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Pulm

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bananas's version from 2015-07-17 23:04

Pulm Basics

Question Answer
Physiologic dead spaceVD = VT x (PaCO2 - PECO2)/PaCO2
What factors cause O2 affinity for HgB to decrease?Right shift: 2,3-BPG, CO2, H+, hot temperature
Alveolar gas equationPAO2 = 150 - PaCO2/0.8
What does an A-a gradient mean?More O2 in Alveoli than arterioles
[PAO2-PaO2]
Normal A-a gradient10-15 mmHg
Causes of increased A-a gradient?Hypoxemia
Shunt
V/Q mismatch
FIbsosis (impaired diffusion)
↑FiOe
Increased age
↓PaO2 with Normal A-a gradientHypoxemia due to:
- High altitude
- Hypoventilation (ex. opioids)
↓PaO2 with ↑ A-a gradientV/Q mismatch
Fibrosis: diffusion limtition
Right to Left shunt: Deoxygenated blood enters systemic circulation and ↓PaO2
HypoxiaDecreased O2 delivery to the ~tissue
Causes of Hypoxia↓ CO (CHF): can't deliver O2
Anemia: HgB doesn't have O2 content to deliver
CO poison: HgB can't carry O2
Hypoxemia
What part of the lung is V/Q mismatch >1?Apex (zone 1): ↓Perfusion (Q) causes ↑V/Q
What part of the lung is V/Q mismatch <1?Base (zone 3): ↑Perfusion (Q) causes ↓V/Q
What causes V/Q to approach infinity?Blood flow obstruction: V/↓Q
What causes V/Q to approach 0?Airway obstruction: (↓V)/Q
100% O2 will improve only one V/Q mismatch state... which one?<1 (perfusion): the parts that are perfused get more O2
How is CO2 transported in the body?1. HCO3- (Carbonic Anhydrase): 90% 2. Bound to N-terminus of globin (Carbaminohemoglobin 3. Dissolved in blood
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ARDS

Question Answer
Causes of ARDSShock
Infection
Toxic gas
ASpiration
High O2
Pancreatitis
Heroin OD
Sepsis
Trauma
Uremia
Amniotic Fluid embolism
Ground glass CXRNRDS
Prevention of NRDS?Give mom steroids
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Pneumoconioses

Question Answer
Silicosis jobsMiners
Glass manufacturers
Sandblasters (denim)
Stone cutters
Quarry workers
Mechanism of silicosisMacrophages release fibrogenic factors → fibrosis
Increased susceptibility to TB?Silicosis: Silica impairs macrophages and disrupts phagolysosomes
Which lobes are affected in silicosis?Upper lobes [Silica is from the base (earth) but affects the roof (upper lobes)]
Eggshell calcification of hilar lymph nodesSilicosis
Asbestos jobsShipbuilding
Roofing
Plumbing
Insulation
Brake lining
Ivory white calcified pleural plaques ?Asbestosis
Fibrosis of lung and pleuraAsbestosis
Asbestos increases risk forBronchogenic carcinoma
Mesothelioma
Laryngeal CA
MesotheliomaSilcosis
Golden-brown fusiform dumbell rodsFerruginous bodies in alveolar septum: ~Asbestos
Which lobes are affected in Asbestosis?Lower lobes [From the roof, found in the base]
Coal workers pneumoconiosisCoal dust exposures: macrophages laden with carbon leads to inflammation and fibrosis
Black lung diseaseCoal worker pneumoconiosis
Which lobes are affected in Coal worker pneumoconiosis?Upper lobes
Normal finding in city dwellers?Anthracosis
Rheumatoid arthritis + Coal worker PneumoconiosesCaplan syndrome
Mimics sarcoidosis?Berylliosis
Berylliosis jobaerospace (NASA) and manufacturing
Noncaseating granulomatous in the lung and hilar LNBerylliosis
Which lobes does berylliosis affect?Upper
Berylliosis increases risk forLung cancer
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Rapid fire

Question Answer
insulation workasbestos
shipyard workasbestos
construction workasbestos
brake lining workasbestos
pipe fitterasbestos
fluorescent light bulb workberylliosis
aerospace workberryliosis
nuclear weapons workberryliosis
electronics industriesberryliosis
minerssilicosis
glass manufacturerssilicosis
sand blasterssilicosis
denim blasterssilicosis
stone cutterssilicosis
quarry workerssilicosis
coal minerscoal workers' pneumoconiosis (aka black lung)
Battery factoryLead poisoning
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Sarcoidosis

Question Answer
Sarcoidosis: A GRUELING DiseaseACE enzyme
Granulomas
RA
Uveitis
Erythema nodosum (tibial)
Lymphadenopathy (bilateral hilar)
Idiopathic
Noncaseating Granuloma
Gammaglobulinemia
Vitamin D
Immune mediated widespread noncaseating granulomasSarcoidosis
What enzyme is elevated in Sarcoidosis?ACE
What inflammatory cells are elevated in Sarcoidosis?CD4+ > CD8+
Which population is at risk? Black women
CXR findingsBilateral adenopathy and coarse reticular opacities
Treatment of SarcoidosisSteroids
Protein inclusions in Langerhans giant cellsSchaumann bodies or asteroid bodies
MC source of metastasis?Breast
Colon
Prostate
Bladder
MC metastasize toBrain
Bone
Adrenals
Liver
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Lung cancer

Question Answer
MC lung cancerAdenocarcinoma
2MC lung cancerSquamous cell carcinoma
MC in nonsmokersAdenocarcinoma
Seen in womenAdenocarcinoma
CentralSmall cell carcinoma
Squamous cell carcinoma
PeripheralAdenocarcinoma
Large cell carcinoma
Excellent prognosisAdenocarcinoma
Bronchial carcinoid tumor
Worst prognosis Large cell carcinoma
Small cell carcinoma
Mesothelioma
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Question Answer
NeurendocrineSmall cell carcinoma
Small dark blue cellsSmall cell carcinoma
Chromogranin A+Small cell carcinoma
High Nucleus:Cytoplasm ratioSmall cell carcinoma
Keratin pearlsSquamous cell carcinoma
Hilar mass from bronchusSquamous cell carcinoma
CavitationSquamous cell carcinoma
Anaplastic undifferentiationLarge cell carcinoma
Pleomorphic giant cells Large cell carcinoma
GlandularAdenocarcinoma
Stains Mucin+Adenocarcinoma
Thickened alveolar wallsAdenocarcinoma: Bronchioloalveolar subtype
Nests of neurendocrine cellsBronchial carcinoid tumor
Psamomma bodiesMesothelioma
Exudative with Pleural thickeningMesothelioma
Apex of lungPancoast
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Question Answer
Weakness improves with useSmall cell carcinoma: Lambert eaton myasthenic syndrome
HyponatremiaSmall cell carcinoma: SIADH
Moon facies, Central obesity, WeaknessSmall cell carcinoma: Cushing syndrome from secreting ACTH
EncephalitisSmall cell carcinoma
HypercalcemiaSquamous cell carcinoma: PTHrP syndrome
Beta HCGLarge cell carcinoma
Hypertrophic osteoarthropathy (clubbing)Adenocarcinoma
Flushing, Diarrhea, Wheezing, Right heart lesionsBronchial carcinoid tumor: Serotonin syndrome
AsbestosisMesothelioma
Smoking not a risk factorMesothelioma
Ptosis, miosis and anhydrosisPancoast: Horner's syndrome from cervical lymphatic chain invasion
HoarsenessPancoast: Recurrent laryngeal nerve
Blanching in the neck and edema in the upper extremitiesSVC syndrome:
- Bronchogenic CA (mediastinal mass)
- Pancoast
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Question Answer
TP53Small cell carcinoma
RbSmall cell carcinoma
MYCSmall cell carcinoma
KRASAdenocarcinoma
EGFRAdenocarcinoma
ALKAdenocarcinoma
ROSAdenocarcinoma
METAdenocarcinoma
RETAdenocarcinoma
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Rapid Fire Pneumonia

Question Answer
ImmunocompromisedPCP
CMV (interstitial)
Atypical/walkingMycoplasma pneumonia
AlcoholicsKlebsiella
Bird handlersChlamydia Psittaci
Bats and bat droppings (spelunking)Histoplasma
Southeast U.S.Coccidioides
Currant jelly sputumKlebsiella
FarmersCoxiella: Q fever
Air conditionersLegionella
Children < 1 y.o.RSV
Neonate < 28 daysGBS or E.coli
Children/young adultsMycoplasma pneumonia
MC viralRSV
Wool sorter (mail man)Bacillus anthracis
Ventilated patientsPseudomonas
MRSA
Cystic FibrosisPseudomonas
Pontiac feverLegionella
COPDH. influenza
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Question Answer
LobarS. pneumonia, Klebsiella
Intra-alveolar exudate (neutrophils)Lobar
BronchopneumoniaS. aureus
S. pneumonia
H.inifluenza
Multifocal, bilateral and patchyBronchopneumonia
Interstitial pneumoniaViruses
Mycoplasma
Legionella
Chlamydia
Diffuse patchy inflammation in alveolar wallsInterstitial pneumonia
More lung markingsInerstitial (atypical) pneumonia
Aspiration pneumoniaBacterioides
Fusobacterium
Pepticoccus
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Cystic Fibrosis

Question Answer
What gene is defective in Cystic fibrosisCFTR gene on Chromosome 7
What is the most common mutation?Delta F508 deletion: post-translational misfolding of CFTR protein resulting in proteasome degradation
What does CFTR encodeTransmembrane Cl- ATP-channel: Secretes Cl- in Pancreatic ducts and Airways, Reabsorbs Cl- in sweat glands
Symptoms of CFRecurrent pulm infections, Bronchiectasis, pancreatic insufficiency
What bacteria is associated with CF?Pseudomonas
Most common mechanism in CF?Misfolded protein Ž protein retained in RER and not transported to cell membrane, causing  Cl− (and H2O) secretion;  intracellular Cl− results in compensatory  Na+ reabsorption via epithelial Na+ channels Ž  H2O reabsorption Ž abnormally thick mucus secreted into lungs and GI tract.
Diagnosis of CF?Chloride sweat test: High [Cl-] > 60 mEq/L in sweat
- Also: Nasal transepithelial potential difference
Newborn CF screeningImmunoreactive Trypsinogen
Reproductive effects of CFInfertility: Bilateral absence of Vas Deferens
Treatment of Cystic FibrosisN-acetylcystine and Antibiotics... can put on fluoroquinolones
What endogenous nutrients need to be replaced in CF?Replace Pancreatic enzymes
Fat soluble vitamins
What channels are affected in CF?CFTR: ↑Mucosal Cl secretion ↓Sweat Cl concentrations
ENaC: ↑Sweat and Nasal Na absorption ↓Mucosal Na absorption
Nasal transeptithelial potential differenceDetects mild CFTR
Confirmation if transepithelial potential difference is more negative
CF in the respitory/gastric glands↑CFTR: ↑Cl- secretion
↓ENaC: ↓Na+ absorption
CF in the sweat glands↓CFTR: ↓Cl- secretion
↑ENaC: ↑Na+ absorption
CFTR in the PancreasCan't pump Cl- into lumen of duct →No secretion→Pancreatic duct obstructed→Can't release enzymes→Can't absorb fat soluble vitamins
What kind of transmembrane protein is CFTR?ATP-gated cassette transmembrane Chloride channell: establishes membrane that draws sodium across
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