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Quarter 3 > Clin Med Exam 2 > Flashcards

Clin Med Exam 2 Flashcards

1
Q

Coin Lesion

A

<3 cm SMALL well defined bordered lung lesion- completely surrounded by pulmonary parenchyma

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2
Q

Coin lesion

A

<3 cm
not assoc w/ infiltrate, atelectasis, or adenopathy

Most BENIGN
smooth edges

dense central calfification

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3
Q

Coin Lesion (SPN)

A

<3 cm

most common are infectious granulomas

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4
Q

Mass

A

> 3 cm

more likely Cancerous

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5
Q

After what age, chance of an SPN being malignant increases to 50%?

A

60 or older!!

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6
Q

Risk factors for SPN being malignant

A

Obvious ones: tobacco, family hx, previous CA, asbestos

ALSO:
Female> Male, emphysema

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7
Q

SPNs in AZ

A

good chance it is Cocci 60% are

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8
Q

1st step approach to SPN

A

Review old films

Malignant nodules usually double in 1-13 months

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9
Q

Minimal growth of SPN

A

minimal in 2 years suggests BENIGN lesion

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10
Q

Calcification of SPN

A

usually benign

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11
Q

No calcification of SPN

A

bad sign

Increase risk of Malignancy

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12
Q

Size of lesions

A

<3cm is considered Small Pulm Nodule (SPN)

IF 5 cm or greater = 90% CA

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13
Q

Preferred imaging for SPN

A

Helical CT WITHOUT contrast with low dose radiation

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14
Q

Helical CT without contrast details:

A

thin 1 mm sections

Most reliable for: nodule size, growth, lobar location, density and borders

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15
Q

Solid nodule > 8mm and Low probability, what next?

A

CT at 3 months
no growth: another CT at 9-12 and 18-24

growth: pathologic eval

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16
Q

Solid nodule > 8mm and Intermediate probability, what next?

A

FDG PET/CT and or Biopsy

CT again at 3, 9-12, and 18-24 months

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17
Q

Solid nodule >8mm and High probability, what next?

A

Biopsy or excision!!! not only CT in this case- need to do more

Staging with PET/CT may be helpful

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18
Q

Solid nodule 6-8 mm

A

Follow w CT at 6-12 months, repeat as indicated

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19
Q

Solid nodule < 6mm

A

does not require f/u

CT at 12 months is optional (pt dependent)

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20
Q

Indications for Referral

A

New/enlarging lesion
Lesion is, unstable, not calcified, irregular shape, >3cm
Lesions are are indeterminate

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21
Q

Small cell CA is associated with

A

SIADH, Cushings syndrome, Eaton Lambert Synd, and Mets to BRAIN

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22
Q

Staging of Small Cell

A

Limited (to ipsilateral hemithorax) vs Extensive (extends beyond hemithorax, includes pleural effusions)

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23
Q

Staging of Non Small Cell

A

“T-N-M”
T: primary tumor
N: nodal involvement
M: distant Mets

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24
Q

Performance status

A

0: fully active
1: strenous PE restricted, but able to carry out light work
2: capable of all self care, but unable to carry out work activities, about 50% of waking hours
3: capable of only light, limited self care
confined to bed >50% of waking hours
4: completely disabled, cannot carry out any self care

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25
Q

If FEV1 is <60% and Lung CA

A

<60 is the strongest indicator of post-op complications

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26
Q

What is used in PET scans

A

FDG

Fluorodeoxyglucose

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27
Q

Downfall of PET scan

A

does not detect all CA (i.e. bronchoalveolar CA)

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28
Q

Air is

A

Black on X Ray

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29
Q

Bone is

A

White on X Ray

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30
Q

Fluid is

A

Grey on X Ray

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31
Q

PA (posterior anterior view)

A

Good for X Ray bc it doesn’t falsely enlarge the heart

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32
Q

Systematic approach for reading CXR

A 
A-airway (trachea midline?)
B- bones (fracture)
C- cardiac outline
D- diaphragm (free air?)
E- edges (pleural plaques, effusion?
F- fields (infiltrates, nodules?)
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33
Q

PA and Lateral view of CXR allow us to see

A

structures behind the heart and diaphgram

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34
Q

PA and Lateral decubitis CXR

A

good to evaluate for PNA vs effusion

with effusion (Fluid) will lay out when person lies down

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35
Q

Pulmonary infarct

A

“Hamptons hump” on CXR

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36
Q

CT

A

a bunch of cross sectional slices thru body

a bunch of X ray slices

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37
Q

Indications for CT

A 
Clarify abnormal CXR
Characterize pulm nodules
Assist in dx of clinical sx
Detect and Stage CA
Evaluate suspected mediastinal or hilar mass
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38
Q

Conventional CT scan

A

10 mm slice
Step and shoot
25-30 min

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39
Q

Helical (spiral) CT

A

Faster
Continuous
<5 minutes

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40
Q

HRCT

A

1mm slice

best detail

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41
Q

Low dose CT

LDCT

A

Used for Screening

less detail

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42
Q

CT angiography

A

CTPA

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43
Q

Special populations to consider with CT scans

A

Peds- more radiosensitive than adults, inc risk of leukemia and brain tumors, radiation risk compounded d/t lifespan

Pregnant- in utero exposure linked to pediatric CA mortality

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44
Q

CT WITH contras

A

Iodine

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45
Q

When is contrast needed with a CT?

A

Vessels
Malignancy
Trauma

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46
Q

3 main risk of Iodine contrast with a CT scan

A
  • Allergic rxn
  • Contrast induced Nephropathy (kidney)
  • Lactic acidosis (if taking glucophage/Metformin)
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47
Q

Allergic rxn to Radiocontrast

A

5-60 min after exposure
Risk factors: prior rxn, hx of Asthma or Atopy

Pre-tx with Prednisone and Diphenhydramine (benadryl)

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48
Q

CIN- Contrast Induced Nephropathy

A

Increased serum creatinine >/ -.5 or >/ 25 % from baseline

1-2 day after exposure, peaks at 3-5 days

Usually reversible

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49
Q

Caution using contrast in pts with impaired kidney fx

A

Creat > 1.5
GFR <60
Use alternative (CT without contrast, MRI without gadolinium, or US)

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50
Q

Check Renal fx prior to giving contrast IF

A 
>60 YO
Renal dz
HTN on meds
Diabetes
Taking Glucophage
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51
Q

CTPA

A

replaced conventional catheter directed pulmonary angiography

less invasive, less $, and less time

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52
Q

CTPA

A

detect PE, Aortic dissection, SVC syndrome

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53
Q

Gold standard in evaluation of PE (even though it is invasive)

A

Catheter-directed Pulmonary Angiography

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54
Q

Catheter directed pulmonary angiography (invasive)

A

Needle/catheter is inserted into R femoral or internal jugular vein; into R side of heart and pulmonary arteries

Dye is injected and X rays taken

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55
Q

When is catheter directed pulmonary angiography especially useful?

A

When V/Q scan or CTPA is inconclusive BUT high clinical suspicion for PE

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56
Q

MRI has limited use in Pulmonary field, BUT use if

A

Hilar or mediastinal density
Sulcus tumor (pancoast)
Cyst/lesion of chest wall

HIGH QUALITY images of blood vessels

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57
Q

If person is allergic to Iodine (used in CT)

A

can do MRI with Gadolinium instead

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58
Q

MRI is less detailed for

A

Lung parenchyma (compared to CT chest)

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59
Q

No bone artifact seen on

A

MRI

AND no ionizing radiation

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60
Q

Limitations with MRI

A

Claustrophobia

Nephrogenic Systemic Fibrosis- avoid use of Gadolinium if GFR <30

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61
Q

Possible contra to MRI

A

Implanted pacemaker/defib
Metal in eye
Aneursym clip in brain
Cochlear implant

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62
Q

V/Q

A

Evaluate PE and

Pre-op assessment (before lung resection)

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63
Q

V/Q process

A

IV phase (perfusion): Tach 99 labeled to albumin

Inhalation (ventilation): radio labeled Xenon gas

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64
Q

Test of choice to dx PE in pregnant woman

A

V/Q scan

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65
Q

V/Q scan is best utilized in:

A

pts with normal CXR and high suspicion for PE

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66
Q

Absolute contra for V/Q?

A

NONE

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67
Q

PET

A

Standardized uptake value (SUV)

>2.5 raises possibility of CA

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68
Q

Indications for Ultrasound in the Pulmonary field

A

Bedside detection of pleural fluid, hemothorax, or pneumothorax
Guide thoracocentesis
Place thoracostomy tubes

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69
Q

Normal lung on US

A

Positive motion lung beach “seashore sign”

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70
Q

Diseased lung with no chest wall motion (pneumothorax) on US

A

“Barcode/stratosphere sign”

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71
Q

Bronchoscopy

A

Diagnostic and therapeutic

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72
Q

Bronchoscopy Dx indications

A

Evaluate PNA, hemoptysis, cough
Dx tracheoesophogeal fistula/tracheobronchomalacia
Tissue sampling

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73
Q

Bronchoscopy Therapeutic

A

Remove excess mucus or FB

ET tube placement

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74
Q

Contraindications to Bronchoscopy

A 
Severe hypoxia
Bleeding risk
Pulm HTN
Severe cough/gag
Tracheal stenosis
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75
Q

How to perform spirometry

A
  1. relax and breathe normally
  2. deep Inhale
  3. Forceful exhale
  4. another deep Inhale
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76
Q

Forced vital capacity on Spirometry

A

Deep breath in, blow air out as fast as possible = total volume of air with max effort

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77
Q

FEV-1

A

most useful information for obstructive

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78
Q

FEV1/FVC ratio

A

Defines severity of obstruction

Diff b/w Obstructive and Restrictive

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79
Q

Ratrio

A

<0.7 is RESTRICTVE

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80
Q

Bronchodilator reversibility testing

A 
Nebulizer/inhaler
2-4 puffs 
Hold inhaled med for 5-10 seconds
Spirometry test again 15 min after med provided 
3-8 rounds of testing
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81
Q

Reversibility is positive IF

A

FEV1 increases by 12% and 200 ml with Bronchodilator testing

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82
Q

Bronchoprovocation

BUT BE CAREFUL

A

Dilute solution of Methacholine

Spirometry at 30 and 90 seconds

Positive if FEV1 decreases by 20%

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83
Q

Quality of curve must meet these parameters

A

curve plateaus
expiration >6 seconds
two best efforts w/in 0.2 L
volume loop free of Artifact

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84
Q

Obstructive

A

wide and scooped out

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85
Q

Restrictive pattern

A

Steep and overall less volume

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86
Q

DLCO

A

ability of lungs to txr gas and Saturate Hgb

misleading if person is anemic

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87
Q

DLCO technique

A

Pt inhales a single breath of gas with helium and Carbon Monoxide, expires, and measurement of exhalation is taken

Healthy lung: little CO collected (bc most of it was txr in persons lung)

Diseased lung: high levels measured in exhaled gas bc lung txr in persons body is not working well

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88
Q

Obstructive pattern

A

Can get air in, but cant get it out
High lung volumes
TLC: Increased
Ratio decreased

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89
Q

Restrictive pattern

A

Trouble getting air IN and OUT
Reduced lung volumed
EVERYTHING: decreased, except
Ratio: normal or increased

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90
Q

Most things we hear about often are Obstructive

A 
Asthma
Bronchitis
COPD
Cystic Fibrosis
Emphysema 
Obstruction
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91
Q

Examples of Restrictive

A 
Pulm Fibrosis
Infectious lung dz
Thoracic deformity
Effusion
Tumor
Neuromusc dz
Obesity
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92
Q

FEV1 value is decreased by more than 15-20% of predicted

A

OBSTRUCTIVE

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93
Q

FEV1 <80% predicted

A

OBSTRUCTIVE

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94
Q

With obstructive

A

FEV1 decreased

but TLC increased (bc person can get air in, trapped, cant get it out)

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95
Q

Ratio <70%

A

Obstructive

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96
Q

Ratio is normal or increased

A

Restrictive

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97
Q

How often to take Lung fx tests?

A

At diagnosis
3-6 months after starting tx (FEV1)
Every 1-2 yrs (more for high risk and children)

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98
Q

Asthma

A

Chronic inflammation
Intermittent and REVERSIBLE obstruction
Bronchial hyper-responsiveness

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99
Q

Often develop sx before age 5, but misdx

A

Cough (nocturnal)

Wheezing*- hallmark sx

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100
Q

Wheezing in asthma can be heard with Ins and Exp but usually heard with

A

EXP due to obstructive pattern

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101
Q

Look for signs of Severe obstruction

A 
Tripod position
Tachycardic
tachypneic
Access muscle use
Pulsus paradoxus
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102
Q

ASA Triad/ Samter’s triad

A

Sinus dz with: Nasal polyps, ASA sensitivity, severe asthma

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103
Q

Atopic triad

A

Atopic dermatitis –> (food allergy) –> allergic rhinitis –> asthma

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104
Q

Gold standard ratio of COPD for Ratio

A

<70%

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105
Q

Reversibility bronchodilator test

A

> 12% adults

>8% in young children

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106
Q

Intermittent Asthma

A

Sx 2 or less days/wk
No PM awakenings for younger, 2 or less/month for older

FEV> 80%
Ratio: normal
2 or less SABA use

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107
Q

Mild Persistent Asthma

A

Sx >2 days wk
PM awakenings 1-2/mo for younger, 3-4/mo for older

FEV >80% still
Ratio: normal
>2 days/wk SABA use

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108
Q

Moderate Persistent Asthma

A

Daily sx
PM awakenings 3-4/mo for younger, once a week for older

FEV 60-80% !!!!
Ratio: reduced!!
Daily SABA use

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109
Q

Severe Persistent Asthma

A

Sx throughout day
PM awakenings once/mo for younger, nightly for older

FEV1 <60%
Ratio reduced
Extremely limited activity
SABA use several times daily

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110
Q

Stage 1 asthma

“Intermittent”

A

SABA prn

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111
Q

Stage 2 asthma

“Mild persistent”

A

Low dose ICS daily
OR
LTRA or Cromolyn

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112
Q

Stage 3 asthma
“Moderate persistent”

consider specialist

A

Medium dose ICS
OR
(Low dose ICS + LABA)

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113
Q

Any time LABA is seen, if you are <5 YO,

A

replace with LTRA

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114
Q

Stage 4 asthma
“Severe persistent”

definitely refer to specialist

A

Medium dose ICS and LABA
OR

(Medium dose ICS + LTRA)

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115
Q

Poorly controlled Step 5 asthma

A

High dose ICS and LABA

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116
Q

Poorly controlled Step 6 asthma

A

High dose ICS and LABA and Oral steroids

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117
Q

Step 5 and 6 poorly controlled Asthma

A

Consider adding Omalizumab (Xolair) for ages 12 or greater with allergies

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118
Q

PEFT: Peak Expiratory Flow Rate

A

> 80% green: good control
50-80% yellow: SABA and med
<50%: Medical alert!!!! ED

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119
Q

Tx for Exacerbation

A 
Oxygen
SABA
Systemic corticosteroids
Abx prn
Respiratory monitoring if in ED/inpatient
Severe: C-PAP, BiPAP, intubation
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120
Q

How soon to f/u after an Acute Exacerbation of Asthma?

A

within 1 week!!

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121
Q

Small airway dz vs. Parenchymal destruction

A

Small airway- inflammation and remodeling

Parenchymal destruction- loss of alveolar attachments and elastic recoil

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122
Q

COPD former terms

A

Emphysema and Chronic Bronchitis

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123
Q

Emphysema

A

destruction of alveoli

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124
Q

Chronic Bronchitis

A

Cough and sputum >3 months in each of past 2 consecutive years

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125
Q

Small airway dz

A

Inflammation bronchial wall, infiltration of submucosal layer by NEUTROPHILs, bacterial colonization, airway hyper-reactive

Mucous glands enlarge, hypersecretion, loss of ciliary transport, bronchial squamous metaplasia

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126
Q

Parenchymal dz

A

Destruction of alveolar walls, extensive ELASTASE or ANTITRYPSIN deficiency, reduced alveolar exchange

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127
Q

Parenchymal dz structural change

A

Decreased elastic recoil

Enlargement of air spaces DISTAL to terminal bronchioles

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128
Q

Systemic effects of COPD

A 
Cor pulmonale
Cyanosis
Wt gain or loss
Resp Acidosis
Hypoxemia, Hypercapnia
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129
Q

Sx of COPD (3)

A

Chronic cough, dyspnea, Sputum production

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130
Q

Sx of CODP

A

5th or 6th decade

most common early sx: DOE

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131
Q

Elastase and relation to COPD

A

Degenerative changes in elastin and alveolar structures

Release of cytoxic oxygen radicals from WBC in lung tissue

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132
Q

A-1 Antitrypsin Deficiency

A

Hereditary
causes premature emphysema
AAT is an inhibitor of Elastase
If not present, elastase does its thing too much

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133
Q

Main sx of COPD

A

Dyspnea
Cough
Sputum production

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134
Q

PE findings of COPD

A 
Tripod
Access muscle usage
Pursed lip
Cyanosis
Tobacco staining
S3 gallop or RV lift
Muscle wasting
Peripheral edema
Barrel chest
Prolonged expiration
Dec breath sounds
Wheezing or Rhonchi
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135
Q

Pursed lip breathing

A

Keeps intrabronchial pressure high during exhalation, keeping bronchi open and allowing more air to be expelled

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136
Q

Most common cause of Cor Pulmonale

A

COPD

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137
Q

What is required to establish a COPD dx?

A

Spirometry

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138
Q

What is normal ratio?

A

70-80% of predicted OR

greater than Lower limit normal which is >5th percentile

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139
Q

Ratio of what confirms obstructive?

A

<0.7 %

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140
Q

Mild COPD

A

FEV1 >/ 80%

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141
Q

Moderate COPD

A

FEV1 50-80%

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142
Q

Severe COPD

A

FEV1 30-50%

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143
Q

Very severe COPD

A

FEV1 <30%

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144
Q

As COPD progresses, what is common?

A

Respiratory acidosis

not able to breathe off CO2

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145
Q

When is Arterial Blood Gas indicated?

A

FEV1 <50
SPO2 <92
Depressed LOC
Acute exac of COPD

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146
Q

Why do we get BNP

A

Evaluate suspected Heart Failure

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147
Q

When to get AAT (Alpha-1 Antitrypsin) lab?

A

sx in a young pt <45
Non smoker
Family hx emphysema

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148
Q

What might you see on CXR of someone with COPD?

A

Increased AP diameter
Hyperinflation and hyperlucency
Flattened diaphragm

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149
Q

Blebs/ Bullae are pathognomic for on CXR

A

Emphysema

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150
Q

Perivascular/peribronchial markings on CXR

A

Chronic Bronchitis

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151
Q

Chest CT, obtain if sx of COPD suggest

A

Complication
Alternative dx
Considering lung volume reduction surgery (order HRCT)

152
Q

ABCD assessment tool

A

mMRC and CAT questionarre

153
Q

Best predictor of having frequent COPD exacerbations (2 or more per year)

A

is a hx of earlier treated events

154
Q

Exacerbation history in the past year:

A

0-1 exacerbations: low risk

2 or more OR 1 hospitalization: High risk

155
Q

GOLD standard based on

A

FEV1

156
Q

How to classify COPD:

A

GOLD (based on FEV1), exacerbation hx, and Sx questionarre

157
Q

Vaccines imp to get for COPD pts

A

Influenza
Pneumococcal
-13 AND 23 for all pts 65 or older
-at least 23 for those younger than that

158
Q

When to give supplemental oxygen?

A

SpO2 <88

PaO2 <55

159
Q

Target oxygen sat

A

88-92%

160
Q

Initiation of meds of COPD is based on

A

GOLD ABCD and risk of exacerbation

161
Q

F/u management of COPD is based on

A

questionaries and exacerbation frequency

162
Q

Grade A COPD

A

SABA, SAMA or combo

163
Q

Grade B COPD

A

LAMA or LABA

164
Q

Grade C COPD

A

LAMA

165
Q

Grade D COPD

A

LAMA, or if severe SOB: LABA-LAMA

166
Q

Bronchodilators- B2 agonists

A

SABA- albuterol

LABA- salmeterol, formeterol

167
Q

Bronchodilators- Anticholinergics

A

Short acting- Ipratroprium

Long acting- Tiotropin, Umeclidirium

168
Q

Corticosteroids

A

Inhaled form alone
Inhaled form + LABA
Inhaled form + LABA-LAMA

169
Q

Antiprotease therapy

A

those w AAT deficiency
weekly infusions
expensive

170
Q

Acute exac of COPD triggers

A 
Respiratory illness (70% of time)
Viral often leading to bacterial
171
Q

Most common bacterial pathogens

A 
H. inf
S. PNA
M. Cat
Mycoplasma PNA
Pseudamonas
172
Q

Outpt management of COPD Exacerbations

A

Increase SABA with or without SAMA
Oral steroids- 40 mg daily x 5 days
Abx x 5-7 days

173
Q

Consider hospitalization for Acute Exacerbation of COPD IF:

A 
Severe sx
FEV1 <50%
Significant comorbid
Onset of new sx
Failure to respond to meds
Older age
Insufficient home conditions
174
Q

Acute bronchitis

A

cough >5 days

usually 1-3 wks

175
Q

Chronic bronchitis

A

Cough and sputum > 3 months for 2 consecutive years

176
Q

Acute Bronchitis

A

Self limited inflamm of bronchi d/t URI

USUALLY VIRAL

177
Q

Acute Bronchitis is viral

A

90% of time

178
Q

If Acute Bronchitis is bacterial, only tx with Abx if the causative pathogen is:

A

Bordetella Pertussis!!!

179
Q

Acute Bronchitis sx

A

cough
chest wall tenderness
wheezing

180
Q

Acute Bronchitis PE

A

Wheezing
Bronchospasm
Rhoncih- often clears with coughing

181
Q

What will you see in physical for Acute bronchitis?

A

Rhonchi but NO RALES or CRACKLES

that would be signs of consolidation

182
Q

Bronchitis is rhoncy

A

will see RALES- that often clear with coughing

183
Q

PNA is unlikely if all of these are absent:

A

Tachycardic
Tachypneic
Fever
Consolidation on exam (crackles, fremitus, egophony)

184
Q

If pt presents with Acute Bronchitis like sx and has any of the 4 PNA warning sx, OR cough >3 wks

A

get CXR

185
Q

Tx for Acute Bronchitis

A 
NSAIDs
Intranasal Ipratropium (Atrovent)
Antitussive (dextro..)
B2 agonist- Alubterol
OTC lozenge

AVOID CODEINE

186
Q

1st phase of Pertussis

A

Catarrhal
URI sx and fever
1-2 wks

187
Q

2nd phase of Pertussis

A

Paroxysmal
“whooping” and post tussive emesis
2-6 wks

188
Q

3rd phase of Pertussis

A

Convalescent
cough resolves
wks-months

189
Q

Gold standard for Pertussis dx

A

Bacterial culture

190
Q

Timing overlap for Pertussis dx

A

0-2 wks: bacterial culture
0-4 wks: PCR
2-8 wks: Serology

Culture, PCR, then Serology

191
Q

Pertussis tx: start Empiric therapy while waiting for results to come back

A

Abx decreases spread but might not make pt feel much better

192
Q

Tx for Pertussis (adults)

MACROLIDES

A

Azithro 500 followed by 250x 4 days
Clarithro 500 BID x7days
Erythro 500 QID x14 days

193
Q

Alternative tx for Pertussis for Adults if they can’t take Macrolides

A

Bactrim BID x14 days

194
Q

Children tx for pertussis

A

69% of children <6 mo need admission
sx control
MACROLIDES

195
Q

Vaccinate for Pertussis

A

T dap booster recommended as teen

196
Q

Abx prophylaxis for Pertussis

A

Recommended for:

  • close contact exposure
  • home,work,school,daycare
197
Q

High risk populations for INFLUENZA

A 
<2 YO
65 or older
Underlying chronic dz
Immunosupp
Pregnant
Morbidly obese
Nursing home
198
Q

Influenza presentation

A

ABRUBT onset
fever, HA, myalgia, malaise
Chest exam usually negative unless PNA

199
Q

Influenza dx

A

RIDT (rapid influenza diagnostic test)
10-30 min

low-mod sensitivity
high specificy
can get FALSE NEGATIVE

200
Q

Most sensitive and specific dx test for Influenza

A

RT-PCR 2-6 hours

201
Q

Viral culture for Influenza

A

48-72 hours

Confirmatory (public health surveillance) but not used for initial clinical mgmt

202
Q

Influenza

A

generally improved 2-5 days

203
Q

PNA

A

Acute INFLAMMATION of pulmonary PARENCHYMA

Inflammation and consolidation of lung tissue from infectious agent

204
Q

PNA

A

inflammation and consolidation of parenchyma (consolidation is when normally compressible tissue becomes filled with fluid)

205
Q

CAP epidemiology

A

M> F

African american> caucasion

206
Q

CAP transmission most common cause

A

Aspiration from oropharynx (right behind soft palate)

207
Q

CAP pathophys

A

Alveolar macrophages can no longer handle the bacterial load coming into the alveoli

208
Q

Macrophages response to being overload by bacteria in PNA

A

initiate an inflammatory response to recruit help

209
Q

Most common bacterial cause of Typical PNA

A

Streptococcus. PNA

210
Q

Most common cause of Atypical PNA

A

Mycoplasma PNA

211
Q

Atypical PNA can be

A

Bacterial
Fungal
Viral

212
Q

CAP risk factors

A 
Asthma
Immunosupp
70 or older
Alcoholism
Instutionalism
213
Q

Risks for Pneumococcal PNA specifically

A 
Dementia
Seizure
HF
CVD
Alcoholism
Smoking
COPD
HIV
214
Q

CAP typical presentation

what makes it different?

A

ACUTE onset
FEVER

cough
sputum
dyspnea
night sweats*
pleuritic CP
CP, chills, rigor*
215
Q

CAP physical exam

A

Decreased or bronchial breath sounds
crackles/rales
Signs of CONSOLIDATION: dullness to percussion, increased fremitus, bronchopohony, egophony

216
Q

CAP dx

A

Leukocytosis with left shift

CXR: Infiltrate!

217
Q

CAP dx Gold Standard

A

Infiltrate on plain CXR

218
Q

May also see this in CAP on CXR

A

Lobar consolidation
Interstitial infiltrates
Cavitation

219
Q

Urine antigen tests for CAP will only show two things

A

Legionella and S. PNA

220
Q

Tests to help with choice and duration of Abx when treating CAP

A

Procalcitonin and CRP
(inflammatory markers)

can also help tell bacterial vs viral

221
Q

Sputum cultures with PNA not entirely helpful bc

A

diff to produce

can be from resp tract and not lungs/lower airway

222
Q

CURB 65 to classify PNA

A 
Confusion
Urea >7, BUN >20
RR 30 or more
BP systolic <90, diastolic 60 or less
65 or older age
1 point for each
223
Q

CURB 65 score (1 pt for each)

A

0-1 outpatient
2 ADMIT
3-5 possible ICU

224
Q

CAP tx

A

AT LEAST 5 days

225
Q

Sx resolution with CAP

A

fever: 3 days
cough/fatigue: 14 days
at least 1 sx left: 38 days

226
Q

RETURN TO WORK after CAP

A

6 days

227
Q

F/u CXR for CAP?

A

only if >40 YO or
smoker

get one in 7-12 wks

228
Q

Uncomplicated CAP

previously healthy and no abx use in previous 3 mo

A

Macrolide: Azithro 500 day 1 then 250 x 4 days

OR

Doxy 100 BID x7-10 days

229
Q

Complicated CAP

A

B-lactam + Macrolide
Amoxicillin-clavulanate 500 BID + Azithro

OR

Fluoroguinolone: Levofloxacin 750 x5 days

230
Q

If you are treated for CAP, must meet these parameters in order to be able to go home:

A 
>5 days abx
Afebrile for 48-72 hrs
Supp O2 not needed
HR <100bpm
RR <24
Systolic at least 90
231
Q

Who should get Pneuomcoccal vaccine?

A

65 or older

19-64 if you are high risk (CVD, sickle cell, tobacco, splenectomy, liver dz)

232
Q

CAP tx uncomplicated

A

Macrolide (azithro) or Doxy

233
Q

CAP tx complicated

A

Beta lactam + Macrolide
OR
Resp Fluoroquinolone

234
Q

HAP

A

48 hrs or more after admission and was not sick at time of admission

235
Q

Highest risk for Hospital acquired PNA

A

ICU

Pseudomonas has the worst prognosis

236
Q

Ventilator assoc PNA

VAP

A

48-72 hrs after endotracheal intubation

237
Q

HAP/VAP pathophys

A

Altered upper respiratory tract flora

238
Q

HAP/VAP dx

A

New or progressive INFILTRATE on lung imaging AND at least 2:

  • Fever
  • Purulent sputum
  • Leukocytosis
239
Q

Diagnosing HAP or VAP

A

Sputum gram stain and culture are indicated

(expectorated or suctioned secretions

240
Q

prevention of VAP (ventilator)

A

Avoid acid blocking meds PPIs

+ others

241
Q

Pneumocystis Jirovecii PNA

A

PCP nickname used
now considered Fungi
ASSOC w HIV!!!

242
Q

PJP/ PCP sx

A

Fever, cough, progressive dyspnea, extra-pulm lesions

243
Q

PJP/PCP

ASSOC W HIV

A

High LDH
Low CD4
CXR: Reticular, ground glass opacities
Sputum: may require broncheoalveolar lavage

244
Q

Tx for PCP/PJP

Assoc W HIV

A

Bactrim!!

And do prophylaxis in HIV pts with:
hx of previous PCP
CD4 <200
Oropharyngeal thrush

245
Q

Aspiration PNA

A

displacement of gastric contents into the lung

Microbio: Gram (-) and anaerobic

246
Q

Risk factors for Aspiration PNA

A 
Post-op
Neuro compromise (Parkinsons, CVA, ALS, sedation)
Anatomical defect or aberrancy
247
Q

Aspiration PNA

A

often in RLL because R main bronchus is more straight

248
Q

ILD also referred to as DPLD

A

commonly involves extensive distortion of airway and alveolar compartment, alone w interstitium

249
Q

ILD

A

progressive scarring of lung tissue

250
Q

ILD Pathophys

A

Process of fibrosis and aberrant healing

Sometimes inflammatory but NOT infectious

251
Q

ILD sx

A

Progressive DOE
Dry cough

extrapulm sx: MSK pain, weakness, joint pain, fever, dry eyes

252
Q

Physical Exam of ILD

A

Crackles at bases (velcro)

Inspiratory squeaks

253
Q

Physical Exam of ILD

A

Digital clubbing assoc w advanced dz only in certain types

254
Q

Erythema Nodosum

A

Sarcoidosis

255
Q

Gottron papule

A

Dermatomyositis

256
Q

Highest yield for a NON-INVASIVE test in diagnosing ILD

A

HRCT

High resolution CT

257
Q

Gold standard for dx ILD

A

Tissue biopsy

258
Q

Most common CXR finding associated with ILD

A

Reticular “netlike”, nodular, or mixed pattern of opacities

259
Q

Honeycombing

A

small cystic spaces

POOR PROGNOSIS

260
Q

Which type of ILD is most Steroid responsive?

A

NSIP

Non specific Interstitial PNA

261
Q

Which type of ILD is considered the worst pattern?

A

Usual interstitial PNA

262
Q

To r/o Auto-immune dz when dealing with ILD, order:

A

ANA
RF- rheumatoid factor
CCP- Citrullinated peptide

263
Q

To evaluate for Vasculiitis when dealing with ILD, order:

A

ANCA
Antiphospholipid
Antistreptococcal antibodies

264
Q

Most ILD are consistent with

A

Restrictive pattern

265
Q

Diffusing Capacity of Lungs for Carbon Monoxide

A

may be the only finding in some cases of ILD

normal: 80% of predicted

266
Q

Bronchoalveolar Lavage

A

Allows sampling from distal airways and alveoli

-Cell counts, cultures, cytology

267
Q

Gold standard for ILD

A

Lung biopsy

268
Q

Indications to get lung biopsy

A

Inability to specify dx (age <50, fever, wt loss, hemoptysis, signs of vasculitis)
Atypical/ rapidly progressing HRCT findings
Progressive course of dz
Unexplained extra pulm sx

269
Q

Types of Lung biopsy

A

Transbronchial- CENTRAL locations

Surgical- Video assisted (small incisions, safer) vs Thoracotomy (5-6 cm incision)

270
Q

Lung biopsy

A

Endobronchial US guided transbronchial needle aspiration
EBUS-TBNA
Special to evaluate Hilar and Mediastinal lymphnodes

Esp useful if SARCOID suspected!!

271
Q

Idiopathic Pulm Fibrosis

A 
>50 YO 
Males
"Usual Interstitial PNA"
Most common ILD!!
Poor prog: 2-5 year survival from time of dx
272
Q

Sx special to Idiopathic Pulm Fibrosis

A 
Velcro crackles (insp)
Digital Clubbing in 25-50%
273
Q

Imaging findings of Idiopathic Pulm Fibrosis

A

bibasilar reticulonodular opacities

274
Q

Echocardiogram results for Idiopathic Pulm Fibrosis

A

Pulm HTN present in 20-40%

275
Q

Need HRCT if

A

UIP pattern
Probable UIP
Indetermined UIP
Alt dx

276
Q

Surgical Lung Biopsy + Bronch Lavage indicated if

A

Probable UIP
Indetermined UIP
Alt dx

277
Q

Pharm options for Idiopathic Pulm Fibrosis

A

Nintedanib (TKI)

Pirfenidone

278
Q

Ivan IPF

A

Male
60 ish
Common man
smoker

279
Q

Sarcoidosis

A

Multisystem inflammatory
Non-caseating granulomas
Secrete ACE

280
Q

Sarcoidosis

A

African American
Female
20-40 YO

281
Q

Extra pulm findings assoc w Sarcoidosis

A

Erythema nodosum
Lupus pernio (face rash)
Granulomatous uveitis
Arthralgias

282
Q

CXR of Sarcoidosis

A

Hilar adenopathy

283
Q

Lab testing of Sarcoidosis

A

Elevated ACE
Elevated Calcium
Elevated Alk Phos

284
Q

Biopsy usually required for Sarcoidosis

A

EBUS-TBLB

285
Q

Tx for Sarcoidosis

A

Does not require tx unless stage 2

most spontaneously resolve

286
Q

Stages of Sarcoidosis

A

1: Hilar adenopathy
2: Hilar adenopathy + diffuse infiltrates
3: only diffuse parenchymal infiltrates
4: pulm fibrosis

287
Q

Tx for Sarcoidosis

A

Treat if stage 2 and sx-atic

Inhaled corticosteroids, topical for cutaneous, ocular dz
HIGH DOSE STEROIDS
-taper within 6 months to 10 mg/day

288
Q

With steroid tx of Sarcoidis

A

put pt on PJP prophylaxis

289
Q

Stage 4 Sarcoidosis

A

consider Lung transplant

290
Q

Sally sarcoidosis

A

Female African American
30s
Non-smoker
She’s an ACE with Hilar adenopathy

291
Q

Pneumoconiosis

A

general term for 3 subtypes of lung dz caused by INHALATION and deposition of mineral dust

292
Q

Silicosis

A

Fibronodular lung dz
Inhale silica dust
Mining
Smoking increases risk

293
Q

Silicosis

A

Acute and Chronic
Acute is rare: would be d/t massive/rapid exposure (sandblasters)
“Crazy paving” pattern on HRCT

294
Q

Coal workers Pneumoconiosis- CWP

A

Black lung

inhaled coal dust

295
Q

Silica and Coal workers

A

CXR, then HRCT

296
Q

Chronic simple Silicosis & Coal workers

A

10-12 yrs exposure
May be A-sx
Stops progressing once exposure is eliminated

297
Q

Chronic simple Silicosis & Coal

A

Hilar node calcification (egg shell)

Small, round, nodular opacities on CXR

298
Q

Chronic COMPLICATED Silicosis and Coal workers

A

> 20 yrs exposure
Progressive even after exposure gone
Conglomerate masses- CAVITATION from ischemic necrosis or concomitant TB

Angel WING
HONECOMBING on HRCT

299
Q

Not much to do tx wise for Silicosis or Coal workers

A

Steroids may help in ACUTE Silicosis only

300
Q

Asbestos

A

no specific sign/sx
Insidous onset: nonspecific chest discomfort
End-inspiratory Rales
Digital clubbing

301
Q

Asbestosis

A

Lower lung opacity

PLEURAL PLAQUES

302
Q

Hypersensitivity Pneumonitis

A

Fungi, mold, bird droppings, FARMS

REVERSIBLE process

303
Q

Hypersensitivity Pneumonitis

A

PE: diffuse bibasilar crackles, fever, tachypnea, muscle wasting, clubbing, weight loss

304
Q

Tx for Hypsersensitivity Pneumonitis

A

Corticosteroids may speed recovery in severe dz

Otherwise, remove triggers

305
Q

Granulomatosis with Polyangiitis (GPA)

A

Immune mediated
Systemic vasculiits of sm-med vessels
ANCA
Necrotizing granulomas

306
Q

GPA

A

35-55 YO
Relapse is common
Recurrent resp infections

Pulmonary infiltrates
Renal failure
RBC casts
Palpable purpura
Skin ulcers
307
Q

Necrotic, blistering purpura

Saddle nose deformity

A

GPA

Granulomatosis with Poyangiitis

308
Q

GPA- Granulomatosis with Polyangitis

A

CXR: highly variable
Chest CT: Stellate shaped periph pulm arteries “vasculitis sign”

diffuse alveolar hemorrhage

309
Q

Labs for GPA

A

C-ANCA!!!

ESR/CRP elevated

310
Q

GPA tx

A

Cyclophosphamide and Corticosteroids

311
Q

Smoking related ILD

A

Respiratory Bronchiolitis Interstitial Lung dz
Desquamative interstitial pneumotis
pulm Langerhans cell histiocytosis

Most will have sig imp or even complete remittance when stopping smoking

312
Q

Complications of ILD

A

Cor pulmonale/ Cardiovascular dz

313
Q

Smoking accounts for how much Lung CA

A

90%

314
Q

Once you hit this age, the % of a SPN being malignant increases up to 50%

A

60 YO or older

315
Q

No calcification of SPN

A

increased risk

316
Q

Malignant nodules usually double in

A

20-400 days

317
Q

Preferred imaging for SPN

A

Helical CT without contrast with low dose

easy on the person

318
Q

Small Cell-

Oat Cell CA

A

CENTRAL

Large Hilar mass with bulky mediastinal adenopathy

319
Q

Small cell-

Oat Cell CA

A

Highly aggressive-70% w METS

Sx present: cough, SOB, wt loss, debility

320
Q

Small Cell-

Oat Cell classifications

A

Limited (ipsilateral and regional nodes)
vs
Extensive (70% of time)
distant METs

321
Q

Non Small cell-

Adenocarcinoma (most common)

A

Arises frm mucous glands or any epithelial cell distal to terminal bronchioles

METs to distant organs

322
Q

Non small cell-

Adenocarcinoma

A

Peripheral nodules or masses

323
Q

Non small cell-

Squamous cell

A

CENTRAL/Main bronchus

Hemoptysis

METs to regional/close by lymphnodes

Can cavitate

324
Q

Non small cell-

Large cell

A

METs to distant organs

Aggressive clinical course- RAPID FAST doubling times

325
Q

Small Cell -

Oat Cell

A

assoc with SVC syndrome, and paraneoplastic syndromes

326
Q

Non small cell-

Adenocarcinoma

A

Most common
Peripheral
Thrombophlebitis, clubbing
Most d/t smoking

327
Q

Non small cell-

Squamous cell

A 
Central bronchi
Hemoptysis
PTH(hypercalcemia)
Hilum and Mediastinum
Slower growing
May cavitate
328
Q

Non small cell-

Large cell

A

FAST growing

primary a dx of exclusion

329
Q

Pancoast syndrome

A

superior sulcus tumor spread into shoulder causing Neuro sx frm compressing Brachial Plexus

330
Q

Paraneoplastic syndrome

A

non metastatic systemic effects that accompany a malignancy

331
Q

Cough

A

most freq occurs with Squamous cell and Small cell lung CA

332
Q

SVC syndrome

A

mostly assoc with Non small cell CA

333
Q

SVC syndrome dx

A

Superior vena cavogram = GOLD standard

334
Q

Horner’s syndrome

A

part of Pancoast syndrome
Facial involvement
injury of sympathetic nerves of face
Miosis, anhidrosis, ptosis

335
Q

Most commonly assoc with Pancoast syndrome

A

Non small cell

336
Q

Paraneoplastic syndrome

A

altered immune response to neoplasm

Hypercalcemia
Leukocytosis
Thrombocytosis
Hypercoag

337
Q

Paraneoplastic syndrome

A

PTH-like substance
Hypercalcemia
Non-small cell (Squamous)

338
Q

Paraneoplastic syndrome

A

Excess HCG production
Gynecomastia and nipple d/c
Non-small cell (Large cell)

LARGE breasts

339
Q

Paraneoplastic syndrome

A 
SIADH and Cushings (endocrine)
Eaton Lambert (neuro)

SMALL cell association (the only 3 that are small cell related)

340
Q

SIADH

A

Hyponatremia
Small cell
Irritable, confused, personality

341
Q

Cushing’s syndrome

A

Small cell

Muscle weakness, wt loss, HTN, Hirsuitism, Osteoporosis

342
Q

Eaton Lambert syndrome

A

Small cell
Immune mediated
Antibodies at Neuromuscular junction
Muscle weakness and decreased DTRs

343
Q

Brain METs from lung CA is mostly assoc with

A

Small cell

344
Q

Performance with Lung CA, when FEV1 is <60%, this is

A

strongest indicator of post-op complications

345
Q

Tx of Small cell

A

Chemo regardless of stage

80% response rate (Cisplatin + Etoposide)

346
Q

Other tx options of Small cell

A

Radiation
Proph cranial radiation
Relapse common
Surgery only <5%

347
Q

Tx of Non small cell

A

Surgical resection = tx of choice in localized dz!!

348
Q

Stage 1-3a in Non small cell with adequate pulmonary function

A

can proceed to SURGERY

349
Q

Stage 3b-4 in Non small cell

A

Palliative radiation or combo chemo

350
Q

Who do we screen for regarding Lung CA?

A

HIGH RISK
Current smoker 55-74YO with 30 PPY hx
Quit w/in 15 yrs
20 PPY hx with 1 additional risk factor

351
Q

Smoking Cessation

A 
Zyban (wellbutrin, 5-7)
-seizures
Chantix (varenicline, 7)
-HTN, palp, GI
Rx Nicotine replacement
-HTN, palp, GI
OTC Nicotine
352
Q

TB requires

A

prolonged exposure

353
Q

Must have Active TB

A

to spread infection

354
Q

Latent TB

A

most common form

present in body WITHOUT SX

355
Q

Latent TB can become active

A

when immune system unable to fight infection

356
Q

Latent TB

A

Granuloma

unable to transmit

357
Q

TB

A

unintentional weight loss

358
Q

Classic finding of TB

A

Posttussive crackles

359
Q

Other PE findings of TB

A

dullness or decreased fremitus

general area, diffuse

360
Q

Dx TB

A

Mantoux tuberculin skin test (TST)

Measure induration 48-72 hours later

361
Q

Gold standard to confirm TB

A

Culture with sputum collection

362
Q

1st line tx for TB

A

RIPE

Rifampin, Isoniazid, Pyraz, Ethambutol

363
Q

DOT

A

Direct observe tx for TB

must watch pt take medicine

364
Q

Drug tx for Latent TB

A

INH and Rifapentine

12 weeks

365
Q

MDR - TB does not respond to

A

INH and RIFampin

366
Q

XDR-TB

A

responds to even less drugs including Fluoroquinolones, and INH and Rifampin

367
Q

Histoplasmosis

A

Bird and bat droppings

Immunocomp-HIV most likely to get it

368
Q

Presentation of Histoplasmosis

A

90% A-sxatic or mild flu like sx

most resolve in few weeks

369
Q

Sx of Histo Acute sx pulm

A

Fever, fatigue, few resp sx

1 wk- 6 months

370
Q

Progressive disseminated Histo

A

pt usually immunocomp
fever, MARKED fatigue, cough, SOB, wt loss
Multiple organ involvement
Fatal w/in 6 wks

371
Q

Chronic pulm Histo

A

Older COPD pts

Progressive lung changes

372
Q

CXR

A

Hilar adenopath

Patchy/nodular infiltrates in LOWER Lobes

373
Q

Cocci

A

sports

contaminated soil

374
Q

Cocci valley fever

A

only 40sx have sx

many let it go- resolves in wks-months

375
Q

primary sx of Cocci

A

fever
cough
pleuritic CP
other: fatigue, HA, arthralgia (Desert Rheumatism), Rash- erythema nodosum

376
Q

Disseminated Cocci valley fever sx

A

more pronounced lung findings (abscess)
bone lesions
lymphadenitis
meningitis

Quarter 3 (17 decks)

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