Pulmonology Flashcards
What is stertor?
What is the difference between stertor and stridor?
A low-pitched, snoring inspiratory sound caused by nasal or nasopharyngeal obstruction.
Location, in strertor the obstruction is nasal while stridor it is below the larynx
An 8-year-old boy with moderate persistent asthma presents to the emergency department with difficulty breathing. His parent is giving 4 puffs of his home albuterol every 2 hours without effect. He is awake and alert but seems breathless, as he speaks in incomplete sentences. He has moderate accessory muscle use and tachypnea. He has a prolonged expiratory phase and diffuse expiratory wheezes on auscultation. Which of the following is the most appropriate next step?
A) Intramuscular ketamine
B) Intravenous magnesium
C) Nebulized albuterol
D) Oral prednisone
Nebulized albuterol
Albuterol is commonly administered in the emergency department with ipratropium bromide, which is a short-acting anticholinergic bronchodilator that also relaxes smooth muscle.
What score is used to predict mortality in pneumonia patients?
CURB-65
Score is based on mental status, BUN, RR, BP, and age > 65 at time of presentation.
A 6-year-old child presents with recurrent episodes of wheezing, coughing, and breathlessness especially at night. His symptoms seem to worsen when playing outside. What is the most likely diagnosis?
Asthma
A 2-month-old infant is brought to the emergency room with a 3-day history of nasal congestion, cough, and increasing difficulty breathing. On examination, the infant has wheezing and crackles. What is the most likely causative agent?
Respiratory Syncytial Virus
RSV is the most common cause of bronchiolitis and pneumonia in infants and young children.
Describe the typical presentation of a toddler suspected of having aspirated a small object. What are the initial steps in the management of this case?
What is both diagnostic and therapeutic in diagnosing an airway FB?
Typical presentation includes sudden onset of coughing, choking, and wheezing or stridor, depending on the location of the object.
Initial steps include back blows for infants and abdominal thrusts for older children if the child is in distress and cannot breathe, speak, or cry.
Rigid bronchoscopy
A 10-year-old child, who recently immigrated from a country with a high incidence of tuberculosis, presents with a persistent cough, night sweats, and weight loss. What screening tests are indicated?
Screening tests indicated include the Mantoux tuberculin skin test or an IGRA (Interferon-Gamma Release Assay).
These tests identify immune responses to the bacterium causing tuberculosis and are recommended for individuals at high risk.
A 7-year-old boy with known moderate persistent asthma presents with an acute exacerbation. He is currently on low-dose inhaled corticosteroids. Which of the following would be the most appropriate next step in managing this exacerbation?
A. Increase the dose of inhaled corticosteroids
B. Administer a systemic corticosteroid
C. Start an antibiotic
D. Discontinue inhaled corticosteroids
Administer a systemic corticosteroid
During a routine visit, the parent of a 5-month-old infant with RSV bronchiolitis asks about the use of albuterol. What is the most appropriate response regarding the use of albuterol in this case?
A. “Albuterol is effective in reducing symptoms in all cases of bronchiolitis.”
B. “Albuterol is typically not recommended as it has not shown consistent benefit in infants with RSV bronchiolitis.”
C. “Albuterol is mandatory for treating RSV bronchiolitis.”
D. “Albuterol should be used only in severe cases of RSV bronchiolitis.”
“Albuterol is typically not recommended as it has not shown consistent benefit in infants with RSV bronchiolitis.”
Bronchiolitis, particularly due to Respiratory Syncytial Virus (RSV), is a common lower respiratory tract infection in infants and young children, characterized primarily by bronchiolar inflammation and obstruction. The treatment for bronchiolitis is largely supportive, including hydration and sometimes oxygen supplementation, depending on the severity of the symptoms. Clinical trials and the AAP have not found consistent benefit of using albuterol during RSV bronchiolits.
A pediatric patient suspected of foreign body aspiration shows no signs of respiratory distress, but there is concern about a possible aspiration of a small plastic bead. What is the most appropriate diagnostic test to confirm the presence of a foreign body in this scenario?
A. Chest X-ray
B. Bronchoscopy
C. Pulmonary function test
D. Laryngoscopy
Bronchoscopy
Which of the following infants qualifies for RSV prophylaxis with palivizumab according to current guidelines?
A. A 2-month-old infant born at 28 weeks gestation entering their first RSV season
B. A 15-month-old with a history of mild bronchiolitis in the previous RSV season
C. A 10-month-old with bronchopulmonary dysplasia not requiring medical therapy within the last 6 months
D. An 18-month-old born with congenital heart disease who has been surgically corrected and is not receiving medication
A 2-month-old infant born at 28 weeks gestation entering their first RSV season
A 3-year-old child presents with fever, cough, and fast breathing. Chest X-ray indicates lobar pneumonia. Which pathogen is most likely responsible, and what is the first-line treatment?
A. Streptococcus pneumoniae; amoxicillin
B. Mycoplasma pneumoniae; erythromycin
C. Staphylococcus aureus; vancomycin
D. Klebsiella pneumoniae; ceftriaxone
Streptococcus pneumoniae; amoxicillin
An 8-month-old infant presents with wheezing, coughing, and difficulty breathing. A nasopharyngeal swab is taken. Which diagnostic test is most appropriate to confirm RSV infection?
A. Rapid antigen detection test
B. Polymerase chain reaction (PCR) test
C. Serology for RSV antibodies
D. Complete blood count (CBC)
Polymerase chain reaction (PCR) test
A 5-year-old child with fever, non-productive cough, and tachypnea tests positive for influenza virus. What is the most likely diagnosis and the recommended treatment?
A. Bacterial pneumonia; antibiotics
B. Viral pneumonia; supportive care and possibly antiviral therapy
C. Asthmatic bronchitis; inhaled bronchodilators
D. Tuberculosis; antitubercular treatment
Viral pneumonia; supportive care and possibly antiviral therapy
A 6-year-old child presents with sudden onset of high fever, dysphagia, drooling, and a muffled voice. The child appears anxious and is sitting upright, leaning forward. What is the immediate next step in management?
A. Perform a throat examination to visualize the epiglottis
B. Administer a broad-spectrum antibiotic intravenously
C. Secure the airway with endotracheal intubation if respiratory distress worsens
D. Give oral corticosteroids to reduce inflammation
Secure the airway with endotracheal intubation if respiratory distress worsens
Which clinical feature is most suggestive of epiglottitis rather than a viral croup in a young child?
A. Barking cough
B. Stridor at rest
C. Fever and drooling
D. Low-grade fever with mild respiratory distress
Fever and drooling
Fever and drooling are more indicative of epiglottitis, as these symptoms suggest a more severe upper airway obstruction and inflammation than typically seen in viral croup.
In addition to beta-agonist therapy, what other adjunct therapies can be used in an asthma exacerbation?
- IV magnesium sulfate
- Terbutaline (pediatric)
- Epinephrine (pediatric)
- Systemic glucocorticoids
Tactile fremitus is used to assess vibration felt on the chest. Decreased vibiratory sensation on exam is suggestive of what conditions?
Decreased or absent tactile fremitus suggests reduced vibration transmission, which may be caused by:
- Pleural effusion
- Pneumothorax
- Obstructive conditions (COPD)
A 60-year-old man with congestive heart failure presents with dyspnea and decreased breath sounds on the right side. Chest X-ray reveals a large right-sided pleural effusion. What is the most likely type of effusion?
A. Transudative
B. Exudative
C. Chylous
D. Hemothorax
Transudative
Transudative effusions are most commonly associated with CHF due to increased hydrostatic pressure
A 70-year-old woman with a history of pneumonia presents with fever, pleuritic chest pain, and dyspnea. Thoracentesis reveals turbid pleural fluid with a pH of 6.9, glucose <40 mg/dL, and positive Gram stain. What is the most appropriate treatment?
A. Antibiotics alone
B. Chest tube drainage and antibiotics
C. Observation and follow-up imaging
D. Repeat thoracentesis
Chest tube drainage and antibiotics
Empyema (infected pleural effusion) requires drainage via a chest tube in addition to antibiotics.
A 58-year-old man presents to the emergency department with shortness of breath, cough, fever, nausea, and diarrhea for three days. He recently installed a hot tub in his home and has been using it quite frequently. Physical exam reveals a soft, mildly tender abdomen, bilateral crackles on chest auscultation, and a pulse oxygen saturation of 91%. Abnormal laboratory values include leukocytosis, hyponatremia, and elevated liver enzymes. Which of the following causes of atypical pneumonia correlates most closely with this patient’s clinical picture?
A. Klebsiella pneumoniae
B. Legionella pneumoniae
C. Mycoplasma pneumoniae
D. Pseudomonas aeruginosa
What antibiotic is the treatment of choice?
Legionella pneumoniae
Legionella pneumoniae is a gram-negative, aerobic organism responsible for both nosocomial and community-acquired pneumonia. The bacteria are present in water and soil, and infection occurs via contaminated aerosolized particles.
Levofloxacin or Doxycicline
What is Pontiac fever?
A self-limited, acute febrile illness caused by Legionella pneumoniae that results in gastrointestinal and constitutional symptoms but no respiratory symptoms.
In a young patient whom you suspect asthma, what would be the expected results of pulmonary functioning testing?
In asthma, since there is an obstruction (inflammation), you will have a decreased FEV1 and, therefore, a reduced FEV1 to FVC ratio
Will also likely see an increased RV, TLC, and RV/TLC
According to the National Asthma Education and Prevention Program (NAEPP) guidelines, what is the first-line maintenance therapy for asthma in adults?
a. Long-acting beta-agonists (LABAs)
b. Inhaled corticosteroids (ICS)
c. Leukotriene modifiers
d. Short-acting beta-agonists (SABA)
Inhaled corticosteroids (ICS)
What antibiotic classes are used to treat pneumonia?
What is the outpatient empiric treatment of community acquired pneumonia
Macrolides (Azithromycin, Clarithromycin) or respiratory Fluoroquinolones (Levofloxacin, Moxifloxacin, and gemifloxacin)
Macrolide or Doxycicline
Fluoroquinalones only used if comorbid conditions are present or recent abx treatment
A 55-year-old man presents with shortness of breath and a productive cough with yellow phlegm for 2 days; he has had blood-tinged sputum for the last 3 hours. He has smoked 2 packs of cigarettes for the past 35 years. He has a temperature of 102°, and rhonchi, wheeze, and crepitations are heard over the right hemithorax. A chest X-ray shows a dense lobar infiltrate in the right hemithorax. What is the diagnosis?
What is the proper outpatient treatment?
Lobar Pneumonia
Macrolide (Azithromycin) or Doxycicline
What is the best test to rule out a pulmonary embolism?
CT Angiography
What groups are at an increased risk of Klebselia Pneumonia?
Alcoholics and Nursing Home Patients
What are some common causes of a chronic cough?
- Post nasal drip syndrome
- COPD or Asthma
- GERD
- ACE inhibitor use
What is the most common cause of acute bronchitis?
What is the treatment?
Viral Infection
Supportive, abx not indicated
Name one key clinical feature that differentiates chronic bronchitis from acute bronchitis
What lung disease is chronic bronchitis most commonly associated with?
Chronic productive cough lasting for at least 3 months in two consecutive years
COPD
Which type of sputum production is more indicative of bacterial infection in acute bronchitis?
Purulent (green or yellow) phlegm
What is the most common long-term complication of chronic bronchitis?
Pulmonary hypertension leading to cor pulmonale
A 35-year-old woman presents to the clinic with a persistent cough that started two weeks ago. She describes the cough as dry initially, but it has recently become productive with clear sputum. She denies fever, chills, or shortness of breath. On physical examination, her lungs are clear to auscultation, and she has no wheezing or rales. She has no significant past medical history and is a non-smoker. What is the most likely diagnosis?
A) Community-acquired pneumonia
B) Acute bronchitis
C) Asthma exacerbation
D) Chronic bronchitis
Acute Bronchitis
Acute Bronchitis = cough > 5 days, can last 2-3 weeks in duration
A 45-year-old male presents to the emergency department with a severe cough, shortness of breath, and wheezing that started five days ago. He reports that he has had similar symptoms in the past, especially during winter months. He is a current smoker with a history of chronic bronchitis. His oxygen saturation is 92% on room air, and he has diffuse wheezing on lung auscultation. What is the best initial treatment for his condition?
A) Antibiotics and expectorants
B) Inhaled bronchodilators and corticosteroids
C) Oral corticosteroids and oxygen therapy
D) Immediate intubation and mechanical ventilation
Inahled bronchodilators and corticosteroids
A 70-year-old woman with a history of interstitial lung disease presents with increasing shortness of breath and fatigue. She is on home oxygen therapy but reports that her symptoms have worsened despite adherence to her oxygen regimen. On physical examination, you observe cyanosis, clubbing of the fingers, and a parasternal heave. What test would be most appropriate to confirm the diagnosis of cor pulmonale?
ECHO
What is the most common organism found in aspiration pneumonia?
Klebselia pneumoniae
What imaging modality is most commonly used to diagnose a pleural effusion?
Chest X-ray, typically showing blunting of costophrenic angles
What is the key test used to distinguish between transudative and exudative pleural effusion?
Pleural fluid analysis using Light’s criteria
What are common types of exudative pleural effusion?
- Malignancy
- Pneumonia
- PE
What is the procedure called to remove pleural fluid for diagnostic or therapeutic purposes?
Thoracentesis
A 67-year-old man with a history of congestive heart failure presents with increasing shortness of breath. Chest X-ray shows a right-sided pleural effusion. Thoracentesis is performed, and the pleural fluid analysis reveals low protein and low lactate dehydrogenase (LDH) levels. According to Light’s criteria, this effusion is classified as:
A) Exudative
B) Transudative
C) Chylous
D) Hemorrhagic
Transudative
Transudative effusions, commonly due to heart failure, are characterized by low protein and low LDH levels. Light’s criteria distinguish transudates from exudates based on these parameters
A 45-year-old woman with a history of rheumatoid arthritis presents with pleuritic chest pain and dyspnea. Chest X-ray reveals a left-sided pleural effusion. Thoracentesis is performed, and the pleural fluid analysis reveals a pleural fluid-to-serum protein ratio of 0.7 and an LDH level greater than two-thirds the upper limit of normal serum LDH. This pleural effusion is most consistent with:
A) Transudative effusion
B) Exudative effusion
C) Empyema
D) Hemothorax
Exudative effusion
This effusion meets Light’s criteria for an exudative effusion (pleural fluid-to-serum protein ratio > 0.5 and LDH > two-thirds of the upper limit of normal). Rheumatoid arthritis is a common cause of exudative effusion
A 60-year-old man presents with dyspnea and a cough. He is a known smoker with a significant weight loss history over the last few months. Chest X-ray reveals a large right-sided pleural effusion. Thoracentesis is performed, and cytology shows malignant cells. What is the most likely cause of his pleural effusion?
A) Congestive heart failure
B) Pulmonary embolism
C) Malignancy
D) Cirrhosis
Malignancy
Malignant effusions are a common cause of exudative pleural effusion and are typically seen in patients with a history of smoking and significant weight loss. Cytology showing malignant cells confirms the diagnosis
A 50-year-old woman with a history of cirrhosis presents with increasing abdominal distension and shortness of breath. Chest X-ray reveals a right-sided pleural effusion. Thoracentesis reveals a low pleural fluid protein concentration and low lactate dehydrogenase (LDH). What is the most likely cause of her pleural effusion?
A) Nephrotic syndrome
B) Congestive heart failure
C) Cirrhosis
D) Pneumonia
Cirrhosis
Pleural effusion secondary to cirrhosis is usually transudative, due to increased hydrostatic pressure and low protein content, consistent with the findings on pleural fluid analysis
A 40-year-old man presents with pleuritic chest pain, fever, and productive cough. Chest X-ray reveals a left-sided pleural effusion. Thoracentesis reveals turbid fluid, and Gram stain is positive for bacteria. What is the next best step in managing this patient?
A) Monitor with serial chest X-rays
B) Intravenous diuretics
C) Chest tube drainage
D) Observation and repeat thoracentesis in 48 hours
Chest tube drainage
The presence of turbid fluid with bacteria in the pleural fluid suggests an empyema (infected pleural fluid). Immediate chest tube drainage is required to prevent complications like fibrosis and sepsis. You can also give streptokinase to facilitate breakup of loculations.
A 55-year-old man with nephrotic syndrome develops shortness of breath. Chest X-ray reveals a moderate pleural effusion. Thoracentesis is performed, and pleural fluid analysis shows a low protein content and a pleural fluid-to-serum protein ratio of 0.3. Which of the following best describes the pathophysiology of his pleural effusion?
A) Increased capillary permeability
B) Decreased oncotic pressure
C) Lymphatic obstruction
D) Increased pleural fluid production due to infection
Decreased oncotic pressure
Nephrotic syndrome causes hypoalbuminemia, leading to decreased oncotic pressure and transudative pleural effusion with low protein content
A 30-year-old man with no significant past medical history presents to the office with a persistent, productive cough for the past week. On examination, his temperature is 99.5°F, and his lungs are clear to auscultation. What is the best treatment for this patient?
A) Azithromycin
B) Guaifenesin
C) Levofloxacin
D) Oseltamivir
Guaifenesin
This patient has acute bronchitis. No abx or anti-viral treatment is needed.
Where should a tube thoracostomy be inserted?
Fourth or fifth intercostal space, above the rib, midaxillary line
What is the most common ECG finding with a pulmonary embolism?
Sinus tachycardia
What is the most common cause of minor hemoptysis?
What will be seen on CXR in acute bronchitis?
Acute Bronchitis
Thickening of the bronchial walls in the lower lobes
A 32-year-old woman with no significant medical history presents with right-sided pleuritic chest pain. Her only medication is an oral contraceptive. Vital signs are within normal limits, and her physical exam, ECG, and chest X-ray are unremarkable. A urine pregnancy test is negative. Blood work shows a D-dimer of 800 ng/mL. Which of the following is the best next step in management with the use of traditional guidelines of pulmonary embolism rule-out criteria?
A) Discharge the patient
B) Perform CTA scan
C) Perform lower extremity duplex ultrasound
D) Perform V/Q scan
Perform CTA scan
Patients with an elevated D-dimer should undergo CTA of the chest, as it is the gold standard for diagnosing PE.
Which of the following conditions will produce an exudative pleural effusion?
A) Cirrhosis
B) Heart failure
C) Nephrotic syndrome
D) Pancreatitis
Pancreatitis
What is the causative agent in patients with fifths disease?
Human parvovirus B19
A thumbprint sign on lateral C-spine X-ray should make you think of what diagnoses?
Epiglotitis
What is the most common pathogen in pediatric bronchiolitis?
Respiratory syncytial virus (RSV)
At what size induration would a PPD be positive for a healthcare worker?
10 mm
