Pulmonary Dx

Question 1

Hilar (mediastinal) lymphadenopthy DDx

1. Young female
2. Young kid with a fever, from Ohio, zoo keeper
3. Old guy in his 60’s works on ceramics

Answer 1

1. Young female = Sarcoidosis
2. Young kid with a fever, from Ohio, zoo keeper = histoplasmosis
3. Old guy in his 60’s works on ceramics = Berylliosis

Question 2

Infectious Pulmonary Disorders x 9

Answer 2

1. Acute bronchitis = Cough which persists > five days, 95% are viral

1. Organisms:
   
   1. Most common: Viral
   2. Chronic lung patients: H. influenzae, S. pneumoniae, M. catarrhalis
2. Presentation:
   
   1. Cough, fever, constitutional symptoms
   2. Typically less severe than pneumonia, normal vital signs, no rales, no egophony
3. CXR: Normal
4. Treatment:
   
   1. Most patients = Symptomatic tx
   2. Exacerbation of chronic bronchitis = cephalosporin (2 gen)

2. Acute bronchiolitis

1. Most often caused by RSV, diagnosed by nasal washing
2. Presentation:
   
   1. Infants, young children
   2. Tachypnea, respiratory distress, wheezing
3. Treatment:
   
   1. RSV- admit if O2 sat < 95% and/or retractions. give IV ribavirin
   2. Not RSV- supportive, suction

3. Acute epiglottitis

1. Caused by Hib, unvaccinated child, Thumbprint sign on X-Ray (lateral neck)

4. Croup

1. Etiology: Parainfluenza virus
2. Presentation:
   
   1. Winter months, patients < 3 years old
   2. Barking cough, stridor at night
   3. AP radiograph: “Steeple sign”
3. Treatment:
   
   1. Supportive (air humidifier)
   2. Severe: IV fluids and racemic epinephrine

5. Influenza

1. Presentation: Fevers, chills, coryza, myalgia
2. Rapid antigen test can be performed in clinic
3. Treatment:
   
   1. Supportive therapy
   2. Zanamivir and Oseltamivir (Tamiflu) both treat influenza A and B must be given within 48 hours
   3. Amantadine and Rimantadine treat only influenza A
   4. Annual vaccine for everyone 6 months and older unless contraindicated

6. Pertussis (Whooping Cough) = Bordetella pertussis (GN capsule)

1. Presentation:
   
   1. Patients < 2 years old
   2. Catarrhal stage: Cold-like symptoms, poor feeding and sleeping
   3. Paroxysmal stage: high-pitched “inspiratory whoop”
   4. Convalescent stage: residual cough (100 days)
2. Diagnostic:
   
   1. diagnose by nasopharyngeal swab
   2. Lymphocytosis
3. Treatment: Macrolide
4. Vaccine: Tdap booster at 11-12 y/o, DTaP

7. Pneumonias

1. Presentation: Tachycardia, tachypnea, dyspnea, febrile, age 65+
2. Physical exam: Egophony, fremitus, rales
3. CXR: Infiltrates and or consolidation
4. Treatment:
   
   1. Community Acquired
      
      1. Adult: Healthy patients:
         
         1. First line: Macrolide (Azithromycin)
         2. Second line: Doxycycline
      2. Comorbidities:
         
         1. First line: Fluoroquinolone
         2. Second line: Beta-lactam + Macrolide
      3. Child:
         
         1. First line: Amoxicillin
         2. Second line: 2nd or 3rd generation Cephalosporin, Clindamycin or Macrolide
   2. Hospital Acquired (HAC): against MRSA + Pseudomonas
      
      1. `Vancomycin + Piperacillin/Tazobactam
   3. AIDs patients - prophylaxis against PCP pneumonia
      
      1. First line: Bactrim
      2. Second line: Dapsone
5. Admission criteria: CURB65
   
   1. Confusion
   2. Urea >7
   3. RR >30
   4. BP <90/<60
   5. age >65
6. Fungus
   
   1. Leukemia, lymphoma, immunosuppressed, AIDs
   2. Histoplasma capsulatum caused by bat droppings -looks like sarcoidosis on CXR
   3. Cryptococcus causes meningitis
   4. Coccidioides (valley fever) in dry states
7. Viral
   
   1. Adults= Influenza
   2. Adenovirus
   3. < 1 yo = RSV
   4. 2-5 yo = Parainfluenza

8. Respiratory syncytial virus infection

1. Bronchiolitis, nasal washing for RSV

9. Tuberculosis = Mycobacterium tuberculosis

1. Presentation: Cough, night sweats, weight loss, post-tussive rales, endemic area, immunocompromised.
2. Xray: cavitary lesions, infiltrates, ghon complexes in apex of lungs
   
   1. Acid-fast bacilli stain
   2. Biopsy: Caseating granulomas
3. Mantoux Test: Test is positive if induration
   
   1. >5 mm in immunosuppressed patients
   2. >10 in patients age <4 or has risk factors
   3. >15mm if there are no risk factors
4. Treatment:
   
   1. Latent: Isoniazid for 9 months
   2. Active: Isoniazid, Rifampin, Ethambutol, Pyrazinamide for 8 weeks
      
      1. Isoniazid- peripheral neuropathy (give with B6)
      2. Rifampin- Red orange urine, hepatitis
      3. Ethambutol- Optic neuritis (eye changes), red-green blindness
      4. Pyrazinamide- hyperuricemia
   3. Prophylaxis for household members: Isoniazid for 1 yr

Question 3

Acute Bronchitis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 3

1. CC. Patient will present with → cough and dyspnea for 6 days
2. Def: Acute bronchitis = cough > 5 DAYS
3. S&S: No fever (if fever think PNA)
   
   1. (95%) of acute bronchitis is VIRAL
   2. Bacterial causes of acute bronchitis include: M. Catarrhalis > H. influenzae, S. Pneumoniae
4. Dx: CXR if sxs refractory to tx
5. Tx: Since most cases (95%) are viral symptomatic treatment is the cornerstone of management:
   
   1. Fluids, rest, PRN bronchodilators, short term inhaled steroids
   2. Antibiotics have no statistical benefit in the treatment of acute bronchitis. They may be considered in elderly, COPD or immunocompromised patients who don’t respond to conservative treatment

Question 4

Acute bronchiolitis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 4

1. CC: Patient will present as → first episode of wheezing in a child 12-24 months with findings of viral respiratory infection.
2. Def: Acute bronchiolitis
   
   1. ​Respiratory syncytial virus (RSV) mc cause - fall & winter
3. S&S:
   
   1. CXR often normal - may show air trapping and peribronchial thickening.
4. Dx: nasal washing for RSV culture & antigen assay
   
   1. Hospitalization and administration of ribavirin if 1 of the following:
      
      1. O2 < 95% (hospitalization)
      2. age < 3 months
      3. respiratory rate > 70
      4. atelectasis on chest radiograph
5. Tx:
   
   1. Treatment is supportive c Humidified 02, antipyretics
   2. Beta agonists, nebulized racemic epinephrine, corticosteroids if h/o underlying reactive airway disease - all are commonly used but do not have proof of efficacy
   3. Ribavirin if severe lung or heart disease and in immunocompromised patients

Question 5

Acute epiglottitis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 5

1. CC: Patient will present with → sudden onset of high fever, respiratory distress, severe dysphagia, drooling and a muffled voice in an unvaccinated child
2. Def: Acute epiglottitis = medical emergency
   
   1. Caused by Haemophilus influenzae Type B virus (HiB)
   2. Kids c/o shots (in developed countries kids get HiB vaccine at 2,4,6 and 12-15 months) or Underserved areas/nations
3. S&S: 3D’s
   
   1. Dysphagia, Drooling, respiratory Distress
   2. Tripod or “sniffing dog” posture (neck extended)
4. Dx: 1st secure airway, culture for H.flu
   
   1. CXR = Thumbprint sign on lateral neck film from swelling of the epiglottis
5. Tx: intubate (if necessary) and provide supportive care
   
   1. Cephalosporins = Ceftriaxone (Rocephin)
   2. May treat as outpatient if no concern about airway, otherwise admit.

Question 6

Laryngotracheobronchitis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 6

1. CC: patient will present with → 2-year-old with barking cough and stridor
2. Def: Coup
   
   1. Caused by parainfluenza virus - fall to early winter
   2. Children 6 mo - 3 yo
3. S&S: barking cough and stridor
4. Dx: 1st secure airway, culture for H.flu
   
   1. CXR = “Steeple sign” on PA neck X-Ray (narrowing of the trachea in the subglottic region)
5. Tx: provide supportive care (antipyretics, hydration)
   
   1. Nebulized racemic epinephrine (only if signs of distress), and corticosteroids.
   2. Prognosis excellent

Question 7

Influenza

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 7

1. CC: Patient will present with → sudden onset of fever, chills, malaise, sore throat, headache coryza and myalgia (especially in the back and legs)
2. Def: Influenza ​
   
   1. Caused by Influenza A & B - winter mos
3. S&S: fever, headache, myalgia and malaise.
   
   1. Complications mc in very young, very old, and those c preexisting comorbidities.
4. Dx: Rapid antigen test
5. Tx: Tx effective only c/in 48 hrs (will decrease 1 day)
   
   1. Zanamivir and Oseltamivir = influenza A and B (think Dr. “OZ” treats the flu)
      
      1. Oseltamivir (Tamiflu) 75 mg PO two times per day for 5 days
   2. Amantadine and Rimantadine = only influenza A
   3. Children < 18 yo, avoid salicylates (bismuth) bc it can cause Reye’s syndrome.
6. Prevention
   
   1. With rare exceptions, all persons > 6 months of age should be vaccinated against influenza yearly.

Question 8

Whooping Cough

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 8

1. CC: Patient will present as → a 24 year old with increasing cough for 3 weeks. Cough comes and goes sometimes lasting for 10 minutes and causing gasping inhalations. Cough was preceded by a mild cough and cold 2 weeks ago. She has completed all immunizations required to attend school and has no known drug allergies
   
   1. Patient will present with → severe paroxysmal cough followed by an inspiratory high-pitched whoop, if untreated will develop a chronic cough lasting for weeks
2. Def: Whooping Cough ​
   
   1. Caused by highly contagious Bordetella Pertussis (Gram -)
3. S&S: adults with cough > 2 weeks
4. Dx: nasopharyngeal secretions & culture
5. Tx: Supportive care (steroids +/- B2agonists)
   
   1. Clarithromycin or Azithromycin
   2. All close contacts should be treated c macrolide prophylaxis regardless of age, immunization history or symptoms.”
6. Prevention
   
   1. Children should get 5 doses of DTaP vaccine: one dose at each of the following ages:
      
      1. 2 mos, 4 mos, 6 mos, 15-18 mos, 4-6 mos
   2. Adolescents 11 - 18 years of age (preferably at age 11-12 years) should receive a single booster dose of Tdap
      
      1. 19 years of age and older who did not get Tdap as an adolescent.
      2. Each pregnancy, at 27-36 weeks.​

Question 9

Pneumonias

1. Bacterial x 6
2. Viral x 2 (adults vs kids)
3. Fungal
4. HIV-related

Answer 9

Bacterial

1. S. Pneumoniae - Rust-colored sputum - mc in splenectomy pts
2. S. Aureus - Salmon colored sputum - MRSA treat c vancomycin
3. Pseudomonas - Ventilators, patients become sick fast - treat c 2 antibiotics
4. Legionella - water contamination (spas, AC) => low NA+ (hyponatremia), GI symptoms (diarrhea) and high fever
5. Mycoplasma - Young people living in dorms, (+) cold agglutinins, bullous myringitis
6. Klebsiella - currant jelly sputum, drinkers, aspiration

Viral

1. Adults → Flu is most common viral cause
2. Kids → RSV, 1st episode of wheezing

Fungal

1. Valley Fever = Coccidioides – patients c non-remitting cough/bronchitis non-responsive to conventional txs. Caused by fungal inhalation in western states.
2. Histoplasma capsulatum - bird or bat droppings (caves, zoo, bird),
3. Cryptococcus – found in soil can disseminate => can cause meningitis.
4. Pulmonary aspergillosis - mc in pts c c underlying illnesses such as tuberculosis or chronic obstructive pulmonary disease (COPD), but with otherwise healthy

HIV-related pneumonia

1. Formerly PCP Pneumonia now called (PJP) Pneumocystis jiroveci Common in HIV-infected patients c low CD4 < 200, treat (and prophylax) c Bactrim

Question 10

Bacterial Pneumonias

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 10

1. CC: Patient will present with → a 71-year-old male who was admitted to acute care hospital 2 days following a massive CVA c possible brainstem infarct. Because he was also experiencing secondary respiratory failure, he was intubated and placed on mechanical ventilation. He was subsequently transferred to the neurointensive care unit where he was stabilized. His present vital signs are: respiratory rate 14 (ventilator rate), temperature 100.4 F. His SpO2 is 95%. His rating on the Glasgow Coma Scale is 5.
2. Def:
   
   1. S. Pneumoniae - Rust colored sputum - common in patients with splenectomy
   2. S. Aureus - Salmon colored sputum - MRSA treat with vancomycin
   3. Pseudomonas - Ventilators, patients become sick fast - treat with 2 antibiotics
   4. Legionella - low NA+ (hyponatremia), GI symptoms (diarrhea) and high fever
   5. Mycoplasma - Young people living in dorms, (+) cold agglutinins, bullous myringitis
   6. Klebsiella - currant jelly sputum, drinkers, aspiration
   7. Pneumocystis jiroveci (PJP) - HIV postive (<200 CD4)
   8. Anaerobes - Poor dental hygiene
   9. Influenza pneumonia - precipitous onset and fulminant course
   10. Atypical pneumonia (Mycoplasma > Legionella, Chlamydia) - indolent course
   11. Lobar consolidation - CAP
   12. Apical infiltration - tuberculosis
3. S&S:
   
   1. (+) egophony - Transmission of vocal sounds through consolidation leads to the changes heard with egophony.
   2. (+) tactile fremitus - Consolidation would increase the transmission of vocal vibrations and manifest as increased tactile fremitus.
   3. (+) dullness to percussion
4. Dx:
   
   1. CXR: patchy, segmental lobar, multilobar consolidation
      
      1. Blood cultures x 2, sputum gram stain
5. Tx:
   
   1. Outpt = Macrolides (azithromycin), Doxycycline
   2. Inpt (hospitalize if > 50 c comorbidities, altered mental status, poor fluid status) = Azithromycin + Ceftriaxone, Respiratory Fluroquinolones
6. Prevention
   
   1. Children should get 5 doses of DTaP vaccine: one dose at each of the following ages:
      
      1. 2 mos, 4 mos, 6 mos, 15-18 mos, 4-6 mos
   2. Adolescents 11 - 18 years of age (preferably at age 11-12 years) should receive a single booster dose of Tdap
      
      1. 19 years of age and older who did not get Tdap as an adolescent.
      2. Each pregnancy, at 27-36 weeks.

Question 11

Viral Pneumonias

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 11

1. CC: Patient will present with → 1 week history of hacking non-productive cough, low grade fever, malaise and myalgias. The chest x-ray reveals bilateral interstitial infiltrates and a cold agglutinin titer that is negative. Examination reveals scattered rhonchi and rales upon auscultation of the chest.
2. Def:
   
   1. Adults → Flu is the most common viral cause
   2. Kids → RSV - 1st episode of wheezing
3. S&S:
   
   1. Adenovirus = fast c GI sxs and lasts about 1 week. May differentiate from bacterial mycoplasma pneumonia as mycoplasma is slow and insidious.(+) dullness to percussion
4. Dx:
   
   1. Rapid antigen test for Influenza
   2. RSV nasal swab
   3. Cold agglutinin titer that is negative
   4. CXR: bilateral interstitial infitrates
      
      1. Blood cultures x 2, sputum gram stain
5. Tx:
   
   1. Influenza = oseltamivir (Tamiflu) c/in 48 hrs
   2. Supportive symptomatic, may use beta 2 agonists, fluids, rest
6. Prevention
   
   1. Influenza vaccine every year (all over 6 months year old)

Question 12

Fungal Pneumonias

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 12

1. CC: Patient will present with → non-remitting cough/bronchitis non-responsive to conventional treatments
2. Def: Fungal Pneumonia - 4 types: Common in immunocompromised patients – AIDS, steroid use, organ transplant.
   
   1. Valley Fever = Coccidioides – patient c non-remitting cough/bronchitis non-responsive to conventional treatments.
      
      1. Caused by fungal inhalation in western states.
      2. Tx: fluconazole or itraconazole.
   2. Pulmonary aspergillosis: underlying illnesses such as TB or COPD), but c otherwise healthy immune systems.
      
      1. Tx: fluconazole or itraconazole.
   3. Cryptococcus – found in soil can disseminate and can cause meningitis
      
      1. Immunocompromised patients usually symptomatic
      2. Lumbar puncture for meningitis
      3. Tx: Amphotericin B
   4. 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.
      
      1. Bird or bat droppings (caves, zoo, bird)
      2. Mississippi or Ohio river valley
      3. Mediastinal or hilar lymphadenopathy (looks like sarcoid)
      4. Tx: Amphotericin B
3. Dx:
   
   1. CXR: Histoplasma capsulatum causes mediastinal or hilar lymphadenopathy (looks like sarcoidosis)
4. Tx:
   
   1. Cryptococcus & Histoplasma - Amphotericin B
   2. Coccidioides & Aspergillus - Fluconazole/ Itraconazole
5. Prevention
   
   1. Influenza vaccine every year (all over 6 months year old)

Question 13

HIV-related pneumonia

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 13

1. CC: Patient will present as → a 32 year-old male with dyspnea and a nonproductive cough. His is tachycardic, tachypneic and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia and his LDH is elevated
2. Def: Formerly PCP Pneumonia now called (PJP) Pneumocystis jiroveci (there are other HIV related pnuemonias but this is the one you will need to know for the test)
   
   1. Common in HIV-infected patients with a low CD4 count of less than 200
3. Dx:
   
   1. CXR is the cornerstone of diagnosis. The radiograph shows diffuse interstitial or bilateral perihilar infiltrates
   2. Diagnose with a bronchoalveolar lavage (PCR), labs and an HIV test.
4. Tx:
   
   1. Trimethoprim-sulfamethoxazole (BACTRIM) and steroids
      
      1. If allergic treat with Pentamidine
   2. Prophylaxis for high risk patients c CD4 count < 200 or c hx of PJP infection
      
      1. Daily Bactrim is the prophylaxis antibiotic of choice.

Question 14

Respiratory syncytial virus infection

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 14

1. CC: Patient will present with → 4-month-old with wheezing, cough and dyspnea
2. Def: Primarily an illness of young children, most common cause is RSV (respiratory syncytial virus)
3. Dx:
   
   1. Nasal washing for RSV, CX and AG assay
4. Tx: Indications for hospitalization include moderate tachypnea with feeding difficulties, visible retractions and oxygen desaturation
   
   1. Supportive measures include, albuterol via nebulizer, antipyretics and humidified oxygen

Question 15

Tuberculosis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 15

1. CC: Patient will present with → fever, hemoptysis, recent travel, night sweats, weight loss, shortness of breath, social contact with same symptoms
2. Def: Tuberculosis is transmitted by respiratory droplets
3. S&S: fever, night sweats, anorexia and weight loss
   
   1. PPD Rules: Area of induration “raised” (not the red area) = < 5 mm in HIV; < 10 mm in high risk area (healthcare worker or possible known exposure); < 15 mm for non-exposer
4. Dx: sputum for AFB smears and cultures
   
   1. CXR - upper (apical) cavitary lesions
   2. Ghon complex (calcified lymph + lesions)
   3. Miliary Tb (Tb spread outside the lungs)
      
      1. Potts dz - Tb to spine
      2. Scrofula - Tb to cervical LNs
5. Tx:
   
   1. If + PPD => CXR
   2. If CXR negative => latent => (INH + B6) x 6 mos
   3. If CXR positive => active => RIPE - all drugs are hepatotoxic so get baseline labs
      
      1. 4 drugs x 8 wks => 2 drugs x 16 wks => can stop tx if 2 negative AFB smear + culture in a row
         
         1. Rifampin (RIF) => Red bodily fluids
         2. Isoniazid (INH) => peripheral neuropathy + hepatitis
            
            1. give B6 to prevent neuropathy
         3. Pyrazinamide (PZA) => GI + hyperuricemia => gout
         4. Ethambutol (EMB) = optic neuritis (red-green vision loss) “Eyes”
            
            1. Also used to tx RA, need to test for TB prior to tx because it can reactivate dormant TB
6. Tx summary
   
   1. isolate hospitalized pts who may have TB (cough for 3 weeks, night sweats, hemoptysis, etc) => send 3 sputum specimens for acid-fast bacilli and Mycobacterium tuberculosis cultures. => order a newer test called nucleic acid amplification (better& quicker at identifying TB vs other Mycobacterium)
   2. Start empiric treatment in those likely to have TB…such as a symptomatic patient with TB exposure. Use culture results to confirm dx (available c/in 6 wks)
   3. Continue to treat c RIPE x 2 mos => (RIF + INH) x 2 mos
   4. Monitor serum creatinine and adjust dosing, if needed. For example, reduce ethambutol and pyrazinamide dosing to three times per week instead of daily in patients with a CrCl of less than 30 mL/min.
   5. Add pyridoxine 25 to 50 mg/day when isoniazid is used in patients at risk for neuropathy...such as those with alcoholism, diabetes, or HIV.
   6. Most outpatients will be managed by your local health department…to directly observe them taking TB meds, for monitoring, etc.
   7. Reinforce ways to improve med efficacy in your office…such as advising to take most TB meds on an empty stomach, since food can reduce absorption. If patients complain of nausea, try adding an antacid.
   8. Watch for hepatotoxicity with isoniazid, pyrazinamide, or rifampin...and severe side effects such as rash, drug fever, etc.
   9. Also be aware of drug interactions…especially with HIV meds. For example, double the raltegravir (Isentress) dose when used with rifampin.

Question 16

Carcinoid tumors

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 16

1. CC: Patient will present with → Carcinoid syndrome = Cutaneous flushing, diarrhea, wheezing and low blood pressure. This is the hallmark sign!
2. Def: Carcinoid tumors are a GI tract cancer that has metastasized to the lungs
   
   1. Mc appendiceal ca => liver => lungs
3. S&S:
   
   1. haemoptysis, cough, focal wheezing or recurrent pneumoniac
   2. Carcinoid syndrome (the hallmark sign) is actually quite rare.
      
      1. Cutaneous flushing
      2. diarrhea
      3. wheezing
      4. low blood pressure
4. Dx: CXR show low grade ca see as pedunculated sessile growth in the central bronchi
5. Tx: surgical excision => good prognosis.
   
   1. lesions are resistant to radiation therapy and chemotherapy. Octreotide can be used to treat symptoms.
6. Image = Endobronchial carcinoid tumor in a Crohn disease patient (centrally located sessile growth is common)

Question 17

Lung Cancer

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 17

1. CC: Patient will present as → a previous smoker c new or changing cough, weight loss, hemoptysis and hoarseness
   
   1. Def: Lung ca classified into 2 major catecories
      
      1. Small cell (SCLC) - 15% => poor px
         
         1. rapidly growing, 80% metastatic @ dx. Spreads early & rarely amendable to surgery.
         2. Assoc. c smoking, ACTH, ADH => hyponatremia & hypercalcemia
         3. Lambert-Eaton myasthenic syndrome = muscle weakness of the limbs caused by ACTH/ADH
         4. CXR: Mediastinal mass or unilateral LNs
   2. Non-small cell (NSLC) - 85% => grow slowly and is more amendable to surgery
      
      1. squamous cell carcinoma (40%) = non smoker, c incidental finding of small peripheral lesion
      2. adenocarcinoma (35%) = smoker c hemoptysis and large central solitary tumor. (started in the lung tissue has invaded the bronchus and this is why they are now coughing up blood)
      3. large cell carcinoma (5%) = Fast doubling rates - responds to surgery rare
2. Dx: New lesions > 0.5 cm need bx due to high malignancy rate (unless lesion is calcified or has been stable for yrs)
   
   1. CXR = help c dx
      
      1. SCLC = mediastinal mass or unilateral LNs - 99% smokers
      2. NSLC
         
         1. Adenocarcinoma = sm peripheral mass
         2. SCC = central mass + hemoptysis
   2. Path = BRONCHOSCOPY + BIOPSY for central lesions or FINE NEEDLE TRANSTHORACIC ASPIRATION
3. Associated syndromes
   
   1. SVC = tumor pushes into SVC => facial/arm swelling
   2. Pancoast = shoulder pain + bony destructio + Horner’s syndrome (miosis, ptosis, anhidrosis)
      
      1. miosis = excessive pupil constriction
      2. ptosis = droopy eyelid
      3. anhidrosis = can’t sweat
   3. Paraneoplastic phenomena = High Ca2+, SIADH, Anemia, DVT, Cushing’s
4. Tx
   
   1. SCLC = Chemo
   2. NSLC
      
      1. stage 1-2 = surgery resection
      2. stage 3 = chemo => surgery
      3. stage 5 = palliative
5. Image = SCLC

Question 18

Pulmonary nodules

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 18

1. CC: Patient will present →incidental finding of small < 3 cm pulmonary lesion, they are likely asymptomatic.
2. Def: < 3 cm = nodule “coin lesions”; > 3 cm = mass
3. WU:
   
   1. Incidental finding on CXR →
   2. Send for CT →
   3. If suspicious (depending on radiographic findings below) will need bx
4. Dx = CXR help define malignant potential of a solitary pulmonary nodule
   
   1. Growth rate compared to previous imaging
      
      1. not enlarged in ≥ 2 yr = benign
      2. Small nodules (< 1 cm) should be monitored at 3 mo, 6 mo, and then yearly for 2 yr.
   2. Calcification = benign dz, central (tuberculoma, histoplasmoma), concentric (healed histoplasmosis), or popcorn configuration (hamartoma).
   3. Margins
      
      1. Lobular/Spiculated/irregular (scalloped) = cancer
      2. Smooth/regular = benign
   4. Diameter
      
      1. <1.5 cm = benign
      2. >5,3 cm = cancer (exceptions include lung abscess, Wegener’s granulomatosis, and hydatid cyst)
5. Path = BRONCHOSCOPY + BIOPSY for central lesions or FINE NEEDLE TRANSTHORACIC ASPIRATION
6. Tx
   
   1. stage 5 = palliative
   2. stage 3 = chemo => surgery
   3. stage 1-2 = surgery resection
7. Image = solitary pulmonary nodule (indicated by a black box) in the left upper lobe

Question 19

Forced Vital Capacity

Answer 19

1. Forced expiratory volume (FEV) measures how much air a person can exhale during a forced breath. The amount of air exhaled may be measured during the first (FEV1), second (FEV2), and/or third seconds (FEV3) of the forced breath.
2. Forced vital capacity (FVC) is the total amount of air exhaled during the FEV test.
3. Obstructive Lung disease
   
   1. Asthma = FEV1 decrease and FVC increase => FEV1/FVC <75-80%
4. Restrictive Lung
   
   1. Idiopathic Interstitial lung Dz = FEV1 increase and FVC decrease => FEV1/FVC normal ration

Question 20

Obstructive (5) vs Restrictive (3) Lung Disease

Answer 20

Obstructive = reduction in airflow, decrease FEV1 and FEV1/FVC <75-80%

1. Asthma
2. Bronchiectasis
3. Chronic Bronchitis
4. Emphysema
5. Cystic Fibrosis

Restrictive = reduced lung volume, TLC < 80% of predicted value

1. Idiopathic Pulmonary Fibrosis
2. Pneumoconiosis
3. Sarcoidosis

Question 21

Obstructive Lung Disease list

Answer 21

Question 22

Asthma

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 22

1. CC: Patient will present with → cough, shortness of breath (dyspnea), tachypnea and prolonged EXPIRATORY wheezing,in more severe cases may assume the tripod position,atopic triad - wheeze, eczema, seasonal rhinitis
2. Def: Asthma is a chronic, REVERSIBLE, inflammatory airway disease characterized by recurrent attacks of breathlessness and wheezing.
3. S&S:
   
   1. lack of wheezing in an acute attack = emergency
   2. Peak flow = inexpensive and easily available monitoring device once the diagnosis of asthma has been established.
   3. NSAIDs & aspirin can precipitate acute attack

Dx = GOLD STANDARD => PEAK EXPIRATORY FLOW RATE

1. Spirometry pre and post therapy (albuterol inhalation) readings
   
   1. Decreased FEV1/FVC (75-80%)
   2. > 10% increase FEV1 c bronchodilator therapy
2. Four major classifications of asthma severity used primarily to initiate therapy:
   
   1. M__ild intermittent: ≤2/wk @ day, ≤2/mo @ night
      
      1. short-acting β-agonist (SABA) use ≤2/week, no interference c normal activity
   2. Mild persistent: ≤1/day @ day, <1/wk @ night
      
      1. SABA use >2/wk but not daily, minor limitations in normal activity
   3. Moderate persistent: ≥1/wk @ day, ≥1/wk @ night
      
      1. SABA use daily, some limitation in normal activity
   4. Severe persistent: ≥1/day @ day, frequent @ night
      
      1. SABA use several times a day, extremely limited normal activity
3. Tx = stepwise fashion
   
   1. SABA→
   2. SABA + ICS daily →
   3. SABA + ICS + LABA + Theophyllines →
   4. SABA + ICS + LABA + Theophyllines + systemic steroids
4. Acute Tx = Inhaled cortical steroids (ICS) + IV steroids (or PO steroids), check every 1-2 hrs

Question 23

Bronchiectasis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 23

1. CC: Patient will present with → foul breath, purulent sputum and hemoptysis along with a CXR demonstrating dilated and thickened airways with “plate-like” atelectasis (scarring)
2. Def: Bronchiectasis is described as the permanent dilation or destruction of the bronchial walls caused by chronic inflammation/infection/idiopathic
   
   1. MC cause is Cystic fibrosis (CF)
   2. <18 yo = staph infections
   3. >18 yo = Pseudomonas infections
3. Dx
   
   1. CXR = linear (“tram track”) lung markings, atelectasis, dilated and thickened airways “Plate-like” atelectasis (scarring)
   2. Chest CT = Gold standard dx
4. Tx
   
   1. Ambulatory oxygen
   2. aggressive antibiotics
   3. CPT (chest physiotherapy = bang on the back)
   4. Eventually lung transplant​
5. Image = typical “plate-like” atelectasis associated with bronchiectasis

Question 24

Chronic Bronchitis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 24

1. CC: Patient will present as → 60-year-old female who has presented to the ED c SOB shortness of breath of recent onset. She has a six year COPD hx and is on oxygen at home. Physical assessment reveals the following: respiratory rate 32, slightly labored, temperature 98.9F. His SpO2 90% while receiving oxygen via nasal cannula at 2 Lpm.
2. Def: Chronic Bronchitis= Cyanosis + pulm. HTN =>Blue Bloaters (2º to chronic hypoxia)
   
   1. chronic productive (most days) cough for 3 months of the year for 2 or more consecutive years c/o otherwise-defined acute cause.
   2. Common in smokers (80% of COPD pts)
   3. Chronic hypoxic state => cyanosis => ↑ Hgb + HCT + RVH => ↑ pulmonary HTN, JVD, hepatomegaly
3. Dx
   
   1. CXR - perivascular and peribronchial markings
   2. Diagnosis is clinical but confirmed by biopsy ↑ Reid index (gland layer is > 50% of total bronchial wall)
4. Tx
   
   1. Ipratropium inhaler (inhaled beta agonists) choice for COPD
   2. Oral steroids
   3. Oxygen = single most important medication in long term
   4. PRN abx for acute exacerbations
      
      1. mild = narrow spectrum
         
         1. amoxicillin
         2. TMX/SMX
         3. doxycyclin
      2. moderate & severe = broad spectrum
         
         1. amoxicillin/clavulanate (augmentem)
         2. TMX/SMX
         3. Cefuroxime axetil
         4. Levofloxacin
         5. Ciprofloxacin
5. Image = solitary pulmonary nodule (indicated by a black box) in the left upper lobe

Question 25

Emphysema

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 25

1. CC = Patient will present with → exertional dyspnea, minimal cough, quite lungs, thin, barrel chest. CXR reveal flattened diaphragm, hyperinflation and small, thin appearing heart
2. Def = Emphysema is a condition in which alveolar septae destruction => enlarged air spaces
   
   1. body’s natural response to ↓ lung function is chronic hyperventilation = Pink Puffers!
   2. Normal HCT
   3. Alveoli destroyed => CO2 retained => body increase ventilation to blow out CO2
3. Dx
   
   1. CXR = loss of lung markings, Parenchymal bullae & blebs, Hyperinflation, flat diaphragms, barrel chest
4. Tx - same as Chronic Bronchitis
   
   1. Ipratropium (also albuterol inhaler)
   2. O2
   3. Oral steroids
   4. Antibiotics

Question 26

Cystic Fibrosis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 26

1. CC. Patient will present as → a young patient c hx of chronic lung disease, pancreatitis or infertility. May have clubbing of fingers CXR may reveal hyperinflation, mucus plugging and focal atelectasis. Labs will reveal an elevated quantitative sweat chloride test
2. Def = Cystic fibrosis: autosomal recessive disorder => abnormal production of mucus by almost all exocrine glands, causing obstruction of those glands and ducts.
   
   1. Lungs histologically nl at birth => develope pulmonary dz in infancy/early childhood => Mucus plugging, chronic bacterial infection, inflammatory response => airway damage => bronchiectasis & respiratory insufficiency => mean survival is 31 yo
   2. Non-pulmonary = pancreatitis & steatorrhea (give fat-soluble vitamins)
   3. Course is characterized by episodic exacerbations with infection and progressive decline in pulmonary function.
3. Dx
   
   1. Elevated quantitative sweat chloride test performed on two different days is diagnostic.
      
      1. ↑ NaCL > 60 mEq/L
      2. Normal result does not rule out dz. If strongly suspected, DNA testing can provide definitive evidence of cystic fibrosis.
   2. CXR may reveal hyperinflation, mucus plugging & focal atelectasis
4. Tx = Initially in the first few months of life, respiratory infection is common with Staphylococcus aureus and Haemophilus influenza, but after that Pseudomonas aeruginosa becomes the major causative organism for infections.
   
   1. Therapies focus on:
      
      1. Clearing the airway of secretions
      2. Reversing bronchoconstriction
      3. Treating respiratory infections (tx for pseudomonas)
      4. Replacement of pancreatic enzymes
      5. Nutritional and emotional support
5. Imaging = hyperinflation, mucus plugging, focal atelectasis

Question 27

Pleural Diseases x 2

Answer 27

Pleural effusion

1. Differentiate exudate and transudate c pleurocentesis and Light’s Criteria
   
   1. Exudate: (local pleural disease) - protein ratio ↑, LDH ↑, infection, malignancy, trauma
   2. Transudate: Congestive heart failure, atelectasis, cirrhosis
2. Dx
   
   1. CXR: Lateral decubitus and upright films
      
      1. Blunting of costophrenic angle. Mediastinal shift away from effusion
   2. Thoracentesis is the gold standard

Pneumothorax

1. Absence of breath sounds and hyperresonance to percussion c tracheal deviation
2. Spontaneous:
   
   1. Primary spontaneous PTX occurs in absence of underlying disease - tall, thin males between 10 and 30 years of age are at greatest risk of primary pneumothorax
   2. Secondary spontaneous PTX occurs in presence of underlying disease - asthma, COPD, cystic fibrosis, interstitial lung disease
3. Tension:
   
   1. Etiology: Penetrating injury
   2. Physical exam: Hyperresonance to percussion and tracheal shift to contralateral side
4. Tx/PX
   
   1. Small, <15% diameter hemithorax resolve spontaneously c/o chest tube placement
   2. Large, > 15% of the diameter hemithorax, and symptomatic pneumothoraces, chest tube placement is performed
   3. Patients should be followed c serial CXR every 24 hours until resolved

Question 28

Cystic Fibrosis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 28

1. CC. Patient presents with → dyspnea, & vague discomfort or sharp pain that worsens during inspiration. PE reveals decreased tactile fremitus, dullness to percussion and diminished breath sounds over the effusion
2. Def = Pleural Effusion
   
   1. Transudate = Think “transient/transfer” fluid due to hydrostatic pressure (CHF, cirrhosis, Nephrotic syndrome, atelectasis)
      
      1. Isolated right sided effusion likely transudative
   2. Exudate = Think “existing” fluid due to local pleural disease => infection (PNA, TB), malignancy, immune (PE), trauma
      
      1. Isolated left sided effusion likely exudative
   3. Isolated left-sided pleural effusion is likely
3. S&S
   
   1. decreased tactile fremitus, dull on percussion
4. Dx
   
   1. 1st confirm fluid presence: CXR Lateral decubitus and upright => costophrenic angle blunting. Mediastinal shift away from effusion
      
      1. chest CT, or US if CXR unclear
   2. 2nd determine cause: Thoracentesis is gold standard => determine if fluid is exudate/transudate
      
      1. Light’s Criteria: Think “Light Exists” => ↑protein ratio or ↑LDH => Exudate
         
         1. at least 1 of the following
            
            1. Pleural fluid protein/serum protein ratio > 0.5
            2. Pleural fluid LDH/serum LDH ratio > 0.6
            3. Pleural fluid LDH > 2/3 upper limit of normal LDH serum
5. Tx
   
   1. Thoracocentesis
   2. Chronic/recurrent Effusions that cause sxs = pleurodesis or intermittent drainage c indwelling catheter.
      3.

Question 29

PTX

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 29

1. CC. Patient will present as → 19-year-old male in ED due to AVA. Upon arrival, he is alert and anxious and appears to be in respiratory distress. His left hemithorax more expanded than right. He is receiving oxygen via nonrebreathing mask. His vitals: respiratory rate 36 and labored. SpO2 is 85%. PE shows decreased tactile fremitus, deviated trachea, hyperresonance, and diminished breath sounds
2. Def = Pneumothorax is the accumulation of air in the pleural space
   
   1. Spontaneous (1ry) PTX = 10-30 yo tall, thin males
      
      1. 30% recure c/in 2 yrs
   2. 2ry PTX = underlying dz => asthma, COPD, CF, DPLD
   3. Traumatic = blunt/penetrating trauma, CPR, mechanical ventilation
3. S&S
   
   1. Acute onset of ipsilateral chest pain & dyspnea c diminished breath sounds, decreased tactile fremitus, hyperresonance, deviated trachea,
4. Dx
   
   1. CXR = Expiratory revealing pleural air
5. Tx
   
   1. Small, <15% diameter hemithorax resolve spontaneously, don’t place chest tube
   2. Large, > 15% of the diameter hemithorax, and symptomatic pneumothoraces, place chest tube
   3. Patients should be followed c serial CXR q24 hrs until resolved

Question 30

Pulmonary Circulation Disorders x 3

Answer 30

Cor pulmonale = Right ventricular failure secondary to pulmonary hypertension

1. E: COPD (mc), pulmonary embolism, acute respiratory distress syndrome
2. PE: Lower extremity edema, neck vein distention, hepatomegaly, parasternal lift, tricuspid/pulmonic insufficiency, loud S2
3. EKG: S1Q3T3

Pulmonary embolism = Virchow’s triad (hypercoagulable state, venous stasis, vascular injury)

1. Risk factors: Cancer, surgery, oral contraceptive pills, pregnancy, long bone fracture (fat emboli)
2. Homan’s sign: (Dorsiflexion of foot causes pain in calf) indicative of deep vein thrombosis
3. EKG: Tachycardia (mc), ST changes, S1Q3T3 (Indicates cor pulmonale)
4. Imaging:
   
   1. Spiral CT: Best initial test
   2. Gold Standard is Pulmonary Arteriography
   3. Chest radiograph: Westermark’s sign and Hampton’s Hump - triangular infiltrate secondary to intraparenchymal hemorrhage
5. Treatment: Heparin to Coumadin bridge. for 3-6 mo

Pulmonary hypertension = Pulmonary artery pressure >25 mmHg

1. May cause right ventricular hypertrophy
2. Presentation: Dyspnea on exertion, fatigue, chest pain, edema
3. Diagnose with right heart catheterization
4. Physical Exam: Loud P2, systolic ejection click, parasternal lift

Question 31

Cor pulmonale

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 31

1. CC. Patient will present with → left parasternal systolic lift, a loud pulmonic component of S2 , functional tricuspid and pulmonic insufficiency murmurs, and later, distended jugular veins, hepatomegaly, and lower-extremity edema.
2. Def = Cor pulmonale: lung disorder => pulmonary artery HTN => RV hypertrophy => RV failure
   
   1. Lung disorders = COPD (mc), PE, ARDS, IDS, Asthma,
3. S&S
   
   1. peripheral edema, JVD, hepatomegaly, parasternal lift, tricuspid/pulmonic insufficiency, loud S2
4. Dx
   
   1. EKG = S1Q3T3 OR
   2. Radionuclide imaging +/-
   3. Right heart catheterization.
5. Tx - underlying disorder
   
   1. ID & Tx b4 irreversible cardiac damage
   2. Although there may be significant peripheral edema, diuretics are not helpful and may be harmful; small decreases in preload often worsen cor pulmonale.

Question 32

Pulmonary Embolism

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 32

1. CC. Patient will present with → RF such as COCP use or recent surgery c sudden onset of pleuritic chest pain, dyspnea, apprehension, cough, hemoptysis, and diaphoresis. Signs include tachycardia, tachypnea and crackles.
2. Def = Pulmonary embolism: thrombi in systemic venous circulation or Rt. side of heart, from tumors that have invaded venous circulation, and other sources
   
   1. >90% originate from clots in LE deep vein
   2. Virchow’s triad (RF for PE)
      
      1. hypercoagulable state = Ca, OCT, pregnancy
      2. venous stasis = pregnancy
      3. vascular injury = long bone fx (fat emboli)
3. S&S
   
   1. Homan’s sign: Dorsiflexion of foot causes pain in calf => indicative of DVT
4. Dx
   
   1. Spiral CT = Best initial test (replace VQ scan)
   2. ABG = respiratory alkalosis 2ry to hyperventilation
   3. EKG = tachycardia (mc), ST Changes, S1Q3T3 (Indicates cor pulmonale)
   4. CXR = Westermark’s sign/Hampton’s Hump (triangular/round infiltrate 2ry to intraparenchymal hemorrhage, mc adjacent to hilum)
   5. VQ scan shows perfusion defects c nl ventilation
      
      1. Normal VQ = Rules out PE
      2. Abnormal VQ = non-specific
   6. D-dimer = maybe used to Rule out PE
   7. Pulmonary Arteriography = Gold Standard but reserved for cases which dx is uncertain after noninvasive testing
5. Tx
   
   1. Heparin to Coumadin (warfarin) bridge for 3-6 mo
      
      1. INR 2-3x normal
   2. Thrombolytic therapy (streptokinase, alteplase, urokinase) only for hemodynamically stable
   3. Vena cava filter high risk of recurrence who are unable to tolerate anticoagulants.

Question 33

Pulmonary HTN

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 33

1. CC. Patient will present with → dyspnea, chest pain, weakness, fatigue, edema, and ascites along c narrow splitting of the 2nd heart sound and a systolic ejection click.
2. Def = Pulmonary HTN: Pulmonary artery pressure >25 mmHg @ rest (nl 15/5)
   
   1. Caused by underlying disorder = constrictive pericarditis, mitral stenosis, LV failure, mediastinal disease compressing the pulmonary veins
      
      1. Mitral stenosis (MC) = mitral valve to tight => blood can’t pass LA => back ups into lungs
   2. IPulm. HTN => Vascular resistance => RV hypertrophy => RV failure => Cor Pulmanle
3. S&S - vague S&S
   
   1. Dyspnea on exertion, fatigue, chest pain, edema
   2. Loud P2, systolic ejection click, parasternal lift
4. Dx
   
   1. CXR, CT, PFTs, ECHO etc.
   2. Right heart catheterization = gold standard
5. Tx - underyling cause

Question 34

Restrictive Pulmonary Disease x 3

Answer 34

Idiopathic pulmonary fibrosis

1. Physical exam: Inspiratory crackles
2. CT: Diffuse, patchy fibrosis with pleural honeycombing, reticular opacities
3. FEV1/FVC ratio: Increased

Pneumoconiosis

1. Asbestosis: ship building and chest x-ray findings of interstitial fibrosis and pleural thickening
2. Silicosis: mines and “eggshell” calcification of hilar lymph nodes
3. Berylliosis: aerospace, electrical plants
4. Coal Worker’s Pneumoconiosis: coal miners, CXR demonstrates nodular opacities

Sarcoidosis

1. ↑ ACE levels + Bilateral hilar adenopathy
2. Presentation: Pulmonary manifestations (most common), erythema nodosum, parotid gland enlargement
3. CXR: Bilateral hilar lymphadenopathy. Reticular infiltrates.
4. Biopsy: non-caseating granulomas
5. Treatment: Steroids

Question 35

Idiopathic Pulmonary Fibrosis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 35

1. CC. Patient will present as → a 55-year-old female who is a current smoker presents with a 9-month history of respiratory symptoms, including dyspnea on exertion, thoracic pain and dry cough, which were preceded by a pulmonary infection. On auscultation you hear inspiratory crackles. PFTs show mild impairment of vital capacity c decreased lung volume and normal to increased FEV1/FVC ratio.
2. Def = Idiopathic pulmonary fibrosis (mc DPLD): to be “idiopathic” rule out other common causes such as drugs, environmental/occupational exposures
   
   1. Common “non-idiopathic” causes of pulmonary fibrosis which must be ruled out
      
      1. Smoking
      2. Viral infections
      3. Exposure - silica, hard metals, bacteria, animal protein, gases, fumes, radiation
      4. Meds - methotrexate, amiodarone, nitrofurantoin, rituximab, bleomycin, and cyclophosphamide
      5. Genetics - Cystic fibrosis
      6. GERD
3. S&S
   
   1. Inspiratory crackles
4. Dx
   
   1. PFT = restrictive pattern (opposite of asthma
      
      1. Decreased lung volume
      2. Increased FEV1/FVC ratio
   2. CXR = fibrosis
   3. Chest CT = Diffuse, patchy fibrosis c pleural honeycombing, reticular opacities
5. Tx
   
   1. judicial use of corticosteroids, O2, and eventually lung transplant

Question 36

Pneumoconiosis

1. E
2. CXR
3. Complications
4. Tx

Answer 36

CC. Patient will present with → dyspnea, inspiratory crackles, clubbing of fingers, cyanosis and a work or exposure history that will provide you with the diagnosis

1. Asbestosis: ship building and chest x-ray findings of interstitial fibrosis and pleural thickening
2. Silicosis: mines and “eggshell” calcification of hilar lymph nodes
3. Berylliosis: aerospace, electrical plants
4. Coal Worker’s: coal miners, CXR demonstrates nodular opacities

Treatment

1. Corticosteroids, oxygen, vaccinations and smoking cessation

Question 37

Sarcoidosis

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 37

1. CC. Patient will present as → 30-year-old African American female with a cough, fever and generalized body aches. You order a CXR which shows bilateral hilar adenopathy
2. Def = Sarcoidosis: systemic granulomatous disease that is characterized by noncaseating granulomas that may affect multiple organ systems.
   
   1. 20-40 yo, mc in Northern Europeans & African Americans
3. S&S
   
   1. African Americans = Pulmonary manifestations (mc), erythema nodosum, parotid gland enlargement
   2. Europeans = Fever, weight loss, arthralgias, and erythema nodosum
   3. Other manifestations = hepatic granulomas, granulomatous uveitis, polyarthritis, cardiac symptoms (angina, CHF, conduction abnl), cranial-nerve palsies, diabetes insipidus.
4. Dx = ↑ ACE levels + Bilateral hilar adenopathy
   
   1. Serum blood tests
      
      1. ↑ ACE levels
      2. Hypercalcemia, hypergammaglobulinemia
      3. +/- ↑ ESR, ALP
   2. PFT = Restrictive disease & impared diffusing capacity
   3. Imaging
      
      1. CXR = MEDIASTINAL (Bilateral hilar) LAD c Reticular infiltrates.
      2. Whole-body gallium scans = show sites for bx & follow disease progression.
   4. Diagnostic => non-caseating granulomas
      
      1. peripheral lesions bx
      2. central lesion fiber-optic bronchoscopy
   5. Serial pulmonary function tests = assessing disease progression and guiding treatment.
5. Tx
   
   1. Corticosteroids (90% responsive) - modest maintence dose
   2. Spontaneous improvement is common; however, significant disability can occur c multiorgan involvement.
   3. Pulmonary fibrosis is the leading cause of death. Tx for symptomatic patients consists of corticosteroids, methotrexate, and other immunosuppressive medications if steroid therapy is not helpful.

Question 38

Other Pulmonary Diseases x 3

Answer 38

Acute respiratory distress syndrome (ARDS) = Non-cardiogenic pulmonary edema

1. Etiology: Sepsis, severe trauma, aspiration of gastric contents, near drowning
2. Presentation:
   
   1. Rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event.
   2. Tachypnea, pink frothy sputum, crackles
3. Diagnostic studies:
   
   1. CXR = air bronchograms and bilaterally fluffy infiltrate
   2. Normal BNP, pulmonary wedge pressure, LV function and EKG
4. Treatment: Underlying cause + intubation positive pressure oxygen

Hyaline membrane disease

1. Etiology: Insufficient surfactant
2. Population: Preterm (<30 wks) newborn
3. CXR: Ground glass appearance, air bronchograms, bilateral atelectasis
4. Tx: Ventilation + steroids

Foreign body aspiration

1. Presentation: depends on location of obstruction
   
   1. Inspiratory stridor if high in the airway
   2. Wheezing + decreased breath sounds if low in the airway
2. Complications: Pneumonia, acute respiratory distress syndrome, asphyxia
3. Tx: Remove foreign body with bronchoscope

Question 39

Acute Respiratory Distress Syndrome

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 39

1. CC. Patient will present with → rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event. Physical exam will show tachypnea, frothy pink or red sputum and diffuse crackles.
2. Def = ARDS: increased permeability of alveolar capillary membranes => development of protein-rich pulmonary edema.
   
   1. Three clinical settings account for 75% of cases:
      
      1. Sepsis syndrome (mc cause)
      2. Severe multiple trauma
      3. Aspiration of gastric contents (ETOHics), toxic inhilation, near drowning
3. Dx
   
   1. CXR = demonstrate air bronchograms
4. Tx
   
   1. ID & Manage underlying precipitation & 2ry conditions
   2. Tracheal intubation c lowest level of PEEP is required to
      
      1. maintain PaO2 > 60mmHg OR
      2. SaO2 > 90%
5. Image = air bronchogram appears when an infiltrate surrounds a peripheral bronchi, and is thus important in establishing lung consolidation.

Question 40

Hyaline Membrane Dz

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 40

1. CC. Patient will present as → preterm infant c typical signs of respiratory distress shortly after birth
2. Def = Hyaline membrane dz: mc respiratory disease in preterm (<30 wks) infants
   
   1. premature infants => inadequate surfactant production => decreased lung compliance + airway collapse (atelectasis) => struggle to breathe until they become acidotic => multisystem organ failure begins.
3. Dx
   
   1. CXR = diffuse bilateral atelectasis => “ground glass appearance” + air bronchograms
4. Tx - best is maintaining a healthy pregnant to prevent premature birth
   
   1. Antenatal corticosteroids to mother
      
      1. Betamethasone IM x 2
   2. Give exogenous surfactant as both tx & prophylaxis (through endotracheal tube)
   3. Mechanical ventilation c positive pressure
5. Px
   
   1. Babies may suffer permanent respiratory illness because of hyaline membrane disease, but others make a full recovery and suffer no consequences.

Question 41

Foreign Body Aspiration

1. cc
2. def
3. s&s
4. dx
5. tx

Answer 41

1. CC. Patient will present with → episode of choking and coughing or unexplained wheezing or hemoptysis. Asphyxia may result from the aspiration of obstructing material.
2. Def = Foreign Body: Asphyxia due to aspiration
   
   1. Right (3 lobes) > Left (2 lobes)
   2. Upper airway (20%) = trachea or larynx obstruction
      
      1. Stridor“inspiratory wheeze”
   3. Lower airway (80%) = mainstem or lobar bronchus
      
      1. Wheezing + decreased breath sounds
3. S&S
   
   1. Coughing/Choking
   2. Strider/Wheezing
4. Dx
   
   1. CXR = Expiratory may reveal regional hyperinflation
5. Tx
   
   1. Bronchoscopy may help establish dx and remove
   2. Cultures if pneumonia suspected