5645 Exam 3 Review

Added: 2026-05-28

[00:00:01]hi this is Christy day and I wanted to take a few minutes to go over the pulmonary part one with you uh I I met with the students last evening and my recording didn't work so I'm going to re-record today if you look at the topical outline you will see at the top these that you see on every topical outline that tells you what you need to know about each of the problems listed below and I know we kind of get used to looking at this but it really is important because these are your learning objectives these are the things you need you'll want to think of each problem in terms of primary care and and at what stage do you do you refer some of the problems you will refer immediately some of the problems you will refer at diagnosis as soon as you figure out what's going on you're going to switch straight to referral or hospitalization so but there are problems that you will manage in primary care only so think of the differences there is it is it when do I refer and do I do any management and then there are times for example in um when you have somebody with uh pneumonia or um lung cancer that you would have co-management let's talk about acute bronchitis first acute bronchitis should be able to you should be able to manage all the way from uh 1 to 11 and and let's look at what we what we have in here okay with bronchitis we know that most most of the cases of bronchitis are caused by a virus influenza A and B par influenza respiratory sensial virus adenovirus rhinovirus things like that about 10% of the cases are bacterial so that tells you you know that an antibiotic treats bacteria and not virus so all the recommendations strongly urge practitioners to not use antibiotics for acute bronchitis unless there's something else going on a secondary infection suspicion for a bacterial infection uh those type of things so we know and also you'll hear all kinds of different um time frames for the cough and you sometimes you hear two weeks they'll call for two weeks sometimes you'll hear up to four weeks and and so what what you want to do is just know that they're going to cough for quite a while okay and I don't think anybody's going to ask you exactly the amount of time they'll cough but that's going to be the the chief uh reason that brings them into the clinic usually is the a cough and then you'll have people that have bronchitis and also have asthma or try to differentiate between the two so the difference is is that a cute bronchitis uh the cough you know they don't have an underlying problem they don't have recurrent respiratory problems they don't have um uh uh asthma likee symptoms for throughout the year they have a a they get a virus they get the symptoms of bronchitis which may be um pain in the chest burning in the chest and um to and it's self-limiting they they may get Airway hyper respon iess during a a bronchitis but usually they're pretty healthy and they don't have any underlying Asma um in asthma what they'll have is recurrent lower respiratory symptoms and if they get a a virus or or a um a or a bacterial infection if you H if they have asthma they it may you know go into their chest so to speak and they may and hyperresponsiveness and trigger asthma like symptoms too now in bronchitis you're going to have um exodites you can have exit dates and an asthma you can have exit dates in bronchitis you may hear some wheezing and in asthma you can hear some wheezing so just keep in mind that they sometimes will look very similar but you're going to look for that underlying problem okay and uh and in people under the age of 5 years old and less than two we see adenovirus is the main uh organism uh for from 2 to 5 we see RSV and Par influenza in ages 2 to 5 and you know in adults will get RSV too and older people get RSV but in little babies and little children they get the bronchiolitis associated with RSV uh because of uh the small Airways that they have whereas adults they get the bronchiolitis but it doesn't uh cause usually any kind of respiratory distress in adolescence and adults it's usually viral 5% is um micoplasma pneumonia pneumonia and 5% is a chilia pum pneumonia so they they say cough lasts more than 14 days then you're going to consider pressus okay so in an upper respiratory infection when somebody has an upper respiratory infection without acute bronchitis they usually have a cough for about 5 days but a bronchitis cough is usually 10 to 20 days and may last up to four four weeks and what about purulent sputum is purulent sputum an indication of a bacterial infection um no it's not purin spe speedum alone is not an indication for antibiotic prescription and uh antibiotics are not recommended an uncomplicated acute bronchitis regardless of the duration of cough so it's not going to help uh routine antibiotics are not warranted this is from the American College of Physicians the American College of Chess Physicians and the CDC getsmart c campaign so everybody's telling us no antibiotics and they're indicated only in association with s aitis or heavy growth on throat culture um if there's a reason to suspect a bacterial in infection and the and usually the management of cute bronchitis is symptomatic okay so let's see what up to dat says here and up to date goes through some of the things that we just talked about as far as the the um bacterial versus viral and the clinical features talking about what you're going to see chest x-ray usually doesn't show anything and diagnosis is made usually on a clinical uh clinical exam and history and physical and usually there's no testing involved if there's any suspicion of pneumonia go ahead and and get a chest x-ray just to rule out your to zero in on your diagnosis sputum cultures not recommend Ed um I I haven't seen this prob calcitonin used much maybe y'all have seen that I haven't seen it so but this is interesting and then your differentials are there and treatment is symptomatic and some uh from what I read is that um Bronco dilators um help in those people with any kind of chronic problem or hyperreactivity during the BR bronchitis with a short acting bronchodilator um sometimes oral corticosteroids will be effective um those types of things let's see what um up does up to date says now I'm I also have read that that IDs sometimes are effective for that cough um but I'm I'm not sure if we're reading we're going to read that here okay there it is at the bottom we do not recommend treating bronchitis uh with antibiotics symptomatic treatment may include non-steroidal anti-inflammatory drugs as aspirin acetominophen epot tropanes uh antitussives but um you'll want to use those mainly at night you know if they're keeping them up and things and uh because if it's productive cough you'll want them to kind of get everything out you want them to to produce that sputum and and and get it now an indication for antibiotics in in somebody with acute bronchitis is if they have another problem you know they can have acute bronchitis in the presence of you know a throat culture with a you know strep strep on it or or they can have an acute sinusitis that you decide that you want to treat with antibiotics or they could have a pneumonia um and then that's a different diagnosis you're not treating acute bronchitis with a with a antibiotic you're treating those other problems as indicated with an antibio okay so let's let's move on to asthma and what I wanted to do is is give you a chance to apply some of the asthma guidelines that you you've been learning and there's several asthma resources that I wanted to point out to you uh they they're they're they're available and I know in your readings you've seen some of this stuff but I wanted you to kind of see them uh we have an asthma control test I think that the um the top score is um 25 and there's ways to interpret this um we'll have to look at at what it means you can see here that there is a there's a a paper version of it too I've seen ones with little dots in here we have an asthma Journal these are all uh these are all resources for patients and an asthma action plan and this is the usually green yellow and red and I kind of like this one better than another one I'm going to show you uh that's more of landscape this is a portrait and that kind of makes a little bit more sense to me and then you can also print the test right here so the asthma.com is a is a good is a good resource for all of these documents that you want to look at and it says if your score is less than 19 um you're not as well controlled as you want to be so if somebody's at 20 they're okay so remember that okay another resource you want to look at is um they have a child a child version where it has also where it has um little faces on it and uh a lot of times you know the adult is going to be giving the information but you can also print this one and it comes out with your faces which is kind of cute a stepwise approach to asthma I know that you're you've seen this all over the place it'll be an up to-date it'll be in your in your in your textbook it's it's based on the uh 20 2007 National asthma education prevention program expert panel and so those are still the most current guidelines and you will see these so um let so let's look at these a little bit intermittent asthma step one persistent asthma daily medication consult with asthma specialist is step four care or hire is required consider consultation at step three and what you what the reason you would want consultation is to both improve control and to uh maybe reduce the amount of medications so you'll want to look at these medications understand the classes you know I learn a few maybe the Prototype medication and and you'll want to be able to apply these guidelines so each step patient education environmental control and management of comorbidities so these are these are kind of comp Lex you know to me this is a very complex algorithm you've got you know you've got different medications but you're adding so if you look at step one which is intermittent asthma the recommended uh treatment is short acting inhaled uh beta Agonist which is the Saba which is albuterol but you'll also notice that right here it says quick relief medication for all patients so you're going to have the Saba as needed for in for symptoms and then it gives you some more information about that when you go to step two and the Saba is not listed look down here and it shows that Saba is needed for all levels okay for immediate okay so step two and and you're going to see the low dose inhaled cortical steroid so we're going to be adding that on or chromaline lucat Trine or these other medications remember theophine is an older medication it's often considered cheap but um it is in the same class as caffeine and so it has it has U those type of side effects with uh you know irritability U excitability maybe increased heart rate things like that also the offlin has a narrow therapeutic range and so you would have to do a blood levels and so that makes it changes it from a cheap medication to an expensive medication right way okay step three um you got the lowd dose inhal cortical steroids plus a long acting Bronco dilator this is this is the scale for for people over the age of 12 if you have people under the age of 12 this laa has a black box warning so you have to look at that or you can do a medium dose in inhale cortical steroid or some of these other medications down here step four is a medium do dose inhal corticosteroid Plus a long acting Bronco dilator and then you go on up to high dose with oral cortical steroids so step up if needed first check adherence environmental control and comorbid conditions there this is multifactorial we're going to look at asthma from several measurements of control we multiple measurements of control we're going to look at function daytime symptoms nighttime Awakenings use of the quick relief Saba patient report of self-control are they how are their activities are they missing work or school what is their lung function and utilization of Health Care Resources so there's a lot going on with asthma it's not it's multifactorial so the important thing is our assessment and remember that when you listen to somebody with asthma their lungs may sound fine exam the physical exam of the lung is not really a measure of their asthma control or their lung function okay so let's look at asthma severity this chart a little bit so your evaluation of the asthma and their current control and severity in lung function is is the most important thing that you're going to do and it's it's your diagnosis where is your patient and then that determines the steps so you have to go through all this up here before you can get down to going through those steps that we saw greater than 12 years and you can look at the one for less than 12 years and I recommend that you do and some people say this is the chart of twos a mild moderate severe symptoms you know how often nighttime Awakenings how often are they waking up sure how often are they using your their um saaba are they able to do their normal activities and then lung function and this is really important because something that puts people at risk for asthma exacerbation and death is is not having their their measures not having their lung function not doing their Peak flow meter or having pulmonary function testing other things that put them at risk are low so socioeconomic status elicit drug use psychosocial problems comorbidities but what I find interesting is that people that underestimate their symptoms or their level of at at risk for acute exacerbation and death you know how are they doing and do they know how they're doing are they are they what is their self-report of control and I find that uh that that's an important component because recognizing your level of control is super important to stepping up and that a asthma action plan allows the patient to step up you know they have the action to take and know when to step up to have better control you know asthma can change the lungs if it's if it's not treated properly it it can remodel the lungs and it can change the lung function permanently so we want to have really good control and measurement of lung function what you're want going to want to do is get spirometry or Peak flow meter uh measurements you want to have some objective measure of pulmonary function and if you look at pulmonary function testing what for asthma what you're really going to be looking at is the the you know uh fvc forced vital capacity and the fev1 which is the forced expiratory volume in 1 second so the so the fvc is if they take a huge breath blow it all out at one time which usually takes about 4 to 6 seconds and then also the f fe1 is in 1 second and then they they do a a they divide it they do math and they come up with a ratio and so that's what we're going to look at it's below normal or less than 7 then that's that's the cut off there is the 7 so if you think about uh pulmonary function testing sometimes you'll see on these spirometry results obstructive disease or restrictive disease and remember that when they do these do these tests what they'll do is they'll they'll treat with albuterol in the middle and see if there's any reversibility for one thing but also they'll put in the patient weight and and some data about them so that they can calculate these things properly and if you see the word obstructive disease then this is this is um the airway Airway obstruction in the in the uh bronchiole the obstructive disease air cannot get out so it's it's a mechanical problem it won't pass through that's obstructive there's it's a roadblock but in restrictive disease that's in the Alvi in that case you know sometimes the COPD you'll get consolidation down there and the Alvi you know you get consolidation and they can't be filled with air and so that's a called a restrictive disease the fvc is the how much total volume or in the Alvi and it's less than 80 is 80% is the uh less than predicted that's the cut off and then fev1 uh the cuto off is is 7 and that's how much air can be expelled in one exhaled in 1 second let's go back to our chart here and you can see that the chart continues down and you have intermittent mild moderate severe and and then you go down and it tells you the steps okay at the bottom you'll see the steps right in here and you follow those steps and what's important to remember is that you know this is a clinical judgment and if let's say you have a patient that goes back and forth between these two levels of persistence then you're going to take the highest level okay and it's a clinical judgment if there's no step consider oral systemic corticosteroids in 3 4 and five but if you look at the at the uh steps it doesn't say oral corticosteroids in any of these areas but remember it's a clinical judgment so you'll want to consider those oral steroids if they're needed if you if you're if you feel like you're having an acute exacerbation that needs that's going to need steroids then you're going to give them let's go on and and I want you to take a minute to practice this algorithm so you have a 19-year-old girl female Sarah she's seen in the office day because her asthma symptoms have been worse over the past few months with increased use of Albuterol inhaler Sarah's asthma treatment plan is consistent with which level of asthma severity what step is she being treated at how would you see that and and what additional information do you know need to know to determine these levels so go ahead and take a minute and look at the charts the asthma severity and also the algorithm and and see what are we treating her level of severity what do you need to know about that so I'm going to pause for a couple minutes and let you get your list together and then uh I'll be back okay so here's some information about our patient uh prior exacerbations yes she's been on oral steroids three times in the past year has she had any prior emergency visits or hospitalizations she answered no but she had Urgent Care visits for all of her exacerbations and that's where she receives most of her hair her health care uh poor a poorly controlled asthma yes she experiences asthma symptoms every day with more severe symptoms over the past two months how many times a week does Sarah use her short acting Bronco dilator uh has it increased yes she's using her Saba 4 to six times per day over the past two months she still feels some asthma symptoms even with her Saba use does she awaken at night yes she she awakens 3 to four nights per week and she uses her Saba when she awakens and usually she wakes up because of coughing do her symptoms interfere with her normal activities well sometimes she attends work in school but sometimes she avoids activities like dancing or riding or bike riding with her friends does she have a history of oral systemic corticosteroids yes three times in one year and what is her fe1 well she had no prior measurements but in the office today it's 58 % which is also when we asked uh asked her about her control she said well it's pretty good you know it's okay it's been a bad you know the past couple of months but you know it's okay it's not she's not in bad shape so but by her measures here and by her risk factors for uh acute exacerbations um and her and her current level of severity of asthma she is um not well controlled at all so based on this where is she on on the um severity chart let's take a look okay here we are and remember when patients bounce back and forth back and forth that means that we're going to go at the higher level so you can go through these take a look you know you should have this printed out as you're studying and figure out where she's at on here so uh you might find her in severe on many categories and that's probably where I would put her to and where is she being treated right now what level of control is she what level of control is she at uh what what level of control is she being treated at she's being treated right now what we're saying is that she has uh persistent asthma that is severe right and she's being treated as as if she has intermittent asthma okay okay so um she's not at the right level and what level are we treating her at we're probably going to go with step four or step five right and we also can consider oral corticosteroids so you can go through here and what I want you to do is I want you to look at the list of asthma medications of bronco dilators and I want you to kind of become familiar with with some names of long acting Bronco dilators and controlled in um in inhal corticosteroids and learn those names and the long acting Bronco dilators and the short acting Bronco dilators those type of things I want you to go through and and learn some names of those medications and also read in your uh in your pharmacology book about the other types of medications okay so you'll you'll determine her control and usually we want to see them back in about uh you know depending on your clinical judgment but at least um every uh four to six weeks for the you know during this period while we're while we're stepping up and and trying to get them under control okay so let's move on to chest pain or non-cardiac chest pain now we talked a lot about chest pain in our other course but what we want to look at now is we want to look at a diagnostic approach I'm what I'm looking at that you were assigned butaro and I'm for the ease in in looking at it we're going to go to um we're going to go to up toate and remember that up toate includes information from multiple resources it's kind of like when you write a paper and you look at everything out there you're going to look at all of the um what you can find on the results you know what you find about that topic and then you synthesize that information and and and make some recommendations and that's what up to-date does they have authors and they look at everything and so and and then they may report on everything so within an upto-date article you may get multiple guidelines but if you go to the but if you go to the original guidelines you're going to get one guideline and one recommendation but if you go to up to up to date you're going to get several so but as far as chest pain evaluation of um differential diagnosis of people with chest pain um you know when you look at chest pain what you're going to want to do is you're going to want to have a broad stroke you're going to want to really think about everything that could cause that chest pain don't zero in too quickly you know just be sure and and uh think of all the reasons whether it will be cardiac or non-cardiac chest pain okay so let's just what I'd like to do is just kind of go through some of the differentials and think about them um muscular skeletal pain what you're looking at is is uh usually like a strain a fracture costocondritis and this is reproducible you press on it and you can cause pain um we're going to look at um pulmonary causes pneumonia pneumonia usually has that classic kind of um when they when when they breathe in on one side of the other they have pain with inspiration and that you can you can have pain with pneumonia you can definitely have pain with a pneumothorax and Pulmonary embolism pulmonary pulmonary embolism they usually have a lot of shortness of breath with that um that they really have trouble even uh taking a breath pitic pain you can have asthma I don't know too many people that have asthma pain uh at ch pain with asthma but I guess it would be possible more like a chest tightness and then U there's also bronchitis people with bronchitis usually have um a burning sensation in their in their U main Bron bronchial and it be worse with the cough they'll feel it when they cough and then pulmonary hypertension so those are kind of some of the you have muscular skeletal you have pulmonary causes cardiac causes and then General other reason you might have chest pain like a malignancy shingles you know maybe anxiety depression type of thing U maybe a heightened visceral sensitivity they just feel a lot of stuff more than other people and may be drug induced it can also be uh GI ESOP it can be the gallbladder it can be uh esophageal pain esophageal spasms can be really painful and it can mimic mimic uh heart pain so just be sure that you have those uh those reasons on the radar for for non-cardiac chest pain you're going to you're going to want to know that in evaluating chest pain your history is absolutely the most history and physical or the most important thing in evaluating chest pain okay next we have a chronic cough so usually what you have in people with chronic bronchitis is is you have somebody that's a smoker and you know every morning they wake up and they've got a lot of sputum they're coughing and spitting and kind of clearing that sputum and that's kind of what you see and and they're they probably have uh COPD if you do your uh pulmonary function testing you would probably find COPD and probably but a lot of times these people are you know in their 50s with a cute with a chronic bronchitis they're in their 50s they're working they they don't perceive any change in function and uh but they have really good muscles and they're breathing well you know and and you may still see COPD changes on the X-ray with a flattened diaphragm things like that but and you may diagnose COPD spherometer on these patients so with a chronic cough you need to know the definition of that how long is the cough you know how often do they experience it it's usually not productive we usually have with just a a chronic cough without chronic bronchitis we usually don't have a lot of production so let let's look at what up to dat has to say about a chronic cough Subacute chronic cough is uh present longer than 3 weeks Subacute 3 to 8 weeks and chronic more than 8 weeks okay acute bronchitis I think is every day for 3 months 2 years in a row and so there's a little bit of a u a difference there and and then you have the different reasons for the chronic cough you can have like a post-nasal drip it can be asthma it can be reflux you know that refle the reflux comes up and it stimulates a CA respiratory tract infection ACE inhibitors uh bronchitis lung cancer there can be all kinds of reasons for that and you need to think about those so let's look at treatment and what you're going to do with the chronic cough is you're going to you're going to treat the underlying problem that's the main thing so you know whatever whatever is causing the problem you'll want to identify that and treat the treat the underlying problem problem the thing that's causing the the the cough there's different uh anti-tussive you know so you have de dextrorphan um cating the evidence is limited morphine you have these different um cough uh so just go ahead and look through those and but mainly you're going to identifying the underlying cause and be able to understand uh is this a chronic cough chronic bronchitis um acute problem those type of things okay COPD let's look at COPD now COPD I think is a little bit what I would say easier than uh than the uh asthma because the algorithm is so much uh easier to follow it's pretty straightforward and with with COPD what what we're going to do is we are going to want to prevent exacerbations that's the main thing exacerbations you know shorten their life basically so we have the gold standard and this for chronic obstructive disease and this is the everything in a easy to read document so it's got this type about across it and I think what you're supposed to do is you're supposed to buy and then but it's available for us to read on here indicators for considering a diagnosis of COPD so you look at these chronic cough and a history of exposure exposure to R risk factors tobacco smoke that occupational things um you'll look at those and spirometry is required to make a clinical diagnosis of COPD so when you have a patient that you suspect the COPD you need to get that spirometry and then uh that will below 70 and the on the ratio 7 uh is a diagnosis of COPD okay so then you're going to you're going to go and you're going to determine the uh level the classification of severity just like an asthma you want to classify your secur your your severity of airf flow limitation but when you think of asthma it's a reversible air airway problem and in COPD is not reversible so they have a the COPD assessment test the cat and the COPD questionnaire so some of those are used you're going to assess symptoms that way and then the modified brial British uh medical research Council scale it it talks about breathlessness so those are all included in in kind of the assessment of COPD so what you want to do is first look at the the air flow limitation and determine where they're at where they're are at with their ratio here okay and then you're going to assess risk of exacer ations have they had uh worsening symptoms what is their risk for an acute exacerbation and and how many have they had how many hospitalizations and then comorbidities going to look about what's going on with it do they have c h musle lung cancer any anything else along with the COPD so then you can go down to the rubric that that you put on their symptoms airflow exacerbations and then you're going to uh um uh get your combined assessment and you're going to grade your patient you're going to place them on one of these levels uh that is U you can follow the algorithm of of management so let's say your patient is at a level B then um based on their based on the the table there but COPD is a lot about meds so this is kind of turned over here and what you'll notice is you have the short acting anticholinergic and the short acting anticholinergic is a bronco dilator just like a short acting beta Agonist they they they work along two different Pathways and these anticholinergic uh Bronco dilators are essential to management of of the COPD and so we haven't really seen those on the asthma management so there's your difference but you're going to use an short acting anticholinergic or a short acting beta Agonist anytime you're adding in a short acting anticholinergic you're going to do one or the other so if our person is at level B then that is a long acting antic curl colonic or a long acting beta Agonist what they know is that patients like these long acting uh anticholinergics and beta Agonist because they last longer they they feel better longer and so they perceive them as working better with so what you'll see is you'll see a combination in the drugs you'll see a combination of a short acting anticholinergic with a long acting beta Agonist it's because they get that first um opening up and then they get the long acting so if they take the medication and say every six hours or then they're going to have a kind of a continuous Bronco dilation so those work really nicely and then you'll see in the uh on the inhal cortical steroids now you can go down and I know we've passed around a few charts on this you're going to want to learn some some of these names you know the extensions on short acting versus long acting uh beta Agonist they all entol so you need to kind of learn the the main ones like salmeterol for meterol those are long acting beta agonists and then uh albuterol uh for the short acting uh those are those are probably the the Prototype drugs that you want to remember also in the anticholinergics you're going to look at the epot Tropi versus the tiotropium those are kind of the prototypical drugs and I like really like this chart because it also has a solution for nebulizer here so it it not only does it give you the inhaler uh gives you the nebulizer availability so uh but what we know is is that when they take a an inhaled uh product uh an MDI inhaler versus a nebulizer they're going to get a lot more medication with the nebulizer they just it can be up to you know 10 times as much delivered so if you have somebody that's really you know that's got a problem using an MDI and they need education that's key but also um if they need a lot if they need a good amount of medicine and you want make sure they get it then you can use a nebulizer for a short period or or every day either one sometimes in older people we use them always do nebs because they uh uh they can't manage the MDI okay so that's basically it with with COPD you want to prevent exacerbations you want to do your education and you want to you know follow the algorithm assess their level of control their severity categorize them and then manage their care according to the algorithm so it's a lot of medication okay so now dis here's the up to-date on dnia and disia is actually a symptom and if you look at the icd10 coding it specifically says it's a symptom and so we can use that if we don't have a diagnosis we don't know uh what they are we're we're working up their their symptom you know we're looking for the use that and then you'll order your test related to related to what you're trying to rule in or rule out so sometimes when you're matching up your assessment plan you know my assessment I think it's COPD but I'm not sure but I know that they have dnia and I know that they have tobacco abuse so there's those two things and so under disia you can do you can use that as a as a um uh medical necessity to order your tests okay so you can see here heart failure anemia deconditioning um you can have cardiac problems respiratory problems there's all kinds of reasons so look at this again with a broad stroke and and see what you need to do and for your patient to work up and zero in on the reason for the dnia okay and then we have uh hemoptisis so you're going to want to look at the difference in u the ideology and evaluation of hemoptisis and adults remember that it's it's usually uh there's a difference between GI bleeding versus uh respiratory or pulmonary bleeding usually the GI bleeding is coffee ground a little darker and the the pulmonary bleeding is usually bright red and it can and have uh it can have some you know bubbles in it or or some foaming because of uh the the air but also think about you know bloody nose is things you know where is it actually coming from people don't always um they're not able to quantify the amount of blood but you know try massive hemoptisis I think anybody can kind of figure that one out and then look at the causes Airway you're going to look at uh bronchitis neoplasm forign body Airway trauma all kinds infections and uh just broad stroke if you look at the icd10 code for hemoptisis you'll see that this is a this is a a coughing or spitting up blood from the respiratory tra act and it's a finding you know you have to get to the underlying cause hemoptisis is like chest pain shortness of breath it's a it's a symptom a sign or a symptom that we need to find the underlying CA now we have obstructive sleep apnea so let's take a look at that you know that education is the is the key to management of obstructive sleep apnea we have lifestyle modifications to treat it sleep apnea is is a really serious problem because it it shortens lives and and look if your patient is you know having uh daytime sleepiness hypertension those things always ask about their sleep but you can see that education to change behaviors is the most important thing you can do weight loss and exercise sleep position alcohol avoidance all of those things that we do to help them you know medications can help um but the main state treatment is CPAP and youall know that and we also know that not that compliance with CPAP is very low um I personally have a a son-in-law who's about 35 that has sleep apnea obstructive sleep apnea and does not use a CPAP because it makes them look like an elephant he's embarrassed of it what can you do people are going to do what they're going to do so you know if they won't do the lifestyle modifications or you might do it at the same time you might do lifestyle modifications plus uh the CPAP so look at diagnosis on that and and education as far as smoking sensation know the nspf guidelines and when do we screen how do we get them to uh how do we encourage people to stop smoking should we encourage them to stop smoking those type of things what are the medications that we use you know you can use U I think wellb Trends one of them uh the vi pron and uh also chanics major side effect chance chanics is the nausea and then we're going to you know there's a pneumonic there for for assisting them to quit we want to assess their Readiness all those type of things you know sometimes patients will say I don't want to quit because I don't want to gain weight and they're right they they may gain weight because the tobacco suppresses the appetite so it's not just having something to put in their mouth oral stimulation and actually is a uh the tobacco suppresses their app appetite in a way it's on a neurological level so we'll want to see if they're ready to quit um set a date all of those things behavioral count counseling should just kind of know uh that you that you want to bring that up in what npst says about screening for tobacco use and that's how all I have for today I'm going to try to uh record something for part two to kind of give you a little direction for your studying and um thank you very much