Pulmonology Flashcards
1
Q
What is the next best step after diagnosis of chronic cough with no use of ACEi?
A
- CXR
2
Q
Most common cause of chronic cough in an immunocompetent, non-smoker
A
- PND
- Asthma
- GERD
3
Q
What is a cough variant asthma?
A
cough with hyperactive airway
worse at night or on waking
4
Q
What is the major risk factor for asthma?
A
Atopy
5
Q
Most common allergens to trigger asthma ___
A
Dermatophagoides species (dust mites(
6
Q
Evidence of Variable expiratory airflow limitation
A
- FEV1/FVC ratio (<0.7)
- FEV1 that increases by >12% and at least 200mL from baseline post bronchodilator
- Reduced FEV1 that increases >12% (and by at least 200mL) after 4 weeks on steroid trial
- Decrease in FEV1 by 20% with methacoline or histamine
7
Q
What is the most accurate test for asthma?
A
Pulmonary function test or spirometry (decrease in FEV1 to FVC ration)
8
Q
What is the most accurate test in asymptomatic patients suspected of asthma?
A
- Methacoline / Histamine stimulation test
9
Q
In patients with asthma presenting with clinical urgency, what will you do?
A
- Empiric treatment with ICS and as needed SABA
10
Q
Conditions in which asthma is considered partly controlled
A
- > /1 per year exacerbation
- > 2x per week daytime symptoms
- > 2x/week need for reliever
- <80% lung function
- With limitation of activity
- Nigh awakening
11
Q
[Asthma: Controller and Reliever]
Step 1
A
Controller: Low dose ICS-Formoterol
Budesonide+Formoterol
Reliever: low dose ICS + formoterol
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
13
Q
[Asthma: Controller and Reliever]
Step 3
A
Controller: Low dose ICS-LABA
Reliever: As needed ICS formoterol
14
Q
[Asthma: Controller and Reliever]
Step 4
A
Controller: medium dose ICS-LABA
Reliever: As needed ICS formoterol
15
Q
[Asthma: Controller and Reliever]
Step 1
A
Controller: High dose ICS-LABA
reliever: low dose ICS-formoterl
16
Q
What is the most effective and first line drug for patients with persistent asthma?
A
ICS
17
Q
___ is an IgG against IgE. It decreases the activation and release of mast cells
A
Omalizumab
18
Q
What is the first line drug for acute severe asthma?
A
SABA
19
Q
What are the drugs safe in pregnancy?
A
- SABA
- ICS
- Theophylline
20
Q
[Diagnosis]
smoker, worsening shortness of breath, dyspnea at rest, barrel-shaped chest, faint expiratory wheezes
A
COPD
21
Q
What is the best initial test for COPD
A
CXR
Most accurate test: Pulmonary function test
Best diagnostic test: ABG
22
Q
What muscles helps the COPD patient breath when he assumes a tripod position
A
- SCM
- Scalene
- Intercostal muscles
23
Q
What is the cut off for FEV1/FVC ratio in patients with COPD
A
<0.7
24
Q
[Diagnose]
40/M non-smoker with
COPD
CXR: bullae at the bases of the lungs
A
Alpha 1 antitrypsin deficiency
25
A narrow loop in spirometry suggests a ___ (obstructive/restrictive) lung pattern
Restrictive = decrease volume
26
A short loop in spirometry suggests a ___ (obstructive/restrictive) lung pattern
Obstructive = decrease airflow
27
[GOLD Classification based on post FEV1 test]
FEV1 50 to <80% predicted
Moderate = GOLD 2
28
[GOLD Classification based on post FEV1 test]
FEV1 30 to <50% predicted
Severe = GOLD 3 = 50 + 30
note: 50 + 30% = 80%
GOLD 2 = 50 to 80%
29
What stage of COPD will you start pulmonary rehab?
GOLD B
30
What is the DOC for GOLD A?
1. Bronchodilator
31
What are the vaccines required for patients with COPD
1. Flu
| 2. Pneumo
32
[Modified Medical Research Council Dyspnea Scale]
Shortness of breath walking on level ground or up a slight hill
Grade 1
33
[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
Grade 2 = slow
34
[Modified Medical Research Council Dyspnea Scale]
stops to rest after walking 100m or after walking few minutes on level ground
Grade 3 = 100m
35
[Modified Medical Research Council Dyspnea Scale]
too breathless to leave the house or breathless with ADLs
Grade 4
36
[Pharma: COPD]
PDE4 inhibitor used for moderate to severe exacerbations
Roflumilast
37
What are the 3 interventions that demonstrate influence to the natural history in COPD?
1. Smoking cessation
2. O2 therapy
3. Lung volume reduction
38
When will you start supplemental oxygen therapy in COPD patients?
1. pO2 <55 or Sat 88%
| 2. pO2 <60 or sat 90 if with signs of pulmonary hypertension or heart failure
39
[COPD: Initial Therapy for]
Group A
Bronchodilator
40
[COPD: Initial Therapy for]
Group B
1. Long acting bronchodilator
| 2. LABA/LAMA
41
[COPD: Initial Therapy for]
Group C
LAMA
42
[COPD: Initial Therapy for]
Group D
LAMA or
LAMA + LABA or
ICS + LABA
43
What are the drugs used for smoking cessation?
1. Nicotine
2. Bupropion
3. Varenicline
44
Indications for NIPPV
1. Respiratory acidosis (PCO2 >/ 45mmHg and pH /< 7.35
2. Severe dyspnea with muscle fatigue
3. Persistent hypoxemia despite oxygenation
45
Low risk CAP Criteria
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
Moderate risk CAP
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
What are the components of CURB-65?
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
Based on CURB-65, what is the mortality rate if the patient has a score of 2
13%
Supervised outpatient/brief inpatient
49
Based on CURB-65, what is the mortality rate if the patient has a score of 3
17%
Hospitalize
50
Based on CURB-65, what is the mortality rate if the patient has a score of 4
41.5%
ICU
51
what are the etiologies in low risk pneumonia?
```
S. pneumonia
C. pneumonae
H. influenzae
Enterics
M. catarrhalis
M. pneumonia
```
SCHEMM
52
What are the possible etiologies for moderate risk pneumonia?
```
S. pneumonia
C. pneumonae
H. influenzae
Enterics
M. catarrhalis
M. pneumonia
```
SCHEMM
+ Legionella pneumophila
53
What are the possible etiologies for high risk pneumonia?
```
S. pneumonia
C. pneumonae
H. influenzae
Enterics
M. catarrhalis
M. pneumonia
SCHEMM
```
Legionella pneumophila
P. aeruginosa
S. aureus
54
[Possible etiology: pneumonia]
What are you atypical causes of pneumonia
1. Mycoplasma
2. Chlamydia
3. Legionella
55
[Possible etiology: pneumonia]
stay in hotel or on cruise ship in previous 2 weeks
Legionella
56
[Possible etiology: pneumonia]
patient with stroke, dementia, decreased consciousness
Anaerobes, gram negative enterics
57
[Possible etiology: pneumonia]
recent antibiotic uses, malnutrition, steroid use, bronchiectasis
Pseudomonas
58
What is the best initial test for pneumonia?
CXR
Biomarkers:
CRP - for treatment failure or worsening disease
Procalcitonin - distinguish bacterial from viral
59
[Pharma: Pneumonia]
Low Risk, no co-morbids
1. DOC: Amoxicillin
2. Azithromycin
3. Clarithromycin
60
[Pharma: Pneumonia]
Low ris, stable co-morbids
1. Co-amoxiclav + Sultamicillin OR
| 2. Cefuroxime +/- Extended macrolides
61
[Pharma: Pneumonia]
moderate risk
1. Ampicilin-Sulbactam, Ceftriaxone, Ertapenem + (Levofloxacin Moxifloxacin)
OR
2. Ampicilin-Sulbactam, Ceftriaxone, Ertapenem + Azithromycin
62
[Pharma: Pneumonia]
high risk, no risk for Pseudomonas
1. BLIC, Cephalosporin, Carbapenem + Azithromycin or Clarithromycin
OR
2. BLIC, Cephalosporin, Carbapenem + Levofloxacin or Moxifloxacin
63
[Pharma: Pneumonia]
high risk, with risk for Pseudomonas
1. Piperacillin-Tazobactam, Meropenem, Imipenem-Cilastatin + Azithromycin or Clarithromycin
+ gentamicin or amikacin
OR
1. BLIC, Cephalosporin or carbapenem + IV Ciprofloxacin or IV levofloxacin
64
[Pharma: Pneumonia]
high risk, with risk for Pseudomonas, MRSA SUSPECTED
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
[Response to Pneumonia Treatment]
Fever is expected to resolve after ___ week
1 week
66
[Response to Pneumonia Treatment]
chest pain and sputum production should substantially reduce after ___ weeks
4 weeks
67
[Response to Pneumonia Treatment]
cough and breathlessness should have substantially reduced after ___ weeks
6 weeks
68
[Response to Pneumonia Treatment]
Most symptoms should have resolved, but fatigue may still be present after ___ months
3 months
69
[Response to Pneumonia Treatment]
most people will feel back to normal after ___ months
6 months
70
What is the first evidence that suggests response to treatment?
1. Resolution of fever within a week
| 2. Decreasing WBC within 2 to 4 days
71
[Diagnosis]
Fever, cough, chest pain, discolored phelgm, foul smelling sputum
Lung abscess
Initial test: CXR
Most accurate: Chest CT
72
Most frequently affected side if the lung with lung abscess
Right lung
Tx: IV Clindamycin or IV Beta lactam with BLIC
73
What is the CD4 count to suspect PCP pneumonia?
<200
74
What is the CXR findings in PCP pneumonia?
near normal to diffuse bilateral infiltrate to large cysts or blebs
75
What is the DOC for PCP pneumonia
1. TMP/SMX
2. Adjunct steroid therapy if with PaO2 <70 mmHg or A-a gradient >35
Tx: 21 days
76
[Diagnose]
50F CHF DOB
Mild respiratory distress, absent breath sounds and dullness to percussion at the base of the lung
Dx: Pleural effusion
Initial test: CXR PA Lat
Most accurate: UTZ guided thora
Measure the serum and pleural fluid protein gradient
77
What are the indications for performing an initial thoracentesis?
1. >10mm thick pleural effusion of lateral decubitus CXR
2. With CHF
3. Asymmetric, chest, pain, fever
78
A trial of diuresis to alleviate pleural effusion will last for ___ days
3 days.
then if it persists, do a thoracentesis
79
What are the findings of an exudative pleural effusion?
1. PF/Serum protein > 0.5
2. PF/Serum LDH > 0.6
3. PF LDH > 2/3 upper normal serum limit
80
Most common cause of pleural effusion ____
LV heart failure
81
What is the most common cause of exudative pleural effusion in many parts of the world?
TB
82
What is the 2nd most common cause of exudative effusion
Malignancy
83
If patient is clinically transudative, but criteria is exudative, what will you checK?
Check difference between serum-PF protein.
If gradient >31g/dL, effusion is transudative
84
If the pleural fluid has a glucose of <60 mg/dL, consider
1. Malignancy
2. Bacterial infections
3. Rheumatoid Arthritis
85
In cases of pleural effusion, when will you do a more invasive procedure?
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
When will you remove the CTT in patients warranting CTT drainage?
Drainage rate of 50mL/day
87
[Chylothorax vs Pseudochylothorax]
Milky gross appearance
TAG >400
Chylomicrons present
Chylothorax
if TAG <50mg/dL, its not chylothorax
88
Conditions that can cause pseudochylothorax
1. TB
2. RA
3. Inadequately treated empyema
4. Chronic exudative effusion from almost any cause
89
Rupture of which part of the lungs frequently cause spontaneous pneumothorax?
Apical bleb
90
[Diagnosis]
DOB, pleuritic chest pain
Decreased breathsounds, hyperresonance, absent fremitus, hypoxia and hypercapnia on ABG
Pneumothorax
91
What are the agents used in Pleurodesis?
1. Talc
| 2. Tetracycline
92
Most common cancer associated with asbestos exposure
Lung cancer
93
[Diagnose: CXR findings]
Calcified pleural plaques
Asbestosis
94
[Diagnose: CXR findings]
egg-shell calcification
Silicosis
95
[Diagnose: CXR findings]
nodules along septal line
Berylliosis
96
[Diagnose: CXR findings]
Diffuse infiltrates; hilar adenopathy
Byssinosis
due to cotton
97
[Diagnose: CXR findings]
Progressive fibrosis
coal workers pneumoconiosis
coal exposure
98
What is the most common daytime symptom in OSA?
excessive sleepiness
99
What is the gold standard for diagnosis of OSAHS?
Overnight polysomnogram (PSG)
100
Apnea in OSA is defined as ___
1. Cessation of airflow >10s
| 2. Persistent respiratory effort (obstructive) OR absence of respiratory effort (central)
101
Hypopnea is defined as ____
1. >30% reduction in airflow for at least 10s during sleep
| 2. >3% desaturation or an arousal
102
How will you treat OSA?
1. Weight loss
| 2. CPAP
103
How will you treat central sleep apnea?
1. avoid alcohol and sedatives
| 2. Acetazolamide
104
What is the most common complaint in patients with OSA?
Snoring
