Resp. CIS

Question 1

common cause of wheezing in kids

Answer 1

Viral infections

Question 2

What time of day is more suggestive of asthma?

Answer 2

coughin that’s worse in the middle of the night (midnight to 3 AM)

Question 3

What are some risks for developing asthma?

Answer 3

• RSV infection prior to 6 months of age

- patient hx or family hx of any atopy(allergic rhinitis or eczema)

Question 4

What are some example of common triggers for asthma?

Answer 4

virus
allergies
exercise
cold air
cigarette smoke exposure

Question 5

What are common findings on a CXR in a child with asthma or reactive airway disease (RAD)

Answer 5

Atelectasis
Hyperinflation of both lungs
Perihilar thickening

Question 6

What is capillary refill like in a child

Answer 6

if at 2 sec… concerning

• > 2 sec is terrible
• healthy kids’ cap refill nearly instantaneously!

Question 7

What is the best way to obtain blood gases in a peds patient and what are the caveats of ordering blood gases in a peds patient?

Answer 7

• use capillary blood gases in children
• quicker and less distressing than arterial gas
• can’t use PaO2 from them
• ONLY USEFUL FOR pH and CO2

Question 8

Where should a pediatric patient with asthma exacerbation be admitted?

Answer 8

needs to go to PICU due to significant risk for decompensation

Question 9

Options for mainanence IVF in children?

Answer 9

1/2 NS in >1yo or 1/4 NS in <1 yo

• NS is reserved for bolusing
• in peds usually potassium is added to IVF

Question 10

When is it approptiate to intubate an asthmatic patient and what are potential treatments to add prior to intubation

Answer 10

• “EVERY ATTEMPT SHOULD BE MADE TO MAINTAIN THE KID’S RESPIRATORY STATUS IN THE PICU
• ADD terbutalin drip, Mg, Theophylline, subcu epinephrine, heliox, IN ORDER TO NOT INTUBATE AN ASTHMATIC
• You intubate them, they get worse and then they die
• The time to intubate an asthmatic kid is somewhere between irritable and obtunded (them, not you)

Question 11

Why do you no want to intubate asthmatics?

Answer 11

“they can’t exhale, so you force breaths in with the vent, they get fuller and fuller until they either get bilateral pneumothorax or acute right heart collapse and die”

Question 12

Which population of asthmatics has the highest mortality?

Answer 12

Adolescents- because they don’t carry their rescue inhaler with them

Question 13

What are some signs of respiratory distress in a respiratory patient?

Answer 13

• inspiratory and expiratory wheezing
• nasal flaring and tachypnea
• subcostal, intercostal, and suprasternal retractions
• stridor
• sniffing or tripod positioning
• decreased air movement

Question 14

What are some treatment considerations for peds asthma?

Answer 14

-Albuterol nebulizer or inhaler
-inhaled corticosteroids
-oral corticosteroid
oxygen (put this on first if hypoxic)

Question 15

CF shoud be in the idfferential, what would indicate concern for it and how would you test for it?

Answer 15

• poor height and weight
• clubbing
• foul-smelling stools (evidence of malabsorption)
• recurrent pneumonia
• edema
• failure to thrive
• test with SWEAT CHLORIDE TEST*

Question 16

SUDDEN stridor in a child makes you think of what?

Answer 16

foreign body aspiration

Question 17

O2 options to consider

Answer 17

NC up to 5 L, simple face mask at 5-6 L, NRB at 10-15 L/min, bag valve mask, Bipap, intubation

Question 18

What is GTPAL in regards to obstetrical hx taking?

Answer 18

Gravidity= number of total preggos
Term births= devlieries 38wks or more
Preterm births= <38 weeks
Abortions=... abortions
Living children

Question 19

What is a “total hysterectomy”?

Answer 19

take uterus and ovaries, usually but not always they take the cervix too

Question 20

What can causes be of S2 splitting during cardiac exam?

Answer 20

• physiologic on inspiration
• persistent spliting dureing inspirationa nd expiration can be sensitive and specific screening for : heart disease in adults, the most likely cause being RBBB, and RV pressure overload situations such as acute massive PE is also a cause

Question 21

What can be heard on pulmonary exam of a patient with a PE, 53% of the time?

Answer 21

rales

Question 22

What is an invasive but highly accurate way of measuring blood pressure constantly?

Answer 22

arterial line (excellent in pts with any type of shock)

Question 23

What labs should we consider checking for inherited thrombophilia?

Answer 23

Activated ptnC/ Factor V leiden, homocysteine level, functional assays of antithrombin III/ ptn C/ Ptn S, antiphospholipid antibodies

Question 24

What is the most ocmmon findings on an EKG in a patient with a PE?

Answer 24

nonspecific ST-T wave abnormalities and sinus tachycardia

Question 25

What is the gold standard imaging choice for PE?

Answer 25

``` CT angiogram (CTA) of the chest (PE Protocol) -need to consider the stability of your patient before taking them to radiology ```

Question 26

What acan be seen on EKG that is indicative of PE?

Answer 26

S1 Q3 T3 -S in lead 1 Q in lead 3 -and an inverted T wav in lead 3

Question 27

What is tPA

Answer 27

recombinant rissue type pasminogen activator... "clot buster - binds to fibrin, which increases its affinitiy for plasminogen and enhances plasminogenactivation - systemic thrombolysis preferred as more widespread availability and can give it rapidly as compared to taking to cath lab for angiogram and direct injection to clot itself

Question 28

Are hormones pro-thrombotic?

Answer 28

yes | -Her hormone replacement therapy of Premarin is pro-thrombotic and a risk factor

Question 29

What is Factor V Leiden (FVL)?

Answer 29

mutant form of coagulation factor V - renders factor V insensitive to the actions of activated Ptn C, a natural anticoagulant - increased risk of venous thromboembolism - extrememly common

Question 30

What is Virchow's triad?

Answer 30

- a major theory delineating the pathogenesis of VTE - alterations in blood flow - vascular endothelial injury - Alterations in the constituents of the blood

Question 31

What are some risk factors for VTE?

Answer 31

- FVL - Ptn S or C deficiency - malignancy - pregnancy or oral contraceptives - paroxysmal nocturnal hemoglobinuria

Question 32

What is Wells Criteria?

Answer 32

- clinical assessment for pulmonary embolism - you get points for stuff - gives you probability for PE - >6 is bad, between 6 and 2 is aight, 2 is golden

Question 33

In the modified wells criteria, what is the magic number for if we are going to have a PE or not?

Answer 33

4

Question 34

What are some absolute contraindications to fibrinolytic therapy?

Answer 34

- prior intracranial hemorrahe - active bleeding - pretty much anything up in the brain - suspected aortic dissection - trauma - ischemic stroke within 3 months

Question 35

What are some relative contraindications for fibrinolytic therapy?

Answer 35

hx of chronic, severe, poorly controlled htn - pregnancy - active peptic ulcer - diabetic retinopathy

Question 36

What are the types of shock?

Answer 36

Hypovolemic= high systemic vascular resistance - Cardiogenic= high preload, low pump funciton, high afterload, <65% tissue perfusion - Distributive= low afterload, >65% tissue perfusion - Pericardial tamponade= high pre and afterload bc low pump function, <65% tissue perfusion - Tension pneumothorax= high afterload, >65% tissue perfusion

Question 37

What is MAP?

Answer 37

Mean arterial pressure - diastolic BP+ (systolic-diastolic/3) - >65= good perfusion to all organs - <65= hypotension/hypoperfusion

Question 38

How do you Dx Nontuberculosis Mycobacterial infection- NTM (Kansaii)

Answer 38

sputum Cx and molecular diagnostics

Question 39

Dx TB fungal infection

Answer 39

Cx results, regional exposure

Question 40

Lung cancer dx:

Answer 40

histopathology

Question 41

Lymphoma dx:

Answer 41

histopathology

Question 42

>5 mm induration on PPD | -What makes this result considered positive?

Answer 42

- HIV - Close contact with actively infected person - CXR with fibrotic changes consistent with TB - Immunosuppression

Question 43

>10 mm induration on PPD | -What makes this result considered positive?

Answer 43

- silicosis, DM, CRF w/ dialysis, malignancies....anything that would increase risk of reactivation - children <4 - from country with high prevalence - Residents/employees in high risk setting: jail, healthcare facilities, mycobacterium labs, homeless shelters

Question 44

>15 mm induration on PPD | -what makes this result considered positive?

Answer 44

Healthy individual >4 with low likelihood of true TB infecion

Question 45

Anergy, nothing on PPD | -what does this mean?

Answer 45

no rxn secondary to immune unresponsiveness

Question 46

What are some signs and symptoms that are associated with active pulmonary TB?

Answer 46

-fever -night sweat -cough weight loss lymphadenopathy

Question 47

What do we do for the workup and dx of TB?

Answer 47

Sputum culture (SCx) Sputum staining: RA initially then Zeihl neelsen to confirm -PPD skin test (mantoux) -IFN gamma release assay: used for dx of LATENT TB... indicates there has been a cellular response to TB -CXR: CAVITARY LESIONS IN APICES OF LUNGS -NAAT: nucleic acid amplification test

Question 48

What is the indication for IGRA?

Answer 48

individuals who have recieved a BCG vaccination and those witha positive PPD in whom latent TB is suspected

Question 49

What is the 4 drug standard therapy for TB?

Answer 49

- isoniazid (INH) - Rifampin - Pyazinamide - Ethambutol

Question 50

Side effect of INH

Answer 50

Hepatitis, N/V, peripheral neuropathy (give pt. Vitamin B6), rash

Question 51

Side effect of Rifampin

Answer 51

-Red/orange body fluids, N/V, rash, hepatitis, Steven-Johnson's syndrome

Question 52

Side effect of Pyrazinamide

Answer 52

Urticaria, hyperuricemia/gout, hepatitis, joint aches

Question 53

side effect of ethambutol

Answer 53

optic neuritis, color-blindness

Question 54

Clinical diagnosis of active TB

Answer 54

- clinical symptoms (bloody cough... etc.) - assess risk factors (close contact, immigrants, IV drugs... etc) - order radiography - Sputum culture

Question 55

Do you delay treatment if clinical diagnosis and awaiting culture?

Answer 55

no | -For active TB, start the four drug therapy (INH, rifampin, pyrazinamide, ethambutol)

Question 56

Latent TB considerations

Answer 56

- clinically silent but can become active | - Get screening PPD

Question 57

if there's no history of BCG vaccination, what do you do along with the PPD?

Answer 57

Check CXR to make sure there is no Active TB | -if negative, treat as latent TB with 9 months of INH

Question 58

If there is a hx of BCG vaccine, what do you do along with PPD skin testing?

Answer 58

- Check CXR and IGRA - if CXR is negative and IGRA positive, treat as latent TB with 9 months of INH - if they are both negative, there is no active or latent TB, positive PPD was from BCG vaccine and there is NO TREATMENT NEEDED!