Ominous signs in asthma
paradoxical chest/abd movement
inability to maintain recombancy
absent breath sounds
thick causes plugging
the epitheial basement membrane gets thick
What PFTs are important in Asthma
Pulmonary Function Tests:
peak flows at home
FEV1, FVC, FEF
What level FEV1 is less than what ____% of predicted requires admission?
less than 30% of predicted, admit
If you treat an asthmatic in the ER for an hour and their FEV1 doesn't increase to at least 40% of predicted, what should you do?
CXR of asthmatic shows
steps wise approach to outpatient management of asthma
1) SABA: short acting beta adrenergic (albuterol, rescue and before you exercise)
2) inhaled corticosteroids (pulmicort) (this helps prevent chronic changes that the inflammation causes, not for symptoms, daily maintenance, wash out your mouth)
3) SABA for symptom breakthrough, albuterol (rescue inhaler)
4) LABA long acting beta adrenergic, salmeterol. NOT rescue inhalers.
*5) anticholinergic *On the test, atrovent IS used in asthma for secretions
*6) antiluekotriane: monolukast
inpatient mangement of asthma
inhaled: alupent/albuterol (proventil) are sympathomimetics
corticosteroids: methylprednisone IV (in the hospital)
parenteral (IV) sympathomimetics: SQ epi
anticholingergic to dry secretions: atrovent
severe acute asthma, unremitting, poorly controlled, life threatening
Asthma, COPD, emphysema, chronic bronchitis
are they obstructive or restrictive?
How long do you have to have productive cough for dx of chronic bronchitis?
3 consecutive months for two consecutive years
Emphysema is characterized by:
mild clear sputum
increased lung capacity
alveoli abnormal permanent enlargement
CXR for chronic bronchitis
possible bulea or blebs
normal AP diameter
PFTs for restrictive:
TLC total lung capacity
RV remaining volumes after maximal expiration
FRC functional residual capacaity
in restrictive disease all these are low
restrictive disease: pulmonary fibrosis, pulmonary sarcoidosis (connective tissue where it shouldn't be)
acute: ARDS, PNA,
If you see extrapulmonary TB you should consider
Definitive diagnostic test for TB
honeycomb appearance R upper lobe
4 differentials for night sweats
acronym for TB meds
they are ripe for treatment
INH isoniazid (monitor LFTs)
ethambutal (changes red/green color perception, and visual acuity)
If you are treating pulmonary TB, how often do you get cultures?
every week for first 6 weeks
then monthly until cultures are negative
If you have positive cultures after three months of TB treatment consider
Patient with HIV gets treated for TB for how long?
TB treatment lasts a total of how many months?
*9 months for HIV
Most common organism with CAP?
Lung consolidation is PNA, you can't clear the ronchi with a caugh
Treatment for CAP, consider two things:
how old they are (60)
if they have been on abx recently
CAP in healthy <60, not been on ABX
*new black blox warning for QT prolongation
If CAP patient with other commorbidities and >65 y/o.
CAP >65 not doing well on levaquin, now admit
ADD A BETALACTAM
start on betalactam
continue outpatient (levaquin)
If you admit CAP
azithromycin or levaquin
*if PCN allergic hold betalactam and give
Most common causitive organisms in HAP?
strep + staph (gram positive)
H flu (gram negative)
What is the most common caustive agent in VAP?
*treat with antipseudamonal beta lactam
*zosyn, cefepime, imipenem
Thoracentesis with colored fluid, high protein, high LDH
due to inflammation (lupus)
Thoracentesis clear, normal protein, normal LDH
heart failure, liver failure
In the elderly, does the vital capacity increase or decrease?
it decreases because of increased residual volume increases
What is the only mid-diastolic murmur?
Acute L sided HF what heart sound?
CXR for CHF
kerley B lines
(increased interstitial markings)
What drug is used to treat HTN in pregnancy, can also be used to treat parkinsons?
central alpha 2 agonist
swelling of the optic disk with blurred margins
*found in HTN emergency
Oral drugs in HTN urgency