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Step 2 CK > Pulm > Flashcards

Pulm Flashcards

1
Q

What are main causes of acute asthma exacerbations

A 
Allergens
Infection, Cold air
Exercise
Aspirin, NSAIDs, BBs
GERD
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2
Q

Extrinsic vs Intrinsic Asthma severity

A

Extrinsic is better (ie. has precipitants)

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3
Q

Most likely associations w/ Asthma

A 
Sx worse at night
Nasal polyps and sensitivity to aspirin
Pulsus paradoxus
Eczema or atopic dermatitis
Increased length of expiratory phase
Increased use of accessory muscles
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4
Q

Best initial test for acute exacerbation of asthma

A

Peak expiratory flow or ABG

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5
Q

Why do CXR in asthma

A

Exclude PN or other chest etiology for sx

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6
Q

Most accurate Dx test in asthma

A

PFTs

  • ↓FEV1/FVC
  • ↓FEV1, ↓FVC
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7
Q

Most accurate test in asymptomatic asthma

A

20% decrease in FEV1 w/ use of methacholine or histamine

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8
Q

PFTs in asthma

A

↓ FEV1/FVC
↓ FEV1, ↓ FVC
↑ FEV1 of >20% and 200ml w/ use of albuterol
↓ FEV1 of >20% w/ use of methacholine or histamine

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9
Q

Additional tests in asthma

A

CBC - increased eosinophils
Skin test for allergens
IgE for allergic etiology

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10
Q

Protocol for chronic asthma management

A
  1. SABA
    • ICS
    • LABA or Increase ICS dose
  4. Increase ICS dose to max
    • Omalizumab
    • Oral steroids
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11
Q

Drug that works best in childhood and exercise-induced PPx

A

Cromolyn and Nedocromil

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12
Q

Drug used to help pts ween off steroids

A

Montelukast
Zafirlukast
Zileuton

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13
Q

Steroid AEs

A 
Osteoporosis
Cataracts
Adrenal suppression and fat distribution
Hyperlipidemia, hyperglycemia, acne, hirsuitism
Thinning of skin, striae, easy bruising
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14
Q

Vaccines for all asthmatics

A

Influenxae

Pneumococcal

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15
Q

Best indicator for severity of disease in asthma

A

Respiratory rate (severe SOB = 34)

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16
Q

Quantification of severe SOB

A

Decreased PEF

ABG w/ increased A-a

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17
Q

Rx acute asthma exacerbation

A

O2
Albuterol
Steroids

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18
Q

Best initial therapy for acute asthma exacerbation

A

O2 w/ SABA

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19
Q

Drug of last resort in acute asthma exacerbation

A

Epi

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20
Q

What to do if there is no response to therapy in acute asthma exacerbation

A

Intubation in ICU

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21
Q

What is NOT effective in acute asthma exacerbation

A 
Theophylline
Cromolyn, Nedocromil
LT modifiers
Omalizumab
Salmeterol
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22
Q

What is Mg good for in acute asthma exacerbation

A

Non-responsive to albuterol while waiting for steroids to start working

Relieve bronchospasm

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23
Q

What is COPD

A

SOB from lung destruction due to loss of elastic recoil

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24
Q

Why are steroids ineffective in chronic COPD

A

Non-inflammatory

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25
Q

Major PFT findings in COPD

A

↓ FEV1, FVC

↑ TLC

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26
Q

MCC COPD

A

Tobacco smoking

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27
Q

When to suspect A1AT def causing COPD

A

Young
Non smoker
Transaminitis

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28
Q

Common presentation of COPD

A

SOB
Barrel chest
Cachexia (emphysema)

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29
Q

Best initial test for COPD

A

CXR

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30
Q

CXR findings in COPD

A

Increased AP diameter

Flattened diaphragm

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31
Q

Most accurate test for COPD

A

PFTs

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32
Q

PFTs in COPD

A 
↓ FEV1, FVC, FEV1/FVC
↑ TLC
↓ DLCO (emphysema)
Incomplete improvement w/ albuterol
Not much effect after methacholine
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33
Q

Response to bronchodilators in COPD

A

Little to full reversibility

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34
Q

What is full reversibility in COPD

A

> 12% increase and 200mL increase in FEV1

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35
Q

ABG findings in acute exacerbation of COPD

A

Increased pO2
Hypoxia
Respiratory acidosis if no compensation

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36
Q

What increases survival in COPD

A

Smoking cessation

O2 (when pO2

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37
Q

When to give O2 in COPD when they also have pulm HTN, high HCT or cardiomyopathy

A

pO2

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38
Q

Symptomatic rx in COPD

A 
SABA
Anticholinergics
Steroids (good in acute)
LABA
Pulm rehab
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39
Q

When to give theophylline in COPD

A

When all else fails

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40
Q

Rx when all medical therapy is insufficient for COPD

A

Transplantation

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41
Q

Rx acute exacerbation of chronic bronchitis

A

Same as acute asthma exacerbations

Plus ABX

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42
Q

What do ABX need to cover in AECB

A

Strep pneumo, H. flu, M. catarrhalis

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43
Q

What ABX are given in AECB

A

Macrolides
Cepalosporins
Augmentin
Quinolones

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44
Q

What is bronchiectasis

A

Chronic dilation of large bronchi

Permanent anatomic abnormality

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45
Q

MCC bronchiectasis

A

CF

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46
Q

Other causes of bronchiectasis

A 
Infection
Panhypogammaglobulinemia
Foreign body/tumors
Aspergillosis
Collagen vascular disease
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47
Q

Pathognomonic w/ bronchiectasis

A

Purulent foul smelling cough/sputum

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48
Q

PE and lab findings in bronchiectasis

A 
Hemoptysis
Wt loss
AOCD
Crackles
Dyskinetic cilia
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49
Q

Best initial test in bronchiectasis

A

CXR showing dilated thickened bronchi

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50
Q

Most accurate test in bronchiectasis

A

High resolution CT

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51
Q

Only way to determine specific bacterial etiology of bronchiectasis

A

Sputum Cx

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52
Q

Rx bronchiectasis

A

Chest physio and postural drainage
Treat each infection episode
Rotate ABX 1 weekly each month
Surgical resection

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53
Q

Who gets allergic bronchopulmonary aspergillosis (ABPA)

A

Asthma

Hx atopic disorders

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54
Q

What to look for in ABPA

A

Asthmatic w/ recurrent brown-flecked sputum

Transient infiltrates on CXR

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55
Q

Dx tests for ABPA

A 
Peripheral eosinophilia
Skin test reactivity
Aspergillus Abs
Elevated IgE
Infiltrates on CXR, CT
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56
Q

Rx ABPA

A

Oral prednisone

Itraconazole if reccurent

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57
Q

What is CF

A

AR mutation in chloride transport gene (CFTR)

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58
Q

MCC death in CF

A

Lung disease

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59
Q

What to look for in CF

A

Young adult
Chronic lung disease
Recurrent infections
Sinus pain and polyps

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60
Q

GI features of CF

A 
Meconium ileus
Pancreatic insufficiency - steatorrhea, vit ADEK malabsorption
Recurrent pancreatitis
Distal intestinal obstruction
Biliary cirrhosis
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61
Q

GU features of CF

A

Men - Azoospermia, missing vas deferens

Women - Infertile 2/2 thickening of cervical mucus

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62
Q

Most accurate test for CF

A

Sweat chloride test

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63
Q

ABG in CF

A

Hypoxemia

Resp acidosis

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64
Q

Which cells in the pancreas are spared in CF

A

Beta

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65
Q

Sputum Cx in CF may show

A

H. flu
Pseudomonas
S. aureus
Burkholderia

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66
Q

Rx CF

A 
Routine ABX (same ones as bronchiectasis)
Recombinant human deoxyribonuclease
Inhaled bronchodilators
Pneumococcal and flu vax
Lung transplant in severe disease
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67
Q

What is CAP

A

PN before or within 48hrs of hospitalization

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68
Q

MCC CAP

A

Strep pneumo - REGARDLESS of comorbidities

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69
Q

CAP association w/ COPD

A

H. flu

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70
Q

CAP association w/ recent viral illness

A

S. aureus

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71
Q

CAP association w/ alcoholism/DM

A

Klebsiella

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72
Q

CAP association w/ poor dentition or aspiration

A

Anaerobes

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73
Q

CAP association w/ young healthy pts

A

Mycoplasma pneumoniae

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74
Q

CAP association w/ hoarseness

A

Chlamydophila

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75
Q

CAP association w/ contaminated water sources, AC, ventilation

A

Legionella

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76
Q

CAP association w/ birds

A

Chlamydia psittaci

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77
Q

CAP association w/ animals at time of birth, vets, farmers

A

Coxiella

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78
Q

Common findings in all PN

A

Fever
Cough
Dyspnea
Dullness to percussion if effusion

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79
Q

Features of severe PN

A

Tachy
Hypotension
Tachypnea

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80
Q

Signs of bacteremia

A

Chills and Rigors

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81
Q

Unique presentation of klebsiella PN

A

Current jelly sputum

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82
Q

Unique presentation of Anaerobe PN

A

Rotten egg smelling sputum

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83
Q

Unique presentation of mycoplasma PN

A

Dry cough, rarely severe, bullous myringitis

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84
Q

Unique presentation of Legionella PN

A

GI or CNS sx

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85
Q

Unique presentation of pneumocystis PN

A

AIDS w/ CD4

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86
Q

Infections w/ dry cough

A 
Mycoplasma
Viruses
Coxiella
Pneumocystis
Chlamydia
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87
Q

Best initial test for all resp infections

A

CXR

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88
Q

Most accurate test for resp infections

A

Sputum stain and Cx

Much of the time this is negative

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89
Q

Characteristic CXR finding in bacterial PN

A

Right middle lobe infiltrate

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90
Q

Organisms causing B/L infiltrate in CXR

A 
Mycoplasma
Viruses
Coxiella
PCP
Chlamydia
Legionella
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91
Q

How do you know sputum gram stain is adequate

A

> 25 WBCs and

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92
Q

Tests done in severe disease w/ unclear etiology

A

Thoracocentesis
Empyema analysis
Bronchoscopy only in ICU and worsening

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93
Q

Dx test to confirm mycoplasma

A

PCR
Cold agglutinin
Serology
Special cx media

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94
Q

Dx test to confirm chlamydophila

A

Rising serology titres

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95
Q

Dx test to confirm legionella

A

Urine Ag

Cx on charcoal-yeast extract

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96
Q

Dx test to confirm chlamydia psittaci

A

Rising serology titres

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97
Q

Dx test to confirm coxiella

A

Rising serology titres

98
Q

Dx test to confirm PCP

99
Q

Empiric Rx outpatient if previously healthy

A

Macrolide or Doxy

100
Q

Empiric Rx outpatient if comorbidities or ABX in last 3 mos

A

Resp fluoroquinolone

101
Q

Empiric Rx inpatient

A

Resp fluoroquinolone or (Ceftriaxone and Azithromycin)

102
Q

Reasons to hospitalize for PN

A 
Hypotension
Hypoxia
Elevated BUN or Hyponatremia
Tachy, Confusion
Fever
> 65
103
Q

Management of Empyema

104
Q

CURB65 (2 or more = admission)

A 
Confusion
Uremia
Resp distress
BP low
> 65
105
Q

Features of empyema (Exudate)

A

pH 60% of serum or Protein >50% of serum

106
Q

What causes exudate

A

Infection

Cancer

107
Q

Reasons to give pneumococcal vaccine

A 
>65
Chronic heart, liver, kidney, lung disease
Functional or anatomic asplenia
Blood cancer
Immunosuppression
CSF leak or cochlear implant
108
Q

What is HAP

A

PN >48hrs after admission or after hospitalization within the last 90 days

109
Q

What are the main bugs in HAP

A

E. coli

Pseudomonas

110
Q

What is given for HAP

A 
Antipseudomonal cephalosporins
- Cefepime
- Ceftazidine
Antipseudomonal PCNs
Carbapenems
111
Q

What to look for to suggest VAP

A

Fever with rising white count
New infiltrate
Purulent secretions

112
Q

Dx tests for VAP

A 
Tracheal aspirate
BAL
Protected brush specimen
VAT
Open lung Bx
113
Q

Rx VAP

A 
Antipseudomonal beta lactam
PLUS
Aminoglycoside or fluoroquinolone
PLUS
MRSA agent
114
Q

Imipenem AE

A

Seizures 2/2 renal failure

115
Q

How does large volume aspiration occur

A 
Stroke w/ loss of gag
Seizures
Intoxication
ET tube
Bad teeth
116
Q

When to suspect lung abscess

A

Pt w/ risk factors and weeks of sx

Large volume foul smelling sputum

117
Q

Best initial test for lung abscess

118
Q

Most accurate test for lung abscess

A

Bx - gives microbe

119
Q

Best empiric rx for lung abscess

A

Clindamycin or PCN

120
Q

Presentation of PCP

A

Dry cough and fever in AIDs pt w/ CD4

121
Q

Best initial test for PCP

A

CXR w/ B/L infiltrates

ABG w/ hypoxia and increased A-a

122
Q

Most accurate test in PCP

123
Q

LDH in PCP

A

ALWAYS elevated

124
Q

Next best step w/ negative sputum

125
Q

Best initial therapy for PPx and Rx

A

TMP/SMX

Add steroids if severe

126
Q

TMP/SMX AE

A 
#1 Rash
#2 BM suppression
127
Q

What is severe PCP

128
Q

Rx PCP w/ TMP/SMX tox

A

Clinda and primaquin
OR
Pentamidine

129
Q

PCP PPX w/ TMP/SMX tox

A

Atovaquone or dapsone

130
Q

When is dapsone contraindicated

131
Q

RFs TB

A 
Immigrant, homeless
Prisoners
HIV
Healthcare
Alcoholics
132
Q

Common features of TB

A

RFs

Fever, weight loss, night sweats, cough, hemoptysis

133
Q

Best initial test for TB

134
Q

Sputum protocol in TB

A

Stain and Cx 3 times

135
Q

Most accurate test for TB

A

Pleural Bx

136
Q

Pt w/ TB RFs and +CXR w/ apical infiltrate

A

Sputum stain and Cx

137
Q

Pt w/ TB positive sputum stain and cx

A

Empiric therapy

138
Q

Initial therapy for TB

A

Rifampin
Isoniazid
Pyrazinamide
Ethambutol

139
Q

Rx protocol in TB

A

RIPE for 2 months

Rifampin and INH for another 4

140
Q

When do you extend TB Rx to 9 months

A

Osteo
Milliary
Meningitis
Pregnancy (and any other time pyrazinamide is contraindicated)

141
Q

All TB meds can cause

A

Hepatotoxicity

142
Q

Rifampin AE

A

Red coloured body secretions

143
Q

INH AE

A

Peripheral neuropathy

Pyridoxine to prevent

144
Q

Pyrazinamide AE

A

Hyperuricemia

145
Q

Ethambutol AE

A

Optic neuritis/Colour vision

Decrease dose in renal failure

146
Q

When to give steroids in TB

A

Reduce risk of constrictive pericarditis and meningitis

147
Q

When to do PPD

A

Asymptomatic pts in RISK GROUPS ONLY

Must have neg CXR

148
Q

When is 5mm induration pertinent

A 
HIV
Steroid users
Close contact to TB person
Abnormal calcifications on CXR
Organ transplant recipients
149
Q

When is 10mm induration pertinent

A 
Immigrant
Prisoner
Healthcare worker
Close contact to TB person
Blood cancer, alcoholics, DM
150
Q

When is 15mm induration pertinent

A

People with no RFs

151
Q

First time PPD protocol

A

2nd test 1-2 weeks later if 1st is negative

152
Q

Reactive PPD next step

153
Q

BCG role in PPD testing

A

Doesn’t matter

154
Q

Pt w/ +PPD and -CXR next step

A

INH for 9 months

155
Q

Qualities of benign pulmonary nodule

156
Q

Qualities of malignant pulmonary nodule

A 
>40
Enlarging
Smoker
Spikes
>2cm
Atelectasis
Sparse, eccentric calcification
Abnormal PET
157
Q

Best initial test for all lung lesions

A

Compare to old CXRs

158
Q

Best next step for features of malignant lesions

159
Q

Cytology is positive in pulm nodule, next best step

160
Q

Intermediate probability lesions next best step

A

Central - bronchoscopy

Peripheral - transthoracic Bx

161
Q

MC AE transthoracic bx

162
Q

When is a PET most accurate

163
Q

Most sensitive and specific test for pulm nodule

164
Q

What is interstitial lung disease

A

Thickening of interstitial septum of lung between arterial space and alveolus

165
Q

Specific causes of pulmonary fibrosis

A 
Idiopathic
Radiation
Drugs
Vasculitis
Eosinophilic PN
166
Q

Drugs that can cause pulm fibrosis

A 
Bleomycin
Amiodarone
Methylsergide
Nitrofurantoin
Cyclophosphamide
167
Q

Pneumoconiosis in exposure to coal

A

Coal worker’s lung

168
Q

Pneumoconiosis in exposure to sandblasting, rock mining, tunneling

169
Q

Pneumoconiosis in exposure to shipyards, pipe fitting, insulators

A

Asbestosis

170
Q

Pneumoconiosis in exposure to cotton

A

Byssinosis

171
Q

Pneumoconiosis in exposure to electronic manufacturing

A

Beryliosis (also aerospace)

172
Q

Pneumoconiosis in exposure to moldy sugar cane

A

Bagassosis

173
Q

Features of coal worker’s lung

A 
Upper
↑ IgA, G
↓ C3
ANA+
Can have RA
174
Q

Features of silicosis

A

Upper

Egg-shell calcification of LNs

175
Q

Features of Asbestosis

A

Lower

Dumbbell shaped

176
Q

Features of all pulm fibrosis

A

Dyspnea worse on exertion
Rales
Loud P2
Clubbing

177
Q

Best initial test for pulm fibrosis

178
Q

Most accurate test for pulm fibrosis

179
Q

What does echo show in pulm fibrosis

A

RVH

Pulm HTN

180
Q

CXR pattern in pulm fibrosis

A

Diffuse reticulonodular pattern

Honeycombing

181
Q

What does Bx show in berylliosis

A

Granulomas

182
Q

When are PFTs used in pulm fibrosis

A

Response to therapy

183
Q

PFTs in pulm fibrosis

A

Decreased everything

Decreased DLCO

184
Q

When can you rx interstitial lung disease

A 
Bx shows WBC infiltration
Use Prednisone (berylliosis responds best)
185
Q

Who gets sarcoidosis

A

Young AA woman

186
Q

Presentation of sarcoidosis

A

SOB on exertion

Erythema nodosum and lymphadenopathy

187
Q

Misc findings in sarcoidosis

A 
Parotid gland enlargement
Facial palsy
Heart block and restrictive cardiomyopathy
CNS sx
Iritis, Uveitis
188
Q

Best initial test in sarcoidosis

189
Q

Most accurate test in sarcoidosis

A

LN Bx

Shows noncaseating granulomas

190
Q

Drug of choice in sarcoidosis

A

Prednisone

191
Q

Where do PEs derive from

A

DVT in leg - 70%

DVT in pelvic vein - 30%

192
Q

Causes of DVTs

A 
Immobility
Surgery
Trauma
Joint replacement
Thrombophilia
Malignancy
Pregnancy
193
Q

Inherited thrombophilia causing DVT

A

Factor V Leiden

194
Q

Aquired thrombophilias

A

Lupus anticoagulant
Nephrotic syndrome
OCPs esp in smokers

195
Q

How does nephrotic syndrome cause DVTs

A

Loss of albumin and Anti-thrombin III

Leads to renal vascular thrombosis

196
Q

Most common findings in PE

A

Sudden SOB w/ clear lungs and normal CXR

197
Q

Best initial tests for PE

198
Q

Most accurate test for PE

A

Angiography

199
Q

Mortality rate in angiography

200
Q

MC finding on CXR for PE

A

Atelectasis

201
Q

Other findings on CXR for PE

A

Wedge infarction
Pleural lesion
Westermark sign

202
Q

MC abnormality on EKG for PE

A

Nonspecific ST-T changes

203
Q

ABG findings in PE

A

Hypoxia and resp alkalosis w/ NL CXR

204
Q

Suspect PE what is next best step

A

Start therapy

Do NOT wait for confirmatory testing (Spiral CT or V/Q)

205
Q

MC confirmatory test for PE

206
Q

When to use V/Q as confirmatory test for PE

A 
Pregnancy (Use as 1st test)
CXR NL (but spiral CT is still better)
207
Q

When is D-dimer the answer for PE test

A

Pretest probability for PE is low

208
Q

LE doppler positive in PE pt, what is the next step

A

No more testing

Heparin then warfarin for 6mos

209
Q

-CT, -V/Q, -LE doppler, now what

A

Stop heparin

210
Q

Angiography AE

A

Allergy
Renal tox
Death

211
Q

Best initial therapy for PE or DVT

A

Heparin (warfarin started at same time)

212
Q

When is IVC filter the rx for PE/DVT

A

Contraindication to anticoagulants
Recurrent emboli while on heparin or therapeutic warfarin
RV dysfunction

213
Q

When are thrombolytics the rx for PE/DVT

A

Hemodynamically unstable

Acute RV dysfinction

214
Q

When are direct acting thrombin inhibitors the rx for PE/DVT

215
Q

When is aspirin the rx for PE/DVT

216
Q

What is pulm HTN

A

SBP>25

DBP>8

217
Q

Causes of pulm HTN

A

Idiopathic
Chronic lung disease
- COPD
- Fibrosis

218
Q

Presentation of pulm HTN

A

Dyspnea and fatigue
Syncope
CP
Wide splitting S2, Loud P2

219
Q

Best initial test for pulm HTN

A

CXR and CT

220
Q

Most accurate test for pulm HTN

A

Swan Ganz catheter

221
Q

Rx pulm HTN

A

Treat underlying cause

222
Q

When is idiopathic pulm HTN treated

A

Vascular reactivity

223
Q

Rx idiopathic pulm HTN

A 
Prostacyclin analogues
- Epoprostenol
- Trepostinil
- Iloprost
- Beraprost
Endothelin antagonists
- Bosentan
Phosphodiesterase inhibitors
- Sidenafil
224
Q

Role of O2 in pulm HTN

A

Slowes progression

225
Q

Only cure for pulm HTN

A

Lung transplant

226
Q

MCC OSA

227
Q

Most accurate test for OSA

A

Sleep study

228
Q

How does OSA have increased bicarb

A

Hypoventilation → Hypoxia, hypercapnea, ↓O2 sat → chronic resp acidosis → compensate w/ increased bicarb

229
Q

Rx OSA

A 
Lose weight
No alcohol
CPAP
Keep tongue out of the way
Uvuloplatopharyngoplasty (LAST RESORT)
230
Q

Picture of ARDS

A

Pt in ICU doing better then rapidly deteriorates w/ a pulmonary edema picture

231
Q

Problem in ARDS

A

Loss of surfactant leading to leaky alveoli that fills w/ fluid

232
Q

Causes of ARDS

A 
Sepsis/aspiration
Contusion/trauma
Near-drowning
Burns or pancreatitis
DIC
233
Q

MCC ARDS

A

G- sepsis by pseudomonas

234
Q

CXR in ARDS

A

B/L infiltrates

White-out

235
Q

pO2/FIO2 ratio in ARDS

236
Q

pO2 in ARDS

237
Q

FIO2 in ARDS

238
Q

Wedge pressure in ARDS

239
Q

Does anything reverse ARDS

240
Q

Best support for ARDS

A

Low tidal volume mechanical ventilation

6mL/kg

241
Q

What is used to decrease FIO2

A

PEEP

Maintain plateau pressure of

Step 2 CK (21 decks)

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