Child with prolonged cough >2 Wks and fever… Next step: serology for pertussis

Best inv of BA…………… Spirometry before and after SABA (++ FEV1> 15% at least)

Most imp parameter to be assessed in spirometry of pt with BA…. FEV-1

Most imp parameter to be assessed in spirometry of pt with GB$…. FVC

Management of acute attack???

Pt with low O2 saturation next step……. Give O2

1st step……… Inhaled salbutamol...... Up to 6-12 puffs

Best way to give puffs to the kids…… MDI + Spacer

If no response……. IV MgSo4

If no response…… Steroids

Most common SE of inhaled cortisone…... Oropharyngeal candida

Most serious sign in status asthmaticus…. Silent chest

If cyanosis first step…… Intubation

Long term management:

First line…………. SABA

If still symptomatic……. Inhaled cortisone

If still symptomatic…... LABA (Don’t use in peds)

Prevention:

Best way……... Avoid dust and smoking

Drug used for prevention by inhalation……... Fluticasone

Asthma with exercise……. Salbutamol before the exercise

HOW TO ASSES CRITICAL CASES???... Confused/drowsy/AGITATED vvvvv IMP

Pt returned from long flight develops acute chest pain& dyspnea. Exam shows
clear lung… Dx: Pulmonary embolism (PE)

Best inv of PE/ Inv of choice of PE…... CTPA

Inv of choice in pregnant, pt with ESRD or allergy……. V/Q scan

TTT of choice of PE……… NOACs/LMWH followed by warfarin

Duration of warfarin use… 3-6 Ms with target INR of 2-3

Pt with contraindication to anti-coagulation, non-compliant with anti-coagulation

recurrent despite anticoagulant…… next step: IVC filter

Pt with cough and dyspnea. Exam shows dullness to percussion& ++ TVF… Dx:
pneumonia.

Pt with cough and dyspnea. CXR shows pneumonic patch….. pneumonia

Pt with cough and dyspnea. Exam shows dullness to percussion& -- TVF… Dx:
pleural effusion

MC CO……… S. pneumonia

Best way to give O2 in pneumonia… 1st: mask 2nd: venturi (NOT nasal canula)

TTT:

Criteria of severity:

1. confusion/ empyema
2. Urea >19/>7
3. RR >30
4. BP <90/60
5. Age > 60

When to say severe……….2 or more of the above criteria

Mild cases………. Outpatient TTT……… Oral Amoxycillin

Severe cases……. Inpatient TTT…………...IV Azithro + IV CEFOTRIAXONE

If MRSA………... Add Vancomycin

If mycoplasma pneumonia…. Doxycycline

Pneumonia with dry cough+ skin lesion (EM)… Dx: Mycoplasma pneumonia

TTT of mycoplasma pneumonia… Doxycycline

Trauma + dullness + decreased breath sound…... Pleural effusion

Management of pleural effusion…... Tube decompression

Most imp inv of pleural effusion… Thoracocentesis

Site of chest tube insertion… 5th intercostal space at MAL

Trauma + resonance + decreased breath sound… Pneumothorax

Management of tension pneumothorax… Immediate needle decompression

Site of needle insertion…… 2nd intercostal Space at MCL

Tall smoker young male with pneumothorax and no obvious cause… 1ry
pneumothorax (spontaneous pneumothorax)

When to do aspiration in primary pneumothorax???

1- Symptomatic even if small

if aspiration failed………...chest tube
if pneumothorax not symptomatic……. Conservative and follow up CXR

Pt with pneumothorax of any cause (asthma, COPD…etc)… 2ry pneumothorax

TTT of 2ry pneumothorax:

If more than 30%..............chest drain

If less than 15-30%...........aspiration…...if failed….. Chest drain

If less than 15%........conservative

COPD Pt came with fever OR yellow sputum… infection

Middle age male smoker with history of chronic productive cough and
hyperinflated lung………COPD

MCC of distress in pt with COPD…………………… infection

Most imp Sign of distress in pt with COPD………. pursing lips

Spirometry of pt with COPD “Obstructive lung disease”:

FEV1, FVC and FEV1/FVC ratio ………………… decreased

Residual volume and total lung capacity….. Increased

Lung compliance…………… Increased

Most imp way to decrease mortality in pt with COPD…… stop smoking

Types of ABG WITH COPD pt?? vvvvvvvvvvvv imp

When he comes with EXAGGERATED SYMPTOMS in the ER

PO2………. Decreased

PCO2……...INCREASED

PH………. RESPIRATORY ACIDOSIS

If you by mistake give the pt high flow oxygen????? Vvv imp

PO2……..INCREASED

PCO2…….INCREASED

PH…….RESPIRATORY ACIDOSIS

First step…….decrease the O2 flow

If respiratory failure???

PO2……..MARKED DROP (USUALLY BELOW 60%)

PCO2……..INCREASED

PH…………RESPIRATORY ACIDOSIS

1st step… intubation

Common scenario in the AMC exam

COPD patient with marked dyspnea in the ER

First step……..O2

How you know that you caused O2 toxicity????

By ABG……….. HIGH O2, HIGH CO2& RESPIRATORY ACIDOSIS

First step………… Decrease the flow of oxygen

COPD WITH very LOW O2 saturation (<60%) first step…… Intubation

Most imp cause of confusion in respiratory failure… CO2 narcosis

First test……pulse oximetry

Second inv…… ABG

Management…… Intubation

COPD pt with sudden chest pain……. Pneumothorax (rupture of bleb)

TTT of pneumothorax in COPD pt = TTT of 2ry pneumothorax

If more than 30%..............chest drain

If less than 15-30%........... Aspiration….. If failed….. Chest drain

If less than 15%........ Conservative

MCC of blood stained mucous… Acute bronchitis

MC RF of TB…… immigrant, nurse

Immigrant from endemic areas came with prolonged cough, dyspnea, night sweat
and wt loss……………… 1st step: chest X-ray

Definitive test of TB… sputum analysis

Inv of choice of asymptomatic pt… Mantoux test OR QuantiFERON

Interpretation of Mantoux test:

-ve test………………………….. Reassure

+ve test………………………… Chest X-ray

Then;

If +ve chest X-ray….. Isolation and quadruple therapy

If -ve chest X-ray… Isoniazid+ vitamin B6 for 6-9 ms

Imp complication of Isoniazid… Peripheral neuropathy (give vitamin B6)

Imp complication of rifampin… Red coloration of urine

Nurse with suspected TB…… Immediate isolation

Immigrant with suspected TB and +ve Mantoux test… next step: isolation (before
X-ray) ………...VVVVVVVVV IMP

Most common affected lobe of the lung in TB… Upper lobe

MCC of decreased TB incidence at Australia … Good isolation (NOT vaccination)

Old smoker with any chest complaint + wt loss… Dx: Lung cancer until proven

Old smoker with weakness, paresthesia at hand, CXR shows mass at apex… Dx:
Pancoast tumor

Old smoker with congested neck veins and arm swelling, CXR shows mass at
apex… Dx: Pancoast tumor

1st step in lung cancer pt with pleural effusion… Thoracocentesis

Lung cancer with systemic manifestation… Para-neoplastic $

1st step in pt with suspected lung cancer… Chest CT

Inv of choice of lung cancer….… BRONCHOSCOPY and biopsy

Asymptomatic pt with small lung mass at CXR… 1st step: Ask for old x-ray

Spirometry of pt with lung fibrosis “Restrictive lung disease”:

FEV1, FVC………………… Decreased

FEV1/FVC ratio……… Normal

Residual volume, total lung capacity & lung compliance… decreased

TTT of pulmonary fibrosis… Cortisone

Rt sided heart failure 2ry to pulmonary HTN… Cor pulmonale

Most imp drug in acute pulmonary edema… IV Furosemide

Child with FTT+ recurrent chest infection+ steatorrhea… Dx: Cystic fibrosis (CF)

Genetic of CF… AR

MCC of infertility in pt with CF…… Absence vas deference

Child with rectal prolapse, most imp to ask about… Bowel habit (NOT family H/O
of cystic fibrosis

Most imp inv of CF… Sweat chloride test

Male pt with bronchiectasis, sinusitis, azoospermia… Dx: Young $

Male pt with bronchiectasis, sinusitis, dextrocardia… Dx: Kartagener $

MCC of acute hemoptysis……… Acute bronchitis

MCC of chronic hemoptysis……… Bronchiectasis

Inv of choice of bronchiectasis… Spiral CT scan

TTT of infection with bronchiectasis ……… Amoxiclav (Augmentin)

Farmer with cough, dyspnea while on work BUT is free of symptoms on the week
end = Hypersensitivity pneumonitis. Most imp advice… Change the job

Asbestosis increase risk of…... Mesothelioma (Chest Xray STAT and after 3-5
months, PFT; try to avoid prolonged exposure)

Silicosis increase risk of…………. TB reactivation

Patient with chronic cough and pleural thickening on CXR……. Mesothelioma…...

next step……... CT chest …...vvvvvvvv imp

Inv of choice of Mesothelioma… Bronchoscopy& biopsy

Pt with prolonged symptoms of chest infection not responding to abs, CXR shows
pleural effusion… Dx: Empyema

Definitive TTT of empyema… chest tube + continues abs