Pulmonology Flashcards
What is the best initial test in an acute exacerbation of asthma?
Peak Expiratory Flow (PEF) or ABG
What is the most accurate diagnostic test in asthma?
Pulmonary function testing (PFT)
Spirometry will show:
- dec. ration of FEV1:FVC (the FEV1 decreases MORE than FVC)
A 15-year-old boy comes to the office because of occasional shortness of breath every few weeks. Currently he feels well. He uses no medications and denies any other medical problems. Physical examination reveals a pulse of 70 and a respiratory rate of 12 per minute. Chest examination is normal.
Which of the following is the single most accurate diagnostic test at this time?
a. Peak expiratory flow.
b. Increase in FEv1 with use of methacoline
c. Diffusion capacity of carbon monoxide
d. >20% decrease in FEV1 with use of methacoline
e. Increased alveolar-arterial oxygen difference (A-a gradient)
f. Increase in FVC with albuterol
g. Flow-volume loop on spirometry
h. Chest CT scan
i. increased pCO2 on ABG
When a patient is currently asymptomatic, it is less likely to find an increase in FEV1 with the use of short-acting bronchodilators like albuterol. The test, when the patient is asymptomatic, may be falsely negative. When the patient is asymptomatic, the most accurate test of reactive airway disease is a 20% decrease in FEV1 with the use of methacholine or histamine. Chest CT, like an x-ray, shows either nothing or hyperinflation. The ABG and PEF are useful during an acute exacerbation. Flow-volume loops are best for fixed obstructions such as tracheal lesions or COPD.
What should you expect in the pulmonary function tests in an asthma patient?
- decreased FEV1 and FVC, decreased FEV1/FVC ratio
- increased in FEV1 of more than 12% and 200 mL with the use of albuterol
- decrease in FEV1 of more than 20% with the use of methacholine or histamine
- increase in the diffusion capacity of the lung for carbon monoxide (DLCO)
What does acetylcholine (methacholine) and histamine provoke in pulmonary function testing?
bronchoconstriction and increase in bronchial secretion
Give 2 side effects of inhaled steroids.
Dysphonia and Oral candidiasis
How would you start treating for asthma?
Inhaled short-acting beta agonist (SABA)
Albuterol
Pirbuterol
Levalbuterol
This leukotriene modifier is hepatotoxic and has been associated with Churg-Strauss syndrome.
Zafirlukast
Patient’s symptoms persisted despite giving inhaled SABA. What should you do?
Add long-term agents to a SABA. Low-dose inhaled corticosteroids are the best initial long-term control agent.
Beclomethasone Budesonide Flunisolide Fluticasone Mometasone Triamcinolone
What are your alternatives as long-term agents for low-dose ICS?
Cromolyn and Nedocromil - inhibit mast cell mediator release and eosinophil recruitment
Theophylline
Leukotriene modifiers: Montelukast, Zafirlukast, or Zileuton (best with atopic patients)
Patient’s symptoms persisted even with combined SABA and low-dose ICS. What should you do?
Add a long-acting beta agonist (LABA) to a SABA and ICS, or increase the dose of ICS.
LABA: Salmeterol or Formoterol
Patient is on Abuterol, Budesonide, and Salmeterol. Symptoms persisted. What should you do?
Increase the dose of ICS to maximum in addition to the LABA and SABA. Add Tiotropium, an antimuscarinic agent.
Patient is on Albuterol, maximum dose of Beclomethasone, Formotero, and Tiotropium. Patient still experiencing symptoms. IgE levels were high. What should you do?
Omalizumab may be added to SABA, LABA, and ICS.
What should you give when all other treatment given for asthma were not sufficient to control symptoms?
Oral corticosteroids
Give the adverse effects of Systemic Corticosteroids
Osteoporosis
Cataracts
Adrenal suppression and fat redistribution
Hyperlipidemia, hyperglycemia, acne, and hirsutism (particularly in women)
Thinning of skin, striae, and easy bruising
These agents are used in asthma management if SABAs, LABAs, and inhaled steroids are not sufficient. It dilates bronchi and decreases secretions. They are also VERY EFFECTIVE in COPD.
Anticholinergics (Ipratropium and Tiotropium)
What vaccines are given in all asthma patients?
Influenza and Pneumoccocal vaccines
A 47-year-old man with a history of asthma comes to the emergency department with several days of increasing shortness of breath, cough, and sputum production. On physical examination his respiratory rate is 34 per minute. He has diffuse expiratory wheezing and a prolonged expiratory phase.
Which of the following would you use as the best indication of the severity of his asthma?
a. Respiratory rate
b. Use of accessory muscles
c. Pulse oximetry
d. Pulmonary function testing
e. Pulse rate
A. A respiratory rate of 34 indicates severe shortness of breath.
How can you quantify the severity of an asthma exacerbation?
Decreased peak expiratory flow (PEF)
ABG with an increased A-a gradient
This electrolyte helps relieve bronchospasm. It is used only in an acute, severe asthma exacerbation not responsive to several rounds of albuterol while waiting for steroids to take effect.
Magnesium
What is the best initial therapy for acute, severe asthma exacerbation?
Oxygen combined by inhaled SABA such as albuterol and a bolus of steroids. Corticosteroids need 4-6 hours to begin to work, so give them right away. Ipratropium should be used, but does not work as rapidly as albuterol.
A patient comes in in acute, severe asthma exacerbation. You gave oxygen, albuterol, and steroids, but is not responding. ABG showed respiratory acidosis. What would you do?
Endotracheal intubation then place in ICU
This is defined as the presence of shortness of breath from lung destruction decreasing the elastic recoil of the lungs.
COPD
What would you expect in the PFT of a patient with COPD?
- Decrease in FEV1 and FVC; dec. FEV1/FVC ratio (under 70%)
- increase in total lung capacity (TLC) because of an increase in residual volume
- decrease diffusion capacity of the lung for carbon monoxide (DLCO) (emphysema, not chronic bronchitis)
- incomplete improvement with albuterol
- little or no worsening with methacholine
What is the best initial test for COPD?
Chest X-Ray
What will you see in the Chest X-Ray of a patient with COPD?
Increased AP diameter
Air trapping and flattened diaphragms
What is the most accurate diagnostic test for COPD?
Pulmonary Function Test (PFT)
What can you see in the ABG of those with acute exacerbations of patients with COPD?
increased pCO2 and hypoxia
Respiratory acidosis may be present
What can you see in the CBC of those with acute exacerbations of patients with COPD?
Increase in hematocrit from chronic hypoxia
What can you see in the EKG of those with acute exacerbations of patients with COPD?
- Right atrial hypertrphy and right ventricular hypertrophy
- atrial fibrillation or multifocal atrial tachycardia (MAT)
What can you see in the Echocardiography of those with acute exacerbations of patients with COPD?
- Right atrial and ventricular hypertrophy
- Pulmonary Hypertension
What treatment can you give to a patient with COPD to improve mortality and delay progression of disease?
Smoking cessation
Oxygen therapy for those with pO2 < or = 55 or saturation <88%
Influenza and Pneumococcal vaccines
What treatment can you give to a patient with COPD to improve symptoms but does not decrease disease progression or mortality?
SABA Anticholinergic agents Steroids LABA Pulmonary rehabilitation
What would you consider if a patient with COPD does not respond to all medical therapy?
Refer for transplantation
In a COPD patient that does not respond to albuterol, what is the next step in management?
Anticholinergic agent (tiotropium)
If a COPD patient does not respond to albuterol and anticholinergic agent, what is the next step in management?
Inhaled steroid
This is the only anticholinergic that can be used for acute exacerbation of Chronic Bronchitis.
Ipratropium
What is the most commonly identified cause in acute exacerbation of Chronic Bronchitis?
Infection –> Give Antibiotics (Macrolides, Cephalosporins, Amoxicillin, Quinolones)
This is an uncommon disease from chronic dilation of the large bronchi. It is a permanent anatomic abnormality that cannot be reversed or cured.
Bronchiectasis
What is the single most common cause of bronchiectasis?
Cystic Fibrosis
Patient presents with recurrent episodes of very high volume purulent sputum production. There is also an episode of hemoptysis. He is dyspneic and there are wheezes upon a auscultation. Patient claims that he has lost weight. CBC shows low hematocrit levels. What is the most likely diagnosis?
Bronchiectasis
What is the best initial test for Bronchiectasis?
Chest X-Ray
What will you see in a Chest X-Ray of a patient with Bronchiectasis?
Dilated thickened bronchi, sometimes with “tram-tracks” sign
What is the most accurate test for Bronchiectasis?
High-resolution CT Scan
This is the only way to determine the specific bacterial etiology of the recurrent episodes of infection in Bronchiectasis.
Sputum culture
This is the hypersensitivity of the lungs to fungal antigens that colonize the bronchial tree. It occurs almost exclusively in patient with asthma and a history of atopic disease.
Allergic Bronchopulmonary Aspergillosis (ABPA)
Patient is a known asthmatic who came in with recurrent episodes of brown-flecked sputum and transient infiltrates on Chest X-Ray. What is the most likely diagnosis?
Allergic Bronchopulmonary Aspergillosis (ABPA)
What diagnostic criteria can you see in a patient with Allergic Bronchopulmonary Aspergillosis (ABPA)?
a. Peripheral eosinophilia
b. Skin test reactivity to aspergillus antigens
c. Precipitating antibodies to aspergillus on blood test
d. Elevated serum IgE levels
e. Pulmonary infiltrates on chest x-ray or CT
f. All of the above
F. ALL
How would you treat Allergic Bronchopulmonary Aspergillosis (ABPA)?
- Oral steroids (prednisone) for severe cases
2. Itraconazole orally for recurrent episodes
This is an autosomal recessive disorder caused by a mutation of CFTR gene: genes that code for chloride transport.
Cystic Fibrosis
What is the typical presentation of Cystic Fibrosis?
Look for a young adult with chronic lung disease (cough, sputum, hemoptysis, bronchiectasis, wheezing, and dyspnea) and recurrent episodes of infection. Sinus pain and polyps are common.
What are the GI involvement of Cystic Fibrosis?
- Meconium ileus in infants with abdominal distention
- Pancreatic insufficiency with steatorrhea and Vit A, D, E, K malabsorption
- Recurrent pancreatitits
- Distal intestinal obstruction
- Biliary cirrhosis
What is the GU involvement of Cystic Fibrosis?
Men and Women are infertile
What is the most accurate test for Cystic Fibrosis?
Increased Sweat Chloride Test
Pilocarpine increases aceytlcholine levels which increases sweat production. Chloride levels in swaet above 60 meq/L on repeated testing establishes the diagnosis.
What bacteria can you find in the sputum culture of patient with Cystic Fibrosis?
Nontypable haemophilus influenzae
Pseudomonas aeruginosa
Staphylococcus aureus
Burkholderia cepacia
What are treatment options to Cystic Fibrosis?
- Antibiotics
- Inhaled recombinant human deoxyribonuclease (rhDNase)
- Inhaled bronchodilators such as albuterol
- Pneumococcal and influenza vaccinations
- Lung transplantation is used only in advanced disease not responsive to the therapy previously listed
- Ivacaftor increases the activity of CFTR in the 5% of patients who have a specific mutation
This is defined as pneumonia occurring before hospitalization or within 48 hours of hospital admission.
Community-acquired pneumonia
This is the most common cause of CAP.
Streptococcus pneumonia
This is the pathogen associated with COPD in CAP.
Haemophilus influenzae
This is the pathogen associated with recent viral infection (influenza) in CAP.
Staphylococcus aureus
This is the pathogen associated with alcoholism and diabetes in CAP.
Klebsiella pneumoniae
This is the pathogen associated with poor dentition and aspiration in CAP.
Anaerobes
This is the pathogen associated with young, healthy patients in CAP.
Mycoplasma pneumoniae
This is the pathogen associated with hoarseness in CAP.
Chlamydophila pneumoniae
This is the pathogen associated with contaminated water sources, air conditioning, ventilation systems in CAP.
Legionella
This is the pathogen associated with birds in CAP.
Chlamydia psittaci
This is the pathogen associated with animals at the time of giving birth, veterinarians, famers in CAP.
Coxiella burnetii
How would you distinguish pneumonia from bronchitis?
Dyspnea, high fever, and abnormal chest x-ray
What is the best initial test for all respiratory infections?
Chest X-Ray
This term refers to an organism not visible on Gram stain and not culturable on standard blood agar.
Atypical Pneumonia
What would you see in the chest x-ray of a patient with atypical pneumonia?
Bilateral Interstitial Infiltrates
Give 5 etiology of atypical pneumonia. These organisms often accompanied a “dry” nonproductive cough.
Mycoplasma Viruses Coxiella Pneumocystis Chlamydia
This test is done in severe diseases with an unclear etiology, or those that do not respond to treatment. This is done to analyze the pleural effusion to determine the presence of empyema.
Thoracentesis
This is an infected pleural effusion, acts like an abscess, and will improve more rapidly if it is drained with a chest tube.
Empyema
This is rarely needed in CAP but is used if there is severe disease such as someone needing placement in an ICU when initial testing such as sputum stain and culture and blood cultures do not yield an organism and the patient’s condition is worsening despite empiric therapy.
Bronchoscopy
This is a specific diagnostic test if the culture yielded Mycoplasma pneumoniae.
PCR, cold agglutins, serology, special culture media
This is a specific diagnostic test if the culture yielded Chlamydophila pneumoniae.
Rising serologic titers
This is a specific diagnostic test if the culture yielded Legionella.
Urine antigen, culture on charcoal-yeast extract
This is a specific diagnostic test if the culture yielded Chlamydia psittaci.
Rising serologic titers
This is a specific diagnostic test if the culture yielded Pneumocystis jiroveci (PCP).
Bronchoalveolar lavage (BAL)
This 2 organisms are rarely confirmed because they are simply treated empirically.
Mycoplasma and Chlamydophilia
Patient is diagnosed with Pneumonia. He was previously healthy or no antibiotics in past 3 months and mild symptoms. How would you treat him on an outpatient basis?
Macrolide (Azithromycin or Clarithromycin) or
Doxycyline
Patient is diagnosed with Pneumonia. Upon history, there is presence of comorbidities and antibiotic use in the past 3 months. How would you treat him on an outpatient basis?
Respiratory fluoroquinolone (Levofloxacin or Moxifloxacin)
How would you treat a patient with Pneumonia as inpatient?
Respiratory fluoroquinolone (Levofloxacin or Moxifloxacin)
or
Ceftriaxone and azithromycin
Give factors present in a patient with Pneumonia that warrants you to admit him.
- Hypotension (systolic below 90 mmg Hg)
- Respiratory rate above 30 per minute or pO2 less than 60 mm Hg, pH below 7.35
- Elevated BUN above 30 mg/dL, sodium less than 130 mmol/L, glucose above 250 mg/dL
- Pulse above 125 per minute
- Confusion
- Temperature above 104
- Age 65 or older, or comorbidities such as cancer, COPD, CHF, renal failure, or liver disease
Mnemonic: CURB65 (admission) Confusion Uremia Respiratory distress BP low Age >65 *2 and more points = admit
A 65-year-old woman is admitted to the hospital with CAP. Sputum Gram stain shows Gram-positive diplococci but the sputum culture does not grow a specific organism. Chest x-ray shows a lobar infiltrate and a large effusion. She is placed on ceftriaxone and azithromycin. Thoracentesis reveals an elevated LDH and protein level with 17,000 white blood cells per ul. Blood cultures grow Streptococcus pneumonia with a minimal inhibitory concentration to penicillin less than 0.1 ug/mL. Her oxygen saturation is 96% on room air. Blood pressure is 110/70, temperature is 102F, and pulse is 112 per minute.
What is the most appropriate next step in the management of this patient?
a. Repeat thoracentesis
b. Placement of chest tube for suction
c. Add ampicillin to treatment
d. Place patient in ICU
e. Consult pulmonary
B. Infected pleural effusion or empyema will respond most rapidly to drainage by chest tube or thoracostomy. A large effusion acts like an abscess and is hard to sterilize. Each side of the chest can accommodate 2 to 3 liters of fluid. There is no benefit of adding ampicillin to ceftriaxone. A low MIC to penicillin automatically means that the organism is sensitive to ceftriaxone and, in fact, all cephalosporins. There is no need to be in the ICU just because of an effusion or for chest tube drainage. The patient is not unstable and, despite the effusion, has no evidence of instability.
When do you give Pneumococcal Vaccine?
- > 65 years old
- Chronic heart, liver, kidney, or lung disease (including asthma) should be vaccinated regardless of age
- Functional or anatomic asplenia
- Hematologic malignancy (leukemia, lymphoma)
- Immunosuppression: DM, Alcoholics, Corticosteroid users, AIDS or HIV positive
- CSF leak and cochlear implantation recipients
Define Hospital-acquired pneumonia.
This is defined as a pneumonia developing more than 48 hours after admission or after hospitalization in the last 90 days.
What are the most common organisms associated with HAP?
E. Coli or Pseudomonas
What are your treatment options for HAP?
Antipseudomonal cephalosporins: Cefepime or Ceftazidime
OR
Antipseudomonal penicillin: Piperacillin/Tazobactam
OR
Carbapenems: Imipinem, Meropenem, or Doripenem
Patient is currently intubated. He suddenly developed fever. New infiltrates were seen on Chest X-Ray and purulent secretions were coming from the ET tube. What is the most likely diagnosis?
Ventilator-Associated Pneumonia
This is the easiest diagnostic test to do for VAP but is the least accurate.
Tracheal aspirate
This is the most accurate diagnostic test for VAP but post greater morbidity and potential complication.
Open lung biopsy
How would you treat VAP?
Combine 3 different drugs:
- Antipseudomonal beta-lactam
- Cephalosporin (ceftazidime or cefepime) OR
- Penicillin (piperacillin/tazobactam) OR
- Carbapenem (imipenem, meropenem, or doripenem)
PLUS
- Second antipseudomonal agent
- Aminoglycoside (gentamicin or tobramycin or amikacin) OR
- Fluoroquinolone (ciprofloxacin or levofloxacin)
PLUS
- Methicilline-resistant antistaphylococcal agent
- Vancomycin OR
- Linezolid
This drug is not used for any lung problem. It is inactivated by surfactant.
Daptomycin
A patient is admitted to the hospital for head trauma and a subdural hematoma. The patient is intubated for hyperventilation and a subsequent craniotomy. Several days after admission, the patient starts to vomit blood and is found to have stress ulcers of the stomach, Lansoprazole is started. VAP develops and the patient is placed on imipenem, linezolid, and gentamicin. Phenytoin is started prophylactically. Three days later, the creatinine rises. The patient then starts having seizures. A repeat head CT shows no changes.
What is the most appropriate next step in the management of this patient?
a. Switch phenytoin to carbamazepine
b. Stop lansoprazole
c. Stop imipenem
d. Stop linezolid
e. Perform an electroencephalogram
C. Imipinem can cause seizures.
What anatomical part of the lung does aspiration pneumonia usually occurs?
Upper lobe when lying flat
A patient has been hospitalized for months. He lost a lot of weight and has an ongoing infection that has lasted for several weeks. ET is showing large-volume sputum that is foul smelling. What is the most likely diagnosis?
Lung Abscess
What is the best initial test for lung abscess?
Chest X-Ray
It will show a cavity, possibly with an air-fluid level
What is the more accurate test for lung abscess?
Chest CT
How can you establish the specific microbiologic etiology of lung abscess?
Lung biopsy
How would you treat lung abscess?
Clindamycin or Penicillin
This type of pneumonia occurs almost exclusively in patients with AIDS whose CD4 cell count has dropped below 200/ul and who are not on prophylactic therapy.
Pneumocystis Pneumonia
P. jiroveci - microbe
What is the best initial test for Pneumocystis Pneumonia?
Chest X-Ray showing bilateral interstitial infiltrates OR an ABG with hypoxia/ increased A-a gradient
What is the most accurate test for Pneumocystis Pneumonia?
Bronchoalveolar lavage
If the sputum stain on a patient you suspect Penumocystis Pneumonia came back negative, what should you order?
Bronchoscopy
What is always elevated in the diagnosis of Pneumocystis Pneumonia?
LDH
A normal LDH means you should NOT answer PCP as the diagnosis
What is the best initial treatment and prophylaxis for Pneumocystis Pneumonia?
Trimethroprim/Sulfamethoxazole (TMP/SMX)
What would you add to TMP/SMX for treatment of PCP to decrease mortality if the case is severe?
Steroids
If there is toxicity from TMP/SMX, what should you give instead for PCP?
Clindamycin and Primaquine
OR
Pentamidine
An HIV-positive African American man is admitted with dyspnea, dry cough, high LDH, and a pO2 of 63 mm Hg. He is started on TMP/SMX and prednisone. On the third hospital day he develops severe neutropenia and rash. He has anemia and there are bite cells visible on his smear.
What is the most appropriate next step in the management of this patient?
a. Stop TMP/SMX
b. Begin antiretroviral medications
c. Switch TMP/SMX to intravenous pentamidine
d. Switch TMP/SMX to aerosol pentamidine
e. Switch TMP/SMX to clindamycin and primaquine
C. Rash is the most common adverse effect of TMP/SMX, next is bone marrow suppression. Clindamycin and Primaquine may have more efficacy than Pentamidine but the patient seems to have G6PD (Bite cells), making Primaquine contraindicated. For active disease, intravenous Pentamidine is used, not aerosol.
How would you do prophylaxis for PCP in those with AIDS whose CD4 count is below 200u/l.
TMP/SMX
If there is rash or neutropenia with TMP/SMX, use Atovaquone or Dapsone
Dapsone is contraindicated for G6PD
An HIV-positive woman with 22 CD4 cells/ul is admitted with PCP and is treated successfully with TMP/SMX. Prophylactic TMP/SMX and azithromycin are started. She is then started on antiretroviral medication and her CD4 rises to 420 cells for the last 6 months.
What is the most appropriate next step in the management of this patient?
a. Stop TMP/SMX
b. Stop both TMP/SMX and azithromycin
c. Stop all medications and observe
d. Stop all medications if PCR-RNA viral load is undetectable
e. Continue all medications
f. Stop the azithromycin
B.
Give 3 criteria to diagnose TB.
clear risk factor
A cavity on the Chest X-Ray
Positive smear
What is the best initial test for TB?
Chest X-Ray
When do you stop TB medications?
when transaminases rise to 3 to 5 times the upper limit of normal
What is the manifestation of Rifampicin toxicity and its management?
Red color to body secretions
None, benign finding
What is the manifestation of Isoniazid toxicity and its management?
Peripheral neuropathy
Use pyridoxine to prevent
What is the manifestation of Pyrazinamide toxicity and its management?
Hyperuricemia
No treatment unless symptomatic
What is the manifestation of Ethambutol toxicity and its management?
Optic neuritis/color vision
Decrease dose in renal failure
What should pregnant patients NOT receive if they’re diagnosed with TB?
Pyrazinamide and Streptomycin
This drugs decrease the risk of constrictive pericarditis in those with pericardial involvement. They also decrease neurologic complications in TB meningitis.
Glucocorticoids
What is a positive PPD Test?
Induration larger than 5 millimeters
Should you use PPD and IGRA testing to those who are symptomatic or those with abnormal chest X-Ray?
No. They’re not useful. Do a sputum acid fast test instead
If first test is positive in PPD, should you do a second test?
Not necessary
If first test is negative in PPD, should you do a second test?
Yes. It can be falsely negative. If second test (after 1 to 2 weeks) is still negative, then the patient is truly negative
After active TB has been excluded with Chest X-Ray, patients should receive _______?
9 months of Isoniazid
What is the best initial step in all lung lesions?
to compare the size with old X-rays
What is the most common adverse effect of a transthoracic biopsy?
Pneumothorax
This is defined as the thickening of the interstitial septum of the lung between the arteriolar space and the alveolus.
Pulmonary fibrosis
What type of pneumoconiosis is most probable if the patient is exposed to Coal?
Coal worker’s pneumoconiosis
What type of pneumoconiosis is most probable if the patient is exposed to sunblasting, rock mining, tunneling?
Silicosis
What type of pneumoconiosis is most probable if the patient is exposed to shipyard workers, pipe fitting, insulators?
Asbestosis
What type of pneumoconiosis is most probable if the patient is exposed to Cotton?
Byssinosis
What type of pneumoconiosis is most probable if the patient is exposed to Electronic manufacture
Beryliosis
What type of pneumoconiosis is most probable if the patient is exposed to Moldy sugar cane?
Bagassosis
What is the best initial test for Pulmonary fibrosis?
Chest X-Ray
What is the most accurate test for Pumonary Fibrosis?
Lung Biopsy
Patient is a young African American woman with shortness of breath on exertion and occasional fine rales on lung exam. No wheezes noted. Ertythema nodosum is noted as well as lymphadenopathy on physical exam. What is the most likely diagnosis?
Sarcoidosis
What would you see in the chest X-ray or CT of a patient with Sarcoidosis?
Hilar adenopathy in a generally healthy African Americn woman
What is the drug of choice for Sarcoidosis?
Prednisone
Patient has a sudden onset of shortness of breath. There is clear lungs upon exam and normal Chest X-Ray. What is the most likely diagnosis?
Pulmonary Embolism
What is/are the best initial test for Pulmonary Embolism?
Chest X-Ray
EKG
ABG
After doing Chest X-Ray, EKG, ABG to a patient with Pulmonary Embolism, what is the next best step?
CT Angiogram
What is the most common abnormality you can find in the chest x-ray of a person you suspect with Pulmonary Embolism?
Atelectasis
What is the most common finding in an EKG of a patient you suspect with Pulmonary Embolism?
Sinus Tachycardia
What is the most common abnormality in an EKG of a patient you suspect with Pulmonary Embolism?
nonspecific ST-T wave changes
What will you expect on a the ABG of a patient with Pulmonary Embolism?
Hypoxia and respiratory alkalosis
What is the most common finding in a chest x-ray of a patient you suspect with Pulmonary Embolism?
usually normal
A 65-year-old woman who recently underwent hip replacement comes to the emergency department with the acute onset of shortness of breath and tachycardia. The Chest X-Ray is normal, with hypoxia on ABG, an increased A-a gradient, and an EKG with sinus tachycardia.
What is the most appropriate next step in management?
a. Enoxaparin
b. Thrombolytics
c. Inferior vena cava filter
d. Embolectomy
e. Spiral CT Scan
f. Ventilation/perfusion (V/Q) scan
g. Lower-extremity Doppler studies
h. D-dimer
A. When the history and initial labs are suggestive of PE, it is far more important to start therapy
What is the best initial test for Pulmonary embolism in pregnant patients?
V/Q scan
How would you interpret a D-dimer test>
A negative test excludes a clot but a positive test doesn’t mean anything
What are the adverse effects of angiography?
Allergy
Renal toxicity
Death
When giving Warfarin, what should you give first for initial therapy?
Low-molecular-weight-heparin
Give example of NOACs
Rivaroxaban
Apixaban
Edoxaban
Dabigatran
What are the advantages of NOACs
- cause less intracranial bleeding than warfarin
- do not need INR monitoring and do not need enoxaparin first
- treat DVT and PE with efficacy at least as well as enoxaparin and warfarin
- they reach a therapeutic effect in several hours, instead of several days like warfarin
What is the antidote for Dabigatran?
Idarucizumab
This drug is safe to use with heparin-induced thrombocytopenia (HIT)
Fondaparinux
When will you use Inferior Vena Cava filter for Pulmonary Embolism?
- If there is a contraindication to the use of anticoagulants (e.g. melena, CNS bleeding)
- Recurrent emboli while on a NOAC or fully therapeutic warfarin (INR of 2-3)
- Right ventricular (RV) dysfunction with an enlarged RV on echo
When will you use thrombolytics for Pulmonary Embolism?
- Hypotension (systolic BP<90)
- Acute RV dysfunction
What is the best initial test for pulmonary hypertension?
Chest X-Ray and CT
What will you see in a Chest X-Ray/CT of a patient with Pulmonary Hypertension?
Dilation of the proximal pulmonary arteries with narrowing or “pruning” of distal vessels
What is the most accurate test for Pulmonary Hypertension? It is the most precise method to measure pressures by vascular reactivity.
Right heart or Swan-Ganz catheter
What will you see in the echo of a patient with Pulmonary Hypertension?
RA and RV hypertrophy
What is a curative treatment for Idiopathic Pulmonary Hypertension?
Lung Transplantation
What is the most commonly identified cause of obstructive sleep apnea?
Obesity
What is the most accurate test for Sleep Apnea?
Polysomnography
This is defined as respiratory failure fromover-whelming lung injury or systemic disease leading to severe hypoxia with chest x-ray suggestive of congestive failure but normal cardiac hemodynamic measurements.
Acute Respiratory Distress Syndrome (ARDS)
What will you see in the chest x-ray of a patient with ARDS?
- Bilateral infiltrates that quickly become confluent (“white out”)
- Air bronchograms
What is the pO2/FIO2 ratio needed to define ARDS?
<300
<200 = moderately severe <100 = severe
What is your treatment option for ARDS?
Low tidal-volume mechanical ventilation
use 6ML per kg of tidal volume
