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STEP2 > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

Sarcoid path, presentation, dx, tx

A

Unknown etiology ==> noncaseating granuloma

Usually middle-aged black women
Cough, dyspnea, fever, weight loss
Eye pain (uveitis)
Joint pain (arthritis)
Lymphadenopathy
Erythema nodosum (fat inflammation = COMMON!)

ACE elevation
Hypercalcemia
XR: bilateral hilar (mediastinal & paratreacheal) adenopathy with reticulonodular infiltrates
Eye exam: erythema with leukocytes (uveitis)
Biopsy: noncaseating granuloma ==> required for dx!

Systemic glucocorticoids

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2
Q

Anterior mediastinal ddx*

A 
4T's
Thymoma
Teratoma (all nonseminomatous germ cell tumors: yolk, chorio, embryonal ==> elevated AFP and b-HCG)
Terrible Lymphoma
Thyroid
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3
Q

Emergent vs non-emergent hemoptysis*

A

> 600mL hemoptysis or >100mL/hr ==> immediate intubation ==> lay on side of suspected bleeding ==> bronch

diagnostic workup

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4
Q

Pulmonary nodule workup* (need more help here)

A
  1. Determine risk: high, intermediate, low

High: malignancy hx (breast ca), recent size changes, irregular calcification, pleural involvement, >2cm ==> surgical excision

Intermediate: ??? ==> PET

Low: CXR or CT q3 months for 1 year ==> q6 months onward

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5
Q

Obstructive lung path, ddx, dx*

A

Obstruction causes gas trapping

ABCT
Asthma
Bronchiectasis
COPD
Tracheobronchial obstruction
Increased RV
Increased TLC
Low-normal FVC (functional vital capacity)
Very decreased FEV1 < 75% expected
**FEV1 / FVC < 75% expected**

DLCO: increased with asthma*, normal with bronchitis, decreased with emphysema

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6
Q

Lung volume measurements

A

TLC = IRV + TV + ERV + RV

TV: normal breath = 500mL
ERV: full exhale after normal breath
RV: excess post-exhale; not measured by spirometry
FRC = ERV + RV

IRV: full inhale after normal breath
IC = TV + IRV

VC: total air available for inhale/exhale = ERV + TV + IRV

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7
Q

Restrictive lung path, ddx, dx

A

Loss of compliance decreases lung expansion ==> lower volumes

AIN’T (compliant)
Alveolar: ARDS, edema, hemorrhage [Wegener’s, Goodpasture’s], pus
ILD: sarcoid, silicosis, fibrosis*
Neuromuscular: myasthenia, polio, phrenic nerve palsy
Thoracic wall: kyphosis, obesity, ascites, pregnancy

Decreased FEV1 but proportionally same as FVC ==> thus FEV1/FVC > 75% expected
FVC < 80%
Decreased diffusion capacity
Very decreased RV

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8
Q

Asthma path, presentation, dx, tx* w/ intubation criteria*

A

REVERSIBLE obstruction 2/2 hyperreactivity, inflammation, hypertrophy

Cough, wheezing etc.
Prolonged expiratory phase
Hyperresonance
Pulsus paradoxus (>10mmHg decrease SBP w/ inspiration)
Late: decreased breath sounds
*Nocturnal symptoms with sore throat = GERD, even without dyspepsia ==> PPI!

Mild hypoxia
Respiratory alkalosis ==> progressing to acidosis when severe*
Decreased FEV1 / FVC improves with bronchodilator test*
Eosinophilia

------
Acute tx:
Albuterol ==> ipratroprium ==> steroids
------
Intubate if: 
Fatigue
Altered MS
"Silent chest" 
PCO2 > 50
PO2 < 50

Chronic tx:
Intermittent: sx < 2x week, nighttime awakenings albuterol
Mild persistent: sx < daily, nighttime awakening < 4x per month, 80% FEV1 ==> albuterol + fluticasone
Moderate: sx daily, nighttime awakening weekly, 60% FEV1 ==> albuterol + fluticasone + salmeterol
Severe: constant sx, FEV1 < 60% ==> albuterol + fluticasone + salmeterol + prednisone

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9
Q

Bronchiectasis path, presentation*, dx, tx

A

Bronchial infection / inflammation cycle ==> fibrosis ==> thickening & dilation of bronchi

Recurrent infection hx*
Purulent mucus (more than bronchitis!) 
Occasional hemoptysis
Rales:  crackles
Wheezes
Ronchi:  low pitched moans

XR: increased bronchovascular markings, but non-specific. Must do CT!
CT: thickened, dilated bronchi ==> sputum analysis
Decreased FEV1 / FVC ratio

Abx
Corticosteroids
Lung exercises

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10
Q

COPD path, presentation, dx, tx*

A 
Obstruction 2/2 
Bronchitis:  productive cough > 3 months/yr x2 yrs
Emphysema:  terminal airway dilation 2/2 smoking or alpha-1-antitrypsin (unopposed elastase activity)
-----
SPECTRUM
Bronchitis:  blue bloaters
Dyspnea
Overweight
Rhonchi & wheezes
Early hypercarbia*
Emphysema:  pink puffers
Dyspnea
Thinner
Hyperresonance*
Decrease breath sounds* & wheezes
Later hypercarbia*
-----
Bronchitis:  
Hypoxemia
Early hypercarbia*
XR:  PROMINENT vascular markings, flat diaphragms
NORMAL DLCO
Emphysema:
Hypoxemia
Late hypercarbia*
XR:  MINIMAL vascular markings, pleural blebs & parenchymal bullae
DECREASED DLCO
------
Chronic:
Oxygen & smoking cessation ==> only proven survival tx
Corticosteroids
Prevention (pneumococcal & flu vaccines)
Dilation (albuterol, ipratroprium)

Acute exacerbation*
Ipratroprium + albuterol + systemic steroid
Keep 02 < 95% ==> too much 02 reduces deoxyhemoglobin, which has higher affinity for C02, thus increasing C02 retention ==> hypercarbia MS change, seizure

Intubation: try non-invasive PEEP first, then intubate if refractory, pH <7.1, or MS changes

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11
Q

Interstitial lung disease path, presentation, dx*, tx

A

Inflammation and fibrosis of inter alveolar septa 2/2:
amiodarone, IPF, silicosis etc.

Dyspnea
NON-productive cough

CT: Reticulonodular ground glass w/ honeycombing*
Decreased TLC, FVC
Decreased DLCo
Increased A-a gradient*
Normal FEV1 / FVC*
Biopsy showing interstitial fibrosis to confirm

Lung transplant

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12
Q

Hypersensitivity pneumonitis path, presentation, dx, tx**

A

Environmental exposure causing alveolar inflammation ==> progresses to pulmonary fibrosis

Weird exposure, like a bird-handler
Dyspnea
Fever, chills
Rales

XR: bilateral, lower lung hazy, ground glass

Avoid antigen (even if its their job!) ==> steroids speed recovery

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13
Q

Pneumoconiosis path, ddx w/ presentations, complications, dx

A

Inhalation of small particles ==> restrictive lung disease

Asbestosis:
Construction or shipbuilding
Mesothelioma & other lung cancers
Restrictive lung disease: decreased diffusion capacity*, decreased TLC, normal FEV1/FVC
CXR: opacities @ lung bases; pleural plaques

Coal miner’s black lung pop:
Small upper lung nodular opacities
Restrictive lung disease: decreased diffusion capacity*, decreased TLC, normal FEV1/FVC
Massive fibrosis

Silicosis:
Mines, rock quarries, pottery
Small upper lung nodular opacities with ovoid eggshell calcifications on XR
Restrictive lung disease
Increased TB risk needing annual test

Berylliosis:
Aerospace, nuclear, electronics, dental
Diffuse infiltrates with hilar adenopathy
Lifelong steroids

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14
Q

Alveolar gas equation & shunt vs V/Q mismatch

A

PA(alveolar)02 = 150 - [Pa(arteriolar)02/0.8]

Normally = 10-15

Shunt: no V, all Q ==> no response to 02
Other: responds to 02

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15
Q

ARDS path, presentation, dx, tx including ventilation settings*

A

Endothelial injury ==> decreased lung compliance, pulmonary edema, impaired gas exchange, pulmonary HTN

Acute onset 12-48 hrs
Tachypnea
Tachycardia
Hypoxia

Widened A-a gradient
Respiratory acidosis
Pa02 / Fi02 < 200
Stanz Ganz < 18 [not cardiac origin]
CXR:  bilateral diffuse infiltrates

Ventilation:
High PEEP to open alveoli (risk of tension pneumo*)
Keep TV low to reduce alveolar injury (so don’t answer increase TV)
Fi02 < 40 to prevent oxygen poisoning

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16
Q

Cor pulmonale name, path, ddx, presentation, dx, tx

A

Pulmonary hypertension

Pulmonary artery pressure > 25 2/2:

  1. Pulmonary artery HTN
  2. L-sided heart disease ==> pulmonary venous pressure
  3. Hypoxic vasoconstriction 2/2 lung disease
  4. PE
  5. Idiopathic
Dyspnea
Fatigue
Maybe hemoptysis
Progresses to R-sided CHF sx:  edema, JVD, ascites
Loud, split S2 (P2 closes before A2)

CXR: enlarged pulmonary artery, enlarged R heart border
ECG: RV hypertrophy / R-axis deviation

O2
Diuretics

17
Q

Pulmonary embolism path, presentation, dx, tx

A

Pulmonary vascular occlusion 2/2 clot (usually iliac*, femoral, popliteal upper leg)

*Virchow's triad:  venous stasis, endothelial injury, hypercoagulability
Immobility history
Dyspnea ==> 75%
Chest pain ==> 65%
Fever
Hemoptysis*
Hypoxia
HYPOcarbia 2/2 hyperventilation ==> respiratory alkalosis
Prominent P2
Pleural effusion*

Well’s criteria:
If low risk ==> D-dimer: sensitive, not specific
If high risk ==> spiral CT / angiogram with contrast (or V/Q scan if renal failure)
CT: wedge-shaped pleural opacification*
Elevated A-a gradient
Respiratory alkalosis with pO2
Elevated PA and RA pressure with normal PCWP*

If high risk: immediate anticoagulation* ==> CT ==> embolectomy or thrombolytic if positive
Chronic: warfarin with INR 2-3 or filter if warfarin contraindicated

18
Q

General non-small cell lunger cancer PE signs

A

Horner’s: apical tumor ==> miosis, ptosis, anhidrosis
SVC syndrome: SVC obstruction ==> JVD & facial swelling
Brachial plexus arm pain 2/2 superior sulcus tumor location*

19
Q

Adenocarcinoma path, unique subtype, presentation, dx*, tx

A

Most common lung cancer

Bronchoalveolar: only one not associated with smoking*

Smoker (except bronchoalveolar!)
Cough
Weight loss
Hemoptysis

CXR: peripheral** location (multi nodular if bronchoalveolar)
FNA (bc peripheral)

Resectable if early

20
Q

Squamous cell carcinoma path, presentation, unique pe findings, dx*, tx

A

SCC

Smoker
Cough
Weight loss
Hemoptysis

Horner’s: apical tumor ==> miosis, ptosis, anhidrosis
SVC syndrome: SVC obstruction ==> JVD & facial swelling
Brachial plexus arm pain 2/2 superior sulcus tumor location*

HYPERCALCEMIA 2/2 PTHrP*
CXR: central perihilar location* with potential necrosis/cavitation
Bronchoscopy

Resectable if early

21
Q

Large cell carcinoma

A

Neuroendocrine origin
Uncommon
Poor prognosis

22
Q

Pleural effusion path, presentation, dx**, tx

A 
Transudative = high capillary pressure (CHF*, cirrhosis) or low oncotic pressure (nephrotic syndrome)
Exudative = increased vascular permeability
Transudative:  above
Exudative:  Infection, malignancy, PE*
Dyspnea
Pleuritic chest pain
Dullness to percussion*
Decreased breath sounds*
Decreased fremitus* (only pneumonia consolidation increases fremitus) 
Pleural friction rub maybe

CXR: costophrenic angle blunting
**Thoracentesis unless bilateral or CHF ==> bronchoscopy afterward
Exudate pH < 7.4
LIGHT’S criteria for exudative effusion:
pleural:serum protein > 0.5
pleural:serum LDH > 0.6
pleural LDH > 2/3 normal serum LDH value

Chest tube & drain if complicated / big

23
Q

Cystic fibrosis path, presentation*, dx, tx

A

Autosomal recessive chloride ion transporter dysfunction

Recurrent nasal & pulmonary infection
BILATERAL POLYPS
Digital clubbing

Sweat test or quantitative pilocarpine iontophoresis

24
Q

Consolidation PE*

A

Louder, longer expiratory breath sounds that effusion
Increased* fremitus (effusion doesn’t)
Egophony
Whispered pectoriloquy

25
Q

Exercise induced asthma presentation, tx

A

Wheezing w/ exercise or cold
Associated with atopic dermatitis

Albuterol BEFORE exercise

26
Q

DVT path, presentation, dx, tx*

A

Clot

Painful swelling

ultrasound

Heparin ==> stabilize clot (won’t lyse it) and retard growth
Bridge to warfarin once INR = 2-3 ==> 3-6 months*

27
Q

Aspirin sensitivity syndrome path, presentation, dx, tx

A

Aspirin blocks COX ==> arachidonic acid shifts to 5-lipoxygenase pathway ==> increased leukotrienes ==> bronchoconstriction and polyp formation

MUST consider for any pt with wheezing & aspirin in stem
Nasal blockage 2/2 polyps
Wheezing
Occurs minutes to hours post-aspirin ingestion*

Clinical

Monteleukast

28
Q

Empyema path, presentation, dx, tx

A

Pleural effusion infection 2/2 effusion or other trauma

Dyspnea
Fever

CT
Low glucose (2/2 WBC and bacterial metabolic activity)
If pH < 7.2 or glucose < 60 ==> drainage +/- fibrinolysis
If complex (loculated, rind) ==> surgery
29
Q

Non-productive cough ddx in non-smoker w/ tx*

A

ACE-inhibitor ==> remove
GERD ==> PPi
Post-nasal drip ==> antihistamine
Asthma ==> albuterol

30
Q

Recurrent pneumonia in same place workup*

A

Usually 2/2 to obstruction (usually cancer), Ig deficiency, aspiration (alcoholics, GERD, elderly)

Serum Ig levels
CT to r/o cancer ==> bronchoscopy if obstructive cause found

31
Q

A-1 antitrypsin vs emphysema dx*

A 
Emphysema = centrilobular
AAT = panlobular
32
Q

Atypical pneumonia path, presentation, dx, tx

A

Mycoplasma*, Chlamydia, Legionella, Coxiella etc.

*NONPRODUCTIVE cough, unlike pneumonia
Extrapulmonary signs: erythema multiforme rash, headache, sore throat

Mycoplasma: no cell wall ==> no gram stain

33
Q

Endotracheal tube complication*

A

Enters R mainstem bronchus

34
Q

Alpha-1-antitrypsin deficiency path, presentation, dx, tx

A

Deficiency of liver-produced enzyme that inhibits digestive enzymes (pancreatic trypsin and neutrophil elastase [lung]) with wide phenotypic variation

Emphysema, bronchitis etc.
Cirrhosis, hepatosplenomegaly

Serum levels of alpha-1-antitrypsin levels
Hepatocyte inclusions (unreleased alpha-1-antitrypsin) with positive PAS reagent + diastase resistance

Purified A1AT
Lung transplant

35
Q

Small cell lunger cancer path, presentation, dx, tx

A

Neuroendocrine tumor, commonly paraneoplastic associations

Smoker!
Cough, weight loss, hemoptysis

CXR: central location*
Hyponatremia 2/2 SIADH

Non-resectable ==> chemo only!

STEP2 (16 decks)

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