PULMONARY Flashcards
tactile fremitus and percussion findings for: 1 consolidation/pna 2 pleural effusion 3 pneuothorax 4 emphysema 5 atelectasis
1 increased TF, dull to P 2 decreased TF, dull to P 3 decreased TF, hyperresonant to P 4 same as 3 5 decreased TF, dull to P
best initial test for acute asthma exxacerbation?
most accurate?
peak expiratory flow or ABG
most accurate = PFTs (decreased FEV1/FVC ratio)
if asx, best test to evaluate asthma is
methacholine challenge (20% decrease in FEV1)
if asthma, PFT will show an increase of ____ in response to albuterol
> 12%
stepwise asthma treatment
6 steps
1 inhaled SABA (albuterol)
2 low dose ICS (beclomathasone, budenoside, fluticasone) OR cromolyn/theophylline/leukotriene mods
3 add LABA (salmeterol, formeterol) OR increase ICS
4 increase ICS to maximum and cont LABA + SABA
5 add omalizumab
6 oral corticosteroids (prednisone)
**never use LABA first or alone
tx of acute asthma attack
oxygen
albuterol
steroids
if they dont respnd, intubate
young patient and nonsmoker who has air trapping and copd picture. think
alpha 1 antitrypsin deficiency
best initial test for copd is
most accurate?
cxr
look for increased ap diameter and flattened diaphragm/air trapping
most accurate is PFTs = FEV1 and FVC decreased, FEV1/FVC <70%, increased TLC, incomplete improvement with albuterol (not reversible)
copd treatment
1) things that improve mortality and delay progression
2) improves sx but no change in progression or mortality
3) no benefit
1 - smoking cessation, oxygen therapy, and flu/pneumococcal vaccines
2 - albuterol (SABA), anticholinergics (ipratropium, tipropium), steroids, LABA (salmeterol), and pulmonary rehab
3 cromolyn, leukotriene mods (monteleukast)
criteria for oxygen use in copd
pO2 below 55 or ox sat below 88%
OR
signs of right sided heart failure or elevated hematocrit with pO2 <60 or sat <90%
cxr for bronchiectasis
most accurate test?
thickened dilated bronchi, tram tracks
most accurate test is high res CT
allergic bronchopulmonary aspergillosis
mech?
dx?
tx?
hypersensitivity of the lungs to fungal antigens (patient with asthma and atopy)
brown flecked sputum and infiltrates on cxr
dx: peripheral eosinophilia, skin test reactivity to aspergillus ag, serum IgE elevated, CXR/CT infiltrates
tx: oral prednisone (inhaled DOES not work for ABPA)
+ itraconazole orally for recurrent cases
most accurate test for CF is
increased sweat chloride test (cl>60)
CF treatment
routine abx (inhaled aminoglycosides)
recombinant human deoxyribonuclease
bronchodilators (albuterol)
vaccinations (pneumococcal and influenza)
lung transplant when unresponsive to above therapy
CAP is defined as
pna occuring before hospitalization or within 48 hours of admission
what organism is associated with CAP with reference t contaminated water or ventilation?
legionella
pneumonia presentations:
1 hemoptysis and currant jelly sputum
2 foul sputum “rotten eggs”
3 dry cough, rarely severe, bullous myringitis
4 GI upset (n/v, diarrhea) or CNS (ha/confusion)
5 AIDS with <200 cd4
1 klebsiella 2 anaerobes 3 mycoplasma pneumoniae 4 legionella 5 pneumocytis (PCP)
best initial test (but not most accurate) for pna?
cxr
4 pneumonia orgs not visible on gram stain
coxiella
chlamydia
legionella
mycoplasma
sputum gram stain is “adequate” if ….
there are more than 25 white blood cells and less than 10 epithelial cells
how to diagnose legionella?
urine antigen
or
culture on charcoal yeast agar
outpatient vs inpatient tx for CAP
outpatient is macrolide (azithromycin or clarithromycin) or doxycycline
—if comorbidities do resp fluoroquinolone (levo or moxi)
inpatient is levo or moxi OR ceftriaxone + azithromycin
exudate/empyema is suggested by what labs
LDH >60% of serum
protein >50% of serum
pH <7.2
do healthcare workers need pneumococcal vaccine?
NO
every 65+ should receive the ___ followed by ___ 6-12 months later
pcv13
23pneumococcal
health care associated pneumonia defined as
pna developing more than 48 hours after admission or after hospitalization in past 90 days
often gram - (e coli or pseudomonas)
treatment for healthcare associated pna
NOT macrolines (azithro)
need to treat for gram - bacilli
use: antipseudomonals
cefepime or ceftazidine OR pip/tazo OR imipenem/meropenem
tx for ventilator associated pna
3 drug therapy antipseudomonal beta lactam (piptazo, ceftazidime) \+ aminoglycoside or fluoroquinolone \+ vanc or linezolid
most accurate test for PCP is
when to do it?
BAL
if sputum stain is negative in an aids patient
(if sputum is +, no need to do the BAL)
also if LDH is normal, it cant be PCP!
ppx for PCP?
tx?
if cant tolerate ?
both are tmp-smx
add steroids if pO2 <70 or A-agradient >35
tmp smx can cause rash/bone marrow suppression….can change to clinda + primaquine OR pentamidine
choose pentamidine if patient has G6PD
tb treatment
RIPE for 2 months..then just RI for 4 more
patient with abnrmal CXR or symptoms suggestive of tb should get what next done?
sputum acid fast testing x3
if screening ppdis + and cxr -, tx?
9 months isoniazid + pyridoxine
best initial step in all lung lesions/nodules is…
if it is enlarging…
compare to old cxr
biopsy it
cryoglobulinemia is associated with hx of what disease?
presentation?
hep C
palpable purpura + hepatosplenomegaly + proteinuria and hematuria
drugs that can cause pulmonary fibrosis?
amiodarone bleomycin busulfan cyclophosphamide nitrofurantoin
types of pneumoconioses based one xposure 1 coal 2 sandblasting, mining, tunneling 3 shipyard, insulation 4 cotton 5 electronics manufacturing 6 moldy sugar cane
1 coal workers pneumoconiosis 2 silicosis 3 asbestosis 4 byssinosis 5 berylliosis 6 bagassosis
pulmonary fibrosis presents with
loud P2
clubbing of fingers
dyspnea, worse w exertion
rales/crackles
PFTs of ILD (restrictive)
everything decreases proportionately
FEV1/FVC will be normal
DLCO is decreased
tx for ILD
prednisone
sarcoidosis
presentation?
dx?
tx?
cxr showsbilateral hilar adenopathy, noncaseating granulomas, hypercalcemia (granulomas make vitamin D)
cxr is best initial test
LN biopsy is most accurate test
PFTs will show restrictive picture (normal ratio)
tx with prednisone if symptomatic
mc abnormality on ekg for PE
nonspecific ST-T wave changes
adverse effects of angiography?
allergy, renal toxicity, death
PE treatment
heparin bridge + warfarin (inr 2-3)
when is an IVC filter the tx?
cant use anticoagulation (GI or brain bleeding)
recurrent emboli while on anticoagulation
RV dysfunction with enlarged RV
when to use thrombolytics?
hemodynamically unstable
acute RV dysfunction
If patient has HIT, switch from heparin to…
fondaparinoux
most accurate test for pulm htn?
right heart (swan-ganz) cath
who do you screen for lung cancer?
55-80 yo with 30 pack year hx, quit less than 15 years ago
annual low dose ct scan
