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Flashcards in Pulmonary 3 (Step up son) Deck (29):
1

A guy comes in and he's over 50yo concerned about progressive exercise intolerance and difficulty breathing. You notice dry crackles and JVD on exam. What would be seen on CXR, CT, PFTs, bronchioalveolar lavage, and biopsy that would indicate Idiopathic Pulmonary Fibrosis?

CXR: reticulonodular pattern (and honeycombing in advanced cases)
CT: ground glass appearance
PFTs: restrictive process
Bronchioalveolar lavage: increased PMNs
Biopsy: extensive fribrosis and loss of parenchymal architecture

2

How is IPF treated?

Corticosteroids AND either azathioprine OR cyclophosphamide (helps some patients...follow PFTs)

Lung transplant is often necessary...but rarely occur

3

Youngish black woman comes in with cough, weight loss, sore knees/ankles, chest pain, fever, erythema nodosum, vision loss, and facial asymmetry. What is a likely diagnosis? What is likely to be seen on CXR? Biopsy?

This is likely Sarcoidosis

Hilar lymphadenopathy and ground glass appearance

Noncaseating granuloma*

4

Youngish black woman comes in with cough, weight loss, sore knees/ankles, chest pain, fever, erythema nodosum, vision loss, and facial asymmetry. What would be seen on labs that would indicate that it is indeed sarcoidosis?

Increased serum ACE
Epitheloid macrophages increase vitamin D activation --> hypercalcemia and hypercalciuria
Increased alk phos
Decreased WBC
Increased ESR
PFTs show decreased FVC and decreased D(Lco)

5

Youngish black woman comes in with cough, weight loss, sore knees/ankles, chest pain, fever, erythema nodosum, vision loss, and facial asymmetry. A biopsy shows a noncaseating granuloma. How should this patient be treated? What needs to be considered when testing her for TB?

Sometimes self limited
Corticosteroids if chronic
Cytotoxic drugs if steroids don't work

Sarcoidosis typically causes anergy (no rxn) to PPD

6

A retired demolition man comes in complaining of worsening breathing and hacking stuff up all the time. On exam he has crackles, wheezes, and digital clubbing. What would be expected on CXR? Chest CT? PFTs? What else should be done?

This is asbestosis
CXR: multinodular opacities, pleural effusions, blurring of borders
CT: linear pleural/parenchymal fibrosis
PFTs: restrictive process
*Pleural biopsy*: asbestosis fibers

7

A retired sandblaster comes in with bad breathing and a productive cough. On CXR, small apical nodular opacities and hilar adenopathy is seen. What is the likely disease? What is this guy at increased risk of? What other professions is it common in?

Silicosis puts people at increased risk of TB infection

Mining, pottery, granite cutting

8

A retired coal miner comes in with increased shortness of breath and a cough that won't quit. What will likely be seen on CXR? PFTs?

Coal worker disease causes small apical nodular opacities on CXR and a restrictive pattern on PFTs

9

A retired electrical engineer comes in with a cough and diffuse granulomas. It sounds like he has pulmonary edema on exam. What does he have? what is likely seen on CXR? How should he be treated?

This is possibly berylliosis (also seen with ceramic, tool, and die manufacturing)

CXR: diffuse infiltrates and hilar adenopathy

Corticosteroid treatment to maintain respiratory function

10

A woman comes in with hemoptysis. She recently had a URI, but has otherwise felt well; but notes that her urine is frothy. So you get a CXR and a UA. What are you most concerned about at this time?

Goodpasture syndrome

11

A woman comes in with hemoptysis. She recently had a URI, but has otherwise felt well; but notes that her urine is frothy. So you get a CXR (bilateral alveolar infiltration) and a UA (proteinuria and granular casts). What special lab would you get? If positive, how would you treat?

Anti-GBM (glomerular basement membrane) antibodies are diagnostic for Goodpasture syndrome

Treat with plasmapheresis* to remove antibodies; corticosteroids and immunsuppressive agents

12

A patient comes in and has a bunch of complaints: lung issues, myalgia, sinus issues, nasopharynx ulcers*, hematuria, CNS issues, eye issues, and an arrhythmia. What is the concern? What should the next lab be? What would be seen on biopsies?

This could be granulomatosis with polyangiitis (Wegener)

Get a c-ANCA

Biopsy: noncaseating granulomas; renal vasculitic processes

13

A patient comes in with sudden onset SOB, CP, and a feeling of impending doom. On exam, the patient is tachycardic, tachypneic, and has decreased breath sounds in one of the fields. What imaging is best? What should be done for this patient?

Spiral CT is best

Treat with unfractionated heparin or LMWH; if UF-Hep, convert to either LMWH or warfarin for 3-6 months
Thrombolysis may be indicated if severe or if there are no cardiac contraindications, recent trauma, or surgery

14

What causes a louder S2 with pulmonary hypertension?

The pulmonic valve is being slammed shut from the increased pulmonary pressure

15

What treatment is indicated for patients with idiopathic or pulmonary reasons for pulmonary HTN?

Vasodilators...decreases incoming volume --> decreased pressure

16

What treatment is indicated for patients with idiopathic, embolic, or cardiac reasons for pulmonary HTN?

Anticoagulants...decreases risk of pulmonary thrombus formation

17

What causes pulmonary edema?

Left-sided heart failure
Valvular disease
ARDS

18

What labs/tests indicate a cardiac etiology to pulmonary edema?

Elevated BNP
Elevated Trop I
Increased Pulmonary Wedge Pressure (PWP)...>18mmHg

19

What causes pleural effusion? How is the cause often determined?

Changes in hydrostatic and oncotic pressure (transudative)
Inflammation (exudative)
Lymphatic duct rupture (lymphatic)

According to protein and LDH

20

A patient has a pleural: serum protein ratio less than 0.5, a pleural: serum LDH ratio less than 0.6, and total pleural LDH less than 2/3 the upper limit of normal serum LDH. What type of effusion is it? What are the likely causes?

This is a transudate

CHF, cirrhosis, and nephrotic syndromes all mess up the hydrostatic and onotic pressure

21

A patient has a pleural: serum protein ratio >0.5, a pleural: serum LDH ratio >0.6, and total pleural LDH >2/3 the upper limit of normal serum LDH. What type of effusion is it? What are the likely causes?

This is an exudate

Infection, cancer (25% of all effusions), and vasculitis all cause inflammation

22

How can recurrent malignant effusions be treated?

Pleurodesis (talc or other irritant)

23

What are the common causes of a pneumothorax?

PAIN, CHEST

P-Pneumothorax is caused by:
A-Asthma
I-Iatrogenic
N-Neoplasm
C-Cystic fibrosis
H-HIV
E-Emphysema
ST-Spontaneous Trauma

24

When does a PTX require a chest tube?

When it is large...>15% of lung field
When it is open and small
Tension pneumothorax AFTER needle decompression

25

How is a large open pneumothorax treated?

Attempted closure...low threshold for intubating

26

What can happen if a hemothorax is not drained?

Fibrosis

27

How is malignant mesothelioma treated?

Extrapleural pneumonectomy with adjuvant chemo and radiation
Just chemo for unresectable disease

28

What is a common Epworth sleepiness score with sleep apnea?

> 10

29

How long does it typically take for pneumonia to set in after prolonged atelectasis?

> 72hrs