Pulmonary

Question 0

What is the treatment for ODTS?

Answer 0

“Supportive care is the usual treatment of ODTS. Antibiotics are not needed because the syndrome is mediated by endotoxins rather than direct infection”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 1

What is ODTS?

Answer 1

“Organic dust toxicity syndrome (ODTS) occurs when moldy or decomposed hay and other organic material (such as hog manure) is moved. Endotoxins are aerosolized and inhaled, leading to the symptoms. The tip off here is that everyone on the job site was affected. Since hypersensitivity pneumonitis (“A”) is specific to the individual, generally only one worker at the site”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 2

What is Farmers lung?

Answer 2

“This is caused by exposure to the Actinomyces species, often accompanied by bailing hay. Acute findings include fever, chills, cough, dyspnea, and chest tightness. Occasionally, the radiograph is normal. High-resolution chest CT should then be obtained, which commonly show centrilobular micronodules and ground-glass opacification”

“Oral steroids are effective in the treatment of hypersensitivity pneumonitis”

“Hypersensitivity pneumonitis can become chronic if exposure is not limited. In these cases, patients will generally have systemic complaints such as fatigue and possibly weight loss; fever will be absent. Dyspnea and clubbing of the fingers are also generally noted, reflecting chronic pulmonary disease. Along with this finding, pulmonary fibrosis can occur and the DLCO may be decreased.”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 3

What would a PFT show with mild asthma?

Answer 3

“Patients with asthma will have a decreased FEV1. The FVC may fall as well, but FEV1 falls first and to a greater degree as the lung becomes obstructed. The ratio of FEV1/FVC is very sensitive to airflow limitations, and FEV1/FVC <0.7 (not predicted, just the ratio of the two numbers) is generally considered diagnostic of obstructive airway disease”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 4

What’s the most common EKG finding in PE?

Answer 4

Normal sinus rhythm; sinus tachycardia is also common; textbook finding of S1Q3T3 is relatively uncommon and relate mostly to massive PEs.

Question 5

What’s the most common X-ray findings associated with a PE?

Answer 5

“Approximately 75% of the chest radiographs in the setting of PE are abnormal. However, there are numerous causes for these abnormalities and none of them individually surpass the frequency of the normal chest radiographs. Specifically, the “textbook” findings of Westermark sign (loss of peripheral vascular markings) and Hampton hump (a wedge-shaped opacity due to pulmonary infarction) are infrequent, and both have a low sensitivity and low specificity. In short, all the other options can be seen as the result of a PE but none are more frequent than a normal CXR.

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Question 6

What are the PERC rules?

Answer 6

pulmonary embolism ruleout criteria. “If the patient meets all of the following, PE is ruled out assuming you believe the patient is low risk.”

1) Age 94%.
4) No unilateral leg swelling.
5) No hemoptysis.
6) No recent history of trauma or surgery.
7) No prior DVT or PE.
8) No hormone use.”

Do not get a D-dimer on no-risk patients. This simply increases the CT rate and exposure to unnecessary radiation. The fatal cancer rate in a 20-year-old female undergoing a 64-slice chest CT is 1:142 (really)”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 7

What is considered the standard of care in radiographic tests to diagnose a PE?

Answer 7

“The CTA is considered to be the standard of care. Its benefits include the fact that it is noninvasive, cheaper than pulmonary angiography, and far more available than VQ scans. It should be noted that pulmonary angiography still remains the “gold standard” for diagnosing pulmonary emboli, but that is more of an academic point. As for VQ scans, they are not available in many locales and often return nondiagnostic”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 8

For a stable patient with a PE, how long should anticoagulant therapy be applied?

Answer 8

“For a PE that has a reversible cause (oral contraceptive pills in this patient with a long airplane trip), 3 months of anticoagulation is adequate. For those with a second PE, lifetime anticoagulation is warranted”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 9

What is the classic triad of Wegener’s granulomatosis?

Answer 9

“disease of the upper respiratory tract, lower respiratory tract, and kidneys”

“Common findings include pleuritic chest pain, myalgias, arthralgias, ptosis, fever, weight loss, and purpuric skin lesions, among others”

“The ANCA, and especially c-ANCA which is more specific for Wegener granulomatosis, is present in up to 90% of patients with Wegener granulomatosis”

“An antiglomerular basement membrane antibody may be helpful in diagnosing Goodpasture syndrome, which can be clinically easily confused with Wegener’s granulomatosis.

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 10

Name three abnormal findings with sarcoidosis.

Answer 10

“Sarcoidosis is marked by the presence of noncaseating granulomas. While sarcoid can infiltrate the thyroid, it rarely, if ever, causes hypothyroidism. Pulmonary sarcoidosis includes a decreased diffusion capacity and decreased vital capacity. Other laboratory findings include hypercalcemia, hypercalciuria, elevated liver and pancreatic enzymes, and elevated ACE levels”

“Neurologic involvement occurs in up to 5% of patients and frequently presents as facial paralysis but may present as any CNS lesion. Peripheral nerves may also be involved.”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 11

What is the treatment for something with a nice lady case of pulmonary sarcoidosis?

Answer 11

“Nearly 50% of patients with sarcoidosis may have spontaneous resolution of their symptoms without treatment. In fact, treatment may actually prolong the disease process. If her pulmonary or systemic symptoms worsen or are causing major life problems, she should be started on oral steroids.”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 12

What are the physical exam findings with the pleural effusion?

Answer 12

“Everything is diminished in pleural effusion: there is dullness to percussion, decreased breath sounds, decreased tactile fremitus, and decreased voice transmission”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 13

How do you classify a pleural effusion?

Answer 13

A pleural effusion is either an exudate or a transudate. A pleural fluid LDH >2/3, the upper limit of normal serum LDH, a pleural LDH:serum LDH ratio >0.6, and a pleural protein:serum protein ratio >0.5 are all suggestive of an exudate. All three of these indicators point to an exudate in this case. Also, exudative effusions tend to have a higher degree of cellularity than transudative effusions”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 14

What are the findings on CT scanned of a single pulmonary nodule or coin sized lesion that are in the indicative of cancer?

Answer 14

“scalloped border and the corona radiata sign, which is composed of fine linear strands extending out from the nod”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 15

What is healthcare associated pneumonia?

Answer 15

Pneumonia occurring in a non-hospitalized patient who has had extensive healthcare and (IV therapy or chemotherapy with the last 30 days, residence in a nursing home, attendance at a hemodialysis center with in 30 days, or two or more days in an acute-care hospital in the last 90 days)

Question 16

What is the treatment of healthcare associated pneumonia?

Answer 16

Cefepime or any other cephalosporin with anti-pseudomonal activity

Question 17

What is the significance of increased interstitial markings in the lower lobes on CXR?

Answer 17

May be indicative of restrictive lung disease.
“In interstitial lung disease, spirometry shows a FEV1/FVC ratio >0.7, a decreased diffusing capacity, and decreased TLC (the hallmark of restrictive lung disease)”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 18

What is the significance of a low DLCO?

Answer 18

“The diffusing capacity, as measured by DLCO, is low in the following disease states: emphysema, interstitial lung disease (e.g., sarcoid, alveolitis, pulmonary radiation, pulmonary toxicity from drugs such as amiodarone, pulmonary fibrosis), Pneumocystis pneumonia, and pulmonary vascular disease. Anemia will also cause a low DLCO—so a hemoglobin or hematocrit should always be ordered with DLCO”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 19

What is ABPA?

Answer 19

Allergic bronchopulmonary aspergillosis (ABPA) is a condition characterised by an exaggerated response of the immune system (a hypersensitivity response) to the fungus Aspergillus (most commonly Aspergillus fumigatus). It occurs most often in patients with asthma or cystic fibrosis. Aspergillus spores are ubiquitous in soil and are commonly found in the sputum of healthy individuals. A. fumigatus is responsible for a spectrum of lung diseases known as aspergilloses.

“characterized by the presence of severe asthma, brownish mucus plugs, peripheral eosinophilia above 10%, elevated serum IgE, and central bronchiectasis. IgE elevation is required to be greater than 1000 ng/mL”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 20

What are the criteria for diagnosis of ABPA?

Answer 20

Allergic bronchopulmonary aspergillosis
 Asthma
 Central bronchiectasis
 Elevated total serum IgE >1000 ng/mL
 Immediate skin test reactivity to Aspergillus
 Elevated serum-specific IgE and/or IgG to Aspergillus fumigatus
 Peripheral blood eosinophilia >10%
 Pulmonary infiltrates”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 21

What is the treatment for ABPA?

Answer 21

“Oral corticosteroids are the treatment of choice for ABPA. Patients are typically treated for several months with tapering doses rather than short courses of steroids. Serum IgE levels and chest x-rays are used to monitor response to treatment”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 22

What’s the best way to determine allergic versus vasomotor rhinitis?

Answer 22

“The best way to tell if this is allergic is to do a Hansel stain of the nasal mucous. This will show eosinophils if it is allergic. If this is vasomotor rhinitis, eosinophils will be absent. If it is infectious, there will likely be a predominance of neutrophils”

Hansel stain, a stain used to detect eosinophils in urine or other body fluids, the eosinophils staining red against a background of blue.
Mosby’s Medical Dictionary, 8th edition. © 2009, Elsevier.

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 23

How does one determine from an air blood gas the fall in pH?

Answer 23

The following pH is equal to 0.08 times the change in PaCO2 from baseline. So if baseline PaCO2 is equal to 40 whatever the difference is from 40×0.08 is the predicted pH.

Question 24

What is FiO2 and how is it unequivocally decreased?

Answer 24

Fraction of inspired oxygen (FiO2) is the fraction or percentage of oxygen in the space being measured. Medical patients experiencing difficulty breathing are provided with oxygen-enriched air, which means a higher-than-atmospheric FiO2. Natural air includes 20.9% oxygen, which is equivalent to FiO2 of 0.21. Oxygen-enriched air has a higher FiO2 than 0.21, up to 1.00, which means 100% oxygen.[1] FiO2 is typically maintained below 0.5 even with mechanical ventilation, to avoid oxygen toxicity.[2]

Increase the PEEP to decrease the FiO2.
“PEEP maintains positive pressure in the airways at the end of expiration. Its use increases lung compliance and decreases ventilation/perfusion mismatching, resulting in better oxygenation”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 25

What are the guidelines for weaning a patient off the ventilator?

Answer 25

“ In general, the patient should be awake, cooperative, and alert. She should have reasonably good oxygenation on a lower FiO2, have PEEP 10 L/min, PaO2 35%, and RSBI (see Helpful Tip) >105. Patients with poor cardiopulmonary reserve or who have significant underlying disease may also have difficulty weaning. Allow patients a period of breathing on their own (e.g., a T-piece) before extubating. This way, if the patient fails, you can simply hook her back up to the ventilator”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 26

What is the major vector of hantavirus in North America and why does it matter?

Answer 26

The deer mouse is the major reservoir of the Sin Nombre virus, the most important cause of this syndrome in North America.

It matters because back packers and hunters are at risk.

“Overall, case fatality rate of hantavirus is up to 50%. Care is supportive.”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 27

How does someone with hantavirus present?

Answer 27

“absence of URI symptoms, the presence of GI symptoms, and the noncardiogenic pulmonary edema are all symptoms/signs of hantavirus. In fact, it may present as an acute abdomen”

“thrombocytopenia, a 10% immunoblast count, and a left shift constitute the so-called diagnostic triad in a patient with appropriate clinical findings.

Question 28

How does “valley fever” present?

Answer 28

“lower respiratory symptoms, a thin walled cavitary lesion, erythema nodosum (10%), and eosinophilia. It is generally a low grade, subacute process that lasts weeks to months”

“does not cause noncardiogenic pulmonary edema”

Excerpt From: Mark Graber & Jason Wilbur. “Family Practice Examination and Board Review, Third Edition.” McGraw-Hill Medical, 2013. iBooks.
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Question 29

What causes vocal cord dysfunction?

Answer 29

vocal fold swelling from allergy, asthma, or some sort of obstruction of the vocal folds or throat area that may cause breathing difficulty.