Pulmonology Flashcards Preview

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Flashcards in Pulmonology Deck (123):
1

Which ribs will appear larger on a lateral cxray?

the right ones because these are getting the exposure first

2

If you order a PA cxray what should you also always order?

lateral to get depth

3

what are the 5 things to determine if a chest X-ray is adequate?

penetration (spine should be visible through heart), rotation (spinous processes should be equidistant between clavicles), inspiratory effort (8-10 ribs), magnificantion (of heart in AP view), angulation (clavicle should have an S appearance)

4

what are the ABCDEFs of reading a chest X-ray after determining that its adequate?

airways, bones and soft tissues, cardiac silhouette, diaphragm, effusion (pleural), fields (lung fields)

5

what are the 4 things to look for in an abdominal radiograph?

bones, stones, gas, masses

6

what will a healthy small bowel look like on an abdominal X-ray?

centrally located, diameter

7

what will a healthy small bowel look like on an abdominal X-ray?

frames the image, transverse colon should be

8

asthma: pathophys, triggers/etiology, sx, signs

pathopys: bronchospasm
triggers: triggers: infection, tobacco smoke, allergens, stress, exercise
sx: wheezing, cough, dyspnea, chest tightness
signs :wheezing, prolonged expiration, hypoxia

9

pneumonia: pathophys, triggers/etiology, sx, signs

pathophys: starts with infection. Alevoli fill with fluid leading to impaired gas exchange.
eti: s. pneumnoia, m. pneumonia, c. pneumnoia
sx/signs: sx: cough, +/- sputum, fevers, chest pain, dyspnea; signs: hypoxia, rales, bronchial breath sounds, dullness to percussion

10

what is COPD? pathophys, RFs, sign/sx, complication

emphysema/alveolar wall destruction and reduced surface for gas exchnange, decreased lung elasticity. Assoc w/ chronic bronchitis=inflammation/obstruction of larger airways. Irreversible.
pahtophys: alveolar wall destruction and reduced surface for gas exchnange, decreased lung elasticity leads to small airway collapse and obstructed flow.
RF: smoking
signs/sx: SOB, wheezing, coughing with sputum signs: wheeze, rhonchi, prolonged expiration, hypoxia
complication: complication of chronic bronchitis/infection=ectasia/thickening of bronchi and mucus pooling/plugging

11

what is PE? what are signs and sx? RFS

embolus blocking pulmonary artery branch; area of lung no longer perfused by blood resultng in reduced oxygenation
signs/sx: sharp and pleuritic pain, acute onset, associated with dyspnea, may be preceded by calf pain, well localized, may have accompanying couhg or bright red hemoptysis. Signs of tachypnea, hypoxia, possible pleural rub (less common)
RF: immobilization, recent lower extremity vascular trauma, cancer, obesity,smoking, pregnancy, OCP

12

lung cancer RFs, signs/sx

RFs: smoking, radon, asbestos
signs/sxdyspnea, chronic cough, hemoptysis, CP, weigh loss; signs: nonspecific

13

pneumothorax RFs, sx and signs

RFs: tall, skinny male, trauma, iatrogenic
signs/sx: dyspnea, hypoxia, chest pain; signs: >HR/RR, hypoxia,

14

what can a CT scan dx?

to dx PE, lung ca, pneumonia, aortic dissection

15

which test has a continuous rotating X-ray beam and a quicker high resolution than conventional CT?

spiral CT

16

what test is used for those suspected of PE who can't tolerate the contrast in a CT scan?

V/Q scan

17

how is a V/Q scan performed? what is normal?

pt inhales a radionuclide to assess airways into lungs and they are also given an IV radonuclide injection to assess blood circulation through pulmonary arteries. Results are categorized as normal, low probability, intermediate probability and high probability, although low and intermediate don't rule out pE. normal test if all areas of air/blood match up. discrepancies should be investigated

18

what shows a PE on a V/Q scan?

Need to look in the periphery away from the hilum because the hilum doesn't get much blood. if there is an area of filling defects in the periphery, then that shows that blood is not gettng there.

19

what's an advantage of CT over a V/Q?

V/Q only assesses for pE, while CT can screen for alternate diagnoses. Similar cost.

20

what test is the gold standard for PE? how is it done?

pulmonary angiography; catheter instered under flouroscopy into the pulmonary arteries followed by dye injection and x rays

21

when is a d dimer done? in what cases do you need further follow up? why?

test for DVT, PE: a fibrin-degradation product released by clots during fibrinolysis. need to f/u if elevated because its vey sensitive but not very specific. False positives with inflammation, cancer pregnancy, advanced age, trauma.

22

what are some of the indicaitons for a bronchoscopy?

to look for tumors, sources of hemoptysis can also bx. ,low risks of bleeding, vocal cord trauma, pneuothorax, can also wash "lavage" and culture the fluid

23

what positions are used for very sick pts and pleural effusions for CXR?

PA best. AP for very sick pts that can't stand up, but heart shadow will be larger. Supine fi really sick but diaphragms are higher and lung volume is decreased. Lateral decubitus to show pleural effusions because these will level out when sideways.

24

what does the silhouette sign signify? where is it often seen?

silhouette sign: if a pulmonary opacity is in contact with the heart border, then the heart border will be obscured which is often seen in rml and left lingular infiltrates.

25

wht do you call airfield bronhioles within in an area of consolidation?

airbronchograms

26

what are kersey b lines and what do they signify?

they are horizontal lines seen on a cxr that are found in the lower lung periphery and are significant for pulmonary edema

27

what kinds of signs can be seen in someone with CHF on a CXR?

chest xray may show cardiomegaly, cephalization of pulmonary flow (redistributio of flow to upper lung fields), intersitital edema, Kerley B lines, fluid in fissures, pulmonary edema, pleural effusions

28

what kinds of findings can be seen in someone with pneumonia?

infiltrates settling in lower part of the lobes, silhouette sign if consolidation/infilitrate in RML or lingula

29

if a pneuothorax is suspected, what is the best way to see it?

have the patient breathe out then take the xray

30

what CXR changes are seen in someone with COPD?

diffuse hyperinflation with flattening of diaphragms

31

what do you do to tx a tension pneumothorax?

emergent needle thoracotomy to release air

32

what's the world 2nd deadliest infectious disease?

TB

33

RFs for exposure, RFs for contraction

RF exposure: at higher risk of exposure: foreign born, travel to TB prev. countries, residents+employees of crowded housing: NH, prisons, hosptials, close contects of infected, high risk pops: medically underserved, lower SES, susbstance abusers, or health care workers serving those pops, kids and teens exposed to ^risk adults
R/O contraction: HIV, infected w/I past 2 yrs, infants and children, certain med conditinos, drug users, hx of poorly tx'd TB, DM, corticosteroid or immunesuppessive tx, cancer of head and neck, hematologic and reticuloendothelial disease, end stage renal disease, intestinal bypass or mastectomy, chronic malabsorption syndrome, low body weight (10% lower than ideal)

34

is a latent TB infection infectius?

no

35

how is TB transmitted?

via droplets. 1 bacilli per droplet, 500 droplets per cough.

36

what is the progression of TB/

Progression:2-8 wks in alveoli, after macrophages ingestion=granuloma/tubercle, which is latent. Becomes infectious if immune system can’t control it=multiply in any area of body

37

does a negative rxn to either TST or IGRA rule out TB?

NO

38

who should the BCG vaccine be considered for?

Not rec'd in US. can be given to children who are continually exposed to untreated or poorly tx'd adult. consider giving to health care workers on a case by case basis for those who are at risk of transmission of a drug resistant TB strain. never give BCG to people with immunosuppresion, HIV, or pregnancy.

39

what's a positive tuberculin test? how long will it stay positive?

>5mm is positive. will stay "positive" for at least a week. 5 mm is a positive test in someone with HIV, recent contact with a case, fibrotic changes or CXr showing old TB, pts with organ transplants or immune suppressed. 10 mm is positive in recent arrivals from high prevalence countries, IV drug users, residents/employees of high risk congregate settings, mycobacteriology lab personnel, persons with clinical conditions that place them at high risk, children

40

what do you do if a pt forgot to come in within the 72 window to have their TB test read and it looks negative?

If forgot to come back within 3 days and its negative, need a retest. Never let them say they're mom is a nurse and she can check it at home. Many variations of interpretation.

41

when should you give a PPD with regards to live vaccines?

either day of or 4-6 wks after.

42

how long does it take after infection for a persons's test aka immune response to work and show a positive test?

2-10 wks

43

what can cause false negative results in a TST test?

may get false negative from anergy, viral, bacteiral or fungal co infection, recent TB infection, very young or very old, overwhelming TB disease, live virus vaccine, renal failure/disease, lymphoid disease, low protein states, immunosuppressive drugs, problems with TST administration

44

what are the sx of TB?

prolonged cough (3 wks or longer), hemopytsis, chest pain, loss of appetite, unexplained weight loss, night sweats, fever, fatigue

45

can a medical exam be used to rule in or out TB?

NO

46

what are other sx someone with TB may experience if the disease has spread to other areas?

May have extrapulmonary TB: blood in urine, headache or confusion, back pain, hoarsness, loss of appetite, weight loss, night sweats, fever, fatigue. pE can't be used to rule in or out TB.

47

what are common findings on a cxr of someone with TB?

CXR: often apical or posterior areas of upper lobe will show abnoralities like differences in size, shape, density; cavities, infiltrates, nodule, lymphadenopathy, calcified granulomas, fibrotic or pleural scars

48

what are the requirements for follow up after a positive CXR, TST, or IGRA?

sputum collection (at least 3 sputum specimens at 8-24 hour intervals, at least 1 in AM. Can get sputum via coughing, sputum induction, bronchoscopy or gastric aspiraiton if it keeps getting swallowed) and AFB smear. AFB smear provides a preliminary presumptive dx of TB and is categorized as 4+, 3+,2+,1+

49

if someone has positive tests for TB and is suspected of it and you have taken a specimen or AFB smear, what do you do next?

treat them as positive and send on the DNA probes to MDH.

50

what is the gold std for confirming dx of TB?

culture

51

who should get drug susceptibility testing?

all original cases of m. tb isolate and any subsequent ones that don't respond to tx

52

what are some of the signs of non pulmonary TB?

blood in urine, headache or confusion, back pain, hoarsness, loss of appetite, weight loss, night sweats, fever, fatigue, scrofula (lyphadenitis in neck) or gibbus deformity (spinal curved and weird looking), vision changes

53

what is always the best way to tx someone for TB?

direct observation with public health. adherence is a problem.

54

T or F: you should always start by adding a single drug first to a TB treat ment that a pt isn't responding to

F. never add a single drug. always add 2 because it means the organism is gaining resistance.

55

what are some good resources for drug resistant organisms?

National Jewish Hospital-Denver, Heartland TB Center Texas

56

when are TB pts considered not infections?

pts considered not infectiou s if: 1) on adequate tx 2) significant clinical response to tx 3) 3 consective negative sputum smear results

57

what is sleep apnea?

decrease in cross sectional area of pharynx combined with dysfunctinoal muscular tone

58

what kinds of things can OSA exacerbate?

Less common is a central absent drive to breathe.not sleeping exacerbates mood disorders, increases stress hormone which leads to worse wt, and nocturia because they are awake which can lead to falls in elderly.

59

what are the RFs for OSA?

obesity, male gender, advanced age, nasal obstruction or congestion, adenoidal or tonsillar hypertrophy, micrognathia, macroglossia, acromegaly, hypothyroidism, vocal cord paralysis, neuromuscular diseases, pregnancy, stroke, smoking, menopause, FH, alcohol use, cerain meds (benzodiazepines, narcotics)

60

what are some of the possible pE findings in someone with OSA?

often BMI >30, crowded oropharygneal airway (assess via mallampati classification), large neck circumference (collar >17 inches), HTN

61

what test is the gold std to dx OSA? how is the severity categories?

sleep study is gold std. then categorized by number of obstructive events with apnea hypopnea index; 5-15 events is mild; 15-30 is moderate disease 30+ is severe disease

62

what are some of the complications/risk factors from OSA?

Death b/c of cardiovascular events, daytime sleepiness, systemic HTN, pulmonary artery HTN, cardiac arrythmias, DM, metabolic syndrome, depression

63

how do pediatric cases of OSA present differently? what are they at risk of?

they may only present with inattention, aggression, hyperactivity, somatic complains, anxiety/depression. They are at risk of impaired neurocognitive fcn impairment, learning ability and academic performance.

64

which lobes are usually affected in TB?

upper lobes

65

what primary sx and associated sx are typically of bronchitis?

cough x5 days or more +/- sputum any color. Associated sx: rhinorrhea, nasal congestion, myalgias and arthralgias, dyspnea or SOB wheezing, sore throat (URI sx) (if it started with URI sx its probably a virus. Hx of sx not being any better or worse

66

what is bronchitis?

inflammatory process of bronchi and airway hyperreactivity due to infection

67

what is the normal pathogen that causes bronchitis?

usually viral : usually viral: influenza A, B; coronavirus, rhinovirus, respiratory synctial virus. If bacterial, usually mycoplasma pneumoniae, chlamydia pneumonia

68

what is the general sequence of events for pt ed with regards to a disease dx?

tell them what they have, what that means/how it happened, tell them what causes it, tell them what sx cause it and tell them what pharm and non pharm tx they can do. then follow up if...

69

what do you tell a bronchitis pt about when to follow up?

return if 1) it gets worse or 2) your sx don't improve in 3,4,6 weeks--depending on when they came in, or3) if you get a fever or 4) have a rxn to a med

70

what are some possible complications of bronchitis?

bacterial superinfection, pneumonia (5%), Chronic bronchitis, reactive airway disease

71

what are some PE findings in bronchitis?

may have +/- rhonchi, +/-wheezing, +/-coarse breath sounds

72

whats the tx for bronchitis and how long does it take for them to get better?

tx sx: albuterol (bronchodilator) and antitussive. Rarely abx. Non pharm: fluids, rest. (not caffeiene or alcohol); usually better in 1-3-6 wks.

73

what are the 3 cardinal marks of pneumonia?

abnormal lung fcn, infiltrate on chest radiograph, sx of acute infection

74

what are the 3 different kinds of pneumonia?

community acquired (CAP), Hospital acquired (HAP), Health care associated (HCA)

75

what are the typical and atypical bacterial pathogens assoc with pneumonia?

S. pneumonia, H flu are typical. atypical are mycoplasma pneumonia, chlamydophila pneumonia, and legionella pneumonia. less common are viral or fungal infections

76

what are the RFs of pneumonia?

recent viral infection, hx of pneumonia, hospitalization (esp ICU), recent major surgery, smoking, COPD, seizures, disordered swallowing, immunosuppression, heart disease (comorbidity), etohism, illicit drug use

77

which common pathogens of pneumonia are typically associated with which RFs?

pneumococcal: alcohol use, smoking, COPD, asplenia, immunocompromised
klebsiella: chronic disease: DM, malignancy, COPD
Legionella: chronic lung disease, smoking
PCP (pneumocystis jirovecci pneumonia): immunosuppressed and HIV
aspiraiton: anaerobes, mixed

78

what are some of the signs and sx of pneumonia?

sx: cough, +/- sputum,+/- hemoptysis, fevers, pleuritic chest pain, dyspnea, temp >100.4, rigors, sweats, fatigue, myalsias, N/V/D, mental status change (esp in elderly); signs: hypoxia, crackles, bronchial breath sounds, dullness to percussion, e-a changes on egophony, abnormal tactile fremitus or bronchophony, may be tachycardic, tachypnic

79

what kinds of tests would you do on someone suspected of pneumonia? what's the most common?

MC is CXR. CXR for infiltrate or consolidation. WBC looking for left shift. Certain risk groups: PCR, antibody titers, CRP, PCT, BNP (HF). If hospitalized: ABG, BMP, blood culture, sputum culture and gram stain. Severe: urine antigens (S. pneumo or L pneumo)

80

when should a CXR be considered for pts suspected of pneumonia?

IF one of: fever>100, HR >100, RR>20 or two of: decreased breath sounds, crackles, absence of asthma

81

what might you see on CXR of someone with pneumonia?

lobar consoidation, interstitial infiltrates or airbronchograms on CXR.

82

what are two tests that are used to stratify risk of whether or not a pt should be tx'd outpt or input?

CURB65 and PORT

83

what are the pharm and non pharm ways to tx pneumonia?

NON PHARM: fluids (more than normal), rest. Pharm: abx, sx: NSAIDS, tylenol to reduce fever, honey, cough suppressants

84

when is the normal time frame to give PCV13? what are the catch up recommendations?

all kids 2 yo, 2)got older versions of a vaccine,is

85

which pathogen usually causes lung abscesses?

usually anaerobes or oral flora

86

what are the RFs for aspiration (and thus lung abscesses)

aspiration RFs: oral cavity disease, altered level of conscioiusness or etohism, esopagheagl disease (reflex, achalasia, esophageal obstruction, depressed gag reflex), bronchial obstruction (tumor, FB, stricture) or immunocompromised (corticosteroids, malnutrition, chemo)

87

what are some of the signs/sx of lung abscesses?

hx of fever, night sweats, cough, sputum (red flag if putrid or sour tasting), weight loss, anemia, gingival, abnormal lung sounds +/- signs of consolidation

88

where is it common to find abscesses in the lung?

CXR: +/- infiltrate with cavity (necrosis), post. Part of RUL and sup. Segment of RLL).

89

when would you consider surgery for a lung abscess?

if hemoptysis that doesn't resolve or tx failure of need for tx dx

90

what are the signs and sx of empyema?

sx: cough, fever, pleuritic chest pain, dyspnea, sputum
signs: crackles, decreased breath sounds, decreased tactile fremitus, dullness to percussion

91

how do you tx an empyema?

abx, drainage, fibrinolytics sometimes necessary

92

what are the 3 kinds of vaccine?

live attenuated (weakeneed whole cell), inactivated (inactivated whole cell organism), acellular (fragments)

93

who should adverse events of vaccines be reported to?

vaccine adverse event reporting system.

94

what two characteristics are highly suggestive of pertussis?

paroxysms of cough with whoop and post tussive emesis and exhaustion

95

what things are reportable to MDH regarding reportable disease?

any new cases,any new diseases, any unusual presentations of disease, dangerous or unusual diseases, and recurrence of diseases thought to be eradicated

96

you have a patient with paroxysms of cough and post tussive vomiting. its been 2 weeks. what's the best test to do and how do you make the dx?

fits the clinical index for pertussis: tx with abx esp if live in close quarters but also do a PCR + serology. (too late for culture--the bug has moved down)

97

Influenza:
epi,
eti,
transmission
complications
conditions
sx,
tests,
ddx,

dx,
tx,
pt ed

eti: mostly seasonal, seasonal, avian, novel H1N1 influenza or Influenza B
epi, These seasonal outbreaks affect 10-20% of general pop and 15-42% of school age kids! >200,000 influenza related hospitalizations per year. 36,000 die per year, esp in very old and very young.
transmission: droplets
conditions: nursing home resident, chronic medical conditions like pulmonary disease, asthma, CVD, chronic renal insufficiency, DM, immunosuppressed. American indian/alaska native, >65 yo, morbid obesity, pregnant women, young kids (100, (HA, myalgias, weakness), not attributed to other causes. Confirm pathogen if high risk or severe case.
tx: neuraminidase inhibitors like oseltamivir and zanamivir. Adamantanes (not used much b/c high resistance. Tx can shorted duration of influenza sx by 1-3 days if given within 24-36 hours but doesn't help much beyond that. Consider txing if

98

what are the differnet parts that can change in the flu virus from year to year

The influenza virus has hemagluttinin parts (H) that bind to respiratory epithelium (this part is different in influ A and B) and neuraminidase (N) that liberates new virions for propagation (changes in A only). it has a segmented genome which allows high rates of reassortment

99

Pertussis
epi,
eti,
transmission
complications
conditions
sx,
tests,
ddx,

dx,
tx,
pt ed

epi, highest incidence in infants 2 weeks: PCR +serology. >4 weeks: serology
ddx: viral : adenovirus, parainfluenze, influenza, RSV, coronavirus, rhinovirus; bacterial: B. parapertussis, chlamydophila pneumonia, Mycoplasma pneumonia, TB; noninfectious: asthma, foreign body, post nasal drip, GERD, malignancy. Other pulm: acute bronchitis, post viral cough.

dx: dx often by clinical case definition (cough >2 wks plus either paroxysms of cough, inspiratory whoop or post tussive vomiting without other cuases) if they fit the pattern
tx: may need hospitalization if really severe for close monitoring of respiratory status and fluids or nutritional support. Admit if in respiratory distress (tachypnea, retractions, nasal flaring, grutning, accessory muscle use, evidence of pneumonia, inability to feed, cyanosis or apnea with or without cough, and seizures) although most can be tx'd as output. TX if meets any of the clinical case definition to prevent further spread. initiate abx if significant clinical suspiciou since labs can take a while. best to catch it during catarrhal phase which decreases transmission and severity. Treat if sx less than 3-4 weeks, after that its unclear if there is a benefit to tx, except health care workers who shoudl basically be tx'd no matter what (if 6-8 wks of sx) since they come in contact with many people. tx all infants and pregnant women if

100

fluid accumulation in pleural cavity

pleural effusion

101

pleural effusion from chf

transudate

102

pleural effusion from blockage of lymphatics

exudate

103

pleural effusions causes

transudates: increased hydrostatic pressure in pulmonary vessels from CHF, cirrhosis, nephrotic syndrome, myxedema, peritoneal dialysis. Its usually on both sides with very little protein exudate: increased vascular permeability or problems with lymph drainage from infections, abscess, TB, malignancy, CT disorders (lupus, rheumatoid pleurisy) or pancreatitis, heaptic/splenic absces. PEs are mixed transudates and exudates from pressure from blockage and inflammatory response of increased permeability.

104

pleural effusion signs, sx, CXR

Vital signs: may be tachy, dyspneic, may be hypotensive or hypoxemic). lung exam: decreased bronchophony, egophony, vocal fremitus, may have decreased breath sounds, dullness to percussion, localized pleural friction rub.. Seen on CXR if >250 mL with blunting of costophrenic angle, mediastinal and tracheal deviation if massive. can do lateral decubitus position to see if it is free flowing or loculated (can see as little as 50 ml). CT shows best picture. If unilateral think exudate,if bilateral think transudate. infiltrate if can see landmarks (not an effusion) and effusion if obscures landmarks.

105

pleural effusion: pale yellow normal WBCs normal pH protein 0.6

transudate, probably serum

106

pleural effusion: pus >50,000 WBCs pH 3 protein p:s ratio >0.5 LDH >2/3 p:s LDH ratio >0.6

exudate, empyema

107

mesothelioma: causes, sx, tests, dx, tx

causes: related to asbestos exposure: brakeline workers, insulators, mining/mill work, cigarettes
sx: gradual onset of sx: CP/SOB, cough, fatigue, wt loss.
tests: CXR with unilateral pleural thickening, or pleural plaques. May have large unilateral pleural effusion.
dx: pleural fluid cytology or pleural bx.
tx: surgeyr, chemo, or XRT depending on localized vs. diffuse, and other comorbidities.

108

what are the various causes of pneumothorax? signs/sx, pe/CXR findings

primary: tall skinny male, trauma, secondary: iatrogenic,airway disease (rupture of apical blebs, lung malignancy, CF),necrotizing lung infections (TB, pneumocytis, lung abscess), interstitial lung disease (IPF, sarcoidosis) others: smoking, FH, marfan's syndrome, changes in atmospheric pressure or exposure to loud music.
signs/sx: dyspnea, hypoxia, chest pain; signs: >HR/RR, hypoxia,

109

what's in the ddx for a pneumothorax?

pE, M/S chest pain, pleurisy, pulm infections, MI, exacerbation of underlying pulm disease, large pulmonary bleb

110

how do you tx PTX?

emergent needle thoracotomy to release air if tension pneumo 14/16 G angiocath on syringe along superior margin of 2nd or 3rd rib in mid clavicular line. Primary: usually uncomplicated and

111

pleuritis: causes, hx, pe, tx

causes: usually viral, or any inflammatory condition that causes infection of lung adjacent to pleura or pleural effusion. Other causes: pneumonia, acute PE, PTX, pericarditis, CVD, drug induced lupus, IBD, radiation
hx: unilateral chest pain, pleuritic, sharp stabbing. Can't take a deep breath. Cough, URI sx, may have sputum.may have malaise, fever.
pe: normal 02 if viral; rhinorrhea, pleural friction rub, pharyngeal injection, tenderness on chest wall, no point tenderness, no rash.
DX OF EXCLUSION
TX: sx: anti inflammatory: NSAIDS, etc; analgesics, tx underlying problem

112


ddx of pleuritis

pE, pneumonia, PTX, chest wall pain, herpes zoster, MI

113

what is the most reliable indicator of a benign nodule?

no growth over 2 yr period

114

how does lung cancer grow/spread?

carcinoma originates in cells of bronchial tree, spreads through lymph nodes (bronchial to hilar to mediastinal) and travels to liver, adrenals, bones, brain, lung

115

which type of NSCLC? peripheral nodules, intmdt growth rate and metastasis, no compression but possible pleural effusion or M/S pain

adenocarcinoma

116

which type of NSCLC?central, slow growing, late metastasis, 3-4 yrs before clinically apparent tumor, eventually compresses structures

squamous cell

117

which type of NSCLC? central or peripheral, fast growing, early metastasis.

large cell

118

rapid growth, central with bulky adenopathy, often metastatic at dx, paraneoplastic syndromes common

small cell lung cancer

119

what are the pulm signs/sx of lung cancer? local signs/sx? metastatic signs/sx?

1. signs/sx: asymptomatic (uncommon) dyspnea, wheezing, chronic cough, hemoptysis, CP,pneumonia; signs: nonspecific. 2. Involvement of local structures: pain (pleura, chest wall, brachial plexus), dysphagia, hoarseness, diaphgragmatic paralysis, pleural or pericardial effusion, **SVC syndrome** (compression of svc by tumor resulting in distended veins in neck, chest, arms and face and arm swelling, rubor; pancoast syndrome (apical tumors that involve the brachial plexus and cervical sympathetic nerves resulting in shoulder and arm pain, atrophy of arm and muscles and horner syndrome (ptosis, constricted pupil, anhidrosis) 3. metastasis: if to brain get HA, seizures, focal deficits, if to liver get RUQ pain, hepatomegaly, abnormal LFTs, if to bones get pain, pathologic fractures, spinal cord compression, cytopenias, leukoerythroblastosis

120

what are the systemic signs/sx of lung cx and the paraneopalstic signs?

5. systemic: anorexia, weigh loss, cachexia, fatigue, generalized weakness, fever 6. paraneoplastic: cushings (tumor makes ACTH precursors: moon face, truncal obesity, hyperpigmentation, muscle weakness, HTN, hyperglycemia, hypokalemia with small cell carcinoma), hypercalcemia (tumor makes PTH like hormone: fatigue, lethargy, nausea, deydration, polyuria, constipation, confusion, renal failure with squamous cell carcinoma), SIADH: tumor makes ADH which increases water reabsoprtion in renal tubules, hyponatremia and inappropriately concentrated urine, w/ small cell carcinoma

121

what are some of the possible PE findings in someone with lung cancer? what tests should you do?

may have enlarged lymph nodes (cervical, axillary, supraclavicular), may have pneumonia or effusion, may have hepatomegaly, may have clubbing, osteoarhropathy, may have nerve deficits (arms, horner's syndrome)
CXR, labs (electrolyes, LFTs, ablumin, CBC, coag times), CT/PET, Bx via bronchoscoy, mediastinoscopy/thoracoscopy, percutaneous (CT guided), thoracentesis for cytology, could also do head CT/MRI or bone scan

122

how should the different stages of NSCLC be tx'd?

stages I and II: surgery , radiation does not effect overall survival, post operative adjunctive chemo can improve survival in those with stage II. If can't do surgery, do radiation. Stage III: chemo + radiation, +/-surgery; Stage IV: palliative, radiation if aggravating sx are developing such as pain, hemoptysis, dysphagia, obstructive pneumonia, or if mets to brain, spine, or wt bearing bones)

123

how should SCLC be tx'd?

Small cell; limited: chemo +radiation can cure, extensive: chemo can prolong life but can't cure. radiation only for palliation or prophylaxis to decrease brain mets.