pulmonary UWorld

Question 1

young athlete with episodic dyspnea and noisy breathing during exercise, inspiratory stridor

Answer 1

paradoxical vocal fold motion (vocal cord dysfunction)

in contrast to asthma: expiratory wheezing

Question 2

young patient with chronic dyspnea on exertion, decreased breath sounds, slight LFT’s elevation, family history of cirrhosis

Answer 2

alpha-1 antitrypsin deficiency – presents like COPD with chronic productive cough, dyspnea, wheezing, recurrent resp infection but can also affect the LIVER

Question 3

chronic rhino sinusitis with nasal congestion, frontal headaches with nasal polyps, takes over the counter meds

Answer 3

aspirin exacerbated respiratory disease – due to LEUKOTRIENES

Question 4

pt with wheezing respiratory distress – is given beta-2 agonist albuterol then gets muscle weakness

Answer 4

due to albuterol

Question 5

during acute asthma exacerbation what would be really concerning indicating pt is getting worse

Answer 5

Normal PaCO2 on ABG, since pt should hyperventilate and thus decrease PaCO2 leading towards respiratory alkalosis
but since they dont can suggest severe air trapping and respiratory collapse

Question 6

asthma vs COPD

Answer 6

Question 7

tx for exercise induced bronchoconstriction

Answer 7

Question 8

asthma management

Answer 8

Question 9

pt with asthma symptoms, gets better when he goes on vacation
next best step?

Answer 9

peak expiratory flow measurements at home and work
occupational asthma

Question 10

asthma exacerbation, what should they be discharged with?

Answer 10

course of oral prednisone (to reduce late-phase inflammation, and prevent relapse)
already given SABA (albuterol), SAMA (ipratropium), IV magnesium

Question 11

AE of inhaled corticosteroids

Answer 11

oral thrush

Question 12

SABA given and helped symptoms:

Answer 12

leukocyte induced bronchoconstriction (asthma, showing >12% increase in FEV1 or FVC)

Question 13

TRACHEA DEVIATED to the right, dullness to percussion on the right, breath sounds diminished over right lower lung

Answer 13

atelectasis – mucus plugs

Question 14

hyperinflation “barrel chest” and flattened diaphragm
what is difficult?

Answer 14

difficulty contracting further to produce force. less capable of generating inspiratory flow

Question 15

2 years persistent cough, coughs up whitish sputum, pulmonary function shows vital capacity is 65%
why?

Answer 15

COPD with chronic bronchitis (cough with sputum) and emphysema (dyspnea)
airflow limitation increases leading to more air trapping during expiration, total lung volume increases
air trapping*** and airflow obstruction also lead to decrease in vital capacity

**alveolar capillary membrane gets DESTROYED due to excessive lysis

Question 16

DLCO is normal, CXRAY: prominent thickened bronchovascular markings

Answer 16

chronic bronchitis

Question 17

long term home oxygen therapy : (2)

Answer 17

Resting arterial oxygen tension PaO2 < 55
or pulse oxygen saturation <88%

Question 18

acute exacerbation of COPD, dyspnea, sputum volume, sputum purulence: next step

Answer 18

antibiotics: fluoroquinolone

Question 19

management of COPD exacerbation

Answer 19

1) glucocorticoids (methylprednisone)
2)inhaled bronchodilators
3) antibiotics
4) maintain adequate oxygenation SpO2 88-92%
5) maintain ventilation with NIPPV or invasive mechanical ventilation

Question 20

COPD: what reduces mortality

Answer 20

smoking cessation

Question 21

obese patient with dyspnea

Answer 21

alveolar hypoventilation

Question 22

Answer 22

laryngeal edema

Question 23

ARDS lung protection and supportive care:

Answer 23

limit alveolar distending volume with tidal volume

avoid a positive fluid balance to reduce pulmonary edema
ARDS: neutrophilic lung inflammation with increased vascular permeability leading to pulmonary edema in the absence of cardiac failure or volume overload

Question 24

changes in ARDS (3)

Answer 24

• decreased lung compliance d/t loss of surfactant and increased stiffness/wt of edematous lungs
  impaired gas exchange leading to hypoxemia d/t VQ mismatch
  increased pulmonary arterial pressure d/t hypoxic vasoconstriction and destruction of lung parenchyma

Question 25

Question 26

cariogenic pulmonary edema, how does PPV help?

Answer 26

decreases RV preload by raising intrathoracic pressure causing a drop in venous return increases RV after load by raising intrathoracic pressure compressing alveolar capillaries and raising pulmonary vascular resistance decreases LV preload

Question 27

criteria for extubation :

Answer 27

pH > 7.25 adequate oxygenation PaO2 > 60 on minimal support FiO2 <40% and PEEP <5 intact inspiratory effort and sufficient mental alertness to protect airway then do a SPONTANEOUS BREATHING TRIAL

Question 28

PEEP complications

Answer 28

Pneumothorax, alveolar damage, hypotension

Question 29

shipbuilding, insulation, pipe work, progressive dyspnea bibasilar end inspiratory crackles

Answer 29

asbestos d/t decreased diffusion capacity of lung with interstitial thickening and pleural plaques ***

Question 30

subacute cough management

Answer 30

Question 31

DLCO

Answer 31

Question 32

fev1

Answer 32

Question 33

methotrexate lung ae

Answer 33

pneumonia, inflammatory pneumonitis (ground glass), pulmonary fibrosis (reticulation, honeycomb changes)

Question 34

acute URI leads to persistent dry cough for more than 5 days, no fever or chills, mild wheezing on exam what is it what's next best step?

Answer 34

acute bronchitis symptomatic tx: NSAIDs and/or *bronchodilators **

Question 35

lobar pneumonia on R side, when lay on R side worsening SaO2 why?

Answer 35

intrapulmonary shunting -- pneumonic consolidations are not ventilated(V) but continue to receive blood flor (Q) - more profound V/Q mismatch

Question 36

>3 mo. symptoms: fever, weight loss fatigue, cough, hemoptysis with CT showing cavitary lesion dx? tx?

Answer 36

pulmonary aspergillosis tx: itraconazole or voriconazole -- surgery -- bronchial artery embolization if severe hemoptysis

Question 37

fever, pleuritic chest pain, hemoptysis in pt with transplant nodules with surrounding ground-glass appearance dx? risk factors? tx?

Answer 37

invasive aspergillosis neutropenia, glucoroticoids, hiv voriconzale

Question 38

recurrent pneumonia in pt with parkisnons or Alzheimers next best step?

Answer 38

swallow study as likely d/t impaired swallowing mechanisms

Question 39

nonsmoking pt with chronic production of copious, thick, foul smelling mucus, with streaky hemoptysis, recurrent pulmonary infections dx? next best step for dx?

Answer 39

bronchiectasis -- recurrent bacterial infections and neutrophilic inflammation leading to bronchial wall damage and permanent airway dilation dx with High resolution CT to visualize bronchial wall thickening (tram tracking), lack of distal airway tapering, and bronchial dilation

Question 40

nonsmoking pt with chronic production of copious, thick, foul smelling mucus, with streaky hemoptysis, recurrent pulmonary infections, growing pseudomonas sputum dx? d/t?

Answer 40

bronchiectasis == impaired bacterial clearance (immunodeficiency or structural airway defect) due to cystic fibrosis *** impaired mucociliary clearance lots of neutrophil recruitment leads to excessive elastase release leading to airway damage can also be d/t sjorgens and hypogamaglobinmia

Question 41

COPD management

Answer 41

inhaled LABA + LAMA

Question 42

Dullness to percussion with increased breath sounds over the right lower lung field

Answer 42

lobar pneumonia --> lung consolidation

Question 43

community acquired pneumonia treatment

Answer 43

get an xray ceftriaxone and azithromycin

Question 44

hilar lymphadenopathy with focal reticulonodular infiltrates granuloma with narrow based budding yeasts dx tx

Answer 44

histoplasmosis tx: if severe : oral itraconazole or iv liposomal amphotecerin B

Question 45

exudative fluid causing pleural effusion formation why?

Answer 45

exudative effusions result d/t inflammatory increase in vascular membrane permeability parapneumonic effusions are usually uncomplicated d/t displacement of sterile exudate across intact pleural into pleural space if it was complicated it would involve disruption of pleural membrane and microbial translocation into pleural space

Question 46

exudative pleural effusion d/t ?

Answer 46

increase capillary permeability