Pulmonology Flashcards
Which ribs will appear larger on a lateral cxray?
the right ones because these are getting the exposure first
If you order a PA cxray what should you also always order?
lateral to get depth
what are the 5 things to determine if a chest X-ray is adequate?
penetration (spine should be visible through heart), rotation (spinous processes should be equidistant between clavicles), inspiratory effort (8-10 ribs), magnificantion (of heart in AP view), angulation (clavicle should have an S appearance)
what are the ABCDEFs of reading a chest X-ray after determining that its adequate?
airways, bones and soft tissues, cardiac silhouette, diaphragm, effusion (pleural), fields (lung fields)
what are the 4 things to look for in an abdominal radiograph?
bones, stones, gas, masses
what will a healthy small bowel look like on an abdominal X-ray?
centrally located, diameter
what will a healthy small bowel look like on an abdominal X-ray?
frames the image, transverse colon should be
asthma: pathophys, triggers/etiology, sx, signs
pathopys: bronchospasm
triggers: triggers: infection, tobacco smoke, allergens, stress, exercise
sx: wheezing, cough, dyspnea, chest tightness
signs :wheezing, prolonged expiration, hypoxia
pneumonia: pathophys, triggers/etiology, sx, signs
pathophys: starts with infection. Alevoli fill with fluid leading to impaired gas exchange.
eti: s. pneumnoia, m. pneumonia, c. pneumnoia
sx/signs: sx: cough, +/- sputum, fevers, chest pain, dyspnea; signs: hypoxia, rales, bronchial breath sounds, dullness to percussion
what is COPD? pathophys, RFs, sign/sx, complication
emphysema/alveolar wall destruction and reduced surface for gas exchnange, decreased lung elasticity. Assoc w/ chronic bronchitis=inflammation/obstruction of larger airways. Irreversible.
pahtophys: alveolar wall destruction and reduced surface for gas exchnange, decreased lung elasticity leads to small airway collapse and obstructed flow.
RF: smoking
signs/sx: SOB, wheezing, coughing with sputum signs: wheeze, rhonchi, prolonged expiration, hypoxia
complication: complication of chronic bronchitis/infection=ectasia/thickening of bronchi and mucus pooling/plugging
what is PE? what are signs and sx? RFS
embolus blocking pulmonary artery branch; area of lung no longer perfused by blood resultng in reduced oxygenation
signs/sx: sharp and pleuritic pain, acute onset, associated with dyspnea, may be preceded by calf pain, well localized, may have accompanying couhg or bright red hemoptysis. Signs of tachypnea, hypoxia, possible pleural rub (less common)
RF: immobilization, recent lower extremity vascular trauma, cancer, obesity,smoking, pregnancy, OCP
lung cancer RFs, signs/sx
RFs: smoking, radon, asbestos
signs/sxdyspnea, chronic cough, hemoptysis, CP, weigh loss; signs: nonspecific
pneumothorax RFs, sx and signs
RFs: tall, skinny male, trauma, iatrogenic
signs/sx: dyspnea, hypoxia, chest pain; signs: >HR/RR, hypoxia,
what can a CT scan dx?
to dx PE, lung ca, pneumonia, aortic dissection
which test has a continuous rotating X-ray beam and a quicker high resolution than conventional CT?
spiral CT
what test is used for those suspected of PE who can’t tolerate the contrast in a CT scan?
V/Q scan
how is a V/Q scan performed? what is normal?
pt inhales a radionuclide to assess airways into lungs and they are also given an IV radonuclide injection to assess blood circulation through pulmonary arteries. Results are categorized as normal, low probability, intermediate probability and high probability, although low and intermediate don’t rule out pE. normal test if all areas of air/blood match up. discrepancies should be investigated
what shows a PE on a V/Q scan?
Need to look in the periphery away from the hilum because the hilum doesn’t get much blood. if there is an area of filling defects in the periphery, then that shows that blood is not gettng there.
what’s an advantage of CT over a V/Q?
V/Q only assesses for pE, while CT can screen for alternate diagnoses. Similar cost.
what test is the gold standard for PE? how is it done?
pulmonary angiography; catheter instered under flouroscopy into the pulmonary arteries followed by dye injection and x rays
when is a d dimer done? in what cases do you need further follow up? why?
test for DVT, PE: a fibrin-degradation product released by clots during fibrinolysis. need to f/u if elevated because its vey sensitive but not very specific. False positives with inflammation, cancer pregnancy, advanced age, trauma.
what are some of the indicaitons for a bronchoscopy?
to look for tumors, sources of hemoptysis can also bx. ,low risks of bleeding, vocal cord trauma, pneuothorax, can also wash “lavage” and culture the fluid
what positions are used for very sick pts and pleural effusions for CXR?
PA best. AP for very sick pts that can’t stand up, but heart shadow will be larger. Supine fi really sick but diaphragms are higher and lung volume is decreased. Lateral decubitus to show pleural effusions because these will level out when sideways.
what does the silhouette sign signify? where is it often seen?
silhouette sign: if a pulmonary opacity is in contact with the heart border, then the heart border will be obscured which is often seen in rml and left lingular infiltrates.
wht do you call airfield bronhioles within in an area of consolidation?
airbronchograms
what are kersey b lines and what do they signify?
they are horizontal lines seen on a cxr that are found in the lower lung periphery and are significant for pulmonary edema
what kinds of signs can be seen in someone with CHF on a CXR?
chest xray may show cardiomegaly, cephalization of pulmonary flow (redistributio of flow to upper lung fields), intersitital edema, Kerley B lines, fluid in fissures, pulmonary edema, pleural effusions
what kinds of findings can be seen in someone with pneumonia?
infiltrates settling in lower part of the lobes, silhouette sign if consolidation/infilitrate in RML or lingula
if a pneuothorax is suspected, what is the best way to see it?
have the patient breathe out then take the xray
what CXR changes are seen in someone with COPD?
diffuse hyperinflation with flattening of diaphragms
what do you do to tx a tension pneumothorax?
emergent needle thoracotomy to release air
what’s the world 2nd deadliest infectious disease?
TB
RFs for exposure, RFs for contraction
RF exposure: at higher risk of exposure: foreign born, travel to TB prev. countries, residents+employees of crowded housing: NH, prisons, hosptials, close contects of infected, high risk pops: medically underserved, lower SES, susbstance abusers, or health care workers serving those pops, kids and teens exposed to ^risk adults
R/O contraction: HIV, infected w/I past 2 yrs, infants and children, certain med conditinos, drug users, hx of poorly tx’d TB, DM, corticosteroid or immunesuppessive tx, cancer of head and neck, hematologic and reticuloendothelial disease, end stage renal disease, intestinal bypass or mastectomy, chronic malabsorption syndrome, low body weight (10% lower than ideal)
is a latent TB infection infectius?
no
how is TB transmitted?
via droplets. 1 bacilli per droplet, 500 droplets per cough.
what is the progression of TB/
Progression:2-8 wks in alveoli, after macrophages ingestion=granuloma/tubercle, which is latent. Becomes infectious if immune system can’t control it=multiply in any area of body
does a negative rxn to either TST or IGRA rule out TB?
NO
who should the BCG vaccine be considered for?
Not rec’d in US. can be given to children who are continually exposed to untreated or poorly tx’d adult. consider giving to health care workers on a case by case basis for those who are at risk of transmission of a drug resistant TB strain. never give BCG to people with immunosuppresion, HIV, or pregnancy.
what’s a positive tuberculin test? how long will it stay positive?
> 5mm is positive. will stay “positive” for at least a week. 5 mm is a positive test in someone with HIV, recent contact with a case, fibrotic changes or CXr showing old TB, pts with organ transplants or immune suppressed. 10 mm is positive in recent arrivals from high prevalence countries, IV drug users, residents/employees of high risk congregate settings, mycobacteriology lab personnel, persons with clinical conditions that place them at high risk, children
what do you do if a pt forgot to come in within the 72 window to have their TB test read and it looks negative?
If forgot to come back within 3 days and its negative, need a retest. Never let them say they’re mom is a nurse and she can check it at home. Many variations of interpretation.
when should you give a PPD with regards to live vaccines?
either day of or 4-6 wks after.
how long does it take after infection for a persons’s test aka immune response to work and show a positive test?
2-10 wks
what can cause false negative results in a TST test?
may get false negative from anergy, viral, bacteiral or fungal co infection, recent TB infection, very young or very old, overwhelming TB disease, live virus vaccine, renal failure/disease, lymphoid disease, low protein states, immunosuppressive drugs, problems with TST administration
what are the sx of TB?
prolonged cough (3 wks or longer), hemopytsis, chest pain, loss of appetite, unexplained weight loss, night sweats, fever, fatigue
can a medical exam be used to rule in or out TB?
NO
what are other sx someone with TB may experience if the disease has spread to other areas?
May have extrapulmonary TB: blood in urine, headache or confusion, back pain, hoarsness, loss of appetite, weight loss, night sweats, fever, fatigue. pE can’t be used to rule in or out TB.
what are common findings on a cxr of someone with TB?
CXR: often apical or posterior areas of upper lobe will show abnoralities like differences in size, shape, density; cavities, infiltrates, nodule, lymphadenopathy, calcified granulomas, fibrotic or pleural scars
what are the requirements for follow up after a positive CXR, TST, or IGRA?
sputum collection (at least 3 sputum specimens at 8-24 hour intervals, at least 1 in AM. Can get sputum via coughing, sputum induction, bronchoscopy or gastric aspiraiton if it keeps getting swallowed) and AFB smear. AFB smear provides a preliminary presumptive dx of TB and is categorized as 4+, 3+,2+,1+
if someone has positive tests for TB and is suspected of it and you have taken a specimen or AFB smear, what do you do next?
treat them as positive and send on the DNA probes to MDH.
