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abim prep > AR HY review > Flashcards

AR HY review Flashcards

1
Q

pH and CO2 deviate in the same direction (both up or both down) in which type of disorders?

A

metabolic acid/base disorders

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2
Q

pH and CO2 deviate in the opposite direction in which type of acid base disorders?

A

Respiratory acid base disorders

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3
Q

pH and CO2 both elevated seen in what type of disorder?

A

metabolic alkalosis

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4
Q

pH up and CO2 down in what type of disorder?

A

respiratory alkalosis (hyperventilation)

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5
Q

pH and CO2 both down in what type of disorders?

A

metabolic acidosis

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6
Q

pH down and CO2 up in what type of disorders?

A

respiratory acidosis (hypoventilation/CO2 retention)

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7
Q

Normal pH values

A

7.38-7.44

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8
Q

Normal blood gas CO2 levels

A

38-42

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9
Q

Normal serum bicarb levels:

A

23-28

24 is the value used to calculate delta bicarb (24 - delta gap)

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10
Q
  1. anion gap formula
  2. normal anion gap range
A
  1. Na - (Cl + HCO3)
  2. 7-13 (delta gap nl is 12
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11
Q
  1. urine anion gap formula
  2. UAG results interpretation
A
  1. (urine Na + urine K) - urine Cl
  2. positive = positively the kidneys causing acidosis
  3. negative = neGUTive, i.e. gut is causing acidosis
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12
Q

Things that cause decreased anion gap

A

excess proteins (e.g multiple myeloma)

proteins are usually negatively charged

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13
Q

Bartter syndrome features

  1. pH
  2. salt and water
  3. BP
  4. serum K+ level
  5. serum Cl- level
  6. serum Mg++
A
  1. Metabolic alkalosis (HCO3 high)
  2. salt (NaCl) and water loss
  3. BP: nl/low
  4. K: low serum (K loss in urine)
  5. Cl: low serum (Cl loss in urine)
  6. Mg: normal
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14
Q

Gitelman syndrome

  1. pH
  2. salt and water
  3. BP
  4. K+
  5. Mg+
A

Gitelman: most common inherited salt wasting disorder

  1. metabolic alkalosis (HCO3 high)
  2. salt (NaCl) and water wasting
  3. BP: nl/low
  4. K: low serum (K wasting in urine)
  5. Mg: low (wasting in urine)
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15
Q

Liddle syndrome

  1. pH
  2. salt and water
  3. BP
  4. K
  5. aldosterone
A

Liddle syndrome

  1. pH: metabolic alkalosis (HCO3 high)
  2. salt (NaCl) and water retention
  3. BP high (usually early onset
  4. K: low (urinary wasting)
  5. aldosterone: low (pseudohyperaldosteronism: ie BP high and K low like in high aldo; but aldo is low in reality)
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16
Q

Common causes of metabolic alkalosis

A
  1. volume depletion or diuretics (MCC)
  2. vomiting/NGT suction
  3. Hyperaldosteronism
  4. Cushing (hypercortisol)
  5. Licorice
  6. Bartter/Gitelman/Liddle
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17
Q

Common causes of NAGMA

A
  1. RTA
  2. diarrhea
  3. aggressive saline repletion
  4. early CKD
  5. ureterosigmoidostomy
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18
Q

AGMA with calcium oxalate crystals:

  1. likely ingestion
  2. complication
  3. Rx
A
  1. Ethylene glycol (glycolic acid/antifreeze)
  2. ATN (crystal induced)
  3. supportive care if sml osmolar gap, fomepizole for large gap or severe disease
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19
Q

ASA toxicity acid base response

A

early respiratory alkalosis (primary) followed by metabolic acidosis (secondary)

don’t forget tinnitus/hearing loss

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20
Q

Types of acidosis in DM patients and etiology

A
  1. AGMA = DKA
  2. NAGMA = RTA IV (hypoaldosteronism)
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21
Q

Cirrhotic patient: common acid base disturbance?

A

Respiratory alkalosis (often compensated with nearly nl pH)

d/t hyperventilation for unknown reasons

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22
Q

RTA type II

  1. location
  2. K
  3. stones
  4. etio
A

RTA type II

  1. proximal; HCO3+ resorption defect
  2. K: low/nl
  3. stones: maybe probably not
  4. etio: MM, topiramate, acetazolamide
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23
Q

RTA type I

  1. location
  2. K
  3. stones
  4. etio
A

RTA type I

  1. distal (collecting duct); H+ excretion defect
  2. K: low/nl
  3. stone: yes
  4. etio: SLE, Sjogren, amphotericin B, obstruction
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24
Q

RTA type IV

  1. location
  2. K
  3. stones
  4. etio
A

RTA type IV

  1. DCT, aldo deficiency or resistance
  2. K: high
  3. stones: no
  4. etio: DM or hypoaldosteronism
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25
Q

SIADH serum and urine trends

A

serum: LOW, urine: HIGH
serum: Na and Osm are low
urine: Na (>20) and Osm (usu > serum Osm) are high

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26
Q

Diabetes insipidus: types (2), DDAVP responsiveness, and lab trends

A
  1. Central DI: responsive to DDAVP, Na high/nl, urine Osm very low (<100), goes to > 300 with DDAVP
  2. Nephrogenic DI: not responsive to DDAVP, Na high/nl, urine Osm very low (<100) and stays that wasy after DDAVP
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27
Q

Psychogenic polydipsia/Beer potomania

lab trends and response to treatment

A
  1. Serum Na low
  2. Urine Na low (<20)
  3. Urine Osm low
  4. responds to water deprivation: urine Osm goes from < 100 to > 300
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28
Q

Too rapid of correction of chronic hyponatremia leads to what?

A

osmotic demyelination syndrom

sx: AMS, slurring speech, reguritating food, memory impairment

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29
Q

jockey/bodybuilder/runner: serum K is low: etio?

A

Diuretic abuse. Serum K is low, urine K is high (>20)

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30
Q

Hematuria with blood clots

A

likely bladder origin of pathology; get CT urography and urology consult

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31
Q

microscopic hematuria: benign etiologies

A

UA, fever, exercise, woman during menses, acute (minor) trauma

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32
Q

Hematuria: signs of glomerular etio:

A
  1. RBC casts
  2. dysmorpic RBCs
  3. elevated Cr
  4. HTN
  5. Edema
  6. low albumin
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33
Q

Microscopic hematuria: risk factors for serious etio

A
  1. >35 yo
  2. smoking
  3. exposure to benzene
  4. exposure to cyclophosphamide (alkylating agents)
  5. heavy non-narcotic analgesic use
  6. hx urologic disorder or dx (BPH, nephrolithiasis)
  7. recurrent UTIs
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34
Q

50y M routine physical, UA has 5 RBCs, no casts, no clots. wtd

A

repeat UA in 6 weeks

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35
Q

50y M routine physical, 5 RBCs persistently on multiple UAs, no casts, no clots. wtd

A

CT urography

(he is over 35 yo)

if CT is negative, refer for cystoscopy; if there are casts refer to nephro for renal bx

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36
Q

42y F with dysuria, post-void dribbling, and dyspareunia. dx?

A

urethral diverticulum

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37
Q

Nephrolithiasis

  1. recurr UTIs: a/w?
  2. prior malignancies/gout: a/w?
  3. malabsorbtion (IBC, CF, short gut): a/w?
A
  1. UTI: struvite stones
  2. malignancy/gout: uric acid stones
  3. malabsorption: calcium oxalate stones
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38
Q

Nephrolithiasis stone shapes

  1. cystine stones
  2. calcium oxalate
  3. struvite (Mg ammonium phosphate) stones
  4. uric acid stones
  5. acyclovir
A
  1. cystine: hexagon shape
  2. calcium: square envelope, or rods/dumbells
  3. struvite: coffin lids, staghorn
  4. uric acid: elongated hexagon
  5. acyclovir: needle shaped
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39
Q

Nephrolithiasis

  1. rx for small
  2. rx for large
  3. prevention
A
  1. Rx small (abt 5mm) should pass on own; increase fluid intake, tamsulosin
  2. Rx large (>10mm) require intervention
  3. Prevention: fluid intake, low Na diet (calcium stones), HCTZ, low meat diet, allopurinol (for uric acid stones)
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40
Q

Best way to decrease urinary calcium levels and prevent Ca oxalate stones?

A

HCTZ

low dietary calcium seems to have no benefit

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41
Q

35y M gross hematuria, hx of cough, fever, congestion, a week ago. Wears a hearing aid and has fam hx of hematuria. Cr 1.9, WBC normal. dx and path?

A

Alport syndrome; collage IV abnormality

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42
Q

Glomerular (nephrotic) diseases: 4 types

A
  1. minimal change
  2. FSGS focal segmental glomerular sclerosis
  3. MN membranous nephropathy
  4. MPGN membroproliferative nephropathy
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43
Q

Nephrotic syndrome features

A
  1. proteinuria: >3g/day
  2. hypoalbumiemia: causes edema
  3. loss of ATIII: thrombosis and PE
  4. hyperlipidemia and hyperlipiduria (fat bodies/casts in urine)
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44
Q

Nephrotic syndrome a/w low complement

A

membranoproliferative GN

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45
Q

FSGS etio and epidemiology

A
  1. African american
  2. HIV
  3. heroin
  4. sickle cell
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46
Q

Minimal change disease etio and epidemiology

A
  1. is mcc of nephrotic syndrome
  2. leukemia/lymphoma
  3. NSAIDS
  4. lithium
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47
Q

MPGN etio

A
  1. Hep B, Hep C
  2. cryoglobulinemia
  3. SLE, Sjogren
  4. syphilis
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48
Q

Nephrotic syndromes rx and out look

A
  1. MC: steroids, usually resolves
  2. MN: steroids, ⅓ get better, ⅓ same, ⅓ get worse
  3. FSGS: wt loss, HAART, steroids, 50% ESRD 5y
  4. MPGN: steroids, 50% ESRD or die in 5y
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49
Q

Systemic dz that causes nephrotic syndromes

A
  1. Diabetic nephropathy: usu co-occuring retinopathy
  2. Multiple myeloma
  3. Amyloidosis: Congo red dye: apple green with polarization
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50
Q

Conditions with low serum complement

A
  1. PSGN
  2. MPGN/cryoglobulinemia/Hep C
  3. SLE
  4. subacute bacterial endocarditis
  5. athreroembolism
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51
Q

Nephritic syndromes: HTN and hematuria

A
  1. PSGN
  2. IgA nephropathy
  3. RPGN
  4. Henoch-Schonlein/IgA vasculitis
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52
Q

PSGN vs IgA neprhitis

A
  1. PSGN: low complement (C3), and 1-3 weeks post URI
  2. IgA: nl complement, and < 1 week post URI
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53
Q

Young patient, palpable rash, arthralgia, GI symptoms. dx

A

Henoch-Schonlein/IgA vasculitis

supportive care to Rx

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54
Q

a/w linear IgG deposits

A

RPGN

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55
Q

The 4 pulmonary renal syndromes and features

A
  1. GPA: cANCA anti-PR3, URI involvement (otitis)
  2. eGPA: asthma, eosinophilia
  3. MPA Microscopic polyangiitis: pANCA anti-MPO no granulomas, less respiratory dz
  4. anti-GBM dz (Goodpasture): lower pulm dz, alveolar hemorrhage
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56
Q

Rx for the 4 pulm-renal syndrome

A
  1. GPA, eGPA, MP, and antiGBM
  2. rx steroids and cyclophosphamide, plasmapheresis for serious pulmonary hemorrhage
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57
Q

Large vessel vasculitis types (3)

A
  1. Takayasu arteritis
  2. GCA/temporal arteritis
  3. Behcet syndrome
  4. all have normal complement
  5. all may have prominent systemic symptoms
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58
Q

Medium vessel vasculitis types (2)

A
  1. PAN (testes pain is classic for)
  2. Behcet syndrome
  3. all have normal complement
  4. all may have prominent systemic symptoms
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59
Q

Small vasculitis types (7)

A
  1. MPA
  2. GPA
  3. eGPA (Churg-Strauss)
  4. IgA vasculitis (Henoch-Schonlein)
  5. Cryoglobulinemia
  6. a/w SLE or RA
  7. cutaneous leukocytoclastic angiitis
  8. all usu low complement and less likely systemic sx
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60
Q

TLS freatures vs rhabdo

A
  1. Ph > 4.5
  2. U > 8
  3. Ca < 7
  4. K > 6
  5. rhabdo has urine dipstick + for blood; TLS doesn’t
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61
Q

When to stop ACEi use

A
  1. > 30% incr in Cr after starting
  2. K > 5.5
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62
Q

NSAIDs and ACEi effects on kidney

A
  1. NSAIDS: constrict afferent arteriole
  2. ACEi: dilates efferent arteriole
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63
Q

ATN vs AIN: casts and etio

A
  1. ATN muddy brown casts
  2. ATN etio: aminoglycosides, contrast, rhabdo, TLS etc
  3. AIN WBC casts, peripheral eosinophils
  4. AIN etio: PPI, NSAIDS, abx, diuretics, phenytoin
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64
Q

CKD

  1. anemia Rx
  2. wtd for acidosis
  3. bone lesions (2nd hyperparathyroidism)
  4. complication of rx for #3
A
  1. anemia: EPO + iron, goal hgb 10-11
  2. if HCO3 < 22: give bicarb
  3. bones: Ca and vit D3
  4. adynamic bone disease likley if PTH < 100 or AlkP < 7
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65
Q

Post renal obstruction autodiuresis rx

A

Don’t replete volume lost with 1:1 ratio of IVF. Replace 50-75% of lost volume

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66
Q

Management of ESRD patient

A
  1. low Na, K, phos
  2. low water
  3. no calcium restriction
  4. no phos-based (FLEET) enema→ phos overload
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67
Q

ESRD pt with high Ca, phos and PTH: risk?

A

risk of calciphylaxis.

if Ca x phos > 70 increased risk

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68
Q

Pt renal insufficiency: how to increase nutritional status and slow rate of kidney decline?

A

keep serum bicarb > 22

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69
Q

Patient with short bowel syndrome: add what to diet to decrease risk of kidney stones?

A

calcium: added calcium decreases absorption of oxalate and helps prevent stones

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70
Q

Type of stone seen in RTA type I

A

Ca phosphate

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71
Q

type of stone seen in IBD or pt with hx of gastric bypass?

A

cystine stones

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72
Q

MCC recurrent nephrolithiasis?

A

idiopathic hypercalciuria

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73
Q

Lung nodule vs lung mass size

A

nodule < 30mm

mass > 30mm, increased risk of being malignant

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74
Q

Solid lung nodule < 6mm, wtd

  1. low risk pt
  2. high risk pt
A

Lung nodule < 6mm

  1. low risk: no f/u
  2. high risk: CT 6-12mo (smoker, female, elderly, fam hx)
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75
Q

Solid lung nodule 6-8mm, wtd

  1. low risk
  2. high risk
A

Solid lung nodule 6-8mm

  1. low risk: f/u 6-12mo; if no changed then again 18-24 mo
  2. high risk: same as above, 6-12mo then 18-24mo
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76
Q

High risk features of lung nodules

A

size > 30mm, spiculated, eccentric or low/no calcification

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77
Q

low risk features of lung nodules

A

size < 30mm, smooth border, central or popcorn calcification

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78
Q

Solid lung nodule > 8mm, wtd

A

either f/u CT in 3mo, or PET-CT, or Bx/resect

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79
Q

Ground glass or part solid nodule: f/u schedule

A
  1. < 6mm: no follow up for high or low ris
  2. 6-8mm: CT in 3-6mo for both high and low risk
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80
Q

FEV1 in COPD, asthma, restrictive lung diseases, bronchitis, etc

A

decreased in all lung diseases

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81
Q

FEV1/FVC abnormality in lung diseases

A

decreased in all obstructive diseases

normal in all restrictive lung diseases

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82
Q

DLCO in lung diseases

A

low COPD and intrathoracic restrictive dx

normal in all other obstructive and extrathoracic restrictive dz

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83
Q

Residual volume is low in what type of lung disease?

A

low in intrathoracic restrictive lung dz

high in all other lung dz

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84
Q

DLCO, TLC, and FEV1/FVC values in pulmonary embolism

A
  1. DLCO low
  2. TLC and FEV1/FVC are normal
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85
Q

DLCO is well above normal. Possible etiologies?

A
  1. alveolar hemorrhage
  2. CHF
  3. PDA/ASD/VSD
  4. polycythemia
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86
Q

best discriminative tests to look at to diagnose type of lung disease?

A

TLC: distinguishes obstructive from restrictive

DLCO: low only in COPD and intrathoracic restrictive, nl in all others

87
Q

both inspiratory and expiratory flow loops blunted in what conditions?

A

extra thoracic, fixed obstruction

e.g. tumors and tracheal stenosis

88
Q

normal expiratory but blunted inspiratory flow loop: etio?

A

Blunted bottom (inspiratory) loop

dynamic extrathoracic obstruction

e.g. vocal cord dysfunction or epiglottitis

89
Q

normal inspiratory but blunted expiratory flow loop: etio?

A

blunted top (expiratory) loop

dynamic intrathoracic obstruction

e.g. tracheomalacia

90
Q

FEV1 increase or decrease with asthma diagnostic challenge

A

bronchodilator challenge: 12% improvement

methacholine challenge: 20% worsening

91
Q

Pt with respiratory symptoms at work, but is fine at home and on weekends. Maybe problems with manager accused of sluffing work. wtd

A

peak flow at work and at home

92
Q

With poor asthma control, wtd?

A

check technique and compliance before stepping up therapy

93
Q

Leukotriene use trends and why

A

Less monteleukast use d/t psychosis, hallucinations, etc. Has black box warning

94
Q

Pt with vasomotor rhinitis, gets polyps then asthma. dx, rx

A

dx: likely ASA induced asthma. rx: stop asthma, start ICS. Used to be answer was start Monteleukast, but this is less so now d/t side fx

95
Q

Asthma sx < 2days/wk and <2 nights/mo. rx?

A

prn ICS-SABA; no need for daily meds

96
Q

Asthma sx up to 5-6x/week or >2 nights/mo. rx?

A

daily low dose ICS-SABA, may also add theophylline, Monteleukast

97
Q

Asthma daily sx or > 1 night/week

A

med dose ICS-LABA, may also add monteleukast or theophylline

98
Q

Asthma: continuous symptoms

A

high dose ICS-LABA, may add daily oral steroids

99
Q

post viral hypersensitivity with cough at night and chest tightness. rx

A

ICS (budesonided)

100
Q

Pt with inspiratory wheeze, cough during day, no sx at night. Asthma therapies are ineffective. dx?

A

vocal cord dysfunction (inspiratory rather than expiratory wheeze, no sx at night (not talking)).

flow loop = extrathoracic airway obstruction

101
Q

Asthma poorly controlled on max therapy. Triggers have been eliminated. Doesn’t want oral steroids. IgE level high. wtd?

A

omalizumab

102
Q

Asthma poorly controlled on max therapy. Triggers have been eliminated. Would like to wean oral steroids but can’t due to return of sx. Eos high. wtd

A

Dupilumab (IL-4 inhibitor)

103
Q

Asthma pt on ICS-LABA well controlled, no sx. wtd

A

May step down therapy after 3mo no sx.

104
Q

Pt with hx of CF or asthma previously well controlled. Now with cough, fever, wheeze; normal medications not effective now. Brown flecked mucus. High eos, high IgE. Migratory patchy lung infiltrates. dx? rx?

A

dx: ABPA
rx: steroids with itraconazole

105
Q

hypersensitivity pneumonitis vs ABPA labs to differentiate

A

ABPA: high eos and IgE

pneumonitis: nl eos and IgE

106
Q

Pt with hx TB, sarcoid or COPD. May be asx or have hemoptysis, chronic cough wt loss. CXR with air around a fungus ball. dx? rx?

A

dx: aspergilloma
rx: if asymptomatic, don’t treat; if hemoptysis and seriously ill, get surgery

107
Q

Pt with hx of being very immunosuppressed/neutropenic. Dry cough or hemoptysis, pleuritic CP, sweats, fever. Glactomannan assay +. CXR or CT shows wedge lesion (tissue infarct) or necrotic nodule with surrounding hemorrhage (halo sign). dx? rx?

A

dx: invasive aspergillosis
rx: voriconazole

108
Q

Farmer or bird keeper, exposure to air conditioner mist. Fever, chills, cough, SOB. Eos and IgE nl or not mentioned. Migratory lung infiltrates. BAL CD8 > CD4. dx? rx?

A

dx: hypersensitivity pneumonitis
rx: steroids (pt may have failed abx treatment for misdiagnosis of PNA.)

109
Q

Pt with fever, cough, pleuritis, SOB, maybe pharyngitis; may be mild and subacute “walking PNA”. Maybe birds in hx. Rx with abx for typicals not effective. Mycoplasma and legionella serology negative. dx? rx?

A

dx: Chlamydia PNA.

C pneumoniae is person to person spread. C psittaci has birds in hx. C trachomatis is vertical transmission

rx: azithromycin

110
Q

Pt from Latin America with asthma previously well controlled. Now with cough and wheeze. Eos high. Infiltrates in lung. dx? rx?

A

dx: strongyloides infection (Loeffler syndrome)
rx: thiabendizole

111
Q

Eosinophilic PNA noninfectious causes

A
  1. idiopathic
  2. medication/toxin induced
  3. APBA
  4. Churg-Strauss
    1. smoking or malignancy
112
Q

Eosinophilic PNA infectious causes

A

Typically are parasites

  1. Strongyloides
  2. Ascaris
  3. filarial nemotodes
    1. hookworms
113
Q

35y F hx asthma and smoking. Fever, cough, SOB. Eos in BAL maybe in blood. CXR with diffuse GGO. dx? rx?

A

dx: idiopathic acute eosinophilic PNA (seen more in young women, smokers, asthma)
rx: steroids

114
Q

55 y M nonsmoker; cough, fever, SOB, no sputum. CXR peripheral infiltrates. High ESR and Eos in blood. Eos in BAL. Anemia may be present. BCx negative. dx? rx?

A

dx: chronic eosinophilic PNA
rx: steroids, looong taper

115
Q

22y M recurrent PNA and bronchitis since childhood. No allergies or GERD. Unable to have children. Slender body habitus and nasal polyps. Some GI malabsorption. Hx pancreatitis. CXR with apical bullous changes. dx? screen test? what increases mortality and decline in lung fx?

A

dx: CF
screen: sweat chloride; confirm with CFTR

incr mortality: Burkholderia species

116
Q

Bronchiectaisis, sinusitus, infertility, situs inversus

dx? screen test?

A

Dykinetic cilia syndrome (Kartagner’s)

screen with: inhaled nitric oxide test, confirm with Bx

117
Q

Causes of bronchiectasis

A
  1. Hypogammaglobulinemia
  2. Genetic: CF, A1AT, or Kartagner’s
  3. autoimmune disease
  4. recurr PNA
  5. ABPA
118
Q

58y F chronic/recurrent cough, foul smelling sputum, some hemoptysis. Hx PNA. Streaking opacities in bronchial tree “tram lines”. dx?

A

dx: bronchiectasis: dilation and destruction of bronchi with sputum production

dx with HRCT

119
Q

60y M hx lung transplant or HSCT. Chronically progressive dyspnea and cough, no sputum. No asthma or allergies. May have viral URI or inhaled toxin in past. CXR normal. PFT: obstructive, not reversible. A1AT normal. dx?

A

dx: bronchiolitis obliterans

also a/w autoimmune dz, and RSV in kids

120
Q

High altitude sickness, SOB, pulmonary edema. wtd?

A

altitude sickness

give O2, bring down to lower altitude

121
Q

Planned ski trip. Pt has hx of altitude sickness. wtd?

A

altitude sickness prevention

acetzolamide

122
Q

40y M became acutely ill, initial flu-like sx now with PNA sx but no sputum. Possible toxic fume inhalation. Bilateral, patchy migrating infiltrates. Abx didn’t help. Some wt loss. dx? rx? bx finding?

A

dx: COP (50% are idiopathic)
rx: steroids
bx: granulation tissue plugs, interstitial inflammation, lung architecture maintained

123
Q

Middle aged African American female, tender bruise-like lesions on shins, bilateral hilar LAD, CD4>CD8 on BAL, bx with noncaseating granulomatous disease. Ca++ may or may not be elevated. dx? rx?

A

dx: sardoid
rx: self resolution in majority of cases

124
Q

Indications for treatment in sardoidosis (6)

Rx for sarcoidosis

A
  1. progressive pulm disease
  2. eye involvement
  3. CNS involvement
  4. myocardial involvement
  5. persistent hypercalcemia
  6. disfiguring lesions
  7. Rx: steroids
125
Q

Sarcoidosis

  1. lung disease pattern
  2. tests to get (4)
  3. test not to get (1)
  4. serum lab results (2)
A

Sarcoidosis

  1. lung dz pattern: restrictive usually (may be normal)
  2. tests: Bx, CXR, EKG, eye exam
  3. test not to get: ACEi level
  4. serum labs: leukopenia, elevated ESR
126
Q

Sarcoidosis tests to rule out things on the differential (3)

A

Sarcoidosis tests to rule out other things because can present with fever, weight loss, cough

  1. r/o malignancy
  2. TB
  3. fungal pulmonary dz (histo, coccidio, etc)
127
Q

Procedure for bx in sarcoidosis

A

EBUS with FNA of LN if no other palpable LN or rash is available

128
Q

Uveitis, parotid gland enlargement, facial palsy, fever. Dx?

A

Heerfordt syndrome, a rare subtype of sarcoidosis

129
Q

Interstitial lung disease, ILD (aka diffuse parenchymal lung disease DPLD)

known causes

A
  1. Occupational/expsoure: hypersensitivity pneumonitis, asbestosis, berilyosis, silicosis
  2. XRT/drugs: amio, macrobid, amphotericin, chemo drugs
  3. Granulomatous disease (sarcoid)
  4. Connective tissue dz (SLE, RA, scleroderma)
  5. Vasculitis (GPA, eGPA)
130
Q

Interstitial lung disease, ILD (aka diffuse parenchymal lung disease DPLD)

Idiopathic causes

A
  1. IPF (UIP)
  2. NSIP
  3. COP
  4. AIP
  5. Lymphangiolieomyomatosis
131
Q

Premenopausal woman on OCP, sudden onset SOB, PNX, honeycomb appearance on lungs (many thin walled cysts) but no LAD on HRCT, pleural effusions are chylous. CBC and CMP normal. dx? rx?

A

dx: lymphangioleiomyomatosis: often estrogen related, smooth muscle proliferation
rx: bronchodilators, pulm rehab, sirolimus

132
Q

Male with SOB, hx sandblasting or stone work. Upper lobe fibrosis, hilar LAD, egg shell calcifications. dx? a/w?

A

Rx: Silicosis

a/w: TB, rule it out; get the PPD or other test

133
Q

Male with SOB and dry crackles, hx working with brake pads, roofing products, shipbuilding, fire-proof clothing or something like that. Pleural effusions. Calcified plaques on diaphragm and pleura. eosinophils in effusion dx? a/w

A

asbestosis

a/w: lung cancer, mesothelioma; smoking is synergystic

BAPE: pleural plaques present in 90% of cases, pleural thickening 30%, asbestosis was present in 5%

134
Q

Radiographic features of ILD (UIP

A
  1. bibasilar reticular patchiness/fibrosis
  2. honeycombing
  3. traction bronchiectasis
  4. overall heterogeneous patchy disruption of lung tissue
135
Q

Signs and sx of ILD

A
  1. slow chronic progression with SOB
  2. dry cough and dry crackles
  3. clubbing present usually
  4. restrictive pattern of lung disease: low FEV1, DLCO, TLC, RV, nl FEV1/FVC
  5. not responsive to steroids (fibrotic, not inflammatory dz)
  6. typically no extrapulmonary sx
136
Q

NSIP vs ILD

A

NSIP: patients are younger, onset subacute not chronic, responsive to steroids, is a/w HIV, connective tissue or rheumatologic disease

radiographically they are similar

137
Q

Characterize S1Q3T3

A

rare but specific sign in PE

S wave in I, Q wave in III, and inverted T in II

138
Q

Swollen, tender calf, HR 80, wtd?

A

Duplex US

139
Q

SOB, dry cough, elevated JVP, lungs clear BP 80/60, HR 120, S1Q3T3. wtd

A

Suspect PE. Get bedside echo. pt is too unstable for CT

140
Q

Best test for chronic PE

A

V/Q scan best for CHRONIC PE

141
Q

Rx for HD stable PE patient

provoked and unprovoked

A

heparin product 5 days then warfarin or start doac (no bridge)

provoked: 3mo; unprovoked 6mo reassess if low risk of bleeding then indefinitely

142
Q

Rx HD unstable PE patient

A

tPA, then assess for thromboletomy if no bleeding.

143
Q

Contraindications to catheter-based thrombolysis in PE

A
  1. active bleeding
  2. recent CVA or TIA
  3. recent neurosurgery
  4. recent intracranial trauma
144
Q

ECHO findings suggestive of PE/massive PE

A
  • RV dilation
  • RV free wall hypokinesis w apical sparing (McConnell sign)
  • Interventricular wall septal flattening
  • TR
  • pHTN
  • RV
145
Q

EKG signs of PE (most are fairly nonspecific)

A
  • sinus tach
  • atrial arrhythmias
  • new RBBB
  • S1Q3T3
  • TWI in V1-V4
146
Q

Pt with IVC filter. wtd most of the time if possible?

A

take it out

147
Q

44y M with new fever, AMS, SOB, petechiae over the chest, sinus tach; hx of femur frx 4 d ago. Dx? Rx?

A

Fat embolism (SOB is d/t pulm edema)

supportive care: no AC, no steroids

148
Q

28y F post delivery becomes hypotensive, tachycardic, SOB. Dx?

A

aminotic fluid embolism

149
Q

Pt with pain and swelling in posterior aspect of leg. Exam shows tender indurated cord several cm long. wtd?

A

US duplex. Possible SVT (palpable cord); compression stockings and NSAIDs.

150
Q

Thrombosis in superficial femoral vein, popliteal, or peroneal vein. wtd

A

AC with NOAC. Even though these may have “superficial” in the name or appear superficial, they are in fact deep and need to be treated.

151
Q

Pt with SVT in UE provoked by PICC or midline. wtd?

A

no AC, supportive care; warm compress

152
Q

Pt is s/p knee replacement or hip or acute orthopedic fracture. wtd at discharge?

A

Up to 70% risk DVT!

ppx against DVT w/ LMWH, wafarin, or DOAC

not ASA

153
Q

PNA

  • MCC
  • what to suspect in younger pts
  • older patients
  • COPD/DM
  • necrotizing PNA or post flu PNA
A

PNA

  • MCC: strep pneumoniae
  • younger pts: mycoplasma, H flu
  • older pts: legionella (GI sx and low Na)
  • COPD/DM: moraxella catarrhalis
  • necrotizing/post flu: Staph PNA
154
Q

Good sputum sample labs

A

< 10 epithelial cells, > 25 WBCs

155
Q

URI sx for more than 10d. Rx with doxy, no improvment. Now with cough and post-tussive vomiting. Pt has subconjuntival hemorrhage. dx? rx?

A

Bordatella pertussis; dx with sputum PCR

rx: Macrolide: either erythro, azithro, or clarithro

156
Q

Pt with lobar PNA, treated appropriately. 6 weeks later, still with cough and consolidation persists on XR. dx?

A

Suspect malignancy. PNA consolidation should resolve after 6 weeks.

157
Q

URI sinusitus

when to abx? what abx?

when to image?

A

abx: sx > 10d or fever or pain > 3d; augmentin (not single agent)
imaging: not routinely recommended to diagnose

158
Q

When to admit for PNA?

A

when to admit for PNA?: CURB-65

  • confusion
  • uremia
  • RR > 30
  • blood pressure low?
  • 65 yo or older
  • +2 pts: admit; +3 points ICU
159
Q

Strep diagnosis scoring

A

strep scoring: CENTOR

  • Fever +1
  • exudate +1
  • absent cough +1
  • cervical LAD +1
  • age 3-14 +1
  • age > 44 yo -1
  • 0-1 no rx; 2-4 rapid strep or 3-4 treat empirically
160
Q

Pt with sore throat initially, now with severe pain when moves neck, pain on swallowing. Brawny edema of the hypopharynx on exam. TTP of the sternocleidomastoid. dx?

A

IJ vein thrombosis (Lemierre’s dz)

get CT scan neck w contrast

161
Q

50y M mouth pain, fever, difficulty swallowing, muffled voice. Drooling and secretions and stiff neck with woody induration of the hypopharynx. dx? rx?

A

Ludwig angina (stiff neck, woody induration is specific; submental and submandibular swelling “bull neck”)

unasyn or zosyn: etio is usually infxn of lower molars

162
Q

24 y sore throat, muffled voice, fever, difficulty opening mouth and swallowing; unilateral pain in throat; cervical LAD. Drooling with deviation of the uvula. dx? etio?

A

dx: peritonsilar abscess (uvular deviation is specific)
etio: usu unilateral ear infection

163
Q

40 y pt with hx of URI. Now sudden onset worsening. Pt appears sick/distressed, tripoding, mouth open. Sore throat, painful swallowing, drooling, stridor/resp distress possible, + LAD. dx? etio?

A

dx: epiglottitis (lateral XR: thumb sign)
etio: strep or H flu

164
Q

Pt with runny nose, congestion, several months; itchy eyes, sore throat possible. Swelling below the eyes. Cobblestone appearnce of posterior pharyngeal mucosa. No LAD. dx?

A

allergic rhinitis. (cobble stoning is specific)

165
Q

Pt with nasal congestion and runny nose several months. Hx of allergies, treated nasal decongestants and antihistamines. Use of OTC meds evenually made things worse. Edematous and erythematous mucosa and nares. dx? rx?

A

dx: rhinits medicamentosa
dx: stop vasoconstrictors, start intranasal steroids

166
Q

Side fx of floroquinolones (4)

A
  • GI sx are most common
  • Connective tissue weakness: tendon rupture, aortic dissection/aneurysm
  • hypoglycemia esp in elderly
  • seizures
167
Q

Pt with Klebsiella or E coli PNA. Rx with CTX, patient gets better Bcx negative and afebrile. Four days later new fever, Bcx positive. wtd?

A

Start meropenem for ESBL bacteria that survived the CTX

168
Q

Elderly pt with fever, cough, diarrhea, CXR with RLL infiltrate. Sodium 130. Treated with Vanc and Cefepime, but condition worsens. wtd?

A

rx with Azithromycin as Vanc and cefepime don’t cover atypicals like Legionella.

Levofloxacin does cover atypicals

169
Q

HIV pt with sudden onset SOB and hypoxia. CXR show PNX. Chest tube inserted. wtd next?

A

give Bactrim and steroids for PJP ppx

170
Q

Acutely ill pt with PNA and is intubated. Sputum Gram stain shows lancet shaped diplococci. High WBC and high fever. Pt is treated with PCN, and WBC is improving and fever is gone. Secretions from ETT grow Pseudamonas. wtd?

A

Keep rx with PCN since patient is improving. If failure to improve then change abx.

Gram + lancet shaped diplococci: Strep pneumo

171
Q

If pt is treated for PNA with abx and is improving, and later BCx grows MSSA or MRSA, wtd?

A

continue same rx if pt is improving; BCx results likely contamination

172
Q

Pt with parapneumonic effusion of upright XR. next 2 steps?

A
  1. lateral decub XR
  2. if effusion > 10mm get pleural tap
173
Q

PNA being treated with appropriate abx. Parapneumonic effusion is >10mm and is therefore tapped. pH < 7.2. dx? rx?

A

dx: empyema
rx: chest tube

174
Q

Pt with parapneumonic effusion (pH < 7.2) has appropriate abx and chest tube but not improving, still spiking temps etc. dx? rx?

A

dx: likely loculated effusion
rx: intrapleural tPA/dnase to break up loculations

175
Q

Pt with seizure or alcoholic and later has upper lobe infilatrate and PNA symptoms. MCC?

A

aspiration PNA: peptosteptococcus (anaerobic Gram +)

176
Q

Pt with seizure 1 mo ago or some other condition that impairs mental status. Now with foul smelling sputum. On XR there is infiltrate in RUL and a cavity with air fluid level. Sputum shows mixed flora. dx? rx?

A

dx: lung abscess
rx: PCN + CLINDA

177
Q

Antibiotic with no activity in lung?

A

dapto

178
Q

25 y M ear ache fever, cough. Inflammed tympanic membrane with hemorrhage. Patchy infiltrate on XR. dx? rx?

A

dx: hemorrhagic myrigitis d/t mycoplasma
rx: macrolide (azithromycin)

179
Q

35 y pt nonsmoker with gradual onset cough, mild occasional fever. Mostly able to function but still sick and tired. Going on for weeks. XR: bilateral infiltrates. dx? rx?

A

dx: atypical PNA
rx: macrolide

180
Q

Bullae/vesicle on tympanic membrane. Ear pain like AOM. No ear canal involvement. No middle ear involvement. dx? etio?

A

Bullous myringitis. Often cause by viruses or mycoplasma

If middle ear is involved, then it is AOM

181
Q

MCC PNA

MCC PNA in COPD pts

A

MCC: strep pneumo

MCC COPD: H flu

182
Q

Pt with UTI on nitrofurantoin. Now with SOB and fever. Crackles at lung bases. XR shows GGO. dx?

A

nitrofurantoin induced lung injury (hypersensitivity pneumonitis) also caused by rituximab

183
Q

Post flu PNA. rx?

A

cover for staph!

184
Q

Pt comes from NH with cough, sore throat, myalgia, fever. Had flu shot. Rapid flu test negative. wtd?

A

Oseltamivir even if vaccinated and even if rapid test is negative if clinical suspicion is high

185
Q

Influenza outbreak in NH. wtd?

A

vaccine and oseltamivir for 2 weeks (takes 2 weeks for vax to kick in) for everyone regardless of sx.

186
Q

Age to initiate flu vax?

A

6mo

187
Q

Pt from SW USA with fever and painful lesions on shins. XR with lung infiltrates and thin walled cavities. dx? rx?

A

dx: Coccidiomycosis

  • rx: monitor if self contained
  • fluconazole for immunocompromised
  • disseminated infection gets amphotericin
188
Q

Coxackie symptoms, types, and what they cause

A

Sx: viral prodrome including GI sx and or URI; both can cause hand-foot-mouth dx

Coxackie A: flaccid paralysis

Coxackie B: pericarditis (reduced EF), pleurodynia (CP, SOB, no infiltrate)

189
Q

Pt from south central or midwest. Cough, fever, SOB, chest pain. Leisons on skin, balls, bones. XR: fibronodular infiltrates. Broad based budding on culture. dx? rx?

A

Blastomycosis. May be asx. Progression/disseminated dz common and rapid in immunocompromised.

rx: itraconazole for symptomatic dz

190
Q

TB 5mm positive test in who?

A
  • HIV
  • recent contact
  • immunosuppressed
191
Q

TB 10mm positive test in who?

A
  • homeless
  • foreign born
  • NH pts
  • IVDU
  • Silicosis, DM, ESRD
192
Q

TB 15mm positive test in who?

A

everybody including those who had BCG vax

193
Q

PPD positive. wtd next?

A

CXR

194
Q

PPD +, CXR shows an opacity, but pt has no cough. wtd?

A

induce sputum to r/o active dz

195
Q

Rx for pt who is PPD + but clear XR and no sx?

A

INH (and B6) plus rifapentine 3mo

or

INH (and B6) plus rifampin 4 mo

196
Q

Pt on INH two months, gets fatigue and nausea, possible pruritis. wtd?

A

stop INH, get liver enzymes. INH has black box warning about LIVER TOX.

197
Q

Close contact with TB pt. but PPD is negative. wtd?

A

retest in 6-8 weeks

198
Q

Pt from eastern Europe has cough, fever. Pleural effusion is tapped. what test to get?

A

Pleural fluid adenosine deaminase test to dx TB causing the effusion

199
Q

Pleural effusion, Light’s criteria

A

Light’s criteria: fluid is exudative if any of the following

  • fluid/serum protein >0.5
  • fluid/serum LDH > 0.6
  • fluid LDH > ⅔ ULN
200
Q

Chest tube requirements (3)

A

Chest tube requirements: EMPYEMA diagnosis

  • pH < 7.2
  • glucose < 40
  • Gram stain +
201
Q

Hemothorax criteria

A

fluid hct > 50% serum hct

202
Q

pleural fluid glucose < 30: likely cause of effusion?

A

Glucose < 30 etio of effusion?

RA

203
Q

Pleural effusion TG > 110, likely etio?

A

Chylous effusion: TG > 110

etio: lymphoma or lymphangioleimyomatosis

204
Q

Pleural fluid with > 10% eos. etio?

Pleural fluid with > 50% lymphocytes. etio?

A

eos: asbestosis, BAPE, Churg-Strauss
lymphocytes: TB or malignancy

205
Q

MCCs of transudative effusions (4) ?

A

HF (except after intense diuresis)

Cirrhosis

nephrotic syndrome

PE

206
Q

pathophys of transudative effusion

pathophys of exudative effusion

A

transudative: high hydrostatic or low oncotic pressure
exudative: excess fluid production, capillaries leaky, bad lymphatic drainage

207
Q

Common iatrogenic causes of effusion?

A
  • pacemaker placement → thoracic duct injury → chylothorax
  • postcardiotomy syndrome with friction rub and exudative effusion
208
Q

best way to distinguish PNX from PNA or effusion?

A

percussion. PNA and effusion is dull, PNX is hyperresonant

209
Q

Pt with cirrhosis, ascites and peripheral edema. Pt gets SOB when standing. On exam, PO2 is 92% when lying but 82% when sitting or standing. DLCO 70%. dx? physio?

A

dx: hepatopulmonary syndrome
physio: intrapulmonary R → L shunting

210
Q

Pt with worsening SOB, dullness in R hemithorax. CXR with pleural effusion causing lung collapse. After thoracentesis there is no expansion of the lung. dx?

A

nonexpandable lung (trapped lung)

can be d/t bronchial obstruction, chronic atelectasis, visceral pleural restriction

211
Q

Pt with CABG 6mo ago, now with new SOB when lying esp with left lateral position, morning HA. CXR shows elevated L hemidiaphragm. test to screen?

A

phrenic nerve damage during CABG

do floroscopic sniff test to screen/dx

212
Q

Pt with hallucinations with sleep onset, falls at suprising stimuli, daytime sleepiness. dx? rx?

A

narcolepsy

modafinil, also dc alcohol, opiates, antisphychotics

213
Q

Pt with CHF and daytime sleepiness. Apneic periods during sleep. dx?

A

central sleep apnea

214
Q

polysomnography criteria for apnea

criteria for increase mortality d/t apnea

A

apnea criteria

no breathing for 10 sec or >10 apenic episodes/hr

incr mortality: apnea/hypoxia index > 30

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