Exam 2 Flashcards
(390 cards)
1
Q
What is the initial study used for respiratory sxs and which view is preferred?
A
CXR, PA view preferred
2
Q
If you note a Hampton hump on CXR, what should you be concerned about?
A
Pulmonary infarct
3
Q
What is a c/i to CXR?
A
Pregnancy
4
Q
What systematic approach should be used when reading a CXR?
A
A- airway B- bones C- cardiac silhouette & costophrenic angle D- diaphragms (free air) E- edges F- fields (infiltrates, nodules)
5
Q
CT is equivalent to how many XRays with respect to radiation?
A
80
6
Q
Which form of pulmonary dx imaging is used to clarify abnormal cxr, characterize pulm nodules, eval lung mets/ suspected masses?
A
CT
7
Q
CT’s place beds at increased risk of what due to higher sensitivity?
A
Leukemia/ brain tumors
8
Q
In utero exposure of radiation with CT’s of pregnant women is linked to what?
A
Peds CA mortality
9
Q
Low dose CT’s are used for what?
A
Screening
10
Q
What are the indications for iodine contrast w/ CT?
A
Vessels, malignancy chest trauma
11
Q
Patients should be pretreated with what due to possibility of iodine allergic rxn w/ CT?
A
Prednisone and diphenhydramine (Benadryl)
12
Q
When does CIN occur/ peak?
A
Occurs @ 24-48 hrs post exposure
Peaks @ 3-5 days
13
Q
If you note an increased serum creatinine >/= 0.5 mg/dL or >/= 25% from baseline following an iodine contrast CT, what should you be concerned about?
A
Contrast induced nephropathy (CIN)
14
Q
When should you check kidney fxn prior to an iodine contrast CT due to concerns of CIN?
A
> 60 yo, hx of renal disease/ HTN/ DM, taking Metformin
15
Q
What is the dx imaging of choice for pulmonary vasculature?
A
CT pulmonary angiography (CTPA)
16
Q
What is the gold standard for PE eval?
A
Catheter directed pulmonary angiography (“direct”)
17
Q
What pulmonary imaging is useful if V/Q scan or CTPA is inconclusive, but there is a high clinical suspicion for PE?
A
Catheter directed pulmonary angiography
18
Q
What pulmonary imaging has the following associated risks?
Bleeding @ insertion site, arrhythmia, allergic rxn to contrast, CIN
A
Catheter directed pulmonary angiography
19
Q
What pulmonary imaging is best if there is a normal CXR and high suspicion for PE?
A
V/Q scan
20
Q
What is the pulmonary imaging test of choice for dx in pregnant women?
A
V/Q scan
21
Q
What pulmonary imaging is used to detect cancer?
A
PET scan
22
Q
What pulmonary imaging involves detection of radiation from fluorodeoxyglucose (FDG)?
A
PET scan
23
Q
A PET scan is better than CT for mediastinal imaging due to the fact that you can ID a tumor in what?
A
Normal sized lymph nodes
24
Q
When should an MRI/ MRA be avoided, due to use of Gadolinium contrast dye, and why?
A
Avoid if GFR < 30 mL/min, possibility of nephrotic systemic fibrosis
25
What are the specific risks associated with taking a bx with bronchoscopy?
Bleeding, bronchial perforation, pneumothorax
26
Should airflow spirometry be performed sitting or standing?
Sitting (prevents syncope)
27
Is FEV-1 most useful for obstruction or restriction?
Obstruction
28
What value defines the severity of obstruction and assists in differentiating between obstructive and restrictive diseases?
FEV-1: FVC ratio (< 0.7 = obstructive)
29
What value measures the airflow during the middle 1/2 of forced expiration?
FEF-25-75%
30
What value is non-specific for airway obstruction but may be an early indicator of disease?
FEF-25-75%
31
What is considered + on a reversibility testing for bronchodilation?
FEV-1 increases by 12% and 200mL
32
In which test do you give a dilute bronchoconstrictor at increased concentrations via a nebulizer at 30 and 90 seconds and test FEV1?
Bronchoprovocation (methacholine challenge)
| Med = dilute methacholine
33
What is considered a + on the bronchoprovocation (methacholine challenge) test?
FEV1 decreases by 20%
34
In obstructive diseases, do you have normal inspiration or expiration?
Inspiration N (but decreased expiration)
35
In restrictive diseases, do you have normal inspiration or expiration?
Expiration N (but difficulty expanding lungs during inhalation)
36
What value measures the ability of the lungs to transfer gas and saturate Hgb, and when can it be misleading?
Diffusion capacity of lungs for CO (DLCO)
| Misleading if anemic due to false reduction
37
If lungs are healthy, what will a DLCO show?
Little CO collected during exhalation
38
If lungs are diseased, what will a DLCO show?
Less CO diffused into lungs = higher levels measured in exhaled gas
39
What will the following values show for an obstructive lung disease?
TLC, FVC, RV, FEV1, FEV1/ FVC
```
TLC- inc
FVC- N
RV- inc
FEV1- dec
FEV1/ FVC- dec
```
40
What will the following values show for an restrictive lung disease?
TLC, FVC, RV, FEV1, FEV1/ FVC
```
TLC- dec
FVC- dec
RV- dec
FEV1- dec
FEV1/ FVC- N/ inc
```
41
What are the 5 steps of PFT interpretation?
Examine:
1. flow-volume curve
2. FEV-1 value
3. FEV-1/ FVC ratio
4. response to bronchodilator
5. DLCO
42
Will the flow-volume curve be scooped out or peaked with an obstructive lung disease?
Scooped out
43
What two guidelines classify asthma?
NAEPP and GINA
44
What are the primary sxs of asthma?
Coughing (nocturnal), > 3 weeks
| Wheezing (hallmark)
45
What disease is characterized by tripod positioning, accessory muscle use, pulsus paradoxus, and tachypnea/cardia?
Asthma
46
What will the diagnostic values of FEV1, FEV1/FVC and reversibility be for asthma?
FEV1: < 80%
FEV1/FVC: N (70-85%)
Reversibility: > 12% w/ FEV1 bronchodilator
47
What makes up ASA triad/ Samter's triad?
1. sinus disease w/ nasal polyps
2. ASA sensitivity
3. severe asthma
48
What is made up of atopic derm, allergic rhinitis, and asthma?
Atopic triad
49
What is made up of atopic derm, food allergy, allergic rhinitis, and asthma?
Atopic march
50
What test is used to confirm a dx of asthma?
Spirometry
51
In regards to asthma classification, which steps are considered intermittent?
Step 1
52
In regards to asthma classification, which steps are considered persistent?
Steps 2-4
53
If a patient presents with hx of asthma sxs ≤ 2 days/ week and nighttime awakenings ≤ 2 nights/ month (≥ 5 yo) which step of asthma classification would they be?
Step 1
54
If a patient presents with hx of asthma sxs > 2 days/ week and nighttime awakenings 1-2x/ month (0-4 yo)/ 3-4x/ month (≥ 5 yo), which step of asthma classification would they be?
Step 2
55
If a patient presents with hx of asthma sxs daily and nighttime awakenings 3-4x/ month (0-4 yo)/ >1x/ week (≥ 5 yo), which step of asthma classification would they be?
Step 3
56
If a patient presents with hx of asthma sxs throughout the day and nighttime awakenings >1x/ week (0-4 yo)/ nightly (≥ 5 yo), which step of asthma classification would they be?
Step 4
57
What will the FEV1 value be for steps 1-4 of asthma?
Step 1: > 80%
Step 2: > 80%
Step 3: 60-80%
Step 4: < 60%
58
For which steps of asthma classification will the FEV1/ FVC ratio be decreased by 5%?
Steps 3-4
59
What is the treatment for Step 1 asthma?
SABA prn
60
What is the treatment for Step 2 (mild) asthma?
Low dose daily ICS
OR
LTRA/ Cromlyn (kids that don't want steroid)
61
What is the treatment for Step 3 (moderate) asthma?
- Consider specialist referral
- Medium dose ICS (0-4 to)
OR
- Low dose ICS + LABA (≥ 5yo) or LTRA
62
What is the treatment for Step 4 (severe) asthma?
- Refer to specialist
- Medium dose ICS & LABA (or LTRA 0-4 yo)
OR
- Medium dose ICS + LTRA
63
What is the treatment for Step 5 asthma?
High dose ICS/ LABA (or LTRA if 0-4 yo)
64
What is the treatment for Step 6 asthma?
High dose ICS/ LABA (or LTRA if 0-4 yo) + oral steroids
65
When should you consider adding Omalizumab (Xolair) with steps 5-6 asthma?
If ≥ 12 yo with allergies
66
When would Theophyline with use of ICS be used in the treatment of asthma steps 5-6, and why is this a less attractive alternative?
> 5 yo
| Serum levels must be monitored closely
67
What is the rule of 2's and what disease does it pertain to?
Asthma
- Sx ≥ 2x/ week
- Awaken w/ asthma sx ≥ 2x/month
- Refill SABA ≥ 2x/ yr
- Peak flow meter measures 20% from baseline ≤2x
68
If results of a peak flow meter show green, what does this indicate?
> 80%, good control
69
If results of a peak flow meter show yellow, what does this indicate?
50-80%, caution- SABA + med change
70
If results of a peak flow meter show red, what does this indicate?
<50%, medical alert/ emergency tx
71
If a pt shows the following, how well controlled is their asthma?
- Sx frequency/ SABA use: ≤ 2x/ week
- Nighttime awakenings (0-11 yo): ≤ 1x/ month
- Nighttime awakenings (≥ 12 yo): ≤ 2x/ month
- FEV1: > 80%
- FEV1/ FVC: > 80%
Well controlled
72
If a pt shows the following, how well controlled is their asthma?
- Sx frequency/ SABA use: ≥ 2 days/ week
- Nighttime awakenings (0-4 yo): 1x/ month
- Nighttime awakenings (0-11 yo): ≥ 2x/ month
- Nighttime awakenings (≥ 12 yo): 1-3x/ week
- FEV1: 60-80%
- FEV1/ FVC: 75-80% (5-11 yo)
Not well controlled
73
If a pt shows the following, how well controlled is their asthma?
- Sx frequency/ SABA use: daily
- Nighttime awakenings (0-4 yo): 1x/ week
- Nighttime awakenings (0-11 yo): ≥ 2x/ week
- Nighttime awakenings (≥ 12 yo): ≥ 4x/ week
- FEV1: < 60%
- FEV1/ FVC: < 75% (5-11 yo)
Very poorly controlled
74
What is the tx for exacerbation of asthma?
1. O2
2. SABA/ SVN- Albuterol or Xopenex +/- Ipratropium bromide → repeat PEF, SVN repeated or continuous
3. Systemic corticosteroids- prednisolone ~ 1 mg/kg/day w/ max dose based on weight
75
What role should abx and resp monitoring be considered in the tx of asthma exacerbation?
Abx prn
| Resp monitoring if in ED/ inpatient, severe = C-PAP, BiPAP, intubation
76
How soon should a pt with asthma exacerbation f/u?
Within 1 week
77
Small airway disease --> ?
Obstructive chronic bronchitis
78
Blue bloater (hypoxemia, cyanosis, cor polmonale, weight gain) are associated w/ what disease?
Obstructive chronic bronchitis
79
Infiltration of the submucosal layer by neutrophils is associated w/ what disease?
Obstructive chronic bronchitis
80
Presence of dry cough and sputum production for 3+ months in 2 consecutive years is what?
Obstructive chronic bronchitis
81
Pink puffer (hypercapnia, weight loss, muscle wasting)
Emphysema
82
Parenchyma disease -->
Emphysema
83
Destruction of alveolar walls and reduced alveolar surface area available for gas exchange is associated w/ what disease?
Emphysema
84
Most common early finding ing COPD?
Dyspnea on exertion
85
Last COPD presentation?
Dyspnea, chronic cough, sputum production present at rest
86
Host risk factor for COPD? (3)
1. a1-antitrypsin deficiency (AATD)
2. asthma
3. childhood respiratory infections
87
Tripod positioning, accessory muscle use, and pursed lip breathing are associated w/ what disease?
COPD
88
AP diameter increases or decreases w/ COPD?
Increases
89
Irreversibly after bronchodilator use is consistent w/ what disease?
COPD
90
FEV1/FVC < 70% indicates restrictive or obstructive disease?
Obstructive
91
Gold classes for COPD?
I. ≥ 80%
II. 50-80%
III. 30-50%
IV. <30%
92
TX goals for COPD? (4)
1. Prevent progression (smoking cessation)
2. Relieve sx/improve exercise tolerance
3. Manage/prevent acute exacerbations
5. Reduce mortality
93
Supplemental O2 sat for long term COPD tx?
88-92%
94
TX for COPD exacerbation?
SABA +/- SAMA
Prednisone 40 mg QD x 5 days
```
Mod-severe = + ABX 5-7 days
Sever = +/- hospitalization
```
95
TX for class A COPD?
SABA PRN
96
TX for class B COPD?
SABA + LAMA/LABA
97
TX for class C COPD?
SABA + LAMA
98
TX for class D COPD?
SABA + LAMA (or LABA/LAMA if severe)
99
S3 gallop, RVH, hepatomegaly, and peripheral edema are consistent w/ what disease?
Cor Pulmonale
100
Bleds/bullae are pathognomic for?
Emphysema
101
Is CT needed for routine COPD dx?
No
102
Acute changes in baseline dyspnea, cough, sputum that warrant a change is therapy is considered what?
Acute COPD exacerbation
103
SE of B2 bronchodilators?
Palpitations, tachycardia, insomnia, tremors
104
Albuterol is falls under what drug classification?
SABA (B2)
105
Salmeterol and Formoterol are what type of B2 agonists?
LABA
106
Dry mouth, metallic taste, HA and cough are SEs of what drug class?
Anticholinergics
107
Atrovent and Combivent are SABA or LABA anticholinergics?
SABA
108
Spirival and Incruse Ellipta are SABA or LABA anticholinergics?
LABA
109
Oral candidiasis and bruising are SEs of what meds?
LABA + ICS
110
Advair and Symbicort are fall under waht drug class?
LABA + ICS
111
What deficiency requires tx w/ antiprotease therapy?
a-1 antitrypsin (serum level < 11 micromol/L)
112
ABCD assessment tool combines what tools? (4)
1. GOLD
2. Modified British Medical Research Council (mMRC)
3. COPD assessment tool (CAT)
4. Exacerbation hx
113
Prior hospitalization for COPD exacerbation is predictive of what? (2)
Poor prognosis, ↑ risk of death
114
Grad A associated w/ (sx, risk)?
↓ sx, ↓ risk
115
Grad B associated w/ (sx, risk)?
↑ sx, ↓ risk
116
Grad C associated w/ (sx, risk)?
↓ sx, ↑ risk
117
Grad D associated w/ (sx, risk)?
↑ sx, ↑ risk
118
Cough >5 days is consistent w/ what dx?
Acute bronchitis
119
Acute bronchitis more commonly due to viral or bacterial pathogens?
Viral (90%)
120
Bacterial agent that causes acute bronchitis?
Bordetella pertussis
121
Ronchi > w/ expiration is consistent w/ what dx?
Acute bronchitis
122
First line TX for acute bronchitis?
Reassurance and edu on expected course
123
When are ABX used to tx acute bronchitis?
Pertussis ONLY
124
Cough ≥ 3 months for 2 consecutive years is consistent w/ what dx?
Chronic bronchitis
125
Gold standard diagnostic for pertussis?
Bacterial culture nasopharyngea secretions
126
Catarrhal, paroxysmal and convalescent are 3 phases of what disease?
Bordetella pertussis
127
Whooping cough is consistent w/ what disease?
Bordetella pertussis
128
When is serology used to dx pertussis?
Later stage of disease (2-8 weeks from cough onset)
129
Abx tx for what disease will ↓ transmission but have little effect on sx?
Bordetella pertussis
130
Is Bordetella pertussis a reportable disease?
Yes
131
ABX Tx for Bordetella pertussis in adults?
Macrolide: Azithro, clarithro or erythro
| Bactrim if macrolide not tolerated
132
Fever, HA, myalgia and malaise are consistent with what disease?
Influenza
133
Viral culture, RIDT or PT-PCR is confirmatory dx for influenza?
Viral culture
134
Timeline to give antiviral treatment for influenza?
onset-48 hrs
135
If negative RIDT, but high clinical suspicion can you make dx clinically?
Yes
136
Acute onset fever and cough w/ crackles is consistent w/ what disease?
CAP
137
Aspirations from oropharynx is most common form of transmission for CAP, HAP or VAP?
CAP
138
CXR shoes infiltrate on plane films. This gold standard dx for what?
CAP
139
CURB-65 is used in the dx of HAP, VAP, or CAP?
CAP
140
What is CURB-65?
```
Confusion
Urea > 7 mmol/L & BUN ≥ 20 mg/dl
RR ≥ 30 b/min
BP <90/60
> 65 yrs
```
141
2 requirements to dx uncomplicated CAP?
1. Previously healthy
| 2. No ABX use in last 3 months
142
TX for outpatient CAP? (3)
1. ABX ≥ 5 days
2. Reassurance (resolution of fever in 3 days and 14 days for cough/fatigue)
3. CXR f/u 7-12 wks post tx only in pt >40yrs or smokers
143
TX for uncomplicated CAP?
Azithromycin 500 mg x 1 day, 250 mg x 4 days
OR
Doxycycline 100 mg BID x 7-10 days
144
2 requirements to dx complicated CAP?
1. Recent ABX use
| 2. HX of COPD, CA, DM, drug abuse, IMC
145
Tx for complicated CAP?
Bactrim or Levofloxacin 750 mg QD x 5 days
146
Most common pathogen of sx based pneumonia?
S. pneumoniae
147
Rare cause of CAP, especially in IMC pts?
Fungal infection
148
Is sputum cx definitive dx for CAP?
No, no proof of etiologic agent (not recommend for outpatient)
149
TX for CURB 65 score of 2
Hospitalization
150
TX for CURB 65 score of 3-5?
ICU
151
TX for CURB 65 score of 0-1?
Outpatient
152
CAP prevention measures (2)?
1. Smoking cessation
| 2. Vaccines
153
Pneumonia onset 48+ post admission is CAP, HAP, or VAP?
HAP
154
New or progressive infiltrate and 2+ (fever, purulent sputum, leukocytosis) is dx for what forms of pneumonia?
HAP/VAP
155
First line tx for HAP & VAP?
Prevention + ABX
156
Non-resolving pneumonia is concerning for what? (5)
Atypical infection, aspirations, CHF, CA, fibrosis
157
Pneumonia associated w/ HIV and low CD4?
Pneumocystic Jirovecii Pneumonia (PCP)
158
CXR w/ reticular, ground glass opacities is concerning for?
Pneumocystic Jirovecii Pneumonia (PCP)
159
TX for Pneumocystic Jirovecii Pneumonia (PCP)?
Bactrim
160
When would you tx prophylactically for PCP?
HIV+ or high risk pt
161
Displacement of gastric contents into the lung is concerning for?
Aspiration pneumonia
162
RLL infiltrates is most commonly associated with what type of pneumonia?
Apspiration pneumonia
163
RLL infiltrates is most commonly associated with what type of pneumonia?
Apspiration pneumonia
164
Interstitial lung disease is also known as?
Diffuse parenchymal lung disease (DPLD)
165
ILD is generally reversible or irreversible?
Irreversible
166
Most common cause of IDL?
Idiopathic
167
Fibrosis and adherent scarring is pathophys. associated with what disease?
ILD
168
Progressive DOE and persistent non producrtive cough are consistent with what disease?
ILD
169
ON exam you hear velcro like crackles in the bilateral lung bases and notice digital clubbing what DX are you concerned for?
ILD
170
Ground glass appearance and reticular net like pattern on CXR is an early finding what disease?
ILD
171
Honeycombing is indicative of a good or poor prognosis for ILD?
Poor
172
Why is HRCT used in dx of ILD?
Increased accuracy
173
If PFTs show low DLCO, what disease are you concerned about?
ILD
174
Hypoxemia and respiratory alkalosis on ABG are consistent with what lung disease?
ILD
175
What is the gold standard for dx of ILD?
Lung biopsy
176
What CXR finding is a C/I for lung biopsy in ILD?
Honeycombing
177
Inhalation related diseases (except asbestosis) will appear in the upper or low zones on HRCT?
Upper
178
IPF, connective tissue disease, and asbestosis will appear in the upper or low zones on HRCT?
Lower
179
All PFTS (TLC, FVC, FEV1, FRC and RV) are decreased with what type of lung disease?
Restrictive
180
ILD PFTs are most consistent with restrictive or obstructive defect?
Restrictive
181
Transbronchial bx is used for central or peripheral locations?
Central
182
Surgical bx is used for larger or smaller sample sizes?
Largers
183
What bx technique do you use is sarcoid is suspected?
Endobronchial US guided transbronchial needle aspiration (EBUS-TBNA)
184
What is the most common interstitial lung disease?
Idiopathic pulmonary fibrosis
185
Peripheral reticular opacities an honeycombing on CXR are dx for what disease?
IPF
186
HRCT shows bibasilar reticulonodular opacities, traction, and bronchiectasis what disease are you concerned for?
Idiopathic pulmonary fibrosis
187
When treating IPF what disease must you also treat?
GERD
188
Pirfenidone is used in the tx of what disease?
IPF
189
Non-caseating granulomas secrete what enzyme?
ACE
190
Non-caseating granulomas are associated with what disease?
Sarcoidosis
191
CXR shows hilar adenopathy and labs show increased ACE what disease are you concerned for?
Sarcoidosis
192
Lung disease caused by inhalation/deposition of mineral dust
Pneumoconiosis
193
Black lung is synonymous with?
Coal worker's pneumoconiosis
194
The fibronodular disease characterized by the inhalation of silica dust form occupational hazards is what?
Silicosis
195
What would you expect to see on HRCT for acute silicosis?
Crazy paving pattern
196
Digital clubbing is common or uncommon with pneumoconiosis?
Uncommon
197
PFTs for pneumoconiosis will be restrictive or obstructive?
Restrictive
198
Repeat CXR after the exposure to silica dust has been removed will show the same size or enlarging opacities?
Enlarging
199
Corticosteroids are used to treat chronic or acute pneumoconiosis?
Acute
200
What specific therapy, if any will alter the disease course for pneumoconiosis?
None
201
Chronic simple pneumoconiosis is classified by how many years of exposure?
>10-12 yrs
202
Chronic simple pneumoconiosis is progressive or non-progressive once exposure is eliminated?
Non-progressive
203
Chronic complicated pneumoconiosis is defined as what?
> 20 yrs exposure, progressive even after exposure is eliminated
204
CXR show's "angle wings" what disease are you concerned for?
Chronic complicated pneumoconiosis
205
What occupation exposure has a strong associated with mesothelioma?
Asbestosis
206
What findings should you expect to see on CXR for pt with chronic inhalation of asbestos? (2)
1. Opacities in lower lungs
| 2. Pleural plaques
207
Open lung bx is the definitive treat for what disease, even though it is not usually indicated?
Asbestosis
208
PFTS for asbestosis are restrictive or obstructive pattern?
Restrictive
209
Will immunotherapy and/or steroids alter the disease course for Asbestosis?
No
210
Inflammatory syndrome due to repetitive inhalation of antigens is what?
Hypersensitivity Pneumonitis (HSP)
211
First line tx for HSP?
Antigen avoidance & proper prevention techniques
212
Is HSP reversible?
Yes, remove antigen
213
Immune mediated systemic vasculitis is what?
Graulomatosis w/ Polyangitis (GPA)
214
Necrotic blistering purpura, saddle nose deformity, and pulmonary infiltrates are concerning for what disease?
Graulomatosis w/ Polyangitis (GPA)
215
Stellate shaped peripheral pulmonary arteries on CT chest is concerning for what disease?
Graulomatosis w/ Polyangitis (GPA)
216
Labs reveal elevates ESR and CCRP with + C-ANCA what disease are you concerned about?
Graulomatosis w/ Polyangitis (GPA)
217
What is the initial tx for Graulomatosis w/ Polyangitis (GPA)?
Cyclophosphamide (immunosuppressant) + corticosteroid
218
SX of Cyclophosphamide toxicity
Cardiac, hematologic, renal, GI
219
What labs might you consider for dx Graulomatosis w/ Polyangitis (GPA)?
ANA, RF
220
What is the tx for radiation induced ILD?
Steroids
221
What is the tx for drug induced ILD?
Remove offending drug
222
Pulmonary langerhans cell histiocytosis is a manifestation to what form of ILD?
Smoking ILD
223
What is the biggest RF for getting lung cancer?
Smoking
224
Generally speaking, primary lesions, intrathoracic spread, paraneoplastic syndromes, and metastasis lead to lung cancer being what?
Symptomatic
225
What are the most common sites of distant mets from lung cancer?
Liver (50%), bone, adrenal glands, brain
226
What is needed for the dx of lung cancer?
Tissue biopsy
227
What type of lesions are best evaluated for by sputum culture?
Central lesions
228
What imaging is used to aid in the dx of lung cancer via short lived radioactive isotopes?
PET
229
What causes cancer cells to "light up" in a PET scan?
Metabolically active cells accumulate FDG
230
If a patient w/ lung cancer has no ADL restrictions, what would their performance status be?
0
231
If a patient w/ lung cancer has restricted ability to perform strenuous physical activity, what would their performance status be?
1
232
If a patient w/ lung cancer is capable of all self care and ambulatory for > 50% of walking hours but unable to carry out work activities, what would their performance status be?
2
233
If a patient w/ lung cancer is capable of only limited self care, confirmed to a bed/ chair > 50% of walking hours, what would their performance status be?
3
234
If a patient w/ lung cancer is completely disabled (cannot carry out any self care, totally bed/ chair confined), what would their performance status be?
4
235
With regards to performance status, if FEV1 < 60%, what is this a strong indicator of?
Post op complications
236
N/V, anorexia, weight loss, hematologic toxicity, nephrotoxicity, neurotoxicity, and fatigue are all sxs of what systemic lung cancer therapy?
Cytotoxic chemotherapy
237
What is the 5 yr survival rate for limited SCLC?
10-13%
| Medial survival = 15-20 mos
238
What is the 5 yr survival rate for extensive SCLC?
1-2%
| Median survival = 8-13 mos
239
What is the 5 yr survival rate for NSCLC?
15% (all stages combined)
240
In screening for lung cancer, a LDCT (low-dose CT) should be performed in what cases?
High risk =
Current smokers 55-74 yo w/ 30 pack yr hx
Quit smoking w/i 15 yrs
20 pack yr hx w/ 1 additional RF (not second hand smoke)
241
What is the primary tx for smoking cessation?
Zyban (stop smoking in 5-7 days)
242
What is the MOA for Zyban? (smoking cessation)
Inhibits neuronal uptake of NE and dopamine
243
What does Zyban have a black box warning?
Increased risk of SI in children, adolescents, YA
244
Besides Zyban, what are the possible txs for smoking cessation?
Chantix, (OTC) nicotine replacement
245
A coin lesion is aka what?
Solitary pulmonary nodule (SPN)
246
<3cm, well defined, not associated w/ infiltrate/ atelectasis/ adenopathy, and most are benign describes what?
Solitary pulmonary nodule (SPN)
247
A SPN w/ minimal growth in 2 yrs, calcifications, and smooth, well-defined edges is most likely benign or malignant?
Benign
248
A SPN w/ doubling in 20-400 days, no calcification, poor defined, irregular, and spiculated is most likely benign or malignant?
Malignant
249
What is the primary cause of SPN's in AZ?
Cocci
250
What is the preferred imaging for nodal eval?
Helical CT of chest w/o contrast, low dose radiation
251
If a solid nodule is ≤ 6mm, what is the f/u procedure?
Do not usually require f/u
+/- CT at 12 mos
Individualized care
252
If a solid nodule is 6-8mm, what is the f/u procedure?
F/u w/ CT at 6-12 mos
| Repeat as indicated
253
What is the eval procedure for a solid nodule > 8mm with a low probability (< 5%) of malignancy?
No growth?
Growth?
Get CT @ 3 mos
No growth = serial CT @ 9-12 and 18-24 mos
Growth = pathologic eval
254
What is the eval procedure for a solid nodule > 8mm with an intermediate probability (5-65%) of malignancy?
FDG PET/ CT and/ or bx
255
What is the eval procedure for a solid nodule > 8mm with an intermediate probability (5-65%) of malignancy and FDG avid?
Biopsy/ excision
256
What is the eval procedure for a solid nodule > 8mm with an intermediate probability (5-65%) of malignancy and PET/CT unavailable, negative, or indeterminate?
Individualized management based on clinical suspicion
257
For a solid nodule > 8mm with an intermediate probability (5-65%) of malignancy, what is an acceptable alternative to bx?
CT surveillance at 3, 9-12, and 18-24 mos?
258
What is the eval procedure for a solid nodule > 8mm with an intermediate probability (>65%) of malignancy?
Biopsy/ excision
| +/- staging w/ PET/CT
259
If evaluation of a SPN shows:
- New/ enlarging/ indeterminate lesion
- Lesion > 3cm, unstable, non-calcified, irregular/ spiculated, what should you do?
Refer
260
A solid pulmonary mass (SPM) is what size?
> 3cm
261
Small cell lung cancers are aka what?
Oat cell carcinoma
262
What type of lung cancer is more commonly seen in central airways and is highly aggressive, rapid double times, and early mets?
SCLC
263
Sxs of cough, dyspnea, weight loss, and debility are most commonly associated with what type of lung cancer?
SCLC
264
If upon imaging you see a large hilar mass w/ bulky mediastinal adenopathy, what should you be concerned about?
SCLC
265
What type of lung cancer is associated w/ SVC, SIADH, Cushing's, and Eaton-Lambert syndromes?
SCLC
266
If a SCLC tumor affects ipsilateral hemithorax, what is it staged at?
Limited disease (less common)
267
If a SCLC tumor extends beyond hemithorax and includes pleural effusions, what is it staged at?
Extensive disease (more common)
268
What are the 3 types of NSCLC?
| Which is the most common?
Adenocarcinoma (most common)
Squamous cell
Large cell
269
Which type of lung cancer affects the mucous glands/ epithelial cells in or distal to the terminal bronchioles?
NSCLC - Adenocarcinoma
270
If a pt presents with peripheral nodules/ masses, thrombophlebitis, clubbing, and a hx of smoking, what should you be concerned for?
NSCLC - Adenocarcinoma
271
If a pt presents with evidence of cancer centrally/ in the main bronchus that extends into the main hilum and mediastinum, what should you be concerned for?
NSCLC - squamous cell
272
If a pt presents with slower growing/ late mets, sxs of cough, hemoptysis (& PTH/ hypercalcemia), what should you be concerned for?
NSCLC - squamous cell
273
What will be seen on CXR of a pt with NSCLC - squamous cell?
Cavitations
274
Which type of cancer is associated w/ central or peripheral masses, aggressive/ rapid doubling time, and is primarily a dx of exclusion?
NSCLC - large cell
275
What is the TNM staging?
T- primary tumor
N- nodal involvement
M- distant metastases
276
What is the treatment of choice for localized lung cancers?
Surgical resection
277
What is the tx for lung cancer stage I-IIIa with adequate pulmonary fxn?
Surgery
278
What is the tx for lung cancer stage IIIb-IV?
Palliative radiation or combo chemo
279
What is the 5 yr survival rate for stage 1 lung cancer?
75%
280
What is the 5 yr survival rate for stage 2 lung cancer? (advanced primary tumors/ mets to ipsilateral nodes)
40%
281
What is the 5 yr survival rate for stage 3 lung cancer?
17%
282
What is the 5 yr survival rate for stage 4 lung cancer?
<1%
283
What is the tx for stage 4 lung cancer?
Palliative
| Targeted therapy- EGFR inhibitors
284
Pleural effusion, pericardial effusion, and hoarseness are concerning for what with regards to lung cancer?
Intrathoracic spread
285
What are the 3 types of intrathoracic spread?
SVC syndrome
Pancoast syndrome
Paraneoplastic syndrome
286
What type of intrathoracic spread is due to compression or direct invasion and shows a pathologic process from the right lung > lymph nodes > other mediastinal structures?
SVC syndrome
287
What is the most common cause of SVC syndrome?
Intrathoracic malignancy/ NSCLC
288
If a pt presents w/ the following sxs, what should you be concerned about?
- Dyspnea
- Facial swelling/ head fullness
- Dilated neck veins
- Prominent venous pattern on chest
- Arm swelling, cough, chest pain, dysphagia
SVC syndrome
289
What is the gold standard for dx of SVC syndrome?
Superior vena cavogram (id obstruction, extent of thrombus formation)
290
What is the initial study for sx of SVC syndrome with indwelling devices/ arm swelling?
Duplex US
291
What is the tx for SVC syndrome if there is stridor from central airway obstruction, laryngeal edema, or coma from cerebral edema?
Emergency radiation therapy
292
What type of intrathoracic spread is caused by a tumor involving the superior sulcus causing compression of the brachial plexus and cervical sympathetic nerves?
Pancoast syndrome
293
What is the most common cause of Pancoast syndrome?
NSCLC - squamous cell
294
If a pt presents with rib destruction, atrophy of hand muscles, and pain in the C8, T1, and T2 nerve roots on the same side of the tumor, what should you be concerned about?
Pancoast syndrome
295
If a pt presents with pain greatest closer to the tumor site that radiates down the R shoulder + finger pain, what should you be concerned about?
Pancoast syndrome
296
Injury of the sympathetic nerves of the face, causing mitosis, anhidrosis/ lack of sweating, and ptosis describes what?
What is it associated with?
Horner's syndrome
| Associated w/ Pancoast syndrome
297
What type of intrathoracic spread is triggered by altered immune response to a neoplasm?
Paraneoplastic syndromes
298
A lung cancer pt presents w/ anorexia, weight loss, cachexia, and suppressed immunity... what should you be concerned about?
Paraneoplastic syndromes
299
Can paraneoplastic syndromes be treated?
Can reduce effects but may be temporary
300
What 3 organ systems are likely to be affected with paraneoplastic syndromes?
Hematologic, endocrine, neurologic
301
What neurologic effect of paraneoplastic syndromes is immune mediated, AB at NMJ leading to decreased DTRs, and what type of cancer is it greatest with?
Eaton-Lambert
| > small cell
302
What endocrine effect of paraneoplastic syndromes is associated w/ hypercalcemia and is greatest in SC NCLC?
PTH like substance
303
What endocrine effect of paraneoplastic syndromes is associated w/ gynecomastia and milky nipple discharge and is greatest in LC NCLC?
Excess HCG
304
What endocrine effect of paraneoplastic syndromes is associated w/ personality changes, confusion, coma, and respiratory arrest and is greatest in SCLC?
SIADH
305
What endocrine effect of paraneoplastic syndromes is associated w/ ectopic ACTH, muscle weakness, weight loss, and hirsutism and is greatest in SCLC?
Cushing's syndrome
306
Where in the body does TB present itself?
Lung --> lymph node, kidney's, spine and brain
307
How is TB transmitted?
Airborne droplet nuclei --> into alveoli
308
Is prolonged exposure required for transmission of TB?
Yes
309
What form of TB must a pt have to spread disease?
Active
310
Is a pt has latent TB, will they present with sx?
no
311
Are latent TB pt's able to transmit TB infection?
No
312
Is active or latent TB more common?
Latent
313
When would latent TB become active?
If becomes IMC (unable to fight infection, granulomas breakdown)
314
What pt population is at the highest risk for for active BT infection/
HIV
315
If pt is TB positive, could this be the first indication that they are also HIV positive?
Yes
316
Within what time frame do you need to report TB dx?
24 hrs
317
What are the 3 primary sx of TB?
1. Cough >3+ wks
2. Fever
3. Pleuritic/retrosternal chest pain
318
Primary finding on PE for TB?
Posttussive crackles
| Also dullness/decreased fremitus & clubbing if severe
319
Imaging study for sx TB or if positive infection testing?
CXR (will r/o TB disease if negative)
320
If you notice cavitary lesions and infiltrate, +/- milliary pattern on CXR is this initial presentation of TB, latent TB, or reactivation of latent TB?
Reactivation
```
Initial = hilar lymphadenopathy
Latent = dense nodules
```
321
Due to fact that TB is obligate aerobe where would you expect to find abnormalities on CXR?
Apical/posterior upper lobes
322
Is you notice Gohn lesions and ipsilateral calcified hilar lymph nodes on CXR, what is this concerning for?
Ranke complex.
323
Do you measure induration or erythema on TB skin test (TST)?
Induration
324
Within what time frame should you measure TST?
48-72 hours
325
True or false: TST might be negative 2-8 wks following exposure?
True
326
If pt w/ hx of BCG vaccine, what DX test might produce false positive?
TST
327
TST induration is ≥ 5mm. Who is this a positive test for?
Anyone even w/o TB RF’s
328
TST induration is ≥ 5mm. What populations is this a positive test for? (5)
1. HIV +
2. Recent contacts w/ active TB pt
3. Evidence of TB on CXR
4. IMC (chronic steroids)
5. Organ transplant
329
TST induration is ≥ 10mm. What populations is this a positive test for? (8)
1. ≥ 10mm
2. Recent immigrants from countries w/ high TB infection rates
3. HIV - injection drug users
4. Mycobacteriology lab personnel
5. Residents/ employees of high risk congregate settings
5. High risk medical conditions
7. Children < 4 yo
8. Children/ adolescents exposed to adults @ high risk
330
IGRA: QuantiFeron TB Gold and T-Spot TB measures what in the blood?
The immune responce to TB (IFN-g concentration)
331
What test is used to test for latent TB disease if you received BCG vaccine?
IGRA: QuantiFeron TB Gold and T-Spot TB
332
Does QuantiFeron TB Gold and T-Spot TB distinguish b/w active and latent disease?
No
333
How many sputum specimens needs to be collected for TB dx? And in what time frame?
3 collected 8-24 hrs apart w/ at least 1 in the AM
334
Will AFB smear confirm TB dx?
No
335
Will Nucleic acid amplification (NNA) smear confirm TB dx?
No
336
If pt w/ suspected TB has positive AFB and NNA, do you wait for culture to start tx?
No, start tx ASAP
337
What is gold standard for dx of TB?
Culture, but takes weeks
338
Xpert MTB/RIF assay will identify what? (2)
1. M. tb DNA
| 2. Rifampin resistance
339
Can you used Xpert MTB/RIF in pt that has been on Tb tx < 3 days?
Yes
340
If pt w/ negative TB culture, but high clinical suspicion how do you proceed?
Treat, but monitor response to tx
341
If pt w/ + TB culture, what is your next step?
Drug susceptibility testing
342
Tissue biopsy in TB is taken only if needed, what is the hallmark finding?
Necrotizing granulomas
343
First line drugs to active TB? (4)
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
344
Direct observed therapy (DOT) is required for treatment of what TB disease?
ALL pt's w/ TB disease
345
Initial (intensive) phase for active TB tx?
RIPE meds daily x 8 weeks (56 doses)
346
After completing intensive tx phase for TB what is next? (3)
Repeat CXR, AFB smear, culture
347
RIF and INH daily x 18 weeks (126 doses) is what phase of tx for active TB?
Continuation phase
348
Why would you extend continuation phase for tx of active TB? (2)
Sputum culture, med tolerance
349
Red-orange secretions are SE's for what TB medication?
Rifampin
350
Hepatotoxicty is a SE for what 2 TB drugs?
Isoniazid and Pyrazinamide
351
Ethambutol can cause optic neuritis. In what population is it contraindicated?
Infants/children
352
When is a pt being treated for TB not considered infectious? (3)
1. 2 wks tx regimen
2. 3 neg sputum smears
3. Sxs improve
353
An infectious TB pt is able to go home under what circumstances? (3)
1. Strict f/u arrange w/ DOT
2. No children < 5 yo or IMC living in home
3. No travel (except to health care visits)
354
6-9 month regimen of Isoniazid using DOT is tx for what form of TB? And preferred for what populations?
Latent. Preferred in pregnant women and children 2-11 yo
355
12 doses of INH and Rifampin under DOT/SAT is preferred latent tx for what populations?
Adults & children ≥ 12 yo, otherwise healthy HIV+ pts
NOT during pregnancy
356
If pt's w/ latent TB can't tolerate INH what do you tx with?
Rifampin 120 doses (daily x 4 months)
357
In what populations do you preform targets TB testing? (3)
1. High risk of TB exposure & high risk for developing disease once infected
2. Health care workers
3. Prophylaxis offered to pt's w/ latent TB
358
Resistance to INH and RIF is MDR or XDR?
MDR
359
BCG vaccine is contraindicated in what populations because it is live?
Pregnant and IMC
360
BCG vaccine does not prevent primary infection or activation of LTBI, what is its goal?
Decrease risk of severe consequences to TB disease (meningitis and disseminated TB, especially in children)
361
Exposure to soil contaminated w/ bird/bat dropping is concerning for?
Histoplasmosis
362
Fungal spores are turned into what once inhaled? This leads to Histoplasmosis
yeast
363
HIV+ presents with dysphagia w/ esophageal narrowing, what should you be concerned for?
Histoplasmosis
364
Pt present for physical exam for upcoming spelunking adventure? What disease should you warn them about?
Histoplasmosis
365
Acute symptomatic pulmonary histoplasmosis is self limited or requires tx? If tx, what is it?
Self limited
366
Form of histoplasmosis that is most common in IMC pts, involves multiple organ systems and is fatal w/in 6 weeks?
Progressive disseminated histoplasmosis
367
Chronic pulmonary histoplasmosis results in progressive lung changes in what population?
Older COPD pts
368
Immunodiffusion (ID) serology measures for the presence of what Ab in histoplasmosis and cocci?
IgM - Will tell you if pt has acute or chronic infection
369
Complement fixation (CF) serology measures for the presence of what Ab in histoplasmosis and cocci?
IgG
370
Antigen serology, Enzymes immunoassay (EIA) test is used first in dx the diagnosis of what two diseases?
Histoplasmosis, Cocci
371
CXR for histoplasmosis will show what?
Patchy or nodular infiltrates in the lower lobes
372
What is the tx for asymptomatic histoplasmosis?
None
373
What is the most common form of histoplasmosis in otherwise healthy individuals?
ASX primary histoplasmosis
374
TX for mild-mod acute pulmonary histoplasmosis?
< 4 wk, none
| > 4w itraconazole
375
Tx for acute-severe and progressive disseminated pulmonary histoplasmosis?
AmphoB then itraconazole
376
TX for chronic histoplasmosis?
Itraconazole
377
TX for HIV/Aids pts w/ histoplasmosis?
AmphoB + itraconazole
378
Inhalation of spores from desert soil is concerning for what?
Cocci
379
If pt presents with pulmonary complaints and 1+ of erythema nodosum, erythema multiforme, eosinophilia what should you be concerned for?
Cocci
380
Is sub-acute valley fever infection protective from future disease?
yes
381
Is CAP + fever, cough, pleuritic CP, HA, fatigue, desert rheumatism and erythema nodosum concerning for primary cocci infection or disseminated disease?
Primary infection
382
More pronounced lung findings, bone lesions, lymphadenitis, and meningitis are concerning for what?
Disseminated cocci disease (increased risk in IMC pts)
383
Slight leukocytosis with eosinophilia is concerning for what disease?
Cocci
384
Is coccidiodin or spherulin skin test dx for cocci?
No
385
Thin walled cavities on CXR should disappear in what time frame if Cocci?
2 years
386
If pt with cocci is stable is treatment required?
No
387
If IMC pt with severe cocci infection what is first line med?
"Azole" (no ketoconazole) OR amphoB if pregnant or v severe
388
If no med therapy for cocci when does pt follow up?
Every 2-4 weeks for 1 year
389
True or False all pts dx with cocci will follow up every 2-4 weeks regardless of treatment provided?
True
390
When would a Cocci pt continue annual follow up for 2+ years?
If started on med therapy
