Respiratory

Question 1

Asthma?

Answer 1

Start with Symbicort PRN and up to 8 puffs a day as a scheduled or PRN medication (can be used as a rescue medication).

Asthma - needs ICS to improve. LABA now first line. SABA not so much.

Question 2

COPD Tx?

Answer 2

Start with a LAMA - often Spiriva, can move to a LAMA/ LABA combo and then add on a ICS if needed

Question 3

3 pillars of CAP Dx?

Answer 3

Evidence of infection (fever/ malaise)
Sx localized to the respiratory system (cough/ sputum)
Chest imaging (infiltrates)

Question 4

When should you get a gram stain and culture in CAP

Answer 4

Inpatients, severe, empiric MRSA pseudomonas tx, or risk of HCAP.

Question 5

Should you get blood cultures on a patient with CAP?

Answer 5

Not routinely, no

Question 6

Prediction of severity of pneumonia?

Answer 6

PSI or CURB-65, with evidence for PSI

Question 7

Should this patient with CAP go to the ICU?

Answer 7

IDSA 2007 major criteria or 3 minor warrants ICU admission

Question 8

Tx for CAP for outpatients?

Answer 8

Outpatient, for no comorbidities - Amoxicillin 1g TID, or Doxycycline 100mg BID, AZT is not so strongly recommended

Comorbidities: combo Amox/clav + macrolide or quinolone (moxiflox/levoflox)

Question 9

Inpatients without risk of MRSA/pseumonas tx?

Answer 9

Ceftriaxone or quinolone

No need to add on add on anaerobic coverage for aspiration pneumonia unless lung abscess/ very severe

Question 10

CAP with positive for flu - still give antibiotics?

Answer 10

Yes, usually a co-infection.

Question 11

Bronchiectasis managment?

Answer 11

Get a sputum sample, and start empiric abx

Question 12

Treat lung abcess with?

Answer 12

21-48 days of Amox-clav or other beta lactam - inhibitor combos or penems?

Question 13

Empyema tx?

Answer 13

Thoracentesis or chest tube drainage need to control the source and IV abx - 3rd gen cephalosporins +metronidazole

Question 14

Risk factors for lung CA?

Answer 14

Smoking (duration more important than amount)
Occupational exposures
Genetic predisposition
Radiation exposure

Question 15

Types of Lung CA?

Answer 15

Small cell 
Pancoast (location in the upper part of the lung) 
NSLC: 
- Adenocarcinoma 
- Squamous cell 
- Large Cell

Question 16

Features of Adenocarcinoma?

Answer 16

Not necessarily related to smoking
Diffuse and might be more peripheral
Subtype in bronchioles - might present as an unrelenting pneumonia
Female

Question 17

Squamous cell CA features?

Answer 17

Hilar findings more like a cavitary lung lesion

Associated with smoked

Question 18

Small cell features?

Answer 18

Very aggressive, lots of Mets, smokers centrally located

Can measure chromogranin - this is a neuroendocrine tumour

Question 19

Carcinoids of the lung?

Answer 19

Like pre-small cell CA, endobrachial can be removed easily

Question 20

Common Mets location for Lung CA?

Answer 20

Liver, brain, bone, adrenals

Question 21

Pancoast lung ca presentation?

Answer 21

More likely to show SVC occlusion symptoms (edema of the neck) and hoarseness and dysphagia (recurrent laryngeal, esophagus), horner’s syndrome , brachial plexus involvement, horner’s syndrome

Question 22

What is paraneoplastic syndrome?

Answer 22

The effect of the cancer on the immune system or hormonal signalling

• SIADH
• Etopic Cushing
• Neurological (MG, Eaton- Lambert, dementia)
• Hypercoagulation
• Hypercalcemia

Question 23

Horner’s syndrome?

Answer 23

Mitosis (constriction), ptosis, and anhidrosis (no face sweat)

Question 24

Pemberton sign?

Answer 24

SVC occlusion, raise arm above the head, face turns bright red

Question 25

Screening for Lung CA

Answer 25

Low dose CT - 3 consecutive years then stop Over 55-74, with 30 pack year, who smoke or quit less than 15 years ago Diagnosis pathway: https://www.cancercareontario.ca/en/pathway-maps/lung-cancer

Question 26

CXR findings suspicious for lung CA

Answer 26

Nodule - less than 3cm Mass - more than 3cm Both can be indicative for lung CA (the bigger the more concerning) Pleural effusion Hilar and mediastinal adenopathy Elevated hemidiaphragm

Question 27

Questions to ask if suspicious of lung CA

Answer 27

COPD, Pulmonary fibrosis, radiation exposures, past CA, family history, TB Can think of like this: Constitutional Sx, Metastatic sx, Local sx and risk factor *Also drug coverage. Try to r/out PE/ ACS

Question 28

Cancer performance status measure?

Answer 28

ECOG

Question 29

Hamman’s sign?

Answer 29

A crunching, rasping sound in time with heart beat - heart beating against the air filled mediastinum. Hamman syndrome - pneumomediastinum after excessive pressure such as childbirth, asthma, valsalva

Question 30

Airway sizes and adventitious sounds

Answer 30

Wheezes (smaller), Ronchi (medium), Stridor (large airway)

Question 31

Legionella?

Answer 31

Dyspnea, cough, diarrhea - order an legionella urinary antigen disease.

Question 32

Milliary TB

Answer 32

Acute, severe TB

Question 33

Causes of Pulmonary HTN?

Answer 33

``` Group 1 (directly on vasculature): Idiopathic, Genetic, drugs, HIV, sickle cell disease, Porto pulmonary, connective tissue disease Tx: with pulmonary vasodilators ``` Group 2 (more pressure): Left heart failure, valvular disease, Congenital heart disease Group 3 (hypoxia): COPD, interstitial lung disease, sleep apnea (increases risk factors), Group 4 (obstructive): PE/VTE, malignancy can cause this too, chronic thromboembolic pulmonary hypertension Group 5: misc weird stuff

Question 34

Criteria for pulmonary hypertension

Answer 34

Mean pulmonary artery pressure of >20mmHg Measure the Right ventricular systolic pressure >40mmHg (echo) and then follow up with a right heart catheter to get the mean PAP, PVR >3 and PCWP <15

Question 35

Work up for Pulmonary Hypertension

Answer 35

Should test for HIV, examine joints, ANA/RF/anti-CCP, ECHO (and treat any heart disease), give O2, work up for sleep apnea, get a V/Q scan (for pulmonary embolism) If all negative become concerned for pulmonary arterial hypertension- need right heart cath. Check Pulmonary capillary wedge pressure (should be less than 15mmHg)

Question 36

Treatment of Pulmonary arterial HTN

Answer 36

1) phosphodiesterase 5 2) endothelin antagonists 3) prostacyclin agonists

Question 37

One of the first signs of diabetic kidney disease?

Answer 37

High urine protein, long before there is a Cr rise, this counts as chronic kidney disease