Pulmonary PANCE/PANRE Review Course - PDF

Pulmonary PANCE/ PANRE Review Course by Self Care Self Care and Wellness Notes: Introduction The review course days will feel long and intense. Your wellness is important and we want you to avoid burnout. Here are some tips for self care during the course: While listening we encourage you to stand u...

Pulmonary PANCE/ PANRE Review Course by Self Care Self Care and Wellness Notes: Introduction The review course days will feel long and intense. Your wellness is important and we want you to avoid burnout. Here are some tips for self care during the course: While listening we encourage you to stand up occasionally, roll the neck, lift your arms your head to help keep awake and the blood flowing. If you are on a laptop, walk to another room for a change of scenery. Staring at a screen all day can be intense. One way to prevent headaches and eye strain is to refocus your vision to a different point in the room (different distance from your eyes). Plan to glance away from the screen to a corner of the room you are in or a different focal point every ~15 minutes. Make good use of the breaks. If you can go outside to get a break of fresh air. Do some quick exercises, such as jumping jacks or squats. Plan out and prepare good lunches and snacks ahead of time. You know your energetic and dietary needs best, but if you’re not sure how best to eat in a day like this, plan protein and long-term energy as your morning and midday snacks/meals, and have a couple of emergency fast energy boosts (carbs, etc) ready for later in the day. Have consistent wake up and sleep times. Remind yourself that you are building up stamina for exam day! Introduction Pulmonary PANCE/ PANRE Review Course by Infectious Disorders Infectious Disorders....................... 1 Neoplastic Disease........................ 15 Chronic Obstructive Pulmonary Disease.... 22 Pleural Disease........................... 29 Pulmonary Circulation.................... 36 Restrictive Pulmonary Disease............. 45 Other Pulmonary Disease................. 57 888.427.7737 | [email protected]| https://blueprintprep.com/medical/pa/tutoring Pulmonary Acute Bronchitis Notes: Pathogenesis Symptoms and signs Physical examination +/– wheezing, rhonchi on auscultation +/– URI findings Diagnosis Management Supportive care Resolves spontaneously between 1–3 weeks Infectious Disorders 2 Pulmonary Influenza Notes: Pathogenesis Risk Factors Epidemiology Older adult patients at highest risk ↑ in early winter & cooler months Symptoms and signs Physical examination Mild pharyngeal edema Fever May have focal lung findings in viral pneumonia Infectious Disorders 3 Pulmonary Influenza Notes: Diagnosis Clinical Diagnosis Laboratory studies Molecular assays, antigen detection tests Management Supportive care Neuraminidase inhibitors: oseltamivir, zanamivir Within 48 hours of symptom onset Works against A and B Rimantadine, amantadine Works against A only Complications Infectious Disorders 4 Pulmonary Bacterial Pneumonia (Community-Acquired Pneumonia) Notes: Pathogenesis Symptoms and signs Infectious Disorders 5 Pulmonary Bacterial Pneumonia (Community-Acquired Pneumonia) Notes: Symptoms and signs Physical examination Tachypnea Tachycardia Hypoxemia Lung examination Bronchial sounds Egophony Bronchophony Whispered pectoriloquy ↑ tactile fremitus Dullness to percussion Infectious Disorders 6 Pulmonary Bacterial Pneumonia (Community-Acquired Pneumonia) Notes: Diagnosis Management Empiric antibiotics: outpatient Healthy patients < 65 years of age High dose amoxicillin OR Doxycycline OR Macrolide Patients w/ comorbidities Amoxicillin-clavulanate or cephalosporin PLUS either azithromycin or doxycycline OR respiratory fluoroquinolones Empiric antibiotics: General medical ward Beta-lactam (e.g., ceftriaxone) and macrolide (e.g., azithromycin) OR respiratory fluoroquinolone Infectious Disorders 7 Pulmonary Bacterial Pneumonia (Community-Acquired Pneumonia) Notes: Management Clinical decision tools CURB-65 score Pneumonia severity index Infectious Disorders 8 Pulmonary Bacterial Pneumonia (Community-Acquired Pneumonia) Notes: Complications Bacterial Pneumonia (Hospital-Acquired Pneumonia) Diagnosis Occurring > 48 hours after hospital admission Ventilator-associated pneumonia (VAP) develops 48-72 hours following endotracheal intubation Management HAP/VAP No risk factors for MDR → monotherapy with beta-lactam, ertapenem, or fluoroquinolone Risk factors for MDR → antipseudomonal beta-lactam or carbapenem + fluoroquinolone Risk factors for MRSA → add vancomycin Aspiration pneumonia No abscess → treat same as CAP With abscess → ampicillin-sulbactam, amoxicillin-clavulanate Infectious Disorders 9 Pulmonary Pneumocystis Jiroveci Pneumonia Notes: Pathogenesis Etiology Fungus Pneumocystis jiroveci The most common cause of pneumonia in HIV patients Risk Factors Symptoms and signs Physical examination Fever Diaphoresis, tachycardia Rhonchi, rales, and consolidation upon auscultation Oxygen desaturation with ambulation Infectious Disorders 10 Pulmonary Pneumocystis Jiroveci Pneumonia Notes: Diagnosis Laboratory studies Elevated LDH Definitive diagnosis: bronchoalveolar lavage/lung biopsy Management Management Trimethoprim-sulfamethoxazole (TMP-SMX) Steroids for PaO2 < 70 or A-a gradient > 35 Preventative measures TMP-SMX for prophylaxis in high-risk individuals (e.g., CD4+ T-cell count of < 200 cells/μL) Infectious Disorders 11 Pulmonary Tuberculosis Notes: Pathogenesis Symptoms and signs Infectious Disorders 12 Pulmonary Tuberculosis Notes: Symptoms and signs Physical examination Apical rales or rhonchi Lymphadenopathy Fever Diagnosis Infectious Disorders 13 Pulmonary Tuberculosis Notes: Management Active TB Rifampin, isoniazid, pyrazinamide, and ethambutol x 2 months Followed by rifampin and isoniazid x 4 months Latent TB Isoniazid x 9 months + Pyridoxine supplementation Rifampin x 4 months (alternative) Infectious Disorders 14 Pulmonary PANCE/ PANRE Review Course by Neoplastic Disease Infectious Disorders....................... 1 Neoplastic Disease........................ 15 Chronic Obstructive Pulmonary Disease.... 22 Pleural Disease........................... 29 Pulmonary Circulation.................... 36 Restrictive Pulmonary Disease............. 45 Other Pulmonary Disease................. 57 888.427.7737 | [email protected]| https://blueprintprep.com/medical/pa/tutoring Pulmonary Pulmonary Nodules Notes: Pathogenesis Symptoms and signs Physical examination Benign pulmonary nodules: unremarkable physical exam Evidence of malignant disease Weight loss Fever Decreased breath sounds Rales and rhonchi Neoplastic Disease 16 Pulmonary Pulmonary Nodules Notes: Diagnosis Imaging studies Chest X-ray Low-dose CT chest without contrast PET/CT Suspicious nodules → biopsied via transthoracic needle biopsy or bronchoscopy Management Neoplastic Disease 17 Pulmonary Lung Cancer Notes: Pathogenesis Risk Factors Epidemiology Most common cause of cancer mortality in the United States Symptoms and signs Neoplastic Disease 18 Pulmonary Lung Cancer Notes: Symptoms and signs Local invasion Superior vena cava syndrome Local invasion Pancoast Syndrome Neoplastic Disease 19 Pulmonary Lung Cancer Notes: Symptoms and signs Diagnosis Laboratory studies Cytologic examination of sputum Tissue core biopsy is definitive Imaging studies Chest X-ray CT chest with contrast PET/CT Neoplastic Disease 20 Pulmonary Lung Cancer Notes: Management Neoplastic Disease 21 Pulmonary PANCE/ PANRE Review Course by Chronic Obstructive Pulmonary Disease Infectious Disorders....................... 1 Neoplastic Disease........................ 15 Chronic Obstructive Pulmonary Disease.... 22 Pleural Disease........................... 29 Pulmonary Circulation.................... 36 Restrictive Pulmonary Disease............. 45 Other Pulmonary Disease................. 57 888.427.7737 | [email protected]| https://blueprintprep.com/medical/pa/tutoring Pulmonary COPD Notes: Pathogenesis Chronic Obstructive Pulmonary Disease 23 Pulmonary Chronic Bronchitis Notes: Pathogenesis goblet cells Symptoms and signs Physical examination Expiratory wheezing, crackles Prolonged expiration Cyanosis Peripheral edema Obesity Diagnosis Laboratory findings CBC: ↑ Hgb and Hct ABG: respiratory acidosis Gold standard - Pulmonary function testing ↓ FEV1 and FEV1/FVC < 0.7 Normal or ↑ TLC, ↑ RV Normal diffusing capacity for carbon monoxide (DLCO) Chronic Obstructive Pulmonary Disease 24 Pulmonary Emphysema Notes: Pathogenesis Risk Factors Symptoms and signs Chronic Obstructive Pulmonary Disease 25 Pulmonary Emphysema Notes: Symptoms and signs Physical examination Prolonged expiration and pursed-lip breathing Accessory muscles use Cachexia Tachypnea Barrel chest (increased anteroposterior diameter) Diminished breath sounds Hyperresonance Diagnosis Laboratory findings Gold standard - Pulmonary function testing: Reduced FEV1, FEV1/FVC 15% of the diameter of the hemithorax High concentration O2 Chest tube Serial chest X-rays Tension PTX Emergent needle decompression Chest tube Pleural Disease 35 Pulmonary PANCE/ PANRE Review Course by Pulmonary Circulation Infectious Disorders....................... 1 Neoplastic Disease........................ 15 Chronic Obstructive Pulmonary Disease.... 22 Pleural Disease........................... 29 Pulmonary Circulation.................... 36 Restrictive Pulmonary Disease............. 45 Other Pulmonary Disease................. 57 888.427.7737 | [email protected]| https://blueprintprep.com/medical/pa/tutoring Pulmonary Pulmonary Embolism Notes: Pathogenesis Risk Factors Symptoms and signs Physical examination Tachypnea Rales Tachycardia Prediction criteria Well’s Scoring Criteria for Pulmonary Embolism Pulmonary Embolism Rule-Out Criteria Pulmonary Circulation 37 Pulmonary Pulmonary Embolism Notes: Symptoms and signs Pulmonary Circulation 38 Pulmonary Pulmonary Embolism Notes: Diagnosis Pulmonary Circulation 39 Pulmonary Pulmonary Embolism Notes: Diagnosis Management Hemodynamically stable Anticoagulation Hemodynamically unstable: Thrombolytic therapy Surgical thrombectomy or embolectomy Inferior vena cava filter Pulmonary Circulation 40 Pulmonary Pulmonary Hypertension Notes: Pathogenesis Pulmonary Circulation 41 Pulmonary Pulmonary Hypertension Notes: Symptoms and signs Physical examination Heart sounds 1st heart sound (S1) followed by ejection click Second heart sound (S2) may be narrowly split Increased intensity of the pulmonic component (P2) of S2 Signs of right ventricular failure JVD Peripheral edema Abdominal distention/ascites Diagnosis Management Group 1 Supplemental O2 Anticoagulation CCBs Phosphodiesterase-5 inhibitors Prostacyclin pathway agonists Endothelin receptor antagonists Group 2 Optimize management of the underlying left heart disease Group 3 Treat the underlying lung disease Group 4 and 5 Treat the underlying disorder Pulmonary Circulation 42 Pulmonary Cor Pulmonale Notes: Pathogenesis Symptoms and signs Exercise intolerance Physical examination Wheezing and crackles Parasternal lift JVD, hepatomegaly Peripheral edema Cyanosis Digital clubbing Pulmonary Circulation 43 Pulmonary Cor Pulmonale Notes: Diagnosis Echocardiography Structural changes of the right ventricle ECG RVH Right axis deviation RA enlargement CXR Enlarged right atrium Enlarged right ventricle Enlarged pulmonary arteries Right-heart catheterization Confirms pulmonary HTN Management Treat the underlying pulmonary condition Bronchodilators, antibiotics, O2, noninvasive mechanical ventilation Vasodilators Anticoagulation Cautious diuretic therapy Pulmonary Circulation 44 Pulmonary PANCE/ PANRE Review Course by Restrictive Pulmonary Disease Infectious Disorders....................... 1 Neoplastic Disease........................ 15 Chronic Obstructive Pulmonary Disease.... 22 Pleural Disease........................... 29 Pulmonary Circulation.................... 36 Restrictive Pulmonary Disease............. 45 Other Pulmonary Disease................. 57 888.427.7737 | [email protected]| https://blueprintprep.com/medical/pa/tutoring Pulmonary Idiopathic Pulmonary Fibrosis Notes: Pathogenesis Symptoms and signs Physical examination Bibasilar crackles Finger clubbing Restrictive Pulmonary Disease 46 Pulmonary Idiopathic Pulmonary Fibrosis Notes: Diagnosis Management Supplemental oxygen Antifibrotic medications Nintedanib Pirfenidone Definitive treatment: lung transplant Restrictive Pulmonary Disease 47 Pulmonary Pneumoconiosis: Coal Worker Lung Notes: Pathogenesis Symptoms and signs Physical examination +/- fine crackles Diagnosis Imaging studies Chest radiograph Small, rounded, nodular opacities in the upper lobes Complications Caplan syndrome = rheumatoid pneumoconiosis Rheumatoid nodules in the lungs in patients w/ seropositive rheumatoid arthritis Restrictive Pulmonary Disease 48 Pulmonary Pneumoconiosis: Silicosis Notes: Pathogenesis Risk Factors Symptoms and signs Physical examination Crackles Rhonchi Wheezing Restrictive Pulmonary Disease 49 Pulmonary Pneumoconiosis: Silicosis Notes: Diagnosis Imaging studies Chest radiographs Innumerable, sharply marginated, small, rounded opacities, ↑ in upper lung zone Focal ground glass opacities & patchy areas of consolidation Hilar lymphadenopathy = “egg shell calcifications” Restrictive Pulmonary Disease 50 Pulmonary Pneumoconiosis: Asbestosis Notes: Pathogenesis Risk Factors Symptoms and signs Physical examination Bibasilar, inspiratory crackles Restrictive Pulmonary Disease 51 Pulmonary Pneumoconiosis: Asbestosis Notes: Diagnosis Restrictive Pulmonary Disease 52 Pulmonary Pneumoconiosis: Coal Worker, Silicosis, Asbestosis Notes: Complications Management Management is supportive Pulmonary rehabilitation Supplemental oxygen therapy Steroid and bronchodilators Restrictive Pulmonary Disease 53 Pulmonary Sarcoidosis Notes: Pathogenesis Risk Factors Epidemiology Women > men Third and fourth decade of life Symptoms and signs Physical examination Wheezing Rales Lymphadenopathy Extrapulmonary disease Lupus perino Erythema Nodosum Anterior uveitis Restrictive Pulmonary Disease 54 Pulmonary Sarcoidosis Notes: Symptoms and signs Physical examination Löfgren syndrome Hilar lymphadenopathy Erythema nodosum Arthritis Diagnosis Laboratory studies ↑ Serum ACE levels Hypercalcemia Hypercalciuria ↑ Vitamin D Restrictive Pulmonary Disease 55 Pulmonary Sarcoidosis Notes: Management Asymptomatic patients → Routine monitoring First Line Treatment → Low-dose oral prednisone (long-term therapy) Alternative Treatment → Methotrexate and other immunosuppressive agents Restrictive Pulmonary Disease 56 Pulmonary PANCE/ PANRE Review Course by Other Pulmonary Disease Infectious Disorders....................... 1 Neoplastic Disease........................ 15 Chronic Obstructive Pulmonary Disease.... 22 Pleural Disease........................... 29 Pulmonary Circulation.................... 36 Restrictive Pulmonary Disease............. 45 Other Pulmonary Disease................. 57 888.427.7737 | [email protected]| https://blueprintprep.com/medical/pa/tutoring Pulmonary Asthma Notes: Pathogenesis Risk Factors Other Pulmonary Disease 58 Pulmonary Asthma Notes: Risk Factors Risk Factors Symptoms and signs Physical examination Expiratory wheezing Nasal polyps Eczema Diagnosis Laboratory findings Arterial blood gas: respiratory alkalosis Gold standard: pulmonary function testing with spirometry FEV1/FVC < 0.7 AND reversibility of obstruction post bronchodilator Other Pulmonary Disease 59 Pulmonary Asthma Notes: Diagnosis Other Pulmonary Disease 60 Pulmonary Asthma Notes: Symptoms and signs Management Chronic Decrease exposure to triggers Stepwise approach NAEPP and GINA Other Pulmonary Disease 61 Pulmonary Asthma Notes: Management Management Acute exacerbations Beta-2 agonist bronchodilator Ipratropium Systemic corticosteroids Oxygen IV magnesium sulfate Other Pulmonary Disease 62 Pulmonary Acute Respiratory Distress Syndrome (ARDS) Notes: Pathogenesis Symptoms and signs Physical examination Hypoxemia Tachypnea, retractions, and use of accessory muscles Diffuse crackles Frothy pink-red sputum Multiple-organ failure Other Pulmonary Disease 63 Pulmonary Acute Respiratory Distress Syndrome (ARDS) Notes: Differential Diagnosis Cardiogenic pulmonary edema Diffuse alveolar hemorrhage Bilateral pneumonia Diagnosis Management Treatment of the underlying cause Intubation and mechanical ventilation Fluid management Other Pulmonary Disease 64