Pulm

Question 1

Next steps with intermediate VQ scan results for evaluation of PE

Answer 1

Assuming you did a VQ scan because you can’t do a CTA. If average bleeding risk and pre-test probability is high can consider diagnostic and just treat. BUT if bleeding risk is HIGH should do additional testing such as LE dopplers

Question 2

Next steps in a well appearing febrile asplenic patient

Answer 2

Should have urgent evaluation and antibiotics that cover encapsulated organisms for 72 hours while ruling out overwhelming bacterial infection. Good empiric choices are amox-clav, cefuroxime or levofloxacin

Question 3

Management of <10mm free flowing parapneumonic effusion on lateral decubitus xray

Answer 3

Observe - likely will resolve with antibiotics alone

Question 4

Management of >10mm parapneumonic effusions on lateral decubitus xray

Answer 4

Either diagnostic thora if no high risk features or dranainge if 1 or more high risk features

Question 5

High risk features of parapneumonic effusion on ultrasound/CT imaging

Answer 5

loculations, >1/2 hemithroax, pleural thickening

Question 6

RSBI for extubating

Answer 6

RSBI <105 can extubate, greater probably shouldn’t. RSBI is RR/TV (in Liters)

Question 7

Sudden onset dyspnea, hypoxemia, pulmonary infiltrates on CXR (that were not there prior), within 6 hours of a blood product transfusion in the absence of circulatory overload

Answer 7

Transfusion related acute lung injury (TRALI)

Question 8

Hemoptysis and nephritic syndrome without significant systemic symptoms

Answer 8

Anti-glomerular basement membrane antibody disease (goodpasture)

Question 9

Hemoptysis and nephritic syndrome, often without other systemic symptoms and other organ involvement such as ENT (sinusitis), ophthalmic (ulcers conjunctivitis), skin (leukocytoclastic purpura)

Answer 9

Granulomatosis with polyangitis

Question 10

CXR with pulmonary infiltrates, kidney biopsy with linear deposits of IgG, anti-glomerular basement membrane anitbody +

Answer 10

Goodpastures

Question 11

CXR with nodules, cavitations, periodic infiltrates, kidney biopsy with granulomatosis infiltation in artery or vascular bed, + C-ANCA

Answer 11

Granulomatosis with polyangitis

Question 12

Treatment of restrictive lung diseases due to chest wall mechanics (pectus excavataum, kyphoscoliosis, ankylosing spondylitis)

Answer 12

Supportive. Pulmonary rehab, intermittent NIPPV (often nighttime) can increase symptom control and morbidity

Question 13

Middle age or older adult with progressive dyspnea and hypoxia, clubbing and dry crackles on lung exam. CT demonstrates honeycombing, cystic changes and traction bronchiectasis

Answer 13

Idiopathic Pulmonary Fibrosis

Question 14

Features of an uncomplicated parapneumonic effusion

Answer 14

Small to moderate and free flowing on imaging. pH >7.2, glucose >60, WBC < 50, LDH <1000, gram stain and culture negative. OK Abx alone

Question 15

Features of a complicated parapneumonic effusion

Answer 15

Moderate to large, free flowing or loculated on imaging. pH <7.2, glucose < 60, WBC > 50, LDH >1000, gram stain and culture positive. Needs Abx and drainage

Question 16

First line antibiotic choice for lung abscess

Answer 16

Amp-sulbactam or carbapenem

Question 17

Why do patients with cirrhosis have a respiratory alkalosis?

Answer 17

Known to be chronic. Unknown exactly why. Thought to be related to hormonal effects of increased progesterone and estrogen leading to increased minute ventilation

Question 18

Effusion yellow green in color, low pH, very low glucose and high LDH with WBCs <5000

Answer 18

Rheumatoid effusions

Question 19

Milky white exudative effusion with high triglycerides

Answer 19

Chylothorax. Typically due to either traumatic lymphatic duct or obstructive process to the throacic duct (lymphoma, goiter, sarcoid)

Question 20

What pattern with systemic sclerosis associated interstitial lung disease have on PFTs?

Answer 20

Restrictive

Question 21

Test necessary in diagnosis of obesity hypoventilation syndrome

Answer 21

ABG - to demonstrate daytime hypoxemia and hypercapnea

Question 22

Asthmatics or patients with CF presenting in 30-40s with recurrent asthma exacerbations, fevers, malaise, dark brown mucous plugs and hemoptysis

Answer 22

Allergic Bronchopulmonary Aspergillus

Question 23

Diagnostic testing for Allergic Bronchopulmonary Aspergillosis

Answer 23

skin testing for aspergillus (positive very suggestive, negative mostly rules out), elevated Eos, elevated IgE, IgG and IgE for A fumigatus

Question 24

Immunosupressed patient presenting with fever, cough, pleurtic chest pain, CT chest with GGOs, positive galactomannan

Answer 24

Aspergillus. Can also have positive galactomannan in histo and blasto (so check serum and urine studies for these)

Question 25

How does NPPV help CHF exacerbations?

Answer 25

Increases intrathroacic pressure which decreases venous return to the heart thus reducing LV and RV preload. Also the increased intrathoracic pressure augments ventricular contraction thus reducing afterload as well and improving CO

Question 26

What are the two COPD interventions that prolong survival?

Answer 26

Smoking cessation and long term oxygen therapy when indicated.

Question 27

Initial workup when bronchietasis is found?

Answer 27

Immunoglobulin quantification, CF testing, sputum culture (bacteria, fungi and mycobacteria) and PFTs

Question 28

Patient wiht long bone fracture, respiratory distress, neurologic abnormalities and petechial rash 24-72 hours after traumatic insult

Answer 28

Fat embolism syndrome. Treatment is supportive

Question 29

Air travel recommendations and COPD

Answer 29

Patients stable on room air with sats >95% do not need further evaluation and can fly. If sats 92-95% on room air AND FEV1 <50 or mod-severe pulm HTN need hypoxia altitude stim test. If sats <92% on room air should fly on 2L oxygen, if already on oxygen at baseline should increase oxygen by 2L for flight