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Step 3 > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

A patient comes in with a severe asthma exacerbation but you don’t hear any wheezing. What must be occurring?

A

Act fast. No wheezing is a sign of serious airflow obstruction

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2
Q

How are asthma and other reactive airway diseases confirmed on pulmonary function testing?

A

Rise in FEV1 > 12 seconds

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3
Q

Should asthmatics with respiratory acidosis be placed in the ICU?

A

Yes

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4
Q

Besides inhaled steroids, what are alternate long-term controller meds in patients with COPD?

A

Tiotropium, ipratropium

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5
Q

What is a critical lab to order in patients presenting with COPD and acute SOB?

A

ABG to assess carbon dioxide retention

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6
Q

Patients with COPD often have what baseline acid-base disturbance? Therefore, should you intubate patients with respiratory ____?

A

Respiratory acidosis from CO2 retention but also a high bicarbonate from compensatory degree of metabolic alkalosis.

Do not intubate just for respiratory acidosis, only if it is acutely worsening

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7
Q

What are CXR findings in a patient with COPD?

A

Hyperinflated lung fields, straightening of diaphragm, elongated heart, and substernal air trapping

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8
Q

What abnormality is present on CBC of patients with COPD?

A

Elevated hematocrit due reactive erythrocytosis from hypoxia (microcytic)

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9
Q

What should you find on PFT in a COPD patient?

A

FEV1: decreased
FVC: decreased
FEV1/FVC: decreased (

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10
Q

Can patients with COPD tolerate beta1-blockers?

A

Yes, almost all can

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11
Q

What is recommended chronic medical therapy for COPD?

A 
Tiotropium/ipratropium inhaler
Albuterol
Smoking cessation
Heptavalent pneumococcal vaccine
Yearly influenza vaccine
Supplementary O2 if low sats regularly
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12
Q

Your patient presents with hyperinflated chest on CXR with a low albumin and prolonged PT. Dx?

A

Alpha-1 Antitrypsin Deficiency

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13
Q

What is tx of alpha-1 antitrypsin deficiency?

A

alpha-1 antitrypsin infusion

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14
Q

Buzzwords

CXR with ‘tram tracking’ of bronchi

A

Bronchiectasis

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15
Q

What is the most accurate test to dx bronchiectasis?

A

CT chest

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16
Q

What is tx of bronchiectasis?

A

There is no definitive tx. Chest physiotherapy and rotating antibiotics

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17
Q

Buzzwords

Glass workers, mining, sandblasting, brickyard worker

A

Silicosis (interstitial lung disease)

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18
Q

Buzzwords

Coal worker gets what ILD

A

Coal worker’s pneumoconiosis

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19
Q

Buzzwords

Cotton (textile fiber dust) associated with what ILD

A

Byssinosis

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20
Q

Buzzwords

Electronics, ceramics, fluorescent light bulbs ILD

A

Berrylliosis

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21
Q

Buzzwords

Mercury associated with ILD

A

Pulmonary fibrosis

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22
Q

What are PFT findings in a patient with ILD?

A 
FEV1: decreased
FVC: decreased
FEV1/FVC: normal to increased
RV: decreased
TLC: decreased
DLCO: decreased
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23
Q

What is the most common type of cancer associated with asbestosis?

A

Lung cancer

NOT mesothelioma

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24
Q

Generally there is no specific form of therapy which helps alleviate ILD. Which is the one form that may respond to steroid trials and why?

A

Berrylliosis bc it is a granulomatous disease

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25
Q

A patient presents with signs and symptoms very similar to ILD occurring for 3-4 weeks. The patient also has a fever and malaise. What is the likely dx?

A

Bronchiolitis oblilterans organizing pneumonia (BOOP) aka Cryptogenic organizing pneumonia (COP)

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26
Q

What is the most accurate test for making the dx of BOOP/COP?

A

Open lung bx

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27
Q

Unlike ILD, BOOP/COP has a response to what medications?

A

Steroids

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28
Q

Name the following extrapulmonary findings seen in sacoidosis:

Eye
Neural
Skin
Cardiac
Renal/Hepatic
Electrolyte
A

Eye: uveitis
Neural: CN VII involvement
Skin: Lupus pernioo (purplish lesion of skin on face), erythema nodosum
Cardiac: restrictive cariomyopathy; conduction defects
Renal/hepatic involvement: often asymptomatic
Electrolyte: hypercalcemia (due to vitamin D production by granulomas in sarcoidosis)

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29
Q

Best initial test for dx sarcoidosis

A

CXR (enlarged hilar lymph nodes)

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30
Q

Most accurate test for dx of sarcoidosis

A

Lung or lymph node biopsy with noncaseating granulomas

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31
Q

Buzzwords

Noncaseating granulomas

A

Sarcoidosis

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32
Q

Buzzwords

Elevations in calcium and/or ACE

A

Sarcoidosis

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33
Q

Best therapy for sarcoidosis

A

Steroids

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34
Q

Raynaud’s phenomenon is associated with what pulmonary disorder?

A

Pulmonary hypertension

35
Q

What is the most accurate test for pulmonary HTN?

A

Right heart catheterization

36
Q

What is bosentan?

A

An endothelial inhibitor which prevents growth of pulm vasculature and can be used to treat pulm HTN

37
Q

What are epoprostenol and treprostinil?

A

Prostacyclin analogs which dilate pulmonary vasculature and are used to treat pulm HTN

38
Q

A patient presents with acute SOB but CXR and EKG are normal. What is a dx you must consider?

A

PE

39
Q

If you’re patient comes in with signs of right heart strain and hypotension what medicine should you quickly administer and for what problem?

A

May be a massive PE

Thrombolytics

40
Q

Is it acceptable to provide heparin prior to confirming PE if it is a clear case?

A

Yes

41
Q

What is the test of choice for dx of PE (especially when the CXR is abnormal)?

A

CT angiogram chest

42
Q

In what situations is the V/Q scan useful in ruling out PE?

A

When the CXR is normal (the more normal the CXR the better V/Q is at ruling out). However, only a truly normal V/Q scan can rule out PE. If there is some question they can be unreliable

43
Q

What is the sensitivity and specificity of the D-dimer test (general, not exact values)? In what situations is it most useful?

A

Highly sensitive but not very specific

Very good test in patients with a low probability of PE bc a negative will rule out PE

44
Q

What is the most accurate test for PE? But what is it’s downfall?

A

Angiography but it is invasive and has a mortality risk

45
Q

What are D-dimers?

A

Fragments of fibrin which have been chopped up by plasmin. They can only be chopped off a few hours after a clot forms because after factor VIII stabilizes fibrin.

46
Q

What is the immediate standard of care in PE?

A

Heparin and oxygen

Patients will need warfarin for 6 months after the PE

47
Q

If a patient presents with PE and is unstable (with hypotension) what medicine can be given?

A

Thrombolytics

48
Q

Best initial test to dx pleural effusion?

Most accurate test to dx pleural effusion?

A

Initial: CXR
Accurate: Thoracentesis

49
Q

What are the threshold values for protein and LDH that are used to distinguish a transudative from an exudative pleural effusion?

A

Protein > 50% serum
LDH > 60% serum

Both the above support exudative

50
Q

How are the below pleural effusions managed?

Small
Large
Large and recurrent

A

Small: Can do no therapy or diuretic
Large: Chest tube drainage
Large and recurrent: pleurodesis (pleural space obliterated by fusing two pleural surfaces)

*If pleurodesis fails then decortication

51
Q

If weight loss and CPAP aren’t helpful in OSA then what may be indicated?

A

Surgical resection of uvula, palate, and pharynx

52
Q

How is central sleep apnea managed?

A

Avoid alcohol and sedatives
Acetazolamide (creates metabolic acidosis which ignites respiratory drive)
Medroxyprogesterone: central respiratory stimulant

53
Q

An asthmatic patient presents with worsening symptoms, brown mucous plugs, recurrent infiltrates, central bronchiectasis, and peripheral eosinophilia with high IgE.

Dx?
Diagnostic testing?
Tx?

A

Allergic bronchopulmonary aspergillosis (ABPA)

Aspergillus skin testing, measure IgE levels, circulating precipitins, A. fumigatus-specific antibodies

Tx: oral corticosteroids and if refractory then itraconazole

54
Q

Diffuse, patchy infiltrates on CXR may indicate what serious condition?

A

ARDS

55
Q

What is PO2/FiO2 and how is it a helpful value?

A

If

56
Q

What is the tidal volume goal of ARDS?

A

6mL/kg

57
Q

What is the mgmt of ARDS?

A

Ventilatory support with PEEP and TV goal of 6mL/kg
Possibly diuretics and dobutamine
Prone positioning

58
Q

How can the wedge pressure from a Swan-Ganz be used to distinguish different forms of shock?

A

It will be high in cardiogenic but low in septic and hypovolemic

59
Q

Generally, ho does cardiac output differ among different shock states?

A

High in septic

Low in caridogenic and hypovolemic

60
Q

Most common organism causing CAP

A

Pneumococcus

61
Q

Most common organism causing HAP

A

Gram-negative bacilli

62
Q

Best initial test for dx of PNA

Most accurate test

A

Initial: CXR
Accurate: Gram stain and culture sputum

63
Q

Tx of outpatient PNA

A 
Macrolide (azithromycin or clarithromycin)
Respiratory fluoroquinolone (levofloxacin or moxifloxacin)
64
Q

Tx of inpatient PNA

A

Ceftriaxone and azithromycin

or Fluoroquinolone as single agent

65
Q

Tx of ventilator-associated PNA

A

Imipenem or meropenem, piperacillin/tazobactam, or cefepime
Gentamicin and
Vancomycin or linezolid

66
Q

Buzzwords

Cause PNA with recent viral syndrome

A

Staphylococcus (superimposed infection)

67
Q

Buzzwords

Cause PNA in alcoholics

A

Klebsiella

68
Q

Buzzwords

Cause of PNA with GI symptoms and confusion

A

Legionella

69
Q

Buzzwords

Cause of PNA in young, healthy patients

A

Mycoplasma

70
Q

Buzzwords

Cause of PNA in people present at birth of live animal

A

Coxiella burnetti

71
Q

Buzzwords

Cause of PNA in Arizona construction workers

A

Coccidiodomycosis

72
Q

Buzzwords

Cause of PNA with HIV and CD4

A

Pneumocystis

73
Q

What is best tx of pneumocystis pneumonia?

A

Trimethoprim/sulfamethoxazole and possibly steroids

*Steroids indicated if PO2 35

74
Q

Best initial test for TB dx

Confirmatry test for TB

A

Initial: CXR
Confirmatory: Acid fast stain and culture of sputum

75
Q

Tx of TB

A

Isoniazid (6 months)
Rifampin (6 months)
Pyrazinamide (2 months)
Ethambutol (2 months)

76
Q

All TB meds can lead to what toxicity?

A

Liver toxicity

Stop if LFTs reach 5x upper limit

77
Q

Specific side effect of isoniazid

A

Peripheral neuropathy

78
Q

Specific side effect of rifampin

A

Red/orange body secretions

79
Q

Specific side effect of pryazinamide

A

Hyperuricemia

80
Q

Specific side effect of ethambutol

A

Optic neuritis

81
Q

Describe PPD thresholds

A

15mm: those without increased risk
10mm: healthcare workers, alcoholics, immigrants, homeless, prisoners (high risk)
5mm: active drug users, HIV positive, close TB contacts

82
Q

What is 2-stage testing in TB?

A

If a patient hasn’t been tested in a long time then do two serial tests to make sure truly negative

83
Q

A positive IFN-gamma release assay for TB exposure is an indication for what treatment?

A

Isoniazid

Step 3 (19 decks)

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