Pulmonary

Question 1

Bugs that cause ventilator-associated pneumonia? When is it considered VAP?

Answer 1

Considered VAP 48 hours after intubation

Bugs include Pseudomonas, E. coli, Klebsiella, MRSA, and Strep.

Question 2

ankylosing spondylitis

Answer 2

HLA-B27, low back pain, young male, improvement with exercise, worse with rest, impaired chest expansion (restrictive pattern on PFTs), enesthetitis (pain at the insertion point of tendons), uveitis, buttock pain (SI joint involvement), dactylitis

Question 3

What is the Lights criteria? What is it used for?

Answer 3

pleural fluid protein : serum fluid protein > 0.5

pleural fluid LDH : serum LDH > 0.6

pleural fluid LDH > 2/3 upper limit of normal

If any of these three criteria is fulfilled, then the pleural is more likely to be exudative (infection, malignancy, connective tissue disorders) than transudative (CHF, cirrhosis, nephrotic syndrome)

Question 4

Which primary lung tumor is most common in smokers and nonsmokers? How does it look on imaging?

Answer 4

adenocarcinoma

solitary, peripheral lung nodule

Question 5

mechanism of ARDS? How would you manage?

Answer 5

inflammatory mediators damage the alveoli. Increased alveolar capillary permeability causes fluid to leak in, resulting in pulmonary edema.

Increasing positive end expiratory pressure (PEEP) up to 15 mmH2O prevents the alveoli from collapsing and increases FRC. This would improve oxygenation.

Complications of PEEP: barotrauma, hypotension, and tension pneumothorax.

Question 6

pH of normal pleural fluid?
pH of transudative fluid?
pH of exudative fluid?

Answer 6

normal pleural fluid: 7.6

transudate: 7.4-7.55
exudate: less than 7.45, usu. 7.3 in bacterial

Question 7

what is an electrolyte imbalance caused by beta-2 agonists?

Answer 7

hypokalemia. beta-2 agonists drive K+ into the cells. Beta-2 agonists can also cause headache, muscle weakness, arrhythmias, tremor, and palpitations.

Question 8

What are the Wells criteria? What are they used to assess?

Answer 8

Used to assess pre-test probability of PE

3 points:

• signs of DVT
• alternate diagnosis less likely than PE

1. 5 points:
   - prior PE/DVT
   - HR>100
   - recent surgery/immobilization

1 point:

• hemoptysis
• cancer

0 - 2: low risk
3 - 6: moderate
7: high risk of PE

Question 9

3 most common causes of chronic cough?

Answer 9

GERD, asthma, and upper airway cough syndrome (post-nasal drip).

Question 10

PFT findings for obesity hypoventilation syndrome (Pickwickian syndrome)? Diagnosis? How do you treat?

Answer 10

decreased TV, TLC, and FRC
Diagnosis: BMI >30, daytime hypercapnia, and alveolar hypoventilation
treat with BiPAP/CPAP and weight loss

Question 11

Presentation of P. jiroveci pneumonia?

Answer 11

Immunocompromised individual who comes in with atyptical pneumonia (dry cough, dyspnea, fever). Exam would show few pulmonary findings. CXR would show bilateral diffuse interstitial infiltrates.