Pulmonary 2

Question 1

Oxgenation delivery to tissue depends on what?

Answer 1

CO and amount of Hgb. Thus check BP and Hgb > 10 for adequate oxygen delivery.

Question 2

What is a parapneumonic effusion? Management?

Answer 2

This is a bacterial effusion 2/2 to pneumonia. Need to do thoracentesis to check pH (< 7.2) and make show its not complicated by empyema. If empyema present then Chest tubes need to be placed. Uncomplicated parapneumonic effusions can be treated with abx alone.

Question 3

What condition to consider when pts have lymphocytic predominant exudative pleural effusion? What are the other test for this condition.

Answer 3

TB. Elevated ADA. PCR positive. If the acid fast stain and culture do not show TB. Pleural biopsy confirms diagnosis is most specific and sensitive for pleural TB.

Question 4

Name 2 indications for mechanical ventilation?

Answer 4

1. Increase PC02, decrease pH 2. AMS(neurological depression, loss of epiglottic reflux)

Question 5

2 common causes of aspiration?

Answer 5

1. AMS 2. Upper airway instrumentation (NG tubes)

Question 6

Side of effect of cromolyn in kids?

Answer 6

Can induce asthma exascerbation. used in chronic rx of asthma for children.

Question 7

Name 4 complications of COPD.

Answer 7

1. Hypoxemia with nocturnal desaturation 2. Secondary erythrocytosis (reactive EPO) HCT 60% 3. Pulmonary HTN leading to core pulmonale and MAT(different size p waves) on EKG. 4. Chronic ventilatory failure they remain at 60/60 (PO2 and C02) occurs early in chronic bronchitis but late finding in emphysema.

Question 8

Can be caused by RSV, adenovirus, drugs, toxins, collagen vascular dz and aspiration. Bronchioles are obstructed due reccurent inflammation and fibrosis. Dx?

Answer 8

Bronchiolitis Obliterans.

Question 9

Diagnostic Workup for PE?

Answer 9

1. Pulse Ox 2. ABG 3. CXR (will most likely be normal but may see (Westermark sign and Hamptons Hump) 4. ECG (S1Q3T3 2/2 R heart strain) 5. Spiral CT if pregnant or cant take contrast due to renal insufficiency then V/Q scan. 6. If All test negative then due Doppler and D-dimer (Sensitive but not specific). If all test negative and pts is high risk then do Pulmonary Angiogram.

Question 10

Management of PE in 1. Hemodynamically stable where anticoagu is not contraindicated? 2. Hemodynamically stable and anticogaug contraindicated (Brain or GI bleed, recent surgery) ? 3. Hemodynamically unstable and contraindicated? 4. Hemodynamically unstable and not contraindicated.

Answer 10

1. 02 therapy, IV Heparin or LMWH and bridge with Warfarin for 5-7 days (Until INR is therapeutic 2-3) then continue warfarin for 6 months. If pts 2nd PE then lifelong anticogulation. 2 .IVC filter 3. Pulmonary embolectomy. 4. tPA or Streptokinase

Question 11

Most common complication of DVT. What can prevent this?

Answer 11

Postphlebitic Syndrome (Due to obstruction that remains in the blood or backflow of blood due to destruction of valves or both.) Presents with edema, pain, tender swollen and hyperpigemnetation. Compression stockings.

Question 12

State when you give Noninvasive Positive Pressure Ventilaiton or intubate for COPD exacerbation.

Answer 12

1. NPPV should be tried for at least 2 hrs when a pit is becoming acidotic and hypercabic (7.1 PO2< 90mmgh) despite 02 face mask, combivent, solumedrol and abx.

Question 13

Ventilation but no perfusion? Perfusion but no ventilation?

Answer 13

1. Dead space 2. Physiologic Shunt (PE shunts)

Question 14

Given the exposure name the disease: 1. Coal 2. Sandblasting, rock climbing, tunneling 3. Shipyard workers, pipe fitting, insulators 4. Aerospace, nuclear and electrionic plants.

Answer 14

1. Coal workers lung 2. Silocosis dust (egg shell classification on CXR, increases risk for TB) 3. Asbestosis. 4. Berylliosis.

Question 15

Pulmonary fibrosis: What is the best initial test? What is the most accurate test? Rx?

Answer 15

Pulmonary fibrosis can be due to radiation, infection, drugs and toxins. 1. XRAY 2. High resolution CT like in bronchiectasis. PFTs show decrease DLCO, FEV1/FVC increase or normal - Restrictive pattern. Rx is prednisone to help reduce inflammation. Removal from environmental exposure.

Question 16

African american female presents with cough, SOB, parotid gland enlargement, facial palsy, Heart block from restrictive cardiomyopathy, CNS issues and iritis and uveitis. Dx? Best initial test? Other diganostic test? Rx?

Answer 16

CXR. Ace levels, hypercalemia and hypercaliuria. PFTS shows restrictive lung disease pattern with decreased FEV1 and FVC and TLC and normal Ratio of FEV1/FVC. Prednisone.

Question 17

Pt presents with SOB, dyspnea, tachypnea, tachycardia, pleuritic CP, leg pain and swelling. Dx? Best initial Test? Most accurate test? What is the risk of this test? Rx?

Answer 17

Pulmonary Embolism 2/2 DVT. CXR (Wedge shaped infarction), EKG (tachy, RAD, RBBB, RVH) ABG will show Hypoxia with Respiratory Alkalosis (Decreae in C02 and 02). Spiral CT/CT Angio is most accurate test. Start Heparin and warfarin started at the same time before CT if Wells criteria >3. Keep INR 2-3 (Subtherapeutic.) Can check D-Dimer (sensitive but no specific- any clot elevates the D-Dimer.) PE is a shunt. No pefusion but there is ventilation.

Question 18

When is heparin contraindicated and pt needs to be placed on IVC filter?

Answer 18

GI bleed, CNS bleed, Reccurent Emboli on Heparin/Warfarin.

Question 19

When is the only time you will use tpa (Streptokinase) to lyse PE?

Answer 19

Hemodynamically unstable pt.

Question 20

Pt presents with SOB, fatigue, CP, wide splitting S2 from pulmonary HTN with loud P2 or tricupsid and pulmonary valve regurgitation. Best initial test? Most accurate test? Rx?

Answer 20

This is pulmoary HTN. CXR and CT. Right heart or Swanz-ganz catheter most accurate shows elevate pulmonary arterial pressures. Correct underlying condition. Idiopathic Rx: Phosphodiesterase ihibitors, Prostacyclin analogues Epoprostenol, Any prost drug, Bosentan.

Question 21

Pt presents with obesity, bull neck, loud snoring, daytime somnolence, depression, HA in AM, HTN. Dx? What is the cause of HA. Most accurate test? Rx?

Answer 21

Obstructive sleep apnea. HA caused by the increase hypercabnia upon waking. Polysomnography (sleep study) Weight loss and avoid alcohol. CPAP. Last line is uvuloplatopharyngoplasty.

Question 22

Respiratory distress that occurs after Sepsis or SIRS( Burns, Pancreatitis), Aspiration, Contusion, Trauma. Dx? Test? Rx?

Answer 22

ARDS- diagnosis of exclusion (Criteria: 1. Worsening respiratory status, 2. Non Cardiogenic cause- echo is done to confirm this, 3. Bilateral Lung Opacities, 4. Pa02/Fi02 <100mmmH.) Mechanical Ventilation with Low tidal volumes and PEEP

Question 23

Best initial test for TB? Accurate? Rx? When is therapy extended to 9 months (4 conditions.)

Answer 23

CXR. AFB stain and culture on 3 separate occasions. RIPE therapy 6 months. (All drugs after 2 months, then stop Ethambutol (Optic neuritis) and Pyarzinamide), Continue Rifampin (Red secretions) and Isoniazid (AST/ALT,neuropathy-give B6) for 4 more months. 9 month therapy if pt has potts dz, TB tuberculoma, miliary TB, Pregnancy.

Question 24

PDD: When is induration > 5 mm an issue? 10mm> ?

Answer 24

1. Immunocomprised and Close Contacts with active TB 2. Immigrants, healthcare workers, prisoners.

Question 25

Explain 2 stage testing.

Answer 25

If pt has never had PPD done before then the 2nd PPD is indicated w/in 1-2 weeks if the first test was negative to rule out falsely negative result. If second test negative then pt is truly negative. If second test is positive then pt is truly positive and the first test was falsely negative.

Question 26

Initial Management and treatment of Acute on Chronic Exacerbation of COPD.

Answer 26

CXR. Get ABG if severe. Always check levels of theophylline if pt is on that, CBC, ECG. Rx: 1. 02 2. beta 2/ipatropium (Combivent/Symbicort), 3. IV or PO steroids (Solumedrol) (determine if they can swallow Oral tabs) and 4. Azithromycin. Educate on smoking cessation if pt is still smoking.

Question 27

Name the specific diagnostic test for these organisms. Mycoplasma, Legionella, PCP (Pneumocystis)

Answer 27

1. PCR and cold agglutins. 2. Urine antigen or Chorcal- yeast extract 3. BAL(Bronchoalveolar Lavage) For the other atypicals you can check serology (antibody titers)

Question 28

Management for Latent TB 1. Positive PPD and Negative CXR? 2. Positive PPD and Negative AFB x 3? 3. Positive PPD and Positive AFB x 3?

Answer 28

1. INH + B6 for 9 months 2. INH + B6 for 9 months 3. 6 months INH (AST/ALT), Pyzarazinamide then drop Rifampin (Red secretions) and Ethambutol (Optic Neuritis) after 2 months. Rifampin and Ethambutol always drop first.