Clinical Part 4 Pneumothorax, Sarcoidosis, TB (Tyler)

Question 1

What are the symptoms of pneumothorax?

Answer 1

acute onset of unilateral chest pain and dyspnea

unilateral chest expansion, decreased tactile fremitus

hypperresonance, decreased breath sounds

mediastinal shift, cyanosis, hypotension

Question 2

What are the causes of pneumothorax?

Answer 2

spontaneous: primary and secondary

trauma: increased likelihood of tension PTX

iatrogenic

Question 3

What is a primary spontaneous PTX?

Answer 3

PTX occurs in the absence of an underlying lung disease

typically tall, thin males between 10-30

Question 4

What is a secondary spontaneous PTx?

Answer 4

complication of preexisting pulmonary disease

Question 5

What is a tension PTX?

Answer 5

trauma that causes the presure of air in the pleural space to exceed alveolar and venous pressures throughout the resp cycle resulting in compression of lung and reduction in venous return to the hemithorax

Question 6

How do small PTX, less than 15% of hemithorax present and what is the tx?

Answer 6

physical exam findings are largely normal

with mild tachycardia

–> resolve spontaneously

Question 7

What are the sx of TB?

What are the risk factors

Diagnosis?

Answer 7

fatigue, weight loss, fever, night sweats, cough

household exposure, incarceration, drug use, travel

Sputum culture and chest xray with pulm opacities

Question 8

What occurs in the primary phase of TB?

Answer 8

Often clinically and radiographically silent

Lymphatic and hematogenous spread occurs before coming to clinical attention

T cells and macrophages (histyocites) form granulomas

can be dormant for years

–> infection is contained but not eradicated

Question 9

Can individuals with latent TB spread infection

Answer 9

No, unless is becomes reactivated

Question 10

Latent TB can reactivate and often occurs when?

What can trigger reactivation?

Answer 10

within the first 2 years of the primary infection if not on preventative therapy

gastrectomy, silicosis, DM, impaired immune response (e.g. HIV, corticosteroid therapy, etc.)

Question 11

What are some risks for drug resistant TB?

Answer 11

1) immigration from areas with DR TB
2) close and prlonged contact with individuals with drug-resistant TB
3) unsuccessful previous therapy
4) nonadherence

Question 12

What is DR-TB resistant to what?

Moderately DR-TB is resistant to what?

Extensively DR-TB is resistant to what?

Answer 12

either isoniazid or rifamplin

both isoniazid and rifampin, plus others possibly

pretty much everything that could help: isoniazid, rifampin, fluoroquinolones, and either aminoglyocsides or capreomycin or both

Question 13

What is required for the definitive diagnosis of M. Tubercolosis?

Answer 13

DNA or RNA amplification

• sputum specimens from three consecutive mornings
• if patient has trouble producing enough, can do sputum induction with 3% hypertonic saline solution

Light-microscopy for acid-fast bacilli still mainstay

Question 14

What are some typical XR findings for TB?

Answer 14

Lab doesn’t differentiate primary from reactivation

Radiographic evidence of primary infection include:

small unilateral infiltrates

hilar and paratracheal LAD

segmental atelactasis

pleural effusions (30-40% of pts)

Question 15

What may be seen on XR in elderly and immunocompromised pt’s with TB?

Answer 15

lower lobe infiltrates with or without effusions

(otherwise effusions are often apical)

Question 16

What is the milliary pattern in TB, and what patients are more liekely to present with these symptoms?

Answer 16

Small diffuse nodular densities

more common in immunocompromised patients (esp. late stage HIV) in the lower lungs

Question 17

If a pt with these underlying conditions has a tuberculin skin test is >5mm induration, then they are positive for TB

Answer 17

1. HIV +
2. recent TB contact
3. fibrotic changes in lungs suggestive of previous TB
4. organ transplant or immunospressed

Question 18

If a pt with these underlying conditions has a tuberculin skin test of >10mm induration, then they are TB +.

Answer 18

1. recent immigrant from areas with high TB rate
2. HIV neg injection drug users
3. mycobacterial lab personnel
4. resident/employee in congregate settings
5. recent gastrectomy, low BMI, bypass, Dm, silicosis, CKD, blood/other cancers
6. kids <4, infants children and teens exposed to adults

Question 19

If a tuburculin skin test induration is greater than 15mm, regardless of hx, they are (positive or negative for TB)?

Answer 19

postiive for TB

Question 20

What are the basic principles of anti-TB treatment?

Answer 20

1. administer multiple meds to which the organism is susceptible
2. provide the safest, most effective therapy in the shortest period of time
3. ensure adherence to therapy
4. add at least two new anti-TB drugs to a regimen when treatment failure is suspected

Question 21

What is pulmonary sarcoidosis and who is at high risk?

Answer 21

noncaseating granulomas systemically

90% of pt’s experience lung-related sx

North American African American Women are at highest risk, 30-40 y/o

Question 22

What are some general s/s of Sarcoidosis?

What is generally required to diagnose?

Answer 22

insidious onset: malaise, fever, dyspnea

skin, eye, neuro, heart manifestations

noncaseating granulomas on bioppsy –> required for dx

Question 23

Stage I Sarcoidosis XR findings:

Stage II Sarcoidosis XR findings:

Stage III Sarcoidosis XR findings:

Stage IV Sarcoidosis XR findings:

Answer 23

1 - bilateral hilar adenopathy

2- hilar adenopathy, parenchymal changes

3 - parenchymal changes alone

4 - fibrotic changes in upper lobes

not neccessarily linear/progressive changes, can switch back and forth, though fibrosis is fairly permanent