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Pulm Flashcards

1
Q

What is the length for an acute vs chronic Bronchitis

A

Acute = less than 3 weeks

Chronic = longer than 3 months for 2 consecutive years

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2
Q

Characterization of GPA

A

Glomerulonephritis

Necrotizing granulomatis vasculitis

Small vessel vasculitis

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3
Q

GPA CXR and other physical exam findings

A

Nodular pulmonary infiltrates with cavitation

Tracheal stenosis ; strawberry tongue ; petechia/Purpura ; saddle nose deformity

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4
Q

Time frame for CAPNA

A

Less than 48 hours of hospital onset

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5
Q

4 bacteria responsible for CAPNA

A

Strep pneumo
Mycoplasma PNA
H. Influenza
Chlamydia

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6
Q

2 Vaccines good in elderly (over 65) for CAPNA

A

PCV 13

PPSV23

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7
Q

Physical exam findings and expected CBC for CPNA

A

PE: inspiratory crackles, bronchial breath sounds, egophony, whispering pectoriloquy, and dullness to
percussion

v Dx: CBC (leukocytosis + leftward shift)

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8
Q

Diagnostic tool for CPNA

A

CURB-65
1. Confusion (new onset)

  1. Urea ( > 20)
  2. Respirations ( > 30)
  3. BP (SBP < 90 and/or DBP < 60)
  4. 65 y/o
  5. Score: 1 = outpt, 2 = clinical decision, ≥ 3 = admit, 5 = ICU
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9
Q

Treatment for CPNA ; with no comorbidities ; no MRSA or Psuedomonas risk

A

Empiric

Amoxicillin or Doxy x5days or longer until 72 hours afebrile

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10
Q

CPNA for patients with comorbidities

A

-Resp Flouro x5days or longer until 72 hours afebrile

Augmentin OR cephalosporin plus a macrolide OR doxycyclin

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11
Q

3 common pathogens in HAPNA

A

Staph A. ; Psuedomonas ; gram neg rods

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12
Q

Fever ; Hemoptysis ; Wt. Loss ; Night Sweats ;; Think?

A

TB

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13
Q

Dx techniques if you suspect TB and TXM

A

Dx
1. PPD (cornerstone dx for latent TB)
2. Sputum for smear and culture
3. CXR: done w/ positive PPD or active clinical sxs

TXM = RIPE
Rifampin
Iosonizide
Pyrazinamine
Ethambutol

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14
Q

CXR findings in Coal Workers Dz

A

Diffuse 2-5mm opacities affecting the alveolar lung space ; UPPER LUNG FIELDS

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15
Q

Silicosis CXR ; and increased incidence of what?

A

Egg shell opacities in the hilar lymph nodes; rounded opacities

-TB ; if + get a skin test

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16
Q

Shipyard worker Asbestosis CXR

A

linear streaking at LOWER LUNG FIELDS

, opacities of various shapes/sizes, honeycombing

(advanced dz), and pleural calcifications

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17
Q

Best imaging for asbestosis ; shows what

A

CT ;

Parenchymal fibrosis
Pleural plaques

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18
Q

4 Characteristics of Asthma

A

Enhanced obstructive response of airway smooth muscle

Reversible flow limitation

Recurrent breathlessness and wheezing

FEV1:FVC less than 80

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19
Q

What is the significance of FEV1 ; FVC ; DLPCO ; FEV1:FVC ratio?

A

FEV1 = forced expiratory volume ; air exhaled in 1 second

FVC = amount of air exhaled after deep inhale ; total air exhaled

DLCO = diffusing capacity of air to the bloodstream ; ability to breathe oxygen to destination

FEV1:FVC = total amount of air that you can forcibly exhale!

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20
Q

Obstructive conditions mean it is harder to _____
Restrictive conditions mean its harder to ________

A

O= exhale

R= inhale

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21
Q

What FEV1/FVC ratio indicated COPD? What do you use to grade COPD severity

A

Less than 0.7

SEVERITY GRADING:
Mild = FEV1 greater 80%

Mod = FEV1 50-80%

Severe = FEV1 30-50%

VERY SEVERE = FEV1 less than 30% or less 50% w/ Chronic Respiratory F.

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22
Q

When is the use of SABA indicated in asthma

A

Relief of acute sxs

DOC for acute bronchospasms
Px for exercise induced

“albuterol”

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23
Q

When is the use of LABA indicated in asthma?

A

If you need to step up due to increased sxs/episodes and already on an ICS

“Salmeterol-Serevent”
“Formeterol-Foradil”

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24
Q

Inhaled CS TXM indicated for what in asthma?

A

1st line anti-inflammatory for mild mod persistent asthma

To be used with SABA

fluticasone/budosenide/beclamethasone

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25
In asthma exacerbation what is good management
Oral : Prednisone IV : Methylprednisolone
26
Preferred controller / reliever of intermittent asthma would be? And how freq are they getting sxs
Less than 2 days a week ; nighttime awakenings = less than 2X monthly PRN ICS-Formeterol = controller *prn SABA* = reliever
27
Preferred controller / reliever of mild asthma would be? And how freq are they getting sxs
Greater than 2 days a week ; less than once daily ; nighttime awakenings = 3-4x monthly Daily / PRN ICS/ ICS-Formeterol or LTRA = Montelukast = controller *prn SABA* = reliever
28
Preferred controller / reliever of persistent moderate asthma would be? And how freq are they getting sxs
Daily with nighttime awakenings = greater than 1 weekly Low Dose ICS-LABA or Medium Dose ICS or ICS-LTRA = controller ; consider = Oral Prednisone *prn ICS-Formeterol* = reliever
29
Preferred controller / reliever of severe asthma would be? And how freq are they getting sxs
Sxs occur nightly and several times daily Medium Dose ICS -LABA or High Dose ICS or +Tiotropium or +LTRA = controller ; consider oral prednisone *prn-ICS-Formeterol* = reliever
30
Low Dose / Medium Dose / High Dose -ICS for fluticasone dipropionate and beclamethasone
Low Dose = F =[ 100-250] ; B=[100-200] Medium Dose =F=[250-500] ; B=[200-400] High Dose = F=[over500] ; B =[over400]
31
What is defined as improvement on bronchodilator therapy
improvement defined as : ↑ in FEV1 of > 12% after 2-4 puffs of SABA
32
Hallmark sxs of chronic bronchitis vs emphysema
CB = productive cough = WET ; blue bloater E = DOE = DRY ; pink puffer
33
What genetic deficiency is linked to COPD
Alpha 1 Antitrypsin
34
Gold standard diagnostics for COPD
PFTs / Spirometry W/ post bronchodilator FEV1 = non-reversible
35
ECG findings consistent with COPD
RVH RAD RAE right sided HF
36
How do you assess COPD severity and TXM
mMRC score and Risk Factors =Hospitalizations
37
mMRC score 0-1 with 1 hospitalization in the last year vs 2 hospitalizations TXM
mMRC score 0-1 = SOB increasing pace on the level or going up slight hill 1 = SAMA or SABA 2 = LAMA *LAMA = Tiotropium* *SAMA = Iprotropium Bromide* *SABA = albuterol*
38
mMRC score 2 or greater with 1 hospitalization in the last year vs 2 hospitalizations TXM
mMRC score 2 or greater = walking slower than others of same age; stopping at own pace on the level —> Too breathe less to leave the house or get dressed 1 = LABA or LAMA 2 = LAMA ; LAMA + LABA ; LAMA + LABA + ICS *LAMA = Tiotropium* *SAMA = Iprotropium Bromide* *SABA = albuterol*
39
Caution SABA medications in what?
DM Hyperthyroidism Severe CAD
40
SAMA: short-acting muscarinic antagonist Ipratropium Bromide LAMA: long-acting muscarinic antagonist Tiotropium Are what drug class?
Anti Cholinergic Bronchodilators
41
Only med therapy that decreases mortality in COPD
Oxygen - AT HOME Cor pulmonale with O2 less 88%
42
4 health Mx recommendations in COPD pts
i. Control triggers ii. Smoking cessation iii. Vaccinations: pneumococcal and influenza iv. Azithromycin has anti-inflammatory properties in lung; option for pts on dual or triple therapy w/ frequent exacerbations
43
Management uncomplicated vs complicated COPD exacerbation
Uncomplicated = less4 ; no Comorbids = AZITHROMYCIN or AUGMENTIN Complicated = greater4 = AUGMENTIN or LEVOFLOXACIN or MOXIFLOXACIN +CC / O2 / SABA
44
Hallmark PE finding of Interstial Lung Disease
Crackles Get a Lung bx Mc = Idiopathic ; Sarcoidosis
45
What syndrome is assoc with sarcoidosis
“ Lofgrens “ Triad = Sarcoidosis triad: bilateral hilar lymphadenopathy, erythema nodosum, migratory polyarthralgia (95% specificity for Sarcoidosis)
46
TXM sarcoidosis
Tx sxs: NSAIDs, low-dose glucocorticoids, colchicine, and hydroxychloroquine
47
MC primary lung cancer
Adenocarcinoma
48
SCC Lung CXR findings
Assoc. w/ hilar adenopathy and mediastinal widening on CXR
49
Large Cell carcinoma of the lungs ; example and findings
Pancoast tumors and syndrome a. Lung tumor of superior sulcus at extreme apex of lung
50
Small cell lung cancer is commonly assoc with what
SIADH / paraneoplastic syndrome Prone to hematgenous spread ; high assoc with SMOKING
51
Carcinoid tumors arise from where?
Bronchial mucosa or GI tract
52
Carcinoid tumors secrete what?
Vasoactive Material = serotonin ; histamine ; catecholamine ; prostaglandin ; peptides
53
4 sxs of carcinoid syndrome
Flush Diarrhea Wheeze HYPOTENSION
54
4 associated complications of Pancoast Tumor
Shoulder or Neck pain OOP Horner’s syndrome : anhydrosis Ipsilateral miosis ; ptosis Weakness / Atrophy of hand SVC syndrome = right side ; face neck swelling dyspnea chest pain
55
Squamous cell carcinoma is assoc with
Hypercalcemia *think paraneoplastic syndrome = extra manifestations of lung cancer*
56
Examples of paraneoplastic syndromes ? 4
Cushings Hypercalcemia SIADH SVC
57
Lab findings of SIADH
Hyponatremia with increased urine osmolality > 300
58
Describe Group 1 Pulm HTN
Due to : Vascular Remodeling / Connective Tissue DO / Drugs
59
Describe Group 2 Pulm HTN
Left sided heart F. Cause Increased intra cardiac and venous pressures
60
Describe Group 3 Pulm HTN
Hypoxia due to lung disease; either obstructive/restrictive/ or developmental lung d/o
61
Describe Group 4 Pulm HTN
Obstructive due to emboli -Sarcoidosis -hematologic d/o -NFT
62
Describe txm of Pulm HTN
Get a right heart catherization to confirm PAP greater 20 and rule out left sided intracrdiac pathology TXM = vasodilators
63
Virchow Triad in VTE
Virchow’s Triad 1. Vessel wall injury a. Thrombosis, vessel inflammation, infxn, direct trauma or surgery 2. Venous stasis: immobility (bed rest, obesity, stroke), hyperviscosity (polycythemia), ↑ central venous pressure (pregnancy, low CO states) 3. Hypercoagulability: inherited, deficiency or dysfxn of antithrombin III, protein C, protein S, or prothrombin, antiphospholipid antibody syndrome, acquired (age, OCP, malignancy, surgery)
64
VTE Anticoag therapy :
1. LMWH: enoxaparin 2. Factor Xa inhibitor: Rivaroxaban, Apixaban, Edoxaban
65
MC DVT location to cause PE
Proximal vein thrombosis: involves popliteal, femoral, or iliac veins; MC to cause PE
66
TXM for all types of DVTs [nml; preg/cancer; renal dysfunction; contraindications/recurrent]
Tx a. Factor Xa inhibitors i. DOC for most DVT unless pregnant, cancer, renal dysfxn b. LMWH: use w/ warfarin to provide tx until warfarin starts working, then take off LMWH i. DOC for pregnant and cancer pts c. Unfractionated heparin: first line in pts w/ renal dysfxn d. Warfarin: works well but effects take time to start, use w/ LMWH e. IVC filter i. If anticoag contraindications ii. Recurrent thromboembolism w/ anticoag iii. Recurrent embolism w/ pulmonary HTN iv. Urgent surgery w/out time for anticoag
67
S/Sx: dyspnea, pain on inspiration, cough, hemoptysis, wheezing, tachypnea (only reliable sign), tachycardia, crackles/S4, Homan’s sign, syncope Think?
PE
68
4 labs to get in PE ; SOC
D-dimer Troponin ABG BNP SOC = CTPA / V/Q Scan = preg
69
Wells Score Less than 4 Wells Score Greater than 4
Less = d-dimer Greater = CTPA
70
Nocturnal and Daytime sxs of OSA
Nocturnal sxs: snoring, apneas, choking, nocturia, disrupted sleep Daytime sxs: nonrestorative sleep, morning HA, excessive daytime sleepiness, cognitive deficits, significant other reports sleep issues
71
STOP BANG Screening criteria
Snore loudly Tired Observed apnea Pressure (HTN) BMI > 35 Age > 50 Neck circumference > 40 cm Gender male 3+ = Get Sleep Study Labs = CBC/TSH/FT4
72
3 causes of central sleep apnea
a. Cessation of effort or inadequate ventilator drive b. Narcotics c. Idiopathic
73
Describe spontaneous PTX / PE findings / Risk Factors
Sudden onset of unilateral chest pain and dyspnea, often begins at rest or sleep May present as life-threatening respiratory failure if underlying COPD or asthma is present PE i. Small: mild tachycardia ii. Large: ↓ breath sounds, ↓ tactile fremitus, hyperresonance unilaterally RF: tall, thin men, smokers, family hx, Marfan’s syndrome, previous episode
74
TXM Small (< 3 cm of air btwn lung and chest wall) PTX ; STABLE
Stable: tx conservatively w/ observation in ER; repeat CXR w/in 24 hrs and discharge if no change
75
TXM Large (> 3 cm of air between lung and chest wall) PTX ; STABLE / Severe on ventilation
Stable or symptomatic: needle aspiration Severe or on ventilation: place chest tube
76
TPTX Sxs / Needle D instructions for Tension PTX
S/Sx: severe tachycardia, hypotension, mediastinal or tracheal shift If suspected, large bore needle inserted immediately (needle-D): i. Btwn 2nd and 3rd ICS at mid clavicular line ii. Btwn 4th and 5th ICS mid axillary or anterior axillary line iii. Tube thoracostomy for definitive care
77
Large effusion PE findings
large effusions = dullness to percussion, diminished/absent breath sounds over effusion
78
SOC for Pleural Effusions
CT Chest
79
Lab findings EXUDATIVE vs TRANSUDATIVE
i. Exudative: protein > 0.5, LDH > 0.6, LDH > ⅔ upper limit of normal ii. Transudative: if none of exudative values are met
80
TXM for TRANSUDATIVE / Malignant Effusion / Hemothorax
i. Can remove up to 1.5 L to alleviate sxs ii. Transudative: tx underlying condition iii. Malignant effusion: chemo/radiation, therapeutic thoracentesis if sx iv. Hemothorax: large bore tube thoracostomy
81
Hemoglobin (oxygen affinity) is altered by what? (3)
a. pH (↑ = ↑ affinity for O2) b. PCO2 (↓ = ↑ affinity for O2) c. Temperature (↓ = ↑ affinity for O2)
82
Definition of respiratory f. By lab values
PaO2 < 60 (SaO2 of under 90%) and/or PaCO2 > 45
83
Decrease in what 2 electrolytes leads to hypoventilation
K Phosphate
84
Complications of acute respiratory f. (3)
Complications: stress gastric/ulcer, DVT, PE
85
4 causes of ARDS (4)
Common causes: sepsis, diffuse pna, aspiration of gastric contents, trauma
86
ARDS will often lab values consistent with?
PaO2/FiO2 < 300 mmHg The ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) is an indicator of pulmonary shunt fraction
87
What is PEEP? When is it used?
Positive end-expiratory pressure (PEEP) keeps the airways and small lung spaces open to allow for adequate oxygenation when a person cannot breathe on their own. If the lungs cannot oxygenate properly, the individual may need to be intubated and placed on mechanical ventilation to allow the lungs time to heal.
88
SaO2 goal on PEEP ventilation ; what position in ARDS
Over 88% -Prone
89
Describe septic shock
Type of distributive shock: peripheral vasodilation seen d/t warm extremities and compensatory ↑ in cardiac output S/Sx: fever, hypotension, tachycardia
90
SIRS Criteria
SIRS criteria (temp, pulse, RR, and WBC) a. Fever > 38.3C or < 36C b. Pulse > 90 bpm c. RR > 20 d. Leukocytosis (WBC > 12,000) or leukopenia (WBC < 4,000)
91
TXM Sepsis
a. Assess ABCs and replenish circulating volume → 1-2 L bolus of NS or LR b. No response to volume expansion = give vasopressor (Norepinephrine) c. Give abx ASAP (w/in 1 hr of recognizing sepsis)
92
Describe Anaphylaxis Hypersensitivity
Arises from activation of mast cells and basophils by cross linking of IgE and aggregation of high-affinity receptors for IgE
93
Ultimate shift of sxs in anaphylaxis
respiratory distress, ↓ LOC, circulatory collapse
94
TXM anaphylaxis
a. Airway, breathing, and circulation management b. IV fluids, O2, cardiac rhythm monitoring c. Epinephrine IM d. If pt is taking B-blockers, give glucagon (reversal agent) e. If IM epi fails → start Epi IV f. 2nd line: corticosteroids, antihistamines, vasopressors, glucagon, B2 bronchodilator

Internal Medicine (6 decks)

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