Chronic Respiratory Conditions
Define surface tension.
What is the measure of force acting to pull a liquid's surface molecules together at an air-liquid interface? If there is an increase in surface tension, there is an increase in force to collapse the alveoli since it has a very thin layer of water on them. Although, this is great in elastic recoil (promotes constriction of alveoli), too much is a bad thing which is why surfactant exists. Surfactant DECREASES surface tension.
Obj. 7619
Name the diagnostic test for COPD.
BONUS! Describe the meaning of GOLD 1C
What is spirometry? Additionally, the pt has to have 1 of 3 variables which include: Peak flow <350L/min, diminished breath sounds, smoking Hx 30 pack years or more
BONUS! This means that the individual has an FEV1 80 or greater (1) with 1 or exacerbations with hospitalizations and does not walk slower than others their age due to dyspnea (C).
Obj. 7606
55 y/o male pt presents to the office for a yearly checkup. In determining the tests needed for this year, it is mentioned that the individual is a smoker that quit 10 years ago. Decide if the pt needs to complete a lung cancer screening test.
BONUS! Name the screening test used and a con to this test.
What is yes, this pt needs screened? Pt is no longer, a smoker, but since it has been less than 15 years, it is necessary for them to still get screened.
BONUS! The screening test used is an LDCT which is known to give high false positives.
Obj. 7707
Name the three parts of the diaphragm
What are the sternal, costal, and lumbar parts? The sternal part is two muscular slips that attach to the posterior aspect of the xiphoid process of the sternum. The Costal part is two wide muscular slips that attach to the internal surfaces of the inferior six costal cartilages and their adjoining ribs on each side. The Lumbar part arises from 2 aponeurotic arches, the medial and lateral arcuate ligaments, and the 3 superior lumbar vertebrae
Obj. 7660
Name the first thing to be done when performing a respiratory exam.
BONUS! Identify the fremitus findings in a pt with COPD
What is observe the chest and pt's ability to breathe?
BONUS! Decreased due to the increased amount of air in the lung reducing its ability to transmit vibrations
Objs. 7690 and 7691
Pt is diagnosed with Pulmonary Fibrosis. On PFTs, this individual will show an _____ in TLC and a ______ in FEV1/FVC ratio.
What is decreased and normal/increased? Pulmonary Fibrosis is a condition in which there is decreased complaince in the pt's lungs. With this change comes increased difficulty in inhaling air and stretching the lung. This results in a decrease in TLC, and decreased FEV1, and FRC. Since both the FEV1 and FRC are reduced, and in relative amounts, the FEV1/FRC ration is normal or > 0.8
Obj. 7615, iLAB
Glucocorticoids inhibit the transcription factor ______, which promotes the production of cytokines, COX2, and PLA2
BONUS! Glucocorticoids increase the transcription of ____
What is NF-kB? This is one of the reasons which Glucocorticoids are great to reduce inflammation since the production of the inflammatory response is lowered through the inhibition of this transcription factor.
BONUS! B2 receptor transcription. This is part of the MOA of the bronchodilation seen in these pts and why they are used during both acute and chronic situations.
Obj. 7600
Name the Lung Cancer that is not associated with smoking and the most common areas that metastasize to the lung.
What is Bronchogenic Carcinoid cancer with common metastases coming from the kidneys, colon, and breasts? Is associated with Carcinoid Syndrome though.
Obj. 7708
Name the accessory muscles used in exhalation.
What are the Abdominal expiratory muscles and the internal intercostals?
Obj. 7661
BONUS! Name the main three than can be differentiated by an increased osmolality
What are MUDPILES? Methanol, Uremia, DKA, Polyethylene glycol, Iron poisoning, Lactic acidosis, Ethylene glycol, and Salicylic acid.
BONUS! An increase in osmolality is seen in Ethylene glycol, Polyethylene glycol, and Methanol causes.
Obj. 12074
If a pt has a ventilation rate of 8, describe the direction of change in their [PaCO2].
BONUS! Describe the direction of change in their [PaO2].
What is an increase in [PaCO2]? With a ventilation rate of 8, below normal, the pt is hypoventilation. Hypoventilating means that the individual is not expelling off CO2 so there is an increase in the CO2 in their arterial system.
BONUS! There is a decrease in [PaO2] because the individual is hypoventilation causing a decrease in the amount of O2 able to enter their system.
Obj. 7604
Name the only reversible Obstructive Lung Disease and the result of the bronchodilator diagnostic test.
What is Asthma which responds to bronchodilators? Bronchodilators are used to distinguish types of obstructive lung diseases. When the pt responds, it is asthma, but with no response, it is a chronic lung disease. On the other hand, there is a diagnostic test for Asthma called the methacholine test which is positive when the pt has bronchoconstriction with low dose
iLAB
Identify the lung cancer that is usually centrally localized and demonstrates intercellular bridging and keratin pearls along with a major risk factor.
What are Squamous cell lung carcinoma and smoking? This cancer has a strong association with tobacco smoke and deals with a diverse genetic pool. it can range from chromosomal deletions involving tumor suppressor genes on 3p, 9p, and 17p, but it has the highest frequency of TP53 of all the lung carcinomas
Obj. 7708
Name the diaphragmic hiatus that is present at T8 and the two main structures that pass through it.
What is the Vena Caval Foramen which has the IVC and terminal phrenic nerve branches? To help remember, use the mnemonic I ate (8) 10 eggs at 12.
I 8 --> vena cava foramen (IVC and terminal phrenic)
10 Eggs --> esophageal hiatus (esophagus, anterior and posterior vagal trunks)
At 12 --> aortic hiatus (descending aorta, azygos vein, thoracic duct)
Obj. 7660
Identify at least 5 main points to ask in a pt with a chronic condition (different from an acute condition).
What is, the date diagnosed, monitoring of the condition, last visit/condition since the last visit, treatment(including compliance and side effects), and any complications from the disease?
Obj. 7692
Identify which of the following represents an individual with Asbestosis. (Gamemaster, look at the Onenote for the graphs)
BONUS! Name the lung cancer for which this is the only known risk factor.
What is B? This is shown with the decreased TLC (and maybe that the intrapleural pressure is around -9 indicating a more forced inspiration?).
BONUS! Mesothelioma has Asbestos as the only known risk factor, but Bronchogenic carcinoma is the most common lung cancer linked to Asbestos.
iLAB
Pt presents to the ED with SVT. To return the heart to NSR, the physician prescribes Adenosine, but after administration, nothing happens. Further dive into the pt's Hx reveals they are taking a medication that inhibits Phosphodiesterase for their COPD. Identify this drug and its effects on Adenosine's actions.
What is Theophylline which is a Methylxanthine that inhibits Adenosine Receptors?
Obj.7600
Pt presents to the office for their CT results. It was found that the pt has an irregular, non-calcified, opaque spot that measures 1 cm. Identify if this spot is a nodule or mass and its malignancy potential.
What is a nodule, with the potential to be malignant? Since it is < 3cm, it is defined as a nodule, but since it is over 8mm, it has a malignancy risk. Moreover, since it is irregularly shaped, and is non-calcified, it can be considered malignant. More testing would need to be done, including a PET scan which measures the amount of glucose utilization in the body, malignant nodules/masses shine bright like a diamond from all that glucose use.
Obj. 7709 and iLAB
Pt presents to the office in need of OMM for their constipation. The physician suggests that they do a mesenteric lift on the pt's descending colon. Identify the location in which the physician would place their hands and the direction they would pull.
What is the left anterior axillary line pulling towards the midline(umbilicus) with posterior force? This position is to be held for 20secs up to 2 minutes until the release is felt and is followed into the position of rest. For the ascending colon, the physician would have their hands on the right anterior axillary line with the posterior force pulling midline.
Obj. 7668
T1DM pt presents to the ED with slow, deep breathing, fruity breath, and is obtunded. Labs show:
HCO3 = 11, Cl- = 97, Na+ = 140, Glucose = 250, PaCO2 = 30, pH = 7.24
Identify the tx of this individual and the anion gap
BONUS! Explain the anion gap result
What are isotonic IV saline and IV insulin with a high anion gap? Since this pt is in DKA and insulin prevents ketone production, HCO3 is rarely needed.
140-97-11 = 32
BONUS! There is a reduction in HCO3, but an increase in ketones which accounts for the increased anion gap. (any replacement of HCO3, or Cl- with another, "peasant" anion causes an anion gap)
Obj. 12075, iLAB
Pt presents to the office with c/o dyspnea. Upon examination, they are found to have a barrel chest, and PFTs show an FEV1/FRC ratio of 0.60. Remembering their Chronic Week 8 Prep Guide, they remember a phenomenon of Dynamic Airway Compression that affects this individual's ability to expel air. Describe this concept.
What is the pt has a reduced elastic recoil which allows for the intrapleural pressure to become higher than the alveolar pressure and collapse the airway "trapping air"? First, pt presents with dyspnea, but the barrel chest indicates an obstructive disease. Moreover, the reduced FEV1/FVC ratio (<0.80) proves Obstructive Lung Disease. In normal lungs, the dynamic airway compression is found with forced exhalation and does not affect breathing since it occurs in the cartilaginous airways preventing collapse. On the other hand, since there is a reduced elastic recoil this phenomenon occurs closer tot he alveoli and causes collapse.
Obj. 7617
Pt presents to the office with c/o dyspnea for the past months. Pt states that this has been progressive for the past 2 years and is accompanied by a productive cough. Upon examination, it is found that the pt has slight cyanosis and wheezing. Spirometry results are shown with normal being on the left(GAMEMASTER LOOK AT ONE NOTE). Identify the type of lung disease they have (as specific as possible) and the first line tx.
BONUS! Identify the SpO2 in which home O2 is indicated.
What is Chronic Bronchitis that has the first-line treatment of LAMA drugs? The pt has had a productive cough for 3 months over 2 years (chronic bronchitis). Spirometry findings indicate an Obstructive pattern and it is treated with a LAMA like Tiotropium.
BONUS! 88% or 89% with symptoms of cor pulmonale
Objs. 7600 and 7602
Pt presents to the office with c/o proximal weakness in their bilateral extremities that improves with increased use. The pt is sent for a CT with IV contrast and is found to have a lung nodule that is causing the pt's muscle weakness due to the increased production of autoantibodies. Identify the most likely lung cancer this pt has.
BONUS! Name the target of the autoantibodies.
What is Small Cell Lung Carcinoma? This cancer has the highest association with tobacco smoke and is non-amendable for surgery due to its early metastasis tendencies, but can be treated with Radiation or Chemo. Small Cell Lung carcinoma is usually centrally located and is considered to be a neuroendocrine tumor. Other paraneoplastic syndromes caused by this cancer are Cushing's Syndrome, SIADH, and neurological ones(Anti-hu Abs on neurons)
BONUS! The target of these Auto-Abs are presynaptic VG Ca2+ Channels.
Objs. 7705, 7706, 7708 and iLAB
Pt presents to the office with c/o epigastric pain after a long weekend of partying. Looking into the pt's Hx, it is found that they are an alcoholic. Describe the location in which the physician would place their hands for a ganglionic inhibition for this complaint.
What is below the xiphoid process (location of celiac ganglion)? The pt is described as having "liver pain" or problems with their liver, most likely from their fun weekend. The celiac ganglion innervates the liver which is why it might be the physician's target, especially since sympathetic innervation to the liver promotes ketone formation (product from alcohol).
Objs. 7663 and 7668
Pt is found to have a PaCO2 of 30mmHg and HCO3 of 24mEq/L from a drug overdose. As the pt progresses, they have a repeat ABG which shows a PaCO2 of 24mmHg and an HCO3 of 20mEq/L and normal pH. Describe the likely drug that has caused these values.
BONUS! Describe the tx
What is Aspirin Overdose? This is seen through the initial pure respiratory alkalosis with the later progression of respiratory alkalosis and metabolic acidosis.
BONUS! In this pt, since there is metabolic acidosis, activated charcoal, isotonic saline gastric lavage, and probably IV NaHCO3
Objs. 12073, 12074, and 12075