Hubbard Clin Med DSAs Flashcards
What defines an acute, subacute, and chronic cough?
acute < 3 weeks subacute = 3-8 weeks chronic > 8 weeks
What is the MRC dyspnea scale?
- not troubled by breathlessness except on strenuous exercise
- SOB when hurrying on level or walking up a slight hill
- walks slower than most ppl, stops after a mile or after 15 min at own pace
- stops for breath after 100 yds
- too breathless to leave house, or breathless when undressing
Where does the sensation of dyspnea arise?
sensory input from resp muscles and lungs –> cerebral cortex
When should someone w/ dyspnea be transferred to acute care?
w/ significant tachypnea, accessory m use, or conversational dyspnea
What are the diagnoses of exclusion for acute dyspnea?
panic disorder and hyperventilation syndrome
What is the primary initial diagnostic tool for dyspnea?
chest x-ray
What does presence of a basal opacity w/ a meniscus on CXR represent?
pleural effusion
When is dyspnea considered chronic?
when sx persit longer than 1 month
What is the key to workup of chronic dyspnea?
detailed history
What should the HPI include for dyspnea?
quality
precipitating events
associated features
risk factors for cardiac and pulmonary dz
How do ppl w/ CHF describe their dyspnea?
What about asthmatics?
chf = air hunger
asthma = chest tightness
When do you cardiopulm exercise testing and how is it done?
pt w/ dyspne whose hx, exam, and initial workup are unrevealing
pt exercises on treatmill or stationary bike w/ continuous oximetry and ECG and measurement of exhaled gases
What is the most reliable indicator of the degree of dyspnea?
Pt self-report
What are the most common causes of ARDS?
pulmonary and nonpulmonary sepsis
What is the timing requirement for diagnosis of ARDS?
w/in 7 days of precipitating cause or onset of new/worsening resp sx
What is the chest imaging requirement for diagnosis of ARDS?
bilateral airspace opacities
cannot be explained otherwise
What are the definitions of mild, moderate, and severe oxygenation deficits?
mild PaO2 = 300
moderate = 200
severe = 100
What are the 5 most common direct lung injury causes of ARDS?
pneumonia
gastric aspiration
chest trauma/lung contusion
inhalation injury
near-drowning
What are the 5 most common indirect lung injury causes of ARDS?
nonpul sepsis
acute pancreatitis
severe nonchest trauma
blood transfusions
surface burns
What auscultation sound is typical of ARDS?
rales
What sx dominate the exudative phase of ARDS?
shunting and hypoxemia
What occurs in the proliferative stage of ARDS?
type II pneumocytes begin to regenerate to replace surfactant and type I cells rebuild epithelium
What is the typical length of the proliferative stage and why is it sometimes longer?
days 7-21
longer sometimes as procollagen III is deposited in interstitial space –> fibrosis
What is the best predictor of outcome of ARDS?
degree of hypoxemia
What is the significance of time to recovery in ARDS?
pts who don’t get lower O2 requirements by day 7 are worse off
What is ECMO?
extracorporeal membrane oxygenation
supports hypoxemia w/out ventilator injury
What is HFOV
advanced ventilator with high resp rates but very small tidal volumes
What is the benefit of ventilation in ARDS?
prone vent at least 16 hrs a day decreases 28 ant 90 day mortality
What is the effect of corticosteroids in ARDS management?
no benefit
can see neuromyopathy
What is the mortality rate of ARDS?
35 to 50%
What causes the hypoxemia in ARDS?
edema in alveoli –> V/Q mismatching
What type of ventilation can help ARDS pts w/ refractory hypoxemia?
high-frequency oscillatory ventilation (HFOV)
Where is nasopharyngeal cancer more commonly seen?
in mediterranean countries and far east
What are the most significant risks for head and neck cancer?
alcohol and tobacco
*act synergistically
What viruses are associated w/ head and neck cancer?
EBV - esp med and far east
HPV 16 and 18 - good outcome in young pts
What type of head and neck cancer is frequently associated w/ EBV?
nonkeratinizing and undifferentiated carcinoma (lymphoepithelioma)
What are the premalignant lesions of head and neck cancer?
erythroplakia or leukoplakia
At what age do most tobacco-related head and neck cancers occur?
after age 60
What sex gets head and neck cancer more?
males
How does cancer of the nasopharynx present?
typically no early sx
can cause unilateral serous otitis media
advanced –> neuropathies of cranial nerves
How does oral cancer typically present?
nonhealing ulcers, changes in fit of dentures, or painful lesions
if at tongue base - alterations in speech
How to HPV-related tumors frequently present?
neck lympadenopathy
When would you do a CT scan of the chest for workup of head and neck cancer?
for a heavy smoker to rule out a second lung primary tumor
What are T1-T3 tumors of the head and neck?
primary tumors w/out metastasis
1 = 2 cm
2 = 2-4 cm
3 > 4 cm
What are stage 4a and 4b tumors of head and neck?
4a = invades another structure
4b = invades skull base and or encases carotid A
How are pts with head and neck cancer grossly divided?
those w/ localized dz
those w/ locally or regionally advanced dz
those w/ recurrent and/or metastatic dz
How are pts w/ localized head and neck cancer treated?
surgery or radiation
How are pts w/ locally adv head and neck cancer treated?
metastatic?
local: combined surgery, radiation, and chemo –> 50% 5 yr survival
metastatic: palliative care, regional radiation for pain control
What is the median survival time for pts w/ metastatic or recurrent head and neck cancer?
8-10 months
What new txs have improved survival for pts w/ advanced head and neck cancer?
monoclonal Ab w/ standard chemo
What is the best way to prevent lung cancer?
don’t smoke
What screening strategy for lung cancer is est to reduce lung cancer mortality by 14-16%?
low dose CT scans to screen for early stage lung cancer in smokers
What features characterize benign pulm nodules?
no growth in 2 yrs
calcification in a diffuse, central, or laminar pattern
less than 2 cm w/ round edges
What is bisphosphonate therapy used for in lung cancer?
decreases skeletal complications in pts w/ bony metastases
also can use RANK ligand inhibitor
What is the main tx for small cell lung cancer?
combo chemo w/ platinum agent and etoposide + radiation
improves survival, but most pts still relapse and die
What virus is associated w/ nasopharyngeal cancer?
oropharyngeal?
EBV = nose
HPV = mouth
Who should be screened for early lung cancer?
current and former smokers aged 55-85
What are the 5 Ddxs for COPD?
asthma
bronchiectasis
CF
bronchiolitis
alpha1-antitrypsin deficiency
What criteria are most supportive of COPD?
self-reported history of COPD
>40 pack year hx
max laryngeal height = 4 cm
What does cor pulmonale sound and look like?
increased intensity of pulmonic sound
persistently split S2
parasternal lift due to R ventricular hypertrophy
neck V distention, edema, enlarged liver
What spirometry results confirm COPD?
postbronchodilator FEV1 < 80% of predicted
FEV1/FVC ration <70%
What is the BODE system used for?
evaluating the risk for hospitalization and long-term prognosis in COPD pts
When should a nebulizer be used?
when pt cannot use MDI or inhaler bc of severe sx or coordination issues
What are the txs of COPD based on GOLD criteria?
I: short acting bronchodilater as needed
II: regular tx w/ one or more long-acting bronchodilators; add pulm rehab
III: add inhaled corticosteriods
IV: add long-term O2 therapy if chronic resp failure; consider surgery
How often do you take LABAs?
every 12 hours
What are the most common side effects of beta-agonists?
increased HR and tremor
When do you use inhaled anticholinergics for COPD?
comine w/ SABA or LABA and/or theophylline
dont combine tiotropium w/ short-acting anticholinergic
What is the most common side effect of inhaled anticholinergics?
who do you use them with in caution?
dry mouth
watch out for pts w/ urinary obstruction and narrow-angle glaucoma
How does theophylline work and why is it controversial?
What can you use instead?
nonspec PDE inhibitor
narrow therapeutic index
roflumilast is an oral PDE-4 inh
When do you add oxygen therapy in COPD?
PO2 < 55 mm Hg or O2 sat < 88%
or < 59 and < 89 if pulm htn or r-sided hf
How do you use inhaled glucocorticoids in COPD?
never alone
combine w/ bronchodilator w/ recurrent exacerbations
How do you treat COPD exacerbations?
SABA + anticholinergic if no response to SABA
systemic steroids in hospital tx of severe exacerbations
What defines a severe exacerbation of COPD?
loss of alertness or 2 of the following:
dyspnea at rest
resp rate > 25/min
pulse rate > 110/min
use of accessory resp muscles
Can you use antibiotics for tx of COPD?
What are std meds?
yes, benefit for mod or severe exacerbations
3rd gen cephalosporin w/ macrolide or monotherapy w/ fluoroquinolone
What are the 2 types of ventilation for COPD and when do you use them?
noninvasive intermittent: alleviates resp acidosis and decr respiration rate and other sx
use invasive mechanical vent for pts who are severe and can’t tolerate noninvasive
If pt has low PaCO2, what else can indicate tx w/ O2?
hematocrit > 55%
R heart failure
O2 sat < 88
What is the most effective way to slow progression of COPD?
smoking cessation
What interstitial lung dz should be suspected based on female gender?
lymphangioleimyomatosis (LAM)
What ILD should be suspected if pt has uveitis/conjuctivitis also?
sarcoidosis
connective tissue dz
What ILDs are basal predominant?
IPF
asbestosis
NSIP
What ILDs are upper-lobe predominant?
hypersensitivity pneumonitis
sarcoidosis
silicosis
What ILDs are peripheral predominant?
IPF
chronic eosinophilid pneumo
COP
What ILDs are central predominant?
sarcoidosis pulmonary alveolar proteinosis
What drugs are a common cause of lung dz?
amiodarone
methotrexate
nitrofurantoin
What ILD is very closely associated with smoking?
langerhaan cell histiocytosis
What diagnostic reading is most helpful for diagnosing ILD?
decreased diffusing capacity
What are common sx of obstructive sleep apnea?
impaired daytime attention and memory
daytime sleepiness
disruptive snoring
witnessed apnea
erectile dysfunction
mood changes
night sweats
What are complications of untreated sleep apnea?
secondary hypertension
secondary erythocytosis
increased heart O2 demand and HF
stroke
What is the most impt risk factor for OSA?
obesity
What is an AHI?
apnea-hypopnea index
>5 confirms OSA
What is required for diagnosis of OSA?
polysomnography
What is the general tx plan for OSA?
lifestyle changes (weight loss, sleep on side, avoid alcohol and sedatives before bed)
CPAP
can try mandibular advancement devices if CPAP is not working, but only in mild cases
surgery
Who typically get primary pneumothorax?
tall, thin males ages 10-30
What 2 things are considered risk factors for dev of pneumothorax?
aerosolized pentamidine
prior hx of pneumocystis pneumonia
WHo should get a chest tube?
secondary pneumothorax
large pneumothorax
tension pneumothorax
severe symptoms
Why should ppl stop smoking after a pneumothorax?
recurrence is 50% if you’re a smoker
What are indications for an thoracoscopy or open thoracotomy?
recurrences of pneumothorax
bilateral
failure of tube thoracostomy
What are sx of a pneumothorax?
chest pain
sx usually begin during rest and resolve w/in 24 hours even if the pneumothorax persists
may present w/ resp failure if underlying cOPD or asthma is present
What is the prognosis of a pneumothorax?
30% of spontaneous will recur
recurrence after surgery is less likely
What does a massive pleural effusion suggest?
underlying cancer of lung or pleura
What is assoc w/ bilateral transudative effusions?
heart or liver failure
What do bilateral exudative effusions suggest?
malignancy or SLE and other collagen vascular dzs
What signs suggest an empyema?
loculated effusion on upright and decubitus chest XR
What dzs have exudative effusions?
infection
cancer
collagen vascular dz
intra-abdominal processes
hypothyroidism
Why type of pleural effusion is caused by venous thromboembolic dz?
exudative or less commonly transudative
What is the pleural fluid like in cancer or TB-related pleural effusion?
lymphocyte-predominant
When should you remove fluid in a pleural effusion?
mediastinal shift –> 2.0 L or more can be removed
in other cases don’t remove more than 1.5 L to min risk of reexpansion pulm edema
What defines the anterior mediastinum?
sternum ant to pericardium and brachiocephalic vessels posterioly
thymus gland
ant mediastinal LNS
internal mammary As and Vs
What defines the middle mediastinum and its contents?
heart
ascending and transverse arches of the aorta
Vena cavae
brachiocephalic As and Vs
phrenic Ns
Pulmonary As and Vs
What is contained in the posterior mediastinum?
descending thoracic aorta
esophagus
thoracic duct
azygos and hemiazygos Vs
posterior LNs
What are the common lesions in the anterior mediastinum?
thymomas
lymphomas
teratomas
thyroid tumors
What are the most common masses in the middle mediastinum?
vascular masses
LN enlargement
pleurpericardial and bronchogenic cysts
What are the common lesions in the posterior mediastinum?
neurogenic tumors
GI cysts
esophageal diverticula
What typically causes acute mediastinitis?
esophageal perforation or after median sternotomy for heart surgery
What typically causes chronic mediastinitis?
histoplasmosis or TB
(sarcoidosis, silicosis and other fungi are possible)
What is pneumomediastinum?
air in interstices of mediastinum; 3 causes:
alveolar rupture
perforation of esophagus, trachea, or main bronchi
dissection of air from neck or abdomen into mediastinum
What is hamman’s sign?
crunching or clicking noise synchronous w/ heartbeat
best hear in left lat decubitus pos
heard in pneumomediastinum
How much fluid is needed to blunt the costophrenic angle on plain CXR?
250 ml
this creates a meniscus sign
What imaging sign is indicative of adequate pleural fluid to perform thoracentesis?
1-cm distance from pleural fluid line to the chest wall
What two lab findings can distinguish btw transudative and exudative pleural fluid?
levels of LDH and protein
What cause of pneumonia is acquired hematogenously?
staphylococcus
Who gets pneumonia from gram negative bacteria?
those w/ comorbidities and in extended care facilities
Who is more likely to get pseudomonas pneumonia?
pts w/ structural lung dz
after recent antibiotic therapy or hospitalization
What are the risk factors for pneumonia?
alterations in anatomic barriers
impairment of humoral or cell-mediated immunity or phagocyte function
How effective is the flu vaccine in preventing pneumonia?
reduces pneumonia-related mortality during flu season 27-50%
Who should get the flu shot?
Antiviral for flu?
all persons 6 mos or older
oseltamivir or zanamivir in unvaccinated high-risk persons during epidemic
What versions of the pneumococcal vaccine are available and who/when should get them?
23-valent polysaccharide PPSV23 –> all adults 65 and over and those under 65 in long-term care or who are immunocompromised
13-valent conjugate vaccine PCV13 –> one-time adults 65 and over or those immunocompromised, asplenia, CSF leak, or cochlear implants
In what sequence are the pneumococcal vaccines given?
PCV13 given first –> PPSV23 at least 8 weeks later
if 23 already given –> 13 given 1 yr after
What is the CURB-65?
criteria to ID high-risk pts for pneumo
Confusion
Urea nitrogen > 19.6
Respiration rate 30 or above
BP <90 systolic or <60 diastolic
>65 yrs old
*meet at least 2 –> admitted to hospital*
*meet at least 3 –> ICU*
What tests should you run for pneumonia in an uncomplicated outpt setting?
CXR and pulse oximetry
What tests should your run for a pneumonia pt in the hospital?
CXR
2 sets of blood cultures
routine metabolic panel
pulse ox
CBC
When should you do sputum culture in suspected pneumonia?
pts at risk for resistant or unusual pathogens
those w/ severe pneumonia
When should you consider unusual pathogens as the cause of pneumonia?
if they dont respond to empiric therapy w/in 48-72 hrs
What is the definition of respiratory failure?
inability to maintain o2 sat >90 on max mask oxygen or the presence of hypercarbia
How to treat outpt pneumonia uncomplicated and w/ heart dz or modifying factors?
macrolide or doxycycline
w/ comorbidity: beta-lactam and macrolide or doxycycline
How to tx hospitalized pts w/ pneumonia?
O2, don’t delay antibiotics –> IV
repiratory quinolone or combo of B-lactom and a macrolide or doxy
if aspiration expected –> clindamycin or beta-lactam
How do you tx a lung abscess secondary to aspiration?
w/ clindamycin and consider surgery
How long do you tx pts w/ mild-to-moderate community-acquire pneumonia?
7 days or less if there is agood response, no fever for 48-72 hrs, no sign of other infection
How long do you tx someone w/ legionella?
5-10 days w/ quinolone
How long do you tx pneumo caused by Pseudomonas or S. aureus?
10 days or more
4-6 weeks if bacteremic staph
How can supportive measures improve pneumonia recovery?
use of beta-agonist nebulizer, physical therapy, and OMM –> 25% shorter recovery period
What is HCAP?
heathcare-acquired pneumonia
develops at least 48 hrs after hospitalization
includes VAP, non-vent associated, and post-op
What is the most common cause of HCAP?
microaspiration of bacteria that colonize the oropharynx and upper airways
endotracheal intubation = greatest risk
What antibiotics should be given to someone w/ suspected HCAP?
no risk factors –> ceftriaxone or levofloxacin
risk factors –> antipseudomonal and vancomycin
What defines pulmonary HTN?
elevation of mean pulm a pressure of 25 mm hg or greater during rest
What is idiopathic pulmonary arterial htn and how do you treat it?
uncommon, 2:1 female to male
management focused on vasodilator therapy
What causes most cases of pulm htn?
conditions causing elevation of left-sided heart filling pressures
pulmonary dz
What might you find on PE of a person w pumonary htn?
augmented jugular A wave
pulmonic component of S2 or single S2
tricuspid regurg or pulmonic insufficiency
r ventricular S3 or S4 gallops
How is PHtn confirmed?
only by R heart catheterization and direct measurement of MPAP
How are 6-min walk studies helpful in PHtn?
functional assessment
checking progression and response to therapy
What is group I PHtn?
idiopathic
heritable
drug and toxin-induced
assoc w/ connective tissue dz, HIV, congenital heart dz, anemia, etc.
What is group 2 PHtn?
Left heart disease
systolic disfunction
diastolic dysfunction
valvular disease
What is group 2 PHtn?
secondary to lung disease/ hypoxia
COPD, ILD, other pulm dzs
sleep-disordered breathing
chronic exposure to high altitude
What is group 4 PHtn?
chronic thromboembolic pulm htn
What is group 5 PHtn?
secondary unclear or multifactorial causes
systemic, metabolic, hematologic , tumor obstruction, kidney failure
What is group 1’ PHtn?
pulmonary veno-occlusive and/or pulmonary capillary hemangiomatosis
How is a positive TST defined?
by the diameter of the indurated area, not the size of the erythema
How long can it take for TST test to become positive after exposure?
12 weeks
can do retesting 7-21 days after first
What is an alternative to skin TB testing?
IGRA - assesses T-cell response to spec M. tuberculosis antigens
more expensive and not available in all areas, but can do single blood draw; no false-positives in vaccinated ppl
How do you tell if there is active TB?
positive TST
hx and physical + chest xray
What does reactivation TB look like on imaging?
lesions in apical posterior segments of upper lung and superior segments of the lower lung
What defines multidrug-resistant TB?
extensively drug resisant?
resistant to at least isoniazid and rifampin
extensive: also resistant to fluoroquinolones and at least kanamycin, amikacin, or capreomycin
What does the term fat embolism syndrome mean?
clinical syndrome that follows fat embolism
classic triad: hypoxemia, neurologic abnormalities, patechial rash
What typically causes fat embolism from fracture and who gets them?
long bone and pelvic fractures
more frequent in closed fractures
more common in men aged 10-40
rarely surgical trauma
What are the two theories of the pathogenesis of fat embolism?
mechanical theory: fat globules directly enter bloodstream
biochemical: inflammation results from the production of toxic intermediates of circulating fat
How many people have hypoxemia in fat embolism and how many people have patechial rash?
hypoxemia = 96%
rash = 20-50%
What is seen on imaging of fat embolism?
CXR normal in most ppl, sometimes see air space dz or edema
CT of lung normal or bilateral ground glass opacities or ill-defined centrilobular nodules
Ventilation-perfusion - look for PE, mottled pattern of subsegmental perfusion defects
MRI brain: starfield pattern
What is the only treatment of FES?
What are preventatitve measures?
Tx: supportive
Prevention: ealry immobilization of fractures, intraosseous pressure limitation, prophylactic systemic steroids (controversial)
Why is the pharyngeal airway susceptible to collapse?
doesn’t have rigid structures supporting it unlike oral and nasal cavities
How does upper and lower airway obstruction present?
sx after obstruction has been there for a while
airway diameter 8 mm –> sob on exertion
airway 5 mm or less –> sob at rest
What characterizes stridor?
occurs during inspiration and is loudest in the neck
can be confused w/ asthma, but stridor is heard higher up
What is the imaging technique of choice for the upper airway?
thoracic CT
(trachea usually well visualized on PA XRay, but study showed a ton of tumors were missed this way –> CT now prefered)
How is the Wells criteria for DVT used?
score of 0 or lower –> DVT unlikely –> d-dimer testing –> if positive, U/S, if negative, nothing
score of 1-2 –> moderate risk –> high-sensitivity d-dimer –> if positive do U/S
score of 3 or more –> DVT likely, do U/S
How long should heparin and warfarin overlap when transitioning to warfarin?
How long should someone be on anticoagulants after a DVT?
min of 5 days
min of 3 mos
When should you screen for PE or DVT?
only in symptomatic pts
noninvasive diagnostic tests are insensitive and not assoc w/ improved outcomes
What is d-dimer testing used for?
to rule out PE or DVT in symptomatic pts
(if high risk, don’t use d-dimer and go ahead and tx)
What initial testing should be done for PE?
contrast-enhanced CT (very specific, but kidney issues w/ contrast and might not visualize small subsegmental emboli)
or ventilation-perfusion scanning (less kidney issues, doesn’t provide direct image of clot, less affected by obesity)
When is thromboembolytic therapy appropriate for a PE pt?
may be effective for:
pts w/ circulatory shock
pts w/ acute embolism and PH or R vent dysfunction but without arterial hypotension or shock
What is a westermark sign?
hamptom hump?
westermark: lack of vascularity distal to PE
hamptom: peripheral wedge-shaped density above diaphragm
(both can be seen in PE)
