pulmonology

Question 1

of the following causes of hypoxemia, which have a nl A-a gradient?
shunt
hypoventilation
decreased diffusion (low DLCO)
high altitude

Answer 1

hypovetilation

high altitude

Question 2

how do you calculate the A-a gradient? what is a nl A-a gradient?

Answer 2

nl A-a = age/4 + 4
A-a gradient = PAO2-PaO2
PAO2=150-1.25(PaCO2)

Question 3

how do you eavluate someone for methemoglobin (CO posioning)? what is tx?

Answer 3

have to order a methemoglobin (b/c an ABG will show a falsely normal PaO2)
tx with 100% O2 and methylene blue

Question 4

what might you suspect in a pt who is hyperventilating after the were found in a smoky room (no e/o burned airways) and has a nl ABG? Tx?

Answer 4

CO posioning - should order methemoglobin and CO levels and tx with 100% oxygen and methylene blue

Question 5

what on pulmonary function tests differentiates emphysema from chronic bronchitis/asthma?

Answer 5

all are obstructive but only emphysema has low DLCO

Question 6

is DLCO nl or low in:
ILD
emphysema
chronic bronchitis?

Answer 6

low in ILD and emphysema, nl in chronic bronchitis

Question 7

what is the PFT hallmark of:
restrictive disease
obstructive disease

Answer 7

restrictive: TLC <70%

Question 8

T/F: to diagnose obstructive dz you need only spirometry but for restrictive you need lung volumes as well.

Answer 8

true – need to know residual viume to calculate TLC to diagnose restrictive

Question 9

what is the 1st test to diagnose a suspected asthmatic? anything else you can do if that is normal?

Answer 9

PFTs then methacholine challenge

Question 10

what dz is characterized by decreased FEV1/FVC, increased TLC and decreased DLCO?

Answer 10

emphyseam

Question 11

what dz is characterized by decreased FEV1/FVC, nl/increased TLC and nl DLCO?

Answer 11

chronic bronchitis ( if have emphysema will have decreased DLCO and increased TLC)

Question 12

what dz is characteried by nl FEV1/FVC, decreased TLC, reduced DLCO?

Answer 12

ILD

Question 13

if someone has restrictive dz (ie TLC <80%), how do you tell if the restriction is extrathoracic (obesity, kyphosis) or intrathoracic (ILD)?

Answer 13

in extrathroacic, the reduction in the DLCO will be the same as the reduction in TLC while in intrathoracic the DLCO will be disproportionaetly lower than the TLC

Question 14

When are steroids indicated in asthma exacerbation?

Answer 14

Peak glow kes than eighty percent despite 3 alb utterly txs

Question 15

Can labas be used as monontherpay in asthma?

Answer 15

No! Increase mortality. Use indicated in pts on Saba and ics with mod to severe persistent asthma

Question 16

Describe indications and step ups of therapy for asthma.

Answer 16

Saba alone
If using Saba more than 2 days/week, add ics
If on Saba and ics but still with mod to server persistent asthma, add laba * never use laba without ics–increases mortality*

Question 17

Describe intermittent, mild persistent, mod persistent and severe persistent asthma.

Answer 17

Intermittent: sx 2 days a week or less, use Saba 2 days/ wk or less, 2 nighttime awakenings per month and no activity limitations
Mild persistent: sx 2-6 days/week, use inh no more than 2-6 days awak 3 or 4 nights per month and Minot limitations
Mod persistent:
Severe persistent: constant symptoms, use Saba many days per week, awake every night, fev less than 60

Question 18

What type of asthma hassx 2 days a week or less, use Saba 2 days/ wk or less, 2 nighttime awakenings per month and no activity limitations

Answer 18

Intermittent

Question 19

What type of asthma has:

sx 2-6 days/week, use inh no more than 2-6 days awak 3 or 4 nights per month and Minot limitations

Answer 19

Mild persistent

Question 20

What type of asthma has daily symptoms, daily Saba use, awake more than once a week and fev 60-80 percent

Answer 20

Mod persistent

Question 21

What type of asthma hasconstant symptoms, use Saba many days per week, awake every night, fev less than 60

Answer 21

Severe persistent

Question 22

Give the peak flows at which a pt should go tot their er, be admitted and be admitted to ICU.

Answer 22

Peak flow less than 80 give meds and reassess
Peak flow less than 50 go to er
Peak flow 40 to 60 despite tx admit
Peak flow less than 40 despite tx admit to ICU

Question 23

Is panacinar or centriacinar emphysema assoc with alphaoneantitryosin?

Answer 23

Pan (centri is what smokers get )

Question 24

Describe the gold spirometry criteria for copd. And classes by sympt pms.

Answer 24

Fev 80% mild (gold 1)
50 to 79% moderate (gold 2)
30 to 49% sever (gold 3)
Less than 30 (gold 4)

A= few sx! low risk
B= more sx! low risk
C= few sx! High risk
D=more sx! high risk

Question 25

True or false: ics are used as monotherapy in copd but not asthma.

Answer 25

False. Vice versa

Question 26

What gold stage copd pts benefit from ics?

Answer 26

Three or four (fev less than 50)

Question 27

Describe the tx for each abcd stage of copd.

Answer 27

A (few sx low risk): Saba B (more sx low risk): laba or lama C ( few sx high risk): ics +laba or laba +lama! can use roflumilast D (more sx high risk): ics +laba + lama +/- roflumilast

Question 28

Describe EKG changes for a pE.

Answer 28

S1q3t3 Anterior twi New Rbbb Ra

Question 29

Contrast ipf and cryptogenic organizing pna. Why is it important to differentiate?

Answer 29

Cop has fever, malaise, infiltrate and onseqt of days to week Ipf has months of sx without fever/malaise, just dry cough Can tx cop (steroids)

Question 30

What is diagnosis in premenopausal female with chylous effusion and pneumothorax.

Answer 30

Lymphagnioleiomyomatosis | Tx with progestin

Question 31

What anca is positive in GPa?

Answer 31

Canca and anti-pr3

Question 32

What autoimmune Dx affects sinuses and lungs?

Answer 32

GPA

Question 33

What is diagnosis of pt with bad asthma who gets worse when you add a leukotriene modifier?

Answer 33

Churg Strauss

Question 34

What vascular is has granule as, small vessel vasculitisand peripheral eosinophilia?

Answer 34

Churg Strauss. Also have asthma sx.

Question 35

What vasculitis is associated with hepatitis b?

Answer 35

PAN affects gut kidney heart testes (spares lungs)

Question 36

Diagnosis in hep b pt with tender testicles, skin nodules and abdominal pain.

Answer 36

PAN tx with cyclophosphamide steroids and. Tx hep b

Question 37

What is test to diagnose ABPA?

Answer 37

Start with aspergillus skin prick test. Also check serum Ige level. Tx with itraconazole and steroids.

Question 38

Describe the diff btwn each group of pulm Htn.

Answer 38

``` 1-idiopathic 2-left heart dz 3-lung dz 4-chronic VTE 5-multifactorial/misc ```

Question 39

Loud 2nd heart sound, tricuspid regurg and RV heave are suggestive of what.

Answer 39

Pulm Htn

Question 40

What pulm Htn pts should be anticogaulted?

Answer 40

``` Group 4(chronic VTE) Group 1(idiopathic pah) ```

Question 41

what types of tumors arise from the ant mediastinum?

Answer 41

anterior: thyroid tumors, thymic tumors, and lymphomas middle: bronchogenic cysts, pericardial cysts, and lymphadenopathy posterior: neural, esophageal tumor/cyst

Question 42

what types of tumors arise from the midle mediastinum?

Answer 42

anterior: thyroid tumors, thymic tumors, and lymphomas middle: bronchogenic cysts, pericardial cysts, and lymphadenopathy posterior: neural, esophageal tumor/cyst

Question 43

what types of tumors arise from the posterior mediastinum?

Answer 43

anterior: thyroid tumors, thymic tumors, and lymphomas middle: bronchogenic cysts, pericardial cysts, and lymphadenopathy posterior: neural, esophageal tumor/cyst

Question 44

what is heparin antidote

Answer 44

protamine

Question 45

compare type I and type iI HIT

Answer 45

type I: 1-2 days after start hep; common, no linical onsequence type II: 4-10 days after heparin; have antibodies, can get clotting/bleeding

Question 46

explain why warfarin is initially procoagulant.

Answer 46

protein C (anticoagulant) is inactivated faster than factor VII. after about 4 days factor II and facotr VII are low enough that the net effect is anticoagulant

Question 47

if a unilateral effusion is present from CHF what side is it usually on? pancreatitis?

Answer 47

CHF --> Right | pancreatitis --> left

Question 48

give light's criteria.

Answer 48

if any one of three is there, effusion is exudative: - E:S protein >0.5 - E:S LDH >0.6 - E LDH >2/3 ULN (usually 200ish)

Question 49

what diagnosis is suggested in a bloody pleural effusion?

Answer 49

mesothelioma 2/2 asbestos exposure

Question 50

• A patient who works on an animal farm develops pneumonia. What organism should you think about? • What organism should you consider if pneumonia develops in a patient who spent an afternoon in a bat cave in Mississippi? • What organism should you think about if pneumonia develops in a patient who drove through an Arizona dust storm? • What organism should you consider if a chronic, cavitating pneumonia develops in a male logger from Arkansas?

Answer 50

q fever (coxiella) histoplasmosis coccidiomycoces blastomycoces

Question 51

what pneumonia-causing organism presents as pleomorphinc GN coccobaccilli?

Answer 51

haemophilus influenzae

Question 52

which atypical pneumonia is associted with hemolytic anemia, erythema multiforme, arthirtis and neurologic changes?

Answer 52

mycoplasma

Question 53

what is major SE of ethambutol?

Answer 53

decreased visual acuity (not heaptotoxic but all the other parts of RIPE are)

Question 54

what infectino should you suspect in someone 6 weeks s/p kidney transplant who p/w hepatitis and adrenal insufficiency?

Answer 54

CMV - can cause hepatitis, pneumonitis, adrenalitis; usually 6 to 8 weeks out

Question 55

what is 1st line tx for PCP? when do you add steroids?

Answer 55

bactrim or pentamidine | add steropids if A-a > 35 or PaO2 <70

Question 56

what presents with "halo sign" on chest CT?

Answer 56

aspergillus - caused by pulm infarction

Question 57

what antibiotic can give you a false positive galactomannan?

Answer 57

pip-tazo

Question 58

Name 3 medications associated with pneumonitis.

Answer 58

MTX - causes noncytotoxic hypersensitivity interstitial pneumnitis Bleomycin - cytotoxic pulm. toxicity; uremia, O2 and XRT can worsen bleomycin-related dz amiodarine - pulm fibrosis amio and bleo are dose-related

Question 59

define ARDS. what are ideal ARDs ventilator settings?

Answer 59

PaO2/FiO2 30 may need to decr TV

Question 60

Describe the following ventilator modes: - CMV (controlled mech vent) - AC (assist/control) - SIMV (synch intermit mech vent) - PSV (press surppor vent) - PC (press control)

Answer 60

CMV: ventilator controls everything, no spontaneous breathing allowed AC: set rate & TV; if there is a spontaneous breath vent gives full TV (can have stacking if hyperventilating SIMV: like AC but spontaneous breath overrides machine PSV: extra pressure when pt inspires; can use PS alone or with SIMV; no rate/TV set PC: pressure and rate are set, no TV set; good for people when you want to avoid barotrauma

Question 61

Give the CO, wedge and SVR for : | hypovolemic, cardiogenic, distributive and obstructive shock.

Answer 61

hypovolemic: low CO, low PCWP, high SVR cardiogenic: low CO, high PCWP, high SVR distributive: high CO, low PCWP, low SVR obstructive: low CO, low PCWP, high SVR

Question 62

what are normal pressures in the RA, RV and PA?

Answer 62

RA: 0-8 RV: 15-30/0-8 PA: 15-30/3-12

Question 63

which lung cancers are classically central? peripheral?

Answer 63

Squamous and Small cell are "Sentral" | adeno and large cell are peripheral

Question 64

which lung cancer is the most likely to present with cavitary lesions?

Answer 64

squamous

Question 65

who/how do you screen for lung cancer?

Answer 65

low-dose CT annually if you are between 55-74 years old, smoked >30 pack-years and currently smoker or quit w.in last 15 years

Question 66

which lung cancer is associated with: - SIADH - ectopic ACTH - PTHrP - eaton-lambert

Answer 66

squamous - PTHrP (sCa++mous) | SC - everything else

Question 67

is "popcorn" calcification benign or malignant?

Answer 67

benign -- hamartoma

Question 68

what is hallmark CT finding of hamartoma?

Answer 68

popcorn calcification

Question 69

is "laminated" calcification of pulm nodule benign or malignant?

Answer 69

benign - granuloma