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ABIM > MKSAP9 > Flashcards

MKSAP9 Flashcards

1
Q

What should you think of in a person w/ sx of CF who has dextrocardia?

A

Primary Ciliary Dyskinesia (Kartageners)

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2
Q

Where do silicosis and berylliosis tend to affect the lungs?

A

Often upper lobe predominant; silicosis = sandblasting increased risk of TB; Berryliosis assoc. with aerospace engineer

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3
Q

What should you consider in a patient with hyponatremia with normal or elevated serum osm?

A

Pseudohyponatremia then think about glucose, paraprotein, lipid etc

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4
Q

What is a significant cause of COPD in patients from 3rd world countries who have never smoked?

A

Exposure to Biomass fuels, i.e. using wood etc. to cook in huts and poorly ventilated areas

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5
Q

What is the histopathology of Cryptogenic Organizing Pneumonia?

A

Will see patchy filling of alveoli with loose plugs of granulation tissue; whereas pulmonary alveolar proteinosis has proteinacious material

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6
Q

Does sarcoid usually cause restrictive or obstructive lung dz?

A

Either, or even both (mixed)

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7
Q

How should you evaluate reduced EF within one year of heart transplant?

A

Angiography as the MC cause of reduced EF within 1 year is Cardiac Allograft Vasculopathy

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8
Q

What does progressive dyspnea and sputum production in a smoker or former smoker suggest? Dx?

A

COPD; should check PFTs; obstructive physiology if FEV1:FVC ratio less then 0.7

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9
Q

MC blood products to cause TRALI

A

FFP or Platelets

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10
Q

What is the appropriate mgmt for a patient with persistent hypotension in the setting of acute PE?

A

TPA (100 mg over an hour at HMC) followed by IV heparin gtt; unlike stroke and MI there is NO consensus on timing of when it should be given, i.e. no “window” that you can be “out of”

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11
Q

How can you diagnose paradoxical vocal cord motion? Tx?

A

PFTs or Direct laryngoscopy showing adduction during inspiration; Tx is Speech therapy and CPAP and heliox if severe

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12
Q

How should a patient with bronchiectasis who develops HCAP be treated?

A

Vancomycin plus 2 antipseudomonal abx (cefepime/Zosyn + cipro/levo)

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13
Q

Why is it potentially a bad idea to hold a WHO I pulm HTN who is hypotensive pts home sildenafil or bosentan/ambrisentan?

A

Because these drugs have not been shown in studies to cause systemic HoTN. However, by holding them there will be a rise in PA pressures so less blood can get from R to L and cardiac output will decrease which may ultimately lead to worsening of HoTN

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14
Q

Crunching with each heartbeat is known as ________

A

Hammans sign; seen in pneumomediastinum

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15
Q

What mode on a pacemaker provides AV synchrony? What can it be switched to when undergoing surgery?

A

DDD; DOO (asynchronous mode) allows pacing of the atrium and ventricle but without interference from Bovie

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16
Q

What are the 2 most important things to do for septic patients? Defined based on SOFA of what?

A

Fluids (30 ml/kg bolus within 3 hours) and Abx (in first hour) based on 2018 surviving sepsis campaign guideline; SOFA greater than or equal to 2

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17
Q

What is the recommended initial tx of painful erythema nodosum?

A

NSAIDS

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18
Q

How is Cryptogenic Organizing Pneumonia most often diagnosed? Most appropriate meds?

A

Usually after several failed courses of CAP; appropriate mgmt is with glucocorticoids and if unresponsive then azathioprine

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19
Q

What are the hallmarks of OHS? Dx test?

A

Day time hypoventilation and hypercarbia possibly with resting hypoxemia; draw an ABG

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20
Q

What can imaging of the liver help with a dx of constrictive pericarditis?

A

Doppler US w/ expiratory flow reversal in hepatic veins is c/w the dx

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21
Q

What should you consider in a patient on prophylactic UTI abx who has dyspnea, hypoxemia, and reticulonodular changes on CXR?

A

Nitrofurantoin-induced pulmonary toxicity

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22
Q

What should be the consideration in a patient with unilateral wheezing who is nonresponsive to asthma tx?

A

Concern for endobronchial lesion (i.e. Bronchial carcinoid) and evaluate w/ CT or bronch

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23
Q

What is the mgmt of a tension hemothorax or hydrothorax

A

Unlike tension pneumothorax which requires needle compression, a hemo/hydrothorax causing tension is a surgical emergency and requires immediate placement of a LARGE BORE CHEST TUBE

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24
Q

The presence of what antibody in polymyositis and dermatomyositis increases the risk of ILD?

A

Anti-Jo-1 ab

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25
Q

What is different about ABPA and Eosinophilic Granulomatosis with polyangiitis?

A

ABPA has more of a sever asthma picture w/ maybe some central bronchiectasis and elevated IgE; Churgg-Strauss has migrating infiltrates, sinusitis, peripheral neuropathy and p-ANCA (Anti-MPO)

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26
Q

What should be done for inpatients who have suspected OSA?

A

Referral for an outpatient PSG as overnight O2 sat testing and autotitrating positive pressure ventilation is not recommended

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27
Q

What is the chelation drug of choice for acute iron poisoning, how will it present?

A

Deferoxamine; pt can be in shock, took a bunch of pills, has AGMA - recall that I in MUDPILES is iron and isoniazid

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28
Q

A vasculitis involving the lungs is most likely to be __________

A

An ANCA vascultiis (GPA- anti-PR3 or EGPA- anti-MPO, or microscopic polyangiitis)

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29
Q

What makes the diagnosis of exercise induced asthma?

A

When a patients FEV1 decreases by more than 10% after an exercise challenge (tx is SABA 15 min prior to exercise)

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30
Q

What gene mutation is often found in ppl with Langerhans Histiocytosis?

A

BRAF; recall that Eosinophilic Granuloma = Histiocytosis X and the eosinophilic cells are histiocytes not eosinophils; EM would show Birbeck Granules

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31
Q

Preferred diagnostic test for WHO IV pulm HTN? Mgmt?

A

This is CTEPH so VQ scan or CTA; pulmonary thromboendarterectomy

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32
Q

Tx of severe asthma with high IgE level that doesnt have ABPA

A

Omalizumab (Xolair); if pt also has CXR findings of central bronchiectasis (better on HRCT) would want to check skin test for Aspergillus

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33
Q

What is the dx for a woman undergoing In Vitro fertilization who develops pleural effusions, ascites, edema, and shock?

A

Ovarian Hyperstimulation Syndrome (similar to Meigs Syndrome which involves a tumor) thought to be due to increased capillary hyperpermeability from release of vasoactive stimulants

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34
Q

What are the two main components to treating hypersensitivity pneumonitis? What is seen on BAL?

A

Removal of the offending agent and IV glucocorticoids 0.5-1 mg/kg dose; often a lymphocytic predominant BAL w/ low CD4:CD8 ratio but not specific

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35
Q

Along with a SABA the most appropriate tx for mild persistent asthma is ________

A

inhaled glucocorticoid (fluticasone); inappropriate to start LABA without an inhaled glucocorticoid

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36
Q

What is eosinophilic granuloma? What can be seen on EM?

A

A form of Langerhans Histiocytosis- aka Histiocytosis X; presents in younger ppl w/ hx of smoking; Birbeck Granules and these can be seen in all types of Langerhans histiocytosis

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37
Q

What are the two big ddx for lymphoctyic pleural effusions? How would you further clarify these?

A

Malignancy = get 3 consecutives which will increase sensitivity to 90%; TB = check ADA if >40 more likely, get pleural biopsy to confirm; sputum Cx only if parenchymal TB and IGRA and TST only for latent

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38
Q

What did the SEPSISAM trial show?

A

Patients with chronic HTN who were treated with a MAP goal of 80-85 had decreased need for CRRT but no improvement in mortality while comparing to a MAP goal of 65

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39
Q

What drugs are used for Acute Mountain Sickness? High Altitude Cerebral Edema? High Altitude Pulmonary Edema?

A

Acetzolamide for AMS and HACE; Nifedipine for secondary prevention of HAPE

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40
Q

What pumonary dz has histopathology showing loose plugs of granulation tissue in the alveoli?

A

Cryptogenic Organizing Pneumonia

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41
Q

Lichen planus may have a network of white lines on top called __________

A

Wickham Striae

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42
Q

What disease may be associated with high levels of carbohydrates followed by flaccid paralysis?

A

Hypokalemic Periodic Paralysis (Birthday Cake Paralysis); can be assoc with thyrotoxicosis and an intracellular shift of K

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43
Q

What are lung lesions less than 3 cm called? Greater than 3 cm?

A

Nodule (4-30 mm); mass >3 cm

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44
Q

What are the two most commonly used pneumonia risk stratifiers?

A

CRB-65 and PSI w/ higher class PSI either needing steroids and/or admission to ICU

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45
Q

What is the most common extrapulmonary site of disseminated Nocardiosis?

A

CNS; if so the tx must be carbapenem and not just Bactrim

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46
Q

What is the best step in evaluation of a patient with decompensated RV failure and resting hypoxemia in a patient with OSA?

A

i.e. assuming not acute (would be thinking PE); then thing about OHS which is best Dx with resting ABG to document hypercarbia

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47
Q

These develop as anomalous buds from the foregut during development and become symptomatic in the later decades (often posterior mediastinal masses)

A

Bronchogenic Cysts; if symptomatic tx is surgery

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48
Q

What is diffuse panbronchiolitis and who gets it?

A

An obstructive lung dz with dilated bronchioles on CT w/ centrilobular nodules and sinusitis in East Asian populations; different from constrictive bronchiolitis which occurs in military vets from Middle East

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49
Q

What is the difference between constrictive bronchiolitis and panbronchiolitis?

A

Panbronchiolitis occurs in East Asian populations and has dilated bronchioles and centrilobular nodules w/ chronic sinusitis; Panbronchiolitis occurs in middle east troops w/ narrowed bronchioles d/t inhalents and bombs

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50
Q

What should you think if a person has an elevated PA systolic pressure (i.e. mean PA of 25) and an elevated pulmonary capillary wedge pressure?

A

Likely on basis of either systolic or diastolic LV heart failure; WHO II, pulmonary venous HTN ; try to control their risk factors and re-ECHO as needed to document improvement

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51
Q

What is the utility of hydroxyurea in acute chest syndrome?

A

Not useful in acute setting but can reduce frequency; need to give pain control, IVF, supplemental O2 (which is a pulm. Vasodilator), and simple or exchange xfusion as indicated

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52
Q

What is the purpose of supplemental O2 in IPF? What are two antifibrotic drugs that can be used

A

Always use when there is hypoxemia but it also delays onset of pulmonary HTN (WHO III) bc it is a vasodilator and also delays cor pulmonale; Nintedanib and perfenidone

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53
Q

What is the most appropriate initial tx of Pulmonary Alveolar Proteinosis? Chronic Tx?

A

Whole lung lavage; subQ GM-CSF as it is assoc. with anti-GM-CSF abs

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54
Q

What sort of supplementation does a patient with primary adrenal failure need vs. a person with central adrenal failure (low ACTH)?

A

A primary adrenal failure will need BOTH glucocorticoid AND mineralocorticoid; a person with central adrenal failure only needs glucocorticoid bc aldosterone is part of the RAAS and so as long as the gland itself isnt destroyed is still made appropriately

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55
Q

What disease will have a crazy paving pattern on CT of lung

A

Pulmonary Alveolar Proteinosis; tx whole lung lavage; assoc w/ Anti-GM-CSF abs and tx chronically w/ subQ GM-CSF

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56
Q

What can you say about the long term use of tiotropium in COPD? In whom should it be used carefully?

A

Associated with better outcomes and less frequent exacerbations compared with ipratropium; BPH or bladder outlet issues

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57
Q

What should be on the DDx of precocious bullae in the lungs

A

A1AT def, misuse of IV or inhaled drugs, HIV, autoimmune and congenital, and Idiopathic Giant Bullous Emphysema

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58
Q

What are the 4 variants of Langerhans Histiocytosis?

A

Eosinophilic Granuloma (type assoc with smoking and in younger ppl); Letterer-Siwe - severe/acute disseminated fatal in childhood; Hand-Schuler-Christian Dz w/ bone lesions, diabetes insipidus and bulging eye; and Hashimoto-Pritzker dz- benign self resolving kind

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59
Q

What should be considered in HIV patients with unilateral wheezing not responsive to asthma tx?

A

In general this presentation makes you think of endobronchial lesions; in HIV consider Endobronchial Kaposi Sarcoma

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60
Q

What is the optimal initial tx of pt with hepatic hydrothorax? What broader therapeutic options need to be considered when pt have this?

A

Sodium restriction and diuretic tx; need to be thinking about transplant bc this means they essentially have ESLD

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61
Q

How can you tell if a person has primary hyperaldosteronism due to bilateral adrenal hyperplasia? Tx?

A

If there is failure of lateralization with adrenal venous sampling for levels of aldo then it is bilateral; unilateral = surgery; bilateral = spironolactone which antagonizes aldo receptor

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62
Q

In whom does pyroglutamic acidosis occur?

A

Patients chronically on acetaminophen need to measure urine levels of pyroglutamic acid

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63
Q

What does the histology of IPF show?

A

Usual interstitial pneumonia which has a fibrotic change along with normal lung (like cirrhosis of the lung); whereas cryptogenic organizing pneumonia will have granulation tissue in the alveoli

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64
Q

What can be said about the use of Airway Pressure Release Ventilation (APRV) in ARDS?

A

Has been evaluated in small studies and its use has shown some physiologic improvement but no mortality benefit; will likely worsen hypercapnia

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65
Q

A patient with wheezing exacerbated by exercise who is also symptomatic despite adherence to asthma tx who has a monophasic inspiratory stridor most likely has _________

A

Paradoxical Vocal Cord Motion (will improve on expiratory limb); if intubated will have IMMEDIATE improvement in sx whereas asthma would take time to improve

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66
Q

What should be considered in a scuba diver who experiences acute onset of poor judgment, euphoria, and confusion?

A

Nitrogen Narcosis (different from the Bends bc no muscle pain etc) due to increased solubility of nitrogen under high pressure

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67
Q

What is the most common cause of inherited cardiac amyloidosis?

A

VAL122ILE mutation in transthyretin; important to do amyloid typing as hereditary amyloid is tx supportively while AL is tx with melphalan pred and auto SCT

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68
Q

What needs to be ruled out when diagnosing an IPF pt w/ worsening hypoxemia with an “acute exacerbation of IPF”?

A

This is a legitmate dx but is a dx of exclusion so rule out things like PNA, infxn, pulm edema, or alveolar hemorrhage; may need BAL

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69
Q

What controller medications for COPD have been shown to be effective (3)?

A

LABA (salmeterol), inhaled glucocorticoids, and LAMA (tiotropium)

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70
Q

What is the classic pleural effusion associated with RA?

A

Sterile exudative effusion with low pH and markedly low glucose

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71
Q

What is Dimercaptosuccinate used for?

A

lead, arsenic, and mercury poisoning but not iron; if iron tox then deferoxamine

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72
Q

What is the recommended mgmt of an asymptomatic, unilateral, malignancy-associated pleural effusion?

A

Obervation (British Thoracic Society rec); obviously tx the underlying cancer but can observe the effusion; unless need it for staging then can tap

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73
Q

What is the most likely cause of a chronic cough that is exacerbated by cold or exercise and worsens during sleep?

A

Asthma

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74
Q

What is amyopathic dermatomyositis?

A

Dermatomyositis with just the rash/skin findings (heliotrope rash, Gottrons papules, shawl sign) but no muscle involvement

75
Q

When should COPD patients be considered for lung transplant?

A

If post-bronchodilator test FEV1<25%, baseline PCO2 >50 mmHg, or there is COPD assoc. R heart failure/Cor pulmonale or pulm HTN (WHO III)

76
Q

What is the mechanism of SOB and hypoxia in patients with pulmonary HTN?

A

When pts exert themselves they try to pump more blood to the lungs for oxygenation; with elevated PA pressures they cant get as much blood there and so they become SOB and/or hypoxic

77
Q

What should you consider in pt with ILD that is predominately also assoc with synovitis?

A

RA assoc. ILD; if things like CREST or systemic fibrosis think more about anti-centromere and anti-scl70

78
Q

The studies evaluating prone-positining in severe ARDS showed a 30 day mortality benefit of what?

A

16% mortality in the proned patients vs. 33% in non-proned; severe = P/F of <150 (though that is not exactly how it is usually defined, usually <100)

79
Q

What is the Leser Trelat sign?

A

A sudden erruption of many sebhorreic keratoses

80
Q

What is a bronchopulmonary sequestration?

A

A congenital disorder where a part of the lung does not receive blood supply from pulm circulation; often anomalous from thoracic aorta; diff from bronchogenic cyst bc not anomalous bud from foregut

81
Q

A patient with a 10 day history of cough and suspected infection with Bordatella pertussis should get tx w/ __________

A

Macrolide antibiotic i.e. azithromycin for 5-7 days

82
Q

What is Meigs Syndrome?

A

Triad of benign ovarian tumor with ascites and pleural effusion that resolves with resection of the ovarian tumor; similar things seen in Ovarian Hyperstimulation syndrome with In Vitro Fert

83
Q

What is the primary therapy for a patient with AECOPD?

A

Bronchodilators (albuterol/ipratropium), systemic glucocorticoids, and ONE of a macrolide, a fluoroquinolone, or doxycycline

84
Q

What is the appropriate mgmt for a patient with mild persistent asthma based on clinical sx but with a normal spirometry?

A

Still tx as mild persistent with low dose glucocorticoid and SABA; normal spirometry does NOT exclude the dx; still like spiromety though bc can help track dz longitudinally

85
Q

What situations is Heliox useful?

A

Severe obstructive dz like COPD or status asthmaticus but not for ARDS bc has less than 100% O2

86
Q

What are some features strongly suggestive of pulmonary HTN?

A

Loud P2, LE edema, exercised-induced hypoxemia, and sole reduced DLCO that corrects for alveolar volume

87
Q

What drug is effective for secondary prevention of High Altitude Pulmonary Edema (HAPE)?

A

Nifedipine; it blunts the acute hypoxic pulmonary vasoconstriction and therefore acute/severe pulmonary HTN that leads to pulm edema at high altitude

88
Q

How does supplemental O2 help with pulmonary HTN and delaying the development of it?

A

O2 is a vasodilator and hypoxia leads to hypoxic pulmonary vasoconstriction

89
Q

When is asthma considered to be persistent?

A

When sx occur >2x per week or more than 2 nocturnal awakenings per month

90
Q

When is it ok to start a LABA in asthma tx?

A

Once people have at least been started on inhaled glucocorticoid; there is an increased risk of death in just going to the LABA

91
Q

What is the best step in mgmt of a patient with Hereditary Hemorrhagic Telangiectasia with hypoxemia

A

Could have bleeding pulmonary AVM need CT angio; this dz aka Osler-Weber-Rendu

92
Q

What is a congenital disorder of lung that does not receive its blood supply from the pulmonary circulation?

A

Bronchopulmonary Sequestration (often can manifest as a large, vascular, lower lobe consolidation)

93
Q

What is the best mgmt of hypoventilation resulting from severe kyphosis?

A

BiPAP until the minute ventilation cannot keep up with it, then may need intubation and trache

94
Q

Lupus Pernio is essentially pathognomonic for _______

A

Sarcoidosis; indurated blue-violaceous lesions on ears, cheeks, eyelids, and hands

95
Q

What is the most appropriate tx of aspiration pneumonitis?

A

Supportive car, speech/swallow eval; Aspiration pneumonia often w/ fevers days later

96
Q

What should be considered in patients with known limited cutaneous systemic sclerosis w/ SOB?

A

Pulmonary HTN eval w/ TTE (anti-centromere); if systemic sclerosis then consider ILD (anti-Scl-70)

97
Q

What is Stage IA lung cancer? What is the mgmt?

A

Mass less than 3 cm limited to one lung without involvement of mediastinum, lymph nodes, or distant sites; Surgical resection

98
Q

What is the first line tx of constrictive pericarditis and why?

A

High dose NSAIDs because the constriction may be transient; a patient with ongoing sx can get a pericardiectomy

99
Q

According to the new 2017 ACC/AHA guidelines what is the best tx for BP >140/90

A

Combination tx bc it is stage II HTN

100
Q

What is the intervention most likely to improve OS in a patient with mild ARDS? Severe ARDS?

A

Mild = low tidal volume ventilation (6 mL/kg/IBW); if severe need to do the same but also prone and paralyze w/ cisatracurium; goal always SaO2 >88%, PaO2 >55% and Pplat <30

101
Q

What are some things to consider in an older patient with bronchiectasis?

A

Assuming not CF or ABPA it is likely CVID; CVID dx with quantitative immunoglobulins

102
Q

What is the diagnosis of a young man with a short hx of smoking who has very large bullae in an upper lobe predominant pattern occupying >1/3 of the hemithorax?

A

Idiopathic Giant Bullous Emphysema; Giant Bullae take up >1/3 of the hemithorax

103
Q

How long should patients with severe ARDS be proned for?

A

16 hours per day

104
Q

What is the purpose of primary therapy in COPD exacerbation?

A

Getting bronchodilators (albuterol/ipratropium) on board to reverse bronchoconstriction and aid ventilation

105
Q

What is the most likely dx for a patient with chronic dyspnea and wheeze not responsive to standard asthma meds who has a hx of extended intubation and normal CXR? Dx tests?

A

Tracheomalacia; Can dx with standard and dynamic CT showing dynamic tracheal collapse; if severe may need bronchoscopy with tracheal stent

106
Q

Most appropriate mgmt for suspected HIT

A

Stop heparin and start argatroban, bivalrudin, or fondaparinux

107
Q

What is a reported infectious complication of pulmonary alveolar proteinosis?

A

Nocardia (Tx is bactrim unless CNS then carbapenem)

108
Q

What is the next step in mgmt in a patient with persistent respiratory sx and unchaged opacities after tx for CAP? Diagnostic considerations?

A

CT of chest; can be malignancy or cryptogenic organizing pneumonia which often goes undiagnosed

109
Q

What immunodeficiency can have bronchiectasis?

A

CVID; dx with quantitative immunoglobulins demonstrating hypogammaglobulinemia

110
Q

What is the most likely dx in a farmer who randomly develops dyspnea, abnormal DLCO and ground glass opacities?

A

Hypersensitivity Pneumonitis (thermophylic actinomycetes in moldy hay); different from occupational asthma in that there would not be GG opacities or DLCO issues in asthma

111
Q

What is a consideration in a patient with ARDS, hemoconcentration, thrombocytopenia, and L-shifted leukocytosis?

A

Hantavirus pulmonary syndrome; from rat excrements; Sin Nombre Virus; IgM against the virus can be +

112
Q

A patient with severe COPD and acutely worsening dyspnea whose workup is negative for infectious etiology should be evaluated for _______

A

Pulmonary Embolism (i.e. assuming imaging is normal, can also consider MI or CHF)

113
Q

Eosinophilic Granuloma, Letterer-Siwe, Hand-Schuler-Christian, and Hashimoto-Pritzker dz are ALL variants of _________.

A

Langerhans Histiocytosis; assoc. w/ BRAF gene mutation

114
Q

T/F: interstitial lung disease can be the presenting sx of RA?

A

True; if pt has interstitial lung dz can consider checking RF and CCP

115
Q

When should you do a thoracentesis in a patient with hepatic hydrothorax?

A

If pt is very symptomatic while waiting for sodium restriction and diuresis to kick in; need to consider listing for transplant and maybe a TIPS (esp if failing meds)

116
Q

What can you say about BiPAP vs. endotracheal intubation for COPD exacerbations with decompensated resp acidosis with respect to mortality?

A

NPPV assoc with better overall mortality than ET intubation; HOWEVER, must be able to protect airway etc.

117
Q

A patient with a presumed AECOPD who is not responding to general medical tx should be evaluated for ______

A

PE; meta-analyses have shown that up to 25% of hospitalized pt w/ AECOPD actually have PE

118
Q

When should you consider aspergillus skin testing and IgE levels in asthmatic patients?

A

If pt has severe asthma that is not improving despite optimal medical mgmt for several months need to consider ABPA; also seen frequently in CF population

119
Q

To what degree does OSA cause RV failure?

A

Generally, serious RV failure does not occur due to OSA alone (Van Scoy teaching point); OSA may cause some elevation of PA pressures but severe PA pressure elevation and RV failure unlikely on basis of OSA alone

120
Q

At what level is the NIF pretty concerning for need to intubate in a patient with chronic resp failure from muscular issues?

A

A NIF less than -30 is pretty concerning

121
Q

What is a normal apnea-hypopnea index?

A

less than 5 (if greater think of OSA or CSA); weight loss can improve the apnea-hypopnea index

122
Q

What are some contraindications to thrombolytic therapy (5)?

A

Intracranial neoplasm, Intracranial surgery or trauma in past 2 months, recent hemorrhage, recent CVA hemorrhagic stroke, sugery within the past 10 days

123
Q

What is the tx of PCP PNA? What if PaO2 <70?

A

TMP-SMX; add steroids

124
Q

A small, hemorrhagic and sterile exudative effusion in setting of acute chest pain is likely related to what?

A

Pulmonary Embolism related effusion; can have marked epithelial hyperplasia, some blood can be from infarcted lung

125
Q

What should you do for a patient who has OSA on CPAP who has lost weight and feels better?

A

Repeat PSG with CPAP titration as the apnea-hypopnea index may have improved to <5 (do this if >10% baseline weight reduction)

126
Q

Why are things like sildenafil/tadalafil or bosentan/ambrisentan potentially harmful for people with WHO III pulmonary HTN?

A

They are used in WHO I only really. In WHO III in particular, there is hypoxic pulmonary vasoconstriction in areas of damaged lung i.e. COPD blebs etc. If you give a vasodilator then more blood may be shunted to these areas which can lead to a decrease in baseline oxygenation; thereby worsening hypoxia

127
Q

Best mgmt in AECOPD or status asthmaticus who develop HoTN with elevated peak pressures and a flow-waveform showing expiratory flow not reaching baseline

A

Disconnect from ventilator; pt is auto-PEEPing

128
Q

What is the most appropriate initial mgmt of a patient with chronic bronchiectasis who has massive hemoptysis?

A

Lay bleeding side dependent and EMERGENTLY consult IR to embolize; bronchiectasis can lead to bleeding from a disrupted bronchial artery

129
Q

What is the best step in a patient with asthma not well controlled on a medium dose glucocorticoid and SABA?

A

Add a LABA (salmeterol) often would DC the fluticasone and Rx a combo of fluticasone + salmeterol

130
Q

What is the renal compensation for acute respiratory alkalosis?

A

For every fall in 10 mmHg of PCO2 the bicarb should fall by 1-2; chronically it will fall by 3-4 so similar to resp acidosis

131
Q

Findings of recurrent asthma exacerbations in severe asthmatics w/ central bronchiectasis, eosinophilia, and elevated IgE should prompt dx of what?

A

Allergic Bronchopulmonary Aspergillosis; Dx w/ aspergillus skin testing and IgE levels; tx w/ glucocorticoids and Itra

132
Q

A patient with COPD and hypoxemia on adequate pharmacologic tx should receive what

A

Supplemental O2 if SaO2 <88% or PaO2 <55 mmHg

133
Q

What is the triad of a benign ovarian tumor with ascites and pleural effusion that resolve after resection of the tumor?

A

Meigs Syndrome

134
Q

What is the recommended duration of systemic anticoagulation for provoked DVT

A

3 months (i.e. surgery, leg injury, pregnancy, or OCP use)

135
Q

Aside from removing the offending agent, what is the best adjunctive tx of hypersensitivity pneumonitis?

A

IV glucocorticoids at 0.5-1 mg/kg dose

136
Q

What is the most likely dx in pt from Ohio River valley who recently recovered from URI who has rounded opacity in lung

A

Blastomycosis

137
Q

What are physiologic doses of prednisone in adrenal failure? Fludricortisone? Hydro?

A

Pred 5 mg, Fludri 0.05 to 2, and Hydro 12.5-25 2-3x daily; A dose of 50 hydro daily (25 bid) has sufficient activity to act as both gluco/mineralo for the day; may be supratherapeutic on the gluco end though leading to iatrogenic cushing dz

138
Q

What clinical scenario would you order a thoracic lymphangiogram in?

A

If a person has a chylothorax; tx w/ medium fatty acid diet, avoid fats, octreotide

139
Q

The most likely dx in a patient from East Asia with chronic sinusitis and obstructive lung dz w/ centrilobular nodules and dilated bronchioles on CT is _______

A

Diffuse Panbronchiolitis

140
Q

What is the tx of moderate persistent asthma?

A

Rescue inhaler + inhaled glucocorticoid + LABA

141
Q

What is the most appropriate mgmt of a symptomatic bronchogenic cyst?

A

Surgical removal

142
Q

What are the two drug treatments that have been shown to limit the frequency of COPD exacerbations in pt on maximal therapy?

A

Azithromycin 250 mg daily; Roflumilast (PDE-4 inhibitor) 500 ug daily

143
Q

What is the best empiric tx of a patient with acute bacterial prostatitis at low risk for STI? Considerations if not getting better?

A

Ciprofloxacin (MC bugs are E. coli, Kleb, and Serratia; often from ascending urethritis also why UTI in men always considered complicated bc they have prostate; if not better do transsrectal US to look for abscess then unroof

144
Q

A sterile exudative effusion with a markedly low pH should lead one to inquire about what dz?

A

Rheumatoid Arthritis; often with low glucose and pH <7.3

145
Q

What refractory disease can potentially be treated with an atrial septostomy?

A

Severe WHO I pulm HTN (i.e. refractory to vasodilators, IV prostanoids, etc. can do atrial septostomy which can unload the RV)

146
Q

What disease often has thin-walled cysts and small nodules involving the mid-upper lung zones and is assoc with young ppl who smoke?

A

Langerhans Histiocytosis (Eosinophilic Granuloma variant = Histiocytosis X); differentiated from IPF in that it affects middle and upper lobes as opposed to lower and occurs in younger ppl

147
Q

Only CURABLE form of pulm HTN

A

CTEPH (WHO IV) can do pulm thromboendarterectomy

148
Q

What is the appropriate mgmt of CF exacerbation with Cx positive for pseud?

A

2 antipseudomonal antibiotics; i.e. cefepime + tobramycin

149
Q

What diagnostic test should you consider in an elderly patient with hx of smoking with new generalized fatigue and sedentary lifestyle?

A

Aside from obvious stuff like TSH, BMP etc. would consider PFTs to look for COPD

150
Q

What SLE meds are ok in pregnancy

A

Prednisone, Hydroxychloroquine, and Azathioprine; MMF teratogenic and must be stopped at least 3 months prior

151
Q

Most likely etiology of hypotension in a pt w/ AECOPD shortly after intubation

A

Auto-PEEP; or could be the sedatives

152
Q

This is the diagnostic test of choice to identify DAH

A

Sequential Bronchoalveolar Lavage and see progressively bloodier lavage samples

153
Q

Elevated GM-CSF antibodies can indicate a diagnosis of what interstitial lung disease?

A

Pulmonary Alveolar Proteinosis; can have crazy paving pattern on CT; tx = whole lung lavage

154
Q

What is the general mgmt of WHO I pulm HTN

A

First get on vasodilators; CCB (dilt) if inodilator response (>10 mmHg in PAP w/ inhaled NO); if not then PDE inhib or endothelin antag; if Class III-IV sx then IV epoprostenol and if refractory the atrial septostomy

155
Q

What is the best step in evaluating a patient with hx of antiphospholipid syndrome who has worsening dyspnea, exercise intolerance, and desaturations?

A

VQ scan to evalute for CTEPH (WHO IV pulm HTN) which is curable with pulmonary thromboendarterectomy

156
Q

What is the difference in timing between acute and chronic silicosis?

A

Acute silicosis is in less than 1 year (assoc with sandblasting) and chronic is like 10-30 years later; often upper lobe predominant

157
Q

What is the DOC for candiduria? Candidemia?

A

Fluconazole is good for candiduria and echinocandins aren’t; however, if pt develops candidemia then echinocandins are the DOC

158
Q

What is the most appropriate initial testing in a patient with suspected adult onset asthma?

A

PFTs with pre/post bronchodilator test as it assesses reversible airflow obstruction; obstructive if FEV1:FVC <70%, responsive if >12% increase; afterwards can consider allergy testing to avoid trigger allergies

159
Q

What DOAC can a person just straight up get and leave if they have an uncomplicated provoked PE w/o hemodynamic compromise and adequate renal fxn?

A

Rivaroxaban or Apixaban; dabigatran and edoxaban both need some systemic bridge i.e. either lovenox or fondaparinux

160
Q

What is the most appropriate approach to patients with pleural effusions due to CHF?

A

Diuresis and if they don?t improve consider thoracentesis; may develop trapped lung

161
Q

What direct pulmonary issue can HIV cause?

A

Pulmonary Arterial HTN; look for pt w/ loud S2, LE edema, DOE, etc.; NO CORRELATION TO CD4 COUNTS

162
Q

What is Auto-PEEP?

A

Failure of the expiratory flow to reach zero before the delivery of the next breath; best tx if HD instability is disconnect from ventilator

163
Q

Best Tx for newly dx ankylosing spondylitis? Possible pulmonary issue?

A

NSAIDs are first line; restrictive lung dz

164
Q

What is the cause in occupational asthma of pts who work with Auto body industry

A

Diisocyanates

165
Q

What are some general considerations for pts with wheezing that does not improve despite medical tx?

A

Tracheomalacia (if intubated for a while); if monophasic inspiratory stridor then paradoxical vocal cord motion (adduction in inspiration), or endobronchial lesion if unilateral

166
Q

What is the best study to obtain for an obese pt with suspected OSA who has cardiopulmonary comorbidities and why?

A

In lab PSG bc need to differentiate OSA from CSA, Cheyne-Stokes etc.

167
Q

Best test to confirm dx of pleural tuberculosis

A

Pleural Bx (ADA >40 suggestive but finding acid fast bacilli on pleural bx confirms); recall the effusion will be lymphocyte predominant

168
Q

What test would you order for a patient whose pleural effusion showed high level of triglycerides?

A

Thoracic Lymphangiogram - looking for chylothorax; tx with octreotide, medium chain fatty acid diet, avoid fats

169
Q

What is the most appropriate test for an obese patient with severe hypersomnia and elevated HCO3 on the BMP?

A

ABG to look for OHS; this is important as the mgmt changes so a pt with OHS may require changing the CPAP to BiPAP

170
Q

What is the Macklin effect?

A

When alveoli rupture and the air tracks along the interstitial lining causing pneumomediastinum; can occur in severe asthma/COPD exacerbation; can just observe and tx underlying exacerbation in these settings

171
Q

What should you consider in a patient with intermittent confusion, ataxia, elevated AG w/o clear cause and a normal lactate in patients with small bowel resection?

A

D-lactic acidosis; bacteria create the D enantiomer from excess carbs and not the L so we cant detect on regular lactate labs

172
Q

What disorder needs to be considered in a veteran with SOB coming from Iraq who fought in OIF or operation New Dawn?

A

Constrictive Bronchiolitis- due to bombs, burn pits, and inhalants that cause constriction of the bronchioles and so obstructive physiology

173
Q

What is the etiology of high altitude pulmonary edema?

A

Thought to be due to acute hypoxic pulmonary vasoconstriction leading to acute rise in PA pressures with subsequent pulm edema; Tx for secondary prevention is Nifedipine

174
Q

What infectious dz can have erythema nodosum?

A

Coccidiodes consider in nonresolving PNA w/ EN in SW United States

175
Q

What is the next best step in a patient with imaging findings suggestive of resectable pancreatic CA?

A

Resection; don?t need to waste time checking tissue

176
Q

What do you call if there is a large ovarian tumor that pathology shows is actually gastric adenocarcinoma?

A

Krukenburg Tumor

177
Q

For a patient with no exposure to TB the MC cause of a chronic pneumonia is _______

A

Fungal

178
Q

What is Ovarian Hyperstimulation Syndrome?

A

Development of pleura effusions, ascites, edema and possibly shock in a woman undergoing IVF; can be similar to Meigs syndrome

179
Q

What are some risk factors for developing pseudomonal pneumonia?

A

Structural lung dz and recent hospitalization; 7 days of tx adequate even if VAP

180
Q

What is a potentially serious adverse side effect of long term nitrofurantoin?

A

Drug induced lung injury

181
Q

T/F: modafinil and armodafinil can be used in the tx of OSA

A

True, if somnolence persists despite first line tx; also used in Narcolepsy which is Dx with Multiple Sleep Latency Test

182
Q

What is the tx of severely hypoxemic pts with suspected Amiodarone Pulmonary Toxicity?

A

DC amiodarone and start prednisone (1 mg/kg) which is still recommended despite efficacy in trials

183
Q

A young woman with intermittent hemopneumothorax should be evaluated for ______

A

Catamenial Pneumothorax; often d/t thoracic endometriosis; ask about timing of the PTX to the period

ABIM (18 decks)

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