Pulmonary Disease 9% Flashcards
1
Q
Obstructive dz (dilated)
A
COPD, Bronchiectasis
2
Q
Obstructive (constricted)
A
Asthma
3
Q
Intrathoracic Restrictive (constricted)
A
Fibrosis, Sarcoidosis, pneumoconiosis
4
Q
Extrathoracic Restrictive
A
Chest Cage: kyphosis, spondylitis, obesity.
neuromuscular: (M.gravis, GB syndorme, muscular dystrophy
5
Q
Normal FEV1/FVC
A
> 80%
6
Q
Obstructive dz FEV1/FVC
A
<80%
7
Q
Restrictive dz FEV1/FVC
A
> 80%
8
Q
COPD
A
- dec FEV1,
- dec FEV1/FVC ( <80%),
- inc TLC, (#1..first thing you look at, best test restrict vs obstruct)
- dec DLCO, (#2..2nd thing you look at)
- inc RV
9
Q
Asthma
A
- dec FEV1,
- dec FEV1/FVC,
- inc TLC,
- normal/increased DLCO, **
- inc RV
10
Q
Restrictive intrathoracic
A
- dec FEV1,
- nl FEV1/FVC,
- dec TLC,
- dec DLCO, **
- dec RV **
11
Q
Restrictive extrathoracic
A
- dec FEV 1,
- nl FEV1/FVC,
- dec TLC,
- nl DLCO, **
- inc RV **
12
Q
best test restrictive vs obstructive
A
TLC
13
Q
DLCO 140% predicted, normal FEV1/FVC and TLC. most likely finding of …
A
alveolar hemorrhage
14
Q
Inc DLCO
A
CHF, MS, ASD/VSD, PDA, polycythemia, asthma, squatting, exercise, alveolar hemorrhage.
any reason for increased blood to pulmonary vasculature.
15
Q
Dec DLCO
A
COPD, restrictive lung dz, PE, PHTN, anemia, standing, valsalva.
anything impeding the flow of blood in thoracic cavity
16
Q
Normal DLCO
A
asthma, CO poisoning
17
Q
Fixed extrathoracic
A
tumors/tracheal stenosis….. both inspiratory (bottom) and expiratory (top) loops blunted….. confirm w/ bronch
18
Q
Dynamic extra-thoracic obstruction
A
epiglottis, Vocal cord dysfxn (inspiratory - bottom loops blunted) … confirm w/ laryngoscopy.
19
Q
Dynamic intra-thoracic obstruction
A
intrathoracic tracheomalacia - exhalatory (upper) loop blunted
20
Q
Asthma
A
- Paroxysmal
- Inflammatory
- Nonspecific reactive airway disease.
reactive to: dust, viral infection, cold or exercise, occupasional allergens: isocyanates (urethane paint), cotton dust (byssinosis), wood dust (cedar or oak), metal workers.
- usually present with a combination of symptoms.
- chronic cough –> SOB –> wheeze.
21
Q
If pt has asthmatic symptoms (cough, SOB, wheeze)… what is the next diagnistic step?
A
PFT’s show –> obstructive changes with reversible broncospasm - responding to bronchodilators by increasing FEV1 by about 12%), then asthma is diagnosed.
- if no obst, but clinical suspicion is high, then methacholine challenge test to provoke bronchospasm and should respond to bronchodilator by about 12% increase in FEV1
22
Q
Young man h/o asthma acute asthmatic attack treated with albuterol nebs - f/u now PFT will show
A
Obstructive defect (still has asthma dx)
23
Q
35yo M paroxysmal non-prod cough >6months - no ohther sx - spirometry normal, no improvement with anti-histamine/cough meds
A
methacholine challenge test r/o asthma
24
Q
woman in car factory SOB at work, worse at end of day, better at home, cxr normal
A
check peak flow at work AND home ** sen but not spec
25
Best way to tx patient with asthma
remove offending agent (PPI do not inc or dec sx of asthma)
26
Pt with asthma/eczema moves to new apt, asthma worse - with rug
remove rug, get plastic wraps for mattress, pillow etc
27
Asthma therapy: Intermittent (<2/wk, sx day, <2/mth sx night, FEV1>80%) tx?
no daily meds, rescue SABA
28
Asthma therapy: mild persistent (>2/wk, 2/month, FEV1 >80%)
1. low dose ICS,
2. cromolyn,
3. leukotriene,
4. theophylline
they will tempt you with LABA
29
Asthma therapy: Moderate persistent - daily sx, >5/month at night, FEV1 60-80
1. low - med dose ICS +
| 2. LABA (no beta without inh steroid)
30
Severe persistent (sx continuous, freq at night, FEV1<60)
1. high dose inh steroid +
2. PO steroids with attempts to wean
high dose inhaled steroids have been associated with increased risk of pneumonia.
31
Leukotriene modifiers may be effective treatment for...
1. mild persistent
2. allow dose reduction of inhaled glucocorticoids in moderate and severe persistent asthma
3. ASA-sensitive asthma
32
Pt w/ Vasomotor rhinitis, nasal polyps develops asthma. allergy to NSAIDS. dx?
dx: ASA sensitive asthma
tx: d/c asthma, start leukotriene inhib (monteleukast)
33
Pt with ASA sensitivity asthma. you can use
codeine based analgesic, sodium or choline slicylates, NO COX1 NSAIDS
34
Pt with shoulder pain takes ibuprofen - coupel hours later with SOB/wheezing
NSAID induced broncospasm
35
Pt w/ asthma on mild-mod dose of inhaled steroids with incomplete response. wtd?
start PO theophylline
36
50yo post viral URI several weeks ago with persistent cough, inc'd at night with chest tightness, no heartburn, recent neg cardiac w/u - PFT with mild obstruction - wtd
methacoline challenge test -
dx: post viral hypersensitivity - tx with inhaled steroid (budesonide once a day)
37
Mainstay maintenance therapy for asthma
inhaled steroids
38
30yo F non-prod cough for several months, no heart burn tob or wheeze, PFT normal, methacholine neg - wtf
check sputum for eosinophils - (non-asthmatic eosinophillic bronchitis)
39
Pt with athma on beta agonist still with wheeze
add inhaled steroid
40
Pt with severe asthma exacerbation hospitalized with iv steroid and beta agonist - upon d/c wtd
switch to tapering dose of oral steroid -> start inhaled steroid, beta agonist PRN
41
In addition to reduction of acute/chronic asthma sx what do inhaled steroids do?
reduction of progressive loss of lung fxn in adults and increased symptom free days
42
Pt with asthma on albuterol prn with nocturnal awakening with sx of asthma best medcation
start with inhaled steroids -> THEN add long acting beta agonist
43
increased mortality in asthma related to...
inc FEV1 responsiveness
44
Pt with asthma p/w acute exacerbation - ABG 7.46/34/70/94% - pt receives neb tx with albut, after 3rd tx pt with BS b/l but decreased - now RR>30, HR 130, ABG 7.38/46/70/92% wtd
INTUBATE PT
45
oxygenation goal in asthma
PaO2>60, SaO2>90%
46
Pt with asthma being treated with b2 agonist, inhaled steroid, montelukast still has sx, removes carpet/rug, no cat - SERUM IgE high - wtd?
add omalizumab (anti-IgE ab)
47
Asthmatic on b2 agonist prn, inhaled triamcinolone, almeterol and monteleukast - still with frequent exacerbation, does not like to go on logn term oral steroids - wtd
start tiotropium (spiriva)
48
Chronic cough
upper airway cough syndorme (post nasal drip), asthma, GERD, chronic bronchitis, ACEi, non asthamatic eosinophilic bronchitis*
49
Exercise induced asthma
sx peak 10-15 after stopping exc, resove in 30 min mainly in cold weather - Dx with excercise challenge test in cold air (drop FEV1 by 10-12%)
50
Exercise induced asthma tx
short-acting B2 agonist 30 min prior to excercise - if no effect then add cromyln Na+ ...ppx = TID
51
If exercise induced asthma SOB on cromoyln
add inhaled steroids and monteleukast (3rd line)
52
Pt moves to minnesota (cold weather) - SOB in cold
start B agonist inhaler
53
Mechaism of cromyln Na+
mast cell stabilization (dec histamine release)
54
Pt with exercise induced asthma started on albuterol inhaler also wakes up at night 3x/wk to use albuterol inhaler... wtd?
start inhaled steroid + LABA
55
Allergic Bronco Pulmonary Asergillosis (ABPA)
colonization of upper airway with aspergillus i asthmatics - intense immed hypersensitive type rxn - inc IgE, +skin rxn to aspergillus Ag, serology +IgM, IgE, +eos, +brownish mucous plugs - > migratory pulm infiltrates (eos PNA)
56
pt with steroid dependent asthma p/w cough, wheezing BROWN mucous plugs - WBC: 15% eos, IgE>2000, CXR b/l infiltrates - steroids recently decreased - has parakeet
Allergic Broncopulm aspirgillosis (ABPA)
- incr eosinophils, incr IgE
Tx: incr steroids
57
Hypersensitivity pneumonitis
neg eos, normal IgE
58
Allergic angiitis of churg stauss
+eos, normal IgE
59
Loeffler's syndrome (pulm eosinophilia)
+eos, inc IgE
60
Fungal ball in cavity ASX
monitor
61
Fungal ball in cavity with severe hemoptysis
surgery
62
Hypersensitivity Pneumonitis
farmer's lung - fever, chills dyspnea after work everyday, works in grian elevator, pet bird (bird fancier's lung), methotrexate or nitrofurantoin or works with A/C units
tx: remove the offending agent
63
Etio - hypersensitivity pneumonitis
inhaling organic dust with thermophilic actinomycetes - CXR GROUND GLASS APPEARANCE WITH NO EOSINOPHILS, +serum AB - BAL: CD8>CD4 (opposite of sarcoidosis --> LY,PHOCYTOSIS.)
remove offending agents, +steroids
64
Pt with dog, cat, 2 parakeets and pigeon - cough, progressive SOB, CXR reveals INTERSTITIAL/ALVEOLAR infiltrates (ground glass) - WBC no EOS - PFT restrictive
hypersensitivity pneumonitis (bird fancier lung)
65
70yo M chills, fever, non prod cough, pleuritis CP - recent acute pharygitis - received PCN/Amp w/o improvemnt - CXR with RLL infiltrate - BCtx neg, myoplasma,legionella ab neg - Dx?
Chlamydia pneumoniae
66
Psittacosis
disease asx in birds - complement fixation and serology useful in dx
67
Pt with asthma on fluticasone inhaler/oral steroids - montelukast added, oral steroids tapered down - pw cough, sob, wk righ thand/foot - 25% eos, IgE elevated - cxr bilateral dense pneumonic infiltrates
allergic angiitis/Churg strauss pneumonitis - tx with steroids
68
Latin american pw asthma, recent immigrant - recurrent cough despite B2 agonists - eos 20%, round infiltrates on CXR - ANCA neg, ANA neg
Loeffler's syndrome - strongyloides infxn - tx with thiabendazole
69
35yo non-smoker F pw cough, no sputum, wheezing, nighttime sweats - h/o asthma - b/l crackles on exam - PPD neg, high eos in sputum high ESR
chronic eos PNA - long term steroid treatment
70
35yo construction worker p/w SOB, no wheeze, no CP, no hemoptysis no exp to toxic fumes - b/l crackles - diffuse opacities/GG - bronch with copius tan fluid - alveolar proteinosis
whole lung lavage - defective macrophages causing buildup of surfactant in lungs
71
COPD
dx: h/o chronic smoking dec FEV1/FVC<0.70
72
COPD Spirometry determines?
Severity of disease
73
Gold Criteria Mild COPD stageI
FEV1/FVC <70%, +FEV1 >80 ...................... tx = SABA prn, albuterol +/- ipratropium (SAMA(atrovent*)
74
Gold Criteria Mod COPD stageII
FEV1/FVC <70%, FEV1 < 80% ............. tx = SABA prn plus LABA (tiotropium(LAMA(spiriva)*) +/-salmeterol (LABA(Serevent*))+/- rehab
75
Gold Criteria Severe COPD stage III
FEV1 <50%, .......SABA, LABA + ICS (LABA/ICS combos: symbacort, advair, dulera, breo)
76
Gold Criteria very severe COPD stage IV
FEV1<30 %- use long term O2 therapy at least 15hrs/day. consider sx
... stage 4 w/ acute exacerbation should be treated like CAP
77
Major risk factor for COPD
Smoking
78
Main tx for COPD
bronchodil, antichol, supp O2 SaO2>90%
79
Therapy survival benefit for COPD
O2 supp at least 15hrs/day
80
Pt with COPD hypoxia on O2 therapy, PO2 signficantly improves - cause of low PO2 is...
V/Q mismatch
81
Bronchodilators do what for COPD
reduce hyperinflation, dec RV, improve sx and exc tolerance - DO NOT IMPROVE MORTALITY
82
Tiotropium is better than Ipratropium
True. reduces exacerbations, hospitalizations, lung hyperinflations. improves exercise tolerance. works by blocking muscarinic receptors. more potent than SABA. Superior to Salmeterol at 6 months.
83
Side effect of salmeterol/tioproprium
dry mouth
84
Pt with COPD, +tob - best way to preserve lung fxn
quit smoking
85
Inc'd mortality in COPD
decreased free fat mass. not bmi
86
Criteria for starting O2 on COPD pt
1. PaO2 <55mmHg or O2 sat of 88%. PaO2<59mmHg or O2 sat >88% with evidence of Cor pulmonale, 3. erythrocytosis (Hct>55%)*
87
Role of inhaled steroids COPD
decrease exacerbations
88
Adv COPD pt Pulm rehab
DOES NOT improve FEV1, does NOT dec mortality, does improve sx, QOL, dec exacerbations, reduced dynamic hyperinflation, reduced healthcare utilization
89
Pulm rehab doesn't work, still low exc tol, ABG 7.42, PO2 62, pCO2 48 - FEV120, b/l upper lobe emphysema
lung volume reduction surgery*
if FEV1 < 20 --> lung transplant (improved QOL, decreased mortality, improved increased BMI, decreased dyspnea)
90
Pt gets sick everytime he goes up a mountain to ski. He wants to go back next year.... what is he best advcie for prevention?
acetazolamide 24-48hours prior... watch out for syncope from decr BP.
91
Pt goes to colorado for skiing, on top of the mountain at 8000ft, he gets dyspnea and develops pulmonary edema. Paramedics start O2.. what is the most immediate step.??
bring him down to lower altitude....... pulm edema = leading cause of death with altitude sickenss - h/a, n/v/fatigue, dizzines PLUS SOB - 8000 to 12000 ft - tx descent, dexamethalazone, prev with acetazolamide or nifedipine
92
Thophylline decrease clearance by...
CHF, Liver dz, hypoxia, fever, cipro, erythro, OCP
93
Young woman h/o asthma on multiple meds and OCP c/o n/v - tachycardia/tremors . this is most likely related to her use of ...
theophylline . OCP incr theophylline level which can cause MAT
94
COPD with Po2 60 pCO2 50 - exacerbation of COPD - PO2 55 and pCO2 60 - refuses intubation
BIPAP
95
50yo COPD p/w SOB,cough - awake but in severe distress, using accessory muslces - pCO2= 74, pO2= 50, pH= 7.18, HR 120, RR 36, BP =100/68. wtd?
intubate, mech ventillation........
indications to intubate pt? pH<7.25, RR>35, HR>120. (positive secretions if close to criteria, hemoptysis counts.)
96
Mortality reduction COPD pt
flu vaccine
97
30yo M extensive bullous emphysema, CXR: b/l basal bullous cysts. which test would you do
check serum alpha 1 antitrypsin level
98
58yo F recurrent cough, foul smelling yellow sputum with hemoptysis, h/o PNA >1 yr ago - CXR: prominent cystic spaces in RLL, streaking opacites in the direction of bronchial tree( tram lines). dx? confirm?
dx bronchiectasis, confirm w/ high res CT scan. TIP = h/o PNA in the past
99
Bronchiectasis/sinusitis, infertiility, sinus inversus
Bronchiectasis/sinusitis, infertiility, sinus inversus.......
Dx Dyskinetic cilia syndrome/ Kartagener's syndrome.
Screen by: inhaled nitric oxide test. Confirm by: bx of bronchi or sinus with video electron microscopy
100
22yo M recurrent PNA, bronchitis since childhood, no allergy or GERD, IgG electrophoresis nl, unable to have children. exam: slender body habitus and polyp in nose. clubbing (+), CXR:apical bullous changes. wtd next?
check sweat chloride. >60 = positive
dx : cystic fibrosis, inc'd ris kof endobronchial infxn with pseduomonas, staph, strep Pneum
101
Cystic Fibrosis tx?
1. chest PT, abx (anti pseudom, topical tobramycin spray **, inhaled hypertonic saline, bronchodilators., 2. decrease sputum viscosity by human ribonuclease
3. Treatment of severe bronchiectassis w/ bleed ---> bronch artery embolization
102
Reduce decline in lung fxn with CF patient colonized with pseudomonas
Azithromycin (anti-inflamm effect)
103
35yo non-smoker, h/o RA, no asthma/allergies - p/w cough/dyspnea on exertion, recent viral URI. exam: JVD 6cms, no wheeze, CXR normal - PFT = severe obstruction w/ FEV1/FVC 0.6. DLCO 82%. No change after bronchodilator. alpha antitrypsin level normal
Bronchioitis obliterans - can occur after RA, carcinoid tumor, lung transplant
104
35yo F s/p radiation tx for breast CA p/w SOB, diffuse insp crackles - PaO2 52, PCO2 30, PFT dec DLCO, no response to abx
cryptogenic organizing PNA - dec DLCO, bx rapidly progressive organizing PNA or acute interstitial PNA - tx STEROIDS
105
Interstitial lung dz
```
sarcoid
idiopathic Pulm Fibrosis
hypersensitivity pneumonitis
COP
Allergic bronchopulm aspergillosis
lyphogioleiomyomatosis
Churg strauss
```
106
Sarcoid - indications for steroids
progressive pulm dz, eye involvement, CNS involvement, myocardial involvement, persistent hyperCA, disfiguring lesions
107
24yo F fever, pain, swelling both ankles (erythema nodsum - tender erythematous nodules - wtd
CXR r/o sarcoid - bil hilar LAD - no tx, adenopathy +parenchymal infiltrate - steroids if symptoms, diffuse infiltrates - no adenopathy - steroids if symptom
108
26yo F f/weakness, tenderness over legs - erythematous lesions, CXR b/l mediastinal adnopathy with infiltrates
BAL T4/T8 4:1, start steroids if eye involved, TB bx for non-caseating granulomas
109
All following elevated in sarcoidosis
Calcium in serum/urine, ACE, helper T cells
110
Idiopathic Pulm Fibrosis
insidous onset dry cough, gradual progressive dypsnea, cyanosis, clubbing, CXR diffuse infiltrative progess, reticular opacities, ground glass, honeycombing, PFT FEV1 low, FEV/FVC normal DLCO dec, BAL inc neutrophil
Tx: supportive care, O2 PRN, pneumovax, flu shot +- steroids
111
Asbestosis
Chronic exp x 10yr, lower lobe fibrosis, PFT - RESTRICTIVE patter - a/w mesothelioma, broncogenic CA, Pleural/diaphragm calcified plaques (no lung impairment)
112
Silicosis
chronic exp x 20 yrs (sandblasting, granite cutting) - upper lobe fibrosis with inc'd MTB incidence
EGG SHELL Calcifications with hilar LAD
113
58yo M SOB< CP, reporducible on palpation, 15lb wt loss over couple months, asbesthos exp - used to smoke, no BS in L base - pleural effusion L
mesothelioma/bronchogenic CA
114
Berylliosis
```
metal workers (computers, aerospace, electronics/lights b4 1950's) - can cause tracheobonchitis
Bx - non-caseating granuloma
A/w lung Ca
```
115
Male smoker with SOB, progressive - honeycomb on chest xray interstitial upper lung fields - PFT restrictive - BAL - langerhans cells (giant cells - also on bx
Langerhan cell granuloma/esoinophilic grnauloma/histiocytosis x
c/b - PTX
Tx: quit tobacco
116
Premenopausal woman on OCP with sudden SOB, CXR with PTX, honey comb appearance on CXR with CHYLOUS EFFUSION
lymphangioleiomyomatosis
117
Consequences of hyopxemia
pulm HTN, secondary erythrocytosis, exc intolerance, impaired mental fxn, precip sleep apena
118
COPD dx with pulm HTN - etiology?
hypoxia
119
Tx for pulm HTN pt with COPD
O2 tx keep SaO2 90-95%
120
Pulm arterial HTN
Idiopathic, hertiable, drug (Fen,fen), conn tissue d/o, HIV, portal HTN, congential heart dz
121
Pulm HTN from LH dz
systolic/diastolic dysfxn - valvular dz
122
Pulm HTN from lung dz/hypoxia
COPD, ILD, mixed restr/obst, chronic high altitude
123
Chronic throboembolic pulm HTN
PE of prox or distal pulm vasc
| dx V/Q scan
124
Pulm HTN unclear mech
hematologist, sarcoid, langerhans, lymphagioleiomyomatosis, met d/o, tumor infiltration
125
Pulm pressures
normal 25/15 - RVH (RAD, tall Rwave V1/2, split loud second heart snd - lous P2
126
Pt with near syncope, SOB< SQ calcification, split 2nd heart dound, JVP, pedal edema
TTE
127
Pt with telangiectasias and SOB, h/o syncope, JVP 10cm, loud P2, pansystolic murmur L sternal border - echo with RV dilation and mod TR wtc
RHC with vasodilator testing
128
45yo F h/o PE 4ya tx'd with a/c with SOB, loud P2 EKG with RAD and P pulmonale - echo RV dil - next dx step?
r/o CTEPH - V/Q scan
129
Pt with +v/Q scan - wtd?
eval for thromboembolectomy
130
If pt with RHC responds to vasodilators?
start nifedipine or diltiazem
131
If pt with RHC with NO response to vasodilators?
Mild dz - sildenafil, tadafil, bosentan
Mod dz to severe (limits on physical activity) - IV epoprosterol + sildenafil
Severe dz and hypotensive - inhaled Iloprost
132
Maintenance tx pulm HTN
Coumadin
133
Pulm Embolism
usually from DVT (mostly above Knee - sudden onset SOB, tachypnea, pleuritic CP, pre/syncope, hemoptysis, loud P2, split 2nd heart sound, CXR normal - S1Q3T3, A-a gradient >20 if hyperventilating PO2 may be normal - taxoifen, OCP, nephrotic syndrome, breast CA, protein C/S def, long flight or drive
134
V/Q scan
Normal - no PE
2 or > seg or larger defect with no matching ventil def - > +PE, treat
sugseg perfusion defects or matching ventillation and perfusion deficets or single large defect - PE low or intermed - check for DVT - tx if postive if ng then pulm angiogram
135
Tx for PE
LMW or heparin 7-10 days - then coumadin for 3-6 months
136
High clinical suspicion
start tx before confirmation
137
Best test r/o low prob PE
D-dimer (if neg no PE)
138
Best test r/o mod to high prob PE
V/Q scan
139
Best test dx chronic PE
V/Q scan
140
Contraindications to A/C
neursx, eye sx, open prostatectomy
141
Indication for thrombolytics
acute massive PE with hypotension - large DVT (Iliofemoral DVT)
142
Indication for IVC filter
If another PE pt may die, contraindication to A/C - emboli post A/C
143
52yo M midl CHF is a/w sudden onset of SOB and right sided pleuritic pain on furosemide and digozin - CXR with cardiomegaly - split 2nd heart snd HR 100 - V/Q scan showed small subsegmental match/unmatched deficits - contrast scan lower extrem neg wtd?
CT angiogram
144
44yo M multiple pelvic hip fx and undergoes hip replacemnt - two days after surgery fever, mental confusion and sob - chest xray and diffuse pulm infiltrates - pO2 44 , pCO2 30mm, pH 7.48 EKG wiith sinus tach - inubated and transferred to ICU - dx?
Non cardiogenic pulm edema due to fat emboli
145
Tx for non-cardiogenic pulm edema 2/2 fat emboli
No A/C no steroids
146
Post delivery patient becomes hypotensive and SOB
amnitotic fluid embolism
147
Pt with sudden onset SOB< tachy, hypoxeia and inc'd A-a gradient
V/Q scan
148
Pulm HTN, SOB, tachy, echo with RV strain -
V/Q scan
149
Pt with SOB, tachy cardia, echo RV strain - V/Q scan with 2 large deficits normal ventillation
Anticoagulation
150
Pulm HTN, SOB, tachy, V/Q scan 3 defects 2 matched with ventillaory defects one with unmatched defciit - lower extrem US neg
pulm angiogram
151
Pulm HTN with SOB, V/Q with 2 large unmatched defects, hypotensive
T-PA
152
DVT
D-dimer good neg predictive value
If D-dimer + further w/u needed
Infection good predictor for DVT
LMWH dec's DVT but not mortality
153
Pt with unprovoked DVT 5 months ago now in ED with bleed, coumadin stopped -> wtd?
ASA 325
154
DVT ppx
High risk - Knee replacement, Total hip - ppx LMWH 4 weeks or warfarin or fondaparinex
155
DVT ppx with elev Cr
unfractionated hep, ext pneumatic compression, early mobilization
156
Pt with DVT started on A/C with swelling of leg, 2 months later leg swells again - wtd?
below knee compression stocking
157
Elderly pt with colon CA 2ya p/w swelling of leg
check LE US (high risk patient)
158
45yo p/w swellinig/pain in right leg - wtd?
D-dimer (low risk pt)
159
Hospital Aquired PNA
leading cause of death among hospital aquired infections - 48hr or more after admission
160
Ventilator Associated PNA
within 48 to 72hrs after intubation
161
Healthcare associated PNA
pt either hospitalized w/in 90 days of infxn, resided in NH, chemotx or wound care within 30 days of infxn or attends a hosptial or HD clinic
162
Pt with cholecystitis s/p chole develops PNA
48hr imipenum +aminoglycoside
163
Strep Pneumo
MCC of PNA
164
Myoplasma
PNA in yound adults
165
H flu/M catarrhalis
COPD/DM pts
166
Legionella
cool damp places/water coolers
167
Pseduomonas
nosocomial, neutropenics
168
Klebsiella
alcoholics, NH residents
169
Mixed flora
cavities, lung abscess
170
Good sputum sample
25WBCs
171
pt with cough/yellow expectoration pas 2 days low grade tempHR 84 BP ok lungs with few rales
over the counter anti-tussives
172
Pt with URI sx >2wks tx'd with doxycycline w/o improvement - inc'd cough with post-cough vomiting - exam with SUBCONJ HEMORRHAGE -> organism?
sputum PCR for bordetella
173
Pt with PNA tx'd with Ctx/azithro x 5 days then changed t PO meds - on abx fells better - continues to have cough, 6 wks later opacity persists - dx?
underlying malignancy or bronchial carcinoid
174
Pt with recurrent PNA - CT chest fibrosis in Lt lower lobe area - etiology?
post obstructive PNA
175
40yo pt with hemoptysis and streaks blood x 3 weeks - 4lb wt loss, cough, CXR normal - management?
bronchoscopy
176
25yo p/w purulent nasal discharge, HA for past 2 days, cough+, tx with?
decongestants, analgesics
177
Bacterial sinusitis
< 7 days have bacterial sinusitis - No abx unless sx > 7 days or have fever/pain - no routine CT for dx
178
22yo M with c/o purulent nasal d/c for 3 days and temp 101 with maxillary pain wtd?
abx - amox-clavulanate (augmentin)
179
40yo sore throat and h/a x 3 days - grandchild with cold - 99 deg with pharyngeal erythema, anterior cervical LAD
rapid strep test - confirm with throat ctx
180
Centor criteria for strep
fever, no cough, tonsillar exudate, cervical LAD
0-1 no abx or throat ctx
2-3 throat ctx - tx if +
4 or 5 tx empirically with abx
181
pt with runny/blocked nose, itchy eyes, sore throat - swelling below eyes, coblestone pharynx no LAD dx?
allergic rhinitis
182
Nasal congestion/rhinorrhea for several months, h/o allergies usually controlled with decongestants and antihitamines - using OTD meds and getting worse - red edematous mucousa of nares
rhinitis medicamentosa - rebound congestion from vasoconstrictors - stop vasoconstrictors start intranasal steroids
183
24yo hot potato voice, fever, unable to swallow, drooling - tonsils touching each other, dev of uvula
peritonsillar abscess (Quincy)
184
pt with sore throat few day sand severe pain when moves neck, pain on swallowing - brawny edema of hypopharynx and tenderness of palpation of SCM - dx?
internal jugular vein thrombosis (Lemierre's dz)
185
DM pt with fever from NH, no teeth CXR RL consoldiation - best empirc abx?
newer fluoroquinolone (strep pneumo) - if worsens still febrile and hypotensive then resistant - start vanco or linezolid
186
alcoholic pt with cough/red currant jelly sputum - g neg bacilli with capsure, cxr bulging fissure dx?
klebsiella PNA - 3rd gen cephalosporin (ceftx) + amminoglycoside
187
If above pt worse (etoh abuse with red currant jelly)
ESBL - start impipenum or meropenum
188
S/E flurouinolone
inc QTC -> ventricular arrythmia
189
elerly woman floroquinolone s/e
tendon rupture
190
which abx have hypoglycemia s/e
Levofloxacin
191
CAP tx period
1 week
192
HAP pseudomonas tx period
2 weeks
193
Pt with PNA - early ambulation leads to...
early d/c from hospital
194
65yo DM pt with PNA tx'd with abx - wtd prior to d/c
23 valent pneumococcal vaccine
195
Pt wit LLL PNA tx with Abx with persistent fever, elev WBC for 2 weeks, CXR still with infiltrates
CT scan r/o lung abscess or empyema
196
Fever, cough, DIARRHEA, mental confusion, pulm infiltrated, DEC SODIUM, inc BUN
legionella - urine legionella Ag -> macrolide +- rifampin x 2 weeks
197
AIDs pt with sudden onset SOB, hypoxic on ABG, PTX on CXR - chest tube inserted - wtd
PCP tx (bactrim + steroids)
198
Acute ill pt with PNA and intubated - lancet shaped diplococci - WBC 15, 103 deg - tx'd with PCN - 2 days later still temp, wbc 11, greenish secretions from ET tube grows pseduonas
continue PCN
199
PNA temp 103, WBC 17K tx'd with fluroquinolone - 3 days later WBC 11K - unchanged lobar infiltrate - WTD?
no further testing - continue to tx
200
Pt a/w RL pna - temp 102, WBC 16, started on Ceftx, next day BCtx growing PCN sensitive srep pneumo, - pt changed to PCN - on 5th day shows growth of MRSA (contaminent)
continue PCN
201
Pt with recent Seizure -3 days later UL infiltrate - organism?
Peptostreptococcus
202
Pt with Sz 1 month ago now with fever, foul smelling sputum, CXR cavity with fluid level, sputum shows mixed flora dx?
Lung abscess -> PCN with clindamycin - several days later no fever, same cavity but fluid decreases, WBC dec -> continue abx
203
25yo with ear ache fever cough - inflammed typanic membrane with hemmorhage - CXR patchy infiltrate
Myoplasma -> tx macrolide (erythromycin)
204
35yo non-smoker with gradual onset cough few weeks - WBC < 5, Epith 25/cm2 CXR b/l infiltrates -> tx?
Macrolide
205
50yo COPD, acute onset of cough, rusty sputum, fever, chills LLL consolidation dx?
Strep pneumo - macrolid+ceftx
206
Common pathogens in neutropenics
Pseudomonas, aspergillus, staph, strep
207
CURB65
```
Confusion
bUn>19
RR>30
sBP65
0-low risk - home tx
1 - outpt tx
2 short inpt, clsoely supervised outpt
3 severe PNA - hospitalize consider ICU
4 or 5 - ICU tx/intubation
```
208
55yo COPD SOB, cough, sputum white-> green, low temp scattered rhonci - organism?
H.Flu non-typable
209
50yo farmer 3 month cough, inc dyspnea, skin lesion on nose with pleurtic CP -> CXR alveolar/fibronodular infiltrates
Blastomycosis (thick walled infiltrates)
210
22yo F OCP 3 days fever, pleuritic CP, non prod cough/fatigue CXR clear
Pleurodyna 2/2 coxsackie virus - sx therapy
211
Pt with URI 3 wks ago - fatigue, inc JVD echo EF 20% - cause?
coxsackie B3 virus
212
Pt from southwest - arizona, NM, texas with fever and LUNG infiltrates, thin walled cavity on CXR
Cocoidomycosis - thin walled - self limited or fluconazole -> systemic -> Amphotericin B
213
Influenaza season
```
NOv to march - f/cough/myalgia - vaccine any age > 6 months
Tx Oseltamivir (tamiflu), zanamivir
```
214
Influenza outbreak in NH tx?
vaccine+tamiflu(oseltamivir x 2 weeks - if no vaccine then oseltamivir/amantadine x 6 weeks
215
Pt post influenza more prone to...
staph PNA
216
Which flu med NOT with asthma/COPD
zanamivir (or BB, adenosine, dihydropyridine)
217
Female pt with UTI on nitrofurantoin - SOB/fever, crepitice over lung fields with ground glass
Dx nitrofurantoin rxn
218
PPD
>5mm - HIV, rec TB contact, old CXR TB scar, organ tx, prednisone >15mg/day at least 3 months, anti TNF, rituximab
>10mm - HC workers, etoh, homeless, foreign born, NH resdients, dz with high risk of TB, IVDA, silicosis, DM, CRF gastrectomy, chemo, lymophoma, leukemia, malnutrition
219
PPT+ wtd?
CXR
220
CXR small patch fibronodular opacity no cough -
induce sputum AFB
221
CXR neg after +PPD
tx with INH x 9 months
222
alternate to INH with liver enzyme elevation or HCV
rifampin x 4 monthsbest
223
best tx pt PPD+ (compliance wise)
INH 900/rifampin 900 weekly x 3 months (direct observed therapy)
224
Multidrug resistant TB - asymptomatic roommate PPD 5mm CXR neg - wtz?
PZA/ethambutol for 6 months or PZA+quinolone (levoq/moxiflox) x 6 months
225
Nurse (filipino with PPC x 20mm) BCG in childhood
CXR if neg begin INH and B6 (if 10 or less check gamma IFN if + active TB tx
226
Ukrain resident PPD 10mm BCG in chilhood CXR neg
check IFN gamma
227
Pt on INH/B6 - 3 moths on tx now tired and nausea x 2 days
d/c INH, check AST/ALT, bilirubin check (liver failure) stat
228
Best Screen latent TB
Gamma IFN
229
What is good about gamma IFN vs PPD
decrease confounding with BCG
230
Inner city pt, PPD+, CXR+ started on rif, inh, pza, ethambutol isolated until 3 afb neg still ctx + 1 later wtd
continue 4 meds x 1 more month
231
Pt dx with pulm MTB - homelss lives in shelter periodically wtd?
INH/rifampin/pza/ethambutol x 2 weeks then inh/rif, pza ethambutol twice wekly x 6 weeks then inh/rfampin twic weekly x 4 months
232
Pt from E eurobe/asia with pleural effusion - tap done neg for AFB - wtd?
needs VATs pleural bx
233
Management of MTB resistant to INH - what drug improves outcome?
Fluoroquinolone
234
Homeless pt with RUL infiltrate and pleural effusion wtd?
airborn isolation
235
Pleural effusion lytes criteria
transudate 3g tot protein, fluid/serum protein ratio >0.5, total LDH >200, fluid serum LDH ratio >0.6
236
Causes Transudate effusion
CHF, Nephrosis, cirrhosis, hypothyroid
237
Causes Excudate effusion
neoplasm, infection, inflammation (RA, SLE, Pancreatitis), esophageal perforation (gastrograffin), dresslers syndrome (post cardiac sx)
238
Mesolthelioma/malignance with bloody effusion
chylous eff >115 TGA->trauma, mediastinal lymphoma/lymphangioeiomyomatosis
pseudochylous like in TB, Rh arth
Gluc 80-TB, gluc 60-CA, Gluc 30-Rh arthritis
239
54yo with pleural effusion dx tap reveals fluid serus <0.6 cause of pleural effusion?
Cirrhosis
240
Rh arthritis pt with recurrent effusions after repeated taps wtd?
tub thoracostomy and sclerosing agent
241
Pleural fluid with glucose o29 - cause?
Rh arthritis (<30)
242
55yo M s/p CABG 4 weeks ago p/w fever, dyspnea, non-productive cough, pleuritic CP - pericardial rub - ESR 68, WBC 10, cardiomegaly with b/l basal atelectasis and small pelural effusion - ABG PO2 80, PCO2 34 pH 7.45 - tap done 350cc removed - protein ratio >0.5, LDH ratio >0.6 - V/Q scan with several matched defects - dx?
Post cardiotomy syndrome (dressler's)
243
25yo athlete SOB while sprinting with pleuritic CP - BS dec on R side - hyperresonance on percussion
spontaneous PTX -> chest tube insertion
| if recurs pleurodysis
244
When to tap parapneumonic effusion
If effusion >10mm on lat decubitus CXR, PNA not responding to abx, frank empyema needing chest tube, loculated fluid needs thoractomy
245
Pt with PNA continues to spike temp on Abx, cxr with pleural effusion, protein >3g, LDH rat>0.6, chest tube placed, 72hrs later pt still febrile - loculation on chest CT
VATS (surgery c/s)
246
Chest physical exam
Pleural effusion -> dull percussion, dec BF, Fremoitus absent
Pneumonia ->dull percussion-> bronchial BS, in fremitus
PTX - hyper percussion, dec BS, inc frem
247
Best way to diff PTX from pleural eff o PE
percussion (hyper on PTX)
248
Pt with SOB - exam dec BS on left, inc vocal frem on L - dx?
L side consolidation (PNA)
249
Pt a/w SOB, CXR lower lobe infiltrate and pleural effusion, temp 102.5, HR 110, pleural tap exudative fluid - next day pt worse and more hypoxic with PO2 of 52, CXR complete whiteout of left side - trachea not deviated - dx?
L hemithroax consolidation - needs intubation
250
Pt with PNA, large consolidation on LL, abg while lying on L side 54, while lying on R side 65 - cause?
intrapulmonary shunting 2/2 PNA
251
Pt with cryptogenic cirrhosis with ascites and pedal edema, SOB on sitting or standing up - pulse ox 92% lying down, sitting 82% DLCO 70% - etiology?
intrapulm R to L shunt (hepatopulm syndrome (orthodeoxyia see every 4 beat bubble in LA on bubble study in TTE)
252
Sleep Apnea
Apnea - no breathing for 10 seconds - >10/h - sleep apnea syndrome
253
increased snoring prevents good sleep causing sleepiness?
T
254
Hypoxemia causes daytime sleepiness in OSA
F
255
hypoventilation at right leading to recurrent arousals leas to daytime sleepiness
T
256
Nighttime alkalosis leads to daytime sleepiness
F
257
OSA pt with apnea hypopnea index >30 has?
inc'd mortality
258
Sleep Apnea definitioin
>95% obstructive, snoring, wakes up with h/a, distrubed sleep, neck >17 inches, neuropsych manifestations, somnolence, accidents, firing, high risk for MI/CVA/HTN
Dx with polysomnography - r/o treatable cuase - enlarged tonsils, tumor, hypothyroid
Tx no sedation, no etoh, protriptylin e9mild), mod sleep apnea nasal cpap, , uvulopalatopharygoplasty works 50% of time
259
45yo pt with lethargy, BMI 41, HTN, lift in R parasternal area, panniculus, edema, echo with TR - wtd?
sleep study - etiology of leg edema - pulm HTN from RHF
260
Secondary HTN cause in pt with obestiy
OSA
261
Cause of HTN in pt with OSA
inc'd sodium retention
262
Tx for OSA
improved quality of life, cogn fxn, daytiem sleepiness, HTN, dec mortality
263
Pt with difficult to tx HTN on 4 meds with OSA - best management?
renal denervation
264
22yo BMI 24 tx herself for allergic rhinitis with OTC meds for past few days now unable to sleep well and tired during day dx?
Rhinitis medicamentosa - tx - d/c meds start steroids
265
45yo F BMI 35 p/w DOE - JVD, FEV1/FVC 0.7, mild edema, RVH on echo, no valvular lesions - PCO2 55, PO2 58
dx Obesity hypoventillationi syndrome->pulm HTN
266
Why do ppl with severe obesity have PCO2 elevation?
hypoventillation - check sleep study
267
48yo M dx with OSA - sleepy during day, c/o fatigue, Leg edema, TFT nromal - most appropriate Tx
nasal CPAP
268
Pt with daytime sleepiness, mod musc wk at onlet of sleep gets hallucinations - brother with similar episodes
narcolepsy (autoimmune dz) - tx with modafinil (expensive) or methyphenidate or sodium oxybate)
269
Elderly pt with gradual onset SOB, daytime sleepiness, pedal edema and rales - breaths funny at night and doesn't breath several seconds - BMI 28, EF 30% - most likely cause of daytime sleepiness?
CHF - cheyne stokes breathing (widening of QRS >120)
270
Pulmonary nodules
4-6 low risk f/u CT 12 months if no changes, no f/u, high risk initial CT 6-12 months, then 18-24 months if no changes
6 to 8 - low risk initial CT 6 to 12 months, then 18 to 24 months if no change, high risk initial f/u 3 to 6 months the 9 to 12 adn 24 months if no change
>8mm low risk f/u CT 3,9,24 months, CT, PET and/or bx - same for high risk
271
60yo pt with 1.5cm solitary nodule on CXR wtd first
see old CXR
272
53yo with pulm nodule 1.2 cm - last year 0.9cm wtd?
resection
273
Bronchoalveolar lavage (BAL)
Normal = inc'd PMN
Sarcoid - inc'd lymph CD4>CD8
hypersensitivity Pneumonitis inc'd lymp, CD8>CD4
Eos pNA - peripheral infiltrates - inc'd eos
PJP in HIV - silver metahanamine +
CMV - inclusion bodies
PNA in ARDS - bacteria >10^3
Amiodaraone PNA - foamy witih lamellar inclusions - r/o thyroid issues
274
A pt w/ myasthenia gravis presents w/ weakness w/ vital capacity of < 20ml/kg. Pt is intubated , tx for a wk, extubated and discharged home. He presents 2 weeks later w/ dyspnea. PFTs reveal flattened inspiratory and expiratory flow loops. Most likely dx?
subglottic tracheal stenosis.
275
A 22 yo woman presents w/ dyspnea and wheezing. She has been on inhaled beta2 agonists, inhaled steroids and has used intermittent increasing dose of oral steroids for the past year without much symptomatic relief. Exam reveals a puffy face. Bilateral wheezing during inspiration. The inspiration/expiration ratio is 1. Pulse ox is 96% on room air. Most likely dx?
vocal cord dysfunction
276
Pt with asthma on albuterol, inhaled ICS. Pt still has symptoms. LABA was added with not much improvement. wtd?
dc LABA, begin theophylline PO
277
Pt on ICS + LABA doing well for 3 months -->
1/2 dose ICS, cont LABA. If 3 months stable .. then dc ICS
278
Pt w/ asthma on inhaled fluticasone, salmeterol, tiotropium, and prednisone for past 3 years.. You are trying to wean off the steroids , his last asthmatic attack was more than a year ago. Eosinophil count is high. wtd?
begin mepolizumab (IL-5 inhib).... decreases exacerbation and improved FEV1
279
asthma. symptoms <2/wk and <2nights/month =
intermittent
280
asthma. no daily meds needed, short acting beta agonist prn =
intermittent
281
asthma. >2/wk but < 1/day and >2night/month, low dose inhaled steroid =
mild persistent
282
asthma. daily symptoms, >5nights/mnth =
moderate persistent
283
asthma. start long acting beta agonist and low to moderate dose inhaled steroid =
moderate persistent
284
asthma. continuous symptoms and frequent nocturnal sx
severe persistent
285
asthma. high dose inhaled steroids + long acting beta agonist + PO steroids
severe persistent
286
asthma. post-viral URI w/ increasing wheezing and dyspnea =
exacerbation
287
asthma. nebulization tx with short acting beta agonists --> ipratroprium --> steroids --> IV MgSO4 =
exacerbation
288
asthma. leukotriene inhibitors (montelukast) in ...
mild, moderate, severe persistent.
289
a 20-40 yo male smoker, or recently quit smoking presents with fever, cough, and dyspnea for the past week.Eosinophils 8%. CXR with ground glass appearance. BAL w/ eosiniophils... dx? tx?
acute eosinophilic pneumonia, tx: glucocorticoids.
290
Stage 4 COPD (very severe disease) should be treated like
CAP w/ abx
291
FEV1 is 65% of predicted and FEV1/FVC ratio of 64%.
add long acting anticholinergic
292
FEV1 is 45% of predicted and FEV1/FVC ratio of 55%
add inhaled steroid
293
FEV1 is 28% of predicted. SaO2 87% on room air.
continuous oxygen
294
pt w/ COPD on albuterol and ipratropium still w wheeze .. wtd?
dc ipratropium (SAMA) and begin tiotropium (LAMA)
295
Pt on HCTZ, w/ several exacerbations each year. what has shown to decrease the risk of exacerbations?
moxifloxacin for 5 days every 8 weeks or azithromycin 250mg PO qdaily
since hctz, check for electrolyte distrubances
296
Pt w/ COPD on tiotropium, salmeterol and inhaled steroids presents with COPD exacerbation. LAst exacerbation was treated w/ steroids for 5 days and azithromycin for 5 days... wtd?
begin roflimulast
297
A COPD pt on tiotroprium, salmeterol and inhaled fluticasone presents with increasing bruising. Her last exacerbation was more than a year ago.. wtd?
has exacerbation 2 months later.
dc fluticasone..
start phosphodiesterase 4 inhibitor - roflimulast (daliresp)
298
pt w persistent symptoms, despite adeqate therapy.. wtd?
assess adherence to medications
299
Pt w/ COPD w/ acute hypoxemic respiratory failure, non hypercapneic PCO2 norm,. Best managment that has showed decreased intubation and decreased mortality??
high flow nasal cannula 100%O2.
300
Pt w/ COPD with acute hypercapneic respiratory failure (PCO2 elevated). Best management that has shown decreased intubation and decreased mortality is...
BiPAP
301
Pt w/ COPD w/ hypercapnea. best management ....
BiPAP, shown to decrease mortality
302
what is the role of inhaled steroids in COPD
decrease exacerbations
303
how long to treate acute exacerbation of COPD with steroids 40mg PO daily??
5 days.
304
what is the underlying reason for reduced dyspnea due to decreased respiratory requirement?
improved muscle efficiency
305
what is a required component of pulmonary rehab?
program of exercise training of muscles of ambulation
306
leading bacteria that increaseds mortality in cystic fibrosis
cepacia burkhdorferia.. tx bactrim
307
pulmonary infection or colonization w/ pseudomonas is commn
true
308
cystitic fibrosis should be considered in children or young adults with bronchiectasis or hypogammaglobulinemia
true
309
surgical resection is requried in most cystic fibrosiss patients presenting with massive hemoptysisis
false
