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1

What is an A-a gradient? What is the normal range?

Alveolar [O2] - arterial [O2]

Normal is 5-15mmHg

2

What causes an increased A-a gradient?

Things that would decrease arterial [O2]

Right to left shunt (mixes deoxygenated into oxygenated)
PE (decreased pulmonary capillary perfusion --> less blood can become oxygenated)
Pulmonary edema (increased barrier to diffusion)

3

What are two scenarios in which a person would have decreased arterial [O2], but a 'normal' A-a gradient?

Things that would decrease Alveolar [O2]

Hypoventilation
High altitudes

4

How is Alveolar [O2] determined? what is the normal range?

150mmHg - arterial [CO2] = ~110mmHg

arterial [CO2] via ABG (usually ~40mmHg)

5

How is arterial [O2] determined? what is the normal range?

ABG

90-100mmHg

6

What viruses typically cause the common cold?

Rhinovirus
Coronavirus
Adenovirus

7

Why do you treat strep throat if it is often self limited?

To prevent RHD
Does NOT help to prevent poststrep glomerulonephritis

8

A patient comes in complaining of sore throat, ear pain, and a fever. You try to look at the throat, but he won't open his mouth very wide, but you get a glance and see that one tonsil is larger than the other and the uvula is pointing away from the larger tonsil. What is the concern? How is it treated?

Peritonsillar abscess

IV Abx and I&D...tonsillectomy after resolution

9

What are the common causes of acute sinusitis? How is it treated?

Strep pneumo
H. influ
Moraxella catarrhalis
Viral infection

Amoxicillin x 2wks

10

What is a possible complication of acute sinusitis if untreated?

Meningitis

11

When is sinusitis deemed 'chronic'? What causes chronic sinusitis? How is it treated?

Sinus symptoms for 3+ months

Obstruction + anaerobic infection

Amoxicillin x 6-12wks +/- surgery

12

Patient comes in with a fever and the entire workup is negative. Blood, CSF, urine, CXR, no GI symptoms...nothing. What else could be considered?

Sinus CT...could show fluid levels and/or opacification

13

A nonsmoker comes in with a productive cough, fever, and wheezing. What does she have? What is likely causing it?

Acute bronchitis

Virus (most likely)
Mycoplasma pneumonia (Dx: Cold agglutinin titer Tx: tetracycline, fluoroquinolone, or macrolide)

14

A smoker comes in with an acute bronchitis. What is the likely cause? What else could cause it?

Viral is most likely

Strep pneumo and H. influ are also common

15

What is the most common cause of pneumonia in kids?

Viral (nonproductive cough...self-limited)

16

What is the most common cause of pneumonia in adults?

Strep pneumo (productive cough...beta-lactam or macrolide)

17

Which bacteria commonly infect sickle cell patients?

Strep pneumo
H. influ
Klebsiella

18

What is a common cause of pneumonia in COPD patients?

H. influ (slow onset...beta-lactam or TMP-SMX)

19

Patient has "currant jelly" sputum. What is the likely bug? What risk factors could the patient have?

Klebsiella (cephalsporin AND aminoglycoside [gentamicin, trobramycin])

Increased risk of aspiration (alcoholic)
Prolonged hospitalization
Sickle cell disease

20

What type of pneumonia are cystic fibrosis patients at increased risk of contracting? Who else is more likely to contract?

Pseudomonas (fluoroquinolone, aminoglycoside, or 3rd gen cephalosporin)

Chronically ill (nosocomial)
Immunocompromised

21

What type of bacteria causes pneumonia in neonates/infants?

Group B Strep (beta-lactam)

22

Who is at increased risk of contracting enterobacter pneumonia? How is it treated?

Old people in hospitals

TMP-SMX

23

A young adult comes in with a mild pneumonia and a rash. What should be checked? How should it be treated?

Cold agglutinin test (+ = mycoplasma pneumonia)

Macrolide (azithromycin, clarithromycin, erythromycin)

24

A patient comes in with a slowly progressing pneumonia with some GI and CNS symptoms. What is the likely bug? What was the likely exposure?

Legionella (macrolides; fluoroquinolone)

Aerosolized water (air conditioner)

25

A patient has frequent, recurrent sinusitis and a slowly progressive pneumonia. What is the likely bug?

Chlamydophila pneumonia (doxy, macrolide)

26

A patient comes back from traveling to SW US and now 1-3 weeks later has mild pneumonia symptoms. What is a possible cause?

Coccidiodomycosis...a dimorphic fungi (amphotericin B or fluconazole)

27

A patient has been spelunking and now 1-3 weeks later has mild pneumonia symptoms. What is a possible bug?

Histoplasmosis...often dx with serology; cx takes ~6wks (itraconazole)

28

A patient came back from central america 3-12 weeks ago and now has mild pneumonia symptoms. What is a possible bug?

Blastomycosis...yeast (itraconazole)

29

Patient comes because he has had bad night sweats and hemoptysis. CXR shows apical fibronodular infiltrates. What does this guy have? What is the treatment?

Reactivated TB

RIPE (Rifampin, Isoniazid [INH], Pyrazinamide, Ethambutol) followed by Rifampin and INH for a total of 6 months...give B6 (pyridoxine) to counteract INH competition for neurotransmitter synthesis

30

There are 12 common causes of ARDS. What are they? (HINT: they all start with letters in ARDS)

A:
Aspiration
Acute pancreatitis
Air embolism
Amniotic embolism
R:
Radiation
D:
Drug overdose
Diffuse lung disease
DIC
Drowning
S:
Shock
Sepsis
Smoke inhalation

31

What is seen on ABG with ARDS? Pulmonary Wedge Pressure? PaO2:FiO2?

ABG: Respiratory alkalosis (pH > 7.45; PaCO2 500)

32

How is ARDS treated?

In ICU
On ventilator:
PEEP
Increased inspiratory times
FiO2 to keep sats >90%
Treat underlying cause
Keep fluid volume low (prevent pulmonary edema)
Extracorporeal Membrane Oxygenation (ECMO) may be necessary

33

Besides clinical symptoms and frequency of medication use, what else is used to classify asthma? What is seen on PFTs with asthma?

Peak Expiratory Flow Rate (PEFR)

Decreased FEV1, but not as decreased as FVC, and normal/elevated diffusion

34

A normal CO2 is seen during an asthma exacerbation. Is this normal?

NO...indicates impending respiratory failure

Increase beta-agonists and supplemental O2, and be prepared to ventilate

35

A smoker comes in and says that they have probably had a productive cough for at least 3 months during each of the last two years. What can this person be diagnosed with?

Chronic bronchitis (continuum with emphysema as COPD)

36

What is the reasoning behind the term "blue bloater"?

Chronic bronchitis --> cor pulmonale --> cyanosis (blue) and peripheral edema (bloated)

37

What is the reasoning behind the term "pink puffer"?

Emphysema --> pursed lip breathing (pink) and dyspnea + barrel chest (puffing/puffed)

38

Besides the possible clinical differences that differentiate chronic bronchitis and emphysema (blue bloater vs pink puffer), what can more definitively distinguish the two?

Diffusion capacity D(Lco)
Normal with chronic bronchitis
Decreased with emphysema

39

What is one way a CXR can help differentiate common emphysema (caused by smoking) from alpha1-antitrypsin deficiency emphysema?

Normal --> centrilobular distribution
Alpha1-antitrypsin deficiency --> panlobular distribution

40

Bronchiectasis occurs secondary to chronic airway obstruction. What is seen on radiology with bronchiectasis?

CXR: Multiple cysts and bronchial crowding
CT: bronchial dilation, wall thickening, and wall cysts