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ABIM IM Recert > MKSAP Board Basics Pulmonology > Flashcards

MKSAP Board Basics Pulmonology Flashcards

1
Q

What FEV1/FVC ratio indicates airflow obstruction?

A

Less than 0.7 (70%)

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2
Q

What increase in FEV1 with bronchodilator therapy indicates reversible airway obstruction?

A

12% or more

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3
Q

What increase in FVC with bronchodilator therapy indicates reversible airway obstruction?

A

12% or more

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4
Q

What volume (mL) increase in FEV1 with bronchodilator therapy indicates reversible airway obstruction?

A

200 mL or more

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5
Q

What volume (mL) increase in FVC with bronchodilator therapy indicates reversible airway obstruction?

A

200 mL or more

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6
Q

What is the role of flow-volume loops in obstructive lung disease?

A

Help localize anatomic sites of airway obstruction.

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7
Q

What TLC indicates restrictive lung disease?

A

Less than 80%

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8
Q

If patients have a normal DLCO and low lung volumes - what is the most likely cause?

A

Extra-pulmonary cause such as obesity

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9
Q

If patients have a low DLCO and low lung volumes - what is the most likely cause?

A

Pulmonary fibrosis

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10
Q

If patients have a low DLCO and normal lung volumes - what are the most likely causes?

A
  • Anemia
  • Pulmonary vascular disease
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11
Q

If patients have a low DLCO and FEV1/FVC of less than 0.7 - what are the most likely causes?

A

COPD
Bronchiectasis

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12
Q

If patients have a normal or high DLCO and FEV1/FVC of less than 0.7 - what is the most likely cause?

A

Asthma

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13
Q

What are causes of high DLCO?

A

Pulmonary hemorrhage
Left-to-right shunt
Polycythemia

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14
Q

Measures percentage of oxyhemoglobin; performed at rest or during exercise.

What test is this?

A

Pulse oximetry

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15
Q

What should you use when carbon monoxide poisoning is suspected?

A

Co-oximetry

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16
Q

Airflow is measured before and after challenge.

What test is this?

A

Bronchial (methacholine) challenge testing

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17
Q

Performed for unexplained dyspnea, symptoms disproportionate to the measured pulmonary function abnormality, and other exercise-related symptoms.

What test/investigation is described?

A

Cardiopulmonary exercise testing

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18
Q

Useful to assess disability, need for supplemental oxygen, and prognosis in chronic lung conditions. Simple oximetry and desaturation studies are performed at rest and with exertion.

What test is this?

A

6-minute walk test

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19
Q

Is exhaled nitric oxide increased or decreased in patients with airway inflammation, including asthma?

A

Increased

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20
Q

Is pulse oximetry increased, normal or decreased after carbon monoxide poisoning?

A

Normal

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21
Q

Is pulse oximetry increased, normal or decreased after cyanide poisoning?

A

Normal

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22
Q

What happens to pulse oximetry reading in patients with shock?

A

It is falsely low.

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23
Q

What should you think of with any cough that is nocturnal, seasonal, or related to a workplace or activity?

A

Asthma

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24
Q

What are the nasal polyps and aspirin sensitivity are associated with?

A

Asthma

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25
Q

Does normal spirometry rule out asthma?

A

No

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26
Q

Does a normal bronchoprovocation test rule out asthma?

A

Yes

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27
Q

What does a positive bronchoprovocation test confirm?

A

Airway hyperresponsiveness
(asthma is only one cause)

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28
Q

Is wheezing diagnostic of asthma?

A

No

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29
Q

What should you consider in patients that are wheezing?

A
  • Asthma
  • Heart failure
  • COPD
  • Vocal cord dysfunction
  • Upper airway obstruction
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30
Q

Patient has striking peripheral blood eosinophilia, fever, and weight loss and is a long-term smoker. Chest x-ray shows “photographic-negative” pulmonary edema (peripheral pulmonary edema). Bronchoscopy with biopsy or bronchoalveolar lavage shows a high eosinophil count.

Diagnosis?

A

Chronic eosinophilic pneumonia

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31
Q

Patient has asthma like picture with eosinophilia, markedly high serum IgE levels, and intermittent pulmonary infiltrates. CXR shows radiographic opacities in the upper lobes. Advanced disease can cause fixed obstruction and bronchiectasis.

Diagnosis?

A

Allergic bronchopulmonary aspergillosis

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32
Q

How is allergic bronchopulmonary aspergillosis diagnosed?

A
  • Positive skin test for Aspergillus
  • IgG and IgE antibodies to Aspergillus
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33
Q

Patient has upper airway and sinus disease that precedes difficult-to-treat asthma. There are flares associated with use of leukotriene inhibitors and glucocorticoid tapers. Serum p-ANCA may be elevated, and eosinophilic tissue infiltrate is noted.

Diagnosis?

A

Eosinophilic granulomatosis with polyangiitis

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34
Q

Which tests can you use to diagnose tracheal obstruction and vocal cord dysfunction?

A
  • Direct visualization (laryngoscopy)
  • Flow-volume loops
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35
Q

How do you classify asthma with symptoms 2 times or less per week, and nocturnal symptoms 2 times or less per month?

A

Intermittent

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36
Q

How do you classify asthma with symptoms more than 2 times per week, but less than once a day, and nocturnal symptoms more than 2 times per month?

A

Mild persistent

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37
Q

How do you classify asthma with symptoms daily, and nocturnal symptoms 1 times or more per week, and 2 or more exacerbations per week?

A

Moderate persistent

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38
Q

How do you classify asthma with continual symptoms and frequent nocturnal symptoms?

A

Severe persistent

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39
Q

What is the treatment for intermittent asthma?

A

As needed short acting beta agonist

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40
Q

What is the treatment for mild persistent asthma?

A

Add an inhaled corticosteroid

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41
Q

What is the treatment for moderate persistent asthma?

A
  • Low to medium dose inhaled corticosteroid + long-acting beta agonist
  • Medium dose of inhaled corticosteroid
  • Low to medium dose of inhaled corticosteroid + leukotriene modifier or theophylline.
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42
Q

What is the treatment for severe persistent asthma?

A

High dose of inhaled corticosteroid + long-acting beta agonist or long-acting muscarinic antagonists +/- oral corticosteroids.

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43
Q

Are metoprolol and atenolol selective or non-selective beta blockers?

A

Selective beta blockers

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44
Q

Omalizumab can be used in moderate to severe persistent asthma with inadequate control on inhaled corticosteroids and IgE levels between ______ and _____ kU/L.

A

30 and 700 kU/L

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45
Q

Which anti-interleukin-5 monoclonal antibodies reduce asthma symptoms and are only used in severe cases of asthma when the absolute eosinophil count > 150 cells/microL?

A

Mepolizumab
Reslizumab

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46
Q

Should asthma patients get influenza vaccine?

A

Yes

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47
Q

What happens when you give fluoroquinolones or macrolides to patients taking theophylline?

A

Can cause theophylline toxicity

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48
Q

What happens if you use long-acting beta agonists as a single agent in asthma?

A

Increases mortality

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49
Q

What should you do for an acute exacerbation of asthma during pregnancy?

A

Treatment same as regular asthma except early addition of glucocorticoids is indicated for rapid reversal of airway obstruction during an exacerbation.

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50
Q

Can IV magnesium sulfate be helpful for patients who have life-threatening asthma exacerbations?

A

Yes

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51
Q

What does a normal arterial Pco2 in a patient with severe symptomatic asthma indicate?

A

Impending respiratory failure

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52
Q

What should be considered in patients with asthma signs and symptoms that improve immediately with intubation?

A

Vocal cord dysfunction

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53
Q

What should be measured in COPD patients less than 45 years of age?

A

Alpha-1 anti-trypsin deficiency

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54
Q

Often secondary to an inciting event, such as childhood pneumonia or TB; may be associated with foreign body,
CF, immotile ciliary syndrome, nontuberculous mycobacteria, and aspergillus colonization. Large-volume sputum production with purulent exacerbations; hemoptysis. CXR shows “tram lines”.

Diagnosis?

A

Bronchiectasis

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55
Q

Obstructive pulmonary disease is most common presentation in adult patients; other symptoms may include
recurrent respiratory infections, infertility.

Diagnosis?

A

Cystic fibrosis

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56
Q

Found in current or former smokers; may be idiopathic or associated with other diseases such as RA. Poorly responsive to bronchodilators; responds to smoking cessation and glucocorticoids.

Diagnosis?

A

Adult bronchiolitis

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57
Q

Patient presents with dyspnea without improvement following bronchodilators, normal or hyperinflated lungs on chest
x-ray; associated with injury to small airways; sometimes after lung or stem cell transplantation.

Diagnosis?

A

Bronchiolitis obliterans

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58
Q

Stridor, which may be both inspiratory and expiratory. Flow-volume loop shows expiratory or inspiratory flattening, or both.

Diagnosis?

A

Upper airway obstruction

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59
Q

What is the advantage of COPD patients stopping smoking?

A

It reduces the rate of decline in lung function

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60
Q

When is pulmonary rehabilitation recommended for COPD patients?

A

Symptomatic patients with FEV1 less than 50%.

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61
Q

Which COPD patients is continuous oxygen therapy recommended for?

A
  • Arterial pO2 less than 55 mmHg
  • Oxygen saturation less than 88%
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62
Q

What should you consider for patients with upper lobe emphysema (heterogeneous disease) and low baseline exercise capacity to improve mortality, exercise capacity, and quality of life?

A

Lung volume reduction surgery

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63
Q

When should augmentation therapy with IV human alpha-1 antitrypsin for patients with severe alpha-1 antitrypsin deficiency be considered?

A
  • Alpha-1 antitrypsin activity level < 11 µm
  • FEV1 less than 65%
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64
Q

Can lung transplantation increase quality of life and functional capacity in select COPD patients?

A

Yes

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65
Q

Are PDE-4 inhibitors indicated for acute bronchospasm?

A

No

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66
Q

Is clubbing a feature of COPD?

A

No

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67
Q

What should you consider in patients with cystic fibrosis and acute abdominal pain?

A

Intestinal intussusception

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68
Q

Which vaccines do all cystic fibrosis patients need?

A
  • Pneumococcal conjugate and polysaccharide vaccines
  • Influenza vaccine
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69
Q

What medications do you add in acute pulmonary exacerbations in cystic fibrosis patients?

A

Antipseudomonal antibiotics

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70
Q

What do you use for suppression of chronic pulmonary infections in cystic fibrosis patients?

A

Aerosolized tobramycin

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71
Q

What do you use for persistent airway secretions in cystic fibrosis patients?

A
  • Aerosolized recombinant human DNase (dornase alfa)
  • Hypertonic saline
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72
Q

What do you use for symptoms of airway obstruction in cystic fibrosis patients?

A
  • Inhaled bronchodilators
  • Glucocorticoids
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73
Q

What do you use for nocturnal hypoxemia or hypercarbia in cystic fibrosis patients?

A

Nighttime noninvasive mechanical ventilation (cPAP/BiPAP)

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74
Q

What do you do in cystic fibrosis patients advanced lung disease or liver disease?

A

Evaluation for lung transplant

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75
Q

A patient has flulike illness; x-ray shows focal areas of consolidation that may migrate from one location to another.

Diagnosis?

A

Cryptogenic organizing pneumonia

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76
Q

A > 50 year old patient with chronic, insidious onset of cough and dyspnea; chest x-ray shows honeycombing, bibasilar infiltrates with fibrosis.

Diagnosis?

A

Idiopathic pulmonary fibrosis

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77
Q

What is the mortality rate of acute interstitial pneumonia?

A

50%

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78
Q

Affects women in their 30s and 40s; associated with spontaneous pneumothorax and chylous effusions. Chest CT shows cystic disease.

Diagnosis?

A

Lymphangioleiomyomatosis

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79
Q

Chest x-ray shows “photographic negative” of HF, with peripheral alveolar infiltrates predominating. Other findings may include peripheral blood eosinophilia and eosinophilia on bronchoalveolar lavage.

Diagnosis?

A

Chronic eosinophilic pneumonia

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80
Q

Median age of 40 years, and males predominate among smokers but not in nonsmokers. Diagnosed via bronchoalveolar lavage, which shows abundant protein in the airspaces; chest CT shows “crazy paving” pattern.

Diagnosis?

A

Pulmonary alveolar proteinosis

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81
Q

Are patients with dyspnea for days or weeks (vs months) more likely to have pneumonia or heart failure than diffuse parenchymal lung disease?

A

Yes

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82
Q

What percentage of patients with diffuse parenchymal lung disease have normal chest X-rays?

A

20%

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83
Q

What should you consider in patients with dyspnea and pulmonary crackles but no other findings of heart failure?

A

Diffuse parenchymal lung disease

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84
Q

What improves survival and quality of life in idiopathic pulmonary fibrosis?

A

Lung transplantation

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85
Q

Do pirfenidone and nintedanib demonstrate benefit in slowing disease progression for select patients with interstitial lung disease?

A

Yes

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86
Q

Is oxygen therapy indicated for interstitial lung disease patients with hypoxemia?

A

Yes

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87
Q

Should you intubate and mechanically ventilate patients
with respiratory failure caused by interstitial pulmonary fibrosis (IPF)?

A

No
(can’t extubate them afterwards - they’ll need a tracheostomy and lung transplant)

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88
Q

What is Lofgren syndrome?

A

Sarcoidosis with the following constellation:
- Fever
- Bilateral hilar lymphadenopathy
- Erythema nodosum
- Ankle arthritis

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89
Q

What is a characteristic pathologic finding in sarcoidosis patients?

A

Non-caseating granulomatosis

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90
Q

Should slit-lamp examinations be done for all sarcoidosis patients?

A

Yes

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91
Q

Should an EKG be done to rule out heart block or other cardiac abnormalities in all sarcoidosis patients?

A

Yes

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92
Q

Should you always rule out TB and fungal infections by ordering appropriate stains and culture on tissue biopsy in sarcoidosis patients?

A

Yes

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93
Q

What disease that is often found in workers in light bulb or semiconductor factories may cause a sarcoidosis-like
clinical syndrome?

A

Berylliosis

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94
Q

Does ACE level confirm the diagnosis of sarcoidosis?

A

No

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95
Q

What medications are indicated for progressive or symptomatic pulmonary sarcoidosis; hypercalcemia; or cardiac, ophthalmologic, or neurologic sarcoidosis?

A

Oral glucocorticoids

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96
Q

What medications are prescribed for skin lesions or anterior uveitis in sarcoidosis patients?

A

Topical glucocorticoids

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97
Q

What medications are used for nasal polyps or airway disease in sarcoidosis?

A

Inhaled glucocorticoids

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98
Q

What is the rate of spontaneous remission and resolution in Lofgren syndrome?

A

80%

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99
Q

Should you treat asymptomatic sarcoidosis?

A

No

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100
Q

How is occupational asthma and reactive airways dysfunction syndrome treated?

A

Inhaled glucocorticoids

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101
Q

What should patients with silicosis, fever and cough be evaluated for?

A

Tuberculosis (incidence is increased in silicosis)

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102
Q

What is the latent period for development of asbestosis and mesothelioma?

A

10 - 15 years

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103
Q

Does exposure to asbestos increases the risk of lung cancer in cigarette smokers?

A

Yes

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104
Q

In patients with a history of asbestos exposure or asbestosis, how can the risk of lung cancer mortality be decreased at any time?

A

Smoking cessation

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105
Q

What is the treatment for localized mesothelioma?

A

Surgery

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106
Q

How do you prevent recurrences of mesothelioma?

A
  • Radiation
  • Chemotherapy
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107
Q

What is indicated for any new unexplained pleural effusion?

A

Thoracentesis

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108
Q

When is observation and therapy without thoracentesis reasonable for a pleural effusion?

A
  • Known heart failure
  • Small parapneumonic effusions
  • CABG surgery
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109
Q

What is the pleural fluid protein–serum protein ratio in an exudate?

A

> 0.5

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110
Q

What is the pleural fluid LDH in an exudate?

A

> 200 U/L

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111
Q

What is the pleural fluid LDH–serum protein LDH ratio in an exudate?

A

> 0.6

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112
Q

What is the usual RBC count of the pleural fluid in case of malignancy?

A

RBC count 5000-10,000/µL (bloody)

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113
Q

What is the usual RBC count of the pleural fluid in case of malignancy?

A

RBC count 5000-10,000/µL (bloody)

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114
Q

What is the usual RBC count of the pleural fluid in case of pulmonary infarction?

A

RBC count 5000-10,000/µL (bloody)

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115
Q

What percentage of the white blood cells are lymphocytes in the pleural fluid in case of tuberculosis?

A

> 80%

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116
Q

What percentage of the white blood cells are lymphocytes in the pleural fluid in case of sarcoidosis?

A

> 80%

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117
Q

What percentage of the white blood cells are lymphocytes in the pleural fluid in case of sarcoidosis?

A

> 80%

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118
Q

What percentage of the white blood cells are lymphocytes in the pleural fluid in case of lymphoma?

A

> 80%

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119
Q

If the pleural fluid shows nucleated cells >50,000/µL what should you think of?

A
  • Complicated parapneumonic effusions
  • Empyema
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120
Q

What is the pH of the pleural fluid in case of complicated parapneumonic effusion?

A

pH < 7.0

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121
Q

What is the pH of the pleural fluid in case of esophageal rupture?

A

pH < 7.0

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122
Q

What is the pH of the pleural fluid in case of lupus pleuritis?

A

pH < 7.0

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123
Q

What is the pH of the pleural fluid in case of rheumatoid pleuritis?

A

pH < 7.0

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124
Q

What is the pH of the pleural fluid in case of tuberculosis?

A

pH < 7.0

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125
Q

If the pleural fluid shows pleural fluid amylase to serum amylase ratio > 1 what should you think of?

A
  • Pancreatic disease
  • Esophageal rupture
  • Cancer
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126
Q

What is the glucose level in the pleural fluid in case of complicated parapneumonic effusion?

A

< 60 mg/dL

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127
Q

What is the glucose level in the pleural fluid in case of complicated parapneumonic effusion?

A

< 60 mg/dL

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128
Q

What is the glucose level in the pleural fluid in case of lupus pleuritis?

A

< 60 mg/dL

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129
Q

What is the glucose level in the pleural fluid in case of rheumatoid pleuritis?

A

< 60 mg/dL

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130
Q

What is the glucose level in the pleural fluid in case of tuberculosis?

A

< 60 mg/dL

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131
Q

What is the glucose level in the pleural fluid in case of cancer?

A

< 60 mg/dL

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132
Q

What is the glucose level in the pleural fluid in case of empyema?

A

< 60 mg/dL

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133
Q

Which test is most likely to yield a positive tuberculosis culture?

A

Pleural biopsy

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134
Q

Is the level of adenosine deaminase increased or decreased in most tuberculosis pleural fluid samples?

A

Increased

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135
Q

After how many samples of pleural fluid is the yield for positive malignant cytology is maximized?

A

2

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136
Q

What should be performed for an undiagnosed exudative effusion (two negative cytology examinations) when
malignancy is suspected?

A

Thoracoscopy

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137
Q

At what pleural fluid pH does a parapneumonic pleural effusion require chest tube drainage?

A

pH < 7.2

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138
Q

At what pleural fluid glucose level does a parapneumonic pleural effusion require chest tube drainage?

A

Glucose < 60 mg/dL

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139
Q

For patients with malignant effusions, indwelling pleural catheters provide symptom relief; what percentage of patients achieve spontaneous obliteration of the pleural space (pleurodesis) after 6 weeks?

A

Up to 70%

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140
Q

What is the percentage success rate of chemical pleurodesis with talc in patients in malignant effusions?

A

90%

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141
Q

What should you do for moderate to large effusions associated with pneumonia.

A

Thoracentesis

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142
Q

Are pleural effusions associated with nephrotic syndrome common?

A

Yes

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143
Q

Are pulmonary embolisms and renal vein thromboses common in patients with nephrotic syndrome?

A

Yes

144
Q

What should you consider when chylothorax is diagnosed in a premenopausal woman?

A
  • Pulmonary lymphangioleiomyomatosis
145
Q

What should you think of when tall men who smoke present with chest pain and dyspnea?

A

Spontaneous pneumothorax

146
Q

What is the most common cause of secondary pneumothorax?

A

Emphysema

147
Q

What should you think of with falling BP and oxygen saturation, tracheal deviation, and absence of breath sounds in one
hemithorax?

A

Tension pneumothorax

148
Q

What test should you do in a patient with dyspnea, pleurisy, or both, even if the physical examination is normal?

A

Chest X-ray (upright)

149
Q

Should you wait for chest x-ray results before treating a suspected tension pneumothorax with needle decompression?

A

No

150
Q

When should you put a chest tube in for secondary pneumothorax?

A

When it is more than 2 cm

151
Q

What is considered a small pneumothorax?

A

Less than 2 cm

152
Q

Should patients with scleroderma be screened with a transthoracic echocardiogram for pulmonary hypertension?

A

Yes

153
Q

Should patients with congenital heart disease with systemic-to-pulmonary shunts be screened with a transthoracic echocardiogram for pulmonary hypertension?

A

Yes

154
Q

Should first degree relatives of patients with familial pulmonary arterial hypertension be screened with a transthoracic echocardiogram for pulmonary hypertension?

A

Yes

155
Q

Should liver transplant candidates with portal hypertension be screened with a transthoracic echocardiogram for pulmonary hypertension?

A

Yes

156
Q

What is the resting mean pulmonary arterial pressure in pulmonary hypertension?

A

≥ 25 mm Hg

157
Q

Patient presents with unexplained dyspnea, decreased exercise tolerance, syncope and near-syncope, chest pain, and lower extremity swelling. Physical examination findings include a right ventricular heave, right-sided S3, widely split S2, increased P2, and increased jugular venous distention with a large a wave.

Diagnosis?

A

Pulmonary hypertension

158
Q

What does the presence of Raynaud phenomenon suggest?

A
  • Scleroderma
  • Systemic lupus erythematosus
159
Q

What drugs pre-dispose to development of pulmonary hypertension?

A
  • Cocaine
  • Fenfluramine
  • Amphetamines
160
Q

What is the initial study to diagnoses pulmonary hypertension?

A

Echocardiography

161
Q

What systolic pulmonary artery pressure on echocardiography is suggestive of pulmonary hypertension?

A

More than 40 mmHg

162
Q

What study is indicated to evaluate for intracardiac shunts (e.g., ASD)?

A
  • Bubble contrast echocardiography
  • Transesophageal echocardiography
163
Q

How do you confirm the diagnosis of pulmonary hypertension?

A

Right heart catheterization

164
Q

How do you quantify the degree of pulmonary hypertension?

A

Right heart catheterization

165
Q

How do you exclude left ventricular dysfunction as a cause of pulmonary hypertension?

A

Left heart catheterization and coronary angiography

166
Q

What is the next step if a diagnosis of pulmonary arterial hypertension is confirmed?

A

Vasoreactivity test using vasodilating agents to measure changes in pulmonary artery pressure with a right heart catheter in place

167
Q

What are the two diagnostic criteria for chronic thromboembolic pulmonary hypertension (CTEPH)?

A
  • Pulmonary arterial pressure ≥25 mm Hg in the absence of left-sided heart failure
  • Compatible imaging evidence of chronic thromboembolism by V/Q scanning
168
Q

What are most cases of pulmonary hypertension attributed to?

A
  • Left-sided heart disease
  • Hypoxic respiratory disorders
169
Q

Is a high-resolution CT scan or a V/Q scan superior in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH)?

A

V/Q scan

170
Q

Is long-term term anti-coagulation necessary in patients with chronic thromboembolic pulmonary hypertension (CTEPH)?

A

Yes

171
Q

What is the definitive therapy of chronic thromboembolic pulmonary hypertension (CTEPH)?

A

Pulmonary thromboendarterectomy

172
Q

Should you use calcium channel blockers if pulmonary artery pressure is not decreased with a vasoreactivity test?

A

No

173
Q

What is the treatment for pulmonary hypertension that is not responsive to medical therapy?

A

Lung or heart-lung transplantation

174
Q

When is oxygen therapy indicated in patients with pulmonary hypertension?

A

≤ 90%

175
Q

What should you think of in a patient with hemoptysis, mucocutaneous telangiectasias, and evidence of right-to-left pulmonary shunts (hypoxemia, polycythemia, clubbing, cyanosis, stroke, brain abscess)?

A

Pulmonary arteriovenous malformation

176
Q

What is the initial test to diagnose a pulmonary arteriovenous malformation?

A

CT chest

177
Q

What is the treatment of symptomatic or large pulmonary arteriovenous malformations (>2 cm)?

A
  • Embolotherapy
  • Surgery
178
Q

What does a pulmonary arteriovenous malformation (AVM) look like on Chest X-ray?

A

Pulmonary nodule

179
Q

In high-risk populations, lung cancer screening results in a _____ lung cancer mortality reduction.

A

20%

180
Q

In high-risk populations, lung cancer screening results in a ____% lung cancer mortality reduction.

A

20%

181
Q

Which patients need to be screened for lung cancer?

A

Between ages of 55 to 75-79 years with a 30-pack-year history of smoking, who are either currently smoking, or have quit within the last 15 years.

182
Q

When do you stop screening patients for lung cancer?

A
  • Until age 75 - 80 years
  • More than 15 years since they quit smoking
  • Co-morbidity limiting survival
183
Q

How do you screen patients for lung cancer?

A

Low dose CT imaging annually

184
Q

Should you screen people who are at low risk for lung cancer?

A

No (risk outweighs benefit)

185
Q

What is the initial investigation for hemoptysis?

A

Chest X-ray

186
Q

Does a negative CXR exclude lung cancer?

A

No

187
Q

Which test should be used in patients at high risk of lung cancer who present with hemoptysis and negative chest x-ray?

A
  • Fiberoptic bronchoscopy
  • Chest CT if fiberoptic bronchoscopy is contra-indicated or bleeding persists despite normal bronchoscopic findings
188
Q

What is the cause of death in massive hemoptysis?

A

Asphyxiation from airway obstruction

189
Q

What should be done when adequate gas exchange is threatened in hemoptysis?

A

Intubation and mechanical ventilation

190
Q

How can you localize and treat bronchial artery lesions causing hemoptysis?

A

Angiography

191
Q

What is the definition of a solitary pulmonary nodule?

A

A lesion of the lung parenchyma measuring ≤ 3 cm in diameter that is not associated with other lesions or lymphadenopathy and is not invading other structures.

192
Q

What percentage of solitary pulmonary nodules are bronchogenic carcinoma?

A

35%

193
Q

In what percentage of patients with solitary pulmonary nodule does fiberoptic bronchoscopy with biopsy provides sufficient information?

A

30%

194
Q

Which has a better yield for malignant solitary pulmonary nodules: fiberoptic bronchoscopy with biopsy or percutaneous transthoracic needle aspiration biopsy?

A

Percutaneous transthoracic needle aspiration biopsy (although it is not always diagnostic)

195
Q

What percentage of malignant solitary pulmonary nodules are positive on PET scan?

A

> 90%

196
Q

What is the follow-up for a low-risk patient with a solitary nodule measuring < 6 mm?

A

No follow-up

197
Q

What is the follow-up for a low-risk patient with a solitary nodule measuring > 8 mm?

A

Consider CT at 3 months, PET/CT, or tissue sampling

198
Q

What is the follow-up for a low-risk patient with a solitary lung nodule measuring 6 - 8 mm?

A

CT at 6 - 12 months, then consider CT at 18 - 24 months

199
Q

What is the follow-up for a high-risk patient with a solitary nodule measuring < 6 mm?

A

Optional CT at 12 months

200
Q

What is the follow-up for a low-risk patient with a solitary nodule measuring 6 - 8 mm?

A

CT at 6-12 months, then CT at 18-24 months

201
Q

What is the follow-up for a low-risk patient with a solitary nodule measuring > 8 mm?

A

Consider CT at 3 months, PET/CT, or tissue sampling

202
Q

What is the follow-up for a pure ground glass solitary pulmonary nodule measuring < 6 mm?

A

No follow-up

203
Q

What is the follow-up for a pure ground glass solitary pulmonary nodule measuring ≥ 6 mm?

A

CT at 6 - 12 months to confirm persistence, then CT every 2 years until 5 years

204
Q

What is the follow-up for a part solid solitary pulmonary nodule measuring ≥ 6 mm?

A

CT at 3 - 6 months to confirm persistence. If unchanged and solid component remains < 6 mm, annual CT should be performed for 5 years

205
Q

What is the follow-up for a part solid solitary pulmonary nodule measuring < 6 mm?

A

No follow-up

206
Q

What is definition of a pulmonary mass?

A

Pulmonary nodule more than 3 cm

207
Q

What is the next step in evaluating a pulmonary mass (> 3 cm)?

A
  • Biopsy (absence of suspected metastases)
  • Surgical resection (no evidence of metastases)
208
Q

What should you do before ordering contrast CT, bronchoscopy, or PET scan for a lung nodule?

A

Compare current image with previous image to determine stability over time.

209
Q

When are PET scans falsely negative in pulmonary nodule evaluation?

A

Alveolar cell carcinoma
Lesions < 1 cm in diameter

210
Q

When are PET scans falsely positive in pulmonary nodule evaluation?

A

Various inflammatory lesions

211
Q

Does a nonspecific negative result from fiberoptic bronchoscopy or transthoracic needle aspiration biopsy reliably exclude the presence of a malignant growth?

A

No

212
Q

What are the most common masses in the posterior mediastinum?

A

Schwannomas

213
Q

What are the most common masses in the anterior mediastinum?

A

Thymus (most common)
Lymphoma (second most common)

214
Q

What are the most common masses in the middle mediastinum?

A

Lymph nodes

215
Q

What neck circumference determines obesity?

A

> 17 inches

216
Q

Which condition, if untreated, can lead to CAD, acute MI during sleep, systemic and PAH, HF, recurrent AF, stroke, insulin resistance, mood disorders, or parasomnias?

A

Obstructive sleep apnea (OSA)

217
Q

What is the criteria for diagnosing OSA on a sleep study?

A

Apnea-hypopnea index (AHI) > 5/h

218
Q

What separates obesity-hypoventilation syndrome from obstructive sleep apnea (OSA)?

A

Obesity-hypoventilation syndrome is associated with COPD and always with elevated arterial Pco2 levels when awake.

219
Q

Can obesity-hypoventilation syndrome coexist with obstructive sleep apnea?

A

Yes

220
Q

Has overnight oximetry been validated as a screening tool for obstructive sleep apnea (OSA)?

A

No

221
Q

What is the treatment of coexisting obesity-hypoventilation syndrome and obstructive sleep apnea?

A

BiPAP

222
Q

Are oral appliances as effective as CPAP for a treatment of OSA?

A

No

223
Q

Is supplemental oxygen recommended as a primary therapy for OSA?

A

No

224
Q

Is upper airway surgery recommended as initial therapy for OSA?

A

No

225
Q

Patient at high altitude has repetitive arousals from sleep, often with paroxysms of dyspnea.

Diagnosis?

A

High-altitude periodic breathing (HAPB)

226
Q

Patient at high altitude has headache, fatigue, nausea, and vomiting, in addition to disturbed sleep related to high-altitude periodic breathing (HAPB).

Diagnosis?

A

Acute mountain sickness (AMS)

227
Q

Patient at high altitude has confusion, irritability, ataxia and coma; condition can cause death.

Diagnosis?

A

High-altitude cerebral edema (HACE)

228
Q

Patient at high altitude has cough, dyspnea at rest, pink frothy
sputum, hemoptysis, and pulmonary crackles.

Diagnosis?

A

High-altitude pulmonary edema (HAPE)

229
Q

How can high altitude illnesses be prevented?

A
  • Gradually ascending.
  • Acetazolamide
230
Q

Which medication helps acclimatization to high altitude?

A

Acetazolamide

231
Q

What is the treatment of acute mountain sickness?

A
  • Acetazolamide
  • Dexamethasone
  • Oxygen
232
Q

What is the definitive treatment of high-altitude cerebral edema (HACE)?

A

Immediate descent from altitude

233
Q

What is the adjunct treatment (other than descent from altitude) of high-altitude cerebral edema?

A
  • Dexamethasone
  • Supplemental oxygen
  • Hyperbaric therapy
234
Q

What is the treatment of high-altitude pulmonary edema (HAPE)?

A
  • Supplemental oxygen
  • Rest
235
Q

What test should you order if nocturnal hypoventilation is suspected?

A

Polysomnography

236
Q

What is acute respiratory distress syndrome?

A

Hypoxemic respiratory failure presenting as noncardiogenic pulmonary edema

237
Q

Patient has acute onset respiratory failure not explained by heart failure or volume overload, with bilateral lung opacities on imaging.

Arterial Po2/Fio2 ratio of 201-300 mm Hg, measured with PEEP ≥5 cm H2O

Diagnosis?

A

Mild ARDS (acute respiratory distress syndrome)

238
Q

Patient has acute onset respiratory failure not explained by heart failure or volume overload, with bilateral lung opacities on imaging.

Arterial Po2/Fio2 ratio of 101-200 mm Hg, measured with PEEP ≥5 cm H2O

Diagnosis?

A

Moderate ARDS (acute respiratory distress syndrome)

239
Q

Patient has acute onset respiratory failure not explained by heart failure or volume overload, with bilateral lung opacities on imaging.

Arterial Po2/Fio2 ratio of ≤100 mm Hg, measured with PEEP ≥5 cm H2O

Diagnosis?

A

Severe ARDS (acute respiratory distress syndrome)

240
Q

Patient has history of cardiac disease, enlarged heart, S3, chest x-ray showing an enlarged cardiac silhouette, pleural
effusions, and Kerley B lines. There is rapid improvement with diuresis or afterload reduction.

Diagnosis?

A

Cardiogenic pulmonary edema

241
Q

Patient has acute kidney injury with microscopic or gross hematuria or other evidence of vasculitis present. This is associated with stem cell transplantation. Hemosiderin-laden macrophages present in bronchoalveolar lavage fluid.

Diagnosis?

A

Diffuse alveolar hemorrhage

242
Q

Patient with cough, fever, pleuritic chest pain, and myalgia; may be precipitated by initiation of smoking. There are > 15% eosinophils in bronchoalveolar lavage fluid.

Diagnosis?

A

Acute eosinophilic pneumonia

243
Q

Patient with features of dyspnea, volume overload with onset over weeks with progressive course; however, may present in an advanced stage. Positive exposure history (farmers, bird fanciers, hot tub exposure).

Diagnosis?

A

Hypersensitivity pneumonitis

244
Q

Patient with cough and dyspnea that that may be precipitated by viral syndrome. Onset more than 2 weeks with progressive course; however, may present in an advanced stage.

Diagnosis?

A

Cryptogenic organizing pneumonia

245
Q

Patient with acute onset dyspnea and bilateral pulmonary infiltrates, with hypoxemic respiratory failure. No inciting factors. May respond to glucocorticoid administration.

Diagnosis?

A

Acute interstitial pneumonia

246
Q

What mechanical ventilation settings do you need for ARDS?

A
  • Tidal volume of ≤ 6 mL/kg of ideal body weight
  • Plateau (end-inspiratory) pressure < 30 cm H2O (even if this results in “permissive” hypercapnia and acidosis)
247
Q

Should a higher or lower PEEP be used for ARDS?

A

A higher PEEP is usually used; however, outcomes are the same if the plateau (end-inspiratory) pressure < 30 cm H2O

248
Q

What provides mortality benefit in severe ARDS?

A

Prone position

249
Q

Are glucocorticoids indicated for the acute treatment of ARDS?

A

No

250
Q

How long should you attempt noninvasive positive-pressure ventilation prior to considering intubation (time needed for improvement of blood gases and clinical condition)?

A

2 hours

251
Q

What level of hypoxia is an indication for invasive mechanical ventilation?

A

Arterial Po2 < 60 mm Hg or an O2 saturation < 90% despite supplemental oxygen of 60% or higher.

252
Q

What is the usual tidal volume set at in mechanical ventilation?

A

6 - 8 mL/kg

253
Q

What happens when the tidal volume is too high in patients on mechanical ventilation?

A
  • Barotrauma
  • Respiratory alkalosis
  • Decreased cardiac output
254
Q

What happens when the tidal volume is too low in patients on mechanical ventilation?

A
  • Atelectasis
  • Hypoxemia
  • Hypoventilation
255
Q

What is the usual ventilation rate in mechanical ventilation?

A

8 - 14 breaths/min

256
Q

What happens when the respiratory rate is too low in patients on mechanical ventilation?

A
  • Hypoventilation
  • Acidosis
  • Hypoxemia
  • Patient discomfort
257
Q

What happens when the tidal volume is too high in patients on mechanical ventilation?

A
  • Respiratory alkalosis
  • Air trapping (Auto PEEP)
258
Q

What should the PO2 be maintained at in patients on mechanical ventilation?

A

> 60 mmHg

259
Q

In which situations should respiratory acidosis be tolerated rather than increasing the tidal volume?

A

ARDS (Acute respiratory distress syndrome)

260
Q

What reduces the risk of ventilator associated pneumonia?

A
  • Semi-recumbant position
  • Selective decontamination of oropharynx (topical
    gentamicin, colistin, or vancomycin)
261
Q

What are the parameters (arterial O2 saturation, breathing FiO2, PEEP, and pH) when extubation can be considered?

A
  • Arterial O2 saturation > 90%
  • Breathing Fio2 ≤ 0.5
  • PEEP < 5 cm H2O
  • pH >7.30
262
Q

What should the arterial O2 saturation be before the patient can be extubated?

A

> 90%

263
Q

What should the arterial breathing FiO2 be before the patient can be extubated?

A

≤ 0.5

264
Q

What should the PEEP be before the patient can be extubated?

A

< 5 cm H2O

265
Q

What should the pH be before the patient can be extubated?

A

> 7.3

266
Q

Do paired daily spontaneous awakening trials (withdrawal of sedatives) with daily spontaneous breathing trials result in a reduction in mechanical ventilation time, ICU and hospital length of stay, and 1-year mortality rates?

A

Yes

267
Q

Should synchronized intermittent mandatory ventilation be selected as a weaning mode?

A

No

Studies have demonstrated this mode actually takes longer to liberate patients from the ventilator.

268
Q

What type of shock has low cardiac output, elevated pulmonary capillary wedge pressure (PCWP), and high systematic vascular resistance?

A

Cardiogenic shock

269
Q

What type of shock has low cardiac output, low pulmonary capillary wedge pressure (PCWP), and high systematic vascular resistance?

A

Hypovolemic shock

270
Q

What type of shock has low cardiac output, variable pulmonary capillary wedge pressure (PCWP), and high systematic vascular resistance (may have cardiac tamponade, pulmonary embolism or tension pneumothorax)?

A

Obstructive shock

271
Q

What type of shock has high cardiac output, normal pulmonary capillary wedge pressure (PCWP), and low systematic vascular resistance (may have wheezing, angioedema, urticaria, rash)?

A

Anaphylactic shock

272
Q

What type of shock has high cardiac output that later becomes depressed, and low systematic vascular resistance (fever, leukocytosis)?

A

Septic shock

273
Q

Should you use cortisol stimulation testing in patients with septic shock?

A

No

274
Q

Which route of nutrition is preferred in the ICU?

A

Enteral

275
Q

Should you use non-invasive ventilation in patients with septic shock?

A

No

276
Q

How long should you wait before starting total parenteral nutrition in the ICU in most patients (not malnurished)?

A

After day 7

277
Q

What is the formula used to estimate caloric needs in the ICU?

A

25 - 35 kcal/kg/d

278
Q

Patient has critical illness polyneuropathy (with axonal nerve degeneration) and critical illness myopathy (with muscle myosin loss).

Diagnosis?

A

ICU acquired illness

279
Q

What is the treatment of ICU acquired illness?

A
  • Supportive therapy
  • Early mobilization
  • Physical and occupational therapy
280
Q

Patient is young athlete or soldier with environmental exposure; has encephalopathy and fever.

Diagnosis?

A

Heat stroke (exertional)

281
Q

What it the treatment of exertional heat stroke?

A

Ice water immersion

282
Q

Should you treat exertional heat stroke with ice water immersion?

A

Yes

283
Q

Should you treat non-exertional heat stroke with ice water immersion?

A

No

284
Q

A ≥ 70 years old patient presents with encephalopathy and fever with no evidence of infection; they may use anticholinergic, sympathomimetic, and diuretic drugs.

Diagnosis?

A

Non-exertional heat stroke

285
Q

What it the treatment of non-exertional heat stroke?

A

Evaporative, external cooling

286
Q

Patient with exposure to volatile anesthetic (halothane isoflurane, succinylcholine, or decamethonium); has masseter muscle rigidity and increased arterial Pco2.

Diagnosis?

A

Malignant hyperthermia

287
Q

What is the treatment of malignant hyperthermia?

A
  • Stop inciting drug
  • Dantrolene
288
Q

Patient on haloperidol, olanzapine, quetiapine, and risperidone or withdrawal from L-dopa; onset over days to weeks; with altered mentation, severe rigidity, increased heart rate, increased blood pressure, no clonus, decreased reflexes.

Diagnosis?

A

Neuroleptic malignant syndrome

289
Q

Patient has onset within 24 h of initiation or increasing dose of SSRI; has agitation, rigidity, clonus, increased reflexes.

Diagnosis?

A

Severe serotonin syndrome

290
Q

What is the treatment of severe serotonin syndrome?

A
  • Stop inciting drug
  • Benzodiazepines
  • Cyproheptadine
291
Q

What is the treatment of neuroleptic malignant syndrome?

A
  • Stop inciting drug
  • Dantrolene
  • Bromocriptine
292
Q

How long does it take for neuroleptic malignant syndrome to resolve after treatment?

A

Days to weeks

293
Q

How long does it take for selective serotonin syndrome to resolve after treatment?

A

24 hours

294
Q

Can neuroleptic malignant syndrome occur in patients who have abruptly discontinued L-dopa for Parkinson disease?

A

Yes

295
Q

The serotonin syndrome is often caused by the use of SSRIs and the addition of a second drug that increases serotonin release or blocks its uptake or metabolism.

True or false?

A

True

296
Q

What is the definition of hypertensive emergency?

A

BP ≥ 180/120 mm Hg and symptoms or evidence of end-organ damage

297
Q

Should patients with hypertensive emergency be hospitalized?

A

Yes

298
Q

What is the target blood pressure in severe preeclampsia or eclampsia, or pheochromocytoma crisis?

A

Systolic blood pressure < 140 mmHg in the first hour

299
Q

What is the target blood pressure in aortic dissection?

A

Systolic blood pressure < 120 mmHg in the first hour

300
Q

If a patient without a compelling condition has hypertension emergency how should the blood pressure be reduced?

A

No more than 25% lower in the first hour, and then 160/100 mmHg in the next 2 - 6 hours; and cautiously reduce to normal in the next 24 - 48 hours.

301
Q

What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with acute aortic dissection?

A
  • Esmolol
  • Labetalol
302
Q

What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with acute pulmonary edema?

A
  • Nitroglycerin
  • Nitroprusside
303
Q

What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with acute coronary syndrome?

A
  • Esmolol
  • Nitroglycerin
304
Q

Can you treat hypertensive emergency in the ICU in patients with acute pulmonary edema with IV beta-blockers?

A

No

305
Q

What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with acute kidney injury?

A

Nicardipine

306
Q

What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with eclampsia or preeclampsia?

A
  • Hydralazine
  • Labetalol
  • Nicardipine
307
Q

Should you use sublingual nifedipine for hypertensive urgency?

A

No

308
Q

Should you use sublingual nifedipine for hypertensive emergency?

A

No

309
Q

What is the difference between the mechanism of action of anaphylactic reaction vs anaphylactoid reaction?

A

Anaphylactic reaction is an IgE-allergen interaction
Anaphylactoid reaction is by a non-antibody-antigen mechanism

310
Q

What should you consider as a cause of anaphylaxis during surgery or anaphylaxis in a woman during coitus?

A

Latex allergy

311
Q

What is the drug of choice to treat anaphylaxis?

A

Intramuscular or subcutaneous epinephrine (0.3-0.5 mg of 1:1000)

312
Q

Which medication blocks the effect of epinephrine?

A

Beta-blockers

313
Q

What should you do if anaphylaxis is not responding to epinephrine?

A

Glucagon

314
Q

What is the treatment of anaphylactic shock or refractory symptoms of anaphylaxis?

A

Intravenous epinephrine (1:10,000)

315
Q

Is red man syndrome an allergic reaction?

A

No

316
Q

Patient presents with sudden, temporary edema, usually of the lips, face, hands, feet, penis, or scrotum along with abdominal pain?

Diagnosis?

A

Angioedema

317
Q

Patient with a family history of angioedema presents with sudden, temporary edema; and low C1 inhibitor and C4 levels.

Diagnosis?

A

Hereditary angioedema

318
Q

Patient with lymphoma, MGUS, or systemic lupus erythematosus presents with sudden, temporary edema; low C1q levels (in addition to low C4 and C1 inhibitor levels.

Diagnosis?

A

Acquired C1 inhibitor deficiency causing angioedema

319
Q

Patient on ACE inhibitors presents with sudden, temporary edema; has low C1 inhibitor and C4 levels.

Diagnosis?

A

ACE inhibitor effect causing angioedema

320
Q

Should you diagnose hereditary angioedema in patients with urticaria and angioedema?

A

No

321
Q

What is the treatment of acute episodes of mast cell–mediated (allergic) angioedema with airway compromise or hypotension?

A
  • Epinephrine
  • Antihistamines
  • Glucocorticoids
322
Q

What is the treatment of allergic angioedema?

A

Antihistamines

323
Q

What’s the treatment of acute episodes of bradykinin-mediated angioedema (hereditary or acquired angioedema)?

A

Select C1 inhibitor concentrate

324
Q

What’s the treatment of acute episodes of bradykinin-mediated angioedema (hereditary or acquired angioedema) in an emergency?

A

Fresh frozen plasma

325
Q

What is the long-term management of hereditary angioedema?

A
  • Danazol
  • Stanozolol
326
Q

Is epinephrine effective for hereditary angioedema?

A

No

327
Q

What is the management of patients with smoke inhalation and visibly damaged airway or stridor?

A

Intubation

328
Q

Does a normal LDH level exclude cyanide poisoning?

A

Yes

329
Q

What is the treatment of cyanide poisoning?

A

Hydroxocobalamin

330
Q

Where is the injury when patient presents with clear chest X-ray and wheezing, cough, and dyspnea manifest 12 to 36 hours after smoke inhalation exposure?

A

Lower airways

331
Q

Does normal oxygen saturation exclude carbon monoxide poisoning?

A

No

332
Q

Does normal oxygen saturation exclude cyanide poisoning?

A

No

333
Q

What the treatment of acetaminophen poisoning?

A

N-acetylcysteine

334
Q

What the treatment of benzodiazepines poisoning?

A
  • Observation
  • Flumazenil
335
Q

What the treatment of β-Adrenergic blockers poisoning?

A
  • Glucagon
  • Calcium chloride
  • Pacing
336
Q

What is the treatment of calcium channel blockers poisoning?

A
  • Atropine
  • Calcium
  • Glucagon
  • Pacing
337
Q

What the treatment of digoxin poisoning?

A

Digoxin-immune fab

338
Q

What the treatment of heparin poisoning?

A

Protamine sulfate

339
Q

What the treatment of narcotics poisoning?

A

Naloxone

340
Q

What the treatment of salicylates poisoning?

A
  • Urine alkalinization
  • Hemodialysis
341
Q

What are the (two) treatments of tricyclic antidepressants poisoning?

A
  • Blood alkalinization
  • α-agonist
342
Q

Poisoning with which over the counter medication causes hepatotoxicity?

A

Acetaminophen

343
Q

What kind of poisoning causes sedative affects?

A

Benzodiazepines

344
Q

What kind of poisoning causes bradycardia and hypotension affects?

A
  • β-Adrenergic blockers
  • Calcium channel blockers
345
Q

What kind of poisoning causes dysrhythmias?

A

Digoxin

346
Q

What kind of poisoning causes bleeding diathesis?

A

Heparin

347
Q

What kind of poisoning causes metabolic acidosis/respiratory alkalosis?

A

Salicylates

348
Q

Over-dose of which class of anti-depressants causes anticholinergic effects?

A

Tricyclic antidepressants

349
Q

Patient using grill indoors presents with unexplained flulike symptoms, frontal headache, lightheadedness, difficulty concentrating, confusion, delirium, coma, dyspnea, nausea, and chest pain.

Diagnosis?

A

Carbon monoxide poisoning

350
Q

What tests do you do to evaluate carbon monoxide poisoning?

A
  • ABG studies
  • Serum carboxyhemoglobin
351
Q

What carboxyhemoglobin level is diagnostic of severe acute carbon monoxide poisoning?

A

> 25%

352
Q

Can a pulse oximeter differentiate between carboxyhemoglobin from oxyhemoglobin?

A

No

353
Q

What is the treatment for carbon monoxide poisoning?

A

Normobaric oxygen therapy

354
Q

When is hyperbaric oxygen therapy used for carbon monoxide poisoning?

A
  • Severe carbon monoxide poisoning (loss of consciousness and persistent neurologic deficits)
  • Pregnant patients
  • Patients with cardiac ischemia
355
Q

Patient has persistent cold symptoms for less than 10 days, with nasal drainage and congestion, discomfort in maxillary teeth, and facial pressure. No fever. There is purulent secretion in both nares and edematous nasal turbinates bilaterally.

Diagnosis and organism?

A

Acute rhinosinusitis from rhinovirus

ABIM IM Recert (42 decks)

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