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118 Cards in this Set

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What is Virchow's triad?
Stasis (post-op--in bed, long trips, cast, pregnancy)

Hypercoagulability--sickle cell,
polycythemia, CHF, estrogen excess, smoking

Endothelial damage--fracture, post-op, postpartum

ALL RISKS OF THROMBI/EMBOLI
DVT:
Symptoms
Prophylaxis
Treatment
Swollen foot/ankle, ±pain

Prevention: sq heparin, compression stockings, long-term warfarin

Tx: heparin until warfarin therapeutic
Pulmonary embolism:
Symptoms
Diagnostics
Treatment
Pleuritic chest pain, SOB, cough, hemoptysis (rare), fever, tachypnea, tachycardia, confusion, altered mental status

Elevated D-dimer ±DVT on LE u/s, nl CXR, large Aa gradient on ABG

Tx: If massive PE-->thrombolysis (tPA, streptokinase), but usually just heparin/warfarin
Fat emboli can be the result of _____.
Long bone fractures, liposuction
Which emboli increase risk of DIC?
Amniotic fluid emboli (esp. postpartum)
A patient suffers a stroke after incurring multiple long bone fractures in a skiing accident?

Cause of infarct?
Fat embolus going through patent foramen ovale and causing stroke
A patient with a recent tibial fracture and no history of COPD or asthma presents with hypoxia. CXR is normal.

Cause of hypoxia?
What disease process does this mimic?
Could be PE or fat embolus, probably a PE.

Mimics MI.
Obstructive Lung Disease:
Pathophys
Lung volumes
Causes
Obstruction of air flow resulting in air trapping in lungs.
Airways close preamturely at high lung volumes, resulting in:

High RV
Low FVC
Low FEV1
Low FVC

HALLMARK = LOW FEV1/FVC (UNDER 80%)

V/Q mismatch

Causes:
Chronic bronchitis (blue bloater)
Emphysema (pink puffer)
Asthma
Bronchiectasis
Chronic Bronchitis:
Pathophys
Presentation
Hypertrophy of mucus-secreting glands in bronchioles

Blue bloater--productive cough for >3 consecutive months in >2 years.

FIndings: wheezing, crackles, cyanosis, late-onset dyspnea
Emphysema:
Pathophys
Suptypes and Causes
Presentation
Enlargement of air spaces and dec'd recoil resulting from destruction of alveolar walls, inc'd compliance

Centriacinar--smoking
Panacinar--alpha-1 antitrypsin deficiency-->inc'd elastase activity (loss of elasticity)

Presentation:
PInk puffer, barrel-shaped chest
Dyspnea, dec'd breath sounds, tachycardia, early-onset dyspnea, late-onset hypoxemia
Asthma:
Pathophys
Presentation
Bronchial hyperresponsiveness causes REVERSIBLE bronchoconstriction

Smooth muscle hypertrophy and CURSCHMANN'S SPIRALS, CHARCOT-LEYDEN CRYSTALS

Findings:
Cough, wheezing, dyspnea, tachypnea, hypoxemia, pulsus paradoxus, mucus plugging
What is the differential diagnosis for eosinophilia?
DNAAACP
Drugs
Neoplasm
Allergy, asthma (Churg-Straus)
Addison's (adrenal insuff)
Acute interstitial nephritis
Collagen vascular dz
Parasites (ephilic pneumonitis due to Ascaris lumbricoides--a hookworm)
Isoproterenol:
MOA
Use
NONSELECTIVE beta-blocker; iso means 'same', same effect on beta-1 and beta-2

Relaxes bronchial smooth muscle (beta-2), AE is tachycardia (beta-1)

Use in asthma to relax bronchial SM
Selective Beta-2 agonists:
Examples
Use
Albuterol--acute asthma exacerbation
Salmeterol--LA agent for prophyslaxis, may lead to arrhythmia (some beta-1 activity); salmeterol is Slow
Theophylline:
MOA
Use
Causes bronchodilation by inhibiting PDE-->dec'd cAMP hydrolysis

Narrow therapeutic index (cardiotox, neurotox); blocks actions of adenosine (~caffeien)
Ipratropium:
MOA
Use
Competitive blocker of muscarinig receptors (has -trop- in it!)

Prevents bronchoconstriction

Use to tx COPD
Glucocorticoids in treatment of asthma:
MOA
Inhibit synthesis of cytokines; inactivate NF-kappa B (which normally induces production of TNF-alpha)

1st line tx for CHRONIC asthma
Zilueton:
MOA
5-lipoxygenase inhibitor; blocks conversion of arachidonic acid to leukotrienes
Zafirlukast:
MOA
Use
Block leukotriene receptors. good for ASA-induced asthma.

Patients 5 years and up
Montelukast:
MOA
Use
Block leukotriene receptors. Good for ASA-induced asthma

Patients 1 year and up
A patient presents with an asthma attack.

What immunological reaction is responsible for anaphylaxis in this patient?
Asthma is mast-cell mediated; antigen is crosslinking IgE on pre-sensitized mast cells (Type I hypersens)
Which asthma drug:
Inhaled treatment of choice for chronic asthma
Inhaled steroids
Which asthma drug:
Inhaled treatment of choice for acute exacerbations
Albuterol ± ipratropium
Which asthma drug:
Narrow therapeutic index, drug of last resort
Theophylline
Which asthma drug:
Blocks conversion of arachidonic acid to leukotriene
Zileuton
Which asthma drug:
Inhibits mast cell release of mediators, used for prophylaxis only
Cromolyn
Which asthma drug:
Inhaled treatment that blocks muscarinic receptors
Ipratropium
Which asthma drug:
Inhaled long-acting beta-2 agonist
Salmeterol
Which asthma drug:
Blocks leukotriene receptors
Zafirlukast (5 years and up)
Montelukast (1 year and up)
A patient has an extended expiratory phase.

Diagnosis?
Some type of obstructive lung dz
H1 blockers:
First vs Second-Generation Drugs--
Examples
Uses
AEs
First gen:
Diphenhydramine, dimenhydrinate, chlopheniramine

use: Allergy, motion sickness, sleep aid

AE: Sedation, antimuscarinig, anti-alpha-adrenergic

Second generation:
Ex: Loratadine, desloratadine, fexofenadine, cetirizine

Use: Allergy
AE: Farr less sedating than 1st generation bc there's dec'd entry into CNS
Bronchiectasis:
Pathophys
Causes
Chronic necrotizing infection of bronchi-->permanently dilated airways, purulent sputum, recurrent infections, hemoptysis

Presentation: Cough, wheezing, dyspnea, tachypnea, hypoxemia, mucus plugging

Causes:
CF, poor ciliary motility, Kartagener's syndrome; can develop aspegillosis
Restrictive lung disease:
Pathophys
Lung volumes
Restricted lung expansion causes dec'd lung volumes:
Dev'd FVC
Dec'd TLC
FEV1/FVC ratio >80%

Caused by poor breathing mechanics or interstitial lung dz
Poor breathing mechanics:
Causes
Obstructive/Restrictive
Poor muscular effort--polio, myasthenia gravis

Poor structural apparatus--scoliosis, morbid obestiy

RESTRICTIVE
Acute Respiratory Distress Syndrome:
Pathophys
Shock, infection, toxic gas inhalation, aspiration, high [O2], pancreatitis, heroin OD
-->
Inflammatory cells/mediators and Oxygen free radicals
-->
Damage to endothelial or alveolar epithelial (type I) cells
-->
Diffuse alveolar damage and hyaline membrane disease
Empysema
Emphysema--heavy black carbon deposits typical of smoking
Acute respiratory distress syndrome; persistent inflammn leads to poor pulmonary compliance and edema

Note both alveolar fluid and hyaline membranes
Neonatal respiratory distress syndrome:
Pathophys
Risk factors
Treatment
Surfactant deficiency leading to inc'd surfact tension-->alveolar collapse

Surfactant made by type II pneumocytes after 35th week of gestation. Lecithin:sphingomyelin ratio usually <1.5 in neonatal RDS. RIsk PDA.

Risk factors: prematurity, maternal DM (due to elevated insulin), cesarean delivery (dec'd release of fetal glucocorticoids)

Tx: Maternal steroids before birth, artificial surfactant for infant
Coal workers' pneumoconiosis:
Anthracosis vs Simple CWP vs Complicated CWP
Lobes affected?
UPPER LOBES AFFECTED

Anthracosis = mild; black pigment in lung

Simple CWP = small fibrotic lung nodules

Complicated CWP--progressive massive fibrosis
Silicosis pneumoconioses:
Pathophys
Populations affected
Presentation
Lobes affected?
Assocd w/foundries, sandblasting, mines

Macs respond to silica and release fibrogenic factors-->fibrosis

Affects upper lobes

Presents with EGGSHELL CALCIFICATION on hilar LNs

AFFECTS UPPER LOBES
Asbestosis:
Pathophys
Populations affected
Risks
Presentation
Lobes affected?
Assocd w/shipbuilding, roofing, pulmbing

Results in ivory white, calcified pleural plaques

Inc'd incidence of bronchogenic carcinoma and mesothelioma

AFFECTS LOWER LOBES

Golden-brown fusiform rods resembling dumbbells! (located inside macs)
Asbestosis--ferruginous bodies (asbestos bodies w/Prussian blue iron stain) in lung, microscopic. Inhaled asbestos fibers are ingested by macs.
Amiodarone toxicity--diffuse interstitial bilateral pulmonary markings in a reticular nodular pattern; e/o pulmonary fibrosis

SHOULD NOT BE ABLE TO SEE OUTLINE OF BRONCHI
Sleep apnea:
Central vs Obstructive
Treatment
Central sleep apnea--no respiratory effort

Obstructive sleep apnea--respiratory effort against airway obstruction

Tx: weight loss, CPAP, surgery (T&A )
Lung biopsy from a plumber shows elongated structures with clubbed ends in tissue.

Diagnosis?
Risks?
Asbestosis; inc'd risk mesothelioma, bronchogenic carcinoma
A preterm infant has difficulty breathing.

X-ray reveals diffuse ground glass appearance with air bronchograms.

What is the diagnosis and what could have prevented this condition?
Neonatal distress syndrome

Could have been prevented with steroids
A patient develops ARDS from occupational inhalation of nitrogen dioxide.

What histologic change is seen in a patient recovering from ARDS?
ARDS-->damaged endothelium/epithelium

Type II pneumocytes proliferate and form Type I pneumocytes
Breath sounds:
Bronchial obstruction
Tracheal deviation
Sounds absent/diminished over affected area

Dec'd resonance
Dec'd fremitus

Trachea deviates toward side of lesion due to atelectasis
Pleural effusion:
Bronchial obstruction
Tracheal deviation
Dec'd sounds over effusion
Dull resonance
DEc'd fremitus

No tracheal deviation
Pneumonia (lobar):
Bronchial obstruction
Tracheal deviation
Bronchial breath sounds over lesion
Dull resonance
Inc'd fremitus
Tension pneumothorax:
Bronchial obstruction
Tracheal deviation
Breath sounds diminished
Hyperresonant
No fremitus
Tracheal deviation away from side of lzn

Pneumothorax--puncture lung, air occupies space where lung was.
Tension pneumothorax (collapsed lung)
Spontaneous pneumothorax:
Causes
Bullous emphysema
Pneumothorax--Right lung is collapsed

Straight line off rightmost edge of pleural space indicated by arrow (shows edge of collapsed lung)
Pneumothorax--CT chest image shows collapsed left lung w/ipsilateral inc'd density lung parenchyma
What are the complications of lung cancer?
SPHERE

Superior vena cava syndrome--compression of SVC, can't drain face/neck

Pancoast's Tumpor
Horner's Syndrome--ptosis, eyelid drooping
Endocrine (paraneoplastic)
Recurrent laryngeal syx (hoarseness)
Effusions--plueral or pericardial
Squamous cell carcinoma of lung:
Location
Characteristics
Histology
Squamous, Sentral, Smoking

Sentral (central): located in hilum

Parathyroid like activity (PTHrP)

Kerain pearls, intercellular bridges
Adenocarcinoma of lung:
Location
Characteristics
Peripheral (lobes)

Not related to smoking, can develop in site of prior inflammn
Small cell carcinoma of lung:
Location
Characteristics
Central

Undiff'd; very aggressive.

Often assocd w/ectopic produciton of ACTH (Cushing's, not suppressible by dexamethasone) or ADH-->Lambert-Eaton syndrome (autoab's against calcium channels)

Appear as small dark blue cells
Small cell carcinoma in pulmonary hilar LN.

Almost all related to tobacco use. Arise anywhere in lung, most often near hilum; quickly spread along bronchi.
Carcinoid tumor of lung:
Characteristics
Secretes serotonin-->Carcinoid syndrome

Presents with:
Bronchospasm, wheezing
Flushing
Diarrhea
Right-sided heart lesions
CXR shows pleural effusions.

Clinical findings?
Dullness to Resonance
Dec'd fremitus
Dec'd breath sounds of affected areas
A tall, thin male teenager has abrupt onset dyspnea and left-sided chest pain. Percussion on the affected side reveals hyperresonance, and diminished breath sounds.

Diagnosis?
Spontaneous pneumothorax
CXR shows collapse of middle lobe of right lung and mass in right bronchus; pt has history of recurrent pneumonias.

Diagnosis?
Bronchogenic Carcinoma -->pneumonias
A never-smoker develops bronchogenic lung cancer. He is a coal miner.

Exposure to what substance has put him at risk for developing lung cancer?
Radon--heavy gas that settles into basements and coal mines
Which infectious agent:
Common cause of pneumonia in immunocompromised pts
PCP pneumo
Which infectious agent:
Most common cause of atypical/ walking pneumonia
Mycoplasma pneumoniae
Which infectious agent:
Common causative agent for pneumonia in alcoholics
Klebsiella
Which infectious agent:
Can cause an interstitial pneumonia in bird handlers
Chlamydia psitecci (sp??)
Which infectious agent:
Often the cause of pneumonia in a pt with a history of exposure to bats and bat droppings
Histo
Which infectious agent:
Often the cause of pneumonia in a pt who has recently visited South California, New Mexico, or West Texas
Coccidoides
Which infectious agent:
Pneumonia associated with "currant jelly" sputum
Klebsiella
Which infectious agent:
Q fever
Coxiella burnetti
Which infectious agent:
Associated with pneumonia acquired from air conditioners
Legionella
Which infectious agent:
Most common cause of pneumonia in children 1 year-old or younger
RSV
Which infectious agent:
Most common cause of pneumonia in the neonate (B-28d)
GBS
E coli
Which infectious agent:
Most common cause of pneumonia in children and young adults (including college students, military recruits, and prison inmates)
Mycoplasma
Which infectious agent:
Common cause of pneumonia in pts with other health problems
Klebsiella
Which infectious agent:
Mosl common cause of viral pneumonia
RSV
Which infectious agent:
Causes a wool-sorter's disease (a life-threatening pneumonia)
Bacillus anthracis
Which infectious agent:
Endogenous flora in 20% of adults
Strep pneumo
Which infectious agent:
Common bacterial cause of COPD exacerbation
H flu
Which infectious agent:
Pontiac fever
Legionella
Which infectious agent:
Common pneumonia in ventilator pts and those with cystic fibrosis
Pseudomonas aeruginosa
Examination of a lung at autopsy reveals a peripheral lesion with caseous necrosis.

What is the diagnosis?
TB
A 30 year-old comatose man on ventilatory support in the ICU develops an infection and dies.

Autopsy reveals a pus-filled cavity in his right lung.

What is the likely etiology?
Aspiration-->Lung abscess
A 55 year-old man who is a smoker and heavy drinker presents with a new cough and flu-like symptoms.

Gram stains shows no organisms; silver stain of sputum shows gram-negative rods.

Diagnosis?
Legionella
Lobar pneumonia:
Cause
Pathophys
Pneumococcus
Klebsiella

Intra-alveolar exudate-->consolidation; may involve entire lung
Bronchopneumonia:
Cause
Pathophys
Staph aureus
H flu
Klebsiella
Strep pyogenes

Acute inflammatory infiltrates (nphils) from bronchioles into adjacent alveoli; patchy distribution involving ≥1 lobes
Interstitial pneumonia:
Cause
Pathophys
Viruses--RSV, adenoviruses, Mycoplasma, legionella, chlamydia

Diffuse patchy inflammn localized to interstitial areas at alveolar walls
Exudate vs Transudate
Exudate: high protein content, cloudy; due to malignancy, pneumonia, trauma; must be drained in light of risk of infection

Transudate: low protein content; due to CHF, nephrotic syndrome, hepatic cirrhosis
Describe the appearance of lymphatic effusion.
Milky, high TGs
N-acetylcysteine:
Use
mucolytic expectorant--loosen mucous plugs in CF patients

also used as antidote for acetaminophen OD (regenerates glutathione)
Which pathology:
Most common cause of SIADH
Small cell lung cancer

Brain injury
Which pathology:
Most common testicular tumor
Seminoma
Which pathology:
Most common tumor of infancy
Hemangioma
Which pathology:
Traslocation 9;22 and drug used to treat
Phil chrom; CML, imatinib
What is the triad of Kartagener's syndrome?

Underlying defect?
Sterility, Bronchiectasis, recurrent sinusitis

Dynein arm defect
What are the 3 most common locations of lung cancer mets?
Brain
Bone
Liver
What is the V/Q at the apex of the lung?
3
What is the V/Q at the base of the lung?
0.6
What is the V/Q during airway obstruction?
Toward 0 (shunting)
What is the V/Q during blood flow obstruction?
Toward ∞ (dead space)
How does the emphysema caused by smoking differ from the emphysema caused by alpha-1-antitrypsin deficiency?
Smoking = centriacinar
alpha-1-antitrypsin def = panacinar
What is the hallmark sign of COPD?
Dec'd FEV1/FVC
What is the hallmark sign of restrictive lung disease?
Dec'd TLC, nl FEV1/FVC
Which tumors arise centrally in the lung and are linked to smoking?
Squamous cell
Small cell
Which tumors arise peripherally in the lung and are less linked to smoking (if at all)?
Adenocarcinoma
Large Cell
How does the body compensate for hypoxia at high altitude.
Inc'd ventilation
Inc'd EPO
Inc'd 2,3-DPG
Inc'd mitochondria
Inc'd renal excretion of HCO3
Which cause of pneumonia:
Gram (+)cocci in clusters
Staph aureus
Which cause of pneumonia:
Gram(+) cocci in pairs
Strep pneumo
Which cause of pneumonia:
Gram(-) rods in 80 year-old
E coli
Which cause of pneumonia:
Gram(+) cocci in neonate
GBS
Which cause of pneumonia:
Gram(-) rods in neonate
E coli
What are the common causes of ARDS?
Shock
Infection
Toxic gas inspiration
Heroin OD
High concentrations of O2 for extended pd of time
Aspiration
A 75 year-old patient with a 60 pack/year history presents with difficulty standing from bed when he wakes in the morning. He also presents with difficulty raising his arms in the morning to wash his hair.

Diagnosis?
Lambert-Eaton Syndrome from Small Cell Lung Cancer
What is pulsus paradoxus?

Causes?
Systolic BP drops more than 10 mmHg upon inspiration

Caused by things that hyperinflate lungs:
Asthma
COPD
Group
Cardiac tamponade