pulmonology Flashcards
of the following causes of hypoxemia, which have a nl A-a gradient? shunt hypoventilation decreased diffusion (low DLCO) high altitude
hypovetilation
high altitude
how do you calculate the A-a gradient? what is a nl A-a gradient?
nl A-a = age/4 + 4
A-a gradient = PAO2-PaO2
PAO2=150-1.25(PaCO2)
how do you eavluate someone for methemoglobin (CO posioning)? what is tx?
have to order a methemoglobin (b/c an ABG will show a falsely normal PaO2)
tx with 100% O2 and methylene blue
what might you suspect in a pt who is hyperventilating after the were found in a smoky room (no e/o burned airways) and has a nl ABG? Tx?
CO posioning - should order methemoglobin and CO levels and tx with 100% oxygen and methylene blue
what on pulmonary function tests differentiates emphysema from chronic bronchitis/asthma?
all are obstructive but only emphysema has low DLCO
is DLCO nl or low in:
ILD
emphysema
chronic bronchitis?
low in ILD and emphysema, nl in chronic bronchitis
what is the PFT hallmark of:
restrictive disease
obstructive disease
restrictive: TLC <70%
T/F: to diagnose obstructive dz you need only spirometry but for restrictive you need lung volumes as well.
true – need to know residual viume to calculate TLC to diagnose restrictive
what is the 1st test to diagnose a suspected asthmatic? anything else you can do if that is normal?
PFTs then methacholine challenge
what dz is characterized by decreased FEV1/FVC, increased TLC and decreased DLCO?
emphyseam
what dz is characterized by decreased FEV1/FVC, nl/increased TLC and nl DLCO?
chronic bronchitis ( if have emphysema will have decreased DLCO and increased TLC)
what dz is characteried by nl FEV1/FVC, decreased TLC, reduced DLCO?
ILD
if someone has restrictive dz (ie TLC <80%), how do you tell if the restriction is extrathoracic (obesity, kyphosis) or intrathoracic (ILD)?
in extrathroacic, the reduction in the DLCO will be the same as the reduction in TLC while in intrathoracic the DLCO will be disproportionaetly lower than the TLC
When are steroids indicated in asthma exacerbation?
Peak glow kes than eighty percent despite 3 alb utterly txs
Can labas be used as monontherpay in asthma?
No! Increase mortality. Use indicated in pts on Saba and ics with mod to severe persistent asthma
Describe indications and step ups of therapy for asthma.
Saba alone
If using Saba more than 2 days/week, add ics
If on Saba and ics but still with mod to server persistent asthma, add laba * never use laba without ics–increases mortality*
Describe intermittent, mild persistent, mod persistent and severe persistent asthma.
Intermittent: sx 2 days a week or less, use Saba 2 days/ wk or less, 2 nighttime awakenings per month and no activity limitations
Mild persistent: sx 2-6 days/week, use inh no more than 2-6 days awak 3 or 4 nights per month and Minot limitations
Mod persistent:
Severe persistent: constant symptoms, use Saba many days per week, awake every night, fev less than 60
What type of asthma hassx 2 days a week or less, use Saba 2 days/ wk or less, 2 nighttime awakenings per month and no activity limitations
Intermittent
What type of asthma has:
sx 2-6 days/week, use inh no more than 2-6 days awak 3 or 4 nights per month and Minot limitations
Mild persistent
What type of asthma has daily symptoms, daily Saba use, awake more than once a week and fev 60-80 percent
Mod persistent
What type of asthma hasconstant symptoms, use Saba many days per week, awake every night, fev less than 60
Severe persistent
Give the peak flows at which a pt should go tot their er, be admitted and be admitted to ICU.
Peak flow less than 80 give meds and reassess
Peak flow less than 50 go to er
Peak flow 40 to 60 despite tx admit
Peak flow less than 40 despite tx admit to ICU
Is panacinar or centriacinar emphysema assoc with alphaoneantitryosin?
Pan (centri is what smokers get )
Describe the gold spirometry criteria for copd. And classes by sympt pms.
Fev 80% mild (gold 1)
50 to 79% moderate (gold 2)
30 to 49% sever (gold 3)
Less than 30 (gold 4)
A= few sx! low risk
B= more sx! low risk
C= few sx! High risk
D=more sx! high risk
True or false: ics are used as monotherapy in copd but not asthma.
False. Vice versa
What gold stage copd pts benefit from ics?
Three or four (fev less than 50)
Describe the tx for each abcd stage of copd.
A (few sx low risk): Saba
B (more sx low risk): laba or lama
C ( few sx high risk): ics +laba or laba +lama! can use roflumilast
D (more sx high risk): ics +laba + lama +/- roflumilast
Describe EKG changes for a pE.
S1q3t3
Anterior twi
New Rbbb
Ra
Contrast ipf and cryptogenic organizing pna. Why is it important to differentiate?
Cop has fever, malaise, infiltrate and onseqt of days to week
Ipf has months of sx without fever/malaise, just dry cough
Can tx cop (steroids)
What is diagnosis in premenopausal female with chylous effusion and pneumothorax.
Lymphagnioleiomyomatosis
Tx with progestin
What anca is positive in GPa?
Canca and anti-pr3
What autoimmune Dx affects sinuses and lungs?
GPA
What is diagnosis of pt with bad asthma who gets worse when you add a leukotriene modifier?
Churg Strauss
What vascular is has granule as, small vessel vasculitisand peripheral eosinophilia?
Churg Strauss. Also have asthma sx.
What vasculitis is associated with hepatitis b?
PAN affects gut kidney heart testes (spares lungs)
Diagnosis in hep b pt with tender testicles, skin nodules and abdominal pain.
PAN tx with cyclophosphamide steroids and. Tx hep b
What is test to diagnose ABPA?
Start with aspergillus skin prick test. Also check serum Ige level. Tx with itraconazole and steroids.
Describe the diff btwn each group of pulm Htn.
1-idiopathic 2-left heart dz 3-lung dz 4-chronic VTE 5-multifactorial/misc
Loud 2nd heart sound, tricuspid regurg and RV heave are suggestive of what.
Pulm Htn
What pulm Htn pts should be anticogaulted?
Group 4(chronic VTE) Group 1(idiopathic pah)
what types of tumors arise from the ant mediastinum?
anterior: thyroid tumors, thymic tumors, and lymphomas
middle: bronchogenic cysts, pericardial cysts, and lymphadenopathy
posterior: neural, esophageal tumor/cyst
what types of tumors arise from the midle mediastinum?
anterior: thyroid tumors, thymic tumors, and lymphomas
middle: bronchogenic cysts, pericardial cysts, and lymphadenopathy
posterior: neural, esophageal tumor/cyst
what types of tumors arise from the posterior mediastinum?
anterior: thyroid tumors, thymic tumors, and lymphomas
middle: bronchogenic cysts, pericardial cysts, and lymphadenopathy
posterior: neural, esophageal tumor/cyst
what is heparin antidote
protamine
compare type I and type iI HIT
type I: 1-2 days after start hep; common, no linical onsequence
type II: 4-10 days after heparin; have antibodies, can get clotting/bleeding
explain why warfarin is initially procoagulant.
protein C (anticoagulant) is inactivated faster than factor VII. after about 4 days factor II and facotr VII are low enough that the net effect is anticoagulant
if a unilateral effusion is present from CHF what side is it usually on? pancreatitis?
CHF –> Right
pancreatitis –> left
give light’s criteria.
if any one of three is there, effusion is exudative:
- E:S protein >0.5
- E:S LDH >0.6
- E LDH >2/3 ULN (usually 200ish)
what diagnosis is suggested in a bloody pleural effusion?
mesothelioma 2/2 asbestos exposure
• A patient who works on an animal farm
develops pneumonia. What organism should
you think about?
• What organism should you consider if
pneumonia develops in a patient who spent
an afternoon in a bat cave in Mississippi?
• What organism should you think about if
pneumonia develops in a patient who drove
through an Arizona dust storm?
• What organism should you consider if a chronic,
cavitating pneumonia develops in a male logger
from Arkansas?
q fever (coxiella)
histoplasmosis
coccidiomycoces
blastomycoces
what pneumonia-causing organism presents as pleomorphinc GN coccobaccilli?
haemophilus influenzae
which atypical pneumonia is associted with hemolytic anemia, erythema multiforme, arthirtis and neurologic changes?
mycoplasma
what is major SE of ethambutol?
decreased visual acuity (not heaptotoxic but all the other parts of RIPE are)
what infectino should you suspect in someone 6 weeks s/p kidney transplant who p/w hepatitis and adrenal insufficiency?
CMV - can cause hepatitis, pneumonitis, adrenalitis; usually 6 to 8 weeks out
what is 1st line tx for PCP? when do you add steroids?
bactrim or pentamidine
add steropids if A-a > 35 or PaO2 <70
what presents with “halo sign” on chest CT?
aspergillus - caused by pulm infarction
what antibiotic can give you a false positive galactomannan?
pip-tazo
Name 3 medications associated with pneumonitis.
MTX - causes noncytotoxic hypersensitivity interstitial pneumnitis
Bleomycin - cytotoxic pulm. toxicity; uremia, O2 and XRT can worsen bleomycin-related dz
amiodarine - pulm fibrosis
amio and bleo are dose-related
define ARDS. what are ideal ARDs ventilator settings?
PaO2/FiO2 30 may need to decr TV
Describe the following ventilator modes:
- CMV (controlled mech vent)
- AC (assist/control)
- SIMV (synch intermit mech vent)
- PSV (press surppor vent)
- PC (press control)
CMV: ventilator controls everything, no spontaneous breathing allowed
AC: set rate & TV; if there is a spontaneous breath vent gives full TV (can have stacking if hyperventilating
SIMV: like AC but spontaneous breath overrides machine
PSV: extra pressure when pt inspires; can use PS alone or with SIMV; no rate/TV set
PC: pressure and rate are set, no TV set; good for people when you want to avoid barotrauma
Give the CO, wedge and SVR for :
hypovolemic, cardiogenic, distributive and obstructive shock.
hypovolemic: low CO, low PCWP, high SVR
cardiogenic: low CO, high PCWP, high SVR
distributive: high CO, low PCWP, low SVR
obstructive: low CO, low PCWP, high SVR
what are normal pressures in the RA, RV and PA?
RA: 0-8
RV: 15-30/0-8
PA: 15-30/3-12
which lung cancers are classically central? peripheral?
Squamous and Small cell are “Sentral”
adeno and large cell are peripheral
which lung cancer is the most likely to present with cavitary lesions?
squamous
who/how do you screen for lung cancer?
low-dose CT annually if you are between 55-74 years old, smoked >30 pack-years and currently smoker or quit w.in last 15 years
which lung cancer is associated with:
- SIADH
- ectopic ACTH
- PTHrP
- eaton-lambert
squamous - PTHrP (sCa++mous)
SC - everything else
is “popcorn” calcification benign or malignant?
benign – hamartoma
what is hallmark CT finding of hamartoma?
popcorn calcification
is “laminated” calcification of pulm nodule benign or malignant?
benign - granuloma
