Cvs Flashcards
1
Q
Infective endocarditis caused by micro-organisms affecting ……
A
Chambers, valves(native/prosthetic), blood vessels, congenital anomaly
2
Q
Types of infective endocarditis
A
Acute
Subacute
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
4
Q
The fatality of infective endocarditis increase when…………
A
1.there is prosthetic valve endocarditis
2. Infection with antibiotics resistence organism
5
Q
Does IE (infective endocarditis) increase with age?
A
Yes, more than 50% of pts are over 60yrs
6
Q
Infection with highly virulence organism such as ……………… can induce endocarditis in a previously normal heart which cause ………….. endocarditis.
A
Staphylococcus aureus, Acute
7
Q
IE typically occur at sites of pre-existing ……………
A
Endocardial damage
8
Q
Areas of endocardial damage caused by high pressure jet such as
A
VSD, mitral regurgitation, aortic regurgitation
9
Q
Vegetation of IE made of
A
Platelete, fibrin, micro-organism
10
Q
Vegetation of IE can cause
A
- Obstruction
- Abcess
3.emboli
4.valve regurgitation - Cusp perforation and chordae disruption
11
Q
Extra cardiac features of IE
A
Vasculitis and skin lesion, emboli (lung, spleen,kidney) or immune complex deposition( glomerulonephritis, skin)
Mycotic aneurysm
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
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
14
Q
Clinical dx of IE
A
2major
1 major+ 3 minor
5 minor criteria
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
16
Q
Management of acute IE
A
Amoxicillin + vancomycin/ gentamycin
In prosthetic valve add rifampcin
17
Q
Management of subacute endocarditis
A
Antibiotics should be witheld till results of culture came back
18
Q
Acute pericarditis definition
A
Acute inflammation of pericardium -/+ pericardial effusion can occur as an isolated clinical problem or systemic manifestation
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
20
Q
Arrhythmia occur in pericarditis
A
True but rare
21
Q
Lab results of pericarditis
A
Elevated CRP
Leukocytosis
Elevated CK, CK-MB and troponin
22
Q
Complication of pericarditis
A
Pericardial effusion
Cardiac tamponade
Recurrence
Constrictive pericarditis
23
Q
CT findings of pericarditis
A
Pleural thickening
Calcified percardium
24
Q
Ddx of ST elevation
A
Pericarditis
STEMI
Early repolarization
Myocarditis
Aneurysm
Burgarda
BBB
25
Friction rub of pericarditis is
Triphasic
26
Treatment of pericarditis
Treat as outpatient if stable
Aspirin
NSAID:ibuprofen
Colchicine
Glucocorticoid if NSAID and colchicine fails
Azothioprine, cyclophosphonamide or MTX
Anakinra
Pericardiectomy
27
Which drug shouldn’t be given in pericarditis,why?!
Warfarin and heprin, bcz it increase risk of hemopericardium
28
Steriod therapy in pericarditis should be restricted to those with……………
1. Acute pericarditis due to connective tissue disease
2. Immune mediated pericarditis
3. Uremic pericarditis
29
Chest pain of pericarditis
Sudden onset, anterior chest wall, pleuritic, sharp pain, worsen with lying flat and improve by leaning foreward
30
Types of pericardial effusion
1.fibrinous
2.serous
3. Hemorrhagic
4. Prulent
31
What happen to heart sound and friction rub in pericardial effusion?
Heart sound become quieter
Friction rub may diminish but not always abolished
32
Physical findings of pericardial effusion
Increased JVP
Hypotension
PULSES PARADOXES
Oliguria
Chylopericardium
33
Large effusion in pericardial effusion may by sensed as retrosternal compression
True
34
Definite investigation of pericardial effusion is……………… and confirmation is by……………
Echo
CT/MRI shows ( pericardial effusion, pericardial thickening, pericardial mass
35
Follow up of pericardial effusion is by
TTE
36
Management of pericardial effusion
If pericardial effusion cause HD instability and persist for>3month = pericardiocentesis
37
Cardiac tamponade is a ……………
Medical emergency
38
Cardiac tamponade definition
Accumulation of fluid in pericardial space in quantity sufficient to cause serious obstruction to inflow of blood into ventricles cause cardiac tamponade
39
3 most common cause of cardiac tamponade are
1. Neoplasm
2. Idiopathic
3. Renal failure
Or it may occur from bleeding into pericardial space due to trauma, operstions, Rx with anticoagulants
40
Becks triad is a clinical features of ………… and composed of …………
Cardiac tamponade, ( raised jvp, hypotension, muffled heart sound)
41
Quantity of fluid necessary to cause tamponade ………
May be as small as 200ml or as large as >2000ml
42
Clinical features of tamponade
Dyspnea
Tachycardia
Hypotension
Raised jvp
Pulses paradox
Ecg: low voltage + electrical alternans
43
Hallmark of cardiac tamponade is………
Pulses paradox
44
Dx of tamponade
TTE
45
Management of tamponade
Pericardiocentesis
46
Aortic dissection is more common in male or female!
Male 2:1
47
Aortic dissection more commonly affect ………, in …………, in………………
Descending, winter, morning
48
Acute aortic syndrome is
1.aortic dissection
2.intramural hematoma
3.penetrating aortic ulcer
49
Risk factors for aortic dissection
Hypertension
Genetic
Trauma
Sex
Age
Cocaine
Pregnancy
50
Aortic dissection associated with
Hypertension
Tobacco
Congenital anomalies: bicuspid aortic valve, coarctation of aorta
Genetics marfan and ehlersdanlos
51
Clinical presentation of aortic dissection
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
52
Chronic aortic disection type B clinical features are
Chest pain
Dyspnea
Hoarseness
Wheezing
Dysphagia
Hemoptysis
Hematemesis
53
Physical exam of aortic dissection reveals
1. HTN or hypotensive
2. Different blood pressure between extremities
3. New murmur of aortic valve insuff.
54
Aortic dissection classifications
Standford =group A and group B
Debakey =type 1,2,3
55
Diagnosis of aortic dissection
Biomarkers
Ecg
Aortigraphy
Tee
Chest CT
MRI
56
Rx of aortic dissection
Anti-impulsive
Antihypertensive
Trimethaphan
Reserpine
Guanethidine
+
Surgical treatment( resection , closure, grafting)
57
Leriche syndrome is
Aortic occlusive disease (aortoilliac occlusive disease)
58
Aortic occlusive disease is a type of …………disease
Peripheral arterial disease
59
The occlusion in aortic occlusive disease caused by
Atherosclerosis
Thrombosis
Embolism
60
Aortoillaic disease located beyond
Infrarenal artery
61
Aortic occlusive disease can present acutely or chronically.
True
62
Risk factors for leriche syndrome
Modified: HTN , DM, high cholestrol, hyperlipidemia, obesity, lack of exercise, tobacco
Non-modified: age, sex, fam hx
63
Triad presentation of leriche syndrome
Claudication
Impotence
Absence of femoral pulse
64
Dx of aortic occlusive disease
Lab test= lipid profile and HBa1c
Ankle brachial index lower than 0.9
CTA or duppler ultrasound
MRA
65
Classification of occlusive aortic diseases
Type 1 =till common ilaic
Type2= till external ilaic
Type3= till femoropopliteal
66
Rx of aortic occlusive disease
Non interventional: stop smoking, statin, antihypertensive, anticoagulant, manage DM, walking exercise
Interventional:thrombi endarterectomy, aortofemoral bypass, percutaneous transluminal angioplasty
67
Congenital anomaly of aorta
PDA
Vascular ring
Coarctation of aorta
Aortopulmonary window
Truncus arteriosis
Hypoplasia
68
Vascular ring classification
Complete( double aorta/ Rt aortic arche/ Lt aortic arch)
Incomplete
Pulmonary artery sling
69
Vascular ring caused by
Abnormal persistence or regression of one of the six embryonic aortic arch
70
Aortopulmonary window classification
Type 1= proximal
Type2 = distal
Type3= total absence of aortopulmonary septum
71
Mori classification is
Aortopulmonary window classification
72
Truncus arteriosis is caused by
Seperation failure during development of ventricular outlets and the proximal arterial segment of heart tube
73
Truncus arteriosis seperated from Aortopulmonary window by
Truncus arteriosis have 2-5 cusps , presence of a common truncal valve which is often stenotic and insufficient
74
Truncus arteriosis dx by
CTA and MRA
75
Ascending and arch aneurysm classification are
Fusiform and saccular
76
Cause of ascending aortic aneurysm are
Medial degeneration ( idiopathic / genetic)
Infection
Inflammation
Long standing aortic dissection
77
Arch aneurysm are due to
Chronic dissection
Long standing HTN
Atherosclerosis
78
Dx of aortic aneurysm
CXR
Ecg
Echo
Angiography
CT
CTA
MRA
79
Rx of aortic aneurysm
Avoid exercise
Avoid rapid acceleration and deceleration
Anti impulse
Bblocker
80
Non-elective and elective indication for aortic aneurysm
Non-elective: >4.5-5
Elective=5.5cm and growth rate >1cm/yr in absence of connective tissue disorder or cardiac pathology
81
Clinical presentation of aortic aneurysm
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
82
Constrictive pericarditis is the result of……… &………… of pericardium that lead to heart failure by impairing……… cardiac filling.
Inflammation, fibrosis, diastolic
83
When constrictive pericarditis occur?
Usually happens after multiple episodes of acute pericarditis over time.
84
If ………… & ………… caused pericarditis, there is up to 30% risk of constrictive pericarditis
Bacteria and tuberculosis
85
Why heart failure due to constrictive pericarditis is differ from other types of heart failure?
Bcz pericardiectomy can cure the condition
86
Constrictive pericarditis have HD features similar to
1. Restrictive cardiomyopathy
2. Severe tricuspid regurgitation
87
Etiology of constrictive pericarditis
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
88
Constrictive pericarditis is uncommon feature of …………
Heart failure
89
Constrictive pericarditis is irreversible.
False, it’s reversible
90
Final common pathway of constrictive pericarditis is
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
91
Why constrictive pericarditis result in elevated, equalized diastolic pressure in all chambers?
Bcz noncompliant pericardium limits ventricular relaxation and determines ventricular diastolic pressure
92
Clinical features of constrictive pericarditis
Dyspnea
Fatigue
Raised JVP
Hepatotomegaly and ascites
Edema
Kussmal sign
Pericardial knock
Rapid,low volume pulse
Af is common
93
Hallmark of constrictive pericarditis
Systemic venous congestion
94
Elevated jvp present in all patient with constrictive pericarditis except in
Hypovolemic patients 😂
95
One physical sign of constrictive pericarditis is a rigid pericarium that impairs diastolic filling and suddenly block rapid ventricular filling which is called …………
Pericardial knock
96
Physical signs of constrictive pericarditis are
Pericardial knock
Rt side heart failure with distended JV
Kussmaul sign
Hepatomegaly
Ascites
Edema
97
Severity of heart failure is …………… to degree of myocardial dysfunction in constrictive pericarditis.
Disproportional
98
Constrictive pericarditis is more common in male or female
Male 2:1
99
Investigation for constrictive pericarditis
Echo
CT
MRI
Cardiac catheterization
100
Constrictive pericarditis can present without pericardial calcification or without any obvious pericardial thickening. (T/F)
True
101
Management of constrictive pericarditis
Prior to pericardiotomy
A trial of anti-inflammatory
Steroid if HD instable
Na restrictions +diuretics
102
Mitral stenosis (MS) is characterized by……… at the level of ……………… due to ………………
Obstruction to the Lt ventricular inflow at the level of mitral valve due to structrual abnormality of mitral valve apparatus
103
Most common causes of MS are :
1. RHD
2. Lutembacher syndrome ( ASD + rheumatoid mitral stenosis)
3. Malignant carcinoid
4. SLE
5.RA
6. Congenital mitral stenosis
104
Normal mitral valve orifice is ……… cm2
4-6cm2
105
Pathophysiology of mitral stenosis
Decrease mitral valve orifice this lead to increase in pressure across the mitral valve
106
When will patients with mitral stenosis experience symptoms?
When valve orifice become 2-2.5cm2
107
when will Severe mitral stenosis occur?
When mitral orifice become <1cm2
108
Pathophysiology of MS
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
109
Pulmonary hypertension occur in MS as a result of
Retrograde transmission of Lt atrial pressure
Pulmonary arteriolar constriction
Interstitial edema
Intimal hyperplasia and medial hypertrophy
110
Ms due to rheumatoid disease is much more common in…………
Female 2/3rd
111
Symptoms of MS appear at which stage of life?
3rd and 4th decade
112
Symptoms of MS
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
113
Physical exam of mitral stenosis
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
114
Auscultation of mitral stenosis
1. Low pitch,rumbling mid diastolic murmer accentuated by exercise and reduced by. Valsalva maneuver
2.loud S1
3.accentuated P2 in pulmonary hypertension
4. Opening snap follows S2
115
Dx of mitral stenosis
CXR
ECG
Echo: gold standard
Catheterization
116
Rx of mitral stenosis
Prophylaxis for IE
Diuretics
Control rate BB , CCB
Control rhythm by amiodarone or digoxin
Sodium restriction
Nitrates decrease preload
Anticoagulant
Surgery( vulvoplasty, vulvotomy, replacement)
117
Mitral regurgitation definition
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
118
Pathophysiology of acute MR
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
119
Chronic mitral regurgitation Pathophysiology
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
120
Etiology of acute mitral regurgitation
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
121
Etiology of chronic mitral regurgitation
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
122
Sx of acute / chronic mitral regurgitation
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
123
Examination of MR (palpation)
1. Forceful apex beat
2. Apex beat displaced laterally
3. Systolic thrill at apex
124
Examination of mitral regurgitation (auscultation)
Soft S1
Pansystolic murmur radiate to axills
S3 and S4
Systolic murmur intensified by stain and relieved by valsalva
125
Dx of mitral regurgitation
CXR
ECG
Echo
126
Rx of mitral regurgitation
Diuretics
BBlocker biventricular pacing LV dysfunction
CCB
Digitalis
Anticoagulants
127
AORTIC stenosis is more common in
Male
128
Mitral stenosis is more common …………, while Aortic stenosis is more common in ……………
Female, male
129
Causes of aortic stenosis
Congenital (bicuspid)
Rheumatic
Idiopathic: degenerative wear and tear commonly in elderly
130
Types of aortic stenosis
Supravalvular: narrowing or fibrous diaphragm
Valvular
Subvalvular: membraneous or fibrous diaphragm
131
What are other features associated with supravalvular aortic stenosis( williams syndrome)
Broad forehead
Widely set eyes
Pointed chin
Mental retardation
Hypercalcaemia
132
Pathophysiology of aortic stenosis
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
133
Symptom of AS
Dyspnea
Angina
Syncope
134
Dx of AS
CXR
ECG
Echo
Catheterization
135
Rx of As
Avoid strenuous activity
Sodium restriction
Caution use of diuretic in CHF
VASODILATORS C/I in severe AS
Surgery
136
Types of lung tumors are:
Primary ( bronchogenic carcinoma)
Secondary
Bronchopulmonary carcinoid
Beninign tumor of the lung
137
What is cancer?
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
138
Primary lung cancer definition
Respiratory epithelium undergo neoplasm changes that called bronchogenic carcinoma
139
……………… accounts for 90% of all pulmonary tumors
Primary lung cancer
140
What are the two main types of primary lung cancer?
Non-small cell lung cancer ‘NSCLC’ 85%(adenocarcinoma, SCC, large cell carcinoma)
Small cell lung cancer SCLC 15%
141
2nd most common malignancy in both gender is…………
Primary lung cancer
142
Most common cancer worldwide in terms of both incidence and mortality is………
Primary lung cancer
143
Lung cancer is most commonly dx among persons ………………… yrs of age and rare………………… yrs
55-74
before 35 yrs
144
Risk factors for primary lung cancer
1. Tobacco smoking
2.radon
3.asbestos
4. Environmental tobacco smoke
5.genetic
6.other lung diseases e.g. TB
7. Radiation
145
Combination of risk factors increase the chance of primary lung cancer.
💯
146
Clinical features of primary lung cancer
1.cough 75%
2.dyspnea 50%
3.hemoptysis 50%
4. Chest pain 40%
147
Cough which is most common symptom of primary lung cancer is caused by ………
Bronchial mucosa invasion due to tumor, atelectasis, cavitation, pleural effusion
148
Hemoptysis in primary lung cancer caused by
Tumor necrosis
Mucosal ulceration
Erosion into thoracic blood vessel
149
Metastatic effect of primary lung cancer is seen in …………………
Adrenal, liver(SCLC), CNS , bone
150
Most common cause of cerebral metastasis is …………
Lung cancer
151
Dx of primary lung cancer
CXR
CT
MRI
PET
Sputum cytology
Bronchoscopy
Thoracic Needle aspiration biopsy
152
Types of resection in primary lung cancer
Wedge resection
Segmentectomy
Lobectomy
Bilibectomy
Pneumonectomy
153
The essential aspects of lung cancer evaluation in dx are
Histologic distinction of SCLC from NSCLC
Accurate staging
Decision on operability
Determination of pts performance status
154
Rt paratracheal and subcarineal lymphnode have been approched with ……………………… in primary lung cancer
Cervical mediastinoscopy
155
Biopsy of Lt paratracheal, supra-aortic and aortopulmonary window node have been approached with……………… in primary lung cancer
Anterior mediastinotomy
156
Lungs are common site for secondary metastasis from………………………………
Breast, renal, colon , upper airways
157
Current surgical treatment of pulmonary metastasis are
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
158
Compared with bronchogenic carcinoma, carcinoid tumors occur more frequently in …………… patients and are less likely to be associated with Hx of smoking
Younger
159
Bronchopulmonary carcinoid tumors are classified into…………………&……………… on basis of histologic features
Typical
Atypical
160
What is the difference between typical and atypical carcinoid tumor?
Typical;more common, centrally located and rarely metastasize
Atypical: less common, peripherally located and metastasize occur in pts above 30 yrs
161
Sx of carcinoid tumor
Cough
Hemoptysis
Dyspnea
Wheeze
Recurrent upper respiratory infection
Pneumonia
Some pts may have carcinoid syndrome ( diarrhea, flishing , bronchoconstriction, heart failure)
162
Rx of carcinoid tumor
Complete surgical resection of the tumor
Sparing of paranchyms ehenever possible
LN staging by ipsilateral LN sampling or mediastinal LN dissection
163
Benign lung tumor classification according to presumed origin
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)
164
Benign lung tumors can be classified according to
Pathology
Clinically by location or whether its single or multiple
Presumed origin
165
Bronchiectasis definition
Abnormal, persistent, irreversible dilation of bronchi
May be focal(localized) or diffuse
166
Bronchiectasis distribution may be ………… or ……………
Focal, diffuse
167
Classification of bronchiectasis
1.cylindrical (fusiform)
2.varicose
3, saccular (cystic)
168
Bronchiectasis is caused by destruction of …………&…………
Muscle, elastic tissue
169
In which class of Bronchiectasis the bronchi appear uniformly dilated
Cylindrical
170
Mild form of bronchiectasis is …………
Cylindrical
171
What are the radiographic characteristics of cylinderical Bronchiectasis
1. Parallel tram track lines
2.signet-ring
172
What is signet ring
Is a radiographic feature of cylindrical bronchiectasis that shows dilated bronchus cut in a horizontal secretion with adjacent pulmonary artery representing the stone
173
Irregular or beaded bronchi with alternating areas of dilatation and constriction are found in …………… bronchiectasis
Varicose
174
Moderate bronchiectasis is
Varicose bronchiectasis
175
Honeycomb sign is found in …………bronchiectasis
Saccular
176
Diameter of bronchus lumen normally is ………
1-1.5 times of adjacent vessels
177
Etiology of bronchiectasis
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
Primary infection of bronchiectasis organisms
Klebsiella
Staph
Tb
Mycoplasma pneumonia
Non-TB mycobacterium
Measles
Pertussis
Herpes
Adenovirus
Infection with syncytial virus in childhood
179
A diameter of bronchus lumen greater than 1.5 times of adjacent vessels suggests…………
Bronchiectasis
180
Most common cause of bronchiectasis is
Primary infection
181
Clinical features of bronchiectasis
Cough with mucopurulent lasts month to yrs
Hemoptysis
Dyspnea
Pleuritic chest pain
Wheezing
Fever
Fatigue
Wt loss
182
Rare clinical feature of bronchiectasis
Hemoptysis with little or no cough 😷
183
Physical examination finding of bronchiectasis (6)
Crackle, scattered wheeze
Clubbing
Cyanosis/Plethora/polycythemia
Wt loss
Nasal polyps
Core pulmonale
184
Dx of bronchiectasis is by
HRCT
185
Other Dx criteria helpful in bronchiectsis
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
Vitamin D and bronchiectasis relation
Pts with vitD def and bronchiectasis were more likely colonized with pseudomonas aeruginosa
Had more exacerbation and FEV1 decreasee
187
Core of Management of bronchiectasis is achieved by
Antibiotics and chest physiotherapy
188
Management of bronchiectasis
Antibiotics
Bronchodilator
Steroid
Dietry supplement
Oxygen
Admition
Surgery
189
The goal of therapy in bronchiectasis are:
1.improve sx
2. Reduce complication
3. Control exacerbation
4.reduced mortality and morbidity
5. Manage underlying condition
190
Exacerbation of bronchiectasis may produce the following signs
Increased sputum
Increased viscosity
A foul odor of sputum
Low grade fever
Increased constitutional symptoms (fatigue,malaise)
Increased dyspnea, wheeze , pleuritic pain
191
Anti-inflammatory therapy that are used in bronchiectasis are
Inhaled or oral corticosteroids
Leukotriene inhibitors
NSAIDs
+
Azithromycin known as anti-inflammatory in pt with cystic fibrosis( xoy la asla antibiotics)
192
Can lung transplant be done for moderate cases of bronchiectasis
No, its for severe cases and especially for those with cystic fibrosis
193
When you consider patient with bronchiectasis and cystic fibrosis for lung transplants
When FEV1 falls below 30%+ female pt and younger pts may need to be considered sooner
194
Why Bronchial hygiene in bronchiectasis needed?
Bcz of tenacious (viscosity) of sputum and failure of clearance
195
How brochial hygiene done in patients with bronchiectasis
Postural drainage with percussion and vibration
Vest
Nebulizer with Nal 7%
Mucolytic (acetylecysteine
+general adequatel hydration
196
COPD subtypes are:
Chronic bronchitis
Emphysema
197
Chronic bronchitis is……
Cough and sputum on most days for at least 3 consecutive month for 2 successive yrs
198
Emphysema is ………
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
Asthma is a …………… disorder
Functional
200
Chronic bronchitis is a………… disorder
Clinical
201
Emphysema is an ……… disorder
Anatomical
202
Chronic bronchitis and emphysema are ………… lung diseases.
Obstructive
203
Chronic bronchitis found in ………… patients.
Overweight
204
Emphysema found in …………… patients
Thin
205
Cellular inflammation in chronic bronchitis and emphysema are done by …………&…………
Macrophages and neutrophils
206
Blue bloater are characteristic feature for …………
Chronic bronchitis
207
Pink puffer are characteristic feature of ………
Emphysema
208
Persistent airflow obstruction found in
Chronic bronchitis and emphysema
209
Chronic bronchitis and emphysema are (reversible/irreversible) airway limitations
Irreversible
210
Common sx of chronic bronchitis and emphysema are
Cough, sputum, SOB
211
Trigger for COPD
1. Exposure
Tobacco
Pollutents
Occupation
Drugs
2. Airway hyper-reactivity
3.host factors
Alpha1-antitrypsin deficiency
212
Dx of COPD
1. History
2.spirometry <0.7
3.COPD assessment test CAT
4.clinical COPD questionnaire CCQ
5. mMRC breathlessness scale
7.CXR
8.lung volume and diffusing capacity
9. Oximetry and blood gas
10.alpha1-antitrypsin
213
Ddx of COPD
Asthma
214
How to differentiate COPD from asthma
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
COPD pts are at high risk of
CVD
Respiratory infection
Bronchiectasis
Lung cancer
Osteoporosis
DM
Anxiety and Depression
216
Gold Classification of COPD
Gold1: greater or equale to 80%
Gold2: 50-80%
Gold3: 30-50%
Gold4: less than 30%
217
COPD definition
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
Asthma is a disease of ………… airways but gradually become…………
Large, large and small airways
219
COPD definition
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
Mechanism of COPD
Small airway disease + parenchyma destruction
221
How spirometery dx COPD
Post- SABA FEV1/FVC < 70%
222
Treatment for COPD
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
Consequences of COPD exacerbation
Negative impact on quality of life
Impact on sxs and lung function
Increased economic costs
Increased mortality
Accelerated lung function decline
224
Assessment of exacerbation of COPD
CBC
ABG
CXR
ECG
Biochemical tests
Purulent sputum
225
Asthma is a (homogeneous/ heterogeneous) disease
Heterogeneous
226
Pulmonary fibrosis is the end result of ………………
Many respiratory diseases
227
Pulmonary fibrosis is characterized by………
1. Scar tissue in lung
2.honeycomb lung
3. Decreased compliance, giving a restrictive pattern in PFT (FEV1/FVC >80%)
228
Pulmonary fibrosis classified according to involvement
1. Localized( unresolved pneumonia)
2.bilateral( TB)
3.diffuse (IPF or pneumoconiosis)
229
Clinical features of idiopathic pulmonary fibrosis IPF: (4D)
Dry cough
Dyspnea
Digital clubbing
Diffuse inspiratory crackles
230
1.In pulmonary fibrosis lung compliance …………… while elacticity …………
2. In asthma and COPD lung compliance …………… while elacticity……………
1. Decrease, increase
2.increases, decrease
231
Idiopathic pulmonary fibrosis definition
A specific form of chronic, progressive fibrosing interstitial pneumonia of unknown cause, occurs primarily in older adults, and limited to the lungs.
232
A specific form of chronic, progressive fibrosing interstitial pneumonia of unknown cause, occurs primarily in older adults, and limited to the lungs.
Idiopathic pulmonary fibrosis
233
Pulmonary fibrosis characterized by worsening of …………&…………… & is associated with ………… prognosis
Dyspnea, lung function, poor
234
3 points on idiopathic pulmonary fibrosis
1.chronic
2.progressive
3.irreversible
235
Idiopathic pulmonary fibrosis is a chronic disease characterized by fibroblast ………… and extracellular matrix …………
Proliferation, remodeling
236
Idiopathic pulmonary fibrosis is a primary inflammatory lung disease (T/F)
False, it is a primary epithelial/ fibroblastic disease and inflammation is a secondary event
237
Risk factors for idiopathic pulmonary fibrosis
Cigarette smoking
Environmental exposure
Metal and wood dust
Farming
Raiing birds hair dressing, stone cutting
Microbial agents: herpes virus
238
Pathophysiology of idiopathic pulmonary fibrosis
Injury to alveolar epithelium—>increasing cytokines and pro-inflammatory products——> stimulate fibroblast and myofibroblast——> increase deposition of collagen in extra cellular matrix
239
Dx of pulmonary fibrosis
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
Gold standard dx tool for pulmonary fibrosis is ……………
HRCT
241
Rx of IPF
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
Causes of interstitial lung disease
1. Occupational and environmental (silicosis, asbestosis, hypersensitivity pneumonitis)
2.drug induced: amiodarone, nitrofurantonin, methotrexate, ocaine
3. C.T. Diseases :SLE , RA, scleroderma
4. Primary diseases: sarcoidosis, LAM
5. Idiopathic
6. Genetic
243
What is minimally invasive surgery?
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
The 2 type for minimally thoracic surgery are
Video assisted thoracoscopic surgery & robotic assisted surgery
245
Video-assisted thoracoscopic surgery VATS
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
Robotic assisted surgery
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
Advantages of minimal thoracic invasive surgery
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
Video assisted thoracoscopic surgery is used as …………&…………… tool
Diagnostic & therapeutic
249
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
One
250
In VATS procedures, surgen operate through ………… tiny opening between the ribs.
Each opening is less than ……inch
2-4, one inch
251
———- inch incisions are not uncommon in open thoracic surgery(thoracotomy)
6-10
252
VAST procedure start by some steps which are
Giving anesthesia
Position the patient
Use a trocar to gain access to the chest
Insert endoscope
253
How the patient positioned in video assisted thoracoscopic surgery
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
Port placement in VATS
Anterior (4th ICS)
Posterior (4th ICS)
Mid-axillary (7/8th ICS)
255
Why anterior and posterior port in VATS are placed at the same level (4th ICS)?
To be prepared for changing the procedure to thoracotomy if VATS fails
256
Which port in VATS used for camera
Middle
257
Relative contraindications for VATS
Poor general health of the patient
Fever
Uncontrolled cough
Unstable CV status
Unable to lie flat for minimum 1 hr
258
Absolute contraindications for VATS
Comatose or unresponsive patients
Lack of pleural space
End-stage pleural effusion
Type2 respiratory failure
Uncontrollable bleeding disorder
Pulmonary artery hypertension
SVC obstruction
259
What is the rule of thumb in minimal invasive surgery
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
VATS : The optimal point of entry is localized in ………… ……… bcz there are no large muscles to be passed by trocar in this area
Midaxillary line
261
Early complications of VATS
Vagal Syncope
Pain
Pleural pain, cough, dyspnea
Hypoxia
Subcutaneous/mediastinal emphysema
262
Why dyspnea may occur after VATS
If the fluid is rapidly suctioned off from the cavity without dividing into sessions it results in dyspnea
263
Intermediate complication of VATS
Wound and intercostal tube site discomfort
persistent air leak more than 8 days
Wound infection
Pleural infection
Post-operative fever
264
Late complications of VATS
Failed pleurodesis
Empyma
Pleura-cutaneous fistula
Late tumor seeding at thoracoscopy port and intercostal tube site
265
difference between VATS and robotic assisted surgery
Robotic have smaller incision sites and much more precise than VATS
266
Indications for VATS
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
Anatomical list of areas where VATS is done
Pleura( visceral, parietal)
Mediastinum (anterior, middle, posterior)
Lung( surface/ wedge resection, bullae, lobe)
Other: heart, pericardium, spine surgery, sympathetic chain)
268
Asthma is a (homogeneous/heterogeneous) disease
Heterogeneous
269
Asthma definition
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
Asthma is not a …………… disease
Paranchymal
271
Asthma dx by
Spirometry
272
Pathophysiology of asthma
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
Ddx of asthma
TB
HIV/AIDS associated lung diseases
Parasitic or fungal lung disease
274
GINA recommends confirmation of asthma by ………… , how?
Spirometry,
.20% increase in PEF, 15 min after 2 puffs of salbutamol
275
Asthma management
Identify trigger
Controls inflammation ( corticosteroids/ leukotriene inhibitors/ anti IgE therapy/ thermoplasty
Bronchodilator (SABA/LABA)(SAMA/LAMA)
Assess response
Modify and educate
276
Pleura is a serous membrane line by …………… cells
Mesothelial
277
The intapleural pressure is……………pressure
Subatmospheric ( negative)
278
Pleural space contain ……… fluid
10-20mL
279
Most fluid of pleural space is produced by
Parietal circulation (intercostal arteries)
280
The 2 key function of pleural space fluid are
1. Lubricantes pleural surface
2.generates surface tension
281
What is pleural recess
Are spaces in pleural cavity that does not contain lung parenchyma
282
Areas of pleural recess are
Costodiaphragmatic recess
Costomediastinal recess
283
Importance of pleural recess is that…………
They provide space for fluid accumulation
284
Pleural effusion usually collect in …………
Costodiaphragmatic recess
285
Blood supply of viceral and parietal pleura
Visceral: bronchial circulation
Parietal: intercostal arteries
286
Nerve supply of pleura
Parietal: (costal and cervical portion by intercostal nerve)(diaphragmatic portion by phrenic nerve)
Viceral: autonomic nervous system
287
Which layer of pleura lack sensory innervation
Visceral
288
Main cause of pleuritic chest pain
Viral infection spread from lungs to pleural cavity
289
Common causes of pleurisy
Pulmonary infection (VIRAL)
Pulmonary infarction
Malignancy
290
C/F of pleurisy
Sharp pain aggravated by deep breathing or coughing
Rib movement restricted
Pleural rub
291
Pleural rub more heard on …………
Inspiration
292
How pleural rub differentiated from pericardial rub
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
Investigation of pleurisy
CXR
294
Does a negative CXR exclude pleurisy
Noooooooooooooo
295
Management of pleurisy
Treat underlying cause
NSAID
296
Pleural effusion
Is an abnormal accumulation of fluid in pleural space
Resulting from excess fluid production or decreased absorption
297
In order for pleural effusion to appear up on CXR, effusion level should reach ……………ml
300
298
Blood stained pleural effusion usually is
Malignant
299
Hydrothorax is
Accumulation of serous fluid inside pleural cavity
300
Hemothorax is
Accumulation of blood in pleural cavity
301
Pyeothorax
Accumulation of pus in pleura
302
Chylothorax is
Accumulation of chyle in pleural cavity
303
Pleural effusion etiology
1. Decreased oncotic + increased hydrostatic pressure
2.increase vascular permeability due to inflammatory process result in increased exudation
3.blockage lymphatic drainage
304
Types of hydrothorax ( pulmonary effusion)
Tansudate
Exudate
305
Transudate pleural effusion caused by
Congestive heart failure
Liver failure
Renal failure
Peritoneal dialysis
Hypothyroidism
Hypo albuminemia
Ovarian tumor (meig’s syndrome)
306
Exudate pleural effusion caused by
Pneumonia
Carcinoma of lung
TB
PE
Mesothelioma
Connective tissue disease
Post MI
Acute pancreatitis
Sarcoidosis
Yellow nail syndrome
307
Clinical feature of small pleural effusion
Asymptomatic
308
Clinical picture of large pleural effusion
Dyspnea, pleurisy, dry cough
309
Physical Signs of pleural effusion
Inspection : limited chest movement
Palpation: decreased Tactile Vocal Fremitus,, mediastinal shift
Percussion: stony dullness
Auscultation: decreased air entry + pleural rub
310
Investigation for pleural effusion
CXR
Us
CT
Thoracocentesis
Pleural biopsy abrams needle
311
CXR findings of pleural effusion
Meniscus sign
Blunt costophrenic angle
Disappearance of lung marks
Absent cardiophrenic angle
312
Complete opacification occurs in ………… effusion
Massive
313
Physical examination of thoracocentesis in diagnostic pleural effusion is for
Color, odor, specific gravity, microbiology, cytology
314
Chemical examination of diagnostic thoracocentesis in pleural effusion is for
Total protein
Glucose
PH
LDH
Cholestrol
Triglycerides
Tumor marker
Rheumatoid factors
amylase
315
which type of needle is used for taking Pleural biopsy in pleural effusion? What are the 3 components of it
Abrams needle,
Outer trocer- solid stylet- inner cutting trocer
316
Treatment of pleural effusion
Drainage by thoracocentesis
Pleurodecesis, surgery’”VATS , thoracotomy “- home management with indwelling pleural catheter = for malignant pleural effusion
317
What is pleurodesis
Making adhesion(fusion) between visceral and parietal
318
Bloody pleural effusion indicates
Malignancy
319
Milky pleural effusion indicates
Chylothorax
320
Pleural effusion with pus indicate
Empyema
321
Clear yellowish fluid in pleural effusion indicates
Hydrothorax
322
Empyema thoracis
Accumulation of infected pus in pleural cavity
323
Empyema may be localized or diffuse.(T/F)
Trueeee
324
Most common cause of empyema is
Pneumonia
325
Empyema caused by
Pneumonia
Lung abscess
Mediastinal abscess( esophageal perforation)
Trauma
Iatrogenic
Subphrenic abcess
Hematogenous spread
326
What are the 3 stages of Empyema
1. Exudative
2.fibrinopleurant
3.organizing stage
327
Clinical stages of empyema
Acute <2wk
Subacute >2wk till chronic
Chronic: failure of complete lung expansion after 2 wk
328
C/F of empyema
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
Investigation for empyema
Lab: leukocytosis
CXR
US
CT
330
Rx for empyema
stage 1: Thoracocentesis and culture sensitivity based antibiotic
Tube thoracotomy / pigtail catheter
VATS after fibrnolysis
Decorticatiom (open)
331
Empyema complications
Pyopneumothorax
Peritonitis
Purulent Pericarditis
Sepsis
Bronchopulmonary fistula
Cutaneous fistula
332
When there is pus + air in effusion the radiographic finding will be a
Straight line
333
Pneumothorax
Accumulation of air within the pleural space
334
Types of pneumothorax
Spontaneous (primary /secondary))
Traumatic
335
Primary pneumothorax occur in
Tall thin young male smoker due to rapture of bullae
336
Secondary pneumothorax occur in patients with
COPD
Asthma
Bronchiactasis (cystic fibrosis)
Bronchogenic carcinoma
337
Traumatic pneumothorax is due to
Trauma/ iatrogenic/ barotrauma( patients on ventilators)
338
Resuscitative effort can cause …………
Pneumothorax
339
CXR findings of pneumothorax
Like pleural effusion findings
340
Diagnoses of pneumothorax is by
Clinical + CXR
341
Rx of pneumothorax
Chest tube
VATS/ thoracotomy
Pleurodesis
Surgery
Quit smoking
342
Few points on underwater seal
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
When chest tube removed?
Clinically: equal air entery
Pleural drainage <1500 cc/day
Radiologically lung expanded.
344
Benign pleural tumor are
Lipoma
Endotheliomas
Angioma
Cysts
345
Malignant pleural tumor
Metastatic
Mesothelioma
346
Mesothelioma associated with……………exposure
Asbestos
347
Investigation of mesothelioma
CXR
CT
Pleural aspiration
Bronchoscopy
Pleural biopsy
348
Rx of mesothelioma
Surgical
Brachytherapy
Radiotherapy
Chemotherapy
All are palliative
349
Sxs of methothelioma
Pain
SOBropathy
Pleural effusion
Finger clubbing
Dullness at site
Atrial fibrillation
Hypertrophic pulmonary osteoart
350
Pleural cyst most commonly found at ……………… angle
Pleuropericardial angle
351
70% of pleural cyst located at ………… side
Right
352
CXR finding of pleural cyst
Typical water density
353
Pleural plaques and calcification is often ………… and more common on ………… , do not occur at ………… of chest, don’t cause …………… , appear …………
Bilateral
Lower half of thorax
Apex
Adhesion
Ivory White and smooth
354
Ddx of pleural plaque and calcification
Pleural tumors
355
Tension pneumothorax
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
Common causes of tension pneumothorax
Penetrating trauma, CPR
Mechanical ventilators (barotroma)
357
Sxs of tension pneumothorax
Tachycardia
Tachypnea
Hypotension
Cyanosis
He can’t talk or walk
358
In pleural effusion fluid originate by ………… and absorbed by …………
Intercostal arteries in parietal pleura
Lymphatic system
359
Transudative causes
Congestive heart failure
SVC obstruction
Cirrhosis
Hypoalbuminemia
Peritoneal dialysis
Nephrotic syndrome
Myxedemal
Pulmonary embolization
Meigs syndrome
360
Exudate pleural effusion causes
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
Sxs of pleural effusion
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
………………… 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
Lung abscess
363
CXR finding of lung abscess
Cavity + air-fluid level
364
Types of lung abscess
Primary
Secondary
365
Complications of lung abscess
Bronchopulmonary fistula
Empyema
Pneumothorax
Sepsis
Fibrosis
Bronchiactasis
Amyloidosis
Metastatic cerebral abscess
366
Clinical features of lung abscess
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
Investigation for lung abscess
CXR
CT
CBC and ESR
Sputum exam
Blood cultures
Bronchoscopy
368
Primary lung abscess caused by
Staphylococcus aureus or klebsiella
369
Secondary lung abscess is caused by
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
89% Causative agents for lung abscess is
Anaerobes
371
Most common anaerobes as causative agent for lung abscess are
Peptosretococcus
Bacteriod
Fusibacterium
Microaerophillic
372
Treatment of lung abscess
1. Ampicillin / metronidazole/ clinfamycin/ciprofloxacin
2. Physiotherapy
3.sirgery
4. Prevention by taking precautions
373
What is varicose veins?
Permanent dilated tortuous subcutaneous veins with diameter >= 3mm
374
What is reticular vein?
Thin walled blue venules lying within superficial compartment with diameter ranging between 1-3mm
375
What is telangectasias
Are dilated venules, capillaries or arterioles with 0.1-1mm in diameter
376
Pathophysiology of varicosis & reticular veins?
Venous HTN, valvular incompetence or structural change in vein wall
377
Risk factors for varicose veins
Fam hx
Smoking
Gemale
Immobility
Long standing
Raised intra-abdominal pressure (pregnancy, mass)
Increased progesterone
378
Sxs of varicose veins
Asymptomatic (most common)
Dragging pain
Postrual discomfort
Heaviness in the leg
Night time cramps
Edema
Itching
Discoloration
Ulceration
379
Clinical sign of varicose vein
Visible varicosities
Brodie trenedlenburg test
Multiple tourniquet test( at sapheno-femoral junction, above knee and below knee)
380
Complication of varicose vein
Superficial thrombophlebitis
Bleeding
Eczema
Skin ulcer
381
Investigation for varicose veins
Doppler US
382
Management of varicose vein
Conservatives
Sclerotherapy
Lasar ablation
Stripping and phlebotomy
383
Superficial thrombophlebitis
Inflammatory- thrombotic condition of superficial veins
384
Diagnosis of superficial thrombophlebitis is mainly clinical ,how?!
Pain, tenderness, induration
385
Thrombophlebitis usually affect the……………
Lower extremities
386
2/3 of the cases of superficial thrombophlebitis, which vein is involved?
Greater saphenous vein
387
What are the risk factors for superficial thrombophlebitis?
Chronic venous insufficiency, history of DVT thrombosis or superficial vein thrombosis, sclerotherapy, pregnancy, obesity, long distance travel, thrombophilia, malignancy
388
How superficial thrombophlebitis managed?
NSAID
bandaging
prophylactic anticoagulant
389
What is lymphedema?
It’s a progressive accumulation of protein enriched interstitial fluid
390
Lymphedema can be ………… or………… lymphatic defect.
Primary or secondary
391
The lymphatic system works in conjunction with the arterial and venous system. It has three main roles which are:
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
Clinical classification of lymphedema
Primary lymphedema, which may be a congenital precox tarda
Secondary
393
Morphological classification of lymphedema
Aplasia, hypoplasia, numerical hyperplasia, hyperplasia
394
Anatomical classification of lymphedema
Distal obstruction,
proximal “obstruction
395
Secondary lymphedema may be due to
Iatrogenic
Burn
Trauma
Pregnancy
Bites
Infestation
396
What are the staging of lymphedema?
Latent phase
Grade 1
Grade 2
Grade 3
397
Which stage of lymphedema is irreversible
Stage three
398
Give a brief explanation of each stages of lymphedema
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
Presentation of lymphedema
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
Lymphorrhea occurs in ………
Lymphedema
401
Does clubbing occur in lymphedema ?
Yesssss 👏
402
Complication of lymphedema
Infection
Malnutrition and immuno deficiency
Malignant tumor
Psychological impairment
403
Diagnosis of lymphedema
CBC
Renal hepatic blood test
Eosinophilia
Hypoproteinemia
Urinanalysis my indicate proteinuria,
lymphoscintigraphy CT and MRI
direct contrast lymphangiography
404
Differential diagnosis of lymphedema
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
Management of lymphedema
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
In lymphedema we have to type of failure
High input failure
Low output, failure
407
Most common valvular hear disease is
Aortic stenosis
408
Arctic stenosis is male or female predominance?
Male
409
Aortic stenosis is due to
Congenital bicuspid
Rheumatic
Idiopathic
410
Types of aortic stenosis
Valvular
Subvalvular
Supravalvular
411
Supravalvular may be associated with ……… features
Broad forehead
Widely set eyes
Pointed chin
Mental retardation
Hypercalcemia, which together called William syndrome
412
Symptoms of arctic stenosis( triad of AS)
Dyspnea, angina pectoris aunt syncope
413
What are the physical findings in arctic stenosis?
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
What are the auscultation findings of aortic stenosis?
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
How are aortic stenosis is diagnosed
ECG
Echocardiography
chest x-ray 🩻
cardiac catheterization
416
What is the treatment of aortic stenosis?
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
5. In children, elderly, or pregnancy.: valvotomy may be done, valve replacement may be needed later
6. anticoagulant is necessary, if associated with AF aura, if mechanical valve prosthesis is used.
417
Two most important pathophysiology of arctic stenosis
It may cause myocardial ischemia due to decrease blood supply to the coronary arteries
Or it may cause AF
418
Most common cause of infective endocarditis is
Bacteria
419
Most common cause of pericarditis is
Viral
