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234 Cards in this Set
- Front
- Back
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What are the classic PFT (Pulmonary Function Test) values for Obstructive Lung Disease?
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FEV1/FVC <80%
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Obstructive Pulmonary Disease:
Productive cough on most days during 3 or more consecutive months for 2 or more years that is worst in winter |
Chronic Bronchitis
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Obstructive Pulmonary Disease:
Dyspnea and resultant hypertrophy of accessory muscles of respiration |
Emphysema
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Obstructive Pulmonary Disease:
Cyanosis, rhonchi, wheezes, obesity, and signs of right-sided heart failure |
Chronic Bronchitis
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Obstructive Pulmonary Disease:
normal PaCO2, mildly decreased PO2 |
Emphysema
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Obstructive Pulmonary Disease:
Hypertrophy/hyperplasia of mucus glands lining the airways |
Chronic Bronchitis
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Obstructive Pulmonary Disease:
Destruction of alveolar walls leading to loss of elastic recoil and dilation of airspaces |
Emphysema
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Obstructive Pulmonary Disease:
Acute or subacute onset of dyspnea, expiratory wheezing, prolonged expiratory phase, accessory muscle use |
Asthma
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Obstructive Pulmonary Disease:
Pursed-lip breathing, prolonged expiratory phase |
Emphysema
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Obstructive Pulmonary Disease:
Commonly caused by cystic fibrosis (CF), severe/chronic pulmonary infection or connective tissue disease |
Bronchiectasis
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Obstructive Pulmonary Disease:
Mucous plugging, airway smooth muscle hypertrophy, peripheral eosinophilia |
Asthma
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Obstructive Pulmonary Disease:
Barrel chest, decreased breath sounds, hyperrosonant to percussion |
Emphysema
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Obstructive Pulmonary Disease:
Increased PaCO2, decreased PO2, increased hematocrit (Hct) early in the course of disease |
Chronic Bronchitis
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Obstructive Pulmonary Disease:
Lung hyperinflation on CXR (2) |
Emphysema
Asthma |
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Obstructive Pulmonary Disease:
Airway irritability causing reversible bronchoconstriction Diagnose with methacholine challenge |
Asthma
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Obstructive Pulmonary Disease:
Permanent dilation of bronchioles |
Bronchiectasis
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Obstructive Pulmonary Disease:
Mildly decreased PaO2, respiratory alkalosis |
Asthma
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Obstructive Pulmonary Disease:
Halitosis, hemoptysis and productive cough |
Bronchiectasis
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Obstructive Pulmonary Disease:
CXR may demonstrate subpleural blebs or parenchymal bullae |
Emphysema
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Obstructive Pulmonary Disease:
Exacerbation may be triggered by cold air, exercise, inhaled dust, upper respiratory infection (URI), beta-blockers, stress |
Asthma
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Obstructive Pulmonary Disease:
CXR may show tram-track lung markings |
Bronchiectasis
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What is the most beneficial lifestyle modification for a patient with chronic obstructive pulmonary disease (COPD)?
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Smoking Cessation
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What prophylactic vaccines are recommended for patients with COPD?
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Influenza and Pneumococcal Vaccines
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What are the 3 classes of bronchodilators used for COPD and Asthma?
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1 Beta-2 Selective Agonists
- Albuterol 2 Anticholinergics - Ipratropium 3 Methylxanthine |
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What bronchodilator commonly used in COPD for relief of nocturnal symptoms can also cause nausea, vomiting, seizures and arrhythmias?
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Theophylline
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What 2 classes of drugs are useful during acute COPD exacerbations?
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1 Corticosteroids
2 Antibiotics |
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Which therapy can provide symptomatic relief and improve outcome in COPD patients with hypoxemia?
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Supplemental Oxygen Therapy
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What inherited disorder causes early progression of COPD?
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Alpha-1 Antitrypsin Deficiency
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First-line therapy for Acute Asthmatic Attack
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Oxygen
Bronchodilators Steroids |
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Second-line therapy for Acute Asthmatic Attack
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MgSO4
Intramuscular Epinephrine |
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Initial Therapy for Mild Asthma
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Inhaled Albuterol PRN
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Treatment for Mild Asthma refractory to Albuterol treatments
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Inhaled Glucocorticoids
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Treatment for Asthma refractory to daily Albuterol use
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Systemic Steroid Therapy
Usually with oral prednisone or IV methylprednisolone |
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Prophylaxis for asthma attacks (not including steroids)
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Leukotriene Inhibitors
Cromolyn |
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Describe how glucocorticoids act on airways to control asthma
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Decreased inflammation and decreased reactivity of airways to irritants (eg, cold, cigarette smoke, allergens, exercise)
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Treatment:
Mild Intermittent Asthma |
Daily Treatment:
none Quick Relief: Albuterol |
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Treatment:
Mild Persistent Asthma |
Daily Treatment:
Low-dose steroids Isoniazid (INH) Quick Relief: Albuterol |
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Treatment:
Moderate Persistent Asthma |
Daily Treatment:
low-medium dose INH long-acting beta-2 selective agonist Quick Relief: Albuterol |
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Treatment:
Severe Persistent Asthma |
Daily Treatment:
high-dose steroid INH long-acting beta-2 selective agonist oral steroids Quick Relief: Albuterol |
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What are the classic PFTs for Restrictive Lung Disease?
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FEV1/FVC >70%
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65 yo hay farmer with recent exposure to moldy hay presents with chronic dry cough, chest tightness
PE: bilateral diffuse rales Bronchoscopy: interstitial inflammation Bronchoalveolar Lavage: lymphocyte and mast cell predominance |
Hypersensitivity Pneumonitis
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35 yo male presents with intermittent hemoptysis and hematuria
W/U: alveolar hemorrhage, acute GN |
Goodpasture Syndrome
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40 yo with progressive hypoxemia and cor pulmonale
Lung Biopsy: chronic inflammation of the alveolar wall in a pattern consistent with honeycomb lung Bronchoalveolar Lavage: mild eosinophilia |
Idiopathic Pulmonary Fibrosis
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58 yo former shipbuilder presents with the insidious onset of dyspnea
Transbronchial Biopsy: interstitial pulmonary fibrosis, ferruginous bodies Chest CT: pleural effusion, dense pleural fibrocalcific plaques |
Asbestosis
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55 yo miner (nonsmoker) with dyspnea and dry cough
PFTs: obstructive and restrictive pattern CXR: hilar lymphadenopathy with eggshell calcifications |
Silicosis
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60 yo male with 100 pack-year h/o smoking presents with pleuritic chest pain, hemoptysis and dyspnea
PE: dullness to percussion and absent breath sounds in the right lower lung field |
Pleural Effusion
(secondary to malignancy) |
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50 yo former heavy smoker presents with multiple lung and rib lesions
Excisional Biopsy: lesions composed of cells (similar to the Langerhans cells of the skin) containing tennis racket-shaped Birbeck granules |
Eosinophilic Granuloma
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30 yo black female presents with DOE, fever, arthralgia
PE: iritis, erythema nodosum LABS: eosinophilia, increased serum ACE levels PFTs: restrictive pattern CXR: bilateral hilar lymphadenopathy Lymph Node Biopsy: noncaseating granulomas |
Sarcoidosis
"GRAIN" - Gammaglobulinemia - Rheumatoid Arthritis - ACE increase - Interstitial Fibrosis - Noncaseating Granulomas |
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How is the diagnosis of Lofgren Syndrome (found in 25-50%) made in sarcoidosis patients? (3)
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1 Hilar Lymphadenopathy
2 Polyarthralgias 3 Erythema nodosum |
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4 Stages of Sarcoidosis
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1 Hilar lymphadenopathy alone
2 Lymphadenopathy + Infiltrates 3 Infiltrates alone 4 Fibrosis |
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What are the common presenting symptoms of an infant with Cystic Fibrosis? (7)
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1 Meconium Ileus
2 Diarrhea 3 Steatorrhea 4 Malabsorption 5 Failure to Thrive 6 Prolonged Jaundice 7 Recurrent URIs |
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What are the common presenting signs on examination of an infant with CF? (5)
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1 Cyanosis
2 Clubbing 3 Hyperresonant Lung Fields with occasional Crackles 4 Rectal Prolapse 5 Abdominal Distention |
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What is the traditional diagnostic test for CF?
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Sweat Chloride Test
+ if >60 mEq/L |
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What is the definitive test for CF?
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Genetic Analysis
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Which drugs are know to be beneficial in the management of CF? (3)
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1 Bronchodilators
2 Antibiotics 3 Anti-Inflammatory Agents |
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What dietary supplements are necessary for patients with CF?
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1 Pancreatic Enzyme Supplements
2 Vitamins A, D, E, K (Fat-Soluble) |
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Which 2 methods are used to clear excess pulmonary secretions in patients with CF?
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1 Physical Therapy
2 DNAse Therapy |
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Effect of CF on the Lungs
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1 Recurrent Pulmonary Infections
2 Bronchiectasis 3 Increased Residual Volume (RV) and Total Lung Capacity (TLC) 4 Decreased Forced Expiratory Volume (FEV) in the first second (FEV1)/FVC in acute exacerbation 5 Pulmonary Hemorrhage may occur |
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Effect of CF on the Pancreas
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1 Variable defects in Pancreatic Exocrine Function
2 May cause Pancreatic Insufficiency, Fatty Stool, Weight Loss |
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Effects of CF on the Intestines
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Mucus Plugs leading to Small Bowel Obstruction (SBO)
Meconium Ileus in some infants |
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Effects of CF on Salivary Glands
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1 Ductal Dilation
2 Squamous Metaplasia of Ductal Epithelium and Glandular Atrophy |
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Effect of CF on the Liver
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Plugging of Bile Canaliculi leading to Cirrhosis
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Effect of CF on Epididymis and Ductus Deferens
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Obstruction leading to Azoospermia and Infertility
Azoospermia is the medical condition of a man not having any measurable level of sperm in his semen |
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What is the classic finding on pulmonary examination in a patient with idiopathic pulmonary fibrosis?
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Fine Expiratory Crackles
(Velcro Crackles) |
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How does interstitial lung disease affect alveolar gas diffusion and lung volumes?
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Interstitial fibrosis decreases gas diffusion and lung volumes
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Which group of interstitial lung diseases can present with a combination of obstructive and restrictive pattern on PFTs?
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Pneumoconioses
- Asbestosis - Silicosis - Anthracosis - Siderosis - Berylliosis |
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Which group of interstitial lung diseases is caused by a deposition of immune complexes in the alveoli and granuloma formation?
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Hypersensitivity Pneumonitis
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Drugs know to cause Interstitial Lung Disease (4)
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1 Bleomycin
2 Vincristine 3 Alkylating Agents 4 Amiodarone |
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What are typical findings on CXR in a patient with Interstitial Lung Disease
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Reticular or Reticulonodular Infiltrates or Honeycomb Lung
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Interstitial Lung Disease:
CXR: bilateral linear opacities and broad pleural plaques |
Asbestosis
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Interstitial Lung Disease:
CXR: nodular opacities in the upper lung zones |
Coal Worker's Pneumoconiosis
Silicosis |
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Interstitial Lung Disease:
CXR: diffuse infiltrates in the upper lung zones |
Berylliosis
Hypersensitivity Pneumonitis |
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Patients with silicosis are at increased risk for which infectious disease?
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Tuberculosis
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What is the definitive diagnostic test for interstitial lung diseases?
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Biopsy
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What are the 2 general principles of treatment for hypersensitivity pneumonitis and the pneumoconioses?
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1 Corticosteroids
2 Prevention of exposure to offending agents |
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What is the mainstay of treatment for patients with sarcoidosis?
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Corticosteroids
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Type of Pleural Effusion:
Common presentation includes dyspnea, pleuritic chest pain, hemoptysis, cough |
Transudate
& Exudate |
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Type of Pleural Effusion:
Pathophysiologic mechanism is based on breakdown of the pleural membrane and capillaries |
Exudate
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Type of Pleural Effusion:
Due to excess production or inadequate reabsorption of pleural fluid |
Transudate & Exudate
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Type of Pleural Effusion:
Pathophysiologic mechanism is based on changes in Starling's forces |
Transudate
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Type of Pleural Effusion:
Decreased breath sounds, decreased tactile fremitus and dullness to percussion in the region of the effusion |
Transudate & Exudate
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Type of Pleural Effusion:
Effusion containing bacteria |
Exudate
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Type of Pleural Effusion:
Commonly caused by cirrhosis, nephrotic syndrome, protein losing enteropathy or heart failure |
Transudate
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Type of Pleural Effusion:
Commonly caused by malignancy, tuberculosis, infection, SLE, rheumatoid arthritis (RA) |
Exudate
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Type of Pleural Effusion:
May be caused by a PE |
Transudate & Exudate
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Type of Pleural Effusion:
pH <7.2 Glucose <50 |
Exudate
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Type of Pleural Effusion:
Pleural LDH/Serum LDH >0.6 |
Exudate
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Type of Pleural Effusion:
Pleural Protein/Serum Protein <0.5 |
Transudate
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Type of Pleural Effusion:
Specific gravity of effusion >1.015 |
Exudate
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Name 3 conditions which may lead to a pleural effusion containing amylase:
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1 Pancreatitis
2 Esophageal Rupture (traumatic or postoperative) 3 Malignancy |
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What term is used to describe an exudative pulmonary effusion which contains gross pus, has readily visible bacteria, has glucose <50 or pH <7
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Empyema
(complicated parapneumonic effusion) |
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What type of analysis should be performed on a patient in which malignancy is thought to be the cause of a pleural effusion?
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Cytology
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What class of drugs is often used to treat a transudative effusion?
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Diuretics
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What procedure is performed to prevent reaccumulation of a malignant pleural effusion?
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Pleurodesis
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In addition to antibiotic coverage for pneumonia, what is the appropriate management for an empyema?
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Chest Tube Drainage
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What diagnosis is suggested by pleural fluid containing RBC >100,000 in the absence of trauma or pulmonary infarction?
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Pleural Malignancy
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What is the incidence of PE in autopsies?
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Greater than 50%
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What is the incidence of PE in hospitalized patients?
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20-25%
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What is the etiology of 95% of pulmonary emboli?
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Dislodged lower extremity deep venous thromboses (DVTs)
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What is the most common clinical presentation of PE?
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Sinus Tachycardia
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What are the common presenting symptoms of PE? (7)
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1 Sinus Tachycardia
2 Fever 3 Pleuritic Chest Pain 4 Cough 5 Dyspnea/Tachypnea 6 Swollen and Painful Leg 7 Anxiety |
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What factors favor the development of a DVT?
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Virchow's Triad
1 Stasis 2 Hypercoagulability 3 Endothelial Injury/Dysfunction |
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What are the 2 most common CXR findings in a patient with PE?
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1 Normal CXR
2 Cardiomegaly |
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What are the classic CXR findings in a patient with a PE?
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1 Pleural Effusion
2 Hampton's Hump - a distal wedge-shaped infarct 3 Westermark's Sign - hyperlucency in the region of lung supplied by the infarcted artery |
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What is the most common ECG finding in a patient with PE?
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Sinus Tachycardia
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What is the classic ECG finding in a patient with PE?
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S1Q3T3
S wave in Lead I Q wave in Lead III Inverted T wave in Lead III |
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What are modified Well's Criteria for DVT/PE risk stratification?
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3 POINTS:
No Dx more likely, physical signs of DVT (asymmetric LE edema) 1.5 POINTS: tachycardia, hospitalized in past month/surgery, past hx of DVT 1 POINT: hemoptysis, malignancy 0-1 = Low Risk (rule out with negative D-dimer) 2-6 = Intermediate Risk >7 = High Risk (treat with positive LE Doppler US) |
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What 2 diagnostic tests are commonly used to diagnose PE?
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1 Chest CT with contrast
2 Ventilation/Perfusion Scan (when contrast is contraindicated) |
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What is the gold standard test for diagnosis of PE?
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Pulmonary Angiogram
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What serologic test can assist in ruling out PE when negative in low-risk patients?
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D-dimer
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What thrombolytic drug may be used in massive PE causing hemodynamic instability?
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Tissue Plasminogen Activator (t-PA)
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What therapy is indicated for high-risk patients during the w/u of PE and for patients diagnosed with PE?
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IV Heparin
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What are the contraindications for anticoagulation with heparin?
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1 h/o Heparin-Induced Thrombocytopenia (HIT)
2 Intracranial Hemorrhage or Neoplasm 3 Recent Major Surgery 4 Bleeding Diathesis |
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Why should heparin be continued for several days after warfarin therapy is begun?
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1 Warfarin takes several days to become therapeutic
2 Initially warfarin induces a hypercoagulable state (by inactivating proteins C and S), which may cause skin necrosis |
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What methods are used for long-term prophylaxis for patients at risk of developing DVT?
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Warfarin or IVC Filter
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What is an alternative to warfarin for outpatient DVT prophylaxis?
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Low-Molecular Weight Heparin (LMWH)
- eg, Enoxaparin |
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What type of tumors commonly cause a DVT by inducing a hypercoagulable state?
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Adenocarcinomas
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What commonly used medication increases the risk of DVT?
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Oral Contraceptives
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What is the most common genetic disease that predisposes to the development of DVTs?
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Factor V Leiden
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What syndrome is suggested by the presence of acute, refractory hypoxemia, decreased lung compliance, and pulmonary edema in a patient with normal pulmonary capillary wedge pressure?
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Acute Respiratory Distress Syndrome (ARDS)
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What syndrome is suggested by the presence of pulmonary edema in a patient with an elevated pulmonary capillary wedge pressure?
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Cardiogenic Pulmonary Edema
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What are the diagnostic criteria for ARDS?
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1 Acute onset of respiratory distress
2 PaO2/FIO2 < or = 200 3 Bilateral pulmonary infiltrates on CXR 4 Normal pulmonary capillary wedge pressure |
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What is the most common risk factor for ARDS?
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Sepsis
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6 Most Common Risk Factors for ARDS
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1 Sepsis
2 Lung injury due to aspiration of gastric contents 3 Trauma 4 Pancreatitis 5 Drug overdose 6 Shock |
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What type of respiratory therapy is indicated in ARDS?
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Mechanical Ventilation
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What are the 2 most common presenting symptoms in spontaneous pneumothorax (PTX)?
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1 Unilateral Chest Pain
2 Dyspnea |
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What are common presenting signs in a patient with spontaneous PTX?
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1 Tachypnea
2 Unilateral Diminished/Absent Breath Sounds 3 Hyperresonance to Percussion |
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What is the most common cause of primary spontaneous PTX?
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Rupture of Subpleural Apical Bullae
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What are the most common causes of secondary spontaneous pneumothorax?
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1 COPD (MC)
2 CF 3 Pulmonary Infections (especially PCP pneumonia and TB) 4 Trauma 5 Iatrogenic |
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What widely used ICU procedure carries the risk of PTX?
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Placement of subclavian or internal jugular central venous catheters
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What are the common presenting signs in a patient with tension PTX?
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1 Dyspnea
2 Tachypnea 3 Jugular Venous Distention 4 Hemodynamic Instability 5 Lateral Displacement of Trachea |
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What is the appearance of a PTX on CXR?
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Pleural stripe with absent lung markings
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What are the classic findings on CXR in Tension PTX?
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1 Hyperlucent Lung Field (ipsilateral)
2 Depressed Diaphragm (ipsilateral) 3 Tracheal & Mediastinal Deviation (away from PTX) 4 Compression of the Contralateral Lung |
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What is the treatment of a spontaneous PTX?
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Asymptomatic - observation and oxygen therapy
Symptomatic - may require chest tube drainage |
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What is the management of a Tension PTX?
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Emergent Needle Thoracostomy at the second interspace at the midclavicular line
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Which patients with PTX get tube thoracostomy?
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Symptomatic patients
or PTX 2/2 underlying lung disease |
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Which patients with PTX are treated with needle aspiration?
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1 Those with minimal dyspnea
2 <50 yo 3 Small (<2 cm) PTX |
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What is the common presentation of typical (bacterial) pneumonia?
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1 Fever > 39C (102.2F)
2 Chills 3 Cough productive of blood tinged, purulent sputum 4 Pleuritic Pain (acute onset) |
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What is the common presentation of Atypical "Walking" Pneumonia?
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1 Fever > 39C (102.2F)
2 Nonproductive cough 3 Headache 4 GI upset (insidious onset) |
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What are the common physical findings in pneumonia?
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1 Bronchial Breath Sounds
2 Crackles 3 Wheezes 4 Egophany 5 Dullness to Percussion 6 Tactile Fremitus |
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What is the classic CXR finding in Typical Pneumonia?
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Lobar Consolidation
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What is the classic CXR finding in Atypical Pneumonia?
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Patchy Alveolar Infiltrates
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Most Common Organism:
Lobar Pneumonia |
Streptococcus pneumoniae
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Most Common Organism:
Bronchopneumonia |
Staphylococcus aureus
Haemophilus influenzae |
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Most Common Organism:
Interstitial Pneumonia |
1 Mycoplasma pneumoniae (MC)
2 Legionella pneumophila 3 Chlamydia pneumoniae |
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Most Common Organism:
Fungal Pneumonia in AIDS patient with CD4+ count <200 |
Pneumocystis jiroveci
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Most Common Organism:
Typical Pneumonia in Neonate |
Streptococcus agalactiae (GBS)
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Most Common Organism:
Alcoholic with Typical Pneumonia after Aspiration |
Klebsiella pneumoniae
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Most Common Organism:
Atypical Pneumonia in younger patient with positive cold agglutinin test |
Mycoplasma pneumoniae
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Most Common Organism:
Neonate with Atypical Pneumonia and Trachoma |
Chlamydia trachomatis
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Most Common Organism:
Dairy worker with Atypical Pneumonia |
Coxiella burnetti
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Most Common Organism:
Rabbit hunter with Atypical Pneumonia |
Francisella tularensis
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Most Common Organism:
Pet bird owner with pneumonia, splenomegaly, bradycardia |
Chlamydia psittaci
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Most Common Organism:
Hospitalized patient with lobar pneumonia |
Streptococcus pneumoniae
> Staphylococcus aureus |
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Most Common Organism:
Iv drug user with pneumonia |
Streptococcus pneumoniae
Klebsiella pneumoniae Staphylococcus aureus |
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Most Common Organism:
Patient recovering from viral URI |
Staphylococcus aureus
Haemophilus influenzae |
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Most Common Organism:
Chicken farmer from Ohio River Valley with atypical pneumonia |
Histoplasma capsulatum
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Most Common Organism:
Patient from southwestern US with atypical pneumonia |
Coccidioides immitis
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Most Common Organism:
Most common cause of community-acquired pneumonia |
Streptococcus pneumoniae
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Most Common Organism:
Best treated with nafcillin, oxacillin, methicillin or vancomycin (for penicillin resistant strains) |
Staphylococcus aureus
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Most Common Organism:
Causes severe pneumonia in CF patients and readily develops multidrug resistance |
Pseudomonas spp.
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Most Common Organism:
Cough productive of dark red, mucoid, currant jelly sputum in an alcoholic diabetic |
Klebsiella pneumoniae
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Most Common Organism:
Rust-colored sputum |
Streptococcus pneumoniae
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Most Common Organism:
Lobar pneumonia in a smoker with COPD; sputum with gram-negative rods and many leukocytes; best treated with macrolides |
Haemophilus influenzae
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Most Common Organism:
Recommended treatment includes third-generation cephalosporin or fluoroquinolone |
Gram-Negative Rods:
Pseudomonas spp. Klebsiella pneumoniae Haemophilus influenzae |
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Most Common Organism:
Pneumonia following influenza infection |
Staphylococcus aureus
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Most Common Organism:
Associated with inhalation of contaminated water droplets from air conditioners |
Legionella pneumophila
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Most Common Organism:
Lung abscess with air/fluid level on CXR |
Staphylococcus aureus
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Most Common Organism:
Pneumonia accompanied by hyponatremia, mental status changes, diarrhea, and LDH >700 |
Legionella pneumophila
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Most Common Organism:
Gram-positive, weakly acid-fast organism causing pneumonia in patients with AIDS; associated with peripheral eosinophilia |
Nocardia asteroides
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Most Common Organism:
Fungus ball on CXR |
Aspergillus
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Most Common Causative Pathogen of Pneumonia in Neonates
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Group B Streptococci (GBS)
Escherichia coli Chlamydophila pneumoniae |
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Most Common Causative Pathogen of Pneumonia in Children (6 weeks to 18 years)
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Respiratory Syncytial Virus (RSV) and Other Viruses
Mycoplasma pneumoniae Chlamydophila pneumoniae Streptococcus pneumoniae |
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Most Common Causative Pathogen of Pneumonia in Adults (18-40 years old)
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Mycoplasma pneumoniae
Chlamydophila pneumoniae Streptococcus pneumoniae |
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Most Common Causative Pathogen of Pneumonia in Adults (45-65 years old)
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Streptococcus pneumoniae
Haemophilus influenzae Anaerobes Viruses Mycoplasma pneumoniae |
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Most Common Causative Pathogen of Pneumonia in Adults >65 Years Old
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Streptococcus pneumoniae
Viruses Anaerobes Haemophilus influenzae Gram-Negative Rods |
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Community-acquired pneumonia in a healthy patient <60 years old
Organisms? Empiric Therapy? |
Organisms:
Streptococcus pneumoniae Mycoplasma pneumoniae Chlamydophila pneumoniae Haemophilus influenzae Respiratory Viruses Empiric Therapy: Macrolide (Azithromycin) Fluoroquinolone (Levofloxacin) Tetracycline (Doxycycline) |
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Community-Acquired Pneumonia in a healthy patient >60 years old or with comorbidities (CHF, COPD, DM Alcoholic, Renal or Liver Failure)
Organisms? Empiric Therapy? |
Organisms:
Streptococcus pneumoniae Haemophilus influenzae Aerobic Gram-Negative Bacilli Streptococcus aureus Respiratory Viruses Empiric Therapy: Second-Generation Cephalosporins (Cefuroxime) + Amoxicillin Add Erythromycin if Atypical Pathogens are suspected |
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Community-Acquired Pneumonia in a patient requiring hospitalization
Organisms? Empiric Therapy? |
Organisms:
Streptococcus pneumoniae (including resistant strains) Haemophilus influenzae Mycoplasma pneumoniae Chlamydophila pneumoniae Polymicrobial Empiric Therapy: Antipneumococcal Fluoroquinolone IV |
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Community-Acquired Pneumonia in a patient requiring ICU admission
Organisms? Empiric Therapy? |
Organisms:
Streptococcus pneumoniae (including resistant strains) Legionella spp. Haemophilus influenzae Enteric Gram-Negative Bacilli Staphylococcus aureus Pseudomonas aeruginosa Empiric Therapy: Antipseudomonal Beta-Lactam (Cefepime) + Antipseudomonal Quinolone (Ciprofloxacin) All IV |
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Hospital-Acquired Pneumonia
Empiric Therapy? |
Vancomycin
Cefepime Ciprofloxacin |
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Which patients are at risk for Ventilator-Associated Pneumonia (VAP)?
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Patients with chest trauma
GCS <9 Mechanical ventilation |
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What can be done to help prevent Ventilator-Associated Pneumonia (VAP)?
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Raise head of bed >45
Maintain gastric acid Maximize nutrition Prevent colonization by healthcare workers Use respiratory equipment in a sterile fashion |
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Which patients should receive the pneumococcal vaccine?
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Patient >65 years old
Immunocompromised patients (including postsplenectomy and sickle cell patients |
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4 Common Complications of Lobar Pneumonia
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1 Abscess formation (especially S. aureus and anaerobes)
2 Empyema or spread of infection to the pleural cavity 3 Organization of exudate to form scar tissue 4 Sepsis |
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What type of infection is characterized by localized suppurative necrosis of lung tissue?
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Lung Abscess
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Names several bacterial pathogens capable of causing lung abscesses:
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1 Staphylococci
2 Streptococci 3 Gram-Negative Bacilli 4 Anaerobes 5 Oral Flora |
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Name 2 bacterial pathogens commonly associated with lobar pneumonia complicated by empyema
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Streptococcus pneumoniae
> Staphylococcus aureus |
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What is the most common cause of cancer deaths in the US for both males and females?
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Lung Cancer
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What is the most common type of malignant lung tumor?
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Metastatic Lesions
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What are the most common primary lung tumors?
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1 Adenocarcinoma
2 Squamous cell Carcinoma - equal incidence |
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What are the common presenting symptoms of lung cancer?
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1 Cough
2 Hemoptysis 3 Dyspnea 4 Chest Pain 5 Constitutional Symptoms |
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Type of Primary Lung Cancer:
Central location |
"Sentral"
Squamous Cell Carcinoma Small (Oat) Cell Carcinoma |
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Type of Primary Lung Cancer:
Peripheral location |
1 Adenocarcinoma
2 Large Cell Carcinoma 3 Bronchioalveolar Carcinoma |
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Type of Primary Lung Cancer:
Commonly found within large bronchi |
1 Squamous Cell Carcinoma
2 Small (Oat) Cell Carcinoma |
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Type of Primary Lung Cancer:
Clear link to smoking |
Squamous Cell Carcinoma
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Type of Primary Lung Cancer:
No clear link to smoking |
Bronchoalveolar Adenocarcinoma
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Type of Primary Lung Cancer:
Most malignant tumor (often metastatic at diagnosis) |
Small (Oat) Cell Carcinoma
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Type of Primary Lung Cancer:
Often secretes parathyroid hormone (PTH)-related peptide (PTHrP) |
Squamous Cell Carcinoma
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Type of Primary Lung Cancer:
Associated with production of ADH and ACTH |
Small (Oat) Cell Carcinoma
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Type of Primary Lung Cancer:
Carcinoembryonic Antigen (CEA) + |
Adenocarcinoma
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Type of Primary Lung Cancer:
Secretion of 5-HT results in tachycardia, diarrhea, skin flushing, wheezing |
Carcinoid
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Type of Primary Lung Cancer:
Tumor cells lining alveolar walls |
Bronchioalveolar Adenocarcinoma
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Type of Primary Lung Cancer:
Giant pleomorphic cells, many cerebral metastases, poor prognosis |
Large Cell
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Type of Primary Lung Cancer:
Associated with dermatomyositis, acanthosis nigricans |
All types
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Type of Primary Lung Cancer:
Associated with peripheral neuropathy and Lambert-Eaton myasthenic syndrome |
Small (Oat) Cell Carcinoma
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Type of Primary Lung Cancer:
Associated with thrombophlebitis |
Adenocarcinoma
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Structure Compressed or Irritated by Lung Tumor:
Cough |
Phrenic Nerve
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Structure Compressed or Irritated by Lung Tumor:
Hoarseness |
Recurrent Laryngeal Nerve
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Structure Compressed or Irritated by Lung Tumor:
Facial & upper extremity swelling |
Superior Vena Cava (SVC) Syndrome
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Structure Compressed or Irritated by Lung Tumor:
Ptosis, miosis, hemianhydrosis |
Sympathetic Cervical Ganglion
(Horner Syndrome) |
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What percentage of solitary pulmonary nodules is malignant?
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40%
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What is the differential diagnosis for a solitary pulmonary nodule?
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1 Infectious Granuloma
2 Carcinoma 3 Benign Neoplasm 4 Bronchial Adenoma 5 Pneumonia |
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Are routine CXRs a good way to screen for lung cancer/carcinoma (CA)?
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No
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What is an effective way to lower the risk of lung CA?
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Smoking Cessation
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What is the treatment for small cell carcinoma?
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Radiation
Chemotherapy |
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What is the treatment for non-small cell carcinoma that is local?
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Tumor resection
Radiation therapy |
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What is the treatment for nonsmall cell carcinoma that has metastasized?
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Radiation
Chemotherapy |
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What rare pleural tumor is found in patients with a h/o occupational exposure to asbestos?
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Malignant Mesothelioma
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Benign or Malignant Solitary Pulmonary Nodule:
Age >40 years |
Malignant
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Benign or Malignant Solitary Pulmonary Nodule:
Size >2cm |
Malignant
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Benign or Malignant Solitary Pulmonary Nodule:
Well-circumscribed mass |
Benign
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Benign or Malignant Solitary Pulmonary Nodule:
Absence of calcification or irregular calcification |
Malignant
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Benign or Malignant Solitary Pulmonary Nodule:
Growth in lesion from previous CXRs |
Malignant
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Benign or Malignant Solitary Pulmonary Nodule:
Central, uniform or laminated calcification |
Benign
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7 yo with h/o environmental allergies presents in acute respiratory distress
PE: increased tachypnea, expiratory wheezes, intercostal retractions, accessory muscle use CXR: hyperinflation CBC: eosinophilia |
Bronchial Asthma
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60 yo with 50 pack-year h/o smoking presents with fever and cough productive of thick sputum for the past 4 months
PE: cyanosis, crackles, wheezes, W/U: Hct = 48, WBC = 12,000 CXR: no infiltrates |
Chronic Bronchitis
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60 yo with a 50 pack-year h/o smoking presents with DOE and dry cough, but no chest pain
PE: decreased breath sounds, hyperresonant chest, increased HR, distant S1 and S2 CXR: flattened diaphragm |
Emphysema
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60 yo with 50 pack-year h/o of smoking presents with fatigue, dyspnea, hoarseness, anorexia
PE: miosis, ptosis, anhydrosis, dullness to percussion at right apex Chest CT: large hilar mass extending into the right superior pulmonary sulcus |
Pancoast Tumor
- most likely bronchogenic Squamous Cell Carcinoma, causing Horner Syndrome |
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60 yo patient, POD 4 s/p total knee replacement has the sudden onset of tachycardia, tachypnea, sharp chest pain, hypotension
ABG: respiratory alkalosis ECG: sinus tachycardia Venous Duplex US: clot in right femoral vein |
Pulmonary Embolus
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40 yo white male presents with chronic rhinosinusitis, ear pain, cough, dyspnea
PE: ulcerations of nasal mucosa, perforation of nasal septum W/U: increased c-ANCA, red cell casts in urine Biopsy of Nasal Lesions: necrotizing vasculitis and granulomas |
Wegener's Granulomatosis
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50 yo obese male with resistant hypertension complaining or morning headache, awakening without feeling refreshed and daytime sleepiness
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Obstructive Sleep Apnea
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55 yo female presents with dyspnea and nonproductive cough
PE: "Velcro-like" basilar end-inspiratory crackles and clubbing CXR: basilar infiltrates PFTs: FEV1/FVC >70%, decreased DLCO |
Idiopathic Pulmonary Fibrosis
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40 yo African American woman presents with dyspnea and polyarthritis
PE: acute, nodular erythematous eruption on extensor surface of lower extremities CXR: hilar lymphadenopathy Biopsy: noncaseating granuloma with no infection |
Sarcoidosis
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