Pulmonology

Question 1

Decision to hospitalize for pneumonia

Answer 1

Confusion
Uremia (BUN > 7mmol/L)
Resp rate greater than or equal to 30
BP <90 systolic/less than or equal to 60 diastolic
Age greater than or equal to 65

Question 2

Empirical abx recommendations in pneumonia for previously healthy pts with no abx use in prior 3 mos

Answer 2

Azithromycin 500 mg PO x1 dose then 250 mg PO q24h x4 days OR
Clarithromycin 500 mg PO BID or clarithro ER 1 gm PO q24h x 7days OR
Doxycycline 100 mg PO BID 5-7 days

Question 3

Empirical abx recommendations in pneumonia for comorbidities

Answer 3

Levo 750 mg PO q24h x 5 days

Amoxicillin-clavulanate 1000/62.5 mg 2 tabs PO BID

Question 4

What is considered a comorbidity for pneumonia tx?

Answer 4

Chronic heart, lung, liver, renal dz
DM
Alcoholism
CA
Asplenia
Immunosuppression
Recent abx use

Question 5

Empirical abx recommendations in pneumonia for areas with high rate (>25%) macrolide-resistant S. pneumoniae

Answer 5

Choose alternative

Question 6

What are suggestive findings of an “atypical” pneumonia?

Answer 6

No clinical or laboratory features reliable distinguish from typical
Little sputum
Not “consolidating” (CXR, ausculatation)
Poor response to beta-lactams

Question 7

Mild, intermittent asthma

Answer 7

Day sx 2x/wk
Night sx 2x/mo or less
Lungs fine between attacks

Question 8

Mild, persistent asthma

Answer 8

Day sx 2+/wk
Night sx 2+/mo
Interfere with daily activities

Question 9

Moderate, persistent asthma

Answer 9

Day sx daily
Night sx 1+/wk
Interfere with daily activities

Question 10

Severe, persistent asthma

Answer 10

Day sx daily
Night sx frequent
Daily activities limited

Question 11

What is the maximum amount of usage for a SABA?

Answer 11

No more than 3-4 times/day

Question 12

Step 1 asthma tx

Answer 12

For intermittent asthma

SABA

Question 13

Step 2 asthma tx

Answer 13

For mild persistent asthma
SABA
Low-dose ICS
Alternatives: Sustained-release theophylline or cromone or leukotriene modifier

Question 14

Step 3 asthma tx

Answer 14

For moderate persistent asthma
SABA
Low-to-medium dose ICS + LABA
Alternatives:
Medium-dose ICS + sustained-release theophylline OR
Medium-dose ICS + LABA OR
High-dose ICS OR
Medium-dose ICS + leukotriene modifier

Question 15

Step 4 asthma tx

Answer 15

For severe persistent asthma
High-dose ICS + one or more of the following, if needed:
Sustained-release theophylline
Leukotriene modifier
LABA
Oral glucocorticosteroid

Question 16

Presentation of controlled asthma

Answer 16

Nl physical activity
SABA use < 4x/wk
Daytime sx < 4 days/wk
Nighttime sx <1 night/wk

Question 17

Presentation of uncontrolled asthma

Answer 17

Some interruption with activities
SABA use 4 or more x/wk
Daytime sx 4 or more days/wk
Nighttime sx 1 or more nights/wk

Question 18

Presentation of dangerously uncontrolled asthma

Answer 18

Difficulty talking
Reliever inhaler does work as usual OR
Relief lasts < 2hrs
Daytime sx all the time
Nighttime sx every night

Question 19

Examples of SABAs

Answer 19

Salbutamol

Fenoterol

Question 20

Examples of anticholinergics for asthma

Answer 20

Ipratropium bromide

Tiotropium

Question 21

Examples of LABAs for asthma

Answer 21

Formoterol

Salmeterol

Question 22

Examples of ICS

Answer 22

Ciclesonide
Beclomethasone
Budesonide
Fluticasone

Question 23

Common sx in pts with pulmonary embolism

Answer 23

Dyspnea
Chest pain (pleuritic mmore common than non-pleuritic)
Apprehension
Hemoptysis
Sweating/diaphoresis
Syncope
Palpitations
Wheezing
Leg pain
Leg swelling

Question 24

Work up for PE

Answer 24

Well's score:
1.5 pts for major surgery within 4 wks
3.0 alternative dx less likely
1.5 tachycardia
Score of 2-6= moderate probability
Then, order D-dimer and/or CT chest
CBC
CMP
ABGs
CXR once stable

Question 25

Tx of PE

Answer 25

Thrombolytics rarely used. Consider IV heparin if surgery is a possibility or severe renal failure Heparin- initial bolus based on wt, followed by an infusion, until aPTT at goal Warfarin initiated and titrated until maintaining INR of 2-3 and then continued for at least 3-6 mos Supportive care with IV fluids, oxygen, nutrition Pts are discharged once stable with INR >2

Question 26

Outpatient tx of PE

Answer 26

LMWH > IV heparin Once-daily > twice-daily Choice between fondaparinux and LMWH should be based on cost, availability, and familiarity of use

Question 27

What are alternative to warfarin for prophylaxis and tx of PE?

Answer 27

Apixaban Dabigatran Rivaroxaban Edoxaban

Question 28

F/u after PE tx- First thromboembolic event occurring in the setting of reversible RFs, such as immbobilization, surgery, or trauma

Answer 28

Warfarin therapy for at least 3 mos up to 6 mos

Question 29

F/u after PE tx- pts who have PE and preexisting irreversible RFs, such as deficiency of antithrombin III, protein S and C, factor V Leiden mutation, or the presence of antiphospholipid antibodies

Answer 29

Long-term anticoagulation

Question 30

F/u after PE tx if recurrent thrombosis despite treatments?

Answer 30

Vena Cava filter

Question 31

What is the preferred initial phase regimen for TB?

Answer 31

Combo of isoniazid, ethambutol, and pyrazinamide

Question 32

What should be done after the initial regimen for TB?

Answer 32

Tx is specific to the sputum culture results. Pt needs to be quarantined from the public and immune compromised until no longer contagious Continue isolation until sputum smears are neg for 3 consecutive determinations (usually after 2-4 wks of tx)

Question 33

Stage 1 COPD

Answer 33

Mild COPD | 80% nl lung function

Question 34

Stage 2 COPD

Answer 34

Moderate COPD | 50-80% nl lung function

Question 35

Stage 3 COPD

Answer 35

Severe COPD Typically involves severe restraint of respiration, tininess of breath, and frequently COPD exacerbations 30-50% nl lung function

Question 36

Stage 4 COPD

Answer 36

Very severe COPD Become very severe and risky, thus decreases the QOL with vital COPD exacerbations Lung function FEV1 levels might be lower than 30%

Question 37

Tx of mild COPD

Answer 37

Active reduction of risk factor(s): influenza vaccine | SABA PRN

Question 38

Tx of moderate COPD

Answer 38

Influenza vaccine SABA PRN One or more LABAs PRN Pulmonary rehab

Question 39

Tx of severe COPD

Answer 39

``` Influenza vaccine SABA PRN One or more LABAs PRN Pulmonary rehab ICS if repeated exacerbations ```

Question 40

Tx of very severe COPD

Answer 40

``` Influenza vaccine SABA PRN One or more LABAs PRN Pulmonary rehab ICS if repeated exacerbations Add long-term O2 if chronic respiratory failure Consider surgical treatments ```

Question 41

Specific treatments of COPD and doses

Answer 41

Albuterol: 2 puffs q4-6h prn Advair: one puff every 12 hrs Albuterol/ipratropium: 2 puffs q8h Quit smoking!

Question 42

Pathophys of ARDS

Answer 42

Necrosis Tissue destruction Influx of leukocytes Dilatation of blood vessels

Question 43

Tx of ARDS

Answer 43

Treat the underlying condition, along with supportive care, mechanical ventilation, and conservative fluid management. Antibiotic therapy that is broad enough to cover suspected pathogens is essential

Question 44

Mortality rates of ARDS

Answer 44

30-40%

Question 45

Acute bronchitis

Answer 45

Inflammation of the bronchial tubes (bronchi) from the trachea into the small airways for <3 wks. Most occur in fall and winter

Question 46

Etiology of acute bronchitis

Answer 46

90% is caused from viral infections or irritation of bronchial tubes and NOT from bacterial infections.

Question 47

MC organisms of acute bronchitis

Answer 47

Parainfluenza RSV Coronavirus Influenza A or B

Question 48

Prognosis of acute bronchitis

Answer 48

Almost always self-limited in individuals who are otherwise healthy

Question 49

Complications of acute bronchitis

Answer 49

10%: bacterial superinfection | PNA in 5% of chronic bronchitis pts, reactive airway dz

Question 50

Prevention of acute bronchitis

Answer 50

Quit smoking Avoid inhaling chemicals or other irritants that may harm your lungs Steer clear of infection Wash your hands

Question 51

S/sx of acute bronchitis

Answer 51

``` Cough Sputum production Fever- usually only with flu Sore throat Nasal congestion HA Fatigue Rare- N/V/D ```

Question 52

PE of acute bronchitis

Answer 52

Fever- rare and usually a sign of influenza- R/o pneumonia General malaise Mild injection of posterior pharynx and nares Diffuse wheezes, high-pitched continuous sounds or nl lung sounds