Pulm

Question 1

Order of asthma management

Answer 1

Start with inhaled SABA
Next add low-dose inhaled corticosteroid, alternates include cromolyn, LK modifiers: montelukast
Next add LABA to the SABA and ICS or increase the dose of ICS
Then increase the dose of the ICS to maximum in addition to the LABA and SABA
May add Omalizumab if increased IgE
Finally, oral corticosteroids when all others have failed

Question 2

The severity of an asthma exacerbation is quantified by?

Answer 2

Decreased peak expiratory flow – an approximation of the FVC

Also ABG with an increased A-a gradient

Question 3

Treatment of an asthma exacerbation

Answer 3

Oxygen, albuterol, steroids, iPratropium may help, magnesium only an acute, severe asthma not responsive to several rounds of albuterol

Question 4

COPD diagnosis

Answer 4

best initial: CXR
most accurate: PFT (will have decreased FEV1/FVC less than 70% decreased DLCO) (not reversible -i.e. less than 12% / 200 mL improvement in FEV1)
ABG in acute exacerbations will have increased pCO2 and hypoxia, elevated bicarb to compensate

Question 5

what improves mortality in COPDers?

Answer 5

smoking cessation
O2 if pO2 less than 55 or sat lass than 88% (or 60, 90% if RHF or elevated HCT or pulm HTN)
influenza/pneumo vaccines

Question 6

effective meds in COPD

Answer 6

anticholinergics are most effective**
SABAs, steroids, LABAs, pulm rehab
in contrast to asthmatics, COPD not controlled with albuterol>anticholinergic>ICS

Question 7

management of AECB

Answer 7

bronchodilators, steroids, antibiotics: macrolides, cephas, augmentin, FQs, doxy or bactrim 2nd line

Question 8

high volume purulent sputum, +/- hemoptysis, wheezing, dyspnea, crackles, dilated, thickened bronchi (“tram-tracks”) on CXR, think? best diagnostic tool?

Answer 8

bronchiectasis
most accurate test is high-resolution CT (get CXR first)
sputum culture to determine specific bacteria

Question 9

bronchiectasis tx

Answer 9

“cup and clap” - physiotherapy (associated with CF)
tx infection, rotate abx
sx resection

Question 10

brown sputum, ^IgE, eospinophilia, think?

Answer 10

ABPA

Question 11

sinus pain and polyps are common in ?

Answer 11

CF

biliary cirrhosis, intestinal obstruction, pancreatitis (islets are spared)

Question 12

best diagnostic test for CF

what bugs on sputum cx

Answer 12

sweat chloride (above 60) after pilocarpine tx (^Ach>^Cl-)
genotyping not accurate, too many diff genes
H. flu (nontype), pseudomonas, S. aureus, Burkholderia

Question 13

CF tx

Answer 13

abx: macrolides, cephas, augmentin, FQs, doxy or bactrim 2nd line
inhaled rhDNase, inhaled bronchodilators (albuterol), pneumo/influenza vaccination, lung transplant if refractory
Ivacaftor ^CFTR activity

Question 14

main ways to distinguish pneumonia from bronchitis

Answer 14

abnormal CXR, high fevers, dyspnea?

Question 15

CAP orgs not visible on gram stain

Answer 15

Mycoplasma, Chlamydia, Legionella, Coxiella, viruses

Question 16

sputum gram stain is adequate if ?

Answer 16

more than 25 WBCs and fewer than 10 epithelial cells

Question 17

pleural effusion with:
WBC above 1000, pH less than 7.2?
LDH above 60% and protein above 50% of serum level?

Answer 17

infection

empyema

Question 18

bronchoscopy in pneumonia?

Answer 18

rarely needed, only when stain/cx do not yield org and need for ICU placement
exception: PCP
other uses: foreign bodies, cytology for lung masses

Question 19

Outpatient treatment of pneumonia

Answer 19

If previously healthy: macrolide or doxycycline

If comorbidities or antibiotics in the past three months: floor quinolones – not Cipro

Question 20

Inpatient treatment of pneumonia

Answer 20

Flora quinolone – not Cipro or ceftriaxone and azithromycin

Question 21

Reasons to hospitalize people with pneumonia

Answer 21

Hypotension, respiratory rate above 30 or PO to lesson 60, pH below 7.35, B1 above 30, sodium lesson 130, glucose about 250, possible of 125, confusion, temperature above 104, 65 or older or comorbidities such as cancer COPD CHF renal failure liver disease

Question 22

Curb 65 criteria for pneumonia and mission

Answer 22

Confusion, uremia, respiratory distress, BP low, age over 65
With 0 to 1.: Home
If 2+ points: admission

Question 23

How to manage infected profusion or empyema in addition to antibiotics?

Answer 23

Drainage for a chest tube or thoracostomy, each of the chest can accommodate 2 to 3 L of fluid, a large effusion ask like an abscess and is hard to sterilize

Question 24

Who gets the pneumococcal vaccine

Answer 24

Everyone at 65: first 13 then the 23
Once underlying condition is discovered in those with heart, liver, kidney, lung disease or immunocompromise or cancer
Second those should be given five years after the first dose

Question 25

Difference with HAP

Answer 25

Higher incidence of Graham negatives: E. coli or Pseudomonas, macrolides are not acceptable Need anti pseudomonal cephalosporins or antipseudomonal PCN, (Zosyn) or carbapenem

Question 26

Diagnostic test for VAP from least accurate but easiest to most accurate but most dangerous

Answer 26

Trick your aspirin, BAL, protected brush specimen, VAT, open lung biopsy – thoracotomy

Question 27

Therapy for VAP

Answer 27

Combine three different drugs: Anti-pseudomonal beta-lactam: cephalosporin, penicillin, or carbapenem PLUS SecondAnti-pseudomonal agent: aminoglycoside or floor quinolone PLUS MRSA agent: vancomycin or linezolid no daptomycin! Inactivated by surfactant

Question 28

Best for covering long abscesses

Answer 28

Penicillin or clindamycin CXR is the best initial test, CT is more accurate, only a long biopsy can establish the etiology, sputum culture is wrong

Question 29

Alternative to Bactrim in PCP

Answer 29

Atovaquone if mild, if that Jim toxicity switch to clindamycin and primaquine or pentamadine

Question 30

Diagnosing TB

Answer 30

Best initial test: CXR Sputum stayed in culture, Most accurate test: plural biopsy

Question 31

When to extend six-month treatment for TB

Answer 31

Osteomyelitis,military TV, meningitis, pregnancy or any other time pyrazinamide is not used

Question 32

What to do and hepatotoxicity with TB medications

Answer 32

Only stop when LFTs rise 3 to 5 times upper limit of normal Pregnant patients should not receive pyrazinamide or streptomycin Steroids decrease the risk of constructive pericarditis and neurological complications

Question 33

PPD positive if larger than 5 mm in what people

Answer 33

HIV, steroid users, close contacts of those with active TB, abnormal calcifications on CXR, organ transplant recipients

Question 34

PPD positive pressure than 10 mm and what people

Answer 34

Recent immigrants, prisoners, healthcare workers, close contacts of someone with TV, blood cancers, alcoholics, diabetes

Question 35

If the first PPD is negative and someone who's never had a PPD before, what to do

Answer 35

Get a second PPD, the first test may be falsely negative

Question 36

What to do after positive PPD

Answer 36

Get CXR to rule out active TB, if negative implies latent, get nine months of INH with vitamin B6

Question 37

What do you do if one lesion has malignant features: patient older than 40, enlarging mass, smoker, greater than 2 cm, adenopathy, and normal pet scan

Answer 37

Remove the lesion, the following tissue not be done because a negative test is likely to be a false negative: sputum cytology, needle biopsy, PET scan

Question 38

Most appropriate next step in patients with intermediate probability of malignancy

Answer 38

Bronchoscopy for central lesions and transthoracic needle biopsy for peripheral lesions

Question 39

PET scan does what?

Answer 39

Tells whether the content of lesion is malignant without a biopsy, malignancy you will have increased uptake of glucose, 85 to 95% sensitive, more accurate with larger lesion is greater than 1 cm

Question 40

Most sensitive and specific test for long lesions

Answer 40

Video assisted thoracic surgery – VATS | Can convert to open thoracoscopy and lobectomy if malignancies found

Question 41

Causes of pulmonary fibrosis

Answer 41

Radiation, Drugs: bleomycin, both so fun, amiodarone, metal surgeon, Macrobid, cyclophosphamide Pneumoconiosis: coal, silicosis, asbestosis s, berylliosis

Question 42

All forms of pulmonary fibrosis present with? | What type has granulomas?

Answer 42

DOE, Find rails or crackles, loud P2, clubbing of the fingers Granulomas in berylliosis, Responds best to steroids

Question 43

Parotid gland enlargement, facial palsy, her block, restrictive cardiomyopathy, CNS involvement, Iritis/uveitis, erythema nodosum, lymphadenopathy, think?

Answer 43

Sarcoidosis, CXR is best initial test, lymph node biopsy is most accurate – granulomas are noncaseating

Question 44

Labs in sarcoidosis

Answer 44

Elevated AC E, hypercalciuria, hypercalcemia – granulomas make vitamin D, restrictive long pattern on PFTs BAL shows elevated helper cells Treat with steroids

Question 45

Unique presentation in PE

Answer 45

Fever can arise from any cause a clot/hematoma, extremely severe emboli will produce hypotension

Question 46

PE diagnosis

Answer 46

Get CXR, EKG, ABG 1st | CXR most likely be normal, if abnormal will show atelectasis, ABG will show hypoxia and respiratory alkalosis

Question 47

This patient presents with SOB an elevated heart rate, CXR is normal with hypoxia an ABG, increase it a gradient with EKG showing sinus tack, what to do next?

Answer 47

Do not need CTA as this is high probability, much more important to start therapy – enoxaparin

Question 48

If I find a clot and LE Doppler, what to do?

Answer 48

No need to get CTA, as treatment is the same: heparin and six months of warfarin

Question 49

Most accurate test for PE

Answer 49

Angiography, .5% mortality, Rarely done

Question 50

PE treatment

Answer 50

Heparin to warfarin for an INR of 2 to 3 times normal, fondaparinux is alternative Rivaroxaban and dabigatran our oral agents that can be used in alternative to warfarin, use with LMWH

Question 51

When is TPA The right answer in PE

Answer 51

Hemodynamically unstable and, a Q RV dysfunction – also a reason for IVC filter

Question 52

When our direct acting thrombin inhibitor's the right answer in PE?he

Answer 52

In cases of HIT Examples: argatroban, lepirudin or fonduparinux ASA is never the answer

Question 53

Pulmonary hypertension

Answer 53

Systolic greater than 25, diastolic greater than eight, any chronic lung disease leads to back pressure into the pulmonary artery, obstructing blood flow out of the right heart