Flashcards in Pulm/CC Deck (69):
Name the 2 reasons for hypoxia with a normal A-a gradient.
Name the 3 reasons for hypoxia with abnormal or increased A-a gradient.
Patient presents with hypoxia and a normal A-a gradient when taking opiates/benzos?
Central respiratory depression (neuro disorder)
What drug causes foamy changes in lamellar inclusions on a BAL?
Amiodarone induced disease
How to interpret PFTs?
Obstructive: FEV1/FVC < 0.7
Mild FEV1> 80% = GOLD I
Moderate FEV1 50-79% = GOLD II
Severe FEV1 30-49% = GOLD III
Very severe FEV1 < 30% = GOLD iV
What is the only medication known to improve survival in COPD?
How does pulm rehab contribute?
Pulm rehab decreases healthcare costs and quality of life but does not impact survival
Name the hierarchy of asthma control inhalers?
Albuterol ICS LABA
And you can step down therapy
What BP med is best for asthma patients?
How do you diagnose asthma on PFTs?
Methacholine challenge test. 12% reversability and a 200cc increase with bronchodilators
Test question - you have a pregnant patient admitted for asthma, now improved, what do you do on discharge?
Send home on ICS as 30% will get worse with pregnancy
How do you diagnose exercise induced asthma and what is the treatment?
Exercise challenge test
albuterol 15-30 minutes before exertion
What the diagnosis? Young smokers with bulloous COPD, famhx liver/lung disease
Alpha 1 anti-trypsin deficiency
What testing do you perform for alpha 1 AT? What is the treatment?
serum level testing; genetic testing of Pi locus
Tx: weekly alpha 1 antiprotease infusions, does not treat liver disease
What's the diagnosis? Plumber with GI plaquing and pleural thickening on CXR?
What's the diagnosis? Young AA female with skin lesions on anterior legs, cough, dyspnea, uveitis.
Young AA female with pleural effusion that on tap is lymphocyte predominant
What's the diangosis? Arthritis, erythema nodosum, b/l hilar lymphadenopathy
What's the diagnosis? anterior uveitis, parotid gland enlargement, facial palsy, fever
What's the diagnosis? Premenopausal women, pneumothorax, chylous effusion (TG> 110), tuberous sclerosis. CXR with diffuse honeycombing
What's the next best step after diagnosis LAM?
always image the kidneys
What's the diagnosis? Upper respiratory tract dx, sinusitis, glomerulonephritis and ILD.
Granulomatosis with polyangiitis (Wegners)
What are the serology markers for Wegners?
c-ANCA & anti-PR3
What's the diagnosis? Upper respiratory tract dx, sinusitis, glomerulonephritis, ILD but (-) ANCA
Glomerular basement membrane disease
What's the diagnosis? URI, asthma, eosinophilia
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
What's the serology for Churg-strauss?
p-ANCA, anti-MPO assay positive
What's the diagnosis? Female patient with RA, weight loss, low fevers, dry cough for 2 months, failed treatment with multiple rounds of abx
Cryptogenic Organizing pneumonia
CXR often with migratory consolidations
Treatment for COP?
What's the diagnosis? Allergic rxn to aspergillus, chronic cough, mucus plugging, recurrent pulmonary infiltrates with eosinophilia, elevated IgE > 1000
Usually presents as difficult to control asthma
allergic bronchopulmonary aspergillosis (ABPA)
What is the order of diagnosis for ABPA?
What is the treatment?
2. Aspergillus antigen skin prick test
3. IgE > 1000
4. Serum specific A fumigatus antibody testing
5. Galactomannon test
Tx: Steroids + itraconazole
What are 2 markings you can see on imaging with suspected PE?
Westermark sign: lack of vascular markings downstream of embolism
Hampton's hump: wedge shaped defect from infarction just above the diaphragm
Management of a clinically unstable patient suspected of having PE?
what are the relative contraindications and absolute contraindications for thrombolytics?
Surgery within 10 days is a relative contraindication
Intracranial/intraspinal surgeries are absolute
What are the Wells criteria and number ranking?
Clinical signs/symptoms of DVT: +3
PE is #1 diagnosis OR equally likely: +3
HR > 100: +1.5
Immobilization at least 3 days OR surgery in the previous 4 weeks: +1.5
Previous diagnosis PE or DVT: +1.5
Malignancy w/ treatment within 6 months or palliative: +1
Low risk <2
Moderate risk: 2-6 pts
high risk: >6 points
What's the diagnosis? RLL infiltrate, consolidation, patient incapacitated
aspiration syndromes > 48 hrs before infection leading to chemical pneumonitis, cavitary/empyema
Treatment for aspiration syndromes?
Always think anaerobes. Amox-clavulanate (Augmentin), amp-sulbactam (Unasyn), clinda
What are Light's criteria?
Exudative effusion if:
-fluid prot/serum prot > 0.5
-fluid LDH/serum LDH > 0.6
-fluid LDH > 2/3 upper limits of normal
What are causes of exudative vs transudative effusions?
exudative: PNA, CA, PE
transudative: HF, cirrhosis, nephrotic syndrome/ESRD
Pleural effusion with adenosine deaminase
Pleural effusion with glu<60, glu<30?
<60: infectious, TB, RA, malignancy
<30: empyema, PE
pleural effusion in an AAF with increased lymphocytes =
Indications for CT on pleural effusions?
pH < 7.2, glucose < 60, positive cx or gram stain; loculated pleural thickening
What's the diagnosis? Immunocompromised patient with septate hyphae at narrow/acute angles?
Tx: Voriconazole IV
PNA: alcoholic, currant, jelly sputum
PNA: Gram stain with GN diplococci, COPD-er
PNA: rust colored sputum, lancet shaped G+ diplococci
PNA: reverse bat wing, infiltrate spares hilum
PNA in a young patient and can cause elevated d-dimer
PNA with pharyngitis, hoarsness, CAP in patients > 65 y/o
PNA from inhaled contaminated water, diarrhea, confusion
Patient presents with green sputum, alcoholic with dental caries
Bacteroides, Tx: clinda
Which is the most likely in an aspiration PNA isolate?
URI symptoms unresponsive to cipro
Southwest US fungus
Southern/Midwestern US fungus
Mid-Atlantic/Central/SE US fungus; broad based budding yeast
PNA in immunosuppressed patients, AIDS
Diagnose with GOmori methenamine silver stain (GMS)
In active Tb, give INH with ____ to prevent ____
pyridoxine (B6) to prevent neuropathy
Patient with resistant HTN, next step?
Lung cancer most associated with non-smokers and CEA tumor marker?
Lung cancer that is cavitary and can cause hypercalcemia
Lung cancer associated with SIADH, ectopic ACTH production, Eaton Lambert syndrome
What is the screening recommendation for lung cancer?
55-80 y/o with >30 pack year hx and currently smoking or has quit smoking in the last 15 years
What's the diagnosis? Asthma, allergic rhinitis, atopic dermatitis, food allergies, elevated IgE
Pulm HTN WHO classification
WHO 1 = Idiopathic (autoimmune, heritable, drugs/toxins, HIV)
WHO 2 = cardiac related (left heart failure)
WHO 3 = pulmonary related (COPD, ILD)
WHO 4 = CTEPH
WHO 5 = miscellaneous / multifactorial (sarcoidosis, histiocytosis, vasculitis, ESRD on HD)
Treat underlying cause
WHO 2 = heart failure
WHO 3 = treat copd
WHO 4 = anticoagulation
Remember CTEPH is best confirmed with V/Q scan
What's the diagnosis? Aspirin provoked dyspnea, cough, nasal polyps, asthma
Treat with montelukast
Infusion that can cause hypotension, erythema, urticaria
Next best step in patient with Gram (-) sepsis with refractory hypotension despite negative cx
R/o adrenal insufficiency
Drug for prevention of altitude sickness?