CARDIOVASCULAR SYS ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ MURMURS Turbulent blood flow through great vessels or across a heart valve Timing of murmur – systole or diastole Location of murmur – aortic or mitral Systolic murmurs – MR Peyton Manning AS MVP o Mitral Regurgitation- 35yo 60 yrs. <150/90 ➢ Non-AA – thiazide or ACEI/ARB or CCB alone or in combination ➢ AA – thiazide or CCB alone or in combination ➢ CKD – ACEI or ARB alone or in combination with other class ➢ Maximize dose of 1st med or add 2nd med or start with combo drug. THIAZIDE DIURETICS ➢ MOA: ³ volume, venous pressure and preload ➢ Blacks get better results, associated with ED ➢ Favorable effect with osteoporosis or osteopenia ➢ High dose 25mg or more - potential for negative impact on glucose and dyslipidemia – hyperuricemia (gout), hyperglycemia ➢ Monitor Na+, K+, Mg++ depletion, calcium sparing (good for osteoporosis due to lower observed fx risk) ➢ HCTZ (contraindicated with sensitivity to sulfa drugs) ➢ ➢ ➢ ALPHA-1 BLOCKER <-OZIN= ➢ ➢ Used for BPH and HTN First dose may cause orthostatic hypotension, dizziness, postural hypotension ➢ Give at bedtime, start low, titrate up. ➢ Terazosin (Hytrin), Tamsulosin (Flomax) ➢ Carvedilol is both alpha/beta adrenergic antagonist ➢ ➢ ➢ ALDOSTERONE ANTAGONIST DIURETICS MOA: Systemic vasodilation, slows HR Most potent BP controlling med on the market o DHP (doesn’t hurt pulse) (³ BP): amlodipine o Non-DHP (³ HR and BP a little): diltiazem, verapamil st 1 line choice in African American HTN Causes headaches, ankle edema, bradycardia, reflex tachycardia DO NOT USE: heart block, bradycardia, CHF Avoid grapefruit, macrolides Work better at night ➢ MOA: blocks aldosterone so ±elimination of Na+ and H20 in kidneys to conserve K+ ➢ Used for HTN, CHF, hirsutism, precocious puberty ➢ Adverse effect: Gynecomastia, hyperkalemia ➢ Avoid w/ potassium-sparing diuretics, ACEI or K+ supplements, renal insufficiency, DM2 w/ microalbumin ➢ Spironolactone (Aldactone) Eplerenone (Inspra) ➢ ➢ ➢ ECG in therapeutic: prolonged PR, depressed, cupped ST segment ECG with toxicity: AV heart block Patients with toxicity have anorexia Drug interactions: amiodarone, diltiazem, macrolides, antifungals, cyclosporine and verapamil BETA-BLOCKERS – <-OLOL= MOA: block beta1 receptors in heart Lowers heart rate and stroke volume Monitor for worsening asthma, COPD DO NOT USE: heart block, bradycardia USE: MI, migraines, glaucoma, resting tachycardia, angina, hyperthyroidism Whites get better systolic control than blacks – 4th line anti-HTN med Used more for heart failure and not BP Reduces effects of circulating catecholamines ACEI <-pril= or ARB <-sartan= ➢ ➢ ➢ ➢ ➢ ➢ LOOP DIURETICS Furosemide (Lasix) Bumetanide (Bumex) Inhibits sodium-potassium-chloride pump of kidneys (± UO) ➢ Electrolyte imbalance, hypokalemia, hyponatremia, hypomagnesemia ➢ ➢ ➢ MOA: Block conversion of angiotensin I ² II 1st choice in HTN with DM or renal disease Dry hacking cough, (more w/ACEI), hyperkalemia, angioedema Adjust dose in renal insufficiency AVOID in pregnancy, renal artery stenosis, acute renal insufficiency CARDIOVASCULAR SYS DYSLIPIDEMIA ➢ ➢ ➢ ➢ Screening and detection o Lipid profile in those with cardiovascular risk (DM, HTN, strong family hx and obesity) o 12 hours fasting ▪ Total cholesterol (TC) ▪ Low-density lipoprotein (LDL) ▪ High-density lipoprotein (HDL) ▪ Triglycerides (TC) Dietary options to ³ LDL (5-10%) o Plant sterols – Take Control/Benecol margarine o Oatmeal, oat bran Reduce intake of saturated fat and cholesterol o Avoid trans fat o Total cholesterol < 200 Increase omega-2 fatty acids o Fish twice a week o Flaxseed, walnut, canola and soybean oils o If CHD, take 1-gram EPA + DHA (salmon 4oz daily or fish oil supplement use) High-intensity Avoid in >80, impaired renal function, frailty, multiple comorbidities, with fibrate LDL reduction 50% Moderate-intensity Preferred if high risk for adverse effects Low-intensity Not recommended LDL reduction 30LDL reduction 49% <30% Atorvastatin 40-80 Atorvastatin 10-20 Pravastatin 10-20 Rosuvastatin 20-40 Rosuvastatin 5-10 Lovastatin 20 Simvastatin 20-40 Simvastatin 10 Pravastatin 40-80 Lovastatin 40 ASCVD – high intensity LDL > 190 – high intensity Diabetes – moderate intensity 10 yr. ASCVD risk > 7.5% - moderate to high intensity **Not enough data of benefit > 75 Take at night with baby ASA ➢ BMI – ratio of weight to height o Weight (kilograms)/height (meters) o Muscular patients can have falsely elevated BMI ➢ Underweight < 18.5 ➢ Normal 18.5 to 24.9 ➢ Overweight BMI 25 to 29.9 ➢ Obese BMI > 30 o Male: waist circumference: >40 inches o Female: waist circumference: >35 o Waist-to-hip: 1.0 (males) o Waist-to-hip: 0.8 (females) ➢ Diagnosing metabolic syndrome o 3 characteristics: abd. obesity (weight circumference), HTN, hyperlipidemia or ± triglycerides and ³ HDL (insulin insensitivity), fasting glucose > 100 or dx diabetes ³ LDL 18-55% ± HDL 5-15% ³ TG 7-30% Baseline hepatic enzymes – no further monitoring required Avoid grapefruit juice with simvastatin, atorvastatin, lovastatin Adverse effects: rhabdomyolysis, myositis • Risk factors for myositis (advanced age, low body weight and high-intensity statin therapy) NIACIN ³ LDL 5-25% ± HDL 15-35% ³ TG 20 -50% Adverse effect: flushing (minimize by taking ASA 1-hour prior), hyperglycemia, hyperuricemia, upper GI distress, hepatotoxic ³ LDL 5-20% ± HDL 10 -20% ³ TG 20 -50% Can cause ± in LDL with high TG Adverse effect: dyspepsia, gallstones, myopathy, do not use in severe renal/hepatic Ex: fenofibrate 4 gram/day ³ TG 20 -30% Adverse effect: ± risk of bleeding, GI upset due to fishy taste – freeze capsules, take with food, avoid hot beverages immediately after SECONDARY HYPERTRIGLYCERIDEMIA Untreated/undertreated hypothyroidism Poorly controlled diabetes Excessive alcohol use SELECTIVE CHOLESTEROL ABSORPTION INHIBITOR ³ LDL 15-30% ± HDL 3-5% ±TG if > 400 Examples: cholestyramine, colestipol, colesevelam Adverse effects: constipation, ³ absorption of other meds ³ LDL 15-20% ± HDL 3-5% Examples: ezetimibe (Zetia) Generally used as add-on (Vytorin) CARDIOVASCULAR SYS Name Acute Coronary Syndrome: (STEMI, NSTEMI and unstable angina) Cause Unstable angina: vasoconstriction, nonocclusive thrombus, inflammation or infection Signs/Symptoms Midsternal chest pain, squeezing, tightness, crushing, heavy pressure, band-like, numbness/tingling left jaw/arm, diaphoresis w/ cool/clammy skin. Pain is provoked by eating heavy meal or exercise. Continues to have pain or discomfort at rest; Women present with fatigue, sleep disturbance, dyspnea, anxiety, weakness, back pain, nausea, syncope Lungs have crackles bibasilar and S3 heart sound Crackles, cough, dyspnea, dullness to percussion, paroxysmal nocturnal dyspnea, orthopnea, nonproductive cough and wheezing (20 mm/h Abdominal ultrasound Incidentally: CXR may show widened mediastinum, tracheal deviation, obliteration of aortic knob Cardiac Arrhythmias Atrial Fib Risk factors: HTN, CAD, ACS, caffeine, nicotine, hyperthyroidism, alcohol intake, heart failure, LVH, PE, COPD, sleep apnea May be asymptomatic; May be more than 110 bpm on palpation (if hemodyna mically unstable – chest pain, hypotension, heart failure, cold cla mmy skin, acute kidney failure with new A Fib call 911 12-lead EKG TS H, electrolytes, renal function, 24 H Holter monitor, echo Avoid stimulants Paroxysmal Supraventricular Tachycardia (PSVT) Digitalis toxicity, alcohol, Hyperthyroidism, caffeine, illegal drugs Abrupt onset of palpitations, rapid pulse, lightheadedness, shortness of breath and anxiety HR ran ge from 150-250bpm EKG Monitor weight daily, Avoid ETOH, stop smoking diuretics, ACEI or ARBs, beta-blockers if HFrEF, aldosterone antagonist Limit sodium intake (2-3 grams) Fluid restriction 1.5-2 L daily NYHA classify degree of physical disability Class I – no limitations Class II – activity results in fatigue, exertional dyspnea Class III – limitation in physical activity Class IV – symptoms at rest Antibiotic prophylaxis is no longer recommended for MVP, GU or GI Recommended for: Previous hx of endocarditis – dental procedures, prosthetic valves – resp. procedures, congenital heart disease Amoxicillin 2 grams PO Adult 1 hr. prior Amoxicillin 50 mg/kg 1 hr. prior PCN allergic: Clinda 600mg, Biaxin 500mg, Keflex 2 grams,? macrolide Surgical. If less < 4cm monitor yearly with CT. Search for underlyin g cause; Refer to cardiologist. CHA2 DS2 -VASC score > 2 needs anticoagulants CHF, HTN, Age > 75, Diabetes, Stroke/TIA, Vascular disease, Age 65-74, Sex (female); possible CCB, BB/digoxin to regulate HR Warfarin – A fib INR 2-3; Valves 2.5-3.5 Vagal maneuvers, carotid massage, ice water to face. If WP W or sympto matic call 911 EF < 40% systolic failure (HFrEF) EF > 40% diastolic failure (HFpEF) Meds that contribute to heart failure: amlodipine, metoprolol (but they need it), actos/Avandia (glitazone), NSAIDs Valvular destruction, myocardial abscess, emboli Risk factors: male > 60, smoker, uncontrolled HTN, white race, genetic disease such as Marfan syndrome Most common, classified as SVT – lead to stroke Paroxysmal AF: episodes terminate < 7 days INR >4-5 hold 1 dose and/or reduce maintenance dose May be seen in Wolf Parkinson White Syndrome CARDIOVASCUL Name Pulsus Paradoxus Hypertension Cause Asthma, emphysema, tamponade, pericarditis, cardiac effusion Any change in PVR or CO = change in BP Signs/Symptoms Apical pulse is audible even though radial pulse is no longer palpable. Measured through stethoscope and BP cuff. Chambers of heart are compressed causing exaggerated decrease in systolic BP <10mmHg Asympto matic Normal < 120/80 Prehypertension <120-139/8 0-89 Stage I 140-159/90-99 Stage II >160/100 Secondary HTN : R/O < 30; severe HTN or acute rise in BP (previously stable), Resistant HTN (3 agents); malignant HTN Renal: renal artery stenosis, polycystic kidney, CKD Endocrine: hyperthyroidism, hyperaldosteronism (HTN, low K+, normal to elevated Na+), pheochromocytoma (labile ± BP with palpitations, anxiety, sweating, severe HA) Other causes: sleep apnea, coarctation of aorta Diagnostics Confir m 2 elevated BP on 2 visits >140/90 if <60yo 150/90 if >60yo and no comorbidities Kidneys: creatinine, GFR, UA Endocrine: TSH, fasting blood glucose Electrolyte: K+, Na+, Ca2+ Heart: cholesterol, HDL, LDL, triglycerides Anemia: CBC Baseline EKG and CXR Treatments Hyperten sive emergency diastolic BP > 120 with N/V, CVA/TIA, subarachnoid hemorrhage, MI, acute PE, acute renal failure, retinopathy, papillede ma, acute severe low back pain (dissectin g aorta) Isolated systolic HTN – systolic > 160 caused by loss of recoil in arteries ± PVR Thiazides, CCB, and/or ACE I/A RB Deep Vein Thrombosis (DVT) Thrombi developed from stasis, trauma, inflammation or coagulation Gradual onset of swelling on lower extremity after prolonged sitting; painful, red, warm, swollen extremity. If PE abrupt onset chest pain, dyspnea, dizziness, or syncope + Homan’s sign (33% of pt.), CBC, platelets, PT/PTT, INR, d-dimer, chest x-ray, EKG ultrasound Refer Wells Criteria Warfarin takes effect in 3-5 days INR 2-3 with DVT Clarithromycin ± effects of warfarin Cholestyramine ³ effects of warfarin Direct Thrombin inhibitor (Pradaxa) Superficial Thrombophlebitis Inflammation of superficial vein from trauma/secondary infection (S. Aureus) Acute onset of indurated vein (localized redness, swelling and tenderness). Usually located on extremities. Afebrile and normal vital signs Indurated cordlike vein that is warm and tender to touch without swelling or edema NSAIDs, warm compresses, elevation of limb Peripheral Artery Disease (PAD) Narrowing or occlusion of medium to larger arteries in lower extremities (arterial insufficiency) Worsening pain on ambulation instantly relieved by rest (claudication – angina of calf muscles) Thin skin, hairless toes, toenails are often thick and discolored, possible gangrene of toes; decreased to absent dorsal pedal pulse Check pedal and posterior tibial pulses, ABI < 0.9 Doppler US flow study Refer to vascular Raynaud’s Phenomenon Reversible vasospasm of peripheral arterioles of fingers/toes Chronic color changes on fingertips white (pallor), blue (cyanosis), red (reperfusion); numbness and tingling. Can last for several hours ± risk of autoimmune disorders: thyroid, pernicious anemia, RA More common in females 8:1; scleroderma secondary to Raynaud’s Check distal pulses Smoking cessation, daily ambulation exercises Cilostazal (Pletal) – vasodilator can be used with ASA or Plavix (caution if grapefruit juice, diltiazem and omeprazole taken together) Pentoxifylline (Trental) – effect is marginal Avoid cold objects, cold weather and stimulants, avoid smoking CCB (Nifedipine or amlodipine) or ACEI Avoid vasoconstricting drugs, no BB Concerns Angiotensin I to II: ± vasoconstriction will ± PVR; younger pts have ± renin levels; alpha, beta and calcium channel blockers ³ PVR; pregnancy system vascular resistance is lowered due to hormones Stasis – prolonged bedrest or travel, CHF Coagulation disorders – Factor C deficiency, Leiden ↑ coagulation – contraceptives, pregnancy, fracture, trauma, surgery, malignancy Foot gangrene, CAD, carotid plaquing ± risk with HTN, smoking, diabetes, HLD Can lead to osteo Small ulcers in fingertips/toes Occurs between 15 and 45 yrs. of age CARDIOVASCUL Name Cause Mitral Valve Prolapse Systolic murmur Hyperlipidemia Risk factors: HTN, premature heart disease (women < 65 and men < 55) DM, dyslipidemia, low HDL, cigarette smoking, obesity, microalbuminuria, CAD, PAD Rhabdomyolysis Acute breakdown of skeletal muscle, acute renal failure Nonalcoholic Fatty Liver Disease (NAFLD) (Fatty Liver) Triglyceride fat deposits in liver Varicose Veins Inherited venous defect, leg crossing, wearing constrictive garments, prolonged standing, heavy lifting HEART BLOCK Signs/Symptoms Fatigue, palpitations, chest pain, lightheadedness aggravated by heavy exertion; May be asymptomatic; associated with pectus excavatum, hypermobility of joints, arm span greater then height (Marfan’s syndrome) Total cholesterol: Normal: less than 200 Borderlin e: 200-239 High: greater than 240 HDL: greater than 40 (low HDL is generally from ± carb and ³ fat diet) LDL: less than 100 Triglycerides: less than 150 – pancreatitis associated with > 1000 (if triglycerides are > 500 treat triglycerides first – fenofibrate, niacin, lovanza) (avoid alcohol and Ty len ol; could be metabolic syndrome, DM, familial, alcohol abuse, hyperthyroidism, kidney disease, medications Diagnostics S2 40 screen every 2-3 yrs. If HLD: screen at least annually Asymptomatic needs no treatment MVP w/ palpitations tx with BB, avoid caffeine, alcohol and cigarettes. Holter monitoring can be used to determine arrhythmias ±risk thromboemboli, TIA, AF and ruptured chordae tendineae Target is to lower LDL first unless ± triglycerides (>500) – STATINS Triglycerides are raised by alcohol and sugar Simvastatin interactions: grapefruit, fibrates, antifungals, macrolides, amiodarone Monitor for myalgias Consider stopping cholesterol at age 80 if symptoms, but statins are excellent at keeping atherosclerosis stable so can prevent MI or CVA Statins can cause memory loss, confusion. Triad of muscle pain, weakness and dark urine Muscle pain and aches persistent without associated muscular exertion Usually asymptomatic; may have hepatomegaly If symptomatic, fatigue and malaise with RUQ pain. Associated with obesity, metabolic syndrome, DM and HLD Annual labs show increase of ALT and AST, negative hepatitis A, B, C. ➢ First Degree AV Block: prolonged PR>0.2 seconds o If the R is far from P – FIRST DEGREE ➢ Second Degree Type I (Wenckebach): PR is progressively longer until it drops o Longer, Longer, Longer, drop then you have WENCKEBACH ➢ Second Degree Type II: PR constant but drops QRS periodically o If a QRS don’t get through, then you have MOBITZ II ➢ Third Degree: complete, no pattern between PR and QRS o If Ps and Qs don’t agree, then you have THIRD DEGREE Concerns Exercise, lose weight, eat healthy fats, eliminate trans fats, decrease junk food, stop smoking, DASH diet CK, urinalysis (myoglobinuria/proteinuria), BUN, creatinine, potassium, EKG Tortuous dilated superficial veins; leg aching, mild edema at the end of the day and in warm weather most often great saphenous vein affected Treatments Weight loss, diet Discontinue alcohol, avoid hepatotoxic drugs (acetaminophen, statins) REFER GI for Liver biopsy (gold standard) ***can progress to cirrhosis Risk factors: obesity, diabetes, metabolic syndrome, HTN, certain drugs Most common liver disease in US - #1 reason for liver transplants Laser venous ablation, sclerotherapy, surgery Women are affected 2x as much as men PULMONARY SYSTEM PNEUMONIA - CURB 65 Confusion of new onset Blood Urea nitrogen > 19 Respiratory rate > 30 Blood pressure diastolic < 90 or systolic < 60 Age 65 or older PHYSICAL EXAM FINDINGS CURB-65 Results: 0-1: treat as outpatient 2: consider short stay in hospital or watch very closely as outpatient 3-5: Requires hospitalization with consideration as to whether patient needs to be in the intensive care unit. COPD RANDOM PEARLS ASTHMA LAMA LABA ICS -ium & terol one glycopyrrolate ide SABA (beta2 agonist) How often? 1-2x/wk. More often (add) Less often (drop) INHALED MUSCARINIC ANTAGONIST ➢ Emerging role in asthma ➢ Well established in COPD (offer protracted duration) ➢ Used for prevention, not treatment (use scheduled) o SAMA - Ipratropium bromide (Atrovent) ▪ bronchodilation o LAMA - Tiotropium bromide (Spiriva); umeclidinium (Ellipta) ➢ Anticholinergic – can contribute to worsening BPH o If occurs switch from LAMA to LABA such as salmeterol ➢ Normal chest percussion sound: resonance ➢ Lower lobes: vesicular breath sounds & upper lobes: bronchial ➢ Consolidation o Dullness to percussion o Increased tactile fremitus (have pt. say 99) o Bronchial or tubular breath sounds, often with late inspiratory crackles that do not clear with cough o Egophony: 240(QVAR) 480mcg Budesonide 180>540540mcg 1080mcg (Pulmicort) Fluticasone (Flovent) 88-264mcg 264-440mcg Mometasone 100300-500mcg 300mcg (Asmanex) High dose >480mcg >1080mcg >440mcg >500mcg INHALEDCORTICOSTEROIDS/LONG ACTINGBETA2AGONIST (ICS/LABA) LEUKOTRIENE MODIFIER ➢ Additional benefit with allergic rhinitis, most often in conjunction with ICS ➢ Requires consistent daily use for optimal effect o Montelukast (Singular) ➢ Preferred controller tx for moderate to severe persistent asthma ➢ BLACK BOX: ↑death in asthma patients using LABA ➢ Requires consistent, daily use for optimal effect o Budesonide + formoterol (Symbicort) o Fluticasone + salmeterol (Advair) o Mometasone + formoterol (Dulera) ➢ Pneumonia causes increased right sided heart workload which can be a heart failure trigger in the older adult CLASSIFICATION ➢ Intermittent Asthma (FEV1 > 80% P) o Symptoms < 2 days week ➢ Mild (FEV1>80% Predicted) o Symptoms > 2 days week, but not daily o Night time 3-4/month o Minor limitation ➢ Moderate (most common) 60-80%P o Symptoms daily o Night time > 1x week o Some limitation ➢ Severe (FEV1<60% Predicted) o Symptoms throughout day o Night time often 7x week o Extreme limitation ➢ Intermittent Asthma o SABA ➢ Step 2 o Low dose ICS ➢ Step 3 o Low dose ICS + LABA o Medium dose ICS ➢ Step 4 o Medium dose ICS + LABA and consider omalizumab for allergies ➢ Step 5 o High dose ICS + LABA + or corticosteroid and consider omalizumab for allergies ➢ Roflumilast (can induce psychosis) ➢ Minimizes risk of COPD exacerbation PULMONARY SYSTE ➢ Dramatically increases right sided heart workload In patients with FEV1/FVC<0.70 FEV1 > 80% predicted GOLD 1 Mild 50% < FEV1 < 80% predicted GOLD 2 Moderate 30% < FEV1 < 50% predicted GOLD 3 Severe FEV1 < 30% predicted GOLD 4 Very severe First Line therapy: ➢ GOLD 1-2: (don’t commonly see in clinic) o <1 exacerbation per year o Low risk: SAMA or SABA prn o High risk: LAMA or LABA set schedu ➢ GOLD 3-4: o >2 exacerbation per year o ICS + LABA or LAMA on set schedu ****LAMA + ICS with LABA (commonly used) ➢ Effective use of long-term oxygen requires at least 15 hours a day ➢ Beta agonist – stimulant or bronchodilation o (beta1 heart) (beta2 lung) ➢ SABA (4 hrs.) / LABA (12 hrs.)– palpitations, tachycardia. Use caution in HTN, angina and hyperthyroidism. Avoid combining with caffeinated drinks. ➢ Anticholinergics – (prevent bronchoconstriction) tropium avoid if patient has narrow-angle glaucoma, BPH or bladder neck obstruction ➢ Exacerbations – Corticosteroids with possible ASTHMA ➢ Risk factors for fatality o Hx of ED visits o Frequent use of rescue inhaler o Nocturnal awakenings o Increased dyspnea and wheezing o Respiratory viral infection PNEUMONIA ➢ Young otherwise healthy – atypical pathogen o Macrolide or doxycycline ➢ Complicated o Fluoroquinolone o Macrolide plus beta-lactam THEOPHYLLINE ➢ Bronchodilator ➢ Used on daily set schedule SPIROMETRY ➢ Obstructive dysfunction: (reduction in airflow rates) o Asthma, COPD, bronchiectasis ➢ Restrictive dysfunction: (reduction of lung volume due to decreased lung compliance) o Pulmonary fibrosis o Pleural disease o Diaphragm obstruction ➢ Not recommended during exacerbation ➢ PPSV23 o 19-64 asthma, COPD, CVD, smoke o Age 65+ ➢ PCV13 o 19-64 with asplenia, immunocompromised o Age 65+ PULMONARY EMBOLISM ➢ Tachypnea is most common presentation CHEST X-RAY PEAK EXPIRATORY FLOW: PEF ➢ PEF is based on HAG o Height o Age o gender ➢ How long have you coughed? ➢ Acute < 3 weeks o Acute respiratory infection o Exacerbation of COPD, asthma o Pneumonia o PE ➢ Chronic > 8 weeks o Asthma o GERD o Pertussis, atypical pneumonia o ACE inhibitors (begins 1-2 weeks after starting med) o Chronic bronchitis o Bronchiectasis o Lung cancer ➢ PA – x-ray goes through back ➢ AP – x-ray goes through front of chest ➢ Air: appears black (low density so less absorption) ➢ Bones: appears white ➢ Metals: bright white (high absorption) ➢ Tissue: Different grayish shades (medium absorption) ➢ Fluid: Grayish to whitish ➢ Tissues visible: trachea, bronchus, aorta, heart, lungs, pulmonary arteries, diaphragm, gastric bubbles, ribs ***Unilateral finding on lung exam warrant CXR ***Hilar nodes require follow-up CHRONIC STEROID USE ➢ Osteoporosis o Calcium with Vitamin D 1200mg for menopausal women ➢ Growth failure in children ➢ Glaucoma ➢ Cataracts ➢ Immune suppression ➢ Hypothalamic-pituitary-adrenal suppression PULMONARY SYSTE