Step Up to Medicine Flashcards
(296 cards)
1
Q
3 most common causes of PUD
A
- H Pylori
- NSAID
- acid hyper secretion (ZES)
2
Q
pathogenesis of duodenal ulcer: caused by ________
A
increase in offensive factors
3
Q
pathogenesis of gastric ulcer: caused by ________
A
decrease in defensive factors
4
Q
H Pylori infection more common in _________ ulcers
A
duodenal
5
Q
4 types of gastric ulcers
A
type I: lesser curvature
type II: gastric and duodenal ulcer
type III: prepyloric
type IV: near GE junction
6
Q
dx and tx for uncomplicated PUD
A
initiate empiric therapy
no need for Ba or endoscopy
7
Q
how to work up gastric ulcer
A
must do endoscopy and biopsy to r/o cancer
8
Q
how to dx h pylori
A
gold standard: endoscopic biopsy
urea breath test- acute infection
serology (lower specificity)- positive for life
9
Q
initial and recurrent H pylori therapy
A
initial: triple therapy (PPI, amoxicillin, clarithromycin)
recurrent: quadruple therapy (PPI, bismuth, 2 abx)
10
Q
cytoprotection drugs for PUD
A
sucralfate and misoprostol
11
Q
how to tx NSAID induced ulcer
A
stop NSAID
start PPI or misoprostol for 4-8 weeks
12
Q
when to discontinue PPI after PUD
A
after 4-6 weeks in patient with uncomplicated ulcers who are asymptomatic
13
Q
how to tx PUD that’s NOT related to H Pylori or NSAID use
A
PPI
14
Q
most common cause of upper GI bleeding
A
PUD
15
Q
when to do surgery in PUD
A
to tx complications: perforation, GOO, bleeding
16
Q
common causes of acute gastritis
A
NSAID, H Pylori, alcohol, heavy cigarette smoking
17
Q
how to tx acute gastritis
A
- if pain low/mod and no worrisome sxs –> PPI, stop NSAID
- if no response in 4-8 weeks, then do upper GI endoscopy and ultrasound and test for h pylori
18
Q
most common cause of chronic gastritis
A
h pylori
19
Q
auto-immune gastritis leads to chronic atrophic gastritis with ________ antibodies
A
serum antiparietal and anti-intrinsic factor –> pernicious anemia
20
Q
how to dx and tx chronic gastritis
A
dx with upper GI endoscopy with biopsy
tx symptomatic pt with H. Pylori eradication
21
Q
most gastric cancers are _________ (type of morphology)
A
adenocarcinoma
22
Q
risk factors for gastric adenocarcinoma
A
gastritis, adenomatous gastric polyps, h pylori, pernicious anemia, post-antrectomy, menetrier’s disease
23
Q
dx of gastric cancer
A
EGD with multiple biopsies, Ba upper GI studies (if needed), abdominal CT for staging, FOBT
24
Q
tx gastric cancer
A
wide excision (total or subtotal gastrectomy) with LN dissection \+/- chemo
25
pt with chronic stable angina presents with sxs of USA… 3 initial steps?
1. ECG and cardiac enzymes
2. aspirin
3. IV heparin
26
tests to order for a new pt with CHF
```
CXR
ECG (r/o MI)
cardiac enzymes
CBC (r/o anemia)
echo
```
27
what do you often see on CXR of heart failure?
cardiomegaly
interstitial markings
pleural effusion
kerley B lines (horizontal lines near the costophrenic angle)
28
initial test of choice in heart failure
transthoracic echo
29
cut off for preserved EF and reduced EF
40%
30
most precise test for assessing LV function and EF...
```
nuclear ventriculography (radionuclide ventriculography using technetium 99m)
mostly not ordered...
```
31
treatments for systolic dysfunction heart failure
```
lifestyle modification
diurectis
spironolactone
ACEI/ARBs
beta-blockers
digitalis
hydralazine and isosorbide dinitrates
ICD and CRT
cardiac transplant
```
32
most effective symptomatic relief drug for heart failure
| no benefit for mortality
diuretics
33
spironolactone in heart failure
| when to avoid?
prolongs survival in select patients (classes III and IV)
| avoid in renal failure pts
34
initial treatment in most symptomatic heart failure patients
diuretic and ACEI
35
ACEI in CHF
prolongs survival and alleviates sxs in all classes of CHF
| **all pts with systolic dysfunction should be on an ACEI even if they have no sxs**
36
beta blockers in heart failure
decreases mortality in pts with post-MI heart failure
give only to STABLE pts with class I-III heart failure
carvedilol > metoprolol
37
digitalis in heart failure
no mortality benefit
| for pts with sxs despite optimal therapy (with ACEI, beta blocker, aldo antag, and diuretic)
38
hydrazine and isosorbide dinitrates
used in pts who can't take ACEI
| -improves mortality but just not as good as ACEI
39
standard CHF treatment based on severity of disease
mild: diuretic and ACEI
mod: add beta blocker
severe: add digoxin and then spironolactone
40
most common cause of death from CHF
sudden death from ventricular arrhythmias (2/2 ischemia)
41
meds that lower mortality in CHF
beta blockers
ACEI and ARBs
aldo antags (spironolactone)
hydralazine/nitrates
42
nausea/vomiting, anorexia, ectopic ventricular beats, AV block, a fib, visual disturbances, disorientation
pt with heart failure
signs of digoxin toxicity
43
CCB in CHF
no role/not indicated
| felodipine and amlodipine are safe if needed for another condition
44
what MUST you do if someone is on a VAD (ventricular assist device)
lifelong anticoagulation with heparin or warfarin
45
meds contra-indicated in CHF patients
metformin- lactic acidosis
thiazolidinediones- fluid retention
NSAIDs- exacerbation
antiarrhythmic agents w/ negative inotropic effects
46
2 devices that reduce mortality in CHF patients
```
ICD and CRT (long QRS)
EF < 35%, class II or III with sxs despite meds
```
47
how to tx diastolic dysfunction
beta blockers
diuretics
NO digoxin and spironolactone
MAYBE ACEI/ARBs
48
Treatment of acute decompensating heart failure
O2
Diuretics
Nitrates if not hypotensive
+/- dobutamine (digoxin takes a few weeks to take effect)
49
2 classic types of COPD
chronic bronchitis
| emphysema
50
chronic bronchitis is a _______ dx
| what are the criteria
clinical
| chronic cough productive of sputum for at least 3 months per year for at least 2 consecutive years
51
emphysema is a ______ dx
| what are the criteria
pathologic
| permanent enlargement of air spaces distal to terminal bronchioles due to destruction of alveolar walls
52
COPD is the ______ leading cause of death in the US
4th
53
what type of emphysema is this?
smokers
destruction of only respiratory (proximal) bronchioles
upper lung zones
centrilobular
54
what type of emphysema is this?
alpha-1-antitrypsin deficiency
destruction of both proximal and distal acini
lung bases
panlobular
55
emphysema results due to too much _________ and not enough _______
too much protease (elastase)
| not enough antiprotease (alpha1-antitrypsin)
56
cough, sputum production, dyspnea in a smoker
| most likely dx?
COPD
57
most common early sxs of COPD
exertional dyspnea
58
in COPD,
FEV1 is _____
TLC is _____
RV is _______
decreased
increased
increased
59
```
thin
lean forward
barrel chest
tachypnea
respiratory distress and accessory muscle use
```
pink puffer (emphysema)
60
```
overweight and cyanotic
chronic cough
sputum production
cor pulmonale
respiratory rate normal
no apparent distress
```
blue boaters (predominant chronic bronchitis)
61
signs of COPD
prolonged forced expiratory time
end expiratory wheeze
decrease breath sound
inspiratory crackle
62
to dx airway obstruction, one must have a normal or increased ______ with decreased ________
TLC
| FEV1
63
definitive dx test for COPD
PFTs (spirometry)
64
obstruction on PFT is evidenced by _______ and ________
decreased FEV1
< 50% severe
50-70% moderate
decreased FEV1/FVC ratio
65
```
obstructive pattern lung volumes
TLC
residual volume
FRC
VC
```
increased
increased
increased
decreased
66
CXR as a dx for COPD?
not very sensitive but will show:
hyperinflation
flattened diaphragm
enlarged retrosternal space
67
good screening tool for obstructive dz
if peak flow meter shows < 350 L/min --> get PFT
| this is a good triage method, esp in the ED
68
in patients with personal or FH of emphysema before age 50, do this
measure alpha1-antitrypsin
69
COPD ABG
hypoxemia
hypercapnea
respiratory acidosis with metabolic alkalosis compensation
70
most important intervention in COPD
stop smoking
71
best way to clinically monitor COPD pts
serial FEV1 measurements
72
interventions shown to improve mortality in COPD
smoking cessation
| home O2
73
_________ are contraindicated in acute COPD or asthma exacerbation
beta blockers
74
mechanism of COPD causing cor pulmonale
COPD --> hypoxemia --> hypoxic vasoconstriction --> pulmonary HTN --> cor pulmonale
75
vaccines for COPDers
annual flu
| strep pneumo q5-6 years
76
_____________ are only used for acute COPD exacerbations and should not be used for long term treatment
IV glucocorticoids
77
home O2 therapy criteria for COPDers
any of the following:
PaO2 55
O2 sat < 88% rest or exercise
PaO2 55-49 plus evidence of polycythemia or cor pulmonale
78
theophylline mechanism of action
improve mucociliary clearance and central respiratory drive
79
mild to moderate COPD tx
- first line: bronchodilator (combo of beta agonist and anticholinergic is the most effective)
- inhaled glucocorticoids may be used
- consider theophylline for refractory cases
80
severe COPD tx
- first line: inhaler with bronchodilator (combo of beta agonist and anticholinergic is the most effective)
- inhaled glucocorticoids may be used
- consider theophylline for refractory cases
+
O2, pulm rehab, triple inhaler therapy (LABA, long acting anticholinergic, inhaled glucocorticoid)
81
COPD exacerbation tx
- CXR
- beta agonist +/- anticholinergic
- IV glucocorticoids for pts in the hospital
- don't use inhaled glucocorticoids in exacerbation
- abx (azithromycin, levofloxacin)
- supp O2
- BIPAP or CPAP
- intubation and mechanical ventilation if needed
82
3 complications of COPD
acute exacerbations (noncompliance, infection, cardiac dz)
secondary polycythemia
pulmonary HTN and cor pulmonale
83
chronic tx of asthma
| mild intermittent
2 or fewer times/week
| no meds
84
chronic tx of asthma
| mild persistent
2 or more times/week but not every day
| low dose inhaled corticosteroid
85
chronic tx of asthma
| moderate persistent
daily sxs, frequent exacerbations
- daily inhaled CS (low dose) or
- cromolyn/nedocromil (prophylaxis b4 exercise in kids) or
- methylxanthine or
- antileukotriene (ex. montelukast)
86
chronic tx of asthma
| severe persistent
continual sxs, frequent exacerbations, limited physical activity
- daily inhaled CS (high dose) and LABA or
- methylxanthine and systemic CS
87
triad of asthma
airway inflammation
airway hyper-responsiveness
reversible airflow obstruction
88
asthma is only present in young children (t/f)
F
| it can begin at any age
89
extrinsic vs intrinsic asthma
| which is more common
extrinsic- pts are atopic and become asthmatic at a young age
90
SOB, wheezing, chest tightness, cough, worse at night
| most likely dx
asthma
91
ddx of wheezing
```
asthma
CHF
COPD
cardiomyopathies
lung cancer
```
92
most common PE finding in asthma
wheezing
93
- _______ are required for asthma dx, which show __________
- in order to be considered reversible airflow obstruction, FEV1 or FVC must increase by at least ____% after bronchodilator administration
PFTs, obstructive pattern
| 12%
94
what's the bronchoprovocation test
useful for diagnosing asthma when PFTs are nondiagnostic
-measures lung function before and after inhalation of increasing doses of methacholine; hyperresponsive airways develop obstruction at lower doses
95
CXR in asthma
r/o other conditions
| asthma doesn't really show up very well on CXR
96
ABG interpretation in acute asthma attack
- low CO2 and low O2
| - increased CO2 is a sign of respiratory muscle fatigue or severe airway obstruction
97
what to give for acute asthma attacks
SABA (short acting beta agonists)
98
avoid _______ in asthmatics
beta blockers
99
LABA are particularly good for ________ and __________
night time asthma and exercise induced asthma
100
______ is the quickest method of dxing asthma
peak flow measurement
101
how to manage severe acute asthma exacerbation (hospital admission)
- inhaled beta agonist is first line
- IV CS --> taper when clinical improvement occurs
- IV Mg is third line
- O2- keep sat above 90%
- abx if severe of you suspect infection
- intubation if you suspect respiratory failure/impending respiratory failure
102
side effects of inhaled CS
sore throat
thrush
hoarseness
103
tests to order for acute asthma exacerbation (3)
PEF- decreased
ABG- increased A-a gradient
CXR- r/o pneumonia, ptx
104
3 complications of asthma
status asthmaticus- no response to standard meds
acute respiratory failure- respiratory muscle fatigue
ptx, atelectasis, pneumomediastinum
105
asthma pts with nasal polyps... what are you thinking?
aspirin sensitive asthma
| do not give aspirin or any NSAID
106
permanent abnormal dilation and destruction of bronchial walls, cilia are damaged
bronchiectasis
107
2 major causes of bronchiectasis
CF
| infection
108
infection in a pt with airway obstruction or impaired defense/drainage precipitates __________
bronchiectasis
109
clinical features of bronchiectasis (4)
chronic cough with foul mucopurulent sputum
dyspnea
hemoptysis
recurrent/persistent pneumonia
110
how to dx bronchiectasis
high resolution CT is the best
| PFTs show obstructive pattern
111
how to tx bronchiectasis exacerbation
abx
112
how to tx bronchiectasis on a day to day basis
hydration
chest PT
inhaled bronchodilators
113
goal in the tx of bronchiectasis
prevent pneumonia and hemoptysis complications
114
defect in cystic fibrosis
defect in Cl channel --> impaired Cl and water transport --> thick secretions in respiratory tract, exocrine pancreas, sweat glands, intestines, and GU tract
115
CF shows a (obstructive/restrictive) pattern
obstructive
116
CF often chronically infected with ________ in the lungs
pseudomonas
117
CF treatments
```
pancreatic enzyme replacement
fat soluble vitamin supplement
chest PT
flu and pneumococcus vaccines
tx infections with abx
inhaled rhDNase
```
118
2 broad categories of lung cancers and how common is each
small cell- 25%
| non small cell- 75%
119
risk factors for lung cancer (4)
smoking
asbestos
radon
COPD
120
which lung cancer has the least association with smoking
adenocarcinoma
121
staging system of NSCLC
TNM staging
122
staging system of SCLC
limited- just chest and supraclavicular nodes
| extensive- outside chest and surpaclavicular nodes
123
local manifestations (cough, hemoptysis, obstruction, wheezing) most common with what type of lung cancer
squamous cell carcinoma
124
facial fullness, facial and arm edema, JVD, dilated veins over anterior chest, arms and face
what is it and what is it sometimes associated with
SVC syndrome
| associated with SCLC
125
hemidiaphragmatic paralysis in lung cancer pt
phrenic nerve palsy
126
hoarseness in lung cancer pt
recurrent laryngeal nerve palsy
127
unilateral facial anhidrosis, ptosis, miosis
Horner's syndrome
128
shoulder pain radiating down the arm, upper extremity weakness, Horner's syndrome sometimes
what is this and what is it usually due to?
pancoast's tumor
| usually due to squamous cell
129
lung cancer: malignant pleural effusion = ___________ in terms of prognosis
distant mets
130
most common sites for lung cancer to met to
brain, bone, adrenal, liver
131
lung cancer: SIADH assoc with ________
SCLC
132
lung cancer: ectopic ACTH secretion assoc with
SCLC
133
lung cancer: PTH like hormone secretion assoc with
squamous cell
134
lung cancer: hypertrophic pulmonary osteoarthropathy assoc with
adenocarcinoma and squamous cell
135
lung cancer: Eaton Lambert syndrome assoc with
SCLC
| -proximal muscle weakness/fatigability, diminished DTRs, paresthesias (more common in lower extremity)
136
workup for lung cancer
CXR
CT
tissue biopsy
137
lung cancer dx: what is an important dx test but should not be used as a screening test
CXR
138
lung cancer: what imaging is good for staging
chest CT with contrast
139
lung cancer: what tests are good for dxing central lesions
sputum cytology
| bronchoscopy
140
lung cancer: what test can identify pts with advanced dz who would not benefit from surgical resection
mediastinoscopy
141
lung cancer: what can be used to dx peripheral lesions
transthoracic needle biopsy
142
pathologic confirmation is needed for dx of lung cancer (t/f)
T
143
lung cancer: what should you do for intrathoracic lymphadenopathy?
biopsy
144
tx for NSCLC:
| what is the best option? what do you use as adjunct therapy?
surgery is the best option- not possible for pts with mets
use XRT as adjunct
chemo is debatable
145
tx for SCLC for:
limited dz
extensive dz
limited dz- chemo and XRT
| extensive dz- chemo only --> if they respond, then add on XRT to decrease brain mets and prolong survival
146
most asymptomatic lung masses are benign (t/f)
T
147
solitary pulmonary nodule: high risk features for malignancy
```
age > 50
smoking
size > 2 cm
irregular borders
eccentric asymmetric clacification
enlarging
```
148
solitary pulmonary nodules... what to do with the following
- low probability nodules
- intermediate probability nodules 1 cm
- high probability nodule
- serial CT scans
- serial CT scans
- PET --> if positive, excision
- excision
149
lung nodules with no growth in 2 years are usually benign (t/f)
T
150
locations of lung cancers
- squamous
- adeno
- large cell
- small cell
- usually central
- often peripheral
- usually peripheral
- central
151
most common cause of mediastinal mass in older person
metastatic cancer, esp from lung cancer
152
common mediastinal masses by location
anterior
middle
posterior
anterior-- thyroid, teratogenic tumors, thymoma, terrible lymphoma
middle- lung cancer, lymphoma, aneurysms, cyst, Morgagni hernia
posterior- neurogenic tumors, esophageal masses, enteric cysts, aneurysms, Bochdalek's hernia
153
clinical features of mediastinal masses usually due to ________
compression or invasion of adjacent structures
| -cough, CP, dyspnea, pneumonia, SVC syndrome, horaseness, Horner's, etc
154
how to dx mediastinal masses
chest CT --> if benign looking and pt has no sxs, just observe
155
criteria for exudates (context of pleural effusion)
pleura protein/serum protein > 0.5
pleura LDH/serum LDH > 0.6
pleura LDH > 2/3 the upper limit of normal serum LDH
156
most common cause of pleural effusion + other causes
CHF
| other causes: pneumonia (bacterial), malignancy (lung, breast, lymphoma), PE, viral diseases, cirrhosis with ascites
157
signs of pleural effusion
dullness to percussion
decreased BS over the effusion
decreased tactile fremitus
158
elevated pleural fluid amylase... think these 3 things
esophageal rupture
pancreatitis
malignancy
159
milk opalescent pleural fluid
chylothorax
160
purulent pleural fluid
empyema
161
blood in the pleural space
malignancy
162
exudative pleural effusion that's primarily lymphocytic
TB
163
pH < 7.2 for the pleural effusion
parapneumonic effusion or empyema
164
if pleural fluid glucose < 60, rule out ________
| low glucose in pleural fluid can be assoc with (4 things)
r/o RA
| could be TB, esophageal rupture, malignancy, lupus
165
3 ways to dx pleural effusion
```
CXR- need 250 mL to visualize; lateral decubitus films are best
CT- more reliable than CXR
thoracentesis- good for dx and symptomatic relief
the 4 C's: chemistry (glucose, protein)
cytology
cell count (CBC with diff)
culture
complication is ptx
```
166
tx of transudative pleural effusions
diuretics, Na restriction
| thoracentesis only if it's massive and causing SOB
167
tx of exudative pleural effusions
tx underlying dz
168
tx of parapneumonic effusions
uncomplicated- abx
| complicated- chest tube, intrapleural injection of streptokinase, surgical lysis of adhesions
169
parapneumonic effusion vs. empyema
- parapneumonic effusion = noninfected pleural effusion secondary to bacterial pneumonia
- empyema = complicated parapneumonic effusion (infected)
170
empyema usually occurs as complication of ___________
bacterial pneumonia
171
how to dx empyema
CXR and CT
172
how to tx empyema
abx, aggressive drainage of pleura vis thoracentesis
| -if severe and persistent, rib resection and open drainage
173
always get a CXR after these 3 procedures to make sure you didn't create a ptx
central line placement
thoracentesis
transthoracic needle aspiration
174
2 categories of spontaneous ptx and characteristics of each
primary/simple- no lung dz, young tall lean men, severe respiratory distress usually not present
secondary/complicated- underlying lung dz (esp COPD), more life threatening due to lack of pulmonary reserve
175
recurrence rate of spontaneous ptx
high- 50% in 2 years
176
_________ hastens the resorption of air in pleural space and is first tx for spontaneous ptx
supp O2
177
how to tx primary spontaneous ptx
- if small and no sxs --> observation (resolve in 10 days) or small chest tube
- if large and/or there are sxs --> give O2 and insert chest tube
178
how to tx secondary spontaneous ptx
chest tube
179
malignant mesotheliomas assoc with __________
| common presentation includes:
asbestos
| -SOB, weight loss, cough, bloody effusion
180
drugs that cause interstitial lung disease (name 5 of many)
```
amiodarone
nitrofurantoin
bleomycin
phenytoin
illicit drugs
```
181
if interstitial lung disease is suspected, ask about _____ and _____
meds and jobs/exposures
182
signs of ILD
rales at the bases
digital clubbing
pulmonary HTN and cyanosis in advanced dz
183
what is an endstage finding of many ILDs
honeycomb lung
184
```
dxing ILD
______ is nonspecific
______ is very good at showing fibrosis
______ is controversial
others (3)
```
CXR is nonspecific
CT good for showing fibrosis
bronchoalveolar lavage controversial
tissue biopsy often required for pts with ILD
PFTs show a restrictive pattern (see other flashcard for PFT findings)
U/A to look for glomerular injury
185
PFT findings in ILD
restrictive pattern
- increased FEV1/FVC
- all lung volumes are low
- FEV1 and FVC are low, but the latter more so
- low DLCO (diffusing capacity)
186
if someone has digital clubbing, get _______
a CXR b/c chronic hypoxemia is the underlying cause in most cases
187
young pt with constitutional sxs, respiratory complaints, erythema nodosum, blurred vision, bilateral hilar LAD
sarcoidosis
188
chronic systemic granulomatous dz characterized by noncaseating granulomas
sarcoidosis
189
sarcoidosis- typical demographic
AA women
190
most common cause of death in sarcoidosis
cardiac disease
191
dx of sarcoidosis is based on ______, _______, and _______ findings
clinical, radiographic, histologic (must see noncaseating granulomas)
192
CXR in sarcoidosis pt:
| __________ is the hallmark of disease
bilateral hilar LAD
193
other findings in sarcoidosis
skin anergy
ACE elevated in serum
hypercalcemia and hypercalciuria
194
staging of sarcoidosis (on CXR)
- stage I: bilateral hilar LAD
- stage II: bilateral hilar LAD + parenchymal infiltrates
- stage III: diffuse parenchymal infiltrates w/o hilar LAD
- stage IV: pulmonary fibrosis with honeycombing and fibrocystic parenchymal changes
195
least favorable sarcoidosis stage
III
196
how to tx sarcoidosis
- most resolve spontaneously so no tx
- if pts have sxs, then systemic CS
- if refractory to CS, then methotrexate
197
chronic interstitial pneumonia caused by abnormal prolif of histiocytes (related to Langerhan's cells in the skin)
histiocytosis X
198
presentation, dx, and tx of histiocytosis x
- cigarette smokers with dyspnea and nonproductive cough +/- spontaneous ptx, lytic bone lesions, DI
- CXR shows honeycombing, CT shows cystic lesions
- variable prognosis
- tx with CS (sometimes effective) and lung transplant (may be necessary)
199
necrotizing granulomatous vasculitis in the kidneys, lungs, and upper airway
Wegener's granulomatosis
200
presentation, dx, and tx of Wegener's granulomatosis
- upper and lower respiratory infections, glomerulonephritis, pulmonary nodules
- dx gold standard is tissue bx, + for c-ANCA
- tx with immunosuppressants and glucocorticoids
201
granulomatous vasculitis in patients with asthma
churg-strauss syndrome
202
presentation, dx, and tx of churg-strauss syndrome
- pulmonary infiltrates, rash, eosinophilia
- skin, muscle, and nerve lesions
- dx: blood eosinophilia, p-ANCA
- tx: systemic glucocorticoids
203
c-ANCA assoc with
| p-ANCA assoc with
Wegener's granulomatosis
| Churg-Strauss syndrome, sometimes Goodpasture's syndrome
204
most simple coal worker's pneumoconiosis need no treatment (t/f)
T
205
complicated coal worker's pneumoconiosis is characterized by _________
fibrosis
206
asbestosis has predilection for ____________ of the lung
lower lobes
207
asbestosis puts you at increased risk for ______ and _______
bronchogenic carcinoma and malignant mesothelioma
208
classic CXR findings in the following:
- asbestosis
- silicosis
pleural plaques
| "egg shell" calcifications
209
silicosis: localized and nodular peribronchial fibrosis (______ lobes more common)
- increased risk of _______
upper
| TB
210
berylliosis has both _____ and ______forms
- chronic dz very similar to _________ (granulomas, skin lesions, hypercalcemia)
- dx with _____
- tx with _________
acute and chronic
sarcoidosis
beryllium lymphocyte proliferation test
glucocorticoid therapy
211
serum IgG and IgA to te inhaled antigen
acute form has flu like features and CXR shows pulm infiltrates
chronic form more insidious
what is it and how to tx?
hypersensitivity pneumonitis
| tx by removing offending agent and sometimes glucocorticoids
212
fever and peripheral eosinophilia
peripheral pulmonary infiltrates
what is it and how to tx?
eosinophilic pneumonia
| tx with glucocorticoids
213
IgG antibodies against glomerular and alveolar basement membranes
-hemorrhagic pneumonitis and glomerulonephritis
-presents with dyspnea and hemoptysis
what is it, how to dx, and how to tx?
goodpasture's syndrome
- dx with tissue biopsy, anti-GBM antibodies
- tx with plasmapheresis, cyclophosphamide, and corticosteroids
214
accumulation of surfactant-like protein and phospholipids in the alveoli. what dz is this?
pulmonary alveolar proteinosis
215
```
pulmonary alveolar proteinosis
CXR findings
dx
tx
what not to give
```
- ground glass appearnace with b/l alveolar infiltrates that resemble a bat shape
- dx: lung bx
- tx: lung lavage, newer is granulocyte-colony-stimulating factor
- DON'T GIVE STEROIDS
216
IPF is more common in _____ and _______
- definitive dx is _______
- no effective tx but these may help (3 things)
men and smoker
open lung biopsy
O2, corticosteroids w/ or w/o cyclophosphamide, lung transplant
217
cryptogenic organizing pneumonia
- most cases are caused by __________
- CXR and clinical findings
- tx with _______, not ________
idiopathic
cough, dyspnea, flu-like sxs, bilateral patchy infiltrates
corticosteroids, NOT abx
218
radiation pneumonitis
- active form (______ after radiation)
- chronic form (______ after radiation)
- dx with __________
- tx with ________
- 1-6 months
- 1-2 years
- CT scan: diffuse infiltrates, ground glass, patchy/homogenous consolidation, pleural/pericardial effusion
- CS
219
severe hypercapnea can cause what important and terrible thing
increased ICP via vasodilation
220
criteria defining acute respiratory failure
hypoxia (PaO2 < 60 and PaCO2 > 50)
| hypercapnia (PCO2 > 50)
221
2 major classes of acute respiratory failure
-hypoxemic respiratory failure- low PaO2 with a low or normal PaCO2
-caused by lung disease, often V/Q mismatch and
intrapulmonary shunt
-hypercarbic respiratory failure- decrease in minute ventilation or increase in physiologic dead space leads to CO2 retention and then hypoxia
-caused by lung disease and by NM dz, CNS depression,
mechanical restriction of lung inflation, etc.
222
V/Q mismatch causes ________ without ________ and is/is not responsive to supplemental oxygen
hypoxia without hypercapnia
| responsive to supplemental oxygen
223
hypoxia due to shunt is/is not responsive to supplemental oxygen
is NOT
224
hypoventilation causes ______ with secondary ________
hypercapnia with secondary hypoxemia
225
diffusion impairment causes _______ w/o _______
hypoxemia w/o hypercapnia
226
what tests to get in acute respiratory failure
ABG
CXR or CT
CBC and BMP
+/- cardiac enzymes if concerned about cardiogenic pulm edema
227
list 3 causes of hypoxemia
V/Q mismatch
intrapulmonary shunting
hypoventilation
228
why not give lots of O2 to chronic COPDers
hypoxia drives their breathing
| if you give them oxygen, they hypoventilate and hypercapnia worsens causing a respiratory acidosis
229
BIPAP and CPAP are meant to ______________
attempt to avoid intubation and ventilation in patients with impending respiratory failure
-best for hypercarbic respiratory failure (COPD)
230
- diffuse inflammatory process involving both lungs
| - involves neutrophil activation
ARDS
231
key pathophys event in ARDS:
| other findings:
- key pathophys event: intrapulm shunting leads to severe hypoxemia with no improvement on 100% oxygen
- interstitial edema and alveolar collapse --> stiff lungs, increased A-a gradient, decreased compliance, increased dead space (destruction of pulmonary capillary bed), low VC and FRC
232
common causes of ARDS
```
sepsis
aspiration of gastric contents
severe trauma, fractures, pancreatitis, massive transfusion
drug OD
intracranial HTN
cardiopulmonary bypass
```
233
criteria to dx ARDS
- hypoxemia refractory to O2 therapy: PaO2/fiO2 < 200
- b/l diffuse pulmonary infiltrates on CXR
- no evidence of CHF: PCWP < 18
234
diagnostic tests for ARDS
CXR
ABG- hypoxemia and respiratory alkalosis then acidosis
pulmonary artery catheter
bronchoscopy if infection is suspected
235
how to tx ARDS
PEEP- keep O2 sat > 90%
avoid volume overload
tx underlying cause
feed them
236
2 goals of mechanical ventilation in respiratory failure
maintain alveolar ventilation
| correct hypoxemia
237
when you need to be mechanically ventilated (5)
- significant respiratory distress
- impaired level of consciousness and unable to protect airway
- metabolic acidosis w/ inadequate hyperventilation
- respiratory muscle fatigue
- hypoxemia (PaO2 < 70), hypercapnia (PaCO2 > 50), resp acidosis (pH < 7.2) with hypercapnia
238
most common cycling method for ventilators
volume cycled
239
initial ventilator mode in most pts with respiratory failure
- guarantees a "backup minute ventilation that has been preset
- pt can go over the determined rate but not under it
- every breath "over" delivers the same predetermined tidal volume
- all breaths delivered by ventilator
assisted controlled (AC) ventilation
240
- patients can breathe on their own above the mandatory rate w/o help from the ventilator (tidal volume of these extra breaths is not determined by the ventilator)
- if no spontaneous breath, predetermined mandatory breath is delivered by the ventilator, thus guaranteeing rate
- good for support and for weaning
synchronous intermittent mandatory ventilation (SIMV)
241
- positive pressure is delivered continuously by the ventilator
- good to use to assess whether patient is ready to be extubated
CPAP
242
- pressure is delivered with an initiated breath to assist breathing
- enhances respiratory efforts made by patient
- good for weaning trials
pressure support ventilation (PSV)
243
ET tube should be ______ above the carina
3-5 cm
244
minute ventilation = _______ x _______
RR x tidal volume
245
initial tidal volume:
| RR:
8-10 mL/kg (lower is recommended for pts with ARDS and COPD)
| 10-12 breaths/min
246
what to do with fiO2
initially 100% then quickly titrate down
fiO2 < 60% generally safe
if fiO2 of 0.5 doesn't cut it, add PEEP or CPAP
247
normal I:E ratio
1:2
248
normal amount of PEEP
2.5-10 cm H2O
249
ET tube prevents aspiration (t/f)
F
250
perform tracheostomy when ventilator dependent for more than _____
2 weeks
251
some complications of mechanical ventilation
- anxiety, discomfort --> give benzos and opioids
- suction tracheal secretions
- nosocomial pneumonia
- barotrauma
- oxygen toxicity
- hypotension
- tracheomalacia
- laryngeal damage during intubation
- GI effects: stress ulcers, cholestasis
252
definition of pulmonary hypertension
mean PA pressure > 25 at rest or > 30 during exercise
253
how to determine cause of pulm HTN
CXR, PFTs, ABGs, serology, echo, cardiac cath
- if stil not clear, get V/Q scan; either PE or primary pulm HTN (PPH)
- PPH is a dx of exclusion
254
sxs and signs of pulm HTN
sxs: fatigue, exertional SOB/CP/syncope
signs: loud pulmonic component of S2 and subtle lift of sternum (sign of RV dilation), signs of RV failure later on
255
dx pulm HTN with 2 tests
ECG and echo
256
pulmonary HTN in the absence of heart or lung disease
primary pulmonary hypertension (PPH)
257
demographic and prognosis of PPH
young or middle aged women
| poor prognosis with mean survival of 2-3 years
258
common finding in PPH
exertional syncope
259
dx of PPH
- cardiac cath establishes the dx
- CXR- enlarged central pulmonary arteries, enlarged RV, clear lung fields
- PFTs- restrictive pattern
- ECG- RAD and RVH
260
how to tx PPH
- pulmonary vasodilators- IV prostacyclins (epoprostenol) and CCBs --> perform a vasodilator trial before initiating therapy
- warfarin (INR 2) for anticoagulation
- lung transplant may be an option
261
define cor pulmonale
RVH with eventual RV failure resulting from pulm HTN secondary to pulmonary disease
262
cor pulmonale most commonly caused by ______
COPD
263
signs of cor pulmonale
```
decrease in exercise tolerance
cyanosis, clubbing
hepatomegaly, edema, JVD
parasternal lift
polycythemia if COPD is the cause of cor pulmonale
```
264
how to tx cor pulmonale
```
tx underlying disorder
be careful with diuretics b/c pts may be preload dependent
long term home oxygen if pt is hypoxic
give digoxin only if LV has problems
vasodilators.... eh results
```
265
many COPD and PE patients die from ______
cor pulmonale
266
up to 2/3 of patients who survive PE get _________
pulmonary HTN
267
2 studies related to PE
PIOPED- guides treatment if V/Q is performed
| Christopher Study- guides treatment if spiral CT is performed
268
most PE arise from _________
DVT of the lower extremities above the knee (ileofemoral)
269
a very large PE could result in acute ______
cor pulmonale
270
PE causes ______ physiology which reads to ______ and ______
dead space --> hypoxia and hypercarbia leading to tachypnea
271
course: most often, PEs are __________
recurrences are common which lead to ____ and ________
mortality is ______ if PE is diagnosed early
_______ also reduces mortality
clinical silent
chronic pulm HTN and chronic cor pulmonale
decreased
anticoagulation
272
if pt has sxs of PE and a DVT is found, you can dx PE w/o further testing (t/f)
T
273
most common sxs and signs of PE
sxs: dyspnea, pleuritic CP, cough, hemoptysis, DVT, syncope (if very large)
signs: tachypnea, rales, tachyardia, S4, increased P2, shock (if very large)
274
risk factors for DVT/PE
```
age > 60 years
malignant
prior DVT, PE
hereditary hypercoagulable state
prolonged immobilization or bed rest
CHF
obesity
nephrotic syndrome
major surgery
trauma
pregnancy, estrogen use
```
275
ABG in PE
not diagnostic
will show hypoxemia and hypocapnia (due to hyperventilation) --> respiratory alkalosis
A-a gradient usually elevated
276
CXR in PE
usually normal
- mainly used to r/o alternative dxs
- Hampton's hump and Westermark's sign rarely present
277
venous duplex ultrasound of the lower extremities in PE
very useful if positive, not so useful if negative
| if positive, tx with heparin regardless
278
V/Q scan in PE
mostly replaced by helical CT now...
- normal --> no further testing
- high probability --> tx with heparin
- low or intermediate probability --> clinical suspicion determines next step
- will need pulm angiography and/or LE venous duplex
- if duplex is positive --> tx with heparin
- if duplex is negative --> do the angiography
279
spiral CT for PE
decent sensitivity (85%) and good specificity (over 95%)
replaced V/Q in most places
combine with Wells criteria to guide treatment
-sxs and signs of DVT, alternative dx less likely than PE, HR > 100, immobilization, previous DVT or PE, hemoptysis, malignancy
-see pg. 108 of Step Up to Medicine
280
_______ is the gold standard dx for PE
pulmonary angiography
- only do it when noninvasive testing is equivocal and risk of anticoagulation is high OR
- patient is hemo unstable and embolectomy may be required
281
how to use D-dimer in PE
high sensitivity, low specificity
only use if low clinical suspicion
-if negative, then r/o PE
-if positive, this doesn't help you
282
workup of PE
| how to definitely treat or definitely not treat people
need to tx:
-high probability V/Q or CT and clinical suspicion
-DVT diagnosed by ultrasound and clinical suspicion
-positive angio
no need to tx:
-low probability V/Q or negative CT and low clinical suspicion
-negative angio
-negative D-dimer and low clinical suspicion
283
how to tx PE
-supplemental O2
-give heparin (unfractionated or LMWH) and warfarin acutely with bridge to just warfarin for 3-6 months or longer; if high clinical suspicion, don't wait for studies before starting anticoagulation
goal PTT: 1.5-2.5 time control
goal INR: 2-3
LMWH may be better than unfractionated heparin
-thrombolysis only for pts who are hemo unstable or evidence of right heart failure
-IVC filter for ppl who can't be anticoagulated or have failed anticoagulation or who have low pulmonary reserve and have high risk of death from PE
284
aspiration pneumonia most often affects __________ and ________
lower segments of right upper lobe
| upper segments of right lower lobe
285
aspiration pneumonia develops in ______ of patients who aspirate usually _____ after aspiration. organisms are usually ________
40%
2-4 days
mixed (aerobic-anaerobic)
286
CXR of pulmonary aspiration
variable
infiltrates resembling bacterial pneumonia
atelectasis and local areas of collapse
287
aspiration can lead to ________ if untreated. Poor oral hygiene predisposes to such infections. Foul smelling sputum often indicates ________ infection
lung abscess
| anaerobic infection
288
if aspiration pneumonia is suspected, give _______
abx (penicillin G or clinda)
| prophylactic abx is controversial
289
if obstruction is present after aspiration of something, do this
bronchoscopy
290
most common causes of acute dyspnea
```
CHF exacerbation
pneumonia
bronchospasm
PE
anxiety
```
291
tests to get for dyspnea
CXR
sputum gram stain and culture
PFTs ABGs
ECG, echo
292
paroxysmal nocturnal dyspnea can indicate ______ and/or _______
CHF and/or COPD
293
definition of massive hemoptysis
> 600 mL of blood in 24 hours
294
massive hemoptysis
most common causes:
_________ is key. intubate if necessary
_________ can help identify source of bleeding
_________ to stop the bleeding if indicated
most common causes: bronchiectasis, bleeding diathesis
airway protection
bronchoscopy
bronchial artery embolization or balloon tamponade of the airway
295
most common causes of hemoptysis in general
```
bronchitis
lung cancer (bronchogenic carcinoma)
TB
bronchiectasis
pneumonia
others: goodpasture's, PE w/ pulm infarct, aspergilloma within cavities, mitral stenosis, hemophilia
```
296
evaluation of hemoptysis (3 things)
- CXR- may clearly show the etiology but normal CXR does not r/o a serious condition
- bronchoscopy- do this even if CXR is normal if there is a high suspicion for lung cancer, may localize tumor and/or site of bleeding
- CT scan- complement to bronchoscopy or substitute when bronchoscopy is contraindicated
