pulmonary hypertension + PE, DVT, pneumothorax

Question 1

complications of pulmonary hypertension

Answer 1

arteriosclerosis
hypertrophy of media of pulmonary arteries
fibrosis of intima
cor pulmonale (right sided heart failure due to lung disease)

Question 2

BMPR2: bone morphogenetic protein receptor type 2 mutation → ↑ vascular smooth muscle proliferation → reduced vessel radius, high resistance →↑ pulmonary arterial pressure
women around 36 yo
associated with HIV + karposi sarcoma (HHV-8)

Answer 2

primary pulmonary hypertension (idiopathic)

Question 3

complication of chronic lung disease (COPD, pulmonary fibrosis): poor oxygenation → vasoconstriction
secondary to mitral stenosis: ↑ resistance →↑ back pressure to LA, pulmonary veins, caps, then pulm artery
recurrent thromboemboli
autoimmune disease
L-to-R shunt (VSD): right side can’t handle increase R sided pressure
sleep apnea or high altitude: hypoxic vasoconstriction

Answer 3

secondary pulmonary hypertension

Question 4

purpose of BMPR2 protein

Answer 4

prevents proliferation of vascular smooth muscle

Question 5

associated with HIV + karposi sarcoma (HHV-8)

Answer 5

primary pulmonary hypertension (idiopathic)

Question 6

treatment of pulmonary hypertension

Answer 6

bosentan, ambrisentan
PG analog
sildenafil
nifedipine

Question 7

substances that cause for methemoglobin (oxidized form of Hb - ferric, Fe3+)

Answer 7

nitrates and nitrites (had MI, give for chest pain while waiting for cath lab)
antimalarial drugs: chloroquine, primaquine
dapsone (AIDS patient)
sulfonamides (prevent pneumocystis pneumonia)
local anesthetics: lidocaine
metoclopramide

Question 8

treatment for methemoglobinemia

Answer 8

acute: methylene blue, vitamin C
prevent: cimetidine (H2 blocker): gradually lowers level, use if on drugs that cause methemoglobin

Question 9

what is virchow’s triad: ↑ risk of blood clots

Answer 9

1) stasis: post-op/bed rest, long trip (many hours), cast, paralyzed, pregnancy
2) hypercoagulability: sickle cell, polycythemia, congestive heart failure, estrogen excess, cancer, smoking (don’t give OCP >35 yo), pregnancy, OCP
3) endothelial damage: fracture, post-op, postpartum, bacterial infection, foreign bodies, surgery
examples: fractured bone in cast on bed rest (2), postpartum women after Csection (3)

Question 10

venous return from lower extremities back to heart depends on

Answer 10

muscle contraction

valves in veins of legs

Question 11

UNILATERAL foot/ankle edema or lower leg
\+/- pain
\+/- Homan sign
\+/- palpable cord (vein)
measure calf to see if swollen

Answer 11

DVT

Question 12

homan sign

Answer 12

calf pain with ankle dorsiflexion with knee extended

not specific or sensitive for DVT (negative means nothing)

Question 13

diagnosis of DVT

Answer 13

immediate compression US (if high probability: red, painful leg, hx of cancer, hypercoaguable risk factors)
D dimer then US if +D dimer (low probability)

Question 14

prevention of DVT if in hypercoaguable state

Answer 14

heparin subq 2-3/day
LMWH: enoxaprin 1-2/day
compression stalkings or sequential compression device (SCD)

Question 15

treatment of DVT

Answer 15

heparin + warfarin → stop heparin once warfarin is therapeutic

Question 16

fibrin degradation product

elevated when plasmin is dissolving a clot

Answer 16

D-dimer

Question 17

negative D dimer

Answer 17

r/o DVT or PE (sensitive test - good for screening)

Question 18

complication of DVT

Answer 18

embolize → right heart → lung: PE

if patent foramen ovale → cross to left heart and enter brain: stroke

Question 19

pleuritic chest pain + hypoxia (mimics MI)
SOB (common), cough, hemoptysis (rare)
fever
*tachypnea
*tachycardia
*AMS (less responsive, sick appearing)/confusion
if seen in any hospitalized pt: r/o PE

Answer 19

pulmonary embolism

Question 20

saddle embolus =

Answer 20

sudden death

straddles bifurcation of pulmonary arteries→ no O2 blood

Question 21

treatment of PE

Answer 21

normally: heparin/warfarin
if massive (blocking pulmonary artery): thrombolysis (tPA, streptokinase, urokinase)

Question 22

↑ D-dimer
\+/- DVT on LE US
normal CXR
large A-a gradient on arterial blood gas (not profusing lung well)
\+/- ECG changes (S1Q3T3)
CT scan WITH CONTRAST: most common method of diagnosis
if bad kidneys: V/Q scan
pulmonary angiogram: invasive, not used

Answer 22

diagnosis of PE

Question 23

S1Q3T3 EKG changes that may be seen in PE

Answer 23

lead 1: deep S

lead III: large Q, inverted T

Question 24

V/Q scan

Answer 24

1) inhale radionucleide (ventilation phase) → see if any decreased uptake: pneumonia
2) during perfusion phase, inject contrast and see if any decreased uptake: PE

Question 25

long bone fractures → venous blood→ PE (stroke if PFO) | liposuction

Answer 25

fat embolus

Question 26

Caisson disease (decompression sickness) IV ventilator

Answer 26

air embolus

Question 27

bacterial endocarditis → clots throughout body

Answer 27

bacteria embolus

Question 28

emboli that can cause DIC postpartum | can present like PE

Answer 28

amniotic fluid embolus

Question 29

Caisson disease (decompression sickness)

Answer 29

gas embolus

Question 30

abnormal collection of air in pleural space | acts to separate lung from chest wall

Answer 30

pneumothorax

Question 31

no precipating event or lung disease (= secondary) tall, thin young males rupture of apical blebs

Answer 31

primary spontaneous pneumothorax

Question 32

UNILATERAL chest pain SOB +/- ↓ breath sounds on affected side

Answer 32

pneumothorax

Question 33

diagnosis of pneumothorax

Answer 33

see space between chest wall and lung CXR (hyperluscent = black vs PE is normal) CT scan

Question 34

every breath: air into pleural space and doesn't escape→ MEDIASTINAL DEVIATION TO OPPOSITE SIDE

Answer 34

tension pneumothorax

Question 35

treatment of pneumothorax

Answer 35

tension: immediate decompression of lung with needle | chest tube: needle in pleural space to remove air until lung repairs self and stops leaking air into pleural space