Vascular and Pleural Disease

Question 0

What are the three physiological mechanisms of increased pulmonary pressure?

Answer 0

Flow
Increased Pulmonary vascular Resistance
Increased left heart pressure (increased pulm venous pressure)

Question 1

What are the three risk factors for venous thrombosis?

Answer 1

Hypercoagulability
Stasis
Injury to vein wall

Question 2

What is the typical presentation of a deep venous thrombosis?

Answer 2

Swelling - entire leg or below knee 
Pitting edema
Difference in calf size
Warmth
Homan's sign - pain elicited by foot dorsiflexion

Question 3

What is the most common test used to diagnose a DVT?

Answer 3

Compression duplex ultrasonography
Vein should collapse when you compress it - doesn’t if clot
Then Doppler to look at blood flow

Question 4

What test is used for pelvic vein DVT testing?

Answer 4

Venography
Gold standard for all DVT but invasive and requires IV contrast
CT - contrast required
Sometime MRI

Question 5

Who should not take estrogen containing oral contraceptives?

Answer 5

Individuals who are factor v Leiden positive

Question 6

What are symptoms of a pulmonary infarction?

Answer 6

Hemoptysis
Pleural rub
Low grade fever
Peripheral wedge shaped defect on CXR - hamptons hump right above diaphragm

Question 7

What are common symptoms of a PE?

Answer 7

Tachypnea
Acute dyspnea
Chest pain

Question 8

What symptoms suggest a large PE?

Answer 8

Tachycardia
Syncope
Hypotension

Question 9

What are lab and imaging findings in a PE?

Answer 9

Hypoxemia, widened Aa gradient, usually paO2 <80
Sometimes atelectasis or small pleural effusion
Westermarks sign - paucity of blood vessels in lobe from infarct
Elevated d dimer

Question 10

What are the different tests for a PE?

Answer 10

D dimer - high sensitivity, low specificity - can rule it out but not done if suspicion already high
Ct angiogram - high sensitive and specific, requires contrast
VQ scan - if unable to receive contrast, test of choice for chronic PE
Pulmonary angiography - gold standard but invasive and contrast

Question 11

What is the definition of pulmonary hypertension?

Answer 11

PA systolic > 40 or PA mean > 25

PulmVR usually above 240

Question 12

What are the five groups of clinical classifications of pulm HT?

Answer 12

1 - pulm arterial hypertension = small vessels, low wedge pressure, has medications, diagnosis of exclusion
2 - pulmonary venous hypertension = left heart, most common, elevated wedge pressure
3 - pulm HT from hypoxia and/or lung disease, oxygen therapy in COPD can prevent, irreversible once develops
4 - chronic PE, can be cured by surgery
5 - miscellaneous and uncommon conditions

Question 13

What diagnostic tests are used to work up pulm ht?

Answer 13

Echo
Cath
(VQ, not CTA, PFTs and CXR)

Question 14

What are general radiographic feature of pulm HT?

Answer 14

Enlarged pulmonary arteries
RV dilation
Azygous vein distention

Question 15

What are radiograph findings of pulmonary VENOUS hypertension?

Answer 15

Cephalization of pulmonary veins
Interstitial edema, Kerley b lines
Alveolar edema

Question 16

What is this presentation of a person with pleural disease?

Answer 16

Dyspnea
Pleuritic pain (but not with transudative processes)
Cough
Weight loss, fatigue (systemic complaints)
Fever, rigors

Question 17

What are the six mechanisms responsible for pleural fluid accumulation?

Answer 17

Increased hydrostatic pressure (pulm venous HT)
Decreased oncotic pressure
Decreased intrapleural pressure (like PTX)
Increased permeability of micro vasculature (inflammation)
Lymphatic obstruction
Movement of fluid from peritoneum

Question 18

What are the most common causes of transudative effusions?

Answer 18

CHF
Hypoalbuminemia
Ascites with hypoalbuminemia

Question 19

What are the most common causes of exudative effusions?

Answer 19

Inflammation or lymphatic obstruction

Extensive differential

Question 20

If someone comes in with pain and fever what kind of effusion is present?

Answer 20

Exudative

Question 21

What lab values differentiate between transudative and exudative effusions?

Answer 21

Ratio of fluid/serum LDH - >.6 exudate, .5 exudate, .3 exudate, >10,000 or RBC&raquo_space;50,000 is exudate
Albumin gradient - >1.2 transudate, <1.2 exudate

Question 22

What is empyema?

Answer 22

A para pneumonic effusion
Always exudate
Loculated fluid 
Ph < 7.2
Glucose < 40
High WBC 
Continued fever
Enlarging effusion

Question 23

What is a unilateral pleural effusion suspicious for?

Answer 23

TB

If unilateral and positive ppd treat for tb

Question 24

What are the different effusions in collagen vascular diseases?

Answer 24

RA - uni or bilateral, glucose < 10, RF high

SLE - bilateral, glucose normal, complement low

Question 25

What does an esophageal rupture present like?

Answer 25

Left pleural effusion
PTX or pneumomediastinum
Ph < 7, amylase >5000

Question 26

What can cause a bloody effusion (RBC > 100,000)?

Answer 26

Tumor
Trauma
PE with infarction
Tb

Question 27

What are the common causes of PTX?

Answer 27

Iatrogenic
Trauma
Emphysema with bullae
Necrotizing Bacterial pneumonias (staph, gram -, anaerobes), Tb, Pneumocystis Carinii (PCP)
Necrotizing granulomatous processes (sarcoidosis, eosinophilic)
Non malignant implants on pleura: endometriosis

Question 28

When is VATS indicated to assess pleural effusions?

Answer 28

Difficult to diagnose pleural effusion when infectious or neoplastic etiology is likely

Question 29

When can a tension PTX develop?

Answer 29

Patient on a ventilator

Almost never happens in spontaneously breathing patient

Question 30

What is the treatment of PTX?

Answer 30

Placement of chest tube to drain air using suction