Pulmonology Flashcards
a 23-year-old female with a one-week history of cough productive of whitish sputum. This was preceded one week prior by a URI. She denies chills, night sweats, shortness of breath, or wheeze. Temperature is 99.9°F (37.7°C). What is the likely diagnosis
Acute/chronic bronchitis
What is the DX criteria for acute bronchitis
Cough > 5 days with or without sputum production, lasts 2-3 weeks
What is the most common cause of acute bronchitis
Virus –> symptomatic tx only unless pneumonia is also suspected
a 5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged, expiratory wheezes. What is his likely diagnosis
Asthma
What is the atopic triad
Eczema
Asthma
Allergies
How do you diagnose someone with asthma
monitor with peak flow. PFT’s: Greater than 12% increase in FEV1 after bronchodilator therapy
*you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio
What is the acute treatment for asthma
- Albuterol (neb) + O2 + Oral steroids + Ipratropium (SAMA)
What is the tx of intermittent asthma
Albuterol (SABA) PRN
What is considered intermittent asthma
- Daytime symptoms ≤2 days/week
- Nocturnal awakenings ≤2/month
- Normal FEV1
- Exacerbations ≤1/year
How do you treat mild persistent asthma
Low-dose ICS daily with SABA as needed
What is considered mild persistent asthma
Daytime symptoms >2 but <7 days/week
Nocturnal awakenings 3 to 4 nights/month
Minor interference with activities
>2 exacerbations per year
How do you treat moderate asthma
Combination low-dose ICS-formoterol daily and 1 to 2 inhalations as needed up to 12 inhalations/day
What is considered moderate asthma
Daily symptoms
Nocturnal awakenings >1/week
Daily need for SABA
Some activity limitation
FEV1 60 to 80% predicted
What is severe asthma
Symptoms all-day
Nocturnal awakenings nightly
Need for SABA several times/day
Extreme limitation in activity
How do you treat severe asthma
Combination medium dose ICS-formoterol daily and 1 to 2 inhalations as needed to 12 inhalations/day
a 25-year-old cystic fibrosis patient complaining of chronic, frequent coughing productive of yellow and green sputum. She recently recovered from a Pseudomonas spp. Pneumonia requiring hospitalization. On physical examination, you notice foul breath, purulent sputum, and hemoptysis, along with a CXR demonstrating dilated and thickened airways with “plate-like” atelectasis. What is the likely diagnosis
Bronchiectasis
What is bronchiectasis
A condition in which the lungs’ airways become dilated and damaged, leading to inadequate clearance of mucus in airways
What are the symptoms of bronchiectasis
daily cough that occurs over months or years, production of copious foul-smelling sputum, and frequent respiratory infections
How do you diagnose bronchiectasis
linear “tram track” lung markings, dilated and thickened airways – “plate-like” atelectasis
*GOLD STANDARD is chest CT
a 43-year-old man who comes to the emergency department because of a 3-week history of episodic cutaneous flushing, diarrhea, and wheezing. He has a past medical history of hypertension and type 2 diabetes mellitus. His temperature is 36.6°C (97.9°F), pulse is 125/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulmonary examination shows diffuse wheezes in both lung fields. Cardiac examination shows a prominent “v” wave of the jugular vein and a 1/6 holosystolic murmur best heard on the left lower sternal border. Abdominal examination shows hyperactive bowel sounds. What is the likely diagnosis
Carcinoid tumor
What is a carcinoid tumor
A tumor arising from neuroendocrine cells → leading to excess secretion of serotonin, histamine, and bradykinin
What are the common primary sites of a carcinoid tumor and where is the most common site for it to metastasize
Primary: GI (small and large intestines, stomach, pancreas, liver), lungs, ovaries, and thymus
Metastasize: Liver
What are the hallmark signs of a carcinoid tumor
Cutaneous flushing, diarrhea, wheezing and low blood pressure ( but rare to see)
a 56 yo female with shortness of breath, as well as a productive cough that has occurred over the past two years for at least three months each year. She is a heavy smoker. Physical exam reveals a respiratory rate of 32, slightly labored breathing, and a temperature of 98.9F. Her SpO2 is 90% while receiving oxygen via nasal cannula at 2 Lpm. What is the most likely dx
COPD
What is the largest risk factor for COPD
Cigarette smoking
What is the hallmark symptom of emphysema
DOE
Why are those with emphysema considered pink puffers
Individuals are able to oxygenate blood (pink) but they have to purse their lips to do so
What will be seen on CXR with those who have emphysema
loss of lung markings, hyperinflation, increased anterior-posterior diameter
What is the dx criteria for chronic bronchitis
chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause
PFT’s: FEV1/FVC ratio of less than 0.7
What are the signs of cor pulmonale
peripheral edema and cyanosis
what is the best treatment regimen for chronic bronchitis
Short-acting (SAMA) or long-acting (LAMA) muscarinic agent (also known as an anticholinergic agent) (ipartropium and tiotropium)
When is theophylline utilized
only used in refractory cases due to narrow therapeutic index – higher doses are needed in smokers and coffee drinkers- DONT USE IN ACUTE EXACERBATIONS
When is long term oxygen therapy needed with those who have COPD
all patients with COPD who have chronic hypoxemia defined as resting PaO2 < 55 mmHg or SaO2 <89%
65 y/o with 3 days of progressive dyspnea and purulent sputum production. The patient takes albuterol and tiotropium bromide for moderate COPD. His PMH is relevant for a 40 pack-year smoking history, type II DM, hyperlipidemia, and coronary artery stenting 2 years ago. PE shows barrel-shaped chest, inspiratory crackles, hepatojugular reflux, pulsus paradoxus, and ventricular gallop. His temperature is 38.1°C (100.5°F), his pulse is 130/min, respirations are 28/min, blood pressure is 130/84 mmHg, and pulse oximetry on room air shows an oxygen saturation of 86%. What is the likely diagnosis
Cor pulmonale
What is the most common cause of cor pulmonale
COPD
What is the gold standard for dx of cor pulmonale
Right heart Cath
Can diuretics be used in those with right heart failure
NO! can be harmful
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. Pulmonary function tests (PFTs) show only mild impairment of vital capacity with decreased lung volume and a normal to increased FEV1/FVC ratio. What is the likely diagnosis
Idiopathic pulmonary Fibrosis
What will be seen on a chest CT in those who have IPF
diffuse patchy fibrosis with pleural-based honeycombing
What are the treatments for IPF
antifibrotic drugs (pirfenidone or nintedanib), oxygen therapy, and eventually lung transplant
a 53-year-old man presents to the office complaining of progressive dyspnea over the past few years. History reveals that he has worked in construction for the past 20 years demolishing and refurbishing old buildings. He rarely uses any protective breathing equipment. Physical examination demonstrates an afebrile man in mild respiratory distress with inspiratory crackles. The chest x-ray reveals a reticular linear pattern with basilar predominance, opacities, and honeycombing. What is the likely diagnosis
Pneumoconiosis
What is seen on CXR in those who have prolonged silicosis exposure
small rounded opacities throughout the lung, hilar lymph nodes may be calcified - “eggshell” calcifications
Who is at an increased risk of mesothelioma
Those who have a prolonged exposure of asbestos
What is the tx of pulmonary aspergillosis
Itraconazole or fluconazole
What is the treatment for histoplasmosis
Amp B
Which patient demographics are at high risk of developing PJP
HIV patients
What is the treatment for PJP
Bactrim and steroids
a 43-year-old woman with a history of COPD presents to the office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal chest pain. On examination, she has persistent widened splitting of S2. What is the likely diagnosis
Pulmonary hypertension
What are the normal pulmonary pressures and what are they in pulmonary hypertension
normal: 15/5
Pulmonary hypertension: >20
What typically causes pulmonary hypertension
an underlying disorder (constrictive pericarditis, mitral stenosis = MC, LV failure, mediastinal disease compression pulmonary veins)
How do you diagnose pulmonary hypertension
Right heart Cath
What type of lung cancer has the worst prognosis
Small cell lung cancer
Which patients typically get small cell lung cancer
Smokers
What is the most common type of non-small cell lung cancer
Adenocarcinoma
What type of lung cancer can NOT be treated with surgery
SCLC
What is Horners syndrome
unilateral miosis, ptosis, and anhidrosis
a 30-year-old African American female with a cough, fever, and generalized body aches. You order a CXR which shows bilateral hilar adenopathy. what is the likely diagnosis
Sarcoidosis
What is sarcoidosis
Chronic autoimmune inflammatory disease in which small nodules (granulomas) develop in lungs, lymph nodes, and other organs
What will be seen on biopsy with sarcoidosis
Non-caseating granulomas
What is the treatment of sarcoidosis
Steroids
What will be seen on CXR in those with sarcoidosis
bilateral hilar lymphadenopathy
