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Internal Medicine > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q 
Acute bronchitis 
Path:
Pt:
Dx:
Tx:
A

Path: Inflammation of trachea/bronchi. Often follows URI
MC-> Adenovirus

Pt:
Cough +/- productive/ lasts 1-3w
Wheezing and rhonchi

Dx: Clinical
CXR usually normal/nonspecific
Thickening of bronchial walls in lower labs

Tx:
Sxs-> fluids, rest, bronchodilators, antitussives
Dextromethorphan
Guaifenesin
Abx if elderly, COPD, immunocompromised or pts not responsive to conservative tx, cough >7-10d (macrolide, doxycycline, fluoroquinolone)

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2
Q

Mild intermittent asthma
Dx
Tx

A

of sx:
Days: 2 day/week
Nights: 2 days/month

FEV1: 80%

Tx: beta-2 agonist prn
inhaled corticosteroid (low dose)
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3
Q

Mild persistent asthma
Dx
Tx

A

of sx:
Days: >2 days/week
Nights: 3-4 days/month

FEV1: 80%

Tx: beta-2 agonist prn

inhaled corticosteroid (low dose) + LABA
OR
inhaled corticosteroid (medium dose dose)
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4
Q

Moderate persistent asthma
Dx
Tx

A

of sx:
Days: daily
Nights: 5 days/month

FEV1: 60-80%

Tx: beta-2 agonist prn
inhaled corticosteroid (medium dose) + LABA
and/or leukotriene receptor antagonist

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5
Q

Severe persistent asthma
Dx
Tx

A

of sx:
Days: continual
Nights: frequent

FEV1: =60%

Tx: beta-2 agonist prn
inhaled corticosteroid (high dose) + LABA
and/or 
leukotriene receptor antagonist
oral corticosteroid 
omalizumab
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6
Q 
Sarcoidosis 
Path:
Pt:
Dx:
Tx:
A

Path: autoimmune, infiltrating dz

Pt: young African American female w/ bilateral hilar lymphadenopathy
erythema nodosum

Dx:
1st CXR-> bilateral hilar lymphadenopathy
Then: PFT-> restrictive dz
Best: bx-> noncaseating granuloma

Tx: prednisone
hypercalcemia… vit D from granuloma
bradycardia/block = infiltrating heart
restrictive cardiomyopathy

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7
Q 
Bronchiectasis
Path:
Pt:
Dx:
Tx:
A

Path: Irreversible bronchial dilation 2/2 transmural inflammation-> obstruction of airflow and impaired clearance of mucus secretions-> lung infections
Recurrent/chronic lung infections
-H influenza
-CF-> pseudomonas

Pt: Cough, dyspnea, copious sputum, hemoptysis

Dx:

  • CXR: scattered or focal rings of bronchial cuffing, dilated, thick airways
  • PFTs: obstructive low FEV1; FEV1/FVC <70%
  • Chest CT: airway dilation and thickening (“tram-track” appearance), +/- cystic changes, infiltrates, adenopathy

Tx: Tx underlying condition: mucolytics, bronchodilators

  • Pseudomonas (CF): fluoroquinolone, pip/tazo, aminoglycoside
  • MAC: clarithromycin + ethambutol
  • Aspergillus: steroids + itraconazole
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8
Q 
Carcinoid tumor
Path:
Pt:
Dx:
Tx:
A

Path: Rare neuroendocrine tumor; slow growth; low mets
GI tract MC site; Lungs 2nd MC site
May secrete serotonin, SCTH, ADH, melanocyte stimulating hormone

Pt: MC <60 yr
Asx 25-40%; +/- focal wheezing, cough, recurrent pneumonia, hemoptysis
+/- SIADH, Cushing’s syndrome, obstruction
Carcinoid syndrome:
Diarrhea 2/2 inc serotonin -> flushing, tachycardia, bronchoconstriction (wheezing), hemodynamic instability, acidosis

Dx:
Bronch-> pink to purple well-vascularized central tumor
Tumor localization-> CT scan & octreotide scintigraphy

Tx:
Surgical excision -> definitive (often resistant to chemo/radiation)
Octreotide may reduce sx

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9
Q 
COPD
Path:
Pt:
Dx:
Tx:
A

Path: Loss of elastic recoil + increased airway resistance
Emphysema: abnormal, permanent enlargement of terminal airspaces
Chronic Bronchitis: productive cough >/=3m x2 consecutive years

Pt:
E: dyspnea, accessory muscle use, tachypnea, prolonged exhalation
CB: productive cough, rale/rhonchi/wheeze, cor pulmonale

Dx:
GS: spirometry: obstruction -> dec FEV1, FVC and FEV1/FVC<70%
moderate-severe exacerbation FEV1<50%
CXR/CT scan: flattened diaphragm, dec/inc vascular markings, +/- bullae, inc AP diameter, enlarged right heart border
EKG: cor pulmonale, a-fib/a-flutter, mutifocal atrial tachycardia

Tx:

  • Smoking cessation
  • Bronchodilators: anticholinergic + beta agonist
  • inhaled corticosteroids
  • Oxygen -> ONLY medical therapy proven to decrease mortality
  • Prevent exacerbations-> smoking cessation, pneumonia/influenza vaccines, pulmonary rehab
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10
Q

GOLD staging criteria + tx

A

I: Mild FEV1>/=80%
tx: short acting bronchodilators; vaccinations

II: Moderate FEV1 50-70%
tx: above + long acting bronchodilator

III: Severe FEV1 30-50%
tx: above + pulmonary rehab, steroids if increased exacerbations

IV: Very severe FEV1<30%, cor pulmonale, respiratory failure, heart failure
tx: above + oxygen therapy

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11
Q 
Cor pulmonale 
Path:
Pt:
Dx:
Tx:
A 
Path: Altered structure (hypertrophy, dilation) &amp; function of RV 2/2 pulmonary HTN-> lung, upper airway, pulmonary vasculature or chest wall
COPD- MC cause in US
PE (MC acute cause)
Pulm fibrosis
Sleep apnea
Myasthenia gravis
Poliomyelitis 
Sarcoidosis

Pt: dyspnea, angina, syncope on exertion, lethargy and fatigue

Dx:
Peripheral edema, elevated JVP w/ prominent v-wave, inc/narrowing split second heart sounds, L holosystolic murmur at left lower sternal border
EKG: RVH, right axis deviation, right atrial enlargement, right bundle branch block
-Echo
-CXR
-R heart cath

Tx: Tx underlying cause

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12
Q

OSA

dx:

A

STOP BANG: High risk yes to 3+ items-> refer to sleep study

Snoring
Tiredness
Observed you stop breathing
blood Pressure 
BMI >35
Age >50
Neck circumference >40cm
Gender: male
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13
Q 
Idiopathic pulmonary fibrosis
Path:
Pt:
Dx:
Tx:
A

Path: Fibrosing interstitial pneumonia
Linked to cigarette smoking
Exposure to stone, metal, wood organic dusts
GERD
Exact cause is unknown-> likely related to epithelial cell damage and improper repair leading to chronic and progressive symptoms

Pt: Chronic nonproductive cough, Gradual exertional dyspnea (usually develops over several months)

Dx:
-PE: Bibasilar crackles, Digital clubbing
-High resolution lung CT: Traction bronchiectasis, Honeycombing
PFTs, restrictive: dec FVC and FEV1, Near normal FEV1/FVC

Tx:
Acute exacerbations-> corticosteroids 
Nintedanib, pirfenidone delay progression 
Supportive Care
Supplemental oxygen
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14
Q

Pneumoconiosis

A

Path: Restrictive lung disease 2/2 inhalation
-Silica (silicosis)-> masonry, pottery, stone working, sandblasting
-Asbestos (asbestosis)-> plumbing, insulation removal/instal
-Coal dust (anthracosis)
Macrophages engulf particles and release a number of cytokines, growth factors and chemotactic substance that result in inflammation, fibrosis and ischemic necrosis

Pt: Dyspnea, cough, pleuritic pain , Reduced chest expansion, rales, clubbing, Cor pulmonale

Dx: 
Chest XR + hx of exposure 
-Multiple small nodules throughout lungs and hilar lymph node calcification 
-Miliary calcification of spleen 
PFTs are NOT diagnostic

Tx:
Minimizing/removing exposure
Smoking cessation

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15
Q 
Pneumonia-bacterial 
Path:
Dx:
Tx:
Complication
A

Path:
CAP: strep pneumonia
COPD: H flu, M cat
Hospital: pseudomonas, MRSA

Dx: CXR, PE findings

Tx:
Out pt: Macrolide or doxycycline
Fluoroquinolone if comorbid conditions/recent abx use

In pt: B lactam + macrolide, Broad spectrum fluoroquinolone

Aspiration: Clinda, Metronidazole, Augmentin

Complication-> MC cause of lung abscess
Tx: Clinda

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16
Q

Pneumonia PATHs:
Viral
Fungal
HIV

A

Viral:
RSV & parainfluenza-> MC viral cause in infants/small children
Influenza-> MC viral cause in adults
CMV-> transplant recipients and pts w/ AIDS
Varicella zoster-> severe in adults

Fungal
Pneumocystis jirovecii (PCP)-> compromised host w/ O2 desaturations w/ ambulation
Histoplasmosis capsulatum-> Mississippi & Ohio river valley, soil contaminated w/ bird and bat droppings
Coccidioides -> soil SW US (desert areas)

HIV:
Pneumocystis jirovecii (PCP) 
tx: IV TMP-SMX, Steroids for PaO2<70
Histoplasmosis capsulatum
tx: itraconazole, amphotericin B
Coccidioides
17
Q 
Pulmonary HTN
Path:
Pt:
Dx:
Tx:
A

Path: inc pulm vascular resistance -> RVH -> r-sided heart failure
Stages:
I: idiopathic Pulm Arterial HTN-> DOE
II: Pulm HTN due to left heart disease
III: Pulm HTN due to hypoxemic or chronic lung disease (COPD)
IV: Pulm HTN due to chronic thromboembolic disease

Pt: Dyspnea, chest pain, weakness, fatigue, cyanosis, edema
Severe-> Exertional syncope
Accentuated S2
Signs R-sided heart failure: inc JVP, peripheral edema, ascites
+/- systolic ejection clock, pulmonary regurgitation, right ventricular heave

Dx:
-CXR: enlarged pulmonary arteries, interstitial/alveolar edema, signs of heart failure
-EKG: cor pulmonale: RVH, right axis deviation, right atrial enlargement, right bundle branch block
-Echo: large RV, RA hypertrophy, +/- right to left shunt
-Right-sided heart cath: GOLD STANDARD
Mean pulmonary artery pressure >/= 25 @ rest (>30 during exercise)
-CBC: polycythemia w/ increased hematocrit

Tx:
Type I: idiopathic: Vasoreactivity with inhaled nitric oxide, IV adenosine or CCB
-If vasoreactive-> CCB
-Not vasoreactive: prostacyclin (epoprostenol, iloprost), Phosphodiesterase-5 inhibitors (sildenafil, tadalafil), Endothelin receptor antagonists (bosentan)
-Definitive heart-lung transplantation 
Type II: 2/2 L heart disease: tx underlying disease
Type III: hypoxemia/COPD
-Oxygen dec mortality
-Tx underlying cause
Type IV: chronic thromboembolic dz
-Anticoagulation 
-Tx underlying cause
18
Q 
Lung cancer
Path:
Screening:
Pt:
Dx:
Tx:
A

Path:
85% non-small cell: adenocarcinoma (MC), large cell, squamous
15% small cell (strong correlation to smoking)

Screening: Age 55-77, No sxs of lung cancer
>30 pack year smoking history
Current smoker or quit within the past 15yrs

Pt: cough, dyspnea, hemoptysis, weight loss

Dx:
CXR and CT
Sputum cytology- for central lesions
Bronchoscopy- for central lesions
Pleural fluid analysis
Trans-thoracic needle biopsy 
Mediastinoscopy

Tx:
Non-small cell: surgical intervention first line
Small cell: chemo and radiation

19
Q

Solitary pulmonary nodules
Path:
Dx:

A

Path:

  • Granulomatous infections: TB (MC), histoplasmosis, coccidioidomycosis
  • Tumors
  • Inflammation: RA, sarcoidosis, Wegner’s granulomatosis
  • Mediastinal tumors: thymoma MC

Dx:
Observe: if low malignant probability
Transthoracic needle aspiration or bronch: intermediate probability
Resection w/ bx: high probability of malignancy

Internal Medicine (10 decks)

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