What is DLCO?
DLCO measures ability of lungs to transfer gas into red blood cels.
Low in conditions characterized by barriers to diffusion: Interstitial edema, interstitial infiltrates, tissue fibrosis, or emphsema.
What is a methacholine challenge test
It induces bronchocnstriction, even when patient is asymptomatic and spirometry is normal.
Methacholine = Non-selective muscarinic receptor agonist
Neuromuscular causes of respiratory fialure
ALS or Myasthenia gravis (auto antibodies against postsynaptic ACh receptors)
opposite of orthopnea. Better breathing when lying down.
Dyspnea, platypnea, hypoxemia in setting of chronic liver disease. Can have clubbing and cyanosis.
Vocal cord dysfunction
- Throat or neck discomfort, wheezing, stridor.
- Difficult to differentiate from asthma, but patients do not respond to usual asthma therapy.
- O2 Sat is typically normal.
Laryngoscopy with sx patient can reveal adduction of vocal cords during inspiration.
Symptoms and signs of pulmonary arterial hypertension
Loud P2, fixed split S2, pulmonic flow murmur, TR.
CXR usually nL at first, then shows enlargement of pulmonary arteries, RA, RV.
Lactate Dehydrogenase (LDH) in pleural effusions
- The higher it goes, the more likely it is an exudate rather than a transudate. Usually cut-offi s 200-300.
- In an empyema it is freq. >1000
Indications for chest tube drainage
- ph < 7.20
- Glucose < 60
- LDH > 1000
- Positive Gram Stain/Cx
PE findings w/ pleural effusion
- Blocks sound transmission between lung and chest wall
- percussion is dull
- Tactile vocal fremitus is diminished
- breath sounds diminished
Tuberculous pleural effusion
- Tuberculous pleural effusion typically presents with a lymphocyte-predominant effusion.
- Also longer course than typical bacterial pneumonia case.
- Blockage of thoracic duct (which is left-sided). Malignancy is most common cause. Trauma second.
- Triglycerides > 50 mg/dL
Respiratory acidosis in asthma exacerbation
Indicate impending respiratory failure.
Long-acting anticholinergic drugs?
Used in COPD, their role in management of asthma is not defined
Antibiotics in COPD
- For moderate to severe CPOD exacerbations,
- Use levofloxacin (Fluroquinolone)
- or 3rd generation cephalosporin with a Macrolide
Difference between ipratropium and tiotropium
- Anticholinergics for COPD
- Ipratropium = Short-Acting
- Tiotropium= Long-acting
- Should not be combidned.
Cryptogenic organizing pneumonia
- Interstitial Lung disease
- COP is often acute or subacute,
- doesn't respond to abx.
- Alveolar opacification that migrates on serial exams
Idiopathic Pulmonary Fibrosis (IPF)
- Prolonged course interstitial lung disease.
- Reticular pattern on CXR w or w/o opacities.
Lung findings of sarcoidosis
- Most commonly 3rd decade presentation.
- 90% have lung involvement
- CXR: Hilar lymphadenopathy
- reticular pattern in upper lung zone
- Restrictive lung pattern.
Antibody test for systemic sclerosis/scleroderma
- anti-topoisomerase / anti-Scl-70
- Restrictive lung disease
Drug-induced lung toxicity versus acute eosinophilic pneumonitis
- Acute eosinophilic pneumonitis = a few days
- Drug-induced lung toxicity = sub acute
- Both cause eosinophilia
When can you d/c heparin when moving to warfarin for DVT prophylaxis
- 5 days.
- 2 INRs > 2 at least 24 hours apart.
Medial and Lateral Epicondylitis
- Lateral Epicondylitis is more common (tennis elbow)
- Medial Epicondylitis = Golf's elbow.
Diagnosis a meniscal tear
Twisting injury of the foot with weith-bearing followed by severe pain, swelling (over hrs).
McMurray Test (flexing hip and knee and abducting or adducting knee while extending).
Focal tenderness on upper inner tibia, about 5cm distal to medial articular line of the knee.
- Pseudogout = Positive, rhomboidal crystals
- Gout = Negative, Needle-shaped crystals
DIP and PIP boney enlargements in OA
- PIP - Bouchard nodes
- DIP = Heberden nodes
Chronic pain at base of dominant thumb
Suggestive of OA
de Quervain tenosynovitis
Inflammation of abductor pollics longus and extensor pollicis brevis tendons.
- Pain on distal aspect of radial styloid.
- Pain on flexing thumb into palm, closing fingers over thumb, and bending wrist in ulnar direction
Leukocyte count in septic arthritis
Usually greater than 50,000 and PMN predominance
<2000 leukocyte count is nL in joint.
Cardinal X-Ray feature of RA
- Erosions in proximal joints
- Metacarpal-phalangeal, PIPs,
Parvovirus B19 and arthritis
- Parvovirus B19 infection in adults may induce an acute RF postive oligo or polyarthritis.
- Most adult pts. with Parvo B19 infection also develop rash, but rearely slapped cheek rash of childhood.
Contraindication for first-line use of MTX?
- Alcohol use.
- Use hydroxychloroquine first in this case.
- Rare infection syndrome cased by Tropheryma whippelii.
- Arthritis --> Migratory and chronic.
- Constitiutional Syxs
- Local scleroderma
- Esophageal dysmotility
- Also called progressive systemic sclerosis
- Widespread skin involvement
- Rapid progression
- Early visceral involvement
- Assoc. w/ anti-Scl-70 Ab (Anti-DNA topoisomerase I antibody)
- Immune-mediated widespread noncaseating granulomas and elevated serum ACE levels.
- Gammaglobulinemia (Low antibodies)
- ACE increase
- Interstitial Fibrosis
- Noncaseating granulomas.
- Assoc. w/ RF and HLA-B27
- Psoriatic Arthritis
- Ankylosing Spondylitis --> Spine and sacroiliac jts, uveitis, AR
- Reactive (Can't see, can't pee, can't climb a tree) after shigella, salmonella, yersina, campylobacter, chlamydia.
Anti-Ro and anti-La
- Seen in patients w/ anti-TNF-alpha drugs
- Usually spares renal and neurologic symptoms.
- D/C offending agent.
- Add prednisone.
Anti-HTN drug of choice in patients with lupus nephritis
ACE inhibitors, because help control proteinuria.
distinguishing rosacea from SLE malar rash
- Rosacea does not spare nasolabial fold
- SLE does.
Treatment for Raynaud phenomenon
- Nonglomerular renal vessels vasculitis associated with HTN, kidney insufficiency, proteinuria, hematuria.
Granulomatosis with polyangitis
- Wegener granulomatosis.
- A vasculitis. Necrotizing granulomatous vasculitis affecting small arteries and veins.
- Effects nose, sinuses, lungs, and kidneys.