Pulm 6/17 Quiz Review

Question 1

Lung CA:

define pulmonary nodule

Answer 1

Lung CA

= small opacities,
less than 3 cm in size

Notes:
usually asymptomatic
usually detected incidentally
or at time of screening

Question 2

Lung CA:

define lung mass

Answer 2

Lung CA

= any opacity larger than 3 cm in size

Notes:
malignant until proven otherwise

Question 3

Lung CA:

two primary categories of Lung CA are:

Answer 3

Lung CA

• non small cell lung cancer (NSCLC)
• small cell lung cancer (SCLC)

Question 4

Lung CA:

growth rate of small cell lung cancer (SCLC) =

Answer 4

Lung CA

grow very very fast

Question 5

Lung CA:

who predominantly gets SCLC?

Answer 5

Lung CA

```
smokers do
“occur predominantly in smokers”
~~~

Question 6

Lung CA:

what are the two stages of SCLC? How are they defined?

Answer 6

Lung CA

Limited Stage & Extensive Stage

Limited Stage = all disease w/in single radiation field (i.e. single hemithorax, possibly with some supraclavicular lymph nodes thrown in)
Extensive Stage = disease OUTSIDE a single hemithorax

Question 7

Lung CA:

what is the most common non-small cell lung cancer (NSCLC)?

Answer 7

Lung CA

adenocarcinoma

Question 8

Lung CA:

what is the TNM system of staging? What does TNM stand for?

Answer 8

Lung CA

T = tumor
N = node
M = metastasis

I = solitary tumor, tumor <= 4 cm, no lymph node involvement

II = tumor > 4 cm, regional lymph nodes involved, invasion into local structures

III = medistinal lymph nodes positive

IV = distant metastatic disease (includes pleural effusion)

Question 9

Lung CA:

how to treat lung cancers at different stages –>

Answer 9

Lung CA

FIRST = biopsy, determine if NSCLC or SCLC!

I - surgical resection
II - surgical resection + chemo
III = chemoradiation
IV = palliative care (incurable)

Question 10

Lung CA:

name some NSCLC presentations

Answer 10

Lung CA

hyperalcemia
hypertrophic pulm osteoarthropathy (NOT finger clubbing)
inflammatory myopathies

Question 11

Lung CA:

what is most common subtype of lung cancer?

Answer 11

Lung CA

NON-small cell lung cancer (NSCLC)

Question 12

Lung CA:

common symptoms for lung cancer = ?

Answer 12

Lung CA

typical: cough, increased sputum, shortness of breath
common: fatigue, wt loss, anorexia, low-grade fever

Question 13

Lung CA:

name some SCLC presentations

Answer 13

Lung CA

paraneoplastic syndromes:
hyponatremia (SIADH)
hypertrophic pulm osteoathropathy (NOT finger clubbing, same as NSCLC)
inflammatory myopathies (same as NSCLC)
Cushing Syndrome
Lambert-Eaton syndrome
cerebellar degeneration

Question 14

CF Dx/Trtmt: Epi

What ethnicity carries highest rates of cystic fibrosis?

Answer 14

CF Dx/Trtmt: Epi

Caucasian

Question 15

CF Dx/Trtmt: Dx approach, newborn screening:

To dx CF, pt must have at least one of these three symptoms:

Answer 15

CF Dx/Trtmt: Dx approach, newborn screening

  >1 typical phenotypic features of CF
  sibling with CF
  positive newborn screening test

Question 16

CF Dx/Trtmt: Dx approach, newborn screening:

To dx CF, pt must ALSO have one of these three symptoms (in addition to the three required):

Answer 16

CF Dx/Trtmt: Dx approach, newborn screening

- elevated sweat chloride on 2 occasions
 - TWO disease-causing CFTR mutations
 = abnormal nasal potential difference

Question 17

CF Dx/Trtmt: Dx approach, newborn screening:

Why is newborn screening helpful/important?

Answer 17

CF Dx/Trtmt: Dx approach, newborn screening

“With widespread adoption of newborn screening in recent years, we have seen a….an increasing number of infants diagnosed before a month of age”

Question 18

CF Dx/Trtmt: Dx approach, newborn screening:

Three most common phenotypical symptoms seen in CF diagnoses

Answer 18

CF Dx/Trtmt: Dx approach, newborn screening

acute/persistent respiratory symptoms (37.3%)
steatorrhea (22.4%)
meconium ileus/intestinal obstruction (17.6%)

Question 19

CF Dx/Trtmt: Dx approach, newborn screening:

What is the GOLD STANDARD For CF dx?

Answer 19

CF Dx/Trtmt: Dx approach, newborn screening

SWEAT CHLORIDE TESTING (done at an accredited CF Care Center)

Question 20

CF Dx/Trtmt: Dx approach, newborn screening:

What is required for a positive genetic test for CF?

Answer 20

CF Dx/Trtmt: Dx approach, newborn screening

“TWO defective genes in trans configuration”

Question 21

CF Dx/Trtmt: Dx approach, newborn screening:

What is the most common mutation for CF?

Answer 21

CF Dx/Trtmt: Dx approach, newborn screening

F508del (70% of mutations)

Question 22

CF Dx/Trtmt: Dx approach, newborn screening:

How do we test newborns for CF?

Answer 22

CF Dx/Trtmt: Dx approach, newborn screening

We check for immunoreactive trypsinogen

(this is an exocrine pancreatic protein, which is elevated in newborns with CF (3-5 x higher))

Question 23

CF Dx/Trtmt: CF pathophys:

Describe CFTR

Answer 23

CF Dx/Trtmt: CF pathophys

what is it? gene
location: long arm of chromosome 7
function: codes for protein in cell membrane of many organs
action: acts as chloride channel
(also controls other channels)

Question 24

CF Dx/Trtmt: CF pathophys:

name three basic symptoms of CFTR mutation

Answer 24

CF Dx/Trtmt: CF pathophys

GI
Upper Respiratory System
Lower Respiratory System

Question 25

CF Dx/Trtmt: CF pathophys: Name three common GI symptoms of CF

Answer 25

CF Dx/Trtmt: CF pathophys ``` pancreatic insufficiency (85%) hepatobiliary disease (70%) GERD (25-100%) ```

Question 26

CF Dx/Trtmt: CF pathophys: Name two common upper respiratory symptoms of CF

Answer 26

CF Dx/Trtmt: CF pathophys ``` recurrent or chronic sinus disease (100% of CF pts) nasal polyps (up to 25% of CF pts) ```

Question 27

CF Dx/Trtmt: CF pathophys four manifestations of lower respiratory symptoms of CF

Answer 27

CF Dx/Trtmt: CF pathophys inflammation (occurs early after birth) CF-specific pathogens bronchiectasis pulmonary exacerbations (lead to loss of lung fxn)

Question 28

CF Dx/Trtmt: Epi: | Why do we see increased numbers of adult patients? two reasons

Answer 28

CF Dx/Trtmt: Epi mild phenotype diagnosis discovered in adulthood increased life expectancy

Question 29

CF Dx/Trtmt: Dx approach, newborn screening: What are three requirements for sweat chloride testing?

Answer 29

CF Dx/Trtmt: Dx approach, newborn screening newborn > 36 weeks (gestational age) two weeks old (post-partum) minimum body wt = 2 kg

Question 30

CF Dx/Treatment: quality care is dependent upon these two factors

Answer 30

CF Dx/Trtmt CF Foundation's evidence-based or consensus standards Healthcare Team of PCP and CF Care Center personnel they have to coordinate & communicate

Question 31

CF Dx/Treatment Functional Mutation Classes Should we know this slide???

Answer 31

Class I – altered biosynthesis No CFTR produced Class II – altered maturation Minimal and dysfunctional CFTR at cell surface Class III – altered regulation Adequate CFTR at cell surface, reduced or no function Class IV – altered conductance Adequate CFTR at cell surface, reduced function Class V – reduced synthesis Decreased but functional CFTR Class VI – increased turnover

Question 32

CF Dx/Treatment: CF clinical practice guidelines: What three pharmacological interventions are used as anti-inflammatory treatments for CF?

Answer 32

CF Dx/Treatment: CF clinical practice guidelines corticosteroids, oral ibuprofen (high dose) azithromycin (macrolide anitbiotics)

Question 33

CF Dx/Treatment: CF clinical practice guidelines: When pts are diagnosed at a younger age, the community acquired bacteria that most commonly colonize the airways are _________ (name three).

Answer 33

CF Dx/Treatment: CF clinical practice guidelines H. influenza Strep pneumo MSSA (methicillin-susceptible Staphylococcus aureus)

Question 34

CF Dx/Treatment: CF clinical practice guidelines: As CF pts get older, two bacteria are the most common infection threat. They are _________ .

Answer 34

CF Dx/Treatment: CF clinical practice guidelines Pseudomonas aeruginosa MRSA (Methicillin-resistant Staphylococcus aureus) Note: these two cause decreased life expectancy and worsening outcomes!

Question 35

CF Dx/Treatment: CF clinical practice guidelines: What is done to monitor for bacterial infection in CF patients?

Answer 35

CF Dx/Treatment: CF clinical practice guidelines throat cultures, 4x/year (have pt return to clinic 4x/year to culture and monitor for Pseudomonas and MRSA).

Question 36

CF Dx/Treatment: CF clinical practice guidelines: What are the four basic components of lower respiratory tract therapy pulmonary toilette?

Answer 36

CF Dx/Treatment: CF clinical practice guidelines Bronchodilators Mucolytics Hypertonic Saline Airway Clearance

Question 37

Pulm HTN: definition Define pulmonary hypertension

Answer 37

Pulm HTN: definition condition of the lungs in which blood vessels of lungs become narrow rare pathological narrowing progresses over time results in increase of bp in these vessels

Question 38

Pulm HTN: WHO definition What is Group 1 Pulmonary Hypertension?

Answer 38

Pulm HTN: WHO definition Group 1 = pulmonary arterial hypertension (PAH) Idiopathic, familial (only group 1 is called pulmonary "arterial" hypertension, but all 5 grooups may be referred to as PH)

Question 39

Pulm HTN: WHO definition What is Group 2 Pulmonary Hypertension?

Answer 39

Pulm HTN: WHO definition Group 2 = PH due to L heart disease (most common)

Question 40

Pulm HTN: WHO definition What is Group 3 Pulmonary Hypertension?

Answer 40

Pulm HTN: WHO definition Group 3 = PH due to lung disease and/or hypoxemia

Question 41

Pulm HTN: WHO definition What is Group 4 Pulmonary Hypertension?

Answer 41

Pulm HTN: WHO definition Group 4 = PH due to chronic thromboembolism

Question 42

Pulm HTN: WHO definition What is Group 5 Pulmonary Hypertension?

Answer 42

Pulm HTN: WHO definition Group 5 = PH with unclear multifactorial mechanisms

Question 43

Pulm HTN: where would you expect back flow in the heart in a case of Pulmonary Hypertension?

Answer 43

Pulm HTN backflow of blood from pulmonary artery into R ventricle and even further back into R tricuspid and R atrium

Question 44

Pulm HTN: Name some signs of PH

Answer 44

Pulm HTN ``` Cyanosis (bluish lips and skin) Chest pain Fluttering chest Shortness of breath Fatigue, weakness Dizziness, lightheadedness Dry cough Abdominal bloating Rapid weight gain Swollen ankles, legs ```

Question 45

Pulm HTN: What does a split in the S2 heart sounds indicate?

Answer 45

Pulm HTN (this split is b/w aortic (A2) and pulmonic (P2) valve closures...Aortic valve may close earlier due to higher resistance from systemic circulation) This means there is less resistance in the pulmonary arterial bed causing a later P2

Question 46

Pulm HTN: How do we assess PH?

Answer 46

Pulm HTN cardiac catheterization ("cath") Gold Standard (just not always possible, esp for little kids) echocardiogram --> R ventricle pressure estimated via flow through tricuspid valve EKG Chest Xray

Question 47

Pulm HTN: What is the basic pathogenesis of PH?

Answer 47

Pulm HTN increased vasoconstrictors decreased vasodilators

Question 48

Pulm HTN: What three therapy pathways do we use to treat Pulmonary Hypertension via Vascular Biology?

Answer 48

Pulm HTN NO-cyclic guanosine monophosphate (cGMP) (and phosphodiesterase inhibitors like Viagra) ET-1 (Bosentan, Ambrisentan) PGI2 (Epoprostenol, Flolan, as continuous IV....not the best option) Treprostinil is preferred now.

Question 49

Foxworth Pharm: Pneumonia Trtmt, adults, first line:

Answer 49

Foxworth Pharm Amoxicillin Doxycycline

Question 50

Foxworth Pharm: Pneumonia Trtmt, adults, if comorbidity exits

Answer 50

Foxworth Pharm amox/CA + AZ

Question 51

Foxworth Pharm: Pneumonia Trtmt, adults, if pneumonia is respiratory

Answer 51

Foxworth Pharm quinolone or amox/CA

Question 52

Foxworth Pharm: If pneumonia treatment resistance to macrolides is <25%, what treatment should be chosen?

Answer 52

Foxworth Pharm AZ

Question 53

Foxworth Pharm: How long do we usually treat pneumonia?

Answer 53

Foxworth Pharm 5-7 days (pt should be afebrile >48 hrs, clinically stable, not vomiting, able to eat (these are all po treatments!))

Question 54

Foxworth Pharm: How do we treat pneumonia with alcoholism, COPD, or post-influenza comorbidity?

Answer 54

Foxworth Pharm ``` respiratory flouroquinolones (FQ) or AZ + high dose amox or high dose amox/CA ```

Question 55

Foxworth Pharm: List some side effects for flouroquinolones (FQ)

Answer 55

Foxworth Pharm * Wt bearing cartilage damage in children * Tendon rupture in adults * MS changes (agitation, delirium, nervousness, < memory) * Food and drug interactions * QTc * hypoglycemia & hyperglycemia (DM, > age, renal disease) * C diff

Question 56

Foxworth Pharm: Explain admission criteria CURB-65 and CRB-65

Answer 56

Foxworth Pharm ``` give a point for each of the following ~ CURB-65 = Confusion Uremia Resp rate Blood pressure >65 y/o ``` ``` CRB-65 = Confusion Resp rate Blood pressure >65 y/o ```

Question 57

Foxworth Pharm: When would you admit w/ a CURB-65 of 0?

Answer 57

Foxworth Pharm ``` o Immunocompromised o DM o Someone with pulse ox that’s low o Someone w/ complications o Someone who will not follow treatment plan after discharge ```

Question 58

Foxworth Pharm: After culture confirms bacterial agent, how would one treat CAP with a hospitalized (not ICU) pt?

Answer 58

Foxworth Pharm ceftriaxone (CFTX) IV + AZ

Question 59

Foxworth Pharm: After culture confirms bacterial agent, how would one treat CAP with AN ICU pt?

Answer 59

Foxworth Pharm ``` ceftriaxone (CFTX) IV + levofloxacin + AZ IV + van or linezolid ```

Question 60

Foxworth Pharm: After culture confirms bacterial agent, how would one treat nosocomial pneumonia?

Answer 60

Foxworth Pharm cefepime or "pip/tazo" Note: add vanc if hospital acquired MRSA is >20% prevelant, or if antibiotics were used w/in 90 days, or in case of septic shock

Question 61

Foxworth Pharm: resistance Which antibiotic has shown some Strep pneumo resistance?

Answer 61

Foxworth Pharm AZ Note: use FQ as an alternative

Question 62

Foxworth Pharm: What is recommended treatment for bronchitis?

Answer 62

Foxworth Pharm NO ANTIBIOTICS Note: treatment is controversial! maaayyybeeee consider AZ for persistent cough bronchitis.