Pulmonology Flashcards
What organism is most commonly responsible for community acquired pneumonia?
Strep pneumoniae
At what size induration would a PPD be positive for a healthcare worker?
10mm
What is the 4 medications used to treat tuberculosis?
What vitamin needs to be added to treatment therapy?
RIPE
* Rifampin
* Isoniazid
* Pyrazinamide
* Ethambutol
Given for 2 months followed by 4 months continuation phase with Rifampin and Isoniazid
Pyridoxine (Vitamin B6)
What are the known side effect of isoniazid?
What is recommended when initaiting isoniazid for treatment of TB?
- Peripheral neuropathy (prevented by the addition of Vitamin B6)
- Hepatitis (espeically over the age of 35)
- Drug-induced lupus, rash
- Abdominal pain
Baseline LFTs, addition of pyridoxine (vitamin B6)
What defines emphysema?
Perminant airspace enlargement distal to the terminal bronchioles with destruction of the airspace wall
Besides smoking, what are the other risk factors for emphysema?
- Alpha-1 antitrypsin deficiency
- Enviromental exposures
According to the guidelines from the National Asthma Education and Prevention Program, what is their preferred pharmacologic agent to add once a patient has 3-4 nighttime awakenings/month?
3-4 nighttime awakenings puts them in what asthma diagnosis category?
Daily low-dose ICS and PRN SABA
Mild Persistent
Describe mild persistent asthma?
What is the treatment?
- Symptoms > 2 days per week (not daily)
- 3-4 nighttime awakenings/month
- FEV1 > 80% predicted
Daily Low dose ICS + PRN SABA
Describe moderate persistent asthma?
- Symptoms daily
- > 1 nighttime awakening/week but not nightly
- FEV1 60-80% predicted
Describe severe persistent asthma?
What is the treatment?
- Symptoms throughout the day
- Nightly awakenings common
- FEV1 < 60% predeicted
Daily medium-high dose ICS-LABA PLUS LAMA and PRN SABA
What is the most common cause of respiratory distress in premature infants?
Respiratory distress syndrome caused by deficient surfactant lining the alveoli
Hyline Membrane Disease (this is the old name of the chronic lung disease of prematurity)
What are the clinical symptoms of respiratory distress syndrome (RDS) in the newborn?
What will be seen on CXR?
- Tachypnea
- Nasal flaring
- Expiratory grunting
- Retrations
- Cyanosis
Decreased lung volume, air bronchograms, and ground glass appearance
What is the gold standard for diagnosing a pulmonary embolism?
Arteriogram
What genetic disorder leads to panacinar emphysema?
Alpha-1 antitrypsin deficiency
What GI complications is an infant with cystic fibrosis at risk of developing?
Meconium ileus and intussusception
Describe Cheyne-Stokes respiratory pattern (AKA agonal breathing)
Cyclic periods of shallow and deep breathing and apneic episodes
What disease is associated with the finding of a Ghon complex on chest x-ray?
Primary tuberculosis
A Ghon complex is a pulmonary lesion and nearby lymph node involvement caused by tuberculosis (TB).
In a patient with alcohol use disorder, cough, fever, and currant colored sputum, what organism is suspected?
Klebsiella pneumoniae
Using Light’s criteria, how would you characterize a new right-sided pleural effusion in a patient recently diagnosed with lung cancer?
Exudative
What is an accumulation of blood in the pleural space due to internal bleeding called?
Hemothorax
Which condition is defined by pus-filled pockets that have developed in the pleural space?
Empyema
What is the most likely organism in a patient presenting with fever, cough, yellow sputum, and lobar consolidation on CXR?
Streptococcus pneumoniae
A patient being treated for tuberculosis presents with orange colored urine, which medication do you suspect the patient is taking?
Rifampin
A lateral neck film revealing “thumbprint sign” is indicative of what diagnosis?
Acute epiglottitis
What is the most common EKG finding in pulmonary embolism?
Sinus tachycardia
A patient with FEV1/FVC decreased ratio, polycythemia on CBC, and a history of smoking, most likely has what disorder?
COPD
COPD is associated with polycythemia because the chronic lung damage in COPD leads to chronic hypoxia (low oxygen levels), which triggers the body to produce more red blood cells in an attempt to compensate by increasing oxygen carrying capacity, resulting in a condition called secondary polycythemia; this response is driven by the hormone erythropoietin, released by the kidneys in response to low oxygen levels.
Of the three primary pneumoconioses, which are associated with eggshell calcifications on CXR and an increased risk of tuberculosis?
Silicosis
Classic finding of silicosis is hilar lymph node calcification with a characteristic “eggshell” appearance on CXR.
Silica impairs macrophage function, predisposing to TB.
What is the most common sleep related breathing disorder?
Obstructive sleep apnea
What diagnosis is suspected in a patient with recurrent lung infections, pancreatitis, and infertility?
Cystic Fibrosis
A patient who is a chicken farmer presents with 2 weeks of fatigue, cough, and fever found to have hilar lymphadenopathy likely has what diagnosis?
Histoplasmosis
A 5 mm pulmonary nodule in a patient with no risk factors for lung cancer requires what outpatient follow-up?
No follow-up required
What are the three phases of pertussis?
- Catarrhal
- Paroxysmal
- Convalescent
What is the best initial test for diagnosing sarcoidosis, and what are the associated findings?
CXR - will show bilateral hilar lymphadenopathy
Can also see findings associated with interstitial lung disease like reticular opacities, ground glass appearance, eggshell calcifications and fibrosis
Which diagnosis is suspected in a patient with shortness of breath, elevated serum angiotensin converting enzyme (ACE), and bilateral hilar lymphadenopathy?
Sarcoidosis
In a patient with a Wells score of 1 and a negative D-dimer, what diagnosis is ruled out?
Pulmonary embolism
Which diagnosis is suspected in a premature infant born with tachypnea, grunting, and intercostal retractions?
Respiratory distress syndrome
What are the anatomical landmarks for a thoracostomy?
Second intercostal space, midclavicular line
What disease is a recognized long-term complication of severe hyaline membrane disease in infants?
Chronic lung disease (bronchopulmonary dysplasia)
An HIV patient presents with a nonproductive cough and CXR showing diffuse bilateral interstitial infiltrates. What diagnosis should you be thinking of?
Pneumocystis jirovecii pneumonia (PCJ)
On, CXR you see bilateral interstital inflitrates that look like a bat wings. What is the diagnosis?
Pneumocystis jirovecii pneumonia
What is the treatment for pneumocystis pneumonia (PCP)?
- Trimethoprim-sulfamethoxazole (Bactrim)
- Corticosteroids for PaO2 < 70
What is Hamman Sign?
Crunching sound during auscultation (suggestive of a pneumomediastinum)
What is the gold standard diagnostic test for spontaneous pneumomediastinum?
How are pneumomediastinum’s treated?
CT Scan
Usually self-resolving, supportive tx
Persistent coughing with hemoptysis and focal wheezing should make you think of what diagnosis?
Carcinoid Tumor
What are some common symptoms related to carcinoid syndrome?
- Diarrhea
- Flushing
- Head and neck edema
- Bronchospasm
- Hives
How is carcinoid syndrome diagnosed?
24-hour urinary excretion of 5-hydroxyindoleacetic acid
What is the gold standard for assessing proper tube placement in a ventilated patient?
Capnography
What is contraindicated in massive pulmonary emboli?
How should nitroglycerin be given in a PE?
IV Fluids
Nebulized, to reduce intravascular resistance
What determines the PE classification?
Vital Signs
What is another name for croup?
Laryngotracheobronchitis
What is the most common etiology of croup?
Parainfluenza virus
In the ED, what medications have been associated with decreasing the need for hospitalization in an asthma exacerbation?
Duonebs - inhaled albuterol with ipratropium
What is the most important nonpharmacologic component of management to discuss with asthma patients?
Trigger avoidance
Is the lactate dehydrogenase level high or low in an exudative pleural fluid?
High
Does total lung capacity go up or down in COPD?
Total lung capacity (TLC) increases in COPD primarily due to air trapping and hyperinflation caused by a combination of airway narrowing, loss of elastic recoil, and dynamic airway collapse
What is the most accurate test to confirm cor pulmonale?
Right heart catheterization
Does aspiration pneumonitis require antibiotics?
No, as it is caused by chemical irritation of the pulmonary tissues there is no active infection. Repeat CXR to evaluate for pneumonia.
What X-ray findings are associated with foreign body aspiration?
Hyperinflation maybe be noted distal to the obstruction, as the object may cause partial obstruction and air trapping
Which pediatric pneumonia is classically associated with a shaggy right heart border?
Pertussis pneumonia
When should providers taper the dose of a systemic glucocorticoid to prevent adrenal insufficiency?
Treatment durations greater than one week
A very sick patient with diffuse infiltrates that spare the cosophrenic angles should make you think of what diagnosis?
Acute respiratory distress syndrome (ARDS)
What will the LDH levels be in a transudative pleural effusion?
What about in exudative?
LDH will be normal
LDH will be elevated
Caseating granulomas should make you think of what diagnosis?
Tuberculosis
Honeycombing and tram tracks on CXR should make you think of what diagnosis?
Bronchiectasis and idiopathic pulmonary fibrosis
Pleural plaques on CXR are pathognomonic for which lung disease?
Asbestosis - CXR will show pleural thickening especially in the lower lung fields
A pearl formation on CXR should make you think of what diagnosis?
Squamous cell lung cancer
What is the most common cause of pneumonia in children less than 1?
RSV
Pertussis is most commonly treated with what antibiotic?
Azithromycin and clarithromycin
Nodular opacities in the upper lung fields should make you think of what diagnosis?
What else will be seen on CXR in this disease?
Silicosis
Eggshell Calcifications
Blunting of the costophrenic angles on CXR should make you think of what diagnosis?
Pleural effusion
Coal miners lung often shows nodular opacities in what lung fields?
Upper lung fields
What is the most common organism causing pneumonia in COPD patients?
Haemophilus influenza
Paradoxical pulses may be found in what pulmonary disorder?
Asthma
A physical exam finding of egophony should make you think of what diagnosis?
Lobar pneumonia
Posttussive rales should make you think of what diagnosis?
Tuberculosis
At what size induration would a PPD be positive for an HIV patient?
Equal to or greater than 5mm
A college student presents with pneumonia. What two organisms should be considered?
Chlamydia and mycoplasma
A contralateral mediastinal shift should make you think of what diagnosis?
Tension pneumothorax
Hyperinflation on CXR as well as eosinophilia on CBC should make you think of what diagnosis?
Asthma
Any question about rabbits and pneumonia should make you think of what diagnosis?
Tularemia
What age is Pneumovax 23 approved for?
Over 23 months (indicated if patient is at high risk for pneumonia)
Prolonged expiration (low FEV1) should make you think of what diagnosis?
COPD or Asthma
When performing a decompression for a tension pneumothorax, where do you put the needle?
2nd intercostal space at the midclavicular line
What two lung cancers are typically found centrally on CXR?
Small cell and squamous cell
What is the gold standard for the diagnosis of pleural effusion?
Thoracentesis
An elevated ACE level can be found in 40-80% of patients with which restrictive lung disease?
Sarcoidosis
Wheeze on physical exam is most commonly associated with what types of lung conditions?
Most common obstructive lung diseases (asthma, COPD, bronchitis). Can also suggest infectious etiology causing obstruction (RSV, pneumonia)
Cromolyn sodium may be used for the treatment of asthma. What drug class does it belong?
Mast cell stabilizer - inhibits the release of histamine
A thumbprint sign on CXR should make you think of what two diagnoses?
Lateral C-spine film: epiglotitis
Abdominal film: intestinal ischemia
Hyperresonance to percussion should make you think of what diagnosis?
Emphysema, pneumothorax, asthma
What is the best test to diagnose bronchiectasis?
CT
An enlarged parotid gland is associated with what restrictive lung disease?
Sarcoidosis
At what age should vaccinations for pneumococcal pneumonia begin?
65 years old
What is the first line antibiotic for epiglottis?
Empiric combination therapy with a third generation cephalosporin (e.g. ceftriaxone or cefotaxime) AND an antistaphylococcal agent (vancomycin)
What organism is the most common cause of pneumonia in a patient with cystic fibrosis?
Pseudomonas
Asbestosis is the only known risk factor for the development of what type of malignancy?
Mesothelioma
Ethambutol has what two major side effects?
Optic neuritis, red-green vision loss
Rhonchi or wheezes that clear after coughing suggest what diagnosis?
Bronchitis or atelectasis
Eggshell opacities on CXR should make you think of what diagnosis?
Silicosis
List some causes of decreased tactile fremitus?
- COPD
- Asthma
- Pleural effusion
- Pneumothorax
How is cystic fibrosis inherited?
What is the gold standard for diagnosis?
Autosomal recessive
Sweat chloride test
If you hear crackles in the lung fields on exam, list three pulmonary differentials?
- Pneumonia
- Fibrosis
- CHF
- Bronchitis
The term currant jelly sputum should make you think of what diagnosis?
Klebsiella pneumonia
At what size induration would a PPD be positive for a patient with no risk factors?
Equal to or greater than 15mm
