4⼀PULMONARY/ALLERGY/ENT Flashcards
(249 cards)
1
Q
What would you expect PFT for a patient with Asthma to be?
A
NORMAL PFT
but
[FEV1⬇︎ ≥20% (on methacholine challenge)]
“Either [BD → ⇪EVC] or [MC → ⬇︎EV]”
2
Q
What are the recommendations regarding Influenza vaccine and [patients with “egg” allergy] ? (3)
A
pt s/p…
- [urticarial (egg rxn)]? → give [IM dead influenza vaccine]
- [SEVERE (egg rxn)]? → give [IM dead influenza vaccine] in healthcare setting under supervision
- [SEVERE (VACCINE rxn)]? → [INFLUENZA VACCINE❌CONTRAINDICATED]
3
Q
Management for Asthma Exacerbation (3)
A
PIR
1st: [PAWSS respiratory failure?]
2nd: [Initial tx(SMC vs Mechanical Ventilation)
3rd: [Reassess q2-4h]
4
Q
Whats the best medication for Awake Intubation induction?
_________________
why? (6)
A
Ketamine
_________________
“has a BAD RUP”
provides [BronchoDilation | Analgesia | Dissociative amnesia]
+
maintains [Respiratory drive | Upper airway tone | Protective reflex]
5
Q
How is smoking/secondhand smoking a/w Chronic Sinusitis?
_________________
Name 3 other major causes of Chronic Sinusitis
A
cigarette smoke damage cilia ➜ ⬇︎mucus flow throughout the sinus ➜ chronic sinusitis
_________________
poorly treated acute sinusitis / [structural abnormality (nasal septum/palate)] / rhinitis
SMHHsx = [Snotty purulent nasal discharge/Maxillary facial pain/HA/Hot>39C]
6
Q
Most epistaxis originate from the ⬜ in the ⬜
How do you manage this? -4
A
[Kisselbach Plexus] ; [ANTERIOR Nasal Septum]
________________
- try each tx until epistaxis resolved*
1st: Nostril pinching
2nd: [Topical Vasoconstrictor]
3rd: [Cautery (silver nitrate vs electrical)]
4th: [ANT nasal packing with bacitracin-sponge]
7
Q
Tx for [Bacterial Aspiration PNA] -3
look for infiltrate in dependent portion of the lung
A
βMα
_________________
[CefTriaxone + Azithromycin](community acquired PNA)
+
[anaerobic abx if empyema or lung abscess present]
8
Q
treatment regimen for GASP? -2
________________
What are the alternatives if a patient is allergic? -3
________________
Why is it important to treat GASP?
GASP = [Group A Strep Pyogenes]
A
[PO PCN VK]10d or [PO amoxicillin]10d
________________
allergy mild = Cephalosporin
allergy anaphylaxis = Azithromycin | Clindamycin
________________
prevention of Rheumatic Fever
9
Q
What’s the most common cause of hemoptysis?
A
[Bronchial infxns (Bronchitis / Bronchiectasis)]
10
Q
What are the most common organisms to cause Sinus infection (Rhinosinusitis)? - 3
________________
Tx?
A
Strep Pneumo > HFlu nontypeable > moraxella
________________
Tx = Amoxicillin/clavulanate
11
Q
[Haemophilus Influenzae] Tx (5)
A
HaEMOPhilus
[FAT MC]
[Fluroquinolone vs. Ampicillin vs. Tetracycline vs. Macrolide(NOT ERYTHRO) vs. Ceftriaxone]
12
Q
🄰. [Daily Cough with mucopurulent sputum and [Recurrent multiLobar PNA] likely indicates what dx?
________________
🄱 . How does this disease cause hemoptysis?
_________________
🄲. Explain why [Recurrent single lobe PNA] has a different workup
A
🄰 . Bronchiectasis
________________
🄱.
💥[multilobar poor ciliary clearance(2/2 Kartagener | CF | ABPA, etc) ] → *multilobar *bronchial wall infection ➜
💥[inflammatory bronchial wall thickening and permanent airway dilation]+ inflammation predisposes to repeat infections
💥➜ more bronchial wall thickening and dilation= [cycle of bronchial airway dilation + bronchial wall thickening+ bronchial wall inflammation]
💥➜chronic [bronchial wall inflammation] ➜ rupture of [bronchial wall superficial blood vessels] ➜ hemoptysis
c.
Focal bronchiectasis (involvement of single lobe/segment only) indicates airway blockage (malignancy/foreign body) ⼀ = Dx/Tx = FLEX bronchoscopy (since HRCT may not reveal/remove the obstructing lesion)
so…
🧠pts with [persistent Recurrent PNA] in:
[single lobe → 🔬FLEX BRONCHOSCOPY]
vs
[Multi lobe → 🔬HRCT]
13
Q
Name the Causes of ARDS (10)
A
ARDS
A= Aspiration vs. [Acute Pancreatitis] vs. [Air Fluid Embolus (amniotic)]
R= Radiation
D= Drugs vs. DIC vs. Drowning
S= Sepsis vs. Smoking vs. Shock
ARDS is a restrictive pattern that –> [⬇︎Lung Compliance], [Group 3Pulm HTN] and impaired gas exchange
14
Q
What are the 3 criteria for COPD Exacerbation
A
Co-P-D
[Cough ⇪ with SPUTUM ∆]
[Pulmonic WHEEZING BL]
[Dyspnea ( ➜respiratory acidosis)]
15
Q
Out of the Tx for COPD Exacerbation
Which improves survival?
________________
Which ⬇︎future events?
A
“I’m having COPD Exacerbation! Give me DOPA! (but not really)”
[O2 PRN via BiPAP (goal: 90-94% O2 Sat)]
________________
Abx (Azithro-⬇︎future events or Levoflox or Doxy)
16
Q
Tx for COPD Exacerbation-4
A
“I’m having COPD Exacerbation! Give me DOPA! (but not really)”
- Duoneb (albuterol + ipratropium)
- O2 PRN via BiPAP (goal: 90-94% O2 Sat)
- [Prednisone 40 mg qd x 5]
- Abx (Azithro-⬇︎future events or Levoflox or Doxy)
17
Q
how is [PPSV 23 (Pneumococcal PolySaccharide Vaccine)] used in peds? (3)
A
PPSV23 in kids is used for peds at high risk for pneumococcal disease
- [Sickle Cell Anemia\Asplenia]
- Cardiac ❌
- cochlear implants
18
Q
diagnostic criteria for Acute Otitis Media -2
________________
Which organisms cause AOM? -3
A
BULGING TM + [Middle Ear effusion with TM inflammation (fever/otalgia/erythema)]
________________
STREP PNEUMO = [HFLU NONTYPEABLE**] >> moraxella
________________
** also causes otitis conjunctivitis syndrome
19
Q
Prophylactic abx tx and tympanostomy tube ⬇︎ [recurrent AOM],
and are recommended for which 4 patient groups?
A
[≥ 3 AOM in 6 mo] or
[≥4 AOM in 12 mo] or
[craniofacial DO] or
[neurodevelopmental DO = speech/hearing ❌]
20
Q
How long does it take Malignant [Solitary Pulmonary Coin Nodules] to double in size?
________________
How does this affect diagnostics?
A
1 month - 1 year
________________
Pt with stable [Solitary Pulm Coin Nodule] > 1 year = NO CA!
21
Q
Pt with hemoptysis comes in with [Solitary Pulmonary Coin Nodule] on CXR
What are the 3 [preDiagnostic Mgmt] steps for SPN?
A
A: LOCATE PREVIOUS CXR ≥ 1y old!
_________________
b: If SPN unchanged = NO CA
C: If [(SPN ∆) OR (NO PRIOR CXR)] ➜ [Diagnostic Mgmt] (image)
Coin lesions = 80% chance malignancy
22
Q
List 5 characteristics of [solitary pulmonary coin nodules] that help to determine their Malignancy & workup
A
Smoking hx | Location | Age | Border || size
-Smoking Hx
-Location: Endobronchial proximal extension/Local invasion/Satellite Nodules
-Age
-Border: : Spiculated / Retracted from surrounding tissue / irregular
-size: {≥8mm}
23
Q
After the [SPN 3-step prediagnostic mgmt]
How do you workup [Solitary Pulmonary Coin Nodule]?
Round, < 3mm, no LAD
A
24
Q
[Solitary Pulmonary Coin Nodule] DDx -5
A
- CA(hamartoma/metastasis/primary)
- Infectious [granulomatous/fungal (blasto,histo)]
- Pneumoconiosis
- Vasculitis
- Scar
25
How do you treat ANAPHYLAXIS ? -8
***EPIC ➜ chag***
**[E**PINEPHRINE {[IM ≤ 3x] ➜ [IVgtt if severe]}]
[**P**roair Albuterol + O2]
[**I**NTUBATION ⼀early\** for upper airway obstruction]
[**C**rystalloid IV/Trendelenburg for hypOtension]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**C**TS / [**H**istamine1/2 R blockers] / [**A**dmission to Hospital if severe|persistent]/ [**G**lucagon if on BBlocker]
## Footnote
*peds epi = [0.01 mg/kg]*
26
epinephrine MOA-2
alpha1🟢 → vasoconstriction
beta2🟢 → bronchoDilation
## Footnote
🟢 = receptor agonist
27
*Acute Otitis Media*
initial tx?
[AmoxicillinHD]10d
28
Recurrent AOM should raise concern for ⬜, and warrants treatment with ⬜
beta-Lactamase producing [Strep Pneumo or HFlu NT] ➜ **resistance** ; amoxicillin/clavulanic acid
## Footnote
*normal AOM tx = [AmoxicillinHD]10d*
29
How do you treat [*Acute Otitis Media* **with PCN allergy**]? -2
Azithromycin or Clindamycin
30
How do you treat [*Acute Otitis Media* **refractory persistent**]?
[Tympanostomy with tympanocentesis]
31
Out of the 3 organisms that cause Acute Otitis Media, which is unique? why?
HFLU*nontypeable*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
can also cause [otitis conjunctivits syndrome] in which purulent conjunctivitis occurs at same time as AOM
32
Acute Mastoiditis is a complication of ⬜ and is caused by *[ ⬜ microbe]*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
clinical presentation? -2
Acute Otitis Media ; [middle ear infection*(with Strep Pneumo)* ] spreads to [mastoid air cells]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. **AURICLE** **DISPLACEMENT**
2. mastoid TTP
| tx = [amoxHD]10d
## Footnote
*other sx: otalgia, fever*
33
Paradoxical Emboli are a more common cause of ⬜ in young than elderly
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
explain etiology of Paradoxical Emboli
stroke
\_\_\_\_\_\_\_\_\_\_\_\_\_\_
emboli from venous system (DVT) travels **thru intracardiac shunt** into arterial system ➜ stroke
*dx = TTE and bubble study*
34
[Eczema Atopic Dermatitis] cp -4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Where do you find this cp in infants? -3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
where in Adults/Kids?
*"Eczema making you [**PPP** →**P**]sx? needs **LEGIT**tx"*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
{acute [**P**ink*(Erythematous)* **P**atch & **P**apules] →CHRONIC[ **P**laqueswith LICHENIFICATION]}
## Footnote
[infant = face, trunk, extensor surfaces]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Adults/Kids = flexor surfaces]
35
[Eczema Atopic Dermatitis] MOD (4)
1) [skin barrier dysfunction]
2) + [**Th2 skewed immune response**]
3) + INC production of IgE
4) = chronic inflammatory skin disorder
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*This [Th2 skewed immune response] can be balanced by a [Th1 cytokine profile] built only from EARLY MICROORGANISM EXPOSURE*
## Footnote
*"Eczema making you [**PPP** →**P**]sx? needs **LEGIT**tx"*
36
## Footnote
(fill-in-Blank)
37
[Eczema Atopic Dermatitis] Tx -5
*"Eczema making you [**PPP** →**P**]sx? needs **LEGIT**tx"*
1. [**L**ifestyle ∆ (avoid hot/dry climate, harsh soaps, harsh detergents)]
2. [**E**mollientsTOP(skin hydration) + antihistaminesPO]
➜
3. [**G**lucocorticoidsTOP (low potent = hydrocortisone / medium = triamcinolone / HIGH = Betamethasone) -- *contraindicated on face and flexural surfaces*]use only in acute exacerbations
4. [**I**nhibitors of CalcineurinTOP {i.e. Tacrolimus} = for face and flexural surfaces]
5. [**T**herapy ⼀phototherapy vs immunosuppressants = SEVERE]
## Footnote
*"Eczema making you [**PPP** →**P**]sx? needs **LEGIT**tx"*
38
Classic Sx of Sarcoidosis-8
**CCuBBeDD**
**C**ardiomyopathy Restrictive
HYPER**C**alcemia: *elevated ACE and 1-25VitD production --\> HYPERCalcemia and HYPERCalciuria*
**u**veitis --\> Vision loss
**B**ilateral Hilar LAD! = COMMON = CXR is 1st screening test!
**B**ell's Palsy
**e**rythema Nodosum (SubQ Fat lesions)
[**D**ry cough & Dyspnea]
**D**iffuse interstitial fibrosis
## Footnote
* Image showing b/l Hilar LAD. Hepatosplenomegaly and generalized LAD also occur*
39
What is the 1st screening test for Sarcoidosis? Why?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What is the confirmatory test for Sarcoidosis? (2)
CXR ; [\>90% of patients have **B**ilateral Hilar LAD]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[**Lymph Node Biopsy** revealing noncaseating granulomas] --(if no lymph node accessible)--\> [Lung biopsy via bronchoscopy]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**CCuBBeDD**
*Image showing b/l Hilar LAD*
40
Sarcoidosis Etx-2 (Etiology)
[CD4 Helper T] inappropriately respond to environmental triggers + Suppressed TRegs --\> Non-Caseating Granulomas in Lung = [Asx vs pulmonary sarcoidosis(give 1 year CTS)] ➜
**75% sarcoidosis is self-limited and non-reocurring**
*Image showing b/l Hilar LAD*
## Footnote
[*Sarcoidosis: sx**CCuBBeDD*** | tx**SCAM** ]
41
Sarcoidosis Tx-4
"Sarcoidosis is a **SCAM**"
[**S**teroids1y]
**C**yclosporine
**A**zathioprine
**M**TX
*Image showing b/l Hilar LAD*
## Footnote
[*Sarcoidosis: sx**CCuBBeDD*** | tx**SCAM** ]
42
Chronic Cough is defined as ⬜
Initial evaluation for Chronic Cough is with ⬜ -- and this helps to rule out/in [Obstructive Airway Disease (asthma)]
idiopathic cough \> 4 weeks
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Pulmonary Function Test *Spirometry*
43
Exposure to ⬜ is an important risk factor for Acute Otitis Media
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you reduce frequency of *recurrent* Acute Otitis Media -4
smoking
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
NO ❌SMOKING
NO ❌DAY CARE
NO ❌ PACIFIER
✅give breastfeeding
44
[Chronic Spontaneous Urticaria]
MOD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx -2
[(Spontaneous idiopathic)urticaria episodes] \> 6 wks
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2nd gen[H1 R blocker]
+
[avoid NSAIDs]
## Footnote
*[non-sedating 2nd gen H1 R Blocker] = loratadine / cetirizine*
45
ABPA occurs in patients with ⬜ or ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
clinical features of ABPA? (4)
[ABPA (Allergic BronchoPulmonary Aspergillosis)]
[preexisting asthma] or
[preexisting cystic fibrosis]
with
**BACH**
* -[**B**rown sputum cough with fever]*
- [***A**sthma exacerbations recurrently]*
* -[**C**XR fleeting infiltrates* *(transient & different parts of lung)**]*
* -[**H**RCT central bronchiectasis]*
46
ABPA occurs in patients with ⬜ or ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
MOA?
*[ABPA = (Allergic BronchoPulmonary Aspergillosis)]*
pts with [preexisting asthma or preexisting cystic fibrosis] may develop
noninvasive colonization of of airways by *Aspergillus* -→ [EXAGGERATED IgG and IgE mediated response -→ **BACH** sx
47
Dx for [ABPA (Allergic BronchoPulmonary Aspergillosis)] -4
1. initial = [skin testing for Aspergillus]
2. [elevated total IgE]
3. [elevated Aspergillus IgE]
4. [elevated Aspergillus IgG]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
***BACH** = [**B**rown sputum cough with fever] [**A**sthma exacerbation recurrently] [**C**XR fleeting infiltrates (transient & different parts of lung)] [**H**RCT central bronchiectasis]*
48
tx for [ABPA (allergic bronchopulmonary aspergillosis)] -2
[Systemic CTS + itraconazole]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*tx = directed at acutely stopping underlying inflammation and reducing Aspergillus burden*
49
Patients s/p smoke inhalation have ⇪ risk for ⬜, and thus warrant low threshold for ⬜ if +signs of airway injury
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
For pts s/p smoke inhalation, but [stable with NO signs of airway injury] what's the alternative initial mgmt?
## Footnote
*airway injury = oropharyngeal blistering/hypoxia*
progressive airway edema and obstruction ; intubation
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[bedside fiberoptic laryngoscopy] to evaluate
50
Guidelines for Lung CA screening - 3
**low dose annual CT** if fits all 3 criteria:
1. [55-80 yo]
2. smoked for ≥20 pack years
3. still smoking or quit within last 15 years
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Pack Year = [# of packs/day x # of years smoking]*
*ex: [4 packs/ day x 30 years smoking = 120 pack years]*
51
what's the cause of hypoxemia in COPD patients?
poor elastic recoil + bronchitis/bronchospasm/mucus plugs ➜ ⬇︎ventilation = **[low V/Q ratio] =** poor oxygen delivery to well perfused areas
*supplemental O2 ⇪ delivery of O2 to (and ergo) ⇪ oxygen exchange in lung regions with low V/Q*
52
SOLC is associated with *LEMS* and ⬜ syndrome?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When this occurs, how is it treated?
SIADH
## Footnote
( ➜ euvolemic hypOnatremia)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Water Restriction
53
*Pts p/w anaphylaxis can be discharged or admitted*
What determines if a pt with anaphylaxis should be admitted for observation? (2)
1.SEVERE (hypOtension | upper airway edema | respiratory distress)
or
2.PERSISTENT (REQD MULTIPLE EPI DOSES)
## Footnote
***EPIC ➜ chag***
*these pts have ⇪ risk for potentially fatal biphasic anaphylaxis (recurrence of sx after initial resolution)*
54
# PE classification is based on the clinical presence of ⬜ and ⬜
When is a pulmonary embolism considered *submassive*? -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
treatment? (2)
(**R**& **H**)
[**R**V dysfunction = hypOkinesis vs Dilation]
[**H**ypOtension SBP less than 90]
| *"MASSIVE PE diagnosis **R**equire **H**aste!"*
## Footnote
[⊕**R** : ⊝**h** *= subMassive*] → [(UFH anticoag) vs (catheter-thrombolysis)]tx
55
# PE classification is based on the clinical presence of ⬜ and ⬜
When is a pulmonary embolism considered *MASSIVE*? -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
treatment? (2)
(**R**& **H**)
[**R**V dysfunction = hypOkinesis vs Dilation]
[**H**ypOtension SBP less than 90]
| *"MASSIVE PE diagnosis **R**equire **H**aste!"*
## Footnote
[⊕**R** : ⊕**H** *= MASSIVE*] → [(Embolectomy) vs (**systemic** thrombolysis)]tx
56
# PE classification is based on the clinical presence of ⬜ and ⬜
When is a pulmonary embolism considered *low risk*? -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
treatment?
(**R**& **H**)
[**R**V dysfunction = hypOkinesis vs Dilation]
[**H**ypOtension SBP less than 90]
| *"MASSIVE PE diagnosis **R**equire **H**aste!"*
## Footnote
[⊝**r** : ⊝**h** *= low risk*] → [(UFH anticoag)*unless CTX*]tx
57
Explain why Obstructive sleep apnea is important in assessing if patient can have surgery or not?
OSA ⇪ risk for periOperative **RESPIRATORY FAILURE** if pharmacologic hypOventilation [sedation/neuromuscular blocker/opioids/anesthesia] occurs
##Footnote
*will p/w HYPERCapnia and hypoxia*
58
Criteria for Pulmonary HTN
Pulm Arterial presure **≥25**(normal = 20)
59
# *Pulm HTN = [≥25 Pulm Arterial Pressure ] (nl=20)*
What are the causes of Pulmonary HTN?-4
What's most common cause?
①{*pulm***ARTERY** *(intrinsic)*(Idiopathic, [Limited CREST Scleroderma], HIV, Schistosomiasis, SLE)
② ⭐{*L***HEART**❌= MOST COMMON CAUSE}⭐
③**LUNG**(Chronic Lung Dz/Hypoxemia/OSA)
④ *pulm***VEIN**(CTEPE)
| *[(pulmonary HTN ≥25 PAP) females] should AVOID PREGNANCY!*
## Footnote
*🔎CTEPH = Chronic ThromboEmbolic Pulm HTN*
60
Acute Bronchitis sx (4)
*the bronchitis* **CAWS**
1. [**COUGH (+/- productive) 5D-3W** ⼀self-limited]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2. ALS
3. [Wall (chest wall tenderness)]
4. [SYSTEMIC SX ABSENT (FEVER = C/F bPNA)]
*aLS = Adventious Lung Sounds (wheezing/rhonchi) / bPNA = bacterial PNA*
61
Acute Bronchitis MOD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is Acute Bronchitis treated? (3)
[preceding*viral URI*]*➜* bronchial epithelial sloughing ➜ bronchial inflammation
➜{[**COUGH (+/- productive) 5D-3W** ⼀self-limited] (CAWS sx)} 2/2 lung's attempt to clear slough debris
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. bronchoDilators
2. NSAIDs
3. NO ABX
62
Acute Bronchitis MOD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is Acute Bronchitis diagnosed? (2)
[preceding*viral URI*]*➜* bronchial epithelial sloughing ➜ bronchial inflammation ➜ {[**COUGH (+/- productive) 5D-3W** ⼀self-limited] (CAWS sx)} 2/2 lung's attempt to clear slough debris
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Clinical
(CXR if PNA suspected)
63
What paraneoplastic syndromes is Squamous cell lung carcinoma associated with?
s**Ca****++**mous cell carcinoma!
⬆︎⬆︎PTHrelatedProtein --\> **HYPERCALCEMIA**
64
Which **bacteria** cause Community Acquired PNA-8
1. Strep Pneumo
2. H. Flu
3. Moraxella
4. MRSA
5. Mycoplasma pneumoniae-*AT (ATypical)*
6. Chlamydophila pneumoniae-*AT*
7. Chlamydophila Psittaci-*AT*
8. Legionella-*AT*
65
Which **NON**-bacteria cause Community Acquired PNA-3
1. Flu
2. TB
3. Histoplasmosis
66
*Vancomycin is not typically used for empiric CAP tx*
When would Vancomycin be used in CAP? (4)
1. septic shock
2. respiratory failure
2. [MRSA imaging (multilobar PNA with cavitation)]
3. [MRSA colonization (HD, HF, MRSA colonization hx)]
67
How do you determine disposition for Community Acquired PNA ?
**CURB 65**
**C**onfusion
B**U**N \> 20
**R**espiratory Rate \> 30
**B**P \< [(90) / (60)]
**65** y/o +
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[0-1 = outpatient with f/u] | [2 = inpatient] | [3+ = ICU]
68
Treatment for *ICU* CAP (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Community acquired pneumonia
**βF** | **βM**
69
Treatment for *Inpatient* CAP (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Community acquired pneumonia
**F** | **βM**
70
Treatment for *Outpatient* CAP (4)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Community acquired pneumonia
**A** | **D** | **F**\* | **βM**\*
71
What is an Auricular hematoma?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What's the management for it? (3)
blunt ear trauma → hematoma between [outer ear cartilage] and perichondrium
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. [**STAT hematoma evacuation**]*to avoid infection, avascular necrosis and permanent cauliflower ear deformity*]
## Footnote
*also*:
2. POabx
3. Pressure dressing*to prevent re-accumulation of blood s/p evac*
72
# *PE mgmt is based on HDS vs HDUS.* [PE HDUS = ⬜]
How do you workup [HD**S**Pulmonary Embolism]?
PE HDUS{[(SBP< 90)x ≥15m]
or
[requires vasopressor|inotrope support]}
73
# *PE mgmt is based on HDS vs HDUS.* [PE HDUS = ⬜]
How do you workup [HD**US**Pulmonary Embolism]?
(PE) HD**US** = {[(SBP< 90)x ≥15m]
or
[requires vasopressor|inotrope support]}
74
*HDUS patient (SBP \< 90) with suspected obstructive shock 2/2 **massive** pulmonary embolism*
How do you manage this? (2)
[Thrombolysis**Systemic**]
and/or
Embolectomy
75
# *pt w suspected PE → HDS →[no RV_TTE❌]→ pretest probability*
describe how to determine pretest probability for suspected *HDS* Pulmonary Embolism? (3)
wells: " *Don't Die | Tell Team To | Calculate Criteria* "
[HIGH ≥**6**]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[3-**5** = INTERMEDIATE]
[ low ≤2]
76
What are the EKG signs for Pulmonary Embolism? (3)
*"for PE EKG use **RST**"*
1. **R**AD👇🖐🏾
2. [**S**1Q3T3]
3. [**T**WIin precordial V1-V6]
77
What are the 3 different ways you can diagnose ANAPHYLAXIS?
rapid onset of...
1. [🅂 + (🆁↔🆅)any antigen]
2. [≥2 🅂 🅲 🆁 🅶{+🄽*\*} Likely antigen]
3. [🆅**KNOWN antigen**]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[🅂kin/mucosa] [🅲 ardio] [🆁 espiratory] [🅶I] [🆅ascular low BP]
*these pts should be prescribed self-injectable epinephrine!*
| \*\* add 🄽euro ⼀if peds
## Footnote
tx = ***EPIC ➜ chag***
78
Chronic Spontaneous Urticaria
dx? (5)
1. **skin bx (to exclude urticarial vasculitis or mastocytosis)**
2. CBC
3. UA
4. [CRP or ESR]
5. LFT
79
# a Chronic spontaneous urticaria patient has been given [2nd gen H1 R blocker] with no relief
What therapies can be tried next? (4)
1. [1st gen H1 R blocker] at bedtime
2. [Leukotriene R blocker (*montelukast*)]
3. H**2** R blocker
4. CTS PO
80
# Chronic Spontaneous Urticaria
prognosis?
self-limited to 2-5 years
81
chronic Cough is a common (and sometimes the only) symptom of ⬜ and is treated with ⬜ weeks of PPI
GERD; 8
82
What is the MOST RELIABLE method for verifying ETT placement?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the *less reliable* methods of verifying ETT placement? (4)
**[CO2 CAPNOGRAPHY]** - *(CO2 analysis)* either via [waveform (quant vs rectangular) analysis] or [colorimetric litmus (purple ➜ yellow) analysis]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[bs Auscultation], [chest rise], [ETT passing thru vocal cord visualization], [ETT fogging]
83
# HIV+ pts have higher risk for [Active TB Infection]
Explain how CD4 count is *specifically* related to TB -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* ⇪ CD4 = Cavitary apical lung TB
* ⬇︎CD4 = [Lobar/Pleural/Disseminated] TB
84
clinical findings for [**TB** pleural effusion] (5)
*commonly found in advanced HIV*
* ⇪ Adenosine DeAminase
* lymphocyte predominant
* exudative
* negative smear
* dx = [pleural biopsy demonstrating histopathologic pleural granuloma]
85
# Meniere disease
clinical presentation (5)
[***24*VATH**]
* *24m - 24H*episodes
- **V**ertigo
- **A**ural fullness
- **T**innitus
- **H**earing loss uL (*low freq sensorineural*)
86
# Meniere disease
etx?
defective inner ear endolymphatic resorption ➜ ⇪ [endolymph volume/pressure distension = **endolymphatic hydrops**] ➜ vestibular and auditory damage ➜ [***24*VATH**]Meniere sx
87
# Meniere disease
dx? -2
- comprehensive audiogram
- MRI(to r/o other *central* vertigo etx)
## Footnote
*"Meniere must"**DAB**tx on ****24*VATH***sx *"
88
# Meniere disease
Tx? (5)
1. [**(D)iet ∆***(⬇︎Salt, ⬇︎Caffeine, ⬇︎EtOH)*]
2. RxMaintenance[**HCTZ** | **(B)etahistine**]
3. RxACUTE[**(A)ntiemetics** | **vestibular suppressants**]
## Footnote
*"Meniere must"**DAB**tx on ****24*VATH***sx *"
89
# BPPV
MOD
*Ca+ otoliths accumulated within semicircular canals --\>*
[brief < 1 min] episodes ([triggered by head position ∆*ie Dixhall-Pike*] ) of:
-**N**auseous
-**D**izzy(Vertigo)
-**N**ystagmus
| "*BPPV gave me...***N**auseous **D**izzy **N**ystagmus"
90
What does pulmonary contusion look like on radiograph?
localized irregular lung opacification - *up to 24h s/p blunt chest trauma*
91
how do you treat pulmonary contusion? (2)
1. supplemental O2
2. pain control
92
# patient with suspected PE, CTA CTD ➜ abnormal V/Q
How do you interpret V/Q scan? (4)
93
What is Pulmonary Cachexia Syndrome? (2)
* loss of lean muscle mass 2/2 SEVERE COPD (⇪ WOB ➜ energy imbalance ➜ wt dysregulation)
* and (systemic inflammation ➜ ⬇︎appetite)
*tx = optimize lung function and nutrition*
94
In patients with impaired renal function, ⬜ is most appropriate to evaluate for acute PE. How is acute PE positively confirmed using this modality?
V/Q scan;
95
[T or F] Fever is not a symptom of Pulmonary Embolism
FALSE! ⼀15% of PE has fever
*(= abx not indicated if no other infectious s/s)*
96
# "Flash" pulmonary edema occurs from ⬜
▶For *FLASH* pulmonary edema, between **F**urosemide*diuretic IV* and [**N**TG*venoDilator IV* )], which takes priority?
▷why?
[HTN Emergency \> 180/120]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[**N**TG venoDilator IV]
◁⼀venoDilation by *NTG rapidly DEC cardiac preload* *(which rapidly DEC intracardiac filling pressures*)*➜ rapid “flash” pulmonary edema improvement*
97
What condition is a/w hyperacute stridor after extubation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Explain
Laryngeal edema
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
direct mechanical damage from intubation ➜ laryngeal inflammation/edema ➜ does not symptomatically present until pt extubated and breathing on their own = **PostExtubationStridor ➜ REINTUBATE TX**
98
a. In acute PE, What is the [most important *predictor* of INC PE Mortality]?
b. explain why
a.[**HDUS *severe hypOtension*✳**]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
b.
▶{[HDUS *severe hypOtension*] ⬅︎ [RV❌] ⬅︎ [*MASSIVE* (Obstructive) PE = INC PE Mortality]}
▶so... [HDUS *severe hypotension*] is an important *predictor* for INC PE Mortality
| INC *short term* PE mortality
## Footnote
✳*{[SBP < 90 x ≥15m] |vasopressor💊|inotrope💊}*
*🔎RV❌ = RV Dilation|RV hypOkinesis*
*📖 {[HDUS *severe hypOtension*] likely indicates [RV❌] which likely 2/2 a [*MASSIVE* (Obstructive) PE] which → INC PE Mortality*}
99
⬜ is the MOST IMPORTANT predictor of increased short term mortality in acute PE patients
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Name other predictors (7)
[**HDUS severe hypOtension*([SBP < 90 x ≥15m]|vasopressors|inotropes)***
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* Age
* AMS
* CA
* Tachypnea
* Tachycardia
* hypOthermia
* hypOxemia severe
100
Describe the 4 treatment options for patients with acute PE
101
Describe [Exercise Induced Bronchoconstriction] (3)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
MOD?
-{[asthma-*like* reaction] to exercise}
-**WITH OR WITHOUT PREEXISTING ASTHMA**
-in mostly athletes
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Hyperventilation shortens time for humidification] ➜ cool dry air stimulates mast cell degranulation ➜ bronchoconstriction
102
# EIB = asthma-"LIKE" rxn during exercise ( +/- hx of asthma)
How do you diagnose [Exercise Induced Bronchoconstriction]?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is it treated?
[Exercise challenge ➜ (FEV1 ⬇︎ GOE15% from baseline)] = EIB
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[bronchoDilator 10m before exercise]
103
# Usually, Influenza treatment consist of {⬜ **+/-** [O|Z]}
Which patients are eligible for [Oseltamivir|Zanamivir]? (3)
***APAP**(symptomatic care)*
+/- [O|Z] if...
1. [ < 48h **exposure***(w/wo sx)*]
2. pt presenting **AT sx onset**
3. {[High risk comorbidities(DM, CardioPulm❌, prior flu hospitalization) = add [PNA CXR r/o] }
104
What causes Snoring?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What factors increase Snoring? (3)
[relaxed upper airway during sleep (habitual vs OSA)]➜ respiration induced soft tissue vibrations
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. EtOH before bed
2. smoking
3. [obese BMI>35]
105
For patients p/w Snoring, how can you initially screen them for OSA?
[**STOPBang**] ≥3 = ⊕OSA
106
Dx Criteria for *screening* test of Obstructive Sleep Apnea
[**STOPBang**] ≤ 2 = not OSA
*a/w mild cognitive impairment in elderly*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Other causes of sleepiness: narcolepsy, restless leg, depression, drugs*
107
List for *confirmation* test for Obstructive Sleep Apnea
POLYSOMNOGRAPHY
## Footnote
*Other causes of sleepiness: narcolepsy, restless leg, depression, drugs*
108
Why does INC respiratory drive in a patient receiving chronic Opioids concerning?
chronic opioids should ➜ DEC respiratory drive, and since Opioids blunt respiratory response … breakthrough [INC respiratory drive] in the setting of chronic Opioids **likely indicates abnormal NON-opioid process (SUCH AS Pulmonary Embolism)**
109
*The Centor Criteria is used to differentiate Patients with Acute Pharyngitis*
Recite the Criteria
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Explain the Interpretation
*\*old AGE: [add 1pt← (15-44) → subtract 1pt]*
110
# (malignant) Mesothelioma
Sx (4)
1. [**PLEURAL EFFUSION**
2. with [pleuritic chest pain, cough and SOB]
3. Night sweats
4. Wt loss
111
# (malignant) Mesothelioma
How is it diagnosed? (3)
1. *Chest Imaging *[**PLEURAL CALCIFICATION** and **THICKENING**]
* * *
2. [Thoracentesiswith Cytology]
3. [Thoracotomy bxOpen vs VATS]
112
# (malignant) Mesothelioma
occurs typically from ⬜ but arises ⬜ after exposure.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx includes ⬜3 and median survival after dx is ⬜
[occupational asbestos(cement/tile/ships) exposure]; 15-30y
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[**Palliative**, Surgery, Chemoradiation] ; 9-13 months
113
Thoracic duct obstruction can cause ⬜. Diagnosis is supported by ⬜ lab
chylothorax ; [pleural fluid TAG \> 110]
| *from milky white lymph leaking out of the thoracic duct into lung*
114
Chronic silicosis is an occupational lung disease that commonly affects which job professions? (4)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What would you expect on CXR? (2)
Miners | sandblasters | foundry workers | masons
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
upper lobe nodules + lower lobe emphysema
115
What are the following measurement values for EXUDATIVE pleural fluid :
[Pleural:Serum Protein]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Pleural:Serum LDH]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Usually caused by ⬆︎capillary or pleural membrane permeability*
**Pleural:Serum protein \>0.5**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**Pleural:Serum LDH \>0.6**
116
What are the following measurement values for transudative pleural fluid :
[Pleural:Serum Protein]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Pleural:Serum LDH]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**Pleural:Serum protein ≤0.5**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**Pleural:Serum LDH ≤0.6**
117
What are the following measurement values for EXUDATIVE pleural fluid :
pH
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Glucose
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Usually caused by ⬆︎capillary or pleural membrane permeability*
pH\<2
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
Glucose\<60
118
What are the following measurement values for transudative pleural fluid :
pH
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Glucose
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**pH = 7.4 - 7.55**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**Glucose \> 60**
119
Causes of transudative pleural effusion -2
hypOalbumin (Cirrhosis / nephrOtic syndrome)
CHF
120
Causes of EXUDATIVE pleural effusion -3
[INFECTION (TB / FUNGAL)]
CA
PE
121
[Pleural Fluid LDH] that is \> [2/3 Upper Limit of Normal Serum LDH] is
(⬜ transudate | EXUDATE)
EXUDATE
122
[Pleural Fluid LDH] that is ≤ [2/3 Upper Limit of Normal Serum LDH] is
(⬜ transudate | EXUDATE)
transudate
123
Explain MOD for CHF pts experiencing pulmonary edema after a MI
[precipitating factor(HTN* = "flash pulmonary edema"* , MI, arrhythmia, valve dysfxn) ] causes abrupt INC in [L atrial pressure (Pulmonary Capillary Wedge Pressure)]
➜ INC transmitted back pressure to the pulmonary venous system = pulmonary edema
124
CHF Exacerbation
treatment? (3)
🆂🅿︎🅸
1.🆂table?([Respiratory❌→ NIPPV,O2] , [Cardiac shock → inotropes])
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2.🅿︎[**P.O.N.D. *PRELOAD REDUCTION*][*****➜ DEC PCWP******* **(+/- DEC afterload)**] = {[PPV&Positionupright], [O2], [NTG&Nitroprusside*(prn afterload DEC)*], Diuretics]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
3.🅸nvestigate cause(EKG, troponin, echo, CXR, BNP)
125
# *Pulm HTN = [≥25 Pulm Arterial Pressure ] (nl=20)*
How is a female patient with new dx Pulmonary HTN related to pregnancy?
females with pulmonary HTN carry extremely high pregnancy mortality risk = **[pulmonary HTN females] should AVOID PREGNANCY!**
126
# *Pulm HTN = [≥25 Pulm Arterial Pressure ] (nl=20)*
*There are ⬜# causal groups for Pulmonary HTN*
Briefly List general mgmt *all* Pulm HTN pts should receive? (6)
4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
🎯**REFER TO ACCREDITED PH CENTER**
🎯Stabilize
🎯[Contraception⚠️*Pulmonary HTN females on Pulm HTN meds should AVOID PREGNANCY!*]
🎯Immunization
🎯 ❤️Rehab
🎯BL lung transplant*if Refractrory PH*✳
127
[hot potato muffled voice] is one of the features of PTA (and other dz) caused by ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the other clinical features of Peritonsillar abscess? (5)
[***(PTA/epiglottitis/RTA/mass)***]DEC space in POST pharynx ➜
1.⭐{DEC voice resonance = [hot potato muffled voice]⭐
## Footnote
2.[PTA**TRISMUS⊕**]
3.[CTL uvea deviation *uvula deviates *OPPOSITE* the lesion*]
4.Sore throat w/dysphagia
5.Fever
6.saliva pooling
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*[trismus(inflammatory spasm of nearby pterygoid m)] differentiates [PTA(TRISMUS⊕)] from [tonsillitis(trismus⊝)]*
128
Tx of Peritonsillar Abscess (2)
[Drain Abscess**Needle aspiration** > I&D ]
+
[AbxGASP + Respiratory AnAerobes]
## Footnote
✏️*[trismus(inflammatory spasm of nearby pterygoid m)] differentiates [PTA(TRISMUS⊕)] from [tonsillitis(trismus⊝)]*
129
Trismus is defined as ⬜
How is it related to Peritonsillar Abscess and Tonsillitis?
inflammatory spasm of pterygoid muscles ➜ inability to open mouth = SURGICAL INTERVENTION if PTA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*[trismus differentiates [PTA**(TRISMUS⊕/surgical intervention)**] from [tonsillitis**(trismus⊝)**]*
130
A pt with throat pain also begins having ear pain. why?
referred ear pain occurs with multiple throat pathologies 2/2 overlapping innervations from the *afferent*[glossopharyngeal CN9] and *afferent*[Vagus CN10] --both traveling into ear
131
# Smoking Cessation tx = CBT + Rx
List and Briefly describe the 4 [Rx pharmacologic] options for smoking cessation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Although ⬜ is the MOST effective, which of these treatments are better together than alone?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
VARENICLINE ; [LANRT + SANRT *(combined NRT is better!*]
132
*benign* [Solitary Pulmonary coin nodules] have what type of radiographic Calcification? (4)
[Hamartoma *POPCORN* calcification]
concentric
central
[diffuse homogenous]
133
*MALIGNANT* [Solitary Pulmonary coin nodules] have what type of radiographic Calcification? (3)
***RIP***
**R**ETICULAR
[**I**RREGULAR = ECCENtR**I**C, asymmetrical]
**P**UNCTATE
134
[Alpha 1 antitrypsin deficiency] __(*MOD)*\_ is a potential cause of ⬜
[*α1aT inhibits neutrophil elastase from breaking down lung tissue*
. so
⬇︎α1aT → ⇪ neutrophil elastase lung tissue breakdown which → emphysema)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
; emphysema
135
What is Hypersensitivity Pneumonitis?
[inhaled antigen(poultry/mold/meth?)] overactivates Pulmonary immune system → Dyspnea & Cough
136
“Double Sickening” is a a common clinical sign of ⬜ by ⬜3.
Explain (2)
[ABRS (Acute Bacterial RhinoSinusitis)]; [***SMH** (Strep pneumo/Moraxella catarrhalis/HFlu)*] ;
* Double Sickening Effect= { *[viral URI]* → [_initial_ improvement]**≥5d** → ***[sudden clinical deterioration*** **(SMHH sx)*** * *from ABRS]* }
* Tx = {[Amox/clav PO]7d + [intranasal saline irrigation] + analgesics}
137
etx for [ABRS 2/2 viral URI]
## Footnote
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*ABRS: Acute Bacterial RhinoSinusitis*
[Viruses (rhino/flu/adenovirus)] are most common to infect nasal/sinus mucosa = [(ARS) Acute rhinosinusitis] (resolves within 10d)
BUT…10% people develop secondary bacterial infection in which
[***SMH***bacteria→ **SMHH**sx = ABRS] ⼀this is *Double Sickening effect*
* * *
*(**S**trep pneumo/**M**oraxella catarrhalis/**H**Flu)*
[**S**notty _purulent_ nasal discharge/**M**axillary facial pain/**H**A/**H**ot\>39C] ≥3d = *ABRS*
138
Diagnostic criteria for [(ABRS) Acute Bacterial RhinoSinusitis] -3
*any 1 of the following:*
1. mild[**smhh**sx ]≥10d ⼀*(persistent)*
2. SEVERE[**SMHH**sx]≥3d
3. Double Sickening effect
* * *
## Footnote
ABRS = [*(**S**trep pneumo/**M**oraxella_catarrhalis/**H**Flu)* → **SMHH**sx ]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**SMHH**sx = [**S**notty _purulent_ nasal discharge/**M**axillary facial pain/**H**A/**H**ot\>39C]
139
Tx for [(ABRS) Acute Bacterial RhinoSinusitis] -3
* * *
What are 2 alternative abx if [1st line abx] is unavailable?
{[Amox/clav PO]7d+ [intranasal irrigation] + analgesics}
* alt: Doxy or Fluoroquinolones*
* * *
[SMH → SMHH = ABRS]: (**S**trep pneumo/**M**oraxella catarrhalis/**H**Flu) →
[**S**notty _purulent_ nasal discharge/**M**axillary facial pain/**H**A/**H**igh Fever\>39C]
140
▶ Pts with [mild rhinosinusitis sx] less than ___ days likely have viral ARS and should receive symptomatic treatment only
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶ when should you suspect Acute **B**acterial RhinoSinusitis? (3)
| ARS: Acute RhinoSinusitis
▶10 (*viral ARS resolves by 10 days*)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
▶
*any of below:*
1. mild[**smhh**sx ]≥10d ⼀*(persistent)*
2. SEVERE[**SMHH**sx]≥3d
3. Double Sickening effect
141
Varenicline MOA (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*There are 4 stages for [smoking cessation (NRSQ)]*
At what stage of smoking cessation is Varenicline indicated? and why?
1. [Nicotine R BLOCKER]*= ⬇︎ cigarette gratification*
PLUS
2. [Nicotine R agonist]*= prevents nicotine withdrawal sx*
* * *
1S[**N**ot ready*to quit*]
( in [“future quitters” ⼀*patients unable to give quit date now BUT interested in cutting down in undetermined future*]…Varenicline **DOUBLES** probability of smoking cessation!
= prescribe [Varenicline12w trial] to “future quitters” as part of *reduce-to-quit* strategy)
142
# The 4 [smoking cessation stages] are ⬜
Describe the 3 interventions employed for smoking cessation stage
1 _____?
1[**N**ot ready*to quit*] → 2[**R**eady*to quit*] → 3[**S**truggling*to quit*]→ 4**Q**UIT
* * *
1[**N**ot ready*to quit*]
1.MIV: Motivational Interviewing (reswo)
2.Repeat screening every visit
3.1º🚭Rx[Varenicline12w trial]
## Footnote
*🚭= smoking cessation*
143
# The 4 [smoking cessation stages] are ⬜
Describe the 4 interventions employed for smoking cessation stage
2 _____?
**NRSQ**
1[**N**ot ready*to quit*] → 2[**R**eady*to quit*] → 3[**S**truggling*to quit*]→ 4**Q**UIT
* * *
2[**R**eady*to quit*]
1. 2º🚭Rx[Varenicline*prescribe stage 1-N* /NRT/Bupropion]x 12w trial
2. [SET FIRM QUIT DATE]
3. [DISARD PARAPHERNALIA]
4. Behavioral counseling
| *NRT=Nicotine Replacement Therapy*
144
# The 4 [smoking cessation stages] are ⬜
Describe the 3 interventions employed for smoking cessation stage
3 _____?
**NRSQ**
1[**N**ot ready*to quit*] → 2[**R**eady*to quit*] → 3[**S**truggling*to quit*]→ 4**Q**UIT
* * *
3[**S**truggling*to quit*]
1. [Reinforce partial achievement]
2. [Identify & link struggling triggers to other activities]
3. Biofeedback loops*(exhaled CO monitoring, mobile app gamification)*
145
# The 4 [smoking cessation stages] are ⬜
Describe the 4 interventions employed for smoking cessation stage
4 _____?
**NRSQ**
1[**N**ot ready*to quit*] → 2[**R**eady*to quit*] → 3[**S**truggling*to quit*]→ 4**Q**UIT
## Footnote
4**Q**UIT
1.Congratulate
2.Continue support
3.Continue 🚭Rx x 12w
4.[encourage *reflection**"how has your life changed?"*]
146
# [Motivational interviewing (MIV)] guides “quitting addictions or habit”.
Describe the 4 rungs of *MIV*
{stage 1N[r*e s w o*]MIV}
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
r*_o_*adblocks*to quitting the a/h*
⬆
re*_w_*ards*to quitting the a/h*
⬆
ri*_s_*ks*to quitting the a/h*
⬆
r*_e_*levant*⼀Based on how an addiction/habit is affecting pt's life rn⼀does pt consider quitting that a/h a relevant interest at this time? [Y → next rung | N → inquire why not]*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
“*climb 4 rungs of MIV up and out of of addiction”*
147
# The 4 [smoking cessation stages] are ⬜
*In which [smoking cessation stage] is\_\_\_X\_\_\_ employed?*
a. [MIV (Motivational Interview)]
* * *
b. [Biofeedback loops *(i.e. ⬜*2*)*]
* * *
c. [Nicotine Replacement Therapy or bupropion]
**NRSQ***to quit*
a. 1[**N**ot readytq]
* * *
b. (*i.e. exhaled CO monitoring, mobile app gamification*) = 3[**S**trugglingtq]
* * *
c. 2[**R**eadytq]
148
# The 4 [smoking cessation stages] are ⬜
*In which [smoking cessation stage] is\_\_\_X\_\_\_ employed?*
[Setting a firm Quit Date & Discarding Smoking Paraphernalia]
2[**R**eadytq]
## Footnote
* * *
**NRSQ***to quit*
149
clinical features of [*Cough Variant* Asthma] (6)
1. [chronic nonproductive cough]
2. triggered by **forced expiration**, nighttime, exercise, allergens
3. NO classic asthma [sx*(wheeezing/SOB)*]
4. NO classic asthma [pex*(rhonchi)*]
5. Dx: ⊕methacholine challenge (inducible airway obstruction)
6. Tx: same as Asthma
150
# Sudden SensoriNeural Hearing Loss
a. SSNHL presents as ⬜, and once diagnosed requires what course of management? (2)
b. How would you expect Rinne and Weber to result for Sensorineural Hearing loss?
a. Sudden Hearing loss with [**normal** **H & P]**:
-[**URGENT ENT CONSULT**( [+/- MidEar CTS_high dose] within 24H) ] (for audiogram, MRI)
## Footnote
- nml hx (no recent trauma, no recent pain)
- nml ear exam
- nml neuro exam (aside from SSNHL)
151
a. [normal Rinne = ⬜] and [normal Weber = ⬜]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
b. How would you expect Rinne and Weber to result for *Conductive* Hearing loss?
normal***R***aa***W***M
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
cdl***r***b***w***a
152
a. [normal Rinne = ⬜] and [normal Weber = ⬜]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
b. How would you expect Rinne and Weber to result for *Sensorineural* Hearing loss?
normal***R***aa***W***M
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SSL***R***aa***W***U
153
a. [normal Rinne = ⬜] and [normal Weber = ⬜]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
b. How would you expect Rinne and Weber to result for *mixed* hearing loss?
normal***R***aa***W***M
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
mXL***R***b***W***u
154
name the 4 groups (*with examples*) of asthma triggers
## Footnote
[Viral URI] > [House dust mites] > {[Animal dander] = [Aspergillus mold]}
155
# Inhaled allergens are the most common group of asthma triggers
**Of the Inhaled allergens group**, ⬜ is the overall most common asthma trigger; with ⬜ and ⬜ following after.
[House dust mites]60-90% of cases \> [Animal dander] = [Aspergillus mold]
## Footnote
⚠️note: [Viral URI] is *the* most common trigger of asthma exacerbation
156
# Inhaled allergens are the most common group of asthma triggers
Explain why **[House Dust Mite]** *control* is an important adjunctive tx for persistent asthma
60-90% asthma exacerbation are related to HDM (microscopic translucent critters that infest woven material like bedsheets/carpets) leave immunogenic fecal particles→ allergic inflammation = Mite control DEC exacerbations & improves lung fxn
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[House dust mites]60-90% of cases \> pet dander = [Aspergillus mold]
## Footnote
[Viral URI] > [House dust mites] > {[Animal dander] = [Aspergillus mold]}
157
[SVC syndrome] must be suspected in any _high risk CA_ pt who presents with what 4 things?
The best diagnostic test for [SVC syndrome] is ⬜
1. [**⭐BILATERAL⭐** facial/neck edema*(uL = brachiocephalic vein obstruction)*]
2. subQ venous dilationcervical, UE
3. dyspnea
4. coughpersistent
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[contrast CTNeck / Chest]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Superior Vena Cava syndrome is likely 2/2 bronchogenic carcinoma*
## Footnote
✏️*Both SVC and brachiocephalic vein obstruction → facial/neck edema but [SVC is **BL**] and [brachiocephalic = uL]*
158
⬜ should be considered in the ddx for HD patients with sudden dyspnea and flushing shortly after starting HD and receiving iron infusions (or other meds) during HD
Anaphylaxis1A
| GIVE [**EPIC ➜ chag**]!
## Footnote
*[ironIV] is a known allergen, and is commonly used for treating anemia in HD pts.*
159
⬜ is the most common trigger of asthma exacerbation. What is the clinical definition of asthma exacerbation? (2)
viral URI
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INC asthma sx (cough, SOB, wheezing)
+
DEC peak expiratory flow rate \>20%
160
a. treatment for [mild *resistant(unresponsive to initial bronchoDilator)* asthma exacerbation] in an outpatient setting
b. Why this treatment? (2)
a. [Prednisone40-60mg PO QD x 7d] (CTS short course)
b. [INC long term control] / [DEC future hospitalization]
161
Pts with smoker hx p/w non-resolving PNA should make you s/f ⬜. If so, obtaining ⬜-2 is 1st step for this diagnosis. Why?
[endobronchial malignancy (*since obstructive endobronchial malignancy would prevent complete PNA drainage/resolution → nonresolving PNA*)];
[CT chest → bronchoscopy]
→ will help diagnose & workup malignancy as well as diagnose other causes of nonresolving PNA (abscess/empyema)
162
# bronchiectasis is characterized by ⬜ and ⬜
b. MOD for [*focal* bronchiectasis]
c. how do you diagnose and treat [*focal* bronchiectasis]?
[**permanent airway dilation]** and [daily copious mucus production]
* * *
b. Focal bronchiectasis (involvement of single lobe/segment only) indicates airway blockage (malignancy/foreign body) ⼀mucus becomes trapped behind obstruction → [bacterial overgrowth (i.e.post-obstructive PNA)] → inflammatory bronchial wall damage → focal **permanent airway dilation**.
c. bronchoscopy *(allows for diagnostic and therapeutic removal of obstructing lesion {since note: initial CT may not reveal obstructing lesion})*
| general bronchiectasis dx = [airway dilation on High Res CT]
163
Clinical features of Bronchiectasis (3)
1.{***impaired airway clearance →*** [chronic copious (+/- blood tinged)mucus production]}
2. → {[acute recurrent lung infections +/- frank hemoptysis*2/2 airway destruction*]}
3. → {[permanent airway dilationon HRCT = dx]*2/2 continued airway destruction*}
164
Major causes of Bronchiectasis (5)
*(i\initial airway insult} -->
**impaired airway clearance 2/2***:
1. airway obstruction (*focal*)
2. Mucostasis (CF, Kartagener)
3. Immune (HYPER/Auto = Sjogren syndrome vs hypo = immunodeficiency)
4. Infection (TB, ABPA)
5. Toxic inhalation
| -->chronic mucous -->chronic inflammation --> blood bronchi dilatation🔃
165
Bronchiectasis dx (3)
-**[HRCT chest(airway Dilation)] = needed for dx**
## Footnote
-[PFT(Obstructive pattern)]
-[Investigate etx(cx, Ig levels)]
166
Bronchiectasis
tx (3)
- [Airway clearancechest physiotherapy , mucolytics]
- [Abxtreats overgrowth & exacerbations]
- [Address underlying etx]
167
(⬜ dx?) is typically caused by ⬜
Pts with risk factors should undergo ⬜ and make Modifications to their ⬜-2 to prevent recurrence
Lung Abscess; [aspiration of anaerobic bacteria]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[speech/swallow evaluation] ;
Diet (thickened liquids) and/or Positioning (chin tuck)
168
Describe the Chest CT
What's the dx?
Lung **[AIR FLUID LEVEL]** amid pulmonary consolidation = LUNG ABSCESS
## Footnote
*these pts also have sour tasting sputum*
169
*Anaphylaxis is difficult to diagnose in peds*
describe the criteria
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx for peds Anaphylaxis -8
after allergen exposure, pt has acute allergic sx in ≥2 systems
[≥2 🅂 🅲 🆁 🅶{🄽\*\*} Likely antigen]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**EPIC ➜ chag** *but*
[Epinephrine 0.1 mg/kg IM]
| \*\* peds only
## Footnote
* [Skin/Neurologic/Respiratory/CV/GI]*
170
tx for [Necrotizing Malignant Otitis Externa] -4
| NMOE
**mild = topical acetic acid**
moderate = topical cipro
[SEVERE (canal 100% occluded) = wick placement adjunct]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INVASIVE! = CIPRO IV
*7 day treatment*
## Footnote
[NMOE = ⊕FEVER] vs [BOE= ⊝fever]
171
management of Acute Mastoiditis -2
[middle ear drainage (via mastoidectomy or {tympanostomy +/- ear tube placement})]
+
IV Abx
172
# BPPV
CP-3
| (Benign Paroxysmal Positional Vertigo)
"*BPPV gave me...***N**auseating **D***ixHallpike* **N**ystagmus"*
## Footnote
*Ca+ otoliths accumulated within semicircular canals --\>*
[brief < 1 min] episodes ([triggered by head position ∆*ie Dixhall-Pike*] ) of:
-**N**auseating
-**D***ixpike*-dizzy(Vertigo)
-**N**ystagmus
173
*After receiving anesthesia, pt develops hypOtension, elevated peak pressures and DEC end tidal CO2. This is concerning for ⬜*
how should you work this up? Tx?
ddx: Anaphylaxis (*to rocuronium/abx/skin antisepsis products/blood*);
dx: PHYSICAL EXAM (look for cutaneous rash/flushing!)
tx: Epinephrine
174
[PSPST (Pancoast SUP Pulmonary Sulcus Tumor)]
has 4 main clinical symptoms
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
⬜ is the most common PSPST sx
\> ⬜ and ⬜
which are \> [⬜ (only present in 25% PSPST pts)]
1. **R SHOULDER PAIN**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
2.[*PAM* Horner Syndrome(2/2 sympathetic chain/stellate ganglion invasion)]
3.[Hand atrophy/weakness(2/2 C8-T2 spinal cord invasion)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
4.[asymmetric LE HYPERreflexia(2/2 spinal cord compression)]= *only 25% of PSPST pts*
175
In Smokers, ⬜ may be first sign of Bronchogenic Carcinoma
Why is this?
[*persistent* Recurrent PNA]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
{[Bronchogenic Carcinoma*older|smokers*] or [Carcinoid tumoryoung | NONsmoker*[FOCAL Endobronchial Obstruction]*
= **[FOCAL endobronchial obstruction]** ➜ ⬇︎clearance and eventually causes stasis of airway secretions
➜ [*persistent* Recurrent PNA (despite previous tx success)]
## Footnote
🔬Gold Standard dx = FLEX BRONCHOSCOPY
176
how do you diagnose Bronchogenic Carcinoma (or any endobronchial obstructing lesion) ?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Name an alternative
[CONFIRMATORY FLEXIBLE BRONCHOSCOPY]
## Footnote
\_\_\_\_\_\_\_\_or\_\_\_\_\_\_\_\_\_
[alternative **non**Confirmatory HRCT]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*HRCT: High Res CT*
177
Although RARE, Recurrent Pulmonary Embolism can (rarely) present as nonresolving [*PE-related*⬜] ;
but this condition will have what distinguishing symptom from its sister condition [**NON***PE-related*⬜] ?
*PE-related*[*persistent* Recurrent PNA]
; *PE-PNA → *[**pleuritic cp** with hypoxia]
| PE causes **Pleurisy**
## Footnote
*PE-**PNA** → *[pleuritic cp with hypoxia]
NON*PE (or regular) PNA *has no [pleuritic cp with hypoxia]
178
[Bacterial otitis externa] and [Necrotizing malignant otitis externa] both present with ⬜ and ⬜ from ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
how do you differentiate the two?
[pain with ear manipulation] and [purulent ear drainage] ; pseudomonas
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
NMOE = **FEVER**+[involves neighboring skull bone] + [only in elderly|DM|immunocompro]
vs
BOE = **NO fever**
179
cp for [Suppurative Bacterial Otitis Media] (4)
[fever + cranky]
➜ [purulent ear drainage w resolution of cranky]
and [NO **pinna manipulation pain]**
180
[Suppurative Bacterial Otitis Media] etx
GASP (from nasopharynx) infects middle ear ➜ TM pressure/bulging --(if untreated)--\> TM perforation ➜ *nonpainful* otorrhea purulent ear drainage **with [NO pinna manipulation pain**] = SBOM
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*[fever + cranky(from GASP nasopharyngeal infxn)] ➜ [ *nonpainful* suppurative (purulent) ear drainage with resolution of cranky]
⭐*nonpainful* = [NO **pinna manipulation pain**]*
181
[Serous Otitis Media with effusion] etx
sOME = asymptomatic middle ear effusion **in the absence of infection /inflammation**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*SBOM (➜sOME)*
182
*postop*
CXR shows [linear opacifications in the b/l lung bases]
dx?
Atelectasis
183
Postoperative atelectasis is common ⬜ days after operation
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
how is this managed? -2
2-5
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
+respiratory secretions = [Chest Physiotherapy + suctioning]
NO respiratory secretions = CPAP
184
Name the 6 major causes of Postoperative Hypoxemia
185
Name 5 distinguishing features for differentiating [**Non**Allergic rhinitis] from [Allergic Rhinitis]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx for NAR? -3
_N_AR :
1. [No Kids (= cp\> 20 yo)]
2. [No ocular sx (= Nasal sx **with NO** ocular sx - *blockage/rhinorrhea/postnasal drip*)]
3. [No identifiable allergen]
4. [No identifiable season / perennial (year long) sx]
5. [No blue Nasal mucosa (= NAR = erythematous Nasal mucosa)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Intranasal Fluticasone] or [Intranasal Azelastine (antihistamine)] --(prn) --> BOTH
186
*Pediatric patient comes in with c/f PNA*
What are the 4 classic symptoms of PNA?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you work up pediatric PNA ?
*PNA?* **FACT**
**F**ever / **A**dventitious lung sounds / **C**ough / **T**achypnea
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
187
Which 2 abx are used for *pediatric* [Community Acquired PNA]?
{**amoxicillin**([LOE4 yo] or [focal lung sounds])}
vs
{**AZithromycin**([ GOE5 yo] or [BL lung sounds i\well appearing])}
## Footnote
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*PNA?* **FACT**sx
188
Postoperative pulmonary complications occur most in pts undergoing ⬜ or ⬜ surgery.
What 4 factors make this Risk Greatest? How do you mitigate these?
thoracic; upper abd
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
COPD / smoker / CHF / OSA
*SURGERY IS DELAYED until these pulm/cardiac conditions are treated and optimized*
189
BPPV p/w ⬜ and is treated with ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you diagnose BPPV?
| *BPPV= Benign Paroxysmal Positional Vertigo*
[brief < 1 min] episodes ([triggered by head position ∆*ie Dixhall-Pike*] ) of:
-**N**auseous
-**D**izzy(Vertigo)
-**N**ystagmus
; [Epleycanalith *repositioning* procedure]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
dx: [Dix-Hallpikecanalith *diagnositc* procedure]
| "*BPPV gave me...***N**auseous **D**izzy **N**ystagmus"
190
*Both Meniere disease and [Middle ear effusion 2/2 nasopharyngeal mass] have aural fullness and hearing loss*
How do you differentiate them?
{Meniere disease (***24*VATH**])}
= effusion is in the labrinyth and not observed on physical exam
\_\_\_\_\_\_\_\_vs\_\_\_\_\_\_\_\_\_
MEE = effusion*(persistent, uL, middle ear)* **IS observed on physical exam**,
etx possibly 2/2 nasopharyngeal carcinoma mass obstructing eustachian tube orifice. requires fiberoptic nasal endoscopy
## Footnote
*"Meniere must"**DAB**tx on ****24*VATH***sx *"
*🔎24VATH = [24m-24H] Vertigo, Aural fullness, Tinnitus, Hearing loss uL*
191
Biostatistically, what are the major benefits of smoking cessation? (2)
{**AT ANY AGE** ⼀ [within 5 years of Smoking cessation]}
*pt will have ⬇︎ risk of:*
1. [all-cause mortality]
2. [CV events]
192
Although tx for OSA in adults is ⬜ , what's the first line tx for OSA in children?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
*OSA = Obstructive Sleep Apnea*
CPAP ;
[Tonsillectomy with Adenoidectomy] = 1st line for peds
193
Anaphylaxis is a Type __ reaction
Describe the reaction
1**A**
[**IgE-**mediated immediate hypersensitivity] rxn
194
Autoimmune Hemolytic Anemia is a Type __ reaction
Describe the reaction
2**C**
**Autoantibodies** directed against the host cells
195
Contact Dermatitis is a Type __ reaction
Describe the reaction
4**D**
[**D**elayed hypersensitive T-cell mediated] rxn
196
Serum Sickness is a Type __ reaction
Describe the reaction
3**i**
## Footnote
(***F***ree antigen binds to ***I***gG → binds ***C***omplement = [***FIC*** Immune Complex] ➜ embeds in membranes where it cont activating more ***C***omplement → tissue damage(fever, polyarthritis, dermatitis)
197
pts with [*persistent* Recurrent single lobe PNA*(despite previous tx successes)* ] raises suspicion for ⬜ as the cause
**[FOCAL Endobronchial Obstruction]**
## Footnote
✏️*2/2 {[Bronchogenic Carcinoma*older|smokers*(+/- focal bronchiectasis)]
or
[Carcinoid tumor*young | NONsmoker*]**(+/- focal bronchiectasis*)}
✏️GOLD STANDARD DX = FLEX BRONCHOSCOPY
198
In PostOp Hypoxemia, how do you tell the difference between Atelectasis and Residual Anesthetic Effect?
Atelectasis = POD 2-5
[Residual Anesthetic Effect] (DEC central resp drive)can occur immediately
199
Allergic Rhinitis Sx -4
1. 👃[Rhinitis with **pale/blue nasal mucosa**]
2. 👁️ [ Itchy / watery/periorbital edema ]
3. Young onset < 20 year old
4. Associated with other allergy DO (asthma, eczema, allergy season)
Rhinitis = Cough 2/2 postnasal drip , watery rhinorrhea, congestion, sneezing, [🤧allergic pale/blue nasal mucosa] vs [NAR🐽erythematous nasal mucosa])
| [🤧= *Allergic* Rhinitis only] / [🐽= *NONAllergic* Rhinitis only]
200
ALLERGIC RHINITIS
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TREATMENT -3
1st: **ALLERGEN AVOIDANCE**
--(prn)-➜
{[Intranasal fluticasone] + [PO antihistamine]}
201
What are the ONLY contraindications for the MMR vaccine? -4
*"(❌-M-M-R) to (**P-A-I-d**)*"
1. **P**regnancy
2. [**A**GPN(**A**naphyalxis to **P**rior MMR|**N**eomycin|**G**elatin)]
3. [**I**mmunodeficiencySEVERE]
⛔ 4.*[**d**o NOT give APAP px for pts with pre-existing fever. They don't need it.]*
202
MOD Type 1 Hypersensitivity Reaction? (2)
**ACID**
1A. [(**A**AAA)⼀free Ag] rapidly crosslinks [preformed IgE bound to *hypersensitive* basophil & mast cells ]➜ [hyperacute histamine-mediated vasodilation/bronchoconstriction/edema]
+
1B. [**A**rachidonic Acid] conversion ➜ Leukotrienes = +/- 6H delayed response also
## Footnote
**A**AAA= Allergy/Asthma/Atopy/Anaphylaxis
203
MOD for Type 2 Hypersensitivity Reaction?
**ACID**
[{**C**ytotoxic IgG or IgM} bind to [fixed antigen on *enemy **C**ell*] ➜ [*enemy **C**ell* undergoes destructive "*D.I.P.*" (Dysfunction|Inflammation|Phagocytosis) ✏️]
## Footnote
✏️
**C**ytotoxic = ➜ [*enemy **C**ell* undergoes destructive "*D.I.P.*"] via:
3. [*enemy Cell* (*D*)ysfunction ⬅︎ {*ec*⼀AbFc}]
4. [*enemy Cell* (*I*)nflammation ⬅︎ {*ec*⼀AbFc⼀Complement}]
5. [*enemy Cell* (*P*)hagocytosis from opsonization ⬅︎ {*ec*⼀AbFc⼀Complement}]
204
MOD for Type 3 Hypersensitivity Reaction?
**ACID**
[**I**mmune complex *fiC*] = {(Free Ag +IgG) together binds/activates Complement}] all 3 = [**I**mmune complex *fiC*] ➜ neutrophils release lysosomal enzymes
205
MOD for Type 4 Hypersensitivity Reaction?
**ACID**
[**D**elayed T cell rxn] involving [(hyper)sensitized T-cells that *(WITH NO ANTIBODY INVOLVEMENT)]* secrete [macrophage-activating cytokines] when encountering certain antigens ➜ macrophage phagocytosis
206
Define Presbycusis
gradual [high frequency sensorineural hearing loss]
| *ex.⬇︎ ability to discriminate (make out) speech in a noisy environment*
207
What kind of hearing loss does Presbycusis cause?
gradual [**high frequency** sensorineural hearing loss]
| *ex.⬇︎ ability to discriminate (make out) speech in a noisy environment*
208
How does [High Frequency Loss from Presbycusis] affect hearing?
DECREASES ability to discriminate (make out) speech in a noisy environment
209
Which pharmacologic agents cause asthma exacerbation? (4)
1. ASA
2. NSAIDs
3. [*general*Beta Blockers]
4. [tartrazine(coloring agents)]
210
How do ASA and NSAIDs exacerbate asthma?
inhibition of COX1 and COX2 shunts Arachidonic Acid down the [(LipOxygenase → Leukotriene) pathway] --\>🔥Leukotrienes*{[🔥LT: C4/D4/E4]*→ broncho**constriction} = [🔥LTB4 → chemotaxis of neutrophils]** = asthma exacerbation
| *🔥=PROinflammatory*
211
# fill-in-Blank (19)
## Footnote
NSAIDs and ASA inhibition of COX1 and COX2 shunts Arachidonic Acid down Leukotriene pathway --> INC Bronchial tone ➜ worsens asthma
212
acute asthma exacerbation ABG shows (⬜ low/high) paCO2
low
213
status asthmaticus ABG shows (⬜ low/high) paCO2
HIgh
214
# the [5 step Asthma plan] is based on both {**[SABA]** and [**⬜**]}
Recite the [5 step Asthma plan]
⼀based on [**SABA**]
| **[SABA]** *use*
[**NightAwakenings**]
## Footnote
"Treating Asthma is **SILIO**!"
Tx for Asthma Step_\_:
① [**S**ABA prn]
② [**I**CSLd]
③ [**L**ABA vs LAA vs Leukotriene🟥]
④ [**I**CS**HIGH** DOSE]
5⃣[**O**ral CTSLd +/- Anti-IgE]
215
# the [5 step Asthma plan] is based on both {[**⬜**] and [**N.A.**]}
Recite the [5 step Asthma plan]
⼀based on [**NightAwakenings**]
| *🔎N.A. = NightAwakenings*
**[SABA]***use*
## Footnote
"Treating Asthma is **SILIO**!"
Tx for Asthma Step_\_:
① [**S**ABA prn]
② [**I**CSLd]
③ [**L**ABA vs LAA vs Leukotriene🟥]
④ [**I**CS**HIGH** DOSE]
5⃣[**O**ral CTSLd +/- Anti-IgE]
216
Name the 5 ways you can diagnose Asthma?
"*Either*...
*[BD ➜ ⇪ GOE **12E**| **12V**| **200C**]*
OR
*[Methacholine ➜ ⬇︎GOE **20E**| **20V**]* "
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. BD ➜⇪ GOE [12% F**E**V1]
2. BD ➜⇪ GOE [12% F**V**C]
3. BD ➜⇪ GOE [200 C**C** FVC]
4. Methacholine ➜⬇︎GOE [20% F**E**V1]*= bH*
5. Methacholine ➜⬇︎GOE [20% F**V**C]*= bH*
## Footnote
🔎
[🔎BD = BronchoDilator]
[🔎**E** = F**E**V1]
[🔎**V** = F**V**C]
[🔎**C** = C**C** of FVC]
[🔎bH = bronchial Hyperresponsiveness]
217
asthma exacerbation MOA
Excess TH2 cells (recruited by hypersensitive APC to inhaled allergens) secrete IL4
-->IL4 activates [B-lymphocyte class switching for IgE Ab]
--> IgE binds to Mast cells which will then secrete IL5
-->IL5 Recruits Eosinophils-->which release mediators like [Leukotrienes & Histamine]
→[**bronchoconstriction + inflammation**]
218
radiographic finding associated with Asbestos? -2
1. calcified pleural plaques
2. honeycomb lung (eventually)
## Footnote
MOA: lung macrophages phagocytose [mineral silicate fibers] ➜ release lysosomal enzymes ➜ [ILD fibrosis] ➜ progressive dyspnea/cough ➜ {[+/- bronchogenic carcinoma] \> mesothelioma}
219
Asbestos MOA (6)
lung macrophages phagocytose
[mineral silicate fibers] ➜ release lysosomal enzymes ➜ [ILD fibrosis] ➜ progressive dyspnea/cough ➜ {[+/- bronchogenic carcinoma] \> mesothelioma}
220
Asbestos Tx
NONE
221
complications of Asbestos exposure? -3
1. [ILD fibrosis]
2. Bronchogenic Carcinoma (INC risk with smoking)
3. Mesothelioma
## Footnote
MOA: lung macrophages phagocytose [mineral silicate fibers] ➜ release lysosomal enzymes ➜ [ILD fibrosis] ➜ progressive dyspnea/cough ➜ {[+/- bronchogenic carcinoma] \> mesothelioma}
222
Which additional vaccines do COPD patients need? -2
*MUST ADD...*
1. Pneumococcal Q5 year
2. influenza Q1 year
223
How does cigarette smoking cause Emphysema -5
**ACAMP***→ emphysema*
1. ciliary mvmt abnormalities
2. [mucus-secreting gland] hyperplasia
3. alveolar macrophage inhibition
4. Proteolytic enzyme release from neutrophils
5. AntiProteolytic enzyme inhibition
## Footnote
*emphysrema MOD = **alveolar septae destruction** ➜ irreversible dilatation of distal air space + loss of airway elastic recoil (AKA radial traction) ➜ airway collapse during forced expiration) ➜ prolonged expiratory phase + [INC residual volume/air trapping] + [INC WOB] ➜ [dead space physiology(more air ventilated than can be perfused)]*
224
MOD emphysema
**alveolar septae destruction** ➜ irreversible dilatation of distal air space + loss of airway elastic recoil (AKA radial traction) ➜ airway collapse during forced expiration) ➜ {prolonged expiratory phase + [INC residual volume/air trapping] + [INC WOB]} ➜ [dead space physiology(more air ventilated than can be perfused)]
225
Antitrypsin is an enzyme that inhibits ______ and _______ in the lung
Patients with Antitrypsin deficiency develop \_\_\_\_\_\_\_\_\_\_\_
= trypsinase and elastinase
= Panacinar emphysema
226
Describe the 2 types of emphysema
1. centroacinar = respiratory bronchioles alone
2. panacinar =[respiratory bronchioles] + [distal airways (consider Antitrypsin deficiency)]
227
T or F: Obstructive sleep apnea increases Risk for Cardiovascular Mortality
TRUE
228
Obstructive Sleep Apnea dx -3
1. **Polysomnography** ⼀ *OSA dx confirmation*
2. [AHI(Apnea-Hyponea Index) ] ⼀ *measures OSA severity*
3. [STOPBang ≤2 = no OSA] ⼀*OSA screening*
229
Describe how *severity* of Obstructive Sleep Apnea is measured?
AHI (Apnea-Hypopnea Index) = sum of apnea and hypOpnea events in 1 hour of sleep
5-15/hr = mild
16-30 = moderate
\> 30 = SEVERE
230
T or F: Supplemental Oxygen alone prevents OSA complications
FALSE
*(supp O2 + correct upper airway obstruction)*
231
Describe radiographic findings for Granuloma -3
1. dense
2. centrally calcified
3. smoothly bordered
232
radiographic central calcification in pulmonary nodules indicate ________ [malignant/benign] neoplasia
BENIGN
*("popcorn", "onion skin", "bull's eye")*
233
radiographic eccentric calcification in pulmonary nodules indicate ________ [malignant/benign] neoplasia
[MALIGNANT or BENIGN]
234
Bronchial carcinoid tumors are ______-grade malignant neoplasm made of ___ cells , and about \_\_\_\_\_% of all lung tumors
low ; neuroendocrine ; 2
235
Why do Carcinoid tumors cause
\_\_\_\_\_\_\_\_\_ in lungs?
**[lobar atelectasis]** ; [Carcinoid tumors are located in the bronchus*(which → lobar atelectasis)*]
236
patients GOE _____ years old with significant smoking hx, should receive _____ for pulmonary nodules
45 ; biopsy
237
what are the 3 most critical parameters to stabilize in Anaphylaxis
**ABC**
1. (A) airway (obstructed)?
2. (B) Breathing/bronchioles bronchoconstricted?
3. (C) hypOtension
238
what type hypersensitivity is Anaphylaxis?
1**A**
239
examples of [type 1 "A" hypersensitivity reaction] -5
* [type 1 AAAA hypersensitivity reaction]*
1. [**A**llergy (PCN)]
2. **A**naphylaxis
2. **A**topic (**A**sthma, rhinitis, eczema, hay fever)
3. Ig**A** deficient patients ➜if receive blood products ➜ possible anaphylaxis (px = use WASHED RBC)
240
## Footnote
note: PG**E1** also keeps PDA patent during cyanotic heart defects = "kEEps ur Penis and PDA Open"
241
## Footnote
note: PG**E1** also keeps PDA patent during cyanotic heart defects = "kEEps ur Penis and PDA Open"
242
243
Which Leukotriene(s) responsible for
Bronchoconstriction?
LT**C**4 / LT**D**4 / LT**E**4
## Footnote
C/D/E
244
Which Leukotriene(s) responsible for
Neutrophil Chemotaxis?
LT**B**4
## Footnote
B
245
**[PGE1 Prostaglandin]**
Function (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Rx
1. *\**PENIS*\**vaso**DILATOR**
2. "kEEps PDA... patent"
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Alprostadil*PG**E1** Prostaglandin*]
| "PGE1 kEEPS Penis and PDA open!"
246
**[PGE2 Prostaglandin]**
Function (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Rx
1.***ANTI**inflammatory*
2.[⇪ Uterine tone]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Dinoprostone*PG**E2** Prostaglandin*]
## Footnote
B
247
**[PGF2 Prostaglandin]**
Function
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Rx
[⇪ Uterine tone]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Carboprost*PG**F**2 Prostaglandin*]
## Footnote
B
248
**[pGi2 prostaCyclin]**
Function (3)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Rx
1. **ANTI**inflammatory❄
2. [⬇︎ platelet aggregation]*(⬇︎clotting)*
2. vaso**DILATOR**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[EpoProstenol*pG**i2** prostaCyclin*]
## Footnote
B
249
**[TXA2 Thromboxane]**
Function (3)
1. 🔥**PRO**inflammatory
2. [⇪ platelet aggregation]
2. vaso**constrictor**
## Footnote
B
