Pulmonology Flashcards
1
Q
Common causative agents of community acquired pneumonia (CAP)
A
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- Staphylococcus aureus
- Klebsiella pneumoniae
2
Q
Atypical causative agents of CAP
A
Legionella, mycoplasma, and chlamydia
3
Q
Mycoplasma pneumoniae typical manifestations
A
- Low grade fever
- Cough
- Bullous myringitis
- Cold agglutinins
4
Q
Pneumocystis jiroveci (nee carinii) typical manifestations
A
- Slower onset, immunosuppression
- Increased lactate dehydrogenase
- More hypoxemic than appears on CXR
- Intersitital infiltrates
5
Q
Legionella pneumoniae typical manifestations
A
- Chronic cardiac or respiratory disease
- Hyponatremia
- Diarrhea, other systemic symptoms
6
Q
Chlamydia pneumoniae typical manifestations
A
- Longer prodrome
- Sore throat, hoarseness
7
Q
Streptococcus pneumoniae typical manifestations
A
- Single rigor
- Rust-colored sputum
8
Q
Klebsiella pneumoniae typical manifestations
A
- Currant jelly sputum
- Chronic illness, including alcohol abuse
9
Q
What patient group is more likely to have klebsiella pneumoniae?
A
Alcohol abuse
10
Q
What patient group is more likely to have hameophilus pneumoniae?
A
COPD
11
Q
What patient group is more likely to have pseudomonas sp.?
A
cystic fibrosis
12
Q
What patient group is more likely to have mycoplasma pnemoniae and/or chlamydia pneumoniae?
A
Young adults, college settings
13
Q
What patient group is more likely to have legionella pneumoniae?
A
Air conditioning/aerosolized water
14
Q
What patient group is more likely to have encapsulated organisms, streptococcus pneumoniae, and/or haemophilus pneumoniae?
A
Postesplenectomy
15
Q
What patient group is more likely to have fungus as the causative organism in CAP?
A
Leukemia, lymphoma
16
Q
What patient group is more likely to have RSV as the causative organism in CAP?
A
Children <1 year
17
Q
What patient group is more likely to have parainfluenza virus as the causative organism in CAP?
A
Children <2 years
18
Q
Treatment of CAP in outpatient setting
A
A macrolide (azithromycin, clarithromycin) or doxycycline
19
Q
Treatment of CAP in outpatient setting for patients with underlying chronic disease
A
Fluoroquinolone (levofloxacin, moxifloxacin) or a macrolide (azithromycin, clarithromycin) plus a beta lactam (amoxicillin, amoxicillin-clavulanate, cefpodoxime, or cefuroxime)
20
Q
What are indications for hospitalization in CAP?
A
- Neutropenia
- Poor host resistance
- Involvement of more than one lobe
21
Q
What are other considerations for hospitalization in CAP?
A
- Patients >50 years of age w/comorbidities
- Altered mental status
- hemodynamic instability
22
Q
Inpatient treatment of CAP
A
Fluoroquinolone (levofloxacin or moxifloxacin) or a combination beta lactam (i.e., ceftriaxone or cefotaxime) plus a macrolide (i.e., azithromycin)
23
Q
Pneumococcal polysaccharide vaccine (PPSV) recommendations
A
- Recommended for children 2-5 years of age who have not been previously immunized
- Persons >65 years of age
- Any person with a chronic illness that increases the risk of CAP
24
Q
Chronic illnesses that increases the risk of CAP
A
- Cardiopulmonary diseases
- Sickle cell disease
- Tobacco use
- Splenectomy
- Liver disease
25
Pneumococcal conjugate vaccine (PCV) recommendations
Recommended as a series of four doses for children aged 6 week to 15 months
26
Which organism is the most common cause of atypical pneumonia?
Mycoplasma pneumoniae
27
Antibiotic treatment for atypical pneumonia
Regimens include erythromycin or doxycycline (for suspected M. pneumonia and Legionella infection) and tetracycline (for suspected Chlamydia infection)
28
What is the recommended treatment for influenza?
Neuraminidase inhibitors (inhaled zanamivir or oral oseltamivir)
29
What is the CDC recommendation for confirmed cases of influenza A?
Combination treatment with oseltamivir and rimantadine
30
Management of hospital-acquired (nosocomial) pneumonia
Includes use of appropriate empiric antibiotics to cover Pseudomonas (ceftriaxone; respiratory fluoroquinolone; imipenem; cefepime; etc.)
- Once an organism is isolated, therapy should be based on the culture and sensitivity results
- Mechanical ventilation if appropriate
31
What is the prophylactic treatment of choice for patients with a CD4 count of less than 200 cells/µL or with a history of Pneumocystis infection?
Trimethoprim-sulfamethoxazole (Bactrim)
32
Cough in TB
It begins as a dry cough and progresses to a productive cough, with or without hemoptysis, typically over 3 weeks or longer
33
What does the CXR show in primary TB?
Homogenous infiltrates, hilar/paratracheal lymph node enlargement, segmental atelectasis, cavitation with progressive disease
34
What does the CXR show in reactivation TB?
Fibrocavitary apical disease, nodules, infiltrates, posterior and apical segments of the RUL, apical-posterior segments of the left upper lobe, superior segments of the lower lobes
35
Ghon complexes (calcified primary focus) and Ranke complexes (calcified primary focus and calcified hilar lymph node) represent what?
Healed primary infection
36
What is the histologic hallmark of TB?
Biopsy revealing caseating granulomas (also known as necrotizing granulomas)
37
What group(s) have a reaction size of ≥5 mm in TB skin tests?
- HIV positive persons
- Recent contacts of those with active TB
- Persons with evidence of TB on CXR
- Immunosuppressed patients on steroids
38
What group(s) have a reaction size of ≥10 mm in TB skin tests?
- Recent immigrants from countries with high rates of TB
- HIV-negative injection drug users
- Mycobacteriology laboratory personnel
- Residents/employees of high-risk congregate settings
- Persons with certain medical conditions: DM, silicosis, chronic renal failure, etc.
- Children <4 years of age
- Infants, children, and adolescents exposed to adults at high risk
39
What group(s) have a reaction size of ≥15 mm in TB skin tests?
Persons with no risk factors for TB
40
What are the antituberculous drugs?
- Isoniazid (INH)
- Rifampin (RIF)
- Pyrazinamide (PZA)
- Ethambutol (EMB)
41
Latent TB infection treatment regimen
-Isoniazid for 9 months OR rifampin for 4 months OR rifampin and pyrazinamide for 2 months (only if in contact with TB-resistant persons)
42
Active TB infection treatment regimen
Isoniazid/rifampin/pyrazinamide/ethambutol for 2 months, followed by 4 months of addition multi drug treatment based on culture and sensitivity results (usually isoniazid and rifampin)
43
Isoniazid side effects
Hepatitis, peripheral neuropathy, coadminister vitamin B6 (pyridoxine) to reduce the risk
44
Rifampin side effects
- Hepatitis
- Flu syndrome
- Orange body fluid (e.g., orange urine)
45
Ethambutol side effects
-Optic neuritis (red-green vision loss)
46
Besides anti TB drugs, what other treatment is needed for patients with active TB disease and for how long?
Combination chemotherapy for 6-9 months; patients infected with HIV require therapy for at least 1 year
47
What is the prophylaxis of choice in patients who have tested negative for TB in the past but are now positive with known or unknown exposure (recent converters)?
Isoniazid for 6-12 months
48
Children, adolescents, and the immunocompromised who have been in close contact with a person with active TB should be offered treatment until when?
Until a TB skin test is negative 12 weeks after exposure
49
What is the definition of bronchitis?
Inflammation of the airways (trachea, bronchi, bronchioles) characterized by cough
50
What is the treatment for acute exacerbation of chronic bronchitis in which bacterial causes are more likely?
- First line treatment is a second generation cephalosporin (cefoxitin)
- Second line treatment is a second-generation macrolide or Bactrim
51
Antibiotic in bronchitis is indicated for which patients?
- Elderly patients
- Those with underlying cardiopulmonary disease and a cough for more than 7-10 days
- Immunocompromised patients
52
What is bronchiolitis?
Inflammation of the bronchioles (airways smaller than 2 mm in diameter). It is primarily an illness of young children and infants
53
Most common cause of bronchiolitis
RSV
54
Management of acute bronchiolitis
1. If RSV is present, consider hospitalization and administration of ribavirin. This is especially important for infants born premature or who are severely ill
2. Supportive measures (i.e., nebulized albuterol, IV fluids, antipyretics, chest physiotherapy, humidified oxygen)
55
In acute epiglottitis, what does the lateral neck radiograph show?
Swollen epiglottis (thumbprint sign)
56
Management of acute epiglottitis
1. Secure the airway
2. Administer broad-spectrum 2nd or 3rd generation cephalosporin such as cefotaxime or ceftriaxone for 7-10 days.
3. Dexamethasone may also be indicated
57
Most common cause of croup
Parainfluenza virus types 1 and 2
58
What does the PA neck film show in croup?
Subglottic narrowing (steeple sign)
59
Management of croup
1. Mild croup usually does not need treatment. Patients should be well hydrated
2. Corticosteroids, humidified air oxygen, and nebulized epinephrine may be recommended
3. Hospitalization may be required for patients with severe symptoms
60
Small cell lung CA characteristics
- More likely to spread early and rarely is amenable to surgery
- Tends to originate in the central bronchi and to metastasize to regional lymph nodes
- Prone to early metastasis and an aggressive clinical course; assume micrometastases at presentation
61
Non-small cell lung CA (NSCLC) characteristics
- Grows more slowly and is more amenable to surgery
| - It includes squamous cell carcinoma, adenocarcinoma, and large cell carcinoma
62
Squamous cell carcinoma
- Bronchial in origin and a centrally located mass
| - More likely to present with hemoptysis and therefore more likely to be diagnosed with sputum cytology
63
Adenocarcinoma
- Most common type of bronchogenic carcinoma
- Typically metastatic to distant organs
- Tumor arises from mucous glands, usually appears in the periphery of the lung, and is not amenable to early detection through sputum examination
64
Bronchoalveolar cell carcinoma
- Subtype of adenocarcinoma
| - Low-grade carcinoma
65
Large cell carcinoma
- Heterogenous group of undifferentiated types that do not fit elsewhere
- Cytology typically shows large cells
- Doubling time is rapid, and metastasis is early
- There may be central or peripheral masses
66
What are the endocrine/metabolic paraneoplastic syndromes of lung CA?
- Cushing syndrome
- SIADH
- Hypercalcemia
- Gynecomastia
67
Cushing syndrome histologic type
Small cell
68
SIADH histologic type
Small cell
69
Hypercalcemia histologic type
Squamous cell
70
Gynecomastia histologic type
Large cell
71
What are the neuromuscular paraneoplastic syndromes of lung CA?
- Peripheral neuropathy
- Myesthenia (Eaton-Lambert)
- Cerebellar degeneration
72
Peripheral neuropathy histologic type
Small cell
73
Myasthenia (Eaton-Lambert) histologic type
Small cell
74
Cerebellar degeneration histologic type
Small cell
75
What are the cardiovascular paraneoplastic syndromes of lung CA?
Thrombophlebitis
76
Thrombophlebitis histologic type
Adenocarcinoma
77
What are the hematologic paraneoplastic syndromes of lung CA?
- Anemia
- DIC
- Eosinophilia
- Thrombocytosis
78
Anemia histologic type
All
79
DIC histologic type
All
80
Eosinophilia histologic type
All
81
Thrombocytosis histologic type
All
82
What are the cutaneous paraneoplastic syndromes of lung CA?
Acanthosis nigricans
83
Acanthosis nigricans histologic type
All
84
Management of NSCLC
Surgery remains the treatment of choice
85
Management of SCLC
Combination chemotherapy is the treatment of choice and results in improved median survival
86
What are the complications of lung CA?
SPHERE
- SVC syndrome
- Pancoast tumor
- Horner syndrome
- Endocrine
- Recurrent laryngeal nerve
- Effusions
87
SVC syndrome
Compression of SVC; plethora, HA, mental status changes
88
Pancoast tumor
- Tumor of the lung apex
- Causes Horner syndrome and shoulder pain
- Affects brachial plexus and cervical sympathetic nerve
89
Horner syndrome
Unilateral face anhidrosis, ptosis, miosis
90
Endocrine in lung CA complications
Carcinoid syndrome: flushing, diarrhea, telangiectasias
91
Recurrent laryngeal nerve
Hoarseness
92
Effusions in lung CA complications
Exudative
93
Characteristics of malignant lesions
- Occasionally are symptomatic
- Tend to occur in patients older than 45 years of age
- Usually are greater than 2 cm in diameter
- Often have indistinct margins
- Exhibit rapid progression in size
- Rarely are calcified
94
What are carcinoid tumors (aka carcinoid adenomas or bronchial gland tumors)?
- Well-differentiated neuroendocrine tumors that affect men and women equally
- Patients are usually younger than 60 years of age
95
Are carcinoid tumors high grade or low grade malignant neoplasms?
Low-grade. They grow slowly and rarely metastasize
96
Where are carcinoid tumors commonly found at?
In the GI tract
97
Bronchoscopy reveals what in a carcinoid tumor?
Pink or purple central lesion that is well vascularized. The lesion can be pedunculate or sessile
98
Treatment of carcinoid tumor
- Surgical excision (carries a good prognosis)
- The lesions are resistant to radiation therapy and chemotherapy
- Octreotide (somatostatin analog) can be used to treat symptoms
99
What drugs are associated with asthma exacerbations?
Beta blockers, ACE-I, ASA, NSAIDs
100
Intermittent asthma symptoms
Symptoms ≤2 days per week
| No interference with daily activities
101
Intermittent asthma nighttime symptoms
≤2 times per month
102
Intermittent asthma use of rescue medication
<2 days per week
103
Intermittent asthma lung function
FEV1 >80% predicted
| FEV1/FVC normal
104
Mild persistent asthma symptoms
>2 days per week but not daily
| Minor limitation
105
Mild persistent asthma nighttime symptoms
3-4 times per month
106
Mild persistent asthma use of rescue medication
>2 days per week but not daily and not more than once on any day
107
Mild persistent asthma lung function
FEV1 >80% of predicted
| FEV1/FVC normal
108
Moderate persistent asthma symptoms
- Daily symptoms
| - Some limitation in daily activity
109
Moderate persistent asthma nighttime symptoms
>1 time per week but not nightly
110
Moderate persistent asthma use of rescue medication
Daily
111
Moderate persistent asthma lung function
FEV1 >60% but <80% predicted
| FEV1/FVC reduced 5%
112
Severe persistent asthma symptoms
- Continual symptoms
| - Extremely limited physical activities
113
Severe persistent asthma nighttime symptoms
Often 7 times per week
114
Severe persistent asthma use of rescue medication
Several times per day
115
Severe persistent asthma lung function
FEV1 5%
116
When is radiography indicated in asthma?
If pneumonia is suspected, the asthma is complicated, or another disorder is suspected
117
What objective device is encouraged in patients with chronic asthma?
Handheld peak expiatory flow meters
118
What test may help to establish the diagnosis of asthma when spirometry is non diagnostic and what is the diagnostic value?
A histamine or methacholine challenge test (bronchial provocation test); an FEV1 decrease of more than 20% is diagnostic
119
Bronchiectasis definiton
Defined as an abnormal, permanent dilation of the bronchi and destruction of bronchial walls. It can be congenital (cystic fibrosis), or acquired from recurrent infections (TB, fungal infection, lung abscess) or obstruction (tumor)
120
Bronchiectasis pathophysiology
Results from bronchial injury subsequent to severe infection and/or inflammation
121
What is the imaging modality of choice in bronchiectasis and what does it reveal?
High-resolution chest CT; it reveals dilated, tortuous airways
122
What is a characteristic finding of bronchiectasis on an CXR?
Crowded bronchial markings and basal cystic spaces
123
What are the antibiotics of choice for bronchiectasis?
Levofloxacin, amoxicillin, amoxicillin-clavulanate, bactrim, or cipro for 10-14 days
124
What does an CXR show in emphysema?
- Decreased lung markings at apices
- Flattened diaphragms
- Hyperinflation
- Small, thin-appearing heart
- Parenchymal bullae and blebs
125
What does an CXR show in bronchitis predominant COPD?
- Increased interstitial markings at bases
| - Diaphragms not flattened
126
What may a CBC show in COPD?
Polycythemia (increased RBC count) due to chronic hypoxemia
127
What type of inhalers are superior to beta-adrenergic agonists in achieving bronchodilation in COPD patients?
Anticholinergic inhalers (ipratropium or tiotropium)
128
Patients with cystic fibrosis are at increased risk of what?
Malignancies of the GI tract, osteopenia, and arthropathies
129
The diagnosis of cystic fibrosis should be suspected in any young patient that presents with what?
A history of chronic lung disease, pancreatitis, and infertility
130
ABG reveals what in cystic fibrosis?
Hypoxemia and in advanced disease, a chronic, compensated respiratory acidosis
131
What does pulmonary function tests reveal in cystic fibrosis?
Mixed obstructive and restrictive pattern
132
What are the 4 types of pleural effusions?
Exudates, transudates, empyema, and hemothorax
133
Exudate
Associated with "leaky capillaries"; examples include infection, malignancy, and trauma
134
Transudate
"Intact capillaries" are associated with increased hydrostatic or decreased oncotic pressure; examples include congestive heart failure, atelectasis, and renal or liver disease (cirrhosis)
135
Empyema
An infection within the pleural space
136
Hemothorax
Bleeding into the pleural space, commonly as a result of trauma or malignancy
137
What is the gold standard for pleural effusions?
Thoracentesis
138
Light's criteria (Transudates vs. exudates)
Fluid is considered to be an exudate if it meets any one of the following:
1. Pleural fluid protein to serum protein ratio of greater than 0.5
2. Pleural fluid LDH to serum LDH ratio of greater than 0.6
3. Pleural fluid LDH greater than two-thirds the upper limit of normal for serum LDH
139
Signs of pulmonary HTN
Narrow splitting and accentuation of the second heart sound and a systolic ejection click
140
What could and ECG show with pulmonary HTN
RVH, atrial hypertrophy, and right ventricular strain
141
An echo may be useful in estimating pulmonary arterial pressure, but what offers more precise hemodynamic monitoring?
Right heart catherization
142
Treatment of primary pulmonary HTN
1. Chronic oral anticoagulants
2. CCB to lower systemic arterial pressure
3. Prostacyclin (a potent pulmonary vasodilator)
4. Usually a heart-lung transplantation is needed
143
Treatment of secondary pulmonary HTN
Treating the underlying disorder and treatments for primary pulmonary HTN (chronic oral anticoagulants, CCB, prostacyclin)
144
What are the three histopathologic patterns of idiopathic fibrosing interstitial pneumonia with different natural histories and treatments?
1. Usual interstitial pneumonia
2. Respiratory bronchiolitis-associated interstitial lung disease
3. Acute interstitial pneumonitis
145
What will PFTs show with idiopathic fibrosing interstitial pneumonia?
Restrictive pattern (decreased lung volume with a normal to increased FEV1/FVC ratio)
146
Abestosis occupation
Insulation, demolition, construction
147
Abestosis diagnosis
Bx: asbestos bodies
CXR: Linear opacities at bases and pleural plaques
148
Abestosis complication
Increased risk of lung CA and mesothelioma, especially if a smoker
149
Coal workers' pneumoconiosis occupation
Coal mining
150
Coal workers' pneumoconiosis diagnosis
CXR: nodular opacities at upper lung fields
151
Coal workers' pneumoconiosis complications
Progressive massive fibrosis
152
Silicosis occupation
Mining, sand blasting, quarry work, stone work
153
Silicosis diagnosis
CXR: nodular opacities at upper lung fields
154
Silicosis complications
Increased risk of TB; progressive massive fibrosis
155
Berylliosis occupation
High technology fields: aerospace, nuclear power, ceramics, foundries, tool and die manufacturing
156
Berylliosis diagnosis
CXR: diffuse infiltrates and hilar adenopathy
157
Berylliosis complications
Requires chronic steroids
158
What levels are elevated in about 40-80% of Sarcoidosis patients?
Angiotensin-convertin enzyme levels
159
What are the radiographic findings in sarcoidosis?
Symmetric bilateral hilar and right paratracheal adenopathy and bilateral diffuse reticular infiltrates
160
What does transbronchial biopsy show in sarcoidosis?
Noncaseating granulomas
161
What are the three clinical settings that account for 75% of ARDS cases?
1. Sepsis syndrome (the single most important)
2. Severe multiple trauma
3. Aspiration of gastric contents
162
What is the underlying abnormality in ARDS?
Increased permeability of the alveolar capillary membranes, which leads to development of protein-rich pulmonary edema
