Pulmonary Flashcards
Diagnostic test for bronchiactesis?
HRCT
Patient with dyspnea and dry cough, O/E dullnes in lower left lung zone with decreased breath sound, reduced lung expansion, best next step??.
Erect CXR
lateral decubetus
CT chest
Lateral decubetus CXR are the most sensitive x-ray and can detect small PE
this is pleural effusion case
Erect CXR detect >300ml fluid
Lateral CXR detect >50ml fluid
US detect >5 ml fluid 😱
الصوره ذي تحفظينها زي اسمك 😘😘😘😘😘😘
Challenge
Mention all the 5 indication of diagnostic thoracosentesis (aka pleurocentesis )😏
You did diagnostic thoracocentesis for patient with PE, the result are inconclusive and you still don’t know the diagnosis 😣, next step?
Rule out malignancy
Ddx of pleural effusion with low glucose? And which one has the lowest glucose level ever?
RA pleurisy has the lowest, veeerrrrry low (<30)
What is the indication of THERAPEUTIC thoracocentesis ?
Large effusion with dyspnea and/or cardiac decompensation
Complicated parapneumonic effusions
Patient with large pulmonary effusion due to TB, was treated in king Khalid hospital were they drained 3L at once, after 3hr patient developed dyspnea, frothy sputum and cough, what is the next step??
CXR
Re-expansion syndrome
Pleural fluid criteria for complicated parapneumonic effusion
PH ?
LDH ?
Glucose ?
pH (very acidic ) < 7.2
High LDH
Low glucose <60mg
Alcoholic patient with poor dental hygiene, developed acute cough dyspnea fever with currant jelly sputum, CXR show consolidation
What is the organism.
Patient developed pneumonia after 7 days of intubation, most likely organism?
Areej ☺️
Patient with fever and productive cough
You do CXR shows cavity, next imaging?
CT
When to consider failure of TB management?
Positive culture at 5 months
You diagnosed a patient with active TB, next step immediately to prevent disease spread😱😱
airborne negative pressure isolation 😷
+N95 mask
Young person got COPD, what is your differential !
Patient with COPD and FEV1 is 35, this is GOLD class what?
3
What is the Indications for NIPPV in COPD patient
Respiratory acidosis: PH <7.35 or
hypercapnia → PCO2 >45 2)
RR > 25/min with fatigue of respiratory muscles
Procedure: BiPAP (M/C used)
In COPD you should maintain O2 in range of ?
88-92
Mention as much as you can from the indication of mechanical ventilation in COPD
FEV1/FVC =78 , TLC =40 , diagnosis.
Restrictive lung disease
Patient with acute pulmonary edema , best way to deliver O2 ?
Face mask
Venturi mask
High flow O2 nasal canula
Low flow nasal canula
Best O2 mask for COPD patient?
When its better to use CPAP and when to use BIPAP
COPD patient , not well controlled with albeturol , what to add?
COPD patient with O2 85% at rest, what to add?
Long term o2 therapy is indicated if
2 readings of ABG (when patient is not in attack ) are paO2 <55
Asthmatic patient in acute attck
He can speak in words, agitated, sitting in tripod position, O2 88%,
Is it mild , moderate, severe or life-threatening attack?
Severe
If you have no time just remeber the severe and life-threatening, many Q on this topic
Remember : PEFR, HR, Po2
Vaccines recommended for asthmatic patient?
Influenza + pneumococcal for all
Which drug from asthma drug increases risk of death if used alone ! ☠️
LABA (formoterol, salmoterol )
Patient in acute asthma attach
Yoy noticed that th CO2 level changed form low to normal, next step?☠️☠️☠️☠️
Intubation
Normal or high CO2 is sign of respiratory failure 😞
Indication of intubation ( respiratory acidosis + normalization or high CO2 )
In patient with obstructive pattern in PFT, all parameter usually low except one thin is high, what is it??
TLC
Young patient with SUDDEN onset and OFFSET or recurrent episodes of SOB + STRIDOR with exercise, with no allergy family history of asthma and no response to ventolin.
, DX?
vocal cord dysfunction
Remeber , stridor = URT symptoms
Differential diagnosis of difficult to control asthma?.
When is positive methacholine test ?
If there is fall in FEV1 > 20%
In any asthma pt who don’t respond to medications, you need to check for?
Proper Use of the inhaler
Add spacer
Medication adherence
Last drug we can try to help patient in acute severe asthma attack before going for intubation?
Mg sulfate
Drugs that are contraindicated in asthamtic patient ?
Mention 5
Management of exercise induced asthma
SABA 30 min before exercise
Most important parameter to monitor progression of COPD??.
FEV1
What measures improve survival = reduce mortality in COPD ?
Smoking cassation + O2 therapy + NPPV + vaccination (MCC of exacerbation is infection)
Only
What changes in ECG you found in COPD patient ?
And ttt
Dx: MAT
Mx: amiodarone
COPD patient developed a secondary pneumothorax (size 2cm) , Mx?
Any secondary pneumothorax is treated by chest tube regardless of size
Patient with incidental finding of solitary lundpg nodule, there was no previous imaging so, CT obtain and nodule measured 1cm , next step?
Any nodule >8mm ===== biopsy
Lung cancer + low PTH + high Ca
What is the cause?
PTH related peptide
Gives -ve feedback and inhibit PTH hormane + rise the level of Ca
Common in non-small cell lung cancer (sqaumous cell cancer )
Lung nodule in non-smoker, with popcorn calcification
Composed of fat and calcium
Dx?
حمار ضيع الطريق =hmar =hamar
Hamartoma
Mention all important extrapulmonary menifestation of lung cancer
🔺Very improtant and have many Q on this topic
Horner syndrome is associated with which type of lung cancer?.?.??
Squamous = pancost tumor
Patient with pneumonia + positive cold aglutinin test
Dx?
Review it
This is so important
MCC of CAP
MCC of HAP, VAP , bronchiactesis?
?
Butterfly pattern (bilateral perihilar infiltraion ) on CXR + Pneumomatocele (cystic fluid-filled place in lung ) on CT + HIV = PCP
dx PCP
Investigation
1st line= induced sputum sample
2nd line bronchioalveolar lavage
Tx
High dose TMP-SMX
Best antibiotic for lung abscess?
Clindamycin as it covers the anarobes
Pneumonia patient with CURP-65 is 1
Next step?
Outpatient mx
How long did the patches of pneumonia or whatever takes to disappear/ resolve on CXR ?
6 weeks
To consider a fluid from pleural effusion a exudate
It most be
Pleural protein/ serum protein = 0.5 of more than 0.5 or both ?
Focus on the cutoff point
In pleural fluid analysis
What sensitive test can detect TB pleural effusion?
ADA
Indication of chest tube insertion in pleural effusion patient?
Loculated + empyema + hemothorax = any highly viscus fluid
Tube thoracostomy = chest tube + TPA
In parapneumonic effusion
Which of the following is and indication of chest tube?
Glucose < 0.4
PH< 7.2
PH< 7.2
Indication = empyema
Type of staining in TB culture ?
Ziehl-neelsen stain
What is the pneumoconiosis associated with TB?
silicosis
Child 4 years
With tuberculin test induration of 10cm , is it positive or negative test?
Positive
Positive PPD (TB screen ), next step??
CXR
Then AFB sputum and culture
Ttt of latent TB?
Before starting anti-TB what lab test you need to order 🟫?
Liver function test
Because all antiTB are hepatotoxic , and the most hepatotoxic is pyrezenamide
Constructive pericarditis
Patient with
Clubbing + Persistent + DAILY + purulent foul sputum and cough
Best test to diagnose?
HRCT
dx: bronciectesis
Patient with tram track appearance on CXR + signet ring on HRCT , what is dx and mx?
Patient with post TB bronchiectasis (MCC of acquired bronchiectasis)
Present with massive hemoptysis, CXR done shows right cavitary lesion, next step?????????
CT
angiography
I am gonna kill you without regret if you answer this simple Q wrongly ☠️
Answer is ABC + place pt in RT decubitus😂
Make sure pt is stable
Bronchiectasis patient present with massive hemoptysis , next sept???
CXR
+ABC
if stable then do CT to see the source
If CT didnt find the source do bronchoscopy
And treat by embolisation
Do asthma , TB and chronic bronchitis cause clubbing?
Memorize it by heart
Many Q on this
MCC of chronic cough
MCC of chronic hemoptysis
Post-nasal drip (Upper airway cough syndrome)
Chronic bronchitis
Patient present after 24hr post-surgery with HYPOXIC DYSPNEA, dx?
Atalectasis
Mx: incentive spirometry
Next?
Dx?
Sarcoidosis
Next is CXR
Key word if didn’t mention non-caseating granuloma
Erythema nodusum: The characteristic lesions are painful nodules on the lower legs (particularly shins).
Best diagnostic test for chronic pulmonary embolism?
Best diagnostic test for Acute pulmonary embolism?
V/Q scan
Spiral CT
Obese + snoring + bad sleep + cyanosis + hypertension
Best investigation in this case?
Polysomnography
Obese patient with daytime hypercapnia, Dx?
Best ventilation for OSA ?
CPAP
Most common site for foreign body aspiration ?
Right or left bronchus?
Right main bronchus
Patient with VELCRO-like breath sound ( bilateral inspiratory crepitation ) + clubbing
Dx.
Septic patient + acute bilateral pulmonary infiltration after admission + hypoxic respiratory failure + not attributed to cardiac or overload causes
Dx?
Criteria name for dx
MCC of this condition?
ARDS
Berlin
MCC is sepsis, then pneumonia and aspirations
Pregnant with asthma what will change (physiologic changes in lung function
Does RR and vital capacity increases???
Tidal volume decrease??
Elaf : focus on tidal volume and functional residual capacity
In pulmonary function test how to differentiate between emphysema vs chronic bronchitis ?
Hint: DLCO is low where?
Ddx of difficult to control asthma ?
Patient with cough
Spot diagnosis? (this is a pathognomic)
Photographer negative (bat wing appearance or reversed edema) pulmonary edema
Pathognomic for chronic eosinophilic pneumonia
Ddx of difficult to control asthma
Patient with typical asthma hx but normal PFT, next step? And when to consider it positive test
Methacholine challenge test
+Ve = fall in FEV1 >20%
Asthma patient on SABA + ICS, what to add when escalating ?
LABA
Challenge time 🕰️
Side effect of SABA and ICS ?
SABA= 3TH, tachy, tremor, tolerance, hypokalemia
Histological finding of chronic bronchitis?
Chronic bronchitis = hypertrophic bronchial mucus-secreting glands
Emphysema = dilated beonchioles and distructed alveolar wall
Asthma= smooth muscle hypertrophy and eosinophilic infilterate
Bronchiectasis = dilated and thickening of bronchi, fibrosis of parenchyma
Initial step in all COPD management is?
Smoking cessation
Patient with COPD symptoms + post-bronchodilator test is FEV1>30
what to add in management
ICS
This is COPD asthma overlap syndrome
NIPPV
Indication for home oxygen therapy in COPD
Indications to add inhaled corticosteroid for COPD:-
Lung screening
How?
Whom?
When (age )?
Low dose CT
Pleural plaques indicate esposure to what?
Asbestos = high risk for mesothelioma
SVC syndrome associated with which type of lung cancer?
And pancoast?
Important test before any lung cancer surgery??
Pulmonary function test
See the key word
Dx?
See the key word
Dx?
Patient homosexual, oral thrush, with cough, dyspnea and bilateral opacity on chest x-ray, diagnosed with PCP + pO2 <70, alveolar-arterial gradient (A-a gradient ) =>35
What to add in the treatment
Steroid
Pneumonia
45 patient
Confused
Urea 6
RR 30
BP 90/70
Where to admit?
3
ICU
Approach of pneumonia ttt in young healthy ?
Indication of chest tube in pleural effusion ?
Anti TB that causes hyperglycemia ?
Pyrazimade
Patient on Anti-TB treatment + liver fusion increases 5 fold
Why to do?
Stop all ttt
Patient with
HIV and TB
what to treat first ‼️
TB for
Isolated low DLCO indicate?
Pulmonary embolism
Treatment of bronchiectasis
Mention causes of acquired bronchiectasis
When we have to treat sarcoidosis ?
Hypercalcemia
Decrease PFT
If no indication to treat just observe
Can you remember wills and per criteria??
For how long should the anticoagulation continued in patient with provoked PE
3 month
What is the Duration of anticoagulation for unprovoked distal leg DVT ?
Never🤭
Does of enoxaparin in DVT prophylaxis ?
40
Dose of enoxaparin in DVT prophylaxis ?
40
In shock
Which types had a low after load???
After load = SVR 😂
In shock
Which types had a low after load???
After load = SVR 😂
What type of shock usually follow the Myocardial infarction?
Patient with COPD
And had a pneumothorax 2cm and vitally stable, what to do?
Chest tube
In stable
Any spontaneous pneumothorax =>2 ➡️ chest tube + hospitalization
If <2 with symptoms ➡️ chest tube + hospitalization
If <2 asymptomatic ➡️ observe
In unstable (tension pneumothorax)➡️needle decompression ➡️ chest tube
In patient with lung nodule
Which will make you suspect malignancy ?
Popcorn and chondroid classification is characteristic of ?
Hamartoma
Bening lung nodule calssification appearance on x-ray ?
Central
Diffuse
Lamillated
Popcorn
Patient in shock and lost consciousness, what is the class of shock?
4
Prenganct with SOB and leg swelling with DVT signs, wells score is 6, next step?
Not CTPA🥹
Leg US
What causes increase in BNP?
Obesity ??
DVT prophylaxis in patient with renal failure ???
UFH
Asthma drug increase mortality if used alone?
LABA (salmetrol, formetrol
Patient was resuscitated from shock
Which values indicate successful resuscitation?
Lactate level ( high or low? )
Urine output?
MAP ?
سؤال مدري وش يبي بس احفظي يا دكتوره
Good 👧
Best contraception in patoent with history if DVT PE
IUD
Patient with massive DVT and recent hemorrhagic stroke
How to manage ?
Patient with classic triad of acute fever + erythema nodusum + bilateral hilar lymphadenopathy
Dx?
Ttt?
Lofgren syndrome
If mild ➡️supportive
if severe ➡️short term steroid
Difference between SIRS and septic shock ?
COPD exacerbation + signs of right side heart failure
Best intial investigation ??
Never 👎 say spirometry
ECHO + CXR
COPD exacerbation + signs of right side heart failure
Best intial investigation ??
Never 👎 say spirometry
ECHO + CXR
Diagnostic imaging for interstitial lung disease?
HRCT
Child + cough and SOB and fever + hemlytic anemia + cold aglutinin + erythema multi nodusum, dx?
