Pulmonology Flashcards
1
Q
2 classic aspects of clinical presentation for PE?
A
Tachycardia, Hypoxemia … in a patient with recent immobilization
2
Q
Best test for evaluation of suspected PE?
A
CT angiogram
3
Q
When would CT angiogram be contraindicated for suspected PE?
A
Patient with CKD
4
Q
Best alternate study for patient with suspected PE and CKD?
A
VQ scan
5
Q
3 risk factors for PE?
A
Hip fracture, Smoking, Immobilization
6
Q
What accounts for fever in setting of PE?
A
Tissue necrosis in setting of pulmonary infarction
7
Q
5 aspects of clinical presentation that make infection unlikely as cause of fever in setting of PE?
A
Stable WBCs, No consolidation on CXR, NML UA, No incisional purulence, No PIC line erythema
8
Q
How can you differentiate aspiration pneumonitis from aspiration PNA?
A
Aspiration pneumonitis = no clinical signs of infection
9
Q
Best treatment for aspiration pneumonitis?
A
Supportive
10
Q
ABX of choice for aspiration PNA?
A
Clindamycin, or blactam + b lactam inhibitor
11
Q
Appearance of pulmonary contusion on CXR?
A
Irregular, localized opacification at site of injury
12
Q
Best treatment for pulmonary contusion?
A
Admission + supportive care (supplemental O2, adequate pain control to avoid hypoventilation, pulmonary hygiene)
13
Q
CXR appearance of mesothelioma?
A
Nodular thickening of the pleura
14
Q
Appearance of large cell carcinoma on CXR?
A
Large peripheral mass
15
Q
Appearance of squamous cell carcinoma on CXR?
A
Central cavitary lesion
16
Q
Lab value + paraneoplastic syndrome associated with small cell carcinoma?
A
Hyponatremia; SIADH
17
Q
Best treatment for mild SIADH-associated hyponatremia (without neurologic symptoms)?
A
Water restriction
18
Q
3 medications that can be used to treat moderate SIADH-associated?
A
Furosemide, Lithium, Demeclocycline
19
Q
Pattern of pulmonary nodule calcification that is typically benign?
A
Popcorn, concentric, central, diffuse homogeneous
20
Q
Popcorn calcification in a pulmonary nodule is suggestive of …
A
Pulmonary hamartoma
21
Q
Pattern of pulmonary nodule calcification that is typically malignant?
A
Eccentric, reticular, punctate
22
Q
3 lifestyle modifications that may reduce snoring?
A
Weight loss, Decreased EtOH consumption, Smoking cessation
23
Q
Pathogen responsible for Allergic Bronchopulmonary Aspergillosis?
A
Aspergillus
24
Q
Pathophysiology of Allergic Bronchopulmonary Aspergillosis?
A
Hypersensitivity reaction to Aspergillosis
25
Hypersensitivity reaction in Allergic Bronchopulmonary Aspergillosis is mediated by …
IgE + IgG
26
Epidemiology of Allergic Bronchopulmonary Aspergillosis?
Patients with asthma or cystic fibrosis
27
Clinical presentation for Allergic Bronchopulmonary Aspergillosis?
Recurrent asthma exacerbations
28
Hallmark CXR finding for Allergic Bronchopulmonary Aspergillosis?
Fleeting infiltrates (transient infiltrates in different parts of lung)
29
Hallmark CT finding for Allergic Bronchopulmonary Aspergillosis?
Central bronchiectasis
30
2 lab values that suggest Allergic Bronchopulmonary Aspergillosis?
Elevated IgE, Eosinophilia
31
Best treatment for Allergic Bronchopulmonary Aspergillosis?
Glucocorticoids + Itraconazole
32
77 yo male presents with worsening fever, productive cough … after several days of viral URI symptoms – diagnosis?
Secondary PNA
33
Best management of suspected Secondary PNA in patients of advanced age + underlying comorbidities?
Present to ER for labs, CXR
34
2 characteristics of pleural effusions seen in TB?
lymphocytes, elevated adenosine deaminase
35
Next step for evaluation of suspected pleural effusions seen in TB?
Pleural biopsy
36
Pattern of TB lung involvement seen in newly-diagnosed HIV cases?
Cavitary apical lesions
37
Pattern of TB lung involvement seen in chronic HIV cases?
Pleural, lobar disease
38
Role of Pleural biopsy in TB?
Histopathologic demonstration of pleural granulomas
39
Metabolic abnormality associated with obstructive sleep apnea (OSA)?
Hypercapnic, hypoxic respiratory acidosis
40
Change to HCO3- in setting of chronic respiratory acidosis?
Increased
41
Complication of OSA in peri-operative setting (sedation, anesthesia)?
Increased risk of respiratory complications
42
Change to CXR in setting of acute respiratory failure?
Bibasilar atelectasis
43
Hallmark CXR finding for malignant mesothelioma?
Plural calcification, thickening
44
Typical management of malignant mesothelioma?
Palliative care
45
PE finding that is almost always present in patients with malignant mesothelioma?
Pleural effusion
46
2 most important predictors of survival during COPD exacerbation?
Age, FEV1 <40%
47
Clinical appearance of children with complete airway obstruction?
Cyanosis, difficulty speaking/coughing/breathing
48
Best management for conscious children > 1 yo with complete airway obstruction?
Abdominal thrusts (Heimlich maneuver)
49
Best management for conscious children < 1 yo with complete airway obstruction?
Place infant face-down on arm; Deliver alternating chest and back blows
50
Best management for unconscious children with complete airway obstruction?
CPR
51
Clinical presentation of COPD exacerbation?
Wheezing, prolonged expiration, SOB, productive cough
52
4 common post-operative pulmonary complications?
Atelectasis, respiratory failure, infection, hypoxia
53
When should smoking cessation occur prior to surgery?
4+ weeks
54
Best management of pre-op patient who develops COPD exacerbation?
Delay surgery to treat COPD exacerbation
55
5 extra-pulmonary manifestations of sarcoidosis?
Hepatomegaly, LAD, erythema nodosum, uveitis, facial nerve palsy
56
Initial step of workup for sarcoidosis?
CXR
57
Diagnostic test for sarcoidosis?
Biopsy … of either lung OR lymph node
58
(+) biopsy result for sarcoidosis?
Non-caseating granulomas
59
4 lab changes seen in setting of sarcoidosis?
Hyper-Ca2+, Elevated ACE, Elevated ESR, Elevated alkaline phosphatase
60
CXR findings associated with sarcoidosis?
Bilateral hilar + mediastinal adenopathy
61
62 yo male presents with new-onset, RLE pain; Reports CABG performed 3 months ago; Presented to ED 2 nights ago for recurrent CP; Troponin = elevated, angiogram was (+) for coronary artery stenosis; Patient was treated with heparin, anti-platelet agents, b blocker, NTG; Stenting was performed; ECHO was (-); PE shows RLE that is cool to touch, diminished pulses; Labs show thrombocytopenia – diagnosis?
Type 2 HIT
62
3 hallmark clinical findings for Type 2 HIT?
Thrombocytopenia, Onset after Heparin administration, Thrombosis
63
Etiology of Type 2 HIT?
Auto-Ig directed against heparin-platelet factor 4 complexes
64
Difference between Type 1 HIT and Type 2 HIT?
Type 1 = non-immune mediated; Type 2 = immune mediated
65
Diagnostic test for Type 2 HIT?
HIT antibody testing
66
Best management of Type 2 HIT?
Discontinue all heparin-containing products; Begin non-heparin anticoagulants … Don’t wait for (+) HIT antibody testing to return
67
2 types of non-heparin anticoagulants that can be used in setting of Type 2 HIT?
Argatroban, Fondaparinux
68
Approach to future heparin use in a patient diagnosed with Type 2 HIT?
Avoid all forms of heparin for life
69
Alternate name for upper airway cough syndrome?
Post-nasal drip
70
In addition to cough, what are 2 other aspects of clinical presentation seen in Post-nasal drip?
Rhinorrhea, Pharyngeal Cobblestoning
71
Clinical presentation of laryngeal nodules?
Hoarseness
72
Etiology of tracheomalacia?
Weakness of tracheal walls … leading to expiratory airway collapse
73
1 aspect of physical exam seen in setting of tracheomalacia?
Stridor
74
Most common time of cough seen in asthma?
Nighttime cough
75
Cough in asthma is triggered by which 3 events?
Cold weather, exercise, forced expiration
76
Which allergen has the strongest association with asthma?
House dust mites
77
Result of PFTs in patient without active symptoms?
Normal
78
Result of PFTs in patient with active symptoms?
Obstructive pattern
79
Change to FEV1 in obstructive PFT pattern?
Decreased
80
Change to FEV1/FVC in obstructive PFT pattern?
Decreased
81
Change to total lung capacity in obstructive PFT pattern?
Normal
82
Change to DCLO in obstructive PFT pattern?
Normal
83
Medication that can induce asthma symptoms before PFTs?
Methacholine
84
Size that corresponds to pulmonary nodule?
Size < 3 cm
85
Size that corresponds to pulmonary mass?
Size > 3 cm
86
First step in evaluation of pulmonary nodule?
Compare to old film
87
Next step in evaluation of pulmonary nodule, changed from previous films OR no previous film?
Order CT
88
Solitary pulmonary nodules with size ___ require additional management or surveillance
> 0.8 cm
89
Best management of Solitary pulmonary nodules with size > 0.8 and spiculated appearance?
Surgical excision, Biopsy
90
Classic triad of clinical symptoms seen in invasive pulmonary aspergillosis?
Chest pain, Cough, Hemoptysis
91
Epidemiology of invasive pulmonary aspergillosis?
Immunosuppression … chronic steroid use, prolonged neutropenia, organ transplant
92
2 hallmark appearances of invasive pulmonary aspergillosis on chest CT?
Nodules with ground-glass opacity (halo sign), Cavitation with air-fluid levels
93
Treatment for invasive pulmonary aspergillosis?
Voriconazole
94
Definition of mild-moderate asthma exacerbation, using Peak Expiratory Flow?
Peak Expiratory Flow = 40-70%
95
Best management of mild-moderate asthma exacerbation?
Inhaled b agonists (SABA)
96
2 AEs of SABAs?
Tachycardia, tremors
97
Definition of severe asthma exacerbation, using Peak Expiratory Flow?
Peak Expiratory Flow < 40%
98
Best management of severe asthma exacerbation?
Inhaled b agonists (SABA) + Ipratropium
99
3 signs of impeding respiratory failure in a patient who presents with asthma exacerbation?
AMS, Depressed respiratory drive, Hypoxemia
100
Best management of impeding respiratory failure in a patient who presents with asthma exacerbation?
Immediate intubation
101
4 signs of clinical deterioration in a patient who presents with asthma exacerbation?
Accessory muscle use (with suprasternal retractions), Diaphoresis, Exhaustion, PaCO2 > 42 mmHg
102
Most likely cause of recurrent PNA episodes in a patient with 50 pack-year smoking HX?
Partial endobronchial obstruction … most likely lung CA
103
What is next best test for patient with recurrent PNA and 50 pack-year smoking HX?
Lung CT
104
Best confirmatory test for patient with recurrent PNA and 50 pack-year smoking HX?
Flexible bronchoscopy … can visualize obstruction AND perform a biopsy
105
Best diagnostic test for suspected PNX in the acute setting?
Bedside US
106
Best diagnostic test for suspected PNX in the non-acute setting?
Upright PA CXR
107
Etiology of hemoptysis in setting of acute bronchitis?
Erosion of superficial lung vessels
108
Best initial test for patient with COPD exacerbation presenting with hemoptysis?
CXR
109
Best management of acute COPD exacerbation?
Glucocorticoids, ABX (azithromycin), Albuterol
110
Which lobes of lung are typically affected by aspiration PNA?
R
111
ABX of choice for aspiration PNA?
Clindamycin (anaerobic coverage)
112
Next step of worup for patient with confirmed aspiration PNA?
Fluoroscopic swallow study
113
Clinical presentation of laryngeal edema after intubation?
Post-extubation stridor
114
Best method for prevention of laryngeal edema after intubation?
Steroids prior to extubation
115
Best management for laryngeal edema in patient with signs of respiratory failure?
Reintubation
116
4 clinical predictors of increased 30-day mortality in patients with pulmonary embolism?
Hypotension, tachycardia, hypothermia, AMS
117
1 radiological predictor of increased 30-day mortality in patients with pulmonary embolism?
RV dysfunction
118
2 laboratory predictors of increased 30-day mortality in patients with pulmonary embolism?
Troponin, BNP
119
Best management of pulmonary embolism with hypotension (hemodynamic instability)?
Thrombolysis
120
What is the most important indication for thrombolysis in setting of pulmonary embolism?
Hemodynamic instability
121
Additional indication for thrombolysis in setting of pulmonary embolism?
RV dysfunction
122
Clinical presentation of bronchiectasis?
Recurrent infection, Daily cough with mucopurulent sputum production
123
What accounts for hemoptysis in setting of bronchiectasis?
Airway damage causes rupture of superficial blood vessels
124
74 yo male presents with recent memory problems; Reports HA, poor sleep, decreased libido, irritibality, mood changes; PE shows BMI 34, BP 155/95 – diagnosis?
OSA … causing cognitive impair (irritability, poor sleep, short-term memory loss)
125
Classic HEENT finding associated with OSA?
Increased neck circumference > 17 inches
126
Appearance of post-operative atelectasis on CXR?
Linear opacifications,
127
Best management of post-operative atelectasis?
Chest physiatry + Suctioning
128
Change to Aa gradient in post-operative atelectasis?
Increased
129
Typical time of presentation for post-operative atelectasis?
2-5 days post-operatively
130
Recommended test for lung CA screening?
Low-dose CT chest
131
How oftern should patients undergo low-dose CT chest for lung CA screening?
Yearly
132
Age for lung CA screening via low-dose CT chest?
50-80 yo
133
Eligibility for low-dose CT chest as lung CA screening?
20+ pack-year HX … AND … current smoking or quit smoking within past 15 years
134
Benefit of smoking cessation?
Reduces risk of lung CA and COPD exacerbations … even in heavy, long-term smokers
135
56 yo female presents for shortness of breath, generalized itching; Just ate a PB cookie; BP 88/60, HR 124, O2 sat 92% on RA, RR 26; PE shows use of accessory muscles, exhalation through pursed lips, wheezing; Patient given IM dose of epinephrine; 10 minutes later, no significant change in condition - what is next best step of treatment?
IM epiphrine
136
4 aspects of initial management for anaphylaxis?
IM epinephrine (up to 3 doses), albuterol, IVF
137
Is there benefit to smoking cessation after 60 yo?
Lowers risk of all-cause mortality and cardiovascular events
138
When is the all-cause mortality and cardiovascular benefit of smoking cessation after 60 yo seen?
Within 5 years of cessation
139
When is the benefit on osteoporosis seen after smoking cessation?
Within 10 years of cessation
140
What accounts for hypoxemia in COPD?
Low V/Q ratio
141
Which clinical finding would suggest need for urgent intervention in a patient with a Pancoast tumor?
Asymmetric LE reflexes … suggests tumor spread near spinal cord
142
Ventilator-associated PNA (VAP) is a common complication of …
ARDS
143
Etiology of VAP?
Micro-aspiration of virulent oropharyngeal organisms
144
Most common pathogens responsible for VAP?
E. coli, Strep species
145
Clinical presentation of VATS?
Increased oxygenation, increased respiratory secretions, fever, worsening pulmonary infiltrates on CXR, worsening WBCs
146
38 yo female in ICU develops worsening hypoxia; Intubated about 1 week ago; Now having increased tracheobronchial secretions; T 102, HR 114; Increased FiO2 from 40% to 70%, increased PEEP from 5 to 10; Increased WBC from 11 to 18 – what is next best step in diagnosis?
Tracheobronchial aspiration sampling, BAL
147
46 yo male presents for 3 days of cough, wheezing, SOB; Reports congestion, sore throat, myalgias about 1 week ago; PE shows prolonged expiration, peak expiratory flow = 30% lower than BL – diagnosis?
Asthma exacerbation
148
Definition of acute asthma exacerbation on PFTs?
Reduction of peak expiratory flow >20% lower than BL
149
Most common trigger for acute asthma exacerbation?
Viral URI
150
Best management of acute asthma exacerbation?
Systemic corticosteroids (if moderate exacerbation, of mild unresponsive to bronchodilators)
151
Best dosing of systemic corticosteroids for asthma exacerbation?
PO prednisone 40-60mg x 5-10 days
152
38 yo female in ICU develops worsening hypoxia; Intubated about 1 week ago; Now having increased tracheobronchial secretions; T 102, HR 114; Increased FiO2 from 40% to 70%, increased PEEP from 5 to 10; Increased WBC from 11 to 18 – diagnosis?
Ventilator-associated PNA (VAP)
153
29 yo female develops cough, SOB, joint pain, fatigue; PFTs show FEV1 60%, FEV1/FVC 80%, DCLO 60%; Labs show hypercalcemia, high ESR - diagnosis?
Sarcoidosis
154
Pattern of lung disease seen in Sarcoidosis?
Mixed obstructive and restrictive
155
Long-term prognosis for Sarcoidosis?
Resolution
156
Best management of Sarcoidosis?
Oral steroids
157
Classic appearance of Sarcoidosis on CXR?
Bilateral hilar adenopathy
158
38 yo female presents for DOE; PE shows BP 143/91, prominent S2, BMI 34; CXR shows prominent pulmonary arteries; EKG shows R axis deviation – diagnosis?
Pulmonary HTN
159
First step in management of Pulmonary HTN?
TTE
160
Definitive diagnosis for Pulmonary HTN?
R heart catheterization
161
Classic appearance of Pulmonary HTN on CXR?
Enlargement of pulmonary arteries
162
Appearance of Pulmonary HTN on TTE?
Increased R-sided pressure, RV dilation
163
TTE results that suggest idiopathic pulmonary HTN?
Elevated pulmonary arterial pressure, NML pulmonary capillary wedge pressure (so not due to LH failure)
164
DOC for management of Pulmonary HTN?
Endothelin receptor antagonist
165
2 examples of endothelin receptor antagonists?
Bosentan, Ambrisentan
166
16 yo female presents with SOB, which occurs 10-15 minutes after she starts exercising; PE shows no murmur, normal splitting of P2 heart sound – what is next step of workup?
Bronchoprovocation test
167
16 yo female presents with SOB, which occurs 10-15 minutes after she starts exercising; PE shows no murmur, normal splitting of P2 heart sound – diagnosis?
Exercise-Induced Bronchoconstriction
168
Description of Bronchoprovocation test for Exercise-Induced Bronchoconstriction?
Inhalation of cold air … diagnostic if FEV1 decreases by at least 15%
169
Best management of Exercise-Induced Bronchoconstriction in patients with occasional symptoms?
Pre-exercise warmup
170
Best management of Exercise-Induced Bronchoconstriction in patients with persistent symptoms, but exercise infrequently?
Short-acting b2 agonists
171
Best management of Exercise-Induced Bronchoconstriction in patients with persistent symptoms, but exercise very frequently?
Daily inhaled corticosteroids + SABAs PRN
172
___ should be suspected when patients with extensive smoking history have delayed resolution of PNA
Endobronchial malignancy
173
What is best next step of workup for patients with suspected Endobronchial malignancy?
Chest CT
174
36 yo male presents for sudden-onset L-sided CP, described as a stabbing, worsens with deep inspiration; HX of T1DM and R TMA after stepping on nail 1 month ago and developing osteomyelitis; Vitals show O2 sat 92%, tachycardia; PE shows pleural friction rub, heart sounds with accentuated P2 sound; CXR shows blunting of L costophrenic angle – diagnosis?
PE
175
60 yo male is taken to post-anesthesia care unit less than 1 hour after elective laparoscopic CCY; HX of OSA; PE shows RR 7, O2 sat drops to 87% on RA; CXR shows mild hypo-inflation; pH 7.25, PaCO2 58, PaO2 170 – what is most likely cause of respiratory distress?
Residual anesthesia effect
176
Which condition pre-disposes patients to post-operative respiratory failure?
OSA
177
Etiology of post-operative respiratory failure?
Decreased central respiratory drive, depressed state of arousal
178
Clinical presentation of post-operative respiratory failure?
Decreased RR, Hypoinflated lungs on CXR
179
ABG results associated with post-operative respiratory failure?
Respiratory acidosis with normal Aa gradient
180
42-year-old female presents for right-sided neck pain, cough, shortness of breath; significant smoking history; PE shows decreased breath sounds in upper right lung, moderate swelling and erythema of neck, moderate right sided JVD, increased venous marks on right arm; CXR reveals right-sided opacity; what is best immediate step in management?
CT chest/neck with contrast
181
42-year-old female presents for right-sided neck pain, cough, shortness of breath; significant smoking history; PE shows decreased breath sounds in upper right lung, moderate swelling and erythema of neck, moderate right sided JVD, increased venous marks on right arm; CXR reveals right-sided opacity; diagnosis?
Superior vena cava syndrome, secondary to lung malignancy
182
Most common etiology of superior vena cava syndrome?
Bronchogenic carcinoma
183
19-year-old male presents after MVA; BP 150/95, HR 110; PE shows anterior bruises on chest, peripheral cyanosis, shallow and rapid respiration -- diagnosis?
Flail chest
184
Best management of uncomplicated flail chest?
Supplemental O2, pain control
