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192 Cards in this Set
- Front
- Back
What differentiates COPD from asthma?
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COPD is not fully reversible and progressive
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What are the leukocytes that infiltrate lung parenchyma in COPD? (Pick all that apply)
neutrophils, eosinophils, lymphocytes, macrophages |
neutrophils, macrophages and (CD8+) lymphocytes
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What are the major inflammator mediators in COPD?
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IL4, IL8 and TNF-a
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What does alpha-1 anti-trypsin do in a healthy individual?
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Protects the lungs from destruction by elastase (a protease carried by neutrophils)
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Where is the major site of airway narrowing in COPD?
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Small airways
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What pattern of cellular damage is characteristic of alpha-1 antitrypsin related COPD?
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alpha-1 antitrypsin = Panacinar - diffuse damage after terminal bronchioles
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What pattern of cellular damage is characterised by smoking-related COPD?
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smoking COPD affects proximal acinus: Centriacinar region (respiratory bronchioles) in irregular pattern
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Why do COPD sufferers trap air?
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The small airways become obstructed, leading to air trapping and eventually hyperinflation
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What causes pulmonary hypertension in COPD patients?
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Chronic hypoxia leads to vascular remodeling
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What might account for COPD being associated with CVD?
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Lung inflammation may upregulate systemic inflammation, destabilizing vascular endothelium and plaques
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What type of COPD is associated with "blue bloaters?"
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Chronic bronchitis - tend to be hypoxic and overweight. More V/Q mismatch
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What type of COPD is associated with "pink puffers?"
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Emphysema - less hypoxic and better V/Q match, but dyspnea is noticable
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What lung function results would you expect to see in COPD?
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FEV1/FVC <70%
FEV1 determines stage: 100-80 = mild 50-80 = moderate 30-50 = severe <30 = very severe |
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When would you order arterial blood gas for a COPD patient?
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For a type B (chronic bronchitis), or moderate/severe disease
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What Ig is linked to asthma/exzema?
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IgE
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What is the difference between intrinsic and extrinsic asthma?
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Intrinsic is lifelong with chronic inflammation between attacks.
Extrinsic has a precipitating factor and acts like allergy (goes away with precipitator) |
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What is the asthma triad?
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Bronchospasm
Edema Hypersecretion of mucus |
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Which of the asthma triad is associated with late phase vs. early phase?
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Late stage: airway edema (hyperresponsiveness)
Early stage: bronchospasm, mucus secretion |
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Why is asthma obstructive?
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Airways open on inspiration, but tend to collapse on expiration
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Why does tachypnea worsen asthma symptoms?
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Air is trapped because of obstructed airways. Asthmatic wants to expel leftover dead air, but its getting hypoxic, so breathes faster. This lessens time for exhalation, exacerbating air trapping and hypoxia.
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What blood test finding would be suggestive of asthma?
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Eosinophilia, elevated IgE
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What is a methacholine challenge test?
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For asthma - give doses of methacholine (bronchoconstrictive) until FEV1 reduced by 20% from baseline. Small # doses = might be asthma. Lots of doses, probably not asthma.
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What 2 common disease are linked with asthma?
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Allergic rhinitis, GERD
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Why is helium/oxygen helpful in an acute asthma attack?
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Helium is less dense and viscous than Nitrogen. Helps get O2 into lungs and push CO2 out.
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What tx are first line for acute asthma?
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Albuterol, steroids, O2 /vent if needed
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What are the severity stages of asthma?
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1a. Mild intermittent (</=2/week, 2/month at night)
1b. Mild persistent (>2/week but not daily, >2/month at night) 2. Moderate persistant (daily sx and use of rescue inhaler, >1/week at night, exacerbations >2/week, obstruction on PFTs) 3. Severe persistent (continuous sx and frequently at night) |
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What viruses predominate in wheezing children under 2 vs. 2 or older?
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RSV <2
Rhinovirus >/=2 |
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When are asthma hospitalizations highest?
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When school is in session and when there are respiratory viral infection outbreaks
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What viruses are associated with protection vs. increased risk for asthma?
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2 common colds before age 1 = protection
1 lower-respiratory tract infection with wheeze before age 3 = increased risk |
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What receptor may be faulty in some asthmatics?
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glucocorticoid receptor may be mutated (GCR-beta) - leading to steroid insensitivity because it does not bind well to DNA and induce downstream effects of steroids
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In the hygiene theory for asthma, different T cells mediate chronic infection vs. parasite responses. Which type of T cell is associated with each?
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TH1 = chronic infection: TNF, IFN, IL2
TH2 = parasites: IL4,5,6,10,13 |
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What is shunt, and what conditions cause it?
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Pulmonary shunt: blood never gets to air: Filled or collapsed alveoli
Vascular shunt: AV malformation or patent FO |
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What is V/Q mismatch, and what conditions cause it?
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Ventilation and perfusion of blood are not well matched: ILDs/fibrosis, COPD, dead space, PE - overdistention and compression of capillaries
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What is meant by "won't breathe" vs. "can't breath?"
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Won't breath is hypoventilation when the subject isn't working hard = drugs, ideopathic, hypothyroid
Can't breath is when the subject is working hard but can't overcome increased work, get fatigued, as in COPD, ILD, NMD |
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Explain Shunt vs. Dead space on the V/Q spectrum
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Shunt is where there is no chance for air to get to the blood (Pneumonia/atelectasis)
Dead space is perfused alveoli with no perfusion (PE) |
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Why does V/Q change from top to bottom of the lung?
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Due to perfusion (Q). Low V/Q due to high Q at base of lungs.
High V/Q due to low Q at apex of lungs |
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What causes improvement of V/Q mismatch in pneumonia (shunt)?
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Hypoxia turns on K+ pump, opens Ca++ channels which cause vascular smooth muscle to contract, diverting blood away from shunted alveoli.
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What causes improvement of V/Q mismatch in PE (dead space)?
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Fibrous bands surrounding alveoli sense lack of perfusion via lack of CO2. Contract around dead space alveoli, decreasing compliance and diverting air to areas with good Q.
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What is associated with DECREASED DLCO?
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Emphysema, parenchymal disease, vascular disease and anemia
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What is associated with INCREASED DLCO?
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Asthma, pulmonary hemhorrhage, polycythemia, L-R Shunt
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Where in the lungs are centrilobular emphysematic lesions prominently found?
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Apices
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When would you expect to see distal acinar emphysema?
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Adjacent to scarring - causes pneumothorax in otherwise healthy young people
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When would you expect to see irregular acinar distribution of emphysema?
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Incidentally in an autopsy of an elderly person - least clinically significant emphysema
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What is the hallmark pathology behind chronic bronchitis?
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Excess mucus secretions in large airways, produced as a response to irritants/infection
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What are the cellular features here typical of chronic bronchitis?
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Thickened mucus gland layer
Squamous metaplasia |
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What is the Reid index for mucosal gland size, and what is it used for?
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Reid index is mucosal gland thickness / thickness of bronchial wall to cartilage.
>.4 indicates chronic bronchitis |
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Is asthma associated with TH1 or TH2 lymphocytic response?
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TH2 - acute parasite response instead of chronic response
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What is the prominent Immunoglobulin of asthma?
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IgE
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What is the prominent leukocyte of asthma?
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Eosinophils
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What do eosinophils release in asthma that is damaging to epithelium and causes late phase bronchoconstriction?
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Major basic protein
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What is wrong with this picture from an asthmatic?
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ASTHMA:
Neutrophils and macrophages, thickened basement membrane, extra mucus secretions |
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What lab tests for diagnosing asthma are helpful in sputum samples?
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Charcot-Leyden crystals (Eosinophil product), Curschmann spirals (mucus)
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What is bronchiectasis, and what causes it?
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Chronic infections of the bronchi with permanent dilation:
Obstruction: Tumors, foreign bodies Hereditary: CF Intralobar sequestration Immotile cilia Immune deficiency Pneumonia: Staph or TB |
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What two insults are required for bronchiectasis?
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Obstruction and infection:
Inflammatory response causes dilated airways, which eventually becomes irreversible |
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What is evident on gross examination?
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Bronchiectasis - dilated airways with thin walls, areas of necrosis (This is a CF case)
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What did the owner of these lungs have?
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CF, with pseudomonas aeruginosa causing green discoloration. Note prominent dilated airways and mucus plugging.
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What is the Alveolar gas equation
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PaO2 = FiO2 x (Barometric pressure - PH20 vapor) - PACO2 / R
= .21 (at room air)x(760 - 47) - Palveolar CO2 / .8 |
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What does alveolar hypoxia induce in pulmonary arterial supply?
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Vasoconstriction, increasing resistance and pulmonary arterial pressure
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What are the short term physiologic responses to altitude?
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Increased minute ventilation
Increased 2,3 DPG in RBCs (to cause hypoxic RBCs to release O2) Increased hemoglobin Compensated respiratory alkalosis |
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What are the long term physiologic responses to altitude?
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Decreased response to hypoxia
Increased DLCO, Increased vascularity of heart and muscles |
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At what height does mountain sickness occur?
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Above 3000 feet above sea level
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What are symptoms of mountain sickness?
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Hangover: headache, n/v malaise
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What are the triggers for anion-gap metabolic acidosis?
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MUDPILES
Methanol Uremia DKA Paraaldehyde Isoniazid Lactic acidosis Ethylene glycol Salicylates |
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What is the equation to determine if an anion-gap acidosis is compensated?
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If compensated:
PCO2 = 1.5 (bicarb) +8 |
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How do you calculate serum osmolarity?
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2xNA + Glucose / 18 + BUN/2.8
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What is a normal anion gap?
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10-14
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What organism type causes an interstitial pattern of infection?
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Viral
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What leukocyte infiltrate is pneumonia characterised by?
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Polys
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What is seen here? The patient had pneumonia.
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Interstitial fibrosis, fibrotic tissue in airspaces from incomplete resolution of pneumonia
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What bugs are community acquired pneumonia most commonly caused by?
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SHPKV
Strep pneumo (1) H Flu Pseudomonas Klebsiella Viral |
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What is pictured here? This is from a 6 month old baby with consolidation on CXR.
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RSV pneumonia
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What is seen here? The patient had received a liver transplant 10 months prior.
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CMV pneumonia
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What is seen here? The patient had a cold followed by pneumonia.
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Adenovirus pneumonia - chronic inflammation, congestion and hemhorrhage
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What is seen here, possibly caught in the Mississippi or Ohio River valleys?
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Histoplasmosis ball in lung
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What infection is seen here, possibly caught in the San Joaquin Valley?
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Coccidiomycosis - note non-budding spherule with endospores
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What fungal infection is seen here?
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Blastomycosis - from Mississippi valley. Broad based buds, nuclei apparent unlike in other fungi
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What fungus can colonize a hole left by another disease?
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Aspergillus - aspergilloma in a TB or tumor cavity
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What fungus has near right-angle branching of non-septated hyphae?
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Mucormycosis
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What is represented here, staining black on GMS?
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PCP (pneumocystis jiroveci), only a problem in immunocompromised
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What is solute component in healthy vs. CF mucus?
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3% healthy
up to 15% CF Solute level affects function |
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What are the main antimicrobial functions of mucus?
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Bacteriostatic (iron binding)
Bactericidal (Lysozymes and defensins) Opsonizing (Complement, ficolins, collectins) |
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What are the two layers of airway mucus?
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Sol (acqueous, cilia move freely)
Gel (viscous, traps particals and is beaten by cilia toward the head) |
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What is the normal arrangement of microtubules in respiratory cilia?
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9+2 doublets
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What non-ciliary abnormality (i.e., not infertility) is associated with primary ciliary dyskinesia?
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situs inversus
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What may happen with aging that impairs mucociliary elevator function?
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microtubular disarrangement, impairing coordinated ciliary beating
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Why do the elderly have impaired humoral immunity
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Loss of Th cells (B cells largely are unaffected by aging)
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What is the protein mutated in Cystic Fibrosis?
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CFTR, which regulates Cl secretion, causing viscous mucous
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What are reasons that cough can fail?
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Muscular weakness (cervical injury - expiratory, diaphragm weakness - inspiratory)
Mucus problem (CF) |
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What mutation is associated with recurrent gram-negative bacterial infections?
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TLR4 receptor on macrophages (PAMP for lipopolysaccharide)
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What cell cleans up excess surfactant?
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Macrophages
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What causes pulmonary alveolar proteinosis?
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Alveolar macrophage defect, leaving surfactant undigested and filling in alveoli, causes dyspnea and hypoxia (shunt)
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What kinds of infections are people with Pulmonary alveolar proteinosis predisposed to?
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Atypical, ex: nocardia, fungi
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What is the role of surfactant proteins A and D in immune response?
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Surfactant A/D are the collectins (opsonization). Inhibit macrophage phagocytosis, tend to down-regulate inflammation
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Where is bronchus-associated lymphoid tissue most commonly found? (BALT)
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At bifurcations
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What is a neutrophil NET?
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Extracellular trap - meshwork of antimicrobial proteins that the PMN spits at an enemy
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What does chronic granulomatous disease cause in long term?
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Bronchiectasis and fibrosis
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What sort of cough does an interstitial lung disease produce?
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Dry (alveolar damage is distal to mucociliary elevator)
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What is the clinical name that encompasses all these pathological terms:
Usual interstitial pneumonitis, Desquamative IS pneumonitis, Bronchiolitis Obliterans-Organizing pneumonia |
Idiopathic pulmonary fibrosis
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Of all the idiopathic pulmonary fibroses, which should you separate from the others for dx/ treatment purposes:
Usual ISP Desquamative ISP Lymphocytic ISP Giant cell ISP Bronchiolitis ISP Bronchiolitis Obliterans - Organizing Pneumonia |
Separate Usual ISP from all others, because it is usually fatal and does NOT respond to steroids
All the others respond to steroids and are not typically fatal |
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Why don't steroids help usual interstitial pneumonitis/ idiopathic pulmonary fibrosis?
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It is a fibrosing disease, not an inflammatory disease
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What can you expect to see on a gross specimen of UIP/IPF?
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Holes as in emphysema, but fibrosis surrounding (honeycombing). Heterogeneous pattern with some healthy areas.
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What typical feature of UIP/IPF is seen here?
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A fibroblastic focus, will develop into UIP/IPF
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What stage of UIP is seen here?
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End stage - fibrosis with epithelium lined cavities
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What might you expect to see in a non-specific interstitial pneumonitis on gross inspection that would be different from UIP/IPF?
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On gross, UIP/IPF is heterogenous: some of the lung will appear normal, while other areas are destroyed.
NSIP is more homogenous, the whole lung will look pretty similar on gross |
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In what areas of the lungs do you typically see greater involvement for non-specific IPF?
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Upper lobes
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What behavior is linked with desquamative interstitial pneumonitis?
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Smoking
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What leukocytic infiltrate is seen here in desquamative interstitial pneumonitis?
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Alveolar macrophages
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What is the difference between desquamative ISP and bronchiolitis?
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They are similar, both associated with smoking, but bronchiolitic macrophages are concentrated at bronchioles instead of alveoli
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What is anthracosis?
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Carbon dust in lung - seen in coal miners and some urban residents. Asymptomatic and hardly a disease
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What is the difference between anthracosis and simple coal workers pneumoconiosis?
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CWP is a step up from anthracosis. May also be asymptomatic, but associated with emphysema.
CWP get macules (1-2mm) and nodules (larger) - aggregates of pigment and macs |
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What would you expect this patient's work history to include?
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Coal miner
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To what vascular disease does progressive massive progress?
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Pulmonary hypertension, cor pulmonale
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Apart from the black pigment, what finding is typical of PMF?
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collagen (stains pink)
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What is silica's main effect in the lung?
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Fibrogenic
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Besides coal mining, what exposure can cause PMF?
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Silica (sand) exposure - Black lung without the black
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What happens after silica is inhaled that causes fibrosis?
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Macrophages attempt to digest silica, but die instead. Necrosis attracts fibrogenic mediators. In the process, the silica is released and another macrophage tries to eat it.
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What pulmonary function changes would you expect to see in someone with a pleural plaque?
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None - sometimes an incidental finding, and only indicates asbestos exposure, not disease.
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What differentiates asbestosis from pleural plaques?
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Asbestosis is an actual disease. Ferruginous bodies, and diffuse interstitial fibrosis
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What pulmonary function changes would you expect to see in someone with a pleural plaque?
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None - sometimes an incidental finding, and only indicates asbestos exposure, not disease.
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What differentiates asbestosis from pleural plaques?
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Asbestosis is an actual disease. Ferruginous bodies, and diffuse interstitial fibrosis
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What feature typical of hypersensitivity pneumonitis can you see here?
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Inflammatory infiltrate at airways, which can progress to fibrosis.
Other feature is non-caseating granulomas |
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What is the prominent cell in a TB focus?
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Epithelioid histiocyte (macrophage)
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How does TB reactivate?
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When a focus of necrosis extends into the bronchial tree, producing a contagious cough
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What does the pattern of growth suggest about the type of cancer seen here?
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Lepidic growth - adenocarcinoma is growing along the alveoli using it as scaffolding. This may present not as a mass, but appear to be pneumonia
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What mutation is associated with non-mucinous adenocarcinoma of the lung?
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EGFR (non-smoker type)
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What mutation is associated with mucinous adenocarcinoma of the lung?
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K-RAS (smoker type)
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What is Horner's syndrome?
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eyelid drop (ptosis) anhidrosis, meiosis due to cervical sympathetic nerve invasion by a pancoast tumor
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What tumor has cavitary, central presenting lesions with HIGH CALCIUM
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squamous cell carcinoma
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What type of cancer may present with myasthenic syndrome?
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Small Cell LC - cancer produces antibodies to calcium channels
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What is the pattern of the lesion seen here, and what is it likely to be?
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Popcorn lesion, likely to be hamartoma
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What is a spiculated border suggestive of on a pulmonary nodule by CT?
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Malignancy
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What is wrong with this picture?
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Pulmonary edema
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What are alveolar macrophages filled with in pulmonary edema?
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hemosiderin (blood biproduct)
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What is the different between exudate and transudate?
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Exudate has protein, cells
Transudate is serum only |
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What specifically is damaged in diffuse alveolar injury (DAD)?
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capillary endothelium, alveolar epithelium or both
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Why is surfactant lost in diffuse alveolar damage?
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The Type II pneumocytes are damaged and stop producing surfactant
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What do macrophages release to recruit neutrophils to the sites of diffuse alveolar damage?
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IL-8
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What stage of interstitial edema is this?
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Early - but still greater distance for O2 to travel
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What are hyaline membranes composed of?
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Protein, fibrin, and necrotic epithelium
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What causes transfusion-related acute lung injury?
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plasma products that contain antibodies to leukocytes from the donor
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What lung condition is scleroderma associated with?
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PH
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What disease is associated with BMPR2 (bone morphogenetic protein receptor) mutations?
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Primary pulmonary hypertension, AR with incomplete penetrance
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What two features characteristic of pulmonary hypertension are seen here?
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Intimal thickening, and a plexiform lesion (at bottom)
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What do lines and dots in the base of lungs on CXR indicate? Patient also has dry crackles.
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Interstitial disease
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What is this, and what are depicted in the periphery?
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A non-caseating granuloma of sarcoidosis. Epithelioid histiocytes are at periphery
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What cell marker gets depleted in sarcoidosis peripheral blood?
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CD4 cells
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Sarcoidosis elevates serum levels of 2 substances. Which ones?
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Vitamin D (=hypercalcemia and hypercalciuria)
ACE |
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What do lines and dots in the base of lungs on CXR indicate? Patient also has dry crackles.
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Interstitial disease
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What would you expect to find on the CXR of this patient?
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Hilar/mediastinal lymphadenopathy, and interstitial lung infiltrates.
Sarcoidosis |
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Why is PEEP ventilation good?
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Keeps alveoli open, so you can decrease O2 sat and prevent O2 injury
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Why is PEEP ventilation bad?
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Ventilation causes trauma, and reduces cardiac output
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What cells become hyperplastic in recovery of ARDS?
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Type II pneumocytes
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When would you set PEEP higher than 5mmHg H20?
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For someone who was morbidly obese, or with airspace disease bilaterally
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What are the cornerstones of TB DOT therapy?
|
Political will
Standardized Tests Standardized Tx Uninterrupted drug supply Workers to observe patients take drug |
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What would a D-dimer help you diagnose?
|
Coagulopathy - thrombus forming likely.
If D-dimer negative, probably not PE |
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When would you use a IVC filter?
|
For a patient with DVT/PE who cannot receive anticoagulants
|
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How much time is spent in REM vs. non REM sleep?
|
20-25% REM
|
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How long is the sleep cycle?
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90 min
|
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Do you get the bulk of REM sleep at the beginning or end of a sleep episode?
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More at the end
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When awake with eyes closed, what EEG rhythm predominates?
alpha beta gamma theta |
alpha waves in awake with eyes closed
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At sleep onset, what EEG wave form predominates?
alpha beta gamma theta |
theta waves at sleep onset
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What sleep stage is characterised by slow rolling eye movements on EOG (electrooculography), and switch to theta waves?
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N1
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What sleep stage is characterised by sleep spindles and K waves?
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N2 - where you spend about half of a good night's sleep
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What are delta waves?
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Slow wave sleep - N3
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Is REM characterised by regular or irregular breathing?
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Irregular breathing
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What level of sleep is characterised by saw-tooth waves?
|
REM
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What is the function of the suprachaiasmatic nuclei of the hypothalamus?
|
Biological clock for circadian rhythms
|
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How does the SCN of the hypothalamus get information about light/dark conditions?
|
From the retina through the retinohypothalamic tract (RHT)
|
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What autonomic nervous system predominates during non REM sleep?
|
Parasympathetic (Rest and Digest)
|
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What autonomic nervous system predominates during REM sleep?
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Parasympathetic, with some sympathetic incursions
|
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What sleep neurotransmitters promote REM vs. NREM?
|
promotes REM - acetylcholine
inhibits REM - GABA, adenosine, serotonin |
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What happens to the hypercapnia/hypoxia response during sleep?
|
Gets blunted
|
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What happens to delta waves in SWS with age?
|
Gets blunted
|
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What is Pickwickian syndrome?
|
Hypoventilation related to obesity - hypercapnia also while awake
|
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What is Congenital central hypoventilation syndrome?
|
Blunted response to hypercapnia while awake, absent during sleep.
Ondine's curse |
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How many incidents of apnea/hypopnea per hour are required to designate obstructive sleep apnea syndrome?
|
at least 5/hour
|
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What kind of patient would exhibit Cheyne-Stokes respiration during sleep, in which they would breath quickly followed by periods with apnea?
|
Heart failure - brain isn't getting enough blood and doesn't know you're hypoxic yet. Then has to breathe rapidly to catch up
|
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Why is acetazolamide helpful for central sleep apnea?
|
It acidifies blood, making chemoreceptors kick in respiratory drive
|
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All of the following are characteristics of N2 sleep EXCEPT:
a) Comprises most sleep across the night b) K-complexes c)Delta waves d) Sleep spindles e) 12-14 hz eeg |
Delta waves
|
|
The neurotransmitter most implicated in generating REM sleep is:
a) norepinephrine b) acetylcholine c) dopamine d) serotonin e) histamine |
acetylcholine
|
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Response to hypercapnia is lowest during:
a) wakefulness b) N1 c) NREM d) slow wave sleep (N3) e) REM |
REM
|
|
59 y/o woman with loud snoring, BMI=33.7 kg/m2, daytime fatigue, AHI = 4.8 events/hr, ABG on room air: pH=7.34; PO2=38 mm Hg; PCO2=65.8 mm Hg; SaO2 =68 %
Cheyne-Stokes Respiration Central Sleep Apnea Obesity Hypoventilation Syndrome Obstructive Sleep Apnea Ondine’s Curse |
Obesity hypoventilation syndrome
|
|
47 y/o man with loud snoring, BMI=23.8 kg/m2, daytime fatigue, AHI = 11.8 events/hr on his side & 18.3 supine, ABG on room air: pH=7.39; PO2=92 mm Hg; PCO2=41 mm Hg; SaO2 =99%
Cheyne-Stokes Respiration Pickwickian Syndrome Obesity Hypoventilation Syndrome Obstructive Sleep Apnea Primary snoring |
Obstructive sleep apnea
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|
47 y/o man with loud snoring, BMI=23.8 kg/m2, daytime fatigue, AHI = 11.8 events/hr on his side & 18.3 supine, ABG on room air: pH=7.39; PO2=92 mm Hg; PCO2=41 mm Hg; SaO2 =99%.
Which of the following is NOT an appropriate treatment? CPAP Tracheostomy Nasal steroids Body position training Mandibular advancement device |
Tracheostomy
|
|
Which layer of the pleura is drained by pulmonary veins?
|
Visceral pleura
|
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What are the two main causes (and types) of pleural effusion?
|
Disrupted membrane = exudate (Infection)
Altered driving pressure = transudate (CHF, cirrhosis, nephrosis) |
|
What is the proximal cause of hepatic hydrothorax?
|
Ascites (though may not be apparent) as results from liver disease
|
|
What is the cause of empyema?
|
A lung infection near visceral pleura, which causes pus to leak into pleural space. Must be drained!
|
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What happens to percussion and breath sounds with pleural effusion?
|
Dullness, decreased breath sounds
|
|
Why is a loculated pleural effusion alarming
|
When the effusion does not follow gravity, it's probably larger and more viscous/solid than a transudate
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What are Light's criteria and what are they used for?
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Used to decide whether pleural fluid is transudate or exudate.
1. Pleural lactate dehydrogenase is >.6 of serum LDH 2. Pleural LDH is in upper 2/3 of normal serum level 3. Pleural protein is >.5 of serum protein If any one of these is true, fluid is exudate |
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Under what pH do you consider a pleural effusion complex?
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<7.2 pH = complex pleural effusion
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