Hubbard DSA's Flashcards
1
Q
How long does acute cough last?
A
less than 3 weeks
2
Q
What is a subacute cough?
A
cough lasting 3-8 weeks
3
Q
What is the most common cause of acute cough?
A
viral upper respiratory infection
4
Q
What viruses are most often associated with cough?
A
lower respiratory tract disease: influenza A/B, parainfluenza virus, RSV
upper respiratory tract disease: coronavirus, adenovirus, rhinovirus
5
Q
Diagnosis of influenza includes a temperature greater than 100 (37.7C) and at least one of the following 3 symptoms?
A
- cough
- pharyngitis
- rhinorrhea
6
Q
When should neuraminidase inhibitor treatment be started for influenza?
A
within the first 2 days of symptom onset
7
Q
What 3 organisms are non-viral causes of uncomplicated acute bronchitis and cough in adults?
A
bordatella pertussis, mycoplasma pneumoniae, chlamydophila pneumoniae
NOTE: gram stain and culture of sputum will not reliably detect these
8
Q
Does routine antibiotic treatment have an effect on acute bronchitis?
A
no
9
Q
What is the diagnostic gold standard for B. pertussis?
A
recovery of bacteria in culture or by PCR
10
Q
What is the third most common (and most serious) cause of acute cough?
A
pneumonia
11
Q
What are the treatments of acute cough?
A
antitussive agents, expectorants, mucolytic agents, antihistamines, nasal anticholinergic agents
12
Q
What is considered a chronic cough?
A
cough lasting more than 8 weeks
13
Q
What is the initial workup for a patient with chronic cough?
A
smoking cessation, discontinuation of ACE-I for 4 weeks before additional workup
14
Q
What three disorders are responsible for 90% of cases of chronic cough in nonsmokers?
A
upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD)
15
Q
What is recommended for patients with allergic rhinitis?
A
avoiding allergens and the daily use of intranasal glucocorticoids or cromolyn sodium
16
Q
What is recommended treatment for GERD patients before invasive testing?
A
therapeutic trial with a proton pump
17
Q
Chronic cough with airway eosinophilia. But normal findings on chest radiography, normal spirometry and a negative methacholine challenge test?
A
nonasthmatic eosinophilic bronchitis (NAEB)
18
Q
What is the hallmark symptom of chronic bronchitis?
A
cough with sputum
19
Q
CT results showing thickened bronchial walls in a “tram line” pattern
A
bronchiectasis
20
Q
How long does it take for ACE-I cough to disappear
A
median time to resolution is 26 days
NOTE: can substitute and androgen receptor blocker for ACE-I
21
Q
What must the differential diagnostic of hemoptysis include?
A
upper airway (nasopharyngeal) sources of bleeding and GI bleed
22
Q
What should all patients with hemoptysis undergo?
A
chest radiography
- chest CT and fiberoptic bronchoscopy if a clear cause of hemoptysis is not identified
23
Q
What is the treatment for patients with lower respiratory tract infection and normal chest radiograph?
A
oral antibiotics
24
Q
What is considered massive hemoptysis?
A
blood loss greater than 200mL/day
NOTE: death results from asphyxiation, not exsanguination
25
What should be considered in massive hemoptysis?
urgent bronchoscopy
NOTE: surgery is considered last resort treatment for massive hemoptysis
26
not troubled by breathlessness except on strenuous exercise
MRC dyspnea scale grade 1
27
short of breath when hurrying on the level or walking up a slight hill
MRC dyspnea scale grade 2
28
walks slower than most people on the level, stops after a mile, or after 15 minutes walking at own pace
MRC dyspnea scale grade 3
29
stops for a breath after walking about 100 yards or after a few minutes on level ground
MRC dyspnea scale grade 4
30
too breathless to leave the house, or breathless when undressing
MRC dyspnea scale grade 5
31
what are the cardiovascular causes of acute dyspnea related to?
decrease in left ventricular function, or any event that increases pulmonary capillary pressure
32
what are the respiratory causes of acute dyspnea?
airway dysfunction, disruption of gas exchange by parenchymal disease, vascular disease, or disturbance of the ventilatory pump
33
what does low oxygen saturation suggest in acute dyspnea?
abnormalities of gas exchange
- points to processed such as asthma, acute exacerbation of COPD, ARDS, heart failure, pulm fibrosis, or pulm vascular disease
34
What is the primary diagnostic tool of acute dyspnea?
chest radiography
35
what do focal infiltrates on CXR indicate?
pneumonia
36
what does air in pleural space on CXR indicate?
pneumothorax
37
what does the presence of basal opacity with a meniscus on CXR indicate?
pleural effusion
38
what do cardiomegaly and vascular congestion on CXR indicate?
heart failure
39
when would high resolution CT be useful in patient with dyspnea?
when chest radiography is nondiagnostic and there's a high suspicion of parenchymal lung disease
40
when would laryngoscopy and broncoscopy be useful to diagnose dyspnea?
suspected foreign body aspiration, airway obstruction and vocal cord dysfunction
41
what can dry crackles on lung examination signify in patient with dyspnea?
presence of pulmonary parenchymal disease
42
what is the workup of suspected pulmonary causes of chronic dyspnea?
chest imaging (plain chest radiography or CT) and pulmonary function testing
43
what is conjunctival pallow, tachycardia and a flow murmur suggestive of in pt with dyspnea?
anemia
44
what would a goiter and tachycardia indicate in pt with dyspnea?
hyperthyroidism and high output heart failure
45
what might kyphoscoliosis indicate in pt with dyspnea?
pulmonary restriction
46
what further workup should be considered in patients whose history, exam, and initial workup are unrevealing in pt with dyspnea?
cardiopulmonary exercise testing
| - arterial blood gas measurements
47
what is considered mild oxygenation on the Berlin definition of ARDS?
PaO2 < 300 with PEEP or CPAP >5cm H2O
48
what is considered moderate oxygenation on the Berlin definition of ARDS?
PaO2 < 200 with PEEP >5cm H2O
49
what is considered severe oxygenation on the Berlin definition of ARDS?
PaO2 < 100 with PEEP >5cm H2O
50
what is part of the diagnostic criteria of ARDS?
severe hypoxemia
51
what indicates failure of compensatory ventilation, is especially worrisome and warrants immediate attention?
concominant hypercapnia (CO2 retention)
52
what are some direct predisposing causes of ARDS?
pneumonia, gastric aspiration, chest trauma/lung contusion, inhalation injury, near drowning
53
what are some indirect predisposing causes of ARDS?
non-pulmonary sepsis, acute pancreatitis, severe non-chest trauma, blood transfusions, surface burns
54
what is the typical physical exam finding of ARDS?
tachypnea and auscultation of rales
NOTE: may also present with heart failure, pneumonia, occult interstitial lung disease
55
what will CXR show of ARDS pt?
bilateral, diffuse airspace infiltrates
| - patchy infiltrates may become more confluent as the syndrome evolves
56
what causes the exudative stage of ARDS?
vascular hydrostatic and protein osmotic pressures, together with vascular integrity, set the stage for accumulation of **proteinaceous pulmonary edema**
57
what other disorders can be indistinguishable from ARDS?
acute infectious pneumonias that cause either interstitial pattern or diffuse airspace disease
NOTE: P. jiroveci may present with a similar CXR and refractory hypoxemiawithout the same cellular toxicity seen in ARDS
58
have coticosteriods been shown to work in ARDS?
no
59
what is the best treatment for ARDS?
low tidal volume ventilation or high frequency oscillatory ventilation (HFOV) -> very high respiratory rates with very low tidal volumes
60
what are the management strategies for ARDS?
- low tidal volumes
- prone ventilation
- fluid management
- cardiopulm monitoring
NOTE: simple interventions like daily ventilator liberation, proper oral care, venous thomboembolic dz prophylaxis and OMM can improve ventilation
61
what are the most significant risk factors for head and neck cancer?
alcohol and tobacco
62
what is EBV infection frequently associated with?
nasopharyngeal cancer (esp in Mediterranean and far East)
63
what is HPV associated with in Western countries?
tumors of the oropharynx (tonsillar bed and base of tongue)
64
what effect do fruits and vegetables have on head and neck cancers?
cancer rates are higher in people with lowest consumption of fruits and vegetables
NOTE: certain vitamins, including carotenoids may be protective
65
when are HPV-related malignancies usually diagnosed?
40's-50's
66
when are EBV-related nasopharyngeal cancers diagnosed?
all ages, including teenagers
67
what can cause unilateral serous otitis media?
cancer of the nasopharynx, due to obstruction of the eustachian tube, nasal obstruction or epistaxis
68
what can advanced nasopharyngeal carcinomas cause?
neuropathies of the cranial nerves due to skull base involvement
69
how do carcinomas of the oral cavity present?
nonhealing ulcers, changes in the fit of dentures, or painful lesions
70
what can tumors of the tongue base or oropharynx cause?
decreased tongue mobility and alterations in speech
71
what is frequently the first sign of HPV-related tumors?
neck lymphadenopathy
72
what can be an early symptom of laryngeal cancer?
hoarseness
NOTE: requires referral to specialist for indirect laryngoscopy/radiography
73
if enlarged nodes are located in the upper neck and tumor cells are squamous cell histology, where did the malignancy most likely arise from?
mucosal surface in the head or neck
74
other than palpating the floor of the mouth, tongue and neck, what further workup should be considered in a malignancy is suspected?
CT scan, PET scan (to help ID/exclude distant metastases)
75
what is the definitive staging procedure to diagnose head/neck malignancy?
endoscopic examination under anesthesia
76
what is a stage 1 TNM definition tumor?
<2cm without extraparenchymal extension
77
what is a stage 2 TNM definition tumor?
>2cm but not more than 4cm, without extraparenchymal extension
78
what is a stage 3 TNM definition tumor?
tumor >4cm, WITH extraparenchymal extension
79
what is a stage 4a TNM definition tumor?
tumor invades skin, mandible, ear canal and/or fascial nerve
80
what is a stage 4b TNM definition tumor?
tumor invades skull base and/or pterygoid plates and/or encases carotid artery
81
what are common sites of metastasis for T4 tumors?
lungs, bones, and liver
82
what should be performed is squamous cell carcinoma is found?
panendoscopy
83
where do HPV-positive tumors spread early?
locoregional lymph nodes
84
what is the treatment for stage 1 or 2 (localized) lesions?
radiation
85
what is the treatment for stage 3 and early 4 (intermediate) lesions?
concominant chemo-radiotherapy
86
what is the treatment for recurrent and/or metastatic disease?
supportive/palliative. can be given chemotherapy for pain control, but response is only 30-50%
87
what are complications of head/neck cancer treatment?
mucositis, dysphagia, xerostomia, loss of taste, decrease tongue mobility, hypothyroidism
88
what are the majority of lung cancers?
non-small cell cancer (85%)
89
what type of lung cancer is diagnosed almost exclusively in smokers?
small cell lung cancer
90
what are examples of paraneoplastic syndromes that patients with small cell lung cancer often present with?
acromegaly, Cushing syndrome, hypercalcemia, hypertrophic pulmonary osteoarthropathy, hyponatremia, superior vena cava syndrome, Trousseau syndrome, vocal cord paralysis, **Horner syndrome**
91
what is the workup if lung cancer is suspected?
CXR to look for masses
- CT may be required to detect smaller lung cancers
- peripheral node biopsy (will dx stage of cancer)
- sputum cytology (only in pt with poor pulmonary function who cannot tolerate invasive procedures)
92
what is the staging evaluation in non-small cell lung cancer?
chest/abdomen CT, and PET-CT (may ID advanced disease and can preclude unnecessary thoracotomy)
93
what are small cell lung tumors exquisitely sensitive to?
radiation and chemotherapy
94
what is the mainstay treatment for patients with stage 1 or 2 lung cancer?
surgery
95
what is the treatment for patients with stage 4 (inoperable) non-small cell lung cancer?
combined tx, including local radiation for a symptomatic mass and/or palliative chemotherapy
96
what is the mainstay of treatment for small cell lunger cancer?
combination chemotherapy with a platinum-based agent
97
what is a stage 1 non-small cell lung cancer?
tumor surrounded by lung or pleura, more than 2 cm from carina
98
what is a stage 2 non-small cell lung cancer?
locally advanced disease without mediastinal involvement
99
what is a stage 3 non-small cell lung cancer?
mediastinal involvement or two separate tumor nodules in same lobe without mediastinal involvement
100
what is a stage 4 non-small cell lung cancer?
metastatic (including malignant pleural nodules and pleural/pericardial effusions)
101
what are the differential diagnoses of COPD
asthma, bronchiectasis, cystic fibrosis, bronchiolitis, a1-AT deficiency
102
what is the best way to prevent COPD?
smoking cessation
103
what are the smoking-related changed the airway undergoes?
bronchial mucous gland hypertrophy, goblet cell metaplasia and inflammatory cell infiltrates -> squamous epithelial metaplasia, ciliary loss and dysfunction
104
what are the signs of hyperinflation to look for in diagnosing COPD?
barrel chest, hyperresonant percussion, distant breath sounds, prolonged expiratory time.
also pursed lip breathing
105
what are the cardiac symptoms in COPD?
cor pulmonale, split S2, ad a parasternal lift due to RV hypertrophy
106
what is the gold criteria stage 1?
FEV > 80%
107
what is the gold criteria stage 2?
FEV: 50-80%
108
what is the gold criteria stage 3?
FEV 30-50%
109
what is the gold criteria stage 4
FEV < 30%, or FEV <50% plus chronic respiratory failure
110
what should be suspected with early-onset COPD, with panacinar emphysema?
a1-AT deficiency
111
when would you give short acting b-agonists in COPD?
as needed for relief of persistent or worsening symptoms, to improve exercise tolerance (not continuous symptoms)
effects last 4-6 hours
112
when would you give long acting b-agonists?
for more sustained/predictable improvement in lung function (for more chronic symptoms, decreasing the need for rescue medication)
effects last 12 hours
113
what should tiotropium NOT be combined with?
short-acting anticholinergic drugs
NOTE: anticholinergic agents should be used with caution in patients with urinary obstruction and narrow-angle glaucoma
114
what medication should not be used alone to treat COPD?
inhaled glucocorticoids
115
what medication is indicated in stage 1 COPD?
short-acting bronchodilator
116
what medication is indicated in stage 2 COPD?
regular treatment with one or more long-acting bronchodilators; add pulmonary rehabilitation
117
what medication is indicated in stage 3 COPD?
add inhaled corticosteroids if repeated exacerbation
118
what medication is indicated in stage 4 COPD?
add long-term oxygen therapy if chronic respiratory failure. consider surgical treatments
119
what is the preferred treatment for COPD exacerbation?
short acting b-agonist
120
what treatment alleviates respiratory acidosis, decreases respiration rate, severity of dyspnea, length of hospital stay and mortality in severe COPD patients?
noninvasive intermittent ventilation
121
heterogenous involvement of the lung with different stages of progression of fibrosis in adjacent areas of the lung.
- starts in subpleural regions and honeycombing is seen
usual interstitial pneumonitis (UIP)
122
uniform involvement of lung parenchyma with cellular infiltration or fibrosis
- bilateral/subpleural with ground-glass infiltrates on CT imaging
nonspecific interstitial pneumonitis (NSIP)
123
small-airway bronchiolotis with granulation tissue and organizing pneumonia
- **granulomas** are hallmark (well-formed, noncaseating are typical for sarcoidosis, loosely formed granulomas are more commonly seen in hypersensitivity pneumonitis)
bronchiolitis obliterans organizing pneumonia (BOOP).cryptogenic organizing pneumonia (COP)
124
patient presents with progressive dyspnea (over months), reduced exercise tolerance and persistent dry cough
DPLD
NOTE: history should look for underlying causes
125
PE shows oxygen desturation with exertion, basilar inspiratory crackles on lung exam, digital clubbing, signs of autoimmune disease (systemic sclerosis or RA), and evidence of right side heart failure
DPLD
126
what should plain CXR show in DPLD?
increased interstitial reticular or nodular infiltrates
127
what is crucial tool in diagnostic evaluation of DPLD?
high-resolution CT, provides detail about the distribution and extent of disease (often times don't need a biopsy)
128
what drug is a common cause of lung disease? what is the therapeutic intervention?
amiodarone
| - discontinuation (glucocorticoids may also benefit)
129
what two other drugs are commonly associated with DPLD?
methotrexate and nitrofurantoin
130
what is the management of connective-tissue associated DPLD?
focused on the underlying connective tissue disease and supportive care for the lung manifestations
131
why is diagnosing idiopathic pulmonary fibrosis important?
because it has a poor prognosis
NOTE: no medical treatment has shown consistent improved mortality
132
dyspnea on exertion, exercise intolerance, dry cough, crackles on inspiration
imaging shows lower lung zone and subpleural linear reticular markings, volume loss, honeycombing and traction bronchiectasis
idiopathic pulmonary fibrosis
133
what is the next line of treatment in idiopathic pulmonary fibrosis?
patients with acute exacerbations should be evaluated for underlying and treatable infection or volume overload
134
rare illness, acute/abrupt onset
imaging shows bilateral alverolar disease with ground-glass changes. histology shows diffuse alveolar damage
acute interstitial pneumonia (aka Hamman-Rick syndrome)
135
how is AIP diagnosed?
open lung biopsy
136
small airway bronchiolitis with granulation tissue, presents as flu-like illness and radiography shows peripheral opacities that change over time
BOOP/COP
137
do BOOP/COP respond to glucocorticoids?
yes
138
granulomatous disease of unclear cause that affects multiple organs, including the lung. highest incidents of age groups under 18 and 50-60. those with lung involvement commonly present with cough, dyspnea, and chest heaviness.
sarcoidosis
139
what would imaging of sarcoidosis show?
bilateral hilar adenopathy and/or interstitial infiltrates
140
what is the treatment for DPLD?
smoking cessation, supplemental oxygen
| - symptomatic treatment for reactive airways or cough, maintenance of nutrition/fitness, treatment of infections
141
what do many patients with severe \/chronic DPLD develop?
pulmonary hypertension
142
what occurs in people with repeated episodes of inhalation of antigens with immunologic reaction?
hypersensitivity pneumonitis
NOTE: clues should be fungal elements or bird droppings, etc
143
how does hypersensitivity pneumonitis present?
acute flu-like symptoms, crackles on physical exam, labs show leukocytosis
hi-res CT shows ground-glass opacities with **centrilobular nodules and noncaseating granulomas
144
what is the treatment for hypersensitivity pneumonitis?
avoidance of causative antigen. can also use systemic steroids for patients with chronic symptoms
145
what are the clinical features of obstructive sleep apnea (OSA)?
habitual snoring, nighttime awakening, insomnia, daytime fatigue, erectile dysfunction
146
what is the most important risk factor for OSA?
excess body weight
NOTE: post-menopausal women also at risk)
147
what physical exam findings are likely with OSA?
crowded pharynx, nasal obstruction, retrognathia, systemic HTN, decreased oxygen saturation, accentuated pulmonic component of S2, or S3 gallop
148
what labs can be done for OSA?
* *polysomnography** (test of choice)
| - overnight oximetry, CBC, serum TSH, ECG, arterial blood gas
149
what are the differential diagnoses of OSA?
central sleep apnea, upper airway resistance syndrome, periodic limp movements of sleep, narcolepsy, obstructive or restrictive lung disease, GERD, sinusitis, heart failure, epilepsy, sleep deprivation, hypothyroidism, acromegaly
150
what is the treatment of OSA?
* *lifestyle changes and CPAP** are the cornerstones of therapy
- it aims to improve daytime sleepiness and cognitive performance, and to prevent long-term sequelae
151
what are the physical exam findings of pneumothorax?
diminished breath sounds, decreased tactile fremitus, decreased movement of the chest
152
physical exam findings of tension pneumothorax?
marked tachycardia, hypotension, and mediastinal/trachial shift
153
what would left sided primary pneumothorax produce of ECG?
QRS and precordial T-wave changes that may be misinterpreted as AMI
154
what imaging should be ordered for pneumothorax? what does it show?
expiratory CXR
| - tension pneumothorax: show a large amount of air in the affected hemithorax and contralateral shift of the mediastinum
155
what is the treatment for pneumothorax
(depends on the severity of the pneumothorax and nature of underlying disease)
- simple aspiration drainage of pleural air with small-bore catheter for spontaneous primary pneumothoraces that are large or progressive
156
when would a patient need a chest tube with a pneumothorax?
secondary pneumothorax, large pneumothorax, tension pneumo, or severe symptoms
157
when would thoracoscopy or ope thoracotomy be indicated in pneumothorax?
recurrence of spontaneous pneumothorax, any occurrence of bilateral pneumothorax and failure of tube thoracostomy for the first episode
158
what two mechanisms lead to the accumulation of excessive fluid in the pleural space?
1. increased capillary hydrostatic pressure
| 2. decreased plasma oncotic pressure
159
what are the leading causes of pleural effusion in the US?
heart failure, pneumonia, cancer
160
what are the physical exam findings of pleural effusion (large accumulations of fluid)?
dull to percussion, diminished/absent tactile fremitus, decreased/absent breath sounds on auscultation, and a pleural friction rub
161
what is the workup of pleural effusion?
CXR and CT, because it can more effectively define the size and location of the pleural effusion and distinguish parenchymal from pleural disease
NOTE: thoracentesis should also be considered
162
what are bilateral transudative effusions commonly associated with?
bilateral exudative effusions?
heart or liver failure
malignancy or pleuritis due to SLE
163
what is the major complication of thoracentesis?
pneumothorax
164
what causes exudative pleural effusions?
inflammation, infection, malignant conditions
165
what causes transudative pleural effusions?
unbalanced hydrostatic forces, heart failure and cirrhosis
166
what is the treatment of pleural effusions?
large effusions should be evacuated
NOTE: shouldn't remove more than 1.5L at a time to minimize the likelihood of re-expansion pulmonary edema
167
what are the most common lesions in the anterior mediastinum?
thymomas, lymphomas, teratomas, thyroid masses
168
what are the most common lesions in the middle mediastinum?
vascular masses, lymph node enlargement from metastases/granulomatous dz, pleuropericardial and bronchogenic cysts
169
what are the most common lesions in the posterior mediastinum?
neurogenic tumors, meningoceles, meningomyoloceles, gastroenteric cysts, esophageal diverticula
170
what is the best imaging technique for mediastinal masses?
CT**
| - only one that should be done in most cases
171
what is the appropriate treatment of acute mediastinitis?
exploration of the mediastinum with primary repair of the esophageal tear and drainage of the pleural space
172
what are most cases of chronic mediastinitis caused by?
histoplasmosis or tuberculosis
| - can also be sarcoidosis silicosis and other fungal diseases
173
what are the symptoms of fibrosing mediastinitis?
compression of a mediastinal structure (SVC or large airway, phrenic or recurrent laryngeal nerve paralysis)
174
what is the treatment of chronic mediastinitis?
antituberculous therapy
NOTE: no other medical or surgical therapy has been shown to work
175
gas in the interstices of the mediastinum
pneumomediastinum
176
what are the 3 main causes of pneumomediastinum?
1. alveolar rupture
2. perforation/rupture of esophagus, trachea, or main bronchi
3. dissection of air from the neck or abdomen into mediastinum
177
what are the symptoms of pneumomediastinum?
severe substernal check pain with or without radiation into the neck/arms
178
what physical exam findings in pneumomediastinum?
subcutaneous emphysema in the suprasternal notch, Hamman's sign (crunching/clicking with the heartbeat)
179
how is diagnosis of pneumomediastinum confirmed?
chest radiograph
180
how is compression relieved in pneumomediastinum?
needle aspiration
181
what is the most common pathogen causing CAP?
strep pneumo
other pathogens = H. influenzae, mycoplasma pneumo, chlamydophila pneumo, legionella
182
what can cause severe pneumonia in patients with alcoholism?
Klebsiella pneumo
183
what pathogen is more common to cause pneumonia in patients with structural lung disease?
Pseudomonas
184
who is the PCV13 vaccine indicated for?
adults over 65, patients with immunocomprimising conditions, asplenia, CSF leaks, or cochlear implants
NOTE: PCV23 and 13 are NOT administered together
185
pneumonia symptoms + chronic heart and lung disease?
Pneumococci, H. influenzae
186
pneumonia + travels to SW US?
SE Asia?
- Coccidioides
| - Mycobacterium
187
pneumonia + IV drug use?
Staph aureus, M. tuberculosis
188
pneumonia + bats?
Histoplasmosis
189
pneumonia + farm animals?
Coxiella burnetii
190
what are the physical exam findings of pneumonia?
tachypnea, fever, crackles, bronchial breath sounds, pleural effusion (egophony and dullness to percussion)
191
how many CURB-65 criteria must be met for a patient to be hospitalized?
2
192
what is the workup for patient with pneumonia?
CXR
193
what do the presence of cavities with air-fluid levels suggest on a CXR of patient with pneumonia?
abscess formation
194
what should you do if a pleural effusion is present in patient with suspected pneumonia?
decubitus film or chest CT
195
what is the treatment for outpatient pneumonia?
macrolide or doxycycline
196
what is treatment for patient with cardiopulm disease?
respiratory quinolone or combination of beta-lactam + macrolide or doxycycline
197
what medication is given to hospitalized patient when aspiration is suspected?
clindamycin or beta-lactam/beta-lactamase inhibitor
198
how long should you treat patients with Legionella infection?
5-10 days with quinolone is used
NOTE: mild-moderate <7days
199
pneumonia that develops at least 48 hours after hospitalizaition, including ventilator-associated pneumonia and post-op pneumo
HCAP
200
what is the most common type of HCAP?
ventilator-associated (VAP)
201
what is the most common cause of HCAP?
microaspiration of bacteria that colonize the oropharynx/upper airway
202
what are common pathogens of HCAP?
Enterobacter, pseudomonas, Klebsiella, E.coli, Strep and S. aureus
203
what is VAP diagnosis based on?
clinical presentation, leukocytosis, new/changing CXR findings
204
how does treatment of PAH differ from most other causes of PH?
treatment is focused on vasodilator therapy
205
what causes over 80% of PH cases?
conditions causing elevation of left-sided heart filling pressures or pulmonary disease
206
what are the most common symptoms of PH?
fatigue and dyspnea with exertion
| - may also have palpitations or chest pain
207
how is a diagnosis of PH confirmed?
ONLY by right heart catheterization and direct measurement of mean pulmonary artery pressure
- can also do CMP, BNP, 6 minute walk test
208
what is group 1 pulmonary hypertension?
idiopathic PAH: resting mPAP >25mmHg, PCWP<15mmHg
209
what is group 2 PH?
secondary left heart disease: mPAP>25mmHg, PCWP elevated
| - systolic, diastolic or valvular dysfunctions
210
what is HIV/AIDS a major risk factor for?
primary progression and reactivation of quiescent tuberculosis
211
why should you consider retesting or treating high-risk TB patients empirically?
because skin test result may not become positive for up to 12 weeks
212
what is an IGRA screen?
it assesses the T-cell response to specific M. tuberculosis antigens
- ** is the preferred screen for those who are BCG vaccinated**
213
what is mandatory to rule out active disease in all patients with a positive skin test or IGA result?
CXR and history, PE
214
what do hemoptysis and chest pain from pleural involvement indicate?
advances stage tuberculosis
215
what are radiologic abnormalities of reactivation Tb?
lesions in the apical posterior segments of the upper lung and superior segments of the lower lobe
216
what is the standard treatment for active Tb?
at least 6 months of 4-drug regimen
| - usually isoniazid, rifampin, pyrazinamide, ethambutol
217
what is the recommended follow up of Tb?
monthly sputum cultures to monitor treatment response, and adjust the drug regimen based on susceptibilities and length of therapy
218
what is the main cause of fat embolism syndrome (FES)?
long bone and pelvic fractures
219
what is the clinical presentation of FES?
24-72 hours after initial insult, classic triad: hypoxemia, **neurologic abnormalities, petechial rash**
NOTE: can develop a syndrome indistinguishable from ARDS
220
what are the imagine/lab findings in FES?
- CXR normal, CT normal
- MRI may show "starfield" pattern of diffuse, punctate, hyperintense lesions
- **CRP generally elevated in critical illness**
221
what is the treatment for FES?
therapy is largely supportive, no definitive tx
NOTE: do NOT give corticosteriods or heparin!!
222
progressive lower extremity edema with achy pain in the legs (may be worse with standing)
- shiny, atrophic skin, cutaneous telangiectasia (dilated blood vessels close to skin), varicose veins
- breakdown of skin in severe cases, ulceration (especially around medial malleolus)
venous stasis
223
lower extremity edema secondary to venous stasis must be differentiated from what?
CHF, mechanical venous obstruction, liver failure, chronic kidney disease
224
what is the first line of treatment for venous stasis?
external compression, behavior modification
NOTE: ulcers are difficult to treat and often reoccur
225
why is DVT of the upper extremities rising in incidence?
secondary to increasing use of indwelling venous catheters
226
patient presents with erythema, swelling, tenderness of affected limb
- Homan sign (pain in calf on forced dorsiflexion)
lower extremity DVT
227
what testing should be done for patient with low clinical liklihood of DVT?
D-dimer (blood clot test)
| **highly sensitive and specific test**
228
what does a positive D-dimer test indicate?
high clinical likelihood of DVT
229
what are the differential diagnoses of DVT?
venous insufficiency, muscle strain, ruptured baker cyst, cellulitis, lymphedema
230
what is the treatment for DVT?
immediate anticoagulation
- IV unfractionated (or low MW) heparin
- longer-term warfarin can be used simultaneously
231
what should happen once a patient is on stable anticoagulation for DVT?
therapy should be continued for a duration based on their risk factor profile
-**alll pt should be treated minimum of 3 months**
232
what treatment can be used if there is a strong contraindication for anticoagulation therapy?
IVC filter
233
what does a Wells Criteria score of 3+ indicate?
DVT is likely
234
what does a Wells Criteria score of 102 indicate?
moderate risk
- should proceed to D-dimer testing
- > negative D-dimer rules out DVT
- > positive D-dimer --> US
- > positive US is concerning for DVT
235
what are the Wells criteria categories?
- active cancer
- bedridden recently
- calf swelling
- superficial (nonvaricose veins present)
- entire leg swollen
- localized tenderness
- pitting edema
- paralysis/immobilization
- previously document DVT
236
when should IVC filters not be used?
for perioperative prophylaxis for pulmonary embolism
237
what are the most common symptoms of PE?
dyspnea, pleuritic chest pain, cough, hemoptysis, tachypnea, crackles, tachycardia, accentuated pulmonic component of S2
238
what does CXR show in PE?
atelectasis, small pleural effusion, focal oligemia, wedge-shaped density
239
what does a normal D-dimer value effectively rule out?
PE -> correlated with excellent outcome, no further workup required
240
what is the initial imaging for PE?
contrast-enhanced CT (CT angiography), ventilation-perfusion (V/Q) scanning (measures alteration in pulmonary blood flow)
NOTE: only a totally normal V/Q scan can exclude PE
241
what is the treatment for PE?
managed in the hospital until stable, including treatment of hypoxia and management of hemodynamic instability
242
when is surgical embolectomy for massive PE indicated?
if patient is unstable and thrombolytic therapy is contraindicated
243
what Wells criteria score is PE considered likely?
>4
<4 is unlikely
