Pulm: Block 1 Flashcards

1
Q

What is the pathophysiology of COPD

How does it present and what is seen on PE?

A

Abnormal and permanent enlargement of airspace due to wall destruction

Older PT w/ smoking Hx w/ Dyspnea
Dec sounds
Hyperresonance

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2
Q

What will be seen on diagnostic studies of COPD?

What are two complications that can arise from emphysema?

A

Dec FEV, Inc TLC

Pneumothorax from bullae
Weight loss due to breathing efforts

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3
Q

What mechanism allows us to breathe?

A

TP: 4mmHg, inflate
TTP: -4mmHg, deflate
TRP: air flow to/from atmosphere and to/from lungs
-4mmHg in interstitial space pulls lungs during inspiration

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4
Q

What is the criteria to receive the term ‘blue bloater’?

What will be seen/heard on exam and PFT?

A

Productive cough x3mon for two consecutive years

Inc resonance
Dec sounds
Accessory muscle use
FEv/FVC ratio <0.7
FEV <80%
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5
Q

What are the two causes of the Cor Pulmonale showing in Blue Bloaters?

What is the most common and four less common causes of bronchiolitis?

A

RV failure
PHTN

MC= RSV
LC= Parainfluenza, Rhino, Influenza, Metapneumo
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6
Q

How is bronchiolitis Dx and Tx

What are three potential complications?

What is the most common cause of Acute Bronchitis and how does it present?

A

Child under 2yrs w/polyphonic wheezes and ralesafter 1-3 day URI; Tx w/ Support

Dehydration, Apnea, Aspiration pneumo

Viruses- productive cough <1wk
Tx: support, dilators

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7
Q

How does acute bronchitis present?

What are the 6 viruses that can cause acute bronchitis?

What 3 bacteria could cause acute bronchitis?

A

Cough x 5days or more
Non/purulent sputum
URI prodrome

RPM RIC
Rhino Parainfluenza Metap
RSV Influenza Corona

Bordatella pertussis
Mycoplasma pneumo
Chlamydia pneumo

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8
Q

How does bronchiectasis present?

What will be seen on imaging of bronchiectasis

How is the Dx confirmed?

A

Large amount of sputum
Crackles and wheezing

Tram tracks- dilated and thickened airway

CT: Signet ring sign (wall thickening and plugs_ and
Tree-in-bud (trapped debris)

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9
Q

What is the most common cause of bronchiectasis

How is it Tx?

A

CF

Therapy Hydrate ABD Dilator

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10
Q

Define Bronchiectasis

What type of airway dz is it?

What vaccine has significantly reduced the prevalence of epiglottitis?

A

Dilation w/ decreased airway clearance causing mucus pooling

Obstructive

HIB

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11
Q

What are the top three the most common causes of URIs?

How do these PTs present?

How is it Tx?

A

Strep Pneumo- MC, in carriers
HIB- unvaccinated Peds PT
Moraxella- smokers

Rapid onset fever/dysphagia
Stridor, Tripod, drooling
Thumb sign on x-ray

ABX (Cephtriaxone, Vanc)- safe for young, old, pregnant

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12
Q

What is the full term of Croup

Croup is most commonly caused by ? and in ? age PT

How is Croup Tx?

A

Laryngotracheitis

Parainfluenza virus, 6mon-3yrs

Cool temps
Dexameth, Racemic Epi

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13
Q

What respiratory sound is made in Croup PTs and what Sx is rarely seen?

What hallmark image is seen on x-ray for these PTs?

What is the difference between this fever and epiglottitis fever?

A

Inspiratory stridor
Rare= hypoxia

Steeple sign on PA view

Croup: low, non toxic PT
Epiglottitis: high, toxic PT

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14
Q

Who and how does Bacterial Tracheitis present?

How is this one different?

What meds are used to Tx Bacterial Tracheitis

What is different about these PTs Tx process?

A

3-5y/o w/ high fever (+102), barky cough, stridor

Toxic appearing
Pseudomembrane development

IV Ceftriaxone/Vanc
IV fluids

Sedate, Intubate, Bronchoscope

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15
Q

How does influenza appear in clinic?

How is Influenza Dx

How are they Tx and what med can be given to high risk PTs if Dx is made within 48hrs

A
HA
Myalgia
Fevers
Sudden onset fever
Non-productive cough

Reverse PCR, rarely culture

Support- PO fluids
Oseltamivir- don’t use w/ statin due to liver damage

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16
Q

What is the most common cause of viral pneumonia in adults?

What are the differences between the three types of this microbe

How is this microbe spread?

A

Influenza

A: pandemic (PT more sick)
B: epidemic
C: sporadic

Respiratory droplet

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17
Q

What microbe causes Whooping Cough?

How does this present?

A

Bordetella Pertussis

Hx of nasal congestion, Cough
Low fever
Repetitive cough, whoop, post-cough emesis

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18
Q

What med is used to Tx Pertussis?

What are the three stages of pertussis?

A

Azith. preferred <1mon
Alt: TMP/SMX if macrolide c/i

Catarrhal- 1-2wks; fever, non-productive cough, rhinorrhea
Paroxysma- 2-6wks; whooping, stridor
Convalescent- 1-2wks; reduced Sxs

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19
Q

What microbe is the most common cause of bacterial pneumonia?

What can be seen on PE to ID this?

A

Strep Pneumo

Rust colored sputum, Gram Pos

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20
Q

What microbe is the most common cause of pneumonia in alcoholics?

What is the most common cause of pneumonia in drug users?

A

Klebsiella- currant jelly sputum, bulging fissures

Staph A: gram pos cocci in clusters seen post influenza, most dangerous

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21
Q

What is the most common cause of pneumonia in CF, nursing homes and cyanosis?

What microbe is most common cause in COPD PTs and is usually post-URI?

A

Pseudomonas

H Infleunza, gram NEG pleomorphic rods

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22
Q

What are the two microbes most likely to cause health care associated pneumonia?

How are pneumonias Tx?

A

Pseudomonas
MRSA

Outpatient, healthy: Macrolide or Doxy*- few s/e, no QTc lengthening

OutPT w/ comorbidity/Inpatient: respiratory flouroquinolone

ICU: Ceftriaxone/Cefotaxime and Azith or Respiratory fluoroquinolone

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23
Q

What comorbidities in a pneumonia PT change the Tx protocol?

“Walking Pneumonia” can be from what six microbes?

A

DM, HTN, Obese, Apnea

CCC FML
Chlamydia Pneumo(mild)
Chlamydia Psitt.
Cox Burnetti
F. Tularemia
Mycoplasma pneumo (young PTs)
Legionella Pneumo
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24
Q

Most common cause of Typical CAP, follows URI/influenza and has acute onset

May follow influenza, cavitary and possible MRSA

Present in DM, ImmComp, long term care facilities and aspiration pneumonia

Chronic lung Dz PTs or PTs on mechanical vents

A

Strep Pneumo- rust color sputum

Staph A

Klebsiella

Pseudomonas

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25
What are the five atypical organisms that can cause | atypical pneumonia?
Mycoplasma- young adult, NOT visible on x-ray Legionella- hot tub, GI, Neuro, effusions Chlamydia Pneumo- young adult after pharyngitis Cox Burnetti- livestock, inc LFTs Chlamydia psittaci- parrott exposure, temp/pulse dissociation
26
What microbe cause pneumonia after exposure to birds, NOT parrot? Define Bullous Myringitis
Birds: Crypto Neoformans, H Capsulatum Hemorrhagic bleb on TM during Mycoplasma Pneumonia Tx w/ macrolide
27
What is the presenting cough Sx of atypical pneumonia? How are Atypical Pneumonias Tx and what classes are avoided?
Non-productive cough Rales Interstitial infiltrate (CXR) Tetracyclines- D/T Macrolides- A/C Fluoroquinolones NO: B-Lactam/Sulfonamides
28
PT w/ Histoplasmosis probably has ? travel Hx and exposure? How does this appear on CXR? How is it Dx and Tx?
Fungal infection from Ohio-Mississippi valley, bird/bat droppings Solitary pulmonary calcification Hilar/mediastinal adenopathy Sputum culture Itraconazole/Amphotericin B
29
What causes Pneumocystitis Pneumonia How do these PTs present? What will be seen on lab work and imaging of PCP? How is it Tx?
HIV Hx, most commonly from Pneumocystitis jirovecii Gradual onset of non-productive cough CD4 <200 Inc LDH Bat wing pattern CXR TMP-SMX Steroids if PaO2 <70% or A-gradient >35
30
What will be seen on CXR of TB? How are these Dx?
Primary/Latent: Ghon focus Reactivation: cavitary in upper lobes Primary/Latent: PPD Reactivated: sputum smear for acid fast bacilli or, culture for AFB
31
What causes carcinoid syndrome? How do these PTs? How is Carcinoid Syndrome Dx?
Neuroendocrine tumor secreting histamine, , prostaglandins peptides catecholamine serotonin Skin flush, wheezing, diarrhea 5-HIAA collection x 24hrs
32
What are non-pulmonary Sxs indicative of metastases? What lab results will be seen in PTs w/ Carcinoid Syndrome? What is this the leader of?
Hip/back pain Horners (Pancoast) Neuro Sxs Tachy w/ HOTN HyperCa Cancer related death among men and women
33
What type of lung nodule is most likely benign and malignant?
Benign: Fast/no growth on Q2yr images Popcorn pattern, Multiple nodules <5mm Lifelong non-smoker, <30y/o w/ no CaHx Malignant: >2.5cm, Spiculated Upper lobe Multiple pulmonary nodules +1cm in diameter PT >30y/o w/ smoking or CaHx
34
What is the most common cause of the two type of pleural diseases? What will be seen on PE for these PTs? How are these Dx?
Transudative: CHF Exudative: infection (bacterial pneumonia) Dec sounds Dec tactile fremitus Dull percussion CXR w/ costophrenic and cardiophrenic angles, loss of diaphragm/apex silhouette
35
How are pleural Dzs Tx? How are Transudative and Exudative differentiated?
Thoracentesis | ``` Light's Criteria- Transudate: Protein <0.5 Serum LDH <0.6 LDH <2/3 upper limit HF PE Cirrhosis Nephrotic ```
36
What will be seen on PE of a Spot Pneumo? What will be seen on CXR? How are they Tx?
Dec sounds Dec fremitus Hyper resonance Absence of lung markings ``` <20%= observation w/ O2 >20%= chest tube ```
37
What type of BP is seen in Tension Pneumos? What is the most common chronic and acute cause of compromised pulmonary circulation How doe they present? How is it Tx?
HOTN w/ JVD Chronic: COPD Acute: PE R side HF Edema Dyspnea R heart cath
38
What is the most common presenting Sx and Sign of VTEs? What would be seen on EKG?
Sx: dyspnea S: tachypnea Sinus tachy, S1Q3T3
39
What is Virchow's Triad What would be seen on CXR of VTE? What is the TOC in mod/high probability cases?
Stasis, Trauma, Hypercoag Hampton hump- pleural based wedge infarct Westermak sign- vascular cutoff sign CT pulmonary angiography Alt Test= VQ if bad kidneys
40
What is Well's Criteria
PE Risk Score ``` S/Sxs of DVT= 3 DDx less likely than DVT= 3 HR >100= 1.5 Imm/Surgery in 3 days/4wks= 1.5 DVT/PE Hx= 1.5 Hemoptysis= 1 Malignancy w/ Tx in past 6mon= 1 ``` ``` 0-2= low 3-6= mod >6= high ```
41
How do restrictive pulmonary Dzs present? How do Restrictive Pulmonary Dz appear on diagnostic studies? How is it managed?
Male w/ Hx of smoking and chronic dry cough w/ dyspnea (smoking, dust exposure, GERD) Dec FVC and FEV Near normal FEV/FVC ratio CXR w/ honey comb O2, Pulm rehab
42
What two findings are seen in in PHTN? What are the origins of each type of Pneumoconiosis: Beryillosis, Silcosis, Siderosis, Stannosis, Byssinosis
RVH, elevated Pulm Pressure +25mmHg ``` Asbestos: ship, roof, plumbing Bery: aerospace/fluorescent Sill: miner, sandblasting Side: arc welder, iron Stann: tin Byss: cotton ```
43
What is the key highlight for pneumoconiosis? Which origins of pneumoconiosis affects the upper/lower lobes of the lungs? How do pneumoconiosis PTs present
Dec lung volume Up: Silica, Coal, Bery, Talc Low: Cobalt/hard metals, asbestosis Dyspnea Non-productive cough Chronic hypoxia
44
How does pneumoconiosis appear on Dx studies? Define Lupus Pernio and where is it seen?
CXR shows interstitial fibrosis Dec volume Raised plaques and nodules on face, pathognomonic for Sarcoidosis
45
What is seen on lab work and CXR of PTs w/ Sarcoidosis How are these PTs managed?
HyperCa Elevated serum ACE CXR= hilar adenopathy Mediastinal node biopsy= noncaseating granuloma is Dx Steroids
46
What are S/Sxs that can be seen in Sarcoidosis? What can obstructive sleep apnea lead to? How are these PTs managed?
LUB pH Lupus Uveitis Bells Polyarthritis Hemoptysis PHTN, Cor Pulmonale (RVH) CPAP, Life style changes
47
What is the pathphysiology of ARDS? What is the most common cause of ARDS? How do PTs present during PE?
Aveolar damage increasing permeability causing pulmonary edema Sepsis Hypoxemia refractory to O2
48
What is seen on Dx studies of ARDS PTs? What can cause ARDS? How is ARDS managed?
Bilateral infiltrates PA wedge pressure <18 PaO2 <300mmHg Inc A-gradient ``` Neurogenic pulm edema Transfusion injury High altitude Opioid OD PE Eclampsia ``` Ventilation w/ PEEP
49
Neonatal/Infant Respiratory Distress Dz is AKA ? What causes Hyaline Membrane Dz How does this look on CXR? How is it Tx?
Hyaline Membrane Dz Surfactant deficiency in premature as respiratory difficulty hrs after birth Dec lung volume, Ground glass Intubate, O2, CPAP, Surfactant
50
What is used for Step 1-6 of Asthma Tx?
1: SABA 2: Low dose CCS 3: Low dose CCS + LABA or Medium dose CCS 4: Med dose + LABA 5: High dose + LABA (Allergies= +Omalizumab) 6: High dose + LABA + PO CCS (Allergies= +Omalizumab)
51
How do PTs w/ HyperK present? How does it look on EKG?
Brady, HOTN, dysrhythmia Lethargy, paralysis Peaked T Prolonged PR Wide QRS
52
How is hyperkalemia Tx? If a PT is acidic, they are ?
Ca gluconate to stabilize cell membrane Insulin/albuteral/BiCarb to redistribute K HyperK
53
How do HypoK PTs present? What will be seen on EKG?
Weak, Hyporeflexia, Cramps U waves Flat T QT prolongation ST depression
54
What will happen if HypoNa is Tx too fast? What is the most common cause of HyperCa
Central Pontine Myelinolysis ``` Malignancy, Squamous Cell CA (inpatient) Primary hyperparathyroidism (outpatient) ```
55
Finding cervical/supraclavicular adenopathy can be the first PE finding indicating what two issues? What issue can cause vessel engorgement of the head and neck?
Thoracic malignancy Mycobacterial infection Superior vena cava syndrome
56
What is the initial test for any PT presenting w/ hemoptysis? Oxygen content in arterial blood depends on what two things and tissue perfusion needs what 3rd factor?
CXR PO2 Hg level CO
57
Ventilation is affected by what 3 factors? What factor increases or decreases alveolar surface tension?
Airway resistance Alveolar surface tension Lung compliance Water/fluid- inc Surfactant- dec
58
What causes a left shift/increased affinity? What causes a right shift/decreased affinity?
Inc pH (alkaline) Dec PCO2 Dec temp Dec pH (acid) Inc PC02 Inc temp
59
# Define DLCO What med can be used to stimulate someone to hyperventilate? Orthopnea is most commonly caused by ? but also could be from ?
Diffusing capacity of lungs for carbon monoxide Epi CHF Secretions (pulonary dz) Diaphragm weakness
60
Since there are no pain fibers in the lungs, PTs w/ pulmonary chest pain is indicative of an issue where? What types of pain are indicative of CA?
Pleura Diaphragm Mediastinum Diaphragm pain referring to shoulder Pleural pain localized to chest wall Both inc pain w/ inspiration
61
# Define Tachypnea Define Kussmaul breaths
Breathing due to dec tidal volume >20/min Rapid, large volume breaths due to metabolic acidosis
62
# Define Cheyne Stokes What breathing pattern is a precursor to respiratory failure?
Rhythmic waxing/waning tidal volume w/ apenic periods (high altitude, LV failure, Neuro dz) Rapid, shallow breaths
63
Where and why do we palpate during a pulmonary PE? What findings on percussion mean ?
Trachea- mediastinal shift Posterior wall- fremitus, egophony Anterior wall- cardiac impulse ``` Dull= consolidation, effusion (pneumonia) Hyper= emphysema, pneumothorax ```
64
Central bronchial lung sounds normally have what 4 characteristics? What do wheezes sound like and what are they associated w/?
Louder High pitch, Hollow, Louder on expiration High pitched, musical, whistling Bronchospasm, edema/secretions
65
What do rhonchi sound like and what are they associated w/? What do crackles sound like and what are they associated w/?
Low pitch, gurgling Origin of large airway, cleared w/ cough; due to secretion, collapse Brief, popping Fine= Fibrosis, early pulmonary edema Course= pneumonia, obstructive dz, CHF
66
What are four groups of PTs that can have clubbing? What are two populations clubbing is not common in?
Chronic infections AV malformation Malignancy Interstitial dz Asthma COPD
67
PHTN is mPAP +_ and measured via ?
+25mmHg R heart cath Severe= +35 or +25 w/ high RA pressure Cardiac index is <2L/min
68
What are the five classification s of PHTN? What contrast is used in perfusion/ventilation scans when looking for PEs?
1: pulmonary arterial HTN 2: left side Heart Dz 3: chronic lung dz/hypoxemia (Cor Pulmonale) 4: chronic thromboembolic dz 5: unidentified mechanisms Radioactive albumin- perfusion Radioactive gas- ventilation
69
What are PET scans used for? What Dzs are located in the basal lung?
ID and staging of CA ``` SAID PAB Scleroderma Aspiration Intersitial fibrosis Drug reaction Panlobar emphysema Asbestosis Bronchiectasis ```
70
What is the imaging modality of choice for assessing lung cancer or malignant mesothelioma? When are VQ scans preferred?
MRI RF PE Pregnancy
71
What are two ways lung function is evaluated? What is the "sixth" VS? What 3 pieces of info are required for pulmonary function tests? What two pieces are sometimes used?
PFTs ABGs Pulse Ox Height Age Gender Race Weight
72
What are the c/i to conducting a pulmonary function test? What is the most available and useful PFT?
``` Severe asthma Hemoptysis Angina Active TB Respiratory distress Pneumothorax ``` Spirometry- measures volume exhaled in time
73
What does the Flow-Volume Loop do for testing? What are the two parts?
Graphs max inspiratory and exhalation efforts Flow vs volume FEV1- effort dependent Latter- effort independent and accurately reflect properties of lungs and resistance to flow
74
What does Forced Vital Capacity indicate? What does it measure and indicate?
Degree of expansion Measures total amount of air blow, out as fast as possible after inhaling as deeply as possible. Good indicator of effort Measures volume
75
What does an FEV1 measurement indicate? What does this measurement indicate and measure?
Effort dependent Patency of large airways Indicates large and small airway function Measures volume
76
What is the FEV1/FVC ratio What does a low or high ratio indicate?
% of FVC in 1st second of effort based on Height/Age Low: Obstruction High: Restriction
77
FEF 25-75 is AKA and indicates ? What does it measure?
MMEF rate Patency of small airways, more sensitive for early obstruction Measures FLOW of forced expiration
78
What part of the pFT is the least effort dependent? What does this part of the test measure?
FEF25-75 Flow
79
What are the 4 things that can cause a "scoop" pattern on a spirometry test? What are 4 things that can show a restrictive pattern?
Asthma Bronchiectasis COPD/CF SAID OK Scoliosis ALS Interstitial Dystrophy Obese Kyphosis
80
Obstruction and Restriction category %s
``` O- Mild: >80% Mod: 50-80% Sev: 30-50% VSev:<30% ``` ``` R- M: 65-80% Mod: 50-65% Sev: 30-50% VSev: <30% ```
81
Lung volume measurements are useful when ? What test is the gold standard for assessing PTs w/ obstructive sleep apnea? Define Diffusing Capacity and when is it useful
Spirometry shows dec FVC but not normal ordered PFT Body Plethysmography using Boyle's Law Measures rate of alveolar/capillary gas transfer Infiltrative dz, Emphysema
82
Diffusing capacity is useful in differentiating between ? These test results are dependent on what two factors?
Emphysema (Low) vs Chronic Bronchitis Alveolar surface area Pulmonary blood flow Measure HgB first if PT is anemic
83
What can cause the Diffusing Capacity to be elevated? What would cause it to be decreased? When would these results be seen as normal?
Pulmonary hemorrhage Acute HF Asthma Emphysema Interstitial lung dz Pulmonary vascular dz Asthma Chronic bronchitis
84
What is deemed as one of the most clinically valuable tests of lung function? SpO2 measurements take what 3 physiological factors into assumption?
Transfer Factor for Carbon Monoxide (TLCO) pH, PCO2, Hgb
85
SpO2 is useful for what two things? What is the 40-50-60 SpO2 assumption rule? Today Britanie taught something cool- Minus 30 rule
Tracking trends Detecting Hgb saturation changes SpO2 / PaO2 70%/40mmHg 80%/50mmHg 90%/60mmHg
86
What are the 3 categories of cough? What is the MC cause of an acute cough?
Acute: <3wks Subacute: 3-8wks Chronic: > 8wks Viral respiratory tract infection (acute bronchitis) Others: Pneumonia, PE
87
When is a CXR needed in a PT w/ a cough? Elderly PTs may not present w/ S/Sxs of pneumonia, what VS need to be assessed?
Pulse >100 Resp >24 Temp >100.4 Crackles/consolidation Mental status Respiration SpO2
88
What is the most common cause of sub-acute coughs? What are the most common causes of chronic coughs?
Post-infectious Post nasal drainage- AKA Upper Airway Cough Syndrome Asthma GERD
89
What is the most common cause of chronic cough in non-smokers? What are other causes?
Post Nasal Drainage Non/Allergic rhinitis Vasomotor rhinitis (hot to cold) Chronic sinusitis
90
What etiology of chronic cough usually presents w/ more severe S/Sxs? What part of the PE findings are irrelevant for this issue
Sinusitis Color of sputum
91
When are ABX given to a chronic cough? What meds are given to chronic cough (PND) PTs?
PND w/ proven sinusitis on imaging, can be clinically silent Intranasal CCS PO Montelukasts Antihistamines Decongestants
92
What is the second most common cause of chronic cough? What is the work up process for chronic cough due to asthma?
Asthma- cough variant asthma- wheeze, tight chest, exertional dyspnea Methacholine/Histamine challenge w/ response Spirometry shows reversible obstruction
93
What meds are used for Chronic Cough from asthma? What meds are given to PTs w/ Chronic Cough due to GERD? What is the last resort/last Tx option for Chronic Cough due to GERD?
ICS w/ SABA PO montelukast if ICS isn't available PPIs- Ome/Lansoprazle Should improve in 3mon Nissen Fundoplication
94
What will be seen on PE/CXR of chronic bronchitis What imaging is used if CXR is not Dx?
Base crackles Tracks/Rings in dilated mucus filled bronchi CT- TOC
95
What is the imaging definition of Bronchiectasis? What meds are used for this Dz?
Bronchus larger than adjacent pulmonary artery and bronchi visible w/in 1cm of pleura ABX for exacerbation Respiratory physical therapy Inhaled bronchodilators NO antitussives
96
What are the most common sites CF mucus plugs up and blocks? CF lung issues will cause what sound to be audible on PE?
Exocrine ducts leading to inflammation: Lung, Pancreas, Testes Crackles at apex
97
What will be seen on ABGs of a CF PT? What will be seen on a PFT?
Hypoxemia Compensated resp acidosis in advanced Dz Obstructive > Restrictive Dec FVC, FEV1, TLC, DLCO Inc RV:TLC
98
What is the name of the sweat test needed to Dx CF? What med can be used for these PTs?
Pilocarpine Ionotophoresis 2 tests on different days rhDNAse- dec sputum viscosity and improves FEV1 Inhaled hypertonic saline SABA
99
What is the only definitive Tx of CF What med is given to CF PTs due to the gene mutation?
Lung transplant- 3yr survival rate 55% Ivacaftor
100
What vaccines can CF PTs get? Bronchiolitis is a generic term for ?
Pneumococcal Influenza Inflammation of bronchioles <2mm, usually RSV in Peds
101
What is a constrictive type of bronchiolitis seen in adults? What type os exposure hx makes PT susceptible to Bronchiolitis
Bronchiolitis Obliterans Ammonia/Diacetyl- obliterans Viral Organ transplant- obliterans, proliferative CT d/o- follicular type (RA, Sjogren)
102
How does bronchiolitis present? What would be seen on a PFT?
Insidious onset w/ Tachy, Crackles, Wheezing Irreversible obstructive
103
What is a better imaging modality for bronchiolitis and what is seen? How is it definitively Dx?
Chest CT, trapped air similar to asthma Lung biopsy
104
How is bronchiolitis Tx? Epiglottitis forms a boundary wall of ?
PO CCS for proliferative Inhaled dilators Cough suppressant O2 to maintain SPO2 >88 Back wall of vallecular space below base of tongue
105
What labs are ordered for epiglottitis? What ABX are used for epiglottitis?
CBC w/ Diff Blood culture Intubated PT- epiglottis culture 3rd Gen (Ceftriax/Cefotax) and Vanc
106
What is the common triad of FBA? How do Sxs change by location of obstruction?
Wheeze, Cough, Diminished breath sounds Laryngotracheal: uncommon, most life threatening: stridor, wheeze, dyspnea Large Bronchi: cough, wheeze Lower Airway: little distress after initial choking episode
107
How are objects stuck in throats recommended to be removed? What is the next step for suspected aspirations if there is a mod/high or low suspicion?
<1yr= back blows, chest compression Heimlich, Intubate, O2 Mod/High: PE, Chest/Neck xray, rigid bronchoscopy Low: PE w/ normal x-rays
108
What is the 4th leading cause of death in the US? What is the two of effects smoking causes in airways?
COPD + Asthma Hypertrophy/proliferated mucus glands Cilia paralysis
109
What part of the airway is most effected by smoking? What are the effects of smoking on the lung parenchyma?
Bronchioles Destruction of CT in alveolar walls
110
Smoking on the airways lead to ? while effects on parenchyma lead to ? What is the protector of the lungs that prevent enzymes of inflammatory cells?
Airway: bronchitis Parenchyma: emphysema a1-antitrypsin- lack of this allows elastin degredation
111
When does a1-antitrypsin deficiency COPD develop? What PTs are screened for this deficiency?
30-40yrs All w/ FamHx of COPD
112
Chronic bronchitis as a sole Dx indicated ? What are the two types of emphysema?
Mild COPD Panacinar: involvement of acinus, mostly in lower lung and most common in AAT deficiency Centrilobular: proximal acinus/bronchiole; irregular destruction sparing areas MC in smokers
113
What is considered a high PaCO2 measurement? What is the issue in the lungs during emphysema? What is the Triad of presenting Sxs for the first decade?
>40 Stretched, less recoil and loss of exhalation drive SoB, inc cough, sputum
114
What are late S/Sxs of COPD What is the hallmark of this Dz?
Pneumonia PHTN Cor Pulmonale Chronic resp failure Periodic exacerbation precipitated by infection or environmental cause
115
What two microbes are most likely to cause pneumonia in COPD PTs? What is the common cause of death in COPD PTs?
Strep Pneumo Moraxella Catt. Mulitple/yearly lung infections
116
What is the chief complaint of PTs w/ emphysema? What Sx is rare in these PTs?
Dyspnea No cough, barely any sputum due to destroyed cilia
117
What PFT results will be seen in early, mid and late staged COPD?
Early: FEV 25-75% Mid: dec FEV1 and ratio Late: dec FVC, inc TLC (especially in emphysema)
118
What lung dz is DLCO low? What are the 4 GOLD guidelines?
Emphysema 1 Mild: FEV +80% 2 Mod: 50-79% 3 Sev: 30-49% 4 Very Sev: <30%
119
Although rarely obtained, what results would be expected from an ABG draw in a COPD PT? What work up studies are done?
Compensated Resp Acid Sputum analysis/culture
120
What 3 arrhythmias could be seen on EKG in a COPD PT? Why is a CXR ordered if it's not diagnostic?
MAT- never shock A-Fib/Flutter R/o alternatives or comorbidities
121
What are the expected CXR results for chronic bronchitis and emphysema? What would be the benefit of ordering a CT for COPD work up?
CB: cardiomegaly E: small cardiac silhouette Extent of damage for TPs considered for lobectomy
122
What does it mean if COPD PT has clubbing? What is the single most important intervention in COPD PTs?
CA Normally seen in bronchiectasis w/ pneumonia and hemoptysis Smoking cessation w/ Buproprion or Carenicline
123
When is O2 given to COPD PTs? What is the only therapy w/ evidence of improving COPD progression?
Resting hypoxemia <90% O2 via cannula x 15hrs/day @ 1-3L/min No mortality benefit
124
COPD PTs that start therapeutic O2 see an improvement in ? Sxs?
``` PHTN Impaired cognitive funtion Erythrocytosis Cor Pulmonale Morning MA ```
125
Short acting dilators: Ipratropium Albuteral, metaproterenol
Preferred for longer duration and fewer s/e w/ daily use SABAs Rapid onset w/ more s/e Combined w/ Ipratropium
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Long acting dilators: Tiotropium Formoterol, Salmeterol
LAMA More expensive but fewer exacerbations Improved Sxs, no mortality benefit LABA Combined w/ ICS Monotherapy has no mortality risk
127
CCS: ICS PD4 Inhibitors Roflumilast
Mod/Sev COPD but no mortality benefit LABA + ICS= fewer exacerbations, improved status, fewer admits Dec inflammation and promotes dilation
128
What drug combo is given for acute COPD exacerbation? Giving ABX to these PTs is most beneficial when ? 2 of 3 are present?
10-14 day PO steroids ``` Inc sputum (purulence/quantity) Dyspnea ```
129
ABX for COPD PTs is considered in what 4 circumstances?
>65y/o FEV1 <50% 3+ exacerbations/yr Comorbidities present
130
What ABX are even options for COPD? Which ones are usually used on outpatient basis?
``` TAD CAC Docy TMP/SMT Cefpodoxime Azithromycin Cipro/Levo Amox/Clavulonic ``` Doxy/Azith
131
What is the DOC for HIV Pts w/ Pneumonia Jerivici What is a SABA/ABX combo that can be used for COPD
TMP/SMT Albuterol + Ipratropium
132
What 3 drugs are not given for COPD exacerbation? O2 therapy for 24hrs per day is recommended when PTs have resting hypoxemia which is ?
Suppressants Expectorants Mucolytics <88% PaO2 <56mmHg
133
When are COPD PTs admitted?
``` Severe/worsening Sxs despite Tx Acute/worsening hypoxemia, hypercapnia, peripheral edema, change in mental status Poor home care Inability to sleep Inability to hydrate/nutrition High risk comorbid condition ```
134
How are COPD PTs managed on an inpatient status?
``` O2 @ 90-94% Iprotropium + SABA CCS Broad ABX Chest physiotherapy ```
135
How are COPD Pts w/ Cor Pulmonale managed inpatient?
``` O2 Bed rest Acidemia correction Na/Fluid restriciton Diuretics ```
136
65y/o male w/ PCO2 at 60 and breathing at 35 resp/min. What is the only way to correct the PCO2 and fix the respiratory acidosis? What is the BODE index?
Intubate and Ventilate Only option for high PCO2 (>50) BMI- lower is worse Obstruction: FEV1 after dilator Dyspnea: based on exertion Exercise: based on 6min walk
137
When are COPD PTs referred?
Any PT under 40y/o >2 exacerbation/year on max therapy (LABA+ long anticholinergic +ICS) Severe/rapid progression Disproportionate Sxs Long term O2 therapy Onset of comorbidity (CHF, Bronchiectasis, CA)
138
What vaccine follows Prevnar 13/when is the next one given? PT w/ COPD exacerbation and multiple comorbidities is started on ? ABX?
PPSV23 one year later Levofloxocin
139
To a certain extent, all asthmatics have what five pathophysiological issues?
``` Edema, infiltrates in bronchial walls Epithelial damage Hypertrophy/plasia of smooth muscles Inc collagen beneath epithelium Hypertrophy of glands and goblet cells ```
140
Why do asthmatics have airway remodeling? What is the name of the asthma precipitant that occurs during a menstrual cycle?
GF induced tissue changes Catamenial
141
What is the sequence of events of allergen exposure induced asthma? What drugs are used to stop the two end products?
Allergen IgE Mast cells Mediators Constriction/Permeability ``` Constriction= B agonist Inflammation= inhaled CCS ```
142
What are the four common precipitants to asthma? Why can asthma PTs be sensitive to ASA?
Allergen exposure Inhaled irritant- smoking RTI- viral are most common Exercise- loss of heat/moisture= rapid cooling Leukotriene production from arachidonic acid
143
What causes the obstruction of asthma? What would be an ominous late finding of an asthma attack?
Bronchoconstriction Rising PCO2
144
What are the 3 red flag questions of an asthma attack? Abnormal coughing during what part of the day is indicative of asthma?
Ever been hospitalized, intubated, or on PO steroids? Night
145
What sound is hear on PE of asthma and what makes it worse? What finding is bad?
Wheeze, inc w/ expiration No wheeze= dec airflow
146
What four findings are indicative an asthma PT is having a severe attack? What finding can they develop?
No wheezing Hunched shoulders Accessory muscle use Unable to be recumbent Pulsus paradoxus
147
What are S/Sxs of an impending arrest of an asthma PT?
``` Drowsy/confused Paradoxical abdomen motion No wheeze Bradycardia Absent Pulsus Paradoxus (often in sev cases) ```
148
What would be seen on ABG in a mild, severe or impending asthma failure attack? What will be seen on PFT in asthma?
Mild: alkalosis Sev: hypoxemia Impending: acidosis PEFR, FEV1, Max mid-expiration all decreased
149
What is a severe asthma FEV1 level What test is done if asthma is suspected and spirometry is nondiagnostic?
<50% Mod: 50-70 Mild: +70% Bronchial provocation test: Inhaled histamine or Methacholine challenge += FEV dec >20%
150
What is the difference between neg/pos Bronchial provocation test? When is peak expiratory flow highest and lowest?
Pos is not pos for asthma Neg is neg for asthma Low: upon waking High: hrs before mid-day
151
What would be seen on CXR of asthma? Chart on Slide42
Normal or hyperinflated Of Asthma lecture
152
Asthma PTs can step down their Tx if they're stable for ? What drug class is a preferred 1st line therapy for persistent asthma?
3mon Inhaled CCS
153
What can be added to PTs taking inhaled CCS or what needs to be monitored? What are the long acting dilator B-agonists?
Ca, Vit D DEXA Salmeterol Formoterol Tiotropium Theophylline
154
What mediator inhibitors are used for asthma? When is Tiotropium added to asthma Tx?
Cromolyn, Nedocromil Mild persistent/exercise induced prior to exposure Uncontrolled asthma while on ICS and LABA, usually in COPD
155
When is Theophylline added on to asthma Tx? What asthma med needs to have LFT monitoring?
Persistent nocturnal Sxs Leukotrienes
156
What is the MOA of Omalizumab for asthma? What is done for mild asthma exacerbation?
Recombinent Ab that binds to IgE w/o activating mast cells >80% peak flow w/ full response to SABA If not on ICS, start If on ICS, give 7 day PO steroid dose (don't double dose)
157
What is done for moderate asthma exacerbation
``` O2 for hypoxemia Continuous SABA Systemic CCS Serial PFTs PT education ```
158
What is done for severe asthma exacerbation?
SpO2 >90% (asphyxia is common cause of death) Systemic CCS Continuous high dose SABA Avoid anxiolytics, hyponitcs and mucolytics
159
How are asthma exacerbations managed in the ER? What type of recovery findings are the only ones for discharging a PT?
Repeat assessments after Initial bronchodilator and after 3 doses of inhaler FEV >70% Sustained for 60min No distress Normal exam
160
When do asthma PTs need to be referred?
``` Atypical presentation Complicated comorbidity Suboptimal response High dose ICS 2+ systemic steroids in 12mon Any life threatening hospitalization in 12mon Social/psych d/o ```
161
What ABX can be used for epiglottitis, is safe on Peds kidneys and safe in pregnancy? What are cold agglutants?
Ceftriaxone, Vancomycin IgM Abs indicating where a Dz is in process, Mycoplasma
162
What microbe is most common in PTs w/ aspiration/poor dentition related pneumonia? What microbe predominates infections of PTs that have traveled to SW US?
Staph C. Imitis
163
What are the two major and one minor pathways for pneumonia? MC cause of bacterial pneumonia?
Major: inhalation, aspiration Minor: blood borne Strep Pneumo- 2/3 of all CAP cases
164
When is Staph A pneumonia common? What microbe is most likely to cause pneumonia in PTs in a nosocomial/recent ABX population?
After influenza through hematogenous spread Pseudomonas
165
What is the most deadly infectious Dz in the US? What are the RFs for CAP in order?
CAP Inc age ETOH Tobacco
166
What pathological process allows a CAP infection to grow? What 3 tests can be used to differentiate the microbes of CAP?
Normal defenses prevent lower respiration infections: Cough reflex Immunity Mucociliary clearance PCR, UA, Agglutinin
167
How do atypical microbe CAP appear differently than typical? What is usually the microbe and what drug classes are used for T?
Gradual onset of dry cough, HA, malaise, N/V, low fever Mycoplasma Macrolide, Doxy
168
What does a CXR of a PT w/ atypical pneumonia show? How is CAP Dx?
Worse than PT appearance Culture
169
What microbe causes cavitation seen on CXR?
Staph | TB if in apex
170
Viral pneumonia is usually seen as ? on CXR What education piece needs to go w/ CAP Tx?
Bilateral Clearing CXR takes longer, f/u imaging not needed if clinical response is present Re-image if high risk to r/o malignancy (Smokers >40, Geriatrics >65)
171
What is Procalcitonin's response to a bacterial or viral CAP infection? What two microbes can be detected through urine antigen testing?
Bacteria: released Viral: inhibited Legionella Strep Pneumo
172
Since Macrolide(A/C)/Doxy are used for CAP outpatient Tx, what are used if PT has used ABX in past 90 days, is >65, ImmSupp or has child daycare exposure? What ABX are used for CAP outpatient in areas w/ high macrolide resistance?
Respiratory Fluoroquinolone Macrolide + B-Lactam (Amox/Clavu) Same as above
173
What two ABX are used for atypical pneumo Tx? What two ABX can be used for CAP in an admitted PT?
Azithromycin Doxy Ceftriaxone and Macrolide (A/C) or, Quinolone (Levo, Moxi, Gatifloxacin)
174
If influenza is complicated by a secondary bacteria pneumo infection, what ABX are used? What anti-pseudomonas B-Lactam is used for inpatient CAP PTs?
Oseltamivir and Ceftriax/Ceftaroline and Vanc/Ilnezolid Piper/Tazo, Cefepime
175
CAP outpt microbes CAP hospitalized microbes ICU admitted microbes Nosocomial pneumonia microbe
Strep Pneumo Mycoplasma Chlamydia Strep Pneumo Mycoplasma Chlamydia Strep Penumo H influena Legionella Staph A Pseudomonas Gran Neg rods: Enterobacter, Klebsiella, E Coli
176
How are ICU PTs w/ CAP Tx? What is the CURB-65 criteria
Respiratory fluoroquinolone or Azithromycin and Cefota/Ceftria/Amp (anti-pseudomonal B-lactams) ``` Confused Urea >20mg Resp Rate 30 or higher BP systloic <90, 60 or less D 65 or older 0-1: low 2: mod, consider admit 3: high, admit 4-5: ICU admit ```
177
# Define HAP Define HCAP Define VAP
>48hrs after admit w/out infection at admit Non-hopitalized PT w/ extensive healthcare contact >48hr after intubation development
178
What meds are used as a prophylactic for admitted PTs to prevent nosocomial pneumonia What would be S/Sxs of nosocomial pneumonia?
PPI, H2 blocker, Antacid Fever, Leukocytosis, Purulent sputum Opacity on imaging
179
What labs are drawn on PTs w/ nosocomial pneumonia
``` Blood culture CBC w/ diff CMP ABG Thoracentesis (Staph) ```
180
What may be seen on imaging in PTs w/ anaerobic pneumonia? How are these PTs Tx?
Abscess: + air/fluid level Necrotizing pneumonia- +air/fluid level Empyema- do not have air/fluid level Amxo/Clavu Amox or PCN and Metron No more Clindamycin
181
What microbe causes lung abscesses and empyemas? Outpt pneumo Tx Inpatient pneumo Tx w/ DM
Staph Macrolide/Doxy Resp Fluoroquinolone
182
What is the 2nd most common infectious cause of death in adults? How is TB spread
TB (1st was CAP) Droplet, ingest by macrophage in alveoli
183
What does primary TB develop What is the only S/Sx seen in PTs w/ latent TB?
Infection escapes alveoli, lymph/hematogenous spread, contained by granulomas-> latent No containment= Progressive TB Crackles in apex + PPD
184
What is different about Miliary TB compared to Primary/Latent What are the constitutional Sxs of an active TB dz?
Miliary= hematogenous spread and is primary progressive or reactivated Malaise, Anorexia, Weight loss, Fever, Night sweats
185
What is the MC Sxs of TB and what is a rare Sx? Primary TB is usually ? and ? silent
Chronic cough, progression from dry to purulent w/ blood Rarely: dyspnea Clinically, Radiograph
186
How is TB ID'd w/ labs?
3 sputum specimens Q8hrs induced w/ hypertonic saline for Acid Fast Bacilli Blood culture: rarely + unless CD4 is low Pleura biopsy: 50% chance of + test
187
When is imaging of TB recommended? What is seen on CXR of Primary, Reactivated and Miliary TB?
+ PPD + clinical Sxs Primary: hilar adenopathy, atelectasis, pleural effusion, granuloma/Ghon complex Reactive: Cavitation in posterior upper lobe/superior lower lobe Milliary: small opaque nodules across chest
188
Reactivated TB in lower lobes may be confused as ? PTs that received a BCG vaccine are protected from ? but not ?
CA, Pneumonia Protected: TB meningitis, Disseminated TB Not: Primary, Latent
189
What is the Gold Standard for testing for TB?
Quantiferon Gold/T-spot- blood test measuring reaction w/ M Tuberculosis Ag
190
What test is ordered to confirm a TB Dx if TST is pos but there's a low likelihood of TB infection? What test is ordered in place of, not in addition to, a TST?
Quantiferon Gold Interferon Gamma Release Assay
191
S/e, monitoring and comments on INH
Peripheral neuropathy, Hepatitis, Rash AST/ALT, Neuro Pyridoxine as prophylaxis
192
S/e, monitoring and comments on Rifampin
Hepatitis, Fever, GI, Bleeding, Renal failure CBC, PLT, AST/ALT Fluids turn orange
193
S/e, monitoring and comments on Pyrazinamide
Hyper uricemia, Hepatotoxic Uric acid, AST/ALT -cidal to intracellular organisms
194
S/e, monitoring and comments on Ethambutol
Optic neuritis, rash Red/green discrimination -static, inhibits resistance
195
S/e, monitoring and comments on Streptomycin
CN8 damage, nephrotoxicity Audiogram, BUN/Creatinine
196
What baseline labs are ordered when starting TB Tx? What is done each month as monitoring?
CBC, CMP, Visual acuity, Audiogram, Serum uric acid, HcG Sputum culture until negative
197
What med combo is used for latent TB Tx? How is RSV Dx?
INH w/ pyridoxine x 9mon Nasal wash for PCR Nasopharyngeal/throat swab
198
How is Pertussis Dx?
Culture and PCR | If more than 4wks, serology
199
Exposure to Pertussis can get prophylaxis when? What causes Croup?
Within 21 days of onset of cough Parainfluenza Type 1
200
Mild, Mod and Sev Croup Txs
Mild: no stridor at rest, no respiratory distress= Dexameth or non-pharm Tx Mod: Stridor at rest, retractions Sev: stridor at rest w/ marked retractions and distress Mod/Sev= Nebulized Epi and Dexameth
201
How much of an PFT improvement needs to be seen for the Dx of asthma to be given? What is heard on PE of pneumonia?
12%, 200mL Crackles Bronchial breath sound Dull percussion Egophony= lobar effusion
202
PHTN work up can include ? test What type of CA causes hypercalcemia?
TTE Squamous cell lung carcinoma
203
What microbe is most likely to cause lobar pneumonia? What is the most important drug agent for mod-persistant asthma?
Strep Pneumo- encapsulated, Gram Pos, Tx w/ Azith/Doxy Inhaled fluticansone
204
PTs w/ mod/sev asthma must be on ? drug? Fungal causes of epiglottitis Viral causes
Inhaled CCS Candidia PHIVE Parainflu HSV Influ VZoster EBV
205
What type of non-cell CA is the most common worldwide and leading cause of CA death? What is the most common risk factor for this type of CA?
Bronchiogenic carcionoma Smoking
206
Non-small cell CA includes ? 4 types? What CA are central?
SLAB Squamous Large Adeno Bronchoalveolar/Adeno in situ Small cell carcinoma Squamous cell Large Cell
207
Small Cell Carcinoma
Central Hilar/Mediastinal on imaging Associated w/ SIAD, Paraneoplastic Syndrome Early hematogenous spread, common, poor prognosis
208
Adenocarcinoma
Peripheral in women/non-smoker Grows from mucus gland MC Primary Lung CA
209
Squamous Cell CA
Central from bronchial epithelium- 2*/3* bronchus More likely to show w/ hemoptysis Dx w/ Sputum Cytology Local spread Hilar adenopathy and widened mediastinum, caviation
210
Large Cell CA
``` Hetergenous of undifferentiated Central or Peripheral (MC) Rapid double time Cavitary lesion w/ air/fluid level Rarer than Adenocarcinoma ```
211
What type of CA is a slow spreader? CA in liver equates to ? BUN
Non-Small Cell CA Low or none
212
Pancoast tumor
``` Superior sulcus of lung apex Shoulder*/arm pain following ulnar C8/T1 Horner's Weak/atrophy hand Progression to SVC Syndrome if on R side ```
213
What type of CA can cause SIADH What type can cause HyperCA?
SIADH w/ Small Cell- water retention, HypoNA, concentrated urine HyperCA w/ Squamous
214
? form of pneumonia will trigger a positive Cold Agglutin Test? What causes exercise induced asthma?
Mycoplasma- Tx w/ Azith Bronchospasm
215
What version of paraneoplastic syndrome is seen in Myasthenia Gravis PTs? How is Myasthenia Gravis Dx?
Thymoma Acetylcholine receptor AB test
216
All suspected lung CA PTs get w/ Labs How are each types of tumors Dx
CBC CMP FNA if palpable (cervicle/supraclavicular) Bronchoscopy biopsy if central Transthoracic aspiration for peripheral
217
When is surgery the TOC for CA? Prior to surgery all PTs have ? test
Early non-small cell Stages 1 and 2 PFTs
218
When is Chemo/Radiation the TOC for CA Difference between node and mass?
Small cell CA Adv non-small stage 3-4 ``` Nodule= <3cm Mass= >3cm ```
219
Most common cause of benign solitary pulmonary nodules? Most common cause of malignant nodules?
Infectious granulomas Adenocarcinoma
220
What is the most common type of benign tumor? Hemoptysis + CKDz= ?
Hamartomas Granulomatosis w/ polyangitis (Wegners)
221
Features of a nodule making the likelihood of malignancy greater
``` <30y/o Smokers CAHx Larger size at discovery Eccentric calcification Spiculated Corona Radiata margin ```
222
Features of a nodule making it more likely to be benign
``` <30y/o Smooth/defined borders Dense central/diffuse calcification Small and stable on repeat image <8mm ```
223
4 buzz words for benign patterns 2 buzz words for malignant patterns
Dense Laminated Popcorn Diffuse Stippled Ecentric
224
What is the image TOC for monitoring nodules? What is the f/u schedule for nodule size for low/high risk PTs
Chest CT 4mm or less- none/CT Q12mon >4-6mm- CT Q12mon/CT Q 6-12 and 18-24mon >6-8mm: CT Q6-12mon/CT Q3-6mon, 9-12 and 24mon