Pulmonology

Question 1

most important lab test in evaluation of respiratory compromise?

Answer 1

arterial blood gas measurement

Question 2

hallmark of acute respiratory failure

Answer 2

rise in PCO2 accompanied by drop in pH

Question 3

what PFTs establish the diagnosis of COPD (vs asthma)

Answer 3

postbronchodilator FEV1 < 80% and FEV1/FVC < 0.70

low DLco

Question 4

when is DLco low in a patient?

Answer 4

conditions w/ barriers to diffusion (interstitial edema, interstitial infiltrates, tissue fibrosis) OR loss of lung tissue (emphysema)

Question 5

pulmonary embolism on PFTs

Answer 5

no change in spirometry or lung volumes

decreased DLco

Question 6

cough variant asthma

Answer 6

episodic cough and chest tightness, worse after respiratory infections

Question 7

provocative concentration 20

Answer 7

methacholine dose that leads to 20% decrease in FEV1 in a challenge test; if < 4 mg/ml diagnosis is asthma; > 16 mg/ml is normal

Question 8

FP results on methacholine challenge can be due to

Answer 8

allergic rhinitis
COPD
heart failure
cystic fibrosis
bronchitis

Question 9

when is methacholine challenge test useful?

Answer 9

in evaluating pts w/ suspected asthma who have episodic symptoms and normal baseline spirometry

Question 10

PFTs in pt with neuromuscular respiratory failure

Answer 10

increased RV/TLC ratio
normal FEV1/FVC ratio
low maximum respiratory pressures
normal DLco

Question 11

increased RV/TLC ratio can be seen in..

Answer 11

obstructive disorders

neuromuscular disorders

Question 12

main CF of hepatopulmonary syndrome

Answer 12

dyspnea, platypnea (worse when sitting up), orthodeoxia (fall in PP of O2 when upright), hypoxemia in setting of chronic liver disease, normal CXR

Question 13

characteristic findings in pt with severe aortic stenosis

Answer 13

narrow pulse pressure
delayed, diminished carotid upstroke
sustained apical impulse
late peaking systolic ejection murmur radiating to carotids
S4

Question 14

characteristics findings in pt with ASD

Answer 14

fixed splitting of s2/ RV heave
atrial arrhythmias
pulmonary midsystolic flow murmur OR tricuspid diastolic flow rumble

Question 15

radiographic changes in spontaneous pneumothorax

Answer 15

loss of normal lung markings in periphery

well-defined visceral pleural line

Question 16

vocal cord dysfunction - symptoms

Answer 16

difficult to tell apart from asthma

• throat/neck discomfort
• wheezing/stridor
• anxiety

Question 17

diagnostic test of choice in suspected vocal cord dysfunction

Answer 17

1. laryngoscopy - reveals adduction of vocal cords during inspiration
2. flow-volume loops - inspiratory loop is flattened due to narrowing of airway at level of vocal cords during inspiration

Question 18

most common pulmonary manifestation in patient with systemic sclerosis

Answer 18

pulmonary arterial hypertension

Question 19

physical signs of pulmonary arterial HTN

Answer 19

loud P2, fixed split S2
pulmonic flow murmur
tricuspid regurgitation

Question 20

PFTs in pulmonary arterial HTN

Answer 20

isolated decreased DLco

normal airflow and lung volumes

Question 21

presence of which two findings points towards interstitial lung disease?

Answer 21

late inspiratory crackles

lung volumes < 80% predicted

Question 22

what diagnostic test should be done in suspected pulmonary artery HTN

Answer 22

echocardiography

Question 23

what features of pleural effusion make it more likely that it should be treated with chest tube drainage vs. antibiotics alone (7)

Answer 23

• assoc w/ pneumonia
• presence of loculated fluid
• pH < 7.2
• glucose level < 60
• LDH > 1000 IU/L
• positive gram stain or culture
• presence of gross pus in pleural space

Question 24

when is a CT scan ordered with pleural effusion?

Answer 24

• to detect very small effusions
• to determine thickness of pleural lining
• to distinguish empyema from lung abscess
• to detect underlying malignancy

Question 25

lung auscultation findings in pleural effusion

Answer 25

dullness on percussion diminished tactile fremitus absent breath sounds over effusion

Question 26

lung auscultation findings in lobar pneumonia

Answer 26

dullness on percussion reduced breath sounds increased tactile fremitis

Question 27

lung auscultation findings in pneumothorax

Answer 27

decreased breath sounds | hyperresonance on percussion

Question 28

pt presents with predominantly lymphocytic pale yellow pleural effusion (> 80% lymphocytes)

Answer 28

consider primary TB | - do pleural biopsy to evaluate

Question 29

dx. chylothorax

Answer 29

milky pleural fluid pleural fluid TG conc. > 110 mg/dL low pleural fluid cholesterol conc

Question 30

MCC of chylothorax

Answer 30

cancer trauma others: pulmonary TB, chronic mediastinal infection, sarcoidosis, lymphangioleoimyomatosis, radiation fibrosis

Question 31

in pt. with acute asthma exacerbation what does a normal or slightly elevated PCO2 mean?

Answer 31

need to intubate and mechanically ventilate the pt --> sign of impending respiratory failure

Question 32

indications for intubation and mechanical ventilation in pts with acute asthma attack

Answer 32

1. respiratory acidosis 2. hypoxemia 3. fatigue

Question 33

what do you give a pt. who developed unstable asthma disease after respiratory tract infection?

Answer 33

short course of oral steroids

Question 34

nebulizer therapy at home in asthma management should be reserved for who?

Answer 34

pts who cannot use MDI properly

Question 35

what do you do if your asthma patient becomes pregnant?

Answer 35

if asthma is well-controlled, keep her on the same regimen (SABA and inhaled corticosteroids are safe in pregnancy)

Question 36

what do you give next to a patient with persistent asthma not well controlled by low-mod dose inhaled corticosteroids?

Answer 36

add long acting B-agonist

Question 37

when do you consider theophylline and/or leukotriene antagonists in tx. of asthma?

Answer 37

in pts who remain symptomatic despite addition of long-acting B agonist to corticosteroids therapy

Question 38

main reason why pts with asthma do not respond well to specific asthma therapy

Answer 38

poor inhaler technique

Question 39

Tx. of acute exacerbation of COPD

Answer 39

oral or IV steroids short acting B2 agonist/anticholinergic antibiotics

Question 40

what antibiotics are used in acute COPD?

Answer 40

fluoroquinolone OR | third generation cephalosporin + macrolide

Question 41

criteria for Rx continuing oxygen therapy in COPD patients

Answer 41

1. PO2 < 55 mmHg OR 2. O2 sat < 88% w/ wo hypercapnia 3. pts with symptoms of pulm HTN, cor pulmonale, RHF or Hct > 56%

Question 42

when do you use methylxanthines in COPD pts?

Answer 42

only after long-acting bronchodilators have been tried

Question 43

what two therapies improve survival among COPD pts?

Answer 43

continuous O2 therapy | smoking cessation

Question 44

when should you consider inhaled corticosteroid therapy in COPD pt?

Answer 44

pt whose lung function is < 50% pts with severe/ frequent exacerbations (esp. beneficial when combined with LABA)

Question 45

suitable COPD candidates for NPPV

Answer 45

- pts with moderate-severe dyspnea - use of accessory respiratory muscles - RR > 25/min - pH < 7.35 w/ PCO2 > 45 mmHg

Question 46

C/I to NPPV

Answer 46

``` impending respiratory arrest cardiovascular instability altered mental status high aspiration risk production of copious secretions extreme obesity surgery, trauma deformity of upper airway or face ```

Question 47

what do you Rx. for a pt with COPD on maximal medical treatment?

Answer 47

pulmonary rehabilitation

Question 48

when do you consider lung transplant in COPD pts?

Answer 48

1. pts who are hospitalized w/ COPD exacerbation complicated by hypercapnia 2. pts with FEV1 < 20% and either homogenous dz on HRCT or DLCO < 20%

Question 49

ideal candidate for lung reduction surgery

Answer 49

1. predominantly upper lobe disease 2. FEV1 bw 20-35% predicted 3. DLco > 20% predicted 4. hyperinflation 5. no significant comorbidities

Question 50

what test do you need to do in a pt that presents with early onset COPD, esp. emphysema involving the lung bases?

Answer 50

a1-antitrypsin level

Question 51

diagnostic test to demonstrate sleep apnea

Answer 51

polysomnography and arterial blood gases

Question 52

how do you diagnose obesity-hypoventilation syndrome?

Answer 52

alveolar hypoventilation (PaCO2 > 45) in absence other known causes

Question 53

pt presents with subacute respiratory symptoms resembling respiratory tract infection but unresponsive to antibiotics; CXR shows bilateral alveolar-filling opacities - dx?

Answer 53

cryptogenic organizing pneumonia

Question 54

key radiographic feature of COP

Answer 54

tendency for COP opacities to "migrate" or involve different areas of the lung on serial examinations

Question 55

most specific CXR finding in asbestosis

Answer 55

bilateral partially calcified pleural plaques

Question 56

next best test in someone suspected of having diffuse parenchymal lung disease i.e. pt with CT disease and respiratory symptoms

Answer 56

high resolution CT scan

Question 57

drug-induced lung toxicity

Answer 57

presents as hypersensitivity reaction with symptoms of fatigue, low grade fever, cough and peripheral eosinophilia

Question 58

what drug(s) should be used for venous thromboembolism prophylaxis in hospitalized, medically ill patients?

Answer 58

unfractionated heparin LMWH fondaparinoux - C/I in renal impairment

Question 59

uses of lepirudin (direct thrombin inhibitor)

Answer 59

when a patient has heparin-induced thrombocytopenia

Question 60

what test do you do in someone w/ suspected PE, with elevated creatinine (i.e. kidney disease)

Answer 60

V/Q scan | - avoid CT angiography due to contrast

Question 61

how do you treat DVT?

Answer 61

therapeutic heparin and warfarin - heparin for atleast 5 days - warfarin only once INR > 2.0 for 24 hrs