PULM 3

Question 1

A patient presents with an PROVOKED PE…What is the choice of AC?

How long do you have to AC for?

Answer 1

LMW or unfractionated Heparin bridge to Warfarin (5 day overlap)
OR
Factor Xa inhibitor (RIVAROXABAN)

FIRST PE (AC 3-6 months)
Recurring PE (AC for life)

Question 2

What is the indication for an IVC filter iso PE?

Answer 2

AC contraindicated
OR
AC caused significant bleed (DC AC and place filter)
OR
vey low cardiopulmonary reserve due to prior PE or lung disease.

Question 3

In what two situations should you consider Thrombolysis with a Fibrinolytic therapy iso PE?

In what two situations would you want to consider Embolectomy?

Answer 3

Thrombolysis:
1. HYPOtn SBP <90
AND
2. Low bleed risk.
———————————————————————————–
Embolectomy:
1. PT likely to die from shock within hours
2. Failed or C/I thombolysis with persistent hypoTN

Question 4

A patient has PE and has a small amount of hemoptysis…is this a C/I to starting Anticoagulation?

Answer 4

NO

Question 5

A patient presents with PE and mild fever…should you start ABX?

Answer 5

NO, unless you have evidence of infection in UA, CXR, blood culture, IV lines ext)…

Fever is seen in 20% of PE…unless there is a source of infection identified, abx NOT needed.

Question 6

What neck circumference is the cut off for M and W as a RF for OSA?

Answer 6

M > 17

W >16

Question 7

Acute bronchitis classically present as?

How do you dx?

TRX?

Answer 7

URI symptoms for days…

THEN, after URI resolves, 5 days to 3 weeks of PRODUCTIVE COUGH (green/yellow).

DX = Clinical

TRX = Symptomatic (NSAIDs +/- bronchodilators). NO ABX (associated with adverse outcomes).

Question 8

What four groups of people have an increased incidence of POST-OP pulmonary complications (atelectasis, infection, hypoxia, respiratory failure, ext)?

Answer 8

1. SMOKERS - quit 4 week prior to surgery
2. COPD - make sure NOT in exacerbation
3. SLEEP APNEA
4. HEART FAILURE - make sure to optimize bf surgery.

Question 9

How long do you have to be on Steroids before tapering is needed?

Answer 9

> 3 weeks.

( NO taper needed if < 3 weeks, even if relatively high dose of steroids used).

Question 10

What is the treatment of Allergic Bronchopulmonary Aspergillosis, which presents with fleeting pulmonary infiltrates, recurrent asthma, central bronchiectasis, and peripheral eosinophilia?

Answer 10

1. PO STEROIDS

2. Voriconazole or Itraconazole.

Question 11

Massive PE can cause Acute R heart Strain and precipitate what 3 heart dysfunction?

What are the 3 classic EKG finding when there is R heart strain due to massive PE?

Answer 11

1. Acute RV dysfunciton
2. Tricuspid dilation
3. Tricuspid regurgitation

EKG:

• New RBBB
• Atrial arrhythmias
• Q wave or ST change in inferior leads (AVF, II, III)

Question 12

Cystic Fibrosis presents with recurrent bronchitis and bronchiectasis w productive cough, URIs and sinus infections.

What is the GOLD STANDARD to DX Cystic Fibrosis?

Answer 12

SWEAT CHLORIDE TEST.

Question 13

Why do 1/4 of individuals with Cystic Fibrosis present with Steatorrhea?

Answer 13

Pancreatic disease.

Question 14

An obese male is just coming out of anesthesia, and you are called because there is respiratory distress with respiratory acidosis…
PaO2 is low
PaCO2 is high
Ph is low

CXR shows basilar atelectasis…

What chronic condition increases the risk for this patient post-operatively?

Answer 14

OSA.

Question 15

Patients who are on total parenteral nutrition are at increased risk of what electrolyte disturbance?

What is the mechanism?

Answer 15

HYPOPHOSPHATEMIA (check Ph levels)

Mechanism = Increased cellular uptake of Phosphate associated with increased glucose uptake.