GI/Pulm Flashcards
(145 cards)
1
Q
Severe abdominal pain, fatigue, and nausea. Physical examination is significant for profound jaundice and tenderness to palpation of the right upper quadrant of the abdomen. The patient returned 2 weeks ago from a 1 month-long trip to India
A
Acute hepatitis
2
Q
Causes of acute hepatitis
A
- Viral hepatitides (e.g., HAV, HCV, and HBV)
- Parasites (e.g., toxoplasmosis)
- Alcohol
- Drug-induced (e.g., acetaminophen)
- Autoimmune hepatitis
- Steatohepatitis
- Metabolic disease
3
Q
Sx of acute hepatitis
A
- Initial prodrome of flu-like symptoms (fatigue, nausea, vomiting, headaches) followed by jaundice (1-2 weeks after)
- Right upper quadrant (RUQ) pain, jaundice, scleral icterus, hepatomegaly, splenomegaly, fever
4
Q
Ultrasound findings of acute hepatitis
A
Ultrasound is a good initial imaging modality for rule out of other causes of abdominal pain
- Hepatomegaly (most sensitive sign) and gallbladder wall thickening
5
Q
Labs associated with acute hepatitis
A
- Hepatic panel
- Mixed direct and indirect hyperbilirubinemia
- Dramatically elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
-
ALT usually higher than AST
- AST:ALT > 2, suspect alcoholic hepatitis
-
ALT usually higher than AST
6
Q
Which serology markers will be elevated in acute hepatitis
A
Anti-HbC IgM
C for capsule; M for men go first
+
HBsAg = Subway
7
Q
What is the first hepatitis serology marker that will indicate early acute hep b infection?
A
HBsAG
8
Q
What are the 2 serology markers indicating resolved hepatitis
A
Anti-HbC IgG
+
Anti-HbS
9
Q
Chronic Hep B Serology markers
A
Anti- HBc capsule IgG = men aleady tried so guys left
+
HBsAG = Subway still transporting virus
10
Q
Which serology marker indicates hep B immunity?
A
Anti-HBs
Anti-Subway = Already went through subway and now created antigens
11
Q
IgM or IgG for acute vs chronic hep
A
Men first = GO TO WAR
g= guys after whats left behind
12
Q
MCC of pancreatitis (get smashed)
A
- The mnemonic GET SMASHHED is useful in recalling the most common causes: Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune disease, Scorpion sting, Hypercalcemia, Hyperlipidemia, ERCP and Drugs.
13
Q
MCC for anorexia in ED
A
Appendicitis
14
Q
Consider this in all patients over 50 with new-onset constipation
A
Colorectal cancer
15
Q
hypomobility of the GI tract in the absence of mechanical obstruction, absent bowel sounds
A
Ileus
16
Q
Choledocholithiasis accounts for 60% of cases
A
Cholangitis
17
Q
MCC of cirrhosis
A
- The most common cause is alcoholic liver disease
- Second most common cause: chronic hepatitis B and C infections
18
Q
Budd Chiari Syndrome
A
Hepatic vein thrombosis (Budd Chiari Syndrome): a triad of abdominal pain, ascites, and hepatomegaly
19
Q
If pt has ascites what diagnostic test is performed next?
A
- Abdominal ultrasound, diagnostic paracentesis - measure serum albumin gradient
20
Q
In what condition is Asterixis (flapping tremor) - have patient flex hands seen?
A
Hepatic encephalopathy: ammonia accumulates and reaches the brain causing ↓ mental function, confusion, poor concentration
21
Q
Rome criteria for diarrhea/constipation (less than 3 BM per week)
A
Any of 2 of the following + last three months with symptom onset six months prior to diagnosis
- Straining
- Lumpy hard stools
- A sensation of incomplete evacuation
- Use of digital maneuvers
- A sensation of anorectal obstruction or blockage with 25 percent of bowel movements
- A decrease in stool frequency (less than three bowel movements per week)
22
Q
Common secondary causes of constipation include:
A
- Think of causes of secondary causes of constipation: DM, hypothyroidism, MS, dehydration, medications are common
23
Q
Bulk forming laxatives include:
A
psyllium seed (eg, Metamucil), methylcellulose (eg, Citrucel), calcium polycarbophil (eg, FiberCon®), and wheat dextrin (eg, Benefiber)
24
Q
Osmotic laxatives include
A
Start with low-dose polyethylene glycol (PEG) as it has been demonstrated to be efficacious and well-tolerated in older adults.
25
Diarrhea breakout at daycare most likely organism
Rotavirus
26
MCC of diarrhea after hospital admission?
C. Diff
27
Which organism is MCC of diarrhea after picnic/egg salad?
Staphylococcus Aureus
28
MC organism found in S**eafood**, especially **raw or undercooked shellfish**
Vibrio cholerae, Vibrio parahaemolyticus
29
Which organisms are seen in ground beef or seed sprouts?
Shiga toxin-producing E. coli (e.g., E. coli O157: H7)
30
MC organism seen in pork/poultry
Salmonella
31
MCC or travelers diarrhea
Enterotoxigenic E. coli is most common (traveler's diarrhea)
32
MC organism with fried rice
Bacillus cereus
33
**MC organism seen in camping**, consumption of untreated water:
*Giardia -* incubates for 1-3 weeks**, causes foul-smelling bulky stool** and may wax and wane over weeks before resolving
34
Rice water stool is seen with which organism MC
V. cholerae
35
**Afebrile, abdominal pain with bloody diarrhea**: MC organism is:
Shiga toxin-producing Escherichia coli
36
MC location of diverticulitisq
**Sigmoid colon**
37
Dx of diverticular disease
Diagnose using abdominal and pelvic **CT with oral, rectal, and IV contrast**; do colonoscopy 1 to 3 months after the episode to look for cancer.
* CT revealing **fat stranding** and **bowel wall thickening**
38
**Non-infectious causes of esophagitis**
* **Reflux esophagitis**: mechanical or functional abnormality of the LES
* **Medication-induced:** think NSAIDS or bisphosphonates
* **Eosinophilic:** Pt with Asthma symptoms and GERD not responsive to antacids. Allergic, eosinophilic infiltration of the esophageal epithelium.
* Diagnosed with a biopsy
* A barium swallow will show a ribbed esophagus and [**multiple corrugated rings**](https://smartypance.com/wp-content/uploads/2015/11/Eosinophilic_esophagitis-barium_swallow-500x361.jpg)
* **Radiation:** radiosensitizing drugs include doxorubicin, bleomycin, cyclophosphamide, cisplatin
* **Dysphagia** lasting weeks-months **after therapy**
* Radiation exposure of 5000 cGy associated with increased risk for stricture
* **Corrosive:** Ingestion of alkali or acid from attempted suicide
39
odynophagia (pain while swallowing food or liquids) is the hallmark sign esophagitis MC from
* **Fungal:** Infectious **Candida**: [**linear yellow-white plaques**](https://smartypance.com/wp-content/uploads/2018/03/esophageal_candidiasis.jpg) with odynophagia or pain on swallowing. Tx with Fluconazole 100 mg PO daily
* **Viral:**
* **HSV:** shallow [**punched out lesions on EGD**](https://smartypance.com/wp-content/uploads/2018/03/herpes_esophagitis.jpg), treat with acyclovir
* **CMV**: large [**solitary ulcers or erosions on EGD**](https://smartypance.com/wp-content/uploads/2018/03/CMV-Esophagitis.jpg), treat with ganciclovir
* **EBV**, **Mycobacterium** **tuberculosis**, and **Mycobacterium avium intracellular** are additional infectious causes
40
MCC of gastritis (3)
Infection = H.pylori
Inflammation = NSAIDs/Alcohol
Autoimmune/hypersienisitivy = Pernicious anemia + schilling test → Decreased intrinsic factor
41
**Hematochezia:** bright red blood per rectum (BRBPR) causes
* [Hemorrhoids](https://smartypance.com/lessons/disorders-anus-rectum/hemorrhoids/): painless bleeding with wiping
* [Anal fissures](https://smartypance.com/lessons/disorders-anus-rectum/anal-fissure-reeldx322/): severe rectal pain with defecation
* Proctitis: rectal bleeding and abdominal pain
* [Polyps](https://smartypance.com/lessons/diseases-small-intestine-colon/polyp/): painless rectal bleeding, no red flag signs
* [Colorectal cancer](https://smartypance.com/lessons/diseases-small-intestine-colon/neoplasms-small-intestine-colon/): Painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age
42
Tx of giardia
* TX with **tinidazole (first line)**
* Flagyl (Metronidazole) 250-750 mg PO TID
* Symptoms resolve within 5-7 days
43
**GI symptoms and weight loss**
* Transmission from raw or undercooked meat
* Associated with **B12 deficiency**
Tapeworm = tx w/ Praziquantel (**anthelmintics)**
44
**cough, weight loss, anemia** recent travel
Hookworm - Eosinophilia + Anemia
Tx= Mebendazole or pyrantel
45
**Pancreatic duct, common bile duct,** and **bowel obstruction**
Round worm = **Most common intestinal helminth** worldwide found in **contaminated soil**
**Tx is** TX: albendazole, mebendazole, pyrantel pamoate
46
* Fecal-oral, contaminated water/food, anal-oral
* Bloody diarrhea, tenesmus. abdominal pain
Amebia - Entamoeba histolytica (protozoa)
* TX: **Iodoquinol** or paromomycin and **Flagyl** for **liver abscess**
47
* **Penetration of skin (contaminated freshwater)** → enter the bloodstream and **migrate to the liver, intestines, and other organs**
Schistomiasis = parasitic flatworms
* TX: Praziquantel
48
MCC of hematemesis
* [Peptic ulcer disease](https://smartypance.com/lessons/gastrointestinalnutritional/peptic-ulcer-disease/): hematemesis, abdominal discomfort, dull pain
* [Esophageal varices](https://smartypance.com/lessons/diseases-of-the-esophagus/esophageal-varices-reeldx530/): hematemesis, bleeding, difficulty swallowing
* [Alcohol abuse:](https://smartypance.com/lessons/preoperative-postoperative-care/substance-abuse/) physical dependence, craving, vomiting
* [Mallory-Weiss syndrome](https://smartypance.com/lessons/diseases-of-the-esophagus/mallory-weiss-tear/): a tear in the lining of the stomach just above the esophagus caused by violent retching or vomiting
* [Coagulation disorders](https://smartypance.com/lessons/coagulation-disorders/): characterized by a decreased ability to form a clot
* [Esophageal cancer](https://smartypance.com/lessons/gastrointestinalnutritional/esophageal-cancer/): progressive dysphagia to solid foods along with weight loss, reflux, and hematemesis
* [Gastrointestinal System Neoplasms](https://smartypance.com/lessons/gastrointestinal-system-neoplasms-pearls/): Abdominal pain and unexplained weight loss are most common symptoms along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, guaiac-positive stool
49
Tx of external thrombosed (pain, pruritis, no bleeding) palpable perianal mass with purplish hue
**External** - lower 1/3 of the anus ([below dentate line](https://smartypance.com/wp-content/uploads/2019/05/Dentate-line.jpg))
* **Thrombosed**:
* **Significant pain,** and **pruritus** but **no bleeding**
* Palpable perianal mass with a **purplish hue**
* Treat with **excision** for thrombosed external hemorrhoids
50
**Isolated to the colon** starts at the rectum and moves proximally
* **Continuous** lesions
Ulcerative colitis
51
Sx of UC
* **Hematochezia** and **pus-filled diarrhea**, fever, **tenesmus** (feeling of incomplete defecation) anorexia, weight loss
52
Tx of UC
* **Colectomy** is curative
* Medications: **Prednisone** and **mesalamine**
53
A 24-year-old man with **ulcerative colitis** receives Lomotil for excessive diarrhea and develops **fever, abdominal pain** and **tenderness**
Toxic megacolon
54
Tx of toxic megacolon
**Decompression of the colon** is required
* In some cases, colostomy or even **complete colonic resection may be required**
55
Fifty-year-old with a history of coronary artery disease experiencing recurrent cramping with **postprandial abdominal pain**
Ischemic bowel disease
SMA → MC affected
56
Dx of ischemic boweldisease
* Plain films/CT: Bowel edema, pneumatosis intestinalis (gas within the bowel), portal venous gas
* **Mesenteric angiography is the gold standar**d
57
* Increased indirect/unconjugated bilirubin, mild hyperbilirubinemia
* Dark urine due to hemoglobinuria; dark stool
What is the cause hemolytic or obstructive?
**Hemolytic = prehepatic**
58
Causes of obstructive post hepatic jaundice
* Cholestasis = bile duct blockage ⇒ increased conjugated bilirubin
* Cholestasis / pancreatic CA
* Increased direct/ conjugated hyperbilirubinemia
* GGT and ALP elevated
* Dark urine = increase direct bilirubin
* Acholic stools = biliary obstruction (white)
59
MCC of melena
* Gastric cancer, duodenal ulcers, right-sided colon cancer, portal hypertension with esophageal varices, severe erosive esophagitis, Mallory-Weiss syndrome.
60
4 cardinal signs of strangulated bowel (bowel obstruction)
The 4 cardinal signs of strangulated bowel: fever, tachycardia, leukocytosis, and localized abdominal tenderness.
61
MCC of sm bowel obstruction
MCC: **adhesions** or **hernias**, cancer, IBD, volvulus, and intussusception
62
When do you hospitalize for acute bronchitis
* Hospitalization if **O2 saturation \< 95-96%**, age \<3 months, RR \> 70, nasal flaring, retractions, or atelectasis on CXR
63
Supportive tx for acute bronchitis
* Supportive ⇒ humidified O2, antipyretics, beta-agonist, nebulized **racemic epinephrine**, and steroids
64
What is the prophylaxis given for bronchitis in immunocompromised, premies, or neuromuscular disorder patients?
**Palivizumab prophylaxis** (once per month for five months beginning in November) for **special populations** (immunocompromised, premature infants, neuromuscular disorders)
65
MC bacteria in acute bronchitis
* Most common - **viral (95%)**
* Common bacterial = M. catarrhalis
* Chronic lung patients: H. influenzae, S. pneumoniae, M. catarrhalis
66
**Supraglottic inflammation** and **obstruction of airway** due to infection with **Haemophilus influenzae type B (Hib)**
Acute epiglottitis
67
**3 Ds of epiglottitis:**
Tripod positioning ⇒ **3 Ds of epiglottitis:**
* **D**ysphagia
* **D**rooling
* Respiratory **D**istress
68
The classic finding on **x-ray lateral neck film for epiglottitis**
The classic finding is [**thumbprint sign**](https://smartypance.com/wp-content/uploads/2015/09/Thumb-print-sign.jpg) on **x-ray lateral neck film**, secure airway then **culture for H.flu**
69
Pathophys for acute resp distress
* ⇑ Permeability of alveolar-capillary membranes ⇒ development of protein-rich pulmonary edema **(non-cardiogenic pulmonary edema)**
70
* **Rapid onset** of **profound dyspnea** occurring **12-24 hours after the precipitating event**
* Tachypnea, **pink frothy sputum,** crackles
ARDS
71
Mild intermittent asthma occurs how often
(\<2x/week or \<2 night/month) – SABA prn
72
Mild persistent asthma occurs how often
(\>2x per week or 3-4 night/month) – low dose ICS daily
73
Moderate persistent asthma occurs how often
**Moderate persistent** (daily sx or \>1 night/week)
* Low dose ICS + LABA daily
* Medium dose ICS + LABA daily
74
Severe persistent asthma occurs how often?
**Severe persistent** (sx several times / day + nightly) –
* High dose ICS + LABA Daily
* High dose ICS + LABA + oral steroids
75
**Croup** refers to an **infection of the upper airway**, which **obstructs breathing** and causes a **characteristic barking cough**
Croup
76
MCC of croup
Parainfluenza virus
77
Findings on cxr in a pt with suspected croup
* [**Steeple sign**](https://smartypance.com/wp-content/uploads/2015/09/STEEPLE-SIGN.jpg) on PA CXR (narrowing trachea in the subglottic region)
78
Which type of bronchoscope is used in children vs adults
* **Rigid** bronchoscopy preferred in **children** while **flexible** is diagnostic and therapeutic in **adults**
* Complications include pneumonia, [acute respiratory distress syndrome](https://smartypance.com/lessons/other-pulmonary-disease/acute-respiratory-distress-syndrome/), asphyxia
79
MCC of hemoptysis
* [**Bronchitis (50%)**](https://smartypance.com/lessons/infectious-disorders/acute-bronchitis-reeldx267/): hemoptysis, dry cough, cough with phlegm
* [**Tumor mass (20%)**](https://smartypance.com/lessons/pulmonary-neoplastic-disease/lung-cancer-reeldx495/): hemoptysis, chest pain, rib pain, tobacco history, weight loss, clubbing
* [**Tuberculosis (8%)**](https://smartypance.com/lessons/infectious-disorders/tuberculosis-reeldx471/): hemoptysis, chest pain, sweating
Other causes include [bronchiectasis](https://smartypance.com/lessons/other-pulmonary-disease/bronchiectasis/), pulmonary catheters, trauma, pulmonary hemorrhage
80
Tx of hemoptysis
* Massive hemoptysis warrants a more aggressive early consultation with a pulmonologist
* **ABCs ⇒ Airway maintenance is vital because the primary mechanism of death is asphyxiation, not exsanguination**
81
The **most common** presentation of acute or **mild hemoptysis**
Bronchitis
82
Older smokers with hemoptysis lung cancer must be ruled out with
High resolution CT
## Footnote
**NEGATIVE CXRs DO NOT RULE OUT LUNG CANCER**
83
Who is the flu vaccine contrainidcated in?
* Avoid vaccination: **severe egg allergy**, previous reaction, Guillain-Barré syndrome (GBS) within 6 weeks of previous vaccination, GBS in the past 6 weeks, \<6 mo old. Avoid FluMist in pt with asthma
84
Which 2 medications treat both influenza A & B
* **Zanamivir** and **Oseltamivir** both treat **influenza A and B ⇒ (think Dr. “OZ” treats the flu)**
85
4 subtypes of non-small cell lung cancer
**four subtypes** include adenocarcinoma, squamous cell carcinoma, large cell carcinoma and carcinoid tumor
86
What is the most common location for small cell lung cancer and what is the best tretment?
* **99% smokers**; doesn’t respond to surgery; metastases common at presentation
* **Central location**, very aggressive
* Associated with **paraneoplastic syndromes**; Cushing's, SIADH
**Tx: can’t have surgery; needs chemo**
87
MC type of non-small cell CA
* Adenocarcinoma (35-40%): MOST COMMON, **peripheral mass**; smoking/asbestos exposure; thrombophlebitis
88
Where does large cell lung cancer occur?
Periphery → Associated with gynecomastia
89
What is carcinoid syndrome?
* Carcinoid syndrome = cutaneous flushing, diarrhea, wheezing, hypotension (telltale sign)
* **Adenoma** = MC type of carcinoid tumor (slow-growing, rare)
90
What is dx for carcinoid tumor
* Dx: bronchoscopy – **pink/purple central lesion**, well-vascularized; elevated **5-HIAA**
91
If suspicious pulmonary nodule is noted what is the next step
Biopy → **Ill-defined lobular or spiculated** suggests cancer
92
If pulmonary nodule is not suspicious and less than 1 cm what is the next step?
**If not suspicious \< 1 cm it should be monitored at 3 mo, 6 mo, and then yearly for 2 yr**
**Calcification, smooth well-defined edges,** suggests **benign** disease
93
highly contagious respiratory tract infection marked by a s**evere hacking cough** followed by a h**igh-pitched intake of breath**
Whooping cough
94
MC organism associated with whooping cough
Gram negative - bordatella pertusisis
95
3 stages of whooping cough
* Catarrhal stage: cold-like symptoms, poor feeding, and sleeping
* Paroxysmal stage: high-pitched **"inspiratory whoop"**
* Convalescent stage: residual cough (100 days)
96
How is whooping cough diagnosed
Diagnosed by a **nasopharyngeal swab** of nasopharyngeal secretions – culture
97
Tx of whooping cough
Tx: **macrolide** (clarithromycin/azithromycin); supportive care with steroids / beta2 agonists
* Vaccination: 5 doses – 2, 4, 6, 15-18 mo, 4-6yrs (DTap)
* 11-18 yo = 1 dose Tdap
* Expectant mothers should get Tdap during each pregnancy, usually at 27-36 weeks
98
Accumulation of excess **fluid** between the layers of the **pleura** outside the lungs (pleural space)
Pleural effusion
99
**dyspnea**, and a vague discomfort or **sharp pain that worsens during inspiration**
Pleural effusion
100
How to differentiate between exudate and transudative pleural effusion?
Determine if the pleural fluid is **exudative** by meeting at least one of [**Light’s Criteria**](https://www.mdcalc.com/lights-criteria-exudative-effusions) (increased protein, increased LDH)
* Pleural fluid protein / Serum protein \>0.5
* Pleural fluid LDH / Serum LDH \>0.6
* Pleural fluid LDH \> 2/3
101
Common causes of exudative pleural effusion
**Exudative = protein ratio ↑, LDH** ↑: infection, malignancy, immune; MC cause = pneumonia, cancer, PE, TB
102
Causes of transudate pleural effusion
**Transudate** = transient → from changes in hydrostatic pressure: cirrhosis, CHF, nephrotic syndrome, ascites, hypoalbuminemia
103
Dx pleural effusion
Diagnose with [**lateral decubitus CXR**](https://smartypance.com/wp-content/uploads/2019/12/Pleural_effusion.jpg), chest CT, U/S. **Thoracentesis** is the **gold standard**
104
PE findings of pleural effusion
* PE shows **decreased tactile fremitus** and **dullness to percussion** in pleural effusion
* Isolated left-sided pleural effusion likely exudative
* Right-sided = transudative
105
Tx of pleural effusion
Treatment is with **thoracocentesis**
* Effusions that are chronic or recurrent and causing symptoms can be treated with **pleurodesis** (pleural space is artificially obliterated) or by **intermittent** drainage with an indwelling catheter
106
Common causes of pleuritic chest pain
* Common causes include [pneumonia](https://smartypance.com/lessons/infectious-disorders/pneumonias/), [pericarditis](https://smartypance.com/lessons/forms-heart-disease/acute-pericarditis-reeldx520/), [pericardial effusion](https://smartypance.com/lessons/forms-heart-disease/pericardial-effusion-reeldx507/), [pancreatitis](https://smartypance.com/lessons/disorders-of-the-pancreas/acute-chronic-pancreatitis/)
107
MCC of viral pneumonia
[**Viral**](https://smartypance.com/lessons/infectious-disorders/pneumonias/viral-pneumonia/)**:** adults ⇒ **flu** = MC cause; kids ⇒ **RSV**; comes on fast
108
fever, dyspnea, tachycardia, tachypnea, cough, +/- sputum
Bacterial pneumonia
109
What is seen on cxr if a pt has suspected bacterial pneumonia
* Dx: patchy, segmental lobar, multilobar consolidation; blood cultures x2, sputum gram stain
110
Tx of bacterial pneumonia
* Tx: outpatient = doxy, macrolides; inpatient = ceftriaxone + azithromycin/respiratory FQs
111
Valley fever pnuemonia is suspected if
non-remitting cough/bronchitis non-responsive to conventional tx
## Footnote
Fungal inhalation in western states; test with EIA for IgM and IgG
112
Tx of coccidioides or pulmonary aspergillosis pneumoina
Fluconazole or itraconazole
113
Where is cryptococcus found
CRYPTS = Tombs in the soil
Can cause disseminated meningitis → Perform LP for meningitis
Tx w/ Amphotericin B
114
pulmonary lesions that are apical and resemble cavitary TB; worsening cough and dyspnea, progression to disabling respiratory dysfunction; no dissemination
Histoplasma capsulatam
115
Where is histoplasma found
* Bird or bat droppings (caves, zoo, bird); Mississippi Ohio river valley
116
What are cxr findings associated with histoplasma
* Signs: mediastinal or hilar LAD (looks like sarcoid)
117
Which two weird types of pnuemonia are treated with amphortericin B
Cryptococcus + Histoplasma
118
What is the tx for PCP or PJP pneumonia
Bactrim + steroids
Seen in HIV pts with CD4 below 200
119
What is the CURB-65 score for pnuemonia severity
* **c**onfusion, **u**rea \>7, **R**R \>30, Systolic **B**P \< 90 mmHg or Diastolic **B**P ≤ 60 mmHg, age \>**65**
* 0-1 = low risk, consider home tx
* 2 = probable admission vs close outpatient management
* 3-5 admission, manage as severe
120
**ipsilateral chest pain** and **dyspnea** with **decreased tactile fremitus**, **deviated trachea**, h**yperresonance, diminished breath sounds**
Pneumothorax
121
Causes of pneumothorax
Spontaneous vs traumatic
* **Primary:** occurs in **absence of underlying disease** (tall, thin males age 10-30 at greatest risk)
* **Secondary:** in **presence of underlying disease** (COPD, asthma, cystic fibrosis, interstitial lung disease)
122
Penetrating injury → **air in pleural space increasing** and **unable to escape**
* **A mediastinal shift** to the **contralateral side** and impaired ventilation
Tension pneumo
123
Tx of small vs large pneumothorax
* Small - \< 15% diameter of hemithorax will **resolve spontaneously** without the need for chest tube placement
* Large - \> 15% diameter and symptomatic pneumothoraces require **chest tube placement**
* Serial **CXR every 24 hours** until resolved
124
Tx of tension pneumothorax
* Tension pneumothorax is a **medical emergency!** Large bore needles to allow air out of the chest; chest tube for decompression
125
RF for pulmonary embolism
**Virchow’s triad = hypercoagulable state, trauma, venostasis** (surgery, cancer, oral contraceptives, pregnancy, smoking long bone fracture/fat emboli)
126
What is homans sign
* [**Homan’s sign**](https://youtu.be/RYEzDRJhnf4)**:** (Dorsiflexion of the foot causes pain in calf) indicative of deep vein thrombosis
127
What findings are seen on EKG for suspected PE
* EKG: **TACHYCARDIA** (most common), [**S1Q3T3**](https://smartypance.com/wp-content/uploads/2019/12/S1Q3T3.jpg) (rare), non-specific ST wave changes
128
Gold std tx for pulmonary embolism
* **Pulmonary angiography** = **gold standard definitive**
* CXR: [**Westermark sign**](https://smartypance.com/wp-content/uploads/2019/12/Westermark-sign.jpg) or [**Hampton hump**](https://smartypance.com/wp-content/uploads/2015/11/posttestA13pe-hamptons-hump.jpg) (triangular or rounded pleural base infiltrate adjacent to hilum)
* **VQ scans are "old school"=** perfusion defects with normal ventilation (normal VQ rules out PE; abnormal – non-specific)
* **Venous duplex ultrasound** of lower extremities (normal test does not exclude PE)
129
Anticoag of choice for pulmonary embolism
**Heparin** is the anticoagulant of choice for the acute phase with **factor Xa inhibitors** (eg, rivaroxaban, apixaban, edoxaban) and **oral direct thrombin inhibitors (dabigatran)** thereafter
130
Duration of tx for anticoagulation after pulmonary embolism
* Duration of treatment: minimum of anticoagulation **3 months** with reversible risk factor
* Unprovoked: anticoagulation recommended for at least **6 months** then reevaluate
* Two episodes unprovoked, **long term** with anticoagulation
131
Indications for hospitalization in kids with RSV
Indications for hospitalization ⇒ tachypnea with feeding difficulties, **visible retractions**, **oxygen desaturation \< 95-96%**
132
Tx of RSV
* Supportive measures include **albuterol via nebulizer, antipyretics** and **humidified oxygen**, steroids (controversial), resolves in 5-7 days
* **Vaccine** for children with lung issues or born premature/immunocompromised at birth should get **Synagis prophylaxis (palivizumab)** = once per month for five months beginning in November
133
General tx of SOB
* Oxygen (high flow nasal canal or rebreathing mask)
* Albuterol for asthma and COPD
* Lasix for CHF
* BIPAP for respiratory difficulty and low O2 saturations
* Intubation for severe cases
134
Tuberculosis presentation
**Tuberculosis (TB)** is a disease caused by bacteria called **Mycobacterium tuberculosis (acid-fast bacilli)**
* Presentation: **fatigue, productive cough, night sweats, weight loss**, post-tussive rales
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How is TB transmitted
Transmission: inhalation of **aerosolized droplets**
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TB test \>5mm would be positive in what population
* **\> 5 mm** at high risk, fibrotic changes on CXR, immunocompromised HIV/drugs, steroids/TNF antagonists daily, or close contact with pt with infectious TB
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TB test of **\> 10 mm would be positive in what population?**
* **\> 10 mm** in patients age \< 4 or some risk factors = **hospitals and other healthcare facilities**, IVDU, recent immigrants from high prevalence area, renal insufficiency, prison, homeless shelter, diabetes, head/neck cancer, gastrectomy/jejunoileal bypass surgery
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TB test of **\> 15 mm** is positive in what population
No other risk factors
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How is TB diagnosed
Diagnosis with **sputum for AFB smears** and ***Mycobacterium tuberculosis*** **cultures** – have to be 3 AFB negative
* **NAAT** helps diagnosis better and sooner
* CXR: **cavitary lesions**, infiltrates, ghon complexes in [**the apex of lungs**](https://smartypance.com/wp-content/uploads/2015/09/Tuberculosis.png)
* Biopsy ⇒ **caseating granulomas**
* Miliary TB = spread outside lungs ⇒ vertebral column: [**Pott disease**](https://smartypance.com/wp-content/uploads/2019/12/Potts-Disease.jpg)**;** [**scrofula**](https://smartypance.com/wp-content/uploads/2015/12/cervical-node.jpg) (TB to cervical lymph nodes)
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PPD positive + *CXR negative*:
Latent TB = ***latent TB*** ⇒ **Isoniazid for 9 months** (+ B6 to prevent neuropathy)
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PPD positive + *CXR positive*
***active TB** ⇒***Quad therapy (RIPE):** rifampin, isoniazid, pyrazinamide, ethambutol – all are hepatotoxic
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How is RIPE tx prescribed for TB?
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How is RIPE tx prescribed for TB?
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What are the side effects to the RIPE drugs
Rifampin = Red/orange urine
Isoniazid = I SO NUMB = Peripheral neuropathy cant feel hands \*take B6
Pyrazinamide = Pyramid → Egyptians love salt = GOUT
Ethambutol = EYES = Optic neuritis
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Patients with active TB will need **two negative AFB smears and cultures** in a row negative for **therapy cessation**
* **Prophylaxis** for **household members ⇒** **Isoniazid for 1 year**
* D/C therapy if transaminases \> 3-5 × ULN
* Pt's on **INH** should take **supplemental Vitamin B6 (pyridoxine 25-50mg/day)** to **prevent neuropathy**
