PULMONOLOGY Flashcards
How would you treat a patient’s cough/dyspnea/sore throat x 7-10 days?
For Bronchitis: Tessalan pearls, guaifenesin, acetaminophen/ibu
Start to think about chest xray and abx for pneumonia
Abx: 1stDoxy 2ndMacrolide (Bactrim)
What should you always check when you suspect bronchitis?
Check for hypoxemia, crackles, check for dyspnea or wheezing
How long can the cough persist form bronchitis?
Can last 2-3 weeks
What are the most common viral causes of pneumonia?
RSV, adenovirus, influenza virus, and parainfluenza
If we have an elderly pt with pneumonia, what scoring system would we use to determine if they need to be hospitalized or not?
CURB 65
Confusion, Urea greater than 20, RR greater than 30, Low systolic BP less than 90, and age greater than 65
If 3 or more of the above present – consider hospitalizaiton
Common causes of pneumonia?
Strep pneumoniae (community) or H influ; Pseudomonas & MRSA (hospital)
How do you treat pneumonias?
Community – Doxy or Macrolide Hospital – Floro or ceph + macrolide. Vanc for MRSA Peds – Amoxicillin
Rust colored sputum – cause?
pneumococcus
An alcoholic with pneumonia or Currant jelly sputum – cause?
Klebsiella
How is mycoplasma pneumonia diagnosed?
PCR
If a patient has pneumonia + GI symptoms and confusion – cause?
Legionella
What’s the cause of bacterial influenza?
Staph aureus
Although also most commonly occurs in HIV patients, what other lung disorder should we keep in the back of our minds?
Pneumocystis (fungus)
When does pneumocystits jiroveci present (CD4 count), how does a CXR look, how do you treat?
CD4 under 200 – Tx imperically with TMP-SMX
CXR – diffuse bilateral patchy interstitial infiltrates (ground glass)
In a pt with COPD what type of pneumonia do they get?
H influ
In an IVD user what type of pneumonia do they get?
Staph aureus
Aspiration pneumonia is often what bug?
Klebsiella
What type of pneumonia do cystic fibrosis pts get?
Pseudomonas
When would symptoms have to develop in order to be diagnosed with a nosocomial pneumonia?
Within 48 hours after leaving a hospital
Who should definitely get a yearly flu vaccination?
Those over 65 and all people who work in nursing homes
How do we dx and tx influenza?
Rapid Viral nose swab
Tx with Oseltamivir within 48hours
A patient with CF has a chronic daily cough, with thick, foul smelling sputum – dx? Tx?
Acute bronchiectasis
Tx – culture sputum, floroquinolones, long term azith, chest physiotherapy
What is bronchiectasis?
Abnormal/persistent dilatation of bronchii (CF pts) caused by destruction and recurrent infections
How do you treat pertussis?
Azithro
A vitamin A deficiency is also associated with what other disease?
CF
If on Chest XR you see bilateral hilar adenopathy, what do you think? What do you do next?
Sarcoidosis Get a biopsy – see noncaseating granulomas
erythema nodosum of the LE’s should make you think of what?
Sarcoid
How do we treat sarcoid?
symptomatic pts get corticosteroids
if you see honeycombing on chest CT – dx?
Asbestosis (idiopathic pulmonary fibrosis)
How does a pt present with idiopathic interstitial lung disease?
insidious dry cough, dyspnea, crackles, clubbing
PFTs = restrictive
Diagnosis of exclusion – unless with lung biopsy
How do we classify mildly intermittent asthma?
FEV1 = 80%+ Symptoms less 2x/week Night less than 2x/month FEV1/FVC = decreased
How do we classify mild persistent asthma?
FEV1 = 80%+
Symptoms more than 2x/week
Night more than 2x/month
FEV1/FVC = decreased
How do we classify moderate persistent asthma?
FEV1 = 60-80%
Symptoms Daily
Night more than 6x/month
How do we classify severe asthma?
FEV1 = Less than 60%
Symptoms continuous
Frequent night
If a patient has intermittent asthma, what is the tx?
SABA prn (Albuterol, levalbuterol)
**If used more than 2 days/week need to step-up
If symptoms are more than 2 days/week (but not daily) and nighttime symptoms occur 3-4x/month – what levels of asthma? How do we treat?
Mild Persistent asthma
**ADD a low-dose ICS (fluticasone, budesonide)
If that doesn’t control symptoms enough consider a medium dose ICS OR add a LABA
(Salmeterol, formoterol – short time ONLY)
If asthma symptoms are daily with nighttime symptoms occurring 1+/week – what level? How do we treat?
Moderate persistent asthma - Consult with pulmonologist
Medium ICS + LABA
Emphysema is what? Chronic bronchitis is what?
Emphysema = Loss of lung elasticity, enlarged air spaces
Chronic bronchitis = inflammation, excessive sputum production
Cough present for more than 3 months
If a patient has moderate COPD, what is their FEV1 & FEV1/FVC?
FEV1/FVC less than 70%
FEV1 = 60-80%
What is considered mild COPD?
FEV1/FVC greater than 70%
FEV1 greater than 80%
What’s the treatment progression for COPD?
AlbuterolTiotropriumICS (symbicort)
What’s the leading cause of cancer death?
Lung cancer
What form of lung cancer is common in nonsmokers?
Bronchogenic adenocarcinoma
What form of lung cancer is common in smokers and is very aggressive?
Small cell
What form of lung cancer develops centrally?
Squamous cell
What are the sxs of lung cancer?
Cough, chest pain, weight loss, dyspnea
Hemoptysis is lung cancer until proven otherwise
Is there any screening for lung cancer?
Not really – anyone who is ages 55-80 with a 30 pack year hx and currently smokes or quit within the past 15 years needs a Low-Dose CT until quit x 15 years
What are the different types of pleural effusions?
Exudates (infection), Transudates (CHF), Empyema, and Hemothorax
How do we Dx and Tx a pleural effusion?
Dx = CXR (blunting) or U/S
Tx = Thoracentesis
Thoarcentesis comes back with a large amount of protein – cause?
Exudate (Light’s Criteria)
Thoracentesis comes back with minimal protein and minimal LDH – cause?
Transudate
Thoracentesis comes back with pus – cause?
Empyema
What are the two types of sleep apnea?
Cental and *Obstructive
What are the characteristic sxs of sleep apnea?
loud snoring, disrupted sleep, nocturnal gasping/choking, witnessed apnea, daytime sleepiness/fatigue
What’s a PE finding in sleep apnea?
Neck circumference in women greater than 16in; 17in in men
Your patient is hypoxic, tachy, and complaining of pleuritic CP – what do you think of?
PE!!
If you are highly suspicious of a PE – what do you do?
get the CT
If there is low risk of a PE what should you do?
Go through PERC =Age <50; HR <100; O2 sat on room air >94%; No prior history of DVT/PE; No recent surgery or trauma; No hemoptysis; no exogenous estrogen; no clinical signs suggesting DVT?
*MUST be able to say “correct” to all of them in order to pass all of them - Pass = do nothing
What happens if you fail PREC?
Go through WELLS criteria
What are the componenets of the WELLS criteria?
Sxs of DVT PE judged most likely diagnosis Surgery or bedridden more than 3 days in the past 4 weeks Previous DVT or PE HR greater than 100 Active cancer treatment
If you fail WELLS – then what?
If low = D-Dimer
If mod-high = do imaging
If your pt actually has a PE – tx?
FULL ANTICOAG x 3-6 months
Unless unprovoked = lifetime☹
What are some fun facts/PE findings of a PE?
ECG = S1Q3T3 (S wave in 1, Q wave inversion in 3)
CXR = Hampton hump (peripheral wedge of airspace) and westermark’s sign
If a patient is not responding to 100% oxygen – what do you think about?
ARDS
