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My Step 2 CK > Pulmonary > Flashcards

Flashcards in Pulmonary Deck (214)
1

What is the most accurate diagnostic test for asthma?

Pulmonary function test (PFTs)
(decrease FEV1/FVC that responds to bronchodilator; increased DLCO)

2

What is the best initial test in acute asthma exacerbation?

1. peak expiratory flow (PEF)
2. arterial blood gas (ABG)
(quantifies severity of exacerbation)

3

What are to atopic diseases?

1.asthma
2.allergies
3. eczema

4

What is step 1 treatment for chronic asthma?

inhaled short acting beta agonist (albuterol puffer)

5

What is step 2 treatment of chronic asthma?

add low dose inhaled steroids (fluticasone, triamcinolone)

6

What are adverse effects of inhaled steroids?

1. dysphonia
2. oral candidiasis

7

What is step 3 treatment for chronic asthma?

add long acting beta agonist (salmeterol, formoterol)

8

What medication can be added to chronic asthma treatment in a patient with increased IgE level?

Omalizumab

9

What is the treatment for asthma exacerbation?

1. oxygen
2. albuterol
3. oral steroids
(if no response, Magnesium or intubate)

10

A smoker/ ex-smoker presents with SOB worsened by exertion, barrel chest, cough and sputum most likely suffers from...

COPD

11

What is the best initial test for COPD?

Chest X-ray (increased anterior-posterior (AP) diameter, flattened diaphragms)

12

What is the most accurate diagnostic test for COPD?

Pulmonary function test (decreased FEV1/FVC <70^%, increased TLC, increased RV, incomplete improvement with albuterol)

13

What is treatment for COPD improves mortality and delays progression of disease?

1.smoking cessation
2.oxygen (if O2 sat < 88 or pO2< 55)
3. flu and pneumococcal vaccine

14

What medications are used for symptoms relief in COPD?

1. anticholinergics (tiotropium, ipratropium)
2. albuterol
3. pulmonary rehabilitation
4. steroids

15

What medications are used for acute exacerbation of COPD?

1. albuterol
2. steroids
3. antibiotics (macrolide, quinolones, cephalosporins)

16

What is the criteria for oxygen use in COPD?

1. pO2 < 55 mmHg or O2 sat < 88%
2. if right sided HF or elevated hct, pO2< 60 mmHg or Os sat < 90%

17

What is the most common cause of bronchiectasis?

cystic fibrosis
(other causes: infection, immune deficiency, foreign body, tumor, allergic bronchopulmonary aspergillosis)

18

A pt presents with recurrent episode of very high purulent sputum production, hempotysis and SOB most likely suffers from ..

bronchiectasis

19

What is the best initial test for bronchiectasis?

CXR (dilated, thickened bronchi, "tram tracks")

20

What is the most accurate test for bronchiectasis?

high resolution CT scan

21

A pt with a hx of asthma (ectopic disease) presents with recurrent episodes of brown-flecked sputum and transient infiltrates on CXR most likely suffers from ..

Allergic Bronchopulmonary Aspergillosis

22

What is the best treatment for allergic bronchopulmonary aspergillosis?

1. oral steroids (for severe)
2. itraconazole oral (recurrent episodes)

23

What are the GI manifestations of cystic fibrosis? (5)

1. meconium ileus
2. pancreatic insufficiency (steatorrhea, malabsorption of fat vitamins)
3. recurrent pancreatitis
4. intestinal obstruction
5. biliary cirrhosis

24

What is the most accurate diagnostic test for cystic fibrosis?

sweat chloride test (increased)

25

What does treatment of cystic fibrosis exacerbation consist of?

1.antibiotics (inhaled aminoglycosides)
2. inhaled recombinant human deoxyribonuclease (break up clog)
3. albuterol
4. pneumococcal & influenza vaccines
5. lung transplant

26

What is the most common cause of pneumonia in COPD pt?

H. influenzae

27

What is the most common cause of pneumonia in pt with recent viral infection?

S. aureus

28

What is the most common cause of pneumonia in pt with poor dentition, aspiration, foul-smelling sputum (rotten eggs)?

anaerobes

29

What is the most common cause of pneumonia in pt presenting with horseness?

Chlamydophilia pneumoniae

30

What is the most common cause of pneumonia in pt with hx of contaminated water sources/ cruise ship and associated GI and CNS complaints?

Legionella

31

What is the most common cause of pneumonia in patient with exposure to birds?

Chlamydia psittaci

32

What is the most common cause of pneumonia in veterinarian/ farmer (especially when animals tending to giving birth)?

Coxiella burnetii

33

A pt with pneumonia associated with "currant jelly" sputum and hemoptysis is most likely...

Klebsiella pneumoniae

34

What is the best initial test to use to identify specific microbial etiology of pneumonia?

sputum stain and culture

35

What are the indications that a sputum gram stain is adequate?

1.> 25 WBCs
2. < 10 epithelial cells

36

What are the indications that there is a empyema on thoracentesis (analysis of pleural fluid)?

1. LDH > 60% of serum level
2. protein > 50% of serum level
3. WBC count > 1000 or pH <7.2

37

What diagnostic test is specific for PCP (pneumocystic pneumonia)?

bronchoalveolar lavage (BAL)

38

What are the indications to hospitalize someone for pneumonia?

CURB 65:
C-confusion
U-uremia
R-respiratory distress (RR>30 or PO2 < 60)
BP low (SBP125; fever >104)
if more than 2 points, then admission

39

Who should recieve the pneumococcal vaccine?

1. any over 65 y/o
2. pts w/ chronic liver, heart, kidney or lung disease
3. asplenia, HIV, immunosuppressed
4. CF leak and cochlear implant

40

What is the definition of health-care acquired pneumonia?

pneumonia developed more than 48 hous after admission or 90 days after hospitalization

41

What is the best empiric treatment for hospital acquired pneumonia?

1. antipseudomenal cephalosporins (cefepime or ceftazidime)
2. antipseudomonal penicillin (piperacillin/tazobactum)
3. carbapenems

42

A pt on a mechanical ventilator that develops fever, new infiltrate on CXR, and purulent discharge most likely suffers from ...

ventilator associated pneumonia

43

What is the most accurate test for ventilator associated pneumonia?

open lung biopsy

44

What are other diagnostic test for ventilator associated pneumonia?

1. tracheal aspirate
2. BAL
3. protected brush specimen
4. VATS

45

What is the best treatment for ventilator associated pneumonia?

antipseudomonal beta-lactam (same as HAP) with a second anti-pseudomonal agent (aminoglycoside/ fluroquinolone) with an MRSA agent (Vancomycin or linezolid)

46

What is a side effect of imipenem?

seizures (especially in setting of AKI)

47

What are patients with stroke, seizures, intoxification, endotracheal intubation likely to have?

Large volume aspiration leading to lung abscess

48

What diagnostic test can be used to determine microbiologic etiology of lung abscess?

lung biopsy

49

An HIV pt with CD4 count less than 200 who develops respiratory infection most likely has ...

PCP (pneumocystis pneumonia)

50

What is the most accurate test for PCP?

bronchoalveolar lavage (BAL)

51

What is the best initial therapy for PCP?

Bactrim (trimethoprim-sulfmethaoxazole)

52

When do you add steroids to PCP treatment?

Severe
1.pO2 < 70
2. A-a gradient >35

53

What are alternative treatments for PCP in patients allergic to Bactrim?

1. clindamycin with primaquine
2. pentamidine

54

What disease is primaquine contraindicated in?

G6PD deficiency

55

What are the 2 most common side effects of Bactrim?

1. rash
2. bone marrow suppression

56

When do you start PCP prophylaxis with Bactrim?

CD4 count less than 200

57

When do you start atypical pneumonia prophylaxis with azithromycin in an HIV pt?

CD4 count less than 50

58

A pt presenting with fever, cough, weight loss, hemoptysis and night sweats most likely suffers from ...

TB
(most have crisk factor, cavity on CXR, or positive smear)

59

What is the best initial test for symptomatic TB?

CXR

60

What is the most accurate test for TB?

pleural biopsy

61

What diagnostic test must be performed to exclude TB?

3 negative sputum stain and cultures for acid-fast bacilli

62

What is the treatment for active TB?

RIPE- 4 drug regimen for 2 months
(Rifampin, Isoniazid, Pyrazinamide, and ethambutol)
(then just rifampin and isoniazid for 4 months)

63

What is a common side effect of rifampin?

red color of body secretions and hepatotoxicity

64

What are the side effects of isoniazid?

peripheral neuropathy (use pyridoxine to prevent) and hepatotoxicity

65

What are the side effects of pyrazinamide?

hyperuricemia and hepatotoxicity

66

what are the side effects of ethambutol?

optic neuritis affecting color vision and hepatotoxicity

67

What is considered a positive PPD in a pt with HIV/ steroid use/ close contact w/ active TB pt/ transplant/ abnormal calcifications on CXR?

induration > 5 mm

68

What is considered a positive PPD in pts who are recent immigrants/ prisoners/ healthcare workers/ alcoholics/ diabetics?

induration > 10mm

69

What is the next best step in a pt with a positive PPD?

CXR to exclude acitve disease

70

When do you use the 2 stage PPD testing?

if a pt has never had PPD before

71

What screen test can be used in pts with hx of BCG vaccine?

interferon gamma release assay

72

What is the best initial step in management of a patient wiht lung lesions?

compare size to old CXR

73

What risk factors are suggestive of malignancy in a pt with a solitary lung nodule? (9)

1. > 40 y/o
2. enlarging
3. smoker
4. speculated (spikes)
5. large (>2 cm)
6. atelectasis
7. adenopathy present
8. sparse, eccentric calcification
9. abnormal PET scan

74

What is the next best step in management of a pt with a solitary lung nodule and multiple risk factors for malignancy?

resection

75

What is the most common adverse effect of transthoracic biopsy?

pneumothorax

76

What are specific causes of pulmonary fibrosis? (7)

1.amiodarone
2. bleomycin
3. busulfan
4. nitrofurantoin
5. methylsergide
6. cyclophosphamide
7. radiation

77

What is the cause of pneumoconiosis in a coal miner?

coal

78

What is the cause of penumoconiosis in a sandblasting, rockin mining or tunneling worker?

silicosis

79

What is the cause of pneumoconiosis in a shipyard worker, pipe fitter, or insulator?

abestosis

80

What is the most accurate test for pulmonary fibrosis?

high resolution CT

81

what pneumoconiosis is most likely to respond to steroids?

berylliosis (electronic manufacture)

82

An african american women with SOB and hilar adenopathy on CXR or CT most likely suffers from ....

sarcoidosis

83

What is the most accurate test for sarcoidosis?

lymph node biopsy (non-caseating granuloma)

84

What are to associated things that are elevated in some patients with sarcoidosis?

1. ACE (increased BP)
2. Calcium (hypercalcemia & hypercalciuria due to production of vitamin D by granuloma)

85

What is the treatment for sarcoidosis?

steroids

86

A patient presents with sudden onset SOB and clear lungs (possibly with pleuritic chest pain, fever, unilateral leg pain) most likely suffers from ...

pulmonary embolism

87

What is the most accurate test for pulmonary embolism?

angiography

88

What are the best initial tests for pulmonary embolism?

1. CXR
2. EKG
3. ABG

89

What are signs of pulmonary embolism on CXR?

1. atelectasis
2. Hampton hump (pleural-based lesions)
3. wedged infarct
4. oligemia (westermark sign)

90

What are signs of pulmonary embolism on ABG?

hypoxia, respiratory alkalosis (high pH, low CO2)
(extremely suggestive if normal CXR)

91

What is considered abnormal in pulmonary function tests?

< 80% in any lung volume or flow rate

92

What is considered air trapping on pulmonary function tests?

>120% lung volumes
(suggestive of obstructive diseases)

93

What is definition of total lung capacity?

volume of gas in lungs after maximal inspiration

94

What is definition of residual volume?

volume of gas in lungs after forced maximal expiration (unused space)

95

What is the definition of vital capacity?

volume of gas exhaled with maximal forced expiration

96

What is the finding on pulmonary function test for obstructive lung disease?

1. FEV1/FVC < 80%
(b/c decreased FEV1)
2. normal or elevated lung volumes
3. FEF 25-75 < 80%

97

What is the finding on pulmonary function test for restrictive lung disease?

1. decreased lung volumes (TLC, RV, VC)
2. normal FEV1/FVC

98

What does obstructive pattern with decreased DLco on pulmonary function test suggest?

Emphysema
(if normal DLco, chronic bronchitis or asthma)

99

What does restrictive pattern with decreased DLco on pulmonary function test suggest?

1. Interstitial lung disease (intrapulmonary restriction)
2. heart failure
(if DLco normal, extrapulmonary restriction --> obesity, kyphoscoliosis, neuromuscular disease)

100

What does increased DLco suggests?

pulmonary hemorrhage
(goodpastures and wegeners)

101

Who should be considered for methacholine challenge test?

a patient suspected to have asthma but has normal PFT
(methacholine invokes asthmatic crisis that results in decreased FEV1 by at least 20%)

102

An obstructive pattern on pulmonary function test that reverses more than 12% and 7,200 ml after albuterol suggests....

asthma

103

A shift of the flow volume loop to the right suggests .... signifying ....

reduction in lung volume; restrictive disease

104

A shift of the flow volume loop to the left (with decreased airflow rate) suggests....

obstructive disease

105

What does flattening of the top and bottom of the flow volume loops suggest?

Fixed airway obstruction (tracheal stenosis, foreign object obstruction, tracheal tumor)

106

What does flattening of just the bottom of the flow volume loops suggest?

dynamix extrathoarcic airway obstruction (vocal cord paralysis)

107

What is the formula for A-a gradient (partial pressure of oxygen in alveoli versus blood)?

A-a = [150- (1.25 x PaCO2) - PaO2]

(normal range is 5-15 mmHg for pt on room air)

108

What is the most common cause of normal A-a gradient with severe hypoxemia in the emergency department?

Opiate intoxication/ overdose

109

What are the causes of normal A-a gradient with hypoxemia?

1. hypoventilation
2. high altitude

110

What are the 2 most important factors in delivery of oxygen to vital organs?

1. cardiac output
2. hemoglobin

(important to maintain both near normal in ill pt)

111

What is the initial step in the evaluation of an incidentally found pulmonary nodule?

look at prior X-ray (imaging)

112

What makes a pt low risk for lung cancer if has an incidentally found pulmonary nodule without prior CXR to compare to? (6)

1. < 2 cm
5. smooth distinct margins
6. no change in size

113

What should be done in a low risk pt with an incidentally found pulmonary nodule without prior CXR?

repeat CXR or chest CT every 3 months for 2 years
(if no growth after 2 years, benign)

114

What makes a pt high risk for lung cancer if has an incidentally found pulmonary nodule without prior CXR?

1. >50 y/o
2. smoking history
3. nodule likely bronchogenic cancer

115

What should be done in a high risk pt with an incidentally found pulmonary nodule without prior CXR?

open-lung biopsy and removal of nodule

116

What is the difference between transudative effusion and exudative effusion?

trans: due to increased hydrostatic pressure/ decreased oncotic pressure; usually bilateral
exudate: due to local process; usually unilateral

117

What is the best initial test for new or unexplained pleural effusion?

thoracentesis w/ fluid LDH and protein level
(compare to serum LDH and protein)

118

What is Light Criteria for exudative pleural effusion?

1. LDH effusion > 200
2. LDH effusion/ serum ratio > 0.6
3. Protein effusion/ serum ratio > 0.5

119

A pt with lymphocytic predominant exudative pleural effusion suggests .... and the most accurate test is ....

pleural TB; pleural biopsy

120

What is the initial step in management of a patient presenting in respiratory distress?

assess airway for patency and adequate breathing
(intubate if necessary and give oxygen)

121

What is the best initial lab test for a patient presenting with respiratory distress?

arterial blood gas

122

What do popcorn calcifications on CXR suggest?

hamartomas

123

What do bull's eye calcifications on CXR suggest?

Granulomas

124

What is the best test to perform in order to determine the presence of free-flowing fluid in the setting on pleural effusion?

decubitus chest x-ray ( 1 cm or more free flowing fluid --> acceptable to do thoracentesis)

125

What medications are commonly associated with inducing asthma exacerbation?

1. aspirin
2. beta blockers
3. coloring agents (tartrazine)

126

What does malignant pleural effusion signify?

lung cancer is not resectable

127

What is the treatment for a complicated parapneumonic effusion?

chest tube drainage (drain infected pleural effusion)

128

What is the best treatment for nocturnal cough variant asthma and exercise-induced asthma?

Salmeterol (long lasting type of albuterol; 12 hours)

129

What signifies poor control of asthma symptoms?

1. use of short acting B agonist 3 or more days a week
2. increase in symptoms (wheezing, night time cough,SOB)

130

What is the sequence of medical treatment for asthma?

1. mild intermittent- short acting b-agonist as needed
2. mild persistent- inhaled steroid daily w/ short acting b-agonist
3. moderate persistent- long acting b-agonist w/ inhaled steroids & short acting b-agonist
4. severe persistent- leukotriene modifier or oral steroids w/ long acting b-agonist, inhaled steroids & short acting b-agonist

131

Who should be intubated?

1. persistent hypoxemia
2. hypercapnia in asthma
3. upper-airway burn injuries
4. neuromuscular disease involving diaphragm
5. altered mental status

132

What medication is used in acute asthma exacerbation?

1. b-agonist (to relieve symptoms momentarily)
2. oral steroids (to get pt out of exacerbation b/c decrease inflammation)

133

What is the most common side effects of inhaled steroids?

1. oral candidasis
2. bad taste in mouth

(have pt wash mouth out)

134

When do you use leukotriene modifiers in asthma treatment?

in asthmatic patients who are on oral steroids for symptoms control
(to try to decrease need for steroids)

135

When do you use MAST cell stabilizers (cromolyn and nedochromil)?

exercise induced asthma

136

What are the most common causes of chronic cough?

1. post-nasal drip (allergic rhinitis)
2. GERD
3. asthma

137

A non-smoker with abnormal LFTs, tender liver and an obstructive pattern and decreased DLco on pulmonary function test most likely suffers from ...

alpha-1 antitrypsin deficiency
(autosomal recessive disease)

138

What is the best initial test in a pt with suspected COPD?

pulmonary function test

139

What is the initial treatment for COPD other than smoking cessation?

anticholinergics (ipratropium bromide, tiotropium)

140

What are the only interventions that decrease mortality in pts with COPD?

1. smoking cessation
2. home oxygen (PaO2 < 55 mmHg or O2 sat < 88% or PaO2 <59 with cor pulmonale or desat w/ exercise)

141

What characterizes an acute exacerbation in COPD pt?

1. increased SOB
2. increased sputum volume
3. production of purulent sputum

142

What is the treatment for acute exacerbation of COPD?

1. oxygen (sat btw 88-92% to avoid hypercapnia)
2. beta-agonist with anticholinergics (ipratropium)
3. systemic steroids
4, antibiotics (azithromycin, levofloxacin)

(smoking cessation,m continue theophylline if chonically using)

143

What is the best predictor of survival in a pt with COPD?

FEV1 and rate of decline of FEV1

144

A smoker presents with dyspnea on exertion, productive cough, wheezing, distant heart sounds, clubbing, hyperinflation bilaterally with diaphragm flattening on CXR, cor pulmonale and facial plethora most likely suffers from ...

COPD (emphysema, chronic bronchitis)

145

What are complications are COPD?

1. nocturnal desaturation
2. erythocytosis secondary to hypoxemia
3. pulmonary HTN --> cor pulmonale -> right HF

146

What is the difference between emphysema and chronic bronchitis clinically?

bronchitis: facial plethora, productive cough, increased pulmonary markings on CXR; wheezes, rhonchi; normal DLco

emphysema: cachetic appearance; hyperinflation of bilaterally with diaphragm flattening; distant breath sounds; decreased DLco

147

What are the medications used for chronic treatment for COPD in sequence of use?

1. anticholinergic (ipratropium, tiotropium)
2. beta agonist
3. theophylline

148

What are the side effects of theophylline?

1. Nausea, vomiting
2. cardiac arrhythmias
3. drug interactions

149

If pt with COPD was improving on theophylline, but then stops declining while still on treatment, what is the most likely reason?

restarted smoking (smoking decreases level of theophylline)

150

What vaccinations are required in pt with COPD?

1. pneumococcal vaccine every 5 years
2. influenza yearly
3. H. influenza if not already vaccinated

151

A pt presents with chronic cough, hemoptysis, foul smelling sputum and a history of recurrent pulmonary infections most likely suffer from ...

Bronchiectasis (permanent dilated bronchi due to destruction of bronchial elastic/ muscular elements)

152

What diseases are associated with bronchiectasis?

1. cystic fibrosis (chronic productive cough, recurrent sinusitis, nasal polyps, weigh loss, infertility in male)
2. immotile cilia syndrome (primary ciliary dyskinesia, Kartagner's)
3. immunoglobulin deficiency
4. recurrent pneumonias (especially gram neg: Pseudomonas)

153

A pt with bronchiectasis, hx of recurrent pneumonia/ chronic cough, situs inverus and sinusitis most likely suffers from ...

Kartagener syndrome (half of people with primary ciliary dyskinesia)

154

What is seen on CXR in advanced bronchiectasis?

1. 1-2 cm cysts
2. crowding of bronchi (tram-tracking)

155

What is the most accurate non-invasive test to detect bronchiectasis?

high resolution CT

156

What are the treatments for bronchiectasis?

1. bronchodilators, chest PT and postural drainage
2. rotating antibiotics
3. surgery (if localized w/ adequate PFTs or massive hemoptysis)

157

A pt presents with extertional dyspnea, nonproductive cough, coarse crackles, pulmonary hypertension (edema, JVD), with reticular/ reticulonodular/ ground glass opacities pattern on CXR with restrictive pattern on PFTS most likely suffers from ....

interstitial lung disease

158

What is the best diagnostic tests for interstitial lung disease?

1. high resolution CT
2. biopsy

159

A pt with restrictive pattern on PFTs with extensive fibrosis with honeycomb pattern on imaging most likely suffers from ....

Idiopathic Pulmonary Fibrosis
(usually in 50's y/o, just lung involved)

160

What is treatment for idiopathic pulmonary fibrosis?

steroids w/ or w/out azathioprine

161

A black pt presenting with erythema nodosum (tender, red nodules on skins), arthritis and hilar adenopathy on CXR most likely suffers from ...

Lofgren syndrome
(acute presentation of Sarcoidosis)

162

What are the two distinct acute sarcoidosis syndromes?

1. Lofgren syndrome
2. Heerfordt-Waldenstrom syndrome

163

A black pt presenting with fever, parotid enlargment, uveitis and facial palsy most like likely suffers from ...

Heerfordt-Waldenstrom syndrome
(acute presentation of Sarcoidosis)

164

What is diagnostic test for sarcoidosis?

biopsy of involved tissue (non-caseating granulomas)

165

What is the best follow-up test for response to treatment for idiopathic pulmonary fibrosis?

pulmonary function tests

166

What are common complications in patient with sarcoidosis?

1. hypercalcemia & hypercalciuria due to elevated vitamin D
2. elevated ACE levels
3. uveitis/ conjunctivitis (once dx w/ sarcoid, send for opthalmologic exam)

167

A pt presents with pulmonary fibrosis, chest wall pain, wheezing in the setting of hx of shipyard worker/ insulation/ brake linings most likely suffers from ..

Asbestosis

168

What is the finding on biopsy of a pt with asbestosis?

barbell-shaped fibers

169

What cancers are associated with asbestosis?

1. bronchogenic carcinoma (most common)
2. mesothelioma

170

What is treatment for Asbestosis?

Smoking cessation

171

What is the finding on CXR for a pt with Asbestosis?

pleural thickening, pleural plaques and calcifications at the level of the diaphragm

172

When should you always use steroids for sarcoidosis?

1. uveitis
2. CNS disease
3. hypercalcemia

173

What can we use ACE levels for in sarcoidosis?

course of the disease (improvement or worsening)

174

A pt with pulmonary fibrosis in the setting of a hx of mining/ quarrying/ tunneling/ glass or pottery making/ sandblasting most likely suffers from ...

Silicosis

175

What is the finding on CXR for pt with silicosis?

hyaline nodules in upper lobes with eggshell calcifications

176

What test should people with silicosis have performed yearly?

PPD test
(silicosis is associated with TB; if positive, tx for latent TB with INH)

177

A pt presenting with pulmonary fibrosis and hx of being coal miner with associated increased IgA/ IgG/ C3/ ANA/ RF most likely suffers from ....

Coal miner's lung/ pneumoconiosis

178

A pt presents with rheumatoid nodule in lung periphery, rheumatoid arthritis, and pneumoconiosis most likely suffers from ...

Caplan syndrome

179

What are risk factors for DVTs and pulmonary embolism? (6)

1. recent surgery
2. cancer
3. immobile (hospitalized, long travel)
4. acquired thrombophilia (lupus anticoagulant, nephrotic syndrome b/c loss of antithrombin III, OCPs w/ smoking)
5. inherited thrombophilia (factor V leiden, protein C/S/ antithrombin III deficiency)
6. pregnancy

180

A pt presenting with sudden onset dyspnea, calf swelling, pleuritic chest pain, normal CXR increased respiratory rate and increased pulmonic sound (P2) most likely suffers from ...

Pulmonary Embolism (secondary to DVT)

181

What are the findings on EKG for right heart strain?

1. large S wave in lead I
2. deep Q wave in lead III
3. T wave inversion in lead III

(S1,Q3,T3)

182

.... is the lack of vascular markings that occur distal to the pulmonary embolus seen on CXR

Westermark sign

183

... is wedge-shaped infiltrate just above the diaphragm due to pulmonary infarction seen on CXR

Hampton Hump

(associated with pulmonary embolism)

184

How can a pt with a proximal DVT have a systemic circulation clot resulting in stroke, etc?

Clot goes through patent foramen ovale (especially if high pressure in right side of heart)
(paradoxical pulmonary embolism)

185

what is the best initial test for pulmonary embolism?

CT angiogram

(may miss small peripheral emboli)

(avoid if renal failure, iodine allergy, morbidly obese)

186

When should you use V/Q scan for detection of pulmonary embolism?

1. renal failure
2. iodine allergy
3. morbidly obese

187

What is the usefulness of the d-dimer test?

used to rule out thromboembolism disease (DVT, PE) b/c high sensitivity

188

What is the most accurate test for pulmonary embolism?

pulmonary angiogram

189

What is the best next step in management for with high risk of pulmonary embolism prior to diagnostic evaluation?

heparin (anticoagulation immediately)

190

A pt as a significant drop of platelets while on heparin most likely suffers from .... and treatment consists of ....

HIT (heparin induced thrombocytopenia); stop heparin and use argatroban/ lepirudin

191

A pt presents with recurrent pulmonary embolism and DVTs while on heparin most likely suffers from ...

HIT (heparin induced thrombocytopenia)

192

What is the cause of warfarin skin necrosis when a pt is started on warfarin without heparin bridging?

pt has protein C deficiency (protein C has shorter half life compared to factor 7 so results in transient hypercoagulable state

193

What is the best treatment for pulmonary embolism/ DVT for pregnant women?

LMWH (low molecular weight heparin) for 6 months b/c warfarin contraindicated

194

What is the best treatment for pulmonary embolism in a pt with recent neurosurgery or eye surgery?

IVC filter (Greenfield filter)

195

What is the best treatment for pulmonary embolism in a hemodynamically unstable pt?

1. tPA (thrombolytics if not contraindicated)
2. pulmonary embolectomy and interrupt IVC (if anticoagulation contraindicated)

196

What is the most common complication of DVTs?

post-thrombotic syndrome (post-phlebitic syndrome)
-pain, edema, skin ulceration, hyperpigmentation
-tx w/ compression stockings

197

A pt develops acute dyspnea, petechiae of neck and axilla, and confusion in the setting of CPR or femur (long bone) fracture a few days prior most likely suffers from .....

fat embolism

198

A pt developing acute onset dyspnea, increased respiratory rate, diffuse rales & rhonchi, white out on CXR, increased pulmonary artery pressure on Swan-Ganz catheter in pt with recent previous event (sepsis, trauma, DIC, severe disease) most likely suffers from ...

acute respiratory distress syndrome
(due to increased permeability of alveolar membrane)

199

What is treatment for ARDS (acute respiratory distress syndrome)?

intubation with increased positive end-positive pressure

(permitting hypercapnea)

200

An obese pt presence with daytime solmnolence and systemic hypertension (possibly with cor pulmonale) most likely suffers from ....

Obstructive Sleep Apnea (due to floppy airway)

201

What is treatment for obstructive sleep apnea?

1. weight loss
2. CPAP (continous positive airway pressure)

202

What is the diagnostic test for sleep apnea?

polysomnography (sleep study showing cessation of airflow for longer than 10 seconds occuring 10-15 times per hour during sleep)

203

What is the treatment for central sleep apnea (sleep apnea due to inadequate ventilatory drive)?

acetazolamide (induces hyperventilation), progesterone, supplemental oxygen

204

A pt develops fever, tachycardia, dyspnea, unilateral decreased breath sounds and hypoxemia within 24 hours of surgery most likely suffers from ....

Atelectasis

205

What are findings on CXR associated with atelectasis?

1. tracheal deviation to affected side
2. elevation of hemidiaphragm on affected side
3. densely consolidated small affected lobe

206

A pt presents with cough, weight loss, hempotysis, and chest wall pain in setting of hx of smoking most likely suffers

bronchogenic carcinoma (lung cancer)

207

What is the most common cause of thrombophilia?

factor V leiden deficiency (results in decreased activation of protein C)

208

What are the 2 bronchogenic cancers that are centrally located?

1. Squamous cell: cavitary lesions, extension to hilar node & mediastinum, PTH like substance (hypercalcemia)
2. Small -cell carcinoma: metastsis to liver/brain/ adrenals/ bone; associated w/ eaton-lambert/ SIADH/ venocaval obstruction syndrome/ Cushing syndtomr

209

What are the 2 bronchogenic cancers that are peripherally located?

adenocarcinoma: most common, high hyaluronidase in pleural effusions
large-cell: cavitary early; metastasize late

210

What symptoms are indicative of nonresectable bronchogenic carcinoma? (6)

1. Hoarseness
2. weight loss > 10%
3. bone pain
4. CNS symptoms
5. superior vena cava syndrome
6. pleural effusion

211

What are complications of lung cancer?

1. recurrent pneumonia (same area)
2. Superior Vena Cava syndrome (facial & arm edema, JVD, dilated veins of chest/ arms/ face, ams)
3. pancoast tumor (apical tumor, painful neuropathy of upper extremity)
4. Horner's syndrome (miosis, anhydriosis, ptosis)

212

How do we determine if a pt is a surgical candidate for surgery on a resectable cancer?

FEV1 > 50% on pulmonary function tests

213

When is lung cancer unresectable?

1. metastasis outside lung (except single met to brain)
2. metastasis to other lung
3. close to carina
4. pleural effusion
5. hoarseness

214

What is the treatment for atelectasis?

incentive spirometry