Pulm Flashcards
Bronchiectasis
Cough and large amounts of mucopurulent, foul-smelling sputum.
PE will show crackles and wheezing.
CXR will show dilated and thickened airways (“tram-tracks”).
Diagnosis is made by CT: airway dilatation, signet-ring sign, bronchial wall thickening, and mucopurulent plugs and debris accompanied by post-obstructive air trapping (tree-in-bud).
Most commonly secondary to cystic fibrosis (pseudomonas).
Also H influenzae, Strep pneumo, staph aureus.
Treatment is antibiotics, bronchodilators, hydration and chest physiotherapy.
Legionella pneumonia
Patient will be complaining of fevers, malaise, myalgias, cough and GI symptoms.
Labs will show leukocytosis, elevated LFTs and hyponatremia.
CXR will show unilateral patchy alveolar lower lobe infiltrates.
Most commonly caused by gram-negative bacillus and is found in aquatic environments.
Patients at risk: smokers, those with underlying respiratory disease (e.g. COPD) or immunosuppression, and men > 50 years of age.
Txt: azithromycin. Alternative agents include trimethoprim-sulfamethoxazole and fluoroquinolones.
Pneumomediastinum
Air/gas in mediastinum
Spontaneous, trauma, Valsalva (crack users), Boerhaave syndrome (hx of vomiting)
Dyspnea, CP, neck pain
PE: crepitus, Hamman’s sign (crunching on auscultation)
CXR: ring around right pulmonary artery
Gold standard: CT
Usually self-resolving
Pneumocystis pneumonia
Patient with a history of HIV
Complaining of gradual onset of non-productive cough, fever, dyspnea, and decreased exercise tolerance
Weight loss, Oral candidiasis common in undxd HIV
Labs will show CD4 < 200, increased LDH
CXR will show bilateral infiltrates (bat wing pattern) and ground glass opacification
Most commonly caused by Pneumocystis jirovecii
Treatment is TMP-SMX
Kerley B-lines
Pulmonary edema
thickening of the subpleural interstitium
Hampton’s hump
Pulmonary embolism
wedge of airspace opacity on the periphery of the lung
Pulmonary Embolism
Patient will be complaining of dyspnea (most common symptom)
PE will show tachypnea (most common sign)
ECG will show sinus tachycardia, nonspecific ST segment and T wave changes, right heart strain, S1Q3T3 (classic finding)
CXR will show nonspecific abnormalities, Hampton hump (pleural-based wedge infarct), Westermark sign (vascular cutoff sign)
Dx gold standard: CT pulmonary angiography most preferred
Most commonly originate in the lower extremities and pelvis
Treatment is anticoagulation (heparin, LMWH), supportive care, thrombolytics in hemodynamically unstable patients
Comments: In low clinical suspicion: negative D-dimer excludes PE
Post-viral pneumonia
Patient with a history of influenza
Complaining of fever, productive cough with bloody sputum and shortness of breath
CXR will show multiple cavitary lesions
Most commonly caused by Staphylococcus aureus
Most common causes of PNA 40-65 y/o
Streptococcal pneumonia Mycoplasma (walking) Haemophilus influenzae Anaerobes Viruses
Most common causes of PNA >65
Influenza virus Haemophilus influenzae Anaerobes Streptococcus pneumoniae Gram-negative rods (Klebsiella, E.coli, etc)
CAP
Strep pneumo MC
Moraxella cattarhalis
H. Influenza (COPD, smokers)
Gram neg. ex: klebsiella (risk of aspiration-ETOH, poor mentation)
Staph aureus (post-viral)
Legionella (immunocompromised) Txt: Levofloxacin or Azithromycin
>90 days of being in a healthcare facility
<48 hours of being admitted to hospital
Txt: Outpatient: Azithromycin or Doxycycline; Levo/moxifloxacin if beta lactam allergy
Inpatient: ceftriaxone + Azithromycin (or doxy) or BS FQ
Healthcare PNA
Pseudomonas (green sputum, cystic fibrosis, nursing home resident and cyanosis)- cefepime, pip/tazo, ceftazidime, -penem
MRSA - Vancomycin
<90 days since being in a healthcare facility
>48 hours since being admitted
Atypical/walking PNA
Mycoplasma pneumonia MC
Chlamydia, Legionella, viruses
Diffuse, patchy - may not be any signs of consolidation
Low grade fever; dry nonproductive cough; extrapulmonary sx
Staph aureus pna
Post viral, post-influenza
IVDA, elderly
B/l with multilobar infiltrates or abscesses
Can have necrotizing features causing cavitary lesions if MRSA
gram+ cocci in clusters
Legionella PNA
Contaminated water, aerosols
GI sx
Elderly, smokers, immunocompromised
Klebsiella PNA
ETOH, debilitated, chronic illness, aspirations
Associated with CAVITARY lesions
Currant jelly sputum
bulging fissures
Streptococcus PNA
MC cause of CAP Rigors Bullous myringitis Rusty blood tinged sputum gram+ paired lancets
Haemophilus PNA
2nd MC cause of CAP Increased with underlying pulmonary dz: COPD, bronchiectasis, CF ETOH, DM, <6 y/o, elderly Green-tinged sputum gram-negative pleomorphic rods
Typical PNA
Strep pneumo MC H. Influenzae, Klebsiella, Staph aureus Lobar PNA Sudden onset fever, productive cough, pleuritic CP, rigors (S. Pneumo), tachy/tachy Signs of consolidation
Mycoplasma PNA
MC cause of atypical pna Especially <40 Bullous myringitis, pharyngitis No cell wall (no beta lactams) Doxycycline, Azithromycin or levofloxacin
Idiopathic Pulmonary Fibrosis
Male With a history of smoking
Complaining of chronic dry cough and dyspnea
Bibasilar crackles, clubbing
Labs will show restrictive characteristics - decrease FVC and FEV1 but a near normal FEV1/FVC ratio
CXR/CT will show “honeycombing”
Treatment is O2, pulmonary rehabilitation
Chronic bronchitis
Patient will be overweight and cyanotic (“blue bloater”)
Complaining of chronic productive cough for at least 3 months in at least two successive years
PE will show decreased breath sounds, increased resonance upon percussion of the lung fields, and use of accessory muscles to breathe
Diagnosis is made by FEV1/FVC ratio is less than 0.7 and the FEV1 is less than 80% of predicted
Treatment is smoking cessation, lifestyle changes with pulmonary rehabilitation, inhaled bronchodilators, and inhaled steroids
Sarcoidosis
Patient will be an African-American woman
Labs will show hypercalcemia and elevated serum ACE
CXR will show bilateral hilar adenopathy
Biopsy will show noncaseating granulomas
Treatment is steroids
Comments: Lupus pernio (chronic, violaceous, raised plaques and nodules commonly found on the cheeks, nose, and around the eyes) is pathognomonic for sarcoidosis and is the most specific physical exam finding in this disease
Croup/Laryngotracheitis
Patient will be a non-toxic appearing child, 6-months to 3 y/o
Complaining of URI symptoms with barky, seal-like cough, inspiratory stridor, low-grade fever
X-ray will show “steeple sign” on PA view
Most commonly caused by parainfluenza virus
Treatment is steroids, aerosolized epinephrine
Complications: dehydration, otitis media, and pneumonia.
Pertussis/whooping cough
Patient with a history of nasal congestion, cough, and low-grade fever
Complaining of rapid fire repetitive coughing followed by an inspiratory whoop” and post-tussive emesis
Test: PCR of nasopharyngeal secretions.
Most commonly caused by Bordetella pertussis
Treatment is a macrolide - azithromycin or bactrim
Emphysema
Patient will be older
With a history of smoking
Complaining of dyspnea
PE will show pink skin, pursed-lip breathing, barrel chest, decreased breath sounds and hyperresonance to percussion
Diagnostics will show reduced FEV1 and increased TLC
Most commonly caused by abnormal and permanent enlargement of airspaces and airspace wall destruction
Comments: Emphysema in a young non-smoker think alpha-1-antitrypsin deficiency
Fine crackles
PNA
Heart failure
COPD/chronic bronchitis
Asthma
Coarse crackles
Same as fine crackles but more advanced disease (PNA, HF/pulmonary venous congestion, COPD/chronic bronchitis, asthma)
pulmonary edema
pulmonary fibrosis
Wheeze
Asthma
COPD
HF
Rhonchi
Obstructed trachea
Bronchitis
PNA
Pleural friction rub
Pleurisy
Pericarditis
Pericardial effusion
Stridor
epiglottitis
croup
tracheitis
foreign body obstruction.
Carcinoid syndrome
Patient will be complaining of skin flushing, wheezing, and diarrhea
Diagnosis is made by 24-hour excretion of 5-hydroxyindoleacetic acid (5-HIAA) in the patient’s urine
Most commonly caused by carcinoid tumors (neuroendocrine tumors that secrete vasoactive material such as serotonin, histamine, catecholamine, prostaglandins, and peptides)
Asbestosis
shipping, roofing, plumbing
from the roof, but affects the base (lower lobes)
Berylliosis
aerospace, fluorescent bulbs
Byssinosis
cotton
Silicosis
foundries, sandblasting, mines
from the base (earth), but affect the roof (upper lobes) (same as coal)
Siderosis
iron
Stannosis
tin
Cor pulmonale
Patient will be complaining of peripheral edema, dyspnea, fatigue, and signs of right-sided heart failure
PE will show pulmonary HTN + RVH
Most common chronic cause: COPD
Most common acute cause: PE
Diagnosis is made by right heart catheterization
Transudate pleural effusion caused by
HF
Cirrhosis
Nephrotic syndrome
Pulmonary embolism
Exudative pleural effusion caused by
Malignancy Bacterial/viral PNA Pulmonary embolism TB Pancreatitis Esophageal rupture Connective tissue dz Uremia
Superior vena cava syndrome
Malignancy obstructs SVC → ↓ drainage from head (facial plethora), neck (JVD), upper extremities (edema)
SOB
CT chest
Rx: diuretics, steroids (airway compromise), radiation therapy
Löfgren syndrome
acute presentation of sarcoidosis characterized by the triad of hilar adenopathy, erythema nodosum and polyarthralgia
usually self-limited
Txt: NSAIDs
Lung cancer screening
Low dose CT scan annually
Age 55-80
Current smoker with 30 pack year hx or
Quit w/i past 15 years
