1. Boston Criteria (diagnosing heart failure) 

CRITERION	POINTS*
Category I: history
Rest dyspnea	4
Orthopnea	4
Paroxysmal nocturnal dyspnea	3
Dyspnea while walking on level area	2
Dyspnea while climbing	1
Category II: physical examination
Heart rate abnormality (1 point if 91-110 BPM, 2 points if >110 BPM)	1 or 2
Jugular venous elevation (2 points if >6 cm H2O; 3 points if >6 cm H2O plus hepatomegaly or edema)	2 or 3
Lung crackles (1 point if basilar; 2 points if more than basilar)	1 or 2
Wheezing	3
Third heart sound	3
Category III: chest radiography
Alveolar pulmonary edema	4
Interstitial pulmonary edema	3
Bilateral pleural effusion	3
Cardiothoracic ratio greater than 0.50	3
Upper zone flow redistribution	2

*— No more than 4 points are allowed from each of three categories; hence the composite score (the sum of the subtotal from each category) has a possible maximum of 12 points. The diagnosis of heart failure is classified as “definite” at a score of 8 to 12 points, “possible” at a score of 5 to 7 points, and “unlikely” at a score of 4 points or less.

2. Diagnosing COPD (physical exam): 

-One multicenter prospective trial (n=309) in {JAMA} found the following 4 physical exam findings to be diagnostic of obstructive airway disease in multivariate regression models:

-Smoking > 40 pack years (LR 8.3)

-Self reported history of COPD (LR 7.3)

-Maximum laryngeal height <4cm (LR 2.8)

-Age >=45 (LR 1.3) 

All 4 criteria = LR 220, 0 criteria = LR 0.13, ROC area = 0.86

3. Laryngeal height: 

4. Diagnosing COPD (spirometry):

-FEV1/FVC <5th percentile or <70% is diagnostic of COPD 

-FEV1

>80% of predicted: mild

50-80% of predicted: moderate (SOB with exertion)

30-50% of predicted: severe (worse SOB, frequent COPD exacerbations)

<30% of predicted: very severe (significant impairment in quality of life, COPD exacerbations are life-threatening. 

Since asthma responds to albuterol and COPD does not, If the FEV1/FEV improved by greater than 12%, it's more likely asthma than COPD 

-Asthma (eos, mast cells, Th2 helper T cells) vs COPD (m-phage, neutrophils, cytotoxic CD8+ t cells)

5. Quitting smoking & COPD:

{Am J Respir Crit Care Med, 2000} 

"Previous studies of lung function in relation to smoking cessation have not adequately quantified the long-term benefit of smoking cessation, nor established the predictive value of characteristics such as airway hyperresponsiveness. In a prospective randomized clinical trial at 10 North American medical centers, we studied 3,926 smokers with mild-to-moderate airway obstruction (3,818 with analyzable results; mean age at entry, 48.5 yr; 36% women) randomized to one of two smoking cessation groups or to a nonintervention group. We measured lung function annually for 5 yr. Participants who stopped smoking experienced an improvement in FEV1 in the year after quitting (an average of 47 ml or 2%). The subsequent rate of decline in FEV1 among sustained quitters was half the rate among continuing smokers, 31 ± 48 versus 62 ± 55 ml (mean ± SD), comparable to that of never-smokers. Predictors of change in lung function included responsiveness to beta-agonist, baseline FEV1, methacholine reactivity, age, sex, race, and baseline smoking rate. Respiratory symptoms were not predictive of changes in lung function. Smokers with airflow obstruction benefit from quitting despite previous heavy smoking, advanced age, poor baseline lung function, or airway hyper responsiveness." 

6. Treatment of COPD: 

Mild (FEV1 >80% of predicted) -- albuterol inhaler PRN 

Moderate (50-80% of predicted) -- inhaled anticholinergic (tiotropium, ipratropium) maintenance + albuterol inhaler PRN 

Severe (<50% of predicted) -- inhaled steroid + LABA maintenance + albuterol inhaler PRN. 

People who have very severe disease may require continuous oxygen or non-invasive vent support 

7. Vaccinations in people with COPD

-Flu shot (decrease COPD exacerbations by 50%)

-Pneumococcus (decrease incidence of CAP in people with an FEV1<40% predicted)

-Zoster (varicella can cause pneumonia) 

8. COPD exacerbations:

-Like asthma exacerbations/attacks, triggered most commonly by infections and pollutants. 

-Treat with albuterol or duoneb and PO steroids. 

9. Workup for suspected BPH:
-UA to r/o UTI
-BUN/Cr to check renal function
-PSA and prostate exam to check for prostate cancer
-Optional: urine flow rate (>15mL/sec effectively rules out clinically meaningful obstruction), bladder scan
-Optional: prostate symptom score
10. Management of BPH:
-Lifestyle modifications (drink less fluids before bed, less salt/sugar/spicy food, less diuretics including caffeine and alcohol, avoid alpha-agonists like decongestants and antihistamines)
-First line for those with small prostates (<40gms): alpha-antagonist like prazulosin
-For those with large prostates: add 5-a-reductase inhibitor like finasteride. These drugs can take up to a year to have effect
-Those who are experiencing clinically significant consequences of BPH need to get surgery- i.e. hydronephrosis, renal failure, recurrent infections, bladder decompensation (overstretch)