internal med! Flashcards
mycoplasma pneumonia age group
most in 5-20 (school kids, young adults)
RF / common conditions
smoking, immunocompromised, asthma, copd
mycoplasma pneumonia presentation
insidiuous headache, sore throat, low fever then URI sx: nonproductive cough, rhinorrhea, dyspnea
-rhonic, rales, wheezes red TM / bullous myringitis in >2 (rare, but unique)
mycoplasma CXR
bilateral reticulonodular infiltrate w/ patchy lower lobe consolidation
mycoplasma pneumonia treatment
1st line: macrolide
2nd line: FQ - 1st line w/ comorbidities
PCP RF
immunocompromised (HIV), high dose glucocorticoids, heme / solid malignancies
PCP prophylaxis
indicated for HIV CD4 6 y/o
Bactrim 1 DS 3 x week
*can stop once on HAART and CD4 >200 x 3 mo
PCP pres
HIV pt w/ gradual onset dyspnea, tachypnea, nonproductive cough, fever, chills, weak, myalgias
Non HIV: more acute, same sx
*normal lung exam on PE
PCP CXR
bilaterall, symmetric, fine reticular interstitial infiltrates in perihilar regions that becomes progressively more diffuse / homogenous
- *can be NORMAL in 30%
- *cannot culture PCP! get sample via bronchoscopy
PCP tx
1st line: Bactrim x 14 d non hiv, 21 d in hiv
2nd line: pentamidine
-adjunct corticosteroids
leading cause of viral PNA
influenza A and RSV most common
adnovirus and parainfluenza next most
viral pneumonia pres
gradual onset w/ URI sx - fever, ha, myalgias, malaise, cough, rhinorrhea, sore throat
viral PNA workup
CXR: interstitial / alveolar infiltrates, peribronchial thickening, pleural effusion
viral culture - influenza antigen, w/ high risk can do PCR (more sensitive)
viral PNA tx
1st line: oseltamivir (tamiflu) - start w/in 48 hours
- varicella-zoster / cmv / hsv: acyclovir
- most immunocompetent: supportive tx
PCP labs
often normal except ELEVATED LDH and LYMPHOPENIA
ABG: resp alkalosis
IPF - pathophys
- most in 50-70s, male
- for unknown cause, chronic inflammation leading to progressive fibrosis and tissue destruction
- impairs both perfusion and gas exchange
IPF - pres
insidious progressive dyspnea with dry, hacking cough
- initinally dyspnea on exertion, progresses to rest - later: digital cyanosis and clubbing * *often NO FEVER / CP
IPF - cxr
reduced lung volume, increased peripheral densities w/ honeycombing
Lambert Eaton syndrome - pathophys
antibodies directed against calcium channels on motor end plate causing decreased ACh - half is autoimmune, half d/t CA (often small cell) - must r/o occult malignancy
Lambert eaton - pres
- weakness in prox muscle groups
- ptosis, diplopia
- decreased reflexes (normal in MG!!)
- autonomic change (impotence, xerostomia)
- worse in morning, improves w/ exercise (opposite of MG!!)
lambert eaton - dx
***incremental response w/ nerve stimulation - opposite of MG see decreasing response
lambert eaton - tx
plasmaphoresis, immunosuppression, 3,4 diaminopyridine
*rarely regain normal function
myasthenia gravis - pres
- muscular weakness, ptosis, generalized fatigue d/t destruction of acetylcholine receptors
- weakness improves w/ rest, worsens w/ repetition
botulism - pathogen
c. botulinim - anaerobic g +
botulism pres
- paralysis of cranial nn: dysarthria, diplopia, dysphagia at onset w/ progressive descending paralysis (GB is ascending!)
- ileus, constipation, urinary retention
botulism dx
-fever, ptosis, decreased pupillary and gag reflexes w/ normal DTR!
malignant melanoma - pres
-flat / raised pigmented irregular lesion (BCC - pearly papule w/ telangectasia w/ ulcer = rodent ulcer; SCC = raised, red conical nodule w/ ulcer)
ASD - pres
- dyspnea and CHF w/ large shunts
- hallmark: fixed split s2
- systolic ejection mumur on R 2-3ICS and RV heave
case: white cloudy vaginal d/c, mildly painful in 18 y/o who practices unsafe sex
chlamydia - tx w/ 1 g azithro
1 cause of tricuspid stenosis
rheumatic fever - occurs w/ mitral and aortic dz
-RA dilation w/ signs of RHF
toxic megacolon tx for UC
emergent colectomy!
cannot do BE or colonoscopy or proctocolectomy w/ ileal anastomosis during acute exacerbation
case: threw up fresh blood + chronic ibuprofen use
hemorrhagic gastritis!
almost all NSAID users develop gastritis
cushings dz vs syndrome
dz: d/t exogenous cortisol
syndrome: d/t pituitary adenoma
multiple endocrine neoplasia
MEN 1: gastrinoma and insulinoma, pituitary adenomas
MEN 11: parathyroid adenoma
MEN 111: medullary carcinoma of thyroid, pheochromocytoma, oral / intestinal ganglioneuromatosis
pt w/ stroke / parkinsons / poor dentition + signs of pneumonia…
ASPIRATION PNEUMONIA! COVER POS AND ANAEROBES!
unasyn / augmentin or FQ + flagyl / clindamycin
recurrent chest pain post PNA
PE or empyema - get CXR - will be normal w/ PE and have effusion / caviation w/ empyema
infective endocarditis pathogens
- strep viridans (anaerobic, gram positive), staph, enterococcus
- in IV drug users: pseudomonas, staph, candida, strep viridans, enterococcus
ARDS - criteria
- acute hypoxemic respiratory failure that occurs w/in 1 week (most w/in 48-72 hours) of systemic / pulmonary insult
1. progressive hypoxemia refractory to oxygen therapy (pa02/fio2 <300)
2. bilateral diffuse infiltrates on xray
3. edema NOT D/T TO CHF! PCWP less than or equal to 18!
ARDS -patho
systemic / pulmonary insult causing damage to endo cells and alveolar epithelial cells leading to diffuse pulmonary inflam –> increased vasc perm + alveolar collapse + decreased surfactant production - stiff lungs filled with fluid!
ARDS causes
#1 sepsis! -aspiration, trauma, medications (BLEOMYCIN!!!), fracturs, pancreatitis, near-drowning
ARDS pres -
acute onset dyspnea, tachypnea, retractions, progressive hypoxemia
ARDS work up
CXR: bilateral diffuse / patchy infiltrate, often spares costophrenic margins, may see air bronchograms
ABGs: initially resp alk –> acidosis as fatigue occurs, can have metabolic acidosis from toxin
***Pulmonary artery cath – KEY TO DIFFERENTIATE - PCWP IS = OR < 18! to r/o cardiac cause!
ARDS treatment
- tx hypoxemia - keep >88% or 55mmg often w/ tracheal intubation or PEEP - keep at lowest level and reduce fi02 <.6 asap to prevent oxygen tox
- identify and treat underlying cause
- manage fluid status - worsens w/ overload so goal is to keep pcwp 12-15
- reduce oxygen damand - antipyretics, analgesics, sedatives, nutrition and dvt prophylaxis, skin treatment
chronic cough in a nonsmoker + negative CXR…top 3 dx
- postnasal drip
- asthma
- GERD
* *look for ACE-I!!
middle aged african american woman w/ fatigue, nagging dry cough, arthralgias and bilateral pretibial raised tender nodules w/ clear lungs on exam….
SARCOIDOSIS!!
GET CXR - hilar adenopathy and noncaseating granulomas!
25 y/o healthy w/ fever, cough, SOB w/o recent travel. had a sore throat 2 weeks ago……tx?
DOXY OR MACROLIDES!
likely d/t c pneumoniae - common cause of bronchitis / mild PNA sx in young. older more likely have severe / recurrent disaese. often biphasic - fever, malaise, headache and sore throat neg for strep. then 2-3 weeks later pneumonia symptoms.
legionella = more GI and neuro sx w/ hyponatremia and hypophos - tx w/ macrolide or FQ
tuberculosis patho…
caused by mycoplasma tuberculosis - inhaled via aerosol droplets - deposited into lungs, consumed by alveolar macrophages - escapes phagocytosis - spreads via heme / lymph
cellular immunity and macrophages wall it off into granulomas - lays dormant until immune system suppressed
HIV at higher risk d/t poor cell immunity which is needed to fight TB
TB spread
only contagious w/ reactivation TB - NOT CONTAGIOUS w/ latent / primary TB!!
TB pres
Primary is radiographically and clinically asx!
Reactivation TB becomes symptomatic - progressive fever, malaise, night sweats, weight loss
***chronic cough that changes from dry to productive and blood-streaked is main /only pulm sx
*PE - often normal (classic but rare finding apical posttussive rales B)
TB stages
- Primary: initial infection that is asymptomatic when granulomas form
- w/ poor immune reponse can develop progressive primary TB (5%) - constitutional and pulmonary sx
- latent - asx, not contagious
- Secondary / Reactivation: 5-10% develop - symptomatic and contagious stage
- can be complicated by heme / lymph spread
- most reactivation occurs w/in first 2 yrs of infection
- can become complicated by miliary TB: heme dissemination - can hit any organ - more common in HIV
- extrapulmonary TB - w/ impaired immunity - active disease everywhere!
TB RF:
- almost all w/ TB have one or more…
- HIV, chronic steroid use, HC worker, prisoner, recent immigant (w/in last 5 years), alcoholic, diabetic, IV drug use, heme malignancy, close contacts w/ active
TB diagnosis….
- tuberculin skin (PPD) test screening that indicates exposure - DOES NOT INDICATED ACTIVE INFECTION!
- once positive, do not need to repeat again and can be positive if received BCG vaccine
- 2 step - separated by 48-72 hrs
- positive if:
- healthy: 15 mm+
- high-risk i.e. homeless, prisoner, immigrant, hc worker - 10 mm is pos
- HIV / steroid / organ transplant, close contact or w/ radiographic evidence - w/ positive PPD must get CXR to r/o active disease!!
- interferon gamma release assay: in place of PPD for those who received BCG vaccine or preferred in <5 y/o - cannot ID active
- SPUTUM CULTURE - definitive diagnosis!
- get 3 morning sputum specimens - culture takes 4-8 weeks to grow
- can get smear w/in 1 day - less specific
- start treatment before culture returns
- PCR more rapid
- nucleic acid amp - more specific, less sensitive
* *3 negative smears r/o
- positive culture w/ pos NAAT = postivie - CXR: upper lobe infiltrate w/ cavitations! pleural effusion
- more atypical w/ immunocomp / HIV - may have diffuse nodular d/t miliary dz or lower lung infiltrates
treatment
REPORT ALL TO PUBLIC HEALTH!
-positive PPD+ negative CXR = isonizid x 9 mo (even if positive d/t vaccine)
*positive w/ active TB = isolation until sputum negative fo AFB
1st line tx: 2 mo of 4 meds: isoniazid (INH), rifampin, pyrazinamid, and ethambutol or streptomycin then 4 mo of INH and rifampin
-all = hepatox - stop if LFT >3-5 x ULN, hyperuricemia, thrombocytopenia
-isoniazid can cause peripheral neuropathy - give pyridoxine!
**treat for 3 months after negative sputum culture!
TB prognosis
very good! almost all cured w/ adherence to tx and immunocompetent! #1 cause of recurrence is nonadherence
primary TB imaging
more in kids, affects middle and lower lung zones w/ hilar and peritracheal lymphadenopathy
gohn lesion
healed TB granuloma - can see on CXR
most common sites of extrapulmonary TB
most to least: lymph nodes (painless adenopathy), pleura, GU tract (sterile pyuria), bones and joints (weight-bearing, Potts dz = in spine), meninges (low glucose, high lymphocytes and high protein in CSF) and peritoneum
copd w/ signs of PNA, see gram neg diplococci on stain. what bug and best tx?
M. catarrhalis! common cause of PNA and bronchitis in ppl w/ underlying lung pathology
produces beta lactamase and evidence of resistance to both tetracycline and cipro…use AUGMENTIN!!!
CAP w/ rusty sputum and gram postive cocci in pairs….
pneumococcal pneumonia!
gram neg rods w/ red currant sputum….
klebsiella!
stain for primary TB sputum exam
ziehl neelsen - looks red
copd pt + increasing sx of HF think…
Cor pulmonale! chronic requires tx w/ diuretics!
avoid digitalis and vasopressin!
2 y/o male w/ chronic resp infections, pale foul-smelling stool, weight loss wheezing. on exam clubbing, enlarged spleen and lung congestion…
cystic fibrosis! -defective exocrine glands mainly in digestive and pulmonary systems - thick mucus = predisposed to lung infections #1 cause chronic lung infections
CF pres
**no meconium in first 24 hrs!, salty skin, pale colored / foul smelling floaty stool, rec respiratory symptoms, clubbing, diarrhea, weight loss, coughing / wheezing, growth delay
key CF tests
- sweat chloride - high
2. fecal fat test - pos
CF tx
- antibiotics per infection
- pancreatic enzyme supplementation
- breathing tx, percussion
40 y/o w/ 4 day hx of fevers, chills, myalgias, HA, productive cough and mild sinus congestions….
influenza! tx w/ supportive!
miner w/ increased sob and nonproductive cough w/ egg shell calcifications on xray..dx and tx?
silicosis! prednisone!
lung cancer - major types
- small cell (20-25%) - a/w smoking
- nonsmall cell (75-80%)
- 4 types: adenocarcinoma (MOST COMMON OF ALL LUNG CANCERS - NOT / LEAST ASSOCIATION W/ SMOKING!!), squamous (BEST PROGNOSIS), bronchoalveolar, large cell
lung cancer rf
smoking!!!!
chemicals / carcinogens, COPD, radon, asbestos
lung cancer pres
local / pulm symptoms most a/w squamous cell - obstruction, atelectasis, wheezing, hemoptysis, dyspnea
recurrent (postobstructive) pneumonia!
constitutional - often w/ advanced dz!
syndromes w/ lung cancer
- small cell: SVC and Horner’s, paraneoplastic (SIADH, ACTH secretion) and Eaton-lambert
1. SVC - facial and upper extremity swelling / edema, JVD, dilated veins
2. phrenic n palsy: nerve destruction - hemidiaphragmatic paralysis
3. recurrent laryngeal n palsy - hoarseness
4. Horner’s: d/t invasion of cervical sympathetic chain
5. pancoast tumor: invasion of c8-T1/2 causing shoulder pain radiating down arm w/ arm weakness, 60% have horners
- most w/ squamous
6. eaton lambert - prox weakness, decreased DTR, parasthesias
workup for lung cancer
- CXR - always get! almost all show abnormality!!!
- if lesion stable for 2 years = likely benign!
- CT with IV contrast - good for staging to look at lymph node involvement and for mets
- cytologic sputum eval - cannot r/o
- fiberoptic bronchoscope - good for CENTRAL lesions
- IR needle guided biopsy - good for PERIPHERAL lesions
- VATS - get biopsy
- whole body PET for mets
* **must have biopsy for diagnosis and to differentiate small vs nonsmall cell!
* *always get biopsy w/ evidence of intrathoracic lymphyadenopathy! 60% are mets!
met sites
brain, bone, liver, adrenal glands
lung cancer most common locations
small cell and squamous - central
adenocarcinoma and large - peripheral
small cell traits
20-25%
- central mass w/ adenopathy that typically compresses bronchi
- paraneoplastic syndrome common
- horners, svc, eaton-lambert
- *aggressive - widespread mets in 50-75% at diagnosis
staging: limited (w/in chest and supraclavicular nodes) and extensive (outside chest and supraclavicular i.e. in cervical and axillary) - **NEVER CAVITATES!
small cell treatment
can tx w/ surgery if in stage 1 or 2 limited w/o mets (rarely happens)
limited: radiation and chemo 10-13% 5 year survival
-can cure 20-30% w/ radiotherapy and chemo
extensive: chemo 1-2% 5 year survival
good response but relapse common!
nonsmall cell traits
- adenocarcinoma most common - often peripheral w/ pleural involvement and effusions
- least assoc w/ cancer
- ASSOC W/ SCARS AND FOUND IN SCARS FROM PRIOR PNA!! - squamous: least invasive, slowest growing so best prognosis
- central often causing pulm symptoms and CAVITATION on CXR
- commonly presents as pna, atelectasis
- central often causing pulm symptoms and CAVITATION on CXR
- large cell: least common, peripheral
- commonly mets to CNS, mediastinum causing SVC AND HORNERS- 2 types: giant - anaplastic, less than 1 year survival
- clear cell: like renal clear cell
- 2 types: giant - anaplastic, less than 1 year survival
nonsmall cell tx
stage 1 and 2 (no mets): surgery w/ radiation
3: radiation and chemo
4: chemo
most common causes of hemoptysis…
bronchitis and lung cancer!!
- consider bronchitis w/ blood streaked sputum
- chronic copious sputum think about bronchiectasis
- pleurisy + hemoptysis think about PE
1st test to order w/ hemoptysis…
CXR!
-w/ massive, need bed rest and cough suppressant
solitary pulmonary nodule…
single well-circumscribed lesion found on imaging
solitary pulm nodule - risk of CA
increased risk if: >50 y/o, smoking, irregular borders, eccentric / asymm calcification, enlarging, large >2-2.5 cm
**if no change over 2 years likely benign and if it has bulls-eye / popcorn calcification likely benign!
solitary pulm nodule work-up
- cxr - ALWAYS COMPARE TO PREVIOUS!!
- w/ no change in 2+ years - benign - stop workup
- w/ change in couple days – more likely infection / inflammation
- *malignancy often grows over months! w/ pos get:
- CT w/ thin sections
- based on above RF - if low or intermed w/ small (<1 cm lesion) - monitor w/ serial CT q 3 mo
- if intermediate and 1 cm or larger, get biopsy
- if high risk malignancy, excise
interstitial lung disease - patho
chronic inflam of alveolar wall - causing irreversible fibrosis and cahnges architecture leading to decreased in O2 diffusion
-dec lung volumes
ILD key hx….
- meds: amiodarone, gold, penicillamine, bleomycin, macrobid
- occupation
ILD pres
- progressive dyspnea (exertion to rest), nonproductive cough, fatigue
- crackles and clubbing
ILD workup
- CXR: diffuse changes (reticular, groundglass), honeycombing = sign of late / advanced disease and poor prognosis
- CT - high resolution shows extent of fibrosis
- PFT - normal ratio w/ reduced volumes, dec o2 diffusion
- lung biopsy often needed
ILD w/ granulomas…
- sarcoidosis
- wegeners
- histiocytosis x
- churg-strause
sarcoidosis pres…
<40 y/o black female w/ constituional sx + nonproductive cough and dyspnea
- erythema nedosum, anterior uveitis (blurred vision), arthritis, bells palsy, hepatomegaly, parotitis, hypercalcemia, elevated ACE-I
- cardiac involvement only in 5% - #1 cause of death! (arrythmias, SCD)
sarcoidosis dx…
- CXR: symmetric hilar adenopathy, then adenopathy w/ parenchymal infiltrates, then just infiltrates and then signs of fibrosis
- Bx: definitive - NONCASEATING GRANULOMAS! + other clinical signs to dx
sarcoidosis tx….
- most resolve on own in 2 years
- can give corticosteroids or methotrexate if severe
wegeners pres
URI and lower resp sx w/ glomerulonephritis
wegeners workup
- positive C-ANCA
- bx: necrotizing granulomatous inflammation
wegeners tx
steroids, immunosuppressants
histiocytosis x
- abnl proliferation of histiocytes in long-term smoker leading to dyspnea and nonproductive cough
- CXR: honeycombing
- CT: cystic lesions
tx: steroids, lung transplant
churg-strauss
- pulmonary infiltrates, rash and eosinophilia in patient w/ ASTHMA!
- positive P-ANCA
- tx: glucocorticoids
hypertrophic osteoarthropathy…
clubbing + periosteal bone formation + arthritis in patient w/ lung dz
- always get CXR
- side effect of malignancy!
pleural effusion classification
Exudate w/ one or more of: 1. ratio protein fluid: serum >.5 2. effusion LDH / serum LDH ratio >.6 3. LDH pleural fluid >2/3 upper limit of reference range Transudate if all negative!
pleural effusion seen w/…
- empyema
- lymphoma
- RA
- mesothelioma
- empyema - exudate w/ low pH and tons of PMN
- lymphoma - exudate w/ lymphocytes
- RA - low glucose!
- mesothelioma - bloody
beryilliosis occurs in what type of workers?
electronics, nuclear material and ceramics!!!
1 sx of PE?
TACHYPNEA!!! in over 90%
- also tachycardia!
- acute resp alkalosis and chest pain w/ infarction
suspect fat emboli w/?
-neuro changes, petechial rash, hypoxia, tachypnea 12-36 hr after long bone fx
what type of PNA…..
-rapid onset of fever, chills, rigor, CP, cough w/ little sputum and lobar infiltrate….
PNEUMOCOCCAL!!!!
- tx w/ FQ / ceftriaxone
- s. aureus = cavitating PNA!
best test if suspect ards???
PCWP!!!!
increased s2 w/ rvh…?
primary pulm htn! (seen w/ appetite suppressants!)
- tx initially w/ trial of short-acting pulm vasodilators: NO, prostacyclin, adenosine
- w/ positive reponse, try long-acting CCB
bronchiectasis pres….
chronic, high volume daily sputum w/ hx recurrent bronchitis!
signet ring sign???
BRONCHIECTASIS!!!
-on CT: permanent dilation of bronchi w/ signet ring sign and dilated bronchi adjacent to pulmonary artery!
