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Internal Medicine > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

What is the next best step after diagnosis of chronic cough with no use of ACEi?

A
  1. CXR
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2
Q

Most common cause of chronic cough in an immunocompetent, non-smoker

A
  1. PND
  2. Asthma
  3. GERD
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3
Q

What is a cough variant asthma?

A

cough with hyperactive airway

worse at night or on waking

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4
Q

What is the major risk factor for asthma?

A

Atopy

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5
Q

Most common allergens to trigger asthma ___

A

Dermatophagoides species (dust mites(

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6
Q

Evidence of Variable expiratory airflow limitation

A
  1. FEV1/FVC ratio (<0.7)
  2. FEV1 that increases by >12% and at least 200mL from baseline post bronchodilator
  3. Reduced FEV1 that increases >12% (and by at least 200mL) after 4 weeks on steroid trial
  4. Decrease in FEV1 by 20% with methacoline or histamine
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7
Q

What is the most accurate test for asthma?

A

Pulmonary function test or spirometry (decrease in FEV1 to FVC ration)

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8
Q

What is the most accurate test in asymptomatic patients suspected of asthma?

A
  1. Methacoline / Histamine stimulation test
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9
Q

In patients with asthma presenting with clinical urgency, what will you do?

A
  1. Empiric treatment with ICS and as needed SABA
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10
Q

Conditions in which asthma is considered partly controlled

A
  1. > /1 per year exacerbation
  2. > 2x per week daytime symptoms
  3. > 2x/week need for reliever
  4. <80% lung function
  5. With limitation of activity
  6. Nigh awakening
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11
Q

[Asthma: Controller and Reliever]

Step 1

A

Controller: Low dose ICS-Formoterol

Budesonide+Formoterol

Reliever: low dose ICS + formoterol

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12
Q

[Asthma: Controller and Reliever]

Step 2

A

Daily low dose ICS or as needed low dose ICS-formoterol

Reliever: low dose ICS-Formoterol

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13
Q

[Asthma: Controller and Reliever]

Step 3

A

Controller: Low dose ICS-LABA

Reliever: As needed ICS formoterol

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14
Q

[Asthma: Controller and Reliever]

Step 4

A

Controller: medium dose ICS-LABA

Reliever: As needed ICS formoterol

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15
Q

[Asthma: Controller and Reliever]

Step 1

A

Controller: High dose ICS-LABA

reliever: low dose ICS-formoterl

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16
Q

What is the most effective and first line drug for patients with persistent asthma?

A

ICS

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17
Q

___ is an IgG against IgE. It decreases the activation and release of mast cells

A

Omalizumab

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18
Q

What is the first line drug for acute severe asthma?

A

SABA

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19
Q

What are the drugs safe in pregnancy?

A
  1. SABA
  2. ICS
  3. Theophylline
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20
Q

[Diagnosis]

smoker, worsening shortness of breath, dyspnea at rest, barrel-shaped chest, faint expiratory wheezes

A

COPD

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21
Q

What is the best initial test for COPD

A

CXR

Most accurate test: Pulmonary function test

Best diagnostic test: ABG

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22
Q

What muscles helps the COPD patient breath when he assumes a tripod position

A
  1. SCM
  2. Scalene
  3. Intercostal muscles
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23
Q

What is the cut off for FEV1/FVC ratio in patients with COPD

A

<0.7

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24
Q

[Diagnose]

40/M non-smoker with
COPD

CXR: bullae at the bases of the lungs

A

Alpha 1 antitrypsin deficiency

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25
Q

A narrow loop in spirometry suggests a ___ (obstructive/restrictive) lung pattern

A

Restrictive = decrease volume

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26
Q

A short loop in spirometry suggests a ___ (obstructive/restrictive) lung pattern

A

Obstructive = decrease airflow

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27
Q

[GOLD Classification based on post FEV1 test]

FEV1 50 to <80% predicted

A

Moderate = GOLD 2

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28
Q

[GOLD Classification based on post FEV1 test]

FEV1 30 to <50% predicted

A

Severe = GOLD 3 = 50 + 30

note: 50 + 30% = 80%

GOLD 2 = 50 to 80%

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29
Q

What stage of COPD will you start pulmonary rehab?

A

GOLD B

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30
Q

What is the DOC for GOLD A?

A
  1. Bronchodilator
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31
Q

What are the vaccines required for patients with COPD

A
  1. Flu

2. Pneumo

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32
Q

[Modified Medical Research Council Dyspnea Scale]

Shortness of breath walking on level ground or up a slight hill

A

Grade 1

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33
Q

[Modified Medical Research Council Dyspnea Scale]

Walks slower than people of similar age due to breathlessness or has to stop tp rest when walking at own pace

A

Grade 2 = slow

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34
Q

[Modified Medical Research Council Dyspnea Scale]

stops to rest after walking 100m or after walking few minutes on level ground

A

Grade 3 = 100m

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35
Q

[Modified Medical Research Council Dyspnea Scale]

too breathless to leave the house or breathless with ADLs

A

Grade 4

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36
Q

[Pharma: COPD]

PDE4 inhibitor used for moderate to severe exacerbations

A

Roflumilast

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37
Q

What are the 3 interventions that demonstrate influence to the natural history in COPD?

A
  1. Smoking cessation
  2. O2 therapy
  3. Lung volume reduction
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38
Q

When will you start supplemental oxygen therapy in COPD patients?

A
  1. pO2 <55 or Sat 88%

2. pO2 <60 or sat 90 if with signs of pulmonary hypertension or heart failure

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39
Q

[COPD: Initial Therapy for]

Group A

A

Bronchodilator

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40
Q

[COPD: Initial Therapy for]

Group B

A
  1. Long acting bronchodilator

2. LABA/LAMA

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41
Q

[COPD: Initial Therapy for]

Group C

A

LAMA

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42
Q

[COPD: Initial Therapy for]

Group D

A

LAMA or
LAMA + LABA or
ICS + LABA

43
Q

What are the drugs used for smoking cessation?

A
  1. Nicotine
  2. Bupropion
  3. Varenicline
44
Q

Indications for NIPPV

A
  1. Respiratory acidosis (PCO2 >/ 45mmHg and pH /< 7.35
  2. Severe dyspnea with muscle fatigue
  3. Persistent hypoxemia despite oxygenation
45
Q

Low risk CAP Criteria

A

VS are not:

  1. RR >/ 30
  2. HR >/ 125
  3. Temp <36 or >40 degC
  4. SBP <90
  5. DBP <60

Not altered mental status, no suspected aspiration, no unstable co-morbids, CXR not multilobar, pleural eff, or abscess

46
Q

Moderate risk CAP

A

VS are:

  1. RR >/ 30
  2. HR >/ 125
  3. Temp <36 or >40 degC
  4. SBP <90
  5. DBP <60

Withaltered mental status, no suspected aspiration, no unstable co-morbids, CXR not multilobar, pleural eff, or abscess

no severe sepsis and septic shock, no need for mech vent

47
Q

What are the components of CURB-65?

A

Confusion
U - BUN >30
RR >/30
BP SBP >90 DBP<60

65 years old or older

Remember 30
BUN 30
RR 30
DBP 30 + 30 = 60
SBP 30 x 3 = 90
48
Q

Based on CURB-65, what is the mortality rate if the patient has a score of 2

A

13%

Supervised outpatient/brief inpatient

49
Q

Based on CURB-65, what is the mortality rate if the patient has a score of 3

A

17%

Hospitalize

50
Q

Based on CURB-65, what is the mortality rate if the patient has a score of 4

A

41.5%

ICU

51
Q

what are the etiologies in low risk pneumonia?

A 
S. pneumonia
C. pneumonae
H. influenzae
Enterics
M. catarrhalis
M. pneumonia

SCHEMM

52
Q

What are the possible etiologies for moderate risk pneumonia?

A 
S. pneumonia
C. pneumonae
H. influenzae
Enterics
M. catarrhalis
M. pneumonia

SCHEMM

+ Legionella pneumophila

53
Q

What are the possible etiologies for high risk pneumonia?

A 
S. pneumonia
C. pneumonae
H. influenzae
Enterics
M. catarrhalis
M. pneumonia
SCHEMM

Legionella pneumophila

P. aeruginosa
S. aureus

54
Q

[Possible etiology: pneumonia]

What are you atypical causes of pneumonia

A
  1. Mycoplasma
  2. Chlamydia
  3. Legionella
55
Q

[Possible etiology: pneumonia]

stay in hotel or on cruise ship in previous 2 weeks

A

Legionella

56
Q

[Possible etiology: pneumonia]

patient with stroke, dementia, decreased consciousness

A

Anaerobes, gram negative enterics

57
Q

[Possible etiology: pneumonia]

recent antibiotic uses, malnutrition, steroid use, bronchiectasis

A

Pseudomonas

58
Q

What is the best initial test for pneumonia?

A

CXR

Biomarkers:
CRP - for treatment failure or worsening disease

Procalcitonin - distinguish bacterial from viral

59
Q

[Pharma: Pneumonia]

Low Risk, no co-morbids

A
  1. DOC: Amoxicillin
  2. Azithromycin
  3. Clarithromycin
60
Q

[Pharma: Pneumonia]

Low ris, stable co-morbids

A
  1. Co-amoxiclav + Sultamicillin OR

2. Cefuroxime +/- Extended macrolides

61
Q

[Pharma: Pneumonia]

moderate risk

A
  1. Ampicilin-Sulbactam, Ceftriaxone, Ertapenem + (Levofloxacin Moxifloxacin)

OR

  1. Ampicilin-Sulbactam, Ceftriaxone, Ertapenem + Azithromycin
62
Q

[Pharma: Pneumonia]

high risk, no risk for Pseudomonas

A
  1. BLIC, Cephalosporin, Carbapenem + Azithromycin or Clarithromycin

OR

  1. BLIC, Cephalosporin, Carbapenem + Levofloxacin or Moxifloxacin
63
Q

[Pharma: Pneumonia]

high risk, with risk for Pseudomonas

A
  1. Piperacillin-Tazobactam, Meropenem, Imipenem-Cilastatin + Azithromycin or Clarithromycin
    + gentamicin or amikacin

OR

  1. BLIC, Cephalosporin or carbapenem + IV Ciprofloxacin or IV levofloxacin
64
Q

[Pharma: Pneumonia]

high risk, with risk for Pseudomonas, MRSA SUSPECTED

A

Add Vancomycin, Linezolid or Clindamycin

  1. Piperacillin-Tazobactam, Meropenem, Imipenem-Cilastatin + Azithromycin or Clarithromycin
    + gentamicin or amikacin

OR

  1. BLIC, Cephalosporin or carbapenem + IV Ciprofloxacin or IV levofloxacin
65
Q

[Response to Pneumonia Treatment]

Fever is expected to resolve after ___ week

A

1 week

66
Q

[Response to Pneumonia Treatment]

chest pain and sputum production should substantially reduce after ___ weeks

A

4 weeks

67
Q

[Response to Pneumonia Treatment]

cough and breathlessness should have substantially reduced after ___ weeks

A

6 weeks

68
Q

[Response to Pneumonia Treatment]

Most symptoms should have resolved, but fatigue may still be present after ___ months

A

3 months

69
Q

[Response to Pneumonia Treatment]

most people will feel back to normal after ___ months

A

6 months

70
Q

What is the first evidence that suggests response to treatment?

A
  1. Resolution of fever within a week

2. Decreasing WBC within 2 to 4 days

71
Q

[Diagnosis]

Fever, cough, chest pain, discolored phelgm, foul smelling sputum

A

Lung abscess

Initial test: CXR
Most accurate: Chest CT

72
Q

Most frequently affected side if the lung with lung abscess

A

Right lung

Tx: IV Clindamycin or IV Beta lactam with BLIC

73
Q

What is the CD4 count to suspect PCP pneumonia?

A

<200

74
Q

What is the CXR findings in PCP pneumonia?

A

near normal to diffuse bilateral infiltrate to large cysts or blebs

75
Q

What is the DOC for PCP pneumonia

A
  1. TMP/SMX
  2. Adjunct steroid therapy if with PaO2 <70 mmHg or A-a gradient >35

Tx: 21 days

76
Q

[Diagnose]

50F CHF DOB
Mild respiratory distress, absent breath sounds and dullness to percussion at the base of the lung

A

Dx: Pleural effusion
Initial test: CXR PA Lat
Most accurate: UTZ guided thora

Measure the serum and pleural fluid protein gradient

77
Q

What are the indications for performing an initial thoracentesis?

A
  1. > 10mm thick pleural effusion of lateral decubitus CXR
  2. With CHF
  3. Asymmetric, chest, pain, fever
78
Q

A trial of diuresis to alleviate pleural effusion will last for ___ days

A

3 days.

then if it persists, do a thoracentesis

79
Q

What are the findings of an exudative pleural effusion?

A
  1. PF/Serum protein > 0.5
  2. PF/Serum LDH > 0.6
  3. PF LDH > 2/3 upper normal serum limit
80
Q

Most common cause of pleural effusion ____

A

LV heart failure

81
Q

What is the most common cause of exudative pleural effusion in many parts of the world?

A

TB

82
Q

What is the 2nd most common cause of exudative effusion

A

Malignancy

83
Q

If patient is clinically transudative, but criteria is exudative, what will you checK?

A

Check difference between serum-PF protein.

If gradient >31g/dL, effusion is transudative

84
Q

If the pleural fluid has a glucose of <60 mg/dL, consider

A
  1. Malignancy
  2. Bacterial infections
  3. Rheumatoid Arthritis
85
Q

In cases of pleural effusion, when will you do a more invasive procedure?

A
  1. Loculated pleural fluid
  2. Pleural fluid pH <7.20
  3. Pleural fluid glucose <60mg/dL
  4. Positive gram stain or culture of the pleural fluid
  5. Presence of gross pus in the pleural space
86
Q

When will you remove the CTT in patients warranting CTT drainage?

A

Drainage rate of 50mL/day

87
Q

[Chylothorax vs Pseudochylothorax]

Milky gross appearance
TAG >400
Chylomicrons present

A

Chylothorax

if TAG <50mg/dL, its not chylothorax

88
Q

Conditions that can cause pseudochylothorax

A
  1. TB
  2. RA
  3. Inadequately treated empyema
  4. Chronic exudative effusion from almost any cause
89
Q

Rupture of which part of the lungs frequently cause spontaneous pneumothorax?

A

Apical bleb

90
Q

[Diagnosis]

DOB, pleuritic chest pain

Decreased breathsounds, hyperresonance, absent fremitus, hypoxia and hypercapnia on ABG

A

Pneumothorax

91
Q

What are the agents used in Pleurodesis?

A
  1. Talc

2. Tetracycline

92
Q

Most common cancer associated with asbestos exposure

A

Lung cancer

93
Q

[Diagnose: CXR findings]

Calcified pleural plaques

A

Asbestosis

94
Q

[Diagnose: CXR findings]

egg-shell calcification

A

Silicosis

95
Q

[Diagnose: CXR findings]

nodules along septal line

A

Berylliosis

96
Q

[Diagnose: CXR findings]

Diffuse infiltrates; hilar adenopathy

A

Byssinosis

due to cotton

97
Q

[Diagnose: CXR findings]

Progressive fibrosis

A

coal workers pneumoconiosis

coal exposure

98
Q

What is the most common daytime symptom in OSA?

A

excessive sleepiness

99
Q

What is the gold standard for diagnosis of OSAHS?

A

Overnight polysomnogram (PSG)

100
Q

Apnea in OSA is defined as ___

A
  1. Cessation of airflow >10s

2. Persistent respiratory effort (obstructive) OR absence of respiratory effort (central)

101
Q

Hypopnea is defined as ____

A
  1. > 30% reduction in airflow for at least 10s during sleep

2. >3% desaturation or an arousal

102
Q

How will you treat OSA?

A
  1. Weight loss

2. CPAP

103
Q

How will you treat central sleep apnea?

A
  1. avoid alcohol and sedatives

2. Acetazolamide

104
Q

What is the most common complaint in patients with OSA?

A

Snoring

Internal Medicine (10 decks)

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