question

Reticulocytes

answer

Immature red blood cells that still contain ribosomal RNA (look like wavy lines inside the RBC) and nuclear fragments bigger than mature RBC. No bi-concave disc appearance. Normally there are some of these in the marrow and some of these in the peripheral blood

question

MCV: Mean Red Blood Cell Volume

answer

the average size of the RBCs Normal Value - 80-95 fl

question

MCV <80 fl

answer

Microcytosis

question

MCV > 95 fl

answer

Macrocytosis

question

Erthyropoietin

answer

Controls red blood cell production (Erythropoeisis) produced by renal tubule cells in response to O2 saturation in blood

question

Normal RBC life span

answer

120 days

question

Causes of Anemia (6)

answer

Nutritional Deficiencies Congenital Hgb abnormalities Bone Marrow abnormalities Loss of RBC due to bleeding Hemolysis Suppressed Erythropoeisis

question

Nutritional Deficiencies that cause Anemia

answer

1. Iron - stored as ferritin, part of heme. Carries O2. 2. B12 - Essential Vitamin for DNA Synthesis. 3. Folate - Essential Vitamin for DNA Synthesis

question

Thalassemia

answer

defect in alpha or beta globin chains (in HgB). Inherited. Mostly in Mediterranean, Caribbean/African, far east RBCs look like targets (with red middle)

question

Alpha Thalassemia

answer

the HgB acts as a constant spring, and the enlongated protein hemolyzes RBC more frequently.

question

Sickle Cell Anemia

answer

Single-AA mutation in beta chain (Valine for Glutamic Acid), causing the hgB to precipitate and polymerize, causing the rigid elongation. Inherited. Protective against malaria Sub-saharan African, Indian, Arabian Peninsula Unpredictable vaso-occlusal pain crises and strokes

question

G6PD (Glucose 6 Phosphate Dehydrogenase) Deficiency

answer

RBC enzyme that helps keep RBC oxygenated African, Mediterranean, Asian descent most common

question

Aplastic Anemia

answer

empty bone marrow

question

What else can the bone marrow be filled with that would interfere with erythropoeisis?

answer

Leukemia/Lymphoma/other metastatic cancer

question

Hemolysis Causes (4)

answer

Extra-corpuscular Causes Red Cell Membrane Defects Hemoglobin Defects Enzyme Defects

question

Autoimmune hemolytic anemia (AIHA)

answer

IgG-mediated. (spherocytes caused by macrophages taking a bite out of RBCs)

question

Red Cell Membrane Defects

answer

rare. Eg hereditary elliptocytsos or hereditary spherocytosis

question

Chronic Causes of Suppressed Erythropoeisis

answer

1. Renal failure - most common 2. Also - lupus, Crohn's, Rheumatoid Arthritis

question

Haptoglobulin

answer

THIS transfers hemoglobin to liver: if there is increased free hemoglobin from hemolysis, THIS binds to that and the levels of free THIS goes down

question

Signs of Anemia

answer

Pallor Koilonichia Smooth Tongue Tachycardia Bleeding Sx of Bone Marrow Failure Hemolysis Jaundice Splenomegaly

question

Koilonichia

answer

spooning of nails

question

Sx of Bone Marrow Failure

answer

i. Evidence of Severe Infection/Sepsis ii. Bruising iii. Petechiae (usually starting at feet, because lower parts of the body have higher orthostatic pressure, and moving up the body).

question

Causes of Jaundice

answer

When RBC are broken down in circulation, HgB is released. Heme is broken down into bilirubin. Rapid bilirubin increase causes THIS

question

Chronic Disease risk factors for Anemia

answer

i. Discoid Rash (Lupus) ii. Evidence of rheumatoid arthritis, renal failure, severe infection/sepsis iii. Dialysis

question

Anemia Labs - CBC

answer

if more than one cell line is low

question

Anemia Labs - #retic high + anemia

answer

Bone marrow is functioning normally Bleeding Hemolysis Nutritional Deficiency on replacement tx

question

Anemia Labs - #retic low + anemia

answer

Dysfunctional erythropoiesis/bone marrow Bone Marrow pathology chronic disease severe nutritional deficiency (not supplemented)

question

Anemia Labs - MCV < 80

answer

Microcytosis (caused by deficient hemoglobin synthesis): a. Iron Deficiency affects heme b. Thalassemia affects globin chains c. Sideroblastic anemia heme synthesis impaired d. Chronic disease - usually not.

question

Anemia Labs - MCV > 95 ("REALLY BIG")

answer

Megaloblastic Macrocytosis: Caused by DNA Synthesis abnormality a. B12 Deficiency MCV of 128 possible b. Folate Deficiency c. Chemotherapy drugs d. Liver Disease e. Myelodysplastic Syndrome (rare)

question

Anemia Labs - MCV > 95 ("Less Big")

answer

Non-Megaloblastic Macrocytosis: RBCs are big for other reasons (not DNA synthesis). a. Reticulocytosis b. Liver Disease c. Thyroid Disease

question

Reticulocytosis (High #retic)

answer

More immature cells are always bigger. Someone who's just had a bleed will have an elevated THIS, which causes an increase in MCV.

question

Anemia Labs - Normocytosis + #retic low

answer

Primary Bone Marrow Failure - Aplastic Anemia, Leukemia Suppressed Bone Marrow - Renal Failure, Chronic Disease

question

Anemia Labs - Peripheral Blood Smear

answer

i. Microcytes/Macrocytes - look like normal RBCs of unusual size ii. Spherocytes - small RBC with no central pallor iii. Sickle Cells iv. Red Cell Fragments - after-effects of hemolysis v. Acanthocytes - red cells pre-hemolysis, with skinny processes sticking out vi. Elliptocytes - look like normal RBCs, but elongated.

question

Direct anti-globulin test = Coomb's test

answer

To measure IgGs on RBCS (to test for AIHA)

question

Hemoglobin electrophoresis

answer

To identify abnormal HgB

question

COPD

answer

Progressive obstruction and destruction of lung parenchyma leading to decreased elastic recoil, increased compliance, increased airway resistance, irreversible reduction in caliber of small airways, air trapping and lung hyperinflation. Systemic manifestations and increasingly frequent/severe exacerbations

question

COPD Risk Factors

answer

Smoking/exposure to smoke Occupational Exposures Indoor/Outdoor Pollution Low SES, older Age, some genetic factors

question

COPD Symptoms

answer

Dyspnea Chronic Cough Sputum

question

COPD Treatment

answer

Smoking cessation/exercise/self-management SABA prn LAMA (Tiotropium) + SABA prn pulmonary rehab LAMA + LABA + SABA prn If more than 2 exacerbations per year, FEV1 variability > 20%, asthma component, atopy: ADD ICS oxygen opioids (in palliative care)

question

COPD Exacerbation Treatment

answer

At Home: Prednisone (5 days) Increase SABA usage If Admitted: SABA/SAMA (Nebulized) Antibiotics (short course: 5-7 days) CXR - to r/o pneumonia

question

COPD Pathophysiology summary

answer

Inflamed/remodeled airways hypersecretion of sputum causing mucus plugging Small Airway obstruction Dynamic Hyperinflation Alveolar Septae destruction Decreased Airway tethering

question

Expiratory airflow limitation

answer

The pathophysiological hallmark of COPD. Expiratory flow limitations with dynamic collapse of the small airways compromise the ability of patients to expel air during forced and quiet expiration; thus air trapping and lung hyperinflation (overinflation) occurs.

question

Air Trapping/ Dynamic hyperinflation

answer

The principal causes of dyspnea (or breathlessness) in COPD. The physiological mechanism that provides the link between expiratory airflow limitation and patient-centred outcomes.

question

Dyspnea in COPD

answer

a sense of increased effort to breathe, heaviness, air hunger or gasping. Graded with MRC Breathlessness Scale.

question

Deconditioning

answer

Peripheral muscle dysfunction which contributes to exercise intolerance, results from the combined effects of immobility, altered nutritional status, prolonged hypoxia and, possibly, to sustained systemic inflammation.

question

COPD Exacerbations

answer

80% Caused by Infection 20% Caused by environment/medications Sustained (longer than 48 hours) worsening of dyspnea, cough, or sputum production Purulent Sputum indicates possible infection Graded with Gold Staging.

question

Barrel-Chestedness

answer

reconfiguration of the ribcage to contain the over-inflated lungs caused by dynamic hyperinflation Symptom of COPD

question

Hypoxemia PaO2 defining values

answer

<= 55 mmHg OR < 60 mmHg in presence of cor pulmonale

question

Bronchiolitis

answer

small airway disease mural chronic inflammation fibrosis with goblet hyperplasia luminal mucus accumulation obliteration of airway lumen

question

Acute Bronchiolitis

answer

Mostly affects infants, almost always caused by a virus, especially RSV (Respiratory syncytial virus)

question

Acute Bronchiolitis - Symptoms

answer

dyspnea, cough, wheeze, low-grade fever < 3 days, rhinorrhea

question

Acute Bronchiolitis - Treatment

answer

No antibiotics, usually self-limited <14 days If progression to pneumonia, can require hospitalization

question

Emphysema

answer

Parenchymal destruction low expiratory force enlargement of airspaces destruction of alveolar walls damage to elastic fibers in interstitium leading to increased compliance

question

Emphysema - Symptoms

answer

The Pink Puffer progressive dyspnea prolonged expiration barrel chested accessory muscle use often cachexic

question

Centriacinar Emphysema

answer

smoking causes increase recruitment of neutrophils at upper lobe

question

Paraseptal Emphysema

answer

bullae at upper lobe, may lead to pneumothorax

question

Panacinar Emphysema

answer

alpha-1 antitrypsin deficiency leading to destruction of elastin in lower lobe

question

Chronic Bronchitis

answer

Productive cough on most days for ≥ 3 consecutive months per year for at least 2 years hypertrophy and numerous mucus secreting glands in the bronchi increased inflammatory cells in bronchial wall of large airways

question

Chronic Bronchitis Symptoms

answer

The Blue Bloater early onset of cyanosis wheezing crackles late onset of dyspnea

question

Chronic Bronchitis Treatment

answer

Same as COPD

question

Bronchiectasis

answer

Irreversible dilation and damage of a portion of bronchial tree and airway walls loss of normal architecture of the wall accompanying infection mucous cannot be easily removed by damaged or impaired ciliated cells

question

Bronchiectasis - Types on CT

answer

Cylindrical Varicose Saccular NB: CXR is not usually sensitive enough to pick up bronchiectasis

question

Bronchiectasis - Causes

answer

infection impaired drainage (cystic fibrosis, primary ciliary dyskinesia, bronchial tumor) infection precedes bronchiectasis unless there is a tumor or other physical obstruction

question

Infections that can cause Bronchiectasis

answer

Bacterial: TB, atypical bacteria Viral: Pertussis, Measles Immunodeficiency Fungal: eg Aspergillus species

question

Causes of Impaired Drainage that can result in Bronchiectasis

answer

Cystic Fibrosis (tenacious mucus) Primarily Ciliary Dyskinesia Bronchial Tumor (secondary to obstruction)

question

Bronchiectasis - Symptoms & Signs

answer

chronic productive cough recurrent infections copious purulent sputum hemoptysis wheezes/rhonchi clubbing

question

Bronchiectasis - treatment

answer

Antibiotics Bronchopulmonary drainage (clear airway secretions, chest physiotherapy) Bronchodilators

question

Asthma

answer

Inflammatory process that leads to airway injury, which results in airway obstruction and airway hyper-responsiveness (allergy-like process). There is hypertrophy and hyperplasia of smooth muscle cells: bronchoconstriction

question

Asthma - Symptoms

answer

Recurrent episodes of cough (especially at night), wheezing or chest tightness after exposure to airborne allergens, pollutants, exercise or RTI Varies A LOT Better with Bronchodilator Can present with Chronic Cough only.

question

Asthma - Risk Factors

answer

Atopy Environmental/Occupational Exposures - animals, dust Family History of Asthma NB: Smoking isn't a risk factor, but worsens THIS

question

Asthma - Physical Exam Signs

answer

Possible Wheeze on Exhalation Generally Young Onset

question

Asthma - Spirometry (PFT)

answer

Pre-BD: FEV1/FVC ratio Obstructive disease *30 minutes Post-BD: If you see an improvement of 12% AND 200 mL in either FEV1 or FVC*

question

Methacholine Challenge

answer

Measure of Airway Hyperreactivity Asthma: Decreased FEV1 by 20% with less than 4 mg/mL of Methacholine AND history suggestive of asthma Borderline Hyperreactivity: Decreased FEV1 by 20% with 4-16 mg/mL of Methacholine

question

Asthma - Sputum Analysis

answer

Increased #Eosinophil

question

Atopy

answer

allergic pre-disposition. Seasonal allergies, asthma, eczema

question

Asthma - Treatment Progression

answer

Confirm Diagnosis Environmental Controls SABA prn ICS + SABA prn ICS/LABA + SABA prn (or add LTRA) increase ICS/LABA + SABA prn oral CS (Prednisone)

question

Why can't you give non-selective (B1/B2) beta blockers (eg propranolol) to asthmatics?

answer

Because non-selective beta blockers can cause bronchoconstriction

question

Canadian Asthma Control Criteria

answer

Daytime SABA use should be < 4 per week Night time sx should be <1 night/week = none Normal Physical Activity without needing to stop to take SABA DURING activity (before is okay) Mild/infrequent exacerbation No absenteeism due to asthma FEV1/PEF is greater than 85% of personal best PEF diurnal variability less than 15%

question

TH2 Pathway

answer

the prototypical allergic-type inflammatory pathway Responsive to steroids IL4/IL5/IL13 → B lymphocytes → IgE → Eosinophils, Mast Cells, Basophils

question

Release of IL25, IL33, and TSLP

answer

A non-allergic infectious-etiology inflammatory pathway Exposure to viruses/oxidative stress can trigger THIS, which can induce BOTH the TH2 and TH17 pathway

question

v. TH17 Pathway

answer

The Neutrophil Reaction: A non-allergic infectious-etiology inflammatory pathway NOT RESPONSIVE TO STEROIDS The T Lymphocyte differentiates TH17, which stimulates neutrophils

question

Which inflammatory pathway is NOT responsive to steroids?

answer

TH17

question

Sleep Apnea

answer

repeated cessation of breathing for > 10 seconds during sleep

question

Sleep Hypopnea

answer

breathing amplitude goes down and then comes back up with periodicity

question

Sleep Hypoventilation

answer

sustained reduction in breathing associated with hypercapnia and hypoxemia

question

Central Apnea

answer

no respiratory effort

question

Central Apnea - Causes

answer

Hypercapnia "Idiopathic" CNS lesions CHF

question

Obstructive Sleep Apnea

answer

respiratory effort against airway obstruction

question

How does Obstructive Sleep Apnea affect sleep?

answer

Sleep Fragmentation Repeated Hypoxia-reoxygenation

question

Mixed Apnea

answer

Starts as central apnea (no effort) and finishes as obstructive Loss of drive to breath causes the airway to collapse. The increase of effort reflects the obstructive effect

question

Sleep Apnea Risk Factors

answer

Obesity Craniofacial abnormalities Family History Smoking currently Nasal congestion

question

Sleep Apnea Symptoms

answer

loud snoring systemic/pulmonary hypertension arrhythmias morning headache nocturia nocturnal choking excessive daytime sleepiness impaired memory/concentration mood disturbances, eg depression increased motor vehicle/workplace accidents possibly sudden death. Patients will complain of fatigue during the day despite a normal amount of sleep

question

Sleep Apnea Treatment

answer

Weight loss/surgery, CPAP, Mandibular advancement prostheses, recommend position change during sleep, hypoglossal nerve pacemaker, avoid alcohol and sedatives

question

Micro-arousal

answer

transient disruptions of sleep, lasting at least 3 seconds but no more than 15 must be BOTH a burst of EEG activity AND a burst of EMG

question

Cheyne-Stokes Respiration

answer

cyclic Incremental, then decremental breathing pattern with no-effort apneas in between

question

How does CHF cause Cheyne-Stokes Respiration?

answer

there is a delay between the changes in PCO2 in the alveoli and at the chemoreceptors because the blood is travelling slowly. Consequently, as you end a breath, the PCO2 at the chemoreceptor isn't low enough to trigger another breath, so this causes an apnea

question

Cheyne-Stokes Respiration with Adaptive Servo-Ventilation

answer

SaO2 and HR will stay level, but the mask pressure will show the Cheyne-Stokes pattern

question

Restrictive Lung Disease - Spirometry (PFT)

answer

decrease in TLC, RV, FRC, VC, Compliance INCREASE in PEF FEV1/FVC normal or >0.80

question

Sarcoidosis - Symptoms

answer

progressive dyspnea short-rapid breaths fever polyarthritis erythema nodosum can be asymptomatic

question

Sarcoidosis - CXR

answer

non-necrotizing granulomas and bilateral hilar adenopathy +/- interstitial pattern often found as incidentaloma

question

Sarcoidosis - Epidemiology

answer

More common in black women

question

Sarcoidosis - Etiology

answer

idiopathic

question

Sarcoidosis - Treatment

answer

PRN steroids, anti-malaria agents, chemotherapy agents

question

Interstitial Pulmonary Fibrosis (UIP)

answer

idiopathic alveolitis followed by fibrosis from pneumonia or occupational hazard or asbestos or silicon (pneumoconiosis)

question

Interstitial Pulmonary Fibrosis (UIP) - Symptoms

answer

Onset in middle-age dyspnea dry cough clubbing rapid & short breathing May be associated with inflammatory disease processes like rheumatoid arthritis, scleroderma, lupus

question

Interstitial Pulmonary Fibrosis (UIP) - Prognosis

answer

5 years mean survival time from onset of symptoms

question

Interstitial Pulmonary Fibrosis (UIP) - Treatment

answer

improvement in 1/3 of patients with steroids

question

Pneumonia - Prevention

answer

Vaccination for influenza pneumococcal vaccine smoking cessation

question

Pneumonia - Symptoms in Elderly

answer

change mental status confusion loss of appetite

question

Pneumonia - Physical Exam Signs

answer

Tachypnea Hypoxia, cyanosis in severe cases Auscultation: crackles, wheeze, decrease in breath sounds Egophony (saying E sounds like A) Whispered pectoriloquy = transmission of whispers due to consolidation Tactile fremitus = Increased sensation of sound by examiners palms Percussion = dull

question

Typical Pneumonia, eg Streptococcus pneumoniae - Symptoms/Signs

answer

Acute onset Rusty color sputum and Dyspnea High grade fever (≥ 38 °C) Shaking chills Pleuritic chest pain

question

Typical Pneumonia, eg Streptococcus pneumoniae - Pathology

answer

Gram-positive diplococci Inflammatory exudate (edema) fills alveolar space, spreads between alveoli Empyema, Bacteremia possible

question

Typical Pneumonia, eg Streptococcus pneumoniae - Imaging

answer

CXR: lobar consolidation and air bronchograms Edema restricted to alveolar space

question

Typical Pneumonia, eg Streptococcus pneumoniae - most common in:

answer

elderly smokers during the holidays 90% of cases community-acquired Very common, but not very infectious

question

Other Bacterial Pneumonia, eg Staph. Aureus - Pathology

answer

Gram-positive bacterium clusters Airways involved Rapid Spread Necrosis and Cavitation Tissue Destruction Empyema Abscess

question

Other Bacterial Pneumonia, eg Staph. Aureus - Imaging

answer

CXR: no air bronchograms (see fluid line), patchy diffuse lobar distribution, necrotizing cavitation. Frequent pleural effusion. CT: bronchopneumonia, multi-lobar involvement

question

Other Bacteria Pneumonia, eg Staph. Aureus - Most Common in:

answer

nocosomial or post-influenza pneumonia in elderly, children Most common cause of death in influenza epidemics NB: Risk of multidrug-resistance bacteria (MRSA, VRSA)

question

Atypical Bacteria Pneumonia, eg Mycoplasma Pneumonia - Most Common in

answer

Young healthy adults Seasonal (fall and winter)

question

Atypical Bacteria Pneumonia, eg Mycoplasma Pneumonia - Symptoms/Signs

answer

Slower onset "walking pneumonia" = often mild headache sore throat myalgia occasional bullous myringitis (ear drum infection) Sx can be confused with viral illness

question

Atypical Bacteria Pneumonia, eg Mycoplasma Pneumonia - Imaging

answer

CXR: interstitial (reticular) pattern bilateral/diffuse CT: ground glass opacities, nodules

question

Influenza Pneumonia - most common in

answer

Elderly with chronic diseases Elderly living in nursing homes Children

question

Influenza Pneumonia - Symptoms/Signs

answer

Flu-like illness (fever, sore throat, myalgia, lethargy, flushing) Dry cough acute respiratory distress syndrome

question

Influenza Pneumonia - Imaging/Labs

answer

CXR: Multi-focal Diffuse interstitial Reticulonodular Ground glass opacities Similar to "atypical" bacteria pattern Labs: Low/mild elevated WBC Sputum with minimal bacteria/neutrophils

question

Influenza Pneumonia - Pathology

answer

Can cause interstitial pneumonia/diffuse alveolar damage

question

Aspiration Pneumonia - Most common in

answer

Elderly Altered Mental Status Alcoholism Neurological deficits (stroke, seizure, head trauma) Vomiting

question

Aspiration Pneumonia - Pathology

answer

Too much mouth/gastric content aspirated Gram-negatives (oral/enteric), Anaerobic microorganisms Often Polymicrobial Multi-drug resistance and abscess formation in most cases

question

Why does Aspiration Pneumonia more commonly affect the right lung?

answer

Microbes affect the areas where they're most likely to land (depends on body position of patient) Anatomically, the right bronchus is straighter down in an upright person --> right-side predominance.

question

Aspiration Pneumonia - Symptoms/Signs

answer

Foul-smelling/tasting sputum Foul-smelling breath (because anaerobes smell really bad)

question

Aspiration Pneumonia - Imaging

answer

CXR: Predominantly right side Gravity-dependent regions Pleural involvement Cavitation possible

question

Pseudomonas Aeruginosa - Most commonly In:

answer

mostly in immunosuppressed patients

question

Pseudomonas Aeruginosa - Symptoms/Signs:

answer

Green sputum Noxious breath Extremely dangerous - need to isolate Multi-drug resistance and abscess formation in most cases

question

Pseudomonas Aeruginosa - Imaging/Labs

answer

CXR: Variable appearance of lobes Pleural Fluid Analysis via Thoracocentesis: test for complicated/empyema

question

Pleural Fluid Analysis via Thoracocentesis - Empyema

answer

pH < 7.2, loculated, pus, bacteria, protein/LDH high

question

Pleural Fluid Analysis via Thoracocentesis - Complicated Exudate

answer

pH < 7.2, +/- loculated, serosanguinous, +/- bacteria, protein/LDH high

question

Pleural Fluid Analysis via Thoracocentesis - Uncomplicated Exudate

answer

pH >7.2, free flowing, serosanguinous, sterile, protein/LDH high

question

Pleural Fluid Analysis via Thoracocentesis - Transudate

answer

pH >7.2, free flowing, serous, sterile, protein/LDH low

question

What does "Severe" Pneumonia look like?

answer

a. Respiratory failure (eg hypoxemia) b. Sepsis (eg low BP, multi-organ failure) c. Extensive Pneumonia on CXR d. Complications, eg pleural effusion/cavitation e. Abnormal labs (hyponatremia, anemia, very low/high WBC, renal failure) f. Other factors: extrapulmonary infection, renal failure, dehydration, mental status change, inability to eat

question

Lung Cancer - Major Risk Factors

answer

Smoking Chemical/Mineral Exposure Radiation Exposure PMHx: Cancer

question

Lung Cancer - Symptoms

answer

Cough Chest Pain hemoptysis neck nodes hoarseness Swallowing problems

question

Superior Vena Cava Obstruction (SVCO) Syndrome

answer

when the SVC has been invaded by tumor, collateral veins develop on the anterior/posterior chest to compensate. Also, facial swelling

question

Pancoast Syndrome

answer

hand or arm pain from brachial plexus involvement Tumor at the apex of the lung can invade the neck/shoulder area

question

Horner's Syndrome

answer

miosis (constricted pupil), partial ptosis (weak, droopy eyelid), anhydrosis (decreased sweating), w/ or w/o enophthalmos (inset eyeball). Caused by damage to the sympathetic trunk

question

Disseminated Disease (Metastases) Symptoms

answer

weight loss, bony pain from mets, headache from mets, soft tissue masses, skeletal Sx, focal neurological deficits

question

Squamous Cell CA - risk factors

answer

SMOKING ANYTHING that will injure the epithelium of the lung is a risk factor. o Smoking anything o GERD/Trachea-Esophageal Reflux o Alcohol abuse o Airborne Chemical/Particle/Pollutant exposure

question

Squamous Cell CA - Pathology

answer

Grows from the epithelium INTO the LUMEN of the proximal lobar airways, occluding them Necrosis can eat away at blood vessel walls causing hemoptysis or bleeding out Keratin in the lumen Intercellular bridging within the epithelium

question

Squamous Cell CA - Imaging

answer

CXR: obstructive pneumonitis: a lesion from the sternum to the periphery which reflects the mass growing in the proximal airway

question

Small Cell CA - Key Features

answer

Very aggressive cancer (2-3 months of life after diagnosis) Almost exlusively in smokers Paraneoplastic Syndrome

question

Small Cell CA - Pathology

answer

Spreads from Bronchial epithelium INTO the SUBMUCOSA, hence why we don't catch it until it is too late (little to no earlier hemoptysis or occlusion) Metastasizes via the lymph nodes and visceral pleura

question

Small Cell CA - Imaging

answer

CXR: dense mass in the hilum CT identifies a widening of the lymph vessels

question

AdenoCA - Risk Factors & Key Features

answer

GLAND PROLIFERATION DISORDERS AND ASBESTOS most common form of cancer (Including smokers and non-smokers [< 100 cigarettes/life]

question

AdenoCA - Pathology

answer

Mostly located on the periphery of the lung Large amounts of gland formation Identifiable fibrous tissue pearls within the large airway folds

question

AdenoCA - Imaging

answer

CXR: nodule on the periphery of the lung

question

Large Cell Carcinoma

answer

Hyperchromicity with a LOT of cytoplasm Usually peripheral, but variable Accompanied with a lot of necrosis in general

question

Bronchioalveolar AdenoCA

answer

spreads along alveolar walls and can look like pneumonia

question

Pulmonary Embolism - Symptoms and Signs

answer

Sudden dyspnea • Chest pain • Hypoxia (low O2 saturation) • Hypocapnia • Hyperventilation • Hypotension (low BP) • Pleural friction rub • Elevated jugular venous pressure • Edema • Tender, swollen lower limb (indicative of deep venous thrombosis

question

Pulmonary Embolism - Usual History

answer

The story is usually one where a patient has been immobilized for a long period of time without DVT prophylaxis (in the case of hospitalized patients) or on a long flight. Patients taking medications predisposing them to be hypecoagulable are also at risk (for example, those on a birth control pill).

question

Pulmonary Embolism - Diagnostic Tests

answer

CT Pulmonary Angiogram CXR: Hampton's Hump, Westermark Sign Blood gas: respiratory alkalosis due to hyperventilation (to increase alveolar ventilation)

question

Hampton's Hump

answer

wedge-shaped defect at pleural edge representing an infarct

question

Pulmonary Embolism - Treatment

answer

begin as soon as suspected: IV unfractionated heparin or SC low molecular weight heparin (LMWH) bridge to PO Warfarin for 3-6 months + supportive therapy to ensure vital signs are stable - oxygen, fluid, vasopressors Also possible - Thrombin inhibitors Factor Xa inhibitors, eg Rivaroxaban

question

Pneumothorax - Signs/Symptoms

answer

• Chest pain • Dyspnea • Chest expansion • Hyper-resonance upon percussion

question

Pneumothorax - Types

answer

• Spontaneous: accumulation of air in pleural space!trachea deviates towards collapsed lung • Tension: Trauma or lung infection!trachea deviates away from collapsed lung!EMERGENCY to salvage the lung not affected

question

Active TB - Risk Factors

answer

Interval since Infection = Highest risk within 1-2 years after acquiring primary infection. HIV/AIDS - Strongest Known Risk Factor. Contraction will make risk increase, even with a long interval since infection Diabetes, Renal failure (especially if on dialysis) Immunosupression (eg transplantation) Age (0-5, elderly) Smoking, alcohol use Under-weight (including gastrectomy) Silicosis

question

Most contagious form of TB

answer

Laryngeal

question

Moderately contagious TB

answer

Pulmonary a. AFB Smear positive, Cavitation on CXR b. Often in younger, male patients c. Patients who cough more

question

Less contagious TB

answer

Minimal Pulmonary a. Smear negative, non-cavitary disease on CXR, older

question

Non-contagious TB

answer

Extra-pulmonary TB

question

Active TB - Symptoms

answer

productive cough for weeks to months, fever, sweating at night, hemoptysis (late in course)

question

Active TB - Physical Exam

answer

Chest exam usually normal. May have low-grade fever, may look thin/badly nourished, may have lost weight

question

Active TB - CXR

answer

Cavitations Airspace Opacities, Air Bronchograms Look especially closely at apices

question

Active TB - Sputum Smear

answer

Smear Positive (~50% of active TB Cases) More likely to be positive in patients with a lot of symptoms

question

Active TB - Cultures

answer

Culture Positive

question

Active TB - Nucleic Acid Amplification

answer

PCR Positive

question

Active TB - PPD/TST

answer

Positive = >5 mm after 3 days

question

Active TB - IGRA

answer

Positive

question

Active TB - Treatment

answer

Legally compelled multiple drugs needed to prevent drug resistance at least 6 months

question

Latent TB - Treatment

answer

Not everyone needs treatment Individual Decision to treat Single drug therapy adequate Standard treatment is Isoniazid for 9 months, Effective but associated with toxicity, so completion is poor New: Rifampin or Combination of Isoniazid/Rifapentine (3-4 months, 1/week)

question

MDR-TB

answer

Multi-drug resistant TB 1. Resistant to INH, Rifampin 2. Mortality >80% 3. Hospital and Community Outbreaks in NYC in 1989 4. Many patients were HIV+ and/or healthcare workers

question

XDR-TB

answer

Extensive Drug Resistance 1. Resistant to INH, Rifampin + 2 most effective second line drugs 2. Mortality: 59/60 patients with HIV died within 6 months 3. Emerged in Tugela Ferry, South Africa, 2005

question

TDR-TB

answer

Total Drug Resistance 1. Resistance to all anti-TB Drugs 2. Mortality: 100% of patients, all HIV - 3. Emerged in 2011 in Mumbai

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Mycobacterium avium

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M. Avium is most frequently associated with human disease in Canada, and it may be more prevalent than TB. Often seen in people with previous underlying lung disease (CF, other forms of bronchiectasis, including scarring from old TB). Disseminated disease more common in people with advanced, uncontrolled AIDS

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Mycobacterium avium - symptoms

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Indolent Sx: cough, sputum, weight loss over many months Intermittent hemoptysis, moderate exercise-induced SOB possible CXR: nodular lung infiltrates associated with bronchiectasis, cavitary lung disease Disseminated THIS Disease a. Systemic/GI Sx (diarrhea) b. Pulmonary/Lymph Node involvement c. Can culture THIS from blood.

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Mycobacterium avium - treatment

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Not mandated. Depends on species. Much longer than standard TB treatment. Difficult to tolerate Requires 3-4 drugs Not consistently effective

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Dyspnea

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Subjective experience of breathing discomfort Comprised of Qualitatively distinct sensation (ie "choke" vs "wheeze" vs "can't breathe enough in" vs "feels like a snake moving in my lungs")

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Factors that contribute to Dyspnea

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i. Physiological ii. Psychological (anxiety) iii. Social (performance anxiety) iv. Environmental (claustrophobia, light sensitivity)

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Dyspnea - Treatment

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a. Best option = treat the cause b. If the cause is recalcitrant = treat the symptom Oxygen has little effect beyond placebo Diagnosis and ethical considerations guide the treatment Even if the patient is old and/or is sure they're going to die, they may be wrong You have to respect what the patient has expressed/documented in wishes for end-of-life care Palliative care is a continuum that starts early. There is always a balance between palliative care and curative/restorative care. Pleural fluid requires specific intervention

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Cough

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can also be psychological can be neurologically controlled, local respiratory medicine will be ineffective Cough center responds to opiates

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How to convert oral to subcutaneous dosing of morphine:

answer

Calculate oral dose for equivalent of 24 hours. Divide by 2 --> subcutaneous Divide by 6 --> for injections q4h

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Cystic Fibrosis - Pathogenesis

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Defective CF gene Deficient CFTR protein Decreased chloride secretion/altered ionic transport Increased water absorption/abnormal mucus composition Bronchial obstruction Bacterial infections Inflammation Bronchiectasis and Lung Insufficiency

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How does Cystic Fibrosis affect the respiratory epithelium?

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No chloride, sodium, water secreted --> dehydrated layer Mucus sits directly on cilia Because lack of water --> mucus is thicker and stickier Attaches to airway --> causes infection/inflammation

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Cystic Fibrosis - Clinical Symptoms/Signs

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Recurrent Respiratory Infections Sinus Disease - panopacification of paranasal sinus by 8 months Chronic rhinosinusitis Pancreatic Disease - insufficiency from birth. Steatorrhea, malnutrition, failure to thrive Fat-soluble Vitamin Deficiencies (AEDK) Meconium Ileus (small bowel obstruction at birth) Distal Ileal Obstruction Syndrome (small bowel obstruction) Liver & Biliary Disease in Males - infertility secondary to congenital absence of vas deferens in Females - secondary amenorrhea, abnormally tenacious cervical mucus

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Cystic Fibrosis - Diagnosis

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Collection of Sweat with Pilocarpine Iontophoresis - chloride > 60 Genetic panel for CFTR mutations Gene sequencing

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Cystic Fibrosis - Treatments

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Mostly Symptomatic- Antibiotics Bronchodilators Chest physiotherapy DNAse new therapies targeting specific mutations (Ivacaftor, Lumacaftor)

Reticulocytes and MCV: Mean Red Blood Cell Volume

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