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Flashcards in Pulmonary Deck (285)
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1
Q

Obstructive dz (dilated)

A

COPD, Bronchiectasis

2
Q

Obstructive (constricted)

A

Asthma

3
Q

Intrathoracic Restrictive (constricted)

A

Fibrosis, Sarcoidosis, pneumoconiosis

4
Q

Extrathoracic Restrictive

A

Chest Cage, kyphosis, spondyloitis, obesity, neurousc (M.gravis, GB syndorme, muscular dystrophy

5
Q

Normal FEV1/FVC

A

> 80%

6
Q

Obstructive dz FEV1/FVC

A

<80%

7
Q

Restrictive dz FEV1/FVC

A

> 80%

8
Q

COPD

A

dec FEV1, dec FEV1/FVC, inc TLC, dec DLCO, inc RV

9
Q

Asthma

A

dec FEV1, dec FEV1/FVC, inc TLC, nl/inc DLCO, inc RV

10
Q

Restrictive intrathoracic

A

dec FEV1, nl FEV1/FVC, dec TLC, dec DLCO, dec RV

11
Q

Restrictive extrathoracic

A

dec FEV 1, nl FEV1/FVC, dec TLC, N DLCO, inc RV

12
Q

best test restrictive vs obstructive

A

TLC

13
Q

asthma

A

restrictive low FEV1, normal FEV1/FVC, low TLC

14
Q

DLCO 140% predicted, normal FEV1/FVC and TLC

A

alveolar hemorrhage

15
Q

Inc DLCO

A

CHF, MS, ASD/VSD, PDA, pvera

16
Q

Dec DLCO

A

COPD, restrictive lung dz, PE, pHTN, anemia

17
Q

Normal DLCO

A

asthma, CO poisoning

18
Q

Fixed extrathoracic

A

tumors/trachela stenosis both inspir (bottom) and exp(top) loops blunted

19
Q

Dynamic extrathoracic obstruction

A

epiglottitis, Vocal cord dysfxn (insp - bottom loop blunted)

20
Q

Dynamic intrathoracic obstruction

A

intrathoracic tracheomalacia - exhal (upper) loop blunted

21
Q

Asthma

A

reactive to dust, viral, cold, exc, - must show reversible bronchospasm

22
Q

Asthma dx

A

PFT - obstructive changes with reversible broncospasm - responds to brochodilators (inc FEV1 by 15%) - if no obst - methacholinie challenge test (15%)

23
Q

Young man h/o asthma acute asthmatic attack treated with albuterol nebs - f/u now PFT will show

A

Obstructive defect (still has asthma dx)

24
Q

35yo M paroxysmal non-prod cough >6months - no ohther sx - spirometry normal, no improvement with anti-histamine/cough meds

A

methacholine challenge test r/o asthma

25
Q

woman in car factory SOB at work, worse at end of day, better at home, cxr normal

A

check peak flow at home AND home

26
Q

Best way to tx patient with asthma

A

remove offending agent (PPI do not inc or dec sx of asthma)

27
Q

Pt with asthma/eczema moves to new apt, asthma worse - with rug

A

remove rug, get plastic wraps for mattress, pillow etc

28
Q

Asthma therapy Intermittent 80

A

no daily meds, rescue short acting beta

29
Q

therapy mild persistent (>2/wk, 2/month, FEV1 >80%

A

low dose inh steroid, cromolyn, leukotriene, theophylline

30
Q

Mod persistent - daily sx, >5/month at night, FEV1 60-80

A

low - med dose inh steroid + long acting beta (no beta without inh steroid)

31
Q

Severe persistent

A

high dose inh steroid + po steroids with attempts to wean

32
Q

When leukotrienes

A

mild persistent to reduce dose inh steroids, asa sens asthma

33
Q

Vasomotor rhinitis, nasal polyps and asthma dx?

A

ASA sensitive asthma - d/c asthma, start leukotriene (monteleukast)

34
Q

Pt with ASA sensitivity asthma can use

A

codeine based analgesic, sodium or choline slicylates, NO COX1 NSAIDS

35
Q

Pt with shoulder pain takes ibuprofen - coupel hours later with SOB/wheezing

A

NSAID induced broncospasm

36
Q

pt with mod asthma on inhaled steroids+long acting beta+theophylline

A

add monteluekast (leukotriene) to reduced need for steroids

37
Q

50yo post viral URI several weeks ago with persistent cough, inc’d at night with chest tightness, no heartburn, rec neg cardiac w/u - PFT with mild obstruction - wtd

A

methacoline challenge test - post viral hypersensitivity - tx with inhaled steroid (budesonide)

38
Q

Mainstay maintenance therapy for asthma

A

inhaled steroids

39
Q

30yo F non-prod cough for several months, no heart burn tob or wheeze, PFT normal, methacholine neg - wtf

A

check sputum for eosinophils - (non-asthmatic eosinophillic bronchitis)

40
Q

Pt with athma on beta agonist still with wheeze

A

add inhaled steroid

41
Q

Pt with severe asthma exacerbation hospitalized with iv steroid and beta agonist - upon d/c wtd

A

taper with oral steroid -> start inhaled steroid, beta agonist PRN

42
Q

In addition to reduction of acute/chronic asthma sx what do inhaled steroids do?

A

reduction of progressive loss of lung fxn

43
Q

Pt with asthma on albuterol prn with nocturnal awakening with sx of asthma best medcation

A

start with inhaled steroids -> THEN add long acting beta agonist

44
Q

increased mortality in asthma related to…

A

inc FEV1 responsiveness

45
Q

Pt with asthma p/w acute exacerbation - ABG 7.46/34/70/94% - pt receives neb tx with albut, after 3rd tx pt with BS b/l but decreased - now RR>30, HR 130, ABG 7.38/46/70/92% wtd

A

INTUBATE PT

46
Q

oxygenation goal in asthma

A

PaO2>60, SaO2>90%

47
Q

Pt with asthma being treated with b2 agonist, inhaled steroid, montelukast still has sx, removes carpet/rug, no cat - SERUM IGE high - wtd?

A

add omalizumab (anti-IgE ab)

48
Q

Asthmatic on b2 agonist prn, inhaled triamcinolone, almeterol and monteleukast - still with frequent exacerbation, does not like to go on logn term oral steroids - wtd

A

start tiotropium (spiriva)

49
Q

Chronic cough

A

upper airway cough syndorme (post nasal drip), asthma, GERD, chronic bronchitis, ACEi, non asthamatic eosinophilic bronchitis

50
Q

Exc induced asthma

A

sx peak 10-15 after stopping exc, resove in 30 min mainly in cold weather - Dx with exc challenge test in cold air (drop FEV1 by 10-15%)

51
Q

Exc induced asthma tx

A

short acting B2 agon 30 min prior to exc - if no effect then add cromyln Na+

52
Q

If exc induced asthma SOB on cromyln

A

add inhaled steroids and monteleukast

53
Q

Pt moves to minnesota (cold weather) - SOB in cold

A

start B agonist inhaler

54
Q

Mechaism of cromyln Na+

A

mast cell stabilization (dec hitamine release)

55
Q

Pt with exc induced asthma started on alb inhaler also wakes up at night 3x/wk with sx

A

start inhaled steroid

56
Q

Allergic Bronco Pulmonary Asergillosis (ABPA)

A

colonization of upper airway with aspergillus i asthmatics - intense immed hypersensitive type rxn - inc IgE, +skin rxn to aspergillus Ag, serology +IgM, IgE, +eos, +brownish mucous plugs - > migratory pulm infiltrates (eos PNA)

57
Q

pt with steroid dep asthma p/w cough, wheezing BROWN mucous plugs - WBC 15% eos, IgE>2000, CXR b/l infiltrates - steroids recently decreased - has parakeet

A

Allergic Broncopulm aspirgillosis (ABPA) +eos, inc IgE

Tx: inc steroids

58
Q

Hypersensitivity pneumonitis

A

neg eos, normal IgE

59
Q

Alergic angiitis of churg staus

A

+eos, normal IgE

60
Q

Loeffler’s syndrome (pulm eosinophilia)

A

+eos, inc IgE

61
Q

Fungal ball in cavity ASX

A

monitor

62
Q

Fungal ball in cavity with sever hemoptysis

A

surgery

63
Q

Hypersensitivity Pneumonitis

A

farmer’s lung - fever, chills dyspnea after work everyday, works in grian elevator, pet bird (bird fancier’s lung), methotrexate or nitrofurantoin or works with A/C units

64
Q

Etio - hypersensitivity pneumonitis

A

inhaling organic dust with thermophilic actinomycetes - gound glass cxr, +serum AB - remove offending agents, +steroids

65
Q

Pt with dog, cat, 2 parakeets and pigeon - cough, progressive SOB, CXR ground lgass - WBC no EOS - PFT restrictive

A

hypersensitivity pneumonitis (bird fancier lung)

66
Q

70yo M chills, fever, non prod cough, pleuritis CP - recent acute pharygitis - received PCN/Amp w/o improvemnt - CXR with RLL infiltrate - BCtx neg, myoplasma,legionella ab neg - Dx?

A

Chlamydia pneumoniae

67
Q

Psittacosis

A

disease asx in birds - comopletent fixation adn serology useful in dx

68
Q

Pt with asthma on fluticasone inhaler/oral steroids - montelukast added, oral steroids tapered down - pw cough, sob, wk righ thand/foot - 25% eos, normal IgE - cxr dense infiltrates

A

allergic angiitis/Churg strauss pneumonitis - tx with steroids

69
Q

Latin american pw asthma, recent immigrant - recurrent cough despite B2 agonists - eos 20%, round infiltrates on CXR - ANCA neg, ANA neg

A

Loeffler’s syndrome - strongyloides infxn - tx with thiabendazole

70
Q

35yo non-smoker F pw cough, no sputum, wheezing, nighttime sweats - h/o asthma - b/l crackles on exam - PPD neg, high eos in sputum high ESR

A

chronic eos PNA - long term steroid treatment

71
Q

35yo construction worker p/w SOB< no wheeze, no CP, no hemoptysis no exp to toxic fumes - b/l crackles - diffuse opacities/GG - bronch with copius tan fluid - alveolar proteinosis

A

tx - brochial lavage - defective macrophages causing buildup of surfactant in lungs

72
Q

COPD

A

dx: h/o chronic smoking dec FEV1/FVC<0.70

73
Q

COPD Spirometry determines?

A

Severity of disease

74
Q

Gold Criteria Mild COPD

A

FEV1/FVC80 - tx short acting bronchodil prn, alb+=ipratropium

75
Q

Gold Criteria Mod COPD

A

FEV1/FVC<80% - tx - shart acting bronco dil prnn plus long acting broncodil (tiotropium +-salmeterol+- rehab

76
Q

Gold Criteria Severe COPD

A

FEV1/FVC <50%, short/long acting bronchodil + inh steroids

77
Q

Gold Criteria very severe COPD

A

FEV1/FVC<30 - use long term O2 therapy, inh steroids, + bronchodilators short and long

78
Q

Major risk factor for COPD

A

Smoking

79
Q

Main tx for COPD

A

bronchodil, antichol, supp O2 SaO2>90%

80
Q

Therapy survival benefit for COPD

A

O2 supp at least 15hrs/day

81
Q

Pt with COPD hypoxia on O2 therapy, PO2 signficantly improves - cause of low PO2 is…

A

V/Q mismatch

82
Q

Bronchodilators do what for COPD

A

reduce hyperinflation, dec RV, improve sx and exc tolerance - DO NOT IMPROVE MORTALITY

83
Q

Tiotropium is better than Ipratropium

A

True

84
Q

Side effect of salmeterol

A

dry mouth

85
Q

Pt with COPD, +tob - best way to preserve lung fxn

A

quit smoking

86
Q

Inc’d mortality in COPD

A

decreased free fat mass

87
Q

COPD O2 sat goal

A

88-92%

88
Q

Criteria for starting O2 on COPD pt

A

PaO288% with eveidence of Cor pulmonale, erythrocytosis (Hct>55%)

89
Q

Best way to mamage COPD with secondary erythrocytosis

A

continuous O2 supp

90
Q

Consequence of overcorrection of hypoxia

A

hypercarbia

91
Q

Consequence of abrupt O2 supp d/c

A

respiratory arrest

92
Q

Pt with COPD SOB during gold resting PO2 62

A

check O2 during exc - if <55 then start O2 supp

93
Q

COPD Pt with daytime sleepiness/fatigue, resting PO2 64

A

check PO2 at night if <55 start supp O2

94
Q

COPD pt travelsing by plane - resting PO2 64 -

A

If estimated PaO270

95
Q

60yo COPD pt 2L O2 requirement wants to fly

A

needs to have airline arrange for O2 supp

96
Q

Role of inhaled steroids COPD

A

decrease exacerbations

97
Q

COPD acute exacerbation tx (with inc cough/sputum/sob

A

tiopropium + B agonist, IV steroids, empiric abx (azith/doxy -> NO ERYTHRO)

98
Q

Adv COPD pt Pulm rehab

A

DOES NOT improve FEV1, does NOT dec mortality, does improve sx, QOL, dec exacerbations

99
Q

Pulm rehab

A

program excercise training of muscles of ambulation

100
Q

Pulm rehab doesn’t work, still low exc tol, ABG 7.42, PO2 62, pCO2 48 - FEV120, b/l upper lobe emphysema

A

lung volume reduction surgery

101
Q

Acute Mountain Sickness

A

Leading cause altitude sickness - h/a, n/v/fatigue, dizziness, 6000ft, management=descent, dexanelimine, prevent with acetazolamide

102
Q

High altitude pulm edema

A

leading cause of death with altitude sickenss - h/a, n/v/fatigue, dizzines PLUS SOB - 8000 to 12000 ft - tx descent, dexamethalazone, prev with acetazolamide or nifedipine

103
Q

Thophylline decrease clearance by…

A

CHF, Liver dz, hypoxia, fever, cipro, erythro, OCP

104
Q

Young woman h/o asthma on multiple meds and OCP c/o n/v - tachycardia/tremors

A

related to theophylline use

105
Q

COPD with Po2 60 pCO2 50 - exacerbation of COPD - PO2 55 and pCO2 60 - refuses intubation

A

BIPAP

106
Q

50yo COPD p/w SOB,cough - awake but in severe distress, using accessory muslces - pCO2 74, pO2 50, pH 7.18, HR 120, RR 36

A

intubate, mech ventillation

107
Q

Mortality reduction COPD

A

flu vaccine

108
Q

30yo M extensive bullous emphysema, b/l basal bullous cyts

A

check serum alpha 1 antitrypsin level

109
Q

58yo F recurren tcough, foul smelling yllow sputum with hemoptysis, h/o PNA >1 yr ago - prominent cystic spaces in RLL, streamking oapcity, tram lines

A

dx bronchiectasis, high res CT scan - h/o PNA

110
Q

Dyskinetic cilia syndrome

A

Bronchiectasis/sinusitis, infertiility, sinus inversus, Dx kartagener’s syndrome,confirm sperm motility test then testicular bronchi or sinus bx

111
Q

Recurrent PNA cough/sputum x 1 year, mother died of lung dz

A

check High res CT

112
Q

22yo M recurrent PNA, bronchitis since childhood, no allergy or GERD, IgG electrophoresis nl - +clubbing, cxr apical bullous

A

check sweat chloride

113
Q

Cystic Fibrosis

A

inc’d ris kof endobronchial infxn with pseduomonas, staph, strep Pneum
tx: chest PT, abx (anti pseudom, topical tobramycin, inhaled hypertonic saline, bronchodil, ribonuclease, if bleed - bronch artery embolization

114
Q

Reduce decline in lung fxn with CF patient colonized with pseudomonas

A

Azithromycin (anti-inflamm effect)

115
Q

35yo non tob h/o RA no asthma/allergies - p/w cough/dyspnea on exertion, recent viral URI - +JVD, no wheeze, CXR normal - PFT severe obstr FEV1/FVC

A

Bronchioitis obliterans - can occur after RA, carcinoid, lung tx

116
Q

35yo F s/p radiation tx for breast CA p/w SOB, diffuse insp crackles - PaO2 52, PCO2 30, PFT dec DLCO, no response to abx

A

cryptogenic organizing PNA - dec DLCO, bx rapidly progressive organizing PNA or acute interstitial PNA - tx STEROIDS

117
Q

Interstitial lung dz

A
sarcoid
idiopathic Pulm Fibrosis
hypersensitivity pneumonitis
COP
Allergic bronchopulm aspergillosis
lyphogioleiomyomatosis
Churg strauss
118
Q

Sarcoid - indications for steroids

A

progressive pulm dz, eye involvement, CNS involvement, myocardial involvement, persistent hyperCA, disfiguring lesions

119
Q

24yo F fever, pain, swelling both ankles (erythema nodsum - tender erythematous nodules - wtd

A

CXR r/o sarcoid - bil hilar LAD - no tx, adenopathy +parenchymal infiltrate - steroids if symptoms, diffuse infiltrates - no adenopathy - steroids if symptom

120
Q

26yo F f/weakness, tenderness over legs - erythematous lesions, CXR b/l mediastinal adnopathy with infiltrates

A

BAL T4/T8 4:1, start steroids if eye involved, TB bx for non-caseating granulomas

121
Q

All following elevated in sarcoidosis

A

Calcium in serum/urine, ACE, helper T cells

122
Q

Idiopathic Pulm Fibrosis

A

insidous onset dry cough, gradual progressive dypsnea, cyanosis, clubbing, CXR diffuse infiltrative progess, reticular opacities, ground glass, honeycombing, PFT FEV1 low, FEV/FVC normal DLCO dec, BAL inc neutrophil
Tx: supportive care, O2 PRN, pneumovax, flu shot +- steroids

123
Q

Asbestosis

A

Chronic exp x 10yr, lower lobe fibrosis, PFT - RESTRICTIVE patter - a/w mesothelioma, broncogenic CA, Pleural/diaphragm calcified plaques (no lung impairment)

124
Q

Silicosis

A

chronic exp x 20 yrs (sandblasting, granite cutting) - upper lobe fibrosis with inc’d MTB incidence
EGG SHELL Calcifications with hilar LAD

125
Q

58yo M SOB< CP, reporducible on palpation, 15lb wt loss over couple months, asbesthos exp - used to smoke, no BS in L base - pleural effusion L

A

mesothelioma/bronchogenic CA

126
Q

Berylliosis

A
metal workers (computers, aerospace, electronics/lights b4 1950's) - can cause tracheobonchitis
Bx - non-caseating granuloma
A/w lung Ca
127
Q

Male smoker with SOB, progressive - honeycomb on chest xray interstitial upper lung fields - PFT restrictive - BAL - langerhans cells (giant cells - also on bx

A

Langerhan cell granuloma/esoinophilic grnauloma/histiocytosis x
c/b - PTX
Tx: quit tobacco

128
Q

Premenopausal woman on OCP with sudden SOB, CXR with PTX, honey comb appearance on CXR with CHYLOUS EFFUSION

A

lymphangioleiomyomatosis

129
Q

Consequences of hyopxemia

A

pulm HTN, secondary erythrocytosis, exc intolerance, impaired mental fxn, precip sleep apena

130
Q

COPD dx with pulm HTN - etiology?

A

hypoxia

131
Q

Tx for pulm HTN pt with COPD

A

O2 tx keep SaO2 90-95%

132
Q

Pulm arterial HTN

A

Idiopathic, hertiable, drug (Fen,fen), conn tissue d/o, HIV, portal HTN, congential heart dz

133
Q

Pulm HTN from LH dz

A

systolic/diastolic dysfxn - valvular dz

134
Q

Pulm HTN from lung dz/hypoxia

A

COPD, ILD, mixed restr/obst, chronic high altitude

135
Q

Chronic throboembolic pulm HTN

A

PE of prox or distal pulm vasc

dx V/Q scan

136
Q

Pulm HTN unclear mech

A

hematologist, sarcoid, langerhans, lymphagioleiomyomatosis, met d/o, tumor infiltration

137
Q

Pulm pressures

A

normal 25/15 - RVH (RAD, tall Rwave V1/2, split loud second heart snd - lous P2

138
Q

Pt with near syncope, SOB< SQ calcification, split 2nd heart dound, JVP, pedal edema

A

TTE

139
Q

Pt with telangiectasias and SOB, h/o syncope, JVP 10cm, loud P2, pansystolic murmur L sternal border - echo with RV dilation and mod TR wtc

A

RHC with vasodilator testing

140
Q

45yo F h/o PE 4ya tx’d with a/c with SOB, loud P2 EKG with RAD and P pulmonale - echo RV dil - next dx step?

A

r/o CTEPH - V/Q scan

141
Q

Pt with +v/Q scan - wtd?

A

eval for thromboembolectomy

142
Q

If pt with RHC responds to vasodilators?

A

start nifedipine or diltiazem

143
Q

If pt with RHC with NO response to vasodilators?

A

Mild dz - sildenafil, tadafil, bosentan
Mod dz to severe (limits on physical activity) - IV epoprosterol + sildenafil
Severe dz and hypotensive - inhaled Iloprost

144
Q

Maintenance tx pulm HTN

A

Coumadin

145
Q

Pulm Embolism

A

usually from DVT (mostly above Knee - sudden onset SOB, tachypnea, pleuritic CP, pre/syncope, hemoptysis, loud P2, split 2nd heart sound, CXR normal - S1Q3T3, A-a gradient >20 if hyperventilating PO2 may be normal - taxoifen, OCP, nephrotic syndrome, breast CA, protein C/S def, long flight or drive

146
Q

V/Q scan

A

Normal - no PE
2 or > seg or larger defect with no matching ventil def - > +PE, treat
sugseg perfusion defects or matching ventillation and perfusion deficets or single large defect - PE low or intermed - check for DVT - tx if postive if ng then pulm angiogram

147
Q

Tx for PE

A

LMW or heparin 7-10 days - then coumadin for 3-6 months

148
Q

High clinical suspicion

A

start tx before confirmation

149
Q

Best test r/o low prob PE

A

D-dimer (if neg no PE)

150
Q

Best test r/o mod to high prob PE

A

V/Q scan

151
Q

Best test dx chronic PE

A

V/Q scan

152
Q

Contraindications to A/C

A

neursx, eye sx, open prostatectomy

153
Q

Indication for thrombolytics

A

acute massive PE with hypotension - large DVT (Iliofemoral DVT)

154
Q

Indication for IVC filter

A

If another PE pt may die, contraindication to A/C - emboli post A/C

155
Q

52yo M midl CHF is a/w sudden onset of SOB and right sided pleuritic pain on furosemide and digozin - CXR with cardiomegaly - split 2nd heart snd HR 100 - V/Q scan showed small subsegmental match/unmatched deficits - contrast scan lower extrem neg wtd?

A

CT angiogram

156
Q

44yo M multiple pelvic hip fx and undergoes hip replacemnt - two days after surgery fever, mental confusion and sob - chest xray and diffuse pulm infiltrates - pO2 44 , pCO2 30mm, pH 7.48 EKG wiith sinus tach - inubated and transferred to ICU - dx?

A

Non cardiogenic pulm edema due to fat emboli

157
Q

Tx for non-cardiogenic pulm edema 2/2 fat emboli

A

No A/C no steroids

158
Q

Post delivery patient becomes hypotensive and SOB

A

amnitotic fluid embolism

159
Q

Pt with sudden onset SOB< tachy, hypoxeia and inc’d A-a gradient

A

V/Q scan

160
Q

Pulm HTN, SOB, tachy, echo with RV strain -

A

V/Q scan

161
Q

Pt with SOB, tachy cardia, echo RV strain - V/Q scan with 2 large deficits normal ventillation

A

Anticoagulation

162
Q

Pulm HTN, SOB, tachy, V/Q scan 3 defects 2 matched with ventillaory defects one with unmatched defciit - lower extrem US neg

A

pulm angiogram

163
Q

Pulm HTN with SOB, V/Q with 2 large unmatched defects, hypotensive

A

T-PA

164
Q

DVT

A

D-dimer good neg predictive value
If D-dimer + further w/u needed
Infection good predictor for DVT
LMWH dec’s DVT but not mortality

165
Q

Pt with unprovoked DVT 5 months ago now in ED with bleed, coumadin stopped -> wtd?

A

ASA 325

166
Q

DVT ppx

A

High risk - Knee replacement, Total hip - ppx LMWH 4 weeks or warfarin or fondaparinex

167
Q

DVT ppx with elev Cr

A

unfractionated hep, ext pneumatic compression, early mobilization

168
Q

Pt with DVT started on A/C with swelling of leg, 2 months later leg swells again - wtd?

A

below knee compression stocking

169
Q

Elderly pt with colon CA 2ya p/w swelling of leg

A

check LE US (high risk patient)

170
Q

45yo p/w swellinig/pain in right leg - wtd?

A

D-dimer (low risk pt)

171
Q

Hospital Aquired PNA

A

leading cause of death among hospital aquired infections - 48hr or more after admission

172
Q

Ventilator Associated PNA

A

within 48 to 72hrs after intubation

173
Q

Healthcare associated PNA

A

pt either hospitalized w/in 90 days of infxn, resided in NH, chemotx or wound care within 30 days of infxn or attends a hosptial or HD clinic

174
Q

Pt with cholecystitis s/p chole develops PNA

A

48hr imipenum +aminoglycoside

175
Q

Strep Pneumo

A

MCC of PNA

176
Q

Myoplasma

A

PNA in yound adults

177
Q

H flu/M catarrhalis

A

COPD/DM pts

178
Q

Legionella

A

cool damp places/water coolers

179
Q

Pseduomonas

A

nosocomial, neutropenics

180
Q

Klebsiella

A

alcoholics, NH residents

181
Q

Mixed flora

A

cavities, lung abscess

182
Q

Good sputum sample

A

25WBCs

183
Q

pt with cough/yellow expectoration pas 2 days low grade tempHR 84 BP ok lungs with few rales

A

over the counter anti-tussives

184
Q

Pt with URI sx >2wks tx’d with doxycycline w/o improvement - inc’d cough with post-cough vomiting - exam with SUBCONJ HEMORRHAGE -> organism?

A

sputum PCR for bordetella

185
Q

Pt with PNA tx’d with Ctx/azithro x 5 days then changed t PO meds - on abx fells better - continues to have cough, 6 wks later opacity persists - dx?

A

underlying malignancy or bronchial carcinoid

186
Q

Pt with recurrent PNA - CT chest fibrosis in Lt lower lobe area - etiology?

A

post obstructive PNA

187
Q

40yo pt with hemoptysis and streaks blood x 3 weeks - 4lb wt loss, cough, CXR normal - management?

A

bronchoscopy

188
Q

25yo p/w purulent nasal discharge, HA for past 2 days, cough+, tx with?

A

decongestants, analgesics

189
Q

Bacterial sinusitis

A

< 7 days have bacterial sinusitis - No abx unless sx > 7 days or have fever/pain - no routine CT for dx

190
Q

22yo M with c/o purulent nasal d/c for 3 days and temp 101 with maxillary pain wtd?

A

abx - amox-clavulanate (augmentin)

191
Q

40yo sore throat and h/a x 3 days - grandchild with cold - 99 deg with pharyngeal erythema, anterior cervical LAD

A

rapid strep test - confirm with throat ctx

192
Q

Centor criteria for strep

A

fever, no cough, tonsillar exudate, cervical LAD
0-1 no abx or throat ctx
2-3 throat ctx - tx if +
4 or 5 tx empirically with abx

193
Q

pt with runny/blocked nose, itchy eyes, sore throat - swelling below eyes, coblestone pharynx no LAD dx?

A

allergic rhinitis

194
Q

Nasal congestion/rhinorrhea for several months, h/o allergies usually controlled with decongestants and antihitamines - using OTD meds and getting worse - red edematous mucousa of nares

A

rhinitis medicamentosa - rebound congestion from vasoconstrictors - stop vasoconstrictors start intranasal steroids

195
Q

24yo hot potato voice, fever, unable to swallow, drooling - tonsils touching each other, dev of uvula

A

peritonsillar abscess (Quincy)

196
Q

pt with sore throat few day sand severe pain when moves neck, pain on swallowing - brawny edema of hypopharynx and tenderness of palpation of SCM - dx?

A

internal jugular vein thrombosis (Lemierre’s dz)

197
Q

DM pt with fever from NH, no teeth CXR RL consoldiation - best empirc abx?

A

newer fluoroquinolone (strep pneumo) - if worsens still febrile and hypotensive then resistant - start vanco or linezolid

198
Q

alcoholic pt with cough/red currant jelly sputum - g neg bacilli with capsure, cxr bulging fissure dx?

A

klebsiella PNA - 3rd gen cephalosporin (ceftx) + amminoglycoside

199
Q

If above pt worse (etoh abuse with red currant jelly)

A

ESBL - start impipenum or meropenum

200
Q

S/E flurouinolone

A

inc QTC -> ventricular arrythmia

201
Q

elerly woman floroquinolone s/e

A

tendon rupture

202
Q

which abx have hypoglycemia s/e

A

Levofloxacin

203
Q

CAP tx period

A

1 week

204
Q

HAP pseudomonas tx period

A

2 weeks

205
Q

Pt with PNA - early ambulation leads to…

A

early d/c from hospital

206
Q

65yo DM pt with PNA tx’d with abx - wtd prior to d/c

A

23 valent pneumococcal vaccine

207
Q

Pt wit LLL PNA tx with Abx with persistent fever, elev WBC for 2 weeks, CXR still with infiltrates

A

CT scan r/o lung abscess or empyema

208
Q

Fever, cough, DIARRHEA, mental confusion, pulm infiltrated, DEC SODIUM, inc BUN

A

legionella - urine legionella Ag -> macrolide +- rifampin x 2 weeks

209
Q

AIDs pt with sudden onset SOB, hypoxic on ABG, PTX on CXR - chest tube inserted - wtd

A

PCP tx (bactrim + steroids)

210
Q

Acute ill pt with PNA and intubated - lancet shaped diplococci - WBC 15, 103 deg - tx’d with PCN - 2 days later still temp, wbc 11, greenish secretions from ET tube grows pseduonas

A

continue PCN

211
Q

PNA temp 103, WBC 17K tx’d with fluroquinolone - 3 days later WBC 11K - unchanged lobar infiltrate - WTD?

A

no further testing - continue to tx

212
Q

Pt a/w RL pna - temp 102, WBC 16, started on Ceftx, next day BCtx growing PCN sensitive srep pneumo, - pt changed to PCN - on 5th day shows growth of MRSA (contaminent)

A

continue PCN

213
Q

Pt with recent Seizure -3 days later UL infiltrate - organism?

A

Peptostreptococcus

214
Q

Pt with Sz 1 month ago now with fever, foul smelling sputum, CXR cavity with fluid level, sputum shows mixed flora dx?

A

Lung abscess -> PCN with clindamycin - several days later no fever, same cavity but fluid decreases, WBC dec -> continue abx

215
Q

25yo with ear ache fever cough - inflammed typanic membrane with hemmorhage - CXR patchy infiltrate

A

Myoplasma -> tx macrolide (erythromycin)

216
Q

35yo non-smoker with gradual onset cough few weeks - WBC < 5, Epith 25/cm2 CXR b/l infiltrates -> tx?

A

Macrolide

217
Q

50yo COPD, acute onset of cough, rusty sputum, fever, chills LLL consolidation dx?

A

Strep pneumo - macrolid+ceftx

218
Q

Common pathogens in neutropenics

A

Pseudomonas, aspergillus, staph, strep

219
Q

CURB65

A
Confusion
bUn>19
RR>30
sBP65
0-low risk - home tx
1 - outpt tx
2 short inpt, clsoely supervised outpt
3 severe PNA - hospitalize consider ICU
4 or 5 - ICU tx/intubation
220
Q

55yo COPD SOB, cough, sputum white-> green, low temp scattered rhonci - organism?

A

H.Flu non-typable

221
Q

50yo farmer 3 month cough, inc dyspnea, skin lesion on nose with pleurtic CP -> CXR alveolar/fibronodular infiltrates

A

Blastomycosis (thick walled infiltrates)

222
Q

22yo F OCP 3 days fever, pleuritic CP, non prod cough/fatigue CXR clear

A

Pleurodyna 2/2 coxsackie virus - sx therapy

223
Q

Pt with URI 3 wks ago - fatigue, inc JVD echo EF 20% - cause?

A

coxsackie B3 virus

224
Q

Pt from southwest - arizona, NM, texas with fever and LUNG infiltrates, thin walled cavity on CXR

A

Cocoidomycosis - thin walled - self limited or fluconazole -> systemic -> Amphotericin B

225
Q

Influenaza season

A
NOv to march - f/cough/myalgia - vaccine any age > 6 months
Tx Oseltamivir (tamiflu), zanamivir
226
Q

Influenza outbreak in NH tx?

A

vaccine+tamiflu(oseltamivir x 2 weeks - if no vaccine then oseltamivir/amantadine x 6 weeks

227
Q

Pt post influenza more prone to…

A

staph PNA

228
Q

Which flu med NOT with asthma/COPD

A

zanamivir (or BB, adenosine, dihydropyridine)

229
Q

Female pt with UTI on nitrofurantoin - SOB/fever, crepitice over lung fields with ground glass

A

Dx nitrofurantoin rxn

230
Q

PPD

A

> 5mm - HIV, rec TB contact, old CXR TB scar, organ tx, prednisone >15mg/day at least 3 months, anti TNF, rituximab
10mm - HC workers, etoh, homeless, foreign born, NH resdients, dz with high risk of TB, IVDA, silicosis, DM, CRF gastrectomy, chemo, lymophoma, leukemia, malnutrition

231
Q

PPT+ wtd?

A

CXR

232
Q

CXR small patch fibronodular opacity no cough -

A

induce sputum AFB

233
Q

CXR neg after +PPD

A

tx with INH x 9 months

234
Q

alternate to INH with liver enzyme elevation or HCV

A

rifampin x 4 monthsbest

235
Q

best tx pt PPD+ (compliance wise)

A

INH 900/rifampin 900 weekly x 3 months (direct observed therapy)

236
Q

Multidrug resistant TB - asymptomatic roommate PPD 5mm CXR neg - wtz?

A

PZA/ethambutol for 6 months or PZA+quinolone (levoq/moxiflox) x 6 months

237
Q

Nurse (filipino with PPC x 20mm) BCG in childhood

A

CXR if neg begin INH and B6 (if 10 or less check gamma IFN if + active TB tx

238
Q

Ukrain resident PPD 10mm BCG in chilhood CXR neg

A

check IFN gamma

239
Q

Pt on INH/B6 - 3 moths on tx now tired and nausea x 2 days

A

d/c INH, check AST/ALT, bilirubin check (liver failure) stat

240
Q

Best Screen latent TB

A

Gamma IFN

241
Q

What is good about gamma IFN vs PPD

A

decrease confounding with BCG

242
Q

Inner city pt, PPD+, CXR+ started on rif, inh, pza, ethambutol isolated until 3 afb neg still ctx + 1 later wtd

A

continue 4 meds x 1 more month

243
Q

Pt dx with pulm MTB - homelss lives in shelter periodically wtd?

A

INH/rifampin/pza/ethambutol x 2 weeks then inh/rif, pza ethambutol twice wekly x 6 weeks then inh/rfampin twic weekly x 4 months

244
Q

Pt from E eurobe/asia with pleural effusion - tap done neg for AFB - wtd?

A

needs VATs pleural bx

245
Q

Management of MTB resistant to INH - what drug improves outcome?

A

Fluoroquinolone

246
Q

Homeless pt with RUL infiltrate and pleural effusion wtd?

A

airborn isolation

247
Q

Pleural effusion lytes criteria

A

transudate 3g tot protein, fluid/serum protein ratio >0.5, total LDH >200, fluid serum LDH ratio >0.6

248
Q

Causes Transudate effusion

A

CHF, Nephrosis, cirrhosis, hypothyroid

249
Q

Causes Excudate effusion

A

neoplasm, infection, inflammation (RA, SLE, Pancreatitis), esophageal perforation (gastrograffin), dresslers syndrome (post cardiac sx)

250
Q

Mesolthelioma/malignance with bloody effusion

A

chylous eff >115 TGA->trauma, mediastinal lymphoma/lymphangioeiomyomatosis
pseudochylous like in TB, Rh arth
Gluc 80-TB, gluc 60-CA, Gluc 30-Rh arthritis

251
Q

54yo with pleural effusion dx tap reveals fluid serus <0.6 cause of pleural effusion?

A

Cirrhosis

252
Q

Rh arthritis pt with recurrent effusions after repeated taps wtd?

A

tub thoracostomy and sclerosing agent

253
Q

Pleural fluid with glucose o29 - cause?

A

Rh arthritis (<30)

254
Q

55yo M s/p CABG 4 weeks ago p/w fever, dyspnea, non-productive cough, pleuritic CP - pericardial rub - ESR 68, WBC 10, cardiomegaly with b/l basal atelectasis and small pelural effusion - ABG PO2 80, PCO2 34 pH 7.45 - tap done 350cc removed - protein ratio >0.5, LDH ratio >0.6 - V/Q scan with several matched defects - dx?

A

Post cardiotomy syndrome (dressler’s)

255
Q

25yo athlete SOB while sprinting with pleuritic CP - BS dec on R side - hyperresonance on percussion

A

spontaneous PTX -> chest tube insertion

if recurs pleurodysis

256
Q

When to tap parapneumonic effusion

A

If effusion >10mm on lat decubitus CXR, PNA not responding to abx, frank empyema needing chest tube, loculated fluid needs thoractomy

257
Q

Pt with PNA continues to spike temp on Abx, cxr with pleural effusion, protein >3g, LDH rat>0.6, chest tube placed, 72hrs later pt still febrile - loculation on chest CT

A

VATS (surgery c/s)

258
Q

Chest physical exam

A

Pleural effusion -> dull percussion, dec BF, Fremoitus absent
Pneumonia ->dull percussion-> bronchial BS, in fremitus
PTX - hyper percussion, dec BS, inc frem

259
Q

Best way to diff PTX from pleural eff o PE

A

percussion (hyper on PTX)

260
Q

Pt with SOB - exam dec BS on left, inc vocal frem on L - dx?

A

L side consolidation (PNA)

261
Q

Pt a/w SOB, CXR lower lobe infiltrate and pleural effusion, temp 102.5, HR 110, pleural tap exudative fluid - next day pt worse and more hypoxic with PO2 of 52, CXR complete whiteout of left side - trachea not deviated - dx?

A

L hemithroax consolidation - needs intubation

262
Q

Pt with PNA, large consolidation on LL, abg while lying on L side 54, while lying on R side 65 - cause?

A

intrapulmonary shunting 2/2 PNA

263
Q

Pt with cryptogenic cirrhosis with ascites and pedal edema, SOB on sitting or standing up - pulse ox 92% lying down, sitting 82% DLCO 70% - etiology?

A

intrapulm R to L shunt (hepatopulm syndrome (orthodeoxyia see every 4 beat bubble in LA on bubble study in TTE)

264
Q

Sleep Apnea

A

Apnea - no breathing for 10 seconds - >10/h - sleep apnea syndrome

265
Q

increased snoring prevents good sleep causing sleepiness?

A

T

266
Q

Hypoxemia causes daytime sleepiness in OSA

A

F

267
Q

hypoventilation at right leading to recurrent arousals leas to daytime sleepiness

A

T

268
Q

Nighttime alkalosis leads to daytime sleepiness

A

F

269
Q

OSA pt with apnea hypopnea index >30 has?

A

inc’d mortality

270
Q

Sleep Apnea definitioin

A

> 95% obstructive, snoring, wakes up with h/a, distrubed sleep, neck >17 inches, neuropsych manifestations, somnolence, accidents, firing, high risk for MI/CVA/HTN
Dx with polysomnography - r/o treatable cuase - enlarged tonsils, tumor, hypothyroid
Tx no sedation, no etoh, protriptylin e9mild), mod sleep apnea nasal cpap, , uvulopalatopharygoplasty works 50% of time

271
Q

45yo pt with lethargy, BMI 41, HTN, lift in R parasternal area, panniculus, edema, echo with TR - wtd?

A

sleep study - etiology of leg edema - pulm HTN from RHF

272
Q

Secondary HTN cause in pt with obestiy

A

OSA

273
Q

Cause of HTN in pt with OSA

A

inc’d sodium retention

274
Q

Tx for OSA

A

improved quality of life, cogn fxn, daytiem sleepiness, HTN, dec mortality

275
Q

Pt with difficult to tx HTN on 4 meds with OSA - best management?

A

renal denervation

276
Q

22yo BMI 24 tx herself for allergic rhinitis with OTC meds for past few days now unable to sleep well and tired during day dx?

A

Rhinitis medicamentosa - tx - d/c meds start steroids

277
Q

45yo F BMI 35 p/w DOE - JVD, FEV1/FVC 0.7, mild edema, RVH on echo, no valvular lesions - PCO2 55, PO2 58

A

dx Obesity hypoventillationi syndrome->pulm HTN

278
Q

Why do ppl with severe obesity have PCO2 elevation?

A

hypoventillation - check sleep study

279
Q

48yo M dx with OSA - sleepy during day, c/o fatigue, Leg edema, TFT nromal - most appropriate Tx

A

nasal CPAP

280
Q

Pt with daytime sleepiness, mod musc wk at onlet of sleep gets hallucinations - brother with similar episodes

A

narcolepsy (autoimmune dz) - tx with modafinil (expensive) or methyphenidate or sodium oxybate)

281
Q

Elderly pt with gradual onset SOB, daytime sleepiness, pedal edema and rales - breaths funny at night and doesn’t breath several seconds - BMI 28, EF 30% - most likely cause of daytime sleepiness?

A

CHF - cheyne stokes breathing (widening of QRS >120)

282
Q

Pulmonary nodules

A

4-6 low risk f/u CT 12 months if no changes, no f/u, high risk initial CT 6-12 months, then 18-24 months if no changes
6 to 8 - low risk initial CT 6 to 12 months, then 18 to 24 months if no change, high risk initial f/u 3 to 6 months the 9 to 12 adn 24 months if no change
>8mm low risk f/u CT 3,9,24 months, CT, PET and/or bx - same for high risk

283
Q

60yo pt with 1.5cm solitary nodule on CXR wtd first

A

see old CXR

284
Q

53yo with pulm nodule 1.2 cm - last year 0.9cm wtd?

A

resection

285
Q

Bronchoalveolar lavage (BAL)

A

Normal = inc’d PMN
Sarcoid - inc’d lymph CD4>CD8
hypersensitivity Pneumonitis inc’d lymp, CD8>CD4
Eos pNA - peripheral infiltrates - inc’d eos
PJP in HIV - silver metahanamine +
CMV - inclusion bodies
PNA in ARDS - bacteria >10^3
Amiodaraone PNA - foamy witih lamellar inclusions - r/o thyroid issues