MKSAP Board Basics Pulmonology Flashcards
(355 cards)
1
Q
What FEV1/FVC ratio indicates airflow obstruction?
A
Less than 0.7 (70%)
2
Q
What increase in FEV1 with bronchodilator therapy indicates reversible airway obstruction?
A
12% or more
3
Q
What increase in FVC with bronchodilator therapy indicates reversible airway obstruction?
A
12% or more
4
Q
What volume (mL) increase in FEV1 with bronchodilator therapy indicates reversible airway obstruction?
A
200 mL or more
5
Q
What volume (mL) increase in FVC with bronchodilator therapy indicates reversible airway obstruction?
A
200 mL or more
6
Q
What is the role of flow-volume loops in obstructive lung disease?
A
Help localize anatomic sites of airway obstruction.
7
Q
What TLC indicates restrictive lung disease?
A
Less than 80%
8
Q
If patients have a normal DLCO and low lung volumes - what is the most likely cause?
A
Extra-pulmonary cause such as obesity
9
Q
If patients have a low DLCO and low lung volumes - what is the most likely cause?
A
Pulmonary fibrosis
10
Q
If patients have a low DLCO and normal lung volumes - what are the most likely causes?
A
- Anemia
- Pulmonary vascular disease
11
Q
If patients have a low DLCO and FEV1/FVC of less than 0.7 - what are the most likely causes?
A
COPD
Bronchiectasis
12
Q
If patients have a normal or high DLCO and FEV1/FVC of less than 0.7 - what is the most likely cause?
A
Asthma
13
Q
What are causes of high DLCO?
A
Pulmonary hemorrhage
Left-to-right shunt
Polycythemia
14
Q
Measures percentage of oxyhemoglobin; performed at rest or during exercise.
What test is this?
A
Pulse oximetry
15
Q
What should you use when carbon monoxide poisoning is suspected?
A
Co-oximetry
16
Q
Airflow is measured before and after challenge.
What test is this?
A
Bronchial (methacholine) challenge testing
17
Q
Performed for unexplained dyspnea, symptoms disproportionate to the measured pulmonary function abnormality, and other exercise-related symptoms.
What test/investigation is described?
A
Cardiopulmonary exercise testing
18
Q
Useful to assess disability, need for supplemental oxygen, and prognosis in chronic lung conditions. Simple oximetry and desaturation studies are performed at rest and with exertion.
What test is this?
A
6-minute walk test
19
Q
Is exhaled nitric oxide increased or decreased in patients with airway inflammation, including asthma?
A
Increased
20
Q
Is pulse oximetry increased, normal or decreased after carbon monoxide poisoning?
A
Normal
21
Q
Is pulse oximetry increased, normal or decreased after cyanide poisoning?
A
Normal
22
Q
What happens to pulse oximetry reading in patients with shock?
A
It is falsely low.
23
Q
What should you think of with any cough that is nocturnal, seasonal, or related to a workplace or activity?
A
Asthma
24
Q
What are the nasal polyps and aspirin sensitivity are associated with?
A
Asthma
25
Does normal spirometry rule out asthma?
No
26
Does a normal bronchoprovocation test rule out asthma?
Yes
27
What does a positive bronchoprovocation test confirm?
Airway hyperresponsiveness
(asthma is only one cause)
28
Is wheezing diagnostic of asthma?
No
29
What should you consider in patients that are wheezing?
- Asthma
- Heart failure
- COPD
- Vocal cord dysfunction
- Upper airway obstruction
30
Patient has striking peripheral blood eosinophilia, fever, and weight loss and is a long-term smoker. Chest x-ray shows “photographic-negative” pulmonary edema (peripheral pulmonary edema). Bronchoscopy with biopsy or bronchoalveolar lavage shows a high eosinophil count.
Diagnosis?
Chronic eosinophilic pneumonia
31
Patient has asthma like picture with eosinophilia, markedly high serum IgE levels, and intermittent pulmonary infiltrates. CXR shows radiographic opacities in the upper lobes. Advanced disease can cause fixed obstruction and bronchiectasis.
Diagnosis?
Allergic bronchopulmonary aspergillosis
32
How is allergic bronchopulmonary aspergillosis diagnosed?
- Positive skin test for Aspergillus
- IgG and IgE antibodies to Aspergillus
33
Patient has upper airway and sinus disease that precedes difficult-to-treat asthma. There are flares associated with use of leukotriene inhibitors and glucocorticoid tapers. Serum p-ANCA may be elevated, and eosinophilic tissue infiltrate is noted.
Diagnosis?
Eosinophilic granulomatosis with polyangiitis
34
Which tests can you use to diagnose tracheal obstruction and vocal cord dysfunction?
- Direct visualization (laryngoscopy)
- Flow-volume loops
35
How do you classify asthma with symptoms 2 times or less per week, and nocturnal symptoms 2 times or less per month?
Intermittent
36
How do you classify asthma with symptoms more than 2 times per week, but less than once a day, and nocturnal symptoms more than 2 times per month?
Mild persistent
37
How do you classify asthma with symptoms daily, and nocturnal symptoms 1 times or more per week, and 2 or more exacerbations per week?
Moderate persistent
38
How do you classify asthma with continual symptoms and frequent nocturnal symptoms?
Severe persistent
39
What is the treatment for intermittent asthma?
As needed short acting beta agonist
40
What is the treatment for mild persistent asthma?
Add an inhaled corticosteroid
41
What is the treatment for moderate persistent asthma?
- Low to medium dose inhaled corticosteroid + long-acting beta agonist
- Medium dose of inhaled corticosteroid
- Low to medium dose of inhaled corticosteroid + leukotriene modifier or theophylline.
42
What is the treatment for severe persistent asthma?
High dose of inhaled corticosteroid + long-acting beta agonist or long-acting muscarinic antagonists +/- oral corticosteroids.
43
Are metoprolol and atenolol selective or non-selective beta blockers?
Selective beta blockers
44
Omalizumab can be used in moderate to severe persistent asthma with inadequate control on inhaled corticosteroids and IgE levels between ______ and _____ kU/L.
30 and 700 kU/L
45
Which anti-interleukin-5 monoclonal antibodies reduce asthma symptoms and are only used in severe cases of asthma when the absolute eosinophil count > 150 cells/microL?
Mepolizumab
Reslizumab
46
Should asthma patients get influenza vaccine?
Yes
47
What happens when you give fluoroquinolones or macrolides to patients taking theophylline?
Can cause theophylline toxicity
48
What happens if you use long-acting beta agonists as a single agent in asthma?
Increases mortality
49
What should you do for an acute exacerbation of asthma during pregnancy?
Treatment same as regular asthma except early addition of glucocorticoids is indicated for rapid reversal of airway obstruction during an exacerbation.
50
Can IV magnesium sulfate be helpful for patients who have life-threatening asthma exacerbations?
Yes
51
What does a normal arterial Pco2 in a patient with severe symptomatic asthma indicate?
Impending respiratory failure
52
What should be considered in patients with asthma signs and symptoms that improve immediately with intubation?
Vocal cord dysfunction
53
What should be measured in COPD patients less than 45 years of age?
Alpha-1 anti-trypsin deficiency
54
Often secondary to an inciting event, such as childhood pneumonia or TB; may be associated with foreign body,
CF, immotile ciliary syndrome, nontuberculous mycobacteria, and aspergillus colonization. Large-volume sputum production with purulent exacerbations; hemoptysis. CXR shows "tram lines".
Diagnosis?
Bronchiectasis
55
Obstructive pulmonary disease is most common presentation in adult patients; other symptoms may include
recurrent respiratory infections, infertility.
Diagnosis?
Cystic fibrosis
56
Found in current or former smokers; may be idiopathic or associated with other diseases such as RA. Poorly responsive to bronchodilators; responds to smoking cessation and glucocorticoids.
Diagnosis?
Adult bronchiolitis
57
Patient presents with dyspnea without improvement following bronchodilators, normal or hyperinflated lungs on chest
x-ray; associated with injury to small airways; sometimes after lung or stem cell transplantation.
Diagnosis?
Bronchiolitis obliterans
58
Stridor, which may be both inspiratory and expiratory. Flow-volume loop shows expiratory or inspiratory flattening, or both.
Diagnosis?
Upper airway obstruction
59
What is the advantage of COPD patients stopping smoking?
It reduces the rate of decline in lung function
60
When is pulmonary rehabilitation recommended for COPD patients?
Symptomatic patients with FEV1 less than 50%.
61
Which COPD patients is continuous oxygen therapy recommended for?
- Arterial pO2 less than 55 mmHg
- Oxygen saturation less than 88%
62
What should you consider for patients with upper lobe emphysema (heterogeneous disease) and low baseline exercise capacity to improve mortality, exercise capacity, and quality of life?
Lung volume reduction surgery
63
When should augmentation therapy with IV human alpha-1 antitrypsin for patients with severe alpha-1 antitrypsin deficiency be considered?
- Alpha-1 antitrypsin activity level < 11 µm
- FEV1 less than 65%
64
Can lung transplantation increase quality of life and functional capacity in select COPD patients?
Yes
65
Are PDE-4 inhibitors indicated for acute bronchospasm?
No
66
Is clubbing a feature of COPD?
No
67
What should you consider in patients with cystic fibrosis and acute abdominal pain?
Intestinal intussusception
68
Which vaccines do all cystic fibrosis patients need?
- Pneumococcal conjugate and polysaccharide vaccines
- Influenza vaccine
69
What medications do you add in acute pulmonary exacerbations in cystic fibrosis patients?
Antipseudomonal antibiotics
70
What do you use for suppression of chronic pulmonary infections in cystic fibrosis patients?
Aerosolized tobramycin
71
What do you use for persistent airway secretions in cystic fibrosis patients?
- Aerosolized recombinant human DNase (dornase alfa)
- Hypertonic saline
72
What do you use for symptoms of airway obstruction in cystic fibrosis patients?
- Inhaled bronchodilators
- Glucocorticoids
73
What do you use for nocturnal hypoxemia or hypercarbia in cystic fibrosis patients?
Nighttime noninvasive mechanical ventilation (cPAP/BiPAP)
74
What do you do in cystic fibrosis patients advanced lung disease or liver disease?
Evaluation for lung transplant
75
A patient has flulike illness; x-ray shows focal areas of consolidation that may migrate from one location to another.
Diagnosis?
Cryptogenic organizing pneumonia
76
A > 50 year old patient with chronic, insidious onset of cough and dyspnea; chest x-ray shows honeycombing, bibasilar infiltrates with fibrosis.
Diagnosis?
Idiopathic pulmonary fibrosis
77
What is the mortality rate of acute interstitial pneumonia?
50%
78
Affects women in their 30s and 40s; associated with spontaneous pneumothorax and chylous effusions. Chest CT shows cystic disease.
Diagnosis?
Lymphangioleiomyomatosis
79
Chest x-ray shows “photographic negative” of HF, with peripheral alveolar infiltrates predominating. Other findings may include peripheral blood eosinophilia and eosinophilia on bronchoalveolar lavage.
Diagnosis?
Chronic eosinophilic pneumonia
80
Median age of 40 years, and males predominate among smokers but not in nonsmokers. Diagnosed via bronchoalveolar lavage, which shows abundant protein in the airspaces; chest CT shows “crazy paving” pattern.
Diagnosis?
Pulmonary alveolar proteinosis
81
Are patients with dyspnea for days or weeks (vs months) more likely to have pneumonia or heart failure than diffuse parenchymal lung disease?
Yes
82
What percentage of patients with diffuse parenchymal lung disease have normal chest X-rays?
20%
83
What should you consider in patients with dyspnea and pulmonary crackles but no other findings of heart failure?
Diffuse parenchymal lung disease
84
What improves survival and quality of life in idiopathic pulmonary fibrosis?
Lung transplantation
85
Do pirfenidone and nintedanib demonstrate benefit in slowing disease progression for select patients with interstitial lung disease?
Yes
86
Is oxygen therapy indicated for interstitial lung disease patients with hypoxemia?
Yes
87
Should you intubate and mechanically ventilate patients
with respiratory failure caused by interstitial pulmonary fibrosis (IPF)?
No
(can't extubate them afterwards - they'll need a tracheostomy and lung transplant)
88
What is Lofgren syndrome?
Sarcoidosis with the following constellation:
- Fever
- Bilateral hilar lymphadenopathy
- Erythema nodosum
- Ankle arthritis
89
What is a characteristic pathologic finding in sarcoidosis patients?
Non-caseating granulomatosis
90
Should slit-lamp examinations be done for all sarcoidosis patients?
Yes
91
Should an EKG be done to rule out heart block or other cardiac abnormalities in all sarcoidosis patients?
Yes
92
Should you always rule out TB and fungal infections by ordering appropriate stains and culture on tissue biopsy in sarcoidosis patients?
Yes
93
What disease that is often found in workers in light bulb or semiconductor factories may cause a sarcoidosis-like
clinical syndrome?
Berylliosis
94
Does ACE level confirm the diagnosis of sarcoidosis?
No
95
What medications are indicated for progressive or symptomatic pulmonary sarcoidosis; hypercalcemia; or cardiac, ophthalmologic, or neurologic sarcoidosis?
Oral glucocorticoids
96
What medications are prescribed for skin lesions or anterior uveitis in sarcoidosis patients?
Topical glucocorticoids
97
What medications are used for nasal polyps or airway disease in sarcoidosis?
Inhaled glucocorticoids
98
What is the rate of spontaneous remission and resolution in Lofgren syndrome?
80%
99
Should you treat asymptomatic sarcoidosis?
No
100
How is occupational asthma and reactive airways dysfunction syndrome treated?
Inhaled glucocorticoids
101
What should patients with silicosis, fever and cough be evaluated for?
Tuberculosis (incidence is increased in silicosis)
102
What is the latent period for development of asbestosis and mesothelioma?
10 - 15 years
103
Does exposure to asbestos increases the risk of lung cancer in cigarette smokers?
Yes
104
In patients with a history of asbestos exposure or asbestosis, how can the risk of lung cancer mortality be decreased at any time?
Smoking cessation
105
What is the treatment for localized mesothelioma?
Surgery
106
How do you prevent recurrences of mesothelioma?
- Radiation
- Chemotherapy
107
What is indicated for any new unexplained pleural effusion?
Thoracentesis
108
When is observation and therapy without thoracentesis reasonable for a pleural effusion?
- Known heart failure
- Small parapneumonic effusions
- CABG surgery
109
What is the pleural fluid protein–serum protein ratio in an exudate?
> 0.5
110
What is the pleural fluid LDH in an exudate?
> 200 U/L
111
What is the pleural fluid LDH–serum protein LDH ratio in an exudate?
> 0.6
112
What is the usual RBC count of the pleural fluid in case of malignancy?
RBC count 5000-10,000/µL (bloody)
113
What is the usual RBC count of the pleural fluid in case of malignancy?
RBC count 5000-10,000/µL (bloody)
114
What is the usual RBC count of the pleural fluid in case of pulmonary infarction?
RBC count 5000-10,000/µL (bloody)
115
What percentage of the white blood cells are lymphocytes in the pleural fluid in case of tuberculosis?
> 80%
116
What percentage of the white blood cells are lymphocytes in the pleural fluid in case of sarcoidosis?
> 80%
117
What percentage of the white blood cells are lymphocytes in the pleural fluid in case of sarcoidosis?
> 80%
118
What percentage of the white blood cells are lymphocytes in the pleural fluid in case of lymphoma?
> 80%
119
If the pleural fluid shows nucleated cells >50,000/µL what should you think of?
- Complicated parapneumonic effusions
- Empyema
120
What is the pH of the pleural fluid in case of complicated parapneumonic effusion?
pH < 7.0
121
What is the pH of the pleural fluid in case of esophageal rupture?
pH < 7.0
122
What is the pH of the pleural fluid in case of lupus pleuritis?
pH < 7.0
123
What is the pH of the pleural fluid in case of rheumatoid pleuritis?
pH < 7.0
124
What is the pH of the pleural fluid in case of tuberculosis?
pH < 7.0
125
If the pleural fluid shows pleural fluid amylase to serum amylase ratio > 1 what should you think of?
- Pancreatic disease
- Esophageal rupture
- Cancer
126
What is the glucose level in the pleural fluid in case of complicated parapneumonic effusion?
< 60 mg/dL
127
What is the glucose level in the pleural fluid in case of complicated parapneumonic effusion?
< 60 mg/dL
128
What is the glucose level in the pleural fluid in case of lupus pleuritis?
< 60 mg/dL
129
What is the glucose level in the pleural fluid in case of rheumatoid pleuritis?
< 60 mg/dL
130
What is the glucose level in the pleural fluid in case of tuberculosis?
< 60 mg/dL
131
What is the glucose level in the pleural fluid in case of cancer?
< 60 mg/dL
132
What is the glucose level in the pleural fluid in case of empyema?
< 60 mg/dL
133
Which test is most likely to yield a positive tuberculosis culture?
Pleural biopsy
134
Is the level of adenosine deaminase increased or decreased in most tuberculosis pleural fluid samples?
Increased
135
After how many samples of pleural fluid is the yield for positive malignant cytology is maximized?
2
136
What should be performed for an undiagnosed exudative effusion (two negative cytology examinations) when
malignancy is suspected?
Thoracoscopy
137
At what pleural fluid pH does a parapneumonic pleural effusion require chest tube drainage?
pH < 7.2
138
At what pleural fluid glucose level does a parapneumonic pleural effusion require chest tube drainage?
Glucose < 60 mg/dL
139
For patients with malignant effusions, indwelling pleural catheters provide symptom relief; what percentage of patients achieve spontaneous obliteration of the pleural space (pleurodesis) after 6 weeks?
Up to 70%
140
What is the percentage success rate of chemical pleurodesis with talc in patients in malignant effusions?
90%
141
What should you do for moderate to large effusions associated with pneumonia.
Thoracentesis
142
Are pleural effusions associated with nephrotic syndrome common?
Yes
143
Are pulmonary embolisms and renal vein thromboses common in patients with nephrotic syndrome?
Yes
144
What should you consider when chylothorax is diagnosed in a premenopausal woman?
- Pulmonary lymphangioleiomyomatosis
145
What should you think of when tall men who smoke present with chest pain and dyspnea?
Spontaneous pneumothorax
146
What is the most common cause of secondary pneumothorax?
Emphysema
147
What should you think of with falling BP and oxygen saturation, tracheal deviation, and absence of breath sounds in one
hemithorax?
Tension pneumothorax
148
What test should you do in a patient with dyspnea, pleurisy, or both, even if the physical examination is normal?
Chest X-ray (upright)
149
Should you wait for chest x-ray results before treating a suspected tension pneumothorax with needle decompression?
No
150
When should you put a chest tube in for secondary pneumothorax?
When it is more than 2 cm
151
What is considered a small pneumothorax?
Less than 2 cm
152
Should patients with scleroderma be screened with a transthoracic echocardiogram for pulmonary hypertension?
Yes
153
Should patients with congenital heart disease with systemic-to-pulmonary shunts be screened with a transthoracic echocardiogram for pulmonary hypertension?
Yes
154
Should first degree relatives of patients with familial pulmonary arterial hypertension be screened with a transthoracic echocardiogram for pulmonary hypertension?
Yes
155
Should liver transplant candidates with portal hypertension be screened with a transthoracic echocardiogram for pulmonary hypertension?
Yes
156
What is the resting mean pulmonary arterial pressure in pulmonary hypertension?
≥ 25 mm Hg
157
Patient presents with unexplained dyspnea, decreased exercise tolerance, syncope and near-syncope, chest pain, and lower extremity swelling. Physical examination findings include a right ventricular heave, right-sided S3, widely split S2, increased P2, and increased jugular venous distention with a large a wave.
Diagnosis?
Pulmonary hypertension
158
What does the presence of Raynaud phenomenon suggest?
- Scleroderma
- Systemic lupus erythematosus
159
What drugs pre-dispose to development of pulmonary hypertension?
- Cocaine
- Fenfluramine
- Amphetamines
160
What is the initial study to diagnoses pulmonary hypertension?
Echocardiography
161
What systolic pulmonary artery pressure on echocardiography is suggestive of pulmonary hypertension?
More than 40 mmHg
162
What study is indicated to evaluate for intracardiac shunts (e.g., ASD)?
- Bubble contrast echocardiography
- Transesophageal echocardiography
163
How do you confirm the diagnosis of pulmonary hypertension?
Right heart catheterization
164
How do you quantify the degree of pulmonary hypertension?
Right heart catheterization
165
How do you exclude left ventricular dysfunction as a cause of pulmonary hypertension?
Left heart catheterization and coronary angiography
166
What is the next step if a diagnosis of pulmonary arterial hypertension is confirmed?
Vasoreactivity test using vasodilating agents to measure changes in pulmonary artery pressure with a right heart catheter in place
167
What are the two diagnostic criteria for chronic thromboembolic pulmonary hypertension (CTEPH)?
- Pulmonary arterial pressure ≥25 mm Hg in the absence of left-sided heart failure
- Compatible imaging evidence of chronic thromboembolism by V/Q scanning
168
What are most cases of pulmonary hypertension attributed to?
- Left-sided heart disease
- Hypoxic respiratory disorders
169
Is a high-resolution CT scan or a V/Q scan superior in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH)?
V/Q scan
170
Is long-term term anti-coagulation necessary in patients with chronic thromboembolic pulmonary hypertension (CTEPH)?
Yes
171
What is the definitive therapy of chronic thromboembolic pulmonary hypertension (CTEPH)?
Pulmonary thromboendarterectomy
172
Should you use calcium channel blockers if pulmonary artery pressure is not decreased with a vasoreactivity test?
No
173
What is the treatment for pulmonary hypertension that is not responsive to medical therapy?
Lung or heart-lung transplantation
174
When is oxygen therapy indicated in patients with pulmonary hypertension?
≤ 90%
175
What should you think of in a patient with hemoptysis, mucocutaneous telangiectasias, and evidence of right-to-left pulmonary shunts (hypoxemia, polycythemia, clubbing, cyanosis, stroke, brain abscess)?
Pulmonary arteriovenous malformation
176
What is the initial test to diagnose a pulmonary arteriovenous malformation?
CT chest
177
What is the treatment of symptomatic or large pulmonary arteriovenous malformations (>2 cm)?
- Embolotherapy
- Surgery
178
What does a pulmonary arteriovenous malformation (AVM) look like on Chest X-ray?
Pulmonary nodule
179
In high-risk populations, lung cancer screening results in a _____ lung cancer mortality reduction.
20%
180
In high-risk populations, lung cancer screening results in a ____% lung cancer mortality reduction.
20%
181
Which patients need to be screened for lung cancer?
Between ages of 55 to 75-79 years with a 30-pack-year history of smoking, who are either currently smoking, or have quit within the last 15 years.
182
When do you stop screening patients for lung cancer?
- Until age 75 - 80 years
- More than 15 years since they quit smoking
- Co-morbidity limiting survival
183
How do you screen patients for lung cancer?
Low dose CT imaging annually
184
Should you screen people who are at low risk for lung cancer?
No (risk outweighs benefit)
185
What is the initial investigation for hemoptysis?
Chest X-ray
186
Does a negative CXR exclude lung cancer?
No
187
Which test should be used in patients at high risk of lung cancer who present with hemoptysis and negative chest x-ray?
- Fiberoptic bronchoscopy
- Chest CT if fiberoptic bronchoscopy is contra-indicated or bleeding persists despite normal bronchoscopic findings
188
What is the cause of death in massive hemoptysis?
Asphyxiation from airway obstruction
189
What should be done when adequate gas exchange is threatened in hemoptysis?
Intubation and mechanical ventilation
190
How can you localize and treat bronchial artery lesions causing hemoptysis?
Angiography
191
What is the definition of a solitary pulmonary nodule?
A lesion of the lung parenchyma measuring ≤ 3 cm in diameter that is not associated with other lesions or lymphadenopathy and is not invading other structures.
192
What percentage of solitary pulmonary nodules are bronchogenic carcinoma?
35%
193
In what percentage of patients with solitary pulmonary nodule does fiberoptic bronchoscopy with biopsy provides sufficient information?
30%
194
Which has a better yield for malignant solitary pulmonary nodules: fiberoptic bronchoscopy with biopsy or percutaneous transthoracic needle aspiration biopsy?
Percutaneous transthoracic needle aspiration biopsy (although it is not always diagnostic)
195
What percentage of malignant solitary pulmonary nodules are positive on PET scan?
> 90%
196
What is the follow-up for a low-risk patient with a solitary nodule measuring < 6 mm?
No follow-up
197
What is the follow-up for a low-risk patient with a solitary nodule measuring > 8 mm?
Consider CT at 3 months, PET/CT, or tissue sampling
198
What is the follow-up for a low-risk patient with a solitary lung nodule measuring 6 - 8 mm?
CT at 6 - 12 months, then consider CT at 18 - 24 months
199
What is the follow-up for a high-risk patient with a solitary nodule measuring < 6 mm?
Optional CT at 12 months
200
What is the follow-up for a low-risk patient with a solitary nodule measuring 6 - 8 mm?
CT at 6-12 months, then CT at 18-24 months
201
What is the follow-up for a low-risk patient with a solitary nodule measuring > 8 mm?
Consider CT at 3 months, PET/CT, or tissue sampling
202
What is the follow-up for a pure ground glass solitary pulmonary nodule measuring < 6 mm?
No follow-up
203
What is the follow-up for a pure ground glass solitary pulmonary nodule measuring ≥ 6 mm?
CT at 6 - 12 months to confirm persistence, then CT every 2 years until 5 years
204
What is the follow-up for a part solid solitary pulmonary nodule measuring ≥ 6 mm?
CT at 3 - 6 months to confirm persistence. If unchanged and solid component remains < 6 mm, annual CT should be performed for 5 years
205
What is the follow-up for a part solid solitary pulmonary nodule measuring < 6 mm?
No follow-up
206
What is definition of a pulmonary mass?
Pulmonary nodule more than 3 cm
207
What is the next step in evaluating a pulmonary mass (> 3 cm)?
- Biopsy (absence of suspected metastases)
- Surgical resection (no evidence of metastases)
208
What should you do before ordering contrast CT, bronchoscopy, or PET scan for a lung nodule?
Compare current image with previous image to determine stability over time.
209
When are PET scans falsely negative in pulmonary nodule evaluation?
Alveolar cell carcinoma
Lesions < 1 cm in diameter
210
When are PET scans falsely positive in pulmonary nodule evaluation?
Various inflammatory lesions
211
Does a nonspecific negative result from fiberoptic bronchoscopy or transthoracic needle aspiration biopsy reliably exclude the presence of a malignant growth?
No
212
What are the most common masses in the posterior mediastinum?
Schwannomas
213
What are the most common masses in the anterior mediastinum?
Thymus (most common)
Lymphoma (second most common)
214
What are the most common masses in the middle mediastinum?
Lymph nodes
215
What neck circumference determines obesity?
> 17 inches
216
Which condition, if untreated, can lead to CAD, acute MI during sleep, systemic and PAH, HF, recurrent AF, stroke, insulin resistance, mood disorders, or parasomnias?
Obstructive sleep apnea (OSA)
217
What is the criteria for diagnosing OSA on a sleep study?
Apnea-hypopnea index (AHI) > 5/h
218
What separates obesity-hypoventilation syndrome from obstructive sleep apnea (OSA)?
Obesity-hypoventilation syndrome is associated with COPD and always with elevated arterial Pco2 levels when awake.
219
Can obesity-hypoventilation syndrome coexist with obstructive sleep apnea?
Yes
220
Has overnight oximetry been validated as a screening tool for obstructive sleep apnea (OSA)?
No
221
What is the treatment of coexisting obesity-hypoventilation syndrome and obstructive sleep apnea?
BiPAP
222
Are oral appliances as effective as CPAP for a treatment of OSA?
No
223
Is supplemental oxygen recommended as a primary therapy for OSA?
No
224
Is upper airway surgery recommended as initial therapy for OSA?
No
225
Patient at high altitude has repetitive arousals from sleep, often with paroxysms of dyspnea.
Diagnosis?
High-altitude periodic breathing (HAPB)
226
Patient at high altitude has headache, fatigue, nausea, and vomiting, in addition to disturbed sleep related to high-altitude periodic breathing (HAPB).
Diagnosis?
Acute mountain sickness (AMS)
227
Patient at high altitude has confusion, irritability, ataxia and coma; condition can cause death.
Diagnosis?
High-altitude cerebral edema (HACE)
228
Patient at high altitude has cough, dyspnea at rest, pink frothy
sputum, hemoptysis, and pulmonary crackles.
Diagnosis?
High-altitude pulmonary edema (HAPE)
229
How can high altitude illnesses be prevented?
- Gradually ascending.
- Acetazolamide
230
Which medication helps acclimatization to high altitude?
Acetazolamide
231
What is the treatment of acute mountain sickness?
- Acetazolamide
- Dexamethasone
- Oxygen
232
What is the definitive treatment of high-altitude cerebral edema (HACE)?
Immediate descent from altitude
233
What is the adjunct treatment (other than descent from altitude) of high-altitude cerebral edema?
- Dexamethasone
- Supplemental oxygen
- Hyperbaric therapy
234
What is the treatment of high-altitude pulmonary edema (HAPE)?
- Supplemental oxygen
- Rest
235
What test should you order if nocturnal hypoventilation is suspected?
Polysomnography
236
What is acute respiratory distress syndrome?
Hypoxemic respiratory failure presenting as noncardiogenic pulmonary edema
237
Patient has acute onset respiratory failure not explained by heart failure or volume overload, with bilateral lung opacities on imaging.
Arterial Po2/Fio2 ratio of 201-300 mm Hg, measured with PEEP ≥5 cm H2O
Diagnosis?
Mild ARDS (acute respiratory distress syndrome)
238
Patient has acute onset respiratory failure not explained by heart failure or volume overload, with bilateral lung opacities on imaging.
Arterial Po2/Fio2 ratio of 101-200 mm Hg, measured with PEEP ≥5 cm H2O
Diagnosis?
Moderate ARDS (acute respiratory distress syndrome)
239
Patient has acute onset respiratory failure not explained by heart failure or volume overload, with bilateral lung opacities on imaging.
Arterial Po2/Fio2 ratio of ≤100 mm Hg, measured with PEEP ≥5 cm H2O
Diagnosis?
Severe ARDS (acute respiratory distress syndrome)
240
Patient has history of cardiac disease, enlarged heart, S3, chest x-ray showing an enlarged cardiac silhouette, pleural
effusions, and Kerley B lines. There is rapid improvement with diuresis or afterload reduction.
Diagnosis?
Cardiogenic pulmonary edema
241
Patient has acute kidney injury with microscopic or gross hematuria or other evidence of vasculitis present. This is associated with stem cell transplantation. Hemosiderin-laden macrophages present in bronchoalveolar lavage fluid.
Diagnosis?
Diffuse alveolar hemorrhage
242
Patient with cough, fever, pleuritic chest pain, and myalgia; may be precipitated by initiation of smoking. There are > 15% eosinophils in bronchoalveolar lavage fluid.
Diagnosis?
Acute eosinophilic pneumonia
243
Patient with features of dyspnea, volume overload with onset over weeks with progressive course; however, may present in an advanced stage. Positive exposure history (farmers, bird fanciers, hot tub exposure).
Diagnosis?
Hypersensitivity pneumonitis
244
Patient with cough and dyspnea that that may be precipitated by viral syndrome. Onset more than 2 weeks with progressive course; however, may present in an advanced stage.
Diagnosis?
Cryptogenic organizing pneumonia
245
Patient with acute onset dyspnea and bilateral pulmonary infiltrates, with hypoxemic respiratory failure. No inciting factors. May respond to glucocorticoid administration.
Diagnosis?
Acute interstitial pneumonia
246
What mechanical ventilation settings do you need for ARDS?
- Tidal volume of ≤ 6 mL/kg of ideal body weight
- Plateau (end-inspiratory) pressure < 30 cm H2O (even if this results in “permissive” hypercapnia and acidosis)
247
Should a higher or lower PEEP be used for ARDS?
A higher PEEP is usually used; however, outcomes are the same if the plateau (end-inspiratory) pressure < 30 cm H2O
248
What provides mortality benefit in severe ARDS?
Prone position
249
Are glucocorticoids indicated for the acute treatment of ARDS?
No
250
How long should you attempt noninvasive positive-pressure ventilation prior to considering intubation (time needed for improvement of blood gases and clinical condition)?
2 hours
251
What level of hypoxia is an indication for invasive mechanical ventilation?
Arterial Po2 < 60 mm Hg or an O2 saturation < 90% despite supplemental oxygen of 60% or higher.
252
What is the usual tidal volume set at in mechanical ventilation?
6 - 8 mL/kg
253
What happens when the tidal volume is too high in patients on mechanical ventilation?
- Barotrauma
- Respiratory alkalosis
- Decreased cardiac output
254
What happens when the tidal volume is too low in patients on mechanical ventilation?
- Atelectasis
- Hypoxemia
- Hypoventilation
255
What is the usual ventilation rate in mechanical ventilation?
8 - 14 breaths/min
256
What happens when the respiratory rate is too low in patients on mechanical ventilation?
- Hypoventilation
- Acidosis
- Hypoxemia
- Patient discomfort
257
What happens when the tidal volume is too high in patients on mechanical ventilation?
- Respiratory alkalosis
- Air trapping (Auto PEEP)
258
What should the PO2 be maintained at in patients on mechanical ventilation?
> 60 mmHg
259
In which situations should respiratory acidosis be tolerated rather than increasing the tidal volume?
ARDS (Acute respiratory distress syndrome)
260
What reduces the risk of ventilator associated pneumonia?
- Semi-recumbant position
- Selective decontamination of oropharynx (topical
gentamicin, colistin, or vancomycin)
261
What are the parameters (arterial O2 saturation, breathing FiO2, PEEP, and pH) when extubation can be considered?
- Arterial O2 saturation > 90%
- Breathing Fio2 ≤ 0.5
- PEEP < 5 cm H2O
- pH >7.30
262
What should the arterial O2 saturation be before the patient can be extubated?
> 90%
263
What should the arterial breathing FiO2 be before the patient can be extubated?
≤ 0.5
264
What should the PEEP be before the patient can be extubated?
< 5 cm H2O
265
What should the pH be before the patient can be extubated?
> 7.3
266
Do paired daily spontaneous awakening trials (withdrawal of sedatives) with daily spontaneous breathing trials result in a reduction in mechanical ventilation time, ICU and hospital length of stay, and 1-year mortality rates?
Yes
267
Should synchronized intermittent mandatory ventilation be selected as a weaning mode?
No
Studies have demonstrated this mode actually takes longer to liberate patients from the ventilator.
268
What type of shock has low cardiac output, elevated pulmonary capillary wedge pressure (PCWP), and high systematic vascular resistance?
Cardiogenic shock
269
What type of shock has low cardiac output, low pulmonary capillary wedge pressure (PCWP), and high systematic vascular resistance?
Hypovolemic shock
270
What type of shock has low cardiac output, variable pulmonary capillary wedge pressure (PCWP), and high systematic vascular resistance (may have cardiac tamponade, pulmonary embolism or tension pneumothorax)?
Obstructive shock
271
What type of shock has high cardiac output, normal pulmonary capillary wedge pressure (PCWP), and low systematic vascular resistance (may have wheezing, angioedema, urticaria, rash)?
Anaphylactic shock
272
What type of shock has high cardiac output that later becomes depressed, and low systematic vascular resistance (fever, leukocytosis)?
Septic shock
273
Should you use cortisol stimulation testing in patients with septic shock?
No
274
Which route of nutrition is preferred in the ICU?
Enteral
275
Should you use non-invasive ventilation in patients with septic shock?
No
276
How long should you wait before starting total parenteral nutrition in the ICU in most patients (not malnurished)?
After day 7
277
What is the formula used to estimate caloric needs in the ICU?
25 - 35 kcal/kg/d
278
Patient has critical illness polyneuropathy (with axonal nerve degeneration) and critical illness myopathy (with muscle myosin loss).
Diagnosis?
ICU acquired illness
279
What is the treatment of ICU acquired illness?
- Supportive therapy
- Early mobilization
- Physical and occupational therapy
280
Patient is young athlete or soldier with environmental exposure; has encephalopathy and fever.
Diagnosis?
Heat stroke (exertional)
281
What it the treatment of exertional heat stroke?
Ice water immersion
282
Should you treat exertional heat stroke with ice water immersion?
Yes
283
Should you treat non-exertional heat stroke with ice water immersion?
No
284
A ≥ 70 years old patient presents with encephalopathy and fever with no evidence of infection; they may use anticholinergic, sympathomimetic, and diuretic drugs.
Diagnosis?
Non-exertional heat stroke
285
What it the treatment of non-exertional heat stroke?
Evaporative, external cooling
286
Patient with exposure to volatile anesthetic (halothane isoflurane, succinylcholine, or decamethonium); has masseter muscle rigidity and increased arterial Pco2.
Diagnosis?
Malignant hyperthermia
287
What is the treatment of malignant hyperthermia?
- Stop inciting drug
- Dantrolene
288
Patient on haloperidol, olanzapine, quetiapine, and risperidone or withdrawal from L-dopa; onset over days to weeks; with altered mentation, severe rigidity, increased heart rate, increased blood pressure, no clonus, decreased reflexes.
Diagnosis?
Neuroleptic malignant syndrome
289
Patient has onset within 24 h of initiation or increasing dose of SSRI; has agitation, rigidity, clonus, increased reflexes.
Diagnosis?
Severe serotonin syndrome
290
What is the treatment of severe serotonin syndrome?
- Stop inciting drug
- Benzodiazepines
- Cyproheptadine
291
What is the treatment of neuroleptic malignant syndrome?
- Stop inciting drug
- Dantrolene
- Bromocriptine
292
How long does it take for neuroleptic malignant syndrome to resolve after treatment?
Days to weeks
293
How long does it take for selective serotonin syndrome to resolve after treatment?
24 hours
294
Can neuroleptic malignant syndrome occur in patients who have abruptly discontinued L-dopa for Parkinson disease?
Yes
295
The serotonin syndrome is often caused by the use of SSRIs and the addition of a second drug that increases serotonin release or blocks its uptake or metabolism.
True or false?
True
296
What is the definition of hypertensive emergency?
BP ≥ 180/120 mm Hg and symptoms or evidence of end-organ damage
297
Should patients with hypertensive emergency be hospitalized?
Yes
298
What is the target blood pressure in severe preeclampsia or eclampsia, or pheochromocytoma crisis?
Systolic blood pressure < 140 mmHg in the first hour
299
What is the target blood pressure in aortic dissection?
Systolic blood pressure < 120 mmHg in the first hour
300
If a patient without a compelling condition has hypertension emergency how should the blood pressure be reduced?
No more than 25% lower in the first hour, and then 160/100 mmHg in the next 2 - 6 hours; and cautiously reduce to normal in the next 24 - 48 hours.
301
What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with acute aortic dissection?
- Esmolol
- Labetalol
302
What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with acute pulmonary edema?
- Nitroglycerin
- Nitroprusside
303
What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with acute coronary syndrome?
- Esmolol
- Nitroglycerin
304
Can you treat hypertensive emergency in the ICU in patients with acute pulmonary edema with IV beta-blockers?
No
305
What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with acute kidney injury?
Nicardipine
306
What is the preferred anti-hypertensive therapy for hypertensive emergency in the ICU in patients with eclampsia or preeclampsia?
- Hydralazine
- Labetalol
- Nicardipine
307
Should you use sublingual nifedipine for hypertensive urgency?
No
308
Should you use sublingual nifedipine for hypertensive emergency?
No
309
What is the difference between the mechanism of action of anaphylactic reaction vs anaphylactoid reaction?
Anaphylactic reaction is an IgE-allergen interaction
Anaphylactoid reaction is by a non-antibody-antigen mechanism
310
What should you consider as a cause of anaphylaxis during surgery or anaphylaxis in a woman during coitus?
Latex allergy
311
What is the drug of choice to treat anaphylaxis?
Intramuscular or subcutaneous epinephrine (0.3-0.5 mg of 1:1000)
312
Which medication blocks the effect of epinephrine?
Beta-blockers
313
What should you do if anaphylaxis is not responding to epinephrine?
Glucagon
314
What is the treatment of anaphylactic shock or refractory symptoms of anaphylaxis?
Intravenous epinephrine (1:10,000)
315
Is red man syndrome an allergic reaction?
No
316
Patient presents with sudden, temporary edema, usually of the lips, face, hands, feet, penis, or scrotum along with abdominal pain?
Diagnosis?
Angioedema
317
Patient with a family history of angioedema presents with sudden, temporary edema; and low C1 inhibitor and C4 levels.
Diagnosis?
Hereditary angioedema
318
Patient with lymphoma, MGUS, or systemic lupus erythematosus presents with sudden, temporary edema; low C1q levels (in addition to low C4 and C1 inhibitor levels.
Diagnosis?
Acquired C1 inhibitor deficiency causing angioedema
319
Patient on ACE inhibitors presents with sudden, temporary edema; has low C1 inhibitor and C4 levels.
Diagnosis?
ACE inhibitor effect causing angioedema
320
Should you diagnose hereditary angioedema in patients with urticaria and angioedema?
No
321
What is the treatment of acute episodes of mast cell–mediated (allergic) angioedema with airway compromise or hypotension?
- Epinephrine
- Antihistamines
- Glucocorticoids
322
What is the treatment of allergic angioedema?
Antihistamines
323
What's the treatment of acute episodes of bradykinin-mediated angioedema (hereditary or acquired angioedema)?
Select C1 inhibitor concentrate
324
What's the treatment of acute episodes of bradykinin-mediated angioedema (hereditary or acquired angioedema) in an emergency?
Fresh frozen plasma
325
What is the long-term management of hereditary angioedema?
- Danazol
- Stanozolol
326
Is epinephrine effective for hereditary angioedema?
No
327
What is the management of patients with smoke inhalation and visibly damaged airway or stridor?
Intubation
328
Does a normal LDH level exclude cyanide poisoning?
Yes
329
What is the treatment of cyanide poisoning?
Hydroxocobalamin
330
Where is the injury when patient presents with clear chest X-ray and wheezing, cough, and dyspnea manifest 12 to 36 hours after smoke inhalation exposure?
Lower airways
331
Does normal oxygen saturation exclude carbon monoxide poisoning?
No
332
Does normal oxygen saturation exclude cyanide poisoning?
No
333
What the treatment of acetaminophen poisoning?
N-acetylcysteine
334
What the treatment of benzodiazepines poisoning?
- Observation
- Flumazenil
335
What the treatment of β-Adrenergic blockers poisoning?
- Glucagon
- Calcium chloride
- Pacing
336
What is the treatment of calcium channel blockers poisoning?
- Atropine
- Calcium
- Glucagon
- Pacing
337
What the treatment of digoxin poisoning?
Digoxin-immune fab
338
What the treatment of heparin poisoning?
Protamine sulfate
339
What the treatment of narcotics poisoning?
Naloxone
340
What the treatment of salicylates poisoning?
- Urine alkalinization
- Hemodialysis
341
What are the (two) treatments of tricyclic antidepressants poisoning?
- Blood alkalinization
- α-agonist
342
Poisoning with which over the counter medication causes hepatotoxicity?
Acetaminophen
343
What kind of poisoning causes sedative affects?
Benzodiazepines
344
What kind of poisoning causes bradycardia and hypotension affects?
- β-Adrenergic blockers
- Calcium channel blockers
345
What kind of poisoning causes dysrhythmias?
Digoxin
346
What kind of poisoning causes bleeding diathesis?
Heparin
347
What kind of poisoning causes metabolic acidosis/respiratory alkalosis?
Salicylates
348
Over-dose of which class of anti-depressants causes anticholinergic effects?
Tricyclic antidepressants
349
Patient using grill indoors presents with unexplained flulike symptoms, frontal headache, lightheadedness, difficulty concentrating, confusion, delirium, coma, dyspnea, nausea, and chest pain.
Diagnosis?
Carbon monoxide poisoning
350
What tests do you do to evaluate carbon monoxide poisoning?
- ABG studies
- Serum carboxyhemoglobin
351
What carboxyhemoglobin level is diagnostic of severe acute carbon monoxide poisoning?
> 25%
352
Can a pulse oximeter differentiate between carboxyhemoglobin from oxyhemoglobin?
No
353
What is the treatment for carbon monoxide poisoning?
Normobaric oxygen therapy
354
When is hyperbaric oxygen therapy used for carbon monoxide poisoning?
- Severe carbon monoxide poisoning (loss of consciousness and persistent neurologic deficits)
- Pregnant patients
- Patients with cardiac ischemia
355
Patient has persistent cold symptoms for less than 10 days, with nasal drainage and congestion, discomfort in maxillary teeth, and facial pressure. No fever. There is purulent secretion in both nares and edematous nasal turbinates bilaterally.
Diagnosis and organism?
Acute rhinosinusitis from rhinovirus
