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Internal Medicine > Pulm > Flashcards

Pulm Flashcards

1
Q

What is the length for an acute vs chronic Bronchitis

A

Acute = less than 3 weeks

Chronic = longer than 3 months for 2 consecutive years

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2
Q

Characterization of GPA

A

Glomerulonephritis

Necrotizing granulomatis vasculitis

Small vessel vasculitis

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3
Q

GPA CXR and other physical exam findings

A

Nodular pulmonary infiltrates with cavitation

Tracheal stenosis ; strawberry tongue ; petechia/Purpura ; saddle nose deformity

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4
Q

Time frame for CAPNA

A

Less than 48 hours of hospital onset

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5
Q

4 bacteria responsible for CAPNA

A

Strep pneumo
Mycoplasma PNA
H. Influenza
Chlamydia

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6
Q

2 Vaccines good in elderly (over 65) for CAPNA

A

PCV 13

PPSV23

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7
Q

Physical exam findings and expected CBC for CPNA

A

PE: inspiratory crackles, bronchial breath sounds, egophony, whispering pectoriloquy, and dullness to
percussion

v Dx: CBC (leukocytosis + leftward shift)

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8
Q

Diagnostic tool for CPNA

A

CURB-65
1. Confusion (new onset)

  1. Urea ( > 20)
  2. Respirations ( > 30)
  3. BP (SBP < 90 and/or DBP < 60)
  4. 65 y/o
  5. Score: 1 = outpt, 2 = clinical decision, ≥ 3 = admit, 5 = ICU
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9
Q

Treatment for CPNA ; with no comorbidities ; no MRSA or Psuedomonas risk

A

Empiric

Amoxicillin or Doxy x5days or longer until 72 hours afebrile

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10
Q

CPNA for patients with comorbidities

A

-Resp Flouro x5days or longer until 72 hours afebrile

Augmentin OR cephalosporin plus a macrolide OR doxycyclin

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11
Q

3 common pathogens in HAPNA

A

Staph A. ; Psuedomonas ; gram neg rods

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12
Q

Fever ; Hemoptysis ; Wt. Loss ; Night Sweats ;; Think?

A

TB

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13
Q

Dx techniques if you suspect TB and TXM

A

Dx
1. PPD (cornerstone dx for latent TB)
2. Sputum for smear and culture
3. CXR: done w/ positive PPD or active clinical sxs

TXM = RIPE
Rifampin
Iosonizide
Pyrazinamine
Ethambutol

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14
Q

CXR findings in Coal Workers Dz

A

Diffuse 2-5mm opacities affecting the alveolar lung space ; UPPER LUNG FIELDS

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15
Q

Silicosis CXR ; and increased incidence of what?

A

Egg shell opacities in the hilar lymph nodes; rounded opacities

-TB ; if + get a skin test

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16
Q

Shipyard worker Asbestosis CXR

A

linear streaking at LOWER LUNG FIELDS

, opacities of various shapes/sizes, honeycombing

(advanced dz), and pleural calcifications

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17
Q

Best imaging for asbestosis ; shows what

A

CT ;

Parenchymal fibrosis
Pleural plaques

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18
Q

4 Characteristics of Asthma

A

Enhanced obstructive response of airway smooth muscle

Reversible flow limitation

Recurrent breathlessness and wheezing

FEV1:FVC less than 80

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19
Q

What is the significance of FEV1 ; FVC ; DLPCO ; FEV1:FVC ratio?

A

FEV1 = forced expiratory volume ; air exhaled in 1 second

FVC = amount of air exhaled after deep inhale ; total air exhaled

DLCO = diffusing capacity of air to the bloodstream ; ability to breathe oxygen to destination

FEV1:FVC = total amount of air that you can forcibly exhale!

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20
Q

Obstructive conditions mean it is harder to _____
Restrictive conditions mean its harder to ________

A

O= exhale

R= inhale

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21
Q

What FEV1/FVC ratio indicated COPD? What do you use to grade COPD severity

A

Less than 0.7

SEVERITY GRADING:
Mild = FEV1 greater 80%

Mod = FEV1 50-80%

Severe = FEV1 30-50%

VERY SEVERE = FEV1 less than 30% or less 50% w/ Chronic Respiratory F.

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22
Q

When is the use of SABA indicated in asthma

A

Relief of acute sxs

DOC for acute bronchospasms
Px for exercise induced

“albuterol”

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23
Q

When is the use of LABA indicated in asthma?

A

If you need to step up due to increased sxs/episodes and already on an ICS

“Salmeterol-Serevent”
“Formeterol-Foradil”

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24
Q

Inhaled CS TXM indicated for what in asthma?

A

1st line anti-inflammatory for mild mod persistent asthma

To be used with SABA

fluticasone/budosenide/beclamethasone

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25
Q

In asthma exacerbation what is good management

A

Oral : Prednisone

IV : Methylprednisolone

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26
Q

Preferred controller / reliever of intermittent asthma would be? And how freq are they getting sxs

A

Less than 2 days a week ; nighttime awakenings = less than 2X monthly

PRN ICS-Formeterol = controller

prn SABA = reliever

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27
Q

Preferred controller / reliever of mild asthma would be? And how freq are they getting sxs

A

Greater than 2 days a week ; less than once daily ; nighttime awakenings = 3-4x monthly

Daily / PRN ICS/ ICS-Formeterol or LTRA = Montelukast = controller

prn SABA = reliever

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28
Q

Preferred controller / reliever of persistent moderate asthma would be? And how freq are they getting sxs

A

Daily with nighttime awakenings = greater than 1 weekly

Low Dose ICS-LABA or Medium Dose ICS or ICS-LTRA = controller ; consider = Oral Prednisone

prn ICS-Formeterol = reliever

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29
Q

Preferred controller / reliever of severe asthma would be? And how freq are they getting sxs

A

Sxs occur nightly and several times daily

Medium Dose ICS -LABA or High Dose ICS or +Tiotropium or +LTRA = controller ; consider oral prednisone

prn-ICS-Formeterol = reliever

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30
Q

Low Dose / Medium Dose / High Dose -ICS for fluticasone dipropionate and beclamethasone

A

Low Dose = F =[ 100-250] ; B=[100-200]

Medium Dose =F=[250-500] ; B=[200-400]

High Dose = F=[over500] ; B =[over400]

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31
Q

What is defined as improvement on bronchodilator therapy

A

improvement defined as : ↑ in FEV1 of > 12% after 2-4 puffs of SABA

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32
Q

Hallmark sxs of chronic bronchitis vs emphysema

A

CB = productive cough = WET ; blue bloater

E = DOE = DRY ; pink puffer

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33
Q

What genetic deficiency is linked to COPD

A

Alpha 1 Antitrypsin

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34
Q

Gold standard diagnostics for COPD

A

PFTs / Spirometry

W/ post bronchodilator FEV1 = non-reversible

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35
Q

ECG findings consistent with COPD

A

RVH
RAD
RAE
right sided HF

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36
Q

How do you assess COPD severity and TXM

A

mMRC score and Risk Factors =Hospitalizations

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37
Q

mMRC score 0-1 with 1 hospitalization in the last year vs 2 hospitalizations TXM

A

mMRC score 0-1 = SOB increasing pace on the level or going up slight hill

1 = SAMA or SABA

2 = LAMA

LAMA = Tiotropium SAMA = Iprotropium Bromide SABA = albuterol

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38
Q

mMRC score 2 or greater with 1 hospitalization in the last year vs 2 hospitalizations TXM

A

mMRC score 2 or greater = walking slower than others of same age; stopping at own pace on the level —> Too breathe less to leave the house or get dressed

1 = LABA or LAMA

2 = LAMA ; LAMA + LABA ; LAMA + LABA + ICS

LAMA = Tiotropium SAMA = Iprotropium Bromide SABA = albuterol

39
Q

Caution SABA medications in what?

A

DM
Hyperthyroidism
Severe CAD

40
Q

SAMA: short-acting muscarinic antagonist
Ipratropium Bromide

LAMA: long-acting muscarinic antagonist
Tiotropium

Are what drug class?

A

Anti Cholinergic Bronchodilators

41
Q

Only med therapy that decreases mortality in COPD

A

Oxygen - AT HOME

Cor pulmonale with O2 less 88%

42
Q

4 health Mx recommendations in COPD pts

A

i. Control triggers

ii. Smoking cessation

iii. Vaccinations: pneumococcal and influenza

iv. Azithromycin has anti-inflammatory properties in lung; option for pts on dual
or triple therapy w/ frequent exacerbations

43
Q

Management uncomplicated vs complicated COPD exacerbation

A

Uncomplicated = less4 ; no Comorbids = AZITHROMYCIN or AUGMENTIN

Complicated = greater4 = AUGMENTIN or LEVOFLOXACIN or MOXIFLOXACIN

+CC / O2 / SABA

44
Q

Hallmark PE finding of Interstial Lung Disease

A

Crackles

Get a Lung bx

Mc = Idiopathic ; Sarcoidosis

45
Q

What syndrome is assoc with sarcoidosis

A

“ Lofgrens “

Triad = Sarcoidosis triad: bilateral hilar lymphadenopathy,

erythema nodosum,

migratory polyarthralgia

(95% specificity for Sarcoidosis)

46
Q

TXM sarcoidosis

A

Tx sxs: NSAIDs, low-dose glucocorticoids, colchicine, and hydroxychloroquine

47
Q

MC primary lung cancer

A

Adenocarcinoma

48
Q

SCC Lung CXR findings

A

Assoc. w/ hilar adenopathy and mediastinal widening on CXR

49
Q

Large Cell carcinoma of the lungs ; example and findings

A

Pancoast tumors and syndrome
a. Lung tumor of superior sulcus at extreme apex of lung

50
Q

Small cell lung cancer is commonly assoc with what

A

SIADH / paraneoplastic syndrome
Prone to hematgenous spread ; high assoc with SMOKING

51
Q

Carcinoid tumors arise from where?

A

Bronchial mucosa or GI tract

52
Q

Carcinoid tumors secrete what?

A

Vasoactive Material = serotonin ; histamine ; catecholamine ; prostaglandin ; peptides

53
Q

4 sxs of carcinoid syndrome

A

Flush

Diarrhea

Wheeze

HYPOTENSION

54
Q

4 associated complications of Pancoast Tumor

A

Shoulder or Neck pain OOP

Horner’s syndrome : anhydrosis Ipsilateral miosis ; ptosis

Weakness / Atrophy of hand

SVC syndrome = right side ; face neck swelling dyspnea chest pain

55
Q

Squamous cell carcinoma is assoc with

A

Hypercalcemia

think paraneoplastic syndrome = extra manifestations of lung cancer

56
Q

Examples of paraneoplastic syndromes ? 4

A

Cushings
Hypercalcemia
SIADH
SVC

57
Q

Lab findings of SIADH

A

Hyponatremia with increased urine osmolality > 300

58
Q

Describe Group 1 Pulm HTN

A

Due to : Vascular Remodeling / Connective Tissue DO / Drugs

59
Q

Describe Group 2 Pulm HTN

A

Left sided heart F. Cause

Increased intra cardiac and venous pressures

60
Q

Describe Group 3 Pulm HTN

A

Hypoxia due to lung disease; either obstructive/restrictive/ or developmental lung d/o

61
Q

Describe Group 4 Pulm HTN

A

Obstructive due to emboli

-Sarcoidosis
-hematologic d/o
-NFT

62
Q

Describe txm of Pulm HTN

A

Get a right heart catherization to confirm PAP greater 20 and rule out left sided intracrdiac pathology

TXM = vasodilators

63
Q

Virchow Triad in VTE

A

Virchow’s Triad

  1. Vessel wall injury
    a. Thrombosis, vessel inflammation, infxn, direct trauma or surgery
  2. Venous stasis: immobility (bed rest, obesity, stroke), hyperviscosity (polycythemia), ↑ central
    venous pressure (pregnancy, low CO states)
  3. Hypercoagulability: inherited, deficiency or dysfxn of antithrombin III, protein C, protein S, or
    prothrombin, antiphospholipid antibody syndrome, acquired (age, OCP, malignancy, surgery)
64
Q

VTE Anticoag therapy :

A
  1. LMWH: enoxaparin
  2. Factor Xa inhibitor: Rivaroxaban, Apixaban, Edoxaban
65
Q

MC DVT location to cause PE

A

Proximal vein thrombosis: involves popliteal, femoral, or iliac veins; MC to cause PE

66
Q

TXM for all types of DVTs [nml; preg/cancer; renal dysfunction; contraindications/recurrent]

A

Tx
a. Factor Xa inhibitors
i. DOC for most DVT unless pregnant, cancer, renal dysfxn

b. LMWH: use w/ warfarin to provide tx until warfarin starts working, then take off LMWH
i. DOC for pregnant and cancer pts

c. Unfractionated heparin: first line in pts w/ renal dysfxn d. Warfarin: works well but effects take time to start, use w/ LMWH

e. IVC filter
i. If anticoag contraindications ii. Recurrent thromboembolism w/ anticoag
iii. Recurrent embolism w/ pulmonary HTN iv. Urgent surgery w/out time for anticoag

67
Q

S/Sx: dyspnea, pain on inspiration, cough, hemoptysis, wheezing, tachypnea (only reliable
sign), tachycardia, crackles/S4, Homan’s sign, syncope

Think?

A

PE

68
Q

4 labs to get in PE ; SOC

A

D-dimer

Troponin

ABG

BNP

SOC = CTPA / V/Q Scan = preg

69
Q

Wells Score Less than 4

Wells Score Greater than 4

A

Less = d-dimer

Greater = CTPA

70
Q

Nocturnal and Daytime sxs of OSA

A

Nocturnal sxs: snoring, apneas, choking, nocturia, disrupted sleep

Daytime sxs: nonrestorative sleep, morning HA, excessive daytime sleepiness, cognitive deficits,
significant other reports sleep issues

71
Q

STOP BANG Screening criteria

A

Snore loudly

Tired

Observed apnea

Pressure (HTN)

BMI > 35

Age > 50

Neck circumference > 40 cm

Gender male

3+ = Get Sleep Study
Labs = CBC/TSH/FT4

72
Q

3 causes of central sleep apnea

A

a. Cessation of effort or inadequate ventilator drive

b. Narcotics

c. Idiopathic

73
Q

Describe spontaneous PTX / PE findings / Risk Factors

A

Sudden onset of unilateral chest pain and dyspnea, often begins at rest or sleep

May present as life-threatening respiratory failure if underlying COPD or asthma is
present

PE
i. Small: mild tachycardia ii. Large: ↓ breath sounds, ↓ tactile fremitus, hyperresonance unilaterally

RF: tall, thin men, smokers, family hx, Marfan’s syndrome, previous episode

74
Q

TXM Small (< 3 cm of air btwn lung and chest wall)
PTX ; STABLE

A

Stable: tx conservatively w/ observation in ER; repeat CXR w/in 24 hrs
and discharge if no change

75
Q

TXM Large (> 3 cm of air between lung and chest wall)
PTX ; STABLE /

Severe on ventilation

A

Stable or symptomatic: needle aspiration

Severe or on ventilation: place chest tube

76
Q

TPTX Sxs / Needle D instructions for Tension PTX

A

S/Sx: severe tachycardia, hypotension, mediastinal or tracheal shift

If suspected, large bore needle inserted immediately (needle-D):
i. Btwn 2nd and 3rd ICS at mid clavicular line

ii. Btwn 4th and 5th ICS mid axillary or anterior axillary line

iii. Tube thoracostomy for definitive care

77
Q

Large effusion PE findings

A

large effusions = dullness to percussion, diminished/absent
breath sounds over effusion

78
Q

SOC for Pleural Effusions

A

CT Chest

79
Q

Lab findings EXUDATIVE vs TRANSUDATIVE

A

i. Exudative: protein > 0.5, LDH > 0.6, LDH > ⅔ upper limit of normal

ii. Transudative: if none of exudative values are met

80
Q

TXM for TRANSUDATIVE / Malignant Effusion / Hemothorax

A

i. Can remove up to 1.5 L to alleviate sxs

ii. Transudative: tx underlying condition

iii. Malignant effusion: chemo/radiation, therapeutic thoracentesis if sx

iv. Hemothorax: large bore tube thoracostomy

81
Q

Hemoglobin (oxygen affinity) is altered by what? (3)

A

a. pH (↑ = ↑ affinity for O2)

b. PCO2 (↓ = ↑ affinity for O2)

c. Temperature (↓ = ↑ affinity for O2)

82
Q

Definition of respiratory f. By lab values

A

PaO2 < 60 (SaO2 of under 90%) and/or PaCO2 > 45

83
Q

Decrease in what 2 electrolytes leads to hypoventilation

A

K
Phosphate

84
Q

Complications of acute respiratory f. (3)

A

Complications: stress gastric/ulcer, DVT, PE

85
Q

4 causes of ARDS (4)

A

Common causes: sepsis, diffuse pna, aspiration of gastric contents, trauma

86
Q

ARDS will often lab values consistent with?

A

PaO2/FiO2 < 300 mmHg

The ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) is an indicator of pulmonary shunt fraction

87
Q

What is PEEP? When is it used?

A

Positive end-expiratory pressure (PEEP) keeps the airways and small lung spaces open to allow for adequate oxygenation when a person cannot breathe on their own. If the lungs cannot oxygenate properly, the individual may need to be intubated and placed on mechanical ventilation to allow the lungs time to heal.

88
Q

SaO2 goal on PEEP ventilation ; what position in ARDS

A

Over 88%

-Prone

89
Q

Describe septic shock

A

Type of distributive shock: peripheral vasodilation seen d/t warm extremities and compensatory ↑
in cardiac output

S/Sx: fever, hypotension, tachycardia

90
Q

SIRS Criteria

A

SIRS criteria (temp, pulse, RR, and WBC)
a. Fever > 38.3C or < 36C

b. Pulse > 90 bpm

c. RR > 20 d. Leukocytosis (WBC > 12,000) or leukopenia (WBC < 4,000)

91
Q

TXM Sepsis

A

a. Assess ABCs and replenish circulating volume → 1-2 L bolus of NS or LR

b. No response to volume expansion = give vasopressor (Norepinephrine)

c. Give abx ASAP (w/in 1 hr of recognizing sepsis)

92
Q

Describe Anaphylaxis Hypersensitivity

A

Arises from activation of mast cells and basophils by cross linking of IgE and aggregation of
high-affinity receptors for IgE

93
Q

Ultimate shift of sxs in anaphylaxis

A

respiratory distress, ↓ LOC, circulatory collapse

94
Q

TXM anaphylaxis

A

a. Airway, breathing, and circulation management

b. IV fluids, O2, cardiac rhythm monitoring

c. Epinephrine IM d. If pt is taking B-blockers, give glucagon (reversal agent)

e. If IM epi fails → start Epi IV f. 2nd line: corticosteroids, antihistamines, vasopressors, glucagon, B2 bronchodilator

Internal Medicine (6 decks)

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