Pulmonology Flashcards Preview

USMLE Step 3 > Pulmonology > Flashcards

Flashcards in Pulmonology Deck (164):
1

- SOB
- expiratory wheezing

asthma

2

- hyperventilation/increased RR
- decrease in peak flow
- hypoxia
- respiratory acidosis
- possible absence of wheezing

SEVERE asthma exacerbation

3

if asthma diagnosis is unclear

PFT before and after inhaled bronchodilators

4

asthma and reactive airway disease are CONFIRMED with what finding on PFT?

INCREASE in FEV1 of greater than 12%

5

ALL patients with SOB should receive the following

- oxygen
- continuous oximeter
- CXR
- ABG

6

best INITIAL treatment for asthma exacerbation

- inhaled bronchodilator (albuterol); no maximum dose
- steroid bolus (methylprednisolone)
- inhaled ipratropium (ACh receptor antagonist)
- oxygen
- magnesium

7

when should an asthma patient be placed in the ICU?

respiratory acidosis with CO2 retention

8

what is the indication for intubation and mechanical ventilation in asthma?

PERSISTENT respiratory acidosis

9

best INITIAL treatment for nonacute asthma

inhaled bronchodilator (albuterol)

10

if asthma patient is not controlled on inhaled bronchodilator (albuterol)

inhaled steroid

11

if patient is STILL not controlled on inhaled bronchodilator (albuterol), and inhaled steroids

inhaled long-acting beta agonist (LABA) (salmeterol, or formoterol)

12

alternate long-term controller medications besides inhaled steroids: extrinsic allergies, such as hay fever

cromolyn

13

alternate long-term controller medications besides inhaled steroids: atopic disease

montelukast

14

alternate long-term controller medications besides inhaled steroids: COPD

- tiotropium
- ipratropium

15

alternate long-term controller medications besides inhaled steroids: high IgE levels, no control with cromolyn

omalizumab (anti-IgE Ab)

16

last resort for uncontrolled nonacute asthma (if still not controlled on SABA, inhaled steroids, and LABA)

PO steroids (many adverse effects)

17

treatment for exercise-induced asthma

inhaled bronchodilator BEFORE exercise

18

- long-term smoker
- increasing SOB
- decreasing exercise tolerance

COPD

19

treatment for acute exacerbation of COPD

- oxygen (NOT TOO MUCH)
- ABG
- CXR
- inhaled albuterol
- inhaled ipratropium
- steroid bolus (methylprednisolone)

20

what should be added in treatment for acute exacerbation of COPD, if fever, sputum, and/or new infiltrate is present on CXR?

ceftriaxone and azithromycin for CAP

21

management of COPD with mild respiratory acidosis

BiPAP or CPAP

22

COPD physical examination findings

- barrel-shaped chest
- clubbing of fingers
- increased AP diameter mf chest
- loud P2 heart sound (pulmonary HTN)
- edema (blood backing up d/t pulmonary HTN)

23

EKG findings in COPD

- right axis deviation (RAD)
- right ventricular hypertrophy (RVH)
- right atrial hypertrophy (RAH)

24

CXR findings in COPD

- flattening of diaphragm
- elongated heart
- substernal air trapping

25

CBC findings in COPD

- increased hematocrit (sign of chronic hypoxia)
- microcytic

26

chemistry finding in COPD

increased serum bicarbonate

27

mechanism of right heart enlargement in COPD

hypoxia = capillary constriction in lungs = diffuse vasoconstriction = increased pressure in RV and RA

28

expected PFT results in COPD

- decreased FEV1
- decreased FVC (loss of elastic recoil of lung)
- decreased FEV1/FVC ratio
- increased TLC (d/t air trapping)
- increased residual volume (RV)
- decreased diffusion capacity lung carbon monoxide (DLCO) (destruction of lung interstitium

29

chronic treatment for COPD

- tiotropium/ipratropium
- albuterol
- pneumococcal vaccine
- influenza vaccine
- smoking cessation
- long-term home O2

30

when is home oxygen indicated in COPD?

- pO2 less than 55
- oxygen saturation less than 88%

31

what lowers mortality in COPD?

- smoking cessation
- home oxygen

32

- cirrhosis and COPD
- EARLY AGE (

a-1 antitrypsin deficiency

33

CXR findings in a-1 antitrypsin deficiency

- bullae
- barrel chest
- flat diaphragm

34

blood test findings in a-1 antitrypsin deficiency

- low albumin
- elevated PT (caused by cirrhosis)
- LOW a-1 antitrypsin level

35

treatment for a-1 antitrypsin deficiency

a-1 antitrypsin infusion

36

- anatomic defect of lungs (from infection in childhood)
- profound dilation of bronchi
- chronic resolving and recurring episodes of lung infection
- VERY HIGH volume of sputum
- hemoptysis
- fever

bronchiectasis

37

CXR finding in bronchiectasis

- dilated bronchi with "tram tracking"

38

MOST ACCURATE test for bronchiectasis

HRCT (high-resolution CT of chest)

39

treatment for bronchiectasis

- NO curative treatment
- chest PT
- rotating antibiotics

40

causes of interstitial lung disease (ILD)

- idiopathic
- occupational exposure
- environmental exposure
- medication

41

medications that can cause ILD

- trimethoprim/sulfamethoxazole
- nitrofurantoin

42

ILD cause = what disease?

asbestos

asbestosis

43

ILD cause = what disease?

glass workers, mining, sandblasting, brickyards

silicosis

44

ILD cause = what disease?

coal worker

coal worker's pneumoconiosis

45

ILD cause = what disease?

cotton

byssinosis

46

ILD cause = what disease?

electronics, ceramics, fluorescent light bulbs

berylliosis

47

ILD cause = what disease?

mercury

pulmonary fibrosis

48

- SOB with dry, nonproductive cough
- chronic hypoxia
- 6 months or more of symptoms

ILD

49

PE findings in ILD

- dry rales
- loud P2 heart sound (sign of pulmonary HTN)
- clubbing

50

CXR finding in ILD

interstitial fibrosis

51

diagnostic tests for ILD

- CXR
- HRCT
- lung biopsy
- PFT

52

PFT findings in ILD

- decreased FEV1
- decreased FVC
- NORMAL FEV1/FVC ratio (equally decreased)
- decreased TLC
- decreased DLCO

53

treatment for ILD

- no specific treatment

54

if biopsy show inflammatory infiltrate in ILD, what is the treatment?

steroid trial

55

ONLY form of ILD that DEFINITELY responds to steroids

berylliosis

56

- bronchiolitis and alveolitis
- more acute than ILD, presents in days to weeks
- cough, rales, and SOB
- fever, malaise, and myalgias (ABSENT in ILD)

bronchiolitis obliterans organizing pneumonia (BOOP)

(aka, cryptogenic organizing pneumonia (COP))

57

CXR finding in BOOP

B/L patchy infiltrates

58

chest CT findings in BOOP

interstitial disease and alveolitis

59

MOST ACCURATE test for BOOP

open lung biopsy

60

treatment for BOOP

steroids

(no response to antibiotics)

61

- black, female, less than 40 yoa
- cough, SOB, and fatigue over a few weeks to months
- rales

sarcoidosis

62

best INITIAL test for sarcoidosis

CXR (enlarged lymph nodes, and maybe ILD)

63

MOST ACCURATE test for sarcoidosis

lung or LN biopsy (NONcaseating granulomas)

64

what will BAL show in sarcoidosis?

increased # of helper cells

65

best treatment for sarcoidosis

steroids

66

- SOB, more often in young women

pulmonary hypertension

67

pulmonary HTN can occur 2/2?

- MS
- COPD
- PV
- chronic PE
- ILD

68

PE findings in pulmonary hypertension

- loud P2
- TR
- right ventricular heave
- Raynaud's phenomenon

69

TTE findings in pulmonary hypertension

- RVH
- enlarged RA

70

EKG finding in pulmonary hypertension

RAD

71

MOST ACCURATE test for pulmonary hypertension

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

72

treatment for pulmonary hypertension

- bosentan (endothelin inhibitor)
- epoprostenol/treprostinil (prostacyclin analogs = pulmonary vasodilators)
- CCB
- sildenafil

73

- SUDDEN SOB
- CLEAR lungs
- patient with risk factors for DVT: immobility, malignancy, trauma, surgery, hematological abnormalities

pulmonary embolism

74

CXR findings in PE

- MC result is NORMAL
- MC ABNORMALITY is atelectasis

75

EKG findings in PE

- SINUS TACHYCARDIA
- MC abnormality is nonspecific ST-T wave changes
- RAD/RBBB (uncommon)

76

ABG findings in PE

- hypoxia
- increased A-a gradient
- mild respiratory alkalosis (2/2 hyperventilation)

77

mechanism of right heart strain in PE

severe pressure increase in PA and RV d/t clot

78

standard test to confirm PE

CTA

79

for a V/Q scan to be accurate, the CXR MUST be

NORMAL

(the less normal the CXR, the LESS accurate the V/Q scan)

80

if V/Q scan is low-probability, does it exclude PE

NO, 15% still have a PE

81

if V/Q scan is high-probability, does it definitely include PE

NO, 15% don't have a PE

82

sensitivity of LE doppler

70%

83

if D-dimer is negative

PE extremely unlikely

84

MOST ACCURATE test for PE

angiography

85

patient with PE and CONTRAINDICATION to AC, next step in management

IVC filter

86

treatment for PE

- heparin and O2
- warfarin for AT LEAST 6 MONTHS

87

treatment for PE in HEMODYNAMICALLY UNSTABLE patient (hypotension)

thrombolytics

88

thrombolytics MOA

activate plasminogen to plasmin

89

best INITIAL test for pleural effusion

CXR

90

next step after CXR for pleural effusion

decubitus films with pt lying down

91

MOST ACCURATE test for pleural effusion

thoracentesis

92

pleural effusion: exudate

causes and lab findings

- cancer
- infection

- HIGH protein (> 50% of serum level)
- HIGH LDH (> 60% of serum level)

93

pleural effusion: transudate

causes and lab findings

- CHF

- LOW protein (

94

treatment for SMALL pleural effusion

- NO treatment needed
- diuretics can be used, especially for CHF

95

treatment for LARGER pleural effusion, especially from infection (empyema)

chest tube

96

treatment for LARGE, and RECURRENT pleural effusions

pleurodesis

97

treatment if pleurodesis FAILS

decortication (stripping of pleura from lung)

98

- obese patient
- daytime somnolence
- severe snoring
- HTN, HA, ED, fat neck

sleep apnea

99

MCC of sleep apnea (95% of cases)

fatty tissue of neck blocking breathing

100

cause of small % of patients with sleep apnea

central sleep apnea (decreased respiratory drive from CNS)

101

how is sleep apnea diagnosed?

sleep study (polysomnography)

102

definition of MILD sleep apnea

5-20 apneic episodes/hour

103

definition of SEVERE sleep apnea

more than 30 apneic episodes/hour

104

treatment for sleep apnea: OBSTRUCTIVE DISEASE

- weight loss
- CPAP (continuous positive airway pressure, or BiPAP

105

if initial treatment for sleep apnea: OBSTRUCTIVE DISEASE is not effective

- surgical resection of uvula, palate, and pharynx

106

treatment for sleep apnea: CENTRAL SLEEP APNEA

- avoid alcohol and sedative
- acetazolamide (causes metabolic acidosis = helps drive respiration)
- medroxyprogesterone (central respiratory stimulant)

107

mechanism of acetazolamide

carbonic anhydrase inhibitor

108

- asthmatic patient with WORSENING asthma symptoms
- brown mucous plug production
- recurrent infiltrates
- peripheral eosinophilia
- elevated serum IgE
- central bronchiectasis

allergic bronchopulmonary aspergillosis (ABPA)

109

diagnostic tests for allergic bronchopulmonary aspergillosis (ABPA)

- Aspergillus skin testing
- IgE
- precipitins
- A. fumigatus-specific Ab

110

treatment for allergic bronchopulmonary aspergillosis (ABPA)

ORAL corticosteroids

111

allergic bronchopulmonary aspergillosis (ABPA) treatment in refractory disease if steroids don't work

itraconazole

112

- sudden, SEVERE respiratory failure syndrome
- diffuse lung injury 2/2 OVERWHELMING systemic injuries

acute respiratory distress syndrome (ARDS)

113

possible ARDS causes

- sepsis
- aspiration of gastric contents
- shock
- infection: pulmonary or systemic
- lung contusion
- trauma
- toxic inhalation
- near drowning
- pancreatitis
- burns

114

CXR finding in ARDS

diffuse patchy infiltrates that become confluent

115

wedge pressure in ARDS

NORMAL

116

pO2/FIO2 ratio in MILD ARDS

201-300

117

pO2/FIO2 ratio in MODERATE ARDS

101-200

118

pO2/FIO2 ratio in SEVERE ARDS

100 OR LESS

119

treatment for ARDS

- ventilator
- positive end expiratory pressure (PEEP) (keep alveoli open)
- prone positioning
- diuretics
- positive inotropes (dobutamine)
- ICU

120

Swan-Ganz (pulmonary artery) catheterization:

HYPOVOLEMIA

- cardiac output
- wedge pressure
- systemic vascular resistance (SVR)

- LOW
- LOW
- HIGH

121

Swan-Ganz (pulmonary artery) catheterization:

CARDIOGENIC SHOCK

- cardiac output
- wedge pressure
- systemic vascular resistance (SVR)

- LOW
- HIGH
- HIGH

122

Swan-Ganz (pulmonary artery) catheterization:

SEPTIC SHOCK

- cardiac output
- wedge pressure
- systemic vascular resistance (SVR)

- HIGH
- LOW
- LOW

123

- fever
- cough
- +/- sputum
- SOB

pneumonia

124

CAP organism

pneumococcus

125

HAP organism

gram-negative bacilli

126

CURB 65

- confusion
- BUN greater than 19
- RR greater than 30
- BP less than 90/60
- age greater than 65

127

best INITIAL diagnostic test for pneumonia

CXR

128

MOST ACCURATE test for pneumonia

sputum gram stain and culture

129

pneumonia with SOB, order

oxygen

130

pneumonia with SOB and/or hypoxia, order

ABG

131

OUTPATIENT treatment for pneumonia

macrolide OR respiratory fluoroquinolone

macrolide = azithromycin/clarithromycin
fluoroquinolone = levofloxacin/moxifloxacin

132

INPATIENT treatment for pneumonia

- ceftriaxone, AND azithromycin

OR

- fluoroquinolone ONLY

133

treatment for ventilator-associated pneumonia (VAP)

- imipenem/meropenem, piperacillin/tazobactam, or cefepime

AND

- gentamicin

AND

- vancomycin/linezolid

134

does a positive sputum culture mean pneumonia?

NO

135

specific associations for pneumonia:

recent viral syndrome

Staphylococcus

136

specific associations for pneumonia:

alcoholic

Klebsiella

137

specific associations for pneumonia:

GI symptoms, confusion

Legionella

138

specific associations for pneumonia:

young, healthy patient

Mycoplasma

139

specific associations for pneumonia:

birth of animal (placenta)

Coxiella burnetii

140

specific associations for pneumonia:

Arizona construction worker

Coccidioidomycosis

141

specific associations for pneumonia:

HIV with CD4 count less than 200

Pneumocystis jirovecii (PCP)

142

ventilator-associated pneumonia

- fever
- hypoxia
- new infiltrate
- increasing secretions

143

when should steroids be given in PCP pneumonia?

- pO2 less than 70
- A-a gradient more than 35

144

- risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics)
- fever, cough, sputum, weight loss, night sweats

tuberculosis (TB)

145

best INITIAL test for tuberculosis (TB)

CXR

146

test to confirm TB

sputum acid-fast stain and culture

147

treatment for TB

1. isoniazid (INH) x 6 mos
2. rifampin x 6 mos
3. pyrazinamide x 2 mos
4. ethambutol x 2 mos

148

ALL the antituberculosis medications can cause?

hepatotoxicity

149

when should antituberculosis medications be stopped if transaminases become elevated?

reach 5x upper limit of normal

150

adverse effect of isoniazid

peripheral neuropathy

151

adverse effect of rifampin

red/orange-colored bodily secretions

152

adverse effect of pyrazinamide

hyperuricemia

153

adverse effect of ethambutol

optic neuritis

154

which conditions require TB treatment for MORE THAN 6 months

- osteomyelitis
- meningitis
- miliary TB
- cavitary TB
- pregnancy

155

what is a POSITIVE PPD test?

5mm: close contacts, pts on steroids, HIV-positive
10mm: risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics, healthcare workers)
15mm: those without increased risk

156

if a patient has NEVER been tested for TB, how should the patient be tested?

2-stage testing

(if FIRST test is NEGATIVE, repeat test in 1-2 WEEKS to confirm)

157

what is the indication for IGRA (interferon gamma release assay) (Quantiferon)?

same as PPD

158

what is the lifetime risk for HIV-UNinfected individuals with latent TB infection developing active TB d/t reactivation?

10%

159

what is the lifetime risk for HIV-INFECTED individuals with latent TB infection developing active TB d/t reactivation?

10%/year!

160

if PPD is POSITIVE, next step?

CXR

161

if PPD is positive, and CXR is ABNORMAL, next step?

sputum staining for TB

162

if sputum staining for TB is POSITIVE, next step?

treat with full-dose, 4-drug therapy

163

if PPD is POSITIVE, but CXR is NEGATIVE

isoniazid ALONE for 9 MONTHS

164

once a PPD is POSITIVE, should you repeat it?

NEVER