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MCCQE1 > Respirology > Flashcards

Respirology Flashcards

1
Q

Diagnosis of ashtma on PFTs

A

PFTs showing obstructive lung disease =↓ FEV1/FVC <0.8
o Reversible (↑FEV1 improves >12% with b-agonists)
o Inducible with Methacoline: Done if FEV1/FVC is initially normal (FEV1 decreases 20% with methacholine)

It’s called reactive airway disease until recurrent presentations

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2
Q

Patient with daytime symtoms < 2 /wk, nocturnal symptoms < 2 / month, FEV1 > 80%. Asthma stage and tx?

A

Intermitent. Rescue SABA

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3
Q

Patient with daytime symtoms < 1 /day, nocturnal symptoms > 2 / month, FEV1 > 80%. Asthma stage and tx?

A

Mild persistent. Rescue SABA + low dose ICS*

  • Could be replaced with Leukotriene Antagonist (e.g. Motelukast) or theophyline
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4
Q

Patient with daytime symtoms > 1 /day, nocturnal symptoms > 1 / week, FEV1 60-80%. Asthma stage and tx?

A

Moderate persistent. Rescue SABA + low dose ICS + LABA

ICS could be replaced with Leukotriene Antagonist (e.g. Motelukast)

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5
Q

Patient with daytime symtoms > 1 /day, nocturnal symptoms frequent, FEV1 < 60%. Asthma stage and tx?

A

Severe persistent. SABA + high dose ICS + LABA

ICS could be replaced with Leukotriene Antagonist (e.g. Motelukast)

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6
Q

Patient with severe persistent daytime and nocturnal symptoms. Asthma stage and tx?

A

Refractory. SABA + high dose ICS + LABA + PO steroids

But PO steroids should be avoided. Try anti IgE (omalizumab) if IgE related asthma.

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7
Q

ICS are interchangeable with…

A

LTA – Leukotrien receptor antagonis (e.g., montelukast)

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8
Q

Patient with asthma exacerbation + silent chest

A

Medical emergency that might need intubation

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9
Q

Rescue treatment for asthma exacerbation

A

racemic epinephrine, subcutaneous epinephrine, magnesium, nebulizer

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10
Q

Asthma exacerbation treatment

A

O2 for SATO2 > 92%
Short acting b-agonist: Neb/MDI (metered-dose inhaler)
Short acting anticholinergic: Neb/MDI
Steroids: methylprednisolone 125mg IV / prednisone 40-60 mg PO

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11
Q

Ambulatory tx after asthma exacerbation

A

B-agonist MDI + prednisone 1-2 mg/kg x 5 days

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12
Q

Types of emphysema

A

centriacinar (smokers) and panacinar (a1 antitrypsin deficiency)

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13
Q

Clinical characteristics of Emphysema:

A
  • CO2 retention, no hypoxemia, ↑AP dyameter, prolong exhalation, dypnea, minimal cough
  • Pink puffers
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14
Q
  • Hypoxemia, pulmonary hypertension, CHF, edema, productive cough
  • Blue bloaters

Dx?

A

Chronic Bronquitis

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15
Q

Tx COPD

A
  • SABA (albuterol)
  • SABA + long acting muscarinic antagonist – LAMA (tiotropium)
  • SABA + LAMA + LABA (salmeterol)
  • SABA + LAMA + LABA + ICS
  • SABA + LAMA + LABA + ICS + Phosphodiesterase 4 inhibitors – PDE4-i (theophylline)
  • SABA + LAMA + LABA + ICS + PDE4-i + steroids
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16
Q

Chronic treatment of COPD

A
  • C: corticosteroids. ICS /Prednisone PO / methylprednisolone IV
  • O: oxygen if SAT < 88% or PaO2 < 55. Goal, keep SAT 88-92%
  • P: prevention. Influenza and Pneumococcal vaccines, and smoking cessation (first line)
  • D: dilators: SABA, LABA, PO (e.g., PDE4-i, theophylin)
  • E: experimental (surgery)
  • R: rehab

Oxygen and prevention impruve survival

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17
Q

What prolongs survival in COPD?

A

Oxygen and smoke cessation

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18
Q

Anthonisen classification

A

COPD exacerbation:
* Wheezing/SOB
* Increased Sputum production
* Increased sputum purulence

I worse than III

Anthonisen I or II - - >AB

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19
Q

AB in COPD exacerbation

A

Amoxicillin-clavulanic acid (first line), doxycycline, azithromycin (do an ECG first to measure QT)

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20
Q

Bx modalities in lung cancer.

Large proximal lesions?

A

EBUS (Endobronchial ultrasound), e.g., Squamous cell carcinoma

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21
Q

Bx modalities in lung cancer.

Lesion in periphery?

A

CT-guided percutaneous Bx, e.g., Adenocarcinoma

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22
Q

Bx modalities in lung cancer.

In the lung

A

VATS (video-assisted thorascopic surgery)

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23
Q

Patient age > 55, quitted smoking <15 years ago, with spiculated nodule > 2 cm. Next step?

A

Resection of the lesion

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24
Q

Pleural effusion, thoracocentesis positive for malignancy. Stage of disease?

A

IV (metastasic)

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25
Q

Fever, weight loss, hemoptysis and negative CxR for cancer. Next step?

A

Rule out paraneoplastic syndrome before assuming there is no lung CA.

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26
Q

Fever, weight loss, hemoptysis and positive CxR for cancer. Next step?

A

CT scan

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27
Q

Pulmonary mass confirmed with CT scan. Next step?

A

Bx, PET-CT (stage), and PFTs

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28
Q

Lung cancer screening. How and to whom?

A

Screening with Low dose CT-scan yearly
• Age 55-80
• 30 pack/year history
• Quitted smoking less than 15 years ago

CxR no sensitive or specific, so not recommended!!

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29
Q

Pulmonary node definition

A

Lesion < 3 cm. If > 3 cm, it’s called mass

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30
Q

Characteristics of a pulmonary node suggestive of cancer

A

Size > 2cm, spiculated, positive smoking Hx, age > 70

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31
Q

Pulmonary node not suggestive of cancer

A

Size < 8mm, Smooth surface, calcified, no smoking Hx, age < 45

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32
Q

Pulmonary node on CxR, next step?

A

Look old films first!!

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33
Q

Pulmonary node without changes compared to previous films. Next step?

A

No further action needed (not even follow-up)

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34
Q

New pulmonary or changing pulmonary node. Next step?

A

Compare patient’s risks fx and nodule characteristics
• Low risk: serial CTs
• High risk: Bx

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35
Q

Lung cancer treated only with chemo/radiotherapy and never with Sx?

A

Small cell lung cancer

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36
Q

SCLC vs NSCL, which one is more common?

A

SCLC (10-15%); NSCLC (85-90%)

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37
Q

Horner’s syndrome

A

Miosis, anhidrosis, ptosis. Associated with Pancoast tumor

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38
Q

Tx of SCLC

A

Chemo + rad, no matter the stage

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39
Q

Smoking Hx, lung cancer of central location, ADH-SIADH. Dx?

A

SCLC

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40
Q

Smoking Hx, lung cancer of central location, ACTH-Cushing. Dx?

A

SCLC

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41
Q

No smoking Hx, lung cancer of peripheral location, no paraneoplastic syndrome

A

Adenocarcinoma

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42
Q

Smoking history, lung lesions with salt and pepper histology on microscope. Dx and Next step?

A

Carcinoid lung cancer (Serotonin paraneoplastic syndrome: flushing, diarrhea, wheezing)

Urinary 5 HIAA.

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43
Q

Smoking Hx, lung cancer of central location, hipercalcemia. Dx?

A

Squamous cell lung cancer. Paraneoplastic syndrome (hyper PTH)

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44
Q

Causes of pleural effusion (transudate)

A

CHF, nephrotic syndrome, cirrhosis, pulmonary embolism

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45
Q

Causes of pleural effusion (exudate)

A

Malignancy, TB, pneumonia

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46
Q

Most common cause of exudative pleural effusion

A

TB is the most common cause worldwide. Pneumonia (PNA), malignancy, and CHF are the most common in the US

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47
Q

Pleural Effusion of < 1 cm. Next step?

A

Observation

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48
Q

Loculated pleural effusion. Next step?

A

Thoracostomy, if it doesn’t work, thoracotomy

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49
Q

Pleural effusion, > 1 cm, not loculated. Next step?

A

Is it CHF? If so, diuresis and observe. If it fails or isn’t CHF, then tap

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50
Q

Pleural effussion is determined to be transudate. Next step?

A

Treat cause

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51
Q

Light’s criteria

A
  • LDHf > 2/3 upper limit of normal serum LDH
  • LDHf/LDHs > 0.6
  • Proteins f/Proteins s > 0.5

At least one –> Exudate
None of them –> transudate

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52
Q

Tests to run on a pleural effusion

A 
Tube 1: cell count with differential
- PMN: Pneumonia
- Lymph: TB or malignancy
- RBC: Hemothorax or CA
Tube 2: cytology (malignancy)
Tube 3: Glucose, pH, total proteins and LDH (light’s criteria), ADA (TB), triglycerides (chylothorax) 
Tube 4: gram stain and culture
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53
Q

Virchow’s triad?

A

o Venostasis (e.g., hospitalized, POP, inmobiliztion, car rides, no physical activity)
o Endothelial injury (e.g., POP, trauma, HTN, smoking, cath)
o Hypercoagulative state (e.g., contraceptives, malignancy, pregnancy, coagulopathies)

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54
Q

Diagnostic sign of DVT?

A

Difference of 2 cm between diameters 2 cm below the tibial tuberosity

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55
Q

Diagnostic test of DVT?

A

Ultrasound
o If positive –> DVT
o If negative and low risk –> rule out
o If negative and moderate-high risk –> repeat in 5 to 7 days

56
Q

Labs for PE

A

ECG, CxR, ABG, CBC, INR, PTT, creatinine, LFTs

57
Q

ECG in PE?

A

Sinus tachycardia, S1Q3T3 (right heart strain)

58
Q

CxR in PE?

A

Usually normal unless wedge infraction (Hampton’s hump)

59
Q

ABG in PE?

A

Hypoxemic, hypocapnic, respiratory alkalosis

60
Q

Fever, Sudden dyspnea, Chest pain. Next step?

A

PERC criteria first to rule out PE and determine the need of doing the Well’s. If pregnant, do Well’s right away.

Criteria: Age ≥50, HR ≥100, O₂ sat on room air <95%, Unilateral leg swelling, Hemoptysis, Recent surgery or trauma, Prior PE or DVT, Hormone use.

If one present, do well’s

61
Q

When to do a d-dimer?

A

Low probability, to rule out PE

62
Q

When to do a CT scan when PE is suspected?

A

When Well’s is > 3 (moderate probability)
The patient has not CKD
Preferred test in the acute setting

63
Q

When to order a V/Q Scan in the context of pulmonary embolism?

A
  • When Well’s is > 6 (high probability)
  • ↑ Creatinine
  • Pregnancy
  • The CxR is normal
64
Q

What is the gold standard for PE?

A

Angiogram, HOWEVER IT IS (almost) NEVER DONE because it’s invasive!

65
Q

When to do only a U/S of legs for PE?

A

Can’t do CT, can’t do VQ scan

66
Q

When IVC filter for PE or DVT?

A

Proximal DVT + absolute contraindication of anticoagulation
or
Recurrent emboli

67
Q

tPA for PE.When?

A

massive PE (hypotension + PE)

68
Q

Tx of PE

A

Warfarin (1972). Bridge always with LMWH or heparin for 5 days or until INR 2-3

69
Q

Heparin-induced thrombocytopenia. Next step?

A

Draw a HIT panel and change for Argotraban

70
Q

Definition of Acute Respiratory Distress Syndrome (ARDS)

A

Non-cardiogenic pulmonary edema causing acute respiratory hypoxemic failure

71
Q

Pathogenesis of ARDS

A

Pulmonary edema –> Less surface area of the alveolar to the capillaries –> O2 can’t cross the barriers since it is diffusion-limited –> V/Q mismatch –> shunt –> HYPOXEMIA

72
Q

Risk factors of ARDS

A

Septic shock (e.g., caused by pneumonia)
Trauma-related acute lung injury
Drowning
Head trauma, drug overdose

73
Q

Diagnosis of ARDS

A

ARDS is a clinical Dx made with hypoxemic respiratory failure + bilateral pulmonary edema. You DON’T need a pulmonary edema wedge pressure via Swan Ganz cath

74
Q

PaO2 / FIO2 on ARDS?

A

< 300

According to First Aid

75
Q

ARDS VS CHF

A
  • Capillary wedge preausre: ↑ in CHF (hydrostatic pressure); normal or ↓ in ARDS (leaky capilaries)
  • LV function (BPN/Echo): ↓ in CHF; normal or ↑ in ARDS (tachycardia)
76
Q

Treatment of ARDS

A

Intubation

  • CO2: Lox tidal volume, high resp. rate (small shallow breaths to maintain CO2 levels)
  • O2: Positive End Expiratory Pressure (PEEP), which keeps the alveola open
  • Goal of oxygenation: PaO2 > 55mmHg or SpO2 > 88%

Treat the underlying disease
Diuresis (?)

77
Q

Radiologic test to Dx Diffuse parenchymal lung disease (DPLD)?

A

High-resolution CT: ground-glass opacities

78
Q

PFTs in Diffuse parenchymal lung disease (DPLD)?

A

↑ or normal FEV1/FVC and diffusion of CO2 is down (↓DLco)

79
Q

General Tx of most Diffuse parenchymal lung disease (DPLD)?

A

o Steroids (regardless of the pathologic form)
o DMARDS
o Biologics

80
Q

Definition of Acute interstitial pneumonitis (AIP)?

A

Acute (< 6 weeks) Idiopathic Diffuse parenchymal lung disease

81
Q

Definition of Idiopathic pulmonary fibrosis

A

Chronic (> 6 weeks) Idiopathic Diffuse parenchymal lung disease

82
Q

What drugs can induce Idiopathic Diffuse parenchymal lung disease

A

Bleomycin (chemotherapy)
Amiodarone
Radiation

83
Q

What is sarcoidosis ?

A

Is a primary Idiopathic Diffuse parenchymal lung diseaase. It is autoinmune

84
Q

Epidemiology of sarcoidosis?

A

Black women

85
Q

Extrapulmonary manifestations in sarcoidosis?

A
  • Heart block
  • Bell’s palsy
  • Erythema nodosum
  • Uveitis
  • Arthralgia
86
Q

Dx of sarcoidosis?

A

CxR: Hiliar bilateral lymphadenopathies
High res CT: Ground glass
PFTs: restrictive pattern
Bx: Non-caseting granulomas

87
Q

Non-necrotizing granulomas

A

sarcoidosis

88
Q

Hiliar bilateral lymphadenopathies on CxR.

Dx?

A

sarcoidosis

89
Q

Barbell bodies on pulmonary BX. Dx?

A

Asbestosis

90
Q

Pleural plaques on CxR. Dx?

A

Asbestosis

91
Q

Sand blasting or Rock quarry exposure. Lung disease and associations?

A

Sillicosis
Presents in the upper lung as nodules–> rule out TB
Screen for TB annualy because TB incidence is ↑

92
Q

Aeronautics or Ellectronics manufacturer. Lung disease?

A

Berylliosis

93
Q

Pneumoconiosis + rheumatoid arthritis. Dx?

A

Caplan syndrome. Pneumoconiosis is ussualy Coal miners lung

94
Q

Birds fanciers with temporal hypoxemia, dypnea and dry cough which goes away when the person is not working or the exposure is removed. Dx and tx?

A

Hypersensitivity pneumonitis.

Tx: Remove exposure. NO NEED FOR STEROIDS!

95
Q

Risk factors for DVT.

A

Stasis, endothelial injury, and hypercoagulability (Virchow’s
triad).

96
Q

Criteria for exudative pleural effusion.

A

Pleural/serum protein > 0.5; pleural/serum LDH > 0.6; pleural LDH > 2/3 upper limit.

97
Q

Causes of exudative pleural effusion.

A

Think of leaky capillaries. Malignancy, TB, bacterial or viral
infection, pulmonary embolism with infarct, and pancreatitis.

98
Q

Causes of transudative pleural effusion.

A

Think of intact capillaries. CHF, liver or kidney disease, and protein-losing enteropathy.

99
Q

Normalizing PCO2 in a patient having an asthma exacerbation may indicate?

A

Fatigue and impending respiratory failure.

100
Q

Dyspnea, bilateral hilar lymphadenopathy on CXR, noncaseating granulomas, ↑ ACE, and hypercalcemia.

A

Sarcoidosis.

101
Q

PFTs showing ↓ FEV1/FVC.

A

Obstructive pulmonary disease (e.g., asthma).

102
Q

PFTs showing ↑ FEV1/FVC.

A

Restrictive pulmonary disease.

103
Q

Honeycomb pattern on CXR. Diagnosis? Treatment?

A

Diffuse interstitial pulmonary fi brosis. Supportive care.

Steroids may help.

104
Q

Treatment for superior vena cava (SVC) syndrome

A

Radiation.

105
Q

Treatment for mild, persistent asthma.

A

Inhaled β-agonists and inhaled corticosteroids.

106
Q

Treatment for COPD exacerbation.

A

AB: Amoxicillin-clavulanic acid (firs line), doxycycline, azithromycin (do an ECG first to measure QT)
Dilatators MDI with spacer or NEBS
* B-Agonist: Albuterol
* Anticholinergics: Ipratropium
Steroids: Prednisone PO or Methylprednisolone IV
Oxygen aiming at SAT 88-92%

107
Q

Treatment for chronic COPD.

A

Smoking cessation, home O2, β-agonists, anticholinergics,
systemic or inhaled corticosteroids, flu and pneumococcal
vaccines.

108
Q

Acid-base disorder in pulmonary embolism.

A

Hypoxia and hypocarbia (respiratory alkalosis).

109
Q

Non–small cell lung cancer (NSCLC) associated with hypercalcemia.

A

Squamous cell carcinoma.

110
Q

Lung cancer associated with SIADH.

A

Small cell lung cancer (SCLC).

111
Q

Lung cancer highly related to cigarette exposure.

A

Small Cell Lung Cancer (SCLC).

112
Q

A tall white male presents with acute shortness of breath.

Diagnosis? Treatment?

A

Spontaneous pneumothorax. Spontaneous regression.

Supplemental O2 may be helpful.

113
Q

Treatment of tension pneumothorax.

A

Immediate needle thoracostomy.

114
Q

Characteristics favoring carcinoma in an isolated pulmonary nodule.

A

Age > 45–50 years; lesions new or larger in comparison to old films; absence of calcification or irregular calcification; size > 2 cm; irregular margins.

115
Q

Hypoxemia and pulmonary edema with normal pulmonary capillary wedge pressure.

116
Q

Sequelae of asbestos exposure.

A

Pulmonary fibrosis, pleural plaques, bronchogenic carcinoma (most common tumour associated), mesothelioma (pleural mass).

117
Q

↑ risk of what infection with silicosis?

A

Mycobacterium tuberculosis.

118
Q

Causes of hypoxemia.

A

Right-to-left shunt, hypoventilation, low inspired O2 tension, diffusion defect, V/Q mismatch.

119
Q

Classic CXR findings for pulmonary edema.

A

Cardiomegaly, prominent pulmonary vessels, Kerley B lines, “bat’s-wing” appearance of hilar shadows, and perivascular and peribronchial cuffing.

120
Q

Best initial tests for asthma exacerbation

A

Peak expiratory flow (PEF) or ABG

121
Q

Most accurate test for asthma when patient is asymptomatic

A

%20 decrease in FEV1 with methacoline

122
Q

Best indicator in physical of severity of asthma exacerbation

A

Resp. Rate.

Accessory muscle use is hard to assess and subjective

123
Q

COPD sx
< 60 years
No hx of smoking
Panlobular emphysema

A

Alfa 1 antirypsin deficiency

124
Q

Indication of long term O2 therapy

A

Sat < 88%
Cor pulmonale
Pao2 < 59 mmHg

Goal: sat 88-90%

125
Q

Best inicial and most accurate test for COPD

A

Best inicial: CxR

Accurate: PFT
- decreased FEV1
- decreased FVC
- decreased FEV1/FVC
- increased TLC
- no improved with b agonist
- no worsening with methacholine

126
Q

When is ipatropium used?

A

COPD exacerbation

Otherwise, same as asthma exacerbation

127
Q

Wrong answers in COPD

A
  • ICS monotherapy
  • spirometry as screening for ASx
  • n acetylcysteine
  • Terbutaline
128
Q

When to tap a pleural effusion?

A

When it is
- big enough (more than 1cc)
- not loculated
- not due to CHF

129
Q

Dyspnea, pleuritic chest pain, cough
Dullness to percussion, decreased breath sounds

Dx and best initial test

A

Pleural effusion

Next step: CxR

130
Q

Pleural effusion with pH < 7.2 and positive gram

Dx and tx

A

Empyema

Tx with Ab and chest tube

131
Q

Most common abnormality of EKG in PE?

A

Nonspecific ST-T wave changes

132
Q

Medications that may cause DPLD

A

Amiodarone
Nitrofurantoin
Bleomycin
Methotrexate (causes fibrosis of lung and liver)

133
Q

Arthritis
Erythema nodosum
Bilateral hilar adenopathy

A

Lofgren syndrome: type of sarcoidosis

134
Q

Most common type of lung cancer?

A

Adenocarcinoma

  • peripheral
  • not associated to smoking
  • asbestos exposure
135
Q

PFT findings in Interstitial lung disease

A
  • lung restriction (decrease in TLC and VC)
  • decreased lung compliance (increased or normal FEV1/FVC)
  • impaired diffusion (decreased DLco)

Other important information.
- hypoxemia (V/Q mismatch)
- pulmonary hypertension and cor pulmonale

MCCQE1 (19 decks)

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