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IM MTB > Pulm > Flashcards

Pulm Flashcards

1
Q

Order of asthma management

A

Start with inhaled SABA
Next add low-dose inhaled corticosteroid, alternates include cromolyn, LK modifiers: montelukast
Next add LABA to the SABA and ICS or increase the dose of ICS
Then increase the dose of the ICS to maximum in addition to the LABA and SABA
May add Omalizumab if increased IgE
Finally, oral corticosteroids when all others have failed

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2
Q

The severity of an asthma exacerbation is quantified by?

A

Decreased peak expiratory flow – an approximation of the FVC

Also ABG with an increased A-a gradient

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3
Q

Treatment of an asthma exacerbation

A

Oxygen, albuterol, steroids, iPratropium may help, magnesium only an acute, severe asthma not responsive to several rounds of albuterol

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4
Q

COPD diagnosis

A

best initial: CXR
most accurate: PFT (will have decreased FEV1/FVC less than 70% decreased DLCO) (not reversible -i.e. less than 12% / 200 mL improvement in FEV1)
ABG in acute exacerbations will have increased pCO2 and hypoxia, elevated bicarb to compensate

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5
Q

what improves mortality in COPDers?

A

smoking cessation
O2 if pO2 less than 55 or sat lass than 88% (or 60, 90% if RHF or elevated HCT or pulm HTN)
influenza/pneumo vaccines

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6
Q

effective meds in COPD

A

anticholinergics are most effective**
SABAs, steroids, LABAs, pulm rehab
in contrast to asthmatics, COPD not controlled with albuterol>anticholinergic>ICS

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7
Q

management of AECB

A

bronchodilators, steroids, antibiotics: macrolides, cephas, augmentin, FQs, doxy or bactrim 2nd line

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8
Q

high volume purulent sputum, +/- hemoptysis, wheezing, dyspnea, crackles, dilated, thickened bronchi (“tram-tracks”) on CXR, think? best diagnostic tool?

A

bronchiectasis
most accurate test is high-resolution CT (get CXR first)
sputum culture to determine specific bacteria

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9
Q

bronchiectasis tx

A

“cup and clap” - physiotherapy (associated with CF)
tx infection, rotate abx
sx resection

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10
Q

brown sputum, ^IgE, eospinophilia, think?

A

ABPA

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11
Q

sinus pain and polyps are common in ?

A

CF

biliary cirrhosis, intestinal obstruction, pancreatitis (islets are spared)

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12
Q

best diagnostic test for CF

what bugs on sputum cx

A 
sweat chloride (above 60) after pilocarpine tx (^Ach>^Cl-)
genotyping not accurate, too many diff genes
H. flu (nontype), pseudomonas, S. aureus, Burkholderia
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13
Q

CF tx

A

abx: macrolides, cephas, augmentin, FQs, doxy or bactrim 2nd line
inhaled rhDNase, inhaled bronchodilators (albuterol), pneumo/influenza vaccination, lung transplant if refractory
Ivacaftor ^CFTR activity

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14
Q

main ways to distinguish pneumonia from bronchitis

A

abnormal CXR, high fevers, dyspnea?

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15
Q

CAP orgs not visible on gram stain

A

Mycoplasma, Chlamydia, Legionella, Coxiella, viruses

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16
Q

sputum gram stain is adequate if ?

A

more than 25 WBCs and fewer than 10 epithelial cells

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17
Q

pleural effusion with:
WBC above 1000, pH less than 7.2?
LDH above 60% and protein above 50% of serum level?

A

infection

empyema

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18
Q

bronchoscopy in pneumonia?

A

rarely needed, only when stain/cx do not yield org and need for ICU placement
exception: PCP
other uses: foreign bodies, cytology for lung masses

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19
Q

Outpatient treatment of pneumonia

A

If previously healthy: macrolide or doxycycline

If comorbidities or antibiotics in the past three months: floor quinolones – not Cipro

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20
Q

Inpatient treatment of pneumonia

A

Flora quinolone – not Cipro or ceftriaxone and azithromycin

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21
Q

Reasons to hospitalize people with pneumonia

A

Hypotension, respiratory rate above 30 or PO to lesson 60, pH below 7.35, B1 above 30, sodium lesson 130, glucose about 250, possible of 125, confusion, temperature above 104, 65 or older or comorbidities such as cancer COPD CHF renal failure liver disease

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22
Q

Curb 65 criteria for pneumonia and mission

A

Confusion, uremia, respiratory distress, BP low, age over 65
With 0 to 1.: Home
If 2+ points: admission

23
Q

How to manage infected profusion or empyema in addition to antibiotics?

A

Drainage for a chest tube or thoracostomy, each of the chest can accommodate 2 to 3 L of fluid, a large effusion ask like an abscess and is hard to sterilize

24
Q

Who gets the pneumococcal vaccine

A

Everyone at 65: first 13 then the 23
Once underlying condition is discovered in those with heart, liver, kidney, lung disease or immunocompromise or cancer
Second those should be given five years after the first dose

25
Q

Difference with HAP

A

Higher incidence of Graham negatives: E. coli or Pseudomonas, macrolides are not acceptable
Need anti pseudomonal cephalosporins or antipseudomonal PCN, (Zosyn) or carbapenem

26
Q

Diagnostic test for VAP from least accurate but easiest to most accurate but most dangerous

A

Trick your aspirin, BAL, protected brush specimen, VAT, open lung biopsy – thoracotomy

27
Q

Therapy for VAP

A

Combine three different drugs:
Anti-pseudomonal beta-lactam: cephalosporin, penicillin, or carbapenem
PLUS SecondAnti-pseudomonal agent: aminoglycoside or floor quinolone
PLUS MRSA agent: vancomycin or linezolid no daptomycin! Inactivated by surfactant

28
Q

Best for covering long abscesses

A

Penicillin or clindamycin
CXR is the best initial test, CT is more accurate, only a long biopsy can establish the etiology, sputum culture is wrong

29
Q

Alternative to Bactrim in PCP

A

Atovaquone if mild, if that Jim toxicity switch to clindamycin and primaquine or pentamadine

30
Q

Diagnosing TB

A

Best initial test: CXR
Sputum stayed in culture,
Most accurate test: plural biopsy

31
Q

When to extend six-month treatment for TB

A

Osteomyelitis,military TV, meningitis, pregnancy or any other time pyrazinamide is not used

32
Q

What to do and hepatotoxicity with TB medications

A

Only stop when LFTs rise 3 to 5 times upper limit of normal
Pregnant patients should not receive pyrazinamide or streptomycin
Steroids decrease the risk of constructive pericarditis and neurological complications

33
Q

PPD positive if larger than 5 mm in what people

A

HIV, steroid users, close contacts of those with active TB, abnormal calcifications on CXR, organ transplant recipients

34
Q

PPD positive pressure than 10 mm and what people

A

Recent immigrants, prisoners, healthcare workers, close contacts of someone with TV, blood cancers, alcoholics, diabetes

35
Q

If the first PPD is negative and someone who’s never had a PPD before, what to do

A

Get a second PPD, the first test may be falsely negative

36
Q

What to do after positive PPD

A

Get CXR to rule out active TB, if negative implies latent, get nine months of INH with vitamin B6

37
Q

What do you do if one lesion has malignant features: patient older than 40, enlarging mass, smoker, greater than 2 cm, adenopathy, and normal pet scan

A

Remove the lesion, the following tissue not be done because a negative test is likely to be a false negative: sputum cytology, needle biopsy, PET scan

38
Q

Most appropriate next step in patients with intermediate probability of malignancy

A

Bronchoscopy for central lesions and transthoracic needle biopsy for peripheral lesions

39
Q

PET scan does what?

A

Tells whether the content of lesion is malignant without a biopsy, malignancy you will have increased uptake of glucose, 85 to 95% sensitive, more accurate with larger lesion is greater than 1 cm

40
Q

Most sensitive and specific test for long lesions

A

Video assisted thoracic surgery – VATS

Can convert to open thoracoscopy and lobectomy if malignancies found

41
Q

Causes of pulmonary fibrosis

A

Radiation, Drugs: bleomycin, both so fun, amiodarone, metal surgeon, Macrobid, cyclophosphamide
Pneumoconiosis: coal, silicosis, asbestosis s, berylliosis

42
Q

All forms of pulmonary fibrosis present with?

What type has granulomas?

A

DOE, Find rails or crackles, loud P2, clubbing of the fingers
Granulomas in berylliosis, Responds best to steroids

43
Q

Parotid gland enlargement, facial palsy, her block, restrictive cardiomyopathy, CNS involvement, Iritis/uveitis, erythema nodosum, lymphadenopathy, think?

A

Sarcoidosis, CXR is best initial test, lymph node biopsy is most accurate – granulomas are noncaseating

44
Q

Labs in sarcoidosis

A

Elevated AC E, hypercalciuria, hypercalcemia – granulomas make vitamin D, restrictive long pattern on PFTs
BAL shows elevated helper cells
Treat with steroids

45
Q

Unique presentation in PE

A

Fever can arise from any cause a clot/hematoma, extremely severe emboli will produce hypotension

46
Q

PE diagnosis

A

Get CXR, EKG, ABG 1st

CXR most likely be normal, if abnormal will show atelectasis, ABG will show hypoxia and respiratory alkalosis

47
Q

This patient presents with SOB an elevated heart rate, CXR is normal with hypoxia an ABG, increase it a gradient with EKG showing sinus tack, what to do next?

A

Do not need CTA as this is high probability, much more important to start therapy – enoxaparin

48
Q

If I find a clot and LE Doppler, what to do?

A

No need to get CTA, as treatment is the same: heparin and six months of warfarin

49
Q

Most accurate test for PE

A

Angiography, .5% mortality, Rarely done

50
Q

PE treatment

A

Heparin to warfarin for an INR of 2 to 3 times normal, fondaparinux is alternative
Rivaroxaban and dabigatran our oral agents that can be used in alternative to warfarin, use with LMWH

51
Q

When is TPA The right answer in PE

A

Hemodynamically unstable and, a Q RV dysfunction – also a reason for IVC filter

52
Q

When our direct acting thrombin inhibitor’s the right answer in PE?he

A

In cases of HIT
Examples: argatroban, lepirudin or fonduparinux
ASA is never the answer

53
Q

Pulmonary hypertension

A

Systolic greater than 25, diastolic greater than eight, any chronic lung disease leads to back pressure into the pulmonary artery, obstructing blood flow out of the right heart

IM MTB (7 decks)

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