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UWorld Medicine HY > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Alveolar O2 formula?

Normal A-a gradient?

A

PAO2 = 713*FiO2 - PaCO2/0.8
On room air (21% O2), this is:
PAO2 = 150 - PaCO2/0.8

Normal A-a gradient is <15 mm Hg.
Increases with aging but should always be <30 mm Hg

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2
Q

Cause(s) of hypoxemia with a normal A-a gradient

A

Hypoventilation, low inspired oxygen

(Everything else that causes hypoxemia - V/Q mismatch, shunts, barriers to diffusion - causes an elevated A-a gradient).

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3
Q

Light criteria for an exudative effusion

A

At least one of:

  • Pleural fluid protein / serum protein ratio > 0.5
  • Pleural fluid LDH / serum LDH ratio > 0.6
  • Pleural fluid LDH > 2/3 the upper limit of normal for serum LDH
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4
Q

Diagnostic workup of new pleural effusion

A

Thoracocentesis, unless clearly due to CHF

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5
Q

Berlin Criteria (2012) for diagnosis of ARDS

A
  1. Acute onset within 1 week of insult
  2. Bilateral CXR opacities not explained by other lung pathology
  3. Respiratory failure not explained by heart failure or volume overload
  4. Decreased PaO2 / FiO2 ratio, <300, on at least 5 cm H2O of pEEP
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6
Q

How can the severity of ARDS be graded?

A

PaO2 / FiO2 (P/F) ratio:
<100: Severe
<101-200: Moderate
<201-300: Mild

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7
Q

CXR finding in ARDS?

What else can cause a similar image?

A

Bilateral lung opacities (pulmonary edema)

Can also be seen in CHF and volume overload

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8
Q

What is a key intervention in ARDS?

A

PEEP, up to 15-20 cm H2O

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9
Q

O2 saturation goal in ARDS

A

88-95% saturation (PaO2 55-80)

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10
Q

In a ventilated patient with volume control, what can cause an elevated peak inspiratory pressure (PIP)?

How can you tell the difference?

A

Increased airway resistance or decreased pulmonary compliance

Check with inspiratory hold:

  • The “Plateau Pressure” here reflects only pulmonary compliance.
  • The difference between this and PIP (the “Delta Pressure” reflects airway resistance.
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11
Q

Extrapulmonary involvement of sarcoidosis (5)

A
  1. Skin lesions (e.g. erythema nodosum)
  2. Uveitis
  3. Arthralgias
  4. Hypercalcemia
  5. Heart disease
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12
Q

Sarcoidosis on CXR

A

Bilateral hilar lymphadenopathy, reticular infiltrates, +/- scattered opacities

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13
Q

What is Lofgren syndrome?

A

Acute sarcoidosis with erythema nodosum and arthralgias

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14
Q

Manifestations of sarcoidosis heart disease

A
  1. Restrictive cardiomyopathy early, dilated cardiomyopathy late
  2. AV block and other conduction defects
  3. Arrhythmias and sudden cardiac death

(Seen in 5% of sarcoidosis patients, due to noncaseating granuloma in the heart)

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15
Q

Mechanism of hypercalcemia in sarcoidosis?

Treatment?

A

Mechanism: 1-alpha hydroxylse in the granuloma activates viatmin D (converts 25-vitamin D to 1,25-vitamin D)

Treatment: Glucocorticoids (reduce activation by the granuloma)

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16
Q

Treatment for sarcoidosis

A

Monitor if asymptomatic.

Glucocorticoids if symptomatic

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17
Q

Hypoxia with a petechial rash and neurological signs after trauma

A

Fat embolism from long-bone fracture to lungs

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18
Q

Mechanism of secondary spontaneous pneumothorax

A

Rupture of alveolar blebs due to chronic destruction of alveolar sacks

(seen in chronic lung disease like COPD and CF)

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19
Q

Diagnostic test for aspiration pneumonitis?

Treatment?

A

Diagnosis: upright CXR
Treatment: supportive care only

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20
Q

Pattern of PFTs and DLCO in interstitial lung disease

A

Restrictive pattern and decreased DLCO (restrictive pattern with normal DLCO seen with chest wall deformities)

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21
Q

Time course of aspiration pneumonitis and pneumonia

A

Pneumonitis: cough +/- hypoxemia within hours of aspiration of gastric contents

Pneumonia: symptoms several days after aspiration of oropharyngeal secretions

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22
Q

Hypersensitivity pneumonitis:

Presentation?

CXR findings?

A

Presentation: cough, dyspnea, fever, malaise (so it is pneumonia-like) in association with trigger (bird droppings, molds in farming)

CXR: Ground glass / hazy opacities

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23
Q

Secondary polycythemia in an obese man - likely diagnosis?

A

Obstructive sleep apnea

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24
Q

Three most common causes of chronic cough?

An initial test/trial in each?

A
  1. Postnasal drip (upper-airway cough syndrome) (try empiric antihistamine)
  2. Asthma (PFTs)
  3. GERD (try empiric PPI)
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25
Q

Mechanism of chronic nonproductive cough in ACEIs

A

Decreased metabolism of kinins and substance P

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26
Q

Most effective treatment for allergic rhinitis

A

Glucocorticoid nasal sprays (fluticasone, mometasone)

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27
Q

Oropharyngeal physical exam finding that may be seen in allergic rhinitis?

A

Pharyngeal cobblestoning (streaks of lymphoid tissue)

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28
Q

Appearance of flow-volume loop in obstructive lung disease

A

Scooped-out pattern during exhalation (low flow in later, effort-independent phase)

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29
Q

Pattern of PFTs and DLCO in asthma

A

PFTs: Obstruction (FEV1/FVC < 0.7) that is reversible, >12% increase in FEV1 w/ bronchodilator

DLCO: normal

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30
Q

Pattern of PFTs and DLCO in COPD

A

PFTs: Obstruction (FEV1/FVC < 0.7) that is irreversible or only partially reversible

DLCO: often reduced but may be normal in early disease

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31
Q

Patient with severe asthma attack has normal PaCO2. Next step?

A

Intubation (impending respiratory failure)

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32
Q

Pulsus paradoxus with a normal heart, pericardial space, and pericardium

A

Severe asthma and COPD (when generating highly negative (up to 40 mm Hg) intrathoracic pressures during inspiration, so blood pools in lungs)

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33
Q

Asthma, chronic rhinosinusitis with nasal polyps, and bronchospasm after receiving a medication

A

Aspirin-induced respiratory disease (AERD) (can be seen with any NSAID)

34
Q

Sensory complication of aspirin-induced respiratory disease

A

Anosmia (due to nasal polyps from chronic rhinosinusitis)

35
Q

When is long-term suppelemntal oxygen started in COPD?

A

SaO2 < 89% (PaO2 55 mm Hg) ORA in patients with cor pulmonale, right heart failure, or hematocrit >55%

SaO2 <88% (PaO2 <59 mm Hg) ORA in anyone else

36
Q

Mechanisms of oxygen-induced CO2 retention in COPD

A
  1. Decreased respiratory drive
  2. V/Q mismatch (normally poorly perfused areas get more perfused due to more O2)
  3. Haldane effect (CO2 binds better to deoxygenated blood)
37
Q

Some common causes of digital clubbing

What is something noteable that does NOT cause digital clubbing?

A

Causes: Lung cancer, chronic lung infection, interstitial pulmonary fibrosis, endocarditis, cyanotic congenital heart disease

COPD alone does NOT cause digital clubbing (so think cancer if you see this)

38
Q

Theophylline toxicity

A
  1. CNS stimulation (headache, insomnia, seizures)
  2. Arrhythmia
  3. GI effects (N/V)

(Can be induced by illness or inhibition of cytochromes)

39
Q

Treatment for all acute COPD exacerbations?

Moderate-to-severe? How is this defined?

A
  1. Oxygen (to SpO2 of 88-92%)
  2. Inhaled bronchodilators
  3. Systemic glucocorticoids

Moderate-to-severe: add antibiotics

Moderate-to-severe: at least 2 cardinal symptoms (increased dyspnea, increased sputum volume, incerased sputum purulence) or need for NPPV or intubation

40
Q

What can be done to delay or avoid intubation in a COPD exacerbation?

A

Non-invasive positive pressure ventilation (NPPV)

41
Q

Cardinal symptoms of COPD exacerbation

A
  1. Increased dyspnea
  2. Increased sputum volume
  3. Increased sputum purulence
42
Q

Cause of panacinar emphysema in a young person?

Manifestation outside the lung

A

Alpha-1-antitrypsin (AAT) deficiency

Also leads to liver disease (e.g. hepatitis, cirrhosis, HCC)

43
Q

CT finding that is pathognomonic for PE

A

Opacified wedge-shaped infarct

44
Q

Rare but specific signs of PE on CXR (3)

A

Westermark’s sign: area of hyperlucency distal to a visible pulmonary vessel

Hampton’s hump: peripheral wedge of lung opacity due to infarct

Fleischner sign: enlarged pulmonary artery

45
Q

Rare but classic sign of PE on EKG

A

S1Q3T3:

  • Deep S wave in I
  • Q wave in III
  • Inverted T wave in III
46
Q

Treatment for PE with hemodynamic instability

A

Thrombolytics, if they are not contraindicated (if fails or CI, then go to embolectomy)

47
Q

Poor prognostic factors on EKG after PE

A

Atrial fibrillation, RBBB

48
Q

When do you empirically anticoatulate prior to imaging in PE?

A
  1. PE likely by Wells criteria
  2. Moderate-to-severe respiratory distress
  3. No reltive CI to coagulation
49
Q

Modified Wells criteria for PE

A 
3 points:
- Clinical signs of DVT
- Alternate diagnosis less likely
1.5 points:
- Previous DVT or PE
- Tachycardia (>100)
- Recent surgery/immobilization
1 point:
- Hemoptysis
- Cancer

PE unlikely if 4 or less, likely if over 4 (4.5 or more)

(Original criteria was 2 or less was low, 2-6 was moderate, and over 6 was high)

50
Q

Diagnostic test if DVT is likely but no signs of PE

A

LE Ultrasound

Do NOT go looking for PE with CTA or V/Q scan unless they have signs of PE

51
Q

Follow up of first unprovoked venous thromboembolism

A

CXR and age-appropriate cancer screening

If other signs of malignancy (e.g. weight loss, pain), then perform more extensive cancer screening (e.g. CT chest/abdomen/pelvis)

(Generally only test for inherited thrombophilias with suggestive history - family history, age unde 45, recurrence, multiple/unusual sites)

52
Q

Options for initial monotherapy of PE or DVT

A

Direct Factor Xa inhibitors: Rivoroxaban, apixaban

Warfarin and dabigatran require initial treatment with heparin as well

53
Q

Who should get an IVC filter?

A

Proximal DVT (popliteal on up) without severe swelling or limb-threatening ischemia and with CI to anticoagulation or in whom appropriate anticoagulation has failed.

54
Q

Who should receive antivirals for influenza?

A
  1. High risk for complications (65 or older, chronic illness, pregnancy)
  2. Anyone who presents within 48 hours of symptom onset
55
Q

Treatment for acute bronchitis

A

Symptomatic treatment

56
Q

Most common causes of post-influenza pneumonia

A

Pneumococcus and Staph aureus

57
Q

Rapidly progressing, necrotizing post-influenza pneumonia in a young person

A

Staph aureus

58
Q

Pneumococcal vaccine recommendations

A

Over 65: both PCV13 and PPSV23
Risk for encapuslated organisms (asplenic, immunocompromise): both PCV13 and PPSV23
Other chronic disease under 65: PPSV23 alone

59
Q

First-line treatment for community acquired pneumonia

A

No recent antibiotics or major comorbidities: macrolide (e.g. azithromycin) or doxycycline

With recent antibiotics or comorbidities: add a beta-lactam (e.g. ceftriaxone), or just use a respiratory fluoroquinolone (e.g. levofloxacin or moxifloxacin)

60
Q

Tool for predicting community-acquired pneumonia severity and management:

A 
CURB-65: one point for each of
Confusion
Urea >20
Respirations >30
BP low (systolic <90, diastolic <60)
65 years or older

0: low mortality, outpatient
1-2: Intermediate mortality, likely admission
3 or more: high mortality, urgent admission

61
Q

Treatment for empyema?

A

Drainage and 2-4 weeks antibiotics

62
Q

Fever, productive cough, large pleural effusion, and pleuritic chest pain in a patient with pneumonia

A

Empyema

63
Q

Types of effusion associated with pneumonia?

Criteria for each?

Treatment for each?

A 
Uncomplicated parapneumonic effusion:
Few WBCs (<50,000), relatively normal pH (>7.2), glucose may be normal or low
Complicated parapneumonic effusion:
Many WBCs (>50,000), acidic pH (<7.2), low glucose (<60)

Empyema: frank pus in the pleural space, lab values like complicated

Treatment: uncomplicated requires antibiotics only. Complicated and empyema require drainage and antibiotics.

64
Q

Presentation of bronchiectasis

Diagnostic test(s)? Findings?

A

Chronic cough with large amounts of mucopurulent speeding (+/- hemoptysis, dyspnea, congestion, fatigue, weight loss).

Test: high-resolution CT, shows bronchial dilation and bronchial wall thickening

65
Q

Treatment options for pneumonia when aspiration suspected

A
  • Amp/sulbactam (IV if inpatient) or amoxicillin/clavulanate (PO if outpatient)
  • Clindamycin
  • Metronidazole + amoxicillin or penicillin
66
Q

Most common organisms for ventilator-associated pnuemonia

A

Gram-negative rods (Pseudomonis, E. coli, Klebsiella pneumonia) or gram positive cocci (Strep and Staph aureus)

67
Q

Causes of pneumonia with high fever and relative bradycardia

A

Legionella and Chlamydia (both intracellular gram negatives)

68
Q

Common cause of pneumonia with high fever and diarrhea?

Diagnostic test?

A

Bug: Legionella

Test: Urine Legionella antigen

69
Q

Pneumonia associated with hyponatremia

A

Legionella (damage to JG cells that secrete renin)

70
Q

Treatment for Legionella

A

Fluoroquinolones (levofloxacin) or macrolides (azithromycin)

71
Q

TB patient on RIPE has mild AST/ALT elevation. Next step?

A

Continue (due to isoniazid, will likely resolve)

If frank hepatitis occurs, then must stop isoniazid and switch to second-line medications

72
Q

Triad of digital clubbing, arthralgias, and ossifying periostitis

A

Hypertrophic pulmonary osteoarthropathy (HPOA): excess proliferation of skin and bone associated with lung disease such as lung cancer, mesothelioma, TB, bronchiectasis, emphysema

73
Q

Definition of single pulmonary nodule

A
  1. Single rounded opacity
  2. <3 cm
  3. Completely surrounding by lung parencyhma
  4. No associated lymphadenopathy
74
Q

Management of SPN with benign features on CT?

Suspicious for malignancy?

Intermediate?

A

Benign serial CT

Suspicious for malignancy: surgical excision

Intermediate - go to size:
If 8 mm or larger: biopsy or FDG-PET
If 4 mm or less and low cancer risk: no follow-up
5-7 mm or 4 or less with intermediate risk: serial CT

75
Q

Specific symptoms of Pancoast tumors

A
  1. Referred shoulder pain
  2. Horner symptom (sympathetic chain invasion)
  3. Brachial plexus invasion leading to arm motor and sensory symptoms
  4. Supraclavicular lymph node
76
Q

Paraneoplastic syndrome(s) associated with lung SCC

A

Hypercalcemia (PTHrp)

77
Q

Paraneoplastic syndrome(s) associated with small cell lung cancer

A
  1. Cushing syndrome (ACTH production)
  2. SIADH
  3. Lam`bert-Eaton myasthenic syndrome (antibodies against NMJ Ca2+ channels)
78
Q

Lung cancer most associated with necrotizing and cavitation on CT

A

SCC

79
Q

Location of different types of lung cancer

A

SCC and SCLC: central

Adenocarcinoma and large cell: peripheral

80
Q

Hallmark of asbestosis on CXR

A

Pleural plaques

Bibasilar reticulonodular infiltrates, honeycombing, and bilateral pleural thickening may be seen

81
Q

Recurrent pneumonia in the same area of lung: diagnostic test?

A

CT to look for obstructing mass

UWorld Medicine HY (7 decks)

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