Pulmonary/Critical Care

Question 1

What are three indications for pleurodesis in pneumothorax?

Answer 1

1: Recurrent ipsilateral primary pneumothorax
2: Primary pneumothorax in a patient with high-risk job (high-altitude, scuba diver)
3: Secondary pneumothorax

Question 2

What do you call it when someone is out on a hot day and they get a fever to 104 with confusion?

Answer 2

Heat Stroke

Question 3

What percentages mark the Gold criteria of COPD?

Answer 3

Group 1: >80%
Group 2: 50-79%
Group 3: 30-49%
Group 4: <30%

Question 4

How do you screen for CTEPH?

Answer 4

V/Q scan (near 100% sensitivity), then if positive would move to RHC and pulmonary angiography

Question 5

what symptom frequency per week should make you upgrade from ICS to LABA-ICS in asthma?

Answer 5

if greater than 2 weekly uses of rescue inhaler

Question 6

Why not use LABA alone in asthma?

Answer 6

masked inflammation and increased mortality/morbidity

Question 7

What lab tests might you order in allergic asthma?

Answer 7

total eosinophils and IgE total

Question 8

What factors in malignant pleural effusion determine whether you go for repeated thoras, indwelling catheter, or pleurodesis?

Answer 8

-If prognosis is poor and fluid reaccumulates slowly, go for repeat thoracentesis.
-If lung is not expandable cannot do pleurodesis.

Question 9

What medications put a patient at risk of neuroleptic malignant syndrome?

Answer 9

Antipsychotics and antiemetics

Question 10

Which syndrome with fever and muscle rigidity is a larger risk with antipsychotics and antiemetics?

Answer 10

neuroleptic malignant syndrome

Question 11

how do you treat neuroleptic malignant syndrome?

Answer 11

not with tylenol (won’t effect heat made from muscle spasm). D/c the causative agent(s) and provide supportive care.

Question 12

how is neuroleptic malignant syndrome different clinically from serotonin syndrome?

Answer 12

NMS doesn’t have myoclonus or hyperreflexia

Question 13

You are called to bedside for patient agitation. On arrival, the patient has hypertension and fever, he is unable to be oriented, and on physical exam he is very stiff. What medication should you not give him?

Answer 13

Haldol or any other antipsychotics. This is neuroleptic malignant syndrome and he needs medications discontinued and supportive care.

Question 14

Which lung cancer generally presents as a bulky symptomatic mass with mediastinal involvement and paraneoplastic syndrome?

Answer 14

Small Cell Lung Cancer

Question 15

What part of the lung does Squamous cell carcinoma usually affect?

Answer 15

central airway

Question 16

which lung cancer usually presents as a peripheral mass with prominent necrosis?

Answer 16

Large cell carcinoma

Question 17

How does lung adenocarcinoma typically present? (location in lung)

Answer 17

peripheral solitary nodule/mass

Question 18

What is a rare complication of previous Histoplasmosis which can affect young patients and has a slow progression over 2-5 years?

Answer 18

Fibrosing mediastinitis. Can cause local compression on the mediastinum.

Question 19

Patient with lymphoma presents with SOB and is found to have moderate pleural effusion. Fluid studies reveal an exudative effusion with TG > 110 and lymphocytic. What is it?

Answer 19

Chylothorax

Question 20

What conditions predispose a patient to cholesterol effusion?

Answer 20

TB, rheumatoid arthritis, other chronic pleural effusion. Cholesterol usually >200.

Question 21

What are the most common causes of chylothorax?

Answer 21

trauma and malignancy (lymphoma)

Question 22

what features would be part of a rheumatoid effusion?

Answer 22

pH <7.2, glucose <40, increased LDH

Question 23

what is the pathophysiology behind high altitude pulmonary edema?

Answer 23

hypoxic pulmonary vasoconstriction and increased pulmonary artery and capillary pressures leading to edema and an inflammatory response

Question 24

What is the treatment for high altitude pulmonary edema?

Answer 24

descend asap, supplemental O2

Question 25

What is the first step in follow up of a subsolid (ground glass) pulmonary nodule?

Answer 25

if groundglass: Repeat CT at 6-12 months if 6 mm or larger

if part solid: CT at 3-6 months and if unchanged, annual CT for 5 years.

Question 26

What are the further recommendations of imaging follow up/biopsy etc for a ground glass nodule after you have reimaged at 6-12 months?

Answer 26

1) if resolved: no follow up
2) if unchanged: repeat CT every 2 years for 5 years
3) if grows or develops solid component: biopsy or resection

Question 27

How do you screen for pulmonary hypertension in patients with systemic sclerosis?

Answer 27

annual echo

Question 28

Which condition do these physical exam findings represent?

persistently split S2, holosystolic lower sternal border murmur, JVD

Answer 28

Pulmonary HTN

Question 29

What findings in an exudative pleural effusion would make you want to drain it?

Answer 29

pH < 7.20, glucose <40, evidence of infection on culture or gram stain

Question 30

At what size is a solid pulmonary nodule optional to follow with imaging?

Answer 30

less than 6 mm (even in high risk individuals)

Question 31

what are the follow up recommendations in a solid pulmonary nodule if <8mm and if > 8 mm.

Answer 31

<8 mm - serial CT scans
>8 mm and moderate probability - PET scan (especially if scary features) or CT scan in 3 months

Question 32

You are following a pulmonary nodule. What do you do in the following cases?

1) patient had groundglass area > 6 mm last time and it is time for CT - repeat shows new solid part.

2) high-risk patient has a 9 mm solid pulmonary nodule that is spiculated

3) patient had groundglass 8 mm area 6 months ago, repeat CT shows unchanged imaging.

Answer 32

1) repeat CT in 3-6 months and if unchanged then follow yearly for 5 years

2) PET scan then biopsy

3) repeat CT every 2 years for 5 years

Question 33

Which type of lung cancer is more greatly benefited by immunotherapy.

Answer 33

NSCLC

Question 34

between SCLC and NSCLC, which is almost exclusively caused by smoking?

Answer 34

SCLC

Question 35

What if a patient has OHS and you think they may need BiPap at night?

Answer 35

check night to morning pH and pCO2 and if both change accordingly, consider BiPap nightly or maybe Cpap if also have OSA

-could consider acetazolamide as it is a respiratory stimulant and can increase ventilation in OHS and in mild to moderate COPD

Question 36

What medication might be helpful in the case of someone with COPD and CHF who is developing a metabolic alkalosis while diuresing?

Answer 36

acetazolamide

Question 37

Why might acetazolamide not be helpful in severe COPD?

Answer 37

it may not increase respiratory drive and as a result may increase pCO2

Question 38

What medications might you consider in a person with severe COPD with chronic bronchitis or frequent exacerbations already on max inhaler therapy?

Answer 38

Roflumilast or azithromycin

Question 39

Does roflumilast help with COPD symptoms or exacerbation reduction or both?

Answer 39

both

Question 40

What is the warning of adverse effect in montelukast?

Answer 40

mental health effects, depression

Question 41

what is the treatment for serotonin syndrome?

Answer 41

benzodiazepines +/- cyproheptadine (there are only oral formulations)

Question 42

what are the symptoms and signs in serotonin syndrome?

Answer 42

AMS, autonomic instability, hyperreflexia, ocular and muscle clonus, tremor, hyperthermia (muscle hyperactivity), diaphoresis

Question 43

You are called to the bedside for altered mental status. The patient is trying to get out of bed. You evaluate them and they are tremoring and sweating after receiving a dose of zofran and compazine earlier today. what else might be helpful to know?

Answer 43

any alcohol use previously? what are their vitals? do they have a fever or changes in autonomic stability? do physical exam to check reflexes and for clonus.

(checking for possible serotonin syndrome)

Question 44

what adverse effects may occur in the lungs after administering an immune checkpoint inhibitor?

Answer 44

ICI pneumonitis (usually won’t cross lung fissure) or radiation recall pneumonitis (in previous areas of radiation even years later)

Question 45

you see a patient in the hospital for SOB after they have just started receiving an immune checkpoint inhibitor. Chest CT shows opacification which crosses the lung fissure. What may be going on?

Answer 45

If they have also received radiation, it may not be the ICI at all and it may be radiation pneumonitis.

OR

They may have radiation recall pneumonitis from radiation even years ago which has been “recalled” by the checkpoint inhibitor.

Question 46

What are findings of hypersensitivity pneumonitis on HRCT?

Answer 46

centrilobular micronodules and/or groundglass opacities

Question 47

When might you start TPN on a critically ill patient?

Answer 47

after 7-10 days of inability to achieve >60% energy and protein requirements enterally

Question 48

What is the initial management of central sleep apnea?

Answer 48

reduction in opioids, medical optimization of heart failure

(not cpap)

Question 49

how do you screen for flight safety in COPD?

Answer 49

resting pulse oximetry

Question 50

a patient with COPD wants to fly. what are you looking for to know if they need O2 for the flight?

Answer 50

resting pulse ox:

• if >95, no O2 needed
• if <92, 2 L O2 for flight
• if in between, may need high-altitude stim test to know

Question 51

patient with COPD wants to fly. resting pulse oximetry is 91%. Good to go or need O2?

Answer 51

Need 2 L O2 (needs to be > 95 for confidence and if 92 or greater, would do a high altitude stim test to be sure)

Question 52

what condition has the following chest imaging:

-LAD and nodules along bronchovascular bundles

Answer 52

Sarcoidosis

Question 53

Patient has chronic cough and frequently has pneumonia. What condition should you consider and what would further work up be?

Answer 53

Bronchiectasis

-immunoglobulins, testing for CTD

consider testing for CF, alpha 1 antitrypsin deficiency, aspiration, ABPA

+/- testing for chronic bacterial and mycobacterial infections

Question 54

What test is used to predict responsiveness to inhaled glucocorticoid in asthma?

Answer 54

Fractional exhaled NO

(levels >50 ppb correlate with eosinophilic airway inflammation)