Pulmonary Medicine

Question 0

How is mild persistent asthma defined?

Answer 0

Mild persistent asthma is characterized by daytime symptoms more than two days per week but less than once per day and nighttime symptoms more than two nights per month. Peak expiratory flow or FEV1 is 80% or more of predicted, with PEF variability of 20 to 30%.

Question 1

How is mild intermittent asthma defined?

Answer 1

Mild intermittent asthma is characterized by daytime symptoms occurring no more than two days per week and nighttime symptoms no more than two nights per month. The peak expiratory flow or forced expiratory volume in one second is 80% or more of predicted.

Question 2

How is moderate persistent asthma defined?

Answer 2

Moderate persistent asthma is characterized by daytime symptoms daily and nighttime symptoms more than one night per week. PEF or FEV1 is 60 to 80% of predicted. PEF variability is greater than 30%.

Question 3

How is severe persistent asthma defined?

Answer 3

Severe persistent asthma is characterized by continuous daytime symptoms and frequent nighttime symptoms. PEF or FEV1 is less than 60% of predicted. PEF variability is greater than 30%.

Question 4

What are the indications and contraindications for live attenuated influenza vaccine?

Answer 4

It is an option for healthy nonpregnant individuals ages age 5 to 49 years. It is not indicated in patients with underlying medical conditions, such as chronic pulmonary or vascular disease, in patients with a history of Guillain-Barré syndrome, pregnant patients, or children and adolescents who receive long-term aspirin or salicylate therapy. Patients with a history of hypersensitivity to eggs he should not receive this vaccine. Household contacts of immunosuppressed patients and healthcare workers he should not receive this vaccine.

Question 5

What condition often presents as BB sized calcifications in a miliary pattern on chest x-ray in an asymptomatic patient?

Answer 5

Histoplasmosis. This is often due to exposure to bird or bat excrement in a person who has been raised in the Midwest.

Question 6

What is the CURB – 65 system for community acquired pneumonia?

Answer 6

It is a system that allows you to decide whether a patient should be hospitalized for CAP. One point each is given for confusion, blood urea nitrogen greater than 19, respiratory rate greater than or equal to 30, systolic blood pressure less than 90, diastolic blood pressure less than or equal to 60, and age over 65.

A score of 0 to 1 means that there is a low risk of death and home treatment should be considered. A score of two gives you about a 7% risk of death and a short in hospital stay or closely supervised outpatient treatment is recommended. A score of 3, 4 or 5 gives you a 14 to 30% risk of death and patient should be hospitalized with consideration given to ICU admission.

Question 7

What is the most common pathogen which causes CAP?

Answer 7

Strep pneumoniae

Question 8

What is the most common pathogen which causes pneumonia in ages four months to four years?

Answer 8

RSV, with a peek at 2 to 7 months of age

Question 9

What is the most common pathogen which causes pneumonia in children ages 5 to 15?

Answer 9

Mycoplasma pneumonia

Question 10

What patients have increased risk for drug-resistant pneumococci?

Answer 10

Patients older than 65, patients treated with a beta-lactam in the last three months, alcoholics, immunosuppressive illness, multiple medical co-morbidities or exposure to children in a day care center.

Question 11

What is the drug of choice for community acquired pneumonia in a previously healthy adult without risk for drug resistant strep pneumoniae?

Answer 11

First choice would be a macrolide such as azithromycin, clarithromycin or Erythromycin. Second choice would be doxycycline if they are unable to take a macrolide.

Question 12

What is the appropriate empirical outpatient therapy for pneumonia with comorbidities present?

Answer 12

There is a risk for drug-resistant strep pneumoniae infection. First choice would be a respiratory floroquinolone such as moxifloxacin, Gemifloxacillin, or levofloxacin. Second choice would be a beta-lactam plus a macrolide. The beta-lactam could be high-dose amoxicillin, 1 g TID, amoxicillin clavulanate, 2 g b.i.d., or ceftriaxone cefpodoxime or cefuroxime 500 mg b.i.d. Doxycycline can be an alternate to the macrolide.

Question 13

If there is a concern that a community acquired asthma might be due to MRSA, what drugs should be added?

Answer 13

Vancomycin or linezolid

Question 14

What drugs are appropriate for treatment of intermediate resistant strains of strep pneumoniae?

Answer 14

High-dose amoxicillin, extended spectrum cephalosporins, or fluoroquinolones. Note that there have been some clinical failures with Cipro or levofloxacin but not to Moxi or Gemi.

Question 15

What drugs are appropriate for highly resistant strains of strep pneumoniae?

Answer 15

Ceftriaxone IV plus moxifloxacin. If completely resistant to quinolones, a third generation cephalosporin and macrolide. Vancomycin plus azithromycin IV.

Question 16

Definition of chronic bronchitis

Answer 16

Presence of cough or sputum production for at least three months duration for two consecutive years

Question 17

How is the diagnosis of COPD confirmed with spirometry?

Answer 17

A post bronchodilator FEV1/FVC of less than 0.7 and an FEV1 of less than 80% is diagnostic of airflow limitation and confirms COPD.

Question 18

Discuss the Gold criteria for COPD staging

Answer 18

All stages have an FEV1/FVC of less than 0.7. Stage I or mild has an FEV1 greater than 80% predicted. Stage II or moderate has an FEV1 of 50 to 79% predicted. Stage III severe has an FEV1 of 30 to 49% predicted stage IV or very severe has an FEV1 of less than 30% predicted or less than 50% with chronic symptoms.

Question 19

Treatment of patients with mild and moderate COPD

Answer 19

Mild disease is treated with a short acting Beta agonist every 2 to 6 hours as needed

Moderate disease is treated with a long acting beta agonist or ipratropium and a short or long acting beta agonist. If not effective a trial of inhaled steroids can be tried, but discontinued if it is ineffective. theophylline also may have some use in this situation.

Question 20

What is the treatment for severe COPD?

Answer 20

Continue the previous medications such as bronchodilators and steroids. Add oxygen, pulmonary rehabilitation, possibly theophylline. Lung volume reduction surgery and lung transplant may be considered.

Question 21

Greater than 10 mm is considered positive for TB skin testing in what patients?

Answer 21

Diabetics, those with renal failure, those with cancer, immigrants of less than five years, patients from a high prevalence area, long term care facility residents or employees, inmates, IV drug users, children less than four, and mycobacteriology lab personnel.

Question 22

At least what percentage of airway reversibility do you need in order to confirm the diagnosis of asthma?

Answer 22

12% or 200 mL in the FEV1

Question 23

What are the six steps of care for asthma in 0 to 4 years of age?

Answer 23

Step one: SABA PRN
Step two: low-dose ICS
Step three: medium dose ICS
Step four: medium dose ICS and LABA or montelukast (Singulair)
Step five: high-dose ICS and LABA or Singulair
Step six: high-dose ICS and oral corticosteroid and LABA or Singulair

Question 24

What are the six steps of care for asthmatics over 12 years old?

Answer 24

Step one: SABA PRN
Step two: low-dose ICS
Step three: low-dose ICS and LABA, LTRA or theophylline, or medium dose ICS
Step four: medium dose ICS and LABA
Step five: high-dose ICS and LABA; consider omalizumab (Xolair) if allergies.
Step six: high-dose ICS and LABA and oral corticosteroid; considerate Xolair if allergies

Question 25

What are the six steps of care for asthmatics age 5 to 11?

Answer 25

Step one: SABA PRN
Step two: low-dose ICS
Step three low-dose ICS and LABA, LTRA or theophylline, or medium dose ICS
Step four: medium dose ICS and LABA
step five: high-dose ICS and LABA
Step six: high-dose ICS and LABA and oral corticosteroids

Question 26

What are alternative therapies besides inhaled corticosteroids for patients greater than or equal to five years old?

Answer 26

Cromolyn, LTRA’s, and sustained-release theophylline.

Question 27

What defines the green, yellow and red zones in and an asthma action plan?

Answer 27

The Green zone: usual activity and a PEF of 80% or more of personal best. Yellow zone: some of usual activity with a PEF of 50 to 80% of personal best. The red zone: cannot do usual activities and PEF is less than 50% of personal best.

Question 28

Define mild asthma exacerbation.

How is it treated?

Answer 28

Dyspnea only with activity. PEF greater than or equal to 70% predicted or personal best. Treatment at home should be recommended as long as there is prompt relief with SABA’s. oral steroids may be prescribed.

Question 29

Define moderate asthma exacerbation. How is it treated?

Answer 29

Dyspnea interferes with or limits normal activity. PEF is 40 to 69% of predicted or personal best. Treatment should involve an office or emergency department visit; there should be relief with frequent use of SABA and the patient should be on PO steroids.

Question 30

Define severe asthma exacerbation. How should it be treated?

Answer 30

Dyspnea at rest, interferes with conversation. There is a PEF of less than 40% of predicted or personal best. Treatment should involve an emergency department visits and likely admission; there is partial relief from frequent SABA use. PO steroids and adjunctive treatment should be used.

Question 31

Define life-threatening asthma exacerbation. How should it be treated?

Answer 31

Too dyspneic to speak, sweating. PEF of less than 25 predicted or personal best. Treatment should involve an emergency department visit, possible ICU admission. there’s little to no relief from frequent SABA use.The patient should be on IV steroids and adjunctive treatment.

Question 32

What are the risk factors for death from asthma?

Answer 32

History of sudden severe exacerbations, prior intubation for asthma, prior admission for asthma to an ICU, greater than or equal to three emergency care visits for asthma in the past year, hospitalization or an emergency care visit for asthma within the past month, and greater than two canisters per month of inhaled SABA.

Question 33

What are alternative treatments for exacerbations of asthma?

Answer 33

Epinephrine, ipratropium added to nebulized SABA, levalbuterol, and increased inhaled corticosteroids, cromolyn, and leukotriene modifiers.

Question 34

How do you assess whether a child in the emergency department with an asthma exacerbation needs admission?

Answer 34

The child should be reassessed one hour after initial treatment. If the criteria for severe exacerbation are met, greater than 86% of children require hospitalization. If the criteria for moderate exacerbation are met, 84% require hospitalization if the criteria dropped to mild level, there’s an 18% chance of hospitalization.

Question 35

How do you make the diagnosis of community acquired pneumonia in a child, and how do you treat it?

Answer 35

The diagnosis of community acquired pneumonia is mostly based on history and physical examination. Pneumonia should be suspected in any child with fever, cyanosis, and any abnormal respiratory finding in the history or physical exam. Laboratory tests are rarely helpful and should not be routinely performed. Outpatient antibiotics are appropriate if the child does not have a toxic appearance, hypoxemia, signs of respiratory distress, or dehydration. High-dose amoxicillin would be the drug of choice for any age group where strep pneumoniae is one of the most common etiologies.

Question 36

What is the typical clinical picture for spontaneous pneumothorax? What is the treatment?

Answer 36

The majority of patients are tall, thin individuals under 40 years of age. Most do not have clinically apparent lung disease, and the chest pain is sometimes minimal at the time of onset and may resolve within 24 hours even if untreated. Patients with small pneumothoraces involving less than 15% of the hemithorax may have a normal physical exam, although tachycardia is occasionally noted. The diagnosis is confirmed bye-bye chest x-ray. When a pneumothorax is suspected but not seen on a standard chest film, and expiratory film may be obtained to confirm the diagnosis. Studies have shown an average of 30% of patients will have a recurrence within six months to two years. The majority of patients with spontaneous pneumothorax, and perhaps almost all of them, will have subcutaneous bullae on a CT scan.

An initial pneumothorax of less than 20% maybe monitored if the patient has a few symptoms follow-up should include a chest x-ray to assess stability a 24 to 48 hours. Indications for treatment include progression, delayed expansion, or the development of symptoms.

Question 38

In what patients should warfarin be started at a low dose, and what should that dose be?

Answer 38

Elderly patients, or patients who have conditions such as heart failure, liver disease, or a history of recent surgery. The warfarin should be started at a dose of less than equal to 5 mg per day. The INR should be used to guide adjustments.

Question 39

What urine antigen testing should be done in adult patients with severe pneumonia?

Answer 39

Urine should be tested for pneumococcal and Legionella antigens.

Question 40

What should be the next treatment for a child in the emergency department with an asthma exacerbation with a peak flow of 40% predicted who has so far received multiple albuterol MDI treatments and oral prednisone at home?

Answer 40

IV magnesium sulfate.

Question 41

What is the dosage of magnesium sulfate for an adult who is having an acute exacerbation of asthma and what are its indications?

Answer 41

A single dose of 2 g infused over 20 minutes is suggested for patients who have a life-threatening exacerbation or whose exacerbation remains severe, with a peak expiratory flow of less than 40% of baseline, after one hour of intensive conventional therapy.

Question 42

What measures should be instituted in hospitalized male patients who require placement of a Foley catheter at the time of insertion, to improve the success of a voiding trial after removing the catheter?

Answer 42

Starting an alpha blocker at the time of insertion.

Question 43

What is Osler Weber Remdu syndrome? What are its clinical manifestations?

Answer 43

Hereditary hemorrhagic telangiectasia. It is an autosomal dominant vascular disorder which has a variety of clinical manifestations. Among the most common are epistaxis, G.I. bleeding, iron deficiency anemia, along with characteristic mucocutaneous telamgiectasias. In addition AV malformations commonly occur in the pulmonary, hepatic and cerebral circulations.

Question 44

What is the most common presentation of Osler Weber Rendu syndrome?

Answer 44

Spontaneous recurrent epistaxes.

Question 45

What screening for AVMs should be done in patients with Osler Weber Rendu syndrome? In what patients should it be done, and when?

Answer 45

Since pulmonary AVMs are found in 15 to 30 percent of patients with this syndrome, screening for PAVM should be performed in all patients with confirmed HHT. In children it should probably be deferred until age 16. It is particularly important that women be screened before becoming pregnant, since PA VM’s can rupture in later pregnancy And to cause hemothorax or hemoptysis.

Question 46

What is the appropriate workup for sudden onset unilateral sensorineural hearing loss?

Answer 46

Audiometry, which should reveal a 30 dB hearing loss at three consecutive frequencies. Physical exam, which should reveal no obvious cause, and neurological exam. Oral corticosteroids may be offered as initial therapy, and hyperbaric oxygen therapy may be helpful within three months of diagnosis. Routine laboratory tests and CT should not be part of the initial valuation but may be part of ongoing evaluation, which also may include auditory brainstem responses, MRI and repeat audiometry.

Question 47

What are the common presenting symptoms of bronchiectasis in an adult? How is it diagnosed?

Answer 47

Cough is present in 98% of patients. Daily sputum production is present in 78%, with tenacious mucopurulent sputum production. Rhinosinusitis is present and 73%, hemoptysis in 27%, and recurrent pleurisy in 20%. Physical findings include include crackles in 75% and wheezing in

Diagnosis is made with a high resolution CT scan. 22%. Digital clubbing occurs in only 2% of patients.

Question 48

What is Kartagener syndrome?

Answer 48

It is a subgroup of primary ciliary dyskinesia which manifests as situs inversus, chronic sinusitis, and bronchiectasis.

Question 49

What is the most useful screening test for primary biliary dyskinesia?

Answer 49

Concentration of exhaled nasal nitric oxide.

Question 50

What are the physical findings in pleural effusion versus lung consolidation versus pneumothorax and emphysema?

Answer 50

Pleural effusion: a dull to flat percussion note, decreased to absent tactile fremitus and decreased to absent breath sounds.

Lung consolidation: bronchial breath sounds and increased fremitus.

Emphysematous blebs and pneumothorax: hyperresonance it to percussion and decreased fremitus.