Pulmonary

Question 1

Hemoptysis

Answer 1

Coughing up of blood or blood stained mucus from bronchi, larynx, trachea, or lungs

MCC

• Bronchitis - 50% hemoptysis, dry cough, cough w/ phlegm
• Tumor mass - 20% hemoptysis, CP, rib pain, tobacco hx, wt loss, clubbing
• TB - 8% hemptysis, CP, sweating
• Bronchiectasis, pulm cath, trauma, pulm hemorrhage

tx cause

Question 2

Lung Carcinoma

Answer 2

NSCLC

1. Adenocarcinoma - 35-40% cases, MCC
   
   • non smoker, incidental finding, small peripheral lesion
2. Squamous Cell Carcinoma - 25-35% cases
   
   • bronchial, centrally located
   • Smoker, hemoptysis*, abn CXR w/ large central solitary tumor
3. Large Cell
   
   • fast doubling, does not respond to surgery

Small Cell

• v aggressive, smokers, mets usu at dx
• a/w ACTH and ADH (hypoNa and hyperCa)
• lambert-eaton myasthenic syndrome - muscle weakness d/t ACTH and ADH
• CXR - mediastinal mass or LN

Dx

• CXR with dx
• bronch and biopsy for central - FNA

Tx

• NSCLC
  
  • stage 1-2 = surgery
  • Stage 3 = chemo then sx
  • Stage 4 = palliative
• SCLC
  
  • can’t be tx with sx - just chemo

Question 3

Weight Loss, Fatigue

ddx

Answer 3

• COPD - fatigue, SOB, dry cough
• Chronic fatigue - fatigue, anxiety, muscle pain
• Sarcoidosis - fatigue, eye redness, skin rash, swollen LN, hilar lymphadenopathy
• Interstitial Lung dz - SOB, tachypnea, wt loss, chronic cough, fatigue
• Pulm HTN - fatigue, can’t exercise, edema
• TB - fatigue, wt loss, hemoptysis, nt swts
• HIV - fatigue, wt loss nt swts, opportunistic infx
• Sleep apnea: fatigue, episodes of apnea, weight gain, snoring
• Rheumatoid arthritis: weight loss, fatigue, joint pain
• Hyperthyroidism: weight loss, fatigue, excessive sweating
• Type 1 diabetes: weight loss, fatigue, hunger
• Type 2 diabetes: weight loss, fatigue, excess thirst, excessive hunger
• Clinical depression/Seasonal affective disorder: fatigue, agitation, anxiety
• Anorexia: weight loss, irregular menstruation, underweight
• Insomnia: fatigue, sleeping difficulty, daytime sleepiness
• Anemia: SOB, pallor, brittle nails, tachycardia, lightheadedness, fatigue
• Anxiety disorder: fatigue, anxiety, excessive worry

Question 4

Pleural Effusion

Answer 4

Accumulation of excess fluids in pleura space

Sxs

• dyspnea
• vague discomfort or sharp pain that worsens during inspiration

Dx

Determine whether pleurocentesis

• exudative (infection, malignancy, immune) or
• transudative (transient changes in hydrostatic pressure - cirrhosis, CHF, nephrotic syndrome, ascites, hypoalbuminemia

Lateral decubitis CXR

• Isolated L Pleural effusion = exudative
• R sided = transudative

Chest CT

US

Thoracentesis - gold std and tx

Question 5

Light’s Criteria

Pleural Effusion

Answer 5

Pleurocentesis to determine if Pleural fluid is exudative:

1. Pleural fluid protein / serum protein >0.5
2. Pleural fluid LDH / Serum LDH >0.6
3. Pleural fluid LDH > 2/3

Exudative - infection, malignancy, immune,

MCC - pna, CA, PE, TB

Question 6

Pneumothorax

Answer 6

Collapsed lung caused by accumulation of air in pleural space

Spontaneous vs traumatic

• primary - abs of underlying dz (tall, thin, male age 10-30 at greater risk)
• Secondary - presence of underlying dz (COPD, asthma, CF, ILD)

Tension PTX

• Excessive pressure builds up around lungs - can cause heart to stop CO = shock

SXS:

• Acute onset ipsilateral chest pain and dyspnea - decreased tactile fremitus
• deviated trachea - to opposite side
• hyperresonance
• Diminished breath sounds

Tx - depends on size

• small < 15% of diameter of hemithorax - resolves spontaneously w/o chest tube placement
• large > 15% diameter & symptomatic - chest tube placement
• Serial CXR q 24 hrs until resolve
• Tension PTX
  
  • needle decompression = 2nd ICS, midclavicular
  • Chest tube after

Question 7

Postoperative PNA

Answer 7

3rd MC complication for all procedures; incr M&M

• HA PNA - develops w/in48-72 hrs after admission
• Ventilator associated PNA - w/in 48-72 hrs after endotracheal intubation

MSSA, S aureus, S pneumo, H influ => Pna w/in 4 to 7 da of hospitalization

Pseudomonas, MRSA, enteric G neg => MC w/ incr’ing LOS

Risk Factors

• > 70yo
• abd or thoracic sx
• functional debilitation

Dx

• CXR or CT
• bronch or blood cultures

Tx

• empirically chosen abx
  
  • pip tazo
  • Cefepime
  • Levo
  • Imipenem, Meropenem
  • Vanc or Linezolid - if MRSA

Question 8

SOB

Answer 8

• Asthma: SOB, flare-ups, wheezing
• COPD: SOB, fatigue, dry cough
• Pneumonia: SOB, fever, coughing
• Congestive heart failure: SOB, water retention, weight gain
• Acid reflux: SOB, nausea, epigastric pain
• Pneumothorax: tachypnea, shallow bread, SOB
• Pulmonary embolism: SOB, tachycardia, tachypnea, chest pain
• Foreign body aspiration: SOM, inspiratory stridor (if high in the airway), wheezing and decreased breath sounds in if low in airway
• Interstitial lung disease: SOB, tachypnea, weight loss, chronic cough, fatigue
• Obesity: SOB in the supine position, sleep apnea, weight gain, fatigue
• Pulmonary hypertension: SOB, fatigue, edema, cough, dizziness, hypotension
• Sarcoidosis: fatigue, eye redness, skin rash, swollen lymph nodes, hilar lymphadenopathy
• Tuberculosis: SOB, hemoptysis, fatigue, fever, weight loss, night sweats
• Anemia: SOB, pallor, brittle nails, tachycardia, lightheadedness, fatigue
• Cardiomyopathy: SOB, fatigue, edema, weight gain
• Pericarditis: SOB, fever, chest pain
• Epiglottitis: dysphagia, drooling, respiratory distress
• Generalized anxiety disorder: fatigue, SOB, irritability, fear, emotional distress, palpitations
• Myasthenia gravis: ptosis, weak chewing, easily fatigued, SOB, weakness in everyday activity (brushing hair)
• Fractured Rib: SOB, chest pain, trauma
• Sudden blood loss