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A Comprehensive Review for the Certification and Recertification Examination for Physician Asistants > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

Common causative agents of community acquired pneumonia (CAP)

A
  1. Streptococcus pneumoniae
  2. Haemophilus influenzae
  3. Moraxella catarrhalis
  4. Staphylococcus aureus
  5. Klebsiella pneumoniae
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2
Q

Atypical causative agents of CAP

A

Legionella, mycoplasma, and chlamydia

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3
Q

Mycoplasma pneumoniae typical manifestations

A
  • Low grade fever
  • Cough
  • Bullous myringitis
  • Cold agglutinins
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4
Q

Pneumocystis jiroveci (nee carinii) typical manifestations

A
  • Slower onset, immunosuppression
  • Increased lactate dehydrogenase
  • More hypoxemic than appears on CXR
  • Intersitital infiltrates
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5
Q

Legionella pneumoniae typical manifestations

A
  • Chronic cardiac or respiratory disease
  • Hyponatremia
  • Diarrhea, other systemic symptoms
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6
Q

Chlamydia pneumoniae typical manifestations

A
  • Longer prodrome

- Sore throat, hoarseness

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7
Q

Streptococcus pneumoniae typical manifestations

A
  • Single rigor

- Rust-colored sputum

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8
Q

Klebsiella pneumoniae typical manifestations

A
  • Currant jelly sputum

- Chronic illness, including alcohol abuse

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9
Q

What patient group is more likely to have klebsiella pneumoniae?

A

Alcohol abuse

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10
Q

What patient group is more likely to have hameophilus pneumoniae?

A

COPD

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11
Q

What patient group is more likely to have pseudomonas sp.?

A

cystic fibrosis

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12
Q

What patient group is more likely to have mycoplasma pnemoniae and/or chlamydia pneumoniae?

A

Young adults, college settings

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13
Q

What patient group is more likely to have legionella pneumoniae?

A

Air conditioning/aerosolized water

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14
Q

What patient group is more likely to have encapsulated organisms, streptococcus pneumoniae, and/or haemophilus pneumoniae?

A

Postesplenectomy

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15
Q

What patient group is more likely to have fungus as the causative organism in CAP?

A

Leukemia, lymphoma

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16
Q

What patient group is more likely to have RSV as the causative organism in CAP?

A

Children <1 year

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17
Q

What patient group is more likely to have parainfluenza virus as the causative organism in CAP?

A

Children <2 years

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18
Q

Treatment of CAP in outpatient setting

A

A macrolide (azithromycin, clarithromycin) or doxycycline

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19
Q

Treatment of CAP in outpatient setting for patients with underlying chronic disease

A

Fluoroquinolone (levofloxacin, moxifloxacin) or a macrolide (azithromycin, clarithromycin) plus a beta lactam (amoxicillin, amoxicillin-clavulanate, cefpodoxime, or cefuroxime)

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20
Q

What are indications for hospitalization in CAP?

A
  • Neutropenia
  • Poor host resistance
  • Involvement of more than one lobe
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21
Q

What are other considerations for hospitalization in CAP?

A
  • Patients >50 years of age w/comorbidities
  • Altered mental status
  • hemodynamic instability
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22
Q

Inpatient treatment of CAP

A

Fluoroquinolone (levofloxacin or moxifloxacin) or a combination beta lactam (i.e., ceftriaxone or cefotaxime) plus a macrolide (i.e., azithromycin)

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23
Q

Pneumococcal polysaccharide vaccine (PPSV) recommendations

A
  • Recommended for children 2-5 years of age who have not been previously immunized
  • Persons >65 years of age
  • Any person with a chronic illness that increases the risk of CAP
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24
Q

Chronic illnesses that increases the risk of CAP

A
  • Cardiopulmonary diseases
  • Sickle cell disease
  • Tobacco use
  • Splenectomy
  • Liver disease
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25
Q

Pneumococcal conjugate vaccine (PCV) recommendations

A

Recommended as a series of four doses for children aged 6 week to 15 months

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26
Q

Which organism is the most common cause of atypical pneumonia?

A

Mycoplasma pneumoniae

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27
Q

Antibiotic treatment for atypical pneumonia

A

Regimens include erythromycin or doxycycline (for suspected M. pneumonia and Legionella infection) and tetracycline (for suspected Chlamydia infection)

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28
Q

What is the recommended treatment for influenza?

A

Neuraminidase inhibitors (inhaled zanamivir or oral oseltamivir)

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29
Q

What is the CDC recommendation for confirmed cases of influenza A?

A

Combination treatment with oseltamivir and rimantadine

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30
Q

Management of hospital-acquired (nosocomial) pneumonia

A

Includes use of appropriate empiric antibiotics to cover Pseudomonas (ceftriaxone; respiratory fluoroquinolone; imipenem; cefepime; etc.)

  • Once an organism is isolated, therapy should be based on the culture and sensitivity results
  • Mechanical ventilation if appropriate
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31
Q

What is the prophylactic treatment of choice for patients with a CD4 count of less than 200 cells/µL or with a history of Pneumocystis infection?

A

Trimethoprim-sulfamethoxazole (Bactrim)

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32
Q

Cough in TB

A

It begins as a dry cough and progresses to a productive cough, with or without hemoptysis, typically over 3 weeks or longer

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33
Q

What does the CXR show in primary TB?

A

Homogenous infiltrates, hilar/paratracheal lymph node enlargement, segmental atelectasis, cavitation with progressive disease

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34
Q

What does the CXR show in reactivation TB?

A

Fibrocavitary apical disease, nodules, infiltrates, posterior and apical segments of the RUL, apical-posterior segments of the left upper lobe, superior segments of the lower lobes

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35
Q

Ghon complexes (calcified primary focus) and Ranke complexes (calcified primary focus and calcified hilar lymph node) represent what?

A

Healed primary infection

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36
Q

What is the histologic hallmark of TB?

A

Biopsy revealing caseating granulomas (also known as necrotizing granulomas)

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37
Q

What group(s) have a reaction size of ≥5 mm in TB skin tests?

A
  • HIV positive persons
  • Recent contacts of those with active TB
  • Persons with evidence of TB on CXR
  • Immunosuppressed patients on steroids
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38
Q

What group(s) have a reaction size of ≥10 mm in TB skin tests?

A
  • Recent immigrants from countries with high rates of TB
  • HIV-negative injection drug users
  • Mycobacteriology laboratory personnel
  • Residents/employees of high-risk congregate settings
  • Persons with certain medical conditions: DM, silicosis, chronic renal failure, etc.
  • Children <4 years of age
  • Infants, children, and adolescents exposed to adults at high risk
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39
Q

What group(s) have a reaction size of ≥15 mm in TB skin tests?

A

Persons with no risk factors for TB

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40
Q

What are the antituberculous drugs?

A
  • Isoniazid (INH)
  • Rifampin (RIF)
  • Pyrazinamide (PZA)
  • Ethambutol (EMB)
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41
Q

Latent TB infection treatment regimen

A

-Isoniazid for 9 months OR rifampin for 4 months OR rifampin and pyrazinamide for 2 months (only if in contact with TB-resistant persons)

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42
Q

Active TB infection treatment regimen

A

Isoniazid/rifampin/pyrazinamide/ethambutol for 2 months, followed by 4 months of addition multi drug treatment based on culture and sensitivity results (usually isoniazid and rifampin)

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43
Q

Isoniazid side effects

A

Hepatitis, peripheral neuropathy, coadminister vitamin B6 (pyridoxine) to reduce the risk

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44
Q

Rifampin side effects

A
  • Hepatitis
  • Flu syndrome
  • Orange body fluid (e.g., orange urine)
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45
Q

Ethambutol side effects

A

-Optic neuritis (red-green vision loss)

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46
Q

Besides anti TB drugs, what other treatment is needed for patients with active TB disease and for how long?

A

Combination chemotherapy for 6-9 months; patients infected with HIV require therapy for at least 1 year

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47
Q

What is the prophylaxis of choice in patients who have tested negative for TB in the past but are now positive with known or unknown exposure (recent converters)?

A

Isoniazid for 6-12 months

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48
Q

Children, adolescents, and the immunocompromised who have been in close contact with a person with active TB should be offered treatment until when?

A

Until a TB skin test is negative 12 weeks after exposure

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49
Q

What is the definition of bronchitis?

A

Inflammation of the airways (trachea, bronchi, bronchioles) characterized by cough

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50
Q

What is the treatment for acute exacerbation of chronic bronchitis in which bacterial causes are more likely?

A
  • First line treatment is a second generation cephalosporin (cefoxitin)
  • Second line treatment is a second-generation macrolide or Bactrim
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51
Q

Antibiotic in bronchitis is indicated for which patients?

A
  • Elderly patients
  • Those with underlying cardiopulmonary disease and a cough for more than 7-10 days
  • Immunocompromised patients
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52
Q

What is bronchiolitis?

A

Inflammation of the bronchioles (airways smaller than 2 mm in diameter). It is primarily an illness of young children and infants

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53
Q

Most common cause of bronchiolitis

A

RSV

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54
Q

Management of acute bronchiolitis

A
  1. If RSV is present, consider hospitalization and administration of ribavirin. This is especially important for infants born premature or who are severely ill
  2. Supportive measures (i.e., nebulized albuterol, IV fluids, antipyretics, chest physiotherapy, humidified oxygen)
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55
Q

In acute epiglottitis, what does the lateral neck radiograph show?

A

Swollen epiglottis (thumbprint sign)

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56
Q

Management of acute epiglottitis

A
  1. Secure the airway
  2. Administer broad-spectrum 2nd or 3rd generation cephalosporin such as cefotaxime or ceftriaxone for 7-10 days.
  3. Dexamethasone may also be indicated
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57
Q

Most common cause of croup

A

Parainfluenza virus types 1 and 2

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58
Q

What does the PA neck film show in croup?

A

Subglottic narrowing (steeple sign)

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59
Q

Management of croup

A
  1. Mild croup usually does not need treatment. Patients should be well hydrated
  2. Corticosteroids, humidified air oxygen, and nebulized epinephrine may be recommended
  3. Hospitalization may be required for patients with severe symptoms
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60
Q

Small cell lung CA characteristics

A
  • More likely to spread early and rarely is amenable to surgery
  • Tends to originate in the central bronchi and to metastasize to regional lymph nodes
  • Prone to early metastasis and an aggressive clinical course; assume micrometastases at presentation
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61
Q

Non-small cell lung CA (NSCLC) characteristics

A
  • Grows more slowly and is more amenable to surgery

- It includes squamous cell carcinoma, adenocarcinoma, and large cell carcinoma

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62
Q

Squamous cell carcinoma

A
  • Bronchial in origin and a centrally located mass

- More likely to present with hemoptysis and therefore more likely to be diagnosed with sputum cytology

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63
Q

Adenocarcinoma

A
  • Most common type of bronchogenic carcinoma
  • Typically metastatic to distant organs
  • Tumor arises from mucous glands, usually appears in the periphery of the lung, and is not amenable to early detection through sputum examination
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64
Q

Bronchoalveolar cell carcinoma

A
  • Subtype of adenocarcinoma

- Low-grade carcinoma

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65
Q

Large cell carcinoma

A
  • Heterogenous group of undifferentiated types that do not fit elsewhere
  • Cytology typically shows large cells
  • Doubling time is rapid, and metastasis is early
  • There may be central or peripheral masses
66
Q

What are the endocrine/metabolic paraneoplastic syndromes of lung CA?

A
  • Cushing syndrome
  • SIADH
  • Hypercalcemia
  • Gynecomastia
67
Q

Cushing syndrome histologic type

A

Small cell

68
Q

SIADH histologic type

A

Small cell

69
Q

Hypercalcemia histologic type

A

Squamous cell

70
Q

Gynecomastia histologic type

A

Large cell

71
Q

What are the neuromuscular paraneoplastic syndromes of lung CA?

A
  • Peripheral neuropathy
  • Myesthenia (Eaton-Lambert)
  • Cerebellar degeneration
72
Q

Peripheral neuropathy histologic type

A

Small cell

73
Q

Myasthenia (Eaton-Lambert) histologic type

A

Small cell

74
Q

Cerebellar degeneration histologic type

A

Small cell

75
Q

What are the cardiovascular paraneoplastic syndromes of lung CA?

A

Thrombophlebitis

76
Q

Thrombophlebitis histologic type

A

Adenocarcinoma

77
Q

What are the hematologic paraneoplastic syndromes of lung CA?

A
  • Anemia
  • DIC
  • Eosinophilia
  • Thrombocytosis
78
Q

Anemia histologic type

A

All

79
Q

DIC histologic type

A

All

80
Q

Eosinophilia histologic type

A

All

81
Q

Thrombocytosis histologic type

A

All

82
Q

What are the cutaneous paraneoplastic syndromes of lung CA?

A

Acanthosis nigricans

83
Q

Acanthosis nigricans histologic type

A

All

84
Q

Management of NSCLC

A

Surgery remains the treatment of choice

85
Q

Management of SCLC

A

Combination chemotherapy is the treatment of choice and results in improved median survival

86
Q

What are the complications of lung CA?

A

SPHERE

  • SVC syndrome
  • Pancoast tumor
  • Horner syndrome
  • Endocrine
  • Recurrent laryngeal nerve
  • Effusions
87
Q

SVC syndrome

A

Compression of SVC; plethora, HA, mental status changes

88
Q

Pancoast tumor

A
  • Tumor of the lung apex
  • Causes Horner syndrome and shoulder pain
  • Affects brachial plexus and cervical sympathetic nerve
89
Q

Horner syndrome

A

Unilateral face anhidrosis, ptosis, miosis

90
Q

Endocrine in lung CA complications

A

Carcinoid syndrome: flushing, diarrhea, telangiectasias

91
Q

Recurrent laryngeal nerve

A

Hoarseness

92
Q

Effusions in lung CA complications

A

Exudative

93
Q

Characteristics of malignant lesions

A
  • Occasionally are symptomatic
  • Tend to occur in patients older than 45 years of age
  • Usually are greater than 2 cm in diameter
  • Often have indistinct margins
  • Exhibit rapid progression in size
  • Rarely are calcified
94
Q

What are carcinoid tumors (aka carcinoid adenomas or bronchial gland tumors)?

A
  • Well-differentiated neuroendocrine tumors that affect men and women equally
  • Patients are usually younger than 60 years of age
95
Q

Are carcinoid tumors high grade or low grade malignant neoplasms?

A

Low-grade. They grow slowly and rarely metastasize

96
Q

Where are carcinoid tumors commonly found at?

A

In the GI tract

97
Q

Bronchoscopy reveals what in a carcinoid tumor?

A

Pink or purple central lesion that is well vascularized. The lesion can be pedunculate or sessile

98
Q

Treatment of carcinoid tumor

A
  • Surgical excision (carries a good prognosis)
  • The lesions are resistant to radiation therapy and chemotherapy
  • Octreotide (somatostatin analog) can be used to treat symptoms
99
Q

What drugs are associated with asthma exacerbations?

A

Beta blockers, ACE-I, ASA, NSAIDs

100
Q

Intermittent asthma symptoms

A

Symptoms ≤2 days per week

No interference with daily activities

101
Q

Intermittent asthma nighttime symptoms

A

≤2 times per month

102
Q

Intermittent asthma use of rescue medication

A

<2 days per week

103
Q

Intermittent asthma lung function

A

FEV1 >80% predicted

FEV1/FVC normal

104
Q

Mild persistent asthma symptoms

A

> 2 days per week but not daily

Minor limitation

105
Q

Mild persistent asthma nighttime symptoms

A

3-4 times per month

106
Q

Mild persistent asthma use of rescue medication

A

> 2 days per week but not daily and not more than once on any day

107
Q

Mild persistent asthma lung function

A

FEV1 >80% of predicted

FEV1/FVC normal

108
Q

Moderate persistent asthma symptoms

A
  • Daily symptoms

- Some limitation in daily activity

109
Q

Moderate persistent asthma nighttime symptoms

A

> 1 time per week but not nightly

110
Q

Moderate persistent asthma use of rescue medication

A

Daily

111
Q

Moderate persistent asthma lung function

A

FEV1 >60% but <80% predicted

FEV1/FVC reduced 5%

112
Q

Severe persistent asthma symptoms

A
  • Continual symptoms

- Extremely limited physical activities

113
Q

Severe persistent asthma nighttime symptoms

A

Often 7 times per week

114
Q

Severe persistent asthma use of rescue medication

A

Several times per day

115
Q

Severe persistent asthma lung function

A

FEV1 5%

116
Q

When is radiography indicated in asthma?

A

If pneumonia is suspected, the asthma is complicated, or another disorder is suspected

117
Q

What objective device is encouraged in patients with chronic asthma?

A

Handheld peak expiatory flow meters

118
Q

What test may help to establish the diagnosis of asthma when spirometry is non diagnostic and what is the diagnostic value?

A

A histamine or methacholine challenge test (bronchial provocation test); an FEV1 decrease of more than 20% is diagnostic

119
Q

Bronchiectasis definiton

A

Defined as an abnormal, permanent dilation of the bronchi and destruction of bronchial walls. It can be congenital (cystic fibrosis), or acquired from recurrent infections (TB, fungal infection, lung abscess) or obstruction (tumor)

120
Q

Bronchiectasis pathophysiology

A

Results from bronchial injury subsequent to severe infection and/or inflammation

121
Q

What is the imaging modality of choice in bronchiectasis and what does it reveal?

A

High-resolution chest CT; it reveals dilated, tortuous airways

122
Q

What is a characteristic finding of bronchiectasis on an CXR?

A

Crowded bronchial markings and basal cystic spaces

123
Q

What are the antibiotics of choice for bronchiectasis?

A

Levofloxacin, amoxicillin, amoxicillin-clavulanate, bactrim, or cipro for 10-14 days

124
Q

What does an CXR show in emphysema?

A
  • Decreased lung markings at apices
  • Flattened diaphragms
  • Hyperinflation
  • Small, thin-appearing heart
  • Parenchymal bullae and blebs
125
Q

What does an CXR show in bronchitis predominant COPD?

A
  • Increased interstitial markings at bases

- Diaphragms not flattened

126
Q

What may a CBC show in COPD?

A

Polycythemia (increased RBC count) due to chronic hypoxemia

127
Q

What type of inhalers are superior to beta-adrenergic agonists in achieving bronchodilation in COPD patients?

A

Anticholinergic inhalers (ipratropium or tiotropium)

128
Q

Patients with cystic fibrosis are at increased risk of what?

A

Malignancies of the GI tract, osteopenia, and arthropathies

129
Q

The diagnosis of cystic fibrosis should be suspected in any young patient that presents with what?

A

A history of chronic lung disease, pancreatitis, and infertility

130
Q

ABG reveals what in cystic fibrosis?

A

Hypoxemia and in advanced disease, a chronic, compensated respiratory acidosis

131
Q

What does pulmonary function tests reveal in cystic fibrosis?

A

Mixed obstructive and restrictive pattern

132
Q

What are the 4 types of pleural effusions?

A

Exudates, transudates, empyema, and hemothorax

133
Q

Exudate

A

Associated with “leaky capillaries”; examples include infection, malignancy, and trauma

134
Q

Transudate

A

“Intact capillaries” are associated with increased hydrostatic or decreased oncotic pressure; examples include congestive heart failure, atelectasis, and renal or liver disease (cirrhosis)

135
Q

Empyema

A

An infection within the pleural space

136
Q

Hemothorax

A

Bleeding into the pleural space, commonly as a result of trauma or malignancy

137
Q

What is the gold standard for pleural effusions?

A

Thoracentesis

138
Q

Light’s criteria (Transudates vs. exudates)

A

Fluid is considered to be an exudate if it meets any one of the following:

  1. Pleural fluid protein to serum protein ratio of greater than 0.5
  2. Pleural fluid LDH to serum LDH ratio of greater than 0.6
  3. Pleural fluid LDH greater than two-thirds the upper limit of normal for serum LDH
139
Q

Signs of pulmonary HTN

A

Narrow splitting and accentuation of the second heart sound and a systolic ejection click

140
Q

What could and ECG show with pulmonary HTN

A

RVH, atrial hypertrophy, and right ventricular strain

141
Q

An echo may be useful in estimating pulmonary arterial pressure, but what offers more precise hemodynamic monitoring?

A

Right heart catherization

142
Q

Treatment of primary pulmonary HTN

A
  1. Chronic oral anticoagulants
  2. CCB to lower systemic arterial pressure
  3. Prostacyclin (a potent pulmonary vasodilator)
  4. Usually a heart-lung transplantation is needed
143
Q

Treatment of secondary pulmonary HTN

A

Treating the underlying disorder and treatments for primary pulmonary HTN (chronic oral anticoagulants, CCB, prostacyclin)

144
Q

What are the three histopathologic patterns of idiopathic fibrosing interstitial pneumonia with different natural histories and treatments?

A
  1. Usual interstitial pneumonia
  2. Respiratory bronchiolitis-associated interstitial lung disease
  3. Acute interstitial pneumonitis
145
Q

What will PFTs show with idiopathic fibrosing interstitial pneumonia?

A

Restrictive pattern (decreased lung volume with a normal to increased FEV1/FVC ratio)

146
Q

Abestosis occupation

A

Insulation, demolition, construction

147
Q

Abestosis diagnosis

A

Bx: asbestos bodies
CXR: Linear opacities at bases and pleural plaques

148
Q

Abestosis complication

A

Increased risk of lung CA and mesothelioma, especially if a smoker

149
Q

Coal workers’ pneumoconiosis occupation

A

Coal mining

150
Q

Coal workers’ pneumoconiosis diagnosis

A

CXR: nodular opacities at upper lung fields

151
Q

Coal workers’ pneumoconiosis complications

A

Progressive massive fibrosis

152
Q

Silicosis occupation

A

Mining, sand blasting, quarry work, stone work

153
Q

Silicosis diagnosis

A

CXR: nodular opacities at upper lung fields

154
Q

Silicosis complications

A

Increased risk of TB; progressive massive fibrosis

155
Q

Berylliosis occupation

A

High technology fields: aerospace, nuclear power, ceramics, foundries, tool and die manufacturing

156
Q

Berylliosis diagnosis

A

CXR: diffuse infiltrates and hilar adenopathy

157
Q

Berylliosis complications

A

Requires chronic steroids

158
Q

What levels are elevated in about 40-80% of Sarcoidosis patients?

A

Angiotensin-convertin enzyme levels

159
Q

What are the radiographic findings in sarcoidosis?

A

Symmetric bilateral hilar and right paratracheal adenopathy and bilateral diffuse reticular infiltrates

160
Q

What does transbronchial biopsy show in sarcoidosis?

A

Noncaseating granulomas

161
Q

What are the three clinical settings that account for 75% of ARDS cases?

A
  1. Sepsis syndrome (the single most important)
  2. Severe multiple trauma
  3. Aspiration of gastric contents
162
Q

What is the underlying abnormality in ARDS?

A

Increased permeability of the alveolar capillary membranes, which leads to development of protein-rich pulmonary edema

A Comprehensive Review for the Certification and Recertification Examination for Physician Asistants (8 decks)

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