IM pulm

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Author:
TerryZ
ID:
246149
Filename:
IM pulm
Updated:
2013-11-27 09:39:31
Tags:
internal medicine IM pulmonary
Folders:
IM
Description:
Internal medicine - pulmonary
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  1. PE - RFs
    • Misc: 60+, CA, prior DVT/PE, 
    • Hereditary: hypercoag states (factor V Leiden, prot C&S defic, ~thromb III defic)
    • Cond: Card dz (CHF), obese, nephrotic syndr
    • Major: surg, trauma
    • Estrogen: preg, OCC
  2. PE - S/Sx
    dysp, tachyp, pleuritic CP, rales, cough, DVT s/sx, tachyc, S4, /P2, shock, LG F, BS, dull on percuss
  3. PE - Dx
    • US: venous duplex of LE (+) hep, (-)?
    • V/Q: nl r/o PE, hi-prob hep, /clin suspicion - PA
    • CT: helical chest - good s/s
    • Pulm angio: gold std - invasive
    • D-dimer: nl & clin susp low - likely not PE (also / MI, CHF, PNA, post-op
    • Modified Wells criteria: .
  4. Modified Wells criteria
    • PE likelihood
    • 3: clin s/sx DVT; alt dx less likely
    • 1.5: HR>100, immob/surg<4wk, prior DVT/PE
    • 1: hemop, CA last 6mo
    • Clinical probability
    • Low: <2 (<=10%)
    • Med: 2-6(<=30%)
    • High: >6(>=705)
    • 4: D-dimer assay, if abnl do spiral CT
    • 5+: Spiral CT scan
  5. PE - Tx
    • O2: correct hypoxia
    • A ~coag tx: UFH/LMWH -> PTT 1.5-2.5x 80ug/kg bolus, 18ug/kg/hr for 5-10 days
    • Warfarin: LT tx, start day1->INR 2-3 for 3-6mo
    • Throbolytic tx: tPA - massive PE, unstable, R HF
    • IVC: CI to ~throm, fail, low pulm reserve
    • Embolectomy: surg/cath - CI tPA/fail
    • Prophyl: hep 5000uSC every 8-12hr; enoxaparin 30mgSC BID or 40mg SC daily. SCD
  6. CAP - typical vs atypical agents
    • Typical: S. pneumo, H. flu, aerobic Gram- rods (klebsiella [EtOH], enterobacteriacae), Staph aureus
    • Atypical: M. pneumo, chlamydia, coxiella burnetii, legionella, viruses (flu, adenovius, parainfluenza, RSV)
  7. CAP - typical vs atypical s/sx
    • Typical:Atypical
    • Acute:Insideous
    • Prod cough:dry cough
    • Purulent sputum:no sputum
    • F w/shaking chills:F w/no chill
    • Tachypnea/tachycardia:pulse/temp dissociation
    • late insp crackles, bronch BS, ^fremitus, dullness on percuss
    • wheeze,ronchi,crackles
  8. CAP - typical vs atypical CXR results
    • Typical: lobar consolidat'n; multi-lobar=serious
    • Atypical: diff reticulonod'r infiltr's; ~consolidat'n
  9. CAP - dx
    • CXR (PA/Lat), Chgs lag 6 wks
    • Pre-tx sputum Gram stain/cx
    • Urinary antigen assay (legionella, S. pneumo)
    • Blood cx
    • CBC
  10. CAP vs H(C)AP
    • CAP: in community or 1st 72 hrs hosp
    • H(C)AP: after 72 hrs hospitalization
  11. HAP - MC bacterial pathogens
    • G(-) rods (E. coli, Psuedomonas)
    • Staph aureus
  12. HAP - tx
    • G- rods
    • Cephalosporins w/pseudomonal coverage:
    • - Ceftazidime, cefepime
    • - Carbapenems (imipedem)
    • - Piperacillin/tazobactam (Zosyn)
    • NOT macrolides (azith, clarith, eryth)
  13. PNA CXR silhouette sign
    • Right <3 border   - RML
    • Left <3 border     - lingula
    • R hemidiaphr       - RLL
    • L hemidiaphr       - LLL
    • Descending aorta - LUL
  14. COPD - classic types
    • C bronchitis: clin dx - c cough+sputum x3mo/yr for 2 yrs. /mucus->inflam&scar, /glands, sm muscle hyperplasia
    • Emphysema: pat dx - alveoli destruct; <-smoke
    • Coexist; /obstruction
  15. COPD - RFs
    Smoke, α-antitrypsin defic, 2nd-hand smoke, POC,     c asthma
  16. COPD - S/Sx
    • Any combo: cough, sputum, /dyspnea
    • DOE: limit activity
    • /FET: prolonged forced expiratory time >=6sec
    • Auscult: end-forced-expir wheezes, breath sounds, inspiratory crackles
    • Misc: tachyp, tachyc, cyanosis, accessory, hyperresonance, signs cor pulmonale
  17. Pink puffers
    • Emphysema > C Bronchitis
    • Thin, lean fwd, barrel chest, tachyp w/pursed lips, distressed, uses accessory musc (straps)
  18. Blue bloaters
    • C Bronchitis > Emphysema
    • Overweight, cyanotic, c cough w/sputum, signs of cor pulmonale, RR nl-slight/, NAD
  19. COPD - Dx
    • PFT (spirometry) - definitive test
    • FEV1: 70% mild, 70-50 mod, 50- severe
    • FEV1/FVC: < 0.70 obstruction
    • /TLC, RV, FRV: .
    • peak exp flow rate: <350L/min do PFT
    • FEF50%: 0.5 = obstruction
    • CXR: HInflat'n, flat diaph, /retrosternal space, vasc markings, r/o PNA/pnuemothorax
    • α-antitrypsin lvl: fam hx <= 50
    • ABG: c pCO2 retention, O2 -> c resp acidosis + metabolic acidosis to compensate
  20. COPD - TX
    • X smoke: sx improve by 1 year
    • O2 tx: lowers mortality (18 hr/day P-HTN) - PaO2 55, O2sat<88, PaO2 55-59 = polycythemia or cor pulmonale
    • i B2-agon: (lev)albuterol - bronchodilators. Long-acting salmeterol, formoterol
    • i ~cholinergic: ipratropium bromide, tiotropium (slower than B2 but last longer); combo
    • i corticosteroids: budesonide, fluticsone, ~inflam - minimal FEV1 decrease
    • Misc: pulm rehab, vaccinations, abx, surg
  21. COPD - Tx guidelines
    • Mild-mod: bronchodilator MDI, LD i glucocorticoids, ?theophylline
    • Severe: Meds + continuous O2 tx, pulm rehab, triple inhaler tx.
  22. Acute COPD exacerbation
    • s/sx: persistent /dysp not relieved by dilators, /sputum, cough
    • complic: acute resp failure
    • organisms: S. pneumo, H flu, M. catarrhalis, V
  23. Acute COPD exacerbation - Tx
    • Bronchodil: (B-agonist) alone w/anticholinergics
    • Syst corticosteroids: hosp IV methylprednisone, taper w/ oral prednisone (NOT inhaled!)
    • Abx: azith, levo, TMP/SMX, amox, doxy
    • O2: >90%
    • NPPV: non-invasive +-pressure vent BIPP CPAP
    • Hosp: or not?
    • CXR: .
  24. COPD complications
    • acute exacerbations: infect, non-comply, HD
    • 2ndary polycythemia: HCT>55M/47F
    • Pulm HTN & cor pulmonale: severe, long-standing
    • RV hypertrophy: <- c bronchitis
  25. Sarcoidosis - etiology
    • Def: c systemic granulomatous dz char by noncaseating granulomas, mult organ sys incl lungs
    • Occur: >AA, W, 75%<40yo, 50% incidental CXR
  26. Sarcoidosis - S/Sx if severe
    • Dyspnea
    • CP
    • HCa
    • Ocular
    • CNS
    • Cardiac involvement
    • Progressive pulmonary dz
  27. Sarcoidosis - Dx
    • CXR: B hilar adenop, 50%
    • /ACE: 50-80%
    • HCaUria/emia: common
    • LFT: abnlities
    • Bx: transbronchial - definitive; see noncase gran
    • PFT: lung vol (VC, TLC), DLco, FEV1/FVC
    • Galium scan: panda sign
  28. Sarcoidosis staging
    • I: B hilar adenopathy w/out parench infiltrates
    • II: hilar adenopathy with parenchymal infiltrates
    • III: diffuse parench infiltrates w/o hilar adenop
    • IV: pulmonary fibrosis w/ honeycombing and fibrocystic parencymal changes
  29. Sarcoidosis - Tx
    • Most resolve in 2 yrs
    • Systemic corticosteroids x 6 wks, 2-3mo taper
    • Methotrexate if refractory to corticosteroids

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