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Pulm by Minnie > Pulm Clinical Medicine (except MDM) > Flashcards

Pulm Clinical Medicine (except MDM) Flashcards

1
Q

Describe the following for Pneumothorax:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Pneumothorax = air in the pleural space

  • Percussion note: Hyperresonant
  • Breath sounds: Decreased or absent
  • Adventitious sounds: None
  • Fremitus: Decreased fremitus
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2
Q

What conditions could cause B lines on ultrasound?

A

B lines are a marker of interstitial fluid or thickening of interstitial tissue

  • Diffuse B lines = pulmonary edema
    • Interstitial fluid
  • Focal B lines = consolidation
    • Fluid fills alveolar spaces, usually interstitial tissue is thickened
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3
Q

A patient has resonant percussion, vesicular breath sounds, normal fremitus, and rhonchi.

What is most likely wrong with the patient?

A

Chronic bronchitis

Rhonchi are caused by narrowing of the large airways

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4
Q

Adventitious breath sounds that are “countious, high-pitched, with a muscial quality and heard on ispiration” are most likely…

A

Stridor

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5
Q

What positions of comfort might indicate that a patient is in respiratory distress?

A
  • Sniffing position
    • Indicates upper airway obstruction (this is an emergency)
  • Tripod breathing
    • Optimizes the mechanics of breathing
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6
Q

Why is it important to collect “collateral information” when evaluating a patient with dyspnea?

A

Collateral information = information about changes to daily life that a patient makes to avoid dyspnea

Ex: They may resport little/no dyspnea, but what are they cutting out to avoid it?

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7
Q

Adventitious breath sounds that are “continous, high-pitched, with a musical quality, and loudest on expiration with an occasional squeek” are most likely…

A

Wheezes

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8
Q

What conditions would result in hyperresonance during percussion?

A
  • More air in the chest cavity (lungs or pleural space)
    • Emphysema
    • Asthma
    • Pneumothorax
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9
Q

What pathological changes cause wheezes on auscultation?

A

Narrowing or partial obstruction of intrathoracic (lower) airways

May be caused by asthma, bronchitis, bronchiolitis, or airway compression

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10
Q

What sign is shown in this image?

What pathology does it indicate?

A

Shred sign

Indicates pneumonia

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11
Q

A patient has hyperresonant percussion, decreased breath sounds, and decreased fremitus.

What is most likely wrong with the patient?

A

Pneumothorax

  • Air in the pleural space
  • Hyperresonant percussion occurs when there is increased air space in the chest
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12
Q

If you hear bronchovesicular or bronchial breath sounds in abnormal places, what pathology might be present?

A

Consolidation

Due to pneumonia or pulmonary hemorrhage

In a normal lung:

  • Bronchovesicular: Large airspaces
    • 1st and 2nd interspaces anteriorly
    • Between the scapulae
  • Bronchial: Large airways
    • Over the manubrium (if at all)
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13
Q

Describe the following for Pleural effusion:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Pleural effusion = fluid in the pleural space

  • Percussion note: Hyporesonant
  • Breath sounds: Decreased
  • Adventitious sounds: None or possible pleural rub
  • Fremitus: Decreased fremitus

Trachea may be shifted toward infolved side if a large area of the lung is affected

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14
Q

In a normal lung, where would you hear bronchovesicular breath sounds? Bronchial breath sounds?

A
  • Bronchovesicular: Large airspaces
    • 1st and 2nd interspaces anteriorly
    • Between the scapulae
  • Bronchial: Large airways
    • Over the manubrium (if at all)
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15
Q

A patient has resonant percussion, vesicular breath sounds, normal fremitus, and crackles.

What is most likely wrong with the patient?

A

Pulmonary edema

  • Crackles are caused by small airways popping open
  • Resonance and fremitus are normal because fluid is in the interstitium, not in the pleural space or airspaces
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16
Q

What will you see on a normal ultrasound of the lung?

A
  • Bright white, horizontally-sliding pleura
  • A-lines (green)
  • Comet tails (a few)
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17
Q

What will you see on ultrasound if the patient has a pneumothorax?

A
  • Comet tails are abent
  • No pleural sliding where the pneumothorax is
    • The rest of the pleura will slide
  • Lung point may be visible
    • Boundary between normal lung and pneumothorax
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18
Q

What conditions would result in increased tactile fremitus?

A
  • Things that increase the amount of fluid in the lungs
    • Pneumonia
    • Pulmonary hemorrhage
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19
Q

If a patient is in respiratory distress, what signs can be seen in the neck?

A

Trapezius and sternocleidomastoid contraction

Tracheal tugging

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20
Q

What special tests can be performed to assess for consolidation of the lungs?

A
  • Bronchophony
    • Words will be louder than normal - “99”
  • Whispered Pectoriloquy
    • Intesnsification of whispered words - “1, 2, 3”
  • Egophony
    • Normal “ee” sounds will sound like a long “a”
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21
Q

If you hear stridor, what pathology is most likely present in the patient?

A

Upper airway obstruction

  • Croup
  • Laryngeal edema
  • Airway compression
  • Airway stenosis
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22
Q

What are the 4 key inputs that can drive dyspnea?

A
  • Mechanoreceptors
  • Chemoreceptors
  • Neurohormonal uncoupling
  • Psychosocial factors

Usually dyspnea is a combination of several of these factors

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23
Q

A patient presents with a cough. List the alarm sysmptoms that would warrant expedited or urgent evaluation

A

CHeWW-D CHESS

  • Current/Former smoker with a New Cough
  • Hemoptysis
  • Wheezing and shortness of breath
  • Weight gain
  • Nocturnal Dyspnea
  • Chest pain
  • Hoarseness
  • Peripheral Edema
  • Trouble Swallowing
  • Systemic (fever, weight loss)
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24
Q

Describe vesicular breath sounds

A

Normal breath sounds

  • Heard over most of the lung field (except near large airways)
  • Louder in inspiration than expiration
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25
Q

If a patient is working harder than usual to breathe, what facial signs might be present?

A
  • Nasal flaring
  • Head bobbing
  • Retractions
  • Grunting/breath holding
  • Neck muscle use
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26
Q

What pathological changes cause stridor on auscultation?

A

Narrowing of the extrathoracic (upper) airway

May be due to croup, laryngeal edema, mass

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27
Q

On which side of the chest is it important to listen in the mid-axillary line?

A

Right

You are listening for the right middle lobe (the left lung does not have a middle lobe)

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28
Q

Describe the following for Consolidation:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Consolidation = fluid in the alveolar spaces

  • Percussion note: Hyporesonant
  • Breath sounds: Decreased
  • Adventitious sounds: Crackles (late inspiratory)
  • Fremitus: Increased fremitus
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29
Q

A 68 year-old man has severe smoking-related chronic obstructive pulmonary disease (COPD) causing lung hyperinflation. He takes an inhaled corticosteroid, an inhaled long-acting beta agonist, and an inhaled long-acting muscarinic antagonist daily. He uses 2 liters per minute supplemental oxygen to maintain adequate oxygen saturations at rest and with activity. The patient reports significant dyspnea with activity. The least likely cause of this patient’s dyspnea is:

  1. Hypoxemia
  2. Lung hyperinflation
  3. Deconditioning
  4. Severe airflow obstruction
A

a. Hypoxemia

Hypoxemia does not have a strong association with dyspnea. Additionally, lung hyperinflaiton, deconditioning, and sever airflow obstruction are all commonly seen in patients with COPD

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30
Q

Adventitious breath sounds that are “brief, intermittent, and discontinuous” are most likely…

A

Crackles

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31
Q

What pathological changes cause rhonchi on auscultation?

A

Narrowing of larger airways from secretions

May be present in bronchitis, bronchiolitis, COPD, and asthma

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32
Q

What are the 4 most important questions that must be answered when a patient presents to your clinic with a cough?

(You don’t need to ask the patients these exact questions, but you need them answered in order to make a diagnosis)

A
  1. Is the cough acute or chronic?
  2. Are any alarm symptoms present?
  3. Does the patient have comorbid conditions (COPD, asthma, bronchiectasis, rhinosinusitis, GERD)
  4. Is environment or medication playing a role?
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33
Q

Will a patient wtih asthma have increased fremitus or decreased fremitus?

Why?

A

Decresed

Asthma is an obstructive lung disease, resulting in hyperinflation of the alveoli. Fremitus is decreased when there is increased air in the alveolar spaces

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34
Q

If your patient has pneumonia, what will you see on ultrasound?

A
  • Focal B lines
    • Chains of white dots, indicate lung consolidatiosn
  • Lung hepatization
  • Dynamic air bronchograms
  • Shred sign
    • Disruption of the pleural line, like a bite is taken out
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35
Q

What is the differential diagnoses for wheezes?

A

Asthma

Bronchitis

Bronchiolitis

Airway compression (foreign body or mass)

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36
Q

What conditions would result in decreased tactile fremitus?

A
  • Things that increase air or fluid in the pleural space
    • Pleural effusion
    • Pneumothorax
  • Things that increase air in the lung
    • Asthma
    • Emphysema
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37
Q

List the 2 primary causes of neurohormonal uncoupling that contribute to dyspnea

A
  1. Increased load on the respiratory system
    - Asthma, COPD, pneumonia, pulm. edema, ILD
  2. Respiratory muscle weakness
    - Muscle fatigue, neuromuscular weakness/disease, lung hyperinflation (associated with COPD)
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38
Q

What is the differential diagnosis for rhonchi?

A

Bronchitis

Bronchiolitis

Asthma

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39
Q

Which ultrasound probe has the highest resolution?

Which one penetrates the deepest?

A

Highest resolution = high frequency probe

Deepest penetration = low frequency probe

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40
Q

What are the 5 major goals in treating patients with dyspnea?

A
  1. Treat the underlying cause
    - Bronchodilators, drain pleural effusion, treat anemia
  2. Increase respiratory muscle function
    - Pulmonary rehabilitation, nutrition
  3. Decrease chemoreceptor input
    - Give oxygen, noninvasive ventilation
  4. Decrease central respiratory drive
    - Opioids in palliative care
  5. Education and coping
    - Pacing, cool air, pursed-lip breathing
41
Q

What will you see on ultrasound if the paient has a pleural effusion?

A
  • Spine sign
    • Fluid surrounding the lung allows ultrasound waves to penetrate, we can then visualize the vertebral bodies
  • Dark triangle of fluid
42
Q

Describe the following for Upper Airway Obstruction:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Upper Airway Obstruction = extrathoracic; croup, laryngeal edema, laryngomalacia

  • Percussion note: Resonant
  • Breath sounds: Vesicular, decreased if obstruction is severe
  • Adventitious sounds: Stridor
  • Fremitus: Normal fremitus
43
Q

Describe the following for Bronchiolitis:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Bronchiolitis = narrowing of the lower (intrathoracic) airway

  • Percussion note: Resonant
  • Breath sounds: Obscured by adventitious sounds
  • Adventitious sounds: Wheezing, rhonchi, crackles
  • Fremitus: Normal fremitus
44
Q

Describe the following for Asthma:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Asthma = Hyperinlated alveoli

  • Percussion note: Resonant to hyperresonant
  • Breath sounds: Often obscured by adventitious sounds
  • Adventitious sounds: Wheeze, possible crackles & rhonchi
  • Fremitus: Decreased fremitus
45
Q

Which ultrasound is abnormal?

What is the pathology?

A

There is a pneumothorax in the image on the left

46
Q

What will you see on ultrasound if the patient has edema?

A
  • Many B lines (diffuse)
    • Bright white lines that shoot all the way down to the bottom of the screen from the pleura
    • More than a few = abnormal
    • They move back and forth with respiration as the pleural line moves
    • More B lines => more fluid in the pleura
  • If severe, the B lines may coalesce to obscure A lines
47
Q

What is the differential diagnosis for crackles?

A

Fibrosis

Pneumonia

Pulmonary edema

48
Q

List 4 locations for mechanoreceptors that are important in sensing dyspnea

A
  1. Face/upper airways
  2. Pulmonary stretch receptors
  3. Irritant receptors
  4. Chest wall
49
Q

A patient has hyporesonant percussion, decreased breath sounds, and decreased fremitus.

What is most likely wrong with the patient?

A

Pleural effusion

Decreased fremitus when there is fluid outside of the alveolar spaces

50
Q

What comorbidities are important to look out for when you are evaluating a patient for cough?

A

COPD

Asthma

Brochiectasis

Rhinosinusitis

GERD

51
Q

What pathology does this lung show?

A

Consolidation

May be caused by pneumonia, alveolar hemorrhage, or anything that causes fluid to replace air in the alveolar spaces

52
Q

What is the differential diagnosis for stridor?

A

Stenosis of the large airway

Laryngeal Edema

Compression

Croup

53
Q

Which image is abnormal? How do you know?

A

The image on the bottom/right is abnormal. The black triangle and spine sign indicate a pleural effusion

Spine sign = you can see the spine clearly

Black triangle = fluid in the pleural space

54
Q

What pathological changes cause crackles on ascultation?

A

Small airways popping open during inspiration

(May be related to secretions in closed, small airways)

Usually due to fibrosis, pneumonia, or pulmonary edema

55
Q

Any cough lasting more than ____ weeks is considered chronic

A

Any cough lasting more than 8 weeks is considered chronic

56
Q

Any cough lasting less than ____ weeks is considered acute

A

Any cough lasting less than 3 weeks is considered acute

57
Q

Describe bronchovesicular breath sounds

A

Heard over large airspaces

  • Inspiratory and expiratory components are equal in volume
  • In a normal lung:
    • 1st and 2nd interspaces anteriorly
    • Between the scapulae
58
Q

A normal adult respiratory rate is ______ breaths/minute

A

A normal adult respiratory rate is 10-14 breaths/minute

59
Q

Describe the following for Emphysema:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Emphysema is a pathology of the alveoli

  • Percussion note: Hyperresonant
  • Breath sounds: Decreased
  • Adventitious sounds: None
  • Fremitus: Decreased fremitus
60
Q

A 35-year-old male presents to the emergency room for 2 weeks of coughing. He is a non-smoker, has no known medical problems, and denies any alarm symptoms. His vital signs and physical examination are unrevealing. A chest radiograph is normal. Which is of the following is the appropriate next step?

  1. Chest CT
  2. Cough-suppressant therapy with outpatient follow-up in 4 weeks
  3. Bronchoscopy
  4. 5-day course of antibiotic therapy for community acquired pneumonia
A

B. Cough-suppressant therapy with outpatient follow-up in 4 weeks

Acute cough + reassuring physical examination + normal x-ray = probably a viral respiratory tract infection that can be managed conservatively with close follow-up

61
Q

Adventitious breath sounds that are “continous, with a low-pitched, sonorous, musical quality” are most likely…

A

Rhonchi

62
Q

What conditions would result in hyporesonance during percussion?

A
  • Increased fluid in the chest cavity
    • Consolidation (Fluid in alveolar spaces)
    • Atelectasis
    • Pleural effusion
63
Q

A 34 year-old woman presents with worsening breathlessness over the past 3 days. She describes a sensation of “chest tightness.” The most likely diagnosis is:

  1. Pneumonia
  2. Pneumothorax
  3. Asthma exacerbation
  4. Pulmonary embolism
A

c. Asthma exacerbation

“Chest tighness” to describe dyspnea is commonly associated with acute bronchospasm, seen in asthma or COPD exacerbation

64
Q

If a patient is in respiratory distress, what signs might be present in the chest/abdomen?

A

Intercostal or subcostal retractions

Accentuated abdominal breathing

65
Q

When imaging the chest, when would you use a high-frequency ultrasound probe?

A

When you are evaluting the pleural line or looking for a pneumothorax

High frequency probes penetrate more shallowly but have higher resolution

66
Q

List the order of step-wise testing and treatment of a chronic cough

A

One at a time!

  1. Asthma - Try corticosteroid therapy
  2. GERD - Try acid-suppression therapy
  3. Rhinosinusits - Try nasal corticosteroids + antihistamine therapy
67
Q

Describe the following for Pulmonary Edema:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Pulmonary edema = fluid in the interstitium

  • Percussion note: Resonant
  • Breath sounds: Vesicular
  • Adventitious sounds: Late inspiratory crackles, possible wheezing
  • Fremitus: Normal fremitus
68
Q

Describe the following for Atelectasis:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Atelectasis = lobular obstruction from mass, mucus, or foreign object

  • Percussion note: Hyporesonant
  • Breath sounds: Decreased or absent
  • Adventitious sounds: None
  • Fremitus: Normal fremitus
69
Q

What are the three most common causes of a chronic cough?

A

Asthma

GERD

Rhinosinusitis

70
Q

Describe the following for chronic bronchitis:

  • Percussion note:
  • Breath sounds:
  • Adventitious sounds:
  • Fremitus:
A

Chronic bronchitis is a pathology of the upper airway

  • Percussion note: Resonant
  • Breath sounds: Vesicular
  • Adventitious sounds: Rhonchi, crackles, wheezes
  • Fremitus: Normal fremitus
71
Q

Which measurement contributes most significantly to a sensation of dyspnea?

  1. Low PaO2
  2. High PaCO2
  3. Low pH
  4. High pH
A

B. High PaCO2

Increased PaCO2 = Hypercapnia

Induces dyspnea in the absence of respiratory muscle activity

72
Q

Describe bronchial breath sounds

A

Heard over large airways

  • Breath sounds are louder and more high-pitched
  • Expiratory component is louder than inspiratory
  • Heard over the manubrium (if at all) in a normal lung
73
Q

On ultrasound, fluid appears ______ and air appears _______.

A

On ultrasound, fluid appears black** and air appears **white.

74
Q

A 65-year-old male presents to urgent care for evaluation of a cough which has been present for 10 weeks. He has smoked 1 pack of cigarettes per day for 40 years. He notes his sputum is frequently streaked with blood and that he has lost 15 pounds in the last 2 months. His vital signs are unremarkable and he has no focal findings on physical exam. The appropriate next step in management is…

  1. Arrange for a non-urgent chest radiograph and prescribe a cough suppressant
  2. Trial of an inhaled corticosteroid for possible cough-variant asthma
  3. Urgent chest radiograph, complete blood count, and chemistry panel
  4. Prescribe a 5-day course of azithromycin for possible bacterial pneumonia
A

C. Urgent chest radiograph, complete blood count, and chemistry panel

Alarm symptoms are present (new cough in an active smoker, hemoptysis, weight loss). Evaluate urgently for malignancy

75
Q

When imaging the chest, when would you use a low-frequency ultrasound probe?

A
  • When you are looking for pleural effusion or hemothorax
  • When the patient is larger

The low-frequency probe penetrates deeper but has lower resolution

76
Q
A
77
Q

What is the difference between wheezes and stridor?

In which disease processes would you hear each?

A
  • Wheezes
    • Ususally expiratory
    • Caused by narrowing of the intrathoracic (lower) airway
    • Seen in asthma, bronchiolitis, bronchitis, and airway compression
  • Stridor
    • Usually inspiratory
    • May contain squeeks
    • Caused by narrowing of the extrathoracic (upper) airway
    • Seen in airway stenosis, laryngeal edema, compression, croup
78
Q

What is the difference between crackles and rhonchi?

In which disease processes would you hear each?

A
  • Crackles
    • Discontinuous
    • Can be fine and dry or coarse and wet
    • Heard in fibrosis, pneumonia, and pulmonary edema
  • Rhonchi
    • Continuous - Usually inspiratory and expiratory
    • Low-pitched snoring
    • Heard in bronchitis, asthma, and bronchiolitis
79
Q

A patient has hyporesonant percussion, decreased breath sounds, increased fremitus, and crackles.

What is most likely wrong with the patient?

A

Consolidation

  • Fluid in the alveolar spaces, likely caused by pneumonia or hemorrhage
  • Increased fremitus occurs when there is fluid inside​ of the alveolar spaces
  • Hyporesonant precussion occurs when there is fluid, consolidation, or mass in the chest cavity
80
Q

A 34 year-old man with hereditary hemorrhagic telangiectasia presents with worsening dyspnea on exertion of 3 month’s duration. On exam, he appears pale but in no acute distress. Vital signs are normal except for a resting heart rate of 105 beats per minute. Examination demonstrates lip telangiectasias, normal heart tones, and normal breath sounds. His oxygen saturation on room air at rest is normal. The most likely cause of this patient’s dyspnea is:

  1. Pulmonary hemorrhage
  2. Anemia
  3. Myocardial ischemia
  4. Pulmonary embolism
A

b. Anemia

Anemia is linked to chronic dyspnea; the other options all cause acute dyspnea

81
Q

Dyspnea that is described as “chest tightness” has a high association with ________________

A

Dyspnea that is described as “chest tightness” has a high association with bonchospasm caused by Asthma or COPD

82
Q

What are the advantages of chest CT over chest x-ray?

A

In a chest CT…

  • No blind spots
  • Can reconstruct in multiple dimensions
83
Q

What are the disadvantages of CT compared to chest x-ray?

A

Hight cost

Higher radiation dose

84
Q

What are the indications for IV contrast in a CT?

A
  • Evaluation of vasculature
    • Dissection (CT angiogram)
    • Pulmonary embolism (CTPA)
  • Evaluation of solid organs
  • Evaluation of mediastinum
  • Lung cancer staging (Not screening)

Contrast not needed to look for lung nodules in screening!

85
Q

What kind of imaging would you use to evaluate a pulmonary embolism?

A

CT with IV contrast

86
Q

What kind of imaging is used for lung cancer screening?

A

Low dose CT

(No contrast)

87
Q

Low-dose chest CT is about the same radiation dose as
______ chest x-rays

Routine chest CT is about the same radiation dose as
______ chest x-rays

A

Low-dose chest CT is about the same radiation dose as
10-15 chest x-rays

Routine chest CT is about the same radiation dose as
​ 50 chest x-rays

88
Q

NLST showed a _____% mortality benefit in chest CT screening group compared wtih the chest x-ray screening group

A

NLST showed a 20% mortality benefit in chest CT screening group compared wtih the chest x-ray screening group

89
Q

What are the indications for lung cancer screening?

Age:

Smoking history:

Symptoms:

A

Age: 55-77 years old

Smoking history: >30 pack years, quit <15 years ago

Symptoms: Asymptomatic

90
Q

What is the major contraindication to IV iodinated contrast?

A

Renal impairment

91
Q

Where are the “blind spots” on a chest x-ray?

How can we visualise them?

A

Behind the diaphragm

Behind the mediastinum

In the lung apices

Visualize with chest CT

92
Q

What kind of imaging is used in lung cancer staging?

A

Routine chest CT with contrast

93
Q

What kind of imaging is used to evaluate interstitial lung disease?

A

HRCT

94
Q

Radiation doses in various imaging modalities

A chest radiograph is about ____ mSv

A low-dose chest CT is about _____ mSv

A regular chest CT is about _____ mSv

A

A chest radiograph is about 0.1 mSv

A low-dose chest CT is about 1-2 mSv

A regular chest CT is about 7 mSv

​Being alive for 1 year ~2 mSv

95
Q

What is the most likely diagnosis of a 4 mm lung nodule in a smoker with >30 pack year history?

A

Granuloma

Very common!

If nodule size has not changed in 1 year => granuloma and not cancer (biopsy not necessary)

96
Q

What are the most common harms of lung cancer screening?

A
  • Additional testing due to incidental findings
    • Ex: Biopsy of a granuloma
  • Overdiagnosis
    • Ex: finding a carcinoid tumor that would not have impacted the patient’s life
97
Q

If disease prevalence is low…

Positive predictive value will be [low/high] and

Negative predictive value will be [low/high]

A

If disease prevalence is low…

Positive predictive value will be low and

Negative predictive value will be high

98
Q

What is is the first line imaging test for the diagnosis of pneumonia or other common disease processes?

A

Chest x-ray

Chest CT can be performed if cxr is negative but clinical suspicion is high

Pulm by Minnie (34 decks)

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