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Family Medicine > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Acute bronchitis

A

MC: viral

  • persistent of cough >5d, most often lasts 10-20d after
  • if febrile, consider pneumonia or influenza

Sxs:

  • cough (wet/dry)
  • reported low grade fever (real fever uncommon)
  • URI, myalgias, wheezing
  • chest wall tenderness from muscle strain
  • lungs often clear

Dx:
- CXR: normal or bronchial wall thickening [not typically needed; indicated for abnormal vitals, extremes of age, comorbidities]

Tx:

  • supportive care, antipyretics (NSAIDs, APAP, decongestants)
  • bronchodilator if wheeze or asthma
  • antitussive likely not helpful
  • NO abx (consider for elderly, significant comorbidity, high suspicion for pertussis)
  • d/c home w/PCP f/u; likely better in 2-3wk
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2
Q

Pertussis

A

May cause acute bronchitis

Post-tussive vomiting; whoop; severe paroxysmal cough

duration > 1wk

Dx: NP swab w/PCR

Tx: Azithro

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3
Q

Influenza

A

MC serious viral airway infection of adults (M/M)

Sxs:

  • sudden onset: HA, F/C, sore throat, myalgias
  • complicated: progressive dyspnea can lead to RF

Dx: NP swab
- rapid IF/EIA for flu A/B

Tx:
Oseltamivir (NA inhibitor)
- pt >2wk; best w/in 48hr x 5d

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4
Q

1’ influenza pneumonia

A

Rapid INC in severity of pulmonary sxs*

  • CXR w/diffuse bilateral opacities
  • hypoxemia
  • scant sputum production
  • culture only yields normal flora
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5
Q

2’ bacterial pneumonia

A

Initial improvement then relapse of pulmonary sxs

MRSA common

Always treat influenza and CAP

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6
Q

Bacterial pneumonia (general)

A

2+ sxs: fever, cough, SOB + acute infiltrate on CXR or auscultory findings

  • other sxs: pleuritic CP, sputum, hypothermia, chills/rigors, sweats; fatigue, myalgias, abd pain, anorexia, HA
  • tachypnea: most sensitive sign for peds

Pneumococcus MC patho across all ages

Dx:
Typical - GS, consolidation on CXR
Atypical - don’t GS; diffuse interstitial pattern on CXR

  • sputum: > 25pmn/LPF and < 10sec/LPF + alveolar macrophages
  • Blcx x2 if admission (prior to abx)
  • suspect sepsis = lactate
  • procalcitonin
  • urinary ag: pneumococcus or legionella
  • invasive procedures reserved for fulminant course (e.g. ICU, complex, unresponsive to abx)
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7
Q

Pneumonia (H flu)

A

Typical
- fever, chills, pleuritic CP

Smokers
Chronic lung disease (COPD)

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8
Q

Pneumonia (H flu)

A

Typical
- fever, chills, pleuritic CP

Smokers
Chronic lung disease (COPD)
Splenectomy

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9
Q

Pneumonia (Legionella)

A

Atypical

Man-made water systems
No human-human transmission
GI sxs, high fever, subtle hyponatremia, relative bradycardia

Dx: sputum w/abundant PMNs but no organism

  • may appear more ill than exam or CXR reads
  • CXR: patchy unilobar infiltrate progressing to consolidation ~3day
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10
Q

Pneumonia (Mycoplasma)

A

“Walking pneumonia” - common in healthy kids and young adults

Atypical

bullous myringitis
GI > cardiac > MS > neuro > derm sxs

Dx: cold agglutinins

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11
Q

Pneumonia (Chlamydophila)

A

Atypical

pharyngitis, laryngitis

Dx: IgM, IgG titers

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12
Q

Pneumonia - other etiologies

A

Alcohol: Klebsiella - currant-jelly sputum (necrosing lung)

Splenectomy: pneumococcus, H flu

CF: pseudomonas

Leukemia or I/C: aspergillus

Milk/postparturition products: coxiella burnetti (fever; usually a farmer or vet)

Rabbits: tularemia

Rats: yersina pestis (plague)

Psittacine birds: chlamydia psittaci

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13
Q

Bacterial Pneumonia Treatment

A

Abx w/in 6hr

OP: azithro, doxy, resp FQ

Gen med/ICU: 2g Ceftriaxone IV q 24hr + 500mg azithro IV q 24

  • OR 750mg Levoflox IV q 24hr
  • add Vanc or Linezolid to cover MRSA

HCAP or I/C: Vanc + anti-pseudo BL

PCP: TMP-SMX

Complications: parapneumonia effusion, empyema

Other:

  • may take 5-7d for fever to disappear
  • switch to PO when clinically improved, stable, can ingest oral meds, and GI functioning
  • smoking cessation and vaccination
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14
Q

CURB-65

A

1 point for each:

  • confusion
  • urea>7
  • RR>30
  • SBP<90 or DBP<60
  • age >65

0-1: outpatient
2: short stay vs. supervised outpatient
3-5: hospital, assess for ICU

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15
Q

Aspiration Pneumonia

A

RF: CVA, dysphagia, severe deconditioning, esophageal disorder

Et: acute aspiration of gastric contents may lead to respiratory failure
- anaerobic pulmonary infection, typically polymicrobial

Sxs:

  • may progress to lung abscess
  • fever, chills, shakes, productive cough, pleuritic CP
  • may present w/wt loss and foul sputum (abscess)

Dx: CXR - infiltrate dependent position

  • may show cavitary lesions +/- air-fluid levels
  • swallow study to determine if aspiration

Tx:

  • Amp/Sulbactam 4.5g q 6hr IV
  • Ceftriaxone + clinda 900mg q 8hr IV OR metro 500 q 8hr IV

Pcn allergy - levo/moxiflox PLUS clinda/metro

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16
Q

Viral pneumonia

A

CAP: influenza (adults)

  • secondary infection: MRSA
  • peds: RSV and parainfluenza
  • transplant/AIDS: CMV
  • severe: varicella zoster

Sxs:

  • HA, fever, chills, sore throat, myalgias; dehydration, hypoxemia
  • dyspnea = viral
  • lasts 7-10d w/residual fatigue

Dx:

  • negative procal
  • respiratory viral panel via NP
  • neg flu PCR cannot r/o flu
  • CXR: diffuse bilateral opacities

Tx: 2’ bacterial pneumonia - Ceftaroline OR Vanc + Oseltamivir

17
Q

Carcinoid Tumor

A

MC small bowel tumor (appendix > ileum > rectum > bronchus)

  • neuroendocrine tumor from Kulchitsky cells
  • SECRETES SEROTONIN*

Sxs: usually asx; can have vague nonspecific abd pain, bowel obstruction

  • pellagra skin changes d/t DEC niacin production
  • Carcinoid syndrome: severe diarrhea, flushing, bronchospasm (also cramps, telangiectasia)
  • Cushing Syndrome & Acromegaly: bronchial carcinoids are MC cause of ectopic ACTH production and extrapituitary GHRH secretion

Dx:

  • 24hr urine for 5-HIAA
  • urine/serum 5HT level
  • CXR: round/ovoid central opacities or SPN
  • Bx, CT, Bronch

Tx: resect localized tumor

  • carcinoid syndrome: IV octreotide, hepatic chemoembolization
  • diarrhea alone: Zofran
18
Q

Pulmonary nodules

A

Benign: infection (TB, fungi)

  • hamartomas: middle aged, lobulated lesion (“popcorn lesion”)
  • calcifications
  • no tx

CA: bronchogenic, often adenocarcinoma
SPN in a smoker = cancer until proven otherwise
- RF: age, smoking, exposures, prior CA hx, underlying lung dz
- spiculated, corona radiata
- doubling time: 20-400d

Sxs: usually asx, may have constitutional sxs w/CA

Dx:

  • High Res CT (best) w/CT guided bx
  • 1+ cm AND intermediate probability of malignancy = PET CT combo + MRI of brain

Refer to pulm to decide if CT surg is indicated for biopsy

19
Q

Asthma General

A

MC chronic disease of childhood

  • episodic wheezing, chronicity, hyper-responsive airways w/REVERSIBLE airway obstruction

RF: exercise, cold, dust, vapors, pollens, danders, occupational, smoke, air pollution

  • drug induced: BB, ACE, ASA
  • comorbid conditions exacerbating: viral URI, GERD, PND

Sxs:

  • worsening dyspnea, inc cough esp at night; inc wheezing and chest tightness
  • use of accessory muscles most reliable indicator of obstruction*
20
Q

Asthma Dx

A

Routine CXR unnecessary - unless:

  • new onset wheezing
  • pneumonia, PTX suspicion
  • respiratory failure

Spirometry (if >5yo) - Obstructive:

  • Dec FVC and FEV1/FVC ratio
  • Inc RV, TLC, compliance, DLCO
    • FEV1 best measure for severity

Methacholine challenge testing
- if no hyper-responsiveness, unlikely asthma

PEF: monitors trends

21
Q

Asthma Mgmt

A

O2 before and after all aerosol tx

Respiratory therapy: albuterol/ipratropium 1.25-2.5mg aerosolized x 3

  • prednisone 1-2 mg/kg [Dexamethasone works as well]
  • unresponsive to SABA: IV Mg 50 mg/kg

Intubate: Dec LOC, apnea, exhaustion, Inc PaCO2, PaO2<60 or pH<7.2

Admit: hypoxia, PF<60%, continuous SOB, underlying CP dz, inability to tolerate meds, poor compliance

D/c: SABA MDI w/spacer + pred x 5d; ICS maintenance

  • f/u in 1wk
  • asthma action plan
22
Q

Bronchiectasis

A

Abnormal dilated, distorted, thick-walled medium-sized bronchi chronically inflamed/infected

  • focal: aspiration, tumor, LN
  • diffuse: infectious, congenital, autoimmune

Sxs: frequent bronchitis requiring repeated abx

  • progress to chronic mucopurulent sputum production; lots of purulent, frothy**
  • cough, SOB, hemoptysis, recurrent pleurisy, crackles, rhonchi, wheezing

Dx:

  • CBC w/diff; quant Ig
  • HRCT* defining test
  • PFTs: obstructive pattern [Dec FEV1, Dec FEV1/FVC ratio]
  • sputum analysis/culture

Mgmt:

  1. control infection w/abx
  2. improve bronchial hygiene
    - pulmonary toilet: hydration, mucolytics, physiotherapy, bronchodilators, steroids
    - pulm rehab, surgical resection, refer to pulm
23
Q

Primary ciliary dyskinesia

A

Kartagener’s syndrome - bronchiectasis, sinusitis, situs inversus

Autosomal rec syndrome
Absence/shortening out arms responsible for propelling mucus out of respiratory tract

24
Q

COPD General

A
  • IRREVERSIBLE disease - dyspnea on exertion, cough, sputum + airflow limitation and chronic inflammation of lungs
  • chronic bronchitis: Inc bronchial secretion w/cough >3mo x 2 consecutive yrs
  • emphysema: permanent air space enlargement distal to terminal bronchial w/wall destruction

Inflammatory changes lead to mucus hypersecretion and ciliary dysfunction
- can lead to vascular changes, pulmonary HTN, cor pulmonale

RF: smoking, occupational, age, ETX, pollution, AAT deficiency, chronic asthma, poor SES

Sxs:

  • prolonged expiration/wheezes on forced expiration
  • barrel chest, accessory muscle use, tripod pose, pursed-lip breathing, central cyanosis
25
Q

COPD Dx

A

PFTs: obstructive

  • Dec FEV1, FEV1/FVC
  • Inc TLC, FVC

R/o lung cancer w/chronic cough*

  • CXR: inc lung volume, hyperinflation, hyperlucency, bulla/blebs
  • ECG/Echo: r/o cardiac involvement
  • Pox: rest, exertion, sleep
  • ABGs: if hypoxic on Pox or FEV1 < 50%

Quantify symptom severity using mMRC or CAT

26
Q

COPD Mgmt

A

Stop Smoking

A: SAMA or SABA or combo
B: LAMA (tiotropium) or LABA (salmeterol)
C: ICS + LABA or LAMA
D: ICS + LABA +/- LAMA

Other: O2, pulm rehab, vaccinations

Stage 0: clinical sxs w/normal spirometry
Stage 1: sxs, FEV1/FVC <0.7, FEV1>80%
Stage 2: FEV1 50-79%
Stage 3: FEV1 30-49%
Stage 4: FEV1 <30% or <50% w/chronic respiratory failure

27
Q

Acute Exacerbation COPD

A

Cause

  • inf: bacterial (H flu, pseudo, S. pneumo, M cat) or influenza
  • other: smoking, compliance, CHF, pollution, allergens

RF: AMS, 3 exacerbation in 1y, BMI >20, marked changes in vitals, comorbidities, poor activity, severe COPD

Sxs: INC sputum, INC cough, INC dyspnea**

  • +/- constitutional
  • confusion = respiratory compromise

Dx: sputum GS/cx, viral studies
- unchanged CXR, variable PFT changes

Tx: O2, bronchodilators (duoneb), systemic glucocorticoids (IV methylprednisolone or OP pred) +/- abx

Family Medicine (17 decks)

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