JH IM Board Review - SOS II Flashcards
(108 cards)
1
Q
The 4 idiopathic interstitial pneumonias:
A
- IPF.
- DIP.
- AIP.
- NSIP.
2
Q
Is complete recovery possible for DIP, AIP, NSIP?
A
YES.
3
Q
2 new drugs for IPF:
A
- Pirfenidone.
2. Nintedanib.
4
Q
AIP is commonly referred to as …
A
Hamman-Rich syndrome.
5
Q
2 interesting lung manifestations of SLE:
A
- Alveolar hemorrhage (+/- APS).
2. Shrinking lung syndrome (!) — Restrictive lung disease in the absence of parenchymal disease.
6
Q
RA lung involvement is more common in men or women?
A
Men (3:1).
7
Q
Sx of RA lung disease precede joint disease in …% of cases.
A
20%.
8
Q
3 interesting manifestations of RA lung disease:
A
- Rheumatoid — necrobiotic — nodules. (Keep in mind Caplan syndrome)
- Constrictive bronchiolitis (or bronchiolitis obliterans).
- Cricoarytenoid arthritis (!) — Pain, hoarseness, dyspnea, stridor, obstruction. (25% of RA)
9
Q
What is the antisynthetase syndrome (keep in mind polymyositis/dm)?
A
- Subclinical myositis.
- ILD.
- Raynaud’s.
- Mechanic’s hands.
- Symmetric polyarthritis of small joints.
10
Q
2 forms of Wegener:
A
CLASSIC ==> UPPER + LOWER RT + KIDNEYS.
LIMITED ==> ISOLATED RT involvement — Up to 40% may be ANCA(-).
11
Q
The 6 eosinophilic lung diseases:
A
- Acute eosinophilic pneumonia.
- Chronic eosinophilic pneumonia.
- Hypereosinophilic syndrome.
- ABPA.
- Churg-Strauss.
- Eosinophilic granuloma.
12
Q
Dx of acute/chronic eosinophilic pneumonia requires …
A
BAL or lung tissue bx showing eosinophils.
13
Q
Both acute and chronic eosinophilic pneumonia are responsive to …
A
STEROIDS.
14
Q
What defines the hypereosinophilic syndrome:
A
- Defined as more than 1500 eosinophils/mm3 in peripheral blood for 6mo.
- Primary targets include ==> Heart, CNS, peripheral nervous system, skin.
==> The lung is LESS commonly involved.
15
Q
Churg-Strauss may be unmasked after …
A
Tapering steroids in an asthmatic.
16
Q
Eosinophilic granuloma presents almost exclusively in …
A
Smoking adults.
17
Q
Eosinophilic granuloma tx:
A
SMOKING CESSATION.
STEROIDS INEFFECTIVE.
18
Q
Eosinophilic granuloma may be a/w which 2 entities?
A
- Bone cysts.
2. DI.
19
Q
Tx of idiopathic BOOP:
A
STEROIDS for >6mo.
20
Q
Obliterative bronchiolitis (NOT BOOP) is or is not responsive to steroids?
A
IS NOT.
21
Q
Mesothelioma risk is or is not affected by smoking?
A
IS NOT.
Lung Ca is
22
Q
What has been seen in pts with FIBROCYSTIC sarco?
A
MYCETOMAS.
23
Q
What is the uveoparotid fever in sarco pts?
A
Heerfordt-Waldenstrom syndrome:
==> Bil lacrimal/parotid duct enlargement + FEVER + Anterior uveitis.
24
Q
What is the Lofgren syndrome?
A
ERYTHEMA NODOSUM +
HILAR ADENOPATHY +
ARTHRALGIAS +
FEVER.
25
Lofgren course?
SPONTANEOUS REMISSION IS COMMON.
26
What should be given to skin sarco lesions?
Chroloquine or pentoxyfylline — NOT STEROIDS.
27
What is the best clinical predictor for sarco liver involvement?
ALP.
28
Factor V leiden homozygotes or heterozygotes have increased risk?
Homozygotes.
Heterozygotes have NO INCREASED RISK.
29
CT venography use in the dx of DVT:
Se and sp comparable to US, so NOT routinely recommended.
==> Useful if INJURED or CASTED leg because US cannot be performed in this scenario.
30
PE - Hypoxemia:
VARIABLE because it is an EPIPHENOMENON OF THROMBUS ==>
Atelectasis, edema, interatrial shunting, low-mixed venous tension.
31
PE/DVT duration of therapy:
3 mo after reversible major RFs ==> Provoked VTE.
3 mo to indefinite ==> First unprovoked VTE. Can continue indefinitely if pt agrees + no significant bleeding risk.
FOREVER for first PE/DVT w/ active cancer OR 2nd unprovoked DVT/PE.
32
Hypopnea means ...
A 50% or greater decrease in airflow
OR
<50% decrease in airflow a/w at least 4% drop in SaO2.
33
Apnea-Hypopnea index (AHI) is the total number of ...
Apneas + Hypopneas per hour of sleep.
34
Normal Apnea-Hypopnea index (AHI) is ...
5 or fewer per hour.
35
Upper airway resistance syndrome (UARS) means ...
1. Repeated arousals 2o to increased upper airway resistance (“crescendo snoring”).
2. AHI is normal.
3. No significant O2 desat episodes.
36
Obesity-hypoventilation syndrome is also known as ...
Pickwickian syndrome.
37
Clinical conditions a/w CENTRAL sleep apnea:
1. Stroke.
2. Stable METHADONE maintenance tx (!).
3. MSA.
4. Autonomic dysfunction.
5. MG.
6. Neuromuscular diseases.
7. Bulbar poliomyelitis.
8. Encephalitis.
38
Dx of an apnea syndrome is made by an ...
Overnight POLYSOMNOGRAM (PSG) sleep study.
39
If AHI is >5 episodes per hour, sleep study is ...
Positive for sleep apnea.
40
OSA vs CENTRAL SA is determined by presence vs absence of ...
CHEST/ABDOMINAL WALL EFFORTS.
41
Mild — Moderate — Severe APNEA means ...
MILD ==> 6-15 events.
MODERATE ==> 16-30 events.
SEVERE ==> More than 30 events.
42
What is the ration of benign — malignant solitary pulmonary nodules?
60 BENIGN — 40 MALIGNANT.
43
SPN doubling time of 25 to 450 days suggests a benign or a malignant process?
A MALIGNANT.
44
SPN doubling time of LESS THAN 25 days or MORE THAN 450 days suggests a benign or a malignant process?
A BENIGN.
45
SPN doubling time refers to what parameter of the nodule?
To the VOLUME ==> MEANING THAT DOUBLING IS 28% INCREASE IN DIAMETER.
46
Calcification patterns in solitary pulmonary nodules:
4 benign patterns:
1. Central (“target”).
2. Diffuse.
3. Popcorn.
4. Laminar (concentric).
47
Calcification patterns in solitary pulmonary nodules:
2 malignant patterns:
1. Eccentric.
| 2. Stippled.
48
If the SPN has doubling time 25-450 and the pt’s cardio status permits surgery, then ...
Thoracotomy with resection is indicated.
49
SPN <1cm, stable for 2y, are most likely ...
Benign and DO NOT require F/U.
50
Role of percutaneous transthoracic needle aspiration (usually under CT guidance) in the dx of SPN?
1. Most useful for peripheral lesions.
| 2. Higher dx yield than bronchoscopic bx — 80-95% (even in lesions less than 2cm).
51
Clinically significant hemoptysis is rarely from the pulmonary circulation, because it’s ...
A low-pressure system + Hypoxic pulmonary vasoconstriction diverts blood flow away from diseased portions of the lung.
52
Massive hemoptysis means ...
>600mL in 24h.
53
Pseudohemoptysis means ...
S.marascens pneumonia.
54
Invasive procedure of choice for NON massive hemoptysis?
Fiberoptic bronchoscopy.
55
What physical finding is a reliable indicator of elevated PA pressure?
A prominent pulmonic component of the S2.
56
Tx of PHTN — Positive response to acute admin of NO:
...-...% are responders (drop 10mm to <40mmHg) and should be tx w/ ...
5-10%.
Should be tx w/ ORAL CCB.
57
NON responders have an increased risk of ... w/ CCBs and should receive ...
DEATH.
They should receive OTHER Tx.
58
Long-term anticoag in PHTN?
INDICATED FOR ALL ==> prevent intravascular thrombosis in the pulmonary circulation as well as deep venous thrombosis.
59
Epoprostenol and bosentan are frequently used for 2o PHTN caused by ...
SCLERODERMA.
60
2 pathophysiologic causes of acute respiratory failure:
1. Failure of oxygenation.
| 2. Failure of ventilation.
61
The 8 mechanisms of pleural fluid accumulation:
1. Increased hydrostatic pressure of vasculature ==> CHF.
2. Decreased oncotic pressure of vasculature ==> Nephrotic syndrome.
3. Decreased pleural pressure ==> Atelectasis.
4. Obstruction of lymphatic drainage ==> Malignancy.
5. Increased capillary permeability ==> Parapneumonic effusion.
6. Rupture of thoracic duct ==> Chylothorax.
7. Increased fluid in peritoneal cavity ==> Hepatic hydrothorax.
8. Iatrogenic ==> Placement of central line into pleural space.
62
MCC of massive pleural effusions that cause complete opacification of one hemithorax?
Malignancy.
63
Rheumatoid pleurisy — Classic presentation is ...
An older man w/ subcutaneous rheumatoid nodules and a unilateral pleural effusion.
==> Frequently mimics a complicated parapneumonic effusion — W/ high LDH (>1000 U/L) + low glu (<40), and low pH (<7.2).
64
Lupus pleuritis may be seen in ...
Drug-induced lupus 2o to procainamide or isoniazid among others.
65
Site of interruption of the thoracic duct determines ...
Side of pleural effusion (chylothorax).
RIGHT if below the T4.
LEFT if above T4.
66
Consider SUBPULMONIC effusions if one ...
HEMIdiaphragm appears elevated and apex of diaphragm is LATERALLY DISPLACED.
67
Sensitivity of single thoracentesis sample for diagnosing malignancy is ...
60%.
3 sequential thoracenteses increase SE to 80%.
68
Pseudochylothorax means ...
Milky fluid but not a true chylothorax.
==> Usually seen in long-standing effusions.
1. Old TB.
2. Rheumatoid pleurisy.
3. Nephrotic syndrome.
69
Tx of chylothorax:
1. Chest tube + bed rest + enteral feeding w/ medium-chain TGs — absorbed to circulation via portal vein, avoiding thoracic duct.
2. Occasionally ==> Thoracic duct ligation or placement of pleuroperitoneal shunt needed.
70
Tx of pneumothorax:
Administer 100% O2 and observe pt if pneumothorax is small (<15% of hemithorax).
==> Increases rate of reabsorption of air from pleural space 4x.
***Larger (>15% hemithorax) pneumothoraces require removal of air, either with catheter (works best w/ young pts) or w/ chest tube (required for most pts).
71
2 pathophysiologic mechanisms of acute respiratory failure:
1. Failure of oxygenation.
| 2. Failure of ventilation.
72
Cyanosis occurs only after deoxyhemoglobin level is > ...g/dL which corresponds to an SaO2 at approx ...%.
>5.
67%.
73
Pulse oximeter may be UNRELIABLE in the following situations:
1. On the steep portion of the oxyhemoglobin dissociation curve (ie at SaO2 <90%).
2. Pts w/ carboxyhemoglobin or methemoglobin (may overestimate oxyhemoglobin).
3. Decreased peripheral perfusion (eg shock).
4. Pts w/ pigmented skin or nail polish.
74
Criteria for use of NON invasive ventilation:
1. COPD exacerbation ==> Hypercapnic resp failure (pH 7.25-7.35, RR 20-30), able to manage secretions.
CIs ==> Shock — Not able to tolerate mask — GCS <8.
2. Resp failure in immunosuppressed w/ bil infiltrates (BMT, HIV, Post-chemo).
CIs ==> Shock — Not able to tolerate mask — GCS <8.
75
Acute resp failure — Supplemental O2 target ==> SaO2 >...% or PaO2 >... mmHg.
88%.
55mmHg.
76
Complications of mechanical ventilation:
1. Auto-positive pressure (PEEP) (dynamic hyperinflation) ==> Air trapping due to inadequate emptying during expiration (eg asthma, COPD).
2. Volutrauma or barotrauma ==> PTX, pneumomediastinum, DAD.
3. VAP.
4. Endotracheal tube complications ==> Subglottal stenosis, vocal cord dysfunction, TEF, sinusitis.
77
The Berlin definition of ARDS requires the following:
1. Onset within 7 days following insult OR progressively worsening symptoms over past 7 days.
2. Diffuse bil infiltrates consistent with pulm edema on CXR or chest CT.
3. Resp failure cannot be caused by heart failure or volume overload.
78
Severity of ARDS is based on ...
PaO2/FiO2
while on CPAP 5cm H2O or greater
OR
end-expiratory pressure of 5cm H2O or greater.
79
Mild — Moderate — Severe ARDS:
1. Mild ==> PaO2/FiO2 ==> 200-300.
2. Moderate ==> PaO2/FiO2 ==> 100-200.
3. Severe ==> PaO2/FiO2 ==> Less than 100.
80
Prevention of ARDS — Mention some measures:
1. Early ABX + resuscitation for severe sepsis.
2. Use of lower Vt.
3. Conservative blood product use.
4. Early CPAP in hematologic malignancy(!) pts w/ signs of resp failure decreases incidence of ARDS.
81
What is now the MCC of sepsis?
GRAM (+) organisms.
Followed closely by gram (-).
82
Abx in sepsis:
Should be infused within 1h in pts w/ hypotension caused by sepsis (door-to-infusion time <1h).
83
Sepsis — In pts w/o adrenal suppression at baseline, steroids are of use?
NO EFFECT ON MORTALITY!
84
Activated charcoal blocks absorption of most drugs — EXCEPTIONS?
1. Alkali.
2. Li.
3. Iron.
4. Insecticides.
85
Gastric lavage role?
Of UNPROVEN efficacy — may be useful if recent ingestion (<1h).
86
Amount of insensible H2O losses through skin and respiratory tract:
500-1000mL.
87
Order of correction of electrolytes:
Mg > Ca > K > Na.
88
5 indications for DIALYSIS:
1. Severe metabolic acidosis.
2. Electrolyte disturbances.
3. Intoxications.
4. Volume overload.
5. Uremia.
89
Important point about FeNa:
Can be >1% w/ prerenal AKI in pts w/ preexisting chronic kidney disease because of impaired ability to reabsorb Na.
Can be <1% w/ glomerulonephritis, iodinated contrast admin, and rhabdomyolysis.
90
Infections that may lead to INTERSTITIAL NEPHRITIS:
1. Staph/strep.
2. Brucella.
3. HIV.
4. CMV.
5. HANTAVIRUS.
6. TB.
7. Schistosoma.
8. Toxoplasma.
91
Eosinophilia/eosinophiluria are or are not sensitive for interstitial nephritis dx?
ARE NOT ==> Their absence should not exclude dx.
92
Interstitial nephritis dx gold standard:
Biopsy.
93
Contrast-induced nephropathy — Cr peaks within ... and usually returns to baseline within ... .
Peak 7 days.
Baseline 10 days.
94
Pigment nephropathy — Mechanism:
Heme pigment (ferrihemate) of myoglobin — hemoglobin.
==> causes VASOCONSTRICTION ==> Ischemia.
95
Keep in mind that obstruction of renal tubules is caused by myoglobin or hemoglobin casts?
MYOGLOBIN casts.
Hemoglobin is TOO LARGE to be substantially filtered at glomerulus into tubules.
96
3 important lab findings in cholesterol atheroembolic disease:
1. Eosinophilia.
2. Eosinophiluria.
3. Hypocomplementemia.
97
Postrenal AKI — Paradoxical polyuria?
PARTIAL OBSTRUCTION ==> Transmitted to the distal renal tubules impaired water reabsorption ==> INCREASE URINE OUTPUT.
98
Nuclear medicine furosemide renogram (!):
Can provide functional status of the kidneys and avoid risk of IV contrast.
99
Renal vein thrombosis is MC with which type of glomerular disease?
Membranous glomerulonephropathy.
100
MCD — The formation of edema is characteristically ...
RAPID.
IN ONE DAY.
101
2o causes of MCD:
1. HL.
2. Thymoma.
3. NSAIDs.
4. Bee stings.
5. Li.
102
HIV-associated nephropathy (HIVAN) presents w/ a ...
COLLAPSING FSGS.
103
Besides HIVAN, collapsing FSGS may be seen in ...
NON-HIV-infected pts — Parvo, pamidronate.
104
DM 1 vs DM 2 importance of retinopathy regarding NEPHROPATHY?
DM 1 + Nephropathy ==> 95% RETINOPATHY.
DM 2 + Nephropathy ==> 50-75% RETINOPATHY.
105
Keep in mind that all DM pts w/ proteinuria should be evaluated for ...
Other systemic diseases — HBV, HCV, SLE, monoclonal gammopathy.
AS UP TO 20% have a NON diabetic cause of proteinuria.
106
4 cases in which you should consider renal biopsy in DM:
1. Presence of proteinuria w/ <10y DM duration.
2. Presence of significant hematuria or RBC casts on urinalysis.
3. Absence of retinopathy in DM 1 and possibly DM 2.
4. ANY evidence of systemic disease.
107
Post-infectious GN following STAPH infection is increasingly ...
Being recognized — Particularly in DIABETICS.
108
Diseases that may present with rapidly progressive renal failure:
1. GN.
2. CH emboli syndrome (transient hypocomplementemia in 25%).
3. HUS, TTP, MHTN, APS.
4. Scleroderma renal crisis.
5. Myeloma cast nephropathy.
