Chronic Cough & Hemoptysis (Johns) - W3

Question 1

How does chronic cough present?

Answer 1

more than 3 weeks.

Question 2

What should you consider when diagnosing chronic cough?

Answer 2

• Postnasal drip
• Asthma
• GI reflux
• URIs
• side effect of ACE
• smoker

Question 3

2 central acting cough medications for chronic cough

Answer 3

codeine vs. dextromethorphan

Question 4

What are sources of vascular origin hemoptysis?

Answer 4

Bronchial arteries - are at systemic pressure, unlike the pulmonary arteries

Question 5

Differential diagnois of hemoptysis:

Answer 5

• acute or chronic bronchitis
• neoplasms
• airway traumua
• infection
• TB
• cocaine use
• pulmonary ebolism
• immune disorder
• AV malforamtion

Question 6

Diagnosis for hemoptysis

Answer 6

History and physical.

Chest x-ray.

CBC, UA, creatinine, coags.

Bronchoscopy.

Question 7

When do you do a bronchscopy for hemoptysis?

Answer 7

• patient has normal CXR but still coughing up blood and has risk factors:
  
  • male sex
  • older than 40
  • smoking > 40 pack years
  • hemoptysis > 1 week.

Question 8

What could be complimentary to a bronchoscopy (it’s a test)

Answer 8

CT

• however, it can’t detect bronchitis and small mucosal lesions
• COMPLIMENTARY - best to do bronchscopy first.

Question 9

What thrombi are source of most PEs?

Answer 9

iliofemoral thrombi or pelvic veins

Question 10

Risk factors for PE

Answer 10

immobilization

surgery within 3 months

stroke

history of thromboembolism

malignancy

obesity

heavy smoking

women - birth control pills, pregnancy

hypertension

air travel > 3,000 miles

Question 11

What could be causes if pulmonary emboli occurs without risk factors?

Answer 11

1. factor V leiden mutation (40%)
2. high concentrations of factor VIII
3. occult malignancy (up to 17%)
   
   1. pancreatic, prostate

Question 12

Patient presents with dypsnea, pleurtic pain, cough and hemoptysis. Physical exam shows tachypnea, crackles, tachycardia, loud P2, and slight fever. What is the diagnosis?

Answer 12

pulmonary embolism

Question 13

What is a loud P2 indicative of?

Answer 13

pulmonary hypertension

Question 14

What can be used for clinical assessment of pulmonary embolism?

Answer 14

ABG’s

ECG’s

CXR

D-dimer

CT - sensitive and specific

Ventilation-perfusion scan

Question 15

What is the issue with using CT for diagnosis of PE?

Answer 15

need contrast, but contrast can’t be used with allergy or renal insufficiency.

Question 16

What is shown in the image? PE?

Answer 16

Normal CT scan (no PE)

can see pulmonary trunk, left and right pulmonary artery

Question 17

What is shown in the image?

Answer 17

Pulmonary embolism

Question 18

do you anticoagulate if there is a low pretest and normal Ddimer?

Answer 18

NO

Question 19

What should you do if there is a moderate or high pretest proability for PE?

Answer 19

proceed with CT.

Question 20

What should you do if there is a high pretest probability with normal CT

Answer 20

conisder angiography

Question 21

What is the treatment for PE?

Answer 21

1. Heparin (LMWH is good)
2. Warfarin - overlap for at least five days w/heparin
   
   1. use instead then on for 6 months.
3. thrombolytics (massive PEs w/hypotension)
4. inferior vena caval filter - patients w/contraindication for anticoagulation or recurrent PE despite anticoagulation.