Week 7 Flashcards
1
Q
Etiology: COPD
A
smoking (primary), air pollution, second-hand smoke, Hx of childhood resp infxs, occupational pollutant exposure, autoimmunity, genetic (alpha-1-antitrypsin deficiency), ashthma
2
Q
SSx (from history): COPD
A
dyspnea (exercise first, then rest), chronic productive cough (morning to all-day), wheezing, hemoptysis, lower extremity edema, small amount of clear sputum
3
Q
PE: COPD
A
barrel chest, Hoover’s sign, pursed-lip breathing, cyanosis, yellowing of fingertips, nail clubbing, weight loss, tripod position
4
Q
Findings (auscultation): COPD
A
decreased breath sounds, crackles at lung bases, distant heart sounds
5
Q
Findings (percussion): COPD
A
hyperresonant, decreased diaphragmatic excursion
6
Q
Dx: COPD
A
PFT, Pulse ox, arterial blood gases, chest CT, alpha-1-antitrypsin level, CXR
7
Q
Findings (PFT): COPD
A
decreased FEV1 (decreased flow rate), TLC normal
8
Q
When FEV1 falls below ___, the lungs are no longer normal.
A
85% of predicted values
9
Q
Pathophysiology: emphysema
A
permanent enlargement of alveolar ducts and air spaces distal to terminal bronchioles; destruction of alveolar walls, elastic recoil, fibrosis, scarring
10
Q
Etiology: emphysema
A
smoking, genetic (alpha-1-antitrypsin deficiency)
11
Q
SSx: emphysema
A
dyspnea, cyanosis, exercise intolerance, cough (hard, spasmodic, tiring)
12
Q
PE: emphysema
A
“pink puffers,” barrel chest, decreased breath sounds, hyperresonance, use of accessory resp. muscles, expiratory crackles/wheezing, PMI deviated toward sternum
13
Q
SSx: chronic bronchitis
A
productive cough (worse in mornings, small amount colorless sputum), dyspnea (6th decade), wheezing, tachypnea, “blue bloaters,” anorexia
14
Q
“Blue bloaters”
A
cyanosis and fluid retention, right CHF (seen in chronic bronchitis)
15
Q
PE: chronic bronchitis
A
increased resp. rate (prop. to severity), use of accessory muscles; advanced dz (cyanosis, elevated JVP, peripheral edema); FET > 6 secs, barrel chest, wheezing, decreased breath sounds, hyperresonance, prolonged expiration, inspiratory crackles
16
Q
Pathophysiology: chronic bronchitis
A
hyper-secretion of mucus secondary to hypertrophy of bronchial glands, leading to thickening of bronchial tubes
17
Q
Primary difference between asthma and COPD
A
degree of reversibility
18
Q
pathophysiology (3 main features): asthma
A
airway obstruction (reversible), inflammation, airway irritability (increased reactivity); manifests as episodes of wide-spread broncho-constriction
19
Q
Etiology (infants): asthma
A
foods, emotional upset, atopy, bottle feeding, early weaning, parental smoking
20
Q
Classifications: asthma
A
extrinsic (allergic) - d/t allergy to external factors, intrinsic (non-allergic) - d/t infx of upper/lower resp tract, irritants, emotions, exercise, cold weather
21
Q
SSx: asthma
A
no sxs between asthmatic episodes, cough (worse at night, w/ exercise), wheezing, dyspnea, chest tightness, sputum
22
Q
Common triggers: asthma
A
URIs, inhalant allergens, medications, food, exercise, irritants, weather, emotions, GERD
23
Q
PE: asthma
A
tachypnea, tachycardia, diaphoresis, use of accessory muscles, anxiousness
24
Q
In a patient with asthma, marked weight loss could be indicative of ____
A
development of severe emphysema
25
Pulsus paradoxus
exaggerated fall in systolic bp/slowing of pulse rate during inspiration; may occur during acute asthma exacerbation
26
Findings (auscultation): asthma
end-expiratory high-pitched/polyphonic wheezing, prolonged expiratory phase, diminished breath sounds/chest hyperinflation during acute exacerbation
27
In a patient with asthma, the presence of inspiratory wheezing (usu expiratory) or stridor may prompt an evaluation of ___
upper airway obstruction (vocal cord dysfunction, vocal cord paralysis, thyroid enlargement, soft tissue mass)
28
RED FLAG symptoms: asthma
confusion, drowsiness, absent lung sounds, cannot speak, cyanosis, status asthmaticus
29
Status asthmaticus
unresponsive to routine therapy; severe, prolonged attack that can be suddenly fatal; unremitting attacks
30
PE (upper airway): asthma
signs of nasal obstruction (polyps, swollen mucosa) which can worsen asthma
31
PE (skin): asthma
atopic derm, eczema, or other signs of skin conditions (extrinsic asthma)
32
DDx: COPD
central airway stenosis, bronchiectasis, heart failure, TB, constrictive bronchiolitis
33
Pathophysiology: bronchiectasis
infx followed by airway obstruction and impaired drainage; permanent damage/dilation of bronchi
34
Etiology: bronchiectasis
infx (bac/virus/fungal), congenital obstruction, immunodeficiency (IgA, IgG, HIV), abnormal secretion clearance (CF), genetic (alpha-1-antitrypsin deficiency), extrapulmonary cause (RA, Crohn's, Sjogren's)
35
SSx: bronchiectasis
chronic daily cough, daily sputum (mucupurulent, thick), hemoptysis, dyspnea, rhinosinusitis, wheezing, pleuritic chest pain, fatigue
36
Age of presentation: bronchiectasis, COPD, asthma
bronchiectasis (45 - 60 yo)
COPD (> 60 yo)
asthma (2-20 yo; > 40 yo)
37
Sex bias: bronchiectasis, COPD, asthma
bronchiectasis (F)
COPD (M)
asthma (none)
38
Etiology: bronchiectasis, COPD, asthma
bronchiectasis (infx, genetic, immune defect) COPD (cigarette smoking)
asthma (FHx of allergies, following URI)
39
Role of infx: bronchiectasis, COPD, asthma
bronchiectasis (primary)
COPD (secondary)
asthma (exacerbations)
40
Predominant organism: bronchiectasis, COPD, asthma
bronchiectasis (H. influenzae, p aeruginosa)
COPD (S. pneumoniae, H. influenzae)
asthma (resp. syncytial virus, parainfluenza virus, rhinovirus, influenza virus)
41
Airflow obstruction and hyper-responsiveness: bronchiectasis, COPD, asthma
present in all
42
Quality of sputum: bronchiectasis, COPD, asthma
bronchiectasis (purulent)
COPD (mucoid, clear)
asthma (rare)
43
Pathophysiology: cystic fibrosis
gene defect (CFTR protein mutation) leading to abnormal production of thick mucus, primarily affecting respiratory and digestive systems
44
Sex bias: cystic fibrosis
M=F
45
Dx: cystic fibrosis
stool analysis (steatorrhea), trypsinogen blood test in newborns, sweat chloride test, chest x-rays, PFTs, genetic screen (CFTR mutation)
46
PE (nose): cystic fibrosis
rhinitis, nasal polyps
47
Sx (sinuses): cystic fibrosis
panopacification, polyps, chronic rhinosinusitis
48
Sx (kidney): cystic fibrosis
nephrolithiasis
49
Sx (musculoskeletal): cystic fibrosis
reduced bone density, clubbing of fingers/toes
50
Sx (reproductive tract): cystic fibrosis
spermatogenesis defects, amenorrhea, cervical mucus
51
Sx (liver): cystic fibrosis
cirrhosis, portal hypertension, cholelithiasis
52
Subtypes of COPD
emphysema, chronic bronchitis, obstructive asthma
53
COPD is the ___ leading cause of death in America.
3rd
54
Hoover's sign
costal margins move inwards w/ inspiration; seen in COPD
55
Chronic bronchitis cough
occurs most days of the month, 3 mos / year, for 2 years w/o other explanation
56
Etiology (10-30 yo): asthma
inhalants
57
Etiology (> 45 yo): asthma
infx
58
Dx: bronchiectasis
CBC (anemia), sputum culture, PFT (low FEV1), CXR, sweat test
59
Etiology: laryngotracheobronchitis
parainfluenza type I (60%) infx of upper/lower resp tracts; also parainfluenza II/III/IV, influenza A/B, adenovirus, coxsackie A/B, rhinovirus, measles, HSV, resp syncytial virus
60
Pathophysiology: laryngotracheobronchitis
resp distress caused by inflammatory response to infx, not infx itself
61
Population: laryngotracheobronchitis
M > F, 6 mos - 3ys
62
SSx: laryngotracheobronchitis
prodrome (mild URI w/ coryza, nasal congestion, sore throat, cough, low-grade fever), followed by horse voice, barking cough, night stridor
63
PE: laryngotracheobronchitis
mild (normal at rest, expiratory wheezing)
| severe (inspiratory stridor, lethargy from hypoxemia, tachypnea, tachycardia)
64
Lab: laryngotracheobronchitis
leukocytosis with left shift
65
Dx: laryngotracheobronchitis
AP X-ray w/ "steeple sign"
66
Prognosis: laryngotracheobronchitis
usu self-limited; death possible from airway obstruction
67
DDX: laryngotracheobronchitis
```
epiglottitis (hot potato voice)
foreign body (no URI/fever Hx)
retropharyngeal abscess (seen on lat x-ray)
diphtheria (grayish pseudomembrane)
```
68
Etiology: acute bronchitis
influenza A/B, parainfluenza, coronavirus 1/2/3, rhinovirus, RSV
69
SSx: acute bronchitis
cough > 5 days w/ purulent sputum
70
PE: acute bronchitis
afebrile/low-grade fever, wheezing (bronchospasm), rhonchi (mucus in upper airways, clear w/ cough), normal percussion
71
In patients with acute bronchitis, a CXR is only necessary when ___ (4)
> 75 yo, developing signs of pneumonia, abnormal vitals, presence of crackles
72
DDx: acute bronchitis
chronic bronchitis, pneumonia, post-nasal drip, GERD, asthma
73
4 Stages of Pneumonia
congestion phase, red hepatization, grey hepatization, resolving stage
74
Extent of involvement: pneumonia
lobar (entire lobe), lobular (part of lobe), broncho-pneumonia (alveoli attached to particular bronchi)
75
Etiology: pneumonia (3 main types)
virus (50%), bacteria MC < 30 yo, mycoplasma
76
SSx: bacterial pneumonia
high fever, cough w/ thick/green/rust mucus, SOB, tachypnea, pleuritic pain w/ deep breaths, abdominal pain, severe fatigue, mb sweating and confusion
77
PE: bacterial pneumonia
fever, cyanosis, wheezes/rhonchi/crackles, increased tactile fremitus, tachycardia/bradycardia, bronchial breath sounds, +egophony, dullness to percussion, mb pleural friction rub
78
Etiology: nosocomial pneumonia
E. coli, Klebsiella, enterobacter spp, P aeruginosa, MRSA, H. influenzae
79
Streptococcus pneumoniae: bacterial pneumonia
```
60-80% of bac pneumonia
usu unilateral
complications: meningitis, endocarditis
No abnormal lung sounds if dehydrated
RED FLAG: BUN >70, WBC <5000, underlying dz
```
80
Klebsiella pneumoniae: bacterial pneumonia
gram-
aggressive lobar pneumonia
more gradual onset than pneumococcus, but spreads quickly
viscid exudates that can't be expectorated - "currant jelly" sputum
risk factors: alcoholism, malnutrition, DM, antibiotics, COPD, >40, sick people
mortality: 30% (tx), 40-60% (w/o tx)
relative bradycardia (pulse rate doesn't rise concurrently with fever)
81
Haemophilus influenzae: bacterial pneumonia
MC winter/spring
| risk factors: asthma, COPD, smoking, immunocompromised
82
Legionella pneumophila: bacterial pneumonia
gram-
most asx
concomitant GI symptoms (n/v, diarrhea, anorexia)
83
Dx: bacterial pneumonia
CXR (dense shadow/well-demarcated), CBC, CMP, CT, bronchoscopy, thoracentesis
84
If symptoms aren't resolving (pneumonia), consider (aggressive organisms).
klebsiella, legionella, staph aureus
85
If symptoms aren't resolving (pneumonia), consider (drug-resistant organisms).
strep pneumoniae, H. flu, P. aeruginosa, S aureus
86
If symptoms aren't resolving (pneumonia), consider (non-bacterial agents).
TB, fungi
87
Complications: bacterial pneumonia
lung abscess, pleural effusion, empyema
88
If symptoms aren't resolving (pneumonia), consider (misdiagnoses).
neoplastic dz, pulmonary embolism, pulmonary edema
89
Etiology: viral pneumonia
influenza virus, RSV, parainfluenza virus, adenovirus, paramyxovirus, CMV, VZV, HSV, EBV, Hantavirus, coronavirus
90
SSx: viral pneumonia
fever, malaise, HA, cough w/ scant sputum, myalgia, neck LA, chest pain, sore throat
91
PE: viral pneumonia
mild fever (mb no other sxs), tachypnea/dyspnea, wheezing/rhonchi/rales, dullness to percussion, tachycardia/bradycardia, sternal/intercostal retractions, decreased breath sounds, pleurisy
92
Dx: viral pneumonia
CBC, CMP, CXR (fuzzy shadows/poor demarcation)
93
Sx: SARS (coronavirus mutation)
high fever, dry cough, nasal congestion, dyspnea, localized chest pain, MS/joint pain, diarrhea, HA
94
Dx: SARS
PCR, ELISA, CXR (patchy infiltrates)
95
Sx: Hantavirus
initially resembles flu, progresses quickly to pulmonary edema
96
Etiology: walking pneumonia
mycoplasma pneumoniae
97
Prognosis: walking pneumonia
often benign, slow progression, resolves w/o tx
98
SSx: walking pneumonia
violent dry coughing attacks w/ scant sputum, chills/fever, occ n/v,
99
PE: walking pneumonia
pharyngeal erythema (no exudate), minimal cervical LA, bullous myringitis
100
Dx: walking pneumonia
PCR (no bacteria found), CXR (normal/diffuse infiltrate)
101
Sputum: bacterial/viral/mycoplasma pneumonia
bacterial - copius, rusty, purulent, many PMNs
viral - scant, thin, mb bloody, no bacteria
mycoplasma - scant, thin, PMNs/macrophages/resp epithelial cells
102
Fever: bacterial/viral/mycoplasma pneumonia
bacterial - high
viral - low/absent
mycoplasma - varies
103
Onset: bacterial/viral/mycoplasma pneumonia
bacterial - sudden
viral - gradual
mycoplasma - gradual
104
Myalgia: bacterial/viral/mycoplasma pneumonia
bacterial - absent
viral - present
mycoplasma - varies
105
WBC: bacterial/viral/mycoplasma pneumonia
bacterial - 15,000+
viral - low, WNL
mycoplasma - WNL
106
Etiology: fungal pneumonia
pneumocysis jirovecii
107
Population: fungal pneumonia
immunocompromised, esp. patients w/ AIDS
108
SSx: fungal pneumonia
gradual onset (malaise, night sweats, weight loss, low-grade fever), dry cough w/o expectoration; when severe, dyspnea/cyanosis/resp failure/chest pain/productive cough
109
Complications: fungal pneumonia
spontaneous pneumothorax and hypoxemia secondary to ARDS-like syndrome
110
Etiology: coccidioidomycosis
coccidoides immitis (SW US, Mex, S America)
111
SSx: coccidioidomycosis
Hx of C. immitis infx, usu subclinical/asx, triad of fever/erythema nodosum/arthralgias; common complaints (fever, cough, dyspnea, HA, chest pain)
112
Dx: coccidioidomycosis
CBC, CXR, skin testing, serology (IgM)
113
Prognosis: coccidioidomycosis
usu self-limited, can be disseminated
114
Sx: allergic bronchopulmonary aspergillosis
patients usu have asthma; cough, wheezing, dyspnea, low-grade fever, sticky plug-forming sputum
115
Dx: allergic bronchopulmonary aspergillosis
CBC differential (E >50%), increased IgE, +RAST, CXR (bronchiectasis, infiltrate)
116
Prognosis: pneumonia d/t aspiration
very severe, high mortality
117
SSx: lipoid aspiration
acute, fever, cough, oil droplets in sputum, chronic weight loss, night sweats
118
Etiology: lung abscess
anaerobic bacteria are sequestered -> necrosis of lung parenchyma; usu complication of aspiration pneumonia or severe bacterial pneumonia
119
SSx: lung abscess
fever, cough, sour-tasting sputum > 2 wks, night sweats, weight loss, hemoptysis, pleurisy
120
Dx: lung abscess
seen as cavitation on CXR and CT
121
Etiology: TB
inhalation of mycobacterium tuberculosis
122
Population (higher prevalence): TB
homeless, prisoners, health care workers w/ high-risk communities, children w/ high-risk adults, foreign-born, travelers, elderly, low income
123
Population (higher risk of progression): TB
infected within previous 2 years, < 4 yrs, untreated TB, HIV/CA/organ transplant/corticosteroid use, DM/CKD/gastrectomy/underweight
124
Age / Sex: TB
22-44; M>F
125
4 broad syndromes of TB
1) similar to atypical pneumonia (fever, non-productive cough), CXR (unilateral infiltrates, hilar adenopathy)
2) TB pleurisy w/ effusion (high fever, pleuritic pain, dyspnea)
3) progression to upper lobes
4) extra-pulmonary TB (14% - kidneys, bones, meninges, peritoneum)
126
What is miliary TB?
minute foci of infx in many organs
127
DDx: TB
pneumonia, lung abscess, pulmonary mycosis, CA, non-TB mycobacterium
128
Only __% of people infected with TB will develop active dz.
10
129
PPD test interpretation
> 5mm + in HIV, known TB contact, TB Hx, organ transplants, immunocompromised
> 10mm + in recent immigrants, IV drug users, < 4 yrs, children exposed to high-risk adults
> 15mm + in any person
130
SSx: active TB
chronic cough MC (>3wks), yellow/green sputum (AM), hemopytsis, malaise/fatigue, anorexia/wt loss, low grade fever (late afternoon), night sweats, pleuritic pain
131
PE: active TB
fever, cachexia, hypoxia, LA, abnormal lung sounds
132
Dx: active TB
mantoux test, acid-fast stain of sputum, WBC - normal, CXR (ipsilateral hilar adenopathy/atelectasis)
133
DDx: pleurisy
acute abdomen (n/v, abd. pain)
intercostal neuritis (no friction rub)
costo-chondritis (trauma hx, localized pain)
herpes (eruptions)
MI (location, concomitant, risk hx, cardiac enzymes)
pneumothorax (tracheal deviation, r/o by CXR)
pericarditis (friction rub w/ ht beat, pain radiating to neck/shoulders, resp cough, ht sounds muffled)
134
Dx: pleurisy
```
CXR (normal, fluid blunting of costo-phrenic angle)
Ultrasound (pleural fluid)
CT (trapped pockets of fluid)
CBC
ABGs
```
135
PE: pleurisy
fever if infx, tachycardia, limited chest motion, decreased breath sounds, pleural friction rub (crackles/grating/creaking on insp/expiration)
136
PE: pleurisy vs pericarditis
pleurisy - pleural friction rub
| pericarditis - pericardial friction rub (present when pt holds breath)
137
PE: pleurisy w/ effusion
decreased/absent breath sounds, percussion dullness, decreased tactile fremitus, egophony at upper border of fluid
138
SSx: pleurisy
sudden onset of pleuritic chest pain, pain w/ coughing/deep breathing -> tachypnea, shallow breathing, dyspnea; referred pain to shoulder/diaphragm; w/ effusion, pain subsides
139
Etiology: pleurisy
infx (virus MC), inhalants, SLE, RA, lung/breast CA, mesothelioma, CHF, PE, lymph obstruction, trauma
140
Pleurisy
inflammation of the pleura w/ possible effusion
141
Etiology: histoplasmosis
histoplasma capsulatum, fungus found in OH/MS river valleys and SE
142
SSx: histoplasmosis
most asx
acute (fatigue, fever, chest pain, dry cough)
chronic (similar to TB)
disseminated (various, multiple organs)
143
PE: histoplasmosis (chronic)
crackles, wheezes
144
PE: histoplasmosis (disseminated)
ulcers (buccal mucosa, tongue, gingiva, larynx), mb vision loss, mb hepatosplenomegaly
145
Dx: histoplasmosis
sputum culture, +skin test, PCR, CXR (calcified hilar lymph nodes, lung scarring in chronic forms)
146
Reactivation risk: latent TB
3-5%
147
Location: latent TB lesions
post. segment of RUL, apicoposterior segment of LLL, apical segment of lower lobes
148
QuantiFERON-TB Gold interpretation
patients infected with M. tuberculosis will have increased IFN-gamma
149
Tx: multi-drug resistant TB (MDR-TB)
4 different antibiotics over 18-24 mos
150
Vaccine: TB
BCG; immunity decreases after 10 years
