Pulm- Uworld

Question 1

70- Q 11. What is indicated for long term management of asthma (ie. first line for chronic asthma)?

Answer 1

inhaled corticosteroid

fluticasone, budesonide

Question 2

70- Q 25. What is radial traction

Answer 2

outward pulling

= chest wall recoil

Question 3

70- Q 25. Explain by which two mechanisms pulmonary fibrosis results in increased FEV1

Answer 3

1. increased lung elastic recoil
2. increased radial traction on airway => airway widening
   * fibrotic tissue around alveoli: pushes air during expiration more easily: increased lung elastic recoil
   * fibrotic tissue around airway: pulling airway (increasing radial traction) so that air can get out more easily

Question 4

70- Q 27. Poor oral dental carries with pneumonia: what bug may cause pneumonia?

Answer 4

Actinomyces

• Actinomyces reside in oral, colon, and vagina

Question 5

70- Q 28. What is virulence factor of H. Infulenza?

Answer 5

PRP (PolyRibosyribotol Phosphate) in capsule

Question 6

70- Q33. Does pulmonary embolism causes diffusion limitation?

Answer 6

NO. diffusion limitation is either changes in surface area (emphysema) or membrane thickness (fibrosis or hyaline)

*PE leads to V/Q mismatch, which can also be caused by diffusion limitation. But PE does not change diffusion

Question 7

70- Q 39. Which pneumocosis shows bifringement particle on polarized microscopy? What is another imaging finding in this pneumocosis?

Answer 7

silicolsis

also shows “eggshell” calcification of hilar lymphnodes

Question 8

71- Q 2. acute otitis media: what two bugs should I think?

Answer 8

• strep.pneumo

- H. infulenza

Question 9

71- Q 3. Is equilibration of O2 and CO2 diffusion limited?

Answer 9

NO. ONLY WHEN blood flow is not adequate to pulmonary circulation

CO2 has very great diffusion rate across membrane. So diffusion limitation will not usually occur unless there is huge blood flow limitation

Question 10

71- Q5. What two pneumoconioses shows calcification on imaging?

Answer 10

• abestosis
• silicosis
• top and bottom in FA chart

Question 11

# 71- Q7. (Heme question) 
Define Absolute vs. Relative erythrocytosis. What is key difference between these two?

Answer 11

Absolute: Absolute increase in RBC mass

• primary: polycythemia vera
• secondary: ectopic EPO synthesis (malignancy), low oxygen state (V/Q mismatch, other lung diseases)

Relative: NO CHANGE in RBC MASS
- dehydration or burns
=> RBC concentration increases due to hypovolemic state, but RBC mass stays normal

• burns cause hypovolemia
• It is RBC MASS that distinguish these two

Question 12

71- Q7. At what PaO2 and SaO2 cause absolute erythrocytosis?

Answer 12

PaO2 < 65mmHg

SaO2 < 92%

Question 13

71- Q 10. Left sided heart failure: describe pathophysiology how this leads to dypsnea

Answer 13

left side HF

• > increased hydrostatic pressure in pulmonary circulation
• > fluid accumulation in interstitium
• > alveolar becomes sticky
• > DECRESASED ALVEOLAR COMPLIANCE

Question 14

71- Q 10. Is left to right cardiac shunting responsible for dyspnea?

Answer 14

NO

left to right CARDIAC shunting refers to shunting WITHIN heart, such as VSD or ASD

Question 15

71- Q 15. What is responsible for green color in sputum?

Answer 15

neutrophil myeloperoxidase

MPO is blue-green heme based enzyme

Question 16

71- Q 17. What rib levels of lung/pleura/liver @

• anterior
• lateral side
• posterior

Answer 16

(6,8) (8,10) (10,12)

Anterior 6,8:

• above 6th rib: lung
• between 6th ant 8th rib: pleura
• below 8th rib: liver

lateral side 8,10

posterior 10.12

• check photo in phone

Question 17

71- Q 21. How body mediates compensation to respiratory alkalosis? How long does it take to occur?

Answer 17

• decrease HCO3- reabsorption (how acetazolamide helps for altitude sickness)
• renal compenstaion occurs about 48 hours after

Question 18

71- Q 23. How can panic attack cause neurologic symptoms? Explain physiology

Answer 18

hyperventilation

• > hypocapnea (low PaCO2)
• > vasoconstriction -> decreased cerebral perfusion
• > dizzness, weakness, blurred vision
• remember CO2 is ONLY ONE metabolite that cause vasoconstriction in brain

Question 19

71- Q 29. At what CD4 T cell count does opportunistic pneumonia caused by pneumocystis jirovecii occur?

Answer 19

CD4 less than 200

• If HIV patient has CD4 T cell count above 500, then it is considered as not severely immunocompromised status. Thus, most likely cause of pneumonia infection should be by S.pneumoniae (most common community acquired pneumonia)

Question 20

71- Q 31. What are two staining methods for cryptococcus?

Answer 20

• india ink
• mucicarmine: red inner capsule
• sketchy: MUmmy in MUsicarmine red container

Question 21

71- Q 37. fatigue, chills, IV drug user present with lung infarct. Explain mechanism for lung infarct

Answer 21

endocarditis -> septic emboli -> pulmonary infraction

• Don’t pick DVT. DVT patient will not have chills!
  If IV drug user is given, there is reason for that.

Question 22

71- Q 40. (nutrition question) Which vitamin is responsible for normal differentiation of epithelial cells into pancreatic cells or mucus secreting cells?

Answer 22

vitamin A

-> Vitamin A deficiency can cause metaplasia in pancreatic ducts

Question 23

72- Q1. gag reflex vs. cough reflex: afferent/efferent?

Answer 23

• gag reflex
  afferent: CN9
  efferent: CN10 (soft palate elevation)
• cough reflex
  afferent: CN 10 ( superior laryngeal nerve sensing irritants)
  efferent: CN 10 (coughing)

Question 24

72-Q 1. Which structure in pharynx runs right anteriorly with regard to superior laryngeal nerve?

Answer 24

piriform recess

• This shit is not on FA

Question 25

72- Q 17. Pulmonary complication for obstructive sleep dyspnea?

Answer 25

pulmonary HTN hypoxia -> pulmonary vasoconstriction

Question 26

72- Q 24. What two masses can cause SVC syndrome? How to differentiate these two different etiology?

Answer 26

- mediastinal mass: no neurological symptoms. Just pure SVC syndrome - pancoast tumor: shoulder pain (axillary gets compressed), Horner

Question 27

72- Q 28. Which bug is the only one gram positive diplococci?

Answer 27

strep. pneumo

Question 28

72- Q 40. Name three anarobes that are associated with lung abscess. What are two major causes of lung abscess? how to differentiate them?

Answer 28

- Bacteriodes - Peptostreptococcus - Fusobacterium Two main causes are: 1. loss of conscious that can lead to aspiration: SEZIURE, alcoholics 2. bronchial obstruction: cancer aspiration vs. bronchial obstrurction : aspiration will show anarobes in abscess while bronchial obstruction is less likely to contain anarobes

Question 29

#73- Q1. work of breathing is sum of what two respiratory works? How increasing breathing frequency affects these two?

Answer 29

- work against lung recoil: opening up alveoli against inward pressure => increasing breathing frequency will reduce it : more rapid breathing, more air is trapped in alveoli (due to not full respiration) -> less work needed to open alveoli - work against airway: getting air out against airway resistance => increasing breathing frequency will increase it : more rapid breathing, more air is hanging out in airway -> more airway resistance

Question 30

#73- Q 13. Chronic transplant rejection occurs at where in lung?

Answer 30

bronchiole, small airway * this process is called Bronchiolitis obliterans

Question 31

#73- Q 27. Explain pathophysiology of lethargy / confusion with high flow oxygen supplementation

Answer 31

high oxygen supplementation - > pulmonary vasodilation - > increased dead space (poorly ventilated alveoli also get perfused) - > hypercapnea *oxygen induced hypercapnea

Question 32

74 - Q5. Describe how eosinophils look like. What lung disease should I think when it comes to eosinophils?

Answer 32

Pink cytoplasm with purple granules Asthma

Question 33

74- Q 9. Alveolar macrophages are located in which two segments along respiratory tract?

Answer 33

alveoli | ALSO in RESPIRATROY BRONCHIOLES this is not clearly presented in FA

Question 34

74 - Q 18. What is the most common cause of death in systemic sclerosis?

Answer 34

pulmonary hypertension * It is not really associated with pulmonary fibrosis like most of other autoimmune disease. Systemic sclerosis induces INTIMAL THICKENING, leading to PULMONARY HTN

Question 35

74- Q 19. Patient comes to clinic with fever, malaise, cough and throat pain. Few days later patient is hospitalized due to progressive chest pain, dyspnea. What bug will be seen in sputum?

Answer 35

S.aureus SECONDARY PNEUMONIA * starting with some viral symptoms (influenza virus in this case), and then pulmonary => always think about secondary pneumonia

Question 36

#74- Q 20. What is the most common benign lung tumor? what is special characteristic of this tumor? (what tissue is contained in this tumor?)

Answer 36

- pulmonary chondroma ( hamartoma) | - epithelium contains hyaline cartilage

Question 37

#74- Q 23. What is initial phase of TB infection? When does helper T cell response begins?

Answer 37

bacterial proliferation is initial phase Helper T cell response (helper T cell -> INF-gamma -> epitheloid macrophage) begins at week 2-4.

Question 38

74- Q 25. How to differentiate between allergic bronchoplumonary Aspergilios vs. asthma

Answer 38

chest x-ray Allergic bronchopulmonary Aspergilios: infiltrate and cavity. also may show bronchiectasis * Asthma usually gives NORMAL chest x-ray

Question 39

74- Q32. What is direct indicator of ventilation status?

Answer 39

PaCO2 Central receptor senses CO2 -> respiratory center * What about PaO2? Not necessarily. It's easy to think that hyperventilation leads to high PaO2. BUT THIS IS NOT TRUE. If there is V/Q mismatch, PaO2 may still stay low even with hyperventilation

Question 40

104- Q 37. How to differentiate brachiocehpalic vein compression vs. SVC syndrome

Answer 40

brachiocephalic compression: unilateral SVC syndrome: bilateral SVC gives rise to Left or Right brachiocephalic vein