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Pulmonology > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

What are the diseases that are obstructive in nature?

A

Asthma
COPD
Bronchiectasis
Bronchiolitis

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2
Q

What are the diseases that are restrictive in nature?

A 
Parenchymal diseases
Interstitial diseases
Neuromuscular disease
Pleural diseases
Chest wall abnormalities
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3
Q

What pulmonary diseases that are due to vascular abnormalities?

A

Pulmonary embolism
Pulmonary AV fistula
Pulmonary hypertension

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4
Q

What necessary diagnostic evaluation in respiratory diseases?

A

Chest imaging
Sputum analysis
Pulmonary function test (eg. Spirometry)
Bronchoscopy

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5
Q

Smokers cough usually occurs at what time of the day?

A

Early morning

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6
Q

Asthmatic cough usually occurs at what time of the day?

A

Midnight or early morning

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7
Q

What should you do to diagnose psychogenic cough?

A

Preoccupy patient with other activities and see if cough disappear

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8
Q

What is a possible cause for stridor?

A

Any tracheal or upper way obstruction like FBO, largyngomalacia, etc

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9
Q

Characteristic of a lung abscess sputum?

A

Foul smelling sputum

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10
Q

What signifies rust-colored and purulent sputum?

A

Pneumococcal pneumonia

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11
Q

What does pink frothy sputum means?

A

Pulmonary edema

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12
Q

Characteristics of an uninfected sputum?

A

Odorless, transparent, whitish gray

Mucoid sputum

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13
Q

Three most common causes of hemoptysis?

A

Bronchitis
Bronchiectasis
Bronchogenic CA

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14
Q

How much volume of blood can you consider as massive hemoptysis?

A

100-600 mL/day

Admit patient immediately!

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15
Q

What volume is considered nonmassive hemoptysis?

A

<100 mL per day

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16
Q

What are the possible causes of hemoptysis?

A 
BATTLE CAMP
Bronchiectasis, bronchitis
Aspergilloma
Tumor
TB
Lung disease
Emboli
Coagulathy
Autoimmune dse, AVM, alveolar hemorrhage
Mitral stenosis
Pneumonia
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17
Q

What do you call the sudden onset of dyspnea at night? It is an important symptom of what system?

A

Paroxysmal nocturnal dyspnea

PND and orthopnea are importantly associated with cardiac dse

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18
Q

What disease/s may exhibit platypnea or difficulty in breathing while sitting up?

A

Atrial myxoma
(Tumor in atrial chamber)
Relieved by supine position

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19
Q

Most common causes of wheezing?

A

Asthma
COPD
Congestive Heart Failure (also assoc. with crackles)

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20
Q

Where can you spot central cyanosis? What is the cause? Estimated O2 saturation that central cyanosis appears?

A

Circumoral area or below the tongue

Decreased arterial oxygenation by intracardiac shunt, diseases that decreases dlco

<85% O2

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21
Q

What is the pathogenesis of peripheral cyanosis?

A

Sluggish blood flow

Limiting blood flow to periphery or extremities

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22
Q

Where will you auscultate a patient with suspected middle lobe involvement/pathology?

A

Right anterior chest

Can no longer appreciate middle lobe in the posterior chest

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23
Q

What phases of respiration does wheezing usually heard? How about stridor?

A

Wheezing expiratory
Stridor inspiratory

(WESI)

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24
Q

Difference between orthopnea in respiratory and in cardiac dses?

A

Respiratory orthopnea occurs only in exacerbation

In cardiac, it occurs even at rest

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25
Q

What do you call the preferred position of patient with obstructive dse? This position aids them in proper breathing and chest expansion?

A

Tripod position

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26
Q

Signs of respiratory distress

A

Supraclavicular amd intercostal retractions
Tachypnea
Nasal flaring
Grunting
Paradoxical respiration ( indrawing of chest in inspiration and expansion during exhalation-reverse in normal)

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27
Q

Usual appearance of COPD patients?

A

Barrel chest
Smokers sign
Tripod position
Prominent scalene and sternocleidomastoid muscles

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28
Q

Flail chest usually found in what patients?

A

Trauma patient with multiple rib fractures

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29
Q

What are the chest wall abnormalities that may compromise breathing?

A 
Kyphoscoliosis
Pectis excavatum (funnel chest)

Pectus carinatum does not cause respiratory abnormalities

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30
Q

Type of breathing in metabolic acidosis?

A

Kussmauls breathing (rapid deep breathing)

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31
Q

Type of breathing in which there is apnea between normal or slow breathing?
Common in meningitis.

A

Biots breathing

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32
Q

Type of breathing in which there is progressive increase and decrease followed by apnea? It occurs when the respiratory center in the medulla loses its sensitivity to fluctuations in CO2 or afferent stimuli

A

Cheyne-Stokes breathing

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33
Q

What is the pathology behind hypoxemia?

A

Chronic hypoxemia

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34
Q

Perform chest lag test.

A

Place both thumbs at the lvl of 10th ribs
Pull skin slightly towards midline
Ask patient to inhale and exhale
Observe for chest lagging by taking note of the disappearance of skin fold line

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35
Q

In what conditions that there is an increased tactile fremitus/vibrations?

A

Consolidation

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36
Q

In what conditions that there is an decreased tactile fremitus/vibrations?

A

Fluid in chest (pleural effusion, pneumothorax)

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37
Q

Describe the diaphragmatic movement in emphysema? Phrenic nerve palsy?

A

Reduced or flattening of the diaphragm because of air trapping
No movement of diaphragm in phrenic nerve palsy

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38
Q

Describe tracheal breath sounds

A

Harsh, loud, high-pitched, extrathoracic

Inspiratory and expiratory components are equal

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39
Q

Describe bronchial breath sounds

A

loud, high-pitched, heard at manubrium

expiratory component is louder and longer than inspiratory

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40
Q

Describe bronchovesicular breath sounds?

A

Equal inspiratory and expiratory components

Heard between first and second scapulae

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41
Q

Describe vesicular breath sounds?

A

Inspiratory component longer than expiratory

Soft and low-pitched

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42
Q

Describe crackles

A 
Short
Discontinuous
Nonmusical
Usually inspiration
Coarser crackles in larger airways
Like rubbing your hair
Fluid filled (pus or blood)
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43
Q

Describe wheezing

A 
Continuous
High pitch
Musical
Usually expiratory
Narrowing of airways
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44
Q

Describe rhonchi

A

Sonorous
Low pitch
Due to transient mucus plugging in larger airways
Disappears upon expectoration

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45
Q

Describe pleural rub

A

Grating sound
Best hear in inspiration
Like creaking leather

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46
Q

Describe egophony

A

Eeee heard as aaaa

May be due to CONSOLIDATION, EFFUSION

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47
Q

Describe whispered petriloquoy

A

Intensification of whispered words

May be due to CONSOLIDATION

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48
Q

Describe bronchophony

A

Increased transmisson of spoken words

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49
Q

Where will be the shift of trachea in pleural effusion? Pneumothorax? Atelectasis?

A

Pleural effusion- contralateral to the affected side
Pneumothorax- contralateral to the affected side
Atelectasis- towards the affected side

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50
Q

Increased local pain distant from anteroposterior compression of the chest indicates?

A

Fractured rib

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51
Q

What is the volume of pleural effusion before it is detectable in chest xray

A

> 200-250mL

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52
Q

Lesions in the chest are not percussible if the distance is greater than ___

A

2-3cm

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53
Q

What ribs are frequently fractured?

A

3rd to 9th ribs

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54
Q

Pulsus paradoxus is a characteristic of?

A

Cardiac tamponade

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55
Q

Characteristics of cardiac tamponade?

A

Becks triad

  • jugular venous distension
  • hypotension
  • muffled heart sounds

Pulsus paradoxus

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56
Q

In chest trauma, what structures need great force to be fractured?

A

Sternum

1st and 2nd ribs

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57
Q

Associated complications in rib fractures?

A 
Rupture of the aorta
Pulmonary contusion
Tracheobronchial injury
Haemorrhage due to intercostal vessels injury
Pneumothorax
Hemothorax
Multiple rib fractures
Atelectasis
Hypoventilation
Inadequate cough
Pneumonia
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58
Q

In chest trauma, what will you suspect if patient from an VE had localized pain in the chest, pain that worsens with movement and coughing, point tenderness, crepitus, and splinting on respiration

A

Rib fracture

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59
Q

Primary goal of treating rib fractures

A

Relief from local pain and intercostal spasm

Pain control

  • IV analgesics
  • IC nerve block
  • intrapleural analgesia
  • epidural anaesthesia (most effective)

Provide airway and ventilation through high positive pressure ventilation

Non-circumferential splinting

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60
Q

In chest trauma, there is a paradoxical motion of chest, then we have a

A

Flail chest (sternal flail chest and ant, lat, pos, flail segments)

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61
Q

What is a closed pneumothorax?

A

Air in pleural space

100% occurrence in penetrating chest trauma, 10-30% in blunt trauma

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62
Q

Signs and symptoms of closed pneumothorax? What to do in prehospital setting in a closed pneumothorax caused by blunt trauma or spontaneous pneumothorax?

A

Needle thoracostomy

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63
Q

What is an open pneumothorax?

A

Sucking/slurping chest wound
Usually caused by penetrating trauma
A to- and fro- motion of air in across the chest wall
Decreased breath sounds in the affected side

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64
Q

Management for open pneumothorax?

A

Occlusive dressing taped on 3 sides

Chest tube insertion

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65
Q

What is tension pneumothorax? Immediate management?

A

One way valve
resulting to one way entrance of air towards the chest, trapping air inside. Continuous increased of air in the pleural cavity.

Needle thoracotomy or chest tube insertion

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66
Q

Signs and symptoms of tension pneumothorax?

A

Mediastinal/tracheal shift contralaterally

Extreme dyspnea
Restless, anxiety, agitation,
Jugular venous distension
Hypotension
Rapid weak pulse
Shock (late)
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67
Q

Where to place needle in needle thoracostomy?

A

Upper border of lower rib

2nd rib

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68
Q

What is hemothorax?

A

Accumulation of blood in the pleural cavity due to vessel injury (intercostal, great vessels)

Massive hemothorax due to major blood vessels

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69
Q

Usual signs of hemothorax

A

Dullness at the base during percussion
Hypotension if loss is massive
Rapid weak pulse due to increasing intravascular volume loss
Collapsed neck veins (engorged neck veins in tension pneumothorax)

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70
Q

What is bronchiectasis?

A

Irreversible airway dilatation that involves the lung in either focal or diffuse manner.

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71
Q

What is the difference between a focal bronchiectasis and diffuse bronchiectasis?

A

Focal bronchiectasis is dilatation of a LIMITED REGION in the pulmonary parenchyma while diffuse bronchiectasis involves more WIDESPREAD DISTRIBUTION and usually arise from systemic or infectious processes.

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72
Q

Important history for bronchiectasis.

A

Being sickly as a child

Women
Usually affects older individuals

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73
Q

3 Categories of bronchiectasis.

A

Cylindrical/tubular
Varicose
Cystic/saccular

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74
Q

Differentiate cylindrical, varicose and cystic/saccular bronchiectasis from each other.

A

Cylindrical/tubular appear UNIFORMLY DILATED and end abrupty at points where there are mucus plugging.

Varicose appears BEADED

Saccular/Cystic appears in the PERIPHERY and ending at BLIND SACS

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75
Q

Pathology of bronchiectasis

A

Destructive and inflammatory changes of the medium sized airways
Neutrophils production of ELASTASE and MMPs
Resulting to pools of purulent sputum in dilated airways and increasing vasculatrity

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76
Q

Etiology of focal bronchiectasis

A

Due to obstruction of airway
EXTRINSIC (lymphadenopathy or enlargement of nearby structures compressing the airway)
INTRINSIC (tumor, FBO, bronchial atresia)

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77
Q

Usual causes of upper lung fields bronchiectasis

A

Cystic or post radiation fibrosis

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78
Q

Usual causes of middle lung fields bronchiectasis

A

Mycobacterium avium complex (mac)

Dyskinetic or immotile cilia syndrome

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79
Q

Usual causes of lower lung fields bronchiectasis

A

Chronic recurrent aspiration pneumonia
Immunodeficiency infections
Fibrotic lung diseases

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80
Q

Possible Infectious causes of bronchiectasis

A

Adenovirus and rhinovirus (lower respi tract involvement)
Staph aureus, klebsiella, anaerobles (untreated pneumonia)
Bordetella pertussis
TB (major cause worldwide)

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81
Q

Possible genetic causes of bronchiectasis

A

Cystic fibrosis
Kartagener syndrome
Alpha 1 antitrypsin deficiency
Dyskinetic/immotile syndrome

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82
Q

What is yellow nail syndrome?

A

Due to hypoplastic lymphatics

Triad of lymph edema, pleural effusion, and yellow nail

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83
Q

Can ABPA lead to bronchiectasis?

A

Yes

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84
Q

What is the most likely diagnosis?
Persistent productive cough
Production of thick tenacious sputum (cough out sputum in a daily basis)
May sometimes present with hemoptysis
History of repeated purulent respiratory infections as a child

May present myalgia, weight loss, and fatigue

A

Brochiectasis

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85
Q

What is the expected PE findings in bronchiectasis?

A

Crackles or wheezing
Clubbing (for chronic hypoxemia)

Acute exacerbations will show:
Increased volume of purulent sputum (important to know baseline production)
Changing nature of sputum

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86
Q

What initial diagnostic evaluation is needed? Expected findings?
More accurate/standard diagnostic tool? Expected findings?

A

Chest x-ray (tram track lines)
Chest CT scan (signet ring, tree in bud, lack of bronchial tapering, airway dilatation at least 1.5times than adjacent vessels, bronchial wall thickening, cyst-like structure emanating from bronchial wall)

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87
Q

Goals of bronchiectasis treatment

A

Control of active infection
Improvement of secretion clearance
Bronchial hygiene (hydration and mucolytics)
Removal of bronchiectatic parts

Azithromycin and inhaled corticosteroid may help control the inflammation

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88
Q

Definitive treatment for bronchiectasis

A

Surgery (esp in refractory cases)

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89
Q

Empiric therapy for bronchiectasis before gram stained guided therapy

A

Amoxicillin
TMP SMX
Levofloxacin

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90
Q

Primarily suspected organisms for bronchiectasis

A

P. Aeruginosa

H. Influenzae

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91
Q

What therapy may show significant improvement for CF related bronchiectasis but not for non CF related?

A

Aerosilizaed recombinant DNAse

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92
Q

Define lung abscess?

A

Often a complication of pneumonia that results to necrosis and cavitation of the lung parenchyma.

Can be single or multiple
Has high microorganism burden

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93
Q

Common cause of lung abscess

A

Aspiration

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94
Q

What are the factors and predisposing conditions leading to aspiration and lung abscess?

A 
Esophageal dysmotility
Seizure disorders
Neurologic condition causing bulbar dysfunction
Periodontal diseases
Alcoholism
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95
Q

Whwat is rhe difference between a primary lung abscess and secondary lung abscess?

A

Primary lung abscess is due mostly to aspiration leading to infection of anaerobes. It comprised 80% of lung abscess cases. Secondary lung abscess occur in the presence of underlying pulmonary lesions like tumors and systemic conditions like HIV

Primary-aspiration
Secondary- immunocompromised

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96
Q

List of possible microorganisms that can cause lung abscess

A

Mycobacteria esp TB
Fungi and other parasites
Staphylococcus aureus
Gram-negative bacilli like klebsiella
Anaerobes
Nocardia and Rhodococcus in immunocompromised
Burkholderia and paragonimus in other countries

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97
Q

This condition refers to infectious thrombophlebitis of the internal jugular vein. It most often develops as a complication of a bacterial sore throat infection in young, otherwise healthy adults. The thrombophlebitis is a serious condition and may lead to further systemic complications such as bacteria in the blood or septic emboli.

It occurs most often when a bacterial (e.g., Fusobacterium necrophorum) throat infection progresses to the formation of a peritonsillar abscess.

A

Lemierre’s syndrome

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98
Q

Clinical manifestations for lung abscess

A 
Usually with periodontal infection with pyorrhea and gingivitis
Fatigue
Fever
Sputum production
Putrid smelling sputum
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99
Q

Diagnostic tests requested for lung abscess

A

CT scan- preferred
Chest xray
Bronchoscopy - to rule out obstruction

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100
Q

What is daptomycin? Why is not used in pulmonary infection?

A

Daptomycin disrupts the cell membrane and is rapidly bacteriocidal. It has a broad range of activity against all gram-positive bacteria including methicillin, vancomycin, and linezolid resistant organisms.

It should not be used to treat pulmonary infections because surfactant inhibits its activity.

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101
Q

Treatment for lung abscess

A

Antibiotics(depending on the type of microorganisms causing the disease)

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102
Q

What are the side effects and risk factor of clindamycin?

When it is usually used? Is it safe for pregnant women?

A

Common side effects include nausea, diarrhea, rash, and pain at the site of injection.

It increases the risk of hospital-acquired Clostridium difficile colitis about fourfold and thus is only recommended when other antibiotics are not appropriate.Alternative antibiotics may be recommended as a result.

It appears to be generally safe in pregnancy.

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103
Q

Most requested chest xray view?

A

PA

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104
Q

What chest xray view makes the heart and other structures bigger and bony structures flatter or less angled?

A

AP

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105
Q

When is AP view requested?

A

Usually in debilitated, intubated, or stroke patients?

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106
Q

Normal cardiothoracic ratio

A

Less than 0.50

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107
Q

Most common causative organism for pulmonary infections in HIV patients

A

Pneumocystis jirovecci/carinii

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108
Q

Greatest risk factor for TB

A

HIV/immunocompromised

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109
Q

Gold standard test for TB in HIV patients

A

IGRA
Tuberculin skin test nay be negative in HIV
HIV patients have atypical presentation, may or may not show normal chest xray

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110
Q

Therapy for TB with HIV patients

A

Anti TB first during the intensive phase then HAART may be introduce during the continuation phase

Do not mix antiretroviral with anti-TB drugs

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111
Q

Normal A-a gradient

A

5-10 mmHg for you non smoker

This increases as a person ages or if with morbidity

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112
Q

Common opportunistic fungal pathogen for solid or hematopoieric transplant patients.

A

Invasive aspergillosis

Do not give flowers to leukemia or to the above mentioned patients

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113
Q

What is the difference between opportunistic and endemic pathogens?

A

Opportunistic -usually normal microbiota or found everywhere

Endemic- found in certain area

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114
Q

Endemic fungal pathogen that can cause pulmonary infections to immunocompetent host and can migrate to brain or disseminated to other parts of the body

A

Cryptococcus neoformans

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115
Q

If suspecting for candida pulmonary infection, what should be requested since KOH test from sputum is not recommended?

A

Broncheoalveolar lavage

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116
Q

Common infection in solid organ recipients (lung/kidney transplants)”?

A

CMV pneumonitis

Higher risk if recipient is seronegative and donor is seropositive

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117
Q

Group of pathogens for humoral immunity deficiency? Cellular or cell-mediated immunity deficiency?

A

Humoral-usually bacterial

Cell mediated-usually viral

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118
Q

_______ is a medical emergency most commonly seen in patients with acute myeloid leukemia. It is characterized by an extremely elevated blast cell count and symptoms of decreased tissue perfusion. The pathophysiology is not well understood, but inadequate delivery of oxygen to the body’s cells is the end result. It is diagnosed when white cell plugs are seen in the microvasculature. The most common symptoms are dyspnea and hypoxia, usually accompanied by visual changes, headaches, dizziness, confusion, somnolence, and coma.

A

Leukostasis

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119
Q

What laboratory test is specific for inflammation?

A

Erythrocyte Sedimentation Rate (ESR)
C reactive protein -sensitive acute phase reactants

High values indicate inflammation

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120
Q

What laboratory test is specific for infection?

A

Procalcitonin

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121
Q

Normal values for esr and crp?

A

ESR: the normal range is 0-22 mm/hour for men and 0-29 mm/hour for women.
CRP: most people without any underlying health problem have a CRP level less than 3 mg/L and nearly always less than 10 mg/L.

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122
Q

Fungal pneumonias with “halo” in CXR is indicative of? The halo represents surrounding hemorrhage?

A

Aspergillosis

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123
Q

What live vaccines should not be given to immunocompromised?

A 
Intranasal influenza
Yellow fever
ORAL polio
Varicella zoster
MMR
Others
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124
Q

What Common prophylaxis to avoid pneumocystis, nocardia, strep pneumoniae, and toxoplasmosis in immunocompromised?

A

TMP-SMX (cotrimoxazole)

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125
Q

What is the most predominant microflora in the mouth and nasopharynx?

A

Streptococcus viridans or alpha hemolytic viridan

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126
Q

2/3 to 3/4 of cases of acute respiratory illnesses are caused by what group of microorganisms?

A

Viruses

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127
Q

what is the common viral etiology for common colds?

A

rhinoviruses (30-40%)

coronaviruses (105)
RSV (10-15%)
influenza/parainfluenza (5%)
adenovirus (5%)

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128
Q

What are the effective treatments for symptoms of common colds?

A

topical/oral adrenergic agents for nasal obstruction
first-gen antihistamines and ipatropium bromide for rhinorrhea
first gen antihistamines for sneezing
NSAIDs, acetaminophen and ibuprofen for sore throat
first-gen antihistamines, bronchodilators for cough

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129
Q

what is a common cold?

A 
most common respiratory illness
also called acute minor coryzal illness
incubation period is around 12 to 72 hrs
symptoms are:
mild or no fever
nasal catarrh 
cough (dry or productive)
hoarseness
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130
Q

most important and common cause of bacterial pharyngitis?

A

streptococcus pyogenes

group A strep

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131
Q

what are the symptoms of pharyngitis?

A

itchy/sore throat
fever
pharyngeal inflammation (edema and erythema, vesicles and exudates)

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132
Q

what are the different types of pharyngitis based on etiology?

A

pharyngitis with common cold
streptococcal pharyngitis
anaerobic pharyngitis/vincents angina/peritonsillitis/peritonsillar abscess (quinsys)
ludwigs angina

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133
Q

Management for pharyngitis with common cold

A

do not give antibiotics

may resolve within 3-4 days if milder symptoms are present

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134
Q

Characteristics of streptococcal pharyngitis that may differentiate it from other types of pharyngitis? this may used to differentiate it from viral origin

A 
marked oahrngeal pain
odynophagia
high grade fever
patchy gray or yellow exudates in tonsils
edema of the uvula
cervical lymphadenopathy
leukocytosis >12 000/mm3
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135
Q

what are the symptoms of a peritonsillar abscess/vincents angina/anaerobic abscess/quinsy?

A 
purulent exudates
foul breath
severe pharyngeal pain
dysphagia
fever
medial displacement of the tonsil (kissing tonsils if severe)

severe complication leads to mediastinitis

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136
Q

First line drugs for bacterial pharyngitis?

A

Pen V or Amoxicillin (for 10 days)

Erythromycin or first-gen cephalosporin for penicillin allergic patients

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137
Q

What is diphtheria?

A

caused by corynebactrium diphtheriae which produces toxin. It develops a pseudomembrane that continues to obstruct the airways.

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138
Q

What are the symptoms of diphtheria?

A 
pseudomembrane
sore throat
fever
dyspnea
myocarditis (cause of death in diphtheria)
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139
Q

What is acute laryngitis?

A

infection of larynx causing hoarseness or dysphonia

usuall causes are bacteria and viruses. Mycobacterium tb and tumor can cause chronic hoarseness

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140
Q

what is the most common cause of inflammation leading to acute sinusitis?

A

viral upper respiratory infection

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141
Q

differentiate acute sinusitis from acute rhinitis

A

acute rhinitis is hypersensitivity reaction characterized by nasal catarrh and watery discharge
while
acute sinusitis is inflammation of the sinuses characterized by pain over the areas of sinuses, purulent nasal discharge, headache and fever

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142
Q

common etiology for bacterila sinusitis?

A

polymicrobrial

give broad spectrum antibiotics

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143
Q

2 Common etiologic causes for hospitally acquired bacterial infection

A

pseudomonas and staph aureus

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144
Q

what is epiglottitis?

A

has a potential for causing abrupt, complete airway obstruction
a fulminant course (6 to 12 hrs)with respiratory obstruction within 30 minutes

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145
Q

what is the common etiology for epiglottitis?

A

Haemophilus influenza B

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146
Q

what are the symptoms of epiglottitis in children and adutls?

A

children: toxic, febrile, irritable, sore throat, dysphagia, prefer to sit leaning forward, drooling, inspiratory stridor
adult: less fulminant presentation, 2-3 days of symptoms, severe sore throat, odynophagia, fever

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147
Q

diagnostic preference for epiglottitis

A

direct flexible fiber optic nasolaryngoscopy

wherein a swollen erythematous epiglottitis is seen

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148
Q

what is acute bronchitis?

A

inflammation of the tracheobronchial tree

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149
Q

what is the most common comorbid with bronchits?

A

proctitis or inflammation of the anus and rectum

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150
Q

symptoms for acute bronchits?

A

may begin with flu-like symptoms
cough (non to productive progression)
burning substernal pain associated with respiration
painful when coughing
there are no signs of consolidation and no opacities in chest xray

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151
Q

what is chronic bronchitis?

A

a component of COPD
smoker’s cough
productive cough of most days for at least 3 months in 2 consecutive years
usually white phlegm

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152
Q

Common etiologies for CAP

A 
S. pneumoniae
H. influenzae
M. catarrhalis
S. aureus
K. pneumoniae
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153
Q

What is atypical pneumonia?

A

pneumonia that has extrapulmonary signs

may not present cough but CXR is positive for pneumonia

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154
Q

3 Common etiologies for atypical pneumonia?

A

legionella pneumophilia
mycoplasma pneumoniae
chlamydia pneumonia

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155
Q

best choice of antibiotics for atypical pneumoniae

A

macrolides (azithromycin, clindamycin, erythromycin)

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156
Q

what is aspiration pneumonia?

A

pneumonia usually in those who have impaired gag reflex, altered consciousness, stroke, imapired gagand swallowing reflexes

usual etiologies are anaerobes like bacteroides, fusobacterium and peptostrep (gram positive cocci)

common site is middle lobe

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157
Q

what are the 2 important viral proteins in influenzae?

A

hemagglutinin (entry)

neuraminidase (exit)

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158
Q

what is viral pneumonia? usual etiologies?

A 
viral origin
has history of flu
CXR shows interstitial infiltrates
ABG with hypoxemia
scanty sputum

CMV, varicella, SARS,COV, influenza, hantavirus, MERS-COV

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159
Q

what is empyema?

A

infection of the pleural cavity with presence of pus

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160
Q

management for empyema?

A

thoracentesis or open surgical drainage

broad spectrum antibiotics

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161
Q

what is lights criteria for pleural fluid?

A

fluid is exudate if: (any of the ff)
effusion/serum protein is greater than 0.5
effusion/serum LDH is greater than 0.6
effusion LDH level is greater than 2/3 of the upper limit of the lab ref range of serum protein

162
Q

what is a lung abscess?

A

a suppurative pulmonary infection with destruction of parenchyma producing one or two large cavities. It involves necrosis of parenchyma.

Etiologies may come from aspiration, periodontal disease, or gingivitis

163
Q

what are the possible etiologies of lung abscess?

A

S. aureus in young patients
Anaerobes (prevotella, bacteroides, fusobacterium) in aspiration patients
M. tuberculosis in tb patients

164
Q

What are mostly requested diagnostic procedures in respiratory tract infections?

A

throat swab
sputum gram stain/culture/sensitivity
antigen detection (Legionella, S. pneumo, P. carinii)
AFB for mycobacteria
KOH for fungi
Giemsa Toluidine blue for P. carinii (fungi)
bronchoscopy for nonresolving pneumonia

165
Q

Describe Strep. pneumoniae in GS

A

gram-positive (purple)
diplococci
lancet-shaped

DOC: penicillin
Give pneumo vaccine to elderly, health care workers

166
Q

Describe H. influenzae in GS

A 
gram negative (pink)
coccobacilli

DOC: 2nd and 3rd gen cephalosporins, BLIC

167
Q

Describe Bordetella pertussis

A 
gram-negative
 coccobacilli
does not cause pneumonia (does not go down the lungs)
causes whooping cough
virulence genes are bvg A and bvg S

DOC: Ilosone (erythromycin estolate) -irritating to the stomach

168
Q

what are the two phases of whooping cough?

A 
catarrhal phase (most infectious stage)
paroxysmal phase (worsening of cough with whooping)
169
Q

suspected agent if with pneumatocoeles

A

S. aureus

170
Q

describe Klebsiella pneumoniae

A

blood agar shows mucoid colony
common etiology in CAP and HAP
gram negative bacilli
common in alcoholics, diabetics

171
Q

describe corynebactrium diphtheria

A

club-shaped appearancee

with metachromatic granules, bacilli lie parellel and acute angles with each other

172
Q

describe pseudomonas aeruginosa

A

greenish pigment in agar
fruity smell
common pathogen in necrotizing fasciitis and burn patients

173
Q

describe acinetobacter baumanii

A

very infectious
if one patient is infected, it may spread to others within a week
gram-negative
diplococci
intravenous catheters can be the source of infection
found in moist surfaces in the hospital

174
Q

culture medium for mycoplasma pneumonia

A

Lowenstein-Jensen medium

has fried egg appearance
atypical cause of pneumonia

175
Q

suspected pathogen for CAP with risk factor of alcoholism

A

Anaerobes,
Klebsiella,
Mycobacterium,
Streptococcus pneumoniae

176
Q

suspected pathogen for CAP with risk factor of aspiration

A

anaerobes

177
Q

suspected pathogen for CAP with risk factor of COPD and smoking

A 
Chlamydophila pneumoniae, 
Haemophiuls influenzae, 
Legionella, 
Moraxella catarrhalis, 
Pseudomonas, 
gram-neg rods, 
S. pneumoniae
178
Q

suspected pathogen for CAP with risk factor of animals or parturient cats

A

Coxiella burnetti (Q fever)

179
Q

suspected pathogen for CAP with risk factor of HIV infection (early)

A

H. influenzae
M. tuberculosis
S. pneumoniae

180
Q

suspected pathogen for CAP with risk factor of HIV (late)

A

aspegillus, cryptococcus, H. capsulatum, P. jirovecii, Nocardia

181
Q

suspected pathogen for CAP with risk factor of hotel or cruise ship

A

Legionella

182
Q

suspected pathogen for CAP with risk factor of IVDU

A

Anaerobes, M. tuberculosis, S. sureus

183
Q

suspected pathogen for CAP with risk factor of lung abscess

A

anaerobes, M. tb, S. aureus (MRSA)

184
Q

suspected pathogen for CAP with risk factor of travel to middle east

A

MERS-COV

185
Q

suspected pathogen for CAP with risk factor of travel to Southeast asia or east asia

A

SARS, or avian influenzae

186
Q

most common viral cause of pneumonia in pediatric patient less than 2 years of age

A

rhinovirus and RSV

187
Q

what is the most common bacterial pathogen in children 3 weeks to 4 years of age with pneumonia?

A

streptococcus pneumoniae

188
Q

What is the suspected agent if patient with pneumonia shows lobar pattern in CXR?

A

bacterial

189
Q

what is the most sensitive and more specific criterion of pneumonia used by WHO?

A

Tachypnea

190
Q

what is the WHO criteria of tachypnea in neonates, how many breaths per min?

A

> or equal to 60

191
Q

what is the WHO criteria of tachypnea in 2 to 12 months of age, how many breaths per min?

A

> or equal to 50

192
Q

what is the WHO criteria of tachypnea in 1 year old to 5 years old,, how many breaths per min?

A

> or equal to 40

193
Q

what is the WHO criteria of tachypnea in children aged 5 years and above, how many breaths per min?

A

> or equal to 30

194
Q

What are the usual characteristics/symptoms and signs of children with pneumonia?

A

fever, tachypnea, wheezing or crackles, nasal flaring, decreased breath sounds, cyanosis, consolidation in chest ultrasound

195
Q

What criteria can you consider to make the diagnosis of pneumonia less likely?

A

absence of fever
O2 saturation greater than 94
absence of tachypnea, nasal flaring, and chest wall retractions

196
Q

When is PCAP A/B considered as the classification of the pneumonia?

A

when there is no sign of respiratory distress (to differentiate from PCAP C, and D)
no altered CNS functions
none or mild malnutrition, dehydration and comorbid,
mild cxr findings

197
Q

When is PCAP C considered?

A

when there are signs of respiratory distress such as head bobbing, cyanosis and IC/subcostal retractions but not yet with grunting and apnea

if with grunting and apnea, considered PCAP D

also with altered CNS and signs of malnutritions and dehydration, and comorbid conditions

198
Q

Where to admit PCAP C patients? PCAP D?

A

PCAP C at wards

PCAP D at ICU

199
Q

When to say that deyhdration is mild?

A

thirsty
increased pulse rate
decreased urine output
normal PE

200
Q

When to say that deyhdration is moderate?

A 
tachycardia,
sunken eyes and fontanels.
little of no urine output
dry mucous membrane,
delayed capillary refill >2s
cool and pale
201
Q

When to say that deyhdration is severe?

A 
rapid and weak pulses
no urine output
very sunken eyeballs and fontanels
no tears
delayed capillary refill >2s
cold and mottled skin
202
Q

what are the essential diagnostic aids to request in suspected pneumonia?

A 
Pulse oximetry for O2 saturation
Gram stain and culture of sputum
Chest Xray PA and lateral
Chest ultrasound
C reactive protein
procalcitonin
CBC
ABG if severe (migh indicate metabolic acidosis)
serum sodium for hyponatremia
203
Q

What is the predictive marker for mortality in pneumonia?

A

pH in ABG

204
Q

In the management of bacterial pneumonia, when can you do switch therapy?

A

when parenteral antibiotics has been gicen for at least 24 hrs
At least afebrile for last 8 hrs without antipyretics
Responsive to current antibiotic therapy
Able to feed without vomiting or diarrhea
Without any pulmonary or extrapulmonary signs

205
Q

What are the 4 series of changes/phases of pathogenesis seen at least in lobar type pneumonia?

A 
edema (proteinaceous exudates)
red hepatization (rbcs are extavasating, bacterial proliferation, neutrophil influx)
gray hepatization (sign of containmment of infection, no more extravasating erythrocyte)
resoliution (macrophage is dominant)
206
Q

What are the most common manifestations of pneumonia in adults?

A

tachypnea
tachycardia
fever
at least one abnormal chest findings (crackles, wheeze, diminished breath sounds, rhonchi)

207
Q

what are the features of moderate risk CAP?

A 
altered mental state
suspected aspiration
decompensated comorbids
unstable vital signs
CXR may show multilobar inflitrates, pleural effusion, abscess
208
Q

what are the features of high risk CAP?

A

any of criteria under moderate risk CAP plus:
severe sepsis and septic shock
need for mechanical ventilation

need for ICU admission

209
Q

what are the features of low risk CAP?

A

stable vital signs
no altered mental state
no suspected aspiration
no or stable comorbids

can be managed as outpatient

210
Q

What diagnostic testing should be requested next if the pneumonia is non-resolving?

A

request for invasive procedures to get samples directly from the lung parenchyma

  • transtracheal biopsy
  • transthoracic biopsy
  • bronchoalveolar lavage
  • protected brush specimen
211
Q

What is CURB-65?

A 
Confusion
Urea (BUN) > or equal 7mmol/L
Respiratory rate > 30breaths/min
Blood pressure <90/60
65- age

interpretation:
0-1: outpatient
2 points: admit patient
> or equal to 3: ICU admission

212
Q

What category risk of CAP does Legionella and Anaerobes cause?

A

moderate to high risk

213
Q

What category risk of CAP does Staph aureus and Pseudomonas aeruginosa?

A

high risk

214
Q

Duration of treatment for P. aeruginosa in CAP?

A

14-21 days

215
Q

Duration of treatment formycoplasma and chalmydophila in CAP?

A

10-14 days

216
Q

Duration of treatment for Legionella in CAP?

A

14-21 days (10 days if azalides are used)

217
Q

Duration of treatment for MRSA/MSSA CAP?

A

7-21 days for MRSA (28 days if with bacteremia

7-14 days for MSSA (28 days if with bacteremia)

218
Q

Duration of treatment for most bacterial pneumonias aside from specific causes?

A

usually around 5-7 days

219
Q

What is the discharge criteria for CAP admission?

A

stable vital signs with >90 O2 saturation and functioning GI tract

220
Q

what does bacteriologically confirmed PTB means?

A

diagnosed as TB through smear positive or culture positive or rapid diagnostic test positive (Xpert MTB/Rif)

221
Q

What does clinically diagnosed PTB means?

A

negative in DSSM and culture but highly suggestive of TB according to symptoms and radiologic findings.
Also, when patient is high risk like HIV/AIDS positive
still treated as TB

222
Q

What does new case TB means?

A

Patient never had TB treatment before or had treatment but only less than 1 month

223
Q

What does retreatment case TB means?

A

Patient treated previously treated with TB drugs for at least 1 month

224
Q

What does relapse TB case means?

A

Patient was previously cured from TB (DSSM neg and culture neg after treatment completion) but ha recurrence of TB after some time

225
Q

What does treatment after failure case in TB means?

A

Patient was treated with TB drugs but still smear positive after 5 months or later of treatment

226
Q

what does lost to follow-up cases mean in TB?

A

patient was previosly treated with TB drugs but was lost to follow up for about 2 months or more

227
Q

what does previous treatment outcome unknown?

A

previosuly treated with TB with outcome unknown not documented

228
Q

What does MDR TB means?

A

TB that is resistant to atleast both rifampicin and isoniazid

229
Q

What does XDR TB means?

A

resistant to fluoroquinolones at at least one of second-line injectable drugs

230
Q

what is considered as positive induration in tuberculin skin test?

A

> 10mm induration

231
Q

what is tuberculin skin test?

A

screening toll for TB infection in children
results are based on induration/whealing of skin test
should not be used alone in diagnosis of TB

232
Q

what is DSSM?

A

used to have definitive diagnosis of TB
monitor progress of antibiotic therapy
confirm cure from antibiotic therapy

two adequate sputum specimens should be submitted

233
Q

What are the 4 first line drugs in TB therapy?

A 
HRZE 
Isoniazid
Rifamipicin
Pyrazinamide
Ethambutol
234
Q

Who are included in Category I TB treatment regimen? what is the recommended regimen?

A

new cases of PTB and EPTB (either bacteriologically or clinically confirmed)

2HRZE, 4HR
(can include ethambutol in 4HR if suspected to be in highly resistant area)

235
Q

Who are included in Category Ia TB treatment regimen? what is the recommended regimen?

A

new case of EPTB with involvement of CNS, bones or joints

2HRZE, 10HR

236
Q

Who are included in Category II TB treatment regimen? what is the recommended regimen?

A

previously treated drug-susceptible PTB or EPTB such as cases of relapse, treatment after failure, lost to follow-up, treatment outcome unknown

2HRZES and 1 HRZE, 5HRE

237
Q

Who are included in Category IIa TB treatment regimen? what is the recommended regimen?

A

previously treated drug-susceptible EPTB with involvement of CNS, bones, or joints

2HRZES and 1HRZE, 9HRE

238
Q

Who are included in drug-resistant TB treatment regimen? what is the recommended regimen?

A

those who are found to be drug-resistant in standard regimen drug-resistant (SRDR) and XDR

individualized based on previous treatment

239
Q

Define COPD

A

characterized by airflow obstruction
irreversible and progressive disease with progression of breathlessness (ask for progression of breathlessness)
composed of chronic bronchitis and emphysema
diagnosed either by spirometry or CT scan/histology (emphysema)

highly link with smoking
disease of the old (35 years beyond)
p

240
Q

Define chronic bronchitis

A

a component of COPD

characterized by airflow obstruction with chronic productive cough everyday for 3 months more in 2 consecutive years

diagnosed through spirometry and presence of productive sputum

linked with smoking

241
Q

Define emphysema

A

a component of COPD

characterized by airflow obstruction due to abnormal increase in size of alveoli/airspace brought by progressive destructiob of alveolar tissue

highly linked with smoking

diagnosed through CT scan or histology

242
Q

What symptoms could differentiate breathlessness with respiratory origin from breathlessness with cardiac origin?

A

breathlessness with cardiac origin usually presents with:
orthopnea/PND
chest pain
palpitations
cardiac pe abnormalities
risk factors for CV disease like hypertension, diabetes, and obesity

anemia may also cause breathlessness, check for Hgb

243
Q

What are the usual causes of pulmonary/airway obstruction?

A

most likely COPD and asthma

may also consider other diseases like
stricture
tumour
compression
obliterative bronchiolitis
pulmonary edema
244
Q

How to differentiate COPD from asthma?

A

Asthma is reversible while COPD is irreversible. Affter inhalation of short acting b2 agonists, check spirometry again and see if FEV1/FVC improves. If it improves, most likely it is asthma.

Improvement in FEV1 of greater or equal to 15% of baseline value or 400mL

asthma also presents with cough more frequent at night and early morning, with wheezing

245
Q

How does COPD cause airflow obstruction?

A

COPD causes airway inflammation and loss of alveoli and lung parenchyma that causes airflow obstruction

246
Q

What is the histological characteristics of airway in chronic bronchitis?

A

Airways in chronic bronchitis are inflamed and scarred.

Many mucus-producing goblet cells replacing the respiratory epithelium

thickened airway walls with increased luminal secretions

INFLAMED
SCARRED
GOBLET CELLS
THICKENED WALLS
INCREASED SECRETIONS
SMOOTH MUSCLE SPASMS
247
Q

How does loss of elastic recoil in emphysema causes airflow obstruction?

A

Elastic recoil contributes to positive intrathoracic pressure that is required to push air out of the lungs to the environment.
Loss of elastic recoil in emphysema leads to loss of positive intrathoracic pressure. Air cannot go out. Therefore, there is air trapping leading to hyperinflation. Thus, obstructive in nature.

248
Q

Assessment of severity of airflow obstruction is based on what parameter in spirometry? How is it classified?

A

FEV1
Mild if 50-80% of predicted
Moderate if 30-49% of predicted
Severe if <30% of predicted

249
Q

What is the histological characteristics of lung parenchyma in emphysema?

A

DESTROYED LUNG PARENCHYMA
BLACK STAINING
MULTIPLE HOLES IN CT SCAN
BULLAE IN CT SCAN

these result to loss of elastic recoil

250
Q

How should you interpret results of CXR in COPD patients?

A

CXR in COPD patients should show:

  • increased aeration (increased lucency)
  • upper border of liver should be at top of 5th ICS midclavicular line
  • flattened diaphragm
  • increased spaces between ribs

also notice for other abnormalities like tumor, vascularities, pneumothorax, pleural effusion

251
Q

What are the main goals in COPD management?

A
  1. Minimize progression of the disease, delaying or preventing further disability.
  2. Relieve symptoms

Cannot treat the damaged done because it is irreversible

252
Q

What treatment should be advised to minimize or prevent progression of disease in COPD?

A

stop the inciting trigger

STOP SMOKING

253
Q

What treatment relieves COPD symptoms like breathlessness?

A

SMOKING CESSATION
PULMONARY REHABILITATION
DRUGS (may help like SABA, LABA, CORTICOSTEROIDS, ANTI-MUSCARINIC)

254
Q

What is pulmonary rehabilitation? When it is usually advised? What are its benefits?

A

pulmonary rehab is a 6-12 weeks of physical exercise, disease education, psychological and social interventions. It is run by multidisciplinary teams

advise usually for COPD and post lung surgery patients

benefits are:
reduced breathlessness
improve exercise capacity
improve health-related quality of life

255
Q

What pharmacologic drugs can be prescribed to COPD patients?

A

SABA (SALBUTAMOL) can help prior to exercise rehab; may help reduce breathlessness
ANTI-MUSCARINICS (IPATROPIUM)

LABA (SALMETROL, EFORMOTEROL) for moderate and severe COPD
LONG-ACTING ANTIMUSCARINICS (TIOTROPIUM)

XANTHINES (not clearly studied but may help)

256
Q

What important symptoms are usually related to lung cancer?

A

weight loss
hemoptysis
smoking (but can also be found in non smokers)

257
Q

How to calculate for pack years of cigarette?

A

(cigarettes per day/20) times number of years smoked

258
Q

What is the relationship between risk of lung cancr and pack years of cigarettes?

A

there is 70% increase risk of lung cancer for every 10 pack years smoke

those who do not smoke has less than 1% risk

259
Q

What are possible effects/disease can tobacco smoking brought to your respiratory system?

A

COPD
lung cancer
laryngeal cancer
mouth cancer (for tobacco chewers)

260
Q

what can you do reduce withdrawal symptoms of a heavy smoker who is trying to quit smoking?

A

Prescribe nicotine patches (15mg) to be applied at day at removed at night

nicotine however may have side effects like chest pain and blood pressure changes

chewing gum

261
Q

what the six forms of nicotine that can be prescribed for smoking cessation?

A 
transdermal patch
chewing gum
lozenge
inhalator
nasal spray
sublingual tablet
262
Q

What is/are the alternatives for nicotine replacement?

A

Bupropion (amfebutamone) -an antidepressant

common side effect is insomnia or dry mouth
can trigger seizures (should not be given to those with seizure history)

263
Q

What are the 5 A’s used by health professionals to brief quit smoking intervention?

A 
ask
advise
assess
assist
arrange
264
Q

what are common features of exacerbation of COPD?

A

worsening breathlessness

change in sputum colour (in bronchiectasis, it’s increasing amount of sputum volume)

265
Q

Define acute exacerbation of COPD

A

It is a sustained worsening of the symptoms from the stable state like:
-increased cough, breathlessness and sputum production
-change in sputum color
which is:
-more than usual day to day variations
-acute in onset (pneumonia usually has sub-acute presentation)
-may require a change in treatment

266
Q

how to differentiate CRP levels when differentiating COPD exacerbations and pneumonia?

A

Both have elevated CRP levels but pneumonia has way higher CRP (187mg/L) level compared to COPD which only has arounf 54 mg/L

267
Q

What is CRP? what is its relevance?

A

CRP is an acute phase protein which means its plasma concentrations increase by at least 25% during inflammatory conditions such as infection and autoimmune disease

Values >100mg/L
-bacterial infection

Values >10 mg/L
-clinically significant inflammation cause by infection and inflammatory conditions such as rheumatoid arthritis

268
Q

Management for acute exacerbations of COPD?

A

acute oxygen therapy
nebulized SABA as bronchodilators
oral corticosteroids to decrease inflammation
antibiotics if with infections

269
Q

What bacteria most likely cause COPD exacerbation?

A

H. influenzae
Moraxella catarrhalis
S. pneumoniae

270
Q

What are the structural changes happens to the airway when there is anaphylaxis?

A

laryngeal edema
bronchoconstriction
vasodilation (leading to hypotension)

271
Q

Why is it important to check for history of drug allergies?

A

A precaution to prevent anaphylaxis or other hypersentivity issues

272
Q

What are first line drugs to immediately manage anaphylaxis?

A

intramuscular adrenaline/epinephrine
intravenous histamine
intravenous hydrocortisone

273
Q

What is the value of PaO2 to say that the patient is in respiratory failure?

A

PaO2 below 8 kPa

274
Q

What id henderson hasselbach equation?

A

(H+) + (HCO3-) -> (H2CO3) -> (H2O) + (CO2) and vice versa

275
Q

What possible differential diagnosis can cause type II respiratory failure?

A

type 2 RF is hypercarbia

Ddx:
severe COPD (due to fatigue of chest wall muscles, and other respiratory muscles)
severe lung disease
neurological
muscular
chest wall disease
276
Q

How can you differentiate severe COPD from other differential dx of type 2 RF?

A

check for wheezing, lung hyperinflation andother COPD symptoms through spirometry, etc.

For neurological, muscular, and other chest wall disease, check through physical examination and neurological examination, and glasgow coma scale

277
Q

why is is oxygen therapy must be cautiously administered to a patient with possible diagnosis of COPD who are at risk of CO2 rentention?

A

Patient with severe COPD has chronic CO2 retention which repeats the cycle of hypoventilation and hypercarbia. This desensitizes the respiratory center which is supposedly sensitive to CO2. In other words, the chemosenstive area becomes desensitized to changes in cO2 and highly relies to weaker stimulus like hypoxia.

In this case, hypoxia should supposedly trigger an increase in ventilation , however, if you administer O2 with high percentage, hypoxia will be corrected thus, removing the stimulus for ventilation. This further worsens the respiratory failure.

but even though oxygen treatment is difficult in this case, it is essnetial to treat hypoxia. Ventilatory support may be needed in this treatment.

278
Q

Cite some indications for invasive ventilation?

A
  • those who are severely unwell with imminent respiratory arrest
  • severely impaired consciousness
  • patients who cannot protect their airways and clear secretions
279
Q

what are the complications of non-invasive ventilation?

A

aspiration in patients with reduced conscioussness
pneumothorax
gastrointestinal distension and perforation

280
Q

what are the clinical features of hypercapnia?

A

bounding pulse
flapping tremor
confusion

(this is due to toxic effects on the brain and circulation)

281
Q

what is the most common cause of type 2 RF?

A

severe COPD and acute exacerbations of COPD

but may type 2 RF may also be caused by neurological, muscular, and chest wall disease

282
Q

what is does scooped expiratory flow in the flow volume loop means?

A

scooped expiratory flow means prolonged expiration suggestive of obstructive disease

283
Q

what is the normal range of A-a gradient?

A

5 to 15 mmHg

this increases if there is hypoxemia
except hypoventilation and high altitude

284
Q

Why is bronchoscopy not really used for diagnosis of cancer in an investigated pulmonary nodule?

A

it is because bronchoscopy will not reach peripheral lesions and will mislabel 10% of central cancers by finding non specific inflammatory changes.

Biopsy either US guided or open lung biopsy is more accurate than bronchosocpy

285
Q

what CXR view is needed to visualize pleural effusions?

A

plain PA then lateral decubitus view

286
Q

How does COPD lead to right heart dysfunction?

A

loss of pulmonary arterioles and capillaries as part og pathology of emphysema
pulmonary arterial vasoconstrictions secondary to hypoxia
increased viscosity og blood caused by polycythemia as a compensatory mechanism for hypoxia

287
Q

What respiratory diseases may lead to cor pulmonale?

A

COPD especially chronic bronchitis
interstital lung disease
pulmonary fibrosis

288
Q

In cor pulmonale, how can you assess further on the pulmonary arteries and right heart?

A

2d-echo and doppler echo
Right heart catherization
ECG

289
Q

How does hypoxia cause polycythemia?

A

chronic hypoxia increases erythropoietin levels leading to blood cell formation in the bone marrow.

290
Q

What respiratory consequence can polycythemia cause?

A

pulmonary hypertension due to high blood viscosity

it also increases systemic consequences like stroke and PE-DVT

291
Q

What is cor pulmonale?

A

often referred as pulmonary heart disease or pulmonary hypertensive heart disease that causes rv hypertrophy and RV dilatation that may lead to Right-sided Heart failure

292
Q

What usually causes Acute cor pulmonale?

A

massive embolus usually cause acute cor pulmonale where RV dilatation without hypertrophy occurs in the right side of the heart

293
Q

What is the ptahophysiolgy of cor pulmonale?

A

it is primarily cause by changes in the pulmonary vasculature and/or the lung parenchyma that are sufficient to cause pulmonary hypertension leading to right sided heart failure

294
Q

What diseases of the pulmonary parenchyma leads to cor pulmonale?

A 
COPD
Interstitial fibrosis
Pneumoconiocosis
Bronchiectasis (TB or recurrent pneumonia)
Cystic fibrosis
295
Q

What diseases of the pulmonary vasculature leads to cor pulmonale?

A

pulmonary thromboembolism
primary pulmonary hypertension
pulmonary arteritis (Wegeners granulomatosis)
tumor microembolism
drug- toxin- radiation- induced vascular obstruction

296
Q

what diseases of the chest wall leads to cor pulmonale?

A

kyphoscoliosis
marked obesity or picwickian syndrome
neuromuscular disease

297
Q

what physiological disorders leads to pulmonary vasoconstriction leading to pulmonary hypertension?

A 
metabolic acidosis
hypoxemia
chronic altitude sickness
idiopathic alveolar hypoventilation
obstruction to major airways
298
Q

what is pickwickian syndrome?

A

it also called as obesity hypoventilation syndrome, a condition in which severely overweight people fail to breathe rapidly or deeply enough resulting to low oxygen levels and carbon dioxide retention

299
Q

Why is it necessary to request PET scan in a suspected cancer (lung cancer) with lympahdenopathy?

A

nodal metastasis has a poor prognosis in cancer therapy. Although lymphadenopathy usually accompanies cancer, it may be caused by other disease. It should be confirmed if the lymphadenopathy is a cancer metastatis and tocheck that is to request for PET scan.

300
Q

what is the most common cause of lymphadenopathy in left supraclavicular area or the virchows node?

A

usually cause by stomach cancer metastasis
Other left sided lympahdenopathies ddx are:
-other abdominal and pelvic malignancies (stomach, pancreas, ovaries, prostate)
-left side lung cancer
-lymphoma

If it is right side supraclavicular nodes, most likely it is caused by:

  • lung cancer metastasis
  • mediastinal cancer
  • esophageal cancer
  • lymphoma

other: TB

301
Q

What diagnostic investigations should be performed to make a histological diagnosis of cancer?

A

Fine needle aspiration
Ultrasound-guided biopsy
Fiberoptic bronchoscopy (if it is in the lung)
CT guided biopsy

302
Q

what is pleural mesothelioma?

A
  • malignant tumor arising from the pleura
  • commonly associated with asbestos exposure
  • may show signs of shortness of breath, pleural rub or pleural effusion
  • mean survival from diagnosis is 8 to 14 months
303
Q

what pulmonary conditions are associated with asbestos exposure?

A

pleural plaques
asbestosis (inflammation and fibrosis of the lung parenchyma dues to asbestos fibers in the lungs)
lung cancer
pleural mesothelioma

304
Q

Why is careful pleural test necessary for a patient with suspected mesothelioma?

A

any pleural intervention with suspected mesothelioma may seed mesothelioma to other parts of the chest, that is why careful intervention is needed.
Thus, number of invasive procedures in the pleural cavity should be minimized if possible.

305
Q

Why was the biopsy performed under CT guidance in a patient suspected with mesothelioma?

A

mesothelioma tends to affect patches of the pleura and therefore blind biopsy may miss disease and may need to be repeated. CT guidance increases the chance of making positive diagnosis and should reduce the number of pleural interventions required

306
Q

Explain WHO analgesic ladder

A

Patient in pain should receive regular analgesia with additional drugs if pain is uncontrolled:

Step 1: regular simple analgesia (paracetamol)
Step 2: Add mild opioid analgesia (codeine)
Step 3: Use stronger opiate (morphine)
Step 4: Increase dose of opiates until pain is relieve

Adjuvant drugs such as NSAIDs or drugs to suppress nerve pain can be added to any step.

307
Q

what causes hoarse voice?

A

laryngeal or vocal cord lesions

  • laryngitis (viral infection, smoking, acid reflux)
  • voice overuse
  • inhaled steroids
  • vocal cord nodules
  • laryngeal carcinoma

damage to recurrent laryngeal nerves

  • lung cancer
  • thyroid surgery
  • thyroid cancer
  • dissection of the thoracic aorta

etc

308
Q

How do secondary lung metastasis differ from primary lung cancer?

A

primary lung cancer is usually isolated while secondary metastasis have a cannonball appearance in CXR

309
Q

What is pancoast’s tumour?

A

tumours in the lung apex which infiltrates the lower brachial plexus causing the symptoms of muscle arm wasting and pain

310
Q

What are the significance of pulmonary function tests PFTs?

A
  • to know the nature if restrictive or obstructive
  • to assess disease severity
  • post-treatment evaluation of lung function
311
Q

What is methacholine challenge test?

A

can be used to test bronchial hyperreactivity

312
Q

normal range of TLC values

A

80-120% of predicted

313
Q

normal range of RV

A

75-120% of predicted

314
Q

FEV1/FVC ratio

A

80% above

315
Q

normal DLCO

A

75-120%

316
Q

FEV1

A

80-120% predicted

317
Q

Another parameter to detect obstructive lung disease aside from FEV1/FVC ratio. It detects obstructive disease earlier.

A

FEF (forced expiratory flow)

318
Q

What is the expected results of PFTs in a patients with interstitial lung disease? heart failure?

A

restrictive nature
lowered DLCO

same with heart failure

319
Q

What is the expected results of PFTs in a patients with emphysema?

A

obstructive nature

decreased DLCO

320
Q

Increased DLCO may be seen in what conditions?

A

pulmonary hemorrhage

goodpasture’s syndrome

321
Q

What is Goodpasture’s syndrome?

A

it is a group of diseases that affect the lungs and kidneys. It is an autoimmune disorder that attacks the basement membrane. Also called as anti-glomerular basement membrane disease. Diagnosis is through antigen-antibody testing.

322
Q

What does scooped expiratory flow volume loop means?

A

scooped expiratory flow volume loop means that the person has obstructive disease.

323
Q

What is the normal value of A-a gradient?

A

5-15 mmHg

324
Q

What is parapneumonic effusion?

A

pleural effusion usually caused by bacterial pneumonia

If it complicates to empyema, it needs immediate chest tube drainage rather than antibiotics alone

325
Q

What are some indications for intubation?

A

upper airway injury (burns, laryngeal edema, trauma)
airway compromise
neurological depression
loss of protective reflex (gag and cough reflex)

326
Q

What prompts the need of mechanical ventilation?

A

usually different types of RF

if with metabolic acidosis and hypercapnia and cannot support spontaneous ventilation by itself

327
Q

What are the most important laboratory tests in the evaluation of respiratory compromise?

A

ABG measurement to see the status of blood gases wheter hypoxemic or hypercapnic or ph level derangements

328
Q

What does pleural effusion with lymphocytic predominance suggest?

A

Tuberculosis

329
Q

What does pleural effusion with hemorrhagic characteristic indicates?

A 
can be:
mesothelioma
lung or breast cancer
pulmonary thromboembolism
trauma
330
Q

what are the possible risk factors for lung cancer?

A
  1. smoking (1st)
  2. radon (2nd most common; from uranium decay)
  3. asbestos (asbestosis, mesothelioma)
  4. arsenic in water (found in ground water from mining, industrial and arsenic pesticides
  5. genetic predisposition (p53)
  6. occupational exposures (arsenic, cobalt, chromium, cadmium, asbestos)
  7. ionizing radiation
331
Q

what are the two most common types of lung cancer?

A

adenocarcinoma (most common)

bronchogenic carcinoma

332
Q

What are the characteristics of lung adenocarcinoma?

A
  • cancer of lung gland cells (glandular)
  • usually found in periphery
  • more common in women
  • most common types in patients who are NON SMOKER
  • has mucinous and non-mucinous subtypes
  • metastasize widely
333
Q

What are the characteristics of lung large cell carcinoma?

A
  • is more like an adenocarcinoma that is poorly differentiated
  • poorly differentiated adenocarcinoma
  • large cells without cytoplasmic differentiation
  • more common peripherally
334
Q

What are the characteristics of lung/bronchogenic squamous cell carcinoma?

A
  • squamous dysplasia from columnar epithelium of the airways
  • centrally located
  • slow growing
  • can be shown in bronchogenic washing or cytological examination of sputum
  • associated with hypercalcemia
335
Q

What are the characteristics of small cell carcinoma of the lung?

A
  • usually centrally located
  • fast growing
  • early metastasis commonly to brain, liver, adrenal glands, and bone
  • associated with eaton-lambert syndrome, paraneoplastic syndrome, inappopriate ADH secretion
  • SVC syndrome
336
Q

What are some systemic effects of paraneoplastic syndrome?

A 
Hypercalcemia
Cushing syndrome
SIADHS
Eaton-Lambert syndrome
Pulmonary hypertrophic osteoarthropathy
Anemia
DIC
337
Q

What is the most common site for metastasis for primary lung cancer?

A
  1. Liver
  2. Bone marrow
  3. Adrenal glands
  4. Brain
338
Q

Why is pet scan not used to diagnose metastasis to the brain? what is the alternative diagnostic tool?

A

brain also uses a lot of glucose which will diffusely light up in PET scan. Thus, brain MRI is used to diagnoses metastasis in the brain.

339
Q

What diagnostic tools are used for staging of cancer?

A

CT scan
PET scan
or combination which is the FDG-PET

340
Q

What does limited disease means in cancer?

A

It means that cancer only invades the lung, hilar, and mediastinal lymph nodes

without invasion of the organs

341
Q

What does extensive disease means in cancer?

A

means that cancer metastasized to other organs

342
Q

What is the advantage of radiation therapy over chemotherapy?

A

radiation treatment kills rapidly dividing cells locally through ionizing radiation, it has no systemic effects compared to chemotherapy

343
Q

what are the disadvantages or complications of radiotherapy in lung cancer treatment?

A 
may have the following complications:
skin reactions
mucositis
hoarseness of voice
hypothyroidism
low blood counts
lung fibrosis
heart complications
secondary cancer brought by radiation
dysphagia is there is stenosing
344
Q

what is neoadjucvant therapy?

A

radiation before surgery to shrink tumor
surgery
radiation or chemotherapy after surgery to eliminate remaining cancer cells

345
Q

What is an external beam radiation therapy or EBRT?

A

it delivers high doses of radiation to lung cancer cells from OUTSIDE of the body. It directs to the tumor.

346
Q

What id High dose rate (HDR) Brachytherapy?

A

Internal radiation
it delivers high doses of radiation from implants placed close to or inside the tumors of the body
-usually used by gynecologist for endometrial and cervical cancer

347
Q

what are the advantages of ERBT?

A

it targets the tumor directly while minimizing damage to healthy cells
does not carry standard surgical risks like bleeding, blood clot, post-operative pain

*this is not given to stage 4 cancer which has already diffuse cancer

348
Q

What is chemotherapy?

A 
it uses drug treatment to kill fast growing cancer cells
examples are: 
Capecitabine (Xeloda)
Doxurubicin
Oxaliplatin
Paclitaxel

Its effects are systemic in nature which also affects fast growing normal cells like GI epithelial cells and hair cells

349
Q

why is there a need for repeated doses or cycles of chemotherapy?

A

chemotherapy only kills a fraction of cancer cells that is why repeated doses are needed to prevent exponential growth of cancer cells.

350
Q

what is targeted therapy for lung cancer?

A

it is a kind of personalized treatment for those who have mutations in the tyrosine kinase domain of EFGR

Phenotype most likely eligible for this treatment are those who are: non-smoker, female, east-asian, adenocarcinoma

351
Q

What is the mechanism of avastatin for cancer therapy?

A

used to block neovascularization in cancer cells

352
Q

What are the target genes in targeted therapy for lung cancer?

A

EFGR

HER1 (increases neovascularization through VEGF and MMP)

353
Q

Give examples of Tyrosine Kinase inhibitor used for treatment of lung cancer with TK mutations?

A

Gefitinib (Iressa)
Erlotinib (Tarceva) -side effect is rash (the more rash, the more effective is the therapy)
Afatinib

354
Q

What is immunotherapy?

A

it is the latest discovered treatment for cancer. Immunotherapy drugs can block tumor cells from deactivating T-cells.

355
Q

What are some complications of chemotherapy?

A 
alopecia
anemia
diarrhea
extravasation
leukopenia
nausea and vomiting
stomatitis
thrombocytopenia
356
Q

What pharyngeal arches give rise to multiple muscles and cartilage structures in the oropharynx and larynx? what pharyngeal arch degenerates?

A

4th and 6th give rise to structures related to respiration

5th pharyngeal arch degenerates

357
Q

Laryn, trachea, and lung bud is an outpouching of the ____?

A

esophagus

358
Q

What is the sensory and motor innervation of the diaphragm?

A

C3, 4, 5 keep the diaphragm alive

345 is the phrenic nerve

359
Q

What are the 4 parts that made up the diaphragm?

A

SPBD (several parts build the diaphragm)

Septum transversum
pleuroperitoneal folds
body wall
dorsal mesentery of the esophagus

360
Q

What is the most common TEF-EA type? 2nd most common?

A

Type C- (esophageal atresisa, distal TEF)

Type A- isolated EA, no TEF

361
Q

Clinical correlation of Potter syndrome to AF volume and pulmonary development?

A

Potter syndrome is a kind of renal malformation in utero. With this condition, there is little volume of AF (OLIGOHYDRAMNIOS). Aspiration of AF is essential for lung development and fetal breathing movements. With too little AF, there is underdevelopment of pulmonary structures or PULMONARY HYPOPLASIA.

362
Q

which side of the body does diaphragmatic hernia occurs? why?

A

left side

because liver on the right prevents herniation of bowel in the right thorax.

363
Q

What is the innervation of visceral pleura? parietal pleura?

A

visceral pleura lacks sensory innervation

parietal pleura is innervated by branches of the INTERCOSTAL and PHRENIC nerves and is highly sensitive to pain but visceral pleura is not

364
Q

Possible differentials for transudate pleural effusion? exudate?

A

transudates are usually from SYSTEMIC causes and usually BILATERAL

  • CHF
  • LIVER CIRRHOSIS
  • NEPHROTIC SYNDROME

Exudates are usually from LOCAL causes and usually UNILATERAL

  • LUNG INFECTION
  • PE
  • MALIGNANCY
365
Q

what structures pierce through the diaphragm and at what levels of the vertebrae?

A

mnemonic (I 8 10 EGGS AAT 12)
Ivc at T8
EsopaGus vaGus at T10
Aorta, Azygous, Thoracic duct at T12

366
Q

What are the arrangement of intercostal vessels from superior to inferior? what part of the rib they are located?

A

VAN (superior to inferior)

located at the INFERIOR BORDER of the rib

367
Q

Paralysis of diaphragm, what nerve is severe?

A

ipsilateral paralysis of diaphragm results fromseverement of the PHRENIC NERVE

368
Q

what is kartagener syndrome?

A

also called as immotile cilia syndrome or primary ciliary dyskinesia), a defect in the protein dynein prevents cilia from moving proplerly,

This results to impaired clearance of secretions and FREQUENT RESPIRATORY INFECTIONS, as well as INFERTILITY, SITUS INVERSUS OR SITUS AMBIGUUS (HETEROTAXY)

369
Q

What do you call the alveolar macrophages that phagocytize RBCs in CHF?

A

HEART FAILURE CELLS

370
Q

What are the 2 roles of ACE?

A
  1. Covert Angiotension I to II
  2. Breakdown bradykinin

increase bradykinin results to cough and angioedema

ACE inhibitors inhibit ACE, which in turns prevent breakdown of bradykinin, increasing its levels

371
Q

What is OSA?

A

OSA occurs when excess body weight, extra pharyngeal tissue, or abnormal anatomy (tonsillar hypertrophy or short mandible) blocks the upper airway passages when the patient is sleeping. The obstruction causes periods of hypoventilation and hypoxia resulting to nocturnal awakenings, poor sleep and daytime somnolence.

Treatment is CPAP

372
Q

For mechanically ventilated patient, hypoxia (low O2) can be corrected by?

A

increasing FiO2 or PEEP

373
Q

For mechanically ventilated patient, hypercarbia can be corrected by?

A

increasing minute ventilation or tidal volume

374
Q

Causes of RIGHT-SHIFTED hemoglobin dissociation (or the decrease of affinity of hemoglobin to oxygen leading to GREATER OXYGEN UNLOADING?

A 
BAT ACES
increased of the following:
BPG (2-3 BPG)
Altitude
Temperature
Acid (decrease in pH)
CO2
Exercise
Sickle cell
375
Q

What is the rule of thumb for translating PO2 and SpO2?

A

40-50-60 PO2 corresponds to 70-80-90% SpO2 respectively

376
Q

What is the pathology behind CO poisoning? What is the immediate management?

A

CO binds to hemoglobin 240 times than O2, thus creating an allosteric change in thehemoglobin that prevents the unloading of O2 from other binding sites. This causes a left shift of the curve and results in hypoxemia in CO poisoning.

Treatment: high-flow O2

377
Q

What is Bosental drug for?

A

for pulmonary hypertension

Bosentan is antagonist of endothelin. It lowers the PVR by relaxing the blood vessels.

378
Q

What is the most potent cerebral vasodilator?

A

CO2

Increased in CO2 decreases cerebral vascular resistance, resulting in increased perfusion and intracranial pressure

379
Q

Obstructive lung diseases mnemonic ABCDE

A 
Asthma
Bronchiectasis
Chronic bronchitis
Decreased FEV1/FVC ratio
Emphysema
380
Q

What are the common non allergic causes of asthma?

A

aspirin
exercise
occupational exposure
viral infection

381
Q

How to tell emphysema in CXR?

A

hyperlucency
increased ICS
enlarged retrocardiac clear space in lateral CXR
flattened diaphragm

382
Q

Why is aspirin not given to asthmatics?

A

Aspirin blocks the cyclooxygenase pathway which favors the leukotriene pathway, exacerbating the roles of leukotriene in asthma pathology. Leukotrienes are potent vasoconstrictor.

383
Q

What is pulsus paradoxus?

A

a decrease of blood pressure by 10 mmHg or more during inspiration.
It is seen in cardiac tamponade, asthma, OSA, and croup.

384
Q

How does asthma exacerbation lead to respiratory failure?

A

asthma exacerbations are typically associated with respiratory alkalosis from tachypnea. Signs of acidosis (decrease pH and increased PaCO2) suggest impending respiratory failure as the patient’s muscle of respiration become fatigues. This is a potential emergency requiring intubation.

385
Q

What are the adverse effects associated with supplemental O2 administration in patients with NRDS?

A

RIB
Retinopathy of prematurity
Intraventricular hemorrhage
Bronchopulmonary dysplasia

386
Q

What part of the lung does asbestosis usually affects? silcosis and coal? (remember the mnemonic for this)

A

Asbestosis is from the roof but affects the base (lower lobes).

Silica and coal are from the base (earth) but affects the upper lobes.

387
Q

What are the causes of hypercalcemia? (CHIMPANZEES)

A 
Calcium excess intake
Hyperparathyroidism, Hyperthyroidism
Iatrogenic (thiazides)
Multuple myeloma
Pagets disease of the bone
Addisons disease
Neoplasms
Zollinger Ellison syndrome
Excess Vitamin D
Excess Vitamin A
Sarcoidosis
388
Q

Pneumoconiosis associations:

Silica –>

A

lung nodules
eggshell calcification inhilar nodes
TB

389
Q

Pneumoconiosis associations:

coal workers pneumoconiosis –>

A

Dust cells (alveolar marcphages with anthracotic pigments)

390
Q

Pneumoconiosis associations:

Asbestosis –>

A

Bronchogenic carcinoma

Malignant mesothelioma

391
Q

Pneumoconiosis associations:

Berylliosis –>

A

Granulomas mimicking sarcoidosis

392
Q

Drugs that causes pulmonary fibrosis (mnemonics: Breathing Air Badly from Medications)

A

Bleomycin
Amiodarone
Busulfan
Methotrexate

393
Q

Pharmacological management for DVT

A

Give HEPARIN for 6 days then starting warfarin simultaneously (or before transitioning to warfarin)

Heparin has a faster onset than warfarin, this also decreases the risk of warfarin-induces skin necrosis

394
Q

What are possible DDx for hypercoagulable states?

A 
FACTOR V LEIDEN 
ANTITHROMBIN DEFICIENCY
PROTEIN C AND S DEFICIENCY
DYSFIBRIGENEMIAS
ANTIPHOSPHOLIPID SYNDROME
IMMOBILITY
PREGNANCY
ORAL CONTRACEPTIVE USE
OBESITY
395
Q

Types of emboli (mnemonic: FATBAT)

A 
Fat
Air
Thrombus
Bacteria
Amniotic fluid
Tumor
396
Q

What structure is the point of interest to differentiate thrombi that form pre- and post-mortem?

A

Lines of Zahn

-an interdigitating pink (platelets) and red (RBCs) found only in thrombi BEFORE DEATH

397
Q

What is Cheyne -Stokes respiration?

A

refer to a cyclic breathing pattern in which a period of apnea is followed by a gradual increase in tidal volume and respiratory rate, then a gradual decrease until the next apneic period.

This occurs when damage to the respiratory center causes a delay between the brain stem’s detection of changes in blood gas levels (afferent response) and the compensatory adjustments in respiration (efferent response)

398
Q

what are signs and symptoms of hypercalcemia?

A

stones, bones, abdominal moans, and pyschic groans

Nephrolithiasis
Bone Pains
Constipation or abdominal pain
Altered mental status (psychiatric overtones)

399
Q

What provides motor innervation to all laryngeal muscles except cricothyroid muscles?

A

recurrent laryngeal nerve

400
Q

What is the most common benign lung tumor?

A

bronchial hamartoma

-they contain islands of mature hyaline cartilage (hamartoma) and presents as well-defined coin lesion with POPCORN CALCIFICATION on CXR

Pulmonology (1 decks)

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