Mike's Final Disease process.txt

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  1. What are the clinical signs of atelectasis?
    They may be absent or subtle. RR will increase. Fine Late inspiratory crackles may be heard over affected areas. Diminished breath sounds over blocked areas. Tachy when leading to hypoxemia, hyperthermia w/ pneumonia.
  2. What are the PFTs for atelectasis?
    Most may be N or decreased. FVC decreased. FEV1% N or increased
  3. What are some treatments for atelectasis?
    ISm IPPB, IPV, PEP, CPAP(PAP/EPAP), flutter, and acapella
  4. What are some preventive measures for atelectasis?
    IS and CPT
  5. What are the three types of atelectasis?
    Resorption atelectasis, Absorption atelectasis, and passive atelectasis
  6. What is the typical chest X-ray seen with atelectasis?
    Increased density in areas of atelectasis, Air bronchograms, Elevation of the hemidiaphragm on the affected side, Mediastinal shift toward the affected side
  7. What is whispered pectoriloquy and what causes it?
    upon auscultation, a pt's whisper can be heard loud and clear. Consolidation will cause this.
  8. When there is a wheal of 10mm or greater on a PPD what does that mean?
    positive test
  9. When there is a wheal of 5mm-9mm on a PPD what does that mean?
    considered suspicious
  10. When there is a Wheal of less than 5mm from a PPD what does that mean?
    Negative test
  11. what is the most common test for TB?
    Mantoux tuberculin skin test (PPD)
  12. Bacilli escape from the tubercle and travel to other sites by means of bloodstream and lymphatic system
    Dissemination of TB
  13. TB that (travels throughout body). Extrapulmonary TB or miliary TB
    Disseminated TB
  14. PT w/ postprimary TB progressively experiences more severe symptoms.
    Violent coughing, greenish/bloody sputum, fatigue, weight loss, low-grade fever, etc
  15. If Postprimary TB is uncotrolled it can lead to what?
    cavitation of the tubercle
  16. also called Reactivation TB, Reinfection TB, Secondary TB. Describes reactivation months or years after initial infection has been controlled. Can occur at any time
    Postprimary TB
  17. This classification of TB is also called infection stage.Inhaled bacilli implant in the alveoli and multiply. Initial response is inflammation similar to pneumonia. Macrophages engulf but do not kill bacilli. Tissue surrounding the infected area develops a cell wall called a tubercle or granuloma. These encapsulate the TB bacilli. X-Ray may reveal sharp areas of opacity - these are referred to as Ghon Nodules or Ghon Complex. This phase coincides with a positive purified protein derivative (PPD) test. Once bacilli are controlled by immune system or antibiotics they can remain dormant for years - dormant or latent TB
    Primary TB
  18. Tuberculosis is classified as either:
    Primary (or primary infection stage), Postprimary, and Disseminated
  19. The most common cause of pulmonary blood clots for Pulmonary Embolism originate?or break away from??
    Deep vein thrombus DVT
  20. For a V/Q scan, what results would determine positive for a Pulmonary Embolism?
    decreased blood flow and normal ventilation (dead spacing)
  21. What clinical manifestations typically are a result of Cystic Fibrosis?
    Atelectasis, Bronchospasm, Excessive Bronchial Secretions
  22. What clinical manifestations occur for pneumonia?
    Alveolar Consolidation, Increased Alveolar-Capillary Membrane Thickness, Atelectasis, Excessive Bronchial Secretions-During the resolution stage of pneumonia
  23. What are tthe clinical manifestations of TB?
    Alveolar consolidation, and increased alveolar-capillary membrane thickness
  24. What are some clinical manifestations Assoc. w/ Pulmonary edema?
    Atelectasis, increased Alveolar-capillary membrane thickness, and excessive bronchial secretions.
  25. What are the clinical manifestations associated w/ flail chest?
    atelectasis and consolidation
  26. What are the anatomic alterations of the lungs with Cystic Fibrosis?
    Excessive mucus production and accumulation of thick, tenacious mucus in the tracheobronchial tree, Partial or total bronchial obstruction (mucus plugging), Atelectasis, Hyperinflation of the alveoli
  27. what are the anatomic alterations associated with pneumonia?
    Inflammation of the alveoli, Alveolar consolidation, Atelectasis (in aspiration pneumonia)
  28. What are the anatomic alterations of the lungs assosiated with TB?
    Alveolar consolidation, alveolar-capillary destruction, caseous TB or granulomas, cavity formation, fibrosis and secondary calcification of the lung parenchyma, distortion and dilation of the bronchi, increased bronchial airway secretions
  29. What is a restrictive disorder associated with the following anatomic alterations:including fluid engorgement of the perivascular and peribronchial spaces and the alveolar wall interstitium, Alveolar flooding, Increased surface tension of alveolar fluids, Alveolar shrinkage and atelectasis, Frothy white (or pink) secretions throughout the tracheobronchial tree
    Pulmonary Edma
  30. What are the alterations of the lungs with flail chest?
    Double fracture of numerous adjacent ribs, Rib instability, Lung restriction, Atelectasis, Lung collapse (pneumothorax), Lung contusion, Secondary pneumonia
  31. What type of Chest radiographs are associated with CF?
    Translucent (dark) lung fields, Depressed or flattened diaphragms, Right ventricular enlargement, Areas of atelectasis and fibrosis, Bronchiectasis (often a secondary complication), Pneumothorax (spontaneous), Abscess formation (occasionally)
  32. Is infertility an indicator of CF?
  33. What chest x-ray findings might you find with pneumonia?
    Increased density (from consolidation and atelectasis), Air bronchograms, Pleural effusions
  34. What are the Lab test and procedures for TB?
    Positive tuberculosis skin test (PPD). Positive sputum acid-fast bacillus (AFB) stain test. Positive sputum culture
  35. What are the radiologic findings for TB?
    increased opacity, Ghon nodule, Ghon complex, cavity formation, cavity lesion, pleural effusion, calcification and fibrosis, retraction of lung segements or lobe, right venticular enlargement.
  36. small sharply defined opacities identifying lesions (in TB).
    Ghon nodule
  37. involvement of the lymph nodes and tubercles including hilar region involvement (in TB).
    Ghon complex
  38. What chest radiograph- noncardiogenic pulmonary edema findings?
    Bilateral fluffy opacities - usually more dense near the hilum
  39. What chest radiograph - cardiogenic pulmonary edema findings?
    Dilated pulmonary arteries, Left ventricular hypertrophy (cardiomegaly), Keley A and B lines, Bat's wing or butterfly pattern, Pleural effusDilated pulmonary arteries, Left ventricular hypertrophy (cardiomegalyion, cardiogenic pulmonary edema, mild left heart failure.
  40. When there is moderate left heart failure in pulmonary edema what is seen?
    There is cardiomegaly, engorgement of the pulmonary arteries, and the presence of Kerley A and Kerley B lines.
  41. What has become the first line test for diagnosis because offers 3-D view and accurately identifies abnormalities for a pulmonary embolism case?
    Spiral (helical) Computerized Tomography (CT) Scan
  42. What will only be reliable if condition of Pulmonary Embolism is extreme?
    Ventilation/Perfusion Scan (V/Q scan)
  43. What provides clear image of blood flow and very accurate but not used due to time requirements and invasiveness in a pulmonary embolism case?
    Pulmonary Angiogram
  44. What are additional test used to detect blood clots in veins? (DDEMMB)
    D-dimer Blood Test (fibrinogen test; ALSO RULES OUT PED- IF NEGATIVE) ? simple test used to test for protein fibrinogen which is essential in clotting. Values higher than 500 ng/mL are considered positive. Duplex Venous Ultrasonography ? noninvasive and very accurate for more superficial clots but not DVT?s. Extremity Venography ? more complex (uses catheters and dyes) and invasive than duplex venous ultrasonography. Magnetic Resonance Imaging (MRI) ? useful when CT is not an option such as pregnancy and allergies to dyes used for contrast. Magnetic Resonance Angiography (MRA) ? used to differentiate between blood and clots. Blood Tests ? used to determine if there any inherited abnormalities (i.e. family history of clots, more than one episode of clots, clots forming for no know reason)
  45. D-dimer Blood Test (fibrinogen test) ? simple test used to test for protein fibrinogen which is essential in clotting. Values higher than what are considered positive?
    500 ng/mL
  46. When the lung on the affected side is compressed during inspiration, gas moves into the lung on the unaffected side. During expiration, air from the unaffected lung moves into the affected lung. As a consequence of the pendelluft, the patient rebreathes dead-space gas and hypoventilates.alveolar ventilation also may be decreased by the lung compression and atelectasis associated with the unstable chest wall. This leads to a decreased V/Q and increased venous admixture.
    Pendelluft Movement
  47. Radiologic findings for flail chest?
    Increased opacity, Rib fractures, Increased density on the affected side
  48. What are Medications and special procedures prescribed by a physician for CF?
    Xanthines-To enhance bronchial smooth muscle relaxation. Expectorants-Added when water and mucolytics are not working. Antibiotic-Prevent and treat secondary infections. Lung or heart/lung transplantation
  49. What is the preferred tx of choice for streptococcus?
    Penicillins: procaine penicillin G or aqueous penicillin G, amoxicillin
  50. What are all the various drug tx options for streptococcus?
    Penicillins: procaine penicillin G or aqueous penicillin G, amoxicillin. Alternative choice: macrolides, cephalosporins, doxycycline, quinolones. cefotaxime or ceftriaxone; antipseudomonal fluoroquinolones (levofloxacin, gatifloxacin, moxifloxacin).
  51. For the Gram-Positive Organism Staphylococcus aureus, what the different tx options?
    Methicillin-susceptible strains: nafcillin or oxacillin with or without rifampin. Methicillin-resistant strains: vancomycin with or without rifampin. Alternative choice: cephalosporins (most broad drug!), clindamycin
  52. For the Gram-Positive Organism Staphylococcus aureus, what the different tx options for Methicillin-susceptible strains:?
    nafcillin or oxacillin with or without rifampin
  53. For the Gram-Positive Organism Staphylococcus aureus, what the different tx options for Methicillin-resistant strains:?
    vancomycin with or without rifampin
  54. For the Gram-Positive Organism Staphylococcus aureus, what are the alternative tx options?
    cephalosporins (most broad drug!), clindamycin
  55. For the Gram-Negative Organism Haemophilus influenzae, what are the tx options?
    Ampicillin, third-or fourth-generation cephalosporin, macrolides (azithromycin, clarithromycin), fluoroquinolones
  56. For the Gram-Negative Organism Klebsiella pneumoniae, what are the tx options?
    Third-and/or fourth-generation cephalosporins (cefotaxime, ceftriaxone) plus aminoglycoside, antipseudomonal penicillin, monobactam (aztreonam), or quinolone
  57. For the Gram-Negative Organism Pseudomonas aeruginosa, what are the tx options?
    Tobramycin (TOBI), Aminoglycoside and antipseudomonal agents (ticarcillin, piperacillin, mezlocillin, ceftazidine)Note: cephalosporins will not work on this organism unless it is specifically ceftazidine (which sounds like its a type of cephalosporrine)
  58. For Mycoplasma pneumoniae, what are the tx options?
    Doxycycline, macrolides or fluoro-quinolones
  59. For Legionella pneumophila, what are the tx options?
    Erythromycin +/- rifampin (in severely compromised patient) or clarithromycin, or a macrolide (azithromycin), or a fluoro-quinolone (ofloxacin, levofloxacin, sparfloxacin)
  60. For anaerobic organsims, what are the tx options?
    metronidazole (Flagyl) or clindamycin; or Metronidazole + ceftriaxone; or penicillin + amoxicillin. Quinolones, penicillins are also useful
  61. For Chlamydia pneumoniae, what are the tx options?
    Tetracycline, erythromycin, macrolide, quinolone
  62. For Influenza virus, what are the tx options?
    Type A: amantadine and rimantadine. Type A/B: zanamivir, oseltamivir phosphate
  63. For Respiratory syncytial virus, what are tx options?
    Ribavirin (Virazole), palivizumab (Synagis)
  64. For Pneumocystis carintii, what are the tx options?
    Pentamidine (NebuPent), Trimethoprim-sulfamethoxazole (TMP-SMZ), dapsone-trimethoprim, primaquine plus clindamycin
  65. What are the tx options for Fungal infections?
    Amphotericin B, itraconazole, fluconazole, ketoconazole
  66. What are the tx options for Tuberculosis (mycobacterium tuberculosis)?
    Isoniazid (INH), rifampin, pyrazinamide, ethambutol, streptomycin
  67. What acid-fast tb stain reveals bright red acid-fast bacilli against a blue background?
    Ziehl-Neelsen stain
  68. What acid-fast tb stain reveals luminescent yellow-green bacilli against a dark brown background
    Fluorescent acid-fast stain
  69. What is the 6-month TX protocol for TB?
    2 months (induction phase) daily dose of isoniazid, rifampin, pyrazinamide, and either ethambutol or stroptomycin. Next 4 months Pt takes isoniazid and rifampin daily or twice weekly
  70. What is the 9-month TX protocol for TB?
    For the first 1 to 2 months, the patient takes a daily dose of isoniazid and rifampin, followed by twice-weekly isoniazid and rifampin until the full 9 month period is completed
  71. What are first-line agents prescribed for the entire 9 months for TB?
    Isoniazid (INH) and rifampin (Rifadin)
  72. What is bactericidal and is most commonly used with isoniazid in tx for TB?
  73. What are the two antibiotics commonly used to treat TB?
    Ethambutol and Streptomycin
  74. What Slow-acting, oral anticoagulants for PE?
    Can be taken prevenatively at home. Warfarin, Coumadin, Panwarfin
  75. What do Thrombolytic agents do to help fight a PE?
    Actually dissolves the clot. Streptokinase, Urokinase, Alteplase, reteplase
  76. What are some Preventive measures of a Pulmonary Embolism?
    Walking, Exercise while seated, Drink fluids, Graduated compression stockings, Vein filter, Pneumatic compression
  77. RT protocols for mild cases of flail chest?
    Meds for pain and routine bronchial hygiene.
  78. RT protocols for severe cases of flail chest?
    Volume controlled ventilation w/ PEEP. 5-10 days for healing.
  79. What causes Flail chest?
    Any blunt crushing injury to the chest such as: MVA, falls, blasts, direct compression, or industrial accident
  80. Double fractures of three or more adjacent ribs producing instability.
    Flail Chest
  81. What color will gram positive bacteria stain?
  82. What color will gram negative bacteria stain?
  83. What bacteria accounts for 80% of all bacterial cases?
  84. Streptococcus is gram negative or positive, and is it in shorts chains or irregular clusters?
    gram positive; short chains
  85. Staphylococcus is gram negative or positive, and is it in shorts chains or irregular clusters?
    gram positive; irregular clusters
  86. What bacteria is the most common cause of hospital acquired pneumonia?
    Staphylococcus (increasing in resistance MRSA)
  87. What are some Gram-negative organisms that cause pneumonia?
    Moraxella catarrhalis, Escherichia coli, Serratia species, Haemophilus influenzae, Klebsiella, Enterobacter species, Pseudomona aeruginosa
  88. What tends to occur in males >40 yrs. and alcoholics?
  89. Leading cause of hospital acquired pneumonia VAP
    Pseudomonas aeruginosa
  90. What gram negative organism is 7% of cases for pneumonia?
    Serratia Species
  91. What is the most common cause of ?Walking Pneumonia??
    Mycoplasma pneumoniae
  92. What is Contained in feces of birds. Transmitted via aerosol or direct contact
    Chlamydia psittaci
  93. What is Detected in schools, military and families. Associated with meningoencephalitis
    Chlamydia Pneumoniae
  94. What is the cause of anaerobic bacterial infections>
    aspiration of oropharyngeal secretions and gastric fluidsOften multimicrobial
  95. What percent of all pneumonia cases caused by viruses?
  96. What type of pneumonia will start with flu-like symptoms: Cough, headache, fever, muscle pain, and fatigue
  97. Approximately __% of acute upper respiratory tract infections and __% of lower respiratory tract infections are caused by viruses
    90; 50
  98. What are the most common types of viruses that cause pneumonia (ICRAP)?
    Influenza virus. Coronavirus (SARS). Respiratory syncytial virus. Adenovirus. Parainfluenza virus
  99. What will children usually have by their second birthday and is rarely fatal?
  100. What is responsible for Croup?
    Parainfluenza virus
  101. What Develops 48 ? 72 hrs after intubation?
  102. When the genioglossus muscle fails to oppose the force that tends to collapse the airway passage during inspiration, the tongue moves into the oropharyngeal area and obstructs the airway.
  103. Durring this stage of sleep:Large eye roles, Low amplitude waves on EEG, Transitional stage between sleep and wakefulness , The sleeper experiences drowsiness
    non-REM stage 1
  104. Durring this satge of sleep: Within minutes most progress to stage 2, Sleep spindles on EEG (a quick burst of wave forms at 12-14 hz), K complexes (Theta waves) -larger, Deeper than stage 2 and predominate stage of non-REM sleep, 10-20 minutes
    non-REM stage 2
  105. Durring this stage of sleep: Deeper stages, Slow wave sleep, Hard to wake, High amplitude waves, Decreases with age and pathologic states
    non-REM stages 3 and 4
  106. Describe non-REM sleep
    Respiratory rate slows, Increase in carbon dioxide in early stages by about 3-7 mm Hg, Respirations are irregular at the beginning in most people, Deeper NREM stages breathing becomes more rhythmic until REM, BP decreases during NREM sleep 5-10% in stages 1 and 2 and 8-14% in Delta sleep (stages 3 and 4)
  107. Durring this stage of sleep: sleep is believed to be the time during which the sleeper experiences dreaming. experiences 4 or 5 episodes each night
    REM sleep
  108. Describe REM sleep
    Begins 60-90 minutes, Dreaming and physiologic changes, Awakened almost always remember dreams, Slow wave sleep (non-REM stages 3 and 4) is most prominent during the first half of the night and decreases as the night progresses , 4 or 5 REM episodes per night, Increase in intensity and duration throughout the night, Initially lasting only 5 minutes in the evening and then can last as long as 30-60 minutes toward morning, In adults and kids it accounts for 20-25% of total sleep time and in newborns is accounts for 55-80% of total sleep time, Poses greater problems for people with sleep disorders, Muscle tone is at a minimum as the skeletal muscles are so relaxed that a partial state of paralysis results. Respiratory efforts are chaotic as responses to hypercapnia and to hypoxia are blunted., Increases vulnerability to upper airway obstruction and hypoxemia, Particularly in pulmonary compromise, Cardiac dysrhythmias are more common as heart rates are variable, BP often increases
  109. Most common type of sleep apnea. is caused by an anatomic obstruction of the upper airway in the presence of continued ventilatory effort. Patient, initially, appears quiet and still. Followed by an increased effort to inhale. often ends only after an intense struggle. Snorting "fricative breathing", suddenly awaken, sit upright in bed, and gasp for air.(CONFUSIONAL AROUSALS)
  110. Named after a character in Charles Dickens? The Posthumous Papers of the Pickwick Club. Character was morbidly obease
    Pickwickian Syndrome. Now known as OSA
  111. Occurs when respiratory centers of the medulla fail to send signals to the respiratory muscles. Characterized by cessation of airflow at the nose and mouth with absence of diaphragmatic excursions. Associated with cardiovascular, metabolic, or central nervous system disorders
    Central sleep apnea
  112. Combination of obstructive and central sleep apnea. Usually begins as central sleep apnea, followed by: Ventilatory efforts without airflow?OSA
    Mixed Sleep Apnea
  113. What are some anatomic alterations of the lungs with a pneumothorax?
    Its restrictive: Lung collapse, atelectasis, chest wall expansion, and compression of the great veins and decreased cardiac venous return.
  114. Gas can gain entrance to the pleural space in three ways:
    1. From the lungs through a perforation of the visceral pleura, 2. the surrounding atmosphere througha perforation of the chest wall and parietal pleura or, rarely, through esophageal fistual or perforated abdominal viscus, 3. gas-forming microorganisms in an empyema in the pleural space (rare)
  115. Gas in pleural space is not in direct contact with the atmosphere
    closed pneumothorax
  116. Pleural space in direct contact with atmosphere, ?Sucking Chest Wound?, and Pendeluft movement
    Open pneumothorax
  117. Intrapleural pressure exceeds intraalveolar pressure
    Tension pneumothorax
  118. Pneumothorax can be classified based on origin too. What are the three classifications?
    Traumatic, spontaneous, and Iatrogenic
  119. Penetrating chest wounds:Knife, Bullet, or Impaling object. May result in open, closed, or tension pneumothorax
  120. Occurs suddenly without underlying cause. May be secondary to underlying pathology: Pneumonia, Tuberculosis, COPD, or Rupture of bleb. Often occurs in tall thin people 15 ? 35 years old. Also may result from high negative intrathoracic pressures generated in the right upper lobe
    Spontaneous pneumothorax
  121. occurs during specific diagnostic or therapeutic procedures?for example: Pleural or liver biopsy, Thoracentesis, Intercostal nerve block, Cannulation of a subclavian vein, or Tracheostomy. We caused it! hazard of PPV.
    Iatrogenic pneumothorax
  122. What is the clinical manifestation on associated pneumo.?
  123. What kind of chest radiograph will be seen with a pneumothorax?
    Increased translucency on the side of pneumothorax, Mediastinal shift to unaffected side in tension pneumothorax, Depressed diaphragm, Atelectasis
  124. When the pneumothorax is relatively small (15% to 20%), what is the management?
    may only need bed rest or limited activity. In such cases, reabsorbtion of intrapleural gas usually occurs within 30 days
  125. When the pneumothorax is larger than 20%, what is the management?
    It needs to be evacuated
  126. What is ARDS?
    Capillary engorgement and increased permeability of A/C membrane leading to alveolar edema and hemorrhage resulting in decreased surfactant and subsequent atelectasis
  127. What are the anatomic alterations of the lungs with ARDS?
    Interstitial and intra-alveolar edema and hemorrhage, Alveolar consolidation, Intra-alveolar hyaline membrane, Pulmonary surfactant deficiency or abnormality, Atelectasis
  128. What is the common mechanism for the development of ARDS?
    Lung inflammation
  129. What values are used to determine ARDS?
    PCWP < 18 BAL is protienaceuous and inflammatory. Diffuse alveolar damage. P/F <200 ( if PCWG > 18 adn BAL nonproteinaceous and noninflammatory then its CHF)
  130. What are the two phases of ARDS Histopathology?
    Exudative phase (1-3 days) Fibroproliferative phase (3-7 days)
  131. How do you use Radiographic findings to differentiate between CHF and ARDS?
    CHF: cardiomegaly, perihilar infiltrates, effusions. ARDS: peripheral alveolar infiltrates, air BRONCHOgrams with normal heart size. Hard to determine heart size and presence of effusions on supine A/P films. Complicated by possible coexistence of CHF and ARDS
  132. What are the clinical manifestations of ARDS?
    Atelectasis, Alveolar Consolidation, Increased Alveolar-Capillary Membrane Thickness
  133. What will the DLCO be for ARDS?
  134. What will a Chest Radiograph look like for ARDS?
    increased opacity
  135. How do you properly set Vt for an ARDS pt on a ventilator?
    Optimal VT set by pressure-volume (P/V) relationships. Should set between upper and lower inflection points (PFLEX). .Initiate VT of 5?7 ml/kg
  136. Compared to normal, ARDS patients require much higher VE to maintain PaCO2, what do we as RT's tend to do with them on a ventilator?
    Small VT used to avoid volutrauma. Permissive hypercapnia used to avoid high Paw. PaCO2 60?8mm Hg common, pH ~7.250 mm Hg common, pH ~7.25
  137. What are the goals when adjusting PEEP for ARDS?
    Goal is to recruit additional alveoli and increase FRC and oxygenation. Improving oxygenation enables a reduction in FIO2 . Reduces the risk of oxygen toxicity. Recruited alveoli avoid opening and closing injury.. Set PEEP at lowest level to ensure. Arterial oxygenation: PaO2 > 60 mm Hg, FIO2 < 0.6 Adequate tissue oxygenation. Alveoli patent throughout ventilatory cycle. Avoid barotrauma with Paw < 35 cm H2O.
  138. If the pulmonary efuusion fluid is a transudate, treatment is directed to what?
    the underlying problem (e.g., congestive heart failure, cirrhosis, nephrosis)
  139. The best way to resolve a pleural effusion is to do what?
    diat what is causing it, rather than treating the effusion itself. If the heart failure is reversed. Lung infection is cured by antibioticsrect the treatment
  140. What will a Chest Radiograph look like for a pleural effusion?
    Blunting of the costophrenic angle, Fluid level on the affected side, Depressed diaphragm, Mediastinal shift (possibly) to unaffected side, Atelectasis, Meniscus sign
  141. What are the Chest Assessment Findings for pleural effusions?
    Tracheal shift ALWAYS away from the affected side. DECREASED tactile and vocal fremitus. DULL percussion note, Diminished breath sounds. Displaced heart sounds. Pleural friction rub (occasionally)
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Mike's Final Disease process.txt
2012-12-01 12:48:20

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