Reviews Before becoming PGY- pulmonary function test

Pulmonary function test

Reference:  "Overview of pulmonary function testing in adults"(2016) Meredith C McCormack, MD, MHS, retrieved from UpToDate

 

Q:  PFT主要的內容？

A:  spirometry(before and 10 to 15 minutes after a bronchodilator, Albuterol 90 to 100 mcg  #4 IH?), lung volume examination

      DLCO, maximal respiratory pressures, flow-volume loops,

      submaximal exercise testing, and bronchoprovocation challenge

 

Q: PFT注意事項？

A: 若平常都用inhalor BID，則PFT四小時前開始不可用SABA、十二小時前開始不可用LABA、二十四小時前開始不可用LAMA。

Q: Spirometry 是測什麼？
A: (白話)測量深吸氣後大力、完整吐氣時，每個時間點的呼氣量。

↑ from wikipedia



Q: FVC減少、呼吸道阻塞時怎麼測？

A: 可以改測SVC(Slow exhalation)，但是如果是restrictive  lung則兩者的結果一樣爛。

 

Q: Spirometry的判讀流程？
A: 先看 FEV1/FVC, 再看DLCO。結果大致分三大種：較確定obstructive type的COPD、變異性較大的asthma、restrictive type的ILD/neuromuscular problem。 



↑from UpToDate



Q: Flow-volume loop的鑑別診斷用途？
A: 當聽到stridor的時候使用，能幫助辨別airway obstruction的部位。

from UpToDate

Q: Maximal respiratory pressures是什麼？
A: 經過有阻力的吹口大力吸氣 / 噘嘴吐力的最大壓力值。
 

* PFT tutorial website: https://depts.washington.edu/uwmedres/Library/eLearning/Pulmonary/

 Here are some notes from the website listed above:
 
- For obstructive pattern, the severity depends on...

	FEV1 > 80% predicted: mild obstruction
	50% < FEV1 < 80% predicted: moderate obstruction
	30% < FEV1 < 50% predicted: severe obstruction
	FEV1 < 30% predicted: very severe obstruction - For decrease DLCO, the severity depends on...      65% predicted < DLCO <80% predicted: Mild      50% < DLCO < 65% predicted: Moderate      DLCO < 50% predicted: Severe

- For reduced DLCO, the meaning is...

1. obstructive--> emphysematous, reduced surface area for gas exchange.
2. normal spirometry and lung volumes-->anemia, pulmonary hypertension, heart problem
3. restrictive -->idiopathic pulmonary fibrosis
4. Not equalled to hypoxemia!

Mind: diffuse alveolar hemorrhage的病人DLCO可能不降反升！
 
- For restrictive pattern, the severity depends on...

     65% < TLC < 80% predicted: mild restriction
     50% < TLC < 65% predicted: moderate restriction
     TLC < 50% predicted: severe restriction
 
- Characteristics of  idiopathic pulmonary fibrosis
    septal thickening
    traction bronchiectasis
    more prominent in the periphery of the lungs (sub-pleural regions)

 

- For mixed obstructive+ restrictive pattern, the severity depends on...
   
     FEV₁ > 80% predicted: mild
     50% < FEV₁ < 80% predicted: moderate
     30% < FEV₁ < 50% predicted: severe
     FEV₁ < 30% predicted: very severe  
 
 

實戰課題Medical Internship Topic 7: CXR案例判讀

* All pictures from https://radiopaedia.org, just for learning purpose

1. Atelectesia
- Displacement of fissure
- Bronchovascular crowding 
- Increase opacity
https://openi.nlm.nih.gov/detailedresult.php?img=PMC2823759_1752-1947-4-17-1&req=4

* Juxtaphrenic peak sign(peaked or tented appearance of a hemidiaphragm which can occur in the setting of lobar collapse): mostly upper lobe atelectasia


* Reverse S sign=Golden S sign: upper lobe atelectasia


* Luftsichel sign: LUL lung collapse

 
* Flat waist sign: LLL lung collapse
http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=28734&ti=86331&searchkey= 

* Paraesophageal line deviation, azygoesophagus recess
 
2. Hilar obstruction: DDx
- Sputum
- Tumor
- TB
- LN
 
 3 Lung lobules
http://slideplayer.com/slide/9428451/29/images/2/Lung+Unit+Acinus+:+That+
part+of+the+lung+supplied+by+a+terminal+bronchiolus.+This+includes+
respiratory+bronchioli,+alveolar+ducts,+and..jpg
 
4. Descriping lung lesions:
- Fluffy margin
- Early coalescence
- Alveologram
- Rapid timing(?)
 
5. Cryptococcus pneumonia
- Lower lungs, nodules, air bronchogram


 
6. Slow in progress nodules
- BAC( a kind of adenocarcinoma)
- Lymphoma
- Autoimmune related, inflammation
 
7. Describing lung nodules
- 2S: size, shape
- 3C: calcification, cavitation, contrast
- DOA: doubling time, density, other, area, age
- scalloped(lobulated), corona radiata, rabbit ears, rat tail sign, pleural tag sign, eccentric cavitation, thick wall(>16mm? ex: SCC with cavitation)
 
8. DDx of lung nodules/masses
- H: hema(spread by blood)
- I: infection
- I: inhalation
- N: neoplasm
 
9. Fungus ball: aspergiilus

 
10. Bronchogenic cyst: homogenous, smooth

 
11. Calcifications:
good signs- popcron(harmatoma), diffuse, laminated, central nidus
bad signs- eccentric, strippled
Ring- teratoma, thymogenic cyst
 
12. Congenital pulmonary airway malformations (multicystic, bronchial proliferation)

13. Lung sequestration
- Often triangular


14. Varicella pneumonia
- Fast
- Skin rashes, vesicles
- Calcification(+)
DDx: miliary TB


15. GGO
- Viral
- Clamydia
- Legionella
- Cryptococcus
- PJP

16. Proteinosis, PJP in AIDS
- Long term
- Crazy paving
- Reticular
DDx: PAS(+), milky BAL  in proteinosis

17. LAM(lymphangioleiomyomatosis)
- Penumothorax
- Chylothorax
- Young people

18. Thymoma
- Anterior mediastinum
- Calcification(-)

19. EMH (extramedullary hematopoiesis)
- Bilateral
- Paraspinal rib widening


20. Hilum overlay


21. Asbestosis (associated with mesothelioma)


22. Diaphragm hernia
Morgagni hernia: right, anterior
Bochdalek hernia: left, posterior
 

實戰課題Medical internship topic 6: Hyponatremia

Hyponatremia

1.      Def: <135mmol/L

2.      First DDx: rule out pseudo-hyponatremia

• Hypertonic: hyperglycemia?

Na在hyperglycemia時會降低，correct Na=Na + 1.4×(sugar－100)

• Isotonic : hyperlipidemia, hyperproteinemia?
• Another consideration: sample mixed with IV injection fluids?

3.      Hypotonic :

• Too much water? (beware of fluid retention)à do not give N/S, but restrict Na+ and water intake
• Not enough solutes? (beware of poor intake)à may give N/S

4.      Symptoms:

nausea and vomiting, headache, confusion, loss of energy and fatigue,

restlessness and irritability, muscle weakness, spasms or cramps, seizures, coma

5. Na supplement if needed

•  Rate of infusion is important
•  應補鈉總量（mmol）=[135-病人血Na+(mmol/L)]×體重(kg)×0.6~0.5
•  補鈉的速度不能超過4~6 mEq/L/hour，24 hrs內不能超過9 Eq/L

6. Monitoring

•   Urine output
•   Na recheck Q4H

神經內科Neurology note 1: stroke

Stroke

1. Categories

- ischemic: 4/5

• atherosclerosis of large vessels, RFs: HTN, DM, hyperlipidemia
• lacunar stroke at small vessels(<1.5 cm on CT), RFs: HTN, DM
• cardiogenic embolism(multiple, unusual, distal sites, RFs: valvular diseases, MI, arrhythmia, rheumatic, op hx 

- hemorrhagic: 1/5

2. Stenosis level

- severe stenosis: >70%

3. Stroke symptoms

- FAST: facial asymmetry, arm drop, slurred speech, time on onset

- motor: treat this part first!

- sensory

- consciousness, cognition etc.

* unspecific symmetric symptom: less likely due to stroke

4. NE:

pupil reflex: CN2 light sensation-->CN3 miosis

diplopia/nystygmus: CN3, CN4, CN6

http://emedicine.medscape.com/article/1214490-differential

temporalis m. strength: CN5

facial asymmetry and wrinkles on forehead: CN7

- central: wrinkle loss

- peripheral

uvula deviation: to the "good" side, CN9

tongue deviation: to the "bad" side, CN12

SCM power: CN11 (little value for localization of lesion)

Barbinski sign: null-->also abnormal!

http://epomedicine.com/clinical-medicine/pathological-reflexes-variations-of-babinski/

tendon reflex: hyper-->seek upper lesion
muscle power: check reaction to pain if patient's unconscious
gait/FNF/HKS/: cerebellar signs
speech:  eight types of aphasia

• can repeat: transcortical(sensory/motor/mixed)/anomic
• cannot repeat: Broca/Wernicke/conductive/global

5. Localization of lesion

http://www.slideshare.net/kurian3/localization-of-stroke-cvs-stroke-for-post-graduates

ICA territory: transient monocular blindness
ACA territory: leg > arm
MCA territory: face & arm > leg, aphasia(dominant side), apraxia&neglect (non-dominant side)
PCA territory: alexia w/o agraphia, macula sparing homonymous hemianopia
Vertebral/PICA
Basilar territory: pupil, longtract sign, CNS, cerebellar, lock-in
Cerebellar
Lacunar

6. Stroke management

- check cause of stroke( young stroke? underlying? )

- keep SBP<200 (or 220/120)in acute phase(14 days or less), SBP 140/90 afterwards

- hydration for 3~5 days
- Atorvastatin 80 mg if LDL >100, goal: LDL <70

- aspirin if no contraindications (GI discomfort-> shift to clopidogrel)

- consider NOAC (dabigatran, rivaroxaban, apixaban, edoxaban) or warfarin for AF patients according to histories and clinical symptoms

- rehabilitation, beware of choking

- tPA o.9mg/kg (max: 90mg) w/in 4.5 hrs if no contraindications(check NIHSS, stroke hx, BP, glucose, bleeding tendency etc.)
- Thrombectomy w/in 6 hrs
- CEA/ stenting if severe stenosis

7. TIA and subsequent stroke risk in one week: ABCD2 score, high risk:4↑
A: age(65↑)
B: BP (140/90↑)
C: clinical (weak  --> 2 points/ speech-->1 point)
D: duration (60 --> 2 points or 10~59 mins-->1 point)
D: DM

8. NIHSS/mRS evaluation
http://www.mdcalc.com/nih-stroke-scale-score-nihss/
http://www.mdcalc.com/modified-rankin-scale-neurologic-disability/

9. PFO and stroke: if 4mm↑, shunting at rest, aneurysm, septal mobility

# Good reference for interns in Taiwan: 
http://intm.vghtc.gov.tw/imd/ch/%E7%A5%9E%E7%B6%93%E5%85%A7%E7%A7%91%E5%B7%A5%E4%BD%9C%E6%89%8B%E5%86%8A.pdf

實戰課題Medical internship topic 5: Insulin_half life and mixed formula

 Insulin_half life and formula

1. Half life

Dr. József Tőzsér, Dr. Tamás Emri, Dr. Éva Csősz , Dr. József Tőzsér (2011) "Chapter 12. Production of human therapeutic proteins" Protein Biotechnology






2. Insulin formula
UCSF Diabetes Education Online: https://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-insulin-rx/designing-an-insulin-regimen/

3. Do not usually treat patients with insulin stimulation oral drugs if the patient is already insulin dependent

Repurposing Drugs to Target the Diabetes Epidemic Turner, Nigel et al. Trends in Pharmacological Sciences , Volume 37 , Issue 5 , 379 - 389

4. Last but not least, treating DM patients with CKD can be difficult.
This is a slide online about treatment in this scenerio.
http://www.slideshare.net/PraveenNagula/management-of-dm-in-ckd-8829991

腎臟科Nephrology random notes 02: Hypokalemia

Hypokalemia

1. K+ pool in body: 3500 mEq l (50 mmol/Kg), extracellular only 60~80 mEq

    Daily intake: 100 mEq

2. K+ balance:

- acute internal balance: transcellular; driving force (inward) including Na/K pump, Na/H exchange, beta 2 agonist, insulin, thyroid hormone

- chronic external balance: renal secretion ; K+ secretion = [K+ ]CCD x Flow rateCCD

- GI: (metabolic acidosis)diarrhea, laxative use, villous adenoma,  (metabolic alkalosis) NG drainage, vomiting

3. Definition 

- K+ <3.5 mEq/L in blood

- does no equal low K+ in sum 

4. Etiologies:

- Uk >30 mEq/ day, >15 mEq/L, TTKG>7 --> renal loss--> check BP, acid-base, Ucl

- Uk <25 mEq/ day, <15 mEq/L, TTKG<3 -->extrarenal loss

TTKG= (urine/plasma [K+ ])/(urine/plasma osmolality)

5.  Common manifestations
- Mild to moderate= 2.5~3.5 mEq, usually asymptomatic

- Arrhythmia ( U wave, QT interval↑, PVCs, VT, VF)

- Muscle cramps and weakness

- Polyuria

- n/v, ileus

- tendon reflex↓

6. Treatment

Lin SH, Halperin ML. Hypokalemia: a practical approach to diagnosis and its genetic basis. Curr Med Chem 2007; 14: 1551-65.
Kunin AS, Surawicz B, Sim EA. Decrease in serum potassium concentrations and appearance of cardiac arrhythmias during infusion of potassium with glucose in potassium-depleted patients. N Engl J Med 1962; 266: 228-33

↓ 1 mEq= 200 mEq total body loss
K+ 2.5~3.5 mEq↓: oral slow-K 40~100 mEq/day, no more than 20 mEq in one dose
K+ 2.5 mEq↓: IV K+ supplement, do not give over 40 mmol/L or 60 mmol/hour
Peripheral line: 20 mEq/L(max 40), 10 mEq/hr
Central line: 40 mEq/L(max 100), 20 mEq/hr~40mEq/hr

IV: DO NOT mix with dextrose solution metabolic acidosis:  use KHCO3, K+ citrate
metabolic alkalosis: use KCl
low phosphorous: use K+ phosphate

Potassium sparing diuretics: 
- amiloride
- triamterene
- spironolactone #1 BID or #2 QD with loop diuretics #1?

腎臟科Nephrology random notes 01

Nephrology random notes 01

1. Blood cells

- Hgb: RBC can remove NO in blood--> RBC infusion can elevate blood pressure

- Platelet decrease: cause-->drug?, infection? DIC? hematologic disease? autoimmune?

2. UTI

Urine analysis

           - pyuria+bacteriuria + symptoms?

           - no need to treat asymptomatic UTI in women except pregnant women 

           - check renal echo if UTI in men

           - Treatment:

                   *quinolone and Baktar not first line--> 

                    drug resistance carried by plasmids, save these drugs for MDR-TB; 

                   *Ceftriaxone has IM form for those who can not stay in the hospital for IV antibiotics

                   * yeast and candida--> can be viewed as normal colonies

                   * Proteus: may be related to stones

3. Proteinuria

- A/C ratio: DM, HTN patients wound check this.

- P/C ratio: generalized protein loss

4. BUN/Cr↑ (pre-renal azotemia) causes

- Breakdown: GI bleeding (RBC), trauma

- Sepsis

- High protein diet

- Steroid use

BUN↓ : may be related to liver function ↓

5. Oliguria----->AKI?

- Pre-renal: try hydration, but beware of heart, kidney, liver function, allergy

- Post-renal: try Foley tube insertion, DDx: stone, malignancy, BPH

- Renal: drug induced? use lasix

6. Skin turgor evaluation spots

- Axillary region

- Inguinal region

7. Diet and CKD in Taiwan

- Avoid: carambole , kiwi fruit, melons, papayas, brown rice, anchovy, salty soup

8.Shortness of breath

- Hypoxia: A/a gradient abnormal, ex. pulmonary edema(CO2 more soluable than O2)

- CO2 retention with muscle fatigue, ex. asthma, COPD

9. ABG/VBG in SOB patients with CKD

- Do not count anion gap because we still cannot differentiate whether metabolic acidosis is caused by infection or renal diseases

- RTA narrowly defined: RTA with normal Cr.

10.  Dialysis

- lung edema: refractory to diuretics

- pericarditis

-K+↑, EKG change(+), fail medical treatment (Cr high-->protect heeart, may not have EKG abnormality; can double-check K+ level if doubting hemolysis) 

- Uremia

- Intoxication: Ca2+, acylovir,aminophylline ,Benzodiazepam(x), with smaller molecular and less protein binding ability

- Elective: acidosis, anemia

- Uremic encephalopathy diagnosed by rule out, DDx: CVA, stroke, sepsis (BP drop after dialysis!)

High Cr without symptoms: This is a strong person ! XD

11. Spider angioma

- Estrogen↑ --> central arteriole, peripheral capillaries--> on liver cirrhosis 

12. Else

-  Imipenem: may induce seizure

-  Cardiac echo: IVS--> septum thickness, LVPW--> left ventricle thickness, concentric hypertrophy--> HTN related