Pulmonology -10% Flashcards

Question

Influenza

Answer 1

Viral respiratory infx by orthomyxovirus (three strains A, B, C) sxs * fever, **coryza**, cough, headache, malaise * uncomplicated - body aches and fever * complicated - dyspnea + above Dx * rapid **antigen test** in clinic * rapid serology more accurate * CXR - **bilateral diffuse _infiltrates_** Tx * symptomatic for most * antivirals w/in \< 48 hrs * Tamiflu/**Oseltamivir** or Zanamivir/Relenza for influ A & B * Zanamivir - c/i in kids \< 7yo powder * Prevent yearly vaccine - trivalent/quadvalent killed or live attenuated intranasal * Gullain Barre or egg allergy

Answer 2

Pleurocentesis to determine if Pleural fluid is exudative: 1. Pleural fluid protein / serum protein \>0.5 2. Pleural fluid LDH / Serum LDH \>0.6 3. Pleural fluid LDH \> 2/3 ULN serum LDH Exudative - infection, malignancy, immune, MCC - pna, CA, PE, TB

Answer 3

35-40% of cases MC type of bronchogenic carcinoma 30-40% MC mucous cells **_non-smoker_** w/ incidental finding and small **_peripheral_** lesion

Answer 4

1-2% tumor that produces excess serotonin (niacin B3 deficiency) Pink purple leasion in the central airway resistant to chemo/radiation surgical excision

Answer 5

Two major categories 1. Small Cell Lung Cancer (SCLC) - 15% and poor prognosis 2. Non-Small Cell Lung Cancer (NSCLC) - 85% * Ad * adenocarcinoma * squamous cell carcinoma * large cell carcinoma * carcinoid tumor Sx * Cough * Dyspnea, * chest pain * hemoptysis - airway involvement * Wt loss - B signs - weight loss, fever, nt swts Dx * CXR to screen * **Bronchoscopy and biopsy or FNA - gold standard** * Squamous Cell or SCLC - central mass * Adenocarcinoma - peripheral mass * LC and Carcinoid - throughout lungs * TNM Staging

Answer 6

rare 5% rapid doubling time rarely response to surgery peripheral

Answer 7

15% ; Highly aggressive always occurs in smokers rapidly growing, mets by dx ; **mediastinal mass** **_cannot be tx with sx, needs chemo/XRT_** a/w * ACTH and ADH - hyponatremia and hypercalcemia * Lambert-Eaton myasthenic syndrome - muscle weakness of limbs d/t ACTH/ADH * SVC syndrome * Horner syndrome * SIADH - decr Na

Answer 8

25-35% of cases Bronchial in origin and centrally located mass MC in smokers likely to have **persistent cough, recurrent PNA,** **hemoptysis,** **central bronchus** solitary tumor **\*\* Hypercalcemia \*\* paraneoplastic syndrome**

Answer 9

_NSCLC_ Surgical resection Adj chemo and Radiation if advanced (Stage 4 = palliative (mets) _SCLC_ **chemo only** 5 year prognosis = 15%

Answer 10

A/w Squamous Cell Carcinoma tumor at lung apex, apical mass crushes **brachial plexus** + **cervical sympathetic chain** * Shoulder pain * UE weakness * **Horner's syndrome - miosis, anhidrosis, ptosis**

Answer 11

Whooping cough - severe hacking cough followed by high pitched intake of breath (sounds like whoop) Gram neg bacteria = **Bordetalla pertusis** Consider in **adults with cough \> 2 wks**, patients \< 2yo 1. catarrhal stage - cold like sxs, poor feeding, sleeping 2. Paroxysmla stage - high pitched **inspiratory whoop** 3. Convalescent stage - residual cough (100 days) Dx - Nasopharyngeal swab of secretions and culture Tx - with M**acrolide (clarithomycin/azithromycin)** * supportive care w/ steroids + B2 agonists * vaccinations * 5 doses - 2, 4, 6, 15-18mos, 4-6 yrs (DTap) * 11-18 yo = 1 dose Tday * Expectant mothers Tdap each pregnancy at 27-36 wks

Answer 12

Accumulation of excess fluids in pleura space Sxs * dyspnea * vague discomfort or sharp pain that worsens during inspiration * **decrease tactile fremitus, decr absent breath sounds** Dx * Determine whether pleurocentesis * **exudative** (infection, malignancy, immune) or * **transudative** (transient changes in hydrostatic pressure - cirrhosis, MCC CHF, nephrotic syndrome, ascites, hypoalbuminemia * **Lateral decubitis CXR** * Isolated L Pleural effusion = exudative * R sided = transudative * Chest CT * **US - guided thoracentesis - gold** Tx * **Thoracentesis**

Answer 13

Inflammation of tissues that line lungs and chest cavity (pleura) sudden, intensely sharp , stabing, burning pain in chest when inhaling and exhaling exacerbated by deep breathing, coughing, sneezing, or laughing **MCC - PNA, pericarditis, pericardial effusion, pancreatitis**

Answer 14

**S pneumo \> H influ \> Moraxella catarrhalis** = show on gram stain **Atypical - Legionella, Mycoplasma pneumo, Chlamydophila pneumo** Sxs * fever, dyspnea, cough, myalgias, rigors/sweat, new cough * +/- sputum - rust - pneumococcal * *S pneumo* - single rigor, pleurisy * *H influ* - underlying COPD * *Legionella* - **high fever**, hypoNa, bad abd pain + diarrhea, appears more ill than CXR * *M. pneumo* - walking pneumo, extrapulm sxs **bullous myringitis (bloody TM)** Dx * CXR - Patchy, segmental **lobar**, multilobar **_consolidation_** * Blood cultures x 2 - only inpatient * Sputum gram stain Tx * Outpatient - **macrolides (azithromycin**), **_Doxy,_** resp FQ (Levofloxacin) * Pneumococcal =\> tx until pts afebrile for 72 hrs (x5d) * atypical pna (legionella, pertussis) =\> x 2-3 wks * Inpt - **_Ceftriaxone + azithromycin_**, or resp FQs * Prevnar and Pneumovax - vaccines

Answer 15

Common in IMC pts (AIDS, steroid use, organ transplant) _Coccidiodes_ (valley fever) * non remitting cough/bronchitis non responsive to conventional tx * Fungal inhalation in **Western States** * Dx with ELISA for IgM and IgG * Tx with **fluconazole/itraconazole** _Pulmonary aspergillosis_ - health immune systems * **fluconazole/itraconazole** _Cryptococcus_ - soil, disseminate and amenintitis * LP for meningitis * Tx with **amp B** _Histoplasmosis_ - apical pulmonary lesions resembling cavitary TB, worsening cough and dyspnea, progression to disabling respiratory dysfx * **bird or bat droppings** - Mississippi Ohio River Valley * Signs - mediastinal or hilar LAD (sarcoid) * tx with **amp B** _HIV - PJP (Pneumocystis jiroveci)_ -Common in HIV pts with CD4 count \< 200 * CXR - diffuse interstitial or bilateral **perihila**r infiltrates * dx - bronchoalveolar lavage PCR, labs, HIV tests, low O2 despite supplemental oxygen * Tx with **bactrim** and steroids

Answer 16

Adults - Flu MC Kids - RSV quick onset Dx * CXR - bilateral interstitial infiltrates * rapid antigen testing for flu * RSV nasal swab * cold agglutinin titer negative Tx * Flu with Tamiflu (A & B) if sxs \< 48hrs onset * symptomatic tx = B2 agonists, fluids, rest

Answer 17

Pulmonary fibrosis with a known cause **Abestosis** * Insulation, demolition, construction * CXR - reticular, linear pattern, w/ basilar predominancy, opacities, honeycombing * can turn into mesothelioma **Coal Workers** * coal mining, * Nodular opacity in upper lung fields; hilar adenopathy not necessarily prominent **Silicosis** * mining, sandblasting, stone or quarry work * **eggshell calcification of hilar nodes** * incr risk of TB and progression to massive fibrosis **Berylliosis** * high tech fields, nuclear power, ceramics, foundries * diffuse infiltrates, **hilar adenopathy** * req's chronic steroids

Answer 18

Collapsed lung caused by accumulation of air in pleural space _Spontaneous vs traumatic_ * primary - abs of underlying dz (tall, thin, male age 10-30 at greater risk), smoker * Secondary - presence of underlying dz (**COPD,** asthma, CF, ILD) _Acquired_ * Iatrogenic * Traumatic -\> penetrating or blunt trauma * Barotrauma - mechanical ventilation SXS: * Acute onset ipsilateral chest pain and dyspnea - **decreased tactile fremitus** * deviated trachea * **hyperresonance** * Diminished breath sounds Tx - depends on size * **small \< 15%** of diameter of hemithorax - resolves spontaneously w/o chest tube placement * **large \> 15%** diameter & symptomatic - chest tube placement * Serial CXR q 24 hrs until resolve

Answer 19

blockage in one of pulmonary arteries in lungs MCC - deep veins of LEs RF: * Virchow's Triad * Hypercoagulable state (sx, CA, OCP, preg, smoking, long bone fracture) * Venous stasis * Epithelial injury Sxs * Dyspnea MC * pleuritic chest pain * Tachycardia --\> EKG with **S1Q3T3, non spec ST waves** * Tachypnea

Answer 20

**Hemodynamically stable** 1. Anticoags * **UFH or LMWH =\> Warfarin** - 3 mos bridge with heparin 3-5 days * INR range 2-3 * LMWH and hep for cancer and pregnant patients\*\* * factor Xa inhibitors **Rivaroxaban or** PO Direct Thrombin Inhibitors **Dabigatran** * Minimal antigoag for 3 mos w/ reversible RFs * if unprovoked - 6 mos then reeval * If two eps unprovoked - long term anticoag 1. **IVC filter -** stable pt who can't take anticoags or unsuccessful UNSTABLE 1. **Thrombolectomy** - if unstable or massive PE

Answer 21

MCC LRTI in children - get by age 3 leading cause of PNA and bronchiolitis sxs * Rhinorrhea * wheezing/coughing that persists for months * low grade fever * nasal flaring/retractions * nail bed cyanosis Tx * hospitalization if * tachypnea w/ feeding difficulties * visible retractions * O2 Sat \<95% * Supportive care * albuterol via neb * antipyretics * humidified O2 * Steroids (controversial) * Resolves in 5-7 days Vaccines for children with lung issues or premature --\> **synagis prophylaxis (palivizumab)** 1x/m for 5 mos in Nov

Answer 22

Granulomatous disease =\> **noncaseating granulomas** that affects multiple organ systems 20-40yo, Northern europeans or AAs Sxs * fever, weight loss, arthralgias, erythema nodosum Dx * Hypercalcemia; **ACE levels x 4 UNL** * ele ESR * Biopsy of peripheral lesions or fiberoptic bronch for central pulm lesions * Serial PFT for progression Tx * Corticosteroids, methotrexate, immunosuppressive meds * ACE-I for periodic HTN

Answer 23

**USPSTF** **Annual low dose CT, if** * 55-80 yo * \>30 pack year hx * current smokers or * quit within last 15 years Incidental finding on CXR * send for CT * if suspicious - need bx * Ill defined borders, lobular or spiculated = cancer * If not suspicious \< 1cm * monitor q 3mos, 6 mos, yearly for two years * calcifications, smooth, well defined edges = benign Mets- Adeno and Small cell = BRAIN METS bone

Answer 24

a/w SCLC obstruction of SVC by tumor resulting in * facial fullness * JVD * dilated veins in anterior chest

Answer 25

penetrating injury -\> air in pleural space increasing and unable to escape **_Mediastinal shift leading to TRACHEAL deviation to contralateral side or severe JVD_** CXR = pleural air ABG = hypoxemia medical emergency - large bore needles to allow air out of chest **Needle decompression - 2nd ICS, midclavicular line, above rib**

Answer 26

**Mycobacterium tuberculosis** RF - endemic area, IMC (HIV), recent immigrants (\<5yo), prisoners, health care workers transmission - inhalation of aerosolized droplets Sxs: * fatigue, productive cough, **bloody sputum** * **night sweats**, wt loss, post tussive rales * miliary TB = spread outside lungs - neuro or GI * vertebral column (Pott disease) Dx: * **Sputum for AFB smears** - have to be 3 AFB negatives * NAAT - quicker dx * CXR - cavitary lesions, infiltrates, **ghon complexes** in **apex of lungs** * Bx - **caseating granulomas**

Answer 27

_Empiric tx_ PPD + & CXR negative - **latent TB** =\> **Isoniazid 9 mos +B6 for neuropathy** PPD + & CXR positive - active TB =\> quad therapy (RIPE) x2 mos, then 2 drugs for 4 mos * **Rifampin** - red orange urine, hepatitis * **Isoniazid** - perip neuropathy (B6 pyridoxine 25-50mg/day) * **Pyrazinamide** - hyperuricemia (gout) * **Ethambutol** - optic neuritis (eye changes), red green blindedness _Need two negative AFB smears and cultures to stop therapy_ Prophy isoniazid for household members - for 1 year dc therapy if transaminases \> 3-5 x ULN

Answer 28

PPD - Tb skin test **Mantoux Test Rules** - tests positive if * \>5mm at high risk, fibrotic changes on CXR, IMC HIV/Drugs, steroids/TNF antagonist daily, or close contact w/ infectious TB * \> 10mm in pts \< 4yo, and risk factors = health care facilities, IVD, recent immigrants with high prevalence, renal insufficiency, prison, homeless shelter, bypass surgery * \> 15mm if no other risk factor

Answer 29

Negative suspicion - rule out

Pulmonology -10% Flashcards

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