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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.
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What is a methacholine challenge test
It induces bronchocnstriction, even when patient is asymptomatic and spirometry is normal.
Methacholine = Non-selective muscarinic receptor agonist
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Neuromuscular causes of respiratory fialure
ALS or Myasthenia gravis (auto antibodies against postsynaptic ACh receptors)
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Platypnea
opposite of orthopnea. Better breathing when lying down.
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Hepatopulmonary Syndrome
Dyspnea, platypnea, hypoxemia in setting of chronic liver disease. Can have clubbing and cyanosis.
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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.
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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.
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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
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Indications for chest tube drainage
- ph < 7.20
- Glucose < 60
- LDH > 1000
- Positive Gram Stain/Cx
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PE findings w/ pleural effusion
- Blocks sound transmission between lung and chest wall
- percussion is dull
- Tactile vocal fremitus is diminished
- breath sounds diminished
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Tuberculous pleural effusion
- Tuberculous pleural effusion typically presents with a lymphocyte-predominant effusion.
- Also longer course than typical bacterial pneumonia case.
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Chylothorax
- Blockage of thoracic duct (which is left-sided). Malignancy is most common cause. Trauma second.
- Triglycerides > 50 mg/dL
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Respiratory acidosis in asthma exacerbation
Indicate impending respiratory failure.
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Long-acting anticholinergic drugs?
Used in COPD, their role in management of asthma is not defined
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Antibiotics in COPD
- For moderate to severe CPOD exacerbations,
- Use levofloxacin (Fluroquinolone)
- or 3rd generation cephalosporin with a Macrolide
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Difference between ipratropium and tiotropium
- Anticholinergics for COPD
- Ipratropium = Short-Acting
- Tiotropium= Long-acting
- Should not be combidned.
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Cryptogenic organizing pneumonia
- Interstitial Lung disease
- COP is often acute or subacute,
- doesn't respond to abx.
- Alveolar opacification that migrates on serial exams
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Idiopathic Pulmonary Fibrosis (IPF)
- Prolonged course interstitial lung disease.
- Reticular pattern on CXR w or w/o opacities.
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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.
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Antibody test for systemic sclerosis/scleroderma
- anti-topoisomerase / anti-Scl-70
- Restrictive lung disease
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Drug-induced lung toxicity versus acute eosinophilic pneumonitis
- Acute eosinophilic pneumonitis = a few days
- Drug-induced lung toxicity = sub acute
- Both cause eosinophilia
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When can you d/c heparin when moving to warfarin for DVT prophylaxis
- 5 days.
- 2 INRs > 2 at least 24 hours apart.
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Medial and Lateral Epicondylitis
- Lateral Epicondylitis is more common (tennis elbow)
- Medial Epicondylitis = Golf's elbow.
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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).
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Anserine bursitis
Focal tenderness on upper inner tibia, about 5cm distal to medial articular line of the knee.
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Birefringence
- Pseudogout = Positive, rhomboidal crystals
- Gout = Negative, Needle-shaped crystals
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DIP and PIP boney enlargements in OA
- PIP - Bouchard nodes
- DIP = Heberden nodes
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Chronic pain at base of dominant thumb
Suggestive of OA
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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
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Leukocyte count in septic arthritis
Usually greater than 50,000 and PMN predominance
<2000 leukocyte count is nL in joint.
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Cardinal X-Ray feature of RA
- Erosions in proximal joints
- Carpal-metacarpal
- Metacarpal-phalangeal, PIPs,
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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.
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Contraindication for first-line use of MTX?
- Alcohol use.
- Use hydroxychloroquine first in this case.
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Whipple Disease
- Rare infection syndrome cased by Tropheryma whippelii.
- Arthritis --> Migratory and chronic.
- Diarrhea
- Malbsorption
- CNS
- Constitiutional Syxs
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CREST Syndrome
- Local scleroderma
- Calcinosis
- Raynaud's
- Esophageal dysmotility
- Sclerodactyly
- Telangectasia
Anti-Centromere Ab
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Diffuse Scleroderma
- Also called progressive systemic sclerosis
- Widespread skin involvement
- Rapid progression
- Early visceral involvement
- Assoc. w/ anti-Scl-70 Ab (Anti-DNA topoisomerase I antibody)
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Sarcoidosis
- Immune-mediated widespread noncaseating granulomas and elevated serum ACE levels.
- GRAIN
- Gammaglobulinemia (Low antibodies)
- RA
- ACE increase
- Interstitial Fibrosis
- Noncaseating granulomas.
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Seronegative spondyloarthopathies
- Assoc. w/ RF and HLA-B27
- Psoriatic Arthritis
- Ankylosing Spondylitis --> Spine and sacroiliac jts, uveitis, AR
- IBD
- Reactive (Can't see, can't pee, can't climb a tree) after shigella, salmonella, yersina, campylobacter, chlamydia.
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Anti-Ro and anti-La
Sjögren's Syndrome
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Drug-induced lupus
- Seen in patients w/ anti-TNF-alpha drugs
- Usually spares renal and neurologic symptoms.
- D/C offending agent.
- Add prednisone.
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Anti-HTN drug of choice in patients with lupus nephritis
ACE inhibitors, because help control proteinuria.
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distinguishing rosacea from SLE malar rash
- Rosacea does not spare nasolabial fold
- SLE does.
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Treatment for Raynaud phenomenon
Amlodipine
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Polyarteritis Nodosa
- Vasculitides
- Nonglomerular renal vessels vasculitis associated with HTN, kidney insufficiency, proteinuria, hematuria.
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Granulomatosis with polyangitis
- Wegener granulomatosis.
- A vasculitis. Necrotizing granulomatous vasculitis affecting small arteries and veins.
- Effects nose, sinuses, lungs, and kidneys.
- C-ANCA
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