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Internal Med EOR > Pulmonary 2 > Flashcards

Pulmonary 2 Flashcards

1
Q

what is bronchiectasis

A

chronic lung disease characterized by permanent and irreversible dilation of the bronchial airways with weakening of the function mucociliary transport mechanism

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2
Q

what is considered the common endpoint of various disorders that cause chronic airway inflammation

A

bronchiectasis

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3
Q

what is the most common cause of bronchiectasis in the US

A

cystic fibrosis

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4
Q

most common colonizers of bronchiectasis

A

pseudomonas aeruginosa in cystic fibrosis
haemophilus influenza if not due to cystic fibrosis

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5
Q

3 main components of bronchiectasis

A

recurrent infections
airway obstruction
peribronchial fibrosis

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6
Q

sx bronchiectasis

A

persistent productive cough with thick sputum (may be purulent)
dyspnea
pleuritic chest pain
hemoptysis due to bronchial artery erosion

nonspecific - fatigue, weight loss, recurrent infections

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7
Q

PE bronchiectasis

A

crackles (MC) & often bibasilar
wheezing
rhonchi

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8
Q

dx bronchiectasis

A

CXR - usually abnormal but nonspecific

High-resolution CT - preferred; thickened bronchial walls, airway dilation and lack of tapering of the airways (parallel or tram-track appearance), signet ring sign (increased airways diameter > adjacent vessel diameter)

PFT - criterion standard;
airway obstruction - decreased FEV1, decreased FEV1/FVC < 70% predicted, decreased FVC
hyperinflation - increased lung volumes (RV, TLC, RV/TLC, FRC)

test for cystic fibrosis

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9
Q

tx bronchiectasis

A

mucus clearance - chest physiotherapy, mucolytics (nebulizer hypertonic saline soln, acetylcysteine), postural drainage

vax against flu and pneumococcal

massive hemoptysis - bronchial artery embolization and/or surgery first line

aggressive abx

eventual lung transplant

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10
Q

abx for bronchiectasis

A

sputum culture unavailable - fluoroquinolone (moxifloxacin, levofloxacin)

sputum grown sensitive organisms but no H influenza or pseudomonas - amoxicillin or macrolide

beta lactamase-positive organism - augmentin, macrolide, cephalosporin, doxycycline, fluoroquinolone

pseudomonas - ciprofloxacin

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11
Q

what does a carcinoid tumor secrete

A

serotonin
histamine
bradykinin

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12
Q

most common mets for carcinoid tumor

A

liver

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13
Q

carcinoid syndrome

A

periodic episodes of diarrhea (serotonin), flushing, tachycardia, bronchoconstriction (histamine) and hemodynamic instability (hypotension)

may have heart murmur due to fibrosis

increased serotonin –> decreased niacin/B3 –> pellagra

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14
Q

dx carcinoid syndrome

A

CT of chest - most useful; confirmed by bronchoscope biopsy for central lesions or transthoracic needle biopsy for peripheral lesions

bronchoscopy - pink to purple well-vascularized centrally-located tumor

tumor localization - CT scan and octreotide scintigraphy

UA - elevated 5-hydroxyindoleacetic acid (5-HIAA)

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15
Q

tx carcinoid tumor

A

tumor resection
niacin replacement
octreotide therapy to reduce sx

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16
Q

what is pneumoconiosis

A

chronic fibrotic lung disease secondary to inhalation of mineral dust

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17
Q

RF for silicosis

A

silica dust inhalation:
coal mining
quarry work with granite, slate, quartz
pottery makers
sandblasting
glass and cement manufacturing
masonry
hydraulic fracturing

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18
Q

sx pneumoconiosis

A

dyspnea on exertion, nonproductive cough
rales
weight loss
fatigue

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19
Q

dx silicosis

A

CXR - multiple small < 10 mm round nodular opacities (miliary pattern) primarily in the upper lobs
eggshell calcifications of hilarious and mediastinal nodes

Higher resolution CT

PFTs - restrictive

Lung biopsy - dust laden macrophages and loose reticulin fibers in the lung

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20
Q

tx silicosis

A

removal from exposure
corticosteroids, oxygen, rehab

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21
Q

what is Caplan syndrome

A

coal worker pneumoconiosis + rheumatoid arthritis

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22
Q

coal worker’s pneumoconiosis is also called

A

black lung disease

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23
Q

dx coal worker’s pneumoconiosis/black lung disease

A

CXR - small nodules predominantly in the upper lung with hyperinflation of the lobes in an obstructive pattern

PFTs - increased RV, TLC, RV/TLC - obstructive pattern

lung biopsy - black lungs - interstitial pigment deposition and an anthracitic macrophage

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24
Q

high risk occupations for berylliosis

A

aerospace
high tech electronics
ceramics
tool and dye manufacturing
alloy manufacturing (jewelry making)

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25
Q

dx berylliosis

A

CXR - normal in 50%; hilar lymphadenopathy and increased interstitial lung markings

the blood beryllium lymphocyte proliferation test is the most appropriate initial dx test for patients suspected of having berylliosis

PFTs - similar to sarcoidosis - restrictive and/or obstructive

bx - noncaseating granulomas

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26
Q

high risk occupations for asbestosis

A

destruction, repair, or renovation of old buildings
insulators
pipe-fitting
boiler-makers
ship building and shipyard workers

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27
Q

dx asbestosis

A

CXR - pleural plaques - bilatéral mid-lung zone parietal pleural thickening or calcification, especially along the lower lung fields and diaphragmatic pleura are hallmark
shaggy heart sign - indistinct heart border, ground glass appearance

PFTs - restrictive lung pattern - increased FEV1/FVC, decreased lung volumes (VC, RV, TLC) decreased DLCO and lung compliance

bx - linear asbestos bodies in the lung tissue (ferruginous bodies)

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28
Q

what is the most common cause of bacterial pneumonia

A

streptococcus pneumonia

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29
Q

sx typical pneumonia

A

fever
productive cough
pleuritic chest pain
dyspnea
rigors

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30
Q

sx atypical pneumonia

A

low grade fever
dry nonproductive cough
extra pulmonary sx (myalgias, malaise, pharyngitis, nausea, vomiting, diarrhea)

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31
Q

PE typical pneumonia

A

tachypnea
tachycardia
bronchial breath sounds
dullness to percussion
increased tactile fremitus
egophony
inspiratory rales (crackles)

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32
Q

PE atypical pneumonia

A

exam often normal
may have crackles

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33
Q

what type of bacteria is strep pneumoniae

A

gram positive diplococci

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34
Q

what type of bacteria is haemophilus influenzae

A

gram negative rod

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35
Q

what type of bacteria is klebsiella pneumoniae

A

gram negative rod

36
Q

what type of bacteria is staph aureus

A

gram positive cocci in clusters

37
Q

classic presentation strep pneumoniae pneumonia

A

blood-tinged rusty sputum

38
Q

classic presentation of klebsiella pneumoniae

A

most often occurs in alcoholics, DM, severe COPD

thick, mucoid, blood-tinged sputum (currant jelly)

39
Q

classic presentation of mycoplasma pneumoniae

A

young and healthy, college students, military recruits

MC cause of atypical/walking pneumonia

cold agglutinin titers elevated in > 50%

40
Q

classic presentation of legionella pneumiphila pneumonia

A

air conditions, potable water, cooling towers, ventilation systems, hot tubs in large facilities

41
Q

dx pneumonia

A

CXR - patchy, segmental, lobar, or multilobar consolidation
blood cultures x 2

42
Q

Outpatient therapy (antibiotics) pneumonia

A

Low risk or no comorbidities and low risk for P. Aerugino aeruginosa or MRSA:
Amoxicillin 1 g PO TID x 5 days
Doxycycline 100 mg P BID x 5 days
Azithromycin 500 PO once, then 250 mg PO daily x 4 days (if local pneumococcal resistance is < 25%)

Significant comorbidities (chronic heart, lung, liver, or renal disease, diabetes, EtOH, active cancer, immunosuppression, asplenia)
Amoxicillin/clavulanate (Augmentin) 875 BID or Cefuroxime 500 mg PO BID PLUS Azithromycin 500 PO once, then 250 mg PO daily x 4 days or Doxycycline 100 mg BID x 5 days
Levofloxacin 750 mg PO daily x 5 days
Moxifloxacin 400 mg PO daily x 5 days

43
Q

inpatient tx pneumonia

A

Inpatient (hospitalize if > 50 with comorbidities, altered mental status, poor fluid status)

Treatment regimens depend on various factors, which include severity, prior hospitalization, and prior abx use. Common options include:
Ceftriaxone + Doxycycline or Azithromycin
Levofloxacin, Moxifloxacin, Cefepime, Piperacillin/Tazobactam, Vancomycin, and Meropenem (alone and in various combinations)

44
Q

when to admit for pneumonia

A

CURB65

Confusion
Uremia > 30 mg/dL
Respiratory rate >/= 30
BP low (SBP < 90 or DBP < 60)
Age > 65

45
Q

what is the most common cause of viral pneumonia in kids vs adults

A

kids - RSV
adults - influenza

46
Q

common causes of fungal pneumonia

A

Coccidioides (valley fever): Look for this in a patient with non-remitting cough/bronchitis non-responsive to conventional treatments; western states

Pulmonary aspergillosis: The majority of cases occur in people with underlying illnesses such as tuberculosis or chronic obstructive pulmonary disease (COPD), but with otherwise healthy immune systems

Cryptococcus: found in soil can disseminate and can cause meningitis

Histoplasma capsulatum: Chronic cavitary histoplasmosis is characterized by pulmonary lesions that are often apical and resemble cavitary TB. Manifestations are worsening cough and dyspnea, progressing eventually to disabling respiratory dysfunction. Dissemination does not occur.

Pneumocystis Jiroveci

47
Q

dx fungal pneumonia

A

Chest X-Ray Findings:

Cryptococcus: Cryptococcal antigen can be detected in CSF and serum. India ink stain or serology with latex agglutination assay or cryptococcal antigen assay (CRAG) is helpful.
Histoplasma capsulatum causes mediastinal or hilar lymphadenopathy (looks like sarcoidosis)

48
Q

tx fungal pneumonia

A

Cryptococcus and Histoplasma - Amphotericin B

Coccidioides - Azoles - fluconazole or itraconazole

Aspergillus - Triazoles - Triazole antifungal agents include voriconazole, posaconazole, itraconazole, and fluconazole

49
Q

what is the most common opportunistic infection in HIV

A

pneumocystis pneumonia esp if CD+ </= 200 cells/microL

50
Q

what can clue you in that your pt has PCP

A

nearly all patients w PCP will have either hypoxemia at rest or with exertion (oxygen desaturation w ambulation is highly suggestive)

51
Q

dx PCP

A

CXR is the cornerstone of diagnosis. The radiograph shows diffuse interstitial or bilateral perihilar infiltrates

Diagnose with bronchoalveolar lavage (PCR), labs, and an HIV test
Methenamine silver stain is used to stain Pneumocystis. Samples of affected tissue, such as lung tissue from biopsy, can be stained to reveal the pathogen
Will often have very low O2 saturation despite supplemental O2

52
Q

tx PJP

A

Treat with Trimethoprim-sulfamethoxazole (BACTRIM) and steroids

If allergic treat with Pentamidine
Prophylaxis for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection.

Daily Bactrim is the prophylaxis antibiotic of choice.

53
Q

what is pulmonary HTN

A

elevated mean pulmonary arterial pressure > 20 mmHg or > 25 mm Hg on resting cardiac cauterization

54
Q

what can pulmonary HTN lead to

A

RVH, increased RV pressure, and eventually right sided HF

55
Q

what are the different classifications of pulmonary HTN

A

group 1 - idiopathic pulmonary arterial HTN

group 2 - pulmonary HTN due to left heart disease

group 3 - pulmonary HTN due to hypoxemia or chronic lung disease

group 4 - pulmonary HTN due to chronic thromboembolic dz

56
Q

sx pulmonary HTN

A

dyspnea on exertion
lethargy
fatigue

57
Q

PE for pulmonary HTN

A

accentuated ST
signs of right sided HF
tricuspid regurgitation (holosystolic murmur)

58
Q

dx pulmonary HTN

A

CXR
EKG
Echocardiograph with bubble study is most important
Right heart Cath - definitive/gold standard
CBC

59
Q

what will CXR show for pulmonary HTN

A

enlarged pulmonary arteries
right sided HF

60
Q

what will EKG show for pulmonary HTN

A

cor pulmonale - RVH, RAD, right atrial enlargement, RBBB
may have LVH

61
Q

what will echo with bubble study show for pulmonary HTN

A

elevated right ventricular systolic pressure
hypertrophied and dilated right ventricle
right ventricular dysfunction

62
Q

what will CBC show for pulmonary HTN

A

polycythemia with increased hematocrit

63
Q

tx for group 1 pulmonary HTN

A

oral CCB
endothelin receptor antagonists + PDE5 inhibitor - Ambrisentan + Tadalafil

64
Q

tx for group 2 pulmonary HTN

A

treating HF and volume overload w diuretics

65
Q

tx for group 3 pulmonary HTN

A

supplemental oxygen if hypoxemia at rest or with physical activity

66
Q

tx group 4 pulmonary HTN

A

long-term anticoagulation

67
Q

what is the MC cardiac cause of pulmonary HTN

A

mitral stenosis

68
Q

what are the 4 subtypes of non small cell lung CA

A

adenocarcinoma
large cell
squamous cell
carcinoid

69
Q

lung CA screening

A

annual low dose CT for those 55-80 who have no sx of lung CA + a 30 PPY smoking hx who currently smoke or who have quit within 15 years

70
Q

MC lung CA

A

adenocarcinoma

71
Q

common gene mutations in adenocarcinoma of the lung

A

KRAS
EGFR
ALK

72
Q

dx adenocarcinoma of the lung

A

CXR - peripherally located
CT guided biopsy - gland formation (glandular appearance) with mucin production

73
Q

second most common cause of lung CA after adenocarcinoma

A

squamous cell

74
Q

characteristics of squamous cell lung CA

A

CCCP
centrally located; associated w wide mediastinum
Cavitary lesions (central necrosis with cavitation)
hyperCalcemia
Pancoast syndrome

75
Q

dx squamous cell lung CA

A

sputum cytology
fiberoptic bronchoscopy
biopsy - keratinization by tumor cells and/or intracellular desmosomes (intercellular bridges)

76
Q

what paraneoplastic syndromes are associated w small cell (oat cell) lung CA

A

SVC syndrome
SIADH (hyponatremia)
Cushing syndrome (ectopic ACTH production)
Lambert Eaton syndrome

77
Q

dx small cell lung CA

A

CXR - centrally located mass
Biopsy - usually CT guided (peripherally located) or via bronchoscopy (centrally located)
Histology - sheets of small dark blue cells w rosette formation (about 2x the size of resting lymphocytes)

78
Q

tx for small cell vs other lung CA

A

small cell - chemo
others - surgery

79
Q

where is large cell lung CA typically located

A

large peripheral mass with prominent necrosis

80
Q

histology of large cell lung CA

A

pleomorphic giant cells (sheets of round to polygonal cells w prominent nucleoli and abundant pale staining cytoplasm w differentiating features)

81
Q

Superior vena cava syndrome sx

A

facial, neck, and upper extremity edema
facial plethora
chest pain
respiratory sx
neurologic sx

dyspnea is MC presenting sx

82
Q

tx SVC syndrome

A

stabilization
immediate endogenous intervention (thrombus removal or stent placement)

83
Q

Lambert-eaten syndroome

A

antibodies against presynaptic voltage gated CALCIUM channels

proximal muscle weakness that improves w repeated use

autonomic sx - dry mouth, postural hypoTN, erectile dysfunction
hyporeflexia

84
Q

superior sulcus (Pancoast) tumors

A

shoulder and arm pain most common initial sx ; pain can progress and radiate to head and neck

Horner syndrome - triad of ipsilateral ptosis, miosis, anhidrosis

weakness atrophy of the muscles of the hand and/or arm
may have ulnar neuropathy

85
Q
A

Internal Med EOR (17 decks)

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