Pulmonary 1

Question 1

1. Rx for COPD and FEV1 < 60% ?
2. Rx for COPD and FEV1 < 50%?
3. Appropriate Add-On Therapy for pt with Severe COPD associated with Chronic Bronchitis and hx of Recurrent Exacerbations?
4. Rx for COPD with Severe Resting Hypoxemia (P02 < 55mmgh, 02 Sat 88%) or P02 55-60mmgh with Signs Polycythemia, PH, R-CHF
5. Management of a patient with COPD who has completed Lung Rehab, Exercise Program, on Maximal therapy, Normal BMI but still has Significant Exertional Dyspnea?

Answer 1

1. LABA or LAMA
2. Add on Pulmonary Rehab
3. Roflumilast, BIPAP, Azithromycin
4. Continuous 02 therapy
5. Lung Reduction Surgery (to improve mortality, exercise tolerance and quality of life)

Question 2

What is the recommended follow up for long nodules 6-8mm in size?

Answer 2

Every 6-12 months
then every 2 years for 5 years due to slow rate of growth ( doubling time is around 2-5 years)

Question 3

Asthma Management

1. Mild Persistent asthma( >2 Days a week, > 2 Nights month)?
2. Moderate persistent asthma (Daily, > 1 night week)?
3. Severe persistent? (All day, All night)

Answer 3

Step 1-2 SABA + Low Dose ICS prn
LABA + Low Dose ICS prn

Step 3 LABA+ Low Dose ICS daily

Step 4 LAB+ Medium Dose ICS daily

Step 5 LABA+ High Dose ICS+ LAMA Daily
Consider Biologic Therapy (Anti-iGE or Anti-IL5/5R) Omalizumab

Question 4

Exudative Pleural Effusion with Hx of Asbestos Exposure.
Dx?

Answer 4

Malignant Pleural Mesothelioma

Question 5

Medication for patient with Asthma and symptoms inadequately controlled with inhaled steroids, evidence of allergies to perennial aeroallergen, serum IgE levels 30-700?

Answer 5

Omalizumab (inhibits IgE)

Question 6

PT found Unconscious, was using Propane Fueled Heater, Carboxyhemoglobin level is 50%.

Next step in management?

Answer 6

Hyperbaric Oxygen Therapy

Question 7

Rx for a patient with Central Sleep Apnea and Cheyne-stokes breathing pattern and Heart Failure symptoms?

Answer 7

Lasix

Question 8

Pt with hx of diffuse cutaneous sclerosis presents with 6 months of progressive dyspnea. Dx?

Answer 8

Do a high resolution CT to check for Diffuse Parenchymal Lung Disease: Nonspecific Interstitial Pneumonia

Question 9

Next step in diagnosing cough variant asthma when spirometry is normal?

Answer 9

Methacholine challenge test

Question 10

Next step in management of hospitalized patient with dyspnea and hx of COPD AND NOT responding to COPD treatments?

Answer 10

CT Pulmonary Angiography (CTA) to evaluate for PE

Question 11

Management of Chronic Hypoventilation due to neuromuscular disease (ALS)?

Answer 11

BIPAP

Start when patients have HYPERcarbia or Respiratory Symptoms.

Question 12

Pt presents with progressive Exertional Dyspnea, fatigue, Edema, Near Syncope event, Pulmonary Artery Systolic pressure is 50mmg hg on Right Heart Cath.

Dx?
Test?
Rx?
What if there was a change with inhaled nitric oxide?

Answer 12

Group 1 PAH.
Echo with Bubble study to r/o Shunt (ASD),

Do Right heart cath to Confirm and Check for Vasodilatory response

Left heart Cath and Angiography to exclude LV dysfunction .

Rx: Bosentan
CCB
(the inhaled nitric oxide determines responsiveness to CCB- cheaper, less side effects).

Lung heart transplant when medications are not successful.

Question 13

Management of Benzodiazepine Over Dose in Chronic Users?

Answer 13

Monitor for signs of Agitation

Do not use Flumazenil it has a short half life and DOES NOT Give SUSTAINED Reversal so patients can go into seizure.

Question 14

Management of Hypertensive Emergency?

Answer 14

No more 25% decrease in Systolic in the first hour

Goal of 160 systolic in next 6 hours

Goal of normal over 24-48 hrs.

Question 15

Management of Cyanide Poisoning?

Answer 15

Hydroxocobalamin
(It combines to Cyanide to make Cyanocobalamin which is Water Soluble)

                  AND 

02 therapy or Hyperbaric 02 when carboxyhemoglobin level is > 25%.

Question 16

Management of a Hypothermic patient with no pulse and unresponsiveness

Answer 16

CPR and Active Re-warming with Warm Blankets, Removing Clothing, body cavity lavage with Warm fluids.

Question 17

Treatment of High Altitude Cerebral edema N/V/, AMS, confusion, irritability)?

Treatment for high altitude pulmonary edema?

Answer 17

Dexamethasone and Decend to lower elevation

Nifedipine

Question 18

Management of Asymptomatic patient with stage 1 pulmonary sarcoidosis?

Answer 18

Observation

75% pt is Spontaneous Resolution of hilar lymphadenopathy

Question 19

When is Multiple Sleep latency Testing indicated?

Answer 19

When pt has Pathological Day TIME Sleepiness.

EVALUATE FOR NARCOLEPSY

Question 20

Pt with Complicated PNA has Serous fluid with negative gram stain and culture.
Diagnosis and why does this occur?
Treatment?

What if the gram stain was positive?

Answer 20

Complicated Parapneumonic Effusion ( the bacteria are rapidly cleared from pleural space).

Rx with thoracostomy.

Empyema.

Question 21

Pt with Reccurent PE presents with Exertiona Dyspnea.
There are Cannon A waves,
Wide split 02
Echo shoes dilated R ventricle
V/Q shows multiple mis match defects
R cath shows mean Pulmonary Arterial Pressure 58mmg and NORMAL Capillary Wedge Pressure.

Diagnosis ?
Rx?

Answer 21

Chronic thromboembolic Pulmonary Hypertension

Pulmonary Thromboendarterectomy

Question 22

What is the most appropriate Intrapleural Treatment of Empyema (pleural fluid and positive gram stain) ?

Answer 22

Tissue plasminogen activator - deoxyribonuclease.

Loculated empyemas that will not drain with thoracostomy Alone. given TPA to lower the rate of surgical intervention (The need for Video Assisted Thorascopic Surgery or Open Debridement VATS)

Question 23

Pt presents with Upper and Lower Lip swelling as well as Urticaria after eating at a picnic.

Next step in management?

Answer 23

Epi

Question 24

What helps decrease mortality and improve survival in severe ARDS patients?

Answer 24

Low tidal volumes and prone positioning (at least 12 hrs per day as standard management. )

Question 25

What is the initial test to assess of ICU acquired muscle weakness for a patient who has has resolved from initial infection but cannot be weaned from vent?

Answer 25

Medical Research Council Muscle Scale Score < 48 considered diagnostic of ICU acquired weakness.

Question 26

Idiopathic Interstitial Pneumonia: 1. Pt presenting with progressive dyspnea. Initially treated for PNA when she she had fevers and sputum production but that has resolved. CXR and CT show new ground glass changes b/l with several areas of nodular consolidation along the peripheral. Dx? Rx? 2. Pt presents with dense Bilateral Acute Lung Injury similar to ARDS? 3. Chronic insidious dyspnea and cough in older patients with honeycomb changes, reticular densities, infection and HF ruled out.

Answer 26

1. Cryptogenic Organizing Pneumonia Respond well to steroids, tapper slowly during the subsequent 6 months. 2. Acute Interstitial Pneumonia 3. IPF

Question 27

Presents in older patients > 60 yrs of age presenting with progressive dry cough and SOB. Ct shows extensive parenchymal involvement with, traction bronchiectasis, honeycomb changes Dx? Rx?

Answer 27

IPF. Lung transplant. Pirfrenidone can slow progression of disease. do not intubate these patients.

Question 28

Pt with NO symptoms, 35 pack year Smoking Hx. CT scan shows centrilobular micronodules, NO traction Bronchiectasis, NO Honeycombing, NO Mediastinal or Hilar Lymphadenopathy, Ground Glass Opacities. Dx? Test? Rx?

Answer 28

Respiratory Bronchiolitis Associated Interstitial Lung Disease Some patients can be symptomatic These are found on low dose lung CTs Management is smoking cessation

Question 29

Presents in young patients, CT shows THIN Walled Cyst with accompanying nodules.

Answer 29

Pulmonary Langerhans Cell Histiocytosis

Question 30

What diagnosis should be considered when a patient with Silicosis develops respiratory impairment, hemoptysis, and Upper Lobe Cavitary Disease on CXR. Diagnosis and Why does this happen? Next Step in Management?

Answer 30

TB Silicosis affects macrophages and puts patients at risk for development of TB as well. Do sputum sample for acid fast bacillus.

Question 31

Pt presents with cough, hemoptysis, dyspnea, weight loss, fever, fatigue and chest pain. CXR shows Pulmonary Cavity or Cyst. Sputum culture and IgG positive. Dx?

Answer 31

Aspergilloma Affects areas of preexisting pulmonary cavity or devitalized lung

Question 32

Safest inhaler glucocorticoid in pregnancy? Which medication to avoid in pregnancy with asthma?

Answer 32

Budesonide Zileuton (leukotriene receptor antagonist. others are safer in pregnancy

Question 33

What is the best management that will decrease hospital stay in a patient with recurrent pleural effusion?

Answer 33

Indwelling pleural catheters

Question 34

1. Formula to calculate Plasma Osmality? 2. How to Calculate for Osmol gap?

Answer 34

2Na + Glucose/18 + BUN/2.8 Measured - Calculated > 10 then there is a gap.

Question 35

What produces a plasma osmol gap but NO Anion Gap? Rx?

Answer 35

Isopropyl alcohol poisoning. Supportive care IsoproNO

Question 36

What produces an Elevated Osmol gap and Positive Anion Gap Metabolic acidosis? Rx?

Answer 36

Ethylene glycol ingestion (antifreeze) and Methanol. Rx with Fomepizole because their active metabolites cause eye blindness and renal dysfunction respectively.

Question 37

Pt presents with Daytime Hypercapnia, Apnea-hypopnea index of 6, BMI 40. Dx?

Answer 37

Obesity Hypoventilation Syndrome CPAP/Bipap Weight loss

Question 38

Rx of Acute Bronchiectasis ( low grade fever, progressive cough, purulent sputum production)?

Answer 38

Levofloxacin Inhaled Tobramycin can be used also

Question 39

When is Pleurodesis indicated for Pneumothorax?

Answer 39

After Second Occurrence of Primary Spontaneous Pneumothorax and after First Occurrence of Secondary Spontaneous Pneumothorax (2/2 lung disease)

Question 40

Test and Rx for Sarcoidosis?

Answer 40

Pt needs Transbronchial lung biopsy. Topical (for oral and eye disease ) and Oral Steroids. Immunosuppressive Therapy for refractory symptoms

Question 41

1. Rx for Acute Mountain Sickness 2.Rx for High-altitude Cerebral Edema 3. Rx for High-altitude Pulmonary Edema

Answer 41

1. Acetazolamide, Dexamethasone and Supplemental 02 2. Immediate Decent from altitude, dexamethasone, Supplemental 02, hyperbaric therapy 3. Supplemental 02 + Rest

Question 42

Name the Shock: 1. Low cardiac output, elevated PCWP, High SVR 2. Low cardiac output, low PCWP, High SVR 3. High cardiac output, normal PCWP, LOW SVR 4. High cardiac output (early) that can become (late) and LOW SVR + fever and leukocytosis

Answer 42

1. Cardiogenic Shock 2. Hypovolemic Shock 3. Anaphylactic Shock 4. Septic Shock