Final Flashcards
(136 cards)
1
Q
Who are head and neck cancers most common in
A
Males 50-60; higher incidence of death in black men
2
Q
What is trismus
A
Inability to open jaw from compression of trigem n or muscle invasion by tumor
3
Q
What is the clinical presentation of head and neck cancer
A
Choking, trouble swallowing, trismus, ear pain, weight loss
4
Q
What must you assess before beginning treatment for head and neck cancer
A
Nutritional and performance status
5
Q
What occupational exposures put people at risk for lung cancer
A
Uranium miners, coal tars, nickel, arsenic, mustard gas, petrochemical exposure (oil field workers), second hand smoke
6
Q
What is another name for pancoast tumor
A
Superior sulcus tumor; paresthesias along C7 or T1 dermatome
7
Q
Besides clubbing, what else presents with hypertrophic pulmonary osteoarthropathy
A
Furrowing of the brow
8
Q
What is the diagnostic procedure of choice for lung cancer detection
A
CXR; can detect primary lesions, LN met if >2cm, serial helpful in trying to evaluate nodular densities
9
Q
When is a CT performed for lung cancer
A
To evaluate suspicious CXR for bronchogenic CA; helps evaluate mediastinum, LN, parenchyma and vertebral bodies
10
Q
When is a PET scan useful for lung cancer diagnosis
A
When fused with CT, gives higher predictability for cancer vs benign dz
11
Q
When is bronchoscopy required
A
In any patient in whom curative resection is being considered
12
Q
What is a mediastinoscopy
A
Allows for evaluation of mediastinum for direct tumor extension and for obtaining LN; valuable for planning of surgical resection
13
Q
What is fine needle aspiration
A
Done with either plain radiograph or CT guidance; *procedure of choice for peripheral lung lesions; risk of pneumothorax
14
Q
What is the staging for lung CA
A
- stage 1: no more than 5 cm and has not spread to LN
- stage 2: no more than 7cm and may have spread to nearby LN
- stage 3A cancer extends into surrounding tissue and spread to LN on same side of tumor
- stage 3B: 2 or more primary tumors present and that cancer spread to LN on opposite side of chest
- stage 4: cancer spread to form new tumors in other parts of body
15
Q
What is the staging for small cell lung cancer
A
- limited dz: tumor confined to one hemithorax and involved LN (encompassed in one radiation field)
- extensive: dz outside of above regions
16
Q
What are the differences of pneumothorax vs pleural effusion on exam
A
Hyperresonant percussion in pneumothorax and dull in pleural effusion; no change of breath sounds with position in pneumothorax, but can change with effusion
17
Q
What are the components of an exudate
A
Pleural protein/serum protein > .5, pleural LDH/serum LDH >.6, pleural fluid LDH > 2/3 upper limit of serum LDH
18
Q
What are the causes of pleural effusion with low pleural glucose
A
Parapneumonic effusion, malignant effusion, TB, hemothorax, rheumatoid arthritis
19
Q
What can cause a lymphocytic effusion (>50%)
A
Malignancy or TB
20
Q
What are the causes of transudate pleural effusions
A
LVF or CHF, misplaced central line, massive cirrhosis, nephrosis
21
Q
What can be done to manage chronic pleural effusions
A
PleurX catheter: indwelling catheter in pleural space allowing for at home drainage
Pleurodesis: closes potential space btw parietal and visceral pleura; Talc or tetracycline
22
Q
What are the 4 Ts of the anterior mediastinum
A
Thymoma, teratoma, thyroid masses, terrible T cell lymphoma (an also have B cell or Hodgkin lymphoma)
23
Q
What are the middle mediastinal masses
A
Vascular, adenopathy, cysts (pleuropericarial or bronchogenic)
24
Q
What are the posterior mediastinal masses
A
Neurogenic tumors, meningoceles, meningomyeloceles, gastroenteritis cysts and esophageal diverticulum
25
Where is the CFTR gene located
Chrom 7
26
What kind of glands does CF affect
Exocrine (secretes via ducts, over target and into epithelial surface - endocrine is ductless and secretes hormones into blood or LN)
27
What is an example of a modifier gene in CF
mannose binding lectin - reduced amounts are association with increased rates of bronchiectasis
28
What are common infections in kids with CF
Staph aureus, Haemophilus influenzae and pseudomonas
29
What is cheilosis
Cracks in the side of the mouth; caused by B deficiency (CF)
30
What is the criteria for diagnosis of CF
One or more of: chronic sinopulmonary dz, characteristics GI and nutritional abnormalities, salt loss syndromes, azospermia, hx of CF in sibling, positive newborn screening
PLUS elevated sweat chloride on 2 or more occasions OR identification of mutations in CFTR OR abnormalities in nasal potential difference
31
What is the neonatal screen for CF
Tests for immuoreactive trypsinogen (pancreatic protein) if positive repeat and do sweat chloride or DNA testing
32
What is pulmozyme
Mucolytic
33
Does COPD or asthma have a chronic productive cough
COPD
34
What cells are involved in COPD
CD8; LTB4, IL-8, TNF
35
What does a vocal cord dysfunction look like on spirometry
Truncated inspiratory loop
36
When is ipratropium used for asthma attack
Within first 2 hours of attack its albuterol
37
What are long term control asthma meds
ICS, inhaled LABA, cromolyn and nedocromil (mast cell stabilizers), inhaled long actin anticholinergic (Tiotropium), leukotriene modifiers, methylxanthines, immunomodulators
38
What are the signs of respiratory arrest in children
- breathlessness while at rest; mute
- doesn’t talk
- drowsy or confused
- resp rate >30/min
- unable to recline
- paradoxical thoracoabdominal movement
- absent wheeze
- bradycardia
- no pulsus paradoxus
- FEV1 <25%
- PaO2 <60
- PCo2 > 42
- SaO2 <90
39
What is the classification for intermittent asthma
Sx < 2 days a week, nighttime awakening < 2 times a month, use of SABA <2 days a week, no interference with normal activity, normal FEV1 btw exacerbation, FEV1>80% of predicted, FEV1/FVC normal; 0-1 exacerbation needing oral systemic corticosteroids
40
What are the 3 components of cardiopulmonary arrest
Respiratory, cardiac (pump), circulatory volume
41
What does the demeanor of a child suggest
- restlessness, anxiety, combativeness: hypoxia
| - somnolence or lethargy: severe hypoxia, hypercapnea, or resp fatigue
42
Why do children in respiratory distress grunt
Attempt to maintain airway opening
43
What can cause a complete upper airway obstruction
Foreign body, angioedema, epiglottitis; no cry or speech
44
What can cause a partial airway obstruction
Will hear stridor; foreign body, croup, injury
45
How do retropharyngeal and peritonsillar abscesses present
Sore throat, trouble swallowing, swelling; hoarse voice (hot potato voice), ENT urgency -> emergency
46
How does croup present
STRIDOR
47
What infectious agents cause bronchiolitis
RSV, parainfluenza, adenovirus; kids <2; URI sx -> wheezing/atelectasis
48
How do lower foreign bodies present
Delayed sx recurrent pneumonia and chronic cough
49
How can CNS dz lead to respiratory distress in kids
Neuromuscular - chronic hypoventilation, infectious, trauma, medication effect
50
What are causes of pulmonary edema in kids
Chemical pneumonia, drowning, secondary to airway obstrution, medication toxicity
51
What systemic diseases can cause resp distress in kids
Hyper or hypothyroidism can cause m weakness, metabolic dz
52
How can sickle cell cause respiratory distress
Acute chest syndrome; sudden onset resp distress, new infiltrate on CXR, fever
53
How do you evaluate interstitial lung dz
Chest CT, PFT, ANA and rheumatoid factor
54
How can scleroderma affect the lung
Pulmonary fibrosis, pulm HTN, aspiration (esophageal dz)
55
How can RA affect the lung
Interstitial pulmonary fibrosis, bronchiectasis, pulmonary rheumatoid nodules, pulm Vasculitis, pleural dz
56
How can SLE affect the lung
Interstitial lung dz, extrapulmonary restriction (shrinking lung syndrome), pulm HTN, pleural dx
57
What autoabs are seen in scleroderma
Anticentomere; SCL-70 (more common in ILD), antinucleolar (worst prognosis)
58
What drugs can induce lung dz
Chemo, amiodarone, nitrofurantoin (abx for UTI)
59
What is the acute vs chronic form of hypersensitivity pneumonitis
Acute: abrupt onset of dyspnea, cough, fever, myalgia, CXR pulm infiltrates
Chronic: pulm fibrosis
60
What are the similarities btw ILD and CHF presentation
Progressive dyspnea, exercise induced hypoxemia, CXR have similar infiltrates; exam: crackles in bases, pulm HTN
61
What are the differences btw presentation of ILD and CHF
History, CXR and CT have specific differences, exam: clubbing, edema, S3 gallops in CHF
62
What is the diff btw ILD and COPD
ILD has a more rapid decline with a nonproductive cough; COPD has more frequent exacerbations, western and NSAIDs worsen it and have a productive cough
63
How do you treat ILD
Remove etiology, corticosteroids for non-IPF causes, pirfenidone (antifibrotic and antiinflammatory)and nintedanib (TK inhibitor) ONLY for IPF
64
What is hamman-rich syndrome
Acute interstitial pneumonia; diffuse symmetrical b/l infiltrates
65
How is IPF diff from AIP
IPF relatable to prior cause, pattern is asymmetrical and favors upper or lower lobes, gradual onset, afebrile, dx made by history, imaging, PFTs (biopsy optional)
66
What is the diff btw CXR and CT findings with sarcoidosis
CXR symmetrical; CT not
67
How do you treat sarcoidosis
Prednisone
68
Which type of COPD patient is CO2 responsive
Pink puffer; compensatory hyperventilation
69
What are the systemic affects of COPD
Ischemic heart dz, cardiac failure, osteoporosis, diabetes, normocytic anemia, depression
70
What is the medical research council dyspnea scale
0: only breathless with strenuous exercise; points = 0
1: only get short of breath when hurrying on ground level or walking up slight hill; points =0
2: on level ground, walk slower than people of same age because of SOB, or stop to breathe when walking at own pace; points =1
3: stop after walking 100 yards or after few min on level ground points = 2
4: too breathless to leave house or breathless when dressing points=3
71
What is the BODE index for COPD survival prediction
-FEV1 after bronchodilator: >65% 0 points, 50-64 1 point, 36-49 2 points, <35 3 points
-6 min walk distance: >350 meters 0 points, 250-349 1 point, 150-249 2 points, <149 3 points
-BMI: >21 0 points, <21 1 point
Add all together: 0-2 points 80% 4 year survival, 3-4 67%, 5-6 57%, 7-10 18%
72
What are the reasons for dyspnea in COPD
Increased dead space which increases PaCO2, altered V/Q leading to hypoxemia, airflow obstruction, reduced mechanical advantage of diaphragm *hoover sign
73
What is the suffix for inhaled corticosteroid
-asone or -ide
74
What is respimat
Propellant free liquid inhaler that makes a loud; pro air, spiriva, stiolto
75
What are the PDE4 inhibitors
Roflumilast and daliresp
76
What can you give to patients with COPD who are <65 and have an FEV1 >50%
Doxycycline (macrolides), trimethoprin-sulfamethoxazole, cephalosporin, advanced macrolides (-omycin)
77
What abx do you give to sicker and older patients with COPD
Amoxicillin-clavulunate; fluoroquinolones
78
What are the indications for supplemental oxygen in COPD
PaO2<56 or SpO2 <89 measured twice over 3 weeks; OR PaO2 >56 but <60 any time with evidence of pulm HTN, CHF, or erythrocytosis (Hct >55%)
79
What is the GOLD stepwise approach
- GOLD I: mild dz; SABA or SAMA prn
- GOLD II: moderate dz; LABA or LAMA
- GOLD III: severe dz; ICS + LABA + LAMA *NEVER USE ICS ALONE IN COPD; with or without roflumilast or theophylline
- GOLD IV: very severe dz; ICS + LABA or ICS + LAMA or ICS + LAMA + LABA with or without roflumilast or theophylline
80
What are the components of pulmonary rehabilitation
Exercise training (intensity and duration matter), education, psychosocial training and support, nutritional support, breathing training, inspiratory m training, chest PT, vaccination (influenza and pneumococcal)
81
What is medication induced pulm HTN
Fen-phen: obesity treatment
82
What is the characteristic XR findings o a patient with pulmonary arterial HTN
Peripheral hypovascularity, prominent central pulm artery, RV enlargement
83
What is the classic PFT seen in pulm HTN
Normal PFT except isolated reduction in DLCO
84
What are the classifications of pulm HTN
- group 1: idiopathic
- Group 2: heart
- group 3: lung
- group 4: pulmonary emboli
- group 5: everything else
85
What are the similarities and differences btw pulm HTN and ischemic heart dz
Similarities: both have exertional dyspnea, similar lack of associated sx, BNP elevated
Difference: increased P2 in PAH
86
What tests do you do for pulm HTN
6 min walk test at diagnosis and periodically, serial testing: echo and right heart cath
87
What are some history clues to point in the direction of obstructive sleep apnea
Impaired daytime attention (MVAs, difficulty with memory, sleepiness), snoring, witnessed apnea, mood alterations (*obese patients with depression)
88
What are some complications of obstructive sleep apnea
More likely to develop cancer or have a CVA
89
What are some lifestyle modifications that can improve OSA
If obese, lose 10% of body weight, avoid EtOH and sedatives 3-4 hours before bed, lateral decubitus sleeping, intranasal steroids or decongestants
90
When do you implement the use of CPAP
If lifestyle modifications dont improve sx
91
How does CPAP work
Props airway open; increased intraluminal airway pressure and FRC
92
What is the diff btw CPAP and BiPAP
BiPAP has separate pressures for inspiratory and expiratory phases more comfortable
93
What oral devices can be used for OSA
Mandibular assist device; pulls jaw forward
94
What surgery can be done for OSA
Uvulopalatopharyngoplasty (UPPP)
95
What is obesity hypoventilation syndrome
Pickwickian syndrome; can mimic COPD but PFTs demonstrate restrictive defect; 90% will also have OSA; have decreased central respiratory drive, pulm HTN, hypoxemia, hypercapnia, coronary a dz, CHF
96
What are the patterns of primary progressive TB
- primary caseous pneumonia: Ghon complex expands to entire lobe; consolidated appearance
- TB bronchopneumonia: secondary to bronchogenic spread to entire lung; patchy foci
- miliary TB: secondary to hematogenous spread
97
What is the BCG vaccination made from
M. Bovis
98
What can cause a false negative TB test
Anergy, <6 months old, recent live virus vaccination or infection (measles, chicken pox), overwhelming TB infection
99
What stain is the most sensitive for acid fast organisms
Auramine-rhodamine
100
What stain is the most specific for TB
Ziehl-neelsen
101
What would you find in the plerual effusion of someone infected with TB
Positive adenosine deaminase
102
What are the characteristics of mycobacterium TB
Aerobic, slow growing, facultative intracellular, caseating granulomas, virulence cord factor (release cachectin - weight loss and inhibits phagosome), sulfaties (inhibits phagosome-lysosome fusion), siderophore (FE+ acquisition)
103
How do you follow treatment for TB
Sputum, CBC, CMP
104
What are the extrapulmonary manifestations of mycobacterium TB
- lymphadenitis (most common) - scrofula
- pleural effusion
- meningitis
- pott’s dz
- intestinal TB: secondary to contaminated milk ingestion (think m bovis)
105
What are the features of mycobacterium kansasii
Acid fast bacilli, nonmotile, picked up from environment NO PERSON TO PERSON CONTACT, seen in older pts with underlying lung dz or long time smokers; men; Midwest an southwest; tx:rifampin,isoniazid,ethambutol for 18 months
106
What is the diff btw lepromatous and tuberculoid leprosy
Lepromatous: foamy macrophages,weak CMI, lepromin negative, multibacillary, nodular lesions on face,ears,elbows, knees
Tuberculoid: linear granuloma following course of nerve, Th1 response, lepromin positive, paucibacillary contracture, paralyses, autoamputation, blindness
107
What is mycobacterium Marinum
Fish tank granuloma; granulomatous lesions of skin and tendon sheaths after exposure to fish tank or aquarium water
108
What is the empiric abx therapy for community acquired pneumonia
* all treatments require min of 5 days
- ambulatory patients: macrolides; if can’t tolerate - doxycycline
- increased drug resistance (abx in past 90 days, immunosuppression or exposure to kids) - fluoroquinolone or macrolide + beta lactam
- hospitalized: fluoroquinolone
- ICU: fluoroquinolone + antipneumococcal beta lactam (3rd gen cephalosporin or ampicillin) add piperacillin-tazobactam, cefipime or penem for pseudomonas
109
What are the causative agents of atypical pneumonia
Mycoplasma pneumoniae, chlamydia pneumoniae, legionella; seen in younger adults with milder sx; follows URI like sx (rhinitis laryngitis, pharyngitis, sinusitis)
110
What sx is unique to chlamydia
Hoarse voice
111
What is the CURB-65 severity score
```
Confusion: 1 point
BUN >20: 1 point
Resp rate >30: 1 point
BP <90/60: 1 point
Age > 65: 1 point
*total score: 0-1: low risk - outpatient tx, 2: short inpatient hospitalization, 3-5: hospitalization required consider ICU
```
112
What are the features of pseudomonas
Gram neg bacillus, encapsulated, pyocyanin and pyoverdine, water lover
113
What are the features of haemophilus influenzae
Gram negative diplococci, chocolate agar, smokers, immunocompromised
114
What are the features of moraxella catarrhalis
Gram negative coccobacillus, fastidious, aerobic, *smokers, COPD, asthmatics, malignancies
115
What are the features of legionella
Gram negative bacillus, aerobic, flagellate, water lover, urinary antigen, buffered yeast charcoal media, hyponatremia
116
What are the fast vs slow lactose fermenters
Fast: klebsiella, e. Coli, enterobacter
Slow: citrobacter, serratia
117
What are the features of strep pneumoniae
Gram positive diplococci encapsulated, alpha hemolytic, optochin sensitive, urinary antigens, lobar PNA, rust colored sputum
118
Who gets the pneumococcal vaccine
Age > 65, immunocompromised, asplenic, pts 2-64 with risk factors
*contraindications: anaphylaxis
119
What should you NOT give to kids with orthomyxovirus
ASA
120
What are the features of adenovirus
Non-enveloped, dsDNA, icosahedral
121
What does blasto affect
Skin, bone, neuro
122
What are the features of burkholderia cepacia
Gram negative, catalase positive, grows on BC agar - colonies are pearly grey; very hard to treat
123
What are the features of enterobacter
Gram negative, lactose fermenter, oxidase negative, anaerobic, mechanical ventilation, coliform bacteria, motile
124
What labs would you see with Hantavirus
Thrombocytopenia, leukocytosis, elevated LDH, pulm infiltrates b/l
125
What are the features of coxiella Burnetti
Obligate intracellular, gram negative, endospore; HIGH fever,, hepatitis with NO jaundice
126
What is the reservoir for chlamydia psittacosis
Birds; can have epistaxis and splenomegaly
127
What organisms are asplenic patients susceptible to
Klebsiella, haemophilus, strep, neisseria
128
What organisms are smokers and COPD susceptible to
Moraxella, haemophilus
129
What color sputum does staph aureus have
Salmon
130
What are the encapsulated pathogens
Strep pneumonia, klebsiella, haemophilus, pseudomonas, neisseria, cryptococcus
131
What is healthcare associated pneumonia
Hospitalized for at least 2 days within last 90 days or in the last 30 days at nursing home, infusions, dialysis, wound care or family member with MDR organism
132
What is ventilator associated pneumonia
ET intubation with 2 of fever, leukocytosis, purulent sputum
133
What assesses the severity of nosocomial pneumonia
CBC and CMP
134
What is the empiric treatment for nosocomial pneumonia
Antipseudomonal (pipe-tazobactam, aztreonam) + 2nd antipseudomoal (levofloxacin) + MRSA coverage (vanc or linezolid)
135
What is used to diagnose OSA
Polysomnography;; apnea-hypopnea index >5 per hour onfirms OSA
136
What are the treatments for the different stages of COPD
I: SABA
II: SABA with LABA or LAMA and pulm rehab
III: add ICS
IV: add oxygen
