Pulmonology

Question 1

What are the features of severe asthma exacerbation?

Answer 1

hyperventilation, decrease peak flow, hypoxia, respiratory acidosis, absence of wheezing

Question 2

What confirms a diagnosis of asthma?

Answer 2

Increase in FEV1 of > 12%

Question 3

What is the best way to diagnose reactive airway disease in asymptomatic patient?

Answer 3

Methacholine challenge test- looks for a decrease in FEV1 after methylcholine (acetylcholine) is given

Question 4

What is the best initial therapy for asthma?

Answer 4

Bronchodilators(albuterol)
bolus of steroid
Inhaled ipratropium
oxygen
Mg

Question 5

All patients with SOB should receive…?

Answer 5

Oxygen, oximeter, CXR, ABG

Question 6

If patient is in respiratory acidosis with CO2 retention, what should they receive?

Answer 6

ICU, persistent acidosis is an indication for intubation and MV

Question 7

What is the best initial therapy for non-acute asthma?

Answer 7

inhaled bronchodilator; if patient is not a controlled asthmatic, add inhaled steroid; if both the above are not cutting it, add long acting inhaled beta-agonist(salmeterol or formeterol)

Question 8

How does COPD present?

Answer 8

long term smoker with increasing SOB and decreased exercise tolerance

Question 9

What should you order with acute exacerbations of COPD?

Answer 9

oxygen, ABG, CXR, albuterol, ipratropium, bolus steroids, chest/heart/extremity/neuro exam
- if fever, sputum, new infiltrate add ceftriaxone and azithromycin for pneumonia

Question 10

What do you find in the following lab tests with COPD patients?
EKG, CXR, CBC, Chemistry

Answer 10

EKG- R axis deviation, RVH, RAH
CXR- Flattening of diaphragm
CBC- increased hematocrit
Chemistry- increased HCO3

Question 11

What are the PFT findings in COPD?

FEV1, FVC, FEV1/FVC, TLC, RV, DLCO

Answer 11

FEV1- decrease
FVC- decrease
FEV1/FVC- decrease
TLC- increase
RV- increase
DLCO- decrease

Question 12

What is the chronic therapy for COPD?

Answer 12

Ipratropium inhaler, albuterol inhaler, pneumococcal vaccine, influenza vaccine, smoking cessation, long term home oxygen (pO2< 88%)

Question 13

What lowers mortality in COPD?

Answer 13

smoking cessation and home O2

Question 14

How does alpha-1 antitrypsin deficiency present?

Answer 14

Young, nonsmoker, cirrhosis, COPD

Question 15

What is the treatment for alpha-1 antitrypsin deficiency?

Answer 15

alpha-1 antitrypsin infusion

Question 16

What is the most accurate diagnostic test for bronchiectasis?

Answer 16

High resolution CT scan of the chest

Question 17

What is the treatment for bronchiectasis?

Answer 17

Chest physiotherapy, rotating antibiotics

Question 18

What are the PFT values with Interstitial Lung Disease?

FEV1, FVC, FEV1/FVC, TLC, RV, DLCO

Answer 18

FEV1- decrease
FVC- decrease
FEV1/FVC- normal/decrease
TLC- decrease
RV- decrease
DLCO- decrease

Question 19

What is the presentation of sarcoidosis?

Answer 19

Black woman under 40, cough, SOB, fatigue

Question 20

What is the best initial test for sarcoidosis?

Answer 20

CXR shows enlarged lymph nodes

Question 21

What is the most accurate diagnosis for sarcoidosis?

Answer 21

lung/lymph node biposy showing noncaseating granuloma

Question 22

What is the best therapy for sarcoidosis?

Answer 22

Steroids

Question 23

Pulmonary hypertension can occur in the following conditions….

Answer 23

MS, COPD, Polycythemia Vera, Chronic Pulmonary Emboli, Interstitial Lung disease

Question 24

What is the best initial test for pulmonary HTN?

Answer 24

TTE

Question 25

What is the most accurate test for pulmonary HTN?

Answer 25

right heart catheterization aka Swan-Ganz(shows increased pulmonary artery pressure)

Question 26

What is the treatment for pulmonary HTN?

Answer 26

bosentan(endothelial inhibitor), epoprostenol, sildenafil

Question 27

What are the ABG findings for PE?

Answer 27

hypoxia with increased A-a gradient

Question 28

How do you confirm PE?

Answer 28

CT angio

Question 29

What is d-dimer good for?

Answer 29

In patient who has low probability of PE in which you want a single test to exclude PE

Question 30

What is the treatment for PE?

Answer 30

heparin warfarin(6 months) IVC Filter(in patients who have contraindication to filter) Thrombolytics(used in hemodynamically unstable patients)

Question 31

What is the best initial test for pleural effusion?

Answer 31

CXR

Question 32

What is the most accurate test for pleural effusion?

Answer 32

Thoracentesis

Question 33

What tests need to be ordered of pleural fluid?

Answer 33

gram stain, culture, Acid fast stain, total protein, LDH, glucose, cell count, triglycerides, pH

Question 34

What is the treatment for pleural effusions?

Answer 34

Small- none, may use diuretics Large- chest tube - If pleural effusion is large and recurrent- pleurodesis can be done

Question 35

What if the pleuodesis fails, what is the next step?

Answer 35

Decortication

Question 36

What are the characteristics of sleep apnea?

Answer 36

Obese, daytime somnolence, sever snoring

Question 37

How is sleep apnea diagnosed?

Answer 37

Polysomnography(sleep study)- periods >10 seconds of apnea

Question 38

What is the treatment for obstructive sleep apnea?

Answer 38

Weight loss, and CPAP/BiPAP; if not effective, can surgically release uvula, palate, pharynx

Question 39

What is the treatment of central sleep apnea?

Answer 39

Avoid alcohol/sedatives, acetazolamide

Question 40

What is the treatment for ARDS?

Answer 40

Ventilatory support, PEEP, possible diuretics and dobutamine

Question 41

What are the measurements of the following parameters in Hypovolemia? CO, Wedge Pressure, Systemic Vascular resistance

Answer 41

CO- low WP- low SVR- high

Question 42

What are the measurements of the following parameters in Cardiogenic Shock? CO, Wedge Pressure, Systemic Vascular resistance

Answer 42

CO- low WP- high SVR- high

Question 43

What are the measurements of the following parameters in Septic Shock? CO, Wedge Pressure, Systemic Vascular resistance

Answer 43

CO- high WP- low SVR- low

Question 44

What is the bug for community acquired pneumonia?

Answer 44

Pneumococcus

Question 45

What is the bug for hospital acquired pneumonia?

Answer 45

Gram negative bacilli

Question 46

What is the best initial and most accurate test for pneumonia?

Answer 46

CXR, sputum gram stain and culture

Question 47

What else needs to be ordered in cases of pneumonia?

Answer 47

Oximeter, O2(if SOB), ABG(if hypoxic)

Question 48

What is the OUTPATIENT treatment for pneumonia?

Answer 48

Macrolide (azithyromycin, doxycyline, clarithromycin) | Fluoroquinolone (levofloxacin, moxifloxacin)

Question 49

What is the INPATIENT treatment for pneumonia?

Answer 49

Ceftriaxone and azithromycin | Fluoroquinolone

Question 50

What is the treatment for ventilator associated pneumonia?

Answer 50

Imipenem, piperacillin/tazobactam, or cefipime Gentamicin and Vancomycin

Question 51

What is the best initial test for TB?

Answer 51

CXR

Question 52

What is the confirmatory test for TB?

Answer 52

sputum AFB and culture

Question 53

What is the treatment for TB once the culture is positive?

Answer 53

``` RIPE- Rifampin- 6 months Isoniazid- 6 months Pyrazinamide- 2 months Ethambutol- 2 months ```

Question 54

What are the toxicities for TB treatments?

Answer 54

``` All can lead to liver toxicity Rifampin- red/orange bodily secretions Isoniazid- peripheral neuropathy Pyrazinamide- hyperuricemia Ethambutol- optic neuritis ```

Question 55

What are the PPD screening tests?

Answer 55

Positive PPD- 5 mm- close contact, steroid users, HIV positive 10 mm- homeless, immigrants, alcoholics, healthcare workers, prisoners 15 mm- those without increased risk