Pulm

Question 1

70 yo M Smoker p/w 5cm nodule, gynecomastia

Answer 1

Large cell carcinoma may produce β- hCG resulting in gynecomastia

Question 2

Nonsmoker F p/w peripheral lung mass, digital clubbing, hypertrophic pulmonary osteoarthropathy, thrombophlebitis, nonbacterial verrucous endocarditis, pleural involvement

Answer 2

Adenocarcinoma of the lungs

Question 3

Nonsmoker p/w multiple nodules on imaging studies, interstitial infiltration, prolific sputum production.

Answer 3

Bronchoalveolar cell carcinoma (subtype of adenocarcinoma)

Question 4

Smoker p/w central cavitary lung lesion and hypercalcemia, kidney stones

Answer 4

squamous cell carcinoma, w/ ectopic parathyroid hormone–related peptide (PTHrP)

Question 5

Paraneoplastic sx a/w small cell lung carcinoma

Answer 5

SIADH (ADH), Cushingoid (ACTH), Eaton-Lambert sx (muscle weakness, ab-presynaptic ca ch.)

Question 6

Child p/w high fever, pharyngitis, dyspnea, difficulty swallowing, keeping neck hyperextended; dx/rx?

Answer 6

Epiglottitis w/ cherry-red swollen epiglottis by laryngoscopy. X-ray: thumb sign with a swollen epiglottis. Rapid nasotracheal intubation.

Question 7

Exacerbations of COPD rx?

Answer 7

Anticholinergic agent (ipratropium bromide) plus a β-agonist (short-acting, albuterol or a long-acting, salmeterol)

Question 8

RDS and treatment with oxygen exposure and mechanical ventilation predisposes?

Answer 8

Retinopathy of prematurity, bronchopulmonary dysplasia, persistent PDA, interventricular hemorrhage, necrotizing enterocolitis.

Question 9

Pt. p/w fever, nightsweats, pulm infiltrate w/ hilar adenopathy, rash on hands arms and joint pain, recent travel to south-west

Answer 9

Coccidioidomycosis, rx Amphotericin B, ketoconazole, fluconazole, or itraconazole

Question 10

TB meds and SE

Answer 10

RIPE- 6mo- Rifampin (LFTs, orange) Isoniazide (LFTs) 2mo- Pyrazinamide (LFTs) Ethambutol (optic neuritis)

Question 11

30 yoF p/w nonproductive cough, dyspnea, erythema nodosum, blurred vision (uveitis), bilateral hilar lymphadenopathy, hypercalcemia

Answer 11

Sarcoidosis; biopsy pulm lymphadenopathy- noncaseating granulomas; rx corticosteroid

Question 12

Hx of stasis, tachypnea, dyspnea, tachycardia, hypotension, low-grade fever, JVD, accentuated pulmonic 2nd heart sound; dx?

Answer 12

PE w/ evated D- dimer on enzyme-linked immunosorbent assay, findings on CT angiogram

Question 13

20yo cotton mill worker hx asthma p/w chest tightness that occurs toward the end of the first day of the work week

Answer 13

Byssinosis, cotton dust exposure, type of hypersensitivity pneumonitis

Question 14

Acute respiratory distress syndrome (ARDS) definition

Answer 14

pulmonary edema in the absence of volume overload or depressed L ventricular function, with a PaO2:FiO2

Question 15

PaO2:FiO2 < 300 in the setting of b/l cxr infiltrates and a pulmonary capillary wedge pressure of < 18 mm Hg define?

Answer 15

acute lung injury (ALI)

Question 16

Newborn p/w tachypnea, cxr fluid in the fissures, prominent pulmonary vascular markings, flattening diaphragm

Answer 16

Transient tachypnea of the newborn (TTN); (pulmonary edema from delayed fetal fluid clearance from lungs)

Question 17

FEV1:FVC ratio 0.7, FEV1 60% of normal with minimal (12%) improvement w bronchodilator

Answer 17

COPD

Question 18

b/l patchy airspace disease, pulm cap wedge pressure

Answer 18

ARDS (interstitial pulmonary edema and bilateral perihilar alveolar edema,“butterfly” pattern)

Question 19

Mild/ Moderate / Severe ARDS PaO2/FiO2 mmHg?

Answer 19

severe ≤ 100 < moderate < 200 < mild < 300 mmHg

Question 20

Pt p/w low-grade fever, anorexia, weight loss, night sweats, productive cough. Cxr- hilar or mediastinal adenopathy, solitary pulmonary nodule or focal infiltrate.

Answer 20

TB

Question 21

incidental solitary pulmonary nodule with a “popcorn” calcification, asymptomatic nonsmoker

Answer 21

Hamartoma, most common cause of benign tumors of the lung

Question 22

Complications of chronic untreated Obesity related Obstructive Sleep Apnea?

Answer 22

Obesity hypoventilation sx w/ hypoxic/hypercapnic resp acidosis w/ compensation bicarb retention and decreased C, 2 erythrocytosis, pulmonary HTN, cor pulmonale

Question 23

Pt. p/w dyspnea, tachypnea, tachycardia, chest pain w/ inspiration, hemoptysis, post flight, on OCP; dx?

Answer 23

Pulmonary infarct 2/2 PE occlusion of peripheral pulmonary artery

Question 24

30yof p/w dyspnea on exersion, clear lungs, cxr prominent pulm arteries and enlarged Rt Ventricle w/ tricuspid regurge, Rt axis deviation

Answer 24

Primary Pulmonary HTN w/ rt ventricular strain and hypertrophy, possibly leading to RVHF and cor pulmonale

Question 25

Smoker p/w wt loss, pulm nodule, urine Osm > 50–100 and sodium > 20 (euvolemic), w serum hyposmolality, hyponatremia; dx?

Answer 25

Small cell carcinoma w/ SIADH

Question 26

Light’s criteria for pleural effusion as exudate (capillary leakage) vs transudate (elevated hydrostatic ie CHF, low oncotic P)? at least 1 of 3 criteria

Answer 26

Pleural Fluid protein:serum > 0.5, LDH PF:serum > 0.6, PF LDH>2/3 upper normal limit of serum LDH (>60); exudates from inf, autoimmune, neoplasm, PE, CT dz

Question 27

Complicated parapneumonia

Answer 27

Exudative effusion w/ glu

Question 28

Pleural fluid with pH

Answer 28

Criteria for tube thoracostomy, chest tube to drain likely empyema

Question 29

Decreased breathsounds, decreased tactile fremetus, dullness to percussion?

Answer 29

Pleural Effusion

Question 30

Full inspiratory and expiratory phases (Bronchial breath sounds), dullness to percussion, increased tactile fremitus, bronchophony, egophonay, whisper pectoriloquy?

Answer 30

Lung consolidation (eg. Community acquire pneumonia)

Question 31

Pleural Plaques, fingernail clubbing, bibasilar end expiratory crackles

Answer 31

Bronchogenic carcinoma or Asbestosis from asbestos exposure

Question 32

Pt. w/ Panacinar emphysema, hepatomegaly, p/w malaise, elevated LFTs, dx? Bx?

Answer 32

Alpha1-antitrypsin deficiency with panacinar emphysema and liver cirrhosis (bx: hepatocyte inclusions stain with PAS resist Diastase digestion)

Question 33

PE w/ GFR< 30, rx?

Answer 33

Unfractioned heparin; enoxaparin, rivaroxaban, fondaparinux are contraindicated in renal failure w/ decreased clearance

Question 34

Carbon monoxide poisoning labs?

Answer 34

In severe poisoning, tissue hypoxia may cause an increased anion gap metabolic acidosis secondary to increased lactic acid production.

Question 35

Most common source of PE?

Answer 35

Proximal leg veins (popliteal, femoral, iliac)

Question 36

Smoker p/w shoulder pain, ipsilateral ptosis, myosis, anhydrosis, enophthalmus, weakness in hand, pain paresthesia 4,5th digits, medial arm; dx?

Answer 36

Pancoast tumor involving sympathetic chain (horner’s sx) and brachial plexus

Question 37

Digital clubbing; a/w?

Answer 37

Intrathoracic neoplasia (brochogenic lung cx), CF, empyema, bronchiectasis, lung cavitary lesions and abscess, fibrosis, asbestosis, mesothelioma, congenital cyanotic heart dz (not hypoxemia/ copd)

Question 38

Peak Airway Pressure = Restrictive Pressure + Plateau Pressure

Answer 38

Increased PAP w/ normal Plateau = Airway obstruction (mucous plug, blonchospasm, ET block)

Question 39

Plateau Pressure = Elastic Pressure + PEEP (Positive End Expiratory Pressure)

Answer 39

Increased PAP w/ increased Plateau P = decreased pulm compliance (pneumothorax, edema, pneumonia, atelectasis)

Question 40

Normal or increased FEV1/FVC >70%; decreased FVC<80%, DLCO (carbon monoxide diffusion capacity), RV and TLC; dx?

Answer 40

Restrictive lung dz from interstitial lung dz, sarcoidosis, asbestosis, heart failure, wegner’s granulomatosis; Honeycombing, fibrosis or traction bronchiectasis on CT

Question 41

Normal FEV1/FVC >70%, decreased FVC<80%, normal DLCO (carbon monoxide diffusion capacity); dx?

Answer 41

Restrictive lung dz from MSK deformity, neuromuscular dz

Question 42

Decreased FEV1/FVC <70%, decreased DLCO (carbon monoxide diffusion capacity); dx?

Answer 42

COPD from emphysema

Question 43

Decreased FEV1/FVC <70%, normal DLCO (carbon monoxide diffusion capacity); dx?

Answer 43

COPD from chronic bronchitis, Asthma

Question 44

Asthma w 2 or less attacks/wk, 2 or less nighttime events/month, normal PFTs, no limitations in activity; dx/rx?

Answer 44

Mild intermittent asthma, rx: PRN albuterol

Question 45

Asthma w/ 2-6 attacks/wk, 3-4 nighttime events/month, normal PFTs, minor limitations in activity; dx/rx?

Answer 45

Moderate intermittent asthma, rx: PRN albuterol and low dose inhaled corticosteroids

Question 46

Asthma w/ daily attacks, weekly nighttime events, FEV1 60-80%, limitations in activity; dx/rx?

Answer 46

Moderate Persistent asthma; rx PRN albuterol, low dose inhaled corticosteroid, and inhaled Solmedurol (long acting inhaled beta agonist)

Question 47

Asthma w/ multiple daily attacks, frequent nighttime events, FEV1<60%, significant limitations in activity; dx/rx?

Answer 47

Severe Persistent asthma; rx PRN albuterol, high dose inhaled corticosteroid, inhaled Solmedurol, can add oral prednisone

Question 48

Recurrent nose bleads, hemoptysis, w/ chronic hypoxemia and reactive polycythemia; dx?

Answer 48

Osler-Weber-Rendu (hereditary telangiectasia) w/ pulmonary AVM causing R to L shunt (hypoxemia, increased Hct)

Question 49

PE likelihood via Wells Criteria? >4 likely do CT angio, 4 or less unlikely so do D-dimer first (<500 excludes PE)

Answer 49

3pts: clinical signs of DVT, other diagnosis less likely than PE; 1.5pts: HR>100, previous PE or DVT, recent surgery or immobilization; 1pt: hemoptysis, cancer

Question 50

A-a gradient calculation? (PAO2 - PaO2) normal <14, abnormal >30

Answer 50

PAO2=FiO2x(Patm-PH2O)-(PaCO2/R)=0.21x(760-47)-(PaCO2/0.8) = 150 - (PaCO2/0.8)

Question 51

Nocturnal wheezing, chest tightness, cough that’s worst at night or after eating, hoarsenss, sore throat, adult hx of asthma, obese, erythematous post pharynx and larynx; dx/rx?

Answer 51

GERD inducing asthma; rx Omeprazole (PPI)