Chest Medicine Flashcards
Triad of Lofgren Syndrome
Sarcodosis with fever
Migratory joint pain
Erythema nodosum
Important information for Sarcodosis
Pts with incidental b/l hilar lymph nodes without symptoms are monitored without biopsy unless symptoms develop
Name the cardiac condition occur due to Sarcodosis
AV blocks
What will be elevated in BAL of Sarcodosis?
CD4/CD8 ratio
Name the condition in which fremitus is increased
Condition/s which causes “Consolidation”
Important information
Only consolidation causing conditions will have increased breath sound (Bronchial Breath sound)
Important information
Cough lasting more than 5 days following URTI is characteristic of Acute Bronchitis
Usually due to Viral cause
What factors would alter PaO2 level?
FiO2
And PEEP
What factors would alter PaCO2 level?
RR
And Tidal volume
PaCO2 measure of ventilation
Name the gradient which determines the cause of Hypoxemia
A-a gradient
Name the condition in which supplemental Oxygen would not recorrect the condition
Shunt (must check the table page number 11)
Risk factors for Obs sleep Apnea
Obesity
Small mandible
Increase Soft tissues
Tonsillar hypertrophy
Diagnostic criteria for Obs sleep apnea
> /=15 obstructive respiratory events (apnea or hypopnea) per hour is diagnostic
What are the causes of Central sleep apnea?
Remember 3Cs
CNS toxicity viz opioid
Congestive heart failure
Cheyne Stokes respiration
What changes occur due to OSA and Obesity hypo ventilation syndrome?
Compensatory metabolic alkalosis
Pulmonary and systematic HTN
Cor pulmonale
Secondary erythrocytosis
Arrhythmia
What is the first line t/m for Obesity hypo ventilation syndrome?
Nocturnal positive pressure ventilation
What is the feature which help in distinguish pulmonary embolism occur before death or after death in post Mortem cases?
Lines of Zahn formed before death
Triad of Pulmonary embolism due to fat?
Trauma of long bones viz femur
Hypoxemia with petechial rash
Neurological SxS
Plus one point in modified Well’s criteria
Cancer
Hemoptysis
Plus 1.5 points in modified Well’s criteria
HR>100
Previous PE or DVT
Recent surgery Or Immobilisation
Plus 3 point in modified Well’s criteria
Clinical Signs of DVT
Alternate dx less likely PE
Patient with PE has contraindications for Anticoagulation would be t/m via;
IVC filter
What acid base balance occur in pulmonary embolism?
Respiratory alkalosis
Name the obstructive lung disease in which FEV1/FVC is less than normal but FEV1 is increased?
Asthma
Triad of Aspirin induced asthma
Chronic sinusitis
Nasal polyp
Asthma SxS
What is Charcot Leyden crystal in asthma?
Eosinophilic Hexagonal double pointed crystal formed from breakdown of eosinophil in sputum
What is curschmann spirals in asthma?
Shed epithelium forms whorled mucous plugs
Describe mild Intermittent asthma?
SxS less than 2 days/wk with night time awakening less than 2 times per month and less than 2 times/wk use of Beta agonist
No limitations of activities
Normal spirometry
How to t/m mild intermittent asthma
Only short acting beta agonist
Describe mild persistent asthma?
SxS more than 2 days/wk but less than daily with night time awakening 3 to 4 times/month
Normal spirometry
Mild limitation of activities
How to t/m mild persistent asthma?
Short acting beta agonist with use of low dose inhaled steroid as controller med
Describe moderate persistent asthma?
SxS daily with night time awakening weekly and FEV1 60-80% predicted
How to t/m moderate persistent asthma?
Short acting beta agonist with low dose steroid inhaler
Long acting beta agonist inhaler
Describe severe persistent asthma?
SxS throughout day with frequent nighttime awakening and FEV1 <60% predicted
T/m of severe persistent asthma?
Short acting beta agonist with high dose inhaler steroid
And long acting beta 2 inhaler
How to dx asthma if patient has only nocturnal SxS?
Nocturnal or early morning peak expiratory flow rates measurement
How to t/m mild to moderate asthma exacerbation?
Oxygen and SABA
If no response then used systemic steroid
How to t/m severe asthma exacerbation?
Initial SABA with NEBS and systematic steroid
No improvement after one hour use MgSO4
SxS of Respiratory failure; admit in ICU and ETT
Important information for asthma
Asthma + acidosis + with CO2 = Respiratory failure admit the patient in ICU
Important information
COPD—mainly treated by long-acting anti-cholinergic inhalers
And asthma—mainly treated by long-term steroid inhalers
CXR findings of chronic bronchitis
prominent bronchovascular markings,
mildly flattened diaphragm
CXR findings of Emphysema
hyperinflated chest,
↓ vascular markings
And Increased AP diameter
What is Reid index in chronic bronchitis?
Thickness of mucosal gland layer to thickness of wall b/w Of Epithelium and cartilage
Indications for Long term Oxygen Therapy in COPD if patient have significant chronic hypoxemia
- Resting PaO2 less than 55 mmhg Or SaO2 less than 88% on room air
- PaO2 less than 59mmHg Or SaO2 less than 89% in patients with cor pulmonale, RH failure or Hematocrit>55%
Name the drug which is given Chronic COPD as a maintenance therapy
Roflumilast—phosphodiesterase inhibitor
Also long acting beta agonist
Triad of Acute Exacerbation of COPD
Increase SOB
Increase cough
Sputum production
Test to dx Acute Exacerbation of COPD
CXR shows Hyperinflation
ABG report shows Hypoxia with CO2 retention
Initial management of Acute Exacerbation of COPD
Oxygen and Inhaled bronchodilator
Systematic Steroids
AbX if more than 2 cardinal Symptoms
Name the bacteria would cause infection in Acute Exacerbation of COPD.
S. pneumonia,
Moraxella cattarhalis,
H. influenza
Important information
No role of Inhaled Steroids in Acute Exacerbation of COPD
Important information
COPD is associated with formation of blebs, which can rupture and cause spontaneous pneumothorax
What is the preferred method of ventilatory support in pts with acute exacerbation of COPD?
NPPV
Triad of Bronchiectasis
Cough with purulent sputum production
Digital clubbing
Hemoptysis with positive hx of URTI
Cough with purulent sputum production
Digital clubbing
Hemoptysis with positive hx of URTI
What are CXR and HRCT finding of Bronchiectasis?
• HRCT—-> bronchial wall thickening with dilation
• CXR—> linear atelectasis with IRREGULAR peripheral opacities
And dilated thickened airway
What are the causes of Bronchiectasis? Remember RICH (H = A)
Rheumatic disease like RA ; Sjogren
I Immunodeficiency like low immunoglobulin Or Inhalation of toxin
Chronic or prior Infection like TB or Aspergillus Or cystic fibrosis
A airway obs (cancer)
HRCT findings Of Interstitial Lung disease
Fibrosis
Honey combing
Traction Bronchiectasis
Name the drugs causing Restrictive lung diseases
Bleomycin
Busulfan
Amiodarone
Methotrexate
Sources of Asbestosis
Shipyard
Mining
Construction workers
Pipe fitters
Carpenter
Insulation workers
Pathognomonic imaging finding of Asbestosis
Pleural plaques
HRCT findings of Asbestosis
subpleural linear densities
and parenchymal fibrosis
Important information of Asbestosis
Asbestos (Ferruginous) bodies are golden brown fusiform rods resembling “Dumbbells”
Found in alveolar sputum sample visualise via Prussian Blue stain
Sources for silicosis
Mines
Sandblasting
Foundries
CXR findings of silicosis
Eggshell calcification of hilar lymph nodes
Important information of Silicosis
Silica disrupts phagolysosome and impair macrophages increases the susceptibility of getting TB
Sources for berylliosis
Aerospace
Manufacturing industries
Why berylliosis responds to steroid?
B/c of formation of non caseating granuloma
Important information for mesothelioma
U/L pleural abnormality typically
Hemorrhagic exudative pleural effusion
Psammoma bodies seen on histology
Tumor marker positive in mesothelioma
Calretinin
Name the condition/s in which there is normal spirometry but DLCO is increased
Pulmonary Hemorrhage
Polycythemia
Name the condition/s in which there is normal spirometry but DLCO is low
Anemia
Pul HTN
Pulmonary embolism
Name the condition in which there is restrictive pattern on spirometry but DLCO is increased
Morbid obesity
Name the condition in which there is restrictive pattern on spirometry but DLCO is normal
Musculoskeletal deformity
Neuromuscular disorders
Name the condition in which there is restrictive pattern on spirometry but DLCO is
Low
All restrictive pulmonary Diseases
Heart failure
Name the condition in which there is obstructive pattern on spirometry but DLCO is increased
Asthma
Name the condition in which there is obstructive pattern on spirometry but DLCO is low
Emphysema
Name the condition in which there is obstructive pattern on spirometry but DLCO is normal
Chronic bronchitis
Asthma
What does mean normal DLCO?
Intact pulmonary capillaries and alveolar structures
Normal pulmonary arterial pressure
10-14mmhg
Value in pulmonary HTN
More than 25mmhg at rest and more than 30mmhg at exertion
Name the gene which mutated resulting in Pulmonary arterial HTN
BMPR2 GENE which normal inhibits vascular smooth muscle proliferation
Name the parasite which can cause Pul aterial HTN
Schistosomiasis
Chest X ray findings of Pulmonary arterial HTN
Clear lung fields
Enlargement of pulmonary arteries with rapid tapering of distal vessels (pruning)
Enlarged right ventricle
How chronic thromboembolic cause Pul HTN?
Recurrent microthrombi–> decreases cross sectional area of pulmonary vascular beds
MCC of Cor pulmonale
COPD
Gold standard test to dx Cor pulmonale
Right heart Catheterization
Which shows Right heart catheterization shows:
↑ CVP,
right ventricular end diastolic pressure and mean pulmonary artery pressure >25mmHg without left heart disease
Chest X rays findings of Cor pulmonale
central pulmonary artery enlargement and loss of retrosternal airspace due to right ventricular enlargement
Important information
Both COPD and cor pulmonale have distant heart sounds buy former is chronic and latter is acute
COPD have hyperinflated lungs that’s why distant heart sounds
Important information for pleural effusion
Before doing thoracocentesis, check if patient has heart failure or not
What to do it cytology of pleural effusion is unclear and there is lung mass?
Bronchoscopy
Bronchoscopy
Normal pH of pleural fluid
7.60
pH of pleural fluid in transudative pleural effusion
7.45-7.55
pH of pleural fluid in Exudative pleural effusion
7.30-7.45
to excessive acid production by pleural fluid cells and bacteria (eg empyema) or decreased hydrogen ion efflux from pleural space (e.g. pleuritis, pleural fibrosis, tumor)
Causes of Exudative pleural effusion if amylase found in pleural fluid
Pancreatitis and Esophagus rupture
What is the cause if glucose is less than 30mg/DL in pleural fluid?
Empyema
Empyema
Important information for pleural fluid
In CHF—can meet exudative criteria in 25% cases if pt has received excessive diuretic therapy prior to thoracocentesis. Mostly B/L (61%), can be U/L on right side in 27% cases and on left side in 12% cases
CURB 65 score is zero what is it indicate?
Low mortality
T/m As outpatient
CURB 65 score is 1-2 what is it indicate?
Intermediate mortality
Likely t/m as inpatient
CURB 65 score is 3-4 what is it indicate?
High mortality
Urgent inpatient admission
Possible ICU if score more than 4
Outpatient t/m of CAP in healthy patient
Macrolide Or Doxycycline
Outpatient t/m of CAP in patients who have co morbids
Quinolones
Or Beta lactam plus macrolide
Non ICU inpatient t/m of CAP
Quinolones
Or Beta lactam plus macrolide
ICU patient t/m of CAP
Quinolones plus Beta lactam
Or Beta lactam plus macrolide
Triad of Uncomplicated parapneumonic effusion
Occur due to increased flow of STERILE exudates into pleural space
Pleural fluid gram stain and culture comes negative
Pleural fluid analysis (((shows pH>7.20
LDH ratio>0.6 Or LDH <1000u/L
glucose >60mg/dl
WBC <50k)))
T/m is Abx
Triad of Complicated parapneumonic effusion
(Occur due to inflammation with pleural membrane disruption and contiguous bacterial spread from the pneumonia into the pleural space)
Pleural fluid gram stain and culture comes negative
Pleural fluid analysis ((shows pH<7.20
LDH ratio>0.6 Or LDH >1000u/L
Glucose <60mg/dl
WBC >50k)))
T/m is Abx and usually require chest tube drainage
Triad of Empyema
Pleural fluid gram stain and culture come positive
Pleural fluid analysis shows pH<7.20/ LDH ratio>0.6 / glucose low
T/m is Abx and chest tube drainage
Important information
Drug induced lupus cause Exudative effusion
With pH <7.2 and glucose<60mg/dl
Important information
Pulmonary embolism causes both exudative and transudative pleural effusion
Bloody pleural effusion but doesn’t cause low pH Or Glucose
What are the causes of Recurrent pneumonia involved d/f region of lungs?
Sinopulmonary disease (cystic fibrosis / Immotile cila) Immunodeficiency Non infectious ( vasculitis/ cryptogenic pneumonia)
What are the causes of recurrent pneumonia involved same region of lungs?
Recurrent aspirations (fits/ alcohol / GERD / Achalasia/ dysphagia)
Local Anatomic Obs viz bronchial compression Or Intrinsic bronchial Obs
Difference b/w Aspiration pneumonia and aspiration pneumonitis
Pneumonia due to aspiration of oral cavity anaerobes
Pneumonitis due to aspiration of gastric contents with subsequent acid injury
Triad of Aspiration pneumonia
Present days after aspiration event
SxS are fever, cough, increases sputum and can progress to abscess
T/m Augmentin Or Clindamycin
Triad of Aspiration pneumonitis
Present hours after aspiration events
Range from No SxS to non productive cough and respiratory distress
Supportive t/m with no Abx
How to define Solitary lung nodule?
Round in opacity with less than 3cm and completely surrounded by pulmonary parenchyma
With associated lymphadenopathy, pleural effusion Or atelectasis
What to do if patient has solitary lung nodule on CXR and previous CXR doesn’t show any change in nodule?
No further testing
What to do if patient has solitary lung nodule on CXR and previous CXR (not taken) or shows changes?
Do CT scan chest
If shows benign changes just do serial CT
If shows highly suspicious for malignancy do surgical excision
What to do if patient has solitary lung nodule on CXR and previous CXR (not taken) or shows changes?
Do CT scan chest
If shows intermediate or Suspicious for malignancy then investigate with biopsy Or PET
Important information for lung nodule suspicious for malignancy
Percutaneous biopsy preferred than bronchoscopy
Do bronchoscopy if lesion is more than 2cm
What to do if the size of lung nodule is ≥8mm?
If FDG-PET Or biopsy shows;
- Suspicious of malignancy do surgical excision
- not Suspicious of malignancy do surgical excision » do serial CT scan » if CT shows growth then do surgical excision
What to do if the size of lung nodule is ≤8mm?
If size is b/w 5-7mm » do serial CT scan » shows growth then do surgical excision
If size is ≤4mm » No risk of malignancy » no follow up OR intermediate risk of malignancy » do serial CT scan » if CT shows growth then do surgical excision
What are the Risk factors for high malignancy risk for solitary lung nodule?
If nodule size >2cm with corona radiata or spiculate margins
60 years old
Smoker Or cessation of smoking less than 5 yrs
What are the Risk factors for low malignancy risk for solitary lung nodule?
If nodule size <0.8cm with smooth margins
40 years old
Never smoke Or cessation of smoking more than 15 yrs
What are the risk factors for intermediate malignancy risk for solitary lung nodule?
If nodule size b/w 0.8-2 with smooth scalloped margins
40-60 years old
Smoker Or cessation of smoking b/w 5-15yrs
Test to screen lung cancer
Low dose CT chest
Recommended age to screen lung cancer
55-80
To whom to screen for lung cancer on the basis on smoking?
Patient has ≥30yr pack year Hx of smoking
Or
Currently smoking Or quit smoking within the last 15 years
At what age screening of lung cancer is terminated?
Age more than 80 yrs
Indications to terminate screening of lung cancer
Quit smoking ≥15 yrs
Or
Co morbid which limit life expectancy Or ability/willing to undergo for surgery
Important information
.
COPD (causing hypoxemia) alone in the absence of occult malignancy DOES NOT cause clubbing.
COPD + clubbing search for occult malignancy
Most common causes of digital clubbing
shunt
lung malignancies
cystic fibrosis
and right to left cardiac shunt
Traid of Pancoast tumor
Shoulder pain
Horner syndrome SxS
Sensorimotor SxS due to compression of brachial plexus C8-T2
How Horner syndrome occurs due to Pancoast tumor?
Due to involvement of Paravertebral Sympathetic chain and inferior cervical ganglion
Important information regarding Pancoast tumor
Pt can also develop ↑ sympathetic activity ↑ flushing and sweating on contralateral side of face during exercise (Harlequin sign)
Why hoarseness occurs in Pancoast Tumor?
Due to Involvement of Recurrent larnygeal nerve
Causes of Lung abscess
Aspiration of Oropharyngeal contents
Bronchial Obstruction
What will be seen on CXR of lung abscess?
Air fluid level which might suggest cavitation
Name the bacteria which would cause Pancoast Tumor
Anaerobes (bacteroides, Fusobacterium, Peptostreptococcus)
S aureus
Triad of pulmonary aspergillosis
Fever
Hemoptysis
Pleuritic chest pain
Imaging findings of lungs in Aspergillosis
Single Or Multiple nodules
Cavities
Consolidation
Peribronchial Infiltrates
How to t/m invasive aspergillosis?
Caspofungin Or
Voriconazole
What is the T/m of Aspergilloma?
Surgical resection
Risk factors for invasive Aspergillosis
Immunocompromised due to;
Low neutrophil
HIV
Steroids
Risk factors for pulmonary aspergillosis
Pre existing lung Diseases like tb Or Lung damage
DDx of masses in Anterior mediastinum
Remember 4Ts
T = Thymoma T = Thyroid T = Teratogenic T = Terrible lymphomas
DDx of masses in Posterior mediastinum
Neurogenic tumor like neurofibroma
Multiple myeloma
DDx of masses in middle mediastinum
Esophageal Carcinoma
Hiatal hernia
Bronchogenic cysts
Mets
Name the organism could cause chronic mediastinitis
Histoplasma capsulatum
Causes of Mediastinitis
Post operative Cardio thoracic procedures
Esophageal perforation
Contiguous spread of Retropharyngeal infection Or odontogenic infection
What is Hamman signs?
Crepitus on cardiac auscultation
How Pulmonary arterial HTN occur in ARDS?
Low O2 leads to hypoxic vasoconstriction
Destruction of lung parenchyma
Compression of vessels due to Positive airway pressure
Name the medicine which are contraindicated in Pul-Embolism if patient has deranged Renal function test
LMWH like enox
Factor Xa direct inhibitor “xaban”
Fondaparinux
Name the 3 famous cause of Chronic cough
Chronic cough
Upper airway cough syndrome
GERD
Asthma
Triad of Non allergic rhinitis (Vasomotor rhinitis)
Erythematous nasal mucosa
Late onset after 20 yrs of age
Nasal congestion with rhinorrhea and postnasal drainage
How to manage Non allergic rhinitis?
Mild—> Intranasal antihistamine or steroid
Moderate to severe—> combination therapy
Triad of Allergic rhinitis
Pale / bluish nasal mucosa
Positive allergic disorder
Sneezing with water rhinorrhea and eye sxs
How to t/m allergic rhinitis?
Intranasal steroid
Antihistamine
Important point of Acute Exacerbation of COPD
There is no role of Inhaled steroid (use Oral or IV)
What are the cardinal sxs of Acute Exacerbation of COPD?
Increase SOB
Increase cough frequency or severity
Increase sputum production
How to manage Acute Exacerbation of COPD?
IV bronchodilator with systematic Steroid (IV or Oral)
Supplemental O2
Give Abx if more than 2 cardinal Sxs
If fail—>Give NIV–>FAIL —-> tracheal intubation
Important point of GRANULOMATOSIS WITH POLYANGIITIS
narrowing and ulceration of trachea involved
What to do if patient has positive screening test of TB?
Get CXR and decide Latent Vs active Tb
What does mean by latent TB?
Positive screening test with negative CXR and asymptomatic Patient
Triad of Lung Abscess
Fever with night sweats and Wt loss
Putrid sputum in cough
Cavitary imaging with air fluid levels on imaging
How to treat lung abscess?
Mero / sulbactum / Imipenem
Alternative—-> Clindamycin
No use of culture as condition cause by multiple bacteria
Important point of Pulmonary embolism
Increase minute ventilation due to increase RR
Important point of Obesity hypoventilation syndrome (Obesity related restrictive pattern)
There will be Restrictive pattern in PFT
Vital capacity and tidal volume Decrease result decrease Minute ventilation
How extra-pulmo restrictive lung disease affect pft?
Due to dimished chest wall and spinal mobility there will be mild reduced VC and TLC but FEV1/FVC normal
Whereas in Pulmo-restrictive lung disease, reduce volume and capacity just increase in FEV1/FVC ratio
How to Approach proximal DVT treatment along with pulmonary embolism with unstable vitals OR Massive proximal DVT with severe swelling or limb threatening ischemia?
Give Thrombolytics if no CI
If contraindications or no response—>mechanical or surgical thrombectomy OR iliac stenting
How to Approach proximal DVT treatment WITHOUT pulmonary embolism with unstable vitals OR Massive proximal DVT with severe swelling or limb threatening ischemia?
Give anticoagulant If no CI
If CI or no response—-> IVC filter
Triad of Pul fat embolism
Petechiae
Pulmonary Infiltrates with hypoxia
Alter mentation
What patient are at risk for lung abscess and how to dx it?
Fits or dysphagia or substance abuse –> chance of aspiration
X-ray chest shows —> Cavitary Infiltrates with air fluid level
Culture rarely useful
How patient with lung abscess present?
Subacute Fever with night sweat
Wt loss
Cough with putrid sputum
How to treat lung abscess?
Augmentin or Imipenem or Meropenem
Alternative—> Clindamycin
How to manage suspected Or confirmed flu Infection?
1) If w/o risk Factor for it complications—>no testing and symptomatic tx
2) If with risk Factor ( like age ≥65 yrs, Comorbids, pregnancy) or those without riskf factor reach hospital within 48 hrs —> Osetlamivir
How Decrease in Interpleural pressure leads to transudative effusions?
Decreases inter pleural pressure seen in atelectasis
Reduced peri vascular pressure pull fluid across the vascular membrane into the pleural space
What Parameters are required to extubate patient from vent (or undergo spontaneous breathing trial)?
Use Rapid shallow breathing index (also use for spontaneous breathing trial)
pH>7.25
PO2>60mmHg on minimal support like fiO2 and PEEP less than (40 and 5) respectively
Intact Respiratory effort and sufficient mental alertness to protect the airway
How Lemierre Syndrome present?
Cause is fusobacterium Necrophorum
Oropharyngeal sxs sore throat, dysphagia, fever or neck pain and swelling
(due non exudative tonsillitis or pharyngitis)
Follow by involvement of neurovascular structures like internal jugular vein thrombosis—>septic emboli form which particularly involved lungs
How to dx and t/m Lemierre Syndrome?
Culture of Blood or pus
Tx:
IV Abx with airway secured
Surgery incase of refractory to Abx
