneumonic pleural effusions
- simple: respond to abx
- complicated: CT or abx
- Empyema: CT
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Tx of hemothorax
- small volume: close observation
- everything else: CT
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tension ptx
secondary to sucking chest wound or pulmonary laceration that allows air to enter with inspiration, but dow not allow it to leave
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lung PE findings in PTX
- diminished breath sounds
- asymmetrical chest wall movement
- hyperresonance
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CXR findings of tension ptx
large am of air and contralateral mediastinal shift
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m/c cause of PE
DVTs in lower extremities
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Virchow's triad
endothelial injury, hypercoaguable state, hemostasis
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Dx of PE
- D-dimer (very Sn, no Sp, need to have low clinical suspicion)
- EKG (S1Q3T3 <20%)
- ABG resp alkalosis, hypoxic with elevated A-a gradient
- CXR needed to exclude other pathology and permanent V/Q read
- V/QL best if high probability, if low probability, do CTA
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EKG findings in PE
S1Q3T3
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When is CTA CI in PE?
dye allergies or renal failure
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Gold standard for PE dx
pulm angiography
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Gold standard for dx of DVT
venography
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Tx of PE
- full dose anticoag with Hep or LMWH
- tx 3-6 months for first episode; 1 year to life for recurrent
- TPA if hemodynamic instability
- IVC filter if anticoag not possible
- thombectomy
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Pulm HTN
present when mean pulm arterial pressure is > 25 mmHg
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Causes of secondary pulm HTN
- Systemic sclerosis
- COPD
- cirrhosis
- left heart failure
- thromboembolic disease
- HIV infection
- sickle cell
- OSA/OHS
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Clinical manifestations of pulm HTN
- edema
- ascites
- cyanosis
- splitting of S2
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Sx of pulm HTN
- dyspnea
- angina like retrosternal CP
- weakness
- fatigue
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CXR findings in pulm HTN
enlarged pulm arteries
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EKG findings in pulm HTN
RVH, RV strain
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Dx of pulm HTN
right heart cath
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Tx of pulm HTN
- chronic anticoag, CCB, prostacyclin, heart-lung transplant
- secondary pulm tx: tx underlying disorder
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Cor pulmonale
RV systolic and diastolic failure resulting from lung disease or pulm vascular disease
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Causes of cor pulmonale
- COPD
- idiopathic pulmonary fibrosis
- OSA
- OHS
- pneumoconiosis
- chronic thromboembolic pulm HTN
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Dx of cor pulmonale
- polycythemia
- hypoxemia on ABG
- PFTs confirm underlying lund disease
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EKG findings in cor pulmonale
RAD, frank RVH
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Echo findings in cor pulmonale
dilated RA, RV; RV dysfunction
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Oxygen
- salt and fluid restriction
- diuretics
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prognosis of cor pulmonale
life expectancy 2-5 years after signs of HF develop
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Labs in idiopathic pulm fibrosis
PFTs show restrictive pattern
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CT findings in idiopathic pulmonary fibrosis
peripheral reticular opacities at the bases, honeycombing
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Tx of idiopathic pulm fibrosis:
contraversial bc nothing has shown to improve survival or quality of life
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Pneumoconiosis
chornic fibrotic lung dz caused by the inhalation of coal dust or various inert, inorganic, silicate dusts
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four types of pneumoconiosis
- coal worker's
- silicosis
- asbestosis
- berryliosis
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occupations at risk for asbestosis
insulation, demolition, shipyard
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CXR/CT findings of asbestosis
linear streaking at base, honeycombing
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complications of asbestosis
increased risk of mesothelioma, lung Ca
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CXR/CT findings in coal worker's lung
opacities prominent in the upper lung
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Caplan syndrome
RA nodules in lung periphery, associated with coal worker's lung
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complications of coal worker's lung
progressive fibrosis, caplan syndrome
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occupations at risk for silicosis
mining, sand blasting, quarry work, stone work
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CXR/CT findings of silicosis
Calcification of periphery hilar LN "shells"
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complications of silicosis
increased risk of TB, fibrosis
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Calcification of periphery hilar LN "shells"
silicosis
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occupations at risk for beylliosis
aerospace, nuclear power, ceramics, foundries
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complications of berylliosis
requires chronic steroids
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Pneumoconiosis labs
restrictive dysfunction
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pneumoconiosis tx
- O2 as needed
- quit smoking
- bronchodilators
- abx when infected
- monitor for complications
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sarcoidosis
multiorgan disease of idiopathic cause
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sarcoidosis characteristics
affects lungs, eyes, liver, skin, LN, heart, nervous system
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Sx and clinical manifestations of sarcoidosis
- cough
- dyspnea
- chest discomfort
- malaise
- fever
- erythema nodosum
- arthritis
- parotid gland, LN enlargement
- HSM
- peripheral neuropathy
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Labs in sarcoidosis
- leukopenia
- eosinophilia
- > SED
- hypercalcemia, hypercalciuria
- ACE
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Imaging in sarcoidosis
- CXR shows symmetric B/L hilar adenopathy
- Bronch shows > lymphocytes
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Tx of sarcoid
- most cases respond to steroids
- immunosuppressives
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complications of sarcoid
- progressive fibrosis, bronchiectasis
- respiratory failure
- death
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4 characteristics of ARDS
- acute onset
- PaO2/FiO2 ratio < 200
- CXR with B/L infiltrates
- No LVD
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Causes of ARDS
- Severe multiple trauma
- sepsis
- aspiration of gastric contents
- drugs
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Dx of ARDS
- CXR with B/L infiltrates
- air bronchograms ni 80%
- Heart nl
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Tx of ARDS
- tx underlying cause
- lung protective vent management
- ? steroids
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M/C cause of respiratory distress in preterm infant
Hyaline membrane disease
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cause of hyaline membrane disease
deficiency of surfactant
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sx and clinical manifestations of hyaline membrane disease
- respiratory distress
- cyanosis
- expiratory grunting
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Imaging in hyaline membrane disease
- CXR shows air bronchograms
- Diffuse B/L atelectasis causing ground glass appearance
- doming of diaphragm
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doming of diaphragm
hyaline membrane disease
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tx of hyaline membrane dz
- oxygen
- SIMV support
- exogenous surfactants
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best method of dx adenovirus pna
PCR
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tx of klebsiella pna
fluoroquinolone
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gram positive diplococci in chains
strep pneumo
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m/c complaint in person with TB
chronic cough
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Which organism can cause hemorrhagic necrotizing consolidation pneumonia
Klebsiella
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dx of sarcoidosis
bronchoscopy with tissue biopsies
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dx of whooping cough
nasopharyngeal culture
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m/c bug in empyemas
staph
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empyema presentation
- pneumonia that persists despite tx
- fever despite abx
- consolidation on CXR
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atelectasis
pulmonary alveoli collapse
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most common cause of ectopic ACTH syndrome
small cell lung carcinoma
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m/c hematologic findings in pulm HTN
polycythemia
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CXR finding in reactivation of TB
fibrocavitary apical disease
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ABG
respiratory alkalosis, d/t hyperventilation
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m/c heart sound in pulm HTN
S2 split
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What range of time does it take for a PPD test to become positive as an immune response?
2-10 weeks
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dense consolidation with bulging fissures
legionella
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Which lobe is most affected by infection of tuberculosis?
RUL
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air hunger and labored, deep respirations
Kussmaul's respirations
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Kussmaul's causes what type of ABG abnormality?
Metabolic acidosis
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most common cause of pneumothorax in a healthy patient?
ruptured bleb
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Which tumor is of bronchial origin, and is known to grow rapidly and have diffuse metastases at the time of diagnosis?
small cell
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primary cause of morbidity in pts with systemic sclerosis
lung dz
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difference between pneumonia and pleural effusion lung exam
in PNA, consolidation INCREASES tactile fremitus; in pleural effusion, tactile fremitus is decreased
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mean survival of sclc
6-18 weeks
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m/c solitary nodules
infectious granulomas from old or active TB, fungal infection, or foreign body reaction
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dilated, tortuous airways on CT
bronchiectasis
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