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pulmonary > internal med! > Flashcards

internal med! Flashcards

1
Q

mycoplasma pneumonia age group

A

most in 5-20 (school kids, young adults)

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2
Q

RF / common conditions

A

smoking, immunocompromised, asthma, copd

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3
Q

mycoplasma pneumonia presentation

A

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)

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4
Q

mycoplasma CXR

A

bilateral reticulonodular infiltrate w/ patchy lower lobe consolidation

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5
Q

mycoplasma pneumonia treatment

A

1st line: macrolide

2nd line: FQ - 1st line w/ comorbidities

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6
Q

PCP RF

A

immunocompromised (HIV), high dose glucocorticoids, heme / solid malignancies

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7
Q

PCP prophylaxis

A

indicated for HIV CD4 6 y/o
Bactrim 1 DS 3 x week
*can stop once on HAART and CD4 >200 x 3 mo

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8
Q

PCP pres

A

HIV pt w/ gradual onset dyspnea, tachypnea, nonproductive cough, fever, chills, weak, myalgias
Non HIV: more acute, same sx
*normal lung exam on PE

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9
Q

PCP CXR

A

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
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10
Q

PCP tx

A

1st line: Bactrim x 14 d non hiv, 21 d in hiv
2nd line: pentamidine
-adjunct corticosteroids

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11
Q

leading cause of viral PNA

A

influenza A and RSV most common

adnovirus and parainfluenza next most

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12
Q

viral pneumonia pres

A

gradual onset w/ URI sx - fever, ha, myalgias, malaise, cough, rhinorrhea, sore throat

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13
Q

viral PNA workup

A

CXR: interstitial / alveolar infiltrates, peribronchial thickening, pleural effusion
viral culture - influenza antigen, w/ high risk can do PCR (more sensitive)

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14
Q

viral PNA tx

A

1st line: oseltamivir (tamiflu) - start w/in 48 hours

  • varicella-zoster / cmv / hsv: acyclovir
  • most immunocompetent: supportive tx
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15
Q

PCP labs

A

often normal except ELEVATED LDH and LYMPHOPENIA

ABG: resp alkalosis

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16
Q

IPF - pathophys

A
  • most in 50-70s, male
  • for unknown cause, chronic inflammation leading to progressive fibrosis and tissue destruction
  • impairs both perfusion and gas exchange
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17
Q

IPF - pres

A

insidious progressive dyspnea with dry, hacking cough

- initinally dyspnea on exertion, progresses to rest - later: digital cyanosis and clubbing * *often NO FEVER / CP
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18
Q

IPF - cxr

A

reduced lung volume, increased peripheral densities w/ honeycombing

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19
Q

Lambert Eaton syndrome - pathophys

A

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

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20
Q

Lambert eaton - pres

A
  • 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!!)
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21
Q

lambert eaton - dx

A

***incremental response w/ nerve stimulation - opposite of MG see decreasing response

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22
Q

lambert eaton - tx

A

plasmaphoresis, immunosuppression, 3,4 diaminopyridine

*rarely regain normal function

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23
Q

myasthenia gravis - pres

A
  • muscular weakness, ptosis, generalized fatigue d/t destruction of acetylcholine receptors
  • weakness improves w/ rest, worsens w/ repetition
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24
Q

botulism - pathogen

A

c. botulinim - anaerobic g +

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25
Q

botulism pres

A
  • paralysis of cranial nn: dysarthria, diplopia, dysphagia at onset w/ progressive descending paralysis (GB is ascending!)
  • ileus, constipation, urinary retention
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26
Q

botulism dx

A

-fever, ptosis, decreased pupillary and gag reflexes w/ normal DTR!

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27
Q

malignant melanoma - pres

A

-flat / raised pigmented irregular lesion (BCC - pearly papule w/ telangectasia w/ ulcer = rodent ulcer; SCC = raised, red conical nodule w/ ulcer)

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28
Q

ASD - pres

A
  • dyspnea and CHF w/ large shunts
  • hallmark: fixed split s2
  • systolic ejection mumur on R 2-3ICS and RV heave
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29
Q

case: white cloudy vaginal d/c, mildly painful in 18 y/o who practices unsafe sex

A

chlamydia - tx w/ 1 g azithro

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30
Q

1 cause of tricuspid stenosis

A

rheumatic fever - occurs w/ mitral and aortic dz

-RA dilation w/ signs of RHF

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31
Q

toxic megacolon tx for UC

A

emergent colectomy!

cannot do BE or colonoscopy or proctocolectomy w/ ileal anastomosis during acute exacerbation

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32
Q

case: threw up fresh blood + chronic ibuprofen use

A

hemorrhagic gastritis!

almost all NSAID users develop gastritis

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33
Q

cushings dz vs syndrome

A

dz: d/t exogenous cortisol
syndrome: d/t pituitary adenoma

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34
Q

multiple endocrine neoplasia

A

MEN 1: gastrinoma and insulinoma, pituitary adenomas
MEN 11: parathyroid adenoma
MEN 111: medullary carcinoma of thyroid, pheochromocytoma, oral / intestinal ganglioneuromatosis

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35
Q

pt w/ stroke / parkinsons / poor dentition + signs of pneumonia…

A

ASPIRATION PNEUMONIA! COVER POS AND ANAEROBES!

unasyn / augmentin or FQ + flagyl / clindamycin

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36
Q

recurrent chest pain post PNA

A

PE or empyema - get CXR - will be normal w/ PE and have effusion / caviation w/ empyema

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37
Q

infective endocarditis pathogens

A
  1. strep viridans (anaerobic, gram positive), staph, enterococcus
  2. in IV drug users: pseudomonas, staph, candida, strep viridans, enterococcus
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38
Q

ARDS - criteria

A
  • 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!
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39
Q

ARDS -patho

A

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!

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40
Q

ARDS causes

A 
#1 sepsis!
-aspiration, trauma, medications (BLEOMYCIN!!!), fracturs, pancreatitis, near-drowning
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41
Q

ARDS pres -

A

acute onset dyspnea, tachypnea, retractions, progressive hypoxemia

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42
Q

ARDS work up

A

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!

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43
Q

ARDS treatment

A
  1. 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
  2. identify and treat underlying cause
  3. manage fluid status - worsens w/ overload so goal is to keep pcwp 12-15
  4. reduce oxygen damand - antipyretics, analgesics, sedatives, nutrition and dvt prophylaxis, skin treatment
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44
Q

chronic cough in a nonsmoker + negative CXR…top 3 dx

A
  1. postnasal drip
  2. asthma
  3. GERD
    * *look for ACE-I!!
45
Q

middle aged african american woman w/ fatigue, nagging dry cough, arthralgias and bilateral pretibial raised tender nodules w/ clear lungs on exam….

A

SARCOIDOSIS!!

GET CXR - hilar adenopathy and noncaseating granulomas!

46
Q

25 y/o healthy w/ fever, cough, SOB w/o recent travel. had a sore throat 2 weeks ago……tx?

A

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

47
Q

tuberculosis patho…

A

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

48
Q

TB spread

A

only contagious w/ reactivation TB - NOT CONTAGIOUS w/ latent / primary TB!!

49
Q

TB pres

A

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)

50
Q

TB stages

A
  1. Primary: initial infection that is asymptomatic when granulomas form
    • w/ poor immune reponse can develop progressive primary TB (5%) - constitutional and pulmonary sx
  2. latent - asx, not contagious
  3. 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
  4. extrapulmonary TB - w/ impaired immunity - active disease everywhere!
51
Q

TB RF:

A
  • 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
52
Q

TB diagnosis….

A
  1. 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!!
  2. interferon gamma release assay: in place of PPD for those who received BCG vaccine or preferred in <5 y/o - cannot ID active
  3. 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
  4. nucleic acid amp - more specific, less sensitive
    * *3 negative smears r/o
    - positive culture w/ pos NAAT = postivie
  5. 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
53
Q

treatment

A

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!

54
Q

TB prognosis

A 
very good! almost all cured w/ adherence to tx and immunocompetent!
#1 cause of recurrence is nonadherence
55
Q

primary TB imaging

A

more in kids, affects middle and lower lung zones w/ hilar and peritracheal lymphadenopathy

56
Q

gohn lesion

A

healed TB granuloma - can see on CXR

57
Q

most common sites of extrapulmonary TB

A 
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
58
Q

copd w/ signs of PNA, see gram neg diplococci on stain. what bug and best tx?

A

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!!!

59
Q

CAP w/ rusty sputum and gram postive cocci in pairs….

A

pneumococcal pneumonia!

60
Q

gram neg rods w/ red currant sputum….

A

klebsiella!

61
Q

stain for primary TB sputum exam

A

ziehl neelsen - looks red

62
Q

copd pt + increasing sx of HF think…

A

Cor pulmonale! chronic requires tx w/ diuretics!

avoid digitalis and vasopressin!

63
Q

2 y/o male w/ chronic resp infections, pale foul-smelling stool, weight loss wheezing. on exam clubbing, enlarged spleen and lung congestion…

A 
cystic fibrosis!
-defective exocrine glands mainly in digestive and pulmonary systems - thick mucus = predisposed to lung infections
#1 cause chronic lung infections
64
Q

CF pres

A

**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

65
Q

key CF tests

A
  1. sweat chloride - high

2. fecal fat test - pos

66
Q

CF tx

A
  1. antibiotics per infection
  2. pancreatic enzyme supplementation
    - breathing tx, percussion
67
Q

40 y/o w/ 4 day hx of fevers, chills, myalgias, HA, productive cough and mild sinus congestions….

A

influenza! tx w/ supportive!

68
Q

miner w/ increased sob and nonproductive cough w/ egg shell calcifications on xray..dx and tx?

A

silicosis! prednisone!

69
Q

lung cancer - major types

A
  1. small cell (20-25%) - a/w smoking
  2. nonsmall cell (75-80%)
    • 4 types: adenocarcinoma (MOST COMMON OF ALL LUNG CANCERS - NOT / LEAST ASSOCIATION W/ SMOKING!!), squamous (BEST PROGNOSIS), bronchoalveolar, large cell
70
Q

lung cancer rf

A

smoking!!!!

chemicals / carcinogens, COPD, radon, asbestos

71
Q

lung cancer pres

A

local / pulm symptoms most a/w squamous cell - obstruction, atelectasis, wheezing, hemoptysis, dyspnea
recurrent (postobstructive) pneumonia!
constitutional - often w/ advanced dz!

72
Q

syndromes w/ lung cancer

A
  • 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
73
Q

workup for lung cancer

A
  1. CXR - always get! almost all show abnormality!!!
    • if lesion stable for 2 years = likely benign!
  2. CT with IV contrast - good for staging to look at lymph node involvement and for mets
  3. cytologic sputum eval - cannot r/o
  4. fiberoptic bronchoscope - good for CENTRAL lesions
  5. IR needle guided biopsy - good for PERIPHERAL lesions
  6. VATS - get biopsy
  7. 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!
74
Q

met sites

A

brain, bone, liver, adrenal glands

75
Q

lung cancer most common locations

A

small cell and squamous - central

adenocarcinoma and large - peripheral

76
Q

small cell traits

A

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!
77
Q

small cell treatment

A

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!

78
Q

nonsmall cell traits

A
  • 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
  • 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
79
Q

nonsmall cell tx

A

stage 1 and 2 (no mets): surgery w/ radiation

3: radiation and chemo
4: chemo

80
Q

most common causes of hemoptysis…

A

bronchitis and lung cancer!!

  • consider bronchitis w/ blood streaked sputum
  • chronic copious sputum think about bronchiectasis
    - pleurisy + hemoptysis think about PE
81
Q

1st test to order w/ hemoptysis…

A

CXR!

-w/ massive, need bed rest and cough suppressant

82
Q

solitary pulmonary nodule…

A

single well-circumscribed lesion found on imaging

83
Q

solitary pulm nodule - risk of CA

A

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!

84
Q

solitary pulm nodule work-up

A
  1. 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:
  2. 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
85
Q

interstitial lung disease - patho

A

chronic inflam of alveolar wall - causing irreversible fibrosis and cahnges architecture leading to decreased in O2 diffusion
-dec lung volumes

86
Q

ILD key hx….

A
  1. meds: amiodarone, gold, penicillamine, bleomycin, macrobid
  2. occupation
87
Q

ILD pres

A
  • progressive dyspnea (exertion to rest), nonproductive cough, fatigue
  • crackles and clubbing
88
Q

ILD workup

A
  1. CXR: diffuse changes (reticular, groundglass), honeycombing = sign of late / advanced disease and poor prognosis
  2. CT - high resolution shows extent of fibrosis
  3. PFT - normal ratio w/ reduced volumes, dec o2 diffusion
  4. lung biopsy often needed
89
Q

ILD w/ granulomas…

A
  1. sarcoidosis
  2. wegeners
  3. histiocytosis x
  4. churg-strause
90
Q

sarcoidosis pres…

A

<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)
91
Q

sarcoidosis dx…

A
  1. CXR: symmetric hilar adenopathy, then adenopathy w/ parenchymal infiltrates, then just infiltrates and then signs of fibrosis
  2. Bx: definitive - NONCASEATING GRANULOMAS! + other clinical signs to dx
92
Q

sarcoidosis tx….

A
  • most resolve on own in 2 years

- can give corticosteroids or methotrexate if severe

93
Q

wegeners pres

A

URI and lower resp sx w/ glomerulonephritis

94
Q

wegeners workup

A
  • positive C-ANCA

- bx: necrotizing granulomatous inflammation

95
Q

wegeners tx

A

steroids, immunosuppressants

96
Q

histiocytosis x

A
  • abnl proliferation of histiocytes in long-term smoker leading to dyspnea and nonproductive cough
  • CXR: honeycombing
  • CT: cystic lesions
    tx: steroids, lung transplant
97
Q

churg-strauss

A
  • pulmonary infiltrates, rash and eosinophilia in patient w/ ASTHMA!
  • positive P-ANCA
  • tx: glucocorticoids
98
Q

hypertrophic osteoarthropathy…

A

clubbing + periosteal bone formation + arthritis in patient w/ lung dz

  • always get CXR
  • side effect of malignancy!
99
Q

pleural effusion classification

A 
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!
100
Q

pleural effusion seen w/…

  1. empyema
  2. lymphoma
  3. RA
  4. mesothelioma
A
  1. empyema - exudate w/ low pH and tons of PMN
  2. lymphoma - exudate w/ lymphocytes
  3. RA - low glucose!
  4. mesothelioma - bloody
101
Q

beryilliosis occurs in what type of workers?

A

electronics, nuclear material and ceramics!!!

102
Q

1 sx of PE?

A

TACHYPNEA!!! in over 90%

  • also tachycardia!
  • acute resp alkalosis and chest pain w/ infarction
103
Q

suspect fat emboli w/?

A

-neuro changes, petechial rash, hypoxia, tachypnea 12-36 hr after long bone fx

104
Q

what type of PNA…..

-rapid onset of fever, chills, rigor, CP, cough w/ little sputum and lobar infiltrate….

A

PNEUMOCOCCAL!!!!

  • tx w/ FQ / ceftriaxone
  • s. aureus = cavitating PNA!
105
Q

best test if suspect ards???

A

PCWP!!!!

106
Q

increased s2 w/ rvh…?

A

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
107
Q

bronchiectasis pres….

A

chronic, high volume daily sputum w/ hx recurrent bronchitis!

108
Q

signet ring sign???

A

BRONCHIECTASIS!!!

-on CT: permanent dilation of bronchi w/ signet ring sign and dilated bronchi adjacent to pulmonary artery!

pulmonary (16 decks)

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