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Cvs Flashcards

1
Q

Infective endocarditis caused by micro-organisms affecting ……

A

Chambers, valves(native/prosthetic), blood vessels, congenital anomaly

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2
Q

Types of infective endocarditis

A

Acute
Subacute

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3
Q

Subacute infective endocarditis caused by ……………… when there is ………………… heart

A

Streptococcal
Diseased(valvular heart disease:rheumatic heart disease, mitral prolapse, aortic calcification, mitral regurgitation, prosthetic valve
Congenital heart disease; VSD
Idiopathic

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4
Q

The fatality of infective endocarditis increase when…………

A

1.there is prosthetic valve endocarditis
2. Infection with antibiotics resistence organism

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5
Q

Does IE (infective endocarditis) increase with age?

A

Yes, more than 50% of pts are over 60yrs

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6
Q

Infection with highly virulence organism such as ……………… can induce endocarditis in a previously normal heart which cause ………….. endocarditis.

A

Staphylococcus aureus, Acute

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7
Q

IE typically occur at sites of pre-existing ……………

A

Endocardial damage

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8
Q

Areas of endocardial damage caused by high pressure jet such as

A

VSD, mitral regurgitation, aortic regurgitation

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9
Q

Vegetation of IE made of

A

Platelete, fibrin, micro-organism

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10
Q

Vegetation of IE can cause

A
  1. Obstruction
  2. Abcess
    3.emboli
    4.valve regurgitation
  3. Cusp perforation and chordae disruption
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11
Q

Extra cardiac features of IE

A

Vasculitis and skin lesion, emboli (lung, spleen,kidney) or immune complex deposition( glomerulonephritis, skin)
Mycotic aneurysm

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12
Q

Clinical features of subacute infective endocarditis

A

Fever, wt loss, night sweat, unusual tiredness, new sign of valvular dysfunction or heart failure, embolic stoke and peripheral arterial embolism, purpura petechia , splinter hemorrhage, osler nodes, CLUBBING, spleen and liver enlarged, microscopic HEMATURIA

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13
Q

Clinical features of acute infective endocarditis

A

CHANGING MURMURS and petechiae , embolic event, cardiac and renal failure, abscess, no sign of chronic endocarditis

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14
Q

Clinical dx of IE

A

2major
1 major+ 3 minor
5 minor criteria

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15
Q

Investigation of IE

A

Culture
Echo
Cbc (anemia, thrombocytopenia, leukocytosis)
Esr elevated but CRP more accurate fpr prognosis
Hematuria and proteinuria
ECG AV block assessment
CXR

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16
Q

Management of acute IE

A

Amoxicillin + vancomycin/ gentamycin
In prosthetic valve add rifampcin

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17
Q

Management of subacute endocarditis

A

Antibiotics should be witheld till results of culture came back

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18
Q

Acute pericarditis definition

A

Acute inflammation of pericardium -/+ pericardial effusion can occur as an isolated clinical problem or systemic manifestation

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19
Q

Dx of pericarditis( presence of 2 out of 4)

A

1.chest pain
2. Pericardial friction rub
3.ECG( PR depression, diffuse concave ST segment elevation without reciprocal changes, electrical alternans)
4.pericardial effusion

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20
Q

Arrhythmia occur in pericarditis

A

True but rare

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21
Q

Lab results of pericarditis

A

Elevated CRP
Leukocytosis
Elevated CK, CK-MB and troponin

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22
Q

Complication of pericarditis

A

Pericardial effusion
Cardiac tamponade
Recurrence
Constrictive pericarditis

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23
Q

CT findings of pericarditis

A

Pleural thickening
Calcified percardium

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24
Q

Ddx of ST elevation

A

Pericarditis
STEMI
Early repolarization
Myocarditis
Aneurysm
Burgarda
BBB

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25
Q

Friction rub of pericarditis is

A

Triphasic

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26
Q

Treatment of pericarditis

A

Treat as outpatient if stable
Aspirin
NSAID:ibuprofen
Colchicine
Glucocorticoid if NSAID and colchicine fails
Azothioprine, cyclophosphonamide or MTX
Anakinra
Pericardiectomy

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27
Q

Which drug shouldn’t be given in pericarditis,why?!

A

Warfarin and heprin, bcz it increase risk of hemopericardium

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28
Q

Steriod therapy in pericarditis should be restricted to those with……………

A
  1. Acute pericarditis due to connective tissue disease
  2. Immune mediated pericarditis
  3. Uremic pericarditis
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29
Q

Chest pain of pericarditis

A

Sudden onset, anterior chest wall, pleuritic, sharp pain, worsen with lying flat and improve by leaning foreward

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30
Q

Types of pericardial effusion

A

1.fibrinous
2.serous
3. Hemorrhagic
4. Prulent

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31
Q

What happen to heart sound and friction rub in pericardial effusion?

A

Heart sound become quieter
Friction rub may diminish but not always abolished

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32
Q

Physical findings of pericardial effusion

A

Increased JVP
Hypotension
PULSES PARADOXES
Oliguria
Chylopericardium

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33
Q

Large effusion in pericardial effusion may by sensed as retrosternal compression

A

True

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34
Q

Definite investigation of pericardial effusion is……………… and confirmation is by……………

A

Echo
CT/MRI shows ( pericardial effusion, pericardial thickening, pericardial mass

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35
Q

Follow up of pericardial effusion is by

A

TTE

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36
Q

Management of pericardial effusion

A

If pericardial effusion cause HD instability and persist for>3month = pericardiocentesis

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37
Q

Cardiac tamponade is a ……………

A

Medical emergency

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38
Q

Cardiac tamponade definition

A

Accumulation of fluid in pericardial space in quantity sufficient to cause serious obstruction to inflow of blood into ventricles cause cardiac tamponade

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39
Q

3 most common cause of cardiac tamponade are

A
  1. Neoplasm
  2. Idiopathic
  3. Renal failure
    Or it may occur from bleeding into pericardial space due to trauma, operstions, Rx with anticoagulants
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40
Q

Becks triad is a clinical features of ………… and composed of …………

A

Cardiac tamponade, ( raised jvp, hypotension, muffled heart sound)

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41
Q

Quantity of fluid necessary to cause tamponade ………

A

May be as small as 200ml or as large as >2000ml

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42
Q

Clinical features of tamponade

A

Dyspnea
Tachycardia
Hypotension
Raised jvp
Pulses paradox
Ecg: low voltage + electrical alternans

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43
Q

Hallmark of cardiac tamponade is………

A

Pulses paradox

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44
Q

Dx of tamponade

A

TTE

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45
Q

Management of tamponade

A

Pericardiocentesis

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46
Q

Aortic dissection is more common in male or female!

A

Male 2:1

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47
Q

Aortic dissection more commonly affect ………, in …………, in………………

A

Descending, winter, morning

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48
Q

Acute aortic syndrome is

A

1.aortic dissection
2.intramural hematoma
3.penetrating aortic ulcer

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49
Q

Risk factors for aortic dissection

A

Hypertension
Genetic
Trauma
Sex
Age
Cocaine
Pregnancy

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50
Q

Aortic dissection associated with

A

Hypertension
Tobacco
Congenital anomalies: bicuspid aortic valve, coarctation of aorta
Genetics marfan and ehlersdanlos

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51
Q

Clinical presentation of aortic dissection

A

Sudden severe tearing chest pain or may be asymptomatic
If the pain felt in the anterior of the chest=ascending aorta
If the pain felt at the back= descending aorta

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52
Q

Chronic aortic disection type B clinical features are

A

Chest pain
Dyspnea
Hoarseness
Wheezing
Dysphagia
Hemoptysis
Hematemesis

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53
Q

Physical exam of aortic dissection reveals

A
  1. HTN or hypotensive
  2. Different blood pressure between extremities
  3. New murmur of aortic valve insuff.
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54
Q

Aortic dissection classifications

A

Standford =group A and group B
Debakey =type 1,2,3

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55
Q

Diagnosis of aortic dissection

A

Biomarkers
Ecg
Aortigraphy
Tee
Chest CT
MRI

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56
Q

Rx of aortic dissection

A

Anti-impulsive
Antihypertensive
Trimethaphan
Reserpine
Guanethidine
+
Surgical treatment( resection , closure, grafting)

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57
Q

Leriche syndrome is

A

Aortic occlusive disease (aortoilliac occlusive disease)

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58
Q

Aortic occlusive disease is a type of …………disease

A

Peripheral arterial disease

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59
Q

The occlusion in aortic occlusive disease caused by

A

Atherosclerosis
Thrombosis
Embolism

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60
Q

Aortoillaic disease located beyond

A

Infrarenal artery

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61
Q

Aortic occlusive disease can present acutely or chronically.

A

True

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62
Q

Risk factors for leriche syndrome

A

Modified: HTN , DM, high cholestrol, hyperlipidemia, obesity, lack of exercise, tobacco
Non-modified: age, sex, fam hx

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63
Q

Triad presentation of leriche syndrome

A

Claudication
Impotence
Absence of femoral pulse

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64
Q

Dx of aortic occlusive disease

A

Lab test= lipid profile and HBa1c
Ankle brachial index lower than 0.9
CTA or duppler ultrasound
MRA

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65
Q

Classification of occlusive aortic diseases

A

Type 1 =till common ilaic
Type2= till external ilaic
Type3= till femoropopliteal

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66
Q

Rx of aortic occlusive disease

A

Non interventional: stop smoking, statin, antihypertensive, anticoagulant, manage DM, walking exercise
Interventional:thrombi endarterectomy, aortofemoral bypass, percutaneous transluminal angioplasty

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67
Q

Congenital anomaly of aorta

A

PDA
Vascular ring
Coarctation of aorta
Aortopulmonary window
Truncus arteriosis
Hypoplasia

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68
Q

Vascular ring classification

A

Complete( double aorta/ Rt aortic arche/ Lt aortic arch)
Incomplete
Pulmonary artery sling

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69
Q

Vascular ring caused by

A

Abnormal persistence or regression of one of the six embryonic aortic arch

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70
Q

Aortopulmonary window classification

A

Type 1= proximal
Type2 = distal
Type3= total absence of aortopulmonary septum

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71
Q

Mori classification is

A

Aortopulmonary window classification

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72
Q

Truncus arteriosis is caused by

A

Seperation failure during development of ventricular outlets and the proximal arterial segment of heart tube

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73
Q

Truncus arteriosis seperated from Aortopulmonary window by

A

Truncus arteriosis have 2-5 cusps , presence of a common truncal valve which is often stenotic and insufficient

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74
Q

Truncus arteriosis dx by

A

CTA and MRA

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75
Q

Ascending and arch aneurysm classification are

A

Fusiform and saccular

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76
Q

Cause of ascending aortic aneurysm are

A

Medial degeneration ( idiopathic / genetic)
Infection
Inflammation
Long standing aortic dissection

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77
Q

Arch aneurysm are due to

A

Chronic dissection
Long standing HTN
Atherosclerosis

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78
Q

Dx of aortic aneurysm

A

CXR
Ecg
Echo
Angiography
CT
CTA
MRA

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79
Q

Rx of aortic aneurysm

A

Avoid exercise
Avoid rapid acceleration and deceleration
Anti impulse
Bblocker

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80
Q

Non-elective and elective indication for aortic aneurysm

A

Non-elective: >4.5-5
Elective=5.5cm and growth rate >1cm/yr in absence of connective tissue disorder or cardiac pathology

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81
Q

Clinical presentation of aortic aneurysm

A

Anterior chest pain
Acute = impeding rupture
Chronic= compression by sternum
Sign of SVC and airway compression
Hoarseness
High output cardiac failure due to rapture into SVC or Rt atrium

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82
Q

Constrictive pericarditis is the result of……… &………… of pericardium that lead to heart failure by impairing……… cardiac filling.

A

Inflammation, fibrosis, diastolic

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83
Q

When constrictive pericarditis occur?

A

Usually happens after multiple episodes of acute pericarditis over time.

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84
Q

If ………… & ………… caused pericarditis, there is up to 30% risk of constrictive pericarditis

A

Bacteria and tuberculosis

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85
Q

Why heart failure due to constrictive pericarditis is differ from other types of heart failure?

A

Bcz pericardiectomy can cure the condition

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86
Q

Constrictive pericarditis have HD features similar to

A
  1. Restrictive cardiomyopathy
  2. Severe tricuspid regurgitation
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87
Q

Etiology of constrictive pericarditis

A

Most common: previous cardiac surgery, chronic idiopathic, viral pericarditis, mediastinal radiation
( It may occur several wks after surgery or decades after radiation)
TB pericarditis,
Chronic constrictive pericarditis can be caused by acute pericarditis such as SLE , RA, previous injury, bacterial infection

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88
Q

Constrictive pericarditis is uncommon feature of …………

A

Heart failure

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89
Q

Constrictive pericarditis is irreversible.

A

False, it’s reversible

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90
Q

Final common pathway of constrictive pericarditis is

A

Development of fibrous thickening or calcification of pericardium resulting in pericardial noncompliance, fabrous scaring and adhesion of both pericardial layers obliterate the pericardial cavity, the heart is encased in a solid shell and can not fill properly

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91
Q

Why constrictive pericarditis result in elevated, equalized diastolic pressure in all chambers?

A

Bcz noncompliant pericardium limits ventricular relaxation and determines ventricular diastolic pressure

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92
Q

Clinical features of constrictive pericarditis

A

Dyspnea
Fatigue
Raised JVP
Hepatotomegaly and ascites
Edema
Kussmal sign
Pericardial knock
Rapid,low volume pulse
Af is common

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93
Q

Hallmark of constrictive pericarditis

A

Systemic venous congestion

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94
Q

Elevated jvp present in all patient with constrictive pericarditis except in

A

Hypovolemic patients 😂

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95
Q

One physical sign of constrictive pericarditis is a rigid pericarium that impairs diastolic filling and suddenly block rapid ventricular filling which is called …………

A

Pericardial knock

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96
Q

Physical signs of constrictive pericarditis are

A

Pericardial knock
Rt side heart failure with distended JV
Kussmaul sign
Hepatomegaly
Ascites
Edema

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97
Q

Severity of heart failure is …………… to degree of myocardial dysfunction in constrictive pericarditis.

A

Disproportional

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98
Q

Constrictive pericarditis is more common in male or female

A

Male 2:1

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99
Q

Investigation for constrictive pericarditis

A

Echo
CT
MRI
Cardiac catheterization

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100
Q

Constrictive pericarditis can present without pericardial calcification or without any obvious pericardial thickening. (T/F)

A

True

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101
Q

Management of constrictive pericarditis

A

Prior to pericardiotomy
A trial of anti-inflammatory
Steroid if HD instable
Na restrictions +diuretics

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102
Q

Mitral stenosis (MS) is characterized by……… at the level of ……………… due to ………………

A

Obstruction to the Lt ventricular inflow at the level of mitral valve due to structrual abnormality of mitral valve apparatus

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103
Q

Most common causes of MS are :

A
  1. RHD
  2. Lutembacher syndrome ( ASD + rheumatoid mitral stenosis)
  3. Malignant carcinoid
  4. SLE
    5.RA
  5. Congenital mitral stenosis
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104
Q

Normal mitral valve orifice is ……… cm2

A

4-6cm2

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105
Q

Pathophysiology of mitral stenosis

A

Decrease mitral valve orifice this lead to increase in pressure across the mitral valve

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106
Q

When will patients with mitral stenosis experience symptoms?

A

When valve orifice become 2-2.5cm2

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107
Q

when will Severe mitral stenosis occur?

A

When mitral orifice become <1cm2

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108
Q

Pathophysiology of MS

A

Left atrial pressure rise result in dilatation of atria which may increase chance of AF and lead to thrombi-embolism phenomena and also dilated atria may cause compression to-recurrent laryngeal nerve and cause hoarseness of voice and persistence cough due to bronchial compression and then
Backward blood flow lead to pulmonary congestion may result in bronchial vein rupture and Hemoptosis occur then pulmonary edema may be seen and this reveals dyspnea, orthopnea, PND
Chance within intimal and medial layer of pulmonary artery result in pulmonary HTN which result in Rt ventricular hypertrophy and stretching which cause tricuspid regurgitation and elevated JVP , hepatomegaly, ascites, pedal edema may be obtained

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109
Q

Pulmonary hypertension occur in MS as a result of

A

Retrograde transmission of Lt atrial pressure
Pulmonary arteriolar constriction
Interstitial edema
Intimal hyperplasia and medial hypertrophy

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110
Q

Ms due to rheumatoid disease is much more common in…………

A

Female 2/3rd

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111
Q

Symptoms of MS appear at which stage of life?

A

3rd and 4th decade

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112
Q

Symptoms of MS

A

Generally asymptomatic during early stage of the disease
Then
AF
Emboli
Horseness
Persistence cough
Hemoptysis
Dyspnea
Orthopenia
Paroxysmal nocturnal dyspnea
Raised JVP
Hepatomegaly
Ascites pedal edema

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113
Q

Physical exam of mitral stenosis

A

Malar rash
Raised JVP
Hepatomegally
Ascites
Pedal edema
P2 may be palpable at 2nd intercostal space
Loud s1 in early stage then decrease when the valve become calcific fibrotic and thickened
Opening snap
Diastolic rumbling
Graham steell murmur
Pansystolic murmure
S3 and S4 MAY BE HEARD IN 4TH INTERCOSTAL space
Diastolic thrill
Apical impulse displaced laterally

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114
Q

Auscultation of mitral stenosis

A
  1. Low pitch,rumbling mid diastolic murmer accentuated by exercise and reduced by. Valsalva maneuver
    2.loud S1
    3.accentuated P2 in pulmonary hypertension
  2. Opening snap follows S2
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115
Q

Dx of mitral stenosis

A

CXR
ECG
Echo: gold standard
Catheterization

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116
Q

Rx of mitral stenosis

A

Prophylaxis for IE
Diuretics
Control rate BB , CCB
Control rhythm by amiodarone or digoxin
Sodium restriction
Nitrates decrease preload
Anticoagulant
Surgery( vulvoplasty, vulvotomy, replacement)

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117
Q

Mitral regurgitation definition

A

Mitral regurgitation is defined as abnormal reversal blood flow from Lt ventricle to left atrium its caused by disruption in any part of mitral valve apparatus

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118
Q

Pathophysiology of acute MR

A

Increase preload, decrease after load cause increase in EDV but decrease in end-systolic volume
Total stroke volume increase but forward stroke volume decreased due to regurgitant stroke volume this lead to increase in Lt atrial pressure so both ventricular pressure and radius is reduced

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119
Q

Chronic mitral regurgitation Pathophysiology

A

Lt atrium and ventricle have time to dilate and accommodate the regurgitation thus Lt atrium pressure is often normal or minimaly elevated. Bcz of eccentric hypertrophy of Lt ventricle , TSV and FSV are maintained

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120
Q

Etiology of acute mitral regurgitation

A

Coronary artery disease
IE
Cordae tendinae rupture
Valvular surgery
Tumor
Myxomatous degeneration ( Mitral prolapse, ehler danlos synd, marfan syndrome
SLE
Acute rheumatoid fever
Acute Lt ventricular dysfunction
Prosthetic mitral valve dysfunction

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121
Q

Etiology of chronic mitral regurgitation

A

Rheumatoid heart disease
SLE
Scleroderma
Myxomatous degeneration (MP, ehler danlos synd. , Marfan syndrome)
Calcification of mitral valve annulus
IE
Ruptured cordae tendinae
HCM
Prosthetic leak
Drug

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122
Q

Sx of acute / chronic mitral regurgitation

A

Acute: Dyspnea fatigue, orthopnea, pulmonary edema
Chronic: asymptomatic for yrs , sx of forward failure (fatigue , dyspnea , SOB) + palpitations if AF develop due to chronic atrial dilatation
More severe chronic MR= symptoms of congestive heart failure

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123
Q

Examination of MR (palpation)

A
  1. Forceful apex beat
  2. Apex beat displaced laterally
  3. Systolic thrill at apex
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124
Q

Examination of mitral regurgitation (auscultation)

A

Soft S1
Pansystolic murmur radiate to axills
S3 and S4
Systolic murmur intensified by stain and relieved by valsalva

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125
Q

Dx of mitral regurgitation

A

CXR
ECG
Echo

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126
Q

Rx of mitral regurgitation

A

Diuretics
BBlocker biventricular pacing LV dysfunction
CCB
Digitalis
Anticoagulants

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127
Q

AORTIC stenosis is more common in

A

Male

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128
Q

Mitral stenosis is more common …………, while Aortic stenosis is more common in ……………

A

Female, male

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129
Q

Causes of aortic stenosis

A

Congenital (bicuspid)
Rheumatic
Idiopathic: degenerative wear and tear commonly in elderly

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130
Q

Types of aortic stenosis

A

Supravalvular: narrowing or fibrous diaphragm
Valvular
Subvalvular: membraneous or fibrous diaphragm

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131
Q

What are other features associated with supravalvular aortic stenosis( williams syndrome)

A

Broad forehead
Widely set eyes
Pointed chin
Mental retardation
Hypercalcaemia

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132
Q

Pathophysiology of aortic stenosis

A

Left ventricle to aortic pressure gradient increase
Peak aortic systolic pressure: 50mmhg
Lt ventricular hypertrophy
Vigorous Lt atrial contraction
AF
Myocardial ischemia
Normal CO at rest

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133
Q

Symptom of AS

A

Dyspnea
Angina
Syncope

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134
Q

Dx of AS

A

CXR
ECG
Echo
Catheterization

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135
Q

Rx of As

A

Avoid strenuous activity
Sodium restriction
Caution use of diuretic in CHF
VASODILATORS C/I in severe AS
Surgery

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136
Q

Types of lung tumors are:

A

Primary ( bronchogenic carcinoma)
Secondary
Bronchopulmonary carcinoid
Beninign tumor of the lung

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137
Q

What is cancer?

A

Abnormal uncontrollable cell growth
Go beyond it’s boundaries
Invade adjoining part of the body and spread to other organs
Characterized by Loss of 1. Proto-oncogene 2. Growth suppresor gene
3.apoptosis gene controlling 4. Gene controlling DNA repair

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138
Q

Primary lung cancer definition

A

Respiratory epithelium undergo neoplasm changes that called bronchogenic carcinoma

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139
Q

……………… accounts for 90% of all pulmonary tumors

A

Primary lung cancer

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140
Q

What are the two main types of primary lung cancer?

A

Non-small cell lung cancer ‘NSCLC’ 85%(adenocarcinoma, SCC, large cell carcinoma)
Small cell lung cancer SCLC 15%

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141
Q

2nd most common malignancy in both gender is…………

A

Primary lung cancer

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142
Q

Most common cancer worldwide in terms of both incidence and mortality is………

A

Primary lung cancer

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143
Q

Lung cancer is most commonly dx among persons ………………… yrs of age and rare………………… yrs

A

55-74
before 35 yrs

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144
Q

Risk factors for primary lung cancer

A
  1. Tobacco smoking
    2.radon
    3.asbestos
  2. Environmental tobacco smoke
    5.genetic
    6.other lung diseases e.g. TB
  3. Radiation
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145
Q

Combination of risk factors increase the chance of primary lung cancer.

A

💯

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146
Q

Clinical features of primary lung cancer

A

1.cough 75%
2.dyspnea 50%
3.hemoptysis 50%
4. Chest pain 40%

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147
Q

Cough which is most common symptom of primary lung cancer is caused by ………

A

Bronchial mucosa invasion due to tumor, atelectasis, cavitation, pleural effusion

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148
Q

Hemoptysis in primary lung cancer caused by

A

Tumor necrosis
Mucosal ulceration
Erosion into thoracic blood vessel

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149
Q

Metastatic effect of primary lung cancer is seen in …………………

A

Adrenal, liver(SCLC), CNS , bone

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150
Q

Most common cause of cerebral metastasis is …………

A

Lung cancer

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151
Q

Dx of primary lung cancer

A

CXR
CT
MRI
PET
Sputum cytology
Bronchoscopy
Thoracic Needle aspiration biopsy

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152
Q

Types of resection in primary lung cancer

A

Wedge resection
Segmentectomy
Lobectomy
Bilibectomy
Pneumonectomy

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153
Q

The essential aspects of lung cancer evaluation in dx are

A

Histologic distinction of SCLC from NSCLC
Accurate staging
Decision on operability
Determination of pts performance status

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154
Q

Rt paratracheal and subcarineal lymphnode have been approched with ……………………… in primary lung cancer

A

Cervical mediastinoscopy

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155
Q

Biopsy of Lt paratracheal, supra-aortic and aortopulmonary window node have been approached with……………… in primary lung cancer

A

Anterior mediastinotomy

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156
Q

Lungs are common site for secondary metastasis from………………………………

A

Breast, renal, colon , upper airways

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157
Q

Current surgical treatment of pulmonary metastasis are

A

1.control primary
2.no other extrapulmonary metastasis, if present immediate control plan with surgery or other Rx should be done
3.pulmonary metastasis that completely resectable, even if located in both lungs
4.adequate cardiopulmonary reserve of pt
5. Technically feasible operation

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158
Q

Compared with bronchogenic carcinoma, carcinoid tumors occur more frequently in …………… patients and are less likely to be associated with Hx of smoking

A

Younger

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159
Q

Bronchopulmonary carcinoid tumors are classified into…………………&……………… on basis of histologic features

A

Typical
Atypical

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160
Q

What is the difference between typical and atypical carcinoid tumor?

A

Typical;more common, centrally located and rarely metastasize
Atypical: less common, peripherally located and metastasize occur in pts above 30 yrs

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161
Q

Sx of carcinoid tumor

A

Cough
Hemoptysis
Dyspnea
Wheeze
Recurrent upper respiratory infection
Pneumonia
Some pts may have carcinoid syndrome ( diarrhea, flishing , bronchoconstriction, heart failure)

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162
Q

Rx of carcinoid tumor

A

Complete surgical resection of the tumor
Sparing of paranchyms ehenever possible
LN staging by ipsilateral LN sampling or mediastinal LN dissection

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163
Q

Benign lung tumor classification according to presumed origin

A

Unknown( hamartoma, clear cell, teratoma)
Epithelial ( papilloma, polyp)
Mesodermal(fibroma, lipoma,eiomyoma, chondroma, granular cell tumor,sclerosing hemangioma)
Other myofibroblastic tumor , xanthoma, amyloid, mucus associated lymphoid tumor)

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164
Q

Benign lung tumors can be classified according to

A

Pathology
Clinically by location or whether its single or multiple
Presumed origin

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165
Q

Bronchiectasis definition

A

Abnormal, persistent, irreversible dilation of bronchi
May be focal(localized) or diffuse

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166
Q

Bronchiectasis distribution may be ………… or ……………

A

Focal, diffuse

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167
Q

Classification of bronchiectasis

A

1.cylindrical (fusiform)
2.varicose
3, saccular (cystic)

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168
Q

Bronchiectasis is caused by destruction of …………&…………

A

Muscle, elastic tissue

169
Q

In which class of Bronchiectasis the bronchi appear uniformly dilated

A

Cylindrical

170
Q

Mild form of bronchiectasis is …………

A

Cylindrical

171
Q

What are the radiographic characteristics of cylinderical Bronchiectasis

A
  1. Parallel tram track lines
    2.signet-ring
172
Q

What is signet ring

A

Is a radiographic feature of cylindrical bronchiectasis that shows dilated bronchus cut in a horizontal secretion with adjacent pulmonary artery representing the stone

173
Q

Irregular or beaded bronchi with alternating areas of dilatation and constriction are found in …………… bronchiectasis

A

Varicose

174
Q

Moderate bronchiectasis is

A

Varicose bronchiectasis

175
Q

Honeycomb sign is found in …………bronchiectasis

A

Saccular

176
Q

Diameter of bronchus lumen normally is ………

A

1-1.5 times of adjacent vessels

177
Q

Etiology of bronchiectasis

A

Primary infection
Obstruction
Ciliary dyskinesia
CF
Connective tissue disorder
Congenital anatomic defect
Autoimmune
Alpha1 antitrypsin deficiency
Allergic Bronchopulmonary aspergillosis
Aspiration
idiopathic
Immunodeficiency state
Toxic gas exposure
Traction from other process

178
Q

Primary infection of bronchiectasis organisms

A

Klebsiella
Staph
Tb
Mycoplasma pneumonia
Non-TB mycobacterium
Measles
Pertussis
Herpes
Adenovirus
Infection with syncytial virus in childhood

179
Q

A diameter of bronchus lumen greater than 1.5 times of adjacent vessels suggests…………

A

Bronchiectasis

180
Q

Most common cause of bronchiectasis is

A

Primary infection

181
Q

Clinical features of bronchiectasis

A

Cough with mucopurulent lasts month to yrs
Hemoptysis
Dyspnea
Pleuritic chest pain
Wheezing
Fever
Fatigue
Wt loss

182
Q

Rare clinical feature of bronchiectasis

A

Hemoptysis with little or no cough 😷

183
Q

Physical examination finding of bronchiectasis (6)

A

Crackle, scattered wheeze
Clubbing
Cyanosis/Plethora/polycythemia
Wt loss
Nasal polyps
Core pulmonale

184
Q

Dx of bronchiectasis is by

A

HRCT

185
Q

Other Dx criteria helpful in bronchiectsis

A

1.hx & exam
2.HRCT
3.check Ig level for hypogagammaglobulinemia
4. Serum alpha-antitrypsin
5. Aspergillus precioitons
6. Autoimmune screening test
7.pulmonary function test
8.bronchography
9.vit d

186
Q

Vitamin D and bronchiectasis relation

A

Pts with vitD def and bronchiectasis were more likely colonized with pseudomonas aeruginosa
Had more exacerbation and FEV1 decreasee

187
Q

Core of Management of bronchiectasis is achieved by

A

Antibiotics and chest physiotherapy

188
Q

Management of bronchiectasis

A

Antibiotics
Bronchodilator
Steroid
Dietry supplement
Oxygen
Admition
Surgery

189
Q

The goal of therapy in bronchiectasis are:

A

1.improve sx
2. Reduce complication
3. Control exacerbation
4.reduced mortality and morbidity
5. Manage underlying condition

190
Q

Exacerbation of bronchiectasis may produce the following signs

A

Increased sputum
Increased viscosity
A foul odor of sputum
Low grade fever
Increased constitutional symptoms (fatigue,malaise)
Increased dyspnea, wheeze , pleuritic pain

191
Q

Anti-inflammatory therapy that are used in bronchiectasis are

A

Inhaled or oral corticosteroids
Leukotriene inhibitors
NSAIDs
+
Azithromycin known as anti-inflammatory in pt with cystic fibrosis( xoy la asla antibiotics)

192
Q

Can lung transplant be done for moderate cases of bronchiectasis

A

No, its for severe cases and especially for those with cystic fibrosis

193
Q

When you consider patient with bronchiectasis and cystic fibrosis for lung transplants

A

When FEV1 falls below 30%+ female pt and younger pts may need to be considered sooner

194
Q

Why Bronchial hygiene in bronchiectasis needed?

A

Bcz of tenacious (viscosity) of sputum and failure of clearance

195
Q

How brochial hygiene done in patients with bronchiectasis

A

Postural drainage with percussion and vibration
Vest
Nebulizer with Nal 7%
Mucolytic (acetylecysteine
+general adequatel hydration

196
Q

COPD subtypes are:

A

Chronic bronchitis
Emphysema

197
Q

Chronic bronchitis is……

A

Cough and sputum on most days for at least 3 consecutive month for 2 successive yrs

198
Q

Emphysema is ………

A

Abnormal PERMANENT enlargement of airspace distal to terminal bronchioles accompanied by destruction of their wall with obvious fibrosis, mucus gland hypertrophy and goblet cell hyperplasia

199
Q

Asthma is a …………… disorder

A

Functional

200
Q

Chronic bronchitis is a………… disorder

A

Clinical

201
Q

Emphysema is an ……… disorder

A

Anatomical

202
Q

Chronic bronchitis and emphysema are ………… lung diseases.

A

Obstructive

203
Q

Chronic bronchitis found in ………… patients.

A

Overweight

204
Q

Emphysema found in …………… patients

A

Thin

205
Q

Cellular inflammation in chronic bronchitis and emphysema are done by …………&…………

A

Macrophages and neutrophils

206
Q

Blue bloater are characteristic feature for …………

A

Chronic bronchitis

207
Q

Pink puffer are characteristic feature of ………

A

Emphysema

208
Q

Persistent airflow obstruction found in

A

Chronic bronchitis and emphysema

209
Q

Chronic bronchitis and emphysema are (reversible/irreversible) airway limitations

A

Irreversible

210
Q

Common sx of chronic bronchitis and emphysema are

A

Cough, sputum, SOB

211
Q

Trigger for COPD

A
  1. Exposure
    Tobacco
    Pollutents
    Occupation
    Drugs
  2. Airway hyper-reactivity
    3.host factors
    Alpha1-antitrypsin deficiency
212
Q

Dx of COPD

A
  1. History
    2.spirometry <0.7
    3.COPD assessment test CAT
    4.clinical COPD questionnaire CCQ
  2. mMRC breathlessness scale
    7.CXR
    8.lung volume and diffusing capacity
  3. Oximetry and blood gas

10.alpha1-antitrypsin

213
Q

Ddx of COPD

A

Asthma

214
Q

How to differentiate COPD from asthma

A

Copd occur in mid life, sxs slowly progress and there is long hx of smoking 🚬
Asthma onset is early in life, sxs vary day to day, worsen at night and in early morning +,there is family hx of asthma + (allergic rhinitis, asthma, eczema)

215
Q

COPD pts are at high risk of

A

CVD
Respiratory infection
Bronchiectasis
Lung cancer
Osteoporosis
DM
Anxiety and Depression

216
Q

Gold Classification of COPD

A

Gold1: greater or equale to 80%
Gold2: 50-80%
Gold3: 30-50%
Gold4: less than 30%

217
Q

COPD definition

A

Is a common preventable and treatable disease, characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory response in airway and lungs to noxious particles or gas, exacerbation and comorbidity contribute s to the severity in individuals patient s

218
Q

Asthma is a disease of ………… airways but gradually become…………

A

Large, large and small airways

219
Q

COPD definition

A

A common preventable and treatable disease characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory response in the airways and the lung to noxious particles or gas

220
Q

Mechanism of COPD

A

Small airway disease + parenchyma destruction

221
Q

How spirometery dx COPD

A

Post- SABA FEV1/FVC < 70%

222
Q

Treatment for COPD

A

Smoking cessation
Nicotine replacement
Influenza and pneumococcal vaccination
Regular exercise
Bronchodilator : SAMA ——> ipatropium
LAMA——> tiotropium
SABA—->albutrol
LABA——>formetrol, salmetrol
Inhaled corticosteroids
Phosphodiesterase-4 inhibitors

223
Q

Consequences of COPD exacerbation

A

Negative impact on quality of life
Impact on sxs and lung function
Increased economic costs
Increased mortality
Accelerated lung function decline

224
Q

Assessment of exacerbation of COPD

A

CBC
ABG
CXR
ECG
Biochemical tests
Purulent sputum

225
Q

Asthma is a (homogeneous/ heterogeneous) disease

A

Heterogeneous

226
Q

Pulmonary fibrosis is the end result of ………………

A

Many respiratory diseases

227
Q

Pulmonary fibrosis is characterized by………

A
  1. Scar tissue in lung
    2.honeycomb lung
  2. Decreased compliance, giving a restrictive pattern in PFT (FEV1/FVC >80%)
228
Q

Pulmonary fibrosis classified according to involvement

A
  1. Localized( unresolved pneumonia)
    2.bilateral( TB)
    3.diffuse (IPF or pneumoconiosis)
229
Q

Clinical features of idiopathic pulmonary fibrosis IPF: (4D)

A

Dry cough
Dyspnea
Digital clubbing
Diffuse inspiratory crackles

230
Q

1.In pulmonary fibrosis lung compliance …………… while elacticity …………
2. In asthma and COPD lung compliance …………… while elacticity……………

A
  1. Decrease, increase
    2.increases, decrease
231
Q

Idiopathic pulmonary fibrosis definition

A

A specific form of chronic, progressive fibrosing interstitial pneumonia of unknown cause, occurs primarily in older adults, and limited to the lungs.

232
Q

A specific form of chronic, progressive fibrosing interstitial pneumonia of unknown cause, occurs primarily in older adults, and limited to the lungs.

A

Idiopathic pulmonary fibrosis

233
Q

Pulmonary fibrosis characterized by worsening of …………&…………… & is associated with ………… prognosis

A

Dyspnea, lung function, poor

234
Q

3 points on idiopathic pulmonary fibrosis

A

1.chronic
2.progressive
3.irreversible

235
Q

Idiopathic pulmonary fibrosis is a chronic disease characterized by fibroblast ………… and extracellular matrix …………

A

Proliferation, remodeling

236
Q

Idiopathic pulmonary fibrosis is a primary inflammatory lung disease (T/F)

A

False, it is a primary epithelial/ fibroblastic disease and inflammation is a secondary event

237
Q

Risk factors for idiopathic pulmonary fibrosis

A

Cigarette smoking
Environmental exposure
Metal and wood dust
Farming
Raiing birds hair dressing, stone cutting
Microbial agents: herpes virus

238
Q

Pathophysiology of idiopathic pulmonary fibrosis

A

Injury to alveolar epithelium—>increasing cytokines and pro-inflammatory products——> stimulate fibroblast and myofibroblast——> increase deposition of collagen in extra cellular matrix

239
Q

Dx of pulmonary fibrosis

A

History and exam(4D)
Lab(serum ACE elevation, ESR/CRP elevation, autoimmune screen)
PFT(>80%)
DLCO : decrease
CXR/HRCT: honeycomb apperance
Bronchoscopy
Lung biopsy
Liver biopsy helful to exclude sarcoidosis

240
Q

Gold standard dx tool for pulmonary fibrosis is ……………

A

HRCT

241
Q

Rx of IPF

A

Cessation of smoking
Avoid environmental exposures
O2 supply
Corticosteroids
Immunosuppressants(azathioprine/cyclophosphanimde)
Antifibrotic agents (colchicine,D-penicillamine, IFNy,IFN-B , pirfenidone)
Antioxident agents (glutathione, n-acetylcysteine)
Anticoagulants
Treat GERD
Stem cell therapy
Lung transplant

242
Q

Causes of interstitial lung disease

A
  1. Occupational and environmental (silicosis, asbestosis, hypersensitivity pneumonitis)
    2.drug induced: amiodarone, nitrofurantonin, methotrexate, ocaine
  2. C.T. Diseases :SLE , RA, scleroderma
  3. Primary diseases: sarcoidosis, LAM
  4. Idiopathic
  5. Genetic
243
Q

What is minimally invasive surgery?

A

A way of performing surgery in the chest through small incisions, doesn’t require spreading apart of the ribs, we use a camera and instruments to get tonthe lungs

244
Q

The 2 type for minimally thoracic surgery are

A

Video assisted thoracoscopic surgery & robotic assisted surgery

245
Q

Video-assisted thoracoscopic surgery VATS

A

Is a procedure in which a small tube called thoracoscope is inserted through a small incision between the ribs at the end of the tube is a camera that lets the surgeon see entire chest cavity without having to open up the chest or spread the ribs. The surgeon then removes lung tissue with specially designed muscles instruments inserted through one or two additional small incisions

246
Q

Robotic assisted surgery

A

A surgeon will sit at a console next tothe patient in the operating room and control the instruments, including a camera, on the robotic surgical system. A small 3D high definition camera is placed through one of the small incision to provide good view of the inside of chest cavity while wristed robotic instruments are inserted through other small incisions made in between ribs. The use of wristed instruments lets the surgen performs the surgery without having to make larger incisions to open up the chest or spreads the ribs

247
Q

Advantages of minimal thoracic invasive surgery

A

Faster recovery
Fewer complications
Shorter hospital stay
Less pain and decrese need for pain medication
Smaller scar
Less blood loss
No cutting of the ribs or breastbone

248
Q

Video assisted thoracoscopic surgery is used as …………&…………… tool

A

Diagnostic & therapeutic

249
Q

VATS is described as a keyhole surgical procedure in the operating room, under general anesthesia with ……… lung ventilation using disposable instruments,generally for therapeutic purposes

A

One

250
Q

In VATS procedures, surgen operate through ………… tiny opening between the ribs.
Each opening is less than ……inch

A

2-4, one inch

251
Q

———- inch incisions are not uncommon in open thoracic surgery(thoracotomy)

A

6-10

252
Q

VAST procedure start by some steps which are

A

Giving anesthesia
Position the patient
Use a trocar to gain access to the chest
Insert endoscope

253
Q

How the patient positioned in video assisted thoracoscopic surgery

A

Lateral decubitus all pressure points padded to prevent tissue and nerve injury
Beanbag(optional) to safely secure the patient
Hip placed below brak point for max. Opening of intercostal space
Contalateral leg flexed
Ipsilateral leg extended
Ipsilateral arm should be in rest in a neutral position to prevent hyperextension or injury to the brachial plexus

254
Q

Port placement in VATS

A

Anterior (4th ICS)
Posterior (4th ICS)
Mid-axillary (7/8th ICS)

255
Q

Why anterior and posterior port in VATS are placed at the same level (4th ICS)?

A

To be prepared for changing the procedure to thoracotomy if VATS fails

256
Q

Which port in VATS used for camera

A

Middle

257
Q

Relative contraindications for VATS

A

Poor general health of the patient
Fever
Uncontrolled cough
Unstable CV status
Unable to lie flat for minimum 1 hr

258
Q

Absolute contraindications for VATS

A

Comatose or unresponsive patients
Lack of pleural space
End-stage pleural effusion
Type2 respiratory failure
Uncontrollable bleeding disorder
Pulmonary artery hypertension

SVC obstruction

259
Q

What is the rule of thumb in minimal invasive surgery

A

Is presence of adequate pleural space at least 6-10 cm in width if not present PNEUMOTHORAX is induced under floroscopic or radiographic/ sonographic control, immediately or a day before thoracoscopy .

260
Q

VATS : The optimal point of entry is localized in ………… ……… bcz there are no large muscles to be passed by trocar in this area

A

Midaxillary line

261
Q

Early complications of VATS

A

Vagal Syncope
Pain
Pleural pain, cough, dyspnea
Hypoxia
Subcutaneous/mediastinal emphysema

262
Q

Why dyspnea may occur after VATS

A

If the fluid is rapidly suctioned off from the cavity without dividing into sessions it results in dyspnea

263
Q

Intermediate complication of VATS

A

Wound and intercostal tube site discomfort
persistent air leak more than 8 days
Wound infection
Pleural infection
Post-operative fever

264
Q

Late complications of VATS

A

Failed pleurodesis
Empyma
Pleura-cutaneous fistula
Late tumor seeding at thoracoscopy port and intercostal tube site

265
Q

difference between VATS and robotic assisted surgery

A

Robotic have smaller incision sites and much more precise than VATS

266
Q

Indications for VATS

A
  1. Dx: lung biopsy/ interstitial lung disease/ inteminate pulmonary nodule/ biopsy of mediastinal LN/ biopsy of mediastinal mass/ biopsy of pleural-based lesion/ pleural biopsy and drainage effusion
    2.therapeutic (lonectomy / sublobar resection/metastasectomy/ resection of blebs for recurrent pneumothorax/ lung volume reduction surgery)
    PLEURAL and PERICARDIUM( drainage of pleural/pericardial effusion, drainage of retained hemothorax, pleurodesis(plwurectomy, mechanical, chemical))
    MEDIASTINUM(excision of masses or cysts, thymectomy, sympathectomy for hyperhidrosis, ligation of thoracic duct for chylothorax, excision of neurogenic tumor)
    ESOPHAGEAL (resection, esophagomyotomy, esophagectomy )
267
Q

Anatomical list of areas where VATS is done

A

Pleura( visceral, parietal)
Mediastinum (anterior, middle, posterior)
Lung( surface/ wedge resection, bullae, lobe)
Other: heart, pericardium, spine surgery, sympathetic chain)

268
Q

Asthma is a (homogeneous/heterogeneous) disease

A

Heterogeneous

269
Q

Asthma definition

A

Chronic airway inflammation
Its defined by the history of respiratory symptoms such as wheeze, SOB, chest tightness and cough that vary over time in intensity together with variable expiratory airflow limitation

270
Q

Asthma is not a …………… disease

A

Paranchymal

271
Q

Asthma dx by

A

Spirometry

272
Q

Pathophysiology of asthma

A

Allergen will triggered dendritic cells which activate TH2 cells to release IL4/5, IL4 activate plasma cells to release IgE that resides on mast celss and wait for another trigger to make mast cells relase histamin leukotrienes and PGE2 which lead to bronchospasm cough , mucus formation , & IL5 will activate eosinophil

273
Q

Ddx of asthma

A

TB
HIV/AIDS associated lung diseases
Parasitic or fungal lung disease

274
Q

GINA recommends confirmation of asthma by ………… , how?

A

Spirometry,
.20% increase in PEF, 15 min after 2 puffs of salbutamol

275
Q

Asthma management

A

Identify trigger
Controls inflammation ( corticosteroids/ leukotriene inhibitors/ anti IgE therapy/ thermoplasty
Bronchodilator (SABA/LABA)(SAMA/LAMA)
Assess response
Modify and educate

276
Q

Pleura is a serous membrane line by …………… cells

A

Mesothelial

277
Q

The intapleural pressure is……………pressure

A

Subatmospheric ( negative)

278
Q

Pleural space contain ……… fluid

A

10-20mL

279
Q

Most fluid of pleural space is produced by

A

Parietal circulation (intercostal arteries)

280
Q

The 2 key function of pleural space fluid are

A
  1. Lubricantes pleural surface
    2.generates surface tension
281
Q

What is pleural recess

A

Are spaces in pleural cavity that does not contain lung parenchyma

282
Q

Areas of pleural recess are

A

Costodiaphragmatic recess
Costomediastinal recess

283
Q

Importance of pleural recess is that…………

A

They provide space for fluid accumulation

284
Q

Pleural effusion usually collect in …………

A

Costodiaphragmatic recess

285
Q

Blood supply of viceral and parietal pleura

A

Visceral: bronchial circulation
Parietal: intercostal arteries

286
Q

Nerve supply of pleura

A

Parietal: (costal and cervical portion by intercostal nerve)(diaphragmatic portion by phrenic nerve)
Viceral: autonomic nervous system

287
Q

Which layer of pleura lack sensory innervation

A

Visceral

288
Q

Main cause of pleuritic chest pain

A

Viral infection spread from lungs to pleural cavity

289
Q

Common causes of pleurisy

A

Pulmonary infection (VIRAL)
Pulmonary infarction
Malignancy

290
Q

C/F of pleurisy

A

Sharp pain aggravated by deep breathing or coughing
Rib movement restricted
Pleural rub

291
Q

Pleural rub more heard on …………

A

Inspiration

292
Q

How pleural rub differentiated from pericardial rub

A

Ask the patient to hold his breath if the rub continues its pericardial, if it ceases its pleural
Bcz pericardial layers continue to rub against each other with each heart beat

293
Q

Investigation of pleurisy

A

CXR

294
Q

Does a negative CXR exclude pleurisy

A

Noooooooooooooo

295
Q

Management of pleurisy

A

Treat underlying cause
NSAID

296
Q

Pleural effusion

A

Is an abnormal accumulation of fluid in pleural space
Resulting from excess fluid production or decreased absorption

297
Q

In order for pleural effusion to appear up on CXR, effusion level should reach ……………ml

A

300

298
Q

Blood stained pleural effusion usually is

A

Malignant

299
Q

Hydrothorax is

A

Accumulation of serous fluid inside pleural cavity

300
Q

Hemothorax is

A

Accumulation of blood in pleural cavity

301
Q

Pyeothorax

A

Accumulation of pus in pleura

302
Q

Chylothorax is

A

Accumulation of chyle in pleural cavity

303
Q

Pleural effusion etiology

A
  1. Decreased oncotic + increased hydrostatic pressure
    2.increase vascular permeability due to inflammatory process result in increased exudation
    3.blockage lymphatic drainage
304
Q

Types of hydrothorax ( pulmonary effusion)

A

Tansudate
Exudate

305
Q

Transudate pleural effusion caused by

A

Congestive heart failure
Liver failure
Renal failure
Peritoneal dialysis
Hypothyroidism
Hypo albuminemia
Ovarian tumor (meig’s syndrome)

306
Q

Exudate pleural effusion caused by

A

Pneumonia
Carcinoma of lung
TB
PE
Mesothelioma
Connective tissue disease
Post MI
Acute pancreatitis
Sarcoidosis
Yellow nail syndrome

307
Q

Clinical feature of small pleural effusion

A

Asymptomatic

308
Q

Clinical picture of large pleural effusion

A

Dyspnea, pleurisy, dry cough

309
Q

Physical Signs of pleural effusion

A

Inspection : limited chest movement
Palpation: decreased Tactile Vocal Fremitus,, mediastinal shift
Percussion: stony dullness
Auscultation: decreased air entry + pleural rub

310
Q

Investigation for pleural effusion

A

CXR
Us
CT
Thoracocentesis
Pleural biopsy abrams needle

311
Q

CXR findings of pleural effusion

A

Meniscus sign
Blunt costophrenic angle
Disappearance of lung marks
Absent cardiophrenic angle

312
Q

Complete opacification occurs in ………… effusion

A

Massive

313
Q

Physical examination of thoracocentesis in diagnostic pleural effusion is for

A

Color, odor, specific gravity, microbiology, cytology

314
Q

Chemical examination of diagnostic thoracocentesis in pleural effusion is for

A

Total protein
Glucose
PH
LDH
Cholestrol
Triglycerides
Tumor marker
Rheumatoid factors
amylase

315
Q

which type of needle is used for taking Pleural biopsy in pleural effusion? What are the 3 components of it

A

Abrams needle,
Outer trocer- solid stylet- inner cutting trocer

316
Q

Treatment of pleural effusion

A

Drainage by thoracocentesis
Pleurodecesis, surgery’”VATS , thoracotomy “- home management with indwelling pleural catheter = for malignant pleural effusion

317
Q

What is pleurodesis

A

Making adhesion(fusion) between visceral and parietal

318
Q

Bloody pleural effusion indicates

A

Malignancy

319
Q

Milky pleural effusion indicates

A

Chylothorax

320
Q

Pleural effusion with pus indicate

A

Empyema

321
Q

Clear yellowish fluid in pleural effusion indicates

A

Hydrothorax

322
Q

Empyema thoracis

A

Accumulation of infected pus in pleural cavity

323
Q

Empyema may be localized or diffuse.(T/F)

A

Trueeee

324
Q

Most common cause of empyema is

A

Pneumonia

325
Q

Empyema caused by

A

Pneumonia
Lung abscess
Mediastinal abscess( esophageal perforation)
Trauma
Iatrogenic
Subphrenic abcess
Hematogenous spread

326
Q

What are the 3 stages of Empyema

A
  1. Exudative
    2.fibrinopleurant
    3.organizing stage
327
Q

Clinical stages of empyema

A

Acute <2wk
Subacute >2wk till chronic
Chronic: failure of complete lung expansion after 2 wk

328
Q

C/F of empyema

A

Chill, fever, dyspnea, chest pain, referred pain, night sweat, malaise, cough, increased sputum production
Pain abdomen and ileus
Tachypnic anxious and pleural rub
Shift of mediastinum
Dull on percussion
Decreased tactile vocal fremitus
Decreased air entry

329
Q

Investigation for empyema

A

Lab: leukocytosis
CXR
US
CT

330
Q

Rx for empyema

A

stage 1: Thoracocentesis and culture sensitivity based antibiotic
Tube thoracotomy / pigtail catheter
VATS after fibrnolysis
Decorticatiom (open)

331
Q

Empyema complications

A

Pyopneumothorax
Peritonitis
Purulent Pericarditis
Sepsis
Bronchopulmonary fistula
Cutaneous fistula

332
Q

When there is pus + air in effusion the radiographic finding will be a

A

Straight line

333
Q

Pneumothorax

A

Accumulation of air within the pleural space

334
Q

Types of pneumothorax

A

Spontaneous (primary /secondary))
Traumatic

335
Q

Primary pneumothorax occur in

A

Tall thin young male smoker due to rapture of bullae

336
Q

Secondary pneumothorax occur in patients with

A

COPD
Asthma
Bronchiactasis (cystic fibrosis)
Bronchogenic carcinoma

337
Q

Traumatic pneumothorax is due to

A

Trauma/ iatrogenic/ barotrauma( patients on ventilators)

338
Q

Resuscitative effort can cause …………

A

Pneumothorax

339
Q

CXR findings of pneumothorax

A

Like pleural effusion findings

340
Q

Diagnoses of pneumothorax is by

A

Clinical + CXR

341
Q

Rx of pneumothorax

A

Chest tube
VATS/ thoracotomy
Pleurodesis
Surgery
Quit smoking

342
Q

Few points on underwater seal

A

It’s one way valve allow air and fluid to go out of pleural cavity
Attachment should be secured
The tube should be clumped if bottle needs to be disconnected
Bottle must be kept below level of thorax

343
Q

When chest tube removed?

A

Clinically: equal air entery
Pleural drainage <1500 cc/day
Radiologically lung expanded.

344
Q

Benign pleural tumor are

A

Lipoma
Endotheliomas
Angioma
Cysts

345
Q

Malignant pleural tumor

A

Metastatic
Mesothelioma

346
Q

Mesothelioma associated with……………exposure

A

Asbestos

347
Q

Investigation of mesothelioma

A

CXR
CT
Pleural aspiration
Bronchoscopy
Pleural biopsy

348
Q

Rx of mesothelioma

A

Surgical
Brachytherapy
Radiotherapy
Chemotherapy
All are palliative

349
Q

Sxs of methothelioma

A

Pain
SOBropathy
Pleural effusion
Finger clubbing
Dullness at site
Atrial fibrillation
Hypertrophic pulmonary osteoart

350
Q

Pleural cyst most commonly found at ……………… angle

A

Pleuropericardial angle

351
Q

70% of pleural cyst located at ………… side

A

Right

352
Q

CXR finding of pleural cyst

A

Typical water density

353
Q

Pleural plaques and calcification is often ………… and more common on ………… , do not occur at ………… of chest, don’t cause …………… , appear …………

A

Bilateral
Lower half of thorax
Apex
Adhesion
Ivory White and smooth

354
Q

Ddx of pleural plaque and calcification

A

Pleural tumors

355
Q

Tension pneumothorax

A

Progressive accumulation of air in pleural cavity, the site of air entry act as one way valve that make mediastinum structures pushed to the contralateral site

356
Q

Common causes of tension pneumothorax

A

Penetrating trauma, CPR
Mechanical ventilators (barotroma)

357
Q

Sxs of tension pneumothorax

A

Tachycardia
Tachypnea
Hypotension
Cyanosis
He can’t talk or walk

358
Q

In pleural effusion fluid originate by ………… and absorbed by …………

A

Intercostal arteries in parietal pleura
Lymphatic system

359
Q

Transudative causes

A

Congestive heart failure
SVC obstruction
Cirrhosis
Hypoalbuminemia
Peritoneal dialysis
Nephrotic syndrome
Myxedemal
Pulmonary embolization
Meigs syndrome

360
Q

Exudate pleural effusion causes

A

Microbial invasion (pneumonia, TB, empyema)
Neoplasm( lung carcinoma, metastasis, mesothelioma)
Pulmonary embolism
Viral pleuritis
GI disorders ( esophageal perforation, pancreatitis, abdominal abscess, diaphragmatic hernia, abdominal surgery, liver transplant )
Collagen vascular diseases (RA, SLE, Sjögren’s syndrome, wegner’s granulomatosis
Miscellaneous ( asbestosis, meigh syndrome, sarcoidosis, CABG, uremia, previous thoracic surgery, yellow nail syndromes)

361
Q

Sxs of pleural effusion

A

Pleuritic chest pain
Dyspnea
Cough non-productive ( can be productive if pneumonia present)
Physical examination findings:
Asymmetrical lung expansion & unilateral lagging of affected site
Reduced tactile vocal fremitus
Reduced or absent breath sound
Pleural friction rub
DULLNESS on percussion

362
Q

………………… is a LOCALIZATED area of destruction of lung paranchymain which infection by PYOGENIC organisms results in an inflammatory process and tissue necrosis with formation if a large localized collection of pus or CAVITY

A

Lung abscess

363
Q

CXR finding of lung abscess

A

Cavity + air-fluid level

364
Q

Types of lung abscess

A

Primary
Secondary

365
Q

Complications of lung abscess

A

Bronchopulmonary fistula
Empyema
Pneumothorax
Sepsis
Fibrosis
Bronchiactasis
Amyloidosis
Metastatic cerebral abscess

366
Q

Clinical features of lung abscess

A

High fever
Onset is acute or gradual
Cough with large amount of sputum
Pleuritic chest pain
Pleural rub
Foul sputum
Rapid deterioration
Wt loss
Digital clubbing

367
Q

Investigation for lung abscess

A

CXR
CT
CBC and ESR
Sputum exam
Blood cultures
Bronchoscopy

368
Q

Primary lung abscess caused by

A

Staphylococcus aureus or klebsiella

369
Q

Secondary lung abscess is caused by

A

Inhalation of septic materials
Iv drug users are at higher risk of developing a lung abscess in association, with endocarditis affecting pulmonary and tricuspid valve

370
Q

89% Causative agents for lung abscess is

A

Anaerobes

371
Q

Most common anaerobes as causative agent for lung abscess are

A

Peptosretococcus
Bacteriod
Fusibacterium
Microaerophillic

372
Q

Treatment of lung abscess

A
  1. Ampicillin / metronidazole/ clinfamycin/ciprofloxacin
  2. Physiotherapy
    3.sirgery
  3. Prevention by taking precautions
373
Q

What is varicose veins?

A

Permanent dilated tortuous subcutaneous veins with diameter >= 3mm

374
Q

What is reticular vein?

A

Thin walled blue venules lying within superficial compartment with diameter ranging between 1-3mm

375
Q

What is telangectasias

A

Are dilated venules, capillaries or arterioles with 0.1-1mm in diameter

376
Q

Pathophysiology of varicosis & reticular veins?

A

Venous HTN, valvular incompetence or structural change in vein wall

377
Q

Risk factors for varicose veins

A

Fam hx
Smoking
Gemale
Immobility
Long standing
Raised intra-abdominal pressure (pregnancy, mass)
Increased progesterone

378
Q

Sxs of varicose veins

A

Asymptomatic (most common)
Dragging pain
Postrual discomfort
Heaviness in the leg
Night time cramps
Edema
Itching
Discoloration
Ulceration

379
Q

Clinical sign of varicose vein

A

Visible varicosities
Brodie trenedlenburg test
Multiple tourniquet test( at sapheno-femoral junction, above knee and below knee)

380
Q

Complication of varicose vein

A

Superficial thrombophlebitis
Bleeding
Eczema
Skin ulcer

381
Q

Investigation for varicose veins

A

Doppler US

382
Q

Management of varicose vein

A

Conservatives
Sclerotherapy
Lasar ablation
Stripping and phlebotomy

383
Q

Superficial thrombophlebitis

A

Inflammatory- thrombotic condition of superficial veins

384
Q

Diagnosis of superficial thrombophlebitis is mainly clinical ,how?!

A

Pain, tenderness, induration

385
Q

Thrombophlebitis usually affect the……………

A

Lower extremities

386
Q

2/3 of the cases of superficial thrombophlebitis, which vein is involved?

A

Greater saphenous vein

387
Q

What are the risk factors for superficial thrombophlebitis?

A

Chronic venous insufficiency, history of DVT thrombosis or superficial vein thrombosis, sclerotherapy, pregnancy, obesity, long distance travel, thrombophilia, malignancy

388
Q

How superficial thrombophlebitis managed?

A

NSAID
bandaging
prophylactic anticoagulant

389
Q

What is lymphedema?

A

It’s a progressive accumulation of protein enriched interstitial fluid

390
Q

Lymphedema can be ………… or………… lymphatic defect.

A

Primary or secondary

391
Q

The lymphatic system works in conjunction with the arterial and venous system. It has three main roles which are:

A

It is part of the immune system
It help to maintain fluid balance
It’s playing essential part in the absorption of fat and fat, soluble nutrients

392
Q

Clinical classification of lymphedema

A

Primary lymphedema, which may be a congenital precox tarda
Secondary

393
Q

Morphological classification of lymphedema

A

Aplasia, hypoplasia, numerical hyperplasia, hyperplasia

394
Q

Anatomical classification of lymphedema

A

Distal obstruction,
proximal “obstruction

395
Q

Secondary lymphedema may be due to

A

Iatrogenic
Burn
Trauma
Pregnancy
Bites
Infestation

396
Q

What are the staging of lymphedema?

A

Latent phase
Grade 1
Grade 2
Grade 3

397
Q

Which stage of lymphedema is irreversible

A

Stage three

398
Q

Give a brief explanation of each stages of lymphedema

A

latent phase excessive fluid accumulate and fibrosis occur around the lymphatic, but no edema is apparent clinically
Grade one Edema Pitts on pressure and is reduce large or completely by elevation. There is no clinical sign of fibrosis
Grade 2: edema does not pit on pressure and is not reduced by elevation moderate to severe fibrosis is evident on clinical examination
Grade 3 Adema is irreversible and develop from repeated inflammatory attack, fibrosis, and sclerosis of the skin and subcutaneous tissue. This is the stage of lymph aesthetic elephantiasis.

399
Q

Presentation of lymphedema

A

Family, history of leg swelling
Teenage girl without any identifiable cause
History of diarrhea on weight loss,
in patient with secondary lymphedema, cause maybe evident from history
Patient travel to tropical countries
Edema(pitting initially, sqaure toe)
, Steemer sign positive (inelastic skin)
skin change ( mildly elevated temperature, severe clubbing, transverse ridging , friability , decreased rate of nail growth, recurrent chronic eczematous dermatitis,
pain (intense pain is rare)
Lymphorrhea

400
Q

Lymphorrhea occurs in ………

A

Lymphedema

401
Q

Does clubbing occur in lymphedema ?

A

Yesssss 👏

402
Q

Complication of lymphedema

A

Infection
Malnutrition and immuno deficiency
Malignant tumor
Psychological impairment

403
Q

Diagnosis of lymphedema

A

CBC
Renal hepatic blood test
Eosinophilia
Hypoproteinemia
Urinanalysis my indicate proteinuria,
lymphoscintigraphy CT and MRI
direct contrast lymphangiography

404
Q

Differential diagnosis of lymphedema

A

Lipedema
Venous insufficiency
System causes are:
underlying cardiac disease
Hepatic, renal failure, hypoproteinemia, Malnutrition, endocrine disorders, myxedema, or allergic rxn, hereditary angioedema, idiopathic cyclic edema
Drugs that cause swelling

405
Q

Management of lymphedema

A

Conservative;
Maintaining daily skin hygiene, and avoid trauma
Elevating the affected limp
Less salt and more protein intake
Compression stocking
Walking and performing aerobic exercise
Surgical treatment: excisional operation, liposuction, reconstructive surgery

406
Q

In lymphedema we have to type of failure

A

High input failure
Low output, failure

407
Q

Most common valvular hear disease is

A

Aortic stenosis

408
Q

Arctic stenosis is male or female predominance?

A

Male

409
Q

Aortic stenosis is due to

A

Congenital bicuspid
Rheumatic
Idiopathic

410
Q

Types of aortic stenosis

A

Valvular
Subvalvular
Supravalvular

411
Q

Supravalvular may be associated with ……… features

A

Broad forehead
Widely set eyes
Pointed chin
Mental retardation
Hypercalcemia, which together called William syndrome

412
Q

Symptoms of arctic stenosis( triad of AS)

A

Dyspnea, angina pectoris aunt syncope

413
Q

What are the physical findings in arctic stenosis?

A

Pulses parvus et tardus (slow rising pulse)
Double peak (bisferiens pulse )
Collapsing pulse
Systemic arterial pressure within normal limits
On palpitation:
forceful, apex beat, laterally displaced, double impulse
systolic thrilled at the base of the heart, jugular notch and along carotid arteries.

414
Q

What are the auscultation findings of aortic stenosis?

A

Systolic ejection sound in congenital noncalcific arctic stenosis
Paradoxic splitting S2
Apical S4 and s3 if LV dilate and fail
Systole crescendo, decrescendo murmur at second right intercostal space radiated to suprasternal notch and carotid occasionally to apex

415
Q

How are aortic stenosis is diagnosed

A

ECG
Echocardiography
chest x-ray 🩻
cardiac catheterization

416
Q

What is the treatment of aortic stenosis?

A
  1. in mild or asymptomatic cases with valvular pressure less than 50 mm mercury follow up + prophylactic pencillin to prevent infective endocarditis.
  2. If symptomatic or a single syncopal attack:immediate valve replacement is needed.
  3. Being asymptomatic patient with severe aortic stenosis, and deteriorating ECG. Valve replacement is needed.
    4.Aortic balloon vulvoplasty
  4. In children, elderly, or pregnancy.: valvotomy may be done, valve replacement may be needed later
  5. anticoagulant is necessary, if associated with AF aura, if mechanical valve prosthesis is used.
417
Q

Two most important pathophysiology of arctic stenosis

A

It may cause myocardial ischemia due to decrease blood supply to the coronary arteries
Or it may cause AF

418
Q

Most common cause of infective endocarditis is

A

Bacteria

419
Q

Most common cause of pericarditis is

A

Viral

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