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USMLE Step 3 MN > Pulmonology > Flashcards

Pulmonology Flashcards

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USMLE® Step 1 flashcards
1
Q
  • SOB

- expiratory wheezing

A

asthma

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2
Q
  • hyperventilation/increased RR
  • decrease in peak flow
  • hypoxia
  • respiratory acidosis
  • possible absence of wheezing
A

SEVERE asthma exacerbation

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3
Q

if asthma diagnosis is unclear

A

PFT before and after inhaled bronchodilators

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4
Q

asthma and reactive airway disease are CONFIRMED with what finding on PFT?

A

INCREASE in FEV1 of greater than 12%

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5
Q

ALL patients with SOB should receive the following

A
  • oxygen
  • continuous oximeter
  • CXR
  • ABG
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6
Q

best INITIAL treatment for asthma exacerbation

A
  • inhaled bronchodilator (albuterol); no maximum dose
  • steroid bolus (methylprednisolone)
  • inhaled ipratropium (ACh receptor antagonist)
  • oxygen
  • magnesium
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7
Q

when should an asthma patient be placed in the ICU?

A

respiratory acidosis with CO2 retention

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8
Q

what is the indication for intubation and mechanical ventilation in asthma?

A

PERSISTENT respiratory acidosis

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9
Q

best INITIAL treatment for nonacute asthma

A

inhaled bronchodilator (albuterol)

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10
Q

if asthma patient is not controlled on inhaled bronchodilator (albuterol)

A

inhaled steroid

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11
Q

if patient is STILL not controlled on inhaled bronchodilator (albuterol), and inhaled steroids

A

inhaled long-acting beta agonist (LABA) (salmeterol, or formoterol)

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12
Q

alternate long-term controller medications besides inhaled steroids: extrinsic allergies, such as hay fever

A

cromolyn

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13
Q

alternate long-term controller medications besides inhaled steroids: atopic disease

A

montelukast

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14
Q

alternate long-term controller medications besides inhaled steroids: COPD

A
  • tiotropium

- ipratropium

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15
Q

alternate long-term controller medications besides inhaled steroids: high IgE levels, no control with cromolyn

A

omalizumab (anti-IgE Ab)

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16
Q

last resort for uncontrolled nonacute asthma (if still not controlled on SABA, inhaled steroids, and LABA)

A

PO steroids (many adverse effects)

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17
Q

treatment for exercise-induced asthma

A

inhaled bronchodilator BEFORE exercise

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18
Q
  • long-term smoker
  • increasing SOB
  • decreasing exercise tolerance
A

COPD

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19
Q

treatment for acute exacerbation of COPD

A
  • oxygen (NOT TOO MUCH)
  • ABG
  • CXR
  • inhaled albuterol
  • inhaled ipratropium
  • steroid bolus (methylprednisolone)
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20
Q

what should be added in treatment for acute exacerbation of COPD, if fever, sputum, and/or new infiltrate is present on CXR?

A

ceftriaxone and azithromycin for CAP

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21
Q

management of COPD with mild respiratory acidosis

A

BiPAP or CPAP

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22
Q

COPD physical examination findings

A
  • barrel-shaped chest
  • clubbing of fingers
  • increased AP diameter mf chest
  • loud P2 heart sound (pulmonary HTN)
  • edema (blood backing up d/t pulmonary HTN)
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23
Q

EKG findings in COPD

A
  • right axis deviation (RAD)
  • right ventricular hypertrophy (RVH)
  • right atrial hypertrophy (RAH)
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24
Q

CXR findings in COPD

A
  • flattening of diaphragm
  • elongated heart
  • substernal air trapping
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25
Q

CBC findings in COPD

A
  • increased hematocrit (sign of chronic hypoxia)

- microcytic

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26
Q

chemistry finding in COPD

A

increased serum bicarbonate

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27
Q

mechanism of right heart enlargement in COPD

A

hypoxia = capillary constriction in lungs = diffuse vasoconstriction = increased pressure in RV and RA

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28
Q

expected PFT results in COPD

A
  • decreased FEV1
  • decreased FVC (loss of elastic recoil of lung)
  • decreased FEV1/FVC ratio
  • increased TLC (d/t air trapping)
  • increased residual volume (RV)
  • decreased diffusion capacity lung carbon monoxide (DLCO) (destruction of lung interstitium
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29
Q

chronic treatment for COPD

A
  • tiotropium/ipratropium
  • albuterol
  • pneumococcal vaccine
  • influenza vaccine
  • smoking cessation
  • long-term home O2
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30
Q

when is home oxygen indicated in COPD?

A
  • pO2 less than 55

- oxygen saturation less than 88%

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31
Q

what lowers mortality in COPD?

A
  • smoking cessation

- home oxygen

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32
Q
  • cirrhosis and COPD

- EARLY AGE (

A

a-1 antitrypsin deficiency

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33
Q

CXR findings in a-1 antitrypsin deficiency

A
  • bullae
  • barrel chest
  • flat diaphragm
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34
Q

blood test findings in a-1 antitrypsin deficiency

A
  • low albumin
  • elevated PT (caused by cirrhosis)
  • LOW a-1 antitrypsin level
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35
Q

treatment for a-1 antitrypsin deficiency

A

a-1 antitrypsin infusion

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36
Q
  • anatomic defect of lungs (from infection in childhood)
  • profound dilation of bronchi
  • chronic resolving and recurring episodes of lung infection
  • VERY HIGH volume of sputum
  • hemoptysis
  • fever
A

bronchiectasis

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37
Q

CXR finding in bronchiectasis

A
  • dilated bronchi with “tram tracking”
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38
Q

MOST ACCURATE test for bronchiectasis

A

HRCT (high-resolution CT of chest)

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39
Q

treatment for bronchiectasis

A
  • NO curative treatment
  • chest PT
  • rotating antibiotics
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40
Q

causes of interstitial lung disease (ILD)

A
  • idiopathic
  • occupational exposure
  • environmental exposure
  • medication
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41
Q

medications that can cause ILD

A
  • trimethoprim/sulfamethoxazole

- nitrofurantoin

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42
Q

ILD cause = what disease?

asbestos

A

asbestosis

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43
Q

ILD cause = what disease?

glass workers, mining, sandblasting, brickyards

A

silicosis

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44
Q

ILD cause = what disease?

coal worker

A

coal worker’s pneumoconiosis

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45
Q

ILD cause = what disease?

cotton

A

byssinosis

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46
Q

ILD cause = what disease?

electronics, ceramics, fluorescent light bulbs

A

berylliosis

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47
Q

ILD cause = what disease?

mercury

A

pulmonary fibrosis

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48
Q
  • SOB with dry, nonproductive cough
  • chronic hypoxia
  • 6 months or more of symptoms
A

ILD

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49
Q

PE findings in ILD

A
  • dry rales
  • loud P2 heart sound (sign of pulmonary HTN)
  • clubbing
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50
Q

CXR finding in ILD

A

interstitial fibrosis

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51
Q

diagnostic tests for ILD

A
  • CXR
  • HRCT
  • lung biopsy
  • PFT
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52
Q

PFT findings in ILD

A
  • decreased FEV1
  • decreased FVC
  • NORMAL FEV1/FVC ratio (equally decreased)
  • decreased TLC
  • decreased DLCO
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53
Q

treatment for ILD

A
  • no specific treatment
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54
Q

if biopsy show inflammatory infiltrate in ILD, what is the treatment?

A

steroid trial

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55
Q

ONLY form of ILD that DEFINITELY responds to steroids

A

berylliosis

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56
Q
  • bronchiolitis and alveolitis
  • more acute than ILD, presents in days to weeks
  • cough, rales, and SOB
  • fever, malaise, and myalgias (ABSENT in ILD)
A

bronchiolitis obliterans organizing pneumonia (BOOP)

aka, cryptogenic organizing pneumonia (COP)

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57
Q

CXR finding in BOOP

A

B/L patchy infiltrates

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58
Q

chest CT findings in BOOP

A

interstitial disease and alveolitis

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59
Q

MOST ACCURATE test for BOOP

A

open lung biopsy

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60
Q

treatment for BOOP

A

steroids

no response to antibiotics

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61
Q
  • black, female, less than 40 yoa
  • cough, SOB, and fatigue over a few weeks to months
  • rales
A

sarcoidosis

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62
Q

best INITIAL test for sarcoidosis

A

CXR (enlarged lymph nodes, and maybe ILD)

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63
Q

MOST ACCURATE test for sarcoidosis

A

lung or LN biopsy (NONcaseating granulomas)

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64
Q

what will BAL show in sarcoidosis?

A

increased # of helper cells

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65
Q

best treatment for sarcoidosis

A

steroids

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66
Q
  • SOB, more often in young women
A

pulmonary hypertension

67
Q

pulmonary HTN can occur 2/2?

A
  • MS
  • COPD
  • PV
  • chronic PE
  • ILD
68
Q

PE findings in pulmonary hypertension

A
  • loud P2
  • TR
  • right ventricular heave
  • Raynaud’s phenomenon
69
Q

TTE findings in pulmonary hypertension

A
  • RVH

- enlarged RA

70
Q

EKG finding in pulmonary hypertension

A

RAD

71
Q

MOST ACCURATE test for pulmonary hypertension

A

right heart catheterization (Swan-Ganz catheterization) (increased pulmonary artery pressure)

72
Q

treatment for pulmonary hypertension

A
  • bosentan (endothelin inhibitor)
  • epoprostenol/treprostinil (prostacyclin analogs = pulmonary vasodilators)
  • CCB
  • sildenafil
73
Q
  • SUDDEN SOB
  • CLEAR lungs
  • patient with risk factors for DVT: immobility, malignancy, trauma, surgery, hematological abnormalities
A

pulmonary embolism

74
Q

CXR findings in PE

A
  • MC result is NORMAL

- MC ABNORMALITY is atelectasis

75
Q

EKG findings in PE

A
  • SINUS TACHYCARDIA
  • MC abnormality is nonspecific ST-T wave changes
  • RAD/RBBB (uncommon)
76
Q

ABG findings in PE

A
  • hypoxia
  • increased A-a gradient
  • mild respiratory alkalosis (2/2 hyperventilation)
77
Q

mechanism of right heart strain in PE

A

severe pressure increase in PA and RV d/t clot

78
Q

standard test to confirm PE

A

CTA

79
Q

for a V/Q scan to be accurate, the CXR MUST be

A

NORMAL

the less normal the CXR, the LESS accurate the V/Q scan

80
Q

if V/Q scan is low-probability, does it exclude PE

A

NO, 15% still have a PE

81
Q

if V/Q scan is high-probability, does it definitely include PE

A

NO, 15% don’t have a PE

82
Q

sensitivity of LE doppler

A

70%

83
Q

if D-dimer is negative

A

PE extremely unlikely

84
Q

MOST ACCURATE test for PE

A

angiography

85
Q

patient with PE and CONTRAINDICATION to AC, next step in management

A

IVC filter

86
Q

treatment for PE

A
  • heparin and O2

- warfarin for AT LEAST 6 MONTHS

87
Q

treatment for PE in HEMODYNAMICALLY UNSTABLE patient (hypotension)

A

thrombolytics

88
Q

thrombolytics MOA

A

activate plasminogen to plasmin

89
Q

best INITIAL test for pleural effusion

A

CXR

90
Q

next step after CXR for pleural effusion

A

decubitus films with pt lying down

91
Q

MOST ACCURATE test for pleural effusion

A

thoracentesis

92
Q

pleural effusion: exudate

causes and lab findings

A
  • cancer
  • infection
  • HIGH protein (> 50% of serum level)
  • HIGH LDH (> 60% of serum level)
93
Q

pleural effusion: transudate

causes and lab findings

A
  • CHF

- LOW protein (

94
Q

treatment for SMALL pleural effusion

A
  • NO treatment needed

- diuretics can be used, especially for CHF

95
Q

treatment for LARGER pleural effusion, especially from infection (empyema)

A

chest tube

96
Q

treatment for LARGE, and RECURRENT pleural effusions

A

pleurodesis

97
Q

treatment if pleurodesis FAILS

A

decortication (stripping of pleura from lung)

98
Q
  • obese patient
  • daytime somnolence
  • severe snoring
  • HTN, HA, ED, fat neck
A

sleep apnea

99
Q

MCC of sleep apnea (95% of cases)

A

fatty tissue of neck blocking breathing

100
Q

cause of small % of patients with sleep apnea

A

central sleep apnea (decreased respiratory drive from CNS)

101
Q

how is sleep apnea diagnosed?

A

sleep study (polysomnography)

102
Q

definition of MILD sleep apnea

A

5-20 apneic episodes/hour

103
Q

definition of SEVERE sleep apnea

A

more than 30 apneic episodes/hour

104
Q

treatment for sleep apnea: OBSTRUCTIVE DISEASE

A
  • weight loss

- CPAP (continuous positive airway pressure, or BiPAP

105
Q

if initial treatment for sleep apnea: OBSTRUCTIVE DISEASE is not effective

A
  • surgical resection of uvula, palate, and pharynx
106
Q

treatment for sleep apnea: CENTRAL SLEEP APNEA

A
  • avoid alcohol and sedative
  • acetazolamide (causes metabolic acidosis = helps drive respiration)
  • medroxyprogesterone (central respiratory stimulant)
107
Q

mechanism of acetazolamide

A

carbonic anhydrase inhibitor

108
Q
  • asthmatic patient with WORSENING asthma symptoms
  • brown mucous plug production
  • recurrent infiltrates
  • peripheral eosinophilia
  • elevated serum IgE
  • central bronchiectasis
A

allergic bronchopulmonary aspergillosis (ABPA)

109
Q

diagnostic tests for allergic bronchopulmonary aspergillosis (ABPA)

A
  • Aspergillus skin testing
  • IgE
  • precipitins
  • A. fumigatus-specific Ab
110
Q

treatment for allergic bronchopulmonary aspergillosis (ABPA)

A

ORAL corticosteroids

111
Q

allergic bronchopulmonary aspergillosis (ABPA) treatment in refractory disease if steroids don’t work

A

itraconazole

112
Q
  • sudden, SEVERE respiratory failure syndrome

- diffuse lung injury 2/2 OVERWHELMING systemic injuries

A

acute respiratory distress syndrome (ARDS)

113
Q

possible ARDS causes

A
  • sepsis
  • aspiration of gastric contents
  • shock
  • infection: pulmonary or systemic
  • lung contusion
  • trauma
  • toxic inhalation
  • near drowning
  • pancreatitis
  • burns
114
Q

CXR finding in ARDS

A

diffuse patchy infiltrates that become confluent

115
Q

wedge pressure in ARDS

A

NORMAL

116
Q

pO2/FIO2 ratio in MILD ARDS

A

201-300

117
Q

pO2/FIO2 ratio in MODERATE ARDS

A

101-200

118
Q

pO2/FIO2 ratio in SEVERE ARDS

A

100 OR LESS

119
Q

treatment for ARDS

A
  • ventilator
  • positive end expiratory pressure (PEEP) (keep alveoli open)
  • prone positioning
  • diuretics
  • positive inotropes (dobutamine)
  • ICU
120
Q

Swan-Ganz (pulmonary artery) catheterization:

HYPOVOLEMIA

  • cardiac output
  • wedge pressure
  • systemic vascular resistance (SVR)
A
  • LOW
  • LOW
  • HIGH
121
Q

Swan-Ganz (pulmonary artery) catheterization:

CARDIOGENIC SHOCK

  • cardiac output
  • wedge pressure
  • systemic vascular resistance (SVR)
A
  • LOW
  • HIGH
  • HIGH
122
Q

Swan-Ganz (pulmonary artery) catheterization:

SEPTIC SHOCK

  • cardiac output
  • wedge pressure
  • systemic vascular resistance (SVR)
A
  • HIGH
  • LOW
  • LOW
123
Q
  • fever
  • cough
  • +/- sputum
  • SOB
A

pneumonia

124
Q

CAP organism

A

pneumococcus

125
Q

HAP organism

A

gram-negative bacilli

126
Q

CURB 65

A
  • confusion
  • BUN greater than 19
  • RR greater than 30
  • BP less than 90/60
  • age greater than 65
127
Q

best INITIAL diagnostic test for pneumonia

A

CXR

128
Q

MOST ACCURATE test for pneumonia

A

sputum gram stain and culture

129
Q

pneumonia with SOB, order

A

oxygen

130
Q

pneumonia with SOB and/or hypoxia, order

A

ABG

131
Q

OUTPATIENT treatment for pneumonia

A

macrolide OR respiratory fluoroquinolone

macrolide = azithromycin/clarithromycin
fluoroquinolone = levofloxacin/moxifloxacin
132
Q

INPATIENT treatment for pneumonia

A
  • ceftriaxone, AND azithromycin

OR

  • fluoroquinolone ONLY
133
Q

treatment for ventilator-associated pneumonia (VAP)

A
  • imipenem/meropenem, piperacillin/tazobactam, or cefepime

AND

  • gentamicin

AND

  • vancomycin/linezolid
134
Q

does a positive sputum culture mean pneumonia?

A

NO

135
Q

specific associations for pneumonia:

recent viral syndrome

A

Staphylococcus

136
Q

specific associations for pneumonia:

alcoholic

A

Klebsiella

137
Q

specific associations for pneumonia:

GI symptoms, confusion

A

Legionella

138
Q

specific associations for pneumonia:

young, healthy patient

A

Mycoplasma

139
Q

specific associations for pneumonia:

birth of animal (placenta)

A

Coxiella burnetii

140
Q

specific associations for pneumonia:

Arizona construction worker

A

Coccidioidomycosis

141
Q

specific associations for pneumonia:

HIV with CD4 count less than 200

A

Pneumocystis jirovecii (PCP)

142
Q

ventilator-associated pneumonia

A
  • fever
  • hypoxia
  • new infiltrate
  • increasing secretions
143
Q

when should steroids be given in PCP pneumonia?

A
  • pO2 less than 70

- A-a gradient more than 35

144
Q
  • risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics)
  • fever, cough, sputum, weight loss, night sweats
A

tuberculosis (TB)

145
Q

best INITIAL test for tuberculosis (TB)

A

CXR

146
Q

test to confirm TB

A

sputum acid-fast stain and culture

147
Q

treatment for TB

A
  1. isoniazid (INH) x 6 mos
  2. rifampin x 6 mos
  3. pyrazinamide x 2 mos
  4. ethambutol x 2 mos
148
Q

ALL the antituberculosis medications can cause?

A

hepatotoxicity

149
Q

when should antituberculosis medications be stopped if transaminases become elevated?

A

reach 5x upper limit of normal

150
Q

adverse effect of isoniazid

A

peripheral neuropathy

151
Q

adverse effect of rifampin

A

red/orange-colored bodily secretions

152
Q

adverse effect of pyrazinamide

A

hyperuricemia

153
Q

adverse effect of ethambutol

A

optic neuritis

154
Q

which conditions require TB treatment for MORE THAN 6 months

A
  • osteomyelitis
  • meningitis
  • miliary TB
  • cavitary TB
  • pregnancy
155
Q

what is a POSITIVE PPD test?

A

5mm: close contacts, pts on steroids, HIV-positive
10mm: risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics, healthcare workers)
15mm: those without increased risk

156
Q

if a patient has NEVER been tested for TB, how should the patient be tested?

A

2-stage testing

if FIRST test is NEGATIVE, repeat test in 1-2 WEEKS to confirm

157
Q

what is the indication for IGRA (interferon gamma release assay) (Quantiferon)?

A

same as PPD

158
Q

what is the lifetime risk for HIV-UNinfected individuals with latent TB infection developing active TB d/t reactivation?

A

10%

159
Q

what is the lifetime risk for HIV-INFECTED individuals with latent TB infection developing active TB d/t reactivation?

A

10%/year!

160
Q

if PPD is POSITIVE, next step?

A

CXR

161
Q

if PPD is positive, and CXR is ABNORMAL, next step?

A

sputum staining for TB

162
Q

if sputum staining for TB is POSITIVE, next step?

A

treat with full-dose, 4-drug therapy

163
Q

if PPD is POSITIVE, but CXR is NEGATIVE

A

isoniazid ALONE for 9 MONTHS

164
Q

once a PPD is POSITIVE, should you repeat it?

A

NEVER

USMLE Step 3 MN (33 decks)

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