Pleura and PE

Question 0

Transdates

Answer 0

Congestive heart failure
Cirrhosis
Nephrotic syndrome
Myxedema
Constrictive pericarditis
SVC obstruction
Total protein ratio 60mg/dL
Leukocytes <1000/ml

Question 1

Normal pleural fluid

Answer 1

pH 7.60-7.64

Protein content < 2g/dL

Question 2

Exudates

Answer 2

Pneumonia
Malignancy
Collagen- vascular disease (Rheumatoid arthritis, SLE)
Tuberculosis
Post-myocardial infarction (Dressler's)
Total protein ratio >0.5
LDH ratio >0.6
Sugar 1000/ml
New criteria
Pleural fluid LDH more than 0.45 of thee upper limit of normal serum values
Pleural fluid cholesterol more than 45mg/dL
Pleural fluid protein more than 2.9g/dL

Question 3

Sx- CHF

Answer 3

Increasing lower extremity edema, orthopnea, and increased JVD, S3 gallop rhythm,

Question 4

Sx- TB

Answer 4

Night sweats, fever, hemoptysis, and weight loss

Question 5

Sx- Bacterial pneumonia

Answer 5

An acute fever, purulent sputum production, and pleuritic chest pain

Question 6

Meniscus sign

Answer 6

Blunting of the costophrenic angle on PA

Question 7

Lateral decubitus films

Answer 7

If the layering fluid is >=1cm thick, it indicates an effusion amenable to thoracentesis

Question 8

Ultrasound

Answer 8

Detect as little as 5-50mL of pleural fluid

Question 9

Complications of hemothorax

Answer 9

Residual clot after tube drainage
Empyema- secondary infectionn of clots
Fibrothorax- a late complication characterized by gradual deposiition of a thick layer of fibrous tissue on the visceral pleura

Question 10

Tx of Hemothorax

Answer 10

Little amound- no tx
Large amount- Chest tube and drain
Fibrinolytic agents- 250,000IU of streptokinase or 100,000IU of urokinase

Question 11

Tx for Pneumothorax

Answer 11

Small (<20%)- no tx
Pneumothorax that causes shortness of breath is best drained with a chest tube
Essential to drain a tension pneumothorax quickly

Question 12

Pulmonary embolism

Answer 12

Massive when: 
it involves both pulmonary arteries or
it results in hemodynamic compromise
Moderate to Large when:
right ventricle hypofunction with normal systemic arterial BP

Question 13

Massive PE sx

Answer 13

Dyspnea
Tachypnea
Syncope
Hypotension
Cyanosis

Question 14

Moderate to Small PE sx

Answer 14

Pleuritic chest pain
Cough
Hemoptysis

Question 15

Signs of acute RVF

Answer 15

Distended neck veins
A parasternal RV heave may be palpable
On auscultation:
tricuspid murmur
loud S2 with prominent splitting of S2
S4 may be present (-25% of patients)

Question 16

Plasma D-dimers ELISA

Answer 16

Levels >500ng/ml is suggestive of PE

high sensitivity, low specificity

Question 17

ECG on PE seen only 20% cases

Answer 17

Right heart strain
Tall, peaked P waves in lead II (P pulmonale)
Right axis deviation, right bundle-branch block
S1Q3T3 pattern (prominent S wave in lead I and a Q wave and inverted T wave in lead III)

Question 18

Chest radiograph of PE

Answer 18

Hampton’s hump- wedge shaped density over diaphragm
Palla’s sign- enlarged right descending pulmonary artery
Westermark’s sign- decreased vascularity

Question 19

Dx of PE

Answer 19

D-dimer-> CT/CTA/ lung scan-> Leg ultrasound-> Pulmonary angiogram

Question 20

Tx of PE

Answer 20

Thrombolysis: 100mg of t-PA IV over 2hrs

2ndary tx:
Anticoagulation
LMW heparin 1000-1500U/hr IV
Warfarin 5mg per day orally