MKSAP9 Flashcards
1
Q
What should you think of in a person w/ sx of CF who has dextrocardia?
A
Primary Ciliary Dyskinesia (Kartageners)
2
Q
Where do silicosis and berylliosis tend to affect the lungs?
A
Often upper lobe predominant; silicosis = sandblasting increased risk of TB; Berryliosis assoc. with aerospace engineer
3
Q
What should you consider in a patient with hyponatremia with normal or elevated serum osm?
A
Pseudohyponatremia then think about glucose, paraprotein, lipid etc
4
Q
What is a significant cause of COPD in patients from 3rd world countries who have never smoked?
A
Exposure to Biomass fuels, i.e. using wood etc. to cook in huts and poorly ventilated areas
5
Q
What is the histopathology of Cryptogenic Organizing Pneumonia?
A
Will see patchy filling of alveoli with loose plugs of granulation tissue; whereas pulmonary alveolar proteinosis has proteinacious material
6
Q
Does sarcoid usually cause restrictive or obstructive lung dz?
A
Either, or even both (mixed)
7
Q
How should you evaluate reduced EF within one year of heart transplant?
A
Angiography as the MC cause of reduced EF within 1 year is Cardiac Allograft Vasculopathy
8
Q
What does progressive dyspnea and sputum production in a smoker or former smoker suggest? Dx?
A
COPD; should check PFTs; obstructive physiology if FEV1:FVC ratio less then 0.7
9
Q
MC blood products to cause TRALI
A
FFP or Platelets
10
Q
What is the appropriate mgmt for a patient with persistent hypotension in the setting of acute PE?
A
TPA (100 mg over an hour at HMC) followed by IV heparin gtt; unlike stroke and MI there is NO consensus on timing of when it should be given, i.e. no “window” that you can be “out of”
11
Q
How can you diagnose paradoxical vocal cord motion? Tx?
A
PFTs or Direct laryngoscopy showing adduction during inspiration; Tx is Speech therapy and CPAP and heliox if severe
12
Q
How should a patient with bronchiectasis who develops HCAP be treated?
A
Vancomycin plus 2 antipseudomonal abx (cefepime/Zosyn + cipro/levo)
13
Q
Why is it potentially a bad idea to hold a WHO I pulm HTN who is hypotensive pts home sildenafil or bosentan/ambrisentan?
A
Because these drugs have not been shown in studies to cause systemic HoTN. However, by holding them there will be a rise in PA pressures so less blood can get from R to L and cardiac output will decrease which may ultimately lead to worsening of HoTN
14
Q
Crunching with each heartbeat is known as ________
A
Hammans sign; seen in pneumomediastinum
15
Q
What mode on a pacemaker provides AV synchrony? What can it be switched to when undergoing surgery?
A
DDD; DOO (asynchronous mode) allows pacing of the atrium and ventricle but without interference from Bovie
16
Q
What are the 2 most important things to do for septic patients? Defined based on SOFA of what?
A
Fluids (30 ml/kg bolus within 3 hours) and Abx (in first hour) based on 2018 surviving sepsis campaign guideline; SOFA greater than or equal to 2
17
Q
What is the recommended initial tx of painful erythema nodosum?
A
NSAIDS
18
Q
How is Cryptogenic Organizing Pneumonia most often diagnosed? Most appropriate meds?
A
Usually after several failed courses of CAP; appropriate mgmt is with glucocorticoids and if unresponsive then azathioprine
19
Q
What are the hallmarks of OHS? Dx test?
A
Day time hypoventilation and hypercarbia possibly with resting hypoxemia; draw an ABG
20
Q
What can imaging of the liver help with a dx of constrictive pericarditis?
A
Doppler US w/ expiratory flow reversal in hepatic veins is c/w the dx
21
Q
What should you consider in a patient on prophylactic UTI abx who has dyspnea, hypoxemia, and reticulonodular changes on CXR?
A
Nitrofurantoin-induced pulmonary toxicity
22
Q
What should be the consideration in a patient with unilateral wheezing who is nonresponsive to asthma tx?
A
Concern for endobronchial lesion (i.e. Bronchial carcinoid) and evaluate w/ CT or bronch
23
Q
What is the mgmt of a tension hemothorax or hydrothorax
A
Unlike tension pneumothorax which requires needle compression, a hemo/hydrothorax causing tension is a surgical emergency and requires immediate placement of a LARGE BORE CHEST TUBE
24
Q
The presence of what antibody in polymyositis and dermatomyositis increases the risk of ILD?
A
Anti-Jo-1 ab
25
What is different about ABPA and Eosinophilic Granulomatosis with polyangiitis?
ABPA has more of a sever asthma picture w/ maybe some central bronchiectasis and elevated IgE; Churgg-Strauss has migrating infiltrates, sinusitis, peripheral neuropathy and p-ANCA (Anti-MPO)
26
What should be done for inpatients who have suspected OSA?
Referral for an outpatient PSG as overnight O2 sat testing and autotitrating positive pressure ventilation is not recommended
27
What is the chelation drug of choice for acute iron poisoning, how will it present?
Deferoxamine; pt can be in shock, took a bunch of pills, has AGMA - recall that I in MUDPILES is iron and isoniazid
28
A vasculitis involving the lungs is most likely to be \_\_\_\_\_\_\_\_\_\_
An ANCA vascultiis (GPA- anti-PR3 or EGPA- anti-MPO, or microscopic polyangiitis)
29
What makes the diagnosis of exercise induced asthma?
When a patients FEV1 decreases by more than 10% after an exercise challenge (tx is SABA 15 min prior to exercise)
30
What gene mutation is often found in ppl with Langerhans Histiocytosis?
BRAF; recall that Eosinophilic Granuloma = Histiocytosis X and the eosinophilic cells are histiocytes not eosinophils; EM would show Birbeck Granules
31
Preferred diagnostic test for WHO IV pulm HTN? Mgmt?
This is CTEPH so VQ scan or CTA; pulmonary thromboendarterectomy
32
Tx of severe asthma with high IgE level that doesnt have ABPA
Omalizumab (Xolair); if pt also has CXR findings of central bronchiectasis (better on HRCT) would want to check skin test for Aspergillus
33
What is the dx for a woman undergoing In Vitro fertilization who develops pleural effusions, ascites, edema, and shock?
Ovarian Hyperstimulation Syndrome (similar to Meigs Syndrome which involves a tumor) thought to be due to increased capillary hyperpermeability from release of vasoactive stimulants
34
What are the two main components to treating hypersensitivity pneumonitis? What is seen on BAL?
Removal of the offending agent and IV glucocorticoids 0.5-1 mg/kg dose; often a lymphocytic predominant BAL w/ low CD4:CD8 ratio but not specific
35
Along with a SABA the most appropriate tx for mild persistent asthma is \_\_\_\_\_\_\_\_
inhaled glucocorticoid (fluticasone); inappropriate to start LABA without an inhaled glucocorticoid
36
What is eosinophilic granuloma? What can be seen on EM?
A form of Langerhans Histiocytosis- aka Histiocytosis X; presents in younger ppl w/ hx of smoking; Birbeck Granules and these can be seen in all types of Langerhans histiocytosis
37
What are the two big ddx for lymphoctyic pleural effusions? How would you further clarify these?
Malignancy = get 3 consecutives which will increase sensitivity to 90%; TB = check ADA if \>40 more likely, get pleural biopsy to confirm; sputum Cx only if parenchymal TB and IGRA and TST only for latent
38
What did the SEPSISAM trial show?
Patients with chronic HTN who were treated with a MAP goal of 80-85 had decreased need for CRRT but no improvement in mortality while comparing to a MAP goal of 65
39
What drugs are used for Acute Mountain Sickness? High Altitude Cerebral Edema? High Altitude Pulmonary Edema?
Acetzolamide for AMS and HACE; Nifedipine for secondary prevention of HAPE
40
What pumonary dz has histopathology showing loose plugs of granulation tissue in the alveoli?
Cryptogenic Organizing Pneumonia
41
Lichen planus may have a network of white lines on top called \_\_\_\_\_\_\_\_\_\_
Wickham Striae
42
What disease may be associated with high levels of carbohydrates followed by flaccid paralysis?
Hypokalemic Periodic Paralysis (Birthday Cake Paralysis); can be assoc with thyrotoxicosis and an intracellular shift of K
43
What are lung lesions less than 3 cm called? Greater than 3 cm?
Nodule (4-30 mm); mass \>3 cm
44
What are the two most commonly used pneumonia risk stratifiers?
CRB-65 and PSI w/ higher class PSI either needing steroids and/or admission to ICU
45
What is the most common extrapulmonary site of disseminated Nocardiosis?
CNS; if so the tx must be carbapenem and not just Bactrim
46
What is the best step in evaluation of a patient with decompensated RV failure and resting hypoxemia in a patient with OSA?
i.e. assuming not acute (would be thinking PE); then thing about OHS which is best Dx with resting ABG to document hypercarbia
47
These develop as anomalous buds from the foregut during development and become symptomatic in the later decades (often posterior mediastinal masses)
Bronchogenic Cysts; if symptomatic tx is surgery
48
What is diffuse panbronchiolitis and who gets it?
An obstructive lung dz with dilated bronchioles on CT w/ centrilobular nodules and sinusitis in East Asian populations; different from constrictive bronchiolitis which occurs in military vets from Middle East
49
What is the difference between constrictive bronchiolitis and panbronchiolitis?
Panbronchiolitis occurs in East Asian populations and has dilated bronchioles and centrilobular nodules w/ chronic sinusitis; Panbronchiolitis occurs in middle east troops w/ narrowed bronchioles d/t inhalents and bombs
50
What should you think if a person has an elevated PA systolic pressure (i.e. mean PA of 25) and an elevated pulmonary capillary wedge pressure?
Likely on basis of either systolic or diastolic LV heart failure; WHO II, pulmonary venous HTN ; try to control their risk factors and re-ECHO as needed to document improvement
51
What is the utility of hydroxyurea in acute chest syndrome?
Not useful in acute setting but can reduce frequency; need to give pain control, IVF, supplemental O2 (which is a pulm. Vasodilator), and simple or exchange xfusion as indicated
52
What is the purpose of supplemental O2 in IPF? What are two antifibrotic drugs that can be used
Always use when there is hypoxemia but it also delays onset of pulmonary HTN (WHO III) bc it is a vasodilator and also delays cor pulmonale; Nintedanib and perfenidone
53
What is the most appropriate initial tx of Pulmonary Alveolar Proteinosis? Chronic Tx?
Whole lung lavage; subQ GM-CSF as it is assoc. with anti-GM-CSF abs
54
What sort of supplementation does a patient with primary adrenal failure need vs. a person with central adrenal failure (low ACTH)?
A primary adrenal failure will need BOTH glucocorticoid AND mineralocorticoid; a person with central adrenal failure only needs glucocorticoid bc aldosterone is part of the RAAS and so as long as the gland itself isnt destroyed is still made appropriately
55
What disease will have a crazy paving pattern on CT of lung
Pulmonary Alveolar Proteinosis; tx whole lung lavage; assoc w/ Anti-GM-CSF abs and tx chronically w/ subQ GM-CSF
56
What can you say about the long term use of tiotropium in COPD? In whom should it be used carefully?
Associated with better outcomes and less frequent exacerbations compared with ipratropium; BPH or bladder outlet issues
57
What should be on the DDx of precocious bullae in the lungs
A1AT def, misuse of IV or inhaled drugs, HIV, autoimmune and congenital, and Idiopathic Giant Bullous Emphysema
58
What are the 4 variants of Langerhans Histiocytosis?
Eosinophilic Granuloma (type assoc with smoking and in younger ppl); Letterer-Siwe - severe/acute disseminated fatal in childhood; Hand-Schuler-Christian Dz w/ bone lesions, diabetes insipidus and bulging eye; and Hashimoto-Pritzker dz- benign self resolving kind
59
What should be considered in HIV patients with unilateral wheezing not responsive to asthma tx?
In general this presentation makes you think of endobronchial lesions; in HIV consider Endobronchial Kaposi Sarcoma
60
What is the optimal initial tx of pt with hepatic hydrothorax? What broader therapeutic options need to be considered when pt have this?
Sodium restriction and diuretic tx; need to be thinking about transplant bc this means they essentially have ESLD
61
How can you tell if a person has primary hyperaldosteronism due to bilateral adrenal hyperplasia? Tx?
If there is failure of lateralization with adrenal venous sampling for levels of aldo then it is bilateral; unilateral = surgery; bilateral = spironolactone which antagonizes aldo receptor
62
In whom does pyroglutamic acidosis occur?
Patients chronically on acetaminophen need to measure urine levels of pyroglutamic acid
63
What does the histology of IPF show?
Usual interstitial pneumonia which has a fibrotic change along with normal lung (like cirrhosis of the lung); whereas cryptogenic organizing pneumonia will have granulation tissue in the alveoli
64
What can be said about the use of Airway Pressure Release Ventilation (APRV) in ARDS?
Has been evaluated in small studies and its use has shown some physiologic improvement but no mortality benefit; will likely worsen hypercapnia
65
A patient with wheezing exacerbated by exercise who is also symptomatic despite adherence to asthma tx who has a monophasic inspiratory stridor most likely has \_\_\_\_\_\_\_\_\_
Paradoxical Vocal Cord Motion (will improve on expiratory limb); if intubated will have IMMEDIATE improvement in sx whereas asthma would take time to improve
66
What should be considered in a scuba diver who experiences acute onset of poor judgment, euphoria, and confusion?
Nitrogen Narcosis (different from the Bends bc no muscle pain etc) due to increased solubility of nitrogen under high pressure
67
What is the most common cause of inherited cardiac amyloidosis?
VAL122ILE mutation in transthyretin; important to do amyloid typing as hereditary amyloid is tx supportively while AL is tx with melphalan pred and auto SCT
68
What needs to be ruled out when diagnosing an IPF pt w/ worsening hypoxemia with an "acute exacerbation of IPF"?
This is a legitmate dx but is a dx of exclusion so rule out things like PNA, infxn, pulm edema, or alveolar hemorrhage; may need BAL
69
What controller medications for COPD have been shown to be effective (3)?
LABA (salmeterol), inhaled glucocorticoids, and LAMA (tiotropium)
70
What is the classic pleural effusion associated with RA?
Sterile exudative effusion with low pH and markedly low glucose
71
What is Dimercaptosuccinate used for?
lead, arsenic, and mercury poisoning but not iron; if iron tox then deferoxamine
72
What is the recommended mgmt of an asymptomatic, unilateral, malignancy-associated pleural effusion?
Obervation (British Thoracic Society rec); obviously tx the underlying cancer but can observe the effusion; unless need it for staging then can tap
73
What is the most likely cause of a chronic cough that is exacerbated by cold or exercise and worsens during sleep?
Asthma
74
What is amyopathic dermatomyositis?
Dermatomyositis with just the rash/skin findings (heliotrope rash, Gottrons papules, shawl sign) but no muscle involvement
75
When should COPD patients be considered for lung transplant?
If post-bronchodilator test FEV1\<25%, baseline PCO2 \>50 mmHg, or there is COPD assoc. R heart failure/Cor pulmonale or pulm HTN (WHO III)
76
What is the mechanism of SOB and hypoxia in patients with pulmonary HTN?
When pts exert themselves they try to pump more blood to the lungs for oxygenation; with elevated PA pressures they cant get as much blood there and so they become SOB and/or hypoxic
77
What should you consider in pt with ILD that is predominately also assoc with synovitis?
RA assoc. ILD; if things like CREST or systemic fibrosis think more about anti-centromere and anti-scl70
78
The studies evaluating prone-positining in severe ARDS showed a 30 day mortality benefit of what?
16% mortality in the proned patients vs. 33% in non-proned; severe = P/F of \<150 (though that is not exactly how it is usually defined, usually \<100)
79
What is the Leser Trelat sign?
A sudden erruption of many sebhorreic keratoses
80
What is a bronchopulmonary sequestration?
A congenital disorder where a part of the lung does not receive blood supply from pulm circulation; often anomalous from thoracic aorta; diff from bronchogenic cyst bc not anomalous bud from foregut
81
A patient with a 10 day history of cough and suspected infection with Bordatella pertussis should get tx w/ \_\_\_\_\_\_\_\_\_\_
Macrolide antibiotic i.e. azithromycin for 5-7 days
82
What is Meigs Syndrome?
Triad of benign ovarian tumor with ascites and pleural effusion that resolves with resection of the ovarian tumor; similar things seen in Ovarian Hyperstimulation syndrome with In Vitro Fert
83
What is the primary therapy for a patient with AECOPD?
Bronchodilators (albuterol/ipratropium), systemic glucocorticoids, and ONE of a macrolide, a fluoroquinolone, or doxycycline
84
What is the appropriate mgmt for a patient with mild persistent asthma based on clinical sx but with a normal spirometry?
Still tx as mild persistent with low dose glucocorticoid and SABA; normal spirometry does NOT exclude the dx; still like spiromety though bc can help track dz longitudinally
85
What situations is Heliox useful?
Severe obstructive dz like COPD or status asthmaticus but not for ARDS bc has less than 100% O2
86
What are some features strongly suggestive of pulmonary HTN?
Loud P2, LE edema, exercised-induced hypoxemia, and sole reduced DLCO that corrects for alveolar volume
87
What drug is effective for secondary prevention of High Altitude Pulmonary Edema (HAPE)?
Nifedipine; it blunts the acute hypoxic pulmonary vasoconstriction and therefore acute/severe pulmonary HTN that leads to pulm edema at high altitude
88
How does supplemental O2 help with pulmonary HTN and delaying the development of it?
O2 is a vasodilator and hypoxia leads to hypoxic pulmonary vasoconstriction
89
When is asthma considered to be persistent?
When sx occur \>2x per week or more than 2 nocturnal awakenings per month
90
When is it ok to start a LABA in asthma tx?
Once people have at least been started on inhaled glucocorticoid; there is an increased risk of death in just going to the LABA
91
What is the best step in mgmt of a patient with Hereditary Hemorrhagic Telangiectasia with hypoxemia
Could have bleeding pulmonary AVM need CT angio; this dz aka Osler-Weber-Rendu
92
What is a congenital disorder of lung that does not receive its blood supply from the pulmonary circulation?
Bronchopulmonary Sequestration (often can manifest as a large, vascular, lower lobe consolidation)
93
What is the best mgmt of hypoventilation resulting from severe kyphosis?
BiPAP until the minute ventilation cannot keep up with it, then may need intubation and trache
94
Lupus Pernio is essentially pathognomonic for \_\_\_\_\_\_\_
Sarcoidosis; indurated blue-violaceous lesions on ears, cheeks, eyelids, and hands
95
What is the most appropriate tx of aspiration pneumonitis?
Supportive car, speech/swallow eval; Aspiration pneumonia often w/ fevers days later
96
What should be considered in patients with known limited cutaneous systemic sclerosis w/ SOB?
Pulmonary HTN eval w/ TTE (anti-centromere); if systemic sclerosis then consider ILD (anti-Scl-70)
97
What is Stage IA lung cancer? What is the mgmt?
Mass less than 3 cm limited to one lung without involvement of mediastinum, lymph nodes, or distant sites; Surgical resection
98
What is the first line tx of constrictive pericarditis and why?
High dose NSAIDs because the constriction may be transient; a patient with ongoing sx can get a pericardiectomy
99
According to the new 2017 ACC/AHA guidelines what is the best tx for BP \>140/90
Combination tx bc it is stage II HTN
100
What is the intervention most likely to improve OS in a patient with mild ARDS? Severe ARDS?
Mild = low tidal volume ventilation (6 mL/kg/IBW); if severe need to do the same but also prone and paralyze w/ cisatracurium; goal always SaO2 \>88%, PaO2 \>55% and Pplat \<30
101
What are some things to consider in an older patient with bronchiectasis?
Assuming not CF or ABPA it is likely CVID; CVID dx with quantitative immunoglobulins
102
What is the diagnosis of a young man with a short hx of smoking who has very large bullae in an upper lobe predominant pattern occupying \>1/3 of the hemithorax?
Idiopathic Giant Bullous Emphysema; Giant Bullae take up \>1/3 of the hemithorax
103
How long should patients with severe ARDS be proned for?
16 hours per day
104
What is the purpose of primary therapy in COPD exacerbation?
Getting bronchodilators (albuterol/ipratropium) on board to reverse bronchoconstriction and aid ventilation
105
What is the most likely dx for a patient with chronic dyspnea and wheeze not responsive to standard asthma meds who has a hx of extended intubation and normal CXR? Dx tests?
Tracheomalacia; Can dx with standard and dynamic CT showing dynamic tracheal collapse; if severe may need bronchoscopy with tracheal stent
106
Most appropriate mgmt for suspected HIT
Stop heparin and start argatroban, bivalrudin, or fondaparinux
107
What is a reported infectious complication of pulmonary alveolar proteinosis?
Nocardia (Tx is bactrim unless CNS then carbapenem)
108
What is the next step in mgmt in a patient with persistent respiratory sx and unchaged opacities after tx for CAP? Diagnostic considerations?
CT of chest; can be malignancy or cryptogenic organizing pneumonia which often goes undiagnosed
109
What immunodeficiency can have bronchiectasis?
CVID; dx with quantitative immunoglobulins demonstrating hypogammaglobulinemia
110
What is the most likely dx in a farmer who randomly develops dyspnea, abnormal DLCO and ground glass opacities?
Hypersensitivity Pneumonitis (thermophylic actinomycetes in moldy hay); different from occupational asthma in that there would not be GG opacities or DLCO issues in asthma
111
What is a consideration in a patient with ARDS, hemoconcentration, thrombocytopenia, and L-shifted leukocytosis?
Hantavirus pulmonary syndrome; from rat excrements; Sin Nombre Virus; IgM against the virus can be +
112
A patient with severe COPD and acutely worsening dyspnea whose workup is negative for infectious etiology should be evaluated for \_\_\_\_\_\_\_
Pulmonary Embolism (i.e. assuming imaging is normal, can also consider MI or CHF)
113
Eosinophilic Granuloma, Letterer-Siwe, Hand-Schuler-Christian, and Hashimoto-Pritzker dz are ALL variants of \_\_\_\_\_\_\_\_\_.
Langerhans Histiocytosis; assoc. w/ BRAF gene mutation
114
T/F: interstitial lung disease can be the presenting sx of RA?
True; if pt has interstitial lung dz can consider checking RF and CCP
115
When should you do a thoracentesis in a patient with hepatic hydrothorax?
If pt is very symptomatic while waiting for sodium restriction and diuresis to kick in; need to consider listing for transplant and maybe a TIPS (esp if failing meds)
116
What can you say about BiPAP vs. endotracheal intubation for COPD exacerbations with decompensated resp acidosis with respect to mortality?
NPPV assoc with better overall mortality than ET intubation; HOWEVER, must be able to protect airway etc.
117
A patient with a presumed AECOPD who is not responding to general medical tx should be evaluated for \_\_\_\_\_\_
PE; meta-analyses have shown that up to 25% of hospitalized pt w/ AECOPD actually have PE
118
When should you consider aspergillus skin testing and IgE levels in asthmatic patients?
If pt has severe asthma that is not improving despite optimal medical mgmt for several months need to consider ABPA; also seen frequently in CF population
119
To what degree does OSA cause RV failure?
Generally, serious RV failure does not occur due to OSA alone (Van Scoy teaching point); OSA may cause some elevation of PA pressures but severe PA pressure elevation and RV failure unlikely on basis of OSA alone
120
At what level is the NIF pretty concerning for need to intubate in a patient with chronic resp failure from muscular issues?
A NIF less than -30 is pretty concerning
121
What is a normal apnea-hypopnea index?
less than 5 (if greater think of OSA or CSA); weight loss can improve the apnea-hypopnea index
122
What are some contraindications to thrombolytic therapy (5)?
Intracranial neoplasm, Intracranial surgery or trauma in past 2 months, recent hemorrhage, recent CVA hemorrhagic stroke, sugery within the past 10 days
123
What is the tx of PCP PNA? What if PaO2 \<70?
TMP-SMX; add steroids
124
A small, hemorrhagic and sterile exudative effusion in setting of acute chest pain is likely related to what?
Pulmonary Embolism related effusion; can have marked epithelial hyperplasia, some blood can be from infarcted lung
125
What should you do for a patient who has OSA on CPAP who has lost weight and feels better?
Repeat PSG with CPAP titration as the apnea-hypopnea index may have improved to \<5 (do this if \>10% baseline weight reduction)
126
Why are things like sildenafil/tadalafil or bosentan/ambrisentan potentially harmful for people with WHO III pulmonary HTN?
They are used in WHO I only really. In WHO III in particular, there is hypoxic pulmonary vasoconstriction in areas of damaged lung i.e. COPD blebs etc. If you give a vasodilator then more blood may be shunted to these areas which can lead to a decrease in baseline oxygenation; thereby worsening hypoxia
127
Best mgmt in AECOPD or status asthmaticus who develop HoTN with elevated peak pressures and a flow-waveform showing expiratory flow not reaching baseline
Disconnect from ventilator; pt is auto-PEEPing
128
What is the most appropriate initial mgmt of a patient with chronic bronchiectasis who has massive hemoptysis?
Lay bleeding side dependent and EMERGENTLY consult IR to embolize; bronchiectasis can lead to bleeding from a disrupted bronchial artery
129
What is the best step in a patient with asthma not well controlled on a medium dose glucocorticoid and SABA?
Add a LABA (salmeterol) often would DC the fluticasone and Rx a combo of fluticasone + salmeterol
130
What is the renal compensation for acute respiratory alkalosis?
For every fall in 10 mmHg of PCO2 the bicarb should fall by 1-2; chronically it will fall by 3-4 so similar to resp acidosis
131
Findings of recurrent asthma exacerbations in severe asthmatics w/ central bronchiectasis, eosinophilia, and elevated IgE should prompt dx of what?
Allergic Bronchopulmonary Aspergillosis; Dx w/ aspergillus skin testing and IgE levels; tx w/ glucocorticoids and Itra
132
A patient with COPD and hypoxemia on adequate pharmacologic tx should receive what
Supplemental O2 if SaO2 \<88% or PaO2 \<55 mmHg
133
What is the triad of a benign ovarian tumor with ascites and pleural effusion that resolve after resection of the tumor?
Meigs Syndrome
134
What is the recommended duration of systemic anticoagulation for provoked DVT
3 months (i.e. surgery, leg injury, pregnancy, or OCP use)
135
Aside from removing the offending agent, what is the best adjunctive tx of hypersensitivity pneumonitis?
IV glucocorticoids at 0.5-1 mg/kg dose
136
What is the most likely dx in pt from Ohio River valley who recently recovered from URI who has rounded opacity in lung
Blastomycosis
137
What are physiologic doses of prednisone in adrenal failure? Fludricortisone? Hydro?
Pred 5 mg, Fludri 0.05 to 2, and Hydro 12.5-25 2-3x daily; A dose of 50 hydro daily (25 bid) has sufficient activity to act as both gluco/mineralo for the day; may be supratherapeutic on the gluco end though leading to iatrogenic cushing dz
138
What clinical scenario would you order a thoracic lymphangiogram in?
If a person has a chylothorax; tx w/ medium fatty acid diet, avoid fats, octreotide
139
The most likely dx in a patient from East Asia with chronic sinusitis and obstructive lung dz w/ centrilobular nodules and dilated bronchioles on CT is \_\_\_\_\_\_\_
Diffuse Panbronchiolitis
140
What is the tx of moderate persistent asthma?
Rescue inhaler + inhaled glucocorticoid + LABA
141
What is the most appropriate mgmt of a symptomatic bronchogenic cyst?
Surgical removal
142
What are the two drug treatments that have been shown to limit the frequency of COPD exacerbations in pt on maximal therapy?
Azithromycin 250 mg daily; Roflumilast (PDE-4 inhibitor) 500 ug daily
143
What is the best empiric tx of a patient with acute bacterial prostatitis at low risk for STI? Considerations if not getting better?
Ciprofloxacin (MC bugs are E. coli, Kleb, and Serratia; often from ascending urethritis also why UTI in men always considered complicated bc they have prostate; if not better do transsrectal US to look for abscess then unroof
144
A sterile exudative effusion with a markedly low pH should lead one to inquire about what dz?
Rheumatoid Arthritis; often with low glucose and pH \<7.3
145
What refractory disease can potentially be treated with an atrial septostomy?
Severe WHO I pulm HTN (i.e. refractory to vasodilators, IV prostanoids, etc. can do atrial septostomy which can unload the RV)
146
What disease often has thin-walled cysts and small nodules involving the mid-upper lung zones and is assoc with young ppl who smoke?
Langerhans Histiocytosis (Eosinophilic Granuloma variant = Histiocytosis X); differentiated from IPF in that it affects middle and upper lobes as opposed to lower and occurs in younger ppl
147
Only CURABLE form of pulm HTN
CTEPH (WHO IV) can do pulm thromboendarterectomy
148
What is the appropriate mgmt of CF exacerbation with Cx positive for pseud?
2 antipseudomonal antibiotics; i.e. cefepime + tobramycin
149
What diagnostic test should you consider in an elderly patient with hx of smoking with new generalized fatigue and sedentary lifestyle?
Aside from obvious stuff like TSH, BMP etc. would consider PFTs to look for COPD
150
What SLE meds are ok in pregnancy
Prednisone, Hydroxychloroquine, and Azathioprine; MMF teratogenic and must be stopped at least 3 months prior
151
Most likely etiology of hypotension in a pt w/ AECOPD shortly after intubation
Auto-PEEP; or could be the sedatives
152
This is the diagnostic test of choice to identify DAH
Sequential Bronchoalveolar Lavage and see progressively bloodier lavage samples
153
Elevated GM-CSF antibodies can indicate a diagnosis of what interstitial lung disease?
Pulmonary Alveolar Proteinosis; can have crazy paving pattern on CT; tx = whole lung lavage
154
What is the general mgmt of WHO I pulm HTN
First get on vasodilators; CCB (dilt) if inodilator response (\>10 mmHg in PAP w/ inhaled NO); if not then PDE inhib or endothelin antag; if Class III-IV sx then IV epoprostenol and if refractory the atrial septostomy
155
What is the best step in evaluating a patient with hx of antiphospholipid syndrome who has worsening dyspnea, exercise intolerance, and desaturations?
VQ scan to evalute for CTEPH (WHO IV pulm HTN) which is curable with pulmonary thromboendarterectomy
156
What is the difference in timing between acute and chronic silicosis?
Acute silicosis is in less than 1 year (assoc with sandblasting) and chronic is like 10-30 years later; often upper lobe predominant
157
What is the DOC for candiduria? Candidemia?
Fluconazole is good for candiduria and echinocandins aren't; however, if pt develops candidemia then echinocandins are the DOC
158
What is the most appropriate initial testing in a patient with suspected adult onset asthma?
PFTs with pre/post bronchodilator test as it assesses reversible airflow obstruction; obstructive if FEV1:FVC \<70%, responsive if \>12% increase; afterwards can consider allergy testing to avoid trigger allergies
159
What DOAC can a person just straight up get and leave if they have an uncomplicated provoked PE w/o hemodynamic compromise and adequate renal fxn?
Rivaroxaban or Apixaban; dabigatran and edoxaban both need some systemic bridge i.e. either lovenox or fondaparinux
160
What is the most appropriate approach to patients with pleural effusions due to CHF?
Diuresis and if they don?t improve consider thoracentesis; may develop trapped lung
161
What direct pulmonary issue can HIV cause?
Pulmonary Arterial HTN; look for pt w/ loud S2, LE edema, DOE, etc.; NO CORRELATION TO CD4 COUNTS
162
What is Auto-PEEP?
Failure of the expiratory flow to reach zero before the delivery of the next breath; best tx if HD instability is disconnect from ventilator
163
Best Tx for newly dx ankylosing spondylitis? Possible pulmonary issue?
NSAIDs are first line; restrictive lung dz
164
What is the cause in occupational asthma of pts who work with Auto body industry
Diisocyanates
165
What are some general considerations for pts with wheezing that does not improve despite medical tx?
Tracheomalacia (if intubated for a while); if monophasic inspiratory stridor then paradoxical vocal cord motion (adduction in inspiration), or endobronchial lesion if unilateral
166
What is the best study to obtain for an obese pt with suspected OSA who has cardiopulmonary comorbidities and why?
In lab PSG bc need to differentiate OSA from CSA, Cheyne-Stokes etc.
167
Best test to confirm dx of pleural tuberculosis
Pleural Bx (ADA \>40 suggestive but finding acid fast bacilli on pleural bx confirms); recall the effusion will be lymphocyte predominant
168
What test would you order for a patient whose pleural effusion showed high level of triglycerides?
Thoracic Lymphangiogram - looking for chylothorax; tx with octreotide, medium chain fatty acid diet, avoid fats
169
What is the most appropriate test for an obese patient with severe hypersomnia and elevated HCO3 on the BMP?
ABG to look for OHS; this is important as the mgmt changes so a pt with OHS may require changing the CPAP to BiPAP
170
What is the Macklin effect?
When alveoli rupture and the air tracks along the interstitial lining causing pneumomediastinum; can occur in severe asthma/COPD exacerbation; can just observe and tx underlying exacerbation in these settings
171
What should you consider in a patient with intermittent confusion, ataxia, elevated AG w/o clear cause and a normal lactate in patients with small bowel resection?
D-lactic acidosis; bacteria create the D enantiomer from excess carbs and not the L so we cant detect on regular lactate labs
172
What disorder needs to be considered in a veteran with SOB coming from Iraq who fought in OIF or operation New Dawn?
Constrictive Bronchiolitis- due to bombs, burn pits, and inhalants that cause constriction of the bronchioles and so obstructive physiology
173
What is the etiology of high altitude pulmonary edema?
Thought to be due to acute hypoxic pulmonary vasoconstriction leading to acute rise in PA pressures with subsequent pulm edema; Tx for secondary prevention is Nifedipine
174
What infectious dz can have erythema nodosum?
Coccidiodes consider in nonresolving PNA w/ EN in SW United States
175
What is the next best step in a patient with imaging findings suggestive of resectable pancreatic CA?
Resection; don?t need to waste time checking tissue
176
What do you call if there is a large ovarian tumor that pathology shows is actually gastric adenocarcinoma?
Krukenburg Tumor
177
For a patient with no exposure to TB the MC cause of a chronic pneumonia is \_\_\_\_\_\_\_
Fungal
178
What is Ovarian Hyperstimulation Syndrome?
Development of pleura effusions, ascites, edema and possibly shock in a woman undergoing IVF; can be similar to Meigs syndrome
179
What are some risk factors for developing pseudomonal pneumonia?
Structural lung dz and recent hospitalization; 7 days of tx adequate even if VAP
180
What is a potentially serious adverse side effect of long term nitrofurantoin?
Drug induced lung injury
181
T/F: modafinil and armodafinil can be used in the tx of OSA
True, if somnolence persists despite first line tx; also used in Narcolepsy which is Dx with Multiple Sleep Latency Test
182
What is the tx of severely hypoxemic pts with suspected Amiodarone Pulmonary Toxicity?
DC amiodarone and start prednisone (1 mg/kg) which is still recommended despite efficacy in trials
183
A young woman with intermittent hemopneumothorax should be evaluated for \_\_\_\_\_\_
Catamenial Pneumothorax; often d/t thoracic endometriosis; ask about timing of the PTX to the period
