Respiratory

Question 1

Criteria for pneumonia admission?

Answer 1

CURB-65: 2
CRB-65- 1
Hypotension requiring vasopressors or Respiratory failure requiring mechanical ventilation = ICU

Question 2

Outpatient pneumonia treatment?

Answer 2

5 days usually sufficient
- No comorbidities: Amoxicillin, Doxycycline, or Macrolide if resistance <25%
- Comorbidities: Chronic heart, liver, lung, kidney disease, or immunocompromised [ DM, asplenia, alcoholic, malignancy ] or IV AB use in the last 3 months: single agent respiratory quinolone [Levo,Moxi,Gemi] or Beta lactam + macrolide
Beta lactam= Augmentin, cefuroxime, cefpodoxime, Cefdinir

Question 3

Indication for steriods in pneumonia

Answer 3

CAP related septic shock refractory to fluid resuscitation and vasopressor

Question 4

Pneumonia vaccine indications?

Answer 4

1- 65 years or older
2- 19-64 with underlying condition

Question 5

Spirometry interpretation for FEV1/FVC ratio and FEV1?

Answer 5

Obstructive: FEV1/FVC <0.7 or <70%
Use bronchodilator
Post-bronchodilator: increase 12% AND at least 200ml of FEV1 is suggestive for asthma, otherwise it’s COPD

Question 6

Rule of oral steroid in COPD exacerbation

Answer 6

Short term low dose oral steroid increase time between exacerbation

IV steriod steroid reserved for poor GI absorption or altered mental status

Question 7

Prevention of Exercise induced asthma?

Answer 7

1- 15 mins before exercise SABA or ICS/formoterol use
2- 15 mins Warm up before exercise
3- if persistent symptoms: Maintenance with daily ICS, daily LTRA montelukast, or Mast-cell stabilizer before exercise

Question 8

Cystic fibrosis [ a disease of exocrine gland function] treatment

Answer 8

1- ADEK vitamins supplements
2- Pancreatic enzyme replacement
3- Long term Hypertonic saline use for patients 6 years or older

For acute exacerbation:
1- bronchodilator
2- deoxyribonuclease
3- antibiotic with anti pseudomonas coverage
4- chest physical therapy

Question 9

Anti-igE [ Omalizumab ] criteria in asthma?

Answer 9

Match all of the following:
1- Allergic asthma as determined by positive skin test or RAST test
2- ig-E within therapeutic tange
3- Age 6 years or older
4- Severe persistent symptoms [ step 4 ] not controlled by other means ( high ICS and LABA ]

Question 10

Cough variant asthma treatment

Answer 10

ICS

Question 11

Aspirin-exacerbated respiratory disease

Answer 11

1- Samster Triad: asthma + chronic rhinosinusitis with nasal polyposis + Aspirin allergy

2- minutes to 2hr > develop asthma attack + rhinorrhea and nasal congestion + conjunctival irritation + scarlet flush of head and neck

3- prevention: avoid COX-1I , when NSAIDs use, use selective COX-2 inhibitor: Meloxicam, Celecoxib

Question 12

Asthma treatment in pregnancy

Answer 12

1- all are safe
2- the greatest safety profile among SABA is Albuterol
3- Try to avoid prolonged use of systemic steroids in the first trimester
4- one third may have worsening of their asthma control

Question 13

Asthma in children

Answer 13

1- chronic use of ICS more than 3 months in prepubertal aged children can suppress growth velocity

3- monitor for Neuropsychiatric symptoms if u start montelukast [ sleep disturbance, anxiety, aggressiveness, irritability ]

4- Nebulizer not superior to MDI in both acute and chronic management of asthma in children

Question 14

When to suspect A1 antitrypsin deficiency in patients with COPD and do screening

Answer 14

1- Caucasian
2- under age of 45
3- strong family history of COPD

Question 15

Indications for home oxygen therapy in COPD

Answer 15

Measure with pulse oximetry ( breathing room air at least 30 mins )

Severe resting hypoxemia :
1- Po2 55mmHg or less, SaO2 88% or less
2- 56-59 or 89 PLUS one : Hematocrit >=55%, cor pulmonale signs, or pulmonary hypertension

Use at least 15hrs a day, with range 88-92%

Question 16

Infectious mononucleosis organism and complications

Answer 16

EBV (kissing disease)
Acute hepatitis 75% but usually mild and subclinical
Splenomegaly

Question 17

Bronchiolitis indications to admission

Answer 17

1- RR >70
2- toxic appearance
3- Poor feeding
4- Lethargy
5- SaO2 <95%

Question 18

Red flags for acute pharyngitis

Answer 18

1- Muffled voice
2- Drooling and Stridor
3- Trismus and crepitus
4- history of penetrating trauma (fishstick)
5- bulging pharygneal wall
6- Tripoid positing
7- Hypoxemia

Question 19

Rule of Abx on GAS pharyngitis complications ( GN, and ARF )

Answer 19

Prevent Rheumatic fever, but NOT GN

Question 20

Spontanous vs Tension pneumothorax and TRACHEA

Answer 20

• Shifted to same side in Spontanous
• Shifted to the opposite site in Tension

Question 21

Tension pneumothorax needle decompression site?

Answer 21

1- Adult: 4th or 5th ics anterior to midaxillary line
2- pedia: 2nd intercostal space midclavicular line

Question 22

Pleural effusion

Answer 22

Transudate and Exudate

Transudate:
Pleural:serum protein: 0.5 or less
Pleural:serum LDH: 0.6 or less
Pleural fluid LDH: <2/3 upper limit of normal serum LDH

Causes: heart failure, cirrhosis, nephrotic, pulmonary embolism, hypothyroidism, Amylodosis

Question 23

PE and DVT (VTE)

Answer 23

Treatment:
Hemodynamic unstable or right ventricular compromise:
- Thrombolysis

Stable with no contraindications:
- LMWH
- DOAC

Stable with contraindications:
IVC filter

———————————————-

DOAC is the preferred due to compliance, and it is not-inferior to LMWH in trials. Some trials also showed lower risk of VTE in the DOACs group

Factors when LMWH is considered over DOACs
1- concerns about drug interactions with DOACs
2- patient preference
3- GI malignancy ( LMWH or Apixaban ); both associated with lower risk of GI bleeding than rivaroxiban or edoxiban
4- Gastritis or enteritis “poor absorption; DOACs abosrbed in the stomach and proximal small bowel”
Duration:
1st episode: 3 months
Recurrence: 6 months
Provoked (strong VTE risk factor such as bedridden, malignancy): indefinite;
Factors to choose to stop: bleeding complications, patient quality-of-life reasons