Pulmonary Approach To Dyspnea, Palpitations, And Fatigue - Dr. Pence

Question 1

Vital signs showing respiratory distress

Answer 1

RR > 20/min
Tachypnea

O2 < 95%

Question 2

What can be both restrictive and obstructive

Answer 2

Bacterial and viral pneumonia

Question 3

Pulmonary HTN dx

Answer 3

Mean pulmonary artery pressure (mPAP) >20mmHg

Question 4

Pulmonary HTN can cause what

Answer 4

Cor pulmonae (RIGTH HF)
= JVD
= bilateral lower leg edema

Question 5

5 groups that can get pulmonary HTN

Answer 5

1. Pulmonary Artery HTN : CT disease, congenital, unknown usually hereditary cause
2. Left HF : valvular dysfunction, LV problem
3. Pulmonary Disease : ILD, COPD, OSA
4. Chronic VTE : chronic small PE
5. Miscellaneous : Sickle cell, sarcoidosis, tumor compression

Question 6

SX Pulmonary HTN

Answer 6

SOB
Fatigue 
Pre-syncope sx
CP
(JVP, edema, exertion syncope)

Question 7

How to DX Pulmonary HTN with ECG

Answer 7

1. RV hypertrophy
2. Right Axis deviation : + AVF, - I
3. RBBB : R and R’ seen in V1
4. RA enlargement : large peaked P waves on lead II

Question 8

Pulmonary HTN labs and imaging

Answer 8

1. BNP : legates when heart is expanding
2. Transthoracic Echocardiogram (TTE) : you can see chamber sizes and pulm artery systolic P (from tricuspid regurgitation gradient)
3. Cardiac Catheterization ** GOLD

Question 9

GOLD for Pulmonary HTN imaging

Answer 9

Swan Ganz Catheter

Question 10

Protein C and S doe what

Answer 10

BLOCK F8 and F5

Question 11

Antithrombin III does what

Answer 11

BLOCK : F2 and F10

Question 12

PE sx

Answer 12

SOB, CP, Palpitations, Unilateral leg edema, can have syncope
Tachycardia, hypoxia

Question 13

Criteria for blood clot of PE

Answer 13

Wells Criteria

Question 14

Low probability of DVT or PE order what

Answer 14

D-Dimer

Question 15

Higher or medium probability of DVT or PE you do what

Answer 15

Imaging study

Question 16

D- Dimer can be + when

Answer 16

Inflammation state
High Clotting
(If - then you know there is no DVT)

Question 17

PE EKG

Answer 17

1. Sinus tachy + Right Axis deviation + HIGH R in V1
2. Inverted T wave V1-V4
3. RBBB
4. S1Q3T3

Question 18

Imaging for PE

Answer 18

CT Chest + CONTRAST

V/Q scan ——> no radiation

Question 19

PE Echocardiogram

Answer 19

1. RV is dilated

2. LV barely opening up (can show D-shaped)

Question 20

Unstable PE is presenting how

Answer 20

Hypotension, RV strain, high cardiac enzymes

Question 21

TX Unstable PE

Answer 21

1. Resuscitation: Ventilation, vasopressin,
2. Anti-coags
3. Thrombolysis can be repeated, emboli to my, surgery thrombectomy

Question 22

TX Stable PE

Answer 22

1. Heparin = FAST , needs monitoring (increase antithrombin 3)
2. Low Molecular Weight Heparin = FAST
3. VIT K antagonist (Warfarin, Coumadin) = only when INR is 2-3 (normal)

Question 23

Newest best anti-coags

Answer 23

Direct Oral Anticoagulants (DOACs)
= Rivaroxaban, Apixaban, Endoxaban, Dabigatran)
= inhibits F10, or dabigatran inhibits F2

Question 24

Reversal agents for LMWH, Warfarin, DOAC

Answer 24

1. LMWH : Protamine Sulfate
2. W : Vit K, Prothrombin concentrate, fresh frozen plasma
3. DOAC : 10a inhibitors = Andexanet alpha, Dabigatran = idarucizumab

Question 25

Duration of tx for PE

Answer 25

``` 3 months (Malignancy or genetic mutation, hypercoagability disease = indefinitely) ```

Question 26

OSA is what

Answer 26

OBSTRUCTIVE SLEEP APNEA Disrupted breathing pattern when sleeping (can drops by more then 3% O2 sat, reduced breathing for 10sec or more, then gasping for air) = tired during day

Question 27

OSA severity measured by

Answer 27

Apnea Hypopnea Index (AHI) (apnea episodes /hour)

Question 28

Sleep causes what

Answer 28

Pharyngeal muscles relax | Brain monitors CO2 levels to constrict muscle and increase breathing rate until normal

Question 29

OSA is associated with what diseases (5)

Answer 29

``` HTN DM Atrial Fib / flutter CAD Occupational hazards ```

Question 30

OSA risks

Answer 30

``` Large tongue Obesity Craniofacial abnormalities Large tonsils Large LN Male ```

Question 31

Questionnaire used for OSA

Answer 31

STOPBANG

Question 32

DX OSA GOLD STANDARD

Answer 32

Polysomnogram = records sleep 6-7hr (EEG, ECG, ocular movements, airflow, O2sat) = gives you the AHI

Question 33

OSE TX 2

Answer 33

1. Continuous Positive Airway Pressure (CPAP) : nasal or oral mast or + P ventilation (low compliance) 2. Oral appliances: thrust mandible forward : mild osa , need frequent adjustments

Question 34

LFT of ILD

Answer 34

1. Restrictive pattern | 2. Decreased DLCO

Question 35

ILD does not have what 2 diseases

Answer 35

No primary infection of malignancy

Question 36

5 types of ILD

Answer 36

1. Idiopathic Interstitial Pneumonia. (Idiopathic Pulmonary Fibrosis) 2. Granulomatous ILD : Sarcoidosis, GPA, Goodpasture 3. CT ILD : RA, SS, Dermatomyositis/Polymyositis 4. Hypersensitivity Pneumonia: Farmers lung, bird poop, baker lung 5. Pneumoconiosis : Coal, silicosis, asbestosis, berylliosis

Question 37

Idiopathic Pulmonary Fibrosis Prevalence, SX, PE

Answer 37

1. Over 60yo 2. SOB, Dry cough, fatigue, can do daily activities 3. Velcro like crackles

Question 38

Idiopathic Pulmonary Fibrosis Imaging and LFT

Answer 38

1. CT : fibrosis HONEYCOMBING + traction bronchiectasis | 2. Restrictive pattern, low DLCO

Question 39

Idiopathic Pulmonary Fibrosis TX dont need to know drugs

Answer 39

1. O2, Steroids 2. Immunomodulators : Azathioprine, cyclophosphamide (moderate benefit) 3. Anti-fibrotic therapy : Pirfenidone, Nintedanib (some benefit)

Question 40

Sarcoidosis is what and prevalence

Answer 40

1. Non-caseating granulomas many locations (lungs most common) 2. F, AA, 2-3rd decade + 6th decade

Question 41

Sarcoidosis sx 4

Answer 41

1. Asymptomatic (25%) 2. Cough, SOB, 3. SLE, erythema nodosum 4. Anterior uveitis

Question 42

Sarcoidosis 2 syndromes and what they include

Answer 42

1. Lofgren’s Syndrome : Erythema nodosum, hilar LA, fever, arthritis 2. Herefordt’s syndrome : anterior uveitis, parotitis, Cranial N 7 palsy, fever

Question 43

Sarcoidosis labs

Answer 43

High CA High ACE High T-cells causing this

Question 44

Sarcoidosis Radiology and LFT

Answer 44

1. Hilar lymphadenopathy | 2. Restrictive obstructive or normal

Question 45

Sarcoidosis TX

Answer 45

1. Steroids * + SUPPORT (O2, rehab, nutrition) 2. Methotrexate , azathioprine, cyclophosphamide 3. Infliximab (TNF -1 inhibitors)

Question 46

GPA affects what locations and what happens and prevalence

Answer 46

1. Lungs, kidneys, sinus 2. Small V vasculitis , SOB, Cough, hemoptysis, saddle nose, chronic rhinitis, recurrent Otis media, fevers 3. Caucasians middle age

Question 47

GPA labs and radiology

Answer 47

1. C-ANCA | 2. Lung nodules, patchy ground glass opacities, hilar LAD

Question 48

GPA TX

Answer 48

Steroids + Cyclophosphamide*

Question 49

Goodpasture Syndrome what happens, prevalence, sX

Answer 49

1. Anti- Glomerular BM and Anti- Alveolar BM 2. Peds, adults , Caucasian 3. WL, fever, proteinuria, Hematuria, SOB, cough, Hemoptysis, hypoxemia

Question 50

Goodpasture Syndrome labs and radiology

Answer 50

1. Anti- GBM | 2. Bilateral ground glass opacities, = diffuse alveolar hemorrhage (DAH)

Question 51

Goodpasture Syndrome TX

Answer 51

1. Plasmapheresis ** | 2. Steroids + cyclophosphamide**

Question 52

CT disorders that can cause ILD 3

Answer 52

1. Systemic Sclerosis 2. RA 3. Dermatomyositis / Polymyositis

Question 53

Dermatomyositis / Polymyositis Labs

Answer 53

Anti- synthase ABs (myositis, reynoalds, mechanic hands, arthritis, ILD, fever)

Question 54

RA causing ILD more common in what gender

Answer 54

M ,all other RA sx more in F

Question 55

Hypersensitivity pneumonitis

Answer 55

Allergic reaction to something inhaled (alveolitis) = farmers, bird poop, woodworkers, bakers = HISTORY IS IMPORTANT

Question 56

Hypersensitivity Pneumonitis SX, radiology , LFT

Answer 56

1. Cough, SOB, fevers at times 2. Diverse, focal consolidation, irregular nodules, honeycombing NOT AT BASES (like in IPF) if chronic 3. Restrictive pattern

Question 57

Hypersensitivity Pneumonitis histology and tx

Answer 57

1. PLASMA CELLS ****, non-caseating granulomas can be seen | 2. Remove Ag (to prevent chronic fibrosis)

Question 58

Pneumoconiosis is what and caused by what

Answer 58

``` Inorganic dust inhaled causing inflammation and fibrosis = silicosis = asbestosis = coal workers (or navy) = Berylliosis ```

Question 59

Pneumoconiosis LFT and TX

Answer 59

1. Restrictive pattern | 2. Remove exposure, immunizations, stop smoking, O2 tx

Question 60

Pneumoconiosis are at risk of what

Answer 60

TB

Question 61

Silicosis comes from what and what is it, radiology

Answer 61

1. Crystalline quartz, miners, stone cutters,, sand blasting, quarry workers, 2. Nodular lung disease + calcified hilar LNs + fibrosis if progressing

Question 62

Asbestosis what is it and radiology and risk of what

Answer 62

1. Fibrous material construction, insulation, automobile worker, demolition 2. Many nodular opacitis, pleural effusion, pleural fibrosis, blurred cardiac and diaphragm image 3. Mesothelioma and lung cancer

Question 63

Coal miners Pneumoconiosis what is it and sx , radiology

Answer 63

1. Coal dust, miners 2. Asymptomatic ——> cough, SOB, sputum production 3. Nodules usually at apex, patchy infiltrates at base , can lead to fibrosis

Question 64

Berylliosis what happens and radiology and tx

Answer 64

1. Manufacturing alloys, electronic devises , similar to hypersensitivity reaction 2. Hilar LAD, diffuse infiltrates High risk of Lung cancer 3. Steroids *, remove Beryllium from environment