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Flashcards in Pulmonology Deck (83):
1

A patient comes in with a severe asthma exacerbation but you don't hear any wheezing. What must be occurring?

Act fast. No wheezing is a sign of serious airflow obstruction

2

How are asthma and other reactive airway diseases confirmed on pulmonary function testing?

Rise in FEV1 > 12 seconds

3

Should asthmatics with respiratory acidosis be placed in the ICU?

Yes

4

Besides inhaled steroids, what are alternate long-term controller meds in patients with COPD?

Tiotropium, ipratropium

5

What is a critical lab to order in patients presenting with COPD and acute SOB?

ABG to assess carbon dioxide retention

6

Patients with COPD often have what baseline acid-base disturbance? Therefore, should you intubate patients with respiratory ____?

Respiratory acidosis from CO2 retention but also a high bicarbonate from compensatory degree of metabolic alkalosis.

Do not intubate just for respiratory acidosis, only if it is acutely worsening

7

What are CXR findings in a patient with COPD?

Hyperinflated lung fields, straightening of diaphragm, elongated heart, and substernal air trapping

8

What abnormality is present on CBC of patients with COPD?

Elevated hematocrit due reactive erythrocytosis from hypoxia (microcytic)

9

What should you find on PFT in a COPD patient?

FEV1: decreased
FVC: decreased
FEV1/FVC: decreased (

10

Can patients with COPD tolerate beta1-blockers?

Yes, almost all can

11

What is recommended chronic medical therapy for COPD?

Tiotropium/ipratropium inhaler
Albuterol
Smoking cessation
Heptavalent pneumococcal vaccine
Yearly influenza vaccine
Supplementary O2 if low sats regularly

12

Your patient presents with hyperinflated chest on CXR with a low albumin and prolonged PT. Dx?

Alpha-1 Antitrypsin Deficiency

13

What is tx of alpha-1 antitrypsin deficiency?

alpha-1 antitrypsin infusion

14

Buzzwords

CXR with 'tram tracking' of bronchi

Bronchiectasis

15

What is the most accurate test to dx bronchiectasis?

CT chest

16

What is tx of bronchiectasis?

There is no definitive tx. Chest physiotherapy and rotating antibiotics

17

Buzzwords

Glass workers, mining, sandblasting, brickyard worker

Silicosis (interstitial lung disease)

18

Buzzwords

Coal worker gets what ILD

Coal worker's pneumoconiosis

19

Buzzwords

Cotton (textile fiber dust) associated with what ILD

Byssinosis

20

Buzzwords

Electronics, ceramics, fluorescent light bulbs ILD

Berrylliosis

21

Buzzwords

Mercury associated with ILD

Pulmonary fibrosis

22

What are PFT findings in a patient with ILD?

FEV1: decreased
FVC: decreased
FEV1/FVC: normal to increased
RV: decreased
TLC: decreased
DLCO: decreased

23

What is the most common type of cancer associated with asbestosis?

Lung cancer

(NOT mesothelioma)

24

Generally there is no specific form of therapy which helps alleviate ILD. Which is the one form that may respond to steroid trials and why?

Berrylliosis bc it is a granulomatous disease

25

A patient presents with signs and symptoms very similar to ILD occurring for 3-4 weeks. The patient also has a fever and malaise. What is the likely dx?

Bronchiolitis oblilterans organizing pneumonia (BOOP) aka Cryptogenic organizing pneumonia (COP)

26

What is the most accurate test for making the dx of BOOP/COP?

Open lung bx

27

Unlike ILD, BOOP/COP has a response to what medications?

Steroids

28

Name the following extrapulmonary findings seen in sacoidosis:

Eye
Neural
Skin
Cardiac
Renal/Hepatic
Electrolyte

Eye: uveitis
Neural: CN VII involvement
Skin: Lupus pernioo (purplish lesion of skin on face), erythema nodosum
Cardiac: restrictive cariomyopathy; conduction defects
Renal/hepatic involvement: often asymptomatic
Electrolyte: hypercalcemia (due to vitamin D production by granulomas in sarcoidosis)

29

Best initial test for dx sarcoidosis

CXR (enlarged hilar lymph nodes)

30

Most accurate test for dx of sarcoidosis

Lung or lymph node biopsy with noncaseating granulomas

31

Buzzwords

Noncaseating granulomas

Sarcoidosis

32

Buzzwords

Elevations in calcium and/or ACE

Sarcoidosis

33

Best therapy for sarcoidosis

Steroids

34

Raynaud's phenomenon is associated with what pulmonary disorder?

Pulmonary hypertension

35

What is the most accurate test for pulmonary HTN?

Right heart catheterization

36

What is bosentan?

An endothelial inhibitor which prevents growth of pulm vasculature and can be used to treat pulm HTN

37

What are epoprostenol and treprostinil?

Prostacyclin analogs which dilate pulmonary vasculature and are used to treat pulm HTN

38

A patient presents with acute SOB but CXR and EKG are normal. What is a dx you must consider?

PE

39

If you're patient comes in with signs of right heart strain and hypotension what medicine should you quickly administer and for what problem?

May be a massive PE
Thrombolytics

40

Is it acceptable to provide heparin prior to confirming PE if it is a clear case?

Yes

41

What is the test of choice for dx of PE (especially when the CXR is abnormal)?

CT angiogram chest

42

In what situations is the V/Q scan useful in ruling out PE?

When the CXR is normal (the more normal the CXR the better V/Q is at ruling out). However, only a truly normal V/Q scan can rule out PE. If there is some question they can be unreliable

43

What is the sensitivity and specificity of the D-dimer test (general, not exact values)? In what situations is it most useful?

Highly sensitive but not very specific

Very good test in patients with a low probability of PE bc a negative will rule out PE

44

What is the most accurate test for PE? But what is it's downfall?

Angiography but it is invasive and has a mortality risk

45

What are D-dimers?

Fragments of fibrin which have been chopped up by plasmin. They can only be chopped off a few hours after a clot forms because after factor VIII stabilizes fibrin.

46

What is the immediate standard of care in PE?

Heparin and oxygen

Patients will need warfarin for 6 months after the PE

47

If a patient presents with PE and is unstable (with hypotension) what medicine can be given?

Thrombolytics

48

Best initial test to dx pleural effusion?
Most accurate test to dx pleural effusion?

Initial: CXR
Accurate: Thoracentesis

49

What are the threshold values for protein and LDH that are used to distinguish a transudative from an exudative pleural effusion?

Protein > 50% serum
LDH > 60% serum

Both the above support exudative

50

How are the below pleural effusions managed?

Small
Large
Large and recurrent

Small: Can do no therapy or diuretic
Large: Chest tube drainage
Large and recurrent: pleurodesis (pleural space obliterated by fusing two pleural surfaces)

*If pleurodesis fails then decortication

51

If weight loss and CPAP aren't helpful in OSA then what may be indicated?

Surgical resection of uvula, palate, and pharynx

52

How is central sleep apnea managed?

Avoid alcohol and sedatives
Acetazolamide (creates metabolic acidosis which ignites respiratory drive)
Medroxyprogesterone: central respiratory stimulant

53

An asthmatic patient presents with worsening symptoms, brown mucous plugs, recurrent infiltrates, central bronchiectasis, and peripheral eosinophilia with high IgE.

Dx?
Diagnostic testing?
Tx?

Allergic bronchopulmonary aspergillosis (ABPA)

Aspergillus skin testing, measure IgE levels, circulating precipitins, A. fumigatus-specific antibodies

Tx: oral corticosteroids and if refractory then itraconazole

54

Diffuse, patchy infiltrates on CXR may indicate what serious condition?

ARDS

55

What is PO2/FiO2 and how is it a helpful value?

If

56

What is the tidal volume goal of ARDS?

6mL/kg

57

What is the mgmt of ARDS?

Ventilatory support with PEEP and TV goal of 6mL/kg
Possibly diuretics and dobutamine
Prone positioning

58

How can the wedge pressure from a Swan-Ganz be used to distinguish different forms of shock?

It will be high in cardiogenic but low in septic and hypovolemic

59

Generally, ho does cardiac output differ among different shock states?

High in septic
Low in caridogenic and hypovolemic

60

Most common organism causing CAP

Pneumococcus

61

Most common organism causing HAP

Gram-negative bacilli

62

Best initial test for dx of PNA
Most accurate test

Initial: CXR
Accurate: Gram stain and culture sputum

63

Tx of outpatient PNA

Macrolide (azithromycin or clarithromycin)
Respiratory fluoroquinolone (levofloxacin or moxifloxacin)

64

Tx of inpatient PNA

Ceftriaxone and azithromycin
or Fluoroquinolone as single agent

65

Tx of ventilator-associated PNA

Imipenem or meropenem, piperacillin/tazobactam, or cefepime
Gentamicin and
Vancomycin or linezolid

66

Buzzwords

Cause PNA with recent viral syndrome

Staphylococcus (superimposed infection)

67

Buzzwords

Cause PNA in alcoholics

Klebsiella

68

Buzzwords

Cause of PNA with GI symptoms and confusion

Legionella

69

Buzzwords

Cause of PNA in young, healthy patients

Mycoplasma

70

Buzzwords

Cause of PNA in people present at birth of live animal

Coxiella burnetti

71

Buzzwords

Cause of PNA in Arizona construction workers

Coccidiodomycosis

72

Buzzwords

Cause of PNA with HIV and CD4

Pneumocystis

73

What is best tx of pneumocystis pneumonia?

Trimethoprim/sulfamethoxazole and possibly steroids

*Steroids indicated if PO2 35

74

Best initial test for TB dx
Confirmatry test for TB

Initial: CXR
Confirmatory: Acid fast stain and culture of sputum

75

Tx of TB

Isoniazid (6 months)
Rifampin (6 months)
Pyrazinamide (2 months)
Ethambutol (2 months)

76

All TB meds can lead to what toxicity?

Liver toxicity

(Stop if LFTs reach 5x upper limit)

77

Specific side effect of isoniazid

Peripheral neuropathy

78

Specific side effect of rifampin

Red/orange body secretions

79

Specific side effect of pryazinamide

Hyperuricemia

80

Specific side effect of ethambutol

Optic neuritis

81

Describe PPD thresholds

15mm: those without increased risk
10mm: healthcare workers, alcoholics, immigrants, homeless, prisoners (high risk)
5mm: active drug users, HIV positive, close TB contacts

82

What is 2-stage testing in TB?

If a patient hasn't been tested in a long time then do two serial tests to make sure truly negative

83

A positive IFN-gamma release assay for TB exposure is an indication for what treatment?

Isoniazid