IM Pulm

Question 1

Asthma

definition

Answer 1

asthma, or reactive airway disease, is an abnormal bronchoconstriction of the airways. Asthma is a reversible obstructive lung disease, which is the main difference between this disorder and chronic obstructive pulmonary disease (COPD)

Question 2

Asthma

etiology

Answer 2

etiology is unknown, association with atopic disorders and obesity

Question 3

Asthma

causes of acute exacerbations include:

Answer 3

allergens like pollen, dust mites, cockroaches, and cat dander

infection and cold air

emotional stress or exercise

catamenial (related to menstrual cycle)

aspirin, nsaids, bblockers, histamine, any nebulized medication, tobacco smoke

GERD

Question 4

Asthma

presentation

Answer 4

the clear presence of wheezing with the acute onset of sob, cough, and chest tightness make a what is the most likely diagnosis question. increased sputum production is common although a fever is not always present

Question 5

asthma prevalence, incidence, and hospitalization rates are all

Answer 5

increasing

Question 6

which of the following is most likely to be associated with/found in this pt?

asthma

Answer 6

symptoms worse at night

nasal polyps and sensitivity to aspirin

eczema or atopic dermatitis on physical examination

increased length of expiratory phase of respiration

increased use of accessory respiratory muscles (intercostals)

Question 7

the oral temperature may not be accuratly measured in pts that are

Answer 7

breathing fast. mouth breezing cools the thermometer

Question 8

the answer to the best initial test question in asthma is based on the

Answer 8

severity of presentation

Question 9

make sure you can understand the sound of

Answer 9

wheezing

Question 10

Asthma

diagnostic tests

best initial test in an acute exacerbation:

Answer 10

peak expiratory flow or arterial blood gas. peak flow can be used by the pt to determine function

Question 11

CXR in asthma

Answer 11

most often normal, but may show hyperinflation

it is usually used to:
exclude pneumonia as a cause of exacerbation
exclude other disease such as pneumothorax or CHF in cases that are not clear

Question 12

asthma can present exclusively as a

Answer 12

cough

Question 13

asthma

most accurate diagnostic test

Answer 13

pulmonary function testing. spirometry will show a decrease in the ration of forced expiratory volume in 1 second (fev1) to forced vital capacity (FVC). the FEV1 decreases more than the FVC.

Question 14

most accurate diagnostic test in a person with asymptomatic asthma

Answer 14

20% decrease in FEV1 wiht the use of methacholine or histamine

Question 15

pulmonary function testing in Asthma

Answer 15

decreased fev1 and decreased fvc with a decreased ration of fev1/fvc

increase in fev1 of more than 12% and 200ml with the use of albuterol

decrease in fev1 of more than 20% with the used of methacholine or histamine

increase in the diffusion capacity of the lung for carbon monoxide (DLCO)

Question 16

with asthma RTFs are normal in between

Answer 16

exacerbations

Question 17

In asthma ACH and histamine

Answer 17

provoke bronchoconstriction and an increase in bronchial secretions. methacholine is an artificial form of ach used in diagnostic testing

Question 18

additional testing options for asthma

Answer 18

CBC may shoe an increased eosinophil count

skin testing is used to identify specific allergens that provoke bronchoconstriction

increased IgE levels suggest an allergic etiology. IgE levels may also help guide therapy such as the used of the anti-IgE medication omalizumab. increased ige levels are also associated with allergic bronchopulmonayr aspergillosis

Question 19

Asthma treatment

step 1

Answer 19

always start the treament of asthma with an inhaled short acting beta agonist (SABA)

examples of SABA are:
albuterol
pirbuterol
levalbuterol

Question 20

Asthma treatment

step 2

Answer 20

add a long-term control agent to a SABA. low-dose inhaled corticosteroids (ICS) are the best initial long term control agent

examples of ICS are:
beclomethasone
budesonide
flunisolide
fluticasone
mometasone
triamcinolone

alternate long term agents are:
cromolyn and nedocromil to inhibit mast cell mediator release and eosinophil recruitment
theophylline
leukotriene modifiers: montelukast, zafirlukast, or zileuton (best with atopic pts)

Question 21

Asthma treatment

step 3

Answer 21

add a long-acting beta agnoist (laba) to a SABA and ICS, or increase the dose of ICS

LABA medications are salmeterol or formoterol

Question 22

Asthma treatment

step 4

Answer 22

increase the dose of the ICS to maximum in addition to the LABA and SABA

Question 23

Asthma treatment

step 5

Answer 23

omalizumab may be added to the SABA, LABA, and ICS in those who have an increased IgE level

Question 24

Asthma treatment

step 6

Answer 24

oral corticosteroids such as prednisone are added when all the other therapies are not sufficient to control sx

Question 25

never use LABA

Answer 25

first or alone

Question 26

zafirlukast is hepatotoxic and has been associated with

Answer 26

churg-strausss syndrome

Question 27

adverse effects of inhale dsteroids are

Answer 27

dysphonia and oral candidiasis

Question 28

adverse effects of systemic corticosteroids

Answer 28

should be used as a last resort bc they can cause: osteoporosis cataracts adrenal suppression and fat redistribution hyperlipidemia, hyperglycemia, acne, and hirsutism (in women) thinning of skin, striae, and easy bruising

Question 29

high dose inhaled steroids rarely lead to the adverse effects associated with

Answer 29

prednisone

Question 30

Antiocholinergics in asthma

Answer 30

the role of ipratropium and tiotropium in asthma management is not clear. anticholinergic agents will dilate bronchi and decrease secretions. they are very effective in COPD.

Question 31

influenza and pnuemococcal vaccine are given in all

Answer 31

asthma pts

Question 32

what is the best indication of the severity of his asthma

Answer 32

respiratory rate, if during an acute exacerbation

Question 33

The severity of an asthma exacerbation is quantified by:

Answer 33

decreased peak expiratory flow (PEF) ABG with an increased A-a gradient the PEF is an approximation of the FVC. there is no precise normal value. it is based predominantly on height and age, not weight. the PEF is used in acute assessment by seeing how much difference there is from the pts usual PEF when the pt is stable. CXR is used to see if there is an infection leading to the exacerbation

Question 34

asthma predisposed to

Answer 34

pneumothorax

Question 35

treatment for acute asthma exacerbation

Answer 35

oxygen albuterol steroids the best initial therapy is oxygen combined with inhaled short acting beta agonists such as albuterol and a bolus of steroids. corticosteroids need 4 to 6 hours to begin work, so give them right away. epinephrine injections are not more effective than albuterol and have more adverse systemiceffects. ipratropium should be used, but does not work as rapidly as albuterol epinephrine is rarely used and only as a drug of last resort. magnesium has some modest effect in bronchodilation. magnesium is not as effective as albuterol, ipratropium, or steroids, but it does help

Question 36

Magnesium helps relieve

Answer 36

bronchospasm, magnesium is used only in acute, severe asthma exacerbation not responsive to several rounds of albuterol while waiting for steroids to take effect

Question 37

the following are not effective in acute exacerbations:

Answer 37

``` theophylline cromolyn and nedocromil (best with exrinsic allergies like hay fever) leukotriene modifiers omalizumab salmeterol ```

Question 38

if a pt having an acute exacerbation does not respond to oxygen, albuterol, and steroids or develops...

Answer 38

respiratory acidosis (increased pco2), the pt may have to undergo endotracheal intubation for mechanical ventilation. these pts should be placed in the icu

Question 39

COPD definition

Answer 39

COPD is the presence of sob from lung destruction decreasing the elastic recoil of the lungs. most of the ability to exhale is from elastin fibers in the lungs passively allowing exhalation. this is lost in COPD, resulting in a decrease in FEV1 and FVC with an increase in the toal lung capacity (TLC). COPD is not always associated with reactive airway disease such as asthma although both are obstructive disease.

Question 40

COPD etiology

Answer 40

tobacco smoking leads to almost all copd. tobacco destroys elastin fibers

Question 41

COPD in a young nonsmoker

Answer 41

alpha-1 antitrypsin deficiency

Question 42

COPD presentation

Answer 42

sob worsened by exertion intermittent exacerbation with increased cough, sputum, and sob often brought on by infection barrel ches from increased air trapping muscle wasting and cachexia

Question 43

COPD best initial test

Answer 43

cxr: increased ap diameter air trapping and flattened diaphragm

Question 44

COPD most accurate diagnostic test

Answer 44

PFT: decreased fev1, fvc, and fev1/fvc ration under 70% increased tlc bc of an increase in residual volume decreased dlco (emphysema, not bronchitis) incomplete improvement with albuterol little or no worsening with methacholine

Question 45

COPD reversibility with inhaled bronchodilators

Answer 45

pts with COPD have a broad range of response to inhaled bronchodilators such as albuterol. this ranges from no reversibility to complete reversibility. about 505 will have some degree of response. plethysmography will show an increase in residual volume

Question 46

full reversibility in response to bronchodilators is defined as greater than

Answer 46

12% increase and 200 ml increase in FEV1

Question 47

COPD reversibility with inhaled bronchodilators arterial blood gas

Answer 47

acute exacerbations of COPD are associated with increased pCO2 and hypoxia. respiratory acidosis may be present if there is insufficient metabolic compensation and the bicarbonate level will be elvated to compensate. in between exacerbation, not all those with COPD will retain CO2

Question 48

COPD reversibility with inhaled bronchodilators CBC:

Answer 48

may have an increase in hematocrit from chronic hypoxia

Question 49

COPD reversibility with inhaled bronchodilators EKG:

Answer 49

R atrial hypertrophy and R ventricular hypertrophy atrial fibrillation or multifocal atrial tachycardia (MAT)

Question 50

COPD reversibility with inhaled bronchodilators echocardiography

Answer 50

R atrial and R ventricular hypertrophy pulmonary htn

Question 51

COPD treatment improves mortality and delays progression of disease

Answer 51

smoking cessation oxygen therapy for those with pO2 less than or equal to 55 or saturation less than or equal to 88%; mortality benefit is directly proportional to the number of hours that the oxygen is used influenza and pnuemococcal vaccines

Question 52

COPD treatment definitely improves symptoms (but does not decrease disease progression or mortality)

Answer 52

saba (albuterol) anticholinergic agents: tiotropium, ipratropium steroids laba (slameterol) pulmonary rehabilitation

Question 53

asthmatics not controlled with albuterol

Answer 53

give inhaled steroid

Question 54

COPD not controlled with albuterol

Answer 54

give an anticholinergic (tiotropium) or inhaled steroids

Question 55

COPD possible improves sx

Answer 55

theophylline lung volume reduction surgery

Question 56

COPD no benefit

Answer 56

cromolyn leukotriene modifiers (montelukast)

Question 57

with COPD when all medical therapy is insufficient the answer is

Answer 57

refer to transplantation

Question 58

inhaled anticholinergics are most effective in

Answer 58

COPD

Question 59

O2 use COPD

Answer 59

pO2

Question 60

treatment of acute exacerbations of chronic bronchitis

Answer 60

the management of acute episodes of increased sob is similar to the treatment of acute asthma exacerbations. the use of bronchodilators and corticosteroid therapy is combined with antibiotics antibiotics are generally used in acute exacerbations of chronic bronchitis (AECB) because infection is by far the most commonly identified cause

Question 61

AECB treatment is identical to

Answer 61

asthma treatment but with less proven benefit

Question 62

treatment of acute exacerbations of chronic bronchitis Most effective

Answer 62

Although viruses cause 20% to 50% of episodes, coverage should be provided against Strep Pneumo, H flu, and moraxella cararrhalis Macrolides: zpak, clarithromycin Cephalosporins: cefuroxime, cefixime, cefaclor, ceftibuten Amoxicillin/clavulanic acid quinolones: levofloxacin, moxifloxacin, gemifloxacin

Question 63

treatment of acute exacerbations of chronic bronchitis second line agents

Answer 63

doxy bactrim

Question 64

Criteria for oxygen use in COPD

Answer 64

oxygen decreases mortality, Criteria are: pO2 below 55 mm Hg or oxygen saturation below 88% or if there are signs of right sided heart disease/failure or an elevated hematocrit: pO2 less than 60 mm Hg or oxygen saturation below 90%

Question 65

although the hypoxic drive elimination concept

Answer 65

is not correct, you would still avoid reflexively placing a pt with COPD on a ver high flow 100% nonrebreather mask. use only as much osgycen as is necessary to the rasie the pO2 above 90% saturation

Question 66

the idea of eliminatign hypoxic drive

Answer 66

is not accurate. dyspneic, hypoxic patients with COPD must get oxygen

Question 67

Bronchiectasis definition

Answer 67

an uncommon disease from chronic dilation of the large bronchi. this is a permanent anatomic abnormality that cannot be reversed or cured. bronchiectasis is uncommon bc of better control of infections of th elung which lead to the weakening of the bronchial walls

Question 68

Bronchiectasis etiology

Answer 68

the single most common cause of bronchiectasis is cystic fibrosis, which accounts for half of cases ``` other causes: infections, tb pneumonia, abscess foreign body or tumors allergic bronchopulmonary aspergillosis (abpa) collagen-vascular disease such as RA ```

Question 69

Bronchiectasis Presentation/what is the most likely diagnosis

Answer 69

recurrent episodes of very hgih olume purulent sputum production is the key to the suggestion of the diagnosis. hemoptysis can occure. dyspnea and wheezing are present in 75% of cases. ``` other findings are: weight loss anemia of chronic disease crackles on lung exam clubbing is uncommon dyskinetic cilia syndrome ```

Question 70

it is impossible to diagnose Bronchiectasis w/out

Answer 70

an imagin study of the lungs such as a CT scan

Question 71

Bronchiectasis best initial test

Answer 71

a cxr that shows dilated thickened bronchi, some times with tram-tracks which is the thickening of the bronchi

Question 72

Bronchiectasis most accurate test

Answer 72

high-resolution CT sputum culture is the only way to determine the specific bacterial etiology of the recurrent episodes of infection

Question 73

Bronchiectasis treatment

Answer 73

1. chest physiotherapy (cupping and clapping) and postural drainage are essential for dislodging plugged-up bronchi 2. treat each episode of infection as it arises. use the same antibiotics as for exacerbations of COPD. the only difference is that inhaled antibiotics seem to have some efficacy and a specific microbiologic diagnosis is preferred since mai (mycobacterium avium intracellulare) can be found 3. rotate antibiotic, 1 weekly each month 4. surgical resection may be indicated

Question 74

Allergic Bronchopulmonary Aspergillosis (ABPA) definition/etiology

Answer 74

abpa is a hypersensitivity of the lungs to fungal antigens that colonize the bronchial tree. ABPA occurs almost exclusively in pts with asthma and a history of atopic disorders

Question 75

Allergic Bronchopulmonary Aspergillosis (ABPA) what is the most likely diagnosis

Answer 75

look for an asthmatic pt with recurrent episodes of brown-flecked sputum and transient infiltrated on cxr cough, wheezing, hemoptysis, and sometiems bronchiectasis occur

Question 76

Allergic Bronchopulmonary Aspergillosis (ABPA) diagnostic tests

Answer 76

peripheral eosinophilia skin test reactivity to aspergillus antigens precipitating antibodies to aspergillus on blood test elevated serum IgE levels pulmonary infiltrates on cxr or CT

Question 77

Allergic Bronchopulmonary Aspergillosis (ABPA) treatment

Answer 77

1. oral steroids (prednisone) for severe cases; inhaled steroids are not effective for ABPA 2. itraconazole orally for recurrent episodes

Question 78

an inhaler cannot deliver a high enough dose of steroids to be effective in

Answer 78

Allergic Bronchopulmonary Aspergillosis (ABPA)

Question 79

Cystic fibrosis etiology

Answer 79

Cystic fibrosis is an autosomal recessive disorder caused by a mutation in the genes that code for chloride transport. this is known as the cystic fibrosis transmembrane conductance regulator (CFTR). mutations in the CFTR gene damage chloride and water transport across the apical surface of epithelial cells in exocrine glands throughout the body. this leads to abnormally thick mucus in the lungs, as well as damage to the pancrease, liver, sinuses, intestines, and gu tract. they all clog up damaged mucus clearance decreases the ability to get rid of inhaled bacteria

Question 80

neutrophils in cf dump ton of

Answer 80

dna into airway secretions, clogging them up

Question 81

lung disease accounts for 95% of deaths in

Answer 81

CF

Question 82

Cystic fibrosis presentation

Answer 82

over 1/3 of CF pts are adults. look for a young adult with chronic lung disease (cough, sputum, hemoptysis, bronchiectasis, wheezing, and dyspnea) and recurrent episodesof infection. sinus pain and polyps are common

Question 83

Cystic fibrosis GI involvement

Answer 83

meconium ileus in infants with abdominal distention pancreatic insufficiency (in90%) with steatorrhea and vitamin ADE and K malabsorption recurrent pancreatitis distal intestinal obstruction biliary cirrhosis

Question 84

Cystic fibrosis gu involvement

Answer 84

men are often infertile, 95% have azoospremia, with the vas deferns missing in 20%. women are infertil bc chronic lung disease alters the menstural cycle and thick cervical mucus blocks sperm entry

Question 85

Cystic fibrosis diagnostic tests

Answer 85

the most accurate test is an increased sweat chloride test. pilocarpine increases ach levels which increases sweat production. chloride levels in sweat above 60meq/l on repeated testing establishes the diagnosis Genotyping is not as accurate as finding an increased sweat chloride level. this is bc there asre so many different types of mutations leading to CF

Question 86

Cystic fibrosis additional diagnostic tests

Answer 86

``` cxr and ct have no single abnormality that confirm diagnosis but may show bronchiectasis pneumothorax scarring atelectasis hyperinlfation ``` ABG may show hypoxemia and in advanced disease a resp acidosis pfts show mixed obstructive and restrictive patterns; decrease in fvc and total lung capacity; and decreased diffusing capacity for carbon monoxide

Question 87

Cystic fibrosis sputum culture

Answer 87

nontypable h flu psuedomonas auruginosa staph aureus burkholderia cepacia

Question 88

Cystic fibrosis treatment

Answer 88

1. abs are routine, same ones as bronchiectasis, inhaled aminoglycosides are seen only in CF 2. inhaled recombinant deoxyribonuclease (rhDNase), this breaks down the DNA in resp mucus that clogs up the airways 3. inhaled bronchodilators like albuterol 4. pneumococcal and influenza vaccination 5. lung transplantation is used only in advanced disease not responsive to herapy 6. ivacaftor increases activity of cftr in some pts

Question 89

community-acquired pnuemonia definition

Answer 89

defined as pneumonia occuring before hospitalization ot within 48 hours of hospital admission. CAP is the most common infectious cause of death int he US, and is the only infectious disease that is among the top 10 causes of death nationwide

Question 90

community-acquired pnuemonia etiology

Answer 90

strep pneumo is the most common cause of CAP. netiher the environemental reservoir of s pneumo nor its method of acquistion is known

Question 91

CAP and COPD

Answer 91

h flue

Question 92

CAP and recent viral infection

Answer 92

s aureus

Question 93

CAP and alcoholism and diabetes

Answer 93

klebsiella pneumonia

Question 94

CAP and poor dentition and aspiration

Answer 94

anaerobes

Question 95

CAP and young healthy pts

Answer 95

mycoplasma pnueomoniae

Question 96

CAP and hoarseness

Answer 96

chlamydophilia pnuemoniae

Question 97

CAP and contaminated water sources air con and ventilation systems

Answer 97

legionella

Question 98

CAP and birds

Answer 98

chlamydia psittaci

Question 99

CAP and anials at the time of giving birth vets and farmers

Answer 99

coxiella burnettii

Question 100

CAP Presentation

Answer 100

``` fever cough dyspnea (severe infection) hemopstysis dullness to percussion if effusion bronchial breath sounds and egophony from consolidation of air spaces rales ronchi and crepitations abdominal pain or diarrhea from lower lobe infection chills or rigors from bacteremia chest pain from pleura inflammation hypothermia is just as bad as fever ```

Question 101

CAP | severe infection vital signs

Answer 101

tachycardia hypotension tachypnea mental status

Question 102

chest pain from pneumonia

Answer 102

is often pleuritic, changing with respiration

Question 103

dyspnea, high fever, and an abnormal cxr distinguish

Answer 103

pneumonia from bronchitis

Question 104

hemoptysis from necrotizing disease "currant jelly" sputum

Answer 104

klebsiella pneumonia

Question 105

foul-smelling sputum, rotten eggs

Answer 105

anaerobes

Question 106

dry cough, rarely severe, bullous myringitis

Answer 106

mycoplasma pneumoniae

Question 107

gi symptoms (pain diarrhea) or CNS sx such as ha and confusion

Answer 107

legionella

Question 108

aids with less than 200 CD4 cells

Answer 108

pneumocystis

Question 109

Infections with a dry or nonproductive cough

Answer 109

``` mycoplasma viruses coxiella pneumocystis chlamydia ``` usually involve the interstitial space and more often leave the air spaces of the alveoli empty, which is why there is less sputum production

Question 110

specific sputum colors

Answer 110

are useless in determining etiology

Question 111

CAP diagnostic tests

Answer 111

best initial test is cxr sputum gram stain and culture are best ways to tre and determine a specific microbial etiology atypical pneumonia refers to an organism not visible on gram stain and not culturable on standard blood agar (mycoplasma, chlamydophila, legionella, coxiella, and other viruses) leukocytosis is often present but is nonspecific

Question 112

CAP CXR

Answer 112

b/l interstitial infiltrates are seen with: ``` mycoplasma viruses coxiella pneumocystis chlamydia ``` same organisms as nonproductive cough, xrays lag behind clinical findings

Question 113

CAP the first cxr can be negative in at least

Answer 113

10-20% of cases or pneumonia

Question 114

CAP sputum gram stain is adequate if there are

Answer 114

more than 25 white blood cells and fewre than 10 epithelial cells

Question 115

CAP ct and mri

Answer 115

show greater definition of abnormlalities found on a chest xray but will still not be able to determine a specific microbiologic etiology

Question 116

with infections dieases the radiology test

Answer 116

is never the most accurate test

Question 117

CAP blood cultures

Answer 117

are positive in 5-10% of cases, usually with s pneumo

Question 118

CAP tests done in severe disease with an unclear etiology or those not responding to treatment

Answer 118

thoracentesis - can determine empyema if diagnosis is unclear, drain empyema (like an abscess, infected pleural effusion) empyema - look for ldh above 60% of serum level and protein avoe 50% of serum level. a white cell coutn above 1000/ul or PH<7.2 is suggestive of infection bronchoscopy - rarely needed, used if need to go to ICU, when initial testing like sputum and culture do not yield an organism and the pts condition is worsening despite empiric therapy. an exception is pneumocystis pneymonia in which onnivasive testing reraely reveals a dx and precise confirmation of the etiology is critical to guide therapy

Question 119

it is impossible to make a specific diagnosis of the cause of pneumonia based on

Answer 119

hx and physical

Question 120

new large effusions secondary to pneumonia should be

Answer 120

tapped

Question 121

Mycoplasma pneumoniae diagnostic test

Answer 121

pcr cold agglutins serology special culture media

Question 122

chlamydophila pneumoniae diagnostic test

Answer 122

rising serologic titers

Question 123

legionella diagnostic test

Answer 123

urine antigen | culture on charcoal yeast extract

Question 124

chlamydia psittaci diagnostic test

Answer 124

rising serologic titers

Question 125

coxiella burnetti diagnostic test

Answer 125

rising serologic titers

Question 126

pneumocystis jiroveci (PCP) diagnostic test

Answer 126

brochoalveolar lavage (BAL)

Question 127

mycoplasma and chlamydophila are rarely confirmed

Answer 127

bc they are simply treated empirically

Question 128

CAP it is the severity of disease not the etiology that drives

Answer 128

initial therapy

Question 129

CAP outpatient treatment

Answer 129

previously healthy or no antibiotics in the pat 3 monthsand mild symptoms > macrolide (azithromycin or clarithromycin)hyp or doxycycline comorbidities or abs int eh past 3 months > resp fluoroquinolone (levofloxacin or moxifloxacin)

Question 130

CAP inpatient treatment

Answer 130

Resp fqs: levo or moxifloxaxin or ceftriaxone and azithromycin

Question 131

hypoxia and hypotension as single factors are a reason to

Answer 131

hospitalize a pt

Question 132

CAP reasons to hospitalize

Answer 132

those with severe disease have a combination of: hypotension (systolic below 90 mm HG) rr above 30 per minute or pO2 less than 60 mm Hg, PH below 7.35 elevated BUN above 30 mg/dl, sodium less tahn 130 mmol/l, glucose above 250 mg/dl pulse above 125 per minute confusion temp above 104 deg age 65 or older, or commorbidities such as cancer, COPD, CHF, renal failure, or liver disease

Question 133

notic that the cxr does not guide what in CAP

Answer 133

admission

Question 134

xray cannot tell severity of

Answer 134

hypoxia

Question 135

CAP Curb65=

Answer 135

admission ``` Confusion Uremia Resp distress BP low Age>65 ```

Question 136

infected pleural effusion or empyemawill respond most rapidly to

Answer 136

drainage by chest tube or thoracostomy

Question 137

exudate VS transudate

Answer 137

pleural effusion with pH o<7.2 suggests empyema and needs chest tube drainage. LDH >60% of serum (0.6) or protein >50% of serum (0.5) suggest an exudate. Exudates are cuased by infection and cancer

Question 138

CURB 65 0-1 point

Answer 138

send home

Question 139

CURB 65 > or equal to 2 points

Answer 139

admission

Question 140

pleural effusion with a large meniscus sign

Answer 140

only a fluid sample from thoracentesis can determine the specific cause

Question 141

effusion should be freely

Answer 141

mobile and form a layer when the pt lies on he rside

Question 142

hydropnuemothorax is both

Answer 142

abnormal air and lfuid in the pleural space, must drain with a chest tube

Question 143

consultation is almost never

Answer 143

the right answer

Question 144

pneumococcal vaccination

Answer 144

everyone aboe 65 should receive vaccination with the 13 polyvalent vaccine. followed in 6-12 months with the 23 polyvalent vaccine. in additon those with chronic heart, liver, kidney, or lung disease (including asthma) should also be vaccinated as soon as their underlying disease is apparent if first dose given before 65, give another dose 5 years later

Question 145

other reasons to vaccinate against pnuemococcal

Answer 145

function or anatomic asplenia (sickle cel) hematologic malignancy (leukemia, lymphoma) immunosuppression: dm, alcoholics, corticosteroid users, AIDS or HIV positive CSF leaks or cochlear implant

Question 146

do healthcare workers need pneumococcal vaccine?

Answer 146

no

Question 147

Healthcare Associated or hospital acquired Pneumonia

Answer 147

defined as a pneumonia developing more than 48 hours after admission or after hopsitalization in the last 90 days. higher incidence of gram neg bacilli like ecoli or pseudomonas macrolides are not acceptable instead use: antipseudomonal cephalosporins: cefepime or ceftazidime or antipseudomonal penicillin: piperacillin/tazobactam or carbapenems: imipenem, meropenem, or doripenem

Question 148

piperacillin and ticarcillin are always used in

Answer 148

combination with a betalactamas inhibitor such as tazobactam or clavulanic acid

Question 149

Ventilator Associated Pneumonia (VAP) definition

Answer 149

mechanical ventilation interferes with normal mucociliary clearance of the respiratory tract such as the ability to cough. postiivte pressure is temendously damaging to the normal ability to clear colonization Ventilator Associated Pneumonia has an incidence as high as 5% per day int he first few days on a ventilator

Question 150

Ventilator Associated Pneumonia what is the most likely diagnosis

Answer 150

bc of multiple conuterncurrent illnesses such as CHF, even a diagnosis of VAP can be hard to establish look for: fever and or rising wbcs new infiltrate on cxr purulent secretion coming from the et tube

Question 151

Ventilator Associated Pneumonia diagnostic tests

Answer 151

bc of coloniztion of the et tube, sputum culture is worthless, dx of specific etiology is difficult. in order from least accurate but easiest to do to most accurate and hardest to do: tracheal aspirate bronchoalveolar lavage protected brush specimen video-assisted thoracoscopy open lung biopsy

Question 152

Ventilator Associated Pneumonia tracheal aspirate

Answer 152

a suction catheter is palced in the et and aspirates the contents below the trachea when the catheter is past the end of the et tube

Question 153

Ventilator Associated Pneumonia bronchoalveolar lavage (BAL)

Answer 153

a bronchoscope is placed deeper into the lungs where there are not supposed to be any organisms. can be contaminated when passed throught he nasopharynx

Question 154

Ventilator Associated Pneumonia protected brush specimen

Answer 154

the tip of the bronchoscope is covered when passed thorugh the nasopharynx then ucovered only inside the lungs much more specific bc of decreased contamination

Question 155

Ventilator Associated Pneumonia video assisted thoracoscopy (VAT)

Answer 155

a scope is placed htrough the chest wall and a sample of the lung is biopsied. this allows a large piece of lung to be taken without the need for cutting the chest open (thoracocotomy). it is like sigmoidoscopy of the chest

Question 156

Ventilator Associated Pneumonia open lung biopsy:

Answer 156

the momst accurate diagnostic test of VAP, but with much greater morbidity and potential complication of the procedure bc of the need for thoracotamy

Question 157

subcutaneous emphysema

Answer 157

air abnormally leaking into the soft tissue of the chest wall, may be caused by chest tube placement

Question 158

Ventilator Associated Pneumonia treatment

Answer 158

combine 3 different drugs 1. antipseudomonal beta lactam cephalosporin (ceftazidime or cefepime) or penicillin (piperacillin/tazobactam) or carbapenem (imipenem, meropenem, or doripenem) Plus 2. second anti pseudomonal agent aminoglycoside (gentamicin or tobramycin or amikacin) or fluoroquinolone (cipro or levo) Plus 3. methicillin- resistant antistaph agent Vancomycin or linezolid

Question 159

culturing an et tube is like culturing urine with a foley catheter in place

Answer 159

it will always grow something bc of colonization

Question 160

no daptomycin for

Answer 160

lungs!! daptomycin is inactivated by surfactant

Question 161

change the initial therapy for VAP

Answer 161

if a specific etiology is identified

Question 162

imipenem

Answer 162

can cause seizures is excreted thorugh the kidneys renal failure causes a rise in impienem levels leading to toxicity

Question 163

carbamazepine is no more effective

Answer 163

than phenytoin at stopping seizures caused by imipenem?

Question 164

lung abscess etiology

Answer 164

rare bc of prompt treatment of aspiration pneumonia occurs only with a large volume of aspiration of oral/pharyngeal contents, usually with poor dentition, and not treated stroke with loos of gag reglex seizures intoxication et tube

Question 165

aspiration pneumonia happens in the upper lobe

Answer 165

when lying flat

Question 166

lung abscess what is the most likely diagnosis

Answer 166

look for a person with one of the risk factors presenting a chronic infection (etiologies) developing over several weeks with large volume sputum that is fould smelling bc of anaerobes, weight loss is common

Question 167

lung abscess diagnostic test

Answer 167

cxr is best initial test and will show a cavity possible with an air gluid level chest ct is more accurate than cxr but only a lung biopsy can establish the specific etiology

Question 168

lung abscess treatment

Answer 168

clindamycin or penicillin are best to cover a lung abscess

Question 169

sputum culture is wrong answer for diagnosing a

Answer 169

lung abscess all sputum has anaerobes from mouth flora

Question 170

chest cavity consistent with an abscess

Answer 170

thick wall and an air fluid level

Question 171

Pneumocystis Pneumonia etiology

Answer 171

the agent causing pcp has been renamed P. Jiroveci instead of P carinii. PCP occurs alomst esclusively in pts with AIDS whose CD4 cell count has dropped below 200u/l and who are not on prophylactic therapy

Question 172

Pneumocystis Pneumonia what is the most likely diagnosis

Answer 172

look for a pt with AIDS presenting with dyspnea on exertion, dry cough and fever. the question will often suggest or directly state that the CD4 count is low (below 200u/l and that he pt is not on prophylaxis

Question 173

Pneumocystis Pneumonia diagnostic testing

Answer 173

the best initial test can be either a cxr showing b/l interstitial infiltrates or an arterial blood gas looking for hypoxia or an increased A-a gradient. LDH levels are always elevated. the most accurate test is a bronchoalveolar lavage. sputum stain for pcp is quite specfic if it is positive there is no need to do further testing a negative sputum stain means you should answer bronchoscopy as the best diagnostic test

Question 174

a normal LDH means you should not answer what as the omst likely diagnosis

Answer 174

pcp

Question 175

you cannot distinguish pcp from mycoplamsa chlamydophila or viruses by xray alon. however in hiv, pcp is most likely with

Answer 175

interstitial infiltrates

Question 176

Pneumocystis Pneumonia treatement

Answer 176

bactrim is the best initial therapy for both best initial therapy and prophylaxis. add steroid to decrease mortality if th epxp is severe atovaquone can be used as an alternative to bactrim if the pcp is mild if bactrim toxicity switch to: clindamycin and primaquine or pentamidine

Question 177

Pneumocystis Pneumonia grading

Answer 177

severe - pO2 less than 70 or an A-a gradient above 35 mild - mild hypoxia

Question 178

adverse effects of Bactrim

Answer 178

rash bone marrow suppression

Question 179

if pt has g6pd deficiency and Pneumocystis Pneumonia give what instead of clindamycin and primaquine ifcant give bactrim

Answer 179

pentamidine

Question 180

antiretrovirals during acute opportunistic infection

Answer 180

no they can exacerbate it

Question 181

Pneumocystis Pneumonia prophylaxis

Answer 181

start treatement to prevent pcp in those with aids whose cd4 count is below 200u/l 1. bactirm if there is a rash or neutropeina form bactrim use: 2 atovaquone or dapsone aerosol pentamidine is not used as second line therapy for prophylaxis bc it has less effiicacy then those listed above

Question 182

always choose therapy based on

Answer 182

efficacy not adverse effects

Question 183

dapsone is ci in those with

Answer 183

g6pd

Question 184

azithromycin for prophylaxis in what for aids

Answer 184

atypical mycobacteria when cd4 is below 50u/l

Question 185

TB overview

Answer 185

continues to diminsh in the US. 2/3rds of domestic TB cases occur in those who are recent immigrants from countries with poor control including those who have been preciously vaccinated with bcg. this is why previous bcg vaccine has no impact or effect on recommendation for treatment of latent tb (positive ppd)

Question 186

almost all pts with tb have one or more risk factors like:

Answer 186

recent immigrants (in the past 5 years) prisoners hiv positive healthcare workers lcose contacts of someone with tb steroid use hematologic malignancy alcoholics dm

Question 187

TB presentation/ what is the most likely diagnosis

Answer 187

look for a person wtih one of the previously listed risk factors presenting with fever, cough, sputum, weight loss, hemoptysis, and night sweats

Question 188

you cannot answer tb without

Answer 188

clear risk factor cavity on cxr or a positive smear

Question 189

TB diagnostic tests

Answer 189

the best initial test is an cxr as well as with all respiratory infections sputum stain and culture specifically for acid fast bacilli (mycobacteria) must be done 3 times to fully exclude TB pleural biopsy is the single most accurate diagnostic test

Question 190

ppd skin testing in TB

Answer 190

never the best test for TB in a symptomatic pt

Question 191

TB treatment

Answer 191

``` when the semar is positive begin therapy with 4 drugs: Rifampin Inh pyrazinamide ethambutol ``` you do not need the ethambutolif it is known at the beginning of therapy that the organism is sensitive to all TB medications ethambutol is given as part of 4 drug empiric therapy prior to konwing the sensitivity of the organism aftreu using ripe for the first 2 months . stop ethambutol and pyrazinamide and continue rifampin and inh for the next 4 motnhs the standard of care is 6 total months of therapy

Question 192

when is treatment for TB extended to longer than 6 months

Answer 192

osteomyelitis miliary tb meningitis pregnancy or any other time pyrazinamide is not used

Question 193

TB toxicity of therapy

Answer 193

all of the TB medications cause hepatotoxicity but do not stop them unless the tansaminases rise to 3 to 5 times the upper limit of normal

Question 194

Rifampin toxicity - management -

Answer 194

toxicity - red color to body secretions management - none, benign finding

Question 195

isoniazid toxicity - management -

Answer 195

toxicity - peripheral neuropathy management - use pyridoxine to prevent

Question 196

Pyrazinamide toxicity - management -

Answer 196

toxicity - hyperuricemia management - no treatment unless symptomatic

Question 197

Ehtambutol toxicity - management -

Answer 197

toxicity - optic neuritis/color vision management - decrese doe in renal failure

Question 198

TB use of steroids

Answer 198

glucocorticoids decrease the risk of contstictive pericarditis in those with pericardial involvement. they also decrease neurologic compication in TB meningitis

Question 199

what should pregnant pts not receive with TB

Answer 199

pyrazinamide or streptomycin

Question 200

Latent TB (PPd testing and treatment) indications for PPd testing

Answer 200

the PPd is not a general screening test for the whole population only those in the risk groups previously described whould be screened. ppd testing is not useful in those who are symptomatic or those with abnormal cxr, these pts need acid fast sputum testing

Question 201

Latent TB (PPd testing and treatment) what is considered a positive test?

Answer 201

only induration is counted towards a positive test, erythema is irrelevant

Question 202

Latent TB (PPd testing and treatment) what is considered a positive test? induration larger than 5 mm

Answer 202

hiv pts glucorticoid users close contacts of those with active tb abnormal calcifications on cxr organ transplant reicpients

Question 203

Latent TB (PPd testing and treatment) what is considered a positive test? induration larger than 10 mm

Answer 203

recent immigrants (past 5 years) prisoners healthcare workers close contacts of someone with tb hematologic malignancy, alcoholics, dm

Question 204

Latent TB (PPd testing and treatment) 2 stage testing

Answer 204

if the pt has never had a ppd skin test before, a second test is indicated within 1 to 2 weeks if the first test is negative. this is bc the first test may be falsely negative. if the second test is negative, it means the pt is truly negative. if the second test is postiive, it means the first test was a false negative intereron gamma realsea ssay (IGRA) is a blood test equal in significance to ppd to excldue tb exposure, there is no cross reaction with bcg

Question 205

Latent TB (PPd testing and treatment) treatment for a positive ppd or igra

Answer 205

after active tb has been excluded with a cxr pts hould receive 9 months of inh. a positive ppd confers a 10% lifetime risk of tb, INH results in a 90% reduction in this risk, after inh the lifterime risk goes down to 1%. the ppd test should not be repeated once it i spoitivie, use pyridoxine (B6) with inh those at hig risk such s healthcare workers should have a ppd done every year to screen for conversion omst of the risk of developing active tb lies withing the first 2 years after conversion

Question 206

everyone with a postiive ppd test should have

Answer 206

cxr to exclude active disease

Question 207

if the first ppd test is positive

Answer 207

a second test is not necessary

Question 208

once the ppd is positive

Answer 208

it will always be positive in the future

Question 209

previous bcg has not effect on what

Answer 209

ppd recommentation, if the ppd is positive the pt ust tak inh for months even if they have had bcg

Question 210

Solitary pulmonary nodule benign

Answer 210

<30 no change in size nonsmoker smooth border small,<1cm normal lung no adenopathy dense, central calcification normal pet scan

Question 211

Solitary pulmonary nodule malignant

Answer 211

>40 enlarging smoker spiculated (spikes) large,>2 c atelectasis yes adenopathy sparse, eccentric aclcification abrnormal pet scan

Question 212

best initial step in all lung lesion

Answer 212

copare the size with old xrays

Question 213

biopsy what lung lesions

Answer 213

all enlargins particularly if they are papidly enlarging

Question 214

Solitary pulmonary nodule mangement of high probability lesions

Answer 214

when many of the features described under malignant in the previous table are present, the answer is to resect )remove) thelesion. when many feeatures of malignancy are present, sputum cytology, needle biopsy, and pet scanning should not be done bc a negative test is liekly a false negative. if resection is one of the choices then it is the best answer

Question 215

Solitary pulmonary nodule management of intermediate probability lesions definition

Answer 215

you may notice there are some gray or inconclusive aspects of the solitary pulmonary nodule in the previous table sugh as the gap in age ranges or size, this is the definition of intermeidate probability

Question 216

Solitary pulmonary nodule management of intermediate probability lesions sputum cytology

Answer 216

sputum cytology: if the question says cytoloy is poitive this is highly specific and the most appropriate next step in mamangeemnt is resection of the lesions, a negative cytology does not exclude malignancy.

Question 217

Solitary pulmonary nodule management of intermediate probability lesions bronchosocpy or thansthoracic needle biopsy

Answer 217

bronchoscopy or transthoracic needle biopsy: these are the most appropriate next step in most pts with intermediate probability of malignancy. use bronchoscopy for central lesions and transthoracic biopsy for peripheral lesions

Question 218

Solitary pulmonary nodule management of intermediate probability lesions positron emission tomgraphy

Answer 218

(pet scan) this is a way of telling whether the content of the lesion is malignant without a biopsy. malignancy has increased uptake of tagged glucose. the sensitivity of pet scan is 85% to 95% a negative scan points swaya from malignancy

Question 219

Solitary pulmonary nodule management of intermediate probability lesions videa ssisted thoracic surgery (VATS)

Answer 219

VATS is both more senitive and more specific than all the othe rforms of testing. frozen section in the operating room allows for immediate conversion to an open thoracoscopy and lobectomy if malignacy is found

Question 220

most common adverse effect of transthoracici biopsy

Answer 220

pneumothorax

Question 221

pet is most accurate with

Answer 221

larger lesion >1cm

Question 222

interstitial lung disease definition

Answer 222

pulmonary fibrosis is thickening of the interstitial septum of the lung between the arteriolar space and the alveolus. fibrosis interegeres with gas exchange in both direction

Question 223

interstitial lung disease etiology

Answer 223

fibrosis can be idiopathic or seconary to a large number of inflammatory conditions, radiation, drugs, or from inhalations of txoins. all of the thicken the septum only some have white cell infiltrates iwth lymphocytes or neutrophils. chornic conditions lead to fibrosis and thickening. it is also known as idiopathic fibrosing interstitial pneumonia

Question 224

Specific causes of pulmonary fibrosis

Answer 224

idiopathic, interstitial pulmonary fibrosis radiation drugs: bleomycin, busulfan, amiodarone, methylsergide, nitrofurantoin, cyclophosphamide

Question 225

coal workers pneumoconioses

Answer 225

coal

Question 226

silicosis

Answer 226

sandblasting, rock mining, tunneling

Question 227

asbestosis

Answer 227

shipyard workers, pipe fitting, insulators

Question 228

byssinosis

Answer 228

cotton

Question 229

berylliosis

Answer 229

electronic manufacture

Question 230

bagassosis

Answer 230

moldy sugar cane

Question 231

interstitial lung disease presentation

Answer 231

dyspnea, worsening on exertion fine rales or crackles on examination loud p2 heart sound clubbing of the fingers

Question 232

interstitial lung disease diagnostic tests

Answer 232

best initial tes is a cxr high resolution ct scan is more accurate then a cxr lung biopsy is the most accurate test echo will often show pulmonary htn and possible right vent hypertrophy pfts: restrictive lung disease with decrease of everything proportionately the FEV1, FVC, TLC, and residual volume will all be decreased, but since everything is decreased the FEV/FVC ration will be normal. the dlxo is decreased in proportion to the severity of the thickening of the alveolar septum

Question 233

inflammatory infiltration with white cells

Answer 233

is reversible whereas fibrosis is irreversible

Question 234

severe long standing interstitial fibrosis produces thick walls between alveoli that give the appearance of

Answer 234

honeycombing

Question 235

interstitial lung disease treatment

Answer 235

most types of interstitial lung diseases are untreateable if the biopsy shows white cell or inflammatory infiltrate, prednisone should be used. of all the causes of pneumoconioses, berylliosis is the most likely to respond to treatement with steroids. this is due to the presence of granulomas, which are a sign of inflammation

Question 236

Sarcoidosis definition/etiology

Answer 236

more common in african american women. it is an idiopathic inflammatory disorder predominantly of th elungs but can affect most of th ebody

Question 237

Sarcoidosis most likely dx

Answer 237

look for a young african american woman with shortness of breath on exertion and occasional fine rales on lung exam, but without the wheezing of asthma. erythema nodosum and lymphadenopathy, either on examination or especially on cxr

Question 238

Sarcoidosis also presents with

Answer 238

parotid gland enlargement facial palsy heart block and restrictive cardiomyopathy cns involvement iritis and uveitis

Question 239

biopsy shows granulomas in

Answer 239

berrylliosis

Question 240

answer sarcoidosis when

Answer 240

a cxr or ct shows hilar adenopathy in a generally healthy african american woman

Question 241

although liver and kidney granulomas are very common on autopsy they are

Answer 241

rarely symptomatic

Question 242

Sarcoidosis diagnostic tests

Answer 242

cxr is best initial test, hilar adenopathy is present in 95% of pts. parenchymal involvement is also present in combination with lymphadenopathy lymph node biopsy is the most accurate test. the granulomas are noncaseating elevated ace -60% hypercalciuria - 20% hypercalcemia - 5% (granulomas in sarcoidosis make vit D PFTs- restricitve lung disease (decreased FEV1, FVC, and TLC with a normal FEv1/FVC ration

Question 243

what does bronchoalveolar lavage show in sarcoidosis

Answer 243

increased helper cells

Question 244

Sarcoidosis treatment

Answer 244

prednisone is the clear drug of choice. few pts fail to respond. asymptomatic hilar adenopathy dies not need to be treated

Question 245

Thromboembolic disease definition

Answer 245

pulmonary emboli (PE) and deep venous thrombosis (DVT) are essentially treated as a spectrum of the same disease. PE derives from DVT of the large vessels of the legs in 70% and pelvic veins in 30%, but since the risks and the treatment are the same they can be discussed at the same time

Question 246

Thromboembolic disease etiology

Answer 246

DVTs arise bc of stais from immobility, surgery, trauma, joint replacement, or thrombophilia such as factor V leiden mutation and antiphospholipid syndrome. malignancy of any kind leads to DVT

Question 247

Thromboembolic disease presentation/what is the most likely dx

Answer 247

look for the sudden onset of sob with clear lungs on examination and a normal cxr

Question 248

other findings in PE

Answer 248

tachypnea, tachycardia, cough, and hemoptysis unilateral leg pain from DVT pleuritic chest pain from lung infection fever can arise from any cause of clot or hematoma extremely severe emboli will produce hypotension

Question 249

most questions about pe concern

Answer 249

diagnostic testing and treatment

Question 250

Thromboembolic disease diagnostic tests

Answer 250

there is no uncomlicated diagnostic test for a pe. cxr, ekg, and abg are athe best initial tests. angiography is the most accurate test, but can be fatal in 0.5% of cases. after doing an ABG cxr and ekg the best next step is most often a CT angiogram

Question 251

main issues to know in pe is

Answer 251

what is the most common finding and what is the most common abnormality when there is an abnormality?

Question 252

Thromboembolic disease cxr

Answer 252

usually normal in pe the most common abnormality is atelectasis, wedge shape infarction, pleural based lesion (hampton hump), and oligemia of one lobe (westermark sign) are much less common than simple atelectasis

Question 253

Thromboembolic disease EKG

Answer 253

usually shows sinus tachycardia. the most common abnormalitiy is nonspecific St-T wave changes. only 5% will show right axid deviation, RV hypertrophy or right bundle branch block

Question 254

Thromboembolic disease ABG

Answer 254

hypoxia and respiratory alkalosis (high PH and low p C02 with a normal chest xray is extremely suggestive of PE

Question 255

the most common wont answer to choose on a pe ekg is

Answer 255

S1, Q3, T3

Question 256

what do you do when you havent dont a spiral ct but initial labs and hx suggest pe

Answer 256

enoxaparin

Question 257

Thromboembolic disease spiral CT scan

Answer 257

also called a ct angiogram, the spiral ct has become the standard of care in tems of diagnostic testing to confirm the presence of a PE after the xray, ekg, and abg are done. the specificity is excellent (over 95%). sensitive for clinically significant lots varies from 95-98%

Question 258

Thromboembolic disease ventilation/perfusion

Answer 258

high probability scans have no clot (false positive) in 15%. low probability scans have a clot (false negative) in 15%. a completely normal scan essentially excludes a lcot

Question 259

v/q is first only in

Answer 259

pregnancy

Question 260

thromboembolic disease D-dimer

Answer 260

theis test is very sensitive (better than 97% negative predictive balue) but the specificity is poor since any cuase of clot or increased lbeeding can elevate the d-dimer level. a negative test excludes a clot, but a positive test doesnt mean anything

Question 261

thromboembolic disease lower extremity doppler study:

Answer 261

if the le doppler is positive no further testing is needed. only 70% of pes originated in the legs, so it will miss 30% of cases. you do not need a spiral Ct or v/q scan to confirm a pe if there is a clot in the legs bc they will not change therapy. the pt will still need heparin and 6 months of warfarin.

Question 262

Spiral Ct (negative)>v/q or le doppler (negatige)>

Answer 262

withhold therapy with heparin

Question 263

thromboembolic disease angiography

Answer 263

the most accurate test with nearly 100% specificity and a falst negative rate under 1%. there is a 0.5% mortality, which is high if you consider the tens of thousands of tests a year that would need to be done to exclude PE in all cases.

Question 264

adverse effects of angiography

Answer 264

allergy renal toxicity and death

Question 265

d dimer is the answer for pe when

Answer 265

the pretest probability of pe is low and you need a simple noninvasive test to exclude thromboembolic disease

Question 266

the cxr must be normal for what in pe

Answer 266

the v/q scan to have any degree of accuracy. do a spiral ct if the cxr is abnormal

Question 267

le dopplers are a good test if what in pe

Answer 267

if the v/q and spiral ct do not give a clear dx

Question 268

when testing for pe angiography

Answer 268

is rarely done

Question 269

thromboembolic disease treatment

Answer 269

heprain is the best initial therapy warfarin should be started at the same time a sthe heparin in order to achieve an therapeutic inr of 2-3 times normal as quickly as possible fondaparinux is an alternative to heparin rivaroxaban and dabigatran or oral agents taht do no require inrmonitoring and can be used for the treatment of pe. they reach a therapeutic effect in several hours, instead of several days like wargarin. they are used after initial therapy with low molecular weight heprarin

Question 270

when do you use an ivc filter in thromboembolic disease

Answer 270

ci to the use of anticoagulants (melena, CNS bleeding) recurrent emboli while on heparin or fully therapeutic warfarin (INR of 2-3) right ventricular (RV) dysfunction with an enlarged RV on echo. in this case, disease is so severe that an IVC filter is placed bc the next emoblus, even if seemingly small, could be fatal.

Question 271

when are thrombolytics the right answer in thromboembolic disease?

Answer 271

hemodynamically unstable pts (e.g. hypotension systolic <90 and tachy) acute rv dysfunction

Question 272

what is the time limit for thrombolytics in pe

Answer 272

there is none, unlike iwth mi

Question 273

when are direct acting thrombin inhibitors (argatroban, lepirudin) the answer in thromboembolic disease?

Answer 273

heparin induced thrombocytopenia (fondaparinux is an inhibitor that is an alternative to heparin)

Question 274

fondaparinux can be used if there is

Answer 274

HIT

Question 275

when is aspirin the answer in thromboembolic disease?

Answer 275

never

Question 276

virchows triad

Answer 276

stasis of blood flow immobilitty CHF recent surgery endothelial injury trauma surgery recent fx hypercoagulability factor Vleidin mutation any alignancy leads to DVT

Question 277

Pulmonary HTN definition

Answer 277

systolid BP>25mmhg, diastolic BP>8mmhg. any chornic lung disease leads to back pressure into the pulmonary artery obstructing flow out of the right side of the heart

Question 278

Pulmonary HTN etiology

Answer 278

by definition is idiopathic. any form of chornic lung disease such as COPD or fibrosis elevates the pulmonary artery pressure. hypoxemia causes vasoconstriction of the pulmonary artery pressure. hypoxemia causes vasoconstriction of the pulmonary artery circulation as a normal reflex in the lungs to shunt blood sway from areas of the lung it considers to have poor oxygenation. this is why hypoxia leads to pulmonary htn and pulmonary htn results in more hypoxemia

Question 279

Pulmonary HTN presentation

Answer 279

dypsnea and fatigue syncope chest pain wide splitting of S2 from pulmonary htn with a loud p2 or tricuspid and pulmonary valve insufficiency

Question 280

it is impossible to know that pumonary htn is causing the dyspnea w/o

Answer 280

tests

Question 281

Pulmonary HTN diagnostic tests

Answer 281

cxr and ct right heart or swan-ganz catheter ekg echocardiography v/q scanning identifies chronic pe as the cause of pulmonary htn cbc shows polycythemia from chronic hypoxia

Question 282

Pulmonary HTN cxr and ct

Answer 282

best initial tests showing dilation of the proximal pulmonary arteries awith narrowing or pruning of distal vessels

Question 283

Pulmonary HTN right heart or swan ganz catheter

Answer 283

most accurate test and the most precise method to measure pressures by vascular reactivity

Question 284

Pulmonary HTN ekg

Answer 284

right axis deviation, right atrial and ventricular hypertrophy

Question 285

Pulmonary HTN echocardiography

Answer 285

RA and Rv hypertrophy. doppler estimates pulmonary arter (PA) pressure

Question 286

Pulmonary HTN treatment

Answer 286

1. correct the underlying cause when one is clear 2. idiopathic disease istreated, if there is vascular reactivity, with: prostacytin analogues (PA vasodilators): epoprotenol, treprostinil, iloprost, beraprost) endothelin antagonsits: bosentan, ambrisentan phosphodiesterase inhibitors: sildenaffil 3. oxygen slows progression, particularaly with COPD

Question 287

wha tis the only think that can cure idiopathic pulmonary htn

Answer 287

lung transplantation

Question 288

Obstructive sleep apnea etiology

Answer 288

obesity is most common cause

Question 289

Obstructive sleep apnea symptoms

Answer 289

daytime somnolence snoring ha impaired memory and judgement depression htn erectile dysfunction bull neck

Question 290

Obstructive sleep apnea testing

Answer 290

most accurate test is polysomnography (sleep study) which shows multiple episodes of apnea. arrhythmias and erytrhocytosis are common

Question 291

with increased bicarb sleep apnea becomes

Answer 291

obesity/hypoventilation syndrome

Question 292

Obstructive sleep apnea treatment

Answer 292

weigth loss and avoidance of alcohol continuous positive airway pressure (CPAP) surgical widening of the airway (uvuloplatopharyngoplasty) if this fails avoid use of sedatives oral appliances to keep the tongue out of the way

Question 293

Acute Respiratory distress Syndrome definition

Answer 293

respiratory failure from over-whelming lung injury or systemic diseaseleading to severe hypoxia with a cxr suggestive of congestive failure but normal cardiac hemodynamic measurements. ARDS decreases surfactant and makes the lung cells leaky so that the alveoli fill up with fluid

Question 294

Acute Respiratory distress Syndrome etiology

Answer 294

idiopathic a large number of illnesses and injuries are associated with alveolar epithelial cell and capillary endothelial cell damage sepsis or aspiration lung contusion/trauma near-drowning burns or pancreatitis

Question 295

Acute Respiratory distress Syndrome diagnostic tests

Answer 295

the cxr shows b/l infiltrates that quickly become confluent (white out). air bronchograms are common ARDs is defines as haveing a pO2/FIO2 ratio below 300. the TIO2 is expressed as a decimal, so room air with 21% oxygen would be 0.21. if the pO2 is 105 on room air (21% oxygen or 0.21), then the ration of Po2/FIO2 is 500 (105/.21). if the pO2 (as measured on ABG) is 70 while breathing 50% oxygen, the ration is 70/0.5 or 140 ards is associated with normal findings on right heart catheterization, the wedge pressure is normal, but dont have to measure

Question 296

pO2/FIO2<300

Answer 296

ards

Question 297

pO2/FIO2<200

Answer 297

moderatly severe ards

Question 298

pO2/FIO2<100

Answer 298

severe

Question 299

ARDS treatment

Answer 299

low tidal volume mechanical ventilation is the best support while wiating to see if the lungs will recover. use 6 ml per kg of tidal volume. steroids are not clearly beneficial in most cases. they may help in late stage disease in which pulmonary fibrosis develops pee is used when the pt is undergoing mechanica ventilation to try to decrease the FIO2. level sof fio2 above 50% are toxic tot eh lungs. maintain the plateau pressure of less than 30cm of water. this is measured on the ventilator

Question 300

no treatment is proven to reverse

Answer 300

areds, dont gorget to treat the underlying cause