Pulm/crit Flashcards
Which type of lung cancer causes SIADH? Which causes Hypercalcemia
SIADH = small cell carcinoma Hypercalcemia/parathyroid like hormone production = squamous cell carcinoma
Radiological descriptions of benign lung nodules
Popcorn calcifications, concentric calcifications, laminated calcifications, central or diffuse homogeneous calcifications
Radiological descriptions of malignant pulmonary nodules
Eccentric or asymmetric calcifications, reticular calcifications or punctuate calcifications, size> 2cm, usually located in the upper lobe, spiculated/ragged edges
Which has a normal diffusing capacity for carbon monoxide(DLco)? Asthma, COPD, restrictive, fibrotic lung disease or extra thoracic restriction?
Asthma has a normal diffusing capacity of carbon monoxide because the alveoli are unaffected. By contrast COPD and restrictive/fibrotic lung diseases will have a decreased DLCO because of alveoli or destroyed and unable for gas exchange.
Asthma, COPD, fibrotic/restrictive lung disease FEV1/FVC? TLC? DLCO?
*Asthma: normal or increased TLC and DLCO, normal or decreased FEV1/FVC * COPD: decreased FEV1/FVC, increased TLC, decreased DLCO * restrictive/fibrotic lung disease: normal or increased FEV1/FVC, decreased TLC, decreased DLCO * extra thoracic long restriction: normal FEV1/FVC, decreased TLC, normal DLCO
What are the three most common cause of chronic cough?
Postnasal drip, GERD, asthma
What pulmonary function test are needed to make a definitive diagnosis of asthma?
An increase of 12% in FEV1 and or FVC with bronchodilators. *FEV1/FVC <0.7
For an acute asthma exacerbation what else can use besides beta agonist and inhaled corticosteroids? Dosage?
2 g of magnesium over 20 minutes IV. Magnesium has a bronchodilator affect however is of no use in COPD. *only indicated if <40% PEF despite >1hr of intestive tx with inhaled SABA & steroids
What pulmonary function testing is needed to diagnose CO PD?
Post bronchodilator FEV1/FVC is less than 0.7 and FEV1 is less than 80% of predictive value, TLC is usually increased
Lights criteria for exudative fluid
exudative fluid if:
- plural fluid protein/serum protein ratio >0.5
- plural fluid LDH/serum LDH ratio > 0.6
- plural fluid LDH level is greater than 2/3 the upper limit of the laboratories reference range.
Features of sarcoidosis
GRUELING-CC Granulomas, rheumatoid arthritis, uveitis, erythema do some, lymphadenitis, interstitial fibrosis, negative PPD, gamma globe anemia, increase calcium, cardiac problems
Guidelines for follow-up of pulmonary nodules
*Less than 6 mm: follow up CT and 12 months *6-8 mm follow up CT 6 to 12 months and again at 18 to 24 months * greater than 8 mm cereal CT/pet scan or excision based on radiographic characteristics
40 yo M s/p 6 units PRBC & 4 units FFP. Now has anxiety, perioral tingling and numbness for the last 2 hrs, muscle spasms of the hands and legs. CBC, CMP normal, vitals normal. dx? tx?
Acute Hypocalcemia due to chelation of Ca after blood(citrate) transfusion(can also chelate w/EDTA & Foscarnet). tx with IV Ca-gluconate/Chloride
CURB65 scoring
Confusion, urea >30, RR>30, BP<90/60 or age 65+ (each is 1 pt) 0 = outpatient treatment 1-2= inpatient treatment 3-4= urgent inpatient w/possible ICU
When is thoracentesis indicated?
>10 mm thickness on lateral decubitus
Lights criteria for transudative and exudative fluids
Transudative: 1. pleural fluid protein/serum protein <0.5 2. Pleural fluid LDH/serum LDH <0.6 3. Pleural fluid LDH <2/3 upper limit of labs normal Exudative: 1. pleural fluid protein/serum protein >0.5 2. Pleural fluid LDH/serum LDH >0.6 3. Pleural fluid LDH >2/3 upper limit of labs normal
When is oxygen therapy indicated?
SaO2 <88%, PaO2<55 or PaO2 <60 w/ HF or erythrocytosis
What size long natural is the cut off for requiring pet scan?
8mm+ >6mm f/u CT 1yr 6-8 f/u CT 6m -12m
Cystic fibrosis Inheritance, gene, sx ?
AR mut in CFTR gene lead to abnormal transfer sodium and chloride. Sx: recurrent pulmonary infections, sinusitis or bronchiectasis, infants may present with meconium ileus or interception. Pancreatic insufficiency most often presents with steatorrhea and poor weight gain along with decrease absorption of fat soluble vitamins. Adult men may present with infertility. Nasal polyps
Treatment of cystic fibrosis?
Bronchodilators and mucolytics. Supplementation of pancreatic enzymes and fat soluble vitamins along with stool softeners. Consider prophylactic anabiotic‘s with azithromycin or Tobramycin
Occupational lung disease associated with those who work in coal mines
Coal workers pneumoconiosis
Occupational long disease associated with those who work in shipyards, roofing and plumbing
Asbestosis
Occupational long disease associated with those who work in sandblasting or mining
Silicosis
Occupational long disease associated with those who work in aerospace or nuclear industry
Berylliosis
CF inheritance? mutation?
AR mut in CFTR gene
MC initial presentation of CF?
meconium ileus
Sx of CF
meconium ileus, FTT, Rectal Prolapse, Persistent cough, infertility(absent vas def), allergic bronchopulmonary aspergillosis, persistant cough, pancreatitis n shit like DM, hernia, amenorrhea, delayed puberty, RVH, portal HTN
Ivacaftor(VX-770)
first drug approved to tx CF = restores some function to the CF protein
3 things you can do for a CF patient that will IMPROVE SURVIVAL?
ibuprofen to reduce inflammation, Azithromycin to slow the rate of decline of FEV, abx during exacerbations
drugs that can worsen asthma?
ASA, NSAIDS, BB
+methacholine challenge test
>20% decrease in FEV1 after methacholine = dx of asthm
FEV, FVC, FEV/FVC, TLC & RV changes in asthma
decreased FEV(major), decreased FVC, FEV/FVC, Increased TLC & RV
what are the only 2 interventions that will decrease mortality and delay disease progression in COPD?
smoking cessation and long term home O2 use
when should a pt with COPD be put on home O2?
PO2 <55% or O2 sat is <90%
what type of pt would you see A1AT def in?
<40, nonsmoker
sx of A1AT def
COPD on CXR, Low albumin, elevated prothombin due to liver cirrhosis, low A1AT
tx of A1AT def?
infusion with A1AT
Bronchiectasis presentation/
anatomic defect resulting in profound dilation of bronchi = often due to multiple infections or CF. sx: episodes of lung infections + HIGH(cups) volume of sputum, hemoptysis and fever, Tram tracking on CXR,
tx of bronchiectasis
chest physiotherapy = cupping and clapping, rotation abx to avoid resistance
Allergic bronchopulomonary aspergillosis(ABPA) SX?
HSR to fungal antigens that colonize the bronchial tree sx: cough up brownish mucous plugs with recurrent infections, peripheral eosinophilia, elevated IgE, cough, wheezing, hemoptysis and bronchiectasis
tx of Allergic bronchopulomonary aspergillosis(ABPA)
ORAL corticosteroids + Itraconazole *cant use inhaled wont get past mucous plugs T.T
MCC of bronchiectasis?
CF
MCC of CAP
pneumococcus
MCC of HAP
gram - bacilli
when should you think pneumonia over bronchiectasis?
pneumo: tachycardia, tachypenia, hypotension
Empyema + criteria
infected pleural effusion that acts like abscess and only improves wiht drainage. - LDH >60% of serum - Protein >50% of serum - pH <7.2, +gram stain or culture
which has a productive cough? lobar or intersitial pneumo?
lobar
name the pneumonia associated with… diarrhea, HA, confusion
legionella
name the pneumonia associated with… Bacteremia
Strep. Pneumo
name the pneumonia associated with… current jelly sputumm hemoptysis
klebsiella
name the pneumonia associated with… rotten egg smell
anaerobes
name the pneumonia associated with… dry cough, bullous myringitis
mycoplasma pneumo
name the pneumonia associated with… CD4<200
PCP
tx of outpatient pneumonia
azithromycin, or clarithromycin OR moxifloxacin
tx of HAP
Vanc + pip/tazo; or ceftazidine, cefipime, TMP/SMX = point being u need pseudomonas coverage
TX of inpatient pneumonia
ceftriaxone + azithromycin or moxifloxacin
bug that causes pneumo that presents with… recent viral illness
staph
bug that causes pneumo that presents with… alcoholic/DM
klebsiella
bug that causes pneumo that presents with… young healthy patients
mycoplasma or chalymidia pneumo
bug that causes pneumo that presents with… persons present at the birth of an animla, vets, farmers
coxiella burnetii
bug that causes pneumo that presents with… arizona construction workers
coccidioidomycosis
bug that causes pneumo that presents with… COPD
H. influenza
bug that causes pneumo that presents with… poor dentition
anaerobes
bug that causes pneumo that presents with… ppl who fucking love birds
chalymdia psittaci
What is interstitial lung disease(ILD)
inflammation or fibrosis of interalveolar septum causing impaired gas exchange and increase in lung stiffness(restritive lung dz)
Dz associated with…. ship yard workers, insulators and pipe fitters
asbestosis
Dz associated with…. glass workers, mining, sandblasting, brickyards
silicosis
Dz associated with…. coal worker
coal works pneumonoconiosis
Dz associated with…. cotton
byssinosis
Dz associated with…. electronics, ceramics, fluorescent lights
berylliosis **has granulomas!!!!
Dz associated with…. mercury
pulmonary fibrosis
drugs that can cause interstital lung dz?
bleomycin, busulfan, amiodarone, methylsergide, nitrofuratonin, cyclophosphamide, etc
Classic presentation of ILD?
SOB with Dry nonproductive cough and chronic hypoxia PE: dry, rales, loud P2(sx of pulmonary HTN), clubbing
Hypersensitivity Pneumonitis cause? tx?
fever, dyspnea, severe cough within 4-6 hr of exposure to antigen! cause: feathers, MAI, hay, compost, A/C tx: avoid + steroids
DX of ILD?
- CXR 2. CT, PFT or Bx **need to do EKG to look for RV hypertrophy due to pulmonary HTN
PFT in ILD? FEV, FVC, FEV/FVC, TLC, RV, DLCO
FEV, FVC, TLC, RV, DLCO = decrease FEV/FVC = increased
why do an EKG for ILD?
looking for RV hypertrophy due to pulmonary hypertrophy
TX of ILD?
- steroids 2. Azathioprine 3. cyclophosphamide
whats Sarcoidosis
idiopathic inflammatory condition involving infiltration of non-caseating granulomas thought out the body. MC in AA women
sx of sarcoidosis
Eye: uveitis(burning, itching, tearing) neural: 7th CN probs Skin: lupus pernio(purple rash of face), Erythema Nodosum(itchy, painful on legs and ankles) Cardiac: restrictive cardiomyopathy RENAL & HEPATIC: OFTEN ASYMPTOMATIC (lean more tword amyloidosis if you see this) Hypercalcemia: excess VitD from granulomas causes this Bilateral hilar lymphadenopathy, Liver & spleen enlargement,
best initial test for sarcoidosis? most accurate test?
initial CXR, accurate = bx of lymph node
tx of sarcoidosis
steroids ONLY IF SYMPTOMATIC = if hilar lymphadenpathy but not symptomatic leave alone
Normal pulmonary vascular values: systolic, diastolic and MAP
Systolic: 25mmHg Diastolic: 8mmHg MAP: 15mmHg
sx of pulmonary HTN
Loud P2, Tricuspid reguritation, RV heave, raynauds phenomenon, wide split S2
SAAG calculations & meaning…
(SAAG = serum albumin - ascites albumin); SAAG = albumin concentration of serum - albumin concentration of ascitic fluid. SAAG > 1.1; Ascites is due to an imbalance between hydrostatic and oncotic pressures;(portal HTN) • Chronic liver disease. • Massive hepatic metastases. • CHF. • Portal-vein Thrombosis. SAAG < 1.1; Ascites is due to protein leakage; • Nephrotic syndrome. • Tuberculosis. • Malignancy, (e.g., ovarian cancer). • Pancreatic ascites. • Biliary ascites. • Serositis. • Bowel obstruction or infarction. • Peritoneal Carcinomatosis.
Allergic Bronchopulmonary Aspergillosis(ABPA) sx?
*asthmatic pt with worsening asthma(cough, wheezing) w/brown mucous plugs(hemoptysis), peripheral eosinophila and elevated IgE and central bronchiectasis,
Allergic Bronchopulmonary Aspergillosis(ABPA) dx?
aspergillus skin testing, meansing IgE, ABPA ab’s
Allergic Bronchopulmonary Aspergillosis(ABPA) tx?
ORAL steroids and if refractory Itraconazole
dx of Acute Respiratory Distress Syndrome?
CXR shows white out, normal wedge pressure, pO2/FiO2 <200.
tx of ARDS
ventilation w/low tidal volume of <6mL/kg(reduces barotrauma), PEEP, prone, diruetics, positive inotropes(doubutamine), ICU
TX of TB
4 for 2: INH, Rifamp, pyrazina, etham for 2 months THEN 2 for 4: INH + Rifampin for an additonal 4 months
PPD + but CXR - ?
9m of INH
side fx of INH
hepatotoxic, peripheral neuropathy = pyridoxine
side fx of Rifampin
red/orange colored body fluids = benign
side fx of pyrazinamide
hyperuricemia = NSAID + Colchine
side fx of Ethambutol
optic neuritis = decrease dose
how do you check someon for TB who has had the BCG vaccine?
INF y release assay = IGRA
Acute Bronchitis sx?
*nonsmoking patient with recent URI & persistant cough + production of yellow, blood tinged sputum. SX: - >5 days w/cough yellow/bloody sputum - No fever, chill or pneumona on CXR present(lungs clear) - Wheezing or rhonchi
Acute Bronchitis tx?
NSAIDs + Bronchodilators
Why do you get yellow/purulent sputum and blood with acute bronchitis?
*Yellow/purulent Sputum = epithelium sloathing not infection *Blood = inflammation due to epithelial damage
Three common causes of chronic cough?
GERD, Post nasal drip & Asthma
Abx should cover for what bugs with COPD exacerbation?
Streptococcus, H.influenza, Moraxella
*tx for 5-7d
Tx for loculated pleural effusion?
Video-assisted thorascopy(VATS) or surgical decortication +/- chest tube
Symptoms of Pulmonary Embolism?
Tx?
Chest pain, SOB, syncope, Hemoptysis or low grade fevers, tachypnea, tachycardia, +/- cyanosis, S1Q3T3(S wave in lead 1 Q wave in lead 3, T wave inversion in lead 3)
TX: anticoagulate: Provoked or 1st time PE 3-6m of anticoagulation
