clinical medicine
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| asthma | chronic inflammatory disorder of the airways
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| atopy | complex interaction between multiple genes and environmental factors, leading to IgE mediated response to allergens
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| asthma clinical findings | cough, sob, wheezing, tachypnea, use of accessory muscles, wheezing, prolonged expiratory phase, agitation, cyanosis
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| differential of cough and wheezing in children | CRADLE (cystic fibrosis, respiratory TI, aspiration, dyskinetic cilia, lung and airwary malformation, edema chf)
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| asthma evolution | plasma cells in lung overreact and tell mast cells about it, in chronic esosinophils degranulate causing airway damage and eventually remodeling-fibrinoblasts lay down collagen
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| inhaled corticosteroid benefits | sx diminish and improve gradually, decreases use of rescues, lung function improves, occurrence of exacerbations reduce
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| COPD | many diseases characterized by chronic airflow obstruction
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| less than 0.7 | post BD- fev1/fvc of_______ confirms COPD
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| Suspect COPD in patients over 40 with | Dyspnea, chronic cough, chronic sputum production, exposure history, family history of COPD
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| Obstruction (PFT) | FEV1 is reduced out of proportion to total volume of forced exhalation (FVC) Ratio of FVV1:FVC is reduced 70%
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| GOLD staging | Gold 1- mild FEV1 >80%
Gold 2- mod 50%<FEV1<80%
Gold 3- Severe 30%<FEV1<50%
Gold 4- very severe FEV1<30%
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| COPD risk factors | Smoking, exposure to products of combustion, occupational dusts/fumes/vapors, airway hyper reactivity, genetics
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| COPD airflow obstruction | Largely determined by resistance in small airways (airway remodeling, loss of elastic recoil, lumenal obstruction with mucous, bronchiolar lumenal narrowing
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| COPD hyperinflation | Obstruction increases end expiratory volume (Increases elastic recoil, increases expiratory flow, mechanical disadvantage, positive alveolar pressure must be overcome to breath)
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| COPD V/Q mismatch | variable from one pt to another, loss of hypoxic vasoconstriction, major determinant of decreases pao2
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| COPD decreased diffusing capacity | loss of alveolar capillary bed, extent proportional to severity of emphysema
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| COPD alveolar hypoventilation | Adaptive response to increase WOB, increase paco2 decrease pao2
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| Pink Puffer | emphysema predominates, less alveolar surface are for gas exchange, hyperventilate to compensate, ABG normal
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| Blue Bloater | Chronic bronchitis, alveolar space intact but airways obstructed, decrease ventilation, V/Q mismatch, air trapping, hypercanpia (CO increase)
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| COPD exacerbations | amplification of baseline airway inflammation, precipitated by infections environmental pollutants smoking, major determinant of outcomes in pts
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| COPD tx, FEV1 >60% and no sx | no pharm or a saba
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| COPD tx, FEV1 <60% | saba, laba, ics, pulm rehab, oxygen, azithromycin
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| COPD exacerbation causes | infections (most common), environmental pollution, unknown
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| Pulmonary Hypertension pathology | small pulmonary arteries, vasoconstriction vascular remodeling
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| Pulmonary Hypertension diagnosis | right heart cath, mean pulmonary artery pressure of greater than 25mmHg or mean pulmonary capillary wedge pressure of less than 15mmHg
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| Pulmonary Hypertension symptoms | dizziness +/- syncope SOB chest pain ascities edema fatigue
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| mTB bacteria | aerobic, nonmotile, bacillus with waxy lipid-rich outer wall (acid fast staining)
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| mTB pathogenesis | TB hits alveoli, macrophages engulf, transport to hilar lymphnodes, CD4 Tcells try to kill create caseous granulomas
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| Primary TB | refers to 1st exposure to inhaled infectious particles followed by flu-like illness, spread controlled sub pleural granulomas form, remain stable and no further spreading
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| Latent TB Infection | mTB survive for decades in walled off lesions, not infectious, risk of reactivation
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| Reactivated TB causes | Immune deficiency, AIDs, Immune modulated agents (occurs in 10-15% of pts half within 2 yrs of primary disease)
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| Reactivated TB symptoms | worsen over months, cough with sputum, low grade fever, weight loss, fatigue, hemoptosis and pleuritic pain (severe disease)
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| Miliary TB | initial exposure to mTB fails to incude cell-mediated immunity
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| Miliary TB physical exam | chronically ill-appearing, LAD choroid TB in eyes (dx with transbronchial biopsy)
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| Screening for TB | PPD (purified protein derivative) or interferon gamma release assay (IGRA)
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| Treating TB | RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) and vit b6
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| Fungal Pneumonia at risk populations | neutropenics, lupus/RA, organ transplant recipients
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| Histoplasmosis | transmitted by airborne spores inhaled from contaminated soil, primarily lungs and lymph chains (bat guano and chicken droppings)
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| Histobelt | southern Ohio, Missouri, Tennessee, Arkansas, Kentucky, Illinois
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| Histo symptoms | fever, fatigue, weight loss, hepatosplenomegaly,
cough and dyspnea for greater than one month
recurrent pneumonia
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| Histo dx testing | urine histo ag or blood/BM cx
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| Histo, coccidiodomycosis, and blasto treatment | liposomal amphotericin and itraconazole
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| Coccidiodomycosis geographic | american southwest, mexico
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| Coccidiodomycosis | transmitting by inhaling c immitis or c posadasil, 1-4 weeks of mild flu like illness, pleuritic chest pain resolves in a few weeks
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| Coccidiodomycosis DX | IgM/IgG serologies, fungal comp fix panel, tissue biopsy
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| Blastomycosis geographic | along mississippi, north, Canadian border
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| Blastomycosis | least common, can infect lungs skin and bone
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| Ubiquitous fungi | cryptococcus neoformans, aspergillosis
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| Cryptococcus neoformans | more commonly meningitis, yeast, mostly infect immunocompromised
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| cryptococcus neoformans sx | fever, weight loss, malaise, pleuritic pain, cough, wheeze, hemoptysis
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| Cryptococcus neoformans dx test | serum cryptococcal
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| Crytococcus neoformans tx | liposomal amphotercin, fluconazole
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| Aspergillosis | mostly infects immunocompromised (leading cause of death in acute leukemia, bone marrow transplant)
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| Aspergillosis dx | culture, serum galactomannan level, X-ray (solitary/multiple nodules, cavitary lesions) CT (halo sign, crescent sign)
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| Aspergillosis treatment | empiric, surgical excision, once diagnosis is established variconazole and caspofungin
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| Normal pulmonary defense | mucociliary clearance, cough and gag reflex, innate flora of oropharynx
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| Pneumonia pathophysiology | inhalation of pathogen, macrophages overwhelmed, inflammatory mediators
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| Phases of pneumonia | edema, red hepatization, gray hepatization, resolution
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| CAP pathogen | strep pneumo (most common) H flu, M cat, M pneumo, RSV
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| MRSA risk factors (pneumonia) | recent illness, flu, esrd, pleural effusion, multifocal infiltration, recent antibiotics, IVDA
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| Pneumonia typical | acute, thick brown yellow sputum, productive cough, high fever shaking chills, consolidation on cxr
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| Pneumonia atypical | gradual, clear sputum, low grade fever, no infiltrates
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| Pneumonia physical exam | inspiration crackles, bronchial breath sounds, dull to percussion, e to a changes
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| CURB 65 | confusion, uremia, rr (>30), bp (<90/<60), 65yo
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| Acute bronchitis | inflammation of tracheobronchial tree, cough 1-3 weeks duration, usually viral
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| DVT | thrombus usually found in the lower extremities, pelvic veins, and upper extremities
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| PE | obstruction of the pulmonary artery or its branches by material (fat, air, tumor, or thrombus)
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| Virchows triad (DVT) | venous stasis, venous injury, hyper-coagulability
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| Cause of death for PE | r ventricle after load increases, rv dilates, rv dysfunction, rv ischemia, rv failure
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| PE "the great masquerader" | non-specific symptoms, tachy, elevated neck veins, loud p2, pleural rub, humans sign (swollen, warm, erythematous)
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| PE EKG | sinus tach, RBBB, right axis deviation, P wave pulmonale, new a fib, rt ventricle strain
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| Wells criteria | clinical prediction model for PE
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| Gold standard for PE diagnosis | pulmonary angiogram
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| Massive PE | PE with systolic BP less than 90mmHg
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| Submassive PE | PE with RHF with normal BP
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| Small Cell carcinoma | extremely rapid growth, central location, almost always smokers, crush artifact
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| Non-small cell carcinoma | squamous cell carcinoma, adenocarcinoma, large cell
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| Squamous cell carcinoma | most common with hemoptysis, central location, exfoliates, aggressive
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| Adenocarcinoma | Most common lung cancer, slow growing, peripheral location, "scar" tumor, more common in non smokers
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| Large cell carcinoma | Poorly differentiated, peripheral, rapid growth
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| Cancer clinical presentation | constitutional symptoms most common, other symptoms related to local tumor growth, local spread, metastasis
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| Pancoast tumor | superior sulcus tumor, compresses brachial and cervical nerve roots, manifests as horners syndrome, anhydrosis, or arm pain
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| Paraneoplastic syndrome | endocrine hormone secretion, clubbing, anorexia, weigh loss/ cachexia, fever
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| Gold standard for cancer diagnosis | Surgical lung biopsy
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| TNM system | Tumor size and invasion, lymph Nodes, Metastasis
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| Stage 1 | no lymph nose involvement, surgical removal
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| Stage 2 and 3 | lymph nodes involved, larger tumor, multiple lung tumors, surgery radiation and chemo
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| Small cell carcinoma staging | limited or extensive both bad
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| Visceral pleura | adheres to lung, covers each lobe, gets blood from the brachial artery, limited lymphatic drainage, no innervation
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| Parietal pleura | adheres to chest wall, blood from systemic capillary, lymphatic drainage, innervated
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| Pleural effusion cause | excess production of fluid, decreased drainage
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| Pleural effusion classification | transudative, exudative
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| Transudative pleural effusion | disorder of hydrostatic or oncontic or hydrostatic forces, fluid seeps from vessels
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| Exudative pleural effusion | Disorder of inflammation, fluid exudes through wide gaps between cells, rich in cells and protein
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| Lights criteria | protein/serum protein ratio >0.5
LDH/serum LDH ratio >0.6
LDH> 2/3 the upper limit of normal serum
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| Treatment of exudative pleural effusion | bacterial infections (empyema) and malignancy need chest tube, chronic can lead to fibrosis, the rest of pts you drain or do surgically debride
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| Treatment of transudative pleural effusion | no chest tube needed, treat underlying cause, can do a thoracentesis to help with dyspnea
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| Pneumothorax physical exam | chest pain, dyspnea, hyperresonant, diminished tactile fremitis, decreased breath sounds
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| Pneumothorax Xray | peripheral absence of lung markings and the presence of a pleural stripe
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| Pneumothorax classifications | spontaneous, traumatic, tension
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| Primary Spontaneous | no underlying lung disease, peak incidence in the 3rd decade of life
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| Blebs | physical stress can cause small patches of irregular architecture which can rupture spontaneously
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| Secondary spontaneous | pneumothorax in a lung with underlying disease
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| Traumatic pneumothorax | penetrating chest injury, blunt chest injury, iatrogenic (healthcare on purpose or an oops)
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| Tension pneumothorax | Rapid accumulation of air in the pleural space, rise in pleural pressure, pressure can reduce blood flow, decrease CO, shock and death
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| Tension pneumothorax exam | low bp, absent/decreased breath sounds, hyperresonant, tracheal deviation
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| Tension pneumothorax treatment | needle decompression, chest tube
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| Pleuritis | pleural inflammation
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| Restriction causes | P (pleural) A (alveolar) I (interstitial) N (Neuromuscular) T(thoracic cage abnormalities)
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| Interstitial lung disease | diseases of the alveoli and interstitum
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| Usual Interstitial Pneumonia | most common idiopathic interstitial pneumonia, worst prognosis, does not respond to anti-inflammatory tx
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| Idiopathic Granulomatous | Sarcoidosis, second most common ILD, frequently a multi system disease
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| Sarcoidosis diagnosis and treatment | transbronchial biopsy to find granulomas, treat with corticosteroids
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| ILD Granulomatous | Chronic beryllium disease, hypersensitivity pneumonitis
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| ILD non-granulomatous | autoimmune disease, occupational exposure, drugs, radiation
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