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Pulmonology USMLE Step 3 > Section 4: > Flashcards

Section 4: Flashcards

3
Q

Peripherally located lung cancers

A

Large cell carcinoma

Adenocarcinoma

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4
Q

Lung ca associated with cavitation

A

Large cell ca

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5
Q

Lung ca associated with pleural effusion with high hyaluronidase levels

A

Adenocarcinoma

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6
Q

Most common initial presentation of cystic fibrosis

A

Meconium ileus

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7
Q

Other clinical features of cystic fibrosis

A

Failure to thrive

Rectal prolapse

Persistent cough

May also present with

  • Infertility
  • Allergic bronchopulmonary aspergillosis
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8
Q

Cystic Fibrosis:

Best initial and most specific test

A

2 elevated sweat chloride concentrations (> 60 mEq/ L) obtained on separate days.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 11299-11300). . Kindle Edition.

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9
Q

List the supportive care in the Rx of cystic fibrosis

A

Aerosol treatment

Albuterol/ saline

Chest physical therapy with postural drainage

Pancrelipase: Aids digestion in patients with pancreatic dysfunction.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 11308-11309). . Kindle Edition.

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10
Q

List and explain Rx that improve survival in patients with cystic fibrosis

A

Ibuprofen is used to reduce inflammatory lung response and slows the patient’s decline.

Azithromycin has also been shown to slow rate of decline in FEV1 in patients < 13 years.

Antibiotics during exacerbations delay progression of lung disease.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 11311-11314). . Kindle Edition.

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11
Q

What are the other management considerations in cystic fibrosis

A

Give all routine vaccinations plus pneumococcal and yearly flu vaccines.

Never delay antibiotic therapy (even if fever and tachypnea are absent).

Steroids improve PFTs in the short term, but there’s no persistent benefit when steroids are stopped.

Expectorants (guaifenesin or iodides) are not effective in the removal of respiratory secretions.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 11316-11318). Kindle Edition.

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12
Q

Antibiotics to Rx cystic fibrosis

  1. Mild disease
  2. Documented infection with Pseudomonas or S. aureus
  3. Resistant pathogens
A

Mild disease: Give macrolide, trimethoprim-sulfamethoxazole (TMP-SMX), or ciprofloxacin

Documented infection with Pseudomonas or S. aureus: Treat aggressively with piperacillin plus tobramycin or ceftazidime

Resistant pathogens: Use inhaled tobramycin.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 11319-11326). . Kindle Edition.

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13
Q

Features that indicate benign solitary lung nodule (on chest X-ray): “low risk”

A

Non-smokers

Lesions

Smooth distinct margins

Calcification typical of benign lesions

  • Popcorn: Harmatomas
  • Bull’s eye: Granulomas

No change in size of nodule compared to an older X-ray

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14
Q

Features that indicate benign solitary lung nodule (on chest X-ray): “high risk”

A

>50 years

Lesions >2cm

Smoker

Irregular contours

No calcification

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15
Q

Management of solitary pulmonary nodule

A
  • Find old X-ray for comparison
    • If available compare dates and determine doubling time (480 days means beningn lesion)
    • Chest X-ray not available: determine low or high risk
      • If low risk do spiral CT scan every 3 months for 2 years; nochange - stop CT scans with no further intervention BUT if lesion double manage with open lung biopsy and resection
      • If high risk do open lung biopsy and resection

N/B: Doublimg time measures volume and not diameter - doubling time between 1 month and 480 days is suspicious for malignancy

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16
Q

What is A-a gradient?

A

A-a gradient is alveolar-arterial gradient (PAO2-PaO2 gradient). It is a useful calculation for the assessment of oxygenation. A-a gradient increases with age and is only valid in room air. It is calculated as follows:

PA02-Pa02 gradient = 150 - 1.25 X PaCO2 - PaO2

i.e.,

A-a gradient = [150 - (1.25 X PaCO2) - PaO2]

This gradient is between 5 and 15 mmHg in normal young adults. It increases with all causes of hypoxemia except hypoventilation and high altitude

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17
Q

List the typical physical findings in COPD

A

Barrel-shaped chest

Clubbing of fingers

Increased anterior-posterior diameter of the chest

Loud P2 heart sound (sign of pulmonary hypertension)

Edema as a sign of decreased right ventricular output (the blood is backing up due to the pulmonary hypertension)

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18
Q

Laboratory findings in COPD

A

EKG: Right axis deviation, right ventricular hypertrophy, right atrial hypertrophy

Chest x-ray: Flattening of the diaphragm (due to hyperinflation of the lungs), elongated heart, and substernal air trapping

CBC: Increased hematocrit is a sign of chronic hypoxia. Reactive erythrocytosis from chronic hypoxia is often microcytic. An erythropoietin level is not necessary.

Chemistry: Increased serum bicarbonate is metabolic compensation for respiratory acidosis.

ABG: Should be done even in office-based cases to assess CO2 retention and the need for chronic home oxygen based on pO2 (you expect the pCO2 to rise and the pO2 to fall).

Pulmonary function testing (PFT): You should expect to find the following:

– Decrease in FEV1

– Decrease in FVC from loss of elastic recoil of the lung

– Decrease in the FEV1/ FVC ratio

– Increase in total lung capacity from air trapping

– Increase in residual volume

– Decrease in diffusion capacity lung carbon monoxide (DLCO) caused by destruction of lung interstitium

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19
Q

Chronic medical therapy for COPD

A

Tiotropium or ipratropium inhaler

Albuterol inhaler

Pneumococcal vaccine: Heptavalent vaccine,

Pneumovax Influenza vaccine: Yearly

Smoking cessation

Long-term home oxygen if the pO2 < 55 or the oxygen saturation is < 88 percent

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20
Q

Name two interventions that lower mortality in COPD

A

Smoking cessation

Home oxygen therapy (continuous)

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21
Q

Spot Diagnosis: A case of COPD at an early age (< 40) in a nonsmoker who has bullae at the bases of the lungs.

A

Alpha-1 antitrypsin deficiency

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22
Q

Rx for alpha-1 antotrypsin deficiency

A

Alpha-1 antitrypsin infusion

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23
Q

What is the most accurate diagnostic test for bronchiectasis?

A

High-resolution CT scan of the chest.

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24
Q

Medication associated with lung fibrosis

A

Nitrofurantoin

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25
Q

What is the most common type of cancer in asbestosis?

A

Lung Cancer

(NOT MESOTHELIOMA)

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26
Q

Causes of silicosis

A

Glass workers

Mining

Sandblasting

Brickyards

27
Q

Causes of berylliosis

A

Electronics

Ceramics

Fluorescent light bulbs

28
Q

Name the interstitial lung disease caused by mercury

A

Pulmonary fibrosis

29
Q

Name the interstitial lung disease caused by cotton

A

Byssinosis

30
Q

Enumerate the PFT in ILD

A

Decreased FEV1

Decreased FVC

FEV1/FVC ratio is normal or increased

Decreased total lung capacity

Decreased DLCO

All the measures are decreased, but they are decreased proportionately.

31
Q

List and explain the rare physical findings in Sarcoidosis

A

Eye: Uveitis that can be sight threatening

Neural: Seventh cranial nerve involvement is the most common.

Skin: Lupus pernio (purplish lesion of the skin of the face), erythema nodosum

Cardiac: Restrictive cardiomyopathy, cardiac conduction defects

Renal and hepatic involvement: Occurs without symptoms

Hypercalcemia: This occurs in a small number of patients secondary to vitamin D production by the granulomas of sarcoidosis.

32
Q

Best initial test for Sarcoidosis

A

Chest x-ray, which always shows enlarged lymph nodes.

33
Q

Most accurate diagnostic test for Sarcoidosis

A

Lung or lymph node biopsy showing noncaseating granulomas.

34
Q

Other important but non-specific tests for Sarcoidosis

A

Calcium and ACE levels may be elevated, but these are not specific enough to lead to a specific diagnosis.

Bronchoalveolar lavage shows increased numbers of helper cells.

35
Q

Therapy for Sarcoidosis

A

Steroids

36
Q

Secondary causes of pulmonary hypertension

A

Mitral stenosis

COPD

Polycythemia vera

Chronic pulmonary emboli

Interstitial lung disease

37
Q

Physical findings in pulmonary hypertension

A

Loud P2

Tricuspid regurgitation

Right ventricular heave

Raynaud’s phenomenon

38
Q

List and explain diagnostic tests in pulmonary hypertension

A

Transthoracic echocardiogram (TTE): Shows right ventricular hypertrophy and enlarged right atrium

EKG: Shows the same findings as well as right axis deviation

Most accurate test: Right heart catheterization (Swan-Ganz catheterization) with increased pulmonary artery pressure

39
Q

Enumerate Rx for pulmonary hypertension

A

Bosentan is an endothelin inhibitor that prevents growth of the vasculature of the pulmonary system.

Epoprostenol and treprostinil are prostacyclin analogs that act as pulmonary vasodilators.

Calcium channel blockers (weak efficacy)

Sildenafil

40
Q

Describe pulmonary embolism (PE)

A

PE presents with the sudden onset of shortness of breath and clear lungs in patients with risk factors for deep venous thrombosis (DVT).

41
Q

List the risk factors for DVT

A

Immobility

Malignancy

Trauma

Surgery, especially joint replacement

Thrombophilia, such a factor V mutation, lupus anticoagulant, or protein C and S deficiency

42
Q

What are the specific physical findings in PE?

A

None

43
Q

Diagnostic tests for PE

A

Chest x-ray: The most common result is normal. The most common abnormality found is atelectasis. Wedge-shaped infarction and pleural-based humps are rare.

EKG: The most common showing is sinus tachycardia. The most common abnormality is nonspecific ST-T wave changes. Right axis deviation and right bundle branch block are uncommon.

ABG: This shows hypoxia with an increased A-a gradient and mild respiratory alkalosis.

44
Q

List and explain the confirmatory test for PE

A

Spiral CT

A spiral CT is standard to confirm the presence of a pulmonary embolus. The spiral CT is excellent if it is positive because of its specificity. The sensitivity of spiral CT may not be ideal, and the test can miss some emboli if they are small and in the periphery. The spiral CT is clearly the test of choice if the x-ray is abnormal.

V/ Q Scan

For a V/ Q scan to be accurate, the chest x-ray must be normal. The less normal the x-ray, the less accurate the V/ Q scan. This is still a good test for PE. The problem is that only a truly normal scan excludes a PE. Of patients with low-probability scans, 15 percent still have a PE, and 15 percent of those with of high-probability scans don’t have a PE.

Lower Extremity Doppler

These are excellent tests if they are positive; if positive, no further diagnostic testing is necessary. The problem is that 30 percent of PEs originate in pelvic veins, and the Doppler scan is normal even in the presence of a PE. Hence, the sensitivity of lower extremity Doppler is about 70 percent.

D-Dimer Testing

This is a very sensitive test with poor specificity. If the D-dimer is negative, PE is extremely unlikely. The best use of D-dimer testing is in a patient with a low probability of PE in whom you want a single test to exclude PE.

Angiography

Angiography is the single most accurate test for PE. Unfortunately, angiography is invasive with a significant risk of death of about 0.5 percent.

45
Q

When a patient has a pulmonary embolism and there is a contraindication to anticoagulation, what should be the next line of action?

A

Place an inferior vena cava filter

46
Q

Outline the Rx for PE

A

Heparin and oxygen: This is the standard of care in pulmonary embolism.

Warfarin: Should be used for at least 6 months after the use of heparin.

Venous interruption filter: This should be placed in all patients who have a contraindication to anticoagulation.

Thrombolytics: These are used in patients who are hemodynamically unstable. Hemodynamic instability can be defined as hypotension. Thrombolytics essentially replace embolectomy, which is rarely performed because of the high operative mortality.

47
Q

Diagnostic tests for pleural effusion

A

Best initial test: Chest x-ray. Decubitus films with the patient lying on one side should be done next to see if the fluid is freely flowing.

Chest CT may add a little more detail to a chest x-ray.

Most accurate test: Thoracentesis

48
Q

List the tests to be carried on pleural fluid for a patient with pleural effusion

A

Gram stain and culture

Acid-fast stain

Total protein (also order serum protein)

LDH (also order serum LDH)

Glucose

Cell count w/ differential

Triglycerides

pH

49
Q

Name causes of transudative pleural effusion

A

CHF

Pulmonary embolism

Liver Cirrhosis

Nephrotic syndrome

Atelectasis

50
Q

Name causes of exudative pleural effusion

A

Pneumonia (parapneumonic effusions)

Cancer (lung, breast, lymphoma)

Empyema

Pulmonary embolism

Tuberculosis (TB)

Collagen Vascular Diseases (RA, SLE)

Pancreatitis

Drug induced

51
Q

List the features of transudative pleural effusion

A

LDH (lactate dehydrogenase) of pleural effusion of

LDH Pleural/Serum ratio

Protein Pleural/Serum ratio

(Remember 200, 0.6 and 0.5)

52
Q

List the features of exudative pleural effusion

A

LDH (lactate dehydrogenase) of pleural effusion of >200 IU/mL

LDH Pleural/Serum ratio >0.6

Protein Pleural/Serum ratio >0.5

53
Q

Rx of pleural effusion

A

Small pleural effusions do not need therapy.

Diuretics can be used, especially for those caused by congestive heart failure (CHF).

For larger effusions, especially those caused by infection (empyema), a chest tube for drainage is placed.

If the effusion is large and recurrent from a cause that cannot be corrected, pleurodesis is performed. Pleurodesis is the infusion of an irritative agent, such as bleomycin or talcum powder, into the pleural space. This inflames the pleura, causing fibrosis so the lung will stick to the chest wall. When the pleural space is eliminated, the effusion cannot reaccumulate.

If pleurodesis fails, decortication is performed. Decortication is the stripping off of the pleura from the lung so it will stick to the interior chest wall. This is an operative procedure.

54
Q

Management of central sleep apnea

A

Central sleep apnea is managed by avoiding alcohol and sedatives.

It may respond to acetazolamide, which causes a metabolic acidosis. This may help drive respiration.

Some patients respond to medroxyprogesterone, which is also a central respiratory stimulant.

55
Q

Diagnosis: Patient presents as an asthmatic with worsening asthma symptoms who is coughing up brownish mucous plugs with recurrent infiltrates. There is peripheral eosinophilia. Serum IgE is elevated. Central bronchiectasis is visible.

A

Allergic Bronchopulmonary Aspergillosis (ABPA)

56
Q

Diagnostic tests for ABPA

A

Aspergillus skin testing

Measurement of IgE levels, circulating precipitins, and A. fumigatus-specific antibodies

57
Q

Rx of ABPA

A

Corticosteroids

Itraconazole for refractory disease

58
Q

List the causes of acute respiratory distress syndrome (ARDS)

A

Sepsis

Aspiration of gastric contents

Shock Infection: pulmonary or systemic

Lung contusion

Trauma

Toxic inhalation

Near drowning

Pancreatitis

Burns

59
Q

Diagnostics tests for ARDS

A

Chest x-ray: This shows diffuse patchy infiltrates that become confluent. May suggest congestive failure.

Normal wedge pressure

pO2/ FIO2 ratio < 200, with the FIO2 expressed as a decimal (e.g., room air is 0.21). For example, if the pO2 is 100/ 0.21, the ratio is 476.

60
Q

Rx of ARDS

A

Ventilatory support with low tidal volume of 6 mL per kg

Positive end expiratory pressure (PEEP) to keep the alveoli open

Prone positioning of the patient’s body

Possible use of diuretics and positive inotropes, such as dobutamine

Transfer the patient to the ICU if not already there

61
Q

What is the role of steroids in ARDS?

A

None; they are ineffective in ARDS

Pulmonology USMLE Step 3 (5 decks)

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