Clin Med I Exam 1 - CS

Study online at quizlet.com/_1zftau

1.

most important element in

evaluating headache patient

accurate, focused
history

2.

features of benign headache

under 35 yoa
Gradual, longstanding
episodic

3.

features of serious headache

over 35 yoa - pot

serious
Abrupt, rapidly
progressive
"thunderclap"

4.

headaches; daily for days to weeks

muscle tension

5.

headache - worse in a.m. or w/

straining

may be elev ICP

6.

the severity of a headache is very

subjective

true

7.

headaces w/ ataxia, diploplia,

unilat weakness

CVA

8.

primary HA w/ N/V

migraines
(pain activates SNS;
slowing digestion)

9.

primary HA w/ photophobia

migraine (also
meningitis)

10.

HA w/ strong family history

migraines

11.

headaches w/ depression

muscle tension
headaches

12.

medications/food that can lead to

headaches - primary

NSAID
withdrawal (narcs,
caffeine)
MSG (non-essential
AA)
OTC meds

13.

more serious; primary vs

secondary headache disorders

secondary

14.

takes up space; can cause

headaches

mass lesion

15.

exams needed w/ headache

gen appearance - ill

looking?
vitals; temp, bp
neuro; CN, sens,
cerebellar, gait, visual

16.

mental status exam - knows

A&O X 3:
WHO they are
WHERE they are
what DATE/TIME it is
(x4 = recent EVENTS)

17.

HA: head & neck

exam focus areas

scalp tender/swelling (rash)

cerv spine - flexibility
temporal arteries
facial symmetry (CN function)
eyes - EOMs, fundoscopic
TMJ - crep (tension HA)

18.

headache; may be
temporal arteritis

new; localized, continuous

focal tenderness direct palpation
scalp tenderness
generalizedaches/pains,
constitutional
JAW CLAUDICATION
PATHOGNOMONIC
(ischemia of maxillary a. supplying
masseter)

19.

causes of 2ndary
headache

SAH
Intracranial hemorrhage
Mass lesion
Meningitis
CVA/stroke (ischemia due to blockage
or rupture)

20.

headache; after
trauma, drug
withdrawal/rebound

are considered primary headaches

21.

lumbar puncture vs
CT sequence

always CT scan first when possible esp w/ signs of ICP; risk of suction
exacerbating herniation due to
ICP/SAH
(also "supratentorial mass lesion")

22.

risks for LP indic CT

first; signs of
elevated ICP

PAPILLEDEMA
altered MS/abnormal neuro eval

23.

LP where

"keep the cord alive - between L3

and 5 "
(cord ends at L2)

24.

CT preferred for

hemorrhage
tumor
hydrocephalus

25.

MRI preferred for

Post/cerebellar lesions

26.

CT vs MRI

CT - bone detail; MRI - soft tissue

detail
CT; rad risk, but faster (5 vs 30 min),
cheaper

27.

LP tubes

1-bugs & count (diff)

2- food (gluc & prot)
3- count (shows traumatic tap)
4 - reserve

28.

CSF protein
elevated w/

infections/inflamm - meningitis
SAH
MS, Guillain Barr,
malignancies, hydrocephalus
(falsely pos: by rbc's/traumatic tap)

42.

tension headache - Tx

rest/relax
analg; ibupr, aceta - combos helpful
for chronic
physical/massage therapy
(antidepressants/psych counseling)

29.

CSF glucose

norm: 2/3 level of serum gluc

decr w/ CNS infect (bugs eat)

43.

tension headache dx

focus on r/o 2ndary more serious

30.

CSF w/ bact
meningitis

gluc low (norm in CSF; bugs have eaten)

protein high

44.

migraine incidence

31.

headaches by age

migraine (middle age)

(vs tension/cluster in YA/adults)
also: migr & cluster - dec w/ age

32.

headaches by sex

sex: cluster (male smoker)

(vs tension/migraine female)

75% are women

25-34 yoa (younger than tension)
hormonal - so declines w/
age/menopause
high incid: 10-20% of pop (25 X
cluster)

45.

33.

headaches by
hereditary

migraines - yes, cluster - no

migraine associated
w/

family history
menstruation; HRT;
estrogen/progesterone
prostaglandins (vasoconstriction)

34.

headaches by
movement

migraines- aggravated by
movement/light/sound
clusters - pain NOT to move; (likes hot
showers)

46.

migraine - clin

photo/phonophobia
transient visual impairment
N&V
(normal neuro otherwise)

35.

headaches by
location

tension - bilateral
migraine/cluster - unilateral

47.

migraine duration

hours to days (4 hrs - 72 hrs)

headache skews

48.

36.

visual aura - typically

20-60 min BEFORE

Flashing lights
Shimmering, zig zag lines
Visual field loss - Scotoma

49.

other migraine
"aura"

numbness; tingling
transient hemiparesis (mistaken for
TIA)

50.

migraine triggers

noise/lights/odors
TYRAMINE (red wine, cheese,
chocolate)
Sulfites/nitrites/MSG
lifestyle-stress, dieting, depression

51.

oral meds less

effective w/
migraines

decreased gastric motility

(associated w/ migraines)

52.

migraine dx

focus on ruling out 2ndary more

serious

53.

migraine Tx

mild/infreq - OTC w/ RN antiemetic

only
abortive & prophylaxis as becomes
more frequent

54.

migraine patho

...

55.

migraine pathophys

constriction followed by uncontrolled

DILATION; dilation causes pain
(relieved w/ constrictors)

56.

5HT receptors in
cranial vessels

B, D

57.

migraine Tx abortive

tryptans
ergotamines

37.

38.

MC headache
characteristic
pain

tension headache
band-like bilat pressure; not
disabling/severe

tension headache
- cause

muscle SPASM in neck/scalp due to

MC; stress
occupational, cervical disk/arthitis
uncorrected ASTIGMATISM
CAFFEINE withdrawal

39.

tension headache
duration

hours

40.

tension headache
- clin

usually no physical; normal neuro

(maybe anxiety/depression)

migraines w/ aura
called
migraines w/o
aura

classic
common

41.

58.

migraine Tx - pain relief

narcotics/opiods

76.

59.

migraine Tx prophylactic

beta blockers (also

antidepressants)

cluster headaches duration

15-90 minutes SHORTER BUT

MANY per day! 10x+, 1-4 mths

77.

migraine Tx - tryptans
MOA

selective 5HT-1 serotonin agonists

(vasoconstrictor - counteracts
dilation)

cluster headache triggers

alcohol
nitrites
(not noise/lights/odors or
tyramine)

78.

cluster headaches - clin

short; excruciating; AWAKENS

from sleep
UNILATERAL
behind eye (radiate to jaw,
temple, teeth)
IPSILATERAL lacr, ptosis, miosis, &
sweating

79.

cluster headaches abortive Tx

Sumatriptan (imitrex) - only FDA

approved
injection; oral too slow attacks so
brief
high flow OXYGEN - can shorten

80.

cluster headache prophylactic Tx

not effective; too unpredictable,

long periods in between

81.

MC causes of secondary
headache

SAH, SD or ED hematoma;
meningitis, tumor, temporal
arteritis (less common)

82.

what are the risk factors

of a SAH

age, smoking, female, black,

alcohol abuse/binge drinking

83.

majority of SAH

spontaneous (vs traumatic), due

to aneurysm

84.

77% of cases are

spontaneous
hemorrhage caused
by...

aneurysms

85.

what does AVM stand

for?

arteriovenous malformation

86.

what are the causes of

SAH

aneurysms
trauma
AVM of the brain or spinal cord
blood dyscrasias
blood thinners
(tumors, infection, and
vasculopathies = less common)

87.

secondary headaches
MC causes

SAH
subdural hematoma
meningitis
tumor
temporal arteritis

88.

SAH vs subdural - by age

SAH under 50 (peaks at 50) vs

SDH over 60 (MC over age 60)

89.

SAH vs subdural - causes

SDH; usually trauma - elderly fall

or child abuse
SAH; trauma & AVmalform,
dyscrasia, thinners

60.

61.

5HT receptors bind

serotonin; a VASOCONSTRICTOR
in brain
(platelets release serotonin to clots
- constrict)

62.

migraine Tx - tryptans
approved

sumatriptan (Imitrex)
almotriptan (Axert)

63.

issue w/ migraine oral

meds

less effective
migraine usually w/ N/V; due to
depressed gastric motility

64.

tryptans SE

CONSTRICTION - flushing;
chest/neck tightness

65.

tryptans
counterindications

vascular issues
(CAD HTN, hemiplegic/basilar
migraines)

tryptans in addition to
vasoconstriction

decrease activity of trigeminal

nerve (CN V)
(also use w/ clusters)

67.

Migraine Tx ergotamine

potent vasoconstrictors; but high

SE
must be given very beginning

68.

Ergotamine SE

NAUSEA
extravasation; over constriction tissue NECROSIS

69.

Ergotamine
counterindications - a
lot

pregnancy
coronary, vascular disease
hepatic/renal insufficiency

70.

Migraine Tx narcs/opiods

last resort; never as monotherapy

causes sedation & N/V; needs antiemetic
high abuse potential

71.

Migraine Tx - beta
blockers

propanolol, timolol
(35-40% success rate)

72.

Migraine Tx antidepressants

amitriptylene - antidepressant
methysergide - 5HT1 agonist

73.

cluster headache causes

dilation of cerebral blood vessels

AND
pressure on TRIGEMINAL nerve

74.

cluster headaches often

misdiagnosed as

trigeminal neuralgia

75.

cluster headache demos

MC MEN
onset, 27-30 yrs (decreases w/
age)
NOT HEREDITARY

66.

90.

SDH vs EDH

Subdural - bridging veins; respects falx

not sutures, (DOESN'T CROSS MIDLINE;
causes shift), crescentic

99.

brudzinski,
kernig

100.

SAH - dx scans vs
time

CT - better early (first 24 hrs)

MRI - better later (4 days+); no rad...but
usually too late
(angiography - not good; neg 1/4 cases)

101.

molecules used
in MRIs

hydrogen ions

102.

CT vs LP

if bleed suspected; CT first if neg; can do

LP to confirm
LP necessary when meningitis
suspected; need to know what bug to
treat

103.

lumbar
punctures when
SAH suspected

reserve for when CT scan negative but

you really believe there is a SAH; use LP
to confirm
[If the CT scan comes back positive, then
there is no reason to get a lumbar
puncture too]

104.

SAH - dx

CT scan; neg DOES NOT R/O SAH - if

suspicion still; use LP to detect rbc's in
CSF
LP only after CT - risk of further
herniation if ICP

105.

estimated to
occur in 10-30%
of LP

a traumatic tap

106.

traumatic tap
from a SAH

lighter in color w/ subsequent tubes

RBC count decreases in subsequent
tubes
there is CLOTTING (should not be in
CSF)
NO XANTHOCHROMIA (takes time to
develop)

107.

xanthochromia
present in SAH or
traumatic tap

SAH

108.

clotting in CSF =
SAH or traumatic
tap

traumatic tap

Epidural - MMA; respects sutures not falx

(can cross ML); lenticular
SAH; deeper into brain
91.

92.

93.

SAH vs SDH vs
EDH pic

Epidural = above
(both) duras they are peeled
off together
(meningeal &
periosteal) - due
to MMA rupture
Duras joined
except at venous
sinuses = space
between
Subdural
hematoma is
under (both)
duras - which are
still attached to
skull
SAH - risk factors

w/age
female;black
smoking/drinking

94.

SAH - MC cause

77% spontaneous hemorrhage due to

aneurysm

95.

SAH - other causes

trauma
AV malformation brain/SC
blood dyscrasias, thinners
tumors; vascular prolif,
impinges/erodesarteries

96.

SAH - mortality

10%; else 1/3 w/ neuro issues

97.

SAH - clin

"worst headache of life"

meningismus (due to blood in CSF)
neurological
(may have sentinel HA; by days or
weeks)

98.

meningismus =

signs of meningeal irritation

109.

= is the yellow discoloration

indicating the presence of
bilirubin in the cerebrospinal
fluid (CSF) .

xanthochromia - takes
time to break down

122.

SDH - dx labs

CBC w/ platelet count, coag studies

alcohol/tox screen
CT scan (MRI superior but not as
available)

110.

SAH - Tx pharm

Anti-HTN/alpha/beta
blockers - Labatelol,
Vasotec
Analgesics - control BP &
agitation
Anticonvulsants - brain
tissue hyper excited
H2 blockers - suppress
nausea

123.

SDH - Tx

ABC's w/ intubate if GCS < 12

(or patient unable to manage own
airway)

111.

SAH - Tx if bleeding secondary

to antithrombolytic

FFP & Vitamin K

112.

NEVER prescribe for a severe

headache

blood thinners or antiplatelet drugs (e.g.

Aspirin)

113.

SAH Tx - non pharm

Bed rest (ICU), ELEVATE

HEAD
protect airway, oxygen
Routine labs &
coagulation studies

114.

chance of recurrent
hemorrhages after a SAH

HIGH 20% rebleed risk

(w/in 2 weeks)

115.

SAH - outcomes

1/3 recovery
1/3 comatose
1/3 neuro deterioration

116.

SDH - causes

blood between brain &

duramater; usually
trauma; may be minor
esp in elderly
bridging veins ruptured

117.

In non traumatic cases of

subdural hematomas,

headache, altered
mental status, neuro
deficits

118.

if a child has a subdural

hematoma....

suspect child abuse

119.

= is the test of choice for

immediate diagnosis of SDH
(subdural)

CT scan (MRI is superior

but not readily available)

120.

SDH - physical eval

Evaluate head for signs

of trauma
Neuro exam - GCS
Look for focal deficits,
SIGNS of ICP
r/o C-spine injury

121.

Glasgow coma scale - scales

HIGHER IS BETTER
eye opening 1-4
verbal response 1-5
motor response 1-6

burr hole if; ML shift > 5mm (inc ICP

signs)
help clotting; w/ FFPlasma and Vitamin K
124.

burr hole

hole drilled into skull; tube inserted

drains hematoma

125.

meningitis risk
factors

pulm/ear/sinus/mastoid infection
head/face trauma; CSF leak
splenectomy
immunosuppresion/alcoholism

126.

MC cause of
meningitis

VIRAL

127.

splenectomy
causes
meningitis/sepsis
how

-spleen macrophages phagocytose

bacteria
-phags activated when bacteria
opsonized/taggged by IgG1, IgG3 or C3b
-w/ asplenia, cannot be removed from
the blood
-patients need immunizations for
pathogens w/ capsules
-only proteins are directly recognized by
macrophages; humoral immunity (IgG
and complement opsonization) is
immune response to capsuled paths

128.

capsulated
pathogens;
problem for
asplenia

-Strep pneumoniae, S. typhi, N.

meningitidis, E. coli, H. influenzae, S.
agalactiae, Klebsiella pneumoniae

129.

meningitis
highest mortality
rate when

babies < 1yr

130.

risk factors
pneumococcal
meningitis
(strep
pneumonia)

ALCOHOL use
DIABETES
....Infection of a heart valve
TRAUMA to head
Recent ear INFECT, pneumonia, URI
SPLEEN removal/dysfunction

131.

meningitis w/
highest mortality
rate
(20-30% adults,
10% children)

Strep pneumonia; PNEUMOCOCCAL

(think lungs)

132.

133.

134.

135.

meningitis w/ lower
mortality; but poor
neuro PROGNOSIS

meningococcal meningitis; spread

by droplets, close conditions;
campuses etc.
(neisseria meningitidis)

meningitis in
NEONATES
(bacteria from birth
canal)

GROUP B STREP (streptococcus

agalactiae)(49%)
E. Coli (18%) - BIRTH CANAL

meningitis in
CHILDREN

H. Influenza (40-60%) - EAR

INFECTS
Neisseria meningitidis (24-40%) SCHOOL
Strep Pneumoniae (10-20%)

meningitis in ADULTS

Strep. Pneumoniae (30-50%)

Neisseria meningitidis (10-35%)
Staph (5-15%) - ADULTS ONLY

136.

meningitis; MC route of
infection

hematogenous spread

137.

meningitis; due to
contigous infect

OM
mastoiditis
sinusitis

138.

139.

140.

meningitis; due to
direct inocculation
hole into spinal
column

head/neck surgery
penetrating head trauma
osteomyelitis of skull

meningitis - clin
neonates
(can vary drastically)

FEVER
Lethargic; Irritable
Bulging FONTANELLE = sign of
intracranial pressure
RASH - petech doesn't blanch
Poor feeding; vomiting
Seizures
(arching neck/back)

meningitis - clin;
adults, children

RAPID ONSET
fever, headache, STIFF NECK
PHOTOPHOBIA
N&V
MSC; Confusion
PETECHIAE (esp meningococc)

146.

normal CSF looks

clear; colorless
cloudy = wbc's or protein

147.

elevated opening
pressure of CSF

> 20cm

148.

elevated opening
pressure suggests

increased ICP; tumors, infect, IC

hemorrhage, hydrocephalus

149.

decreased opening
pressure suggests

hypovolemia; dehydration or shock

150.

elevated
neutrophils in CSF
(left shift)

bacterial meningitis
cerebral abscess

151.

elevate
mononuclear
lymphocytes in CSF

viral or tubercular meningitis (non

bact)
encephalitis

152.

elevated WBCs in
CSF can also
indicate

leukemia (metastatic)

153.

normal RBC, wbc's

in CSF

0; occasional lymphocytes only

154.

normal protein
levels of CSF

very little - 15-45 mg/dl

155.

elevated protein
associated w/

infectious/inflamm of brain/cord;
meningitis, encephalitis, myelitis
CSF tumors, hydrocephalus
SAH

156.

protein enters CSF

in meningitis

inflammed meninges; proteins leak

through caps into SA space

157.

normal glucose
levels in CSF

50-75 mg/dl

158.

meningitis; protein,
glucose levels in CSF

glucose - low (bugs eat)

protein - high inflamm

159.

cytology of CSF will

show

malignant cells - if tumor

160.

meningitis Tx

IV fluid/electrolytes, airway/oxygen,
control fever
ANTICONVULSANTS (seizure in 30%
of patients)
abx - 3rd gen CEPHALOSPORINS &
AMINOGLYCOSIDES (pend C&S; 2-3
wks)
STEROIDS - first 4 days only
(I&D abscess)

141.

meningitis;
inflammation of

pia mater

142.

meningitis - workup

CBC, BMP, UA w/ culture

CT scan before LP
CXR, MRI

143.

CSF visual; w/
meningitis

yellow (xanthochromia); thicker

161.

aminoglycoside
caution

need to test CrCl; can be nephro toxic

144.

xanthochromia

means bilirubin in CSF; not

present if 'traumatic tap'

162.

meningitis Tx anticonvulsants

valium, ativan
dilantin

145.

xanthochromia explanation

rbc's in CSF destroyed &

degraded by enzymes into
bilirubin; takes time to be digested

163.

meningitis Tx control ICP

mannitol

164.

leading oncologic cause of

death < 35 YOA

brain tumors

165.

brain tumors - % primary

50/50
primary/metastatic

166.

in children - cause of cancer

#1 leukemia, #2 brain

167.

brain tumors develop

insidiously, non specific

168.

brain tumor - clin

HA; MC symptom in
CHILDREN
Confusion, MSC
ATAXIA, gait disturbance
Visual defects, speech
abnormalities
Seizures
N&V

169.

motor cortex signals unattenuated - needs

cerebellum - tuning
extrapyramidal nuclei

170.

brain tumor - exam findings

papilledema - MC in
CHILDREN
sensory & motor defects

brain tumor - sensory defects;

location

diploplia - CNVI
upward gaze impaired pituitary
partial visual field occipital (visual cortex)
anosmia - frontal lobe
ataxia/coordination,
nystagcerebellar/brainstem

171.

172.

MC tumor that spreads TO

BRAIN

lung #1
breast, colon, prostate, ...

173.

brain tumor symptoms children

headaches, papilledema

174.

ataxia, uncoordination,
nystagmus (involuntary eye
movements), sensory deficits sign of

cerebellar or brainstem
tumor

brain tumor - workup

CBC, BMP, coagulation

studies
LIVER FUNCTION TESTS
- enzymes will rise
CT - initial test of choice

175.

176.

brain tumor - CT vs MRI

CT scan - initial w/o

contrast first
later; w/ contrast
delineates tumors better
MRI - better for brain
stem, post fossa, dye
allergies, implanted
devices

177.

brain tumors - Tx

STEROIDS - reduce cerebral edema

ANTICONVULSANTS - prophylactic
CONTROL ICP with mannitol
(control airway/oxygen)

178.

brain tumor - surgical

options

removal/debulk
intraventricular SHUNT
radioactive IMPLANTS (sustained
release)
(Oncol consult)

179.

Intraventricular
shunt

if location of tumor closes off ducts of

ventricles; causes hydrocephalus

180.

lumbar puncture
headaches - clin

w/in 24 hrs of LP; N/V

bilateral; relieved when supine

181.

lumbar puncture
headache - MC Tx
(surgical repair very
rare)

Epidural blood patch (slowly injects

blood at defect)

182.

Epidural blood patch

patient's blood injected into

epidural space near defect; clot
forms repairs "leak"

183.

LP headaches last

a few days to 1 week

184.

most useful
diagnostic tests in HA
workup

CT, MRI, LP - guided H&P exam

185.

MC pathogens
swimmer's ear

pseudomonas aeruginosa & listeria

186.

Tx of otitis external
depends on...

w/ cellulitis = syst ABX + local HEAT

w/o cellulitis and no TM perf = ABX
drops

187.

age group most at

risk for OM

young children bc the angle of the

tube is straight and shorter
auditory tube

188.

symptoms of
acoustic neuroma

slowly progressive UNILATERAL

hearing loss

189.

Tx for acoustic
neruoma

surgical removal

190.

should aspirin be
used as an antiinflammatory?

no because of its toxicity (should just

be used as anticoagulant)

191.

which antibiotics are

ototoxic

aminoglycosides

192.

OE w/ cellulitis - Tx

syst ABX (Dicloxaacillin/macrolides)

HEAT

193.

OE w/o cellulitis - Tx

Otic DROPS
(0.3% ofloxacin or polymyxin B +
Neomycin + hydrocortisone*)

194.

OE in diabetic
patients - possibly
invasive can

Invade bone/brain - possible CN

palsies (malignant necrotizing)

195.

OE in diabetic
patients diagnose w/

CT to establish - P. aeruginosa likely

213.

Meniere's
Syndrome clin

FLUCTUATING hearing loss, tinnitus,

EPISODIC vertigo, fullness/pressure in ear;
may be UNILAT

196.

OE in diabetic
patients - Tx

DEBRIDE, longer abx (BROAD SPECT

PCN, antipseudomonal cephalosporin +
Ciprofloxacin or aminoglycoside)

214.

Meniere's
Syndrome cause

edema; ? ENDOLYMPHATIC hydrops;

possible family history

197.

OE pathogens

MC Staph, Strep (P. aeruginosa

swimmer's ear; diabetes)

215.

Slowly subsides but with

unsteadiness/dizziness that may last days

198.

OM pathogens

Strep pneumoniae, H. flu, (Moraxella

catarrhalix); occasional viral

Meniere's
Syndrome resolves

216.

Meniere's
Syndrome Hearing loss

reversible early on

199.

OM viral
pathogens

syncytial virus, influenza virus,

enteroviruses and rhinovirus

200.

OM clin - subj

Ear pain, diminished hearing, VERTIGO,

TINNITUS

217.

Acoustic
Neuroma - Tx

surgical removal

201.

OM clin - obj

fever, TM
erythema/distended/immobile,
fluid/pus

218.

Meniere's
syndrome - Tx

sodium restriction; oral DIURETICS

219.

Deafness other causes

cochlear damage, labryinthitis,occlusion of

ant inf cerebellar art, drugs

220.

Deafness drugs causing

AMINOGLYCOSIDES, cis-platin (anti-CA),

FUROSEMIDE/LASIX (loop diuretic),
SA/tinnitus, oxycontin

202.

serous OM - Tx

no ABX, decon only

203.

bacterial OM - Tx

1st line: Amox-Clav (Augmentin), else

Trimethoprim/Bactrim, Cefaclor

204.

complications of
OM

mastoiditis, bact meningitis, Brain

abscess/subdural empyema

221.

Auditory Tube
Dysfunction may
be due to

Barotrauma caused by
Pharyngotympanic tube dysfunction

allergic
rhinitis - clin

"nose crease" "atopic wave/salute";

Eosinophils in wet prep

222.

rhinitis causes

airborne allergens (most likely); possible

atopic association

when tube
occluded,

residual air absorbed into mucosal

blood vessels, causes suction; retraction
of TM; interfere w/ movement

223.

diff rhinitis vs
CSF

normal CSF: w/ low protein, high glucose

224.

Sinusitis;
bacterial
pathogens

MC S. Pneumoniae, H. Influenzae
(Moraxella catarrhalis) SAME AS OM; also
ANAEROBES, STAPH

225.

Sinusitis;
nosocomial
pathogens

STAPH aureus; gram negs

205.

206.

207.

tube dysfunct pic

blocked route from tympanic cavity to

nasopharynx; edema due to infec,
allergy, etc

208.

tube close w/

changes in pressure, ie. Air travel - need

to swallow/chew; infect, allergy, swelling

209.

Otosclerosis is

Immobilization of the stapes;

overgrowth of bone; conductive hearing
loss

226.

Chronic
sinusitis;
consider

ANAEROBES - colonized in nose

210.

otosclerosis
demos

YOUNG - 70% between ages 11 and 30;

FH 50%

227.

Sinusitis viral
pathogens

rhinovirus, influenza virus, parainfluenza

virus, adenovirus

211.

Acoustic
Neuroma
(vestibular
schwannoma)
clin

Slowly progress; UNILATERAL hearing

loss, tinnitus; vertigo (<20%) but balance
issues (50%); (impaired speech discrim
issues)

228.

Sinusitis - subj

may be indisting from URI; cough,

TOOTHACHE, thick nasal drainage,
headache, past history

229.

Sinusitis - obj

Acoustic
Neuroma
(vestibular
schwannoma)
clin due to

intracranial benign TUMOR; compresses

vestibular nerve

Febrile, TENDER over sinus area, pus

around turbinates, trans-illum of
sinuses/fluid level

230.

Sinusitis - Tx

10-14 day abx, AMOX CLAV (augmentin);

supportive decon

231.

altern to
amox-clav if
PCN allergic

Trimethoprim-sulfamethoxazole (Bactrim),
Clarithromycin

212.

232.

Sinusitis w/
neur manif

Evaluate CT, CSF; for bact meningitis, brain

abscess, subdural empyema

233.

if severe
sinusitis - Tx

I & D, C & S, Antibiotic change

234.

Rhinocerebral
mucormycosis

Fungal sinusitis from fungi (Mucorales)

235.

Rhinocerebral
mucormycosis
causes

Progressive bony destruction, invasion of

brain, vasc thrombosis, CN palsy

236.

Rhinocerebral
mucormycosis
- clin

Black necrotic lesions of palate/nasal

mucosa

237.

Cavernous
Sinus location

base of skull; either side of sella tursica;

post to optic chiasm; CN3-6 all close

238.

239.

cavernous
sinus

cavernous
sinus
thrombosis pic

Cavernous
Sinus
thrombosis
causes

bacteremia, trauma, inf of EAR, maxillary

TEETH, central face, paranasal sinuses (all
are)

241.

Cavernous
sinus receives
drainage from

nose, tonsils, orbits, sphenoid and middle

cerebral veins

242.

Cavernous
sinus drains to

IJV

243.

MC pathogen
cavernous
sinus
thrombosis

STAPH aureus; 70% - if die; sepsis

Cavernous
sinus
thrombosis clin

Headache usually along CN V1, V2; history

of sinusitis, midface inf (furuncle- staph
boil /squeezed in 25%)

Cavernous
sinus
thrombosis late clin

fever, PERIORBITAL EDEMA, CN palsies esp III/EOM; orbital pain/fullness, visual

disturbances, MENINGEAL SIGNS

240.

244.

245.

246.

Cavernous sinus
thrombosis signs

ptosis, mydriasis, eye muscle weakness,

exophthalmos; hypoesthesia of V1, V2;
meningeal signs

247.

cavernous sinus
thrombosis- Tx

BROAD gram +/ - coverage pending

C&S; PCNase resistant penicillin
(Oxacillin), 3rd/4th generation
cephalosporin (Rocephin)

248.

cavernous sinus
thrombosis - labs

leukocytosis, left shift, CSF reflects

infection; + culture; xray, angiography

249.

cavernous sinus
thrombosis, if
2ndary to dental
infection- Tx

add ANAEROBIC coverage (ie.

Metronidazole/Flagyl)

250.

cavernous sinus
thrombosis - long
term therapy

IV ABX 3-4 wk duration (longer than

meningitis); + HEPARIN to prevent
clotting; corticoSTEROIDS

251.

Stomatitis - causes
general

bacterial, viral, NUTRITIONAL (B12, C,

folic acid, niacin), drugs
(chemotherapy), etc

252.

Stomatitis thrush/candidiasis
- susceptible

infants, patients on BROAD-spectrum

abx, steroids, leukopenia, diabetes,
(immunosuppressed)

253.

Stomatitis - clin

mouth PAIN, Difficulty swallowing

254.

Thrush candidiasis
- mild form

White, cheesy exudate on buccal

mucosa/pharynx (scrapes off)

255.

Thrush candidiasis
- severe form

Pain, more diffuse erythema, exudate

256.

Thrush candidiasis
- dx

lesions, w/ KOH-yeast, pseudohyphae

(spagh&meatballs)

257.

Thrush candidiasis
- Tx

Antifungal (Clotrimazole); if
immunocompromised; w/ fluconazole

258.

Thrush candidiasis
- Tx; if resistant

Amphotericin

259.

Herpes Simplex
Virus - dx

Scrape base and stain

(Wrights/Giemsa/Tzanck prep)
revealing intranuclear inclusions and
multinucleated GIANT CELLS

260.

Herpes Simplex Tx

Antiviral agents (Acyclovir or

valcyclovir) may decrease duration

261.

Aphthous
Stomatitis - cause

? possible AI

262.

Aphthous
Stomatitis - clin

Discrete, SHALLOW, painful ulcers with

erythematous base;
LABIAL/BUCCALmucosa

263.

Vincent's
Stomatitis - clin
(trench mouth)

GINGIVAL ulceration/necrosis, FOUL

ODOR, purulent gray EXUDATE; may
spread to peritonsillar space (quinsy)
or neck

264.

Vincent's Stomatitis cause

Spirochetes/fusobacteria (Gm.
Stain)

282.

Viral pharyngitis pathogens

Rhino, corona, adeno-virus (typical

"cold" viruses)

265.

Vincent's Stomatitis - Tx

PCN

283.

Test for strep

266.

Aphthous Stomatitis - Tx

saline washes, topical

anesthetics; if HIV steroids or
thalidomide

Rapid streptococcal AG test (high

false neg)

284.

prob influenza VIRUS

Painless primary chancre, or

painful mucosal patch; may be
> 1cm

pharyngitis - if w/
fever and diffuse
myalgia/malaise

285.

viral/influenza
pharyngitis - Tx

symptoms last a few days and

spontaneously resolve w/o
treatment

286.

Infectious
Mononucleosis caused by

Epstein Barr virus infection with

pharyngitis

287.

Infectious
Mononucleosis - clin

Malaise, fever, tonsil

erythema/edema, white exudate;
DIFFUSE lymphadenopathy;
SPLENOMEGALY

288.

Infectious
Mononucleosis smear

ATYPICAL LYMPHOCYTES - LARGE

289.

Infectious
mononucleosis - dx

Monospot test - detect EB

heterophil ab's; or rise in EB virus
AG

290.

Mono unique how

only virus w/ EXUDATE

291.

Mononucleosis - Tx

Symptomatic, CAUTION re:

splenomegaly and contact activity

292.

Immunodeficiency
virus seroconversion
illness - clin

2nd stage HIV; Fever, pharyngitis,

lymphadenopathy, maculopapular
RASH

293.

Immunodeficiency
virus seroconversion
illness - dx

Requires high index of suspicion for

dx

294.

Streptococcal
Pharyngitis - dx

Throat culture - group A Betahemolytic (Streptococcus pyogenes)

rapid test detects

295.

Streptococcal
Pharyngitis - clin

Mod to sev sympt;

Inflamed/exudative tonsillitis (but
not always)
red spots - cervical
lymphadenopathy

296.

Streptococcal
Pharyngitis - Tx

PCN/Erythromycin
may shorten course; prevents
sequelae

297.

Diphtheria
(Corynebacterium
diphtheriae) RARE
NOW vaccine - clin

GRAY "pseudomembrane" bleeds

with scraping; death by airway
obstruction or via toxins
neuro/cardio effects

298.

Streptococcal
Pharyngitis - sequelae

Rheumatic fever
Acute Glomerulonephritis
scarlet fever

267.

268.

Syphillis - clin

Syphillis - dx

in sex active; confirm

serologically (VDRL/RPR0)
treponema pallidum;
spirochete

269.

"Sore Throat" - MC cause

Viral, Streptococcal; abx to

prevent rheumatic

270.

symptom: more
suggestive of viral vs.
bacterial

Hoarseness

271.

Syphillis - Tx

PCN, 10-14 days, must be

PRIMARY

272.

Danger signs in patients

with "sore throat"

> 1 wk w/o improvement (rare)

resp difficulty/stridor
difficult swallow/secretions
pain w/o erythema
palpable mass
blood in pharynx or ear

273.

if respiratory
difficult/stridor,
secretions, swallowing
consider;

epiglottitis; quincy

274.

if severe pain w/o

erythema - consider

extra respiratory;
epiglottitis
retropharyngeal abscess

275.

if blood in pharynx/ear consider

lateral pharyngeal space

infection
erosion of carotid

276.

if palpable mass consider

soft tissue space infection

277.

Sore throat w/
lymphadenopathy

localized-cervical; if diffuse;
more likely mono

278.

Sore throat MC pathogen

VIRAL, then strep gr A; can

have viral & bact concurrently

279.

Sore throat more likely

strep if

high FEVER, tonsillar EXUDATES,

cervical lymphadenopathy
(and NO COUGH)

280.

if antibiotic resistant w/
normal treatment

must consider other than strep

281.

Strep - dx

If 3 or 4 of above; may often

treat empirically despite neg
strep test

299.

Diphtheria
(Corynebacterium
diphtheriae) - Tx

Antitoxin, erythromycin

317.

Ludwig's Angina cause

MIXED bact infect; ABSCESS of floor of

mouth - 2ary to ODONTOGENIC
infection

300.

Epiglottitis - clin

Sore throat/severe pain/erythema;

difficult swallowing/secretions,
resp difficulty/STRIDOR
LEAN FWD to prevent airway
obstruction

318.

Ludwig's Angina high risk

Laryngeal EDEMA/respiratory
compromise

319.

Ludwig's Angina Tx

High dose Ampicillin-sulbactim , or

metronizadole

320.

Retropharyngeal
Space Abscess clin

Difficul swallowing, dyspnea (Post

pharyngl mass)
Tongue may be DISPLACED
Induration of submandib space

321.

sore throat
EXTRA
RESPIRATORY
causes

elderly
Angina (w/ atypical radiation)
DISSECTING aortic aneurysm (TEARING
pain)
De Quarvain subacute Thyroiditis
(Fever, pain, thyroid tender)

322.

eustachian tube
pic

323.

ear pic

324.

reiter's
syndrome pic

325.

Penicillin
Unresponsive
Pharyngitis

if not self-limiting/ resolved in 4-5 days

326.

Penicillin
Unresponsive
Pharyngitis due
to

HIV
Mono
GC
ALL - dx by smear
Leukopenic states (aplastic anemia,
agranulocytosis)

301.

Epiglottitis concern

Aggressive in child, possible adults

Requires rapid diagnosis, death
possible within hours

302.

Epiglottisis - dx

xray thumb sign; Laryngoscopy

(direct visualization)

303.

Epiglotittis pathogen

H. flu, particularly in child; may

produce B-Lactamase

304.

B-lactamase
inhibitor - adjunct
to abx

clavulanic acid

305.

Epiglottitis - Tx

2nd/3rd gen cephalosporins,

ampicillin-sulbactam preparations;
steroids

306.

Epiglottisis - Tx
prophylaxis

RIFAMPIN

307.

Peritonsillar abscess
- aka "Quinsy" - clin

Difficulty swallowing/secretions
TRISMUS -inability to open mouth
(spasm)

308.

Peritonsillar abscess
- dx

Visualize swelling, lateral deviation of

UVULA

309.

Peritonsillar abscess
- Tx

Early PCN; later I&D

310.

Septic Jugular Vein

Thrombosis - cause

COMPLICATION of bacterial
pharyngitis/QUINSY

311.

Septic Jugular Vein

Thrombosis - clin

w/ pain and tenderness in neck,

often at jaw angle; High fever
bacteremia
septic
PE

312.

Septic Jugular Vein

Thrombosis - Tx

IV PCN + metronidazole (for

anaerobes)

313.

LATERAL Pharyngeal
Space Abscess cause

Rare; complication of JV
thrombophlebitis

314.

Risk w/ LATERAL
pharyngeal space
abscess

serious morbidity/EROSIVE to
CAROTID; EXSANGUINATION

315.

Exsanguination preceded by

blood in ear or pharynx

316.

Retropharyngeal
Space Abscess cause

Complication of TONSILLITIS; rare in

adults; usually 2ndary to cervical
osteoMYELITIS

Penicillin
Unresponsive
Pharyngitis
from GC

Mild but may need high dose PCN

dx w/ Thayer Martin culture media (chocolate
agar)

328.

MC eye
disorder

conjunctivitis

329.

Conjuncitivitis
- MC
pathogens

bacterial, viral, allergic, irritant

LC fungal/parasites
(direct contact)

327.

330.

331.

conjunctivitis
pic

bacterial
conjuctivitis
pic

bacterial
conjuctivitis clin

Purulent discharge
Minimal pain
Minimal blurred vision
Usually self limited

bacterial
conjuctivitis Tx

antibiotic optic solution

334.

viral
conjunctivitis
- clin

(associated with viral pharyngitis)

fever, malaise
Watery (min exudate)
Children > adult
Swimming pools

335.

viral
conjunctivitis
- Tx

Possible optic antibiotic drops (prevent 2ndary

bact infect)

336.

viral life span short /long

hep, ebola; long

332.

333.

337.

problem w/ nasal &

optical decons

rebound; may come back worse

(vasoconstrictors)

338.

allergic conjunctivitis assoc

w/ other atopy; hay fever

339.

allergic conjunctivitis clin

tends to be chronic; atopy

itching, red
minimal stringy discharge

340.

allergic conjunctivitis Tx

symptomatic

341.

chalazion - cause

chronic granulomatous inflam

of meibomian

342.

chalazion - clin

hard swelling on lid

NON tender
may be preceded by 'sty'
conjunct irritation; vision distort

343.

chalazion - Tx

excision (sterile)
old remedy; tea bag/tannic acid
(warm compress NOT helpful)

344.

hordeolum - cause

staph abscess

345.

hordeolum - clin

acutely TENDER
erythematous/edema

346.

hordeolum - locations

internal: of meibomian gland

external: "sty"

347.

hordeolum - Tx

warm compress
abx; I&D

348.

pterygium - cause

chronic wind/dust; benign

surfer motor cyclist

349.

pterygium - clin

fleshy, triangular mass

usually bilateral; nasal side
severe; burning/photophobia

350.

pterygium - Tx

excision if severe

351.

hyphema - cause

blow; contusion w/ hemorrhage

anterior chamber - blood fluid
line

352.

hyphema - Tx

rest; danger of 2ndry

hemorrhage/glauc

353.

uveitis - cause

inflammation of uveal tract

354.

uveal tract

iris
ciliary body
choroid

355.

uveal tract pic

365.

Obstructive Pulm
Disease ------------------------------------

...

366.

Bronchiectasis
generally result of

chronic infections

367.

COPD
characterized by

irreversible airflow limitation

368.

Chronic
obstructive
pulmonary disease
(COPD) air flow
limitation

both progressive & associated with an

abnormal
inflammatory response to
noxious particles or gases

369.

COPD

Irreversible
Fibrosis and narrowing of the airways.
Loss of elastic recoil due to alveolar
destruction.
Destruction of alveolar support that
maintains patency of small airways

370.

Asthma

Reversible
Accumulation of inflammatory cells,
mucus, and plasma exudate in
bronchi.
Smooth muscle contraction in
peripheral and central airways.
Dynamic hyperinflation during
exercise

371.

COPD - clin

Chronic Cough
-Everyday, persistent, for at least 3
months of the year, for 2 successive
years
Wheezing
Dyspnea
Acute Chest illness

372.

COPD - dx

CXR: non diagnostic but helpful to

exclude other illness.
DLCO (see right)
ABG: not essential to diagnosis unless
documented moderate to severe
COPD, then becomes measurement
tool
Spirometry

373.

DLCO C arbon
Monoxide
Diffusing Capacity
Evaluates:

Pulmonary membrane
RBC resistance to bind

356.

inflammation of iris
called

ant uveitis
iridocyclitis
iritis

357.

uveitis - clin

unilateral; can be bilateral

granulomatous or non
granulomatous

358.

uveitis granulomatous
(chronic) - clin

CHRONIC; usually choroid

indolent; blurred vision; mildly
inflamed
white precipitates; focal
"mutton fat", iris nodules
BUT MORE DAMAGE progressively close canal of
schlemm

359.

pathogens causing
granulomatous (chronic)
uveitis

sarcoidosis
TB
syphillis
toxoplasmosis

360.

uveitis granulomatous Tx

...

361.

uveitis non
granulomatous ACUTE clin

ACUTE; marked pain

redness, photophobia
visual loss
diffuse, smaller precipitates; no
nodules
dilated blood vessels around
iris/capillary body

362.

immunodysfunction
diseases - allowing acute
(non granulomatous)
uveitis

(HLA-B27 related - AI
syndromes)
reactive arthritis/reiter's,
psoriasis, ulcerative colitis,
chron's

363.

pathogens causing non

granulomatous (acute)
uveitis

herpes simplex & zoster

374.

DLCO C arbon
Monoxide
Diffusing Capacity

364.

uveitis non
granulomatous ACUTE Tx

Local and systemic

corticosteroids may shorten
course

Objective measurement of lung

function
Ability of lung to take up test gas (CO)
which binds to hemoglobin (CO with
high binding affinity)

375.

why use CO gas in

DLCO test

high affinity for hemeglobin

376.

DLCO procedure

set dose of CO is inhaled; measure

exhaled CO
higher than normal; CO not
absorbing to blood

377.

DLCO procedure
evaluates
pulmonary
membrane

if too thick, won't cross

378.

3 types of disorders
that will decrease
DLCO

obstructive disease (emphysema, CF)

- can't cross
Interstitial lung disease
Pulmonary vascular disease

379.

interstitial lung
disease impacts 2
ways

more difficult to cross - fibrosis

more distance to cross

380.

Pulmonary vascular
disease

gets across membrane but not picked

up
blood not reaching surface to absorb

381.

Factors affecting
diffusing capacity

Ability of gas to reach alveolar gas

exchange surface
Ability to cross alveolar membrane
Mass of RBC in pulmonary capillary
bed to bind CO

382.

383.

384.

385.

386.

387.

388.

cause decreased
diffusion capacity

Pulmonary Vascular Occlusive disease

(PE)
Interstitial lung disease
Emphysema
Pulmonary edema - alveoli filled w/
fluid

cause increased
diffusion capacity

Pulmonary hemorrhage
L to R intracardiac shunt
Asthma (may be normal)

spirometry movement of air

restricted

will show obstructive & restrictive

can use to monitor as well

FEV1/ FVC normal

vs COPD

80% vs 60% (obstructive FEV1

disproportionately decreased;
restrictive both equally decreased)

Chronic bronchitis
- causes

Persistent cough w/ sputum prod > 3

months, in each of past 2 years
Cigarette smoking - major cause
exposure to pollutants

Chronic bronchitispathologic findings

chronic bronchitis clin

Goblet-cell hyperplasia
Mucous plugging
Fibrosis
primary: airway (vs parenchyma in
emphy)
Similar to emphysema
key - sputum production
Possible recurrent bacterial airway
infections

389.

chronic bronchitis dx

PFT
CXR
standard lab

390.

chronic bronchitis Tx

Inhaled bronchodilators,
corticosteroids
If significant sputum - chest
physiotherapy
Rotating antibiotics if appropriate

391.

CB vs emphysema

disease of AIRWAYS vs parenchyma

emphysema; parenchyma destroyed

392.

emphysematous
lungs on x-ray

bubbles
alveolar structure destroyed

393.

emphysema
breathing

accessory muscles needed to breathe;

barrel chested - increased AP
diameter (norm 1:2)

394.

Chronic
bronchiolitis - is

Inflammation, fibrosis, distortion of

SMALL airways;
membranous, respiratory bronchioles

395.

Chronic
bronchiolitis causes

airflow limited due to inc. airway

resistance;
associated airway muscle hyperplasia

396.

Chronic
bronchiolitis - clin

similar to COPD
related to acute viral infections
after exposure to mineral dusts (silica,
asbestos)

397.

bronchiectasis is

Abnormal dilation of bronchi;

inflammation and permanent
destructive changes in elastic and
muscle layers of bronchi

398.

bronchiectasis
usually caused by

recurrent or chronic severe infections

(necrotizing pneumonia, TB, atypical
pneumonias)

399.

bronchiectasis also
caused by

viral and fungal infections

anatomical obstruction
hypersensitivity reaction (allergic)

400.

bronchiectasis causes

more middle-aged to older

in younger w/ congenital defects

401.

bronchiectasis congenital diseases

associated

CF
immotile cilia syndrome =
Kartagener's Syndrome

402.

Kartagener's
syndrome triad

Sinusitis
Situs inversus
infertility

403.

wheezes w/
CB/asthma vs
emphysema

Expiratory (ball valve) vs inspiratory

(emphysema is prolonged expiration
too)

404.

405.

406.

bronchiectasis clin

bronchiectasis dx

Chronic cough and FOUL smelling

sputum
SOB; Abnormal chest sounds
Fatigue
Rare hemoptysis
CLUBBING (40%)
CXR: norm or increased interstitial
markings
Classic finding - "Tram Tracks"
(thickened bronchial walls w/o tapering)
High Res CT more sensitive

bronchiectasis
"tram tracks" pic

407.

emphysema

permanent enlargement of airspaces

distal to terminal bronchioles; w/
destruction of walls w/o obvious fibrosis

408.

Factors
Determining
Severity Of COPD

symptoms & airflow limitation

exacerbations
complications of COPD
respiratory insufficiency
Co-morbidities
General health status
Number of medications needed to
manage

COPD: ABG not

essential to dx,
but for
monitoring

pH, CO2 (more than PaO2)

Stages of COPD
slide 37

...

411.

reducing risk
factors

Smoking cessation -most effective

occupational dusts and chemicals, air
pollutants

412.

COPD - Treatment
general

Reduce risk factors

Manage stable COPD
Education
Pharmacologic
Non-pharmacologic
Manage exacerbations

409.

410.

413.

COPD medications efficacy

meds not shown to alter longterm decline in lung function;

meds only decrease
symptoms/complications

414.

Primary COPD meds bronchodilators

beta2-agonists
anticholinergics
theophylline - narrow TI

415.

COPD: inhaled steroids

indicated when

FEV1 < 50% predicted

reduces frequency of
exacerbations
avoid chronic use: unfavorable
benefit-to-risk ratio

416.

slide 44 COPD stages &

treatments

...

417.

COPD & O2
administration

w/ chronic resp failure O2

shown to increase survival

418.

COPD & exercise training

All patients benefit; improved

exercise tolerance and
dyspnea/fatigue

419.

COPD exacerbated by

inf of tracheobronchial tree

air pollution
1/3 cannot be identified

420.

treatment of COPD
exacerbations

Inhaled bronchodilators
Systemic-- pref oral-- steroids
abx of questionable benefit unless CB

421.

NIPPV noninvasive
intermittent positive
pressure ventilation - in
exacerbations

improves blood gases, pH

reduces in-hospital mortality
decreases need for invasive
mechanical vent/intubation
decreases hospital stay

422.

Asthma is

Airway inflammation, hyperreactivity

reversible airflow obstruction

423.

Asthma incidence

highest in kids; but affects all

ages
7% of US pop
Incr 75% between 1960-94

424.

Asthma cause unknown, assoc w/

atopic history

possible polygenic origin

exacerbated by environmental
factors, abnormal adrenergic
receptors
Inhalants/irritants, infectious
agents
Obese higher incidence

425.

slide 50

...

437.

Theophylline
concerns

into toxic range quite rapidly

438.

LTE inhibitor

Singulair

439.

NSAIDS can
precipitate
asthma

block prostaglandins; shunt to LTE

pathway
(avoid NSAIDS w/ nasal polyps)

440.

Acute severe
"status
asthmaticus"

May occur suddenly and possibly fatal

Often w/ history of progressive dyspnea
over hours to days; w/ increasing
bronchodilator use
Symptoms/signs more severe

441.

Acute
severe/status
asthmaticus Tx

Requires aggressive treatment with

monitoring
Pulse oximetry/ABG's

442.

...

but typically not the rule; grows out

of it usually

recording 3:3, 41
mins.....missed
notes

443.

CF - stats

Asthma lungs look

more hyperinflated; black on xray

air trapping

Autosomal RECESSIVE (fortunately0

MC lethal genetic disorder in white pop

444.

CF affects

asthma - clin
EPISODIC

Triad: wheeze, dyspnea, chronic

cough
chest tightness
Often worse at night or early a.m.
Other symptoms; sputum
production, chest pain or tightness

respiratory
hepatobiliary; GI
reproductive

445.

CF - cause

When active with

airflow limitation

Difficulty talking, using accessory

muscles of expiration
Diaphoresis, MSC due to anxiety
Expiratory wheezes
Pulsus paradoxus

mutation of gene; defective Cl transport

incr Na reabsorption
abnormally thick/viscous secretions
luminal obstruction/destruction exocrine
ducts

446.

CF - disease

432.

Pulsus paradoxus

Pulse weakens during INSPIRATION

433.

asthma dx

History may be sufficient

Bronchoprovocation challenge
testing

Airways colonized with S. aureus or H. flu

(then Pseudomonas aeruginosa)
Persistent inflammation/infection causes
bronchial wall destruction, bronchiectasis
Mucous plugging of small airways
produce cystic dilations and
parenchymal destruction

447.

CF - death

young age; from respiratory failure

448.

CF dx

Consider in pt. with unexplained chronic

sinus disease, bronchiectasis,
malabsorption
PFT - varying degrees of obstruction,
progressive
CXR - normal or bronchiectasis
Meas: Cl conc in sweat; + if > 60 mEq/L
twice
Most dx in childhood
Median survival - mid 3rd decade

449.

CF clin

Salty skin
Persistent cough w/ and w/o sputum
Wheezing; SOB
Poor appetite, FTT; nutrition not
absorbed
(Greasy, bulky stools)
Possible infertility, diab, osteoporosis

426.

427.

428.

429.

430.

431.

asthma pathomechanics

Airway remodeling

Airway remodeling overtime

Airway inflammation
activated inflamm cells in walls
Eosinophils, mast cells, macrophages,
T lymphs
Produce leukotrienes, cytokines,
bradykinins
Hyperplasia/hypertrophy smooth
muscle
Edema; inflamm infiltration
dep of connective tissue (collagen I
and III); thickening
dissoc of airway (from parench)
"Stenting" of airways
may cause;
irreversible airflow limitation
reduced effectiveness of
bronchodilators

434.

Bronchoprovocation
challenge testing

Use bronchoconstrictor (histamine,

methacholine, cold air, exercise) to
trigger episode
(Lungs hyperinflated during active
episode -black xray)

435.

management of
chronic asthma
(in all but mild
intermittent asthma)

maintenance therapy; regular

admin of inhaled steroids
Add bronchodilators PRN
LTE inhibitors also (but don't replace
steroids)
Theophylline useful but w/ narrow
therap window

436.

Diagnostics during
episodes

ABG's, CXR, eosinophilia, increase

IgE
Skin tests to identify allergens

450.

CF cause diabetes how

starts as pancreas enzyme/exocrine destruction; then destroys endocrine

451.

CF Tx

Aggressive airway hygiene; percussion, etc

Bronchodilators as needed
Inhalers to decrease sputum viscosity
pancreatic enzyme replacement
abx PRN
Possible lung transplant

452.

...