Pulmonology Flashcards

Question

Idiopathic pulmonary fibrosis

Answer 1

Ineffective repair of alveolar epithelial cells injured by smoking, pollutants, microaspirations over 40 yo ``` Presentation: Progressive exercise intolerance Dyspnea Dry crackles JVD Tachypnea Possible digital clubbing ``` PFT: decrease lung volume, normal FEV1/FVC ratio Radiology: honey come appearance - reticular Bx: fibrosis with decreased parenchymal architecture ``` Tx: pirfenidone nintedanib sildenafil Corticosteroids Antibiotics One transplant ``` Only survive 3 to 5 years after diagnosis

Answer 2

``` "A GRUELING Disease" ACE elevated in serum Gammaglobulinemia RA Uveitis Erythema nodosum LAD - b/l hilar LAD Idiopathic Noncaseating Grandulomas D vitamin production by activated macrophages in granulomas -> hypercalcemia ``` Pulmonary involvement: cough dyspnea and chest pain Radiology: noncaseating granulomas, b/l hilar LAD, pulmonary infiltrate, skin lesions Tx: Glucocorticoids, cytotoxic drugs, +/- lung transplant Frequently show anergy to skin test or PPD

Answer 3

mining, demolition of concrete, stonecutting, sandblastng Upper lobes "eggshell" calcifications of hilar LN Increased susceptibility to TB risk of lung CA increased x2

Answer 4

mining coal Anthracosis - generally asx or mild -urban dwellers, tobacco smokers Simple coal workers disease - small fibrotic lung nodules Complicated: progressive massive fibrosis and necrosis Presents as chronic bronchitis No increased lung cancer risk, unless radon or smoking exposure

Answer 5

aerospace manufacturing Noncaseating granulomas Increased risk of lung cancer

Answer 6

progressive autoimmune disease of lungs and kidneys Anti-glomerular basement membrane Ab ``` Presentation: hemoptysis dyspnea Respiratory infection proteinuria granular casts hematuria ``` Dx: anti-GBM ab Bx: crescentic GN and IgG deposits along glomerular capillaries Tx: plasmapheresis, corticosteroids, immunosuppressive agents

Answer 7

Triad: Necrotizing granulomas of the upper and/or lower respiratory tract Necrotizing or granulomatous vasculitis in lungs and upper airways Focal necrotizing, often crescentic, glomerulonephritis ``` Presentation: hemoptysis dyspnea myalgias chronic sinusitis ulcerations of nasopharynx saddle nose deformity ``` c-ANCA ``` Tx: corticosteroids, cyclophosphamide methotrexate rituximab plasma exchange ```

Answer 8

Compares O2 status of alveoli to arterial blood Normal 5-15 increased in PE, pulmonary edema, right to left shunt PAlvO2 - PartO2 713 x 0.21 - (PaCO2/0.8) - PaO2

Answer 9

``` Risk factors: Immobilization Malignancy Recent surgery Pregnancy OCP use Smoking Obesity Fractures Prior DVT Severe burns ``` Presentation: dyspnea, pleuritic chest pain, cough, hemoptysis (rare) DVT symptoms (swollen leg) Abrupt AMS Dx: D dimer - r/o DVT/PE in low probability situations CTA - best test CXR: Hampton's Hump - wedge shaped opacification at distal lung fields; usually normal, may have atelectasis, pleural efusions ABG - elevated A-a gradient ECG - sinus tach - classic but rare: S1Q3T3 V/Q scan - if can't use contrast for CTA -ventilatory defects suggest PNA or other parenchymal lung disease -perfusion defects suggest PE Tx: Unstable - thrombolysis (tPA, streptokinase, urokinase) Stable - anticoagulation -state LMWH, heparin or fondaparinux -> warfarin or rivaroxaban, apixaban, edoxaban or dabigatran

Answer 10

``` Causes: PE Valvular disease - MS, MR Left to right shunt COPD (MC) Idiopathic ``` Presentation: dypsnea, fatigue, CP, cough, syncope ``` Exam: cyanosis Digital clubbing loud S2 JVD Hepatomegaly ``` Dx: ECG - RVH - cor pulmonale CXR: pulmonary vascular congestion, enlarged RV ECHO or cath to measure pressure Tx: CCB (nifedipine) endothelin receptor antagonists (ambrisentan, bosentan) cGMP phosphodiesterase inhibitors (sildenafil, tadalafil) Prostanoids (ilprost, treprostinil)

Answer 11

Increased pulmonary venous pressure -> fluid leaks from vessels into lung interstitial and airspaces ``` Causes: Left-sided heart failure MI Valvular disease Arrhythmias ARDS ``` ``` Features: dyspnea orthopnea paroxysymal noctural dyspnea frothy pink sputum tachycardia +/- wheezing ``` Dx: BNP elevated ECG: T wave abnormalities or QT prolongation CXR: diffuse interstitial fluid, cephalization of the vessels, Kerley B lines Tx: NOLIP Nitrates - redistribute blood outside pulmonary vasculature, decreased preload Oxygen - if hypoxemic Loop diuretics Inotropic drugs - dobutamine, milrinone (not first line, increased mortality) Positioning

Answer 12

Excess fluid in the pleural space ``` Presentation: Sob, dyspnea with exertion +/- pleuritic chest pain Fatigue dullness to percussion (over 300 ml) Decreased breath sounds Decreased tactile fremitus egophony +/- tracheal deviation ``` CXR: fluid level or blunting of costophrenic angles Transudate: CHF, cirrhosis, nephrotic sn - Pleural to serum protein less than 0.5 - OR- - Pleural to serum LDH less than 0.6 Exudative: cancer, infection, vasculitis - Pleural to serum protein >0.5 - Pleural to serum LDH >0.6 Tx: underlying pathology Thoracentesis, chest tube Pleurodesis - talc or chemo to scar space Complications: take off too much fluid too quickly -> reexpansion pulmonary effusion

Answer 13

Air in the pleural space Closed PTX: COPD, TB, blunt trauma, spontaneous (thin tall male) Open PTX: penetrating trauma, iatrogenic (central line, thoracentesis) Tension PTX: open with ball valve mechanism, increasing pressure Small PTX - asx ``` Tension PTX sxs: Decrease wall movement Decreased breath sounds Increased resonance to percussion Decreased tactile fremitus hypoxemia JVD Decreased blood pressure Tracheal deviation away from side ``` Tx: less than 15%: O2 and monitoring >15% - chest tube Tension: needle decompression Recurrent - pleurodesis

Answer 14

blood in the pleural space like pleural effusion presentation Complication: clotting blood -> fibrosis pleural space Dx: thoracentesis - grossly bloody Tx: O2, chest tube Tx underlying cause

Answer 15

Strep pharyngitis ``` Cough absent +1 Exudates, tonsillar +1 Nodes- tender anterior cervical +1 Temperature +1 under 15 +1 OR over 44 -1 ``` 0-1 no treatment no cx 2-3: get cx and treat if positive 4-5: tx empirically Tx: b-lactam abx - PCN, amox

Answer 16

cellulitis of floor of mouth, extending into submandibular area Causes: dental ifnection polymicrobial - GAS, staph, Bacteroides Tx: abx I&D protect airway

Answer 17

Infection between the tonsil and pharyngeal constrictors Causes: strep, S. aureus, Bacteroides Presentation: Fever, severe sore throat, muffled "hot potato" Voice Tonsil or uvula deflection to the opposite side Trismus (lockjaw) Drooling Tx: needle aspiration, I&D, abx

Answer 18

EBV ``` Presentation Fatigue 3-6 mo Sore throat malaise LAD - posterior cervical Splenomegaly Fever Tonsillar exudates ``` ``` Labs: heterophil Ab - monospot EBV serology elevated LFTs Hemolytic anemia (rare) thrombocytopenia (rare) ``` Tx: supportive no noncontact supports x3 weeks no contact sports x4 weeks

Answer 19

``` Presentation: arthralgias, myalgias (severe) nasal congestion cough V/D high fevers LAD ``` Lab: rapid swab Tx: zanamivir or oseltamivir within 48 hr of sxs ppx: vaccine - takes 2-4 weeks to kick in

Answer 20

associated with allergic rhinitis, barotrauma, viral infection, prolonged NG tube, asthma Bacterial causes: S. pneumo, H flu, Moraxella catarrhalis Rare spread to CNS -> meningitis Chronic - over 3 mo - obstruction (polyps, deviated septum) or anaerobic infection ``` Presentation: purulent nasal discharge maxillary toothache tendernes of affected sinus foul smell ``` ``` Tx: nasal irrigation analgesics oral decongestants intranasal steroids amox-clav, doxy, levofloxacin ``` DM - mucormycosis severe/chronic - get CT sinuses

Answer 21

features: Cough lasting longer than five days - often productive +/- purulent sputum usually not associated with fever Dx: sputum cx not recommended CXR r/o PNA (fever, abnl V/S, abnl lung exam) Tx: supportive, usually viral

Answer 22

GBS | E. coli

Answer 23

RSV S. pneumo S. aureus

Answer 24

S. pneumo Mycoplasma pneumoniae Chalmydophilla pneumoniae

Answer 25

``` S. pneumo Mycoplasma penumoniae Chlamydophila pneumoniae Haemophilus influenzae Influenza virus Legionella pneumophila (+ diarrhea) ```

Answer 26

S. pneumo Haemophilus influenzae S. aureas

Answer 27

``` presentation: Fever Cough Sputum production SOB ``` CXR: lobar consolidation Pathogens: S. pneumo H flu S. aureus Tx: B-lactams

Answer 28

``` Presentation: Prolonged illness Dry cough Headache Fatigue ``` CXR: interstitial infiltrates ``` Pathogens: Mycoplasma pneumoniae Chlamydophila pneumoniae Legionella pneumophilia Chlamydophila psittaci ``` Tx: macrolides, fluoroquinolones

Answer 29

hospitalize ampicillin + gentamicin or vancomycin + gentamicin

Answer 30

often outpt tx amox or amox-clav for typical azithromycin for atypical or pcn allergy

Answer 31

Azithromycin or doxycycline alone

Answer 32

b-lactam - amox or cefuroxime PLUS macrolide (azith) OR Respiratory fluoroquinolone - levo or moxi

Answer 33

B-lactam PLUS macrolide - ceftriaxone + azithromycin | Respiratory fluoroquinolone

Answer 34

b-lactam PLUS macrolide or respiratory fluoroquinolone

Answer 35

PCV-13 - conjugate - 4 doses before 2 yo PPSV-23 - polysaccharide 19-64 yo: smoker, alcoholic, chronic heart, lung, liver disease, DM Over 65, CSF leak, asplenic, cochlear implant, or immunocompromised

Answer 36

Immunocompromised - HIV CD4 less than 200 - Chronic glucocorticoid use Slow progression to respiratory failure CXR: diffuse, B/L interstitial infiltrates Elevated LDH Sputum with Pneumocystis on stain Tx: 21 days of TMP-SMX (IV or PO) or Pentamidine (IV) or Primaquine (PO) + clindamycin (IV or PO) steroids if pO2 less than 70 on room air or A-a gradient greater than 35

Answer 37

Local infection in the lung Fever +/- cough and chest pain LAD Forms granulomas with central caseous necrosis (Ghon focus) Ghon complex: Ghon focus + hilar LAD 10% untreated -> PNA or disseminated TB 90% -> latent

Answer 38

5-10% with latent TB ``` Risk: Recent primary infection Immunosuppression DM Kidney disease Older age HIV TNF-a inhibitors ``` Lung apices ``` Features: Fever Night sweats Weight-loss Cough and hemoptysis ``` Disseminated involves: bones, CNS, GI, GU

Answer 39

Sputum x3 8 hours apart - Acid fast stain - AFB cx - takes 4-6 weeks, needed for susceptibility TB NAAT - rapid, but no susceptibility info

Answer 40

PPD Interfereon gamma release assay -quantiferon TB- GOLD -T-spot Evaluates release of IFN-gamma by T cells presented with M. tuberulosis antigens positive result - previous immune response to TB Immunosuppression -> unreliable results

Answer 41

5 mm: HIV, close contact with TB, CXR suggestive of TB, immunosuppression 10 mm: homeless, IV drug use, prison, health care, immigrants from endemic areas, DM, HD, kids under 4 15 mm: always considered positive (low risk individuals)

Answer 42

Latent: Isoniazid daily x 9 mo OR Rifapentine + isoniazid q1 wk x3 mo Active: 2 months of RIPE then 4 mo of Rifampin + isoniazid ``` RIPE: Rifampin Isoniazid + B6 Pyrazinamide Ethambutol ```

Answer 43

Respiratory failure following a severe acute injury to lung -sepsis, trauma, aspiration ``` Features: Acute dyspnea and respiratory decompensation Cyanosis Tachypnea Wheezing, rales, Rhonchi ``` Dx: ABG: respiratory alkalosis Wedge pressure less than 18 (if pulm edema w/ CHF over 20) PaO2:FiO2 less than 200 (under 100 severe) CXR: diffuse pulmonary densities Tx: Admit ICU - supportive care and treat underlying cause Mechanical ventilation with low tidal volumes (minimize injury) and adequate PEEP (recruit collapse alveoli) Conservative fluids - goal CVP 4-6 mmHg Furosemide and albumin to prevent pulmonary edema Prone positioning - improves oxygenation (not survival) Minimize O2 consumption: - prevent fever - minimize anxiety and pain - limit respiratory muscle use- paralytics Transfuse blood only if Hgb below 7 - transfusion may increase risk of death in ARDS patient

Answer 44

NC - 24-40% FiO2 (FiO2 increases 3% every 1L/min up to 6 L/min) Face mask- 50-60% FiO2 Non-rebreather - 60-95% FiO2 CPAP -> 80% FiO2 Mechanical vent up to 100% FiO2

Answer 45

Incentivive spirometry Early postop ambulation Upper airway suctioning Bronchoscopic suctioning

Answer 46

Pre-oxygenate - 100% O2 several minutes Pretreat - Lidocaine for increased ICP - Fentanyl for pain - Atropine for secretions, prevent bradycardia Induction agents: Sedatives: etomidate, propofol, midazolam, ketamine Paralytics: succinylcholine, rocuronium Cricoid pressure (Sellick technique) ``` Placement: Watch tube pass vocal cords -Check end tidal CO2 -look for bilateral lung expansions -listen for air sounds in stomach -CXR for positioning ``` Complications: tube misplacement, aspiration, dental injuries Tracheostomy if ET tube in place for few weeks