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Master the Boards > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

best test to assess presence of reactive airway disease in patient with NO current symptoms

A

methacholine stimulation testing

- will decrease FEV1 >20% in asthmatic pt

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2
Q

pt presents to ED with acute SOB - you are unsure of etiology; what is a good test to perform?

A

PFTs pre and post bronchodilator - will tell you if it is due to reactive airway disease

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3
Q

ventilator settings in asthmatic if pt needs to be intubated

A

low RR
small TV
high flow

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4
Q

initial therapies/management to order in acute asthma exacerbation

A
  1. oxygen
  2. continuous oximeter
  3. CXR and ABG
  4. inhaled albuterol
  5. bolus of steroids (methylpred)
  6. inhaled ipratropium
  7. magnesium
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5
Q

when is cromolyn or nedocromil useful

A

extrinsic allergies, ie hay fever

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6
Q

when is montelukast useful

A

atopic disease

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7
Q

when are tiotropium/ipratropium appropriate

A

COPD

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8
Q

when is omalizumab used

A

high IgE levels with no control with cromolyn

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9
Q

obstructive PFTs + normal DLCO

A

asthma

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10
Q

obstructive PFTs + decreased DLCO

A

emphysema (OOPD)

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11
Q

restrictive PFTs with proportionally decreased DLCO

A

extrathoracic restriction

- obesity, kyphosis

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12
Q

restrictive PFTs with disproportionately low DLCO

A

interstitial lung disease

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13
Q

pulmonary alveolar proteinosis

A

Alveolar filling with floccular material that is PAS+; CXR shows a batwing appearance
Dx. BAL
Tx. whole lung lavage

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14
Q

CCS: acute handling of SOB in COPD pt

A
  1. oxygen and ABG
    - always reassess after O2 bc it may make the SOB worse by eliminating hypoxic drive
  2. CXR
  3. Albuterol
  4. Ipratropium
  5. Bolus of steroids
  6. Chest, heart, neuro and extremity exam
  7. if fever, sputum or new infiltrate –> add abx
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15
Q

what abx are used in acute exacerbation of COPD

A

ceftriaxone and azithromycin

- add if increasing dyspnea, increase in sputum and sputum purulence

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16
Q

EKG findings in COPD

A

RAH: biphasic P waves in V1
RVH: deep S wave in V1 and tall R wave in v5/6 > 35 mm

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17
Q

Lab findings in COPD

A
  1. increased hematocrit
  2. reactive erythrocytosis - microcytic
  3. increased serum bicarb (metabolic compensation)
  4. ABG: respiratory acidosis, low pO2
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18
Q

chronic medical therapy of COPD

A
  1. tiotropium or ipratropium inhaler
  2. albuterol, levalbuterol or pirbuterol
  3. pneumococcal and influenza vaccine
  4. smoking cessation
  5. inhaled steroids - if FEV1 < 50 and >3 exacerbations/year
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19
Q

who gets home oxygen therapy in COPD?

A
  1. No sx of RHF and normal htc?

- pO2 < 55 and O2 sat < 60 and O2 sat < 90%

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20
Q

a 35 year old man presents with SOB. You do a CXR and see changes consistent with emphysema and this is supported by PFT results. Lab findings include low albumin level and elevated prothrombin time - dx?

A

alpha 1 antitrypsin deficiency

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21
Q

CF: bronchiectasis

A

repeat episodes of lung infections
cupfuls of sputum
hemoptysis

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22
Q

most accurate test for bronchiectasis

A

high resolution CT scan of chest

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23
Q

Tx. bronchiectasis

A

chest PT

rotating antibiotics

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24
Q

what drugs may cause ILD

A

nitrofurantoin

TMP-SMX (Bactrim)

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25
Q

only form of ILD that is responsive to steroids

A

berylliosis (granulomatous disease)

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26
Q

Pt presents with cough, rales, SOB along with fever, malaise and myalgias. CXR shows bilateral patchy infiltrates and chest CT shows interstitial disease with alveolitis - dx?

A

Dx. BOOP/COP

- similar presentation to ILD but with systemic findings

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27
Q

most accurate diagnostic test for BOOP/COP

A

open lung biopsy

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28
Q

Tx. BOOP/COP

A

steroids

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29
Q

associated findings with sarcoidosis

A
  1. Eyes - anterior uveitis
  2. Bells palsy
  3. Skin - lupus pernio, erythema nodosum
  4. Restrictive CM
  5. hypercalcemia - vit D production by granulomas
  6. elevated ACE levels
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30
Q

best initial test: sarcoidosis

A

CXR

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31
Q

most accurate diagnostic test: sarcoidosis

A

lung or lymph node biopsy –> non caseating granulomas

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32
Q

Tx. sarcoidosis

A

steroids

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33
Q

P/E findings in pulmonary HTN

A

loud P2
TR
RV heave
Raynaud’s phenomenon

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34
Q

secondary causes of pulmonary HTN

A 
mitral stenosis
polycythemia vera
COPD
chronic pulmonary emboli
interstitial lung dz
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35
Q

PFTs in pulmonary HTN

A

decreased DLCO

normal PFTs

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36
Q

gold standard diagnostic test for pulmonary HTN

A

right heart catheterization

- increased pulmonary pressure (>25 at rest or > 30 with exercise)

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37
Q

Tx. pulmonary HTN

A
  1. bosentan (endothelin inhibitor)
  2. epoprostenol/treprostinil (prostacyclin analogs - pulmonary vasodilators)
  3. Nitric oxide gas (vasodilate w/o systemic effects)
  4. sildenafil
  5. CCBs
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38
Q

ABG results in PE

A

hypoxia
increased Aa gradient
respiratory alkalosis

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39
Q

poor prognostic factors in PE

A
  1. increased troponins
  2. hypotension
  3. hemodynamically unstable
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40
Q

gold standard to confirm PE

A

spiral CT

- test of choice if XR is abnormal

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41
Q

when are D-dimers appropriate in dx. of PE

A

when you have a low probability of PE in a patient and you want to RULE OUT the disease

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42
Q

single most accurate test for PE

A

angiography

43
Q

pt with PE presents a few days after with low grade fever - what do you do

A

14% of pts will have a fever and you do not need to give abx even though clinical picture may resemble pneumonia

44
Q

Management of PE

A
  1. oxygen

2. heparin (warfarin for 6 months with INR 2-3; IVC if contraindication to anti-coag)

45
Q

when do you use thrombolytics in tx of PE

A

if pt is hemodynamically unstable (BP < 90) and low risk of bleeding

46
Q

when do you use embolectomy in tx of PE

A

if pt is in shock and death likely within hours or if failed/contraindicated thrombolytics

47
Q

pleural effusion

  • best initial test
  • most accurate test
A 
initial = CXR
accurate = thoracentesis
48
Q

characteristics of exudative pleural effusion

A

pleural/ serum protein > 0.5

pleural / serum LDH > 0.5

49
Q

what tests should be ordered on pleural fluid?

A 
gram stain/culture, acid fast stain
total protein
LDH
glucose
cell count w/ diff
TG
pH
50
Q

mild sleep apnea

A

5-20 apneic events/hour (apnea lasts > 10 sec)

51
Q

severe sleep apnea

A

> 30 apneic events/hour

52
Q

tx. obstructive sleep apnea

A

weight loss
CPAP/BiPAP
if not effective –> resection of uvulate, palate and pharynx

53
Q

tx. central sleep apnea

A
  1. avoid alcohol /sedative

2. may respond to acetazolamide or medroxyprogesterone

54
Q

Asthmatic pt presents with worsening asthma symptoms and recently began coughing up brownish mucus plugs and has recurrent upper lobe infiltrates on XR. Labs show eosinophillia and elevated serum IgE. Dx? First step?

A

dx. allergic bronchopulmonary aspergillosis

first test: aspergillus skin test

55
Q

Tx. ABPA

A

corticosteroids

- refractory disease: itraconazole

56
Q

Dx. test findings in ARDS

A
  1. normal PCWP (< 18 mmHg)

2. pO2 / FiO2 ratio < 200

57
Q

Tx. ARDS

A
  1. Ventilatory support
    - TV at 6 ml/kg
    - PIP < 35 cm h20
    - PEEP > 10 cm H20
  2. prone positioning
  3. possible use of diuretics and positive inotropes (dobutamine)
  4. transfer to ICU
58
Q

Pulm artery cath results for hypovolemia

A

CO low
PCWP low
SVR high

59
Q

Pulm artery cath results for cardiogenic shock

A

CO low
PCWP high (>18)
SVR high

60
Q

Pulm artery cath results for septic shock

A

CO high
PCWP low
SVR low

61
Q

who should get admitted for pneumonia?

A 
elderly pts > 65
significant comorbidities
vitals: tachycardia, hypotension, PO2<60
failure of outpt tx or unable to take meds PO
change in mental status
poor support system
multilobular involvement
62
Q

pneumonia:
best initial test
most accurate test

A

initial- CXR

accurate - sputum gram stain and culture

63
Q

Tx. outpatient pneumonia

A 
macrolide (azithromycin) OR
respiratory FQ (levo or moxi)
64
Q

Tx. inpatient pneumonia

A

ceftriaxone and azithromycin

FQ single agent

65
Q

Tx. ventilator assoc. pneumonia

A
  1. imipenem, Zosyn or cefepime

2. Gentamycin and Vanc

66
Q

recurrent pneumonia in smoker

A

bronchogenic carcinoma

-order CT scan and flexible bronchoscopy

67
Q

pneumonia following viral syndrome

A

staphylococcus

68
Q

pneumonia in alcoholics

A

klebsiella

- carbapenems

69
Q

pneumonia in young, healthy patients

A

mycoplasma

70
Q

pneumonia with GI symptoms and confusion

A

legionella

71
Q

pneumonia in persons present at the birth of an animal

A

coxiella burnetti

72
Q

pneumonia in arizona construction workers

A

coccidioidomycosis

73
Q

pneumonia in HIV pt with CDC <200

A

PCP

74
Q

Tx. PCP

A

Bactrim

Steroids - if PO2 35

75
Q

cough induced by expiration is an indication of…

A

airway hyperreactivity

- recognized clinical clue for asthma

76
Q

allergen most frequently assoc. with asthma

A

house dust mites

77
Q

patient that is receiving treatment for TB and is improving clinically, develops a new pleural effusion - what test should you do?

A

thoracentesis

78
Q

ideal vent settings in ARDS

A
  1. TV < 6 ml/kg
  2. limited plateau pressure < 30-35 Cm H2O
    - want to achieve PaO2 of 55-80 mmHg
  3. ventilator rate < 35 / min
79
Q

single most important prognostic factor in COPD

A

after adjusting for age, FEV1 (if <40% indicates severe obstruction)

80
Q

what ventilator settings allow you to improve oxygenation in ARDS?

A

maintain PaO2 of 55-80 or O2 sat 88-95% by adjusting the FiO2 or the PEEP (increasing)

81
Q

who is permissive hypercapnia not safe in?

A

pts with elevated ICP or a seizure disorder

82
Q

RF for post-op pulmonary complications

A 
upper abdominal/thoracic surgeries
underlying chronic lung dz
history of smoking in last 8 weeks
baseline PaCO2 > 45
duration of surgery >3-4 hours
use of general anesthesia
age > 50
obstructive sleep apnea
83
Q

screening for lung ca

A

annual low dose chest CT in patients age 55-80 who have a > 30 year pack year smoking history and are either current smokers or quit within the last 15 years

84
Q

termination of lung ca screening

A

age > 80 or
patient successfully quit smoking for >15 years or
pt has other medical problems significantly limiting life expectancy

85
Q

pt with sarcoidosis comes in and has bilateral erythema nodosum and hilar adenopathy – management?

A

high rate of spontaneous remission with good prognosis –> no treatment except observation and periodic check up

86
Q

tx of sarcoidosis if pt is symptomatic or has decreased pulmonary function

A

corticosteroids

87
Q

best initial test in tb

A

CXR

88
Q

confirmatory test TB

A

sputum acid fast stain

89
Q

when do you know that TB is noninfectious

A

3 consecutive negative results on sputum acid fast smears performed on different occasions

90
Q

Tx. TB

A

Isoniazid and Rifampin for 6 months

Pyrazinamide and Ethambutol - can stop after 2 months

91
Q

main side effect of TB drugs - when should you stop them due to this s/e

A

liver toxicity; stop is LFTs > 5x upper limit of normal

92
Q

isoniazid toxicity

A

peripheral neuropathy (give with pyridoxine)

93
Q

rifampin toxicity

A

red orange colored bodily secretions

94
Q

pyrazinamide toxicity

A

do NOT use in pregnancy - teratogenic

hyperuricemia

95
Q

ethambutol toxicity

A

optic neuritis

96
Q

what TB conditions require treatment for > 6 months

A 
osteomyelitis
meningitis
miliary TB
cavitary TB
pregnancy
if they are a child with any of the above - require 12 months
97
Q

management: asymptomatic pt with TB but no evidence of active TB who has previously been treated for active TBI or LTBI

A

does not require further TB treatment

98
Q

MC location of epistaxis

A

anterior nasal septal mucosa –> Kiesselbachs plexus or Littles area
- trickling of blood in upright position

99
Q

next step in management if you cannot stop an episode of anterior epistaxis with nostril pinching

A
  1. cotton pledget impregnated with vasoconstrictor (phenlyephrine 0.25%) and lidocaine 2%
  2. followed by silver nitrate chemical cautery or needlepoint electrocautery
100
Q

CF: posterior epistaxis

A

MC in older adults (men in 50s) with HTN and arteriosclerosis

  • Woodruff’s plexus
  • blood visible in posterior oropharynx in upright position
101
Q

Bezold abscess

A

neck abscess resulting from an erosion through the medial aspect of the mastoid tip –> swelling behind the ears in pt with other clinical findings consistent with AOM

102
Q

management: button battery lodged in esophagus

A

immediate removal under direct endoscopic visualization

- if already in the stomach - outpatient management OK

103
Q

patient presents with loud snoring but no other signs or symptoms of OSA, what advice do you give them?

A

lose weight, stop smoking and avoid alcohol near bedtime

104
Q

what can be used to reduce incidence of ear and sinus barotrauma during diving?

A

non sedating decongestants i.e. pseudoephedrine

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