PANCE_pulm 10% Flashcards
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coin lesion
solitary pulmonary nodule
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what is the importance of a solitary pulmonary nodule?
significant risk of malignancy
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if a pt has COPD and significant smoking history, and a chest CT shows a 1cm nodule w/ ill-defined margins and a lobular appearance, what is the most appropriate next step?
surgical referral for excision
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what are the significant pulmonary solid nodule sizes and what are the next steps for each (there are 3 categories)?
<6mm = assess likelihood of malignancy, if high/intermediate –> chest CT at 12 mo
if pt is low-risk, no further f/u required
6-8mm = chest CT at 6 to 12 mo
> 8mm = asses likelihood of malignancy, if low –> chest CT at 3 mo; if high/interm –>biopsy/resection
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preventing post op atelectasis means doing what things (2)?
deep breathing exercises
incentive spirometry
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what diagnostic test is done for suspected influenza?
nasopharyngeal swab sent for rapid immunofluorescence assay
(sputum cultures take days to get results, not commonly ordered for viral illness)
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“24-year-old patient who is ill appearing presents to the clinic with reports of sudden-onset fever, coughing, sore throat, and rhinorrhea. Her symptoms began 3 days prior and have not improved since. PE reveals diffuse pharyngeal erythema w/ nonlocalizing scattered rales, rhonchi, wheezes. What is best intervention?”
symptomatic treatment and acetaminophen (not azithromycin)
acetaminophen = antipyretic
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What is the classification of drugs used in treatment of influenza A and B infections?
neuraminidase inhibitors
(oseltamivir, peramivir, zanamivir)
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influenza is spread via ______
respiratory droplets
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influenza - what are the three types and with what are they associated?
type A = pandemic
type B = epidemic
type C = sporadic
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“An 18-month-old boy presents with a one-week history of upper respiratory congestion and low-grade fever. His parents report noisy breathing increasing over the last 24 hours, and a loud “seal-like” barking cough. He has no significant past medical history. [What], if reported in the history given by parents, is most consistent with your suspected diagnosis?
inspiratory stridor
(this is croup, or laryngotracheobronchitis)
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causative agent of croup/laryngotracheitis
parainfluenza virus
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five clinical s/s of croup
URI-like symptoms
barking, seal-like cough
stridor
symptoms worse at night
hypoxia is UNCOMMON
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what does croup look like on soft-tissue neck XRay?
steeple sign
(subglottic tracheal narrowing)
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croup management
supportive care
corticosteroids (dexamethasone)
racemic epi (moderate to severe cases)
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“Which vaccine is largely responsible for a sharp decrease in the incidence of epiglottitis since its introduction in the United States?”
Hib
(Haemophilus influenza type B)
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most common age for croup
6mo to 3 yrs
(nontoxic appearing, probably)
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MC etiology of primary spontaneous pneumothorax
apical subpleural bullae
(they randomly rupture, causing pleural space to fill with air)
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Tx of small to moderate pneumothoraces
supplemental O2 - they resolve on their own
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physiology - what cells are responsible for production of surfactant?
type II pnemocytes
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three organ systems affected by alpha-1 antitrypsin deficiency
lungs
liver
skin
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emphysema at a young age <= 45 yrs….think….
alpha-1 antitrypsin deficiency
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what is the type of emphysema that is defined by enlargement or destruction of all parts of the acinus?
panacinar emphysema
this type is most often associated with alpha-1 antitrypsin deficiency
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“what are the classic chest radiography signs associated with a pulmonary embolism?
Hampton Hump
Westermark Sign
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uveitis
bilateral hilar adenopathy
dry cough
sarcoidosis
Sarcoidosis is a granulomatous disease that can form nodules in multiple organs.
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what is the skin manifestation of sarcoicosis?
subcutaneous nodules, i.e. erythema nodosum
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management of sarcoidosis
corticosteroids (eg prednisone)
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PE findings that are pathognomonic for sarcoidosis
lupus pernio
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what is lupus pernio?
chronic, violaceous raised plaques and nodules commonly found on cheeks, nose, and around the eyes
(it is pathognomonic for sarcoidosis)
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common CXR findings for sarcoidosis
bilateral hilar adenopathy
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what is the biopsy finding for sarcoidosis?
noncaseating granulomas
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what are the significant causes of disease in aspiration pneumonia and where are they commonly found?
anaerobic bacteria (including Peptostreptococcus, Fusobacterium nucleatum, Bacteroides)
they are present in the oral cavity
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How do you treat aspiration pneumonia when there is no evidence of abscess or empyema?
treat as community-acquired pneumonia
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how do you treat aspiration pneumonia when there is evidence of abscess or empyema?
ampicillin-sulbactam
amoxicillin - clavulanate (Augmentin)
amoxicillin plus metronidazole
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MC cause of lung abscess
aspiration pneumonia
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common history findings of aspiration pneumonia
impaired consciousness
dysphagia
esophageal disease
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what is the preferred anticoagulant for pulmonary embolus?
empiric anticoagulation therapy with LOW-MOLECULAR WEIGHT HEPARIN
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what types of workers are exposed to asbestos fibers and run the risk of asbestosis?
shipyard workers
construction workers
pipe fitters
INSULATORS
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“A transudative pleural effusion is identified after thoracentesis. Which of the following clinical scenarios is most consistent with this type of effusion?
a) 27 y/o F w/ a lupus flare
b) 47 y/o F w/ alcohol use disorder w/ an elevated lipase
c) 65 y/o M w/ an EF of 15% & pulmonary edema
d) 72 y/o M recently diagnosed with lung cancer
C) 65 y/o M w/ AN EF OF 15% & PULMONARY EDEMA
90% of transudative effusions are caused by HF as in the clinical scenario above
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first-line CAP treatment for pts who are >65 yrs, have comorbidities, or used abx w/in last 90 days:
augmentin plus azithromycin
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“what is the duration of treatment for pts being treated for CAP in the ambulatory setting?”
5 days
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common factors that precipitate COPD exacerbations
VIRAL URI (such as rhinovirus infection)
bacterial infections
excessive exposure to smoke/smog
inadequate use of medications that control COPD symptoms
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pursed-lip breathing
emphysema
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pink puffer
emphysema
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blue bloater
chronic Bronchitis (all the b’s are together)
BUZZWORDS
barrel chest
emphysema COPD
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“What daily medication, in addition to an inhaled beta-agonist and an inhaled steroid, should be prescribed for the management of COPD with frequent exacerbations?”
an inhaled LABA or inhaled anticholingergic
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“A patient with acute pancreatitis is noted to have a pleural effusion on chest radiography. Which of the following findings would you expect to find on pleural fluid analysis?
a) elevated amylase concentrations
b) elevated triglyceride concentrations
c) low glucose concentrations
d) low pH of pleural fluid”
A) ELEVATED AMYLASE CONCENTRATIONS
amylase measurements can assist when pleural effusions are caused by a pancreatic or esophageal etiology
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“Is the lactate dehydrogenase level high or low in an exudate pleural fluid?”
high
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what is the most sensitive and specific testing for pertussis?
PCR of nasopharyngeal secretions
(RR) BUZZWORDS
whooping cough
pertussis
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treatment of pertussis
azithromycin
TMP-SMX
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“If macrolide antibiotics are contraindicated in a patient with suspected pertussis, what is the second line alternative medication?”
Trimethoprim-sulfamethoxazole
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what is bronchial provocation testing for asthma?
medication such as METHACHOLINE is given and produces a decreased FEV1 of 20% or more
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the only therapy that has positive impact on patients’ survivial time and the natural course long-term of hypoxemic COPD is:
long-term supplemental oxygen therapy
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“An ECG of a long-time COPD patient would likely show evidence of what?”
“Cor pulmonale, which is characterized by right ventricular hypertrophy, right atrial enlargement, right axis deviation, and signs of right-sided heart failure.”
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any pt with a large pneumothorax or pts who are unstable should undergo immediate _____________
chest tube thoracostomy
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MC cause of minor hemoptysis in ER?
acute bronchitis
Hemoptysis causes = BBATTLECAAAMP (‘battle camp”)
Bronchitis
Bronciectasis
Aspergilloma
Tumor
Tuberculosis
etc
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MC sites of hemorrhage in massive hemoptysis?
bronchial or pulmonary arteries
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aspiration pneumonitis vs aspiration pneumonia
aspiration pneumonitis - aspiration of sterile gastric contents, acute lung injury from acidic and particulate gastric material…often followed marked disturbance of consciousness (eg drug OD, sz, coma)
aspiration pneumonia - aspiration of colonized oropharyngeal material, acute pulmonary inflammatory response to bac and bac products
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histological types of lung cancer w/in NON-SMALL CELL LUNG CA
squamous cell carcinoma
adenocarcinoma
large cell lung cancer
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which types of lung cancer are located more centrally w/in lungs?
small cell lung CA
squamous cell carcinoma
“S”entral, Small cell, Squamous (three s’s)
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which types of lung cancer are located more peripherally?
adenonocarcinoma
large cell lung CA
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MC lung CA in individuals who have never smoked
adenocarcinoma lung cancer
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which type of lung CA is most likely to cause SIADH?
small cell lung ca
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the three pneumococcal vaccines - how do they work?
if a pt receives the 15-valent (PCV15), they get 23-valent (PPSV23) one year later
pts over 65 get 20-valent vaccine (PCV20), 1 dose
CXR findings - negative for acute trauma, findings indicate a 7 mm well-defined, solid lesion in the upper right lung lobe.
what is next step?
CT of chest
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risk of malignancy in nodules greater than 20 mm
> 50%
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preferred modality for initial eval of malignancy risk for lung nodules
CT of the chest w/o contrast
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nodules < 6mm
do not require f/u, regardless of components
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“Which patients should receive regular low-dose CT screening for lung cancer?”
“Patients 50–80 years old who are at high risk of lung cancer (at least a 20 pack-year smoking history and are either current smokers or former smokers having quit within the past 15 years).”
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acute bronchitis can last ____ weeks.
Pts who present with wheezing should get treatment with _____.
1-3 weeks
Patients with wheezing may benefit from a trial of inhaled BETA-AGONISTS, such as albuterol.
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what virusus are MC etiologies of acute bronchitis?
coronavirus
rhinovirus
influenza A and B
parainfluenza
RSV
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three common PE findings in bronchitis
mucopurulent cough > 5 days
RHONCHI
wheezing
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treatment for a large or unstable tension pneumothorax
needle thoracostomy
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what is miliary tuberculosis?
hematogenous dissemination of Mycobacterium tuberculosis, aka acute disseminated TB
this is TB that has spread and become a multisystem problem
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what are Pancoast tumors? what is another name for them?
lung neoplasms located at the apical pleuropulmonary groove, adjacent to the subclavian vessels
aka superior pulmonary sulcus tumors
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clinical presentation of Pancoast tumors
shoulder and arm pain (C8, T1, T2 dermatomes)
Horner syndrome (ipsilateral ptosis, miosis, etc.)
weakness, atrophy of m.m. of hand
(cough, hemoptysis, dyspnea uncommon)
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management of Pancoast tumors
chemoradiotherapy
surgical resection
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MC pathogen causing PNA in CF patients and treatment
Pseudomonas aeruginosa
FQs such as levofloxacin or ciprofloxacin
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how to recognize a CF pt in a vignette
OTC Vit A, D, E, K
pancreatic enzyme replacements
inhaled dornase alfa
chest physiotherapy
daily bronchodilators
PFT = mixed obstructive and restrictive patterns
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“What GI dx should raise suspicion for CF?”
“meconium ileus at birth”
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A pt w/ AFib with RVR is discharged from hospital on amiodarone. What diagnostic study should be followed OP?
CXR
pulmonary toxicity may result from chronic amiodarone therapy (MC is chronic interstitial pneumonitis)
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who gets prednisone before TMP-SMX?
HIV-positive pts with moderate to severe PJP defined by ROOM AIR ARTERIAL OXYGEN PARTIAL PRESSURE OF LESS THAN 70 mm Hg (PaO2 < 70 mmHg)
or A-a oxygen gradient > 35 mmHg
(RR) BUZZWORDS
bilateral ground-glass opacities in a batwing pattern
Pneumocystis Pneumonia
treat with TMP-SMX (and add steroids for moderate to severe disease)
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when do you use chest tube thoracostomy vs needle decompression of pneumothorax?
big pneumo and unstable pt = chest tube thoracostomy
needle decompress if chest tube thoracostomy is delayed
“Any patient who is unstable should undergo immediate chest tube thoracostomy with needle decompression implemented in those with delayed chest tube insertion.”
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overuse of albuterol or any beta-2-adrenergic agonist may result in what lab abnormality?
hypokalemia
(“due to the increased activity of Na-K-ATPase pumps in skeletal m. which drive K+ intracellularly”)
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what counseling should be given to child-bearing-age women regarding smoking?
smoking increases risk for infertility
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T/F: “Nicotine is excreted in breast milk”
TRUE
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define persistent-moderate asthma in terms of symptoms and FEV1
symptoms are daily and
>1 but < 7 nights/week
FEV1 is 60-80%
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define persistent-mild asthma in terms of symptoms and FEV1
symptoms are >2 but <7 days/week and
>3-4 nights/month
FEV1>80%
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three steps of asthma treatment
Step 1 - SABA (prn)
Step 2 - short-acting anticholinergics (ipratropium bromide (Atrovent))
Step 3 - systemic corticosteroids
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usual test of choice for a pt with high clinical probability of PE
what if pt has elevated Cr?
CT angiogram of chest with IV contrast
if Cr is elevated, use V/Q scan
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“How long should an individual undergo treatment for an isolated PE w/ no other risk factors?”
“3 months”
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“in LOW clinical suspicion, negative D-dimer” tells us what?
“negative D-dimer excludes PE”
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indications for a chest xray to r/o PNA
abnml v/s such as
T>38 C
HR >100 bpm
RR >24
or age >75 yrs w/ severe clinical s/s
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gold standard for confirming etiology of a pleural effusion
“A diagnostic THORACENTESIS is gold standard for confirming the underlying etiology of pleural effusion and is indicated whenever there is new pleural effusion without an apparent cause.”
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purpose of lateral decubitus radiograph in terms of pleural effusion
it can help differentiate free flowing fluid from loculated fluid (not sure why that’s important to know)
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common CXR findings of pleural effusion
blunting of costophrenic angles
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treatment for asthma s/s 3 days/week and night s/s 3x/month
this is PERSISTENT-MILD asthma
low dose inhaled corticosteroid and SABA (rescue inhaler)
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superior vena cava syndrome - what is it?
elevated venous pressure in upper body resulting in obstruction of blood flow through the SVC
…usually caused by extrinsic compression, commonly caused by lung cancer tumors
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clinical signs of superior vena cava syndrome
edema - facial and upper extremity
SOB
HA, CP
distended neck and chest veins
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treatment for asthma pt using rescue inhaler 3-4 x/week and waking up 4 night/month with SOB
this is PERSISTENT - MILD asthma
time to add a low dose inhaled glucocorticoid
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treatment for exercise-induced bronchoconstriction
LEUKOTRIENE RECEPTOR ANTAGONIST (LTRA) like montelukast
” Patients with prolonged or recurrent exercise, such as the patient in the vignette above, should also add a leukotriene receptor antagonist (LTRA), such as montelukast, daily for bronchoprotective properties.” “improve overall asthma control”, also could be achieved by adding glucocorticoid.
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When is surgical thoracotomy indicated to follow ER-chest tube for a hemothorax?
if >1500 mL of blood is evacuated
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best imaging for a hemothorax
chest CT scan with contrast
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“when does surfactant begin to be expressed in the fetal lung?”
20 weeks gestation
“surfactant gradually increases until 33-36 weeks gestation” at which point “there is a surge in surfactant”
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what memory tool helps distinguish CXR findings for two key pneumoconiosis?
ASBESTOS: from the ROOF, affects the BASE (lower lobes)
SILICA, COAL: from the BASE of the earth, but affects the ROOF (upper lobes)
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What do you do next if a TB skin test is negative, but pt had close contact with someone w/ active TB?
REPEAT TUBERCULIN SKIN TEST IN 8-10 WKS
“If the skin test is negative, and the patient had recent close contact with someone with active tuberculosis, the patient should have a repeat tuberculin skin test in 8 to 10 weeks to exclude a latent tuberculosis infection. The infection may be so recent that hypersensitivity has not developed to allow for a positive test.”
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pneumonia + otalgia, and fluid-filled vesicles on TM
bullous myrignitis probably caused by Strep pneumo
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first line treatment for TB
RIPE for 2 months, then RI for 4 months
