Nate's Pulmonary Review questions--1

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nivanick
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293250
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Nate's Pulmonary Review questions--1
Updated:
2015-01-19 20:31:21
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pleural disease
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Pleural disease
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pulmonary pleural disease questions
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  1. Top 3 causes of exudative pleural effusions?
    • Pneumonia (parapneumonic)
    • Malignancy
    • Pulmonary Embolism
  2. How often does light's criteria misidentify a transudative effusion as exudative?  What protein gradient should suggest true exudative?
    What BNP level?
    • 25% are misclassified.
    • >3.1 gm/dL
    • NT-BNP >1300 pg/mL
  3. Pleural effusion protein above 5 g/dL is suggestive of what?
    TB effusion
  4. LDH indicates what in a pleural effusion
    • LDH is an intracellular enzyme. Indicates degree of cell turnover and inflammation. 
    • If on repeated thoracenteses LDH increases, suggests that inflammation increases
  5. What are the causes of a lower pleural fluid glucose?
    • 1. Parapneumonic effusion (below 40, place chest tube)
    • 2. Malignant effusion (if low glucose, cytology likely positive)
    • 3. TB effusion
    • 4. Rheumatoid effusion (expect below 30)
    • 5. Hemothorax
    • 6. Paragonimiasis
    • 7. Churg-strauss syndrome
  6. Cell types in acute inflammation?
    In chronic inflammation?
    • Acute: PMN's
    • Chronic: Mononuclear cells
  7. Pleural fluid eosinophilia: >/=10%
    • Most common: Air/blood in pleural space (may see on repeat thoracentesis)
    • Other causes: Once above excluded
    • Idiopathic 40%
    • Malignancy 17%
    • Parapneumonic 13%
    • TB 6%
    • PE 4%
    • Transudates 8%
    • Other causes: 13%
  8. Cytology positive on for malignancy on first tap?  By third tap?
    • 60% on first tap
    • 90% by third tap
    • Also depends on tumor type
  9. 10 causes of pH under 7.2
    • 1. Complicated parapneumonic effusion
    • 2. Esophageal rupture
    • 3. Rheumatoid pleuritis
    • 4. TB pleuritis
    • 5. Malignant pleural disease
    • 6. Hemothorax
    • 7. Systemic acidosis
    • 8. paragonimiasis
    • 9. lupus plueritis
    • 10. urinothorax
  10. What percentage of patients with SLE will have a pleural effusion?
    What percentage of people with SLE will have negative ANA if pleural effusion?
    • 50%
    • Essentially none. Very high negative predictive value.
  11. What percentage of patients with RA will have an effusion
    • 5% at some point in disease. 
    • If pleural fluid rheumatoid factor titer >1:320, clinches dx of RA
  12. CHF effusions:
    1. Bilateral in what percentage? Which side more?
    2. What percentage with unilateral right sided?
    3. What percentage with unilateral left sided?
    • 1. 73% with bilateral, slightly larger on the right.
    • 2. 19% with right sided.
    • 3. 9% with left sided.
  13. What is a protein discordant effusion?
    When diuresis of a heart failure transudate concentrates the fluid to an apparent exudate.  It should be only very slightly exudative. Some things to look for: Pleural fluid protein level >3.1 gm/dL. Or NT-BNP >1300 pg/mL. (not regular BNP)
  14. What 7 factors indicate need for more invasive strategy in a parapneumonic effusion?
    • 1. Pus in pleural space
    • 2. Positive pleural fluid gram stain
    • 3. Pleural fluid glucose <60 mg/dL
    • 4. Pleural fluid pH <7.2
    • 5. Positive pleural fluid culture
    • 6. Pleural fluid LDH >3x upper limit of serum nml.
    • 7. Loculated pleural effusion
  15. What is the significance of a tuberculous pleural effusion?
    Most will resolve spontaneously, and do not need a chest tube. However, if not treated with anti-TB meds, ~50% likelihood of developing active TB in the next 5 yrs.
  16. Of the 5 most common endemic fungi, which are the most likely to cause a pleural effusion?
    • 1. Primary coccidioidomycosis-- ~15% with effusions (can also occur through ruptured coccidiodal cavity-- hydropneumothorax
    • 2. Blastomycosis-- 10% with pleural effusion; 40% + with pleural thickening
    • 3. Aspergillosis-- as complication to lobectomy, pneumonectomy in BP fistula. Previously in articifical PTX for TB therapy
    • 4. Cryptococcus-- from rupture of sub pleural foci.
    • 5. Histoplasmosis-- rare, 1/259 in 1 series.
    • 6. Rare in P.Jirovecii (case reports)
  17. Esophageal perforation is a complication of what 3 procedures mainly?
    Which side does it occur on most frequently?
    What are the notable characteristics?
    • Esophagoscopy, during foreign body removal or esophageal stricture dilation. Also with Blakemore placement. Also seen with TEE, esophageal cancer, gastric intubation, chest trauma or vomiting.
    • Typically right sided.  
    • Expect low pH (often below 7), elevated amylase. Often polymicrobial.
  18. What percentage of patients develop pleural effusions after liver transplant
    ~70%. Only about 10% will require intervention though.
  19. Characteristics of a rheumatoid pleural effusion?
    • Male predominant. 5%, usually in those with sub pleural nodules. Glucose <30, pH <7.2, elevated rheumatoid factor titer >1:320.
    • Develops several years after arthritis typically.

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