Systems - Resp - 2nd half - some pericarditis by mistake

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Systems - Resp - 2nd half - some pericarditis by mistake
2014-11-12 14:07:23
Systems Resp 2nd half some pericarditis mistake
Systems - Resp - 2nd half - some pericarditis by mistake
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  1. What is the definition of chronic cough?
    • 1) duration greater than 8 weeks
    • 2) non-smoker
    • 3) Not on ACEi
    • 4) Normal lung function
    • 5) Normal CXR
    • (i.e. no obvious lung disease)
  2. In order of prevalence, what are the top 3 (4) causes of chronic cough?
    • 1) Asthma/eosinophilic bronchitis
    • 2) Upper airway cough syndrome (formerly, post-nasal drip)
    • 3) GERD
  3. In a normal lung, what happens when pulmonary artery or venous pressureincreases? Generally how high is pulm resistance relative to systolic vasc res
    as pressure increases, the resistance decreases due to recruitment and distension

    normally this resistance is 1/10 of systolic
  4. What are the numerical definitions of pulm HTN and pulm arteriole HTN
    PH: mean pulm art. pressure (PAP)>= 25 mmhg

    PAH: same as above + post capp. wedge pressure (right sided capp's) or LVEDP <= 15mm Hg
  5. What are the three major mechanisms of pulm HTN?
    • 1) hypoxic vasoconstriction
    • 2) decreased area of vascular bed
    • 3) RV volume and pressure overload
  6. Describe the approach to PH in categorizing PAH, lung disease, thromboembolitic PH, unclear causes, and heart disease.
    • Pre-capillary: PAH
    • Low PCWP: Lung disease, TE PH, unclear causes
    • post-capp (high PCWP): heart disease
  7. What are the 5 classifications of pulmonary HTN?
    • PAH (an orphan disease, no other comp's)
    • owing to left heart disease (most common)
    • due to lung disease (e.g. COPD)
    • chronic TE Pulm HTN
    • unclear/multifactorial causes
  8. What are the three elements that combine in PAH?
    • 1) vasoconstriction
    • 2) vascular wall remodeling
    • 3) thrombosis in-situ
  9. What are the three pathways involved in PAH?
    • Endothelin (most potent vasoconstrictor in the body)
    • Nitric oxide (dilator)
    • prostacyclin (dilator)
  10. What are the three major classes in PAH specific therapies
    • the prostenoids
    • endothelin receptor antagonists
    • PDE-5 inhibitors

    All of these vasodilate
  11. Remember the three things that lead to PE? What are they?
    • Venous stasis
    • Endothelial cell damage
    • Hypercoagulable states
  12. What are six substances that cause PE?
    • 1) clot
    • 2) fat
    • 3) talc
    • 4) air
    • 5) septic
    • 6) amniotic fluid
  13. What is the most common cause of preventable death in hospitalized patients?
    venous thrombo embolism
  14. When should you suspect PE?
    sudden dyspnea, chest pain, or collapse 1-2 weeks after surgery
  15. What is on the DDx when someone comes in with sign and symptoms for PE (top 5, other than PE)
    • basically the DDx for chest pain:
    • MI
    • pneumothorax
    • pneumonia
    • Aortic dissection
    • tamponade
  16. Define and describe what you would do for a low well's score. What about an intermediate/high score?
    Low (0-1): use D-dimer to rule out, if it is positive, then do a CT scan to rule in/out

    intermediate or high: go straight to CT scan to rule in or out
  17. How long do you need to anticoagulate in PE? When can you not use warfarin to do this?
    • reversible cause (surgery, injury, pregnancy, etc): 3-6 mon
    • unprovoked:>3 months and then re-evaluate (high bleeding risk: 3 months, low bleeding risk: extend)
    • Irreversible risk factor (ongoing cancer, etc): 12 months to indefinite

    Cannot use warfarin in cancer, in pregnant/postpartum ladies, or in high bleeding risk (can reverse heparin, not warfarin)
  18. What are the top three indications for thrombolysis in PE
    • 1) Hypotension
    • 2) free-floating RA/RV clot
    • 3) Patent Foramen Ovale
  19. Describe the A-a gradient and how to calculate it
    The difference b/n Alveolar and arterial oxygen. Basically determines if an acceptable amount of the oxygen that makes it down to the alveoli is making it into the blood. Normal is 10-12 mm Hg

    A-a = [0.21x(P(barometric)-47)-(Pa(CO2)/0.8)] - Pa(O2)
  20. How do you know if you have a good chest X-Ray
    • RICE
    • Rotation: T3 should be between clavicles
    • Inspiration: should see 6 anterior - 9 posterior ribs
    • Contrast: larynx and costophenic angles visible?
    • Exposure: should be able to see the vertebrae behind the heart
  21. What is the DDx of increased A-a gradient? (3)
    • -diffusion problem
    • -shunt
    • -V/Q mismatch
  22. Describe the approach to diagnosing hypoxia (3 steps)
    • 1) is Pa(CO2) elevated: if yes, then this is hypoventilation. If no, go to 2
    • 2) is the A-a gradient increased: if no, this is low inspired Pi(O2). If yes go to three
    • 3) is the hypoxia fixed if you give O2: If yes, V/Q mismatch. If no, this is a shunt
  23. What is your approach for analysing a CXR
    • ABCDE
    • Airways, and hilar Adenopathy
    • Bones and Breast shadows
    • Cardiac sihouette and Costophrenic angles
    • Diaphragm and Digestive tract
    • Edges of pleura
    • Fields (lung fields)
  24. Compare airspace and interstitial infiltrates on a CXR
    airspace: hazy, indistinct margins, respect lobar boundaries, air bronchograms (bronchi become visible when they are filled with pus)

    Interstitial: does not respect lobar boundaries, no air bronchograms
  25. What are some causes of airspace being visible on CXR (5)?
    • water
    • blood
    • pus
    • tissue
    • protein
  26. Describe the 3 interstitial patterns you see
    • reticular - lines
    • nodular - dots
    • reticulonodular - both of these
  27. What is the DDx for cavitating lesions (nodes) on CXR
    • CAVITY mnemonic
    • Cancer
    • Autoimmune (Wegner's, RA)
    • Vascular (septic emboli)
    • Infectious (TB, abscess)
    • Trauma (pneumatocele)
    • Young ( bronchogenic cyst, laryngotracheal papillomatosis)
  28. Where are most LC mets found
    • in the LABB
    • Liver
    • Adrenals
    • Brain
    • Bone
  29. classify  and describe lung cancer
    • 1) small cell: most likely to produce mets, smoking
    • 2) non-small cell carcinoma: less likely to produce mets
    •   -adenocarcinoma: most common LC, not associated with smoking
    •   -squamous CC: smoking
    •   -Large CC: poor prognosis, smoking
  30. What are the 4 things that can cause an anterior mediastinal mass?
    • remember the 4 T's
    • Thyoma
    • Teratoma
    • Terrible lymphoma
    • Thyroid
  31. When thinking about interstital lung disease what are some important questions to ask (3)?
    • smoking
    • occupational Hx (for them and spouse)
    • medications or chest irradiation
  32. Identify and describe 5 idiopathic interstitial pneumonias. What Sx are common to all
    • -usual interstitial pneumonia (aka IPF): honeycombing on CT, in old men
    • -desqumative interstitial pneumonia: mostly in young males
    • -lymphoid interstitial pneumonia
    • -non-spec interstitial pneumonia: often related to other diseases (Connective tissue disease, HIV, drugs, etc)
    • -acute interstitial pneumonia: 50% mortality

    common Sx: progressive dyspnea and dry cough
  33. What tips you off to Cryptogenic Organizing Pneumonia
    presents like a bacterial pneumonia, but does not respond to Abx treatment
  34. Describe sarcoidosis. how would you diagnose
    sarcoidosis is a multi-system granulomatous disease, diagnose with Bx
  35. Which interstitial lung disease go with the following time courses: days-weeks, weeks-months, months-years
    • d-w: acute interstital pneumonia, hypersens pneum, cryptogenic organizing pneumonia
    • w-m: sarcoidosis, CT disease
    • m-y: IPF (UIP), sarcoidosis
  36. How would you treat interstitial lung disease?
    anti-inflammatories and removal of offending agent
  37. What are some types/causes of hypersens pneumonitis? What are they all characterized by? How would you treat?
    • Farmer's lung: mouldy hay
    • malt worker's lung: fungi
    • bird feeder's lungs: avian protiens

    Char. by: lymphocytic alveolitis and granulomatous pneumonitis

    treat: REMOVE FROM EXPOSURE, steroids, oxygen
  38. What are the three types of pneumoconiosis and where would you expect to see the fibrosis on CXR
    • Silicosis: upper>lower lobes, rounded opacities (looks like shot)
    • Asbestosis: asbestos fibre looks like dumbell under microscope, bilateral diaphragmatic and pleural plaques are specific for this, lower>upper lobes
    • Coal worker's lungs: upper> lower lobes
  39. What is the acute pericarditis triad?
    ECG changes, friction rub (sounds like crunchy snow), chest pain (pleuritic, worse laying on back)
  40. What are five functions of the pericardium
    • -maintains heart position
    • -barrier to infection
    • -lubrication between layers
    • -secretes prostaglandins
    • -restraining effect on cardiac volume
  41. What can cause acute pericarditis?
    • usually idiopathic
    • also infectious, inflammatory, MI etiologies 
    • ask about neoplasms or radiation
  42. How would you treat acute pericarditis?
    • idiopathic is usually self limited
    • treat underlying cause, pain, and inflammation
  43. What is the classic quartet of cardiac tamponade
    • -hypotension
    • -increased JVP
    • -tachycardia (heart tries to maintain CO)
  44. How can you differentiate cardiac tamponade from restrictive pericarditis?
    -Tamponade: always pulsus paradoxus, electrical alternaans

    -RP: rarely pulsus paradoxus, square root sign on catheter, pericardial "knock" due to abrupt stop in filling
  45. describe the pathophysiology of pericardial effusions (cardiac tamponade) and constrictive pericaditis
    pericardial effusions (can lead to cardiac tamponade): increased pressure in pericardial cavity reduces venous return, which in turn reduces CO and BP

    constrictive pericarditis: rapid filling is ABRUPTLY stopped by a fibrosed pericardium, creating a knocking sound. +/- hypotension
  46. Describe pulsus paradoxus
    more than 10 mm Hg drop in sBP on inspiration
  47. Who gets TB? (3)
    • -1/3 of people infected with HIV (30x more likely to get TB)
    • -highest number of cases are foreign born people
    • -highest rates (a per capita) measurement are in Canadian-born aboriginals
  48. describe the disease progression of people infected with TB
    • 1) primary infection: 5% get progressive primary infection, 95% go to latent infection
    • 2) latent infection: 5% reactivate, 90% get no disease ever. 10% reactivation rate in HIV patients
  49. What are the contraindication to tuburculin skin testing?
    • -severe reactions in the test
    • -if they have a documented Hx of active TB
    • -if they have a viral infection (or had one in the past month)
  50. describe when you would say a TST test is positive
  51. What are the 4 drugs used to treat active TB? Side effects for each
    • RIPE mnemonic:
    • Rifampin: Hepatitis, rash, GI upset
    • Isoniazid (INH): hepatitis, neuropathy
    • Pyrazinamide: Hepatitis, rash, aches
    • Ethambutamol: optic neuritis

    He also had SM on there: causes ear and renal toxicity
  52. What is mult drug res TB (MDR) and extensively drug resistant (XDR) TB resistant to?
    MDR: resistant to isoniazide and Rifampin

    XDR: same as MDR + any fluoroqionolone + 1 of the 3 injectable 2nd line agents (capremycin, kanamycin, amikacin)
  53. What are the phases of lung development and what are the chances of survival for each
    • psuedogladular: no alveoli, no survival (mesenchyme is too thick)
    • canalicular (16-24 weeks): gas exchange surface, can survive if all goes well
    • Saccular phase (24-36 weeks): will likely survive, lots of gas exchange surf
    • alveolar (36-40 weeks): alveolar sacs
  54. What are three things you can do to prevent surfactant problems in neonates?
    • small amounts of prenatal corticosteroids to promote lung dev
    • surfactant therapy
    • avoid excess oxygen exposure
  55. what advice can you give pregnant ladies to decrease asthma in the baby (both before and after birth)
    fish oil, vitamin E (avocados, nuts) while pregnant

  56. What dietary/lifestyle advice can you give people with asthma?
    • -more omega 3,
    • -get adequate magnesium,
    • -less salt (less than 1500 mg),
    • -increase dietary antoxidants (especially vit C)

    • -don't become a fatty
    • -chill out (mind-body relaxation)
  57. What is the indication for lung transplant
    Chronic end-stage lung disease failing on MAXIMAL medical therapy. Refer when survival is less than two years. Want to get as much out of the old lungs as possible.
  58. What are the absolute contraindications in lung transplant (5)?
    • -untreatable advanced dysfunction in other organ
    • -malignancy < 2years
    • -non curable infection
    • -non-compliance with previously issued drugs
    • -substance addiction in past six months
  59. What BODE index scores for COPD lung transplant referral, listing
    • referral: >5
    • listing: >7
  60. When do you refer/list for pulmonary fibrosis (UIP, NSIP)
    refer when you get a positive biopsy for either

    • list when UIP + any of the following:
    • DLCO less than 39%
    • PVC decreased by 10% in 6 months
    • SpO2<88%
    • honeycombing on HRCT
  61. What diseases would you transplant lungs for?
    COPD, pulm fibrosis, cystic fibrosis, PAH
  62. What is hypoxemia?
    • -insufficient oxygenation
    • -low oxygen tension in the blood
    • -decrease of partial pressure of oxygen in blood
  63. What is the definition of resp failure? What are the subtypes?
    • PaO2 < 60 mm Hg AND/OR PaCO2 > 46 mm Hg
    • AND pH<7.35
    • Type I: involves lung itself. Acute Hypoxemic RF -> low O2, alkalosis, normal or low CO2
    • Type II: failure of alveolar vent: Acute Hyoxemic Hypercapnic RF. All three of the above criteria.
  64. What are the 5 causes of hypoxemia? What is their effect on A-a grad
    • 1) V/Q mismatch (increases it)
    • 2) alveolar hypoventilation (no change)
    • 3) R to L shunt (increases it)
    • 4) low ambient oxygen (mountains) (no change)
    • 5) diffusion block (like in interstitial lung disease) (increased)
  65. What is the cut off for acidosis and alkalosis
    • acidosis < 7.35
    • alkalosis > 7.45
  66. What are the 4 causes of hypoxia?
    • hypoxemia
    • anemia
    • reduced oxygen delivery to tissues
    • decreased tissue oxygen uptake
  67. What is the Lights criteria for differentiating transudative and exudative pleural effusions?
    • transudative (need all three):
    •  -protein (pleural/serum): <0.5
    •  -LDH (pleural/serum): <0.6
    •  -Pleural LDH: < 2/3 upper limit of N serum LDH

    exudative (only need one): > than all of the above values

    Transudative means formation and absorption of pleural fluid is faulty (HTN, low oncotic pressure, etc; only fluid is getting through)

    exudative means faulty pleural capillaries (everything is getting through)
  68. What are the risk factors for pneumothorax?
    • -trauma
    • -iatrogenic (thoracentesis, etc)
    • -underlying lung disease
    • -spontaneous
  69. What are the top five things on the DDx for dyspnea?
    • asthma
    • COPD
    • pneumonia
    • heart failure
    • PE
  70. Top 3 treatments for asthma with names
    • beta 2 agonists: Salbutamol
    • Anti-cholinergics: Atrovent
    • Corticosteroids: bethamethasone, prednisone
  71. What do you see on PE for COPD?
    • Signs of hypoemia:
    •  -tachypnea
    •  -tachycardia
    •  -hypertension
    •  -cyanosis
    • Signs of hypercapnea
    •  -altered mental status
    •  -hypopnea
  72. What is a normal PaO2?
    90-100 mm Hg
  73. What is a normal A-a gradient?
    normal is 10-12 mm Hg, but this increases with age.
  74. What shifts the oxygen curve to the right?
    • CADET right face
    • CO2
    • Acidosis
    • DPG increase
    • Exercise
    • Temperature

    Think that these are the conditions in an exercising muscle
  75. What does DLCO depend on?
    • membrane thickness
    • hemoglobin conc
    • cardiac output
  76. low low flow oxygen, how much does 1 L of O2 give you for oxygen content? What about for every litre above that?
    • 1L - 24%
    • an additional 3-4% for every litre after that