Pulmonary Flashcards
What are two possible explanations for shortness of breath in the hospital 3 days after a femur fracture?
- Fat embolism
2. Acute respiratory distress syndrome (ARDS)
What is the etiology of ARDS?
lung damage is triggered by NEUTROPHILS that release cytokines. Cytokines produce a variety of compounds that damage the alveolar epithelium.
Vascular damage = leakage of protein rich exudate, hyaline membrane formation = decreased CO2 excretion
What are chest xray findings of typical community acquired pneumonia by klebsiella?
Lobar cavitation
What is the most common cause of croup in a young child?
Parainfluenza type 1
What is the most common cause of typical pneumonia in HIV patients?
Strep Pneumo
What is the use of Oxymetazoline? what are adverse fx to be aware of when using?
topical decongestant applied directly to nasal passage
–if used more than 3 days, pt will experience rebound congestion (because of alpha receptor down-regulation)
What are two uses of N-acetylcysteine?
- acetaminophen overdose
2. mucolytic agent - classically used w cystic fibrosis
How is Asthma diagnosed?
what drug, what receptor?
Methacholine challenge test
–muscarinic (M3) receptor - causes bronchospasm
What is the most common HISTOLOGIC type of lung cancer? what are histologic signs?
Adenocarcinoma - neoplastic, invading glands filled with MUCIN (magenta colored material inside glands)
-lesions are usually peripherally located
How do you distinguish Transudative from exudative pleural fluid?
Light’s criteria: pleural fluid (PF) has to meet 2/3 criteria to be EFFUSION:
- PF protein: serum protein > 0.5
- PF LDH: serum LDH > 0.6
- PF LD 2/3 upper limit of normal serum LDH
identify type of malignancy and explain symptoms:
60 year old who smokes (30 packyear hx)
weightloss. CT shows hilar mass. elevated calcium levels
Squamous cell lung cancer
- -a/w smokers, central lesion
- -PTHrP production = hypercalcemia
identify type of malignancy:
50 year old nonsmoker presents with worsening shortness of breath. CXR shows peripheral nonnecrotic lesions
what other type can present similarly (how do you tell them apart)
Adenocarcinoma of lung
- -a/w nonsmokers
- -peripheral lesion
other peripheral is large cell
–Large cell with have NECROSIS
What is the function of pulmonary surfactant?
DECREASE alveolar surface tension
- decrease lung recoil
- increase lung compliance
What are adverse effects of therapeutic O2 for neonatal respiratory distress syndrome?
RIB
Retinopathy of prematurity
Intraventricular hemorrhage
Bronchopulmonary dysplasia
What type of cells are found
- until the end of bronchi
- until the beginning of terminal bronchioles
- until the end of terminal bronchioles
what segment is this called?
Conducting zone - nose, pharynx, larynx, trachea, bronchi, bronchioles, terminal bronchioles (anatomic dead space)
- cartilage, goblet cells
- Pseudostratified ciliated columnar cells - transition to cuboidal cells at the beginning of terminal bronchioles
- Airway smooth muscles extend to end of terminal bronchioles
What levels do what structures perforate the diaphragm?
I ate ten eggs at 12
T8 - Vena Cava
T10 - Oesophagus
T12 - aortic hiatus, thoracic duct, azygos vein
Cold winter morning, 6 month baby presents to ED for coughing, fever of 100F, respiratory distress. CXR shows hyperinflated lungs.
RR: 66/min with wheezing
what is most likely diagnosis?
Respiratory Syncytial Virus infection
–common cause of cough, fever, resp distress in infants during winter months
—case is NOT pneumonia b/c of CXR findings.
How can you tell if a pulmnoary thrombus was formed before or after death?
before death:
Lines of Zahn = interdigitating areas of pink (platelets, fibrin) and red (RBCs)
What is the light microscopy finding of lung tissue in small cell lung cancer?
Small round blue cells
several elderly patients present with difficulty breathing, high fever, intermittent diarrhea. All pts recently shopped at same grocery store where fresh veggies are stored under mist machines. Cant obtain sputum samples. What is the pathogen and what should be obtained for testing?
Legionnaires disease - Legionella pneumophila
(mild flu-like syndrome w fever, resp sx and diarrhea)
–found in elderly, alcoholics, smokers,
L. pneumophila antigens can be detect in URINE SAMPLES
+ sputum culture on Buffered Charcoal Yeast extract agar
85 year old presents with dyspnea. hemoptysis. Pulm fxn tests shows decreased FEV1, decreased FVC, normal FEV1/FVC ratio. social hx includes 20 pack year hx of cigarette smoking. alcohol use. Served in navy then retired to work in a tractor assembly plant.
What is dz? what is the histological appearance?
Asbestos related lung disease
- -decreased FEV1, FVC
- -normal FEV1/FVC ratio
Gold-grown fusiform, beaded rods that consist of fibers which are coated with iron containing proteinaceous material
40 year old alcoholic presents with fever, dyspnea, and productive cough. normal PaO2. Tender nodule in 4th intercostal space on right. Sputum sample is Pinkish in color, contains gram-positive organisms. CXR shows right middle lobe consolidation. Which is the most likely pathgen?
Staphylococcus aureus
- one of the most common organism that can cause pneumonia in ALCOHOLICS.
- SALMON-colored SPUTUM
What is the most common pathogen that causes pneumonia that requires hospitalization in pts with chronic bronchitis.
Moraxella catarrhalis
4 month old infant is brough to ED in january with respiratory distress. Sx began as runny nose and cough prior night. Now he is breathing heavily with audible wheezing. Breathing with accessory muscles. What is dx and what is most likely pathogen?
Bronchiolitis - acute inflammation of the small airways in children <2 years.
- -Most common cause = RSV in late fall, winter months
- deted by directed fluorescent antibody testing or culture
Pt presents with adenocarcinoma of the stomach with metastasis to the left supraclavicular lymph node (Virchow’s Node) - this can cause regional lymphatic vessel obstruction which can impede the drainage of what?
obstruction of the thoracic duct.
–drains bilateral lower extremities, pelvis, abdomen, left pleural cavity, upper lobe of left lung, left upper extremity, left head and neck.
What parts of the lung are drained the right lymphatic duct drain?
thoracic duct?
Right lymphatic duct:
Upper, middle, lower lobes of Right lung
Lower lobe of left lung
Thoracic duct:
upper lobe of left lung, left pleural cavity
What electrolyte imbalance is observed in Legionnaires disease? what type of organism is the pathogen?
Hyponatremia
Legionella pneumophila = facultative intracellular
–infect alveolar macrophages
7 year old male seen in rural Guatemala clinic. complains of dry cough, dyspnea, chest pain, febrile. CXR - several rounded infiltrates scattered throughout the lung fields bilatearlly. Sputum analysis reveals Charcot-Leyden crystals and eosinophils. Large round eggs are seen in stool sample, several larvae are seen in respiratory secretions, denies prurities in lower extremities. What is the pathogen?
Ascaris lumbricoids - eggs are ingested via fecal oral route
-larvae migrate through lungs
Strongyloides stercorali - also can cause pulmonary sx but NOT a/w Charcot-Leyden crystals
How do you distinguish Mesothelioma from a Carcinoma of the lung?
Mesothelioma
- -a/w asbestosis
- -Psammoma bodies seen on histology
- -**CYTOKERATIN + CALRETININ (negative in carcinoma)
–smoking is not a risk factor
9 year old w history of asthma presents with worsening of ocugh. dry cough which is worse at night and wakes him up. Needs to use his inhaler everyday. What is the first line treatment to prevent his sx from recurring
pt has progressed from mild intermittet asthma to persistent asthma (daily albuterol use + new nighttime cough)
–First line tx for mild persistent asthma = start inhaled steroid (BECLOMETHASONE)
pt who works at local sheep/goat farm presents with nonproductive cough, chills, malaise, fever that waxes and wane over the past 6 months. PMH: unknown valvular heart disease. febrile, mild hepatomegaly
CXR shows non-cavitary unilateral infiltrate.
What is dz? how is it most commonly contracted? what is pt at higher risk for?
Q fever - Coxiella burnetii
–chronic form most commonly in pts that are pregnant, immunocompromised, underlying valvular disease
–chronic form: multiplies in macrophages
= higher risk for Endocarditis (from immune complexes, autoabs)
-most commonly from cattle, goats, sheep placenta
How are squamous cell carcinomas distinguished histologically?
cells with eosinophilic cytoplasm and keratin pearls
intracellular desmosomes = “intracellular bridges”
Which type of lung carcinoma is this:
Sheets of round to polyonal cells with prominent nucleoli and abundant pale staining cytoplasm
-malignant epithelial neoplasm lacking glandular or squamous differentiation by light microscopy
what can this carcinoma secrete?
Large cell Carcinoma
can secrete B-hCG
Pt presents with a knife wound in his side. absent breath sounds on right, right side of thoacoabdominal diaphragm in an inhaled position relative to the left.
What would be seen on CXR?
pt has a tension pneumothorax - commonly from penetrating trauma to lungs
—-acts as one-way valve
CXR: tracheal deviation to the left - from build up of intrathoracic pressure on the right side
Pt presents with acute dyspnea. PMH of asthma. pulse-ox 84%. Physical exam = decreased breath sounds. labored respiration with subcostal retractions, extensive rales and wheezing throughout every lung field. Labs shows eosinophilia. Recent right arm pain with numbness and paresthesias.
What is the dz and what are serum findings?
Churg-Strauss (allergic granulomatous angiitis)
- dx criteria:
1. asthma
2. eosinophilia > 10%
3. Sinusitis
4. Pulmonary infiltrates
5. vasculitis
6. Polyneuropathy
-p-ANCA
What is the paraneoplastic syndromes a/w Small cell Lung cancer?
what are histological markers?
ADH + ACTHsecretion
Positive for:
Chromogranin A
Neuron-specific enolase
previously healthy 21 yr old college student presents with malaise, headache, and muscle pain for past 5 days. febrile, nonproductive cough and sore throat. CXR: extensive diffuse infiltrates. lab findings show elevated WBCs w high percentage of PMN cells.
what is the pathogen? what is the drug of choice? what else would be seen in serum?
Mycoplasma pneumoniae - atypical pneumonia,
- note imaging = diffuse infiltrates/patchy consolidation
- -dx = imaging + hx of living in close quarters (college student or military)
Tx: Macrolides (Erythromycin, Azithromycin) - for atypical pnemonia
serum: Cold agglutinins = IgM Abs to Ags on RBC membranes (anti-erythrocyte Abs)
What structure is located behind the angle of Louis? what spine level is this? What is this location used for in the emergency department?
Carina bifurcation of lung
at T4
used to identify second rib for needle decompression for tension pneumothorax at second intercostal space
pt presents with chronic cough. moved from central america when he was a child. sputum sample is negative on culture and gram stain. Microscopic KOH pprep shows multiple budding yeasts concentrically projecting from the larger yeast
what is pathogen?
Paracoccidioides basiliensis
Pt w PMH of IBS presents with progressive recurrent episodes of wheezing and difficulty breathing. admites to occasional periods of diarrhea, flushing of the neck, and dizziness.
What is the dz and what are additional findings?
Carcinoid syndrome from metastatic neuroendocrine tumor
–systolic murmur of the LLSB
frm Carcinoid heart disease - plaque like deposits of fibrous tissue on endocardium
Carcinoid tumors are most common carcinoma of the appendix and can present as appendicitis - most carcinoid tumors are slow growing = misdiagnosed as IBS
A patient with panacinar emphysema has associated liver disease? what is the mechanism of injury?
Alpha-1 antitrypsin
cirrhosis is caused by the accumulation of an insoluble (A1AT) mutant protein within hepatocytes
Which sinus is most commonly affected in sinusitis?
Maxillary
What is the major health risk for the fetus related to gestational diabetes?
lack of surfactant and massive intrapulmonary shunting = atelectasis
surfactant synthesis is decreased at high insulin levels
What will appear on lung biopsy of asbestosis?
Bx will show Ferruginous bodies =
Stain positive with Prussian blue
