head neck infections obstructive airway disease facts

Clin Med I Exam 1 - CS Study online at quizlet.com/_1zftau 1.

most important element in evaluating headache patient

accurate, focused history

2.

features of benign headache

under 35 yoa Gradual, longstanding episodic

3.

features of serious headache

over 35 yoa - pot serious Abrupt, rapidly progressive "thunderclap"

4.

headaches; daily for days to weeks

muscle tension

5.

headache - worse in a.m. or w/ straining

may be elev ICP

6.

the severity of a headache is very subjective

true

7.

headaces w/ ataxia, diploplia, unilat weakness

CVA

8.

primary HA w/ N/V

migraines (pain activates SNS; slowing digestion)

9.

primary HA w/ photophobia

migraine (also meningitis)

10.

HA w/ strong family history

migraines

11.

headaches w/ depression

muscle tension headaches

12.

medications/food that can lead to headaches - primary

NSAID withdrawal (narcs, caffeine) MSG (non-essential AA) OTC meds

13.

more serious; primary vs secondary headache disorders

secondary

14.

takes up space; can cause headaches

mass lesion

15.

exams needed w/ headache

gen appearance - ill looking? vitals; temp, bp neuro; CN, sens, cerebellar, gait, visual

16.

mental status exam - knows

A&O X 3: WHO they are WHERE they are what DATE/TIME it is (x4 = recent EVENTS)

17.

HA: head & neck exam focus areas

scalp tender/swelling (rash) cerv spine - flexibility temporal arteries facial symmetry (CN function) eyes - EOMs, fundoscopic TMJ - crep (tension HA)

18.

headache; may be temporal arteritis

new; localized, continuous focal tenderness direct palpation scalp tenderness generalizedaches/pains, constitutional JAW CLAUDICATION PATHOGNOMONIC (ischemia of maxillary a. supplying masseter)

19.

causes of 2ndary headache

SAH Intracranial hemorrhage Mass lesion Meningitis CVA/stroke (ischemia due to blockage or rupture)

20.

headache; after trauma, drug withdrawal/rebound

are considered primary headaches

21.

lumbar puncture vs CT sequence

always CT scan first when possible esp w/ signs of ICP; risk of suction exacerbating herniation due to ICP/SAH (also "supratentorial mass lesion")

22.

risks for LP indic CT first; signs of elevated ICP

PAPILLEDEMA altered MS/abnormal neuro eval

23.

LP where

"keep the cord alive - between L3 and 5 " (cord ends at L2)

24.

CT preferred for

hemorrhage tumor hydrocephalus

25.

MRI preferred for

Post/cerebellar lesions

26.

CT vs MRI

CT - bone detail; MRI - soft tissue detail CT; rad risk, but faster (5 vs 30 min), cheaper

27.

LP tubes

1-bugs & count (diff) 2- food (gluc & prot) 3- count (shows traumatic tap) 4 - reserve

28.

CSF protein elevated w/

infections/inflamm - meningitis SAH MS, Guillain Barré, malignancies, hydrocephalus (falsely pos: by rbc's/traumatic tap)

42.

tension headache - Tx

rest/relax analg; ibupr, aceta - combos helpful for chronic physical/massage therapy (antidepressants/psych counseling)

29.

CSF glucose

norm: 2/3 level of serum gluc decr w/ CNS infect (bugs eat)

43.

tension headache dx

focus on r/o 2ndary more serious

30.

CSF w/ bact meningitis

gluc low (norm in CSF; bugs have eaten) protein high

44.

migraine incidence

31.

headaches by age

migraine (middle age) (vs tension/cluster in YA/adults) also: migr & cluster - dec w/ age

32.

headaches by sex

sex: cluster (male smoker) (vs tension/migraine female)

75% are women 25-34 yoa (younger than tension) hormonal - so declines w/ age/menopause high incid: 10-20% of pop (25 X cluster)

45.

33.

headaches by hereditary

migraines - yes, cluster - no

migraine associated w/

family history menstruation; HRT; estrogen/progesterone prostaglandins (vasoconstriction)

34.

headaches by movement

migraines- aggravated by movement/light/sound clusters - pain NOT to move; (likes hot showers)

46.

migraine - clin

photo/phonophobia transient visual impairment N&V (normal neuro otherwise)

35.

headaches by location

tension - bilateral migraine/cluster - unilateral

47.

migraine duration

hours to days (4 hrs - 72 hrs)

headache skews

48.

36.

visual aura - typically 20-60 min BEFORE

Flashing lights Shimmering, zig zag lines Visual field loss - Scotoma

49.

other migraine "aura"

numbness; tingling transient hemiparesis (mistaken for TIA)

50.

migraine triggers

noise/lights/odors TYRAMINE (red wine, cheese, chocolate) Sulfites/nitrites/MSG lifestyle-stress, dieting, depression

51.

oral meds less effective w/ migraines

decreased gastric motility (associated w/ migraines)

52.

migraine dx

focus on ruling out 2ndary more serious

53.

migraine Tx

mild/infreq - OTC w/ RN antiemetic only abortive & prophylaxis as becomes more frequent

54.

migraine patho

...

55.

migraine pathophys

constriction followed by uncontrolled DILATION; dilation causes pain (relieved w/ constrictors)

56.

5HT receptors in cranial vessels

B, D

57.

migraine Tx abortive

tryptans ergotamines

37.

38.

MC headache characteristic pain

tension headache band-like bilat pressure; not disabling/severe

tension headache - cause

muscle SPASM in neck/scalp due to MC; stress occupational, cervical disk/arthitis uncorrected ASTIGMATISM CAFFEINE withdrawal

39.

tension headache duration

hours

40.

tension headache - clin

usually no physical; normal neuro (maybe anxiety/depression)

migraines w/ aura called migraines w/o aura

classic common

41.

58.

migraine Tx - pain relief

narcotics/opiods

76.

59.

migraine Tx prophylactic

beta blockers (also antidepressants)

cluster headaches duration

15-90 minutes SHORTER BUT MANY per day! 10x+, 1-4 mths

77.

migraine Tx - tryptans MOA

selective 5HT-1 serotonin agonists (vasoconstrictor - counteracts dilation)

cluster headache triggers

alcohol nitrites (not noise/lights/odors or tyramine)

78.

cluster headaches - clin

short; excruciating; AWAKENS from sleep UNILATERAL behind eye (radiate to jaw, temple, teeth) IPSILATERAL lacr, ptosis, miosis, & sweating

79.

cluster headaches abortive Tx

Sumatriptan (imitrex) - only FDA approved injection; oral too slow attacks so brief high flow OXYGEN - can shorten

80.

cluster headache prophylactic Tx

not effective; too unpredictable, long periods in between

81.

MC causes of secondary headache

SAH, SD or ED hematoma; meningitis, tumor, temporal arteritis (less common)

82.

what are the risk factors of a SAH

age, smoking, female, black, alcohol abuse/binge drinking

83.

majority of SAH

spontaneous (vs traumatic), due to aneurysm

84.

77% of cases are spontaneous hemorrhage caused by...

aneurysms

85.

what does AVM stand for?

arteriovenous malformation

86.

what are the causes of SAH

aneurysms trauma AVM of the brain or spinal cord blood dyscrasias blood thinners (tumors, infection, and vasculopathies = less common)

87.

secondary headaches MC causes

SAH subdural hematoma meningitis tumor temporal arteritis

88.

SAH vs subdural - by age

SAH under 50 (peaks at 50) vs SDH over 60 (MC over age 60)

89.

SAH vs subdural - causes

SDH; usually trauma - elderly fall or child abuse SAH; trauma & AVmalform, dyscrasia, thinners

60.

61.

5HT receptors bind

serotonin; a VASOCONSTRICTOR in brain (platelets release serotonin to clots - constrict)

62.

migraine Tx - tryptans approved

sumatriptan (Imitrex) almotriptan (Axert)

63.

issue w/ migraine oral meds

less effective migraine usually w/ N/V; due to depressed gastric motility

64.

tryptans SE

CONSTRICTION - flushing; chest/neck tightness

65.

tryptans counterindications

vascular issues (CAD HTN, hemiplegic/basilar migraines)

tryptans in addition to vasoconstriction

decrease activity of trigeminal nerve (CN V) (also use w/ clusters)

67.

Migraine Tx ergotamine

potent vasoconstrictors; but high SE must be given very beginning

68.

Ergotamine SE

NAUSEA extravasation; over constriction tissue NECROSIS

69.

Ergotamine counterindications - a lot

pregnancy coronary, vascular disease hepatic/renal insufficiency

70.

Migraine Tx narcs/opiods

last resort; never as monotherapy causes sedation & N/V; needs antiemetic high abuse potential

71.

Migraine Tx - beta blockers

propanolol, timolol (35-40% success rate)

72.

Migraine Tx antidepressants

amitriptylene - antidepressant methysergide - 5HT1 agonist

73.

cluster headache causes

dilation of cerebral blood vessels AND pressure on TRIGEMINAL nerve

74.

cluster headaches often misdiagnosed as

trigeminal neuralgia

75.

cluster headache demos

MC MEN onset, 27-30 yrs (decreases w/ age) NOT HEREDITARY

66.

90.

SDH vs EDH

Subdural - bridging veins; respects falx not sutures, (DOESN'T CROSS MIDLINE; causes shift), crescentic

99.

brudzinski, kernig

100.

SAH - dx scans vs time

CT - better early (first 24 hrs) MRI - better later (4 days+); no rad...but usually too late (angiography - not good; neg 1/4 cases)

101.

molecules used in MRIs

hydrogen ions

102.

CT vs LP

if bleed suspected; CT first if neg; can do LP to confirm LP necessary when meningitis suspected; need to know what bug to treat

103.

lumbar punctures when SAH suspected

reserve for when CT scan negative but you really believe there is a SAH; use LP to confirm [If the CT scan comes back positive, then there is no reason to get a lumbar puncture too]

104.

SAH - dx

CT scan; neg DOES NOT R/O SAH - if suspicion still; use LP to detect rbc's in CSF LP only after CT - risk of further herniation if ICP

105.

estimated to occur in 10-30% of LP

a traumatic tap

106.

traumatic tap from a SAH

lighter in color w/ subsequent tubes RBC count decreases in subsequent tubes there is CLOTTING (should not be in CSF) NO XANTHOCHROMIA (takes time to develop)

107.

xanthochromia present in SAH or traumatic tap

SAH

108.

clotting in CSF = SAH or traumatic tap

traumatic tap

Epidural - MMA; respects sutures not falx (can cross ML); lenticular SAH; deeper into brain 91.

92.

93.

SAH vs SDH vs EDH pic

Epidural = above (both) duras they are peeled off together (meningeal & periosteal) - due to MMA rupture Duras joined except at venous sinuses = space between Subdural hematoma is under (both) duras - which are still attached to skull SAH - risk factors

w/age female;black smoking/drinking

94.

SAH - MC cause

77% spontaneous hemorrhage due to aneurysm

95.

SAH - other causes

trauma AV malformation brain/SC blood dyscrasias, thinners tumors; vascular prolif, impinges/erodesarteries

96.

SAH - mortality

10%; else 1/3 w/ neuro issues

97.

SAH - clin

"worst headache of life" meningismus (due to blood in CSF) neurological (may have sentinel HA; by days or weeks)

98.

meningismus =

signs of meningeal irritation

109.

= is the yellow discoloration indicating the presence of bilirubin in the cerebrospinal fluid (CSF) .

xanthochromia - takes time to break down

122.

SDH - dx labs

CBC w/ platelet count, coag studies alcohol/tox screen CT scan (MRI superior but not as available)

110.

SAH - Tx pharm

Anti-HTN/alpha/beta blockers - Labatelol, Vasotec Analgesics - control BP & agitation Anticonvulsants - brain tissue hyper excited H2 blockers - suppress nausea

123.

SDH - Tx

ABC's w/ intubate if GCS < 12 (or patient unable to manage own airway)

111.

SAH - Tx if bleeding secondary to antithrombolytic

FFP & Vitamin K

112.

NEVER prescribe for a severe headache

blood thinners or antiplatelet drugs (e.g. Aspirin)

113.

SAH Tx - non pharm

Bed rest (ICU), ELEVATE HEAD protect airway, oxygen Routine labs & coagulation studies

114.

chance of recurrent hemorrhages after a SAH

HIGH 20% rebleed risk (w/in 2 weeks)

115.

SAH - outcomes

1/3 recovery 1/3 comatose 1/3 neuro deterioration

116.

SDH - causes

blood between brain & duramater; usually trauma; may be minor esp in elderly bridging veins ruptured

117.

In non traumatic cases of subdural hematomas,

headache, altered mental status, neuro deficits

118.

if a child has a subdural hematoma....

suspect child abuse

119.

= is the test of choice for immediate diagnosis of SDH (subdural)

CT scan (MRI is superior but not readily available)

120.

SDH - physical eval

Evaluate head for signs of trauma Neuro exam - GCS Look for focal deficits, SIGNS of ICP r/o C-spine injury

121.

Glasgow coma scale - scales

HIGHER IS BETTER eye opening 1-4 verbal response 1-5 motor response 1-6

burr hole if; ML shift > 5mm (inc ICP signs) help clotting; w/ FFPlasma and Vitamin K 124.

burr hole

hole drilled into skull; tube inserted drains hematoma

125.

meningitis risk factors

pulm/ear/sinus/mastoid infection head/face trauma; CSF leak splenectomy immunosuppresion/alcoholism

126.

MC cause of meningitis

VIRAL

127.

splenectomy causes meningitis/sepsis how

-spleen macrophages phagocytose bacteria -phags activated when bacteria opsonized/taggged by IgG1, IgG3 or C3b -w/ asplenia, cannot be removed from the blood -patients need immunizations for pathogens w/ capsules -only proteins are directly recognized by macrophages; humoral immunity (IgG and complement opsonization) is immune response to capsuled paths

128.

capsulated pathogens; problem for asplenia

-Strep pneumoniae, S. typhi, N. meningitidis, E. coli, H. influenzae, S. agalactiae, Klebsiella pneumoniae

129.

meningitis highest mortality rate when

babies < 1yr

130.

risk factors pneumococcal meningitis (strep pneumonia)

ALCOHOL use DIABETES ....Infection of a heart valve TRAUMA to head Recent ear INFECT, pneumonia, URI SPLEEN removal/dysfunction

131.

meningitis w/ highest mortality rate (20-30% adults, 10% children)

Strep pneumonia; PNEUMOCOCCAL (think lungs)

132.

133.

134.

135.

meningitis w/ lower mortality; but poor neuro PROGNOSIS

meningococcal meningitis; spread by droplets, close conditions; campuses etc. (neisseria meningitidis)

meningitis in NEONATES (bacteria from birth canal)

GROUP B STREP (streptococcus agalactiae)(49%) E. Coli (18%) - BIRTH CANAL

meningitis in CHILDREN

H. Influenza (40-60%) - EAR INFECTS Neisseria meningitidis (24-40%) SCHOOL Strep Pneumoniae (10-20%)

meningitis in ADULTS

Strep. Pneumoniae (30-50%) Neisseria meningitidis (10-35%) Staph (5-15%) - ADULTS ONLY

136.

meningitis; MC route of infection

hematogenous spread

137.

meningitis; due to contigous infect

OM mastoiditis sinusitis

138.

139.

140.

meningitis; due to direct inocculation hole into spinal column

head/neck surgery penetrating head trauma osteomyelitis of skull

meningitis - clin neonates (can vary drastically)

FEVER Lethargic; Irritable Bulging FONTANELLE = sign of intracranial pressure RASH - petech doesn't blanch Poor feeding; vomiting Seizures (arching neck/back)

meningitis - clin; adults, children

RAPID ONSET fever, headache, STIFF NECK PHOTOPHOBIA N&V MSC; Confusion PETECHIAE (esp meningococc)

146.

normal CSF looks

clear; colorless cloudy = wbc's or protein

147.

elevated opening pressure of CSF

> 20cm

148.

elevated opening pressure suggests

increased ICP; tumors, infect, IC hemorrhage, hydrocephalus

149.

decreased opening pressure suggests

hypovolemia; dehydration or shock

150.

elevated neutrophils in CSF (left shift)

bacterial meningitis cerebral abscess

151.

elevate mononuclear lymphocytes in CSF

viral or tubercular meningitis (non bact) encephalitis

152.

elevated WBCs in CSF can also indicate

leukemia (metastatic)

153.

normal RBC, wbc's in CSF

0; occasional lymphocytes only

154.

normal protein levels of CSF

very little - 15-45 mg/dl

155.

elevated protein associated w/

infectious/inflamm of brain/cord; meningitis, encephalitis, myelitis CSF tumors, hydrocephalus SAH

156.

protein enters CSF in meningitis

inflammed meninges; proteins leak through caps into SA space

157.

normal glucose levels in CSF

50-75 mg/dl

158.

meningitis; protein, glucose levels in CSF

glucose - low (bugs eat) protein - high inflamm

159.

cytology of CSF will show

malignant cells - if tumor

160.

meningitis Tx

IV fluid/electrolytes, airway/oxygen, control fever ANTICONVULSANTS (seizure in 30% of patients) abx - 3rd gen CEPHALOSPORINS & AMINOGLYCOSIDES (pend C&S; 2-3 wks) STEROIDS - first 4 days only (I&D abscess)

141.

meningitis; inflammation of

pia mater

142.

meningitis - workup

CBC, BMP, UA w/ culture CT scan before LP CXR, MRI

143.

CSF visual; w/ meningitis

yellow (xanthochromia); thicker

161.

aminoglycoside caution

need to test CrCl; can be nephro toxic

144.

xanthochromia

means bilirubin in CSF; not present if 'traumatic tap'

162.

meningitis Tx anticonvulsants

valium, ativan dilantin

145.

xanthochromia explanation

rbc's in CSF destroyed & degraded by enzymes into bilirubin; takes time to be digested

163.

meningitis Tx control ICP

mannitol

164.

leading oncologic cause of death < 35 YOA

brain tumors

165.

brain tumors - % primary

50/50 primary/metastatic

166.

in children - cause of cancer

#1 leukemia, #2 brain

167.

brain tumors develop

insidiously, non specific

168.

brain tumor - clin

HA; MC symptom in CHILDREN Confusion, MSC ATAXIA, gait disturbance Visual defects, speech abnormalities Seizures N&V

169.

motor cortex signals unattenuated - needs

cerebellum - tuning extrapyramidal nuclei

170.

brain tumor - exam findings

papilledema - MC in CHILDREN sensory & motor defects

brain tumor - sensory defects; location

diploplia - CNVI upward gaze impaired pituitary partial visual field occipital (visual cortex) anosmia - frontal lobe ataxia/coordination, nystagcerebellar/brainstem

171.

172.

MC tumor that spreads TO BRAIN

lung #1 breast, colon, prostate, ...

173.

brain tumor symptoms children

headaches, papilledema

174.

ataxia, uncoordination, nystagmus (involuntary eye movements), sensory deficits sign of

cerebellar or brainstem tumor

brain tumor - workup

CBC, BMP, coagulation studies LIVER FUNCTION TESTS - enzymes will rise CT - initial test of choice

175.

176.

brain tumor - CT vs MRI

CT scan - initial w/o contrast first later; w/ contrast delineates tumors better MRI - better for brain stem, post fossa, dye allergies, implanted devices

177.

brain tumors - Tx

STEROIDS - reduce cerebral edema ANTICONVULSANTS - prophylactic CONTROL ICP with mannitol (control airway/oxygen)

178.

brain tumor - surgical options

removal/debulk intraventricular SHUNT radioactive IMPLANTS (sustained release) (Oncol consult)

179.

Intraventricular shunt

if location of tumor closes off ducts of ventricles; causes hydrocephalus

180.

lumbar puncture headaches - clin

w/in 24 hrs of LP; N/V bilateral; relieved when supine

181.

lumbar puncture headache - MC Tx (surgical repair very rare)

Epidural blood patch (slowly injects blood at defect)

182.

Epidural blood patch

patient's blood injected into epidural space near defect; clot forms repairs "leak"

183.

LP headaches last

a few days to 1 week

184.

most useful diagnostic tests in HA workup

CT, MRI, LP - guided H&P exam

185.

MC pathogens swimmer's ear

pseudomonas aeruginosa & listeria

186.

Tx of otitis external depends on...

w/ cellulitis = syst ABX + local HEAT w/o cellulitis and no TM perf = ABX drops

187.

age group most at risk for OM

young children bc the angle of the tube is straight and shorter auditory tube

188.

symptoms of acoustic neuroma

slowly progressive UNILATERAL hearing loss

189.

Tx for acoustic neruoma

surgical removal

190.

should aspirin be used as an antiinflammatory?

no because of its toxicity (should just be used as anticoagulant)

191.

which antibiotics are ototoxic

aminoglycosides

192.

OE w/ cellulitis - Tx

syst ABX (Dicloxaacillin/macrolides) HEAT

193.

OE w/o cellulitis - Tx

Otic DROPS (0.3% ofloxacin or polymyxin B + Neomycin + hydrocortisone*)

194.

OE in diabetic patients - possibly invasive can

Invade bone/brain - possible CN palsies (malignant necrotizing)

195.

OE in diabetic patients diagnose w/

CT to establish - P. aeruginosa likely

213.

Meniere's Syndrome clin

FLUCTUATING hearing loss, tinnitus, EPISODIC vertigo, fullness/pressure in ear; may be UNILAT

196.

OE in diabetic patients - Tx

DEBRIDE, longer abx (BROAD SPECT PCN, antipseudomonal cephalosporin + Ciprofloxacin or aminoglycoside)

214.

Meniere's Syndrome cause

edema; ? ENDOLYMPHATIC hydrops; possible family history

197.

OE pathogens

MC Staph, Strep (P. aeruginosa swimmer's ear; diabetes)

215.

Slowly subsides but with unsteadiness/dizziness that may last days

198.

OM pathogens

Strep pneumoniae, H. flu, (Moraxella catarrhalix); occasional viral

Meniere's Syndrome resolves

216.

Meniere's Syndrome Hearing loss

reversible early on

199.

OM viral pathogens

syncytial virus, influenza virus, enteroviruses and rhinovirus

200.

OM clin - subj

Ear pain, diminished hearing, VERTIGO, TINNITUS

217.

Acoustic Neuroma - Tx

surgical removal

201.

OM clin - obj

fever, TM erythema/distended/immobile, fluid/pus

218.

Meniere's syndrome - Tx

sodium restriction; oral DIURETICS

219.

Deafness other causes

cochlear damage, labryinthitis,occlusion of ant inf cerebellar art, drugs

220.

Deafness drugs causing

AMINOGLYCOSIDES, cis-platin (anti-CA), FUROSEMIDE/LASIX (loop diuretic), SA/tinnitus, oxycontin

202.

serous OM - Tx

no ABX, decon only

203.

bacterial OM - Tx

1st line: Amox-Clav (Augmentin), else Trimethoprim/Bactrim, Cefaclor

204.

complications of OM

mastoiditis, bact meningitis, Brain abscess/subdural empyema

221.

Auditory Tube Dysfunction may be due to

Barotrauma caused by Pharyngotympanic tube dysfunction

allergic rhinitis - clin

"nose crease" "atopic wave/salute"; Eosinophils in wet prep

222.

rhinitis causes

airborne allergens (most likely); possible atopic association

when tube occluded,

residual air absorbed into mucosal blood vessels, causes suction; retraction of TM; interfere w/ movement

223.

diff rhinitis vs CSF

normal CSF: w/ low protein, high glucose

224.

Sinusitis; bacterial pathogens

MC S. Pneumoniae, H. Influenzae (Moraxella catarrhalis) SAME AS OM; also ANAEROBES, STAPH

225.

Sinusitis; nosocomial pathogens

STAPH aureus; gram negs

205.

206.

207.

tube dysfunct pic

blocked route from tympanic cavity to nasopharynx; edema due to infec, allergy, etc

208.

tube close w/

changes in pressure, ie. Air travel - need to swallow/chew; infect, allergy, swelling

209.

Otosclerosis is

Immobilization of the stapes; overgrowth of bone; conductive hearing loss

226.

Chronic sinusitis; consider

ANAEROBES - colonized in nose

210.

otosclerosis demos

YOUNG - 70% between ages 11 and 30; FH 50%

227.

Sinusitis viral pathogens

rhinovirus, influenza virus, parainfluenza virus, adenovirus

211.

Acoustic Neuroma (vestibular schwannoma) clin

Slowly progress; UNILATERAL hearing loss, tinnitus; vertigo ( 1 wk w/o improvement (rare) resp difficulty/stridor difficult swallow/secretions pain w/o erythema palpable mass blood in pharynx or ear

273.

if respiratory difficult/stridor, secretions, swallowing consider;

epiglottitis; quincy

274.

if severe pain w/o erythema - consider

extra respiratory; epiglottitis retropharyngeal abscess

275.

if blood in pharynx/ear consider

lateral pharyngeal space infection erosion of carotid

276.

if palpable mass consider

soft tissue space infection

277.

Sore throat w/ lymphadenopathy

localized-cervical; if diffuse; more likely mono

278.

Sore throat MC pathogen

VIRAL, then strep gr A; can have viral & bact concurrently

279.

Sore throat more likely strep if

high FEVER, tonsillar EXUDATES, cervical lymphadenopathy (and NO COUGH)

280.

if antibiotic resistant w/ normal treatment

must consider other than strep

281.

Strep - dx

If 3 or 4 of above; may often treat empirically despite neg strep test

299.

Diphtheria (Corynebacterium diphtheriae) - Tx

Antitoxin, erythromycin

317.

Ludwig's Angina cause

MIXED bact infect; ABSCESS of floor of mouth - 2ary to ODONTOGENIC infection

300.

Epiglottitis - clin

Sore throat/severe pain/erythema; difficult swallowing/secretions, resp difficulty/STRIDOR LEAN FWD to prevent airway obstruction

318.

Ludwig's Angina high risk

Laryngeal EDEMA/respiratory compromise

319.

Ludwig's Angina Tx

High dose Ampicillin-sulbactim , or metronizadole

320.

Retropharyngeal Space Abscess clin

Difficul swallowing, dyspnea (Post pharyngl mass) Tongue may be DISPLACED Induration of submandib space

321.

sore throat EXTRA RESPIRATORY causes

elderly Angina (w/ atypical radiation) DISSECTING aortic aneurysm (TEARING pain) De Quarvain subacute Thyroiditis (Fever, pain, thyroid tender)

322.

eustachian tube pic

323.

ear pic

324.

reiter's syndrome pic

325.

Penicillin Unresponsive Pharyngitis

if not self-limiting/ resolved in 4-5 days

326.

Penicillin Unresponsive Pharyngitis due to

HIV Mono GC ALL - dx by smear Leukopenic states (aplastic anemia, agranulocytosis)

301.

Epiglottitis concern

Aggressive in child, possible adults Requires rapid diagnosis, death possible within hours

302.

Epiglottisis - dx

xray thumb sign; Laryngoscopy (direct visualization)

303.

Epiglotittis pathogen

H. flu, particularly in child; may produce B-Lactamase

304.

B-lactamase inhibitor - adjunct to abx

clavulanic acid

305.

Epiglottitis - Tx

2nd/3rd gen cephalosporins, ampicillin-sulbactam preparations; steroids

306.

Epiglottisis - Tx prophylaxis

RIFAMPIN

307.

Peritonsillar abscess - aka "Quinsy" - clin

Difficulty swallowing/secretions TRISMUS -inability to open mouth (spasm)

308.

Peritonsillar abscess - dx

Visualize swelling, lateral deviation of UVULA

309.

Peritonsillar abscess - Tx

Early PCN; later I&D

310.

Septic Jugular Vein Thrombosis - cause

COMPLICATION of bacterial pharyngitis/QUINSY

311.

Septic Jugular Vein Thrombosis - clin

w/ pain and tenderness in neck, often at jaw angle; High fever bacteremia septic PE

312.

Septic Jugular Vein Thrombosis - Tx

IV PCN + metronidazole (for anaerobes)

313.

LATERAL Pharyngeal Space Abscess cause

Rare; complication of JV thrombophlebitis

314.

Risk w/ LATERAL pharyngeal space abscess

serious morbidity/EROSIVE to CAROTID; EXSANGUINATION

315.

Exsanguination preceded by

blood in ear or pharynx

316.

Retropharyngeal Space Abscess cause

Complication of TONSILLITIS; rare in adults; usually 2ndary to cervical osteoMYELITIS

Penicillin Unresponsive Pharyngitis from GC

Mild but may need high dose PCN dx w/ Thayer Martin culture media (chocolate agar)

328.

MC eye disorder

conjunctivitis

329.

Conjuncitivitis - MC pathogens

bacterial, viral, allergic, irritant LC fungal/parasites (direct contact)

327.

330.

331.

conjunctivitis pic

bacterial conjuctivitis pic

bacterial conjuctivitis clin

Purulent discharge Minimal pain Minimal blurred vision Usually self limited

bacterial conjuctivitis Tx

antibiotic optic solution

334.

viral conjunctivitis - clin

(associated with viral pharyngitis) fever, malaise Watery (min exudate) Children > adult Swimming pools

335.

viral conjunctivitis - Tx

Possible optic antibiotic drops (prevent 2ndary bact infect)

336.

viral life span short /long

hep, ebola; long

332.

333.

337.

problem w/ nasal & optical decons

rebound; may come back worse (vasoconstrictors)

338.

allergic conjunctivitis assoc

w/ other atopy; hay fever

339.

allergic conjunctivitis clin

tends to be chronic; atopy itching, red minimal stringy discharge

340.

allergic conjunctivitis Tx

symptomatic

341.

chalazion - cause

chronic granulomatous inflam of meibomian

342.

chalazion - clin

hard swelling on lid NON tender may be preceded by 'sty' conjunct irritation; vision distort

343.

chalazion - Tx

excision (sterile) old remedy; tea bag/tannic acid (warm compress NOT helpful)

344.

hordeolum - cause

staph abscess

345.

hordeolum - clin

acutely TENDER erythematous/edema

346.

hordeolum - locations

internal: of meibomian gland external: "sty"

347.

hordeolum - Tx

warm compress abx; I&D

348.

pterygium - cause

chronic wind/dust; benign surfer motor cyclist

349.

pterygium - clin

fleshy, triangular mass usually bilateral; nasal side severe; burning/photophobia

350.

pterygium - Tx

excision if severe

351.

hyphema - cause

blow; contusion w/ hemorrhage anterior chamber - blood fluid line

352.

hyphema - Tx

rest; danger of 2ndry hemorrhage/glauc

353.

uveitis - cause

inflammation of uveal tract

354.

uveal tract

iris ciliary body choroid

355.

uveal tract pic

365.

Obstructive Pulm Disease ------------------------------------

...

366.

Bronchiectasis generally result of

chronic infections

367.

COPD characterized by

irreversible airflow limitation

368.

Chronic obstructive pulmonary disease (COPD) air flow limitation

both progressive & associated with an abnormal inflammatory response to noxious particles or gases

369.

COPD

Irreversible Fibrosis and narrowing of the airways. Loss of elastic recoil due to alveolar destruction. Destruction of alveolar support that maintains patency of small airways

370.

Asthma

Reversible Accumulation of inflammatory cells, mucus, and plasma exudate in bronchi. Smooth muscle contraction in peripheral and central airways. Dynamic hyperinflation during exercise

371.

COPD - clin

Chronic Cough -Everyday, persistent, for at least 3 months of the year, for 2 successive years Wheezing Dyspnea Acute Chest illness

372.

COPD - dx

CXR: non diagnostic but helpful to exclude other illness. DLCO (see right) ABG: not essential to diagnosis unless documented moderate to severe COPD, then becomes measurement tool Spirometry

373.

DLCO ​C arbon Monoxide Diffusing Capacity Evaluates:

Pulmonary membrane RBC resistance to bind

356.

inflammation of iris called

ant uveitis iridocyclitis iritis

357.

uveitis - clin

unilateral; can be bilateral granulomatous or non granulomatous

358.

uveitis granulomatous (chronic) - clin

CHRONIC; usually choroid indolent; blurred vision; mildly inflamed white precipitates; focal "mutton fat", iris nodules BUT MORE DAMAGE progressively close canal of schlemm

359.

pathogens causing granulomatous (chronic) uveitis

sarcoidosis TB syphillis toxoplasmosis

360.

uveitis granulomatous Tx

...

361.

uveitis non granulomatous ACUTE clin

ACUTE; marked pain redness, photophobia visual loss diffuse, smaller precipitates; no nodules dilated blood vessels around iris/capillary body

362.

immunodysfunction diseases - allowing acute (non granulomatous) uveitis

(HLA-B27 related - AI syndromes) reactive arthritis/reiter's, psoriasis, ulcerative colitis, chron's

363.

pathogens causing non granulomatous (acute) uveitis

herpes simplex & zoster

374.

DLCO ​C arbon Monoxide Diffusing Capacity

364.

uveitis non granulomatous ACUTE Tx

Local and systemic corticosteroids may shorten course

Objective measurement of lung function Ability of lung to take up test gas (CO) which binds to hemoglobin (CO with high binding affinity)

375.

why use CO gas in DLCO test

high affinity for hemeglobin

376.

DLCO procedure

set dose of CO is inhaled; measure exhaled CO higher than normal; CO not absorbing to blood

377.

DLCO procedure evaluates pulmonary membrane

if too thick, won't cross

378.

3 types of disorders that will decrease DLCO

obstructive disease (emphysema, CF) - can't cross Interstitial lung disease Pulmonary vascular disease

379.

interstitial lung disease impacts 2 ways

more difficult to cross - fibrosis more distance to cross

380.

Pulmonary vascular disease

gets across membrane but not picked up blood not reaching surface to absorb

381.

Factors affecting diffusing capacity

Ability of gas to reach alveolar gas exchange surface Ability to cross alveolar membrane Mass of RBC in pulmonary capillary bed to bind CO

382.

383.

384.

385.

386.

387.

388.

cause decreased diffusion capacity

Pulmonary Vascular Occlusive disease (PE) Interstitial lung disease Emphysema Pulmonary edema - alveoli filled w/ fluid

cause increased diffusion capacity

Pulmonary hemorrhage L to R intracardiac shunt Asthma (may be normal)

spirometry movement of air restricted

will show obstructive & restrictive can use to monitor as well

FEV1/ FVC normal vs COPD

80% vs 60% (obstructive FEV1 disproportionately decreased; restrictive both equally decreased)

Chronic bronchitis - causes

Persistent cough w/ sputum prod > 3 months, in each of past 2 years Cigarette smoking - major cause exposure to pollutants

Chronic bronchitispathologic findings

chronic bronchitis clin

Goblet-cell hyperplasia Mucous plugging Fibrosis primary: airway (vs parenchyma in emphy) Similar to emphysema key - sputum production Possible recurrent bacterial airway infections

389.

chronic bronchitis dx

PFT CXR standard lab

390.

chronic bronchitis Tx

Inhaled bronchodilators, corticosteroids If significant sputum - chest physiotherapy Rotating antibiotics if appropriate

391.

CB vs emphysema

disease of AIRWAYS vs parenchyma emphysema; parenchyma destroyed

392.

emphysematous lungs on x-ray

bubbles alveolar structure destroyed

393.

emphysema breathing

accessory muscles needed to breathe; barrel chested - increased AP diameter (norm 1:2)

394.

Chronic bronchiolitis - is

Inflammation, fibrosis, distortion of SMALL airways; membranous, respiratory bronchioles

395.

Chronic bronchiolitis causes

airflow limited due to inc. airway resistance; associated airway muscle hyperplasia

396.

Chronic bronchiolitis - clin

similar to COPD related to acute viral infections after exposure to mineral dusts (silica, asbestos)

397.

bronchiectasis is

Abnormal dilation of bronchi; inflammation and permanent destructive changes in elastic and muscle layers of bronchi

398.

bronchiectasis usually caused by

recurrent or chronic severe infections (necrotizing pneumonia, TB, atypical pneumonias)

399.

bronchiectasis also caused by

viral and fungal infections anatomical obstruction hypersensitivity reaction (allergic)

400.

bronchiectasis causes

more middle-aged to older in younger w/ congenital defects

401.

bronchiectasis congenital diseases associated

CF immotile cilia syndrome = Kartagener's Syndrome

402.

Kartagener's syndrome triad

Sinusitis Situs inversus infertility

403.

wheezes w/ CB/asthma vs emphysema

Expiratory (ball valve) vs inspiratory (emphysema is prolonged expiration too)

404.

405.

406.

bronchiectasis clin

bronchiectasis dx

Chronic cough and FOUL smelling sputum SOB; Abnormal chest sounds Fatigue Rare hemoptysis CLUBBING (40%) CXR: norm or increased interstitial markings Classic finding - "Tram Tracks" (thickened bronchial walls w/o tapering) High Res CT more sensitive

bronchiectasis "tram tracks" pic

407.

emphysema

permanent enlargement of airspaces distal to terminal bronchioles; w/ destruction of walls w/o obvious fibrosis

408.

Factors Determining Severity Of COPD

symptoms & airflow limitation exacerbations complications of COPD respiratory insufficiency Co-morbidities General health status Number of medications needed to manage

COPD: ABG not essential to dx, but for monitoring

pH, CO2 (more than PaO2)

Stages of COPD slide 37

...

411.

reducing risk factors

Smoking cessation -most effective occupational dusts and chemicals, air pollutants

412.

COPD - Treatment general

Reduce risk factors Manage stable COPD Education Pharmacologic Non-pharmacologic Manage exacerbations

409.

410.

413.

COPD medications efficacy

meds not shown to alter longterm decline in lung function; meds only decrease symptoms/complications

414.

Primary COPD meds bronchodilators

beta2-agonists anticholinergics theophylline - narrow TI

415.

COPD: inhaled steroids indicated when

FEV1 < 50% predicted reduces frequency of exacerbations avoid chronic use: unfavorable benefit-to-risk ratio

416.

slide 44 COPD stages & treatments

...

417.

COPD & O2 administration

w/ chronic resp failure O2 shown to increase survival

418.

COPD & exercise training

All patients benefit; improved exercise tolerance and dyspnea/fatigue

419.

COPD exacerbated by

inf of tracheobronchial tree air pollution 1/3 cannot be identified

420.

treatment of COPD exacerbations

Inhaled bronchodilators Systemic-- pref oral-- steroids abx of questionable benefit unless CB

421.

NIPPV noninvasive intermittent positive pressure ventilation - in exacerbations

improves blood gases, pH reduces in-hospital mortality decreases need for invasive mechanical vent/intubation decreases hospital stay

422.

Asthma is

Airway inflammation, hyperreactivity reversible airflow obstruction

423.

Asthma incidence

highest in kids; but affects all ages 7% of US pop Incr 75% between 1960-94

424.

Asthma cause unknown, assoc w/ atopic history

possible polygenic origin exacerbated by environmental factors, abnormal adrenergic receptors Inhalants/irritants, infectious agents Obese higher incidence

425.

slide 50

...

437.

Theophylline concerns

into toxic range quite rapidly

438.

LTE inhibitor

Singulair

439.

NSAIDS can precipitate asthma

block prostaglandins; shunt to LTE pathway (avoid NSAIDS w/ nasal polyps)

440.

Acute severe "status asthmaticus"

May occur suddenly and possibly fatal Often w/ history of progressive dyspnea over hours to days; w/ increasing bronchodilator use Symptoms/signs more severe

441.

Acute severe/status asthmaticus Tx

Requires aggressive treatment with monitoring Pulse oximetry/ABG's

442.

...

but typically not the rule; grows out of it usually

recording 3:3, 41 mins.....missed notes

443.

CF - stats

Asthma lungs look

more hyperinflated; black on xray air trapping

Autosomal RECESSIVE (fortunately0 MC lethal genetic disorder in white pop

444.

CF affects

asthma - clin EPISODIC

Triad: wheeze, dyspnea, chronic cough chest tightness Often worse at night or early a.m. Other symptoms; sputum production, chest pain or tightness

respiratory hepatobiliary; GI reproductive

445.

CF - cause

When active with airflow limitation

Difficulty talking, using accessory muscles of expiration Diaphoresis, MSC due to anxiety Expiratory wheezes Pulsus paradoxus

mutation of gene; defective Cl transport incr Na reabsorption abnormally thick/viscous secretions luminal obstruction/destruction exocrine ducts

446.

CF - disease

432.

Pulsus paradoxus

Pulse weakens during INSPIRATION

433.

asthma dx

History may be sufficient Bronchoprovocation challenge testing

Airways colonized with S. aureus or H. flu (then Pseudomonas aeruginosa) Persistent inflammation/infection causes bronchial wall destruction, bronchiectasis Mucous plugging of small airways produce cystic dilations and parenchymal destruction

447.

CF - death

young age; from respiratory failure

448.

CF dx

Consider in pt. with unexplained chronic sinus disease, bronchiectasis, malabsorption PFT - varying degrees of obstruction, progressive CXR - normal or bronchiectasis Meas: Cl conc in sweat; + if > 60 mEq/L twice Most dx in childhood Median survival - mid 3rd decade

449.

CF clin

Salty skin Persistent cough w/ and w/o sputum Wheezing; SOB Poor appetite, FTT; nutrition not absorbed (Greasy, bulky stools) Possible infertility, diab, osteoporosis

426.

427.

428.

429.

430.

431.

asthma pathomechanics

Airway remodeling

Airway remodeling overtime

Airway inflammation activated inflamm cells in walls Eosinophils, mast cells, macrophages, T lymphs Produce leukotrienes, cytokines, bradykinins Hyperplasia/hypertrophy smooth muscle Edema; inflamm infiltration dep of connective tissue (collagen I and III); thickening dissoc of airway (from parench) "Stenting" of airways may cause; irreversible airflow limitation reduced effectiveness of bronchodilators

434.

Bronchoprovocation challenge testing

Use bronchoconstrictor (histamine, methacholine, cold air, exercise) to trigger episode (Lungs hyperinflated during active episode -black xray)

435.

management of chronic asthma (in all but mild intermittent asthma)

maintenance therapy; regular admin of inhaled steroids Add bronchodilators PRN LTE inhibitors also (but don't replace steroids) Theophylline useful but w/ narrow therap window

436.

Diagnostics during episodes

ABG's, CXR, eosinophilia, increase IgE Skin tests to identify allergens

450.

CF cause diabetes how

starts as pancreas enzyme/exocrine destruction; then destroys endocrine

451.

CF Tx

Aggressive airway hygiene; percussion, etc Bronchodilators as needed Inhalers to decrease sputum viscosity pancreatic enzyme replacement abx PRN Possible lung transplant

452.

...