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62 Cards in this Set
- Front
- Back
What are the diagnostic features of acute bacterial sinusitis that distinguish it from the common cold?
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Rhinosinusitis symptoms lasting 7+ days and:
- purulent nasal discharge - maxillary tooth or facial pain - unilateral maxillary sinus tenderness - worsening symptoms after initial improvement |
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What is the treatment for chronic bacterial sinusitis (> 3 months of symptoms)?
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Combined therapy:
- Oral steroids - Oral antibiotics (3-6 weeks of Augmentin or clindamycin) - Intranasal saline irrigation - Intranasal steroids indefinitely - If underlying allergies: antihistamines, antileukotrienes, and/or allergen immunotherapy - If nasal polyps refractory to steroids: surgical debulking - If allergic fungal sinusitis: sinus surgery -> prolonged steroids |
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What are the potential complications of sinusitis?
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Meningitis
Abscess formation Orbital infection Osteomyelitis |
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What are the most common causes of pneumonia in newborns?
What is the empiric treatment? |
GBS > Gram negative coliforms (i.e. E. coli), Listeria, Chlamydia trachomatis
Ampicillin + Gentamycin +/- Vancomycin (if MRSA is a concern) Use Erythromycin for Chlamydia |
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What are the most common causes of pneumonia in infants aged 1-4 months?
What is the empiric treatment? |
RSV, Chlamydia trachomatis, Parainfluenza, Bordetella, Strep pneumo, Staph. aureus
Macrolide (Erythromycin or Azithromycin) +/- cefotaxime |
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What are the most common causes of pneumonia in infants aged 4 months - 4 years?
What is the empiric treatment? |
RSV or other virus, Strep pneumo, H. flu, Mycoplasma, Staph aureus
Amoxicillin or Ampicillin |
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What are the most common causes of pneumonia in infants aged 5-15 years?
What is the empiric treatment? |
Strep pneumo > Mycoplasma, C. pneumoniae, other viruses
1) Amoxicillin + Clarithromycin (or Erythromycin) 2) Azithromycin 3) Amoxicillin + Doxycycline |
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What are the indications for pneumococcal vaccination in adults?
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- 65 years old or older
- serious long-term health problem (Heart disease, sickle cell, alcoholism, lung disease, DM, cirrhosis) - Resistance to infection is lowered due to Hodgkin's, multiple myeloma, cancer treatment, long-term steroid use, bone marrow or organ transplant, HIV/AIDS, lymphoma or other cancers, nephrotic syndrome, spleen pathology - Alaskan native or certain Native American groups |
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What X-ray and lab findings would lead you to highly suspect PCP pneumonia as a cause of respiratory distress?
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- CXR: diffuse, bilateral, interstitial infiltrates (most common finding)
- CD4 usually < 200 - LDH level usually > 220 (and a rising LDH despite appropriate treatment portends a poor prognosis) |
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What is the treatment for PCP?
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21 days of antibiotics
- TMP-SMX - Pentamidine - Trimetrexate + leucovorin - Primaquine + Clindamycin If moderate-severe disease (PaO2 < 70 mmHg, or A-a > 35) -> Hospitalize + Prednisone |
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What is the differential diagnosis for ground-glass opacities (diffuse hazy infiltrate) of the lung on CXR?
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PCP
Interstitial pneumonia Pulmonary edema Pulmonary hemorrhage Hypersensitivity pneumonitis |
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What infectious agent fits the following description?
- Common cause of pneumonia in immunocompromised patients - Most common cause of atypical/walking pneumonia - Common causative agent for pneumonia in alcoholics - Can cause an interstitial pneumonia in bird handlers - Often the cause of pneumonia in a pt with a history of exposure to bats and bat droppings - Often the cause of pneumonia in a patient who has recently visited Southern California, New Mexico, or West Texas |
Common cause of pneumonia in immunocompromised patients
- PCP Most common cause of atypical/walking pneumonia - Mycoplasma pneumoniea Common causative agent for pneumonia in alcoholics - Klebsiella Can cause an interstitial pneumonia in bird handlers - Chlamydia psittaci Often the cause of pneumonia in a pt with a history of exposure to bats and bat droppings - Histoplasma capsulatum Often the cause of pneumonia in a patient who has recently visited Southern California, New Mexico, or West Texas - Coccidioides |
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What infectious agents fits the following description?
- Pneumonia associated with "currant jelly" sputum - Q fever - A/w pneumonia acquired from air conditioners - Most common cause of pneumonia in children 1 year old or younger - Most common cause of pneumonia in the neonate (B-28d) - Most common cause of pneumonia in children and young adults (including college students, military recruits, and prison inmates) |
Pneumonia associated with "currant jelly" sputum
- Klebsiella Q fever - Coxiella burnettsi A/w pneumonia acquired from air conditioners - Legionella Most common cause of pneumonia in children 1 year old or younger - RSV Most common cause of pneumonia in the neonate (B-28d) - GBS Most common cause of pneumonia in children and young adults (including college students, military recruits, and prison inmates) - Mycoplasma |
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Which infectious agent fits the following description?
- Common cause of pneumonia in pts with other health problems - Most common cause of viral pneumonia - Causes a wool-sorter's disease (a life-threatening pneumonia) - Common bacterial cause of COPD exacerbation - Common pneumonia in ventilator pts and those with cystic fibrosis - Pontiac fever |
Common cause of pneumonia in pts with other health problems
- Klebsiella Most common cause of viral pneumonia - RSV Causes a wool-sorter's disease (a life-threatening pneumonia) - Bacillus anthracis Common bacterial cause of COPD exacerbation - Hemophilus influenza Common pneumonia in ventilator pts and those with cystic fibrosis - Pseudomonas Pontiac fever - Legionella |
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What infectious agent is the cause of pneumonia based on the following lab test?
- Gram + cocci in clusters - Gram + cocci in pairs - Gram - rods in 80 y/o - Gram + cocci in neonates - Gram - rods in neonates |
Gram + cocci in clusters
- Staphylococcus Gram + cocci in pairs - Streptococcus Gram - rods in 80 y/o - E. coli Gram + cocci in neonates - GBS Gram - rods in neonates - E. coli |
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How is the diagnosis of active TB made?
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TB organisms seen in any of the following is sufficient for a diagnosis:
- Sputum acid fast stain - if seen in any of 3 samples obtained over 3 days in early AM - Sputum culture for TB (takes 1-8 weeks) - Bronchoscopy with bronchoalveolar lavage or biopsy |
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What treatments are available when managing a patient with Acute Respiratory Distress Syndrome (ARDS)?
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- Treat underlying disease
- Supportive care in ICU - Mechanical ventilation with low tidal volumes and adequate PEEP - Conservative fluid management to reduce pulmonary edema. Goal CVP 4-6 H20. - Prone positioning - Minimize oxygen consumption: prevent fever, minimize anxiety and pain, limit respiratory muscle use (paralytics) - Transfuse blood only if Hb < 7 g/dL (transfusion increases risk of death) |
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In a patient with pulmonary edema, how can pulmonary capillary wedge pressure (PCWP) distinguish a diagnosis of ARDS from cardiogenic edema?
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Normal range: 2-15 mmHg
ARDS has normal PCWP, cardiogenic edema has elevated PCWP. |
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What are the diagnostic characteristics of ARDS?
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- PCWP < 18 mmHg
- Bilateral pulmonary infiltrates consistent with pulmonary edema - PaO2/FiO2 < 200 mmHg - No evidence of cardiac origin |
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What is the differential diagnosis of ground-glass infiltrates on CXR?
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PCP
Pulmonary edema (ie. ARDS) Interstitial pneumonia Pulmonary hemorrhage Hypersensitivity pneumonitis (methotrexate) |
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What is considered a positive TB skin test in an immunocompromised patient?
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5 mm = positive for immunocompromised
10 mm = positive for those are risk for exposure 15 mm = always positive |
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What is a normal A-a gradient? What causes a high A-a gradient?
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Normal A-a gradient = 5-15 mmHg
High A-a gradient: PE Pulmonary Edema (ARDS) Right-to-left shunt High inspired oxygen content |
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What are the signs of peritonsillar abscess?
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- Uvula deviation away from abscess
- Difficulty opening mouth - Muffled "hot potato" voice |
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What is the empiric treatment for pneumonia in a 2 month-old? In a 2-year old?
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2 month old:
Macrolide (Erythromycin) 2 year old: Ampicillin or Amoxicillin |
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What is the treatment for atypical pneumonia?
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Macrolide (Erythromycin or Azithromycin)
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What is the next step in the work-up of a patient with a solitary pulmonary nodule?
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Compare with prior X-rays
If no prior X-rays, CT scan |
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What is the clinical definition of chronic bronchitis?
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Cough and sputum production for at least 3 months, for 2 years.
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At what point do patients with chronic COPD qualify for home O2?
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O2 Sat ≤ 88%
Pulmonary Hypertension Peripheral edema Polycythemia |
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What type of lung cancer is associated with the following paraneoplastic syndrome?
- Elevated ACTH -> Glucocorticoid excess -> Cushing syndrome - Elevated PTH related peptide -> Hypercalcemia - Elevated ADH -> SIADH -> Hyponatremia - Antibodies to presynaptic Ca channels -> Lambert-Eaton syndrome |
Elevated ACTH -> Glucocorticoid excess -> Cushing syndrome
- Small cell Elevated PTH related peptide -> Hypercalcemia - Squamous cell Elevated ADH -> SIADH -> Hyponatremia - Small cell Antibodies to presynaptic Ca channels -> Lambert-Eaton syndrome - Small cell |
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What is the initial treatment for small cell lung cancer?
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Start with chemotherapy
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What is the initial treatment of a localized non-small cell lung cancer?
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Surgical resection
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What findings make a solitary pulmonary nodule more likely to be malignant?
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Smoker
Age > 45 New or progressing lesion No calcifications or irregular calcifications > 2cm or irregular margins |
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What defines mild persistent asthma? What is the outpatient management for this asthma severity?
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Mild persistent asthma:
Symptoms occur > 2 times/week (daytime), nocturnal awakening > every 2 weeks Albuterol + Inhaled low dose steroid Possible Cromolyn or montelukast added to regimen |
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What are the classical radiological findings in idiopathic pulmonary fibrosis?
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Ground-glass appearance
Honey-comb appearance |
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What is the treatment for idiopathic pulmonary fibrosis?
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Steroids + Azathioprine (or Cyclophosphamide) + N-acetylcysteine
Lung transplant |
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Which type of pneumoconiosis matches the following description?
- Progressive fibrosis - Increased risk of TB - A/w working with electronics -> increased cancer risk - Malignant mesothelioma and bronchogenic carcinoma |
Progressive fibrosis
- Silicosis, Coal worker's Increased risk of TB - Silicosis A/w working with electronics -> increased cancer risk - Berylliosis Malignant mesothelioma and bronchogenic carcinoma - Asbestosis |
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A patient chronically has an FEV1 of 40%. What medications are used in the daily management?
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This is stage 3 COPD
Long acting and short acting bronchodilators + inhaled corticosteroids + risk factor reduction + annual influenza vaccine |
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Patient with chronic sinusitis + hemoptysis + hematuria. What is the treatment?
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Wegener's granulomatosis
Cytotoxic therapy (e.g. cyclophosphamide), corticosteroids |
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Patient with anti-glomerular basement membrane antibodies. What is the treatment?
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Goodpasture's syndrome
Plasmapharesis to remove auto-antibodies; corticosteroids and immunosuppressive agents |
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A smoker has rapid onset JVD, facial swelling, and altered mental status. What is the treatment?
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Superior Vena Cava syndrome
High dose steroids Endovascular stenting |
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What is the treatment for obstructive sleep apnea?
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- Weight loss if overweight or obese
- Avoidance of alcohol and other CNS depressants or sedatives - Continuous positive air-way pressure (CPAP) at night - first line - Oral appliance to protrude the mandible forward or prevent posterior tongue displacement - Modafinil for excessive daytime sleepiness - Surgical options: Tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty (UPPP), genioglossus advancement, maxillary-mandibular advancement |
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What is the treatment for croup? What are the indications for hospitalization?
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ER Treatment
- Humidified oxygen mask - Racemic epinephrine - Dexamethasone, prednisone Admission criteria: Hypoxia/cyanosis, respiratory distress, toxic appearance, depressed mentation, progressive stridor or stridor at rest, no improvement 5 hours after steroids Home treatment: cool mist humidifier (esp. at night), however no proven benefit |
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What is the treatment for RSV bronchiolitis?
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- Supportive care such as O2 and IV fluids as needed
- Albuterol nebulizers or racemic epinephrine - Steroids are NOT effective in bronchiolitis - Ribavirin use in children is controversial, generally not used - Hospitalize if: toxic appearing, poor feeding, dehydration, respiratory distress, apnea, hypoxemia (<95%) |
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What chest x-ray characteristics distinguish neonatal respiratory distress syndrome from transient tachypnea of the newborn?
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RDS: low lung volumes, diffuse ground-glass appearance with air-bronchogram
TTN: increased lung volumes with flattening of the diaphragms, prominent vascular markings from the hilum (sunburst pattern), fluid streaking in interlobular fissures, +/- pleural effusions. |
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What is the treatment for neonatal respiratory distress syndrome?
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- Surfactant administration (from porcine or bovine sources)
- CPAP or intubation and mechanical ventilation |
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How is cystic fibrosis diagnosed?
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- Sweat chloride test: sweat chloride concentration > 60 mEq/L on two or more occasions
- Genetic testing for CFTR gene mutations (identifies 90% of CF cases) - Nasal transepithelial chloride secretion |
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What are the general strategies for treating the pulmonary component of cystic fibrosis?
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- Beta-2 agonist
- DNase I to decrease sputum viscosity - Hypertonic saline for chronic cough - Physiotherapy (aerobic exercise) for increased mucus clearance - Azithromycin used liberally when lung function decreases in order to slow the decline in lung function and treat any Pseudomonas aeruginosa infections |
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What substances should be avoided in patients with obstructive sleep apnea?
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Sedatives: benzos, alcohol, anti-histamines
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Shortly after birth a child has stridor, wheezing, and shortness of breath despite medical therapies. What is likely to be causing this patient's symptoms?
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Vascular ring compromising the upper airway and trachea
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What are the general strategies for treating the pulmonary component of cystic fibrosis?
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- Beta-2 agonists
- DNase I - Hypertonic saline - Physiotherapy - Azithromycin |
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What sweat test finding is diagnostic of cystic fibrosis?
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Sweat chloride concentration > 60
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What is the treatment for epiglottitis?
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Minimize anxiety
Antibiotics Intubation |
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What is the treatment for croup?
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O2
Steroids Racemic epinephrine |
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Trauma patient in respiratory distress -> CXR shows pleural effusion -> What is the next step in the management of this patient?
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Hemothorax
Place chest tube |
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What might cause a transudate pleural effusion?
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CHF, Cirrhosis, nephrotic syndrome
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What size pneumothorax requires a chest tube placement?
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Larger than 15%
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What medication is used prior to intubation in head injury patients?
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Lidocaine
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What Xray finding is indicative of croup? What xray finding is indicative of epiglottitis?
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Croup: Steeple sign
Epiglottitis: Thumb sign |
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What is the treatment for RSV bronchiolitis?
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Oxygen
Albuterol or epinephrine |
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What lecithin/sphingomyelin ratio indicates fetal lung maturity?
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> 2.0
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What is the classic (but rare) EKG finding in pulmonary embolism?
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S1Q3T3
Wide S in lead 1 Large Q and inverted T in lead 3 |
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What is the typical CXR appearance of newborn respiratory distress syndrome?
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Low lung volumes
Diffuse ground-glass appearance with air-bronchograms |