AR HY review Flashcards
(214 cards)
1
Q
pH and CO2 deviate in the same direction (both up or both down) in which type of disorders?
A
metabolic acid/base disorders
2
Q
pH and CO2 deviate in the opposite direction in which type of acid base disorders?
A
Respiratory acid base disorders
3
Q
pH and CO2 both elevated seen in what type of disorder?
A
metabolic alkalosis
4
Q
pH up and CO2 down in what type of disorder?
A
respiratory alkalosis (hyperventilation)
5
Q
pH and CO2 both down in what type of disorders?
A
metabolic acidosis
6
Q
pH down and CO2 up in what type of disorders?
A
respiratory acidosis (hypoventilation/CO2 retention)
7
Q
Normal pH values
A
7.38-7.44
8
Q
Normal blood gas CO2 levels
A
38-42
9
Q
Normal serum bicarb levels:
A
23-28
24 is the value used to calculate delta bicarb (24 - delta gap)
10
Q
- anion gap formula
- normal anion gap range
A
- Na - (Cl + HCO3)
- 7-13 (delta gap nl is 12
11
Q
- urine anion gap formula
- UAG results interpretation
A
- (urine Na + urine K) - urine Cl
- positive = positively the kidneys causing acidosis
- negative = neGUTive, i.e. gut is causing acidosis
12
Q
Things that cause decreased anion gap
A
excess proteins (e.g multiple myeloma)
proteins are usually negatively charged
13
Q
Bartter syndrome features
- pH
- salt and water
- BP
- serum K+ level
- serum Cl- level
- serum Mg++
A
- Metabolic alkalosis (HCO3 high)
- salt (NaCl) and water loss
- BP: nl/low
- K: low serum (K loss in urine)
- Cl: low serum (Cl loss in urine)
- Mg: normal
14
Q
Gitelman syndrome
- pH
- salt and water
- BP
- K+
- Mg+
A
Gitelman: most common inherited salt wasting disorder
- metabolic alkalosis (HCO3 high)
- salt (NaCl) and water wasting
- BP: nl/low
- K: low serum (K wasting in urine)
- Mg: low (wasting in urine)
15
Q
Liddle syndrome
- pH
- salt and water
- BP
- K
- aldosterone
A
Liddle syndrome
- pH: metabolic alkalosis (HCO3 high)
- salt (NaCl) and water retention
- BP high (usually early onset
- K: low (urinary wasting)
- aldosterone: low (pseudohyperaldosteronism: ie BP high and K low like in high aldo; but aldo is low in reality)
16
Q
Common causes of metabolic alkalosis
A
- volume depletion or diuretics (MCC)
- vomiting/NGT suction
- Hyperaldosteronism
- Cushing (hypercortisol)
- Licorice
- Bartter/Gitelman/Liddle
17
Q
Common causes of NAGMA
A
- RTA
- diarrhea
- aggressive saline repletion
- early CKD
- ureterosigmoidostomy
18
Q
AGMA with calcium oxalate crystals:
- likely ingestion
- complication
- Rx
A
- Ethylene glycol (glycolic acid/antifreeze)
- ATN (crystal induced)
- supportive care if sml osmolar gap, fomepizole for large gap or severe disease
19
Q
ASA toxicity acid base response
A
early respiratory alkalosis (primary) followed by metabolic acidosis (secondary)
don’t forget tinnitus/hearing loss
20
Q
Types of acidosis in DM patients and etiology
A
- AGMA = DKA
- NAGMA = RTA IV (hypoaldosteronism)
21
Q
Cirrhotic patient: common acid base disturbance?
A
Respiratory alkalosis (often compensated with nearly nl pH)
d/t hyperventilation for unknown reasons
22
Q
RTA type II
- location
- K
- stones
- etio
A
RTA type II
- proximal; HCO3+ resorption defect
- K: low/nl
- stones: maybe probably not
- etio: MM, topiramate, acetazolamide
23
Q
RTA type I
- location
- K
- stones
- etio
A
RTA type I
- distal (collecting duct); H+ excretion defect
- K: low/nl
- stone: yes
- etio: SLE, Sjogren, amphotericin B, obstruction
24
Q
RTA type IV
- location
- K
- stones
- etio
A
RTA type IV
- DCT, aldo deficiency or resistance
- K: high
- stones: no
- etio: DM or hypoaldosteronism
25
SIADH serum and urine trends
serum: LOW, urine: HIGH
serum: Na and Osm are **low**
urine: Na (\>20) and Osm (usu \> serum Osm) are **high**
26
Diabetes insipidus: types (2), DDAVP responsiveness, and lab trends
1. Central DI: responsive to DDAVP, Na high/nl, urine Osm very low (\<100), goes to \> 300 with DDAVP
2. Nephrogenic DI: not responsive to DDAVP, Na high/nl, urine Osm very low (\<100) and stays that wasy after DDAVP
27
Psychogenic polydipsia/Beer potomania
lab trends and response to treatment
1. Serum Na low
2. Urine Na low (\<20)
3. Urine Osm low
4. responds to water deprivation: urine Osm goes from \< 100 to \> 300
28
Too rapid of correction of chronic hyponatremia leads to what?
osmotic demyelination syndrom
sx: AMS, slurring speech, reguritating food, memory impairment
29
jockey/bodybuilder/runner: serum K is low: etio?
**Diuretic abuse**. Serum K is low, urine K is high (\>20)
30
Hematuria with blood clots
likely bladder origin of pathology; get CT urography and urology consult
31
microscopic hematuria: benign etiologies
UA, fever, exercise, woman during menses, acute (minor) trauma
32
Hematuria: signs of glomerular etio:
1. RBC casts
2. dysmorpic RBCs
3. elevated Cr
4. HTN
5. Edema
6. low albumin
33
Microscopic hematuria: risk factors for serious etio
1. \>35 yo
2. smoking
3. exposure to benzene
4. exposure to cyclophosphamide (alkylating agents)
5. heavy non-narcotic analgesic use
6. hx urologic disorder or dx (BPH, nephrolithiasis)
7. recurrent UTIs
34
50y M routine physical, UA has 5 RBCs, no casts, no clots. wtd
repeat UA in 6 weeks
35
50y M routine physical, 5 RBCs persistently on multiple UAs, no casts, no clots. wtd
CT urography
(he is over 35 yo)
if CT is negative, refer for cystoscopy; if there are casts refer to nephro for renal bx
36
42y F with dysuria, post-void dribbling, and dyspareunia. dx?
urethral diverticulum
37
Nephrolithiasis
1. recurr UTIs: a/w?
2. prior malignancies/gout: a/w?
3. malabsorbtion (IBC, CF, short gut): a/w?
1. UTI: struvite stones
2. malignancy/gout: uric acid stones
3. malabsorption: calcium oxalate stones
38
Nephrolithiasis stone shapes
1. cystine stones
2. calcium oxalate
3. struvite (Mg ammonium phosphate) stones
4. uric acid stones
5. acyclovir
1. cystine: **hexagon shape**
2. calcium: **square envelope,** or rods/dumbells
3. struvite: **coffin lids, staghorn**
4. uric acid: elongated hexagon
5. acyclovir: **needle shaped**
39
Nephrolithiasis
1. rx for small
2. rx for large
3. prevention
1. Rx small (abt 5mm) should pass on own; increase fluid intake, tamsulosin
2. Rx large (\>10mm) require intervention
3. Prevention: fluid intake, low Na diet (calcium stones), HCTZ, low meat diet, allopurinol (for uric acid stones)
40
Best way to decrease urinary calcium levels and prevent Ca oxalate stones?
HCTZ
low dietary calcium seems to have no benefit
41
35y M gross hematuria, hx of cough, fever, congestion, a week ago. Wears a hearing aid and has fam hx of hematuria. Cr 1.9, WBC normal. dx and path?
Alport syndrome; collage IV abnormality
42
Glomerular (nephrotic) diseases: 4 types
1. minimal change
2. FSGS focal segmental glomerular sclerosis
3. MN membranous nephropathy
4. MPGN membroproliferative nephropathy
43
Nephrotic syndrome features
1. proteinuria: \>3g/day
2. hypoalbumiemia: causes edema
3. loss of ATIII: thrombosis and PE
4. hyperlipidemia and hyperlipiduria (fat bodies/casts in urine)
44
Nephrotic syndrome a/w low complement
membranoproliferative GN
45
FSGS etio and epidemiology
1. African american
2. HIV
3. heroin
4. sickle cell
46
Minimal change disease etio and epidemiology
1. is mcc of nephrotic syndrome
2. leukemia/lymphoma
3. NSAIDS
4. lithium
47
MPGN etio
1. Hep B, Hep C
2. cryoglobulinemia
3. SLE, Sjogren
4. syphilis
48
Nephrotic syndromes rx and out look
1. MC: steroids, usually resolves
2. MN: steroids, ⅓ get better, ⅓ same, ⅓ get worse
3. FSGS: wt loss, HAART, steroids, 50% ESRD 5y
4. MPGN: steroids, 50% ESRD or die in 5y
49
Systemic dz that causes nephrotic syndromes
1. Diabetic nephropathy: usu co-occuring retinopathy
2. Multiple myeloma
3. Amyloidosis: Congo red dye: apple green with polarization
50
Conditions with low serum complement
1. PSGN
2. MPGN/cryoglobulinemia/Hep C
3. SLE
4. subacute bacterial endocarditis
5. athreroembolism
51
Nephritic syndromes: HTN and hematuria
1. PSGN
2. IgA nephropathy
3. RPGN
4. Henoch-Schonlein/IgA vasculitis
52
PSGN vs IgA neprhitis
1. PSGN: low complement (C3), and **1-3 we**eks post URI
2. IgA: nl complement, and **\< 1 week** post URI
53
Young patient, palpable rash, arthralgia, GI symptoms. dx
Henoch-Schonlein/IgA vasculitis
supportive care to Rx
54
a/w linear IgG deposits
RPGN
55
The 4 pulmonary renal syndromes and features
1. GPA: cANCA anti-PR3, URI involvement (otitis)
2. eGPA: asthma, eosinophilia
3. MPA Microscopic polyangiitis: pANCA anti-MPO no granulomas, less respiratory dz
4. anti-GBM dz (Goodpasture): lower pulm dz, alveolar hemorrhage
56
Rx for the 4 pulm-renal syndrome
1. GPA, eGPA, MP, and antiGBM
2. rx steroids and cyclophosphamide, plasmapheresis for serious pulmonary hemorrhage
57
Large vessel vasculitis types (3)
1. Takayasu arteritis
2. GCA/temporal arteritis
3. Behcet syndrome
4. all have normal complement
5. all may have prominent systemic symptoms
58
Medium vessel vasculitis types (2)
1. PAN (testes pain is classic for)
2. Behcet syndrome
3. all have normal complement
4. all may have prominent systemic symptoms
59
Small vasculitis types (7)
1. MPA
2. GPA
3. eGPA (Churg-Strauss)
4. IgA vasculitis (Henoch-Schonlein)
5. Cryoglobulinemia
6. a/w SLE or RA
7. cutaneous leukocytoclastic angiitis
8. all usu low complement and less likely systemic sx
60
TLS freatures vs rhabdo
1. Ph \> 4.5
2. U \> 8
3. Ca \< 7
4. K \> 6
5. rhabdo has urine dipstick + for blood; TLS doesn't
61
When to stop ACEi use
1. \> 30% incr in Cr after starting
2. K \> 5.5
62
NSAIDs and ACEi effects on kidney
1. NSAIDS: constrict afferent arteriole
2. ACEi: dilates efferent arteriole
63
ATN vs AIN: casts and etio
1. ATN muddy brown casts
2. ATN etio: aminoglycosides, contrast, rhabdo, TLS etc
3. AIN WBC casts, peripheral eosinophils
4. AIN etio: PPI, NSAIDS, abx, diuretics, phenytoin
64
CKD
1. anemia Rx
2. wtd for acidosis
3. bone lesions (2nd hyperparathyroidism)
4. complication of rx for #3
1. anemia: EPO + iron, goal hgb 10-11
2. if HCO3 \< 22: give bicarb
3. bones: Ca and vit D3
4. adynamic bone disease likley if PTH \< 100 or AlkP \< 7
65
Post renal obstruction autodiuresis rx
Don't replete volume lost with 1:1 ratio of IVF. Replace 50-75% of lost volume
66
Management of ESRD patient
1. low Na, K, phos
2. low water
3. no calcium restriction
4. no phos-based (FLEET) enema→ phos overload
67
ESRD pt with high Ca, phos and PTH: risk?
risk of calciphylaxis.
if Ca x phos \> 70 increased risk
68
Pt renal insufficiency: how to increase nutritional status and slow rate of kidney decline?
keep serum bicarb \> 22
69
Patient with short bowel syndrome: add what to diet to decrease risk of kidney stones?
calcium: added calcium decreases absorption of oxalate and helps prevent stones
70
Type of stone seen in RTA type I
Ca phosphate
71
type of stone seen in IBD or pt with hx of gastric bypass?
cystine stones
72
MCC recurrent nephrolithiasis?
idiopathic hypercalciuria
73
Lung nodule vs lung mass size
nodule \< 30mm
mass \> 30mm, increased risk of being malignant
74
Solid lung nodule \< 6mm, wtd
1. low risk pt
2. high risk pt
Lung nodule \< 6mm
1. low risk: no f/u
2. high risk: CT 6-12mo (smoker, female, elderly, fam hx)
75
Solid lung nodule 6-8mm, wtd
1. low risk
2. high risk
Solid lung nodule 6-8mm
1. low risk: f/u 6-12mo; if no changed then again 18-24 mo
2. high risk: same as above, 6-12mo then 18-24mo
76
High risk features of lung nodules
size \> 30mm, spiculated, eccentric or low/no calcification
77
low risk features of lung nodules
size \< 30mm, smooth border, central or popcorn calcification
78
Solid lung nodule \> 8mm, wtd
either f/u CT in 3mo, or PET-CT, or Bx/resect
79
Ground glass or part solid nodule: f/u schedule
1. \< 6mm: no follow up for high or low ris
2. 6-8mm: CT in 3-6mo for both high and low risk
80
FEV1 in COPD, asthma, restrictive lung diseases, bronchitis, etc
**decreased** in **all** lung diseases
81
FEV1/FVC abnormality in lung diseases
**decreased** in all obstructive diseases
**normal** in all restrictive lung diseases
82
DLCO in lung diseases
**low** COPD and intrathoracic restrictive dx
**normal** in all other obstructive and extrathoracic restrictive dz
83
Residual volume is low in what type of lung disease?
**low** in intrathoracic restrictive lung dz
**high** in all other lung dz
84
DLCO, TLC, and FEV1/FVC values in pulmonary embolism
1. DLCO low
2. TLC and FEV1/FVC are normal
85
DLCO is well above normal. Possible etiologies?
1. alveolar hemorrhage
2. CHF
3. PDA/ASD/VSD
4. polycythemia
86
best discriminative tests to look at to diagnose type of lung disease?
TLC: distinguishes obstructive from restrictive
DLCO: low only in COPD and intrathoracic restrictive, nl in all others
87
both inspiratory and expiratory flow loops blunted in what conditions?
extra thoracic, fixed obstruction
e.g. tumors and **tracheal stenosis**
88
normal expiratory but blunted inspiratory flow loop: etio?
Blunted bottom (inspiratory) loop
dynamic extrathoracic obstruction
e.g. **vocal cord dysfunction** or epiglottitis
89
normal inspiratory but blunted expiratory flow loop: etio?
blunted top (expiratory) loop
dynamic intrathoracic obstruction
e.g. tracheomalacia
90
FEV1 increase or decrease with asthma diagnostic challenge
bronchodilator challenge: 12% improvement
methacholine challenge: 20% worsening
91
Pt with respiratory symptoms at work, but is fine at home and on weekends. Maybe problems with manager accused of sluffing work. wtd
peak flow at work and at home
92
With poor asthma control, wtd?
check technique and compliance before stepping up therapy
93
Leukotriene use trends and why
Less monteleukast use d/t psychosis, hallucinations, etc. Has black box warning
94
Pt with vasomotor rhinitis, gets polyps then asthma. dx, rx
dx: likely ASA induced asthma. rx: stop asthma, start ICS. Used to be answer was start Monteleukast, but this is less so now d/t side fx
95
Asthma sx \< 2days/wk and \<2 nights/mo. rx?
prn ICS-SABA; no need for daily meds
96
Asthma sx up to 5-6x/week or \>2 nights/mo. rx?
daily low dose ICS-SABA, may also add theophylline, Monteleukast
97
Asthma daily sx or \> 1 night/week
med dose ICS-LABA, may also add monteleukast or theophylline
98
Asthma: continuous symptoms
high dose ICS-LABA, may add daily oral steroids
99
post viral hypersensitivity with cough at night and chest tightness. rx
ICS (budesonided)
100
Pt with inspiratory wheeze, cough during day, no sx at night. Asthma therapies are ineffective. dx?
vocal cord dysfunction (inspiratory rather than expiratory wheeze, no sx at night (not talking)).
flow loop = extrathoracic airway obstruction
101
Asthma poorly controlled on max therapy. Triggers have been eliminated. Doesn't want oral steroids. IgE level high. wtd?
omalizumab
102
Asthma poorly controlled on max therapy. Triggers have been eliminated. Would like to wean oral steroids but can't due to return of sx. Eos high. wtd
Dupilumab (IL-4 inhibitor)
103
Asthma pt on ICS-LABA well controlled, no sx. wtd
May step down therapy after **3mo** no sx.
104
Pt with hx of CF or asthma previously well controlled. Now with cough, fever, wheeze; normal medications not effective now. Brown flecked mucus. High eos, high IgE. Migratory patchy lung infiltrates. dx? rx?
dx: ABPA
rx: steroids with itraconazole
105
hypersensitivity pneumonitis vs ABPA labs to differentiate
ABPA: high eos and IgE
pneumonitis: nl eos and IgE
106
Pt with hx TB, sarcoid or COPD. May be asx or have hemoptysis, chronic cough wt loss. CXR with air around a fungus ball. dx? rx?
dx: aspergilloma
rx: if asymptomatic, don't treat; if hemoptysis and seriously ill, get surgery
107
Pt with hx of being very immunosuppressed/neutropenic. Dry cough or hemoptysis, pleuritic CP, sweats, fever. Glactomannan assay +. CXR or CT shows wedge lesion (tissue infarct) or necrotic nodule with surrounding hemorrhage (halo sign). dx? rx?
dx: invasive aspergillosis
rx: voriconazole
108
Farmer or bird keeper, exposure to air conditioner mist. Fever, chills, cough, SOB. Eos and IgE nl or not mentioned. Migratory lung infiltrates. BAL CD8 \> CD4. dx? rx?
dx: hypersensitivity pneumonitis
rx: steroids (pt may have failed abx treatment for misdiagnosis of PNA.)
109
Pt with fever, cough, pleuritis, SOB, maybe pharyngitis; may be mild and subacute “walking PNA”. Maybe birds in hx. Rx with abx for typicals not effective. Mycoplasma and legionella serology negative. dx? rx?
dx: Chlamydia PNA.
C pneumoniae is person to person spread. C psittaci has birds in hx. C trachomatis is vertical transmission
rx: azithromycin
110
Pt from Latin America with asthma previously well controlled. Now with cough and wheeze. Eos high. Infiltrates in lung. dx? rx?
dx: strongyloides infection (Loeffler syndrome)
rx: thiabendizole
111
Eosinophilic PNA noninfectious causes
1. idiopathic
2. medication/toxin induced
3. APBA
4. Churg-Strauss
1. smoking or malignancy
112
Eosinophilic PNA infectious causes
Typically are parasites
1. Strongyloides
2. Ascaris
3. filarial nemotodes
1. hookworms
113
35y F hx asthma and smoking. Fever, cough, SOB. Eos in BAL maybe in blood. CXR with diffuse GGO. dx? rx?
dx: idiopathic acute eosinophilic PNA (seen more in young women, smokers, asthma)
rx: steroids
114
55 y M nonsmoker; cough, fever, SOB, no sputum. CXR peripheral infiltrates. High ESR and Eos in blood. Eos in BAL. Anemia may be present. BCx negative. dx? rx?
dx: chronic eosinophilic PNA
rx: steroids, looong taper
115
22y M recurrent PNA and bronchitis since childhood. No allergies or GERD. Unable to have children. Slender body habitus and nasal polyps. Some GI malabsorption. Hx pancreatitis. CXR with apical bullous changes. dx? screen test? what increases mortality and decline in lung fx?
dx: CF
screen: sweat chloride; confirm with CFTR
incr mortality: Burkholderia species
116
Bronchiectaisis, sinusitus, infertility, situs inversus
dx? screen test?
Dykinetic cilia syndrome (Kartagner's)
screen with: inhaled nitric oxide test, confirm with Bx
117
Causes of bronchiectasis
1. Hypogammaglobulinemia
2. Genetic: CF, A1AT, or Kartagner's
3. autoimmune disease
4. recurr PNA
5. ABPA
118
58y F chronic/recurrent cough, foul smelling sputum, some hemoptysis. Hx PNA. Streaking opacities in bronchial tree “tram lines”. dx?
dx: bronchiectasis: dilation and destruction of bronchi with sputum production
dx with HRCT
119
60y M hx lung transplant or HSCT. Chronically progressive dyspnea and cough, no sputum. No asthma or allergies. May have viral URI or inhaled toxin in past. CXR normal. PFT: obstructive, not reversible. A1AT normal. dx?
dx: bronchiolitis obliterans
also a/w autoimmune dz, and RSV in kids
120
High altitude sickness, SOB, pulmonary edema. wtd?
altitude sickness
give O2, bring down to lower altitude
121
Planned ski trip. Pt has hx of altitude sickness. wtd?
altitude sickness prevention
acetzolamide
122
40y M became acutely ill, initial flu-like sx now with PNA sx but no sputum. Possible toxic fume inhalation. Bilateral, patchy migrating infiltrates. Abx didn't help. Some wt loss. dx? rx? bx finding?
dx: COP (50% are idiopathic)
rx: steroids
bx: granulation tissue plugs, interstitial inflammation, lung architecture maintained
123
Middle aged African American female, tender bruise-like lesions on shins, bilateral hilar LAD, CD4\>CD8 on BAL, bx with noncaseating granulomatous disease. Ca++ may or may not be elevated. dx? rx?
dx: sardoid
rx: self resolution in majority of cases
124
Indications for treatment in sardoidosis (6)
Rx for sarcoidosis
1. progressive pulm disease
2. eye involvement
3. CNS involvement
4. myocardial involvement
5. persistent hypercalcemia
6. disfiguring lesions
7. Rx: steroids
125
Sarcoidosis
1. lung disease pattern
2. tests to get (4)
3. test not to get (1)
4. serum lab results (2)
Sarcoidosis
1. lung dz pattern: restrictive usually (may be normal)
2. tests: Bx, CXR, EKG, eye exam
3. test not to get: ACEi level
4. serum labs: leukopenia, elevated ESR
126
Sarcoidosis tests to rule out things on the differential (3)
Sarcoidosis tests to rule out other things because can present with fever, weight loss, cough
1. r/o malignancy
2. TB
3. fungal pulmonary dz (histo, coccidio, etc)
127
Procedure for bx in sarcoidosis
EBUS with FNA of LN if no other palpable LN or rash is available
128
Uveitis, parotid gland enlargement, facial palsy, fever. Dx?
Heerfordt syndrome, a rare subtype of sarcoidosis
129
Interstitial lung disease, ILD (aka diffuse parenchymal lung disease DPLD)
known causes
1. Occupational/expsoure: hypersensitivity pneumonitis, asbestosis, berilyosis, silicosis
2. XRT/drugs: amio, macrobid, amphotericin, chemo drugs
3. Granulomatous disease (sarcoid)
4. Connective tissue dz (SLE, RA, scleroderma)
5. Vasculitis (GPA, eGPA)
130
Interstitial lung disease, ILD (aka diffuse parenchymal lung disease DPLD)
Idiopathic causes
1. IPF (UIP)
2. NSIP
3. COP
4. AIP
5. Lymphangiolieomyomatosis
131
Premenopausal woman on OCP, sudden onset SOB, PNX, honeycomb appearance on lungs (many thin walled cysts) but no LAD on HRCT, pleural effusions are chylous. CBC and CMP normal. dx? rx?
dx: lymphangioleiomyomatosis: often estrogen related, smooth muscle proliferation
rx: bronchodilators, pulm rehab, sirolimus
132
Male with SOB, hx sandblasting or stone work. Upper lobe fibrosis, hilar LAD, egg shell calcifications. dx? a/w?
Rx: Silicosis
a/w: TB, rule it out; get the PPD or other test
133
Male with SOB and dry crackles, hx working with brake pads, roofing products, shipbuilding, fire-proof clothing or something like that. Pleural effusions. Calcified plaques on diaphragm and pleura. eosinophils in effusion dx? a/w
asbestosis
a/w: lung cancer, mesothelioma; smoking is synergystic
BAPE: pleural plaques present in 90% of cases, pleural thickening 30%, asbestosis was present in 5%
134
Radiographic features of ILD (UIP
1. bibasilar reticular patchiness/fibrosis
2. honeycombing
3. traction bronchiectasis
4. overall heterogeneous patchy disruption of lung tissue
135
Signs and sx of ILD
1. slow chronic progression with SOB
2. dry cough and dry crackles
3. clubbing present usually
4. restrictive pattern of lung disease: low FEV1, DLCO, TLC, RV, nl FEV1/FVC
5. not responsive to steroids (fibrotic, not inflammatory dz)
6. typically no extrapulmonary sx
136
NSIP vs ILD
NSIP: patients are younger, onset subacute not chronic, responsive to steroids, is a/w HIV, connective tissue or rheumatologic disease
radiographically they are similar
137
Characterize S1Q3T3
rare but specific sign in PE
S wave in I, Q wave in III, and inverted T in II
138
Swollen, tender calf, HR 80, wtd?
Duplex US
139
SOB, dry cough, elevated JVP, lungs clear BP 80/60, HR 120, S1Q3T3. wtd
Suspect PE. Get bedside echo. pt is too unstable for CT
140
Best test for chronic PE
V/Q scan best for CHRONIC PE
141
Rx for HD stable PE patient
provoked and unprovoked
heparin product 5 days then warfarin or start doac (no bridge)
provoked: 3mo; unprovoked 6mo reassess if low risk of bleeding then indefinitely
142
Rx HD unstable PE patient
tPA, then assess for thromboletomy if no bleeding.
143
Contraindications to catheter-based thrombolysis in PE
1. active bleeding
2. recent CVA or TIA
3. recent neurosurgery
4. recent intracranial trauma
144
ECHO findings suggestive of PE/massive PE
* RV dilation
* RV free wall hypokinesis w apical sparing (McConnell sign)
* Interventricular wall septal flattening
* TR
* pHTN
* RV
145
EKG signs of PE (most are fairly nonspecific)
* sinus tach
* atrial arrhythmias
* new RBBB
* S1Q3T3
* TWI in V1-V4
146
Pt with IVC filter. wtd most of the time if possible?
take it out
147
44y M with new fever, AMS, SOB, petechiae over the chest, sinus tach; hx of femur frx 4 d ago. Dx? Rx?
Fat embolism (SOB is d/t pulm edema)
supportive care: no AC, no steroids
148
28y F post delivery becomes hypotensive, tachycardic, SOB. Dx?
aminotic fluid embolism
149
Pt with pain and swelling in posterior aspect of leg. Exam shows tender indurated cord several cm long. wtd?
US duplex. Possible SVT (palpable cord); compression stockings and NSAIDs.
150
Thrombosis in superficial femoral vein, popliteal, or peroneal vein. wtd
AC with NOAC. Even though these may have “superficial” in the name or appear superficial, they are in fact deep and need to be treated.
151
Pt with SVT in UE provoked by PICC or midline. wtd?
no AC, supportive care; warm compress
152
Pt is s/p knee replacement or hip or acute orthopedic fracture. wtd at discharge?
Up to 70% risk DVT!
ppx against DVT w/ LMWH, wafarin, or DOAC
not ASA
153
PNA
* MCC
* what to suspect in younger pts
* older patients
* COPD/DM
* necrotizing PNA or post flu PNA
PNA
* MCC: strep pneumoniae
* younger pts: mycoplasma, H flu
* older pts: legionella (GI sx and low Na)
* COPD/DM: moraxella catarrhalis
* necrotizing/post flu: Staph PNA
154
Good sputum sample labs
\< 10 epithelial cells, \> 25 WBCs
155
URI sx for more than 10d. Rx with doxy, no improvment. Now with cough and post-tussive vomiting. Pt has subconjuntival hemorrhage. dx? rx?
Bordatella pertussis; dx with sputum PCR
rx: Macrolide: either erythro, azithro, or clarithro
156
Pt with lobar PNA, treated appropriately. 6 weeks later, still with cough and consolidation persists on XR. dx?
Suspect malignancy. PNA consolidation should resolve after 6 weeks.
157
URI sinusitus
when to abx? what abx?
when to image?
abx: sx \> 10d or fever or pain \> 3d; augmentin (not single agent)
imaging: not routinely recommended to diagnose
158
When to admit for PNA?
when to admit for PNA?: CURB-65
* confusion
* uremia
* RR \> 30
* blood pressure low?
* 65 yo or older
* +2 pts: admit; +3 points ICU
159
Strep diagnosis scoring
strep scoring: CENTOR
* Fever +1
* exudate +1
* absent cough +1
* cervical LAD +1
* age 3-14 +1
* age \> 44 yo -1
* 0-1 no rx; 2-4 rapid strep or 3-4 treat empirically
160
Pt with sore throat initially, now with severe pain when moves neck, pain on swallowing. Brawny edema of the hypopharynx on exam. TTP of the sternocleidomastoid. dx?
IJ vein thrombosis (Lemierre's dz)
get CT scan neck w contrast
161
50y M mouth pain, fever, difficulty swallowing, muffled voice. Drooling and secretions and stiff neck with woody induration of the hypopharynx. dx? rx?
**Ludwig angina** (stiff neck, woody induration is specific; submental and submandibular swelling “bull neck”)
**unasyn or zosyn**: etio is usually infxn of lower molars
162
24 y sore throat, muffled voice, fever, difficulty opening mouth and swallowing; unilateral pain in throat; cervical LAD. Drooling with deviation of the uvula. dx? etio?
dx: peritonsilar abscess (uvular deviation is specific)
etio: usu unilateral ear infection
163
40 y pt with hx of URI. Now sudden onset worsening. Pt appears sick/distressed, tripoding, mouth open. Sore throat, painful swallowing, drooling, stridor/resp distress possible, + LAD. dx? etio?
dx: **epiglottitis** (lateral XR: thumb sign)
etio: strep or H flu
164
Pt with runny nose, congestion, several months; itchy eyes, sore throat possible. Swelling below the eyes. Cobblestone appearnce of posterior pharyngeal mucosa. No LAD. dx?
allergic rhinitis. (cobble stoning is specific)
165
Pt with nasal congestion and runny nose several months. Hx of allergies, treated nasal decongestants and antihistamines. Use of OTC meds evenually made things worse. Edematous and erythematous mucosa and nares. dx? rx?
dx: rhinits medicamentosa
dx: stop vasoconstrictors, start intranasal steroids
166
Side fx of floroquinolones (4)
* GI sx are most common
* Connective tissue weakness: tendon rupture, aortic dissection/aneurysm
* hypoglycemia esp in elderly
* seizures
167
Pt with Klebsiella or E coli PNA. Rx with CTX, patient gets better Bcx negative and afebrile. Four days later new fever, Bcx positive. wtd?
Start meropenem for ESBL bacteria that survived the CTX
168
Elderly pt with fever, cough, diarrhea, CXR with RLL infiltrate. Sodium 130. Treated with Vanc and Cefepime, but condition worsens. wtd?
rx with Azithromycin as Vanc and cefepime don't cover atypicals like Legionella.
Levofloxacin does cover atypicals
169
HIV pt with sudden onset SOB and hypoxia. CXR show PNX. Chest tube inserted. wtd next?
give Bactrim and steroids for PJP ppx
170
Acutely ill pt with PNA and is intubated. Sputum Gram stain shows lancet shaped diplococci. High WBC and high fever. Pt is treated with PCN, and WBC is improving and fever is gone. Secretions from ETT grow Pseudamonas. wtd?
Keep rx with PCN since patient is improving. If failure to improve then change abx.
Gram + lancet shaped diplococci: Strep pneumo
171
If pt is treated for PNA with abx and is improving, and later BCx grows MSSA or MRSA, wtd?
continue same rx if pt is improving; BCx results likely contamination
172
Pt with parapneumonic effusion of upright XR. next 2 steps?
1. lateral decub XR
2. if effusion \> 10mm get pleural tap
173
PNA being treated with appropriate abx. Parapneumonic effusion is \>10mm and is therefore tapped. pH \< 7.2. dx? rx?
dx: empyema
rx: chest tube
174
Pt with parapneumonic effusion (pH \< 7.2) has appropriate abx and chest tube but not improving, still spiking temps etc. dx? rx?
dx: likely loculated effusion
rx: intrapleural tPA/dnase to break up loculations
175
Pt with seizure or alcoholic and later has upper lobe infilatrate and PNA symptoms. MCC?
aspiration PNA: peptosteptococcus (anaerobic Gram +)
176
Pt with seizure 1 mo ago or some other condition that impairs mental status. Now with foul smelling sputum. On XR there is infiltrate in RUL and a cavity with air fluid level. Sputum shows mixed flora. dx? rx?
dx: lung abscess
rx: PCN + CLINDA
177
Antibiotic with no activity in lung?
dapto
178
25 y M ear ache fever, cough. Inflammed tympanic membrane with hemorrhage. Patchy infiltrate on XR. dx? rx?
dx: hemorrhagic myrigitis d/t mycoplasma
rx: macrolide (azithromycin)
179
35 y pt nonsmoker with gradual onset cough, mild occasional fever. Mostly able to function but still sick and tired. Going on for weeks. XR: bilateral infiltrates. dx? rx?
dx: atypical PNA
rx: macrolide
180
Bullae/vesicle on tympanic membrane. Ear pain like AOM. No ear canal involvement. No middle ear involvement. dx? etio?
Bullous myringitis. Often cause by viruses or mycoplasma
If middle ear is involved, then it is AOM
181
MCC PNA
MCC PNA in COPD pts
MCC: strep pneumo
MCC COPD: H flu
182
Pt with UTI on nitrofurantoin. Now with SOB and fever. Crackles at lung bases. XR shows GGO. dx?
nitrofurantoin induced lung injury (hypersensitivity pneumonitis) also caused by rituximab
183
Post flu PNA. rx?
cover for staph!
184
Pt comes from NH with cough, sore throat, myalgia, fever. Had flu shot. Rapid flu test negative. wtd?
**Oseltamivir** even if vaccinated and even if rapid test is negative if clinical suspicion is high
185
Influenza outbreak in NH. wtd?
vaccine and oseltamivir for 2 weeks (takes 2 weeks for vax to kick in) for **everyone** regardless of sx.
186
Age to initiate flu vax?
6mo
187
Pt from SW USA with fever and painful lesions on shins. XR with lung infiltrates and thin walled cavities. dx? rx?
dx: Coccidiomycosis
* rx: monitor if self contained
* fluconazole for immunocompromised
* disseminated infection gets amphotericin
188
Coxackie symptoms, types, and what they cause
Sx: viral prodrome including GI sx and or URI; both can cause hand-foot-mouth dx
Coxackie A: flaccid paralysis
Coxackie B: pericarditis (reduced EF), pleurodynia (CP, SOB, no infiltrate)
189
Pt from south central or midwest. Cough, fever, SOB, chest pain. Leisons on skin, balls, bones. XR: fibronodular infiltrates. Broad based budding on culture. dx? rx?
Blastomycosis. May be asx. Progression/disseminated dz common and rapid in immunocompromised.
rx: itraconazole for symptomatic dz
190
TB 5mm positive test in who?
* HIV
* recent contact
* immunosuppressed
191
TB 10mm positive test in who?
* homeless
* foreign born
* NH pts
* IVDU
* Silicosis, DM, ESRD
192
TB 15mm positive test in who?
everybody including those who had BCG vax
193
PPD positive. wtd next?
CXR
194
PPD +, CXR shows an opacity, but pt has no cough. wtd?
induce sputum to r/o active dz
195
Rx for pt who is PPD + but clear XR and no sx?
INH (and B6) plus rifapentine 3mo
or
INH (and B6) plus rifampin 4 mo
196
Pt on INH two months, gets fatigue and nausea, possible pruritis. wtd?
stop INH, get liver enzymes. INH has black box warning about LIVER TOX.
197
Close contact with TB pt. but PPD is negative. wtd?
retest in 6-8 weeks
198
Pt from eastern Europe has cough, fever. Pleural effusion is tapped. what test to get?
Pleural fluid adenosine deaminase test to dx TB causing the effusion
199
Pleural effusion, Light's criteria
Light's criteria: fluid is exudative if any of the following
* fluid/serum protein \>0.5
* fluid/serum LDH \> 0.6
* fluid LDH \> ⅔ ULN
200
Chest tube requirements (3)
Chest tube requirements: EMPYEMA diagnosis
* pH \< 7.2
* glucose \< 40
* Gram stain +
201
Hemothorax criteria
fluid hct \> 50% serum hct
202
pleural fluid glucose \< 30: likely cause of effusion?
Glucose \< 30 etio of effusion?
RA
203
Pleural effusion TG \> 110, likely etio?
Chylous effusion: TG \> 110
etio: lymphoma or lymphangioleimyomatosis
204
Pleural fluid with \> 10% eos. etio?
Pleural fluid with \> 50% lymphocytes. etio?
eos: asbestosis, BAPE, Churg-Strauss
lymphocytes: TB or malignancy
205
MCCs of transudative effusions (4) ?
HF (except after intense diuresis)
Cirrhosis
nephrotic syndrome
PE
206
pathophys of transudative effusion
pathophys of exudative effusion
transudative: high hydrostatic or low oncotic pressure
exudative: excess fluid production, capillaries leaky, bad lymphatic drainage
207
Common iatrogenic causes of effusion?
* **pacemaker placement** → thoracic duct injury → chylothorax
* **postcardiotomy syndrome** with friction rub and exudative effusion
208
best way to distinguish PNX from PNA or effusion?
percussion. PNA and effusion is dull, PNX is hyperresonant
209
Pt with cirrhosis, ascites and peripheral edema. Pt gets SOB when standing. On exam, PO2 is 92% when lying but 82% when sitting or standing. DLCO 70%. dx? physio?
dx: hepatopulmonary syndrome
physio: intrapulmonary R → L shunting
210
Pt with worsening SOB, dullness in R hemithorax. CXR with pleural effusion causing lung collapse. After thoracentesis there is no expansion of the lung. dx?
nonexpandable lung (trapped lung)
can be d/t bronchial obstruction, chronic atelectasis, visceral pleural restriction
211
Pt with CABG 6mo ago, now with new SOB when lying esp with left lateral position, morning HA. CXR shows elevated L hemidiaphragm. test to screen?
phrenic nerve damage during CABG
do floroscopic sniff test to screen/dx
212
Pt with hallucinations with sleep onset, falls at suprising stimuli, daytime sleepiness. dx? rx?
narcolepsy
modafinil, also dc alcohol, opiates, antisphychotics
213
Pt with CHF and daytime sleepiness. Apneic periods during sleep. dx?
central sleep apnea
214
polysomnography criteria for apnea
criteria for increase mortality d/t apnea
apnea criteria
no breathing for 10 sec or \>10 apenic episodes/hr
incr mortality: apnea/hypoxia index \> 30
