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84 Cards in this Set
- Front
- Back
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Pulmonary Nodules
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Solitary pulmonary nodule (Coin lesion) is less than 3cm in diameter, rounded opacity on CXR, isolated, outlined by normal lung not associated with infiltrate, atelectasis or adenopathy.
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Symptoms and PE findings of Pulmonary nodules?
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Asymptomatic and normal PE
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first step when finding a nodule?
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Determine whether it is benign or malignant.
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If it is benign?
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determine whether infection (TB, coccidiomycosis, Lung abscess) or inflammation (Sacoidosis, wegener granulomatosis, atelectasis, rheumotoid nodule).
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DD of pulmonary nodules
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Malignancy
Sarcoidosis Infections granuloma: TB or coccidoiomycosis |
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Diagnosis of Pulmonary nodules
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Chest x-ray
CT scan Serial imaging studies |
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What type of nodules are rare in a person under 30?
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Malignant
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Malignancy increase at what age?
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30 and older
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Increase risk of malignancy in ?
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Smokers and increase risk of # of cigarettes smoked daily
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Rapid progression indicates? (doubling time< 30 days)
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infection
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double time > 465 days
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benign
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PN:
Low probability of malignancy? Treatment? |
<5%
Watchful waiting is appropriate (age<30, stable for 2 years, and benign calcification) |
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PN:
High Probability of malignancy? |
>60%
if no contradiction to surgery (pulmonary function test and cardio), surgical resection following staging |
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PN:
Intermediate probability |
5-60%
Remains controversial Diagnostic biopsy: TTNA and bronchoscopy |
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Prevention/ Patient education of PN:
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follow-up for repeat chest x-ray or CT scan.
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Carcinoid Tumors?
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rare, slow growing neuroendocrine tumors arising from bronchial mucosa; Not related to smoking, mostly centrally located, peripherally located bronchial carcinoid tumors are rare.
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Carcinoid tumors?
Symptoms: |
Asymptomatic
Recurrent pneumonia Hemoptysis Chest pain Leads to misdiagnosis of asthma: dyspnea, wheezing, cough |
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PE findings of Carcinoid tumors?
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Paraneoplastic syndrome: cushings syndrome, acromegaly, zollinger-ellison
Carcinoid syndrome: rare; flushign, diarrhea, wheezing, and hypotension; to much serotonin release Left-sided heart murmur: mitral stenosis or regurgitation, due to serotonin induced valvular damage |
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DD: of carcinoid tumor:
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Asthma
COPD Bronchogenic carcinoma other causes of paraneoplastic syndromes |
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Diagnosis of Carcinoid tumors?
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CT, Indium 111-labeled octreotide scans are useful for determining regional and metastatic spread, Bronchoscopic biopsy of tumor cells, increased urinary serotonin and 5-hydroxyindoleacetic acid levels may or may not be present
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Medical management ?
Surgical management? of Carcinoid tumors |
MM- may or may not chemo
SM- surgical resection of tumor |
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Emergency management of carcinoid tumors?
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Recognized and treat any signs of respiratory distress or failure. also provide supplemental oxygen as needed
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Patient education/maintenance of carcinoid tumors?
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Prognosis depends on type of tumor. 5 year survival rate of typical (well differentiated) carcinoids is greater than 90% for atypical 50-70%.
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Bronchogenic carcinoma?
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Malignant neoplasia marked by uncontrolled growth of cells originating in the lung or bronchus
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Two categories of bronchogenic carcinoma?
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NSCLC- squamous, adenocarcinoma, or large cell
SCLC |
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PE findings and Symptoms of Bronchogenic carcinoma?
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SS: anorexia, weight loss, asthenic, new cough or a change in a chronic cough, hemoptysis, pain (non-specific chest, bony metastases to vertebrae, ribs or pelvis) voice change (recurrent laryngeal nerve).
PE: SVC syndrome Horner's syndrome Paraneoplastic syndromes |
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SS: of SCLC and NSCLC
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digital clubbing, increased ACTH production, anemia, hyper coagulability, peripheral neuorpathy, Eaton-Lambert myasthenia syndrome, SIADH
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Found in NSCLC not in SCLC
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hypercalemia
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Diagnosis of bronchogenic carcinoma?
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Sputum cytology, thoracentesis- malignant pleural effusions, fine needle aspiration of LN, CT and CXR, bronchoscopy biopsy
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Medical management of NSCLC?
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TNM staging:
I- surgical resection II- surgical resection and adjuvant chemotherapy III- chemo, radiation, surgical IV- symptom palliative therapy, dijuvant chemo, antineoplastic drugs following surgery or radiation therapy |
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Small-cell carcinoma treatment
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combination chemo- Cisplatin/etoposide, remission is duration of 6-8 months, overall 2 yr survival is 20% in limited and 5% in extensive
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Difference between SCLC
limited and extensive? |
Limited- tumor is unilateral hemithorax
Extensive- tumor extends beyond hemithroax. |
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Emergency management of Bronchogenic carcinoma?
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Recognize and treat any signs of respiratory distress or failure. provide oxygen as needed
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Metastatic tumors?
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secondary lung cancers that spread from vascular or lymphatic channels or direct extension; usually pulmonary artery, and any cancer can metastasize to the lung
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SS of metastatic tumors?
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asymptomatic, cough, hemoptysis, dyspnea and hypoxemia (in advanced cases)
Anorexia, Weight loss, asthenia, new cough or change in chronic cough. |
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Treatment? of Metastatic lung tumors
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- treat primary neoplasm and complications
- resection of solitary pulmonary nodule -resection of multiple nodules should be considered if low risk surgery and primary tumor is stable. |
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there is a 5 year survival rate in metastatic lung cancer treated surgically is ?
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20-30%
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Cystic fibrosis?
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The most common cause of severe chronic lung disease in young adults and the most common fatal hereditary disorder in whites.
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Cystic fibrosis patho?
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Abnormalities in membrane chloride channel resulting in altered chloride treansport and water flux across the apical surface of epithelial cells. Obstruction results in glandular dilation and tissue damage. Inadequeate hydration of tracheobronchial epithelium causing increased sputum viscosity.
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Cystic fibrosis should be suspected in young adults with a history of?
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Chronic lung disease (especially bronchiectasis), pancreatitis, or infertility.
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SS of cystic fibrosis
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Cough
Sputum production Decreased exercise tolerance recurrent hemoptysis sinus pain or pressure purulent nasal discharge Steatorrhea diarrhea abdominal pain |
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PE of cystic fibrosis
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Digital clubbing
Apical crackles increase AP diameter Hyperresonance to percussion sinus tenderness purulent nasal secretions nasal polyps |
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Diagnosis of CF
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1. Sweat test: Elevated sodium and chloride levels in the sweat (greater than 60); must have two test positive on different days
IF negative and still feel it is CF then you should try genotyping, nasal membrane potential difference, semen analysis, and pancreatic function. 2. Aterial blood gases: hypoxemia and compensation with respiratory acidosis 3. stool elastase: pancreatic fxn 4. PFT: mixed obstructive and restrictive pattern 5. CXR: hyperinflation, peribronchial cuffing, mucus plugging, bronchiectasis, increased interstitial markings, small rounded peripheral opacities, focal atelectasis, pneumothorax. |
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Treatment of CF
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1. Refer to Cystic fibrosis center
2. Clearance and reduction of lower airway secretions: postural drainage, chest percussion or vibration techniques etc. 3. reverse bronchoconstriction: inhaled bronchodilators 4. treatment of respiratory tract infections 5. pancreatic enzyme replacement |
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Surgery for CF:
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Yes.
Lung transplant: double lung or heart-lung |
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Emergency management of CF
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Recognize and treat respiratory distress or failure; give O2 when needed
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Patient eduction of CF
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1. nutritional and psychosocial support
2. stay clear of people who are sick during flu season 3. get vaccines for flu and pneumonia 4. genetic testing for people with family history of CF |
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Sarcoidosis
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is noncaseating granulomas in one or more organs and tissues
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Sarcoidosis usually occurs in ?
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Lungs and Lymphatic system; but can occur in any organ
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Patho of sarcoidosis
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thought to be cause by inflammatory response to an environment exposure
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Hallmark of sarcoidosis
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inflam. process is formation of noncaseating granulomas
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Granulomas in the lung are distributed along?
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lymphatics
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SS of sarcoidosis
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most are asymptomatic.
Dyspnea cough chest discomfort fatique malaise weakness anorexia weight loss and low grade fever |
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With children under 4, most common presentation are:
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arthritis, rash, and uveitis. Misdiagnosed as juvenile rheumatoid arthritis.
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PE findings of sarcoidosis
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erythemia nodosum, parotid gland enlargement, and hepatosplenomegaly.
non tender lymphadenopathy is often the only sign. |
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Diagnosis of sarcoidosis
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Leukopenia
elevated sed rate elevated alkaline phosphatase hypercalcemia or hypercalciuria elevated ACE levels skin test anergy positive Biopsy of granulomas PFT: restrictive pattern with reduced lung volumes (obstructive may be present) |
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CXR of sacroidosis?
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stage 1- hilar adenopathy alone
Stage 2- hilar adenopathy plus infiltrates stage 3- infiltrates along 4- fibrosis |
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Medical management of sarcoidosis
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Oral corticosteroids
long term therapy usually over months to years. must check on patient taking prednisone every month or two. |
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Pneumoconiosis:
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chronic lung disease caused by the inhalation of dust particles.
CWP, silicosis, or asbestosis. |
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Patho of pneumoconiosis:
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Mineral dust introduced into the small airways causes fibrosis of respiratory bronchioles initially small lesions found in upper lobes. then nodules will coalesce together to form massive fibrosis
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Complications of pneumoconiosis?
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cor pulmonale, CHF, and pneumonia.
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SS of pneumoconiosis
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asymptomatic in early stages. could take decades after exposure. Must have good history.
Cough and dyspnea |
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PE findings of pneumoconiosis
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diminished breath sounds, rhonchi, wheezing, rales, fever, edema, jugular vein distention, clubbing, cyanosis and dyspnea
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Diagnosis of pneumoconiosis
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CBC- elevated WBC or polycythemia
CXR- small round opacities PFT- obstructive or restrictive pattern or mixed |
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Asbestosis diagnosis?
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pleural plaques, indistinct cardiac border, coalescence of parenchyma, and obliteration of the acinar units.
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Silicosis diagnosis?
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Hilar lymph node calcification; egg shell pattern
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Medical management of pneumoconiosis
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inhaled beta agonists
inhaled or systemic corticosteroids oxygen therapy avoid exposure |
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Bacterial pneumonia?
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infection of lower respiratory tract and lung tissue, may be CAP or HAP
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Most common bacterial pathogen is ?
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Strep pneumoniae
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OTher common material causes include?
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H. pneumonia, Klebsiella pneumonia, Staph aureus, Chlamydia pneumonia, Neisseria meningitides, M. catarrhalis, and legionella.
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SS of bacterial pneumonia?
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Fever
Cough with or w/o sputum production dyspnea may also have: rigors, sweats, chills, chest discomfort, pleurisy, hemoptysis, fatigue, anorexia, headache, abdominal pain. |
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PE findings of bacterial pneumonia?
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Fever or hypothermia
Tachypnea tachycardia arterial oxygen desaturation may appear acutely ill altered breath sounds and rales egophony or bronchophony may be present over area of consolidation dullness to percussion if pleural effusion is present |
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Diagnosis of CAP?
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Gram stain and culture analysis of sputum. Coccidiomycosis serology( endemic areas); CXR- patchy airspace infiltrates to lobar consolidation with air bronchograms to diffuse alveolar or interstitial infiltrates
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Treatment: of bacterial pneumonia?
Out patient |
1. patient previously healthy who have not taken antibiotics within past 3 months:
a. macrolide or azithromycin b. doxycycline 2. with comorbid medical conditions and s. pneumonia resistant. a. fluoroquinolone b. macrolid and B-lactam |
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Inpatient not in ICU?
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1. fluoroquinolone (IV or oral)
2. macrolide with B-lactam (IV or Oral) |
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Inpatient in ICU?
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IV
1. azithromycin or fluoroquinolone plus antipneumoncoccal B-lactam 2. Allergic to B lactam Fluoroquinolone plus aztreonam 3. antipneumococcal, antipseudomonal B-lactam, cipro or levofloxacin 4. MRSA- add vancomycin or linezolid |
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Surgical of bacterial pneumonia?
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Drainage may be necessary if empyema develops
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HAP
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occurs more than 48 hours after admission to the hospital or healthcare facility. common in people in the ICU or mechanical ventilation
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SS of HAP?
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have at least 2 of the following:
leukocytosis fever purulent sputum |
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Emergency management of bacterial pneumonia?
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Treat respiratory distress or failure.
provide oxygen advanced airway placement identify and treat septic shock IV fluid resuscitation |
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Patient education for bacterial and viral pneumonia?
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Hand washing
vaccines avoid sick contacts |
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Viral pneumonia?
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inflammatory disease of lungs; most occurs from exposure of a susceptible non immune person to infection in the form of aerosolized secretions
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Common causes of viral pneumonia?
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Influenza A,B,C.
Parainfluenza virus syncytical virus adneovirus EBC, CMV, herpes simplex, chickenpox, enterovirus |
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Viral treatment?
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viral culture… much more.
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