Exam 1 Flashcards
What type of murmur is mitral stenosis and where do you listen?
Diastolic, loud S1 murmur, low pitched, apical crescendo rumble.
What kind of murmur do you hear with mitral regurgitation and where do you hear it?
Systolic, S3 with a systolic murmur at 5th ICS MCL.
Heard with MVP
What kind of murmur do you hear with aortic stenosis in where do you listen?
Systolic, “blowing“rough harsh murmur at second RIGHT ICS
What kind of memory do you here with aortic regurgitation and where do you hear it?
Diastolic, “blowing“ murmur at second LEFT ICS
Where to insert a chest tube
4th or 5th ICS, midaxillary line
Indications for a chest tube
– >20% collapse (or 2 cm)
– Unstable patient
– Underlying etiology persists, likely progression (example: mechanical ventilation)
Needle decompression
2nd ICS anterior at MCL
Influenza Types
A, B, and C
2 surface glycoproteins: H & N
B &C- primarily human
A- primarily avian, but can be in humans
Further classified by H and N subtypes.
Groups at high risk for influenza
- <24 mo
- 6 mo-5yrs
- older age (>50)
- long-term care
- pulmonary dz
- cardiac dz (not HTN)
- chronic dz
- immunosuppressive
- pregnant, post-partum
- BMI>35
Influenza testing
Rapid test <15 minutes
Low sensitivity
May not distinguish btwn subtypes
NAAT testing (a few hrs)
Higher sensitivity
Rapid test of choice in hospitalized pts
Viral cx (2-3 days) Nasal, sputum, or secretions Higher sensitivity, longer wait
Influenza: additional testing
CXR
eval for PNA if indicated
Lobular infiltrates are rare
CBC (if indicated)
Leukopenia
Influenza: older adults
(Atypical presentation)
AMS
Cough
Fever
Fewer resp sx’s, but more pulmonary complications
Less common: muscle aches, sore throat
More GI sx’s when compares to other real viruses
Influenza: acute management
ASAP antiviral therapy
Hospitalize if high risk
Xanamivir (inh) or oseltamivir (oral) covers A&B and have both therapeutic and prophylactic dosing regimens
Longer course for highest risk groups
Pleural effusion: risk factors
Malignancy:
Infiltration of pleural space
Lymphatic system obstruction
Non-malignant HF CKD Liver dz Infection Hypothyroidism Trauma/iatrogenic
Pleural effusion: transudative
Transudative
•Without pleural disease
•Example: heart failure (90%), renal failure
•↑ hydrostatic or ↓ oncotic pressure
Pleural effusion: x-ray
CXR confirms presence of effusion
•PA & lateral preferred
•Lateral decub in select cases- bad side down
•Helps refine assessment
Minimum volumes needed for visualization
•75 mL lateral
•175 mL frontal (PA)
Pleural effusion: ultrasound
- Provides target for thoracentesis
- Locates smaller effusions
- Locates loculated effusions
Pleural effusion: CT chest
- Non-contrast unless contrast needed for differential
* Detailed assessment of lungs / effusion
Indications for diagnostic thoracentesis
- New pleural effusion
- Underlying diagnosis is uncertain
- Confirmatory diagnosis needed (example: malignancy)
Indications for therapeutic thoracentesis
- Larger volume
- Dyspnea, discomfort
- Hypoxemia
- Respiratory failure
Chest tube may be considered.
Thoracentesis fluid testing
Chemistry
•Protein
•LDH
•Glucose
Hematology
•WBC – total and differential
•Hct if bloody
Microbiology
•Gram stain and culture
Cytology
•Assessing for malignant cells
•Can be non-diagnostic
Thoracentesis: additional testing
For pleural fluid comparison
•Protein, LDH, glucose
Assessment of underlying disease
•Renal, liver disease, HF
CBC
•Platelets (procedure anticipation)
•WBC (infectious / inflammatory process)
Coags
•Anticipating procedure
Pleural effusion: older adults
Toleration of pleural effusion may be less compared to younger adults
Antibiotic dosing needs to consider renal function and co-morbid conditions
Higher risk of malignancy, particularly lung cancer
Higher risk of chronic, co-morbid disease
Exudative effusion
One or more of the following (Light’s criteria)
•Protein pleural fluid : serum ratio > 0.5
•LDH pleural fluid : serum ratio > 0.6
•LDH pleural fluid < 2/3 upper limit of normal for serum LDH (>200 IU)
Clinical pearl: exudes protein
Transudative effusion
- Pleural glucose = serum glucose
- pH 7.40 – 7.55
- WBC < 1,000
•Clinical pearl: think few cells, transparent
CHARM (Common causes of transudative effusions) •Cardiac failure / carditis •Hypothyroidism •Albuminemia (hypo) •Renal failure •Malabsorption
Pleural fluid analysis
Low pH
•Empyema (ex TB, anaerobes)
•RA
Hct pleural: serum ratio > 0.5
•Hemothorax
Purulent
•Empyema
White
•Empyema vs. chylothorax
•High trig / chylomicron presence: chylothorax
Microbes
•Pleural vs. parapneumonic infection
Thoracentesis: complications
Monitor for complications after large volume drainage (> 1,500 – 2,000 mL)
•Hypotension
•Pulmonary edema
•Inflammatory response (alveolar re-expansion)
Pneumothorax, hemothorax
Pneumothorax: risk factors
Trauma Iatrogenic •Central line •Bronchoscopy (with needle biopsy) •Needle insertion (biopsy of lung or liver, thoracentesis) •Surgery: chest, neck, abdominal •Mechanical ventilation
Intrinsic lung disease
•Examples: COPD (blebs), pneumonia, tumor
- Young, thin males
- Smoking
- HIV with pneumocystis jiroveci pneumonia
Tension pneumothorax
Air is unable to exit
Pressure rises
•Lung collapses
•Mediastinal shift away from injury
•Impairs venous return to right heart
Pneumothorax: physical exam
- Splinting, reduced respiratory expansion of involved side
- Tracheal / mediastinal shift
- Subcutaneous emphysema
- Decreased breath sounds affected side
- Hemodynamic instability with impaired venous return
Pneumothorax: CXR
- First line diagnostic test
- PA and lateral, UPRIGHT POSITION preferred, if possible. LATERAL DECUBITUS also helps detect pneumothorax
- Increased translucency to affected area
- Visible lung collapse demarcation
- Mediastinal shift
- Small pneumothorax may require expiratory CXR instead of standard inspiratory films
- CT (non-contrast acceptable if contrast contraindicated) may be required if diagnosis difficult to establish with underlying lung disease or other complicating factors
Pneumothorax: additional testing
ABG
•With indications of hypoxemia
•When diagnosis uncertain (evaluate differential diagnosis)
ECG
•Not required for diagnosis
•T wave changes may be noted with pneumothorax
Pneumothorax: diagnostic criteria
Clinical diagnosis sufficient for tension pneumothorax: significant history + exam findings
Radiographic diagnosis preferred if non-critical
•CXR, first line
•CT, if CXR non-diagnostic
Pneumothorax: goals of care
Decompression of intrathoracic pressure
•Depending on % of lung compression
Promote resolution of underlying etiology
•Normal healing (example: trauma)
Reduce recurrence
•Procedures to prevent recurrence
•Lifestyle modifications
Tension pneumothorax: acute management
- Clinical diagnosis often sufficient; time is critical
- Requires emergent intervention
- Needle decompression (scalpel acceptable in true emergencies)
- 14 to 16 g needed 2nd ICS anterior at MCL
- Subsequent chest tube placement
Open pneumothorax: acute management
Three-sided occlusive dressing placement until definitive treatment can be performed (surgery / permanent chest tube)
Acute management of pneumothorax (without severe decompensation)
- Determine underlying etiology
- Evaluate extent of pneumothorax
Conservative management (< 15 - 20% collapse)
•Supplemental oxygen (may increase rate of resolution)
•Monitoring
•Frequent vitals
•CXR
•Assessment of symptom worsening
•Small bore chest tube may be an option in select cases
Chest tube placement
- > 20% collapse (or 2 cm in size)
- Unstable patient
- Underlying etiology persists, likelihood of progression (example: mechanical ventilation)
- 4th or 5th ICS and mid-axillary line , over the rib
- Closed chest drainage (water seal)
- Add negative pressure
- If water seal insufficient after 24 – 28 hours
- Clinically unstable persists (hypoxemia / hypercapnia)
Pneumothorax: surgical considerations
Spontaneous pneumothorax
Failure to respond to chest tube
•Does not re-expand
•Persistent air leak
Bilateral pneumothorax
Surgery may play a role in reducing recurrence
Pneumothorax: causes (mneumonic)
Causes: SIT, 3A’s, 3C’s •Spontaneous (particularly tall, thin men) •Iatrogenic •Trauma •Asthma •Alveolitis •AIDS •COPD •Carcinoma •Cystic fibrosis
Pulmonary TB: HPI
Asymptomatic finding on CXR (subclinical)
Productive cough / sputum
•Purulent
•Blood streaked (frankly bloody less common)
•Cough > 3 weeks
Night sweats
Anorexia
Weight loss
Fever in approximately half of cases
Pleuritic CP uncommon unless significant inflammation
Dyspnea uncommon unless extensive disease
Pulmonary TB: risk factors
•HIV
•Immunosuppressive therapy (example: solid organ transplant)
•Young / elderly
•Country of origin with endemic TB
•Exposure to infected individual in close proximity
-Household contact
-Close living quarters: correctional facilities, shelters
-Occupational: healthcare, corrections
-Certain chronic diseases / malignancies
Pulmonary TB: physical exam
- Latent TB has no disease symptoms
- Active TB often “looks ill”
- May not be most helpful in diagnosis
- Dullness to lung percussion
- Hollow-sounding breath sounds
- Crepitations (occasional)
- Evidence of extra-pulmonary disease
TB skin test
•PPD (purified protein derivative) intradermal injection
•Non-specific reaction to mycobacterium
•Assesses 48 – 72 hours after administration
•Assessing INDURATION – if no induration then it is not a positive finding
•Negative findings can be found in recent TB exposure (< 8 – 10 weeks), overwhelming TB disease, immunocompromised / certain illnesses
•Cut-point varies based on population
-15 mm those without risk factors
-10 mm “healthy” with risk factors (such as healthcare workers, foreign-born persons)
-5 mm household contact, CXR suspicious of prior infection, and immunocompromised (example: HIV)
-If negative finding with CD4 count < 200 / uL, repeat once above 200
IGRAs
Interferon-gamma release assays
•Blood test
•Rapid results (24 hours)
•1 visit (compared to follow-up visit for PPD)
•Limited knowledge of role for testing in immunocompromised patients
•May be expensive testing
Sputum microscopy for TB
AFB sputum staining
•Detects any acid fast mycobacterium
Expert MTB/RIF Assay
•Rapid diagnosis test for Mtb complex and resistance to rifampin
Cultures take weeks to months to complete
•Cultures performed on all specimens (including negative AFB)
•Drug sensitivities in positive cultures take additional weeks
Pulmonary TB: CXR
Locations more typical
•Apical & posterior segments upper lobes
•Superior segment of lower lobe
Findings •Hilar adenopathy •Patchy opacities •Consolidation •Cavitation •Pleural effusions in some cases
Findings vary from primary to reactivation disease
•Atypical findings possible in immunocompromised patient (example: not upper lobe predominant) or primary TB
CXR is rarely normal in active pulmonary disease (but possible in patient with + sputum and + symptoms).
A normal CXR can help rule out TB in person with + TST and absence of symptoms
Pulmonary TB: diagnostic findings
•Assess findings in context of the patient (such as, immune compromised vs. non), often a diagnosis of exclusion
•Clinical findings
Symptoms of active infection
- Signs of active infection / transmission risk Those at highest risk of rapid progression warrant earlier treatment without culture confirmation (such as, HIV patients)
- Assessing exposure
- Indicates exposure only, does not distinguish latent vs. active disease, limited role in recent exposure
- Positive tuberculin skin test (PPD)
- Difficult interpretation in immunocompromised and active TB
- IGRA (blood test)
•Assessing active infection
- Sputum findings
- AFB on sputum (about half are negative)
- Bronchoscopy lavage / tissue biopsy
- MIT/RIF Assay (rapid results)
- Culture and sensitivity (delayed results)
- CXR findings
- Active lesions vs. scarring of past infection
- Not diagnostic by itself, supports diagnosis
- Symptoms and PE findings consistent with TB
Pulmonary TB: older adults
•Incidence 2 – 3 x higher
•Risk of death higher
•Risk factors
Long-term care
•Underlying comorbidities
Associated with TB diagnosis: DM, malignancy, CV disease
May delay diagnosis (example: COPD)
•Symptom presentations overall similar to those < 60
More likely: non-specific symptoms
Less likely: fever, sweats, hemoptysis, cavitation, + TST
Assessment of TB
•Latent vs. active TB
Latent: assess risk of developing active TB and prioritize therapy for high risk
Based on TST or IGRA results, clinical findings, risk factors
•Medical / social history
Immunocompromised, liver disease, routine alcohol use
•Baseline labs, when indicated
Liver function tests (if risk factors)
CBC, if indicated
Renal function, if indicated
Active TB: goals of care
•Minimize transmission
-Example: healthcare settings
•Manage treatment issues
- Multi drug-resistance (multi-drug regimens)
- Patient non-adherence (DOT)
- Medication side effects (symptoms, labs)
- Phased therapy
- ~2 month: intensive phase
- 4 – 6 month or more: continuation phase
- Overall, therapy ranges from 6 – 9 months
- Cure the patient
- Basic principles for HIV patients
- Consult specialist
- Longer treatment
- Assess drug-drug interactions
Management of the new diagnosis of TB
•Admission considered for
- Risk of non-adherence to medications
- Serious disease manifestations
- Isolate patient
- Labs, if indicated
- Example: liver function, CBC, renal function
- HIV screening, if not already diagnosed
•Consult specialist for
- Drug-resistance
- HIV (treatment indications, drug interactions)
•Verify health department notification