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116 Cards in this Set

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What are the 4 types of normal breath sounds?
• Tracheal
• Broncial
• Bronchovesicular
• Vesicular
What are characteristics of tracheal breath sounds?
• high-pitched and loud, with a hard and hollow quality
• inspiratory phase = expiratory phase
• definite pause between phases
What are characteristics of bronchial breath sounds?
• normally heard over the upper manubrium
• loud and high-ptiched (but not as harsh and hollow as tracheal breath sounds)
• expiratory phase > inspiratory phase
• usually a pause in between phases
What are characteristics of bronchovesicular breath sounds?
• heard anteriorly in the 1st and 2nd intercostal spaces & posteriorly between the scapula
• inspiratory phase = expiratory phase
• no pause between phases
• soft and less harsh than bronchial sounds
• higher pitched than vesicular sounds
What are characteristics of vesicular breath sounds?
• audible over peripheral lung fields
• soft & low-pitched
• inspiratory phase is about 3 times longer than expiratory phase
• no pause between phases
What are the 2 categories of abnormal breath sounds?
• continuous (wheezing & rhonchi)
• non-continuous (rales/crackles)
Describe wheezes
a hissing, shrill, or whistling sound in the lungs during respiration
What are some causes of wheezing?
• narrowing of the airways, typically from asthma (most common)
• COPD
• chronic heart failure
• foreign body obstruction (aka asthmoid wheeze)
• inflammation (ex. pneumonia & bronchitis)
Describe rhonchi
snoring quality which suggest secretion large airways
What can cause rhonchi?
• mucus
• narrowing of bronchi from inflammation
• spasms of smooth muscle
What is low-pitched rhonchi called? high-pitched w/ a whistling or squeaky quality called?
• Low pitched » sonorous
• High pitched » sibilant
What are characteristics of rales/crackles?
• short, sharp, or rough sounds
• sounds like brief bursts of popping bubbles
• most commonly associated w/ the sudden opening of closed airways
What are causes of crackles?
• abnormalities of the lungs (ex. pneumonia, fibrosis, early CHF)
• abnormalities of the airways (ex. bronchitis, bronchiectasis)
• most often heard in pleurisy w/ fibrinous exudate
What is pleurisy?
• aka pleuritis
• a general term decribing inflammation of the pleural lining
What are some causes of pleurisy?
• connective tissue disorders (ex. SLE)
• infectious disease (ex. pneumonia)
• neoplasms
Where can pain resulting from pleurisy be referred to?
shoulder, neck, or abdomen
What are pleural rubs?
• an indication of pleural inflammation
• sounds like two pieces of sandpaper rubbing together throughout each inspiration and expiration
What is the difference between an effusion and an infiltrate?
• effusion » the accumulation of fluid within a cavity (ex. pleural space)
• infiltrate » involves the lung parenchyma & involves the air spaces
What is empyema?
• an infection that causes pus to accumulate in the pleural space

• can cause a tear in the pleural membrane, allowing infection to spread
What is the definition of pneumonia?
• a condition caused by bacterial or viral infection
• characterized by inflammation of the lungfs and fluid within the air passages
• often an underlying cause of pleurisy
What is the definition of bronchospasm?
• a spasmodic muscular contraction of the bronchi
• usually occurs in the context of asthma
What are causes of bronchospasm, besides asthma?
• acute allergic reactions
• occupation dust exposure
• water inhalation
What does pneumocystis carinii pneumonia look like on chest xray?
bilateral diffuse upper lobe interstitial densities along with patchy infiltrates
What is the definition of acute bronchitis and what is the most common cause?
• inflammation of the trachea and bronchi (tracheobronchial tree)
• MCC is viral URI
What is the most common bacterial etiology of acute bronchitis in nonsmokers?
• Mycoplasma pneumoniae

* Bullous myringitis suggest Mycoplasma pneumoniae infection (although not specific)
What organisms cause acute bacterial exacerbation of chronic bronchitis in smokers?
• S. pneumoniae
• H. Flu
What are signs and symptoms of acute bronchitis?
• persistent cough after a URI (initially nonproductive) but becomes productive of small amounts of sputum
• purulent sputm suggests a bacterial etiology
• fever & sore throat
What does acute bronchitis on chest xray look like?
• chest xray should be normal

* may be necessary to r/o pneumonia
What is the treatment for acute bronchitis?
• Viral » rest, fluids, & analgesics

• Bacterial » Macrolides are the DOC (Azithromycin, Clarithromycin, Erythromycin)
What is acute bronchiolitis?
• a pediatric acute infectious disease of the lower respiratory tract that begins as a URI

• usually due to a viral infection

• causes air trapping & V/Q mismatch
What is the MCC of acute bronchiolitis?
• respiratory syncytial virus (RSV)
• causes 90% of cases
What are characteristics of bronchiectasis?
• repeated infections causing damage to parts of the lung

• causes swelling & scarring of the lungs

• have huge amounts of phlegm in their lungs and coughing cannot get all the phlegm out

• phlegm sits in lungs creating an environment for infections
Bronchiectasis commonly occurs in what patients?
• cystic fibrosis
• foreign body aspiration
• immunodeficiencies
• lung infection (ex. pneumonia)
What are signs and symptoms of bronchiectasis?
• cough productive of large quanities of sputum, dypnea, hemoptysis (classic symptoms)

• recurrent URI and pneumonia are common

• moist rales, rhonci, or wheezing

• clubbing may be present
What does a chest xray show for a patient with bronchiectasis?
• honeycombing of the lung
• areas of atelectasis
What test is the cornerstone for diagnosing bronchiectasis?
high-resolution CT (HRCT) scanning
What is the treatment for bronchiectasis?
• antibiotics, bronchodilators, postural drainage, and chest percussion
• treatment of underlying conditions
• oxygen
• surgical resection (for patients w/ recurrent pneumonia who fail medical therapy)
What is the most common inherited disease in whites?
cystic fibrosis
What are characteristics of Cystic Fibrosis?
• autosomal recessive disorder

• failure of epithelial cells to conduct chloride & the associated water transport abnormalities result in viscous secretion (exocrine gland dysfunction)

• has chronic respiratory infections

• has pancreatic enzyme insufficiency
What organ systems does Cystic Fibrosis affect?
• GI tract
• lungs
• pancreas
• sweat
What test is used to diagnose Cystic Fibrosis?
sweat chloride test
What are symptoms of "the flu"?
• arthralgias
• fever (can be as high as 103ºF)
• generalized malaise
• headache
• myalgias
• nonproductive cough
• runny nose
• sore throat

* symptoms last for several days but may persist for weeks
What is the most common pneumonia seen in children?
• Viral pneumonia

• associated with influenza virus, parainfluenza virus, RSV, & adenovirus
What is the treatment for viral pneumonia?
• supportive care is sufficient
• Amantadine (for early treatment of influenza A pneumonia)
• Tamiflu or Relenza (Tx of influenza A & B)
What are the 2 general types of pneumonia?
• lobar pneumonia (occurs in one lobe of the lung)
• bronchopneumonia (tends to be patchy)
What is the MCC of community-aquired pneumonia?
Streptococcus pneumoniae (pneumococcus)
What are the most common typical organisms that cause CAP?
• Strep pneumoniae (#1)
• Haemophilus
• Staphylococcus
What are the most common atypical organisms that cause CAP?
• Mycoplasma
• Legionella
• Chlamydia
What is the definition of a nosocomial pneumonia?
pneumonia that is contracted after 72 hrs in the hospital
A patient is intubated and devlops a nosocomial pneumonia. What is the most likely etiology?
Pseudomonas
What is most common route that microbes enter the lung to produce infection?
aspiration of oropharyngeal secretions
Patient presents with sudden onset fever, chills, rigors, and cough (producing red-brown sputum). Also pleuritic pain and respiratory distress. What is the most likely cause?
Streptococcus pneumoniae (Pneumococcal Pneumonia)
What does pneumococcal pneumonia look like on chest xray?
• lobar consolidations w/ air bronchograms after 2nd to 3rd fay
• patchy infiltrates
• sometimes small pleural effusion
What does pneumococcal pneumonia look like on gram stain?
gram positive diplococci
What is the treatment of pneumococcal pneumonia?
• PCN are DOC for sensitive organisms
• Cephalosporins (ex. Rocephin) & Fluoroquinolones (ex. Levaquin) are also effective
• Macrolides (25% have resistance)
• Vancomycin
What patients are recommended to have the pneumococcal vaccine (Pneumovax)?
• > 65 y/o
• pt's w/ chronic disease
Patient presents with fever, chills, productive cough, pleurtic pain, and pink "salmon-colored" sputum. What is the most likely etiology?
Staphlycoccus aureaus (Staphylococcal Pneumonia)
Staphylococcal pneumonia is generally seen in what patients?
• hospitalized patients
• IV drug abusers
• patients w/ prosthetic devices
• sequlae to influenza A infection
What does Staphylococcal pneumonia look like on chest xray?
• patchy bronchial infiltration (infiltrates all over; not just 1 lobe)
• parenchymal necrosis
• abscess formation (25%)
• pneumatoceles (benign, thin-walled, air-filled cysts) in infants
What does Staphylococcal pneumonia look like on gram stain?
gram-positive cocci in "grape-like" clusters
Patient presents with pneumonia and skin lesions. What is the most likely etiology?
Staphylococcus aureus
What is the treatment for Staphylococcal pneumonia?
• penicillinase-resistant agents (Nafcillin) OR
• Vancomycin (should be used until MRSA strains are r/o by sensitivity cultures)
Patient has a recent history of rheumatic fever (or glomerulonephritis) and presents with a rapid progression of fever, chills, and cough. Patient also has massive empyema on chest xray. What is the most likely etiology?
Streptococcus pyogenes
What does Streptococcus pyogenes look like on gram stain?
gram-positive cocci in pairs or chains
What is the DOC of Streptococcus pyogenes?
PCN G
Gram-negative pneumonias are frequently found in what patients?
• chronic alcoholics
• COPD
• Cystic Fibrosis
• DM
• kidney disease
• malignancies
• neutropenia
Patient presents with pneumonia and has a history of COPD. What is the most likely etiology?
• Moraxella catarrhalis
• H. Flu
Patient presents with pneumonia and a history of alcoholism. What is the most likely etiology?
Klebsiella pneumoniae
Patients with a recent history of bacteremias resulting from intestinal or urinary tract infections that develop pneumonia are most likely caused by what organism?
E. coli
Intubated patients OR with a history of cystic fibrosis most likely devlop pneumonia from what bacteria?
Pseudomonas
What are signs & symptoms of a patient with pneumonia caused by H. Flu?
similar to pneumococcal pneumonia

• chills
• cough
• fever
• pleurtic pain

BUT

• *onset is generally slower *
What does H. Flu look like on gram stain?
• gram-negative coccobacilli

* H. Flu is commonly seen in the upper respiratory tract of healthy people; not diagnostic unless seen in large numbers
What is the DOC for H. Flu Pneumonia?
• Ampicllin is DOC
• Cephalosporins or Bactrim (for resistant strains)
Patient presents with typical pneumonia symptoms (fever, chills, cough, distress) and cough produces a reddish "current jelly" sputum. What is the most likely etiology?
Klebsiella pneumonia
Besides alcoholics, what patients are at an increased risk for Klebsiella pneumonia and other gram-negative pneumonias?
• elderly
• immunocompromised
• infants
What does the gram stain show for patients with Klebsiella pneumonia (or other gram-negative pneumonias)?
multiple encapsulated gram-negative bacilli
What is seen on chest xray for a patient w/ Klebsiella pneumonia?
• involvement of multiple lobes (esp. RUL)
• possible abscess formation
What is the treatment of Klebsiella pneumonia?
• Cephalosporin + aminoglycoside OR
• penicillinase-resistant PCN
Where is Legionella most commonly found?
organisms distributes widely in water
Name and describe the 2 clinical presentations of Legionellosis
• Legionnaire's Disease: presents as severe pneumonia accompanied by multisystemic disease (GI, CNS, Lung)

• Pontiac fever: acute, febrile, self-limited, viral-like illness
Patient presents with rapidly progressive pneumonia, dry cough, and multi-organ involvement. What is the most likely etiology?
Legionella
What does gram stain show on a patient with Legionella pneumonia?
shows neutrophills and no organisms (its an atypical pneumonia)
What tests can be performed to definitively diagnosis Legionella pneumonia?
• indirect fluorescent antibody (positive ~ 75%)

• direct fluorescent antibody testing of respiratory secretions (most rapid method; 95% specific)
What is the treatment for Legionella pneumonia?
Erythromycin (Macrolides)
What is the most common cause of pneumonia in teens & young adults living in close contact (ex. dorms, military)?
Mycoplasma pneumoniae
Patient presents with gradual onset fever, headache, myalgia, and nonproductive cough. Patient also has cervical lymphadenopathy and fine rales on physical exam. What is the most likely etiology?
Mycoplasma pneumoniae
What does a chest xray of a patient with Mycoplasma pneumonia look like?
• patchy infiltrates (esp. in lower lobes)
• appears much more severe than symptoms suggests
What blood test can be positive on a patient with Mycoplasma pneumonia?
cold agglutinin test
What is the treatment for Mycoplasma pneumonia?
• Macrolides (Azithromycin or Erythromycin)

• many cases resolve spontaneously
What are the 3 species of Chlamydia that are pathogenic to humans?
• Chlamydia pneumoniae
• Chlamydia psittaci (bird exposire)
• Chlamydia trachomatis
What does a chest xray for a patient with Chlamydia pneumonia show?
mild infiltrates
What is the DOC for Chlamydia pneumonia?
• Doxycycline (DOC)
• Erythromycin (as an alternative)
What is the MCC of interstitial pneumonia in immunocompromised patients?
PCP (Pneumocystis Jiroveci Pneumonia)
What is the classic triad of signs & symptoms of patients with PCP?
• fever
• exertional dyspnea
• nonproductive cough

* noted in just over 50% of cases
Patients presents with pneumonia and a history of immunosuppresion. You are clinically suspicious for PCP. What blood test can be done to help confirm your diagnosis?
LDH level of > 460 U/L
What does PCP look like on chest xray?
• bilateral diffuse symmetric finely granular infiltrates

• "ground-glass" appearance
What are the diagnostic methods of choice for PCP?
sputum induction and bronchoalveolar lavage
What are the treatments for PCP?
• TMP/SMX (Bactrim) is DOC
• Dapsone (#2)
• Pentamidine (#3)
• Atavaquone (Mepron): for patients who cannot take the above
Patients has pneumonia and a history of exposure to cattle, goats, or sheep. What is the most likely cause?
• Q Fever
• Brucellosis
Patient has pneumonia and exposure to rabbits. What is the most likely cause?
Tuleremia
Patient has pneumonia and exposure to birds. What is the most likely cause?
• Psittacosis
• Histoplasmosis
Patient has pneumonia and exposure to rodents. What is the most likely cause?
Hantavirus
What can cause a pneumonia for a person who recently traveled to the southwestern US?
Coccidiomycosis
A pneumonia that develops from the Mississippi & Ohio River Valley OR cave diving/sperlunking?
• Histoplasmosis
• blastomycosis
Patient has a pneumonia that develops from travel to a devloping country. What is a possible cause?
tuberculosis
What is a likely cause of pneumonia from a dog tick?
Ehrlichiosis
What organism is related to exposure to infected cats, cattle, sheep, or goats?
Coxiella burnetii
What organism may cause infection from travel to Thailand or other countries in Southeast Asia?
Burkholderia pseudomallei
Patient with pharyngitis or rhinitis and a history of persistent hacking, non-productive cough commonly suggests what?
• respiratory virus (URI, influenza) OR
• Mycoplasma pneumonia
Patients with pneumonia and fever w/o rise in pulse suggests what?
• Legionellosis
• Mycoplasma
Patients with pneumonia and foul breath suggest what?
anaerobic infection
Patients with pneumonia and mental confusion should raise suspicion for what?
pneumococcal pneumonia & possibly meningitis
What bacteria pneumonias can cause green sputum?
• Pseudomonas
• Haemophilus
• Pneumococcus
Clinically, what are the DOC for community-acquired pneumonia?
• Ceftriaxone (Rocephin) 2 gm IV + Azithromycin (Zithromax) 500 mg PO OR

• Levaquin 750 mg PO (or IV)
What are the 3 phases of Pertussis (Whooping Cough)?
• Catarrhal phase (URI symptoms)
• Paroxysmal phase (paroxysmal whooping cough)
• Convalescent phase (chronic cough)
What is the treatment for Pertussis (Whooping Cough)?
Erythromycin