Pulmonary

Question 1

What pneumonia presents with salmon pink sputum?

Answer 1

Staph

Question 2

What are some buzzwords associated with gram negative pneumonia?

Answer 2

currant jelly sputum and bulging fissure sign (klebsiella)

Question 3

What are some lab changes that you might see with legionella pneumophila?

Answer 3

hyponatremia, hypophosphatemia, thrombocytopenia, elevated LDH, elevated CRP

Question 4

ILD: person presents with regular chest tightness toward the end of the 1st day of the workweek. What is causing this?

Answer 4

Monday chest tightness is caused by Byssinosis (organic dust that causes ILD)

Question 5

What’s the most common manifestation of asbestos exposure in the first 10 years?

Answer 5

BAPE = benign asbestos pleural effusions

• vary from serous to bloody
• occur early in the exposure history (within 5 years)
• 1/3 of patients have eosinophils in the pleural fluid

Question 6

Malignant mesothelioma is or is not associated with smoking?

Answer 6

Is not

Question 7

Which part of the lung do asbestosis and silicosis involve?

Answer 7

Asbestosis is the lower lung and silicosis is the upper lung

Question 8

All patients with silicosis have an increased risk for developing what 2 diseases?

Answer 8

Active TB and malignancy; also have a strong association with scleroderma and rheumatoid arthritis

Question 9

What are some diseases that clubbing is almost always, commonly, and almost never seen in?

Answer 9

1. Almost always = advanced IPF; asbestosis
2. Commonly = bronchiectasis; CF; lung cancer
3. Almost never = emphysema; sarcoidosis

Question 10

What is Caplan syndrome?

Answer 10

Seropositive rheumatoid arthritis associated with massive CWP (call workers’ pneumoconiosis). This syndrome is notable for the development of peripheral lung nodules in addition to the upper lung nodules seen in CWP.

Question 11

What are differences in BAL findings of helper/suppressor lymphocyte ratios in sarcoid vs hypersensitivity pneumonitis?

Answer 11

Sarcoid - helper/suppressor > 4:1

Hypersensitivity pneumonitis ratio

Question 12

What are a couple of alternate diagnoses you can think of when assessing a progressively worsening asthmatic?

Answer 12

1. churg-strauss syndrome

2. ABPA

Question 13

What are 4 autoimmune diseases that cause pulmonary hemorrhage?

Answer 13

1. Goodpasture syndrome
2. SLE
3. Granulomatosis with polyangiitis
4. IPH (idiopathic pulmonary hemosiderosis)

Question 14

What is the definition of pulmonary hypertension?

Answer 14

mean PAP >/= 25 at rest and >/= 30 with exercise

Question 15

What conditions lead to a decrease in DLCO?

Answer 15

emphysema, ILD, pulmonary vascular disease, and anemia

Question 16

What are classic signs of a fat embolus?

Answer 16

shortness of breath, confusion, and petechiae

Question 17

What are the most common causes of a malignant pleural effusion?

Answer 17

Lung cancer (1/3), breast cancer (1/4), lymphoma (1/5)

Question 18

A patient just had plastic surgery then went to the beach where she was exposed to sand and water and now has infected surgical wounds. What might me the causative organism?

Answer 18

Non tuberculosis mycobacteria

Question 19

Is it significant if you find Aspergillus or cryptococcus in sputum?

Answer 19

No for Aspergillus but yes for cryptococcus; if you find cryptococcus you need to do a lumbar puncture to evaluate for CNS infection

Question 20

What does the buzzword halo sign indicate?

Answer 20

It is the high resolution CT finding for a invasive pulmonary Aspergillus and it represents a pulmonary infarction

Question 21

How does malignant mesothelioma present?

Answer 21

With pleuritic chest pain and a unilateral hemorrhagic pleural effusion

Question 22

What lung cancers are associated with asbestos exposure?

Answer 22

malignant mesothelioma, squamous, and adenocarcinoma

Question 23

Who should be screened for lung cancer with annual low dose CT scan?

Answer 23

1. Aged 55-74
2. smoked >/= 30 pack years
3. current smoker or quit within the last 15 years

Question 24

What can be the sole cause of a pulmonary infiltrate in a patient with AML? And what needs to be ruled out?

Answer 24

Sole cause - hemorrhage

Rule out - Aspergillus infection as the cause of the hemorrhage

Question 25

(pleomorphic) Gram negative coccobacilli is a common buzz phrase for?

Answer 25

Haemophilus influenza (they may also be described as pleomorphic gram negative rods)

Question 26

pneumonia + pharyngitis + hoarseness = ? type of PNA

Answer 26

chlamydophila pneumoniae

Question 27

pneumonia + lots of extra pulmonary manifestations: hemolytic anemia, splenomegaly, erythema multiforme, SJS, arthritis, pharyngitis, tonsillitis, ear infection, neurological changes like confusion = ? type of PNA

Answer 27

mycoplasma pneumoniae

Question 28

Intracellular lancet shaped gram positive diplococci describes what bacteria?

Answer 28

Strep pneumo

Question 29

What presents with rust colored sputum?

Answer 29

strep pneumo

Question 30

If a pneumonia bacteria is described as gram negative cocci, what should I be thinking?

Answer 30

Neisseria meningitidis or moraxella catarrhalis

Question 31

What are 2 situations that lead to hypoxemia and a normal A-a gradient?

Answer 31

1. breathing air with a reduced concentration of oxygen | 2. hypoventilating

Question 32

What should you think about in a pt with asthma or CF who has uncontrolled dz? They have recurrent exacerbations that improve with prednisone but then the patient has return of wheezing, coughing, and dyspnea shortly after stopping steroids?

Answer 32

ABPA

Question 33

How do you screen for ABPA?

Answer 33

aspergillus antigen skin prick test; if positive then get IgE level

Question 34

A patient gets worse as you are weaning their steroids. What might they have?

Answer 34

Churg-Strauss

Question 35

Which fungal lung infection has erythema nodosum and erythema multiform as associated skin findings?

Answer 35

Coccidioidomycosis

Question 36

What does the cxr of a histoplasmosis patient look like?

Answer 36

hilar adenopathy, focal alveolar infiltrates, multiple nodules

Question 37

What are the DESAT causes that cause a patient to fail to wean off the vent?

Answer 37

``` D - drugs E - electrolyte imbalance and ET tube S - secretions A - alkalemia T - too high a pO2 and too low a pCO2 ```

Question 38

Describe the stages of pertussis in more detail

Answer 38

pertussis disease has 3 phases: catarrhal, paroxysmal, and convalescent. The catarrhal stage presents as a typical, uncomplicated upper respiratory infection lasting 5–12 days. Patients are most infectious during this stage. It is not until the paroxysmal stage develops, with its characteristic paroxysms of coughing followed by a “whoop,” that pertussis becomes clinically apparent. After 1–2 weeks, this stage is followed by an often prolonged convalescent stage, lasting several weeks to months.

Question 39

Which class of antibiotic interacts with theophylline and raises the level?

Answer 39

flouroquinolones (cipro)

Question 40

What criteria must you meet for home O2?

Answer 40

1.Resting PaO2 ≤ 55 mmHg, or 2.O2 saturation ≤ 88%, or 3.PaO2 ≤ 59 mmHg (O2 sat ≤ 89%) with evidence of cor pulmonale Evidence of cor pulmonale in these considerations is: Clinical evidence of right heart failure Pulmonale on ECG (P wave height > 2.5 mm in II, III, and AVF) Hct > 56 (due to polycythemia from chronic hypoxia 2° cor pulmonale)

Question 41

What should a finding of eggshell calcifications make you think of?

Answer 41

Silicosis

Question 42

Sputum with a salty taste should make you think of what?

Answer 42

bronchoalveolar cell carcinoma, now called adenocarcinoma in situ (AIS),

Question 43

The A-a gradient is increased in all causes of hypoxemia except which two causes?

Answer 43

hypoventilation and high altitude

Question 44

What produces a Horner pupil?

Answer 44

pulmonary neoplasms of the superior sulcus