Pulmonology

Question 1

_______ is the treatment of choice in patients with pulmonary embolism with normal ventricular function and no absolute contraindications.

Answer 1

Anticoagulation

Question 2

_____ cancer is common in patients with a smoking history and presents with a central mass, hilar adenopathy, and mediastinal widening

Answer 2

Squamous cell lung cancer

Question 3

Cavitation is seen with a _____ or primary TB.

Answer 3

Lung abscess

Question 4

____ (type of lung cancer) is associated with the poorest prognosis.

Answer 4

Small cell lung cancer is the most common type of lung cancer that is metastatic at the time of discovery, and therefore has the poorest prognosis

Question 5

A PE exam finding of DECREASED tactile fremitus and dullness to percussion would suggest ______.

Answer 5

Pleural effusion (PNA has increased tactile fremitus!)

Question 6

_____ is the MC of cancer deaths in men and women 50-60 y

Answer 6

Lung cancer

*Cigarette smoking is MC

Question 7

The primary sites of METS w/ lung cancer are:

Answer 7

brain, bone, liver, lymph nodes, and adrenals

Question 8

MC type of lung cancer is _______.

Answer 8

A non-small cell carcinoma (85%)

Question 9

What are the 3 types of non-small cell carcinoma?

Answer 9

1. Adenocarcinoma
2. Squamous cell
3. Large cell (anaplastic) carcinoma

Question 10

_____ is the most common type of non-small cell carcinoma in women.

Answer 10

Adenocarcinoma

*Bronchioalveolar is a rare low-grade subtype that has the best prognosis. Presents with voluminous sputum and an interstitial pattern on CXR.

Question 11

______ (type of lung cancer) is typically centrally located and associated with cavitary lesions, HYPERcalcemia, and pancoast syndrome (Think CCCP).

Answer 11

Squamous cell

Question 12

_______ (type of lung cancer) is VERY AGGRESSIVE.

Answer 12

Large Cell (Anaplastic)

Question 13

Describe small cell carcinoma…

Answer 13

Typically METS early–> surgery usually not a treatment option

Question 14

What are the S&S of Small Cell lung cancer?

Answer 14

• dilated neck veins, prominent chest veins
• SIADH/hyponatremia
• Cushing’s syndrome
• Lambert-Eaton syndrome- weakness (improves with movement)

Question 15

What is pancoast syndrome?

Answer 15

Associated with squamous cell carcinoma. Atrophy of hand/arm muscles, tumors at superior sulcus, shoulder pain, Horner’s syndrome (miosis, ptosis, anhydrosis)

Question 16

How is lung cancer diagnosed?

Answer 16

Found on CXR; CT for staging

Question 17

How is Non small cell cancer treated? How is small cell treated?

Answer 17

Non small cell- surgery

Small cell- chemo

Question 18

Name 4 classifications of pleural effusion:

Answer 18

1. Empyema- grossly purulent due to direct infxn of pleural space
2. Parapneumonic- noninfected secondary to bacterial PNA
3. Hemothorax- gross blood (think chest trauma and malignancy)
4. Chylothorax- increased lymph involvement

Question 19

What is transudate and what causes it?

Answer 19

Transudate- circulatory system fluid due to increased hydrostatic pressure and/or decreased oncotic pressure

Etiologies- CHF is the MC cause (also nephrotic syndrome and cirrhosis)

Question 20

What is exudate and what causes it?

Answer 20

Exudate occurs when local factors increase vascular permeability (INFECTION, INFLAMMATION)
-contains plasma proteins, WBCs, platelets, RBCs

Question 21

What is Light’s Criteria?

Answer 21

Exclusive to EXUDATES. Presence of any 3 of the following= exudative.

1. Pleural fluid protein
2. Pleural fluid LDH
3. Pleural fluid LDH (diff parameters than above, see study guide)

Question 22

What are the S&S of pleural effusion?

Answer 22

Usually asymptomatic. May complain of “pleuritic” chest pain, cough, dyspnea

Question 23

PE findings of Pleural Effusion-

Answer 23

DECREASED TACTILE FREMITUS

DECREASED BREATH SOUNDS

DULLNESS TO PERCUSSION

Question 24

How is a pleural effusion diagnosed?

Answer 24

CXR: PA/Lateral
-blunting of costophrenic angles

*LATERAL DECUBITUS films are the best

**Thoracentesis is the test of choice!!

Question 25

How do you treat a pleural effusion?

Answer 25

1. Treat underlying condition- diuretics, sodium restriction 2. Thoracentesis: gold standard! DON'T remove more than 1.5L during any one procedure 3. Chest tube pleural fluid drainage: if empyema may inject with streptokinase to facilitate drainage

Question 26

What is the primary cause of a pulmonary embolism?

Answer 26

95% originate from DVTs in the LE above the knee or pelvis *other= fat emboli from long bone fracture and air emboli from central lines

Question 27

What are the S&S of a PE?

Answer 27

Dyspnea MC symptom | Tachypnea MC sign

Question 28

What is the classic triad of a pulmonary embolism?

Answer 28

Dyspnea, pleuritic chest pain, hemoptysis

Question 29

What is the classic presentation of a pulmonary embolism?

Answer 29

Post-op patient with sudden tachypnea, tachycardia, +/- cough, hemoptysis *Factor V Leiden in the MC predisposing condition

Question 30

How is a pulmonary embolism diagnosed?

Answer 30

Helical CT scan best initial test! (pulmonary angiography is gold standard) CXR: Westermarks sign, Hampton's hump ECG: sinus tach

Question 31

How is a pulmonary embolism managed?

Answer 31

1. Anticoagulation with Heparin - Then warfarin x 3mos or - Dabigitran or edoxaban 2. IVC filter: if pt CI for anticoagulate 3. Thrombolysis: if massive PE and hemodynamically unstable 4. Thrombectomy/Embolectomy: if thrombolysis is CI

Question 32

Prophylactic options for PE?

Answer 32

Early ambulation, elastic stockings/SCDs, LMWH

Question 33

Name and describe the different types of PTX...

Answer 33

1. Spontaneous - Atraumatic & idiopathic. Due to bleb rupture. a. Primary- NO underlying lung dz, mainly affects tall and thin men 20-40y, smokers, ppl w/ family hx of PTX b. Secondary- + underlying lung dz w/o trauma (COPD, asthma) 2. Traumatic - Iatrogenic- during CPR, thoracentesis, PEEP, subclavian line placement, accidents (MVAs) 3. Tension - Any type of PTX in which the positive air pressure pushes lungs, trachea, great vessels & heart to the CONTRALATERAL SIDE. Immediately life threatening! MC seen during TRAUMA, mechanical ventilation, resuscitation efforts - Have increased JVP, pulsus paradoxus, hypotension

Question 34

Describing chest pain and PE findings with PTX...

Answer 34

Chest pain usually pleuritic, unilateral, non exertional, and sudden onset, dyspnea - Hyperresonance to percussion, decreased fremitus, decreased breath sounds - Unequal respiratory expansion, tachycardia, tachypnea

Question 35

How is a PTX diagnosed?

Answer 35

CXR with EXPIRATORY VIEW *may see companion lines

Question 36

How is a PTX treated?

Answer 36

1. Observation in primary spontaneous if small (often resolves within 10 days on its own) 2. Chest tube placement (thoracostomy) if large or severe symptoms 3. Needle Aspiration: if tension PTX followed by chest tube placement. Needle placed in 2nd intercostal space at midclavicular line of the affected side.

Question 37

What are the associated CXR findings for aspiration PNA?

Answer 37

Early-fluffy infiltrate or normal CXR | Late- pneumonia, ARDS

Question 38

What lobes are commonly involved in aspiration PNA?

Answer 38

Supine-RUL | Sitting- RLL

Question 39

Which organisms are commonly involved in aspiration PNA?

Answer 39

Community acquired- gram positive, mixed | Hospital/ICU- gram negative rods

Question 40

What diagnostic studies are indicated for aspiration PNA?

Answer 40

CXR, sputum culture, gram stain

Question 41

What is the treatment for aspiration PNA?

Answer 41

Bronchoscopy with antibiotics if PNA develops, intubation if respiratory failure occurs, ventilation with PEEP if ARDS develops Abx- Zosyn or Cefepime + Cipro (add Vanc if MRSA suspected or Linezolid if Legionella suspected)

Question 42

What is Mendelson's syndrome?

Answer 42

Chemical pneumonitis secondary to aspiration of stomach contents.