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Internal Medicine > 6) Pulmonary (Part 2) > Flashcards

6) Pulmonary (Part 2) Flashcards

1
Q

Virchow’s Triad

A
  • Stasis
  • Endothelial cell injury
  • Hypercoagulable states
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2
Q

Specific risk factors for venous thromboembolism (VTE)

A
  • Malignancy
  • Immobilization
  • Surgery within last 3 months
  • Preexisting respiratory disease
  • Prior Hx of VTE
  • Chronic heart disease
    Stroke
  • Thrombophilia
  • Inflammatory triggers
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3
Q

Inflammatory triggers that can pose risk of VTE

A
  • Infection
  • Tranfusion
  • Erythropoiesis stimulating Rx
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4
Q

Specific risk factors for VTE in women

A
  • Obesity
  • Pregnancy
  • Hypertension
  • Heavy cigarette use
  • Oral Contraceptive Pills/Hormone Replacement Therapy (OCP’s/HRT)
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5
Q

Most common route of VTE

A
  • LE thrombus –> IVC –> R ventricle –> pulmonary arteries
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6
Q

Signs and symptoms of VTE

A
  • Dyspnea (79%)
  • Tachypnea (57%)
  • Pleuritic pain (47%)
  • Leg edema, erythema, tenderness, palpable cord (47%)
  • Cough/hemoptysis (43%)
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7
Q

Other possible findings in VTE

A
  • Tachycardia
  • RV gallop
  • Loud P2, & prominent jugular “a” waves suggest RV failure
  • Syncope or sudden death with massive PE
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8
Q

Typical ABG findings

A
  • Hypoxemia (Low PaO2)
  • Hypocapnia (Low PaCO2)
  • Increased alveolar-arterial oxygen gradient (A-a gradient)
  • 15%-20% have normal ABG’s
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9
Q

A-a gradient

A
  • A measure of how effectively oxygen in your alveoli moves into your pulmonary vasculature
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10
Q

A-a gradient calculation

A
  • PAO2 – PaO2
  • PAO2 is calculated from the alveolar gas equation
  • PaO2 is measured in the arterial blood
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11
Q

A-a gradient measured from the ABG results

A
  • A-a gradient = [ (FiO2) x (Atmospheric Pressure - H2O Pressure) - (PaCO2/0.8) ] - PaO2 from ABG
  • A-a gradient = [.21 x (760-47) – (PaC02/0.8) ] - PaO2
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12
Q

Normal A-a gradient room air

A
  • 10 to 20 mmHg
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13
Q

Increased A-a gradient may be a result of

A
  • V/Q (ventilation-perfusion) imbalance
  • Anatomic shunts
  • Impaired diffusion
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14
Q

Adjunctive studies in the evaluation of PE

A
  • ABG’s
  • EKG’s (S1Q3T3)
  • CXR’s
  • Echocardiograms
  • Doppler (to evaluate for DVT)
  • Cardiac Enzymes and BNP
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15
Q

Primary studies in the evaluation of PE

A
  • D-dimer strategy combined with CT angio
  • V/Q scan based strategy
  • Pulmonary angiography (gold standard, but invasive)
  • MRI/MRA
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16
Q

CXR findings in PE

A
  • That was a “WHALE” of a PE
  • W= Westermark Sign
  • H =Hampton’s Hump
  • A = Atelectasis
  • L = Lovely (Meaning perfectly normal)
  • E = Effusions
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17
Q

Westermark sign

A
  • Seen on plain film radiography CRX
  • Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels (often with a sharp cut off)
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18
Q

Hampton’s Hump

A
  • Pleural based opacities with convex medial margins on CRX
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19
Q

CRX in PE may show

A
  • Collapse
  • Consolidation
  • Small pleural effusion
  • Elevated diaphragm
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20
Q

Ultrasound

A
  • Duplex scanning with compression will aid to detect any thrombus
  • Highly sensitive and specific for diagnosing DVT
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21
Q

Ultrasound looks for

A
  • Loss of flow signal
  • Intravascular defects
  • Non collapsing vessels in the venous system
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22
Q

D-Dimer

A
  • Degredation product of crossed linked fibrin
  • Detectable above 500 ng/ml in nearly all cases of VTE, but common in many other conditions (sensitive but not specific)
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23
Q

V/Q scanning

A
  1. Radioactive cmpd inhaled (distributes evenly in normal lung)
  2. Radioactive cmpd injected into vein, travels to tissues in blood vessels (no injected material in a region indicated embolus)
  3. “Mismatch” of inhaled and injected cmpds on lung scan images = pulmonary embolus
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24
Q

Acute treatment for pulmonary embolism

A
  • Anticoagulation for most patients
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25
Q

Anticoagulation in acute PE Tx

A
  • Low molecular weight heparin (IE Lovenox); Fondaparinux (Arixtra); or unfractionated heparin
  • There are some new approved Oral anticoagulants for acute treatment (IE Rivaroxaban (Xaletro))
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26
Q

“Massive PE”

A
  • “Massive PE” - hypotensive/unstable patient without a pulse
  • If no contraindications – systemic thrombolytics
  • Catheter based therapy to break up the
  • Surgical Thrombolectomy
27
Q

Tx for acute PE if contraindications to Anticoagulation (IE active hemorrhage, low hemagobin/hematocrit)

A
  • IVC Filter
28
Q

Long term PE Tx

A
  • Anticoagulation (Oral) for at least 3 months

- Most continue beyond that if low bleeding risk

29
Q

Bronchitis

A
  • Usually viral, sometimes bacterial
  • Non-smokers: M. pneumoniae
  • Smokers: S. pneumoniae
30
Q

Bronchitis symptoms

A
  • Cough
  • Fever
  • Sore throat
  • Rhonchi
  • Wheezing
31
Q

Bronchitis diagnosis

A
  • Usually clinical

- CXR rules out other causes

32
Q

Bronchitis Tx

A
  • Rest, fluids, analgesics
  • Bronchodilators/steroids may be considered
  • Antibiotics show no benefit for true viral bronchitis (use only if underlying bacterial etiology or high risk patients)
33
Q

Pneumonia organisms

A
  • S. pneumoniae (pneumococcus)
  • Mycoplasma pneumoniae
  • Influenza
  • Gram negative bacilli
  • Legionella pneumonia
34
Q

Pneumonia clinical features

A
  • Fever
  • Chills
  • Productive cough
  • Pleuritic chest pain
35
Q

Pneumonia physical exam findings

A
  • Signs of consolidation (egophony, increased fremitus)

- Bronchial breath sounds and rales/crackles over the affected areas

36
Q

Pneumonia diagnostic studies

A
  • CXR

- Labs

37
Q

Labs for pneumonia diagnostic studies

A
  • WBC normal or slightly elevated
  • Sputum for gram stain and culture may detect specific organisms
  • Blood cultures x 2 may detect specific organisms (especially with septicemia)
  • Urine antigen test (as indicated) – highly specific for Legionella pneumonia
38
Q

Community acquired pneumonia Tx

A
  • Empiric therapy (outpatient)

- Admit if hypoxic (O2 sat < 90%, septic, etc.) for inpatient empiric therapy

39
Q

Empiric therapy (outpatient)

A
  • Amoxicillin (Streptococcus pneumonia coverage)
  • Macrolides (EES, azithromycin, or clarithromycin)
  • Doxycyline/Tetracycline
  • Respiratory fluoroquinolones - levofloxacin [Levaquin], gatifloxacin [Tequin], moxifloxacin [Avelox]
40
Q

Empiric therapy (inpatient)

A
  • Intravenous beta-lactam (cefuroxime, ceftriaxone [Rocephin], cefotaxime [Claforan]) with a macrolide
  • Intravenous respiratory fluoroquinolones
41
Q

Viral pneumonia organisms

A
  • Influenza
  • Parainfluenza
  • Respiratory syncytial virus (RSV)
  • Adenovirus
42
Q

Viral pneumonia CXR shows

A
  • Patchy infiltrates
43
Q

Viral pneumonia Tx

A
  • Supportive care

- Flu antiviral drugs reduce duration but not severity of pneumonia caused by Influenza

44
Q

Pneumonia (Pneumococcal)

A
  • S. pneumoniae (most common in adults)
45
Q

Pneumonia (Pneumococcal) symptoms

A
  • Fever
  • Chills
  • Rusty sputum
46
Q

Pneumonia (Pneumococcal) diagnosis

A
  • Gram stain = gram postitive diplococci

- CXR = lobar consolidation or effusion

47
Q

Pneumonia (H flu)

A
  • Primarily seen with COPD patients

- Dx: CXR, Gram stain = gram negative coccobacilli

48
Q

Pneumonia (Klebsiella)

A
  • Seen in alcoholics, often due to aspiration
  • High mortality
  • S/S: “currant jelly sputum”
  • Dx: CXR, gram negative bacilli on Gram stain
49
Q

Pneumonia (Mycoplasma)

A
  • “Atypical pneumonia”, seen in close quarters (military), is the most common pneumonia in younger patients
  • Dx: CXR, Gram’s stain = nothing (no cell wall), positive cold agglutinin test
50
Q

Pneumonia (Legionella)

A
  • “Atypical” air conditioners, Cruise ships, hotels, etc.
  • S/S: GI and CNS symptoms + fever, cough, etc
  • Dx: CXR, urine antigen test is definitive
51
Q

Pleural effusion symptoms

A
  • Dyspnea

- Pleuritic chest pain

52
Q

Pleural effusion clinical findings

A
  • Dullness to percussion
  • Diminished or inaudible breath sounds
  • Pleural friction rub
  • Decreased tactile fremitus
  • Asymmetric thoracic expansion, with lagging expansion on the affected side
53
Q

Some causes of pleural effusion

A
  • Malignancy
  • Pneumonia
  • Heart failure
  • Cirrhosis
  • Nephrotic syndrome
54
Q

Best next step for pleural efusion

A
  • Thoracentesis
55
Q

Pneumothorax

A
  • Accumulation of air in the pleural space
56
Q

Pneumothorax symptoms

A
  • Sudden onset of dyspnea

- Ipsilateral chest pain

57
Q

Pneumothorax physical exam findings

A
  • Decreased or absent lung sounds (unilateral)
  • Decreased thoracic expansion (unilateral)
  • Decreased tactile fremitus (unilateral)
  • Tachycardia
58
Q

Pneumothorax CXR

A
  • Visceral pleural line on chest radiograph is diagnostic

- Expiratory film will increase sensitivity

59
Q

Primary pneumothorax

A
  • Most commonly seen in tall slim young males, smokers, & Marfan syndrome
60
Q

Primary pneumothorax Tx

A
  • Small pneumothoraces may be managed with O2 tx and repeat observation with CXR
  • Larger pneumothoraces require chest tube placement
61
Q

Secondary pneumothorax

A
  • Complication of underlying lung disease (IE COPD, Cystic Fibrosis)
  • TX: chest tube
62
Q

Traumatic pneumothorax

A
  • Penetrating chest trauma
  • Clinician induced (ie complication from subclavian central line placement)
  • TX: chest tube
63
Q

Tension pneumothorax

A
  • Medical emergency
  • TX: immediate placement of large bore needle with a catheter in the 2nd ICS MCL followed by chest tube placement when available.

Internal Medicine (14 decks)

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