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Flashcards in Pulm/CC Deck (69):
1

Name the 2 reasons for hypoxia with a normal A-a gradient.

Decreased FiO2
Hypoventilation

2

Name the 3 reasons for hypoxia with abnormal or increased A-a gradient.

V/Q mismatch
Shunt
Decreased diffusion

3

Patient presents with hypoxia and a normal A-a gradient when taking opiates/benzos?

Central respiratory depression (neuro disorder)

4

What drug causes foamy changes in lamellar inclusions on a BAL?

Amiodarone induced disease

5

How to interpret PFTs?

Obstructive: FEV1/FVC < 0.7
Mild FEV1> 80% = GOLD I
Moderate FEV1 50-79% = GOLD II
Severe FEV1 30-49% = GOLD III
Very severe FEV1 < 30% = GOLD iV

6

What is the only medication known to improve survival in COPD?
How does pulm rehab contribute?

Oxygen
Pulm rehab decreases healthcare costs and quality of life but does not impact survival

7

Name the hierarchy of asthma control inhalers?

Albuterol ICS LABA
And you can step down therapy

8

What BP med is best for asthma patients?

CCB

9

How do you diagnose asthma on PFTs?

Methacholine challenge test. 12% reversability and a 200cc increase with bronchodilators

10

Test question - you have a pregnant patient admitted for asthma, now improved, what do you do on discharge?

Send home on ICS as 30% will get worse with pregnancy

11

How do you diagnose exercise induced asthma and what is the treatment?

Exercise challenge test
albuterol 15-30 minutes before exertion

12

What the diagnosis? Young smokers with bulloous COPD, famhx liver/lung disease

Alpha 1 anti-trypsin deficiency

13

What testing do you perform for alpha 1 AT? What is the treatment?

serum level testing; genetic testing of Pi locus
Tx: weekly alpha 1 antiprotease infusions, does not treat liver disease

14

What's the diagnosis? Plumber with GI plaquing and pleural thickening on CXR?

mesothelioma

15

What's the diagnosis? Young AA female with skin lesions on anterior legs, cough, dyspnea, uveitis.

Sarcoidosis

16

Young AA female with pleural effusion that on tap is lymphocyte predominant

Sarcoidosis

17

What's the diangosis? Arthritis, erythema nodosum, b/l hilar lymphadenopathy

Lofgren's syndrome

18

What's the diagnosis? anterior uveitis, parotid gland enlargement, facial palsy, fever

Heerfordt syndrome

19

What's the diagnosis? Premenopausal women, pneumothorax, chylous effusion (TG> 110), tuberous sclerosis. CXR with diffuse honeycombing

Lymphangioleioyomatosis

20

What's the next best step after diagnosis LAM?

always image the kidneys

21

What's the diagnosis? Upper respiratory tract dx, sinusitis, glomerulonephritis and ILD.

Granulomatosis with polyangiitis (Wegners)

22

What are the serology markers for Wegners?

c-ANCA & anti-PR3

23

What's the diagnosis? Upper respiratory tract dx, sinusitis, glomerulonephritis, ILD but (-) ANCA

Glomerular basement membrane disease

24

What's the diagnosis? URI, asthma, eosinophilia

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

25

What's the serology for Churg-strauss?

p-ANCA, anti-MPO assay positive

26

What's the diagnosis? Female patient with RA, weight loss, low fevers, dry cough for 2 months, failed treatment with multiple rounds of abx

Cryptogenic Organizing pneumonia
CXR often with migratory consolidations

27

Treatment for COP?

steroids

28

What's the diagnosis? Allergic rxn to aspergillus, chronic cough, mucus plugging, recurrent pulmonary infiltrates with eosinophilia, elevated IgE > 1000
Usually presents as difficult to control asthma

allergic bronchopulmonary aspergillosis (ABPA)

29

What is the order of diagnosis for ABPA?
What is the treatment?

1. Eosinophilia
2. Aspergillus antigen skin prick test
3. IgE > 1000
4. Serum specific A fumigatus antibody testing
5. Galactomannon test
Tx: Steroids + itraconazole

30

What are 2 markings you can see on imaging with suspected PE?

Westermark sign: lack of vascular markings downstream of embolism
Hampton's hump: wedge shaped defect from infarction just above the diaphragm

31

Management of a clinically unstable patient suspected of having PE?

tPA

32

what are the relative contraindications and absolute contraindications for thrombolytics?

Surgery within 10 days is a relative contraindication
Intracranial/intraspinal surgeries are absolute

33

What are the Wells criteria and number ranking?

Clinical signs/symptoms of DVT: +3
PE is #1 diagnosis OR equally likely: +3
HR > 100: +1.5
Immobilization at least 3 days OR surgery in the previous 4 weeks: +1.5
Previous diagnosis PE or DVT: +1.5
Hemoptysis: +1
Malignancy w/ treatment within 6 months or palliative: +1
Low risk <2
Moderate risk: 2-6 pts
high risk: >6 points

34

What's the diagnosis? RLL infiltrate, consolidation, patient incapacitated

aspiration syndromes > 48 hrs before infection leading to chemical pneumonitis, cavitary/empyema

35

Treatment for aspiration syndromes?

Always think anaerobes. Amox-clavulanate (Augmentin), amp-sulbactam (Unasyn), clinda

36

What are Light's criteria?

Exudative effusion if:
-fluid prot/serum prot > 0.5
-fluid LDH/serum LDH > 0.6
-fluid LDH > 2/3 upper limits of normal

37

What are causes of exudative vs transudative effusions?

exudative: PNA, CA, PE
transudative: HF, cirrhosis, nephrotic syndrome/ESRD

38

Pleural effusion with adenosine deaminase

TB

39

Pleural effusion with glu<60, glu<30?

<60: infectious, TB, RA, malignancy
<30: empyema, PE

40

pleural effusion in an AAF with increased lymphocytes =

sarcoidosis

41

Indications for CT on pleural effusions?

pH < 7.2, glucose < 60, positive cx or gram stain; loculated pleural thickening

42

What's the diagnosis? Immunocompromised patient with septate hyphae at narrow/acute angles?

Aspergillosis
Tx: Voriconazole IV

43

PNA: alcoholic, currant, jelly sputum

Klebsiella

44

PNA: Gram stain with GN diplococci, COPD-er

Moraxella catarrhalis

45

PNA: rust colored sputum, lancet shaped G+ diplococci

streptococcus pneumonia

46

PNA: reverse bat wing, infiltrate spares hilum

eosinophilic PNA

47

PNA in a young patient and can cause elevated d-dimer

mycoplasma pneumoniae

48

PNA with pharyngitis, hoarsness, CAP in patients > 65 y/o

Chlamydophila pneumoniae

49

PNA from inhaled contaminated water, diarrhea, confusion

legionella

50

Patient presents with green sputum, alcoholic with dental caries

Bacteroides, Tx: clinda

51

Which is the most likely in an aspiration PNA isolate?

Haemophilus aegyptius

52

URI symptoms unresponsive to cipro

Bordatella pertussis

53

Southwest US fungus

Coccidioides

54

Southern/Midwestern US fungus

Histoplasmosis

55

Mid-Atlantic/Central/SE US fungus; broad based budding yeast

Blastomyces dermatitidis

56

PNA in immunosuppressed patients, AIDS

PJP
Diagnose with GOmori methenamine silver stain (GMS)

57

In active Tb, give INH with ____ to prevent ____

pyridoxine (B6) to prevent neuropathy

58

Patient with resistant HTN, next step?

PSG

59

Lung cancer most associated with non-smokers and CEA tumor marker?

adenocarcinoma

60

Lung cancer that is cavitary and can cause hypercalcemia

squamous cell

61

Lung cancer associated with SIADH, ectopic ACTH production, Eaton Lambert syndrome

SCLC

62

What is the screening recommendation for lung cancer?

55-80 y/o with >30 pack year hx and currently smoking or has quit smoking in the last 15 years

63

What's the diagnosis? Asthma, allergic rhinitis, atopic dermatitis, food allergies, elevated IgE

Jobs Syndrome

64

Pulm HTN WHO classification

WHO 1 = Idiopathic (autoimmune, heritable, drugs/toxins, HIV)
WHO 2 = cardiac related (left heart failure)
WHO 3 = pulmonary related (COPD, ILD)
WHO 4 = CTEPH
WHO 5 = miscellaneous / multifactorial (sarcoidosis, histiocytosis, vasculitis, ESRD on HD)
Treat underlying cause
WHO 2 = heart failure
WHO 3 = treat copd
WHO 4 = anticoagulation
Remember CTEPH is best confirmed with V/Q scan

65

What's the diagnosis? Aspirin provoked dyspnea, cough, nasal polyps, asthma

Samters syndrome
Avoid NSAIDs
Treat with montelukast

66

Infusion that can cause hypotension, erythema, urticaria

Dilaudid

67

Next best step in patient with Gram (-) sepsis with refractory hypotension despite negative cx

R/o adrenal insufficiency

68

Drug for prevention of altitude sickness?

acetazolamide

69

On CXR, with wide mediastinum, think ____

anthrax