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EOR - Internal Med > Internal Med - Pulm > Flashcards

Internal Med - Pulm Flashcards

1
Q

Acute Bronchitis defined as:

A

a cough that persists for MORE THAN 5 DAYS

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2
Q

Sx of acute bronchitis

A

one-week history of cough productive of whitish sputum. This was preceded one week prior by a URI. She denies chills, night sweats, shortness of breath, or wheeze. Temperature is 99.9°F (37.7°C)

Fever is unusual → if fever present consider pnuemonia

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3
Q

Bacterial causes of acute bronchitis

A
  • M. Catarrhalis (the common bacterial cause of acute bronchitis)
  • H. influenzae
  • S. Pneumoniae
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4
Q

Dx for acute bronchitis

A

Chest X-Ray if the diagnosis is uncertain or symptoms have persisted despite conservative treatment

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5
Q

Tx for acute bronchitis

A
  • Supportive measures include hydration, expectorants, analgesics, β2-agonists, and cough suppressants as needed (not recommended for children)
  • For patients who desire medication for cough offer over-the-counter medications such as dextromethorphan or guaifenesin rather than other medications
    • Reserve use of inhaled beta-agonists, such as albuterol, for patients with wheezing and underlying pulmonary disease
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6
Q

When are abx indicated in acute bronchitis?

A
  • Antibiotics are indicated for the following: elderly patients, those with underlying cardiopulmonary diseases and cough for more than 7 to 10 days, and any patient who is immunocompromised
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7
Q

Presentation: Most often young patients present with wheezing and dyspnea often associated with illness, exercise, and allergic triggers

A

Asthma

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8
Q

Airway inflammation, hyperresponsiveness, and reversible airflow obstruction

A

Asthma

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9
Q

Dx of asthma

A

Diagnosis and monitor with peak flow. PFT’s: Greater than 12% increase in FEV1 after bronchodilator therapy

  • FEV1 to FVC ratio < 80% (You would expect the amount of air exhaled during the first second (FEV1) to be the greatest amount
  • In asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio
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10
Q

Tx for mild intermittent asthma

A

Less than 2 times per week or 3-night symptoms per month

  • Step 1: Short-acting beta2 agonist (SABA) PRN
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11
Q

Tx for mild persistant asthma

A

Mild Persistent: More than 2 times per week or 3-4 night symptoms per month

  • Step 2: Low-Dose inhaled corticosteroids (ICS) daily
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12
Q

Tx for moderate persistant asthma

A

Moderate Persistent: Daily symptoms or more than 1 nightly episode per week

  • Step 3: Low-Dose ICS + Long-acting beta2 agonist (LABA) daily
    • Step 4: Medium-Dose ICS +LABA daily
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13
Q

Tx of severe persistent asthma

A

Severe Persistent: Symptoms several times per day and nightly

  • Step 5: High-Dose ICS +LABA daily
  • Step 6: High-Dose ICS +LABA +oral steroids daily
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14
Q

Acute tx of asthma

A

Acute treatment: Oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids

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15
Q

A condition in which the lungs’ airways become dilated and damaged, leading to inadequate clearance of mucus in airways

A

Bronchiectasis

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16
Q
  • Mucus builds up and breeds bacteria, causing frequent infections
  • A common endpoint of disorders that cause chronic airway inflammation (CF, immune defects, recurrent pneumonia, aspiration, tumor)
A

Bronchiectasis

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17
Q

MCC Bronchiectasis

A

½ cases are from Cystic fibrosis

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18
Q

Sx of Bronchiectasis

A

Daily cough that occurs over months or years and production of copious foul-smelling sputum, frequent respiratory infection

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19
Q

Dx of Bronchiectasis

A

CXR = linear “tram track” lung markings, dilated and thickened airways – “plate-like” atelectasis; CT chest = gold standard

  • Crackles, wheezes, purulent sputum
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20
Q

Tx of bronchiectasis

A

TX: ambulatory oxygen, aggressive antibiotics for acute exacerbations, CPT (chest physiotherapy = bang on the back); eventual lung transplant

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21
Q

What is a carcinoid tumor

A

A tumor arising from neuroendocrine cells → leading to excess secretion of serotonin, histamine, and bradykinin

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22
Q

Common primary sites of carcinoid tumor

A

Common primary sites include GI (small and large intestines, stomach, pancreas, liver), lungs, ovaries, and thymus

  • The most common site of a neuroendocrine (carcinoid) tumor to metastasize to is the liver
  • Carcinoid tumor of the appendix is the most common cause. The appendiceal cancer travels from the appendix then to the liver where it metastasizes to the lungs
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23
Q

Carcinoid syndrome

A
  • Carcinoid syndrome (the hallmark sign) = Cutaneous flushing, diarrhea, wheezing and low blood pressure is actually quite rare and occurs in ~ 5% of carcinoid tumors and becomes manifest when vasoactive substances from the tumors enter the systemic circulation escaping hepatic degradation.
  • The syndrome includes flushing, ↑ intestinal motility (diarrhea), itching and less frequently, heart failure, vomiting, bronchoconstriction, asthma, and wheezing
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24
Q

Sx of increase serotonin d/t carcinoid tumor

A
  • ↑ Serotonin leads to collagen fiber thickening, fibrosis = heart valve dysfunction → tricuspid regurgitation, pulmonary stenosis/bronchoconstriction, and wheezing
  • ↑ Histamine and bradykinin = vasodilation and flushing
  • ↑ serotonin synthesis → ↓ tryptophan → ↓ niacin/B3 synthesis = pellagra
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25
Q

Dx of carcinoid tumor

A

CT-Scan to locate the tumors

  • Octreoscan → radiolabeled somatostatin analog (octreotide) binds to somatostatin receptors on tumor cells
  • Urinalysis → elevated 5-hydroxyindoleacetic acid (5-HIAA) → is the main metabolite of serotonin and is used to determine serotonin levels in the body
  • Pellagra (niacin/B3 deficiency) - ↑ serotonin synthesis → ↓ tryptophan → ↓ niacin/B3 synthesis
  • Chest X-Ray shows low-grade CA seen as pedunculated sessile growth in the central bronchi
  • Bronchoscopy- pink/purple central lesion, well-vascularized
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26
Q

Tx of carcinoid tumor

A
  • The lesions are resistant to radiation therapy and chemotherapy
  • Octreotide - a somatostatin analog that binds the somatostatin receptors and decreases the secretion of serotonin by the tumor
    • Niacin supplementation
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27
Q

Defined as a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause

A

Chronic bronchitis

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28
Q

Sx of chronic bronchitis

A

Common in Smokers (80% of COPD patients)

  • Frequent cough and expectoration are typical (compared to emphysema)
  • Stocky, overweight. Occasionally a barrel chest. (compared to emphysema)
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29
Q

Dx of chronic bronchitis

A
  • PFT’s: FEV1/FVC ratio of less than 0.7
  • Chest radiograph: peribronchial and perivascular markings
  • ↑ HGB and HCT are common because of the chronic hypoxic state
  • Auscultation of chest: crackles and wheezes
  • Percussion of chest: Normal
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30
Q

Tx of chronic bronchitis

A
  • Short-acting bronchodilators for mild disease
  • long-acting bronchodilators +/- inhaled corticosteroids for moderate to severe disease
  • Ipratropium bromide is the inhaler of choice for COPD
  • Smoking cessation and supplemental O2 (O2 is the single most important medication in the long term)
  • Antibiotics for acute exacerbations
  • Flu and pneumococcal vaccines are a must
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31
Q
  • The body’s natural response to ↓ lung function is chronic hyperventilation ;
  • CO2 Retainers - the body must increase ventilation to blow off CO2
A

Emphysema

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32
Q

Sx of emphysema

A

Minimal cough (compared to chronic bronchitis), quite lungs, thin, barrel chest

Minimal sputum (compared to chronic bronchitis)

Thin, underweight, and barrel chest

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33
Q

Dx of emphysema

A
  • hest X-ray reveals loss of lung markings and hyperinflation, a flattened diaphragm, small thin appearing heart
    • parenchymal bullae (subpleural blebs) are pathognomonic
  • Normal hematocrit (HCT)
  • Auscultation of chest: Diminished breath sounds. Prolonged expirations. Diminished heart sounds
  • Percussion of chest: hyperresonance
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34
Q

Tx of emphysema

A
  • Ipratropium (also albuterol inhaler)
  • O2
  • Oral Prednisone 40mg x 5days
  • Antibiotics
  • Azithromycin 500 mg x 3 days or Z-pack x 5 days
  • Cefuroxime 500 mg BID x 10 days
  • Doxycycline 100 mg BID x 10 days
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35
Q

Tx of COPD exacerbation

A
  • COPD exacerbations are managed with systemic glucocorticoids, antibiotics (tailored to the likelihood of specific pathogens), antiviral therapy when influenza is suspected
    • Glucocorticoids: prednisone 40 mg per day for five days
    • Antibiotics (examples):
      • Azithromycin 500 mg x 3 days or Z-pack x 5 days
      • Cefuroxime 500 mg BID x 10 days
      • Doxycycline 100 mg BID x 10 days
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36
Q

Dx of chronic bronchitis aka COPD

A

Lung biopsy → Gold Standard

Chest radiographs in chronic bronchitis demonstrate increased interstitial markings, particularly at the bases and thickening of the bronchial walls. Unlike in emphysema diaphragms are NOT flattened

37
Q

What would be expected of the Hbg + Hct in COPD pt?

A

Labs: ↑ HGB and HCT common because of the chronic hypoxic state

38
Q

What is the PFT in chronic bronchitis?

A

PFTs in chronic bronchitis:

FEV1/FVC ratio of less than 0.7

39
Q

In which pt do you see air trapping with

A

Emphysema

40
Q

right ventricular enlargement and eventually failure secondary to a lung disorder that causes pulmonary artery hypertension

A

Cor Pulmonale

41
Q

MCC of Cor pulmonale

A
  • Lung disorders such as PE, vasculitis, ARDS, COPD (most common), asthma, and ILD causes pulmonary artery hypertension
  • Pulmonary artery hypertension then leads to right ventricular failure
42
Q

PE findings of Cor Pulmonle

A

Peripheral edema, neck vein distention, hepatomegaly, and a parasternal lift

43
Q

Tx of Cor Pulmonale

A

Tx underlying pulmonary dz

*Diuretics may be harmful NOT helpful

44
Q

Obesity hypoventilation syndrome (OHS), also known as Pickwickian syndrome

A
  • a condition in which severely overweight people fail to breathe rapidly or deeply enough, resulting in low oxygen levels and high blood carbon dioxide (CO2) levels.
  • s/s: sluggish/sleepy during day
  • Sequelae: pulmonary hypertension, cor pulmonale, secondary erythrocytosis
45
Q

Type of lung disease that results in scarring (fibrosis) of the lungs for an unknown reason

A

Idiopathic pulmonary fibrosis (IPF)

46
Q

MC of all interstitial lung dz

A

Idiopathic pulmonary fibrosis

47
Q

Common non-idiopathic causes of pulmonary fibrosis that must be r/o to dx as idiopathic

A
  • Cigarette smoking
  • Certain viral infections
  • Exposure to environmental pollutants, including silica and hard metal dusts, bacteria and animal proteins, and gases and fumes
  • The use of certain medicines (methotrexate, amiodarone, nitrofurantoin, rituximab, bleomycin, and cyclophosphamide)
  • Genetics
  • Radiation treatment
  • Gastroesophageal reflux disease (GERD)
48
Q

Dx of Idiopathic pulmonary fibrosis

A

CXR shows fibrosis

CT chest: diffuse patchy fibrosis with pleural **based** _honeycombing_

PFTs will demonstrate a restrictive pattern - opposite of what you would see with asthma:

Decreased lung volume with a normal to increased FEV1/FVC ratio

49
Q

Tx of idiopathic pulmonary fibrosis

A

Treatment includes the judicial use of corticosteroids, O2, and eventually lung transplant

50
Q

How does coal workers pneumoconiosis present?

A

Coal mining; complication = progressive massive fibrosis

  • CXR: small nodular opacities in upper lung fields
51
Q

How does silicosis pneumoconiosis present?

A
  • Silicosis: mining, sandblasting, stone, quarry work; increased risk TB and progression to massive fibrosis
  • CXR: small rounded opacities throughout the lung, hilar lymph nodes may be calcified - “eggshell” calcifications
52
Q

How does asbestos pneumoconiosis present?

A
  • Asbestos: insulation, demolition, shipbuilding, construction; complication = mesothelioma
  • CXR: interstitial fibrosis, thickened pleura, calcified plaques appear on diaphragms or lateral chest wall
53
Q

How does Berylliosis pneumoconiosis present?

A
  • Berylliosis: high tech field, nuclear power, ceramics, aerospace, electrical plants, foundries; requires chronic steroids
  • CXR: diffuse infiltrates and hilar adenopathy
54
Q

MCC of Viral pneumonia

A

Viral: adults ⇒ flu = MC cause; kids ⇒ RSV; comes on fast

55
Q

Dx of viral pneumonia

A

Dx: CXR = bilateral interstitial infiltrates; rapid antigen testing for flu, RSV nasal swab, cold agglutinin titer negative

56
Q

Tx of viral pneumonia

A

Tx: flu with Tamiflu (A and B) if sx began <48 hrs; symptomatic tx = beta 2 agonists, fluids, rest

57
Q

Sx of Viral pneumonia

A

Persistent cough, sore throat, headache, myalgia, and malaise for more than three to five days.

The symptoms may worsen with time, and new respiratory signs and symptoms, such as dyspnea and cyanosis, appear.

58
Q

MCC of viral pneumonia in adults

A

Influenza virus

59
Q

Viral pneumonia sx in kids

A

RSV, 1st episode of wheezing

  • Respiratory syncytial virus (RSV) is the most frequent cause of lower respiratory tract infection in infants and children and the second most common viral cause of pneumonia in adults
  • Patients with RSV pneumonia typically present with fever, nonproductive cough, otalgia, anorexia, and dyspnea. Wheezes, rales, and rhonchi are common physical findings.
60
Q

MC bug in bacterial pneumonia, causing rust colored sputum

A

S. Pneumoniae - Rust-colored sputum - common in patients with splenectomy

61
Q

MC bug in bacterial pneumonia, causing salmon colored sputum?

A

Salmon colored sputum - MRSA treat with vancomycin

62
Q

MC bug in bacterial pneumonia on ventilator pts

A

Pseudomonas - Ventilators, patients become sick fast - treat with 2 antibiotics

63
Q

MC bug in bacterial pneumonia + diarrhea

A

Legionella - low NA+ (hyponatremia), GI symptoms (diarrhea), and high fever

64
Q

MC bug in bacterial pneumonia for patients living in dorms?

A

Mycoplasma - Young people living in dorms, (+) cold agglutinins, bullous myringitis

65
Q

MC bug in bacterial pneumonia, causing currant jelly sputum?

A

Klebsiella - currant jelly sputum, drinkers, aspiration

66
Q

Dx of pneumonia

A

Chest radiography usually demonstrates bilateral lung involvement, but none of the viral etiologies of pneumonia result in pathognomonic findings with CXR

  • Rapid antigen testing for influenza
  • RSV nasal swab
  • Cold agglutinin titer that is negativ
67
Q

Tx of bacterial pneumonia

A

Tx: outpatient = doxy, macrolides; inpatient = ceftriaxone + azithromycin/respiratory FQs

68
Q

Tx of viral pneumonia

A

Tx: flu with Tamiflu (A and B) if sx began <48 hrs; symptomatic tx = beta 2 agonists, fluids, rest

69
Q

Patient with non-remitting cough/bronchitis non-responsive to conventional treatments.

A

Coccidioides (valley fever)

70
Q

Dx of fungal pneumonia

A

Serologic tests using enzyme-linked immunoassays (EIA) for IgM and IgG should be ordered first, if possible. If the EIA is positive, a confirmatory immunodiffusion test should be performed.

71
Q

Tx of fungal pneumonia

A

Treatment: fluconazole or itraconazole

72
Q

Histoplasma capsulatum sx

A

pulmonary lesions that are apical and resemble cavitary TB; worsening cough and dyspnea, progression to disabling respiratory dysfunction; no dissemination

Bird or bat droppings (caves, zoo, bird); Mississippi ohio river valley

Signs: mediastinal or hilar LAD (looks like sarcoid)

Tx: amp B

73
Q

What type of fungal pneumonia is seen in Mississippi and Ohio River Valleys

A

Histoplasma capsulatum

opportunistic fungus that is known to cause systemic disease in HIV patients that involves low-grade fevers, cough, hepatosplenomegaly, and tongue ulceration

74
Q

Histoplasma capsulatum dx

A

Culture is the gold standard for diagnosis but requires a lengthy incubation period

75
Q

Tx of Histoplasma capsulatum

A

Treat with itraconazole orally for weeks to months or Amphotericin B if severe or failed Itraconazole

76
Q

Budding yeast found in soil contaminated with pigeon/bird droppings

A

Cryptococcus: Caused by the fungus Cryptococcus neoformans, common in AIDS and immunocompromised states, is considered an AIDS-defining illness

77
Q

Dx of cryptococcus

A

Found in soil; can disseminate and ⇒ meningitis

Lumbar puncture for meningitis

78
Q

Tx of cryptococcus

A
  • Treat with Amphotericin B + Flucytosine for 2 weeks followed by Fluconazole for 10 weeks
  • Prophylaxis if CD4 with Fluconazole
79
Q

Who is at risk for pulmonary aspergillosis

A

The majority of cases occur in people with underlying illnesses such as tuberculosis or chronic obstructive pulmonary disease (COPD), but with otherwise healthy immune systems

80
Q

Tx of pulmonary aspergillosis

A

Treatment: fluconazole or itraconazole

81
Q

Common in HIV-infected patients with a low CD4 count of less than 200, which fungal pneumonia

A

Pneumocystis Jiroveci(formerly PCP Pneumonia now called PJP)

82
Q

Pneumocystis Jirovecitx

A

Trimethoprim-sulfamethoxazole (BACTRIM) and steroids

  • Prophylaxis for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection. Daily Bactrim is the prophylaxis antibiotic of choice.
83
Q

Dx for HIV related pneumonia aka Pneumocystis jiroveci

A

CXR is the cornerstone of diagnosis. The radiograph shows diffuse interstitial or bilateral perihilar infiltrates

  • Bronchoalveolar lavage (PCR), labs, and an HIV test
  • Will often have very low O2 saturation despite supplemental O2
84
Q

What is the lights criteria for transudative pleural effusion?

A

Protein < 0.5

LDH <0.6

Common Causes: Hypoalbuminema (cirrhosis, nephrotic syndrome), CHF, Constrictive pericarditis

85
Q

What is the lights criteria for exudative pleural effusion?

A

Protein >0.5

LDH > 0.6

MCC: Autoimmune dz, esophageal rupture, infection, malignancy, pancreatitis, post-CABG, PE

86
Q

Presents with Acute onset ipsilateral chest pain and dyspnea with decreased tactile fremitus, deviated trachea, hyperresonance, diminished breath sounds

A

Pneumothorax

87
Q

2 types of pneumothorax

A

Can be spontaneous or traumatic

  • Primary: occurs in absence of underlying disease (tall, thin males age 10-30 at greatest risk)
  • Secondary: in presence of underlying disease (COPD, asthma, cystic fibrosis, interstitial lung disease)
88
Q

What is a tension pneumothorax

A

Tension pneumothorax → penetrating injury → air in pleural space increasing and unable to escape

  • A mediastinal shift to the contralateral side and impaired ventilation
  • CXR = pleural air; ABG shows hypoxemia

EOR - Internal Med (9 decks)

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