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Family Medicine EOR > Pulmonary > Flashcards

Pulmonary Flashcards

Focus: Diagnosis, Clinical Therapeutics

1
Q

What spirometry readings are diagnostic of asthma?

A

FEV1/FVC <70%
FVC 80%+

Pre-Post bronchodilator FEV1/FVC increase by 12%

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2
Q

What criteria warrant poor control of asthma?

A
  1. SABA use >2x a week
  2. > 1 canister per month
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3
Q

ICS include?

A

Beclomethasone
Budesonide
Ciclesonide
Fluticasone
Mometasone

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4
Q

SAMA include?

A

ipratropiom

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5
Q

LAMA include?

A

tiotropium
aclidnium
glycopyrrolate
revefenacin
umeclidium

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6
Q

First line medication for asthma tx initiation in ADULTS?

A

Low dose ICS-LABA combo PRN
*ICS-formoterol

LABA has evidence that reduces risk of exacerbatios better than SABA

You can prescribe SABA as an alternative

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7
Q

Asthma tx if first line not sufficient?

Next step?

Next step?

A

Low dose ICS-formoterol daily rather than PRN

Next: Medium dose ICS-formoterol daily

Next: Medium/High dose ICS-formoterol + LAMA daily

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8
Q

First line medication for asthma tx initiation in 6-11?

A

Low dose ICS/SABA combo PRN

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9
Q

Asthma tx if first line not sufficient in 6-11yo?

Next step?

Next step?

A

Low dose ICS daily

Next: Low dose ICS-LABA or medium dose ICS daily

Next: Refer +/- high dose ICS-LABA

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10
Q

5yo and younger with asthma should NOT be prescribed?

A

beta blocker; only give ICS

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11
Q

Asthma exacerbation tx?

A
  1. Nebulizer (albuterol 3 doses in first hour then hourly + SAMA ipratropium)
  2. Injectable/oral methyprednisolone

**if severe exacerbation not resolving add IV mag

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12
Q

First line medication for COPD?

A

LABA + ICS

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13
Q

GOLD ABE Assessment Tool -

what do you use to determine A, B, or E type COPD

A

A = mMRC 0-1; CAT <10
B = mMRC 2+; CAT 10+
E = 2+ moderate exacerbations or 1+ hospitalizations

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14
Q

When do you add ICS to COPD tx?

A

only if
1. eos 300+ and MUST BE USED WITH LABA + LAMA
2. COPD exacerbation

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15
Q

Group A COPD tx?

A

SABA or LABA

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16
Q

Group B COPD tx?

A

LABA + LAMA

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17
Q

Group C COPD tx?

A

LABA + LAMA + ICS if eos 300+

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18
Q

COPD exacerbation tx (5 things to consider)?

A
  1. Albuterol 1-2 puffs q hr x2-3 doses then q2-4hrs or nebulizer 15min
  2. LABA or LAMA + get CBC to check eosinophil count
  3. If eos 300+ = Add ICS
  4. Add antibiotic if sputum and SOB = AMOX/CLAV, AZITHROMYCIN, TETRACYCLINE
  5. Add roflumilast (PDE-4i) to daily tx if chronic bronchitis or hx of exacerbation
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19
Q

LABAs include?

A

arformoterol
formoterol
indacaterol
olodaterol
salmeterol

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20
Q

COPD: emphysema vs chronic bronchitis diagnosis?

A

Emphysema: CXR/CT shows hyperinflation, loss of parenchyma & destruction of airspace distal to terminal bronchioles
-pink puffer, dry cough, little/no mucus, hyperresonance, decreased breath sounds, muscle wasting, barrel chest, pursed-lip breathing when severe

Chronic bronchitis: productive cough 3+ mo for 2+ years

-blue bloater, obesity, peripheral edema, Severe v/q mismatch (hypoxemia, hypercapnia), HIGH Hgb/Hct

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21
Q

COPD diagnosis on spirometry?

A

FEV1/FVC = <70%
FVC = 80%+ OR FVC <80% but TLC is normal

*FVC<80 and low TLC is mixed lung disease

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22
Q

Restrictive lung disease on spirometry?

A

FEV1/FVC 70+
FVC <80%

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23
Q

Acute bronchitis is likely due to what microbe?

Acute bronchitis presentation? typically lasts?

TOC?

A

Flu A & B, adenovirus, rhinovirus, coronavirus, RSV, parainfluenza

Presents: URI sx + cough 1-3 wk (“persistent cough with MSK pain”), wheeze or mild SOB

TOC: rest & fluids + NSAIDs + cough meds (dextromethorphan, guaifenesin)

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24
Q

Bronchiectasis characteristic findings?

Gold-standard dx?

A

COPD-like but CXR findings find abnormal dilation/thickening of airway; linear atelectasis

-chronic productive cough for mo/yrs
-crackles! or wheeze
-history of lung damage from past conditions/illnesses

DX: HRCT shows lack of tapering of bronchi (tram-tracking), signet-ring sign

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25
Q

Chronic productive cough with CXR findings of dilation and thickening of bronchial tree and HRCT shows tram-tracking and signet-ring sign

airway-arterial ratio 1.5+

A

Bronchiectasis

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26
Q

Tx of brochiectasis?

A

COPD tx algorithm
-what is mmRC (0-1?)
-what is CAT (<10?)
-what is eos (<300?)

Determine A, B, or E type
A: LABA
B: LABA + LAMA
C: LABA + LAMA +/- ICS

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27
Q

MC type of lung cancer?

A

Adenocarcinoma

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28
Q

Patients who have occupation of home-remodeling are more at risk of what lung cancer?

A

Mesothelioma

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29
Q

A solid nodule size of ____ suggest malignant lung tumor

A subsolid nodule size of ____ suggest malignant lung tumor

A

> 8mm

6+mm

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30
Q

Any growth of ______ during f/u of a pulm nodule requires _____?

A

Any growth at all requires biopsy

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31
Q

A peripherally located pulm nodule is most likely?

A

Adenocarcinoma or Large cell carcinoma

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32
Q

A centrally located pulm nodule is most likely?

A

Small cell, Squamous cell, carcinoid tumor

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33
Q

A patient showing symptoms of lung cancer experiences additional sx of shooting arm pain/weakness, ipsilateral miosis, ptosis, and anhidrosis. What is the most likely cause?

A

A pancoast tumor - type of sqaumous cell carcinoma that presents with Horner’s sydrome and arm weakness

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34
Q

A patient showing symptoms of lung cancer experiences additional sx of weight gain, fat padding, thrombophlebitis, and oliguria. What is the most likely cause?

A

Paraneoplastic syndrome - the tumor releases hormones/cytokines. Patient can develop SVC syndrome, SIADH, Cushing, Lambert-Eaton syndrome

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35
Q

Steps to diagnosis for central lung tumor and peripheral lung tumor?

A

CXR –> CT w/contrast

Central: transbronchial biopsy
Peripheral: transthoracic aspiration
Histopath labs (TTF-1, neoplastic gland formation, intracytoplasmic mucin, keratin production, or desmosome formation)

36
Q

What sites of pulm nodule location are more likely lung cancer?

A

Peripheral; Upper lobe

37
Q

The only lung cancer where excision is NOT recommended as first line?

A

Small cell lung cancer - chemo + radiation is first line

38
Q

USPSTF recommendation for low-dose lung CT?

A

Annual starting at 50-80 for those with
1. 20PPY hx and currently smoke or quit within 15yrs

39
Q

CAP most common bug?
Tx?

A

*S. pneumoniae
Tx: amoxicillin +/-azithromycin/doxycycline

40
Q

CAP in immunocompromised individuals tx?
Duration?

A

Amox/clav + azithromycin/doxycycline

3-5 days

41
Q

HAP most common bug?
Tx?
Duration?

A

*Pseudomonas
Tx: Pip-tazo/cefepime/ceftazidime

+ Vanc/linezolid if MRSA

7-14 days

42
Q

VAP most common bug?
Tx?
Duration?

A

Meropenem + vanc/linezolid
10-14 days

43
Q

Contact sports, injxn drug use, homosexual, crowded living should raise concern for what organism?

A

MRSA - cover with proper abx (vanc)

44
Q

Aspiration PNA tx?

A

amp-sulbactam/amox-clav/clindamycin +/- metronidazole

45
Q

PNA in a chronic alcoholic raises concern for what most likely organism?

A

Klebsiella

46
Q

Histoplasmosis first line tx?

BIRD mnenomic?

A

Itraconazole - fungal infxn from bird droppings

B - bird/bat dropping
I - itraconazole
R - river valley
D - defining illness for AIDS CD4 <=150

47
Q
A
48
Q

At what CD4 count is an AIDS patient at risk of pneumoncystis pneumonia (PCP)?

A

CD4<200

49
Q

What diagnostic test identifies type of microbe causing pneumonia?

A

Gram stain or PCR of sputum/BAL

50
Q

PCP prophylaxis and tx for patients with CD4 count of ____?

A

CD4 <200 begin preventative low dose TMP-SMX

51
Q

PNA with “Batwing” appearance on X-ray

A

Pneumocystis pneumonia (PCP)

52
Q

TOC for PCP?

A

TMP-SMX x 21 days +/- prednisone

53
Q

TOC for sleep terror/sleepwalking?

A

Benzos

54
Q

Regimen and Duration of TB treatment?

A

RIPE x 2mo then RI x 4mo
Give on empty stomach 1hr before or 2hr after meal
R- rifampin
I - isoniazid
P - pyrazinamide
E - ethambutol

55
Q

TOC for latent TB

A

3HP: RI q1wk or qd for 3mo
4R: Rifampin qd x4mo

56
Q

What med in RIPE therapy most likely to cause AE of optic neuritis?

A

Ethambutol –> d/c if abnormal

57
Q

What med in RIPE therapy most likely to cause AE of petechial rash and thrombocytopenia?

A

Rifampin

58
Q

What TB med is CI or requires caution in pts with gout?

A

Pyrazinamide

59
Q
A
60
Q

Presence of Ghon focus + hilar nodes on CXR is indicative of what?

A

TB

61
Q

Extrapulmonary TB can manifest in what other systems?

A

TB Meningitis
Vertebral TB (Potts Disease)
TB Lymphadenitis
Renal TB
Intestinal TB

62
Q

Cough for 2+ weeks, hemopytsis, night sweats, fever, weight loss, LAD, pleuritic chest pain warrant concern for what diagnosis?

A

TB

63
Q

Diagnosis of active TB?

A

CXR + AFB smear, culture, or NAAT of Sputum x3 and 8+ hrs apart with at least 1 early morning

64
Q

TB skin test vs Interferon-Gamma Release Assays

A

TB skin test - screening of choice although not as specific

*Sputum culture w/ acid fast stain –> Interferon- Gamma Release Assay (IGRA) - patient has hx of Bacille Calmette-Guérin vaccine

65
Q

A positive PPD in HIV patient is?

A

5mm

then get CXR to determine active vs latent TB

66
Q

A positive PPD in children <4 is?

A

10mm

then get CXR to determine active vs latent TB

67
Q

A positive PPD in DM, CKD, IVDU patients is?

then get CXR to determine active vs latent TB

A

10mm

68
Q

A positive PPD in a healthy individual is?

then get CXR to determine active vs latent TB

A

15mm

69
Q

How long does a pt require isolation once started on TB treatment?

A

2 weeks isolation then non-infectious

70
Q
A
71
Q

A patient who is chronically fatigued, daytime sleepiness, and HTN warrants?

A

Sleep study –> Polysomnography

72
Q

A positive sleep apnea polysomnography is an AHI of?

A
  1. 5 or more with sx of OSA or comorbidities
  2. 15 or more without sx of OSA
73
Q

Characteristics symptoms of TB?

A

-Dry to productive cough to blood in sputum
-drenching night sweats and fever
-pleuritic chest pain
-post-tussive rales or signs of consolidation

74
Q

Signs of latent TB vs active TB?

TOC for active TB vs late TB?

A

Latent TB: fibrocaseous calcification, Ranke complex

Active TB: cavitary lesions, caseous necrosis, Ghon’s complex

Active: RIPE 2mo, 4mo
Late: Rifampin 4mo

75
Q

Tx of OSA?
Tx of CSA?

A

OSA: CPAP
CSA: tx cause

76
Q

How is central sleep apnea different from OSA?

A

the drive to breath declines due to respiratory center dysfunction

77
Q

What is the most likely PNA organism?

Young, healthy pts living in close proximity. Presenting with extrapulm sx (cough, sore throat, otalgia)

Organism is resistant to beta-lactam abx, cannot be found on gram stain

A

Atypical PNA: mycoplasma pneumoniae

78
Q

Most common atypical comm-PNA?

A

Mycoplasma pneumoniae

79
Q

Most common organism associated with COPD with PNA?

A

H. influenza

80
Q

Most common organism associated with chronic alcoholism, currant jelly sputum, and cavitary lesions?

A

Klebsiella pneumoniae?
“Clebsiella associated with all of the Cs”

81
Q

What is the most likely PNA organism?

Pt presenting with cough + diarrhea and exposure to water source that has caused whole family to be sick. Hyponatremia and elevated AST/ALT are found

A

Legionella pneumophila

82
Q

PNA diagnostic imaging and labs to order?

A

CXR
CBC - leukocytosis
CMP - dehydration, +/- high AST/ALT
only mod-severe PNA get culture and PCR - 3x over 8hrs apart

83
Q

What severity score is used to determine severity of PNA?

What score indicates inpatient tx?

A

CURB65
C - confusion
U - BUN >7
R - respiratory rate 30+
B - BP <90/60
65 - age

2pts = inpatient
3pts = ICU

84
Q

Tobacco dependence tx?
Patient has cigarette within 30min after waking?
Patient has cig after 30min?

A

3 options

  1. Nicotine gum 4mg, 2mg at least 9 daily for week 1-6; lozenges 4mg, 2mg at least 20 daily week 1-6
  2. nasal spray; patch (>10cigs per day, <10cigs) - 21mg/day to start; 14mg/day to start
  3. Bupropion, Varenicline (Chantix)
85
Q
A

Family Medicine EOR (9 decks)

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