internal case files

chronic bronchitis and emphysema

permanent enlargement of airspaces distal to terminal bronchioles w/ destruction of walls

spirometry

total volume of air expired after full inspiration

normal obstructive
reduced restrictive

reduced in both

percentage of vital capacity expired during first sec

FEV1-reduced
FVC- reduced
FEV1/FVC normal
TLC reduced
VC reduced

smoking, alpha1 antitrypsin def

ABG

FEV1-reduced <80%
FEV1/FVC- reduced <.7

TLC-normal or increased
residual volume in COPD -increased due to air trapping

reduced FEV1/FVC with minimal response to bronchodilators

bronchodilators (beta agonist and anticholinergic)

endotracheal intubation w/ ventilatory support

BABE
bronchiectasis
asthma
bronchitis
emphysema

PMS PAPI
poliomyelitis
myasthenia gravis
scoliosis
pneumonia
ARDS
pulmonary edema
interstital fibrosis

COPD

pulmonary function test with metacholine challenge (increase in FEV1 after challenge of more than 12%)

bronchial hyperactivity and smooth mm hypertrophy leading to inflammation assoc w/ bronchospasm that is reversible

acute (<3 wks)
acute respiratory infection
CHF
pneumonia
PE
chronic (3-8 wks)
postnasal drip
GERD
asthma

COPD

hyperresonance and diminished breath and heart sounds suggest air trapping, and the prolonged expiratory phase indicates air flow obstruction.

wheezing

idiopathic pulmonary fibrosis include digital clubbing and bibasilar end-inspiratory crackles with a Velcro-like quality.

skin, eyes, joints, or lungs.

1. lung cancer
2. bronchietasis
3. lung abscess

1. bronchitis
2. lung cancer
3. TB
4. bronchiestasis (chronic copious sputum)
5. lung abscess
6. PE (acute onset w/ pleuritic chest pain & dyspnea)

adenocarcinoma

bronchoscopy

Contrast-enhanced helical CT scan of the chest is a preferred method to diagnose pulmonary embolism in a patient with clinical risk factors for pulmonary embolism, normal renal function, and an abnormal chest radiograph.

In fact, jugular venous distention has been described in 80% of patients with massive pulmonary embolism Physical examination findings supporting pulmonary embolism include a palpable and accentuated S2 over the second left parasternal space, a left parasternal precordial heave, a holosystolic murmur over the epigastrium that is louder on inspiration, and a presystolic low-pitched extra sound over the subxiphoid area.

low-molecular-weight heparins reduce the risk of clinically important venous thromboembolism

factor V Leiden mutation with recurrent thrombosis should receive long-term anticoagulation therapy with warfarin.

The DLCO reflects the integrity of the alveolar-capillary membrane. Patients with emphysema have a reduced DLCO because of loss of lung parenchyma and less surface area for diffusion and those with pulmonary embolism have a reduced DLCO because of decreased blood flow through the pulmonary vasculature.

flow limiting stenosis by atherosclerotic plaque that cause ischemia during exercise w/o acute thrombosis

ischemia limited to subendocardium

transmural ischemia

leads II, III, aVF

leads V2, V3, V4

leads I, aVL, V5, V6

Arthrocentesis is indicated to evaluate undiagnosed monoarticular arthritis. The differential diagnosis of monoarticular arthritis includes septic arthritis, gout, pseudogout, rheumatoid arthritis, systemic lupus erythematosus, and the spondyloarthritides.

Patients with meniscal tears describe a twisting injury with the foot in a weight-bearing position in which a popping or tearing sensation is often felt, followed by severe pain.

The typical patient with patellofemoral pain syndrome is an active young woman with anterior knee pain worsened by going down steps.

rheumatoid arthritis does not involve the distal interphalangeal joints,

decreasing a patient's uric acid level may induce a gouty attack, continuation of colchicine therapy is indicated while the allopurinol dose is increased

Patients with hereditary hemochromatosis usually present with abnormal liver chemistry test results, arthropathy, fatigue, and impotence.

Intra-articular corticosteroid injections effectively relieve symptoms of knee osteoarthritis.

Symmetric polyarthritis, rash, mucosal ulcer, and constitutional symptoms are compatible with systemic lupus erythematosus, rheumatoid arthritis, and viral infections.

Manifestations of disseminated gonococcal infection in women may include tenosynovitis, oligoarthritis, and dermatitis. A finding of acute nontraumatic monoarticular arthritis, particularly in a sexually active young woman, should prompt consideration of disseminated gonococcal arthritis.

released from necrotic heart muscle after MI

creatine phosphokinase (CK) rise in 4-8hrs return 48-72 hrs
troponin rise 6 hrs return 7-14 days
- 2 sets of normal troponin 4-6 hrs apart rules out MI

2 of 3
1. chest pain >30min
2. EKG findings
3. elevated cardiac enzymes

1-3 hrs after onset of chest pain

accomplished by cardiac cath, small is inflated in an attempt to open blockage and restore blood flow

vfib or vtach

defibrillation followed by amiodarone

adenosine

atropine

1.first degree- PR prolongation
2. 2nd degree - Mobitz 1: gradual prolongation of PR interval until P waves fail to conduct
Mobitz 2: sudden drop in QRS
3. 3rd degree: no P wave conduction

A non-ST elevation acute coronary syndrome is recognized by ST depressions and/or T wave inversions

left bundle branch block is associated with absent Q waves in leads I, aVL, and V6; a large, wide, and positive R wave in leads I, aVL, and V6 (“tombstone” R waves); and prolongation of the QRS complex to >0.12 sec.

n right bundle branch block, lead I will show a small Q wave and tall R wave; lead V6 will show a small positive R wave and a small negative S wave followed by a large positive deflection (the “rabbit ear”). There is ST depression and T wave inversion in right precordial leads and upright T waves in left precordial and limb leads. The QRS complex is >0.12 sec.

* The use of angiotensin-converting enzyme inhibitors should be avoided during pregnancy.
* Hydralazine and nitrates are the vasodilators of choice to treat heart failure during pregnancy.

intravenous lidocaine, procainamide, or amiodarone.

physiologically split S2.and long, late-peaking systolic murmur i

mitral valve regurgitation include a holosystolic murmur at the apex that radiates to the axilla

Classic findings of mitral stenosis include a loud S1 and an opening snap followed by a rumbling diastolic murmur. Previously undiagnosed mitral stenosis often first becomes symptomatic during pregnancy.

In mitral valve prolapse, the Valsalva maneuver and standing from a squatting position and handgrip increase murmur and move the click-murmur complex closer to S1.

difficult to flush (bc of fat)
chronic pancreatitis -> alcoholic

1. Na and water restriction
2. spironolactone
3. loop diuretics
4. frequent abd paracentesis

CT of abdomen

enema and sigmoidscopy

Hep B- sex
Hep C IV drug, tattoo, blood transfusion

villous adenoma

cryptosporidium

1. anemia
2. thrombocytosis
3. Increase ESR

1. epigastric pain that improves with food
2. 90% H pylori
3. amoxicillin + clarithromycin +PPi

1st- antibiotics
2nd ERCP

Hep C

lactulose (nonabsorbable disaccharide), neomycin, laxatives

hepatic adenoma

1st abd U/S or CT
2nd ERCp or PTC

ursodeoxycholic acid

fulminant hep

AFP

elevated alk phosp
normal Ca, phosp, LFTs

low back pain + stiffness
HLA-B27
fatigue, uveitis, pulmonary dz

every 2 yrs at 50-75

skin pigmentation
diabetes
cirrhosis
arthalgia

Hep B- interferon + lamivudine
Hep C- interferon + ribavirin

irregularly irregular, narrow QRS that lack P wave

1st vagal maneuvers (cold water)
2nd adenosine

flushing and pruritis due to prostaglandin reduced by adding aspirin

ACE inh, ARB, beta blocker, spironolactone

beta blocker or calcium channel blocker

cervical spine

pain that radiates to thigh; straight leg raise is positive

distal finger joints
morning stiffness
sausage fingers

NSAIDS, anti-TNF & methotrexate

cigarette, >140/90, HDL<40, family history, men>45, women >55

high risk: CHD or equivalent >100
moderate: 2 or> >160
low risk: 0-1 >190