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Pulmonology USMLE Step 3 > Section 5: > Flashcards

Section 5: Flashcards

4
Q

Most likely organism for community-acquired pneumonia (CAP)

A

Pneumococcus

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5
Q

Most likely organism for hospital-acquired pneumonia (HAP)

A

Gram negative bacilli

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6
Q

Diagnostic tests for pneumonia

A

Best initial diagnostic test: Chest x-ray

Most accurate test: Sputum Gram stain and culture

Order tests as follows: All cases of respiratory disease (fever, cough, sputum) should have a chest x-ray and oximeter ordered with the first screen.

If there is shortness of breath, also order oxygen with the first screen.

If there is shortness of breath and/ or hypoxia, order an ABG.

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7
Q

Rx for outpatient pneumonia

A

Macrolide (azithromycin, doxycycline, or clarithromycin)

Respiratory fluoroquinolone (levofloxacin, moxifloxacin)
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8
Q

Rx for inpatient pneumonia

A

Ceftriaxone and azithromycin

Fluoroquinolone as a single agent

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9
Q

What is ventilator-assisted pneumonia (VAP)?

A
  • Fever
  • Hypoxia
  • New infiltrate
  • Increasing secretions
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10
Q

Rx for VAP

A
  • Imipenem or meropenem, piperacillin/ tazobactam or cefepime;
  • Gentamicin; and
  • Vancomycin or linezolid
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11
Q

When is steroid indicated in PCP?

A

Steroids are indicated if the pO2 < 70 or the A-a gradient > 35.

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12
Q

Patient with pneumonia who had a recent viral infection, what is the likely causative agent?

A

Staphylococcus

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13
Q

Patient with pneumonia who is an alcoholic, what is the likely causative agent?

A

Klebsiella

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14
Q

Patient with pneumonia who has gastrointestinal symptoms and confusion, what is the likely causative agent?

A

Legionella

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15
Q

Young healthy patient with pneumonia, what is the most likely causative organism?

A

Mycoplasma

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16
Q

Patient with pneumonia who was present at the birth of an animal, what is the likely causative agent?

A

Coxiella burneti

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17
Q

Pneumonia in an Arizona construction worker, what is the likely causative agent?

A

Coccidioidomycosis

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18
Q

HIV Patient with pneumonia with a CD4+ count less than 200, what is the likely causative agent?

A

PCP

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19
Q

Risk groups for tuberculosis (TB)

A

Immigrants

HIV-positive patients

Homeless patients

Prisoners

Alcoholics

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20
Q

Diagnostic tests for TB

A

Best initial test: Chest x-ray

Sputum acid-fast stain and culture should be done to confirm the presence of TB

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21
Q

Rx for TB

A

Once the acid-fast stain is positive, treatment with 4 antituberculosis medications should be started. Six months of therapy is the standard of care.

  1. Isoniazid (INH): 6 months
  2. Rifampin: 6 months
  3. Pyrazinamide: Stop after 2 months
  4. Ethambutol: Stop after 2 months
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22
Q

List the complications of TB medications

A

Isoniazid: Peripheral neuropathy

Rifampin: Red/ orange-colored bodily secretions

Pyrazinamide: Hyperuricemia

Ethambutol: Optic neuritis

All of these medications can lead to liver toxicity. TB medications should be stopped if the transaminases reach 5 times the upper limit of normal

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23
Q

Under what conditions should TB Rx be extended beyond 6 months

A

Osteomyelitis

Meningitis

Miliary tuberculosis

Cavitary tuberculosis

Pregnancy

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24
Q

Diagnostic tests for latent TB

A

The PPD is a screening test for those in risk groups, such as the homeless, immigrants, alcoholics, health care workers, and prisoners. A positive test is as follows:

5 mm: Close contacts, steroid users, HIV-positive

10 mm: Those in the risk groups described above

15 mm: Those without an increased risk

If a patient has never been tested or it has been several years since the last test, 2-stage testing is recommended. This means that if the first test is negative, a second test should be performed in 1– 2 weeks to make sure the first test was truly negative.

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25
Q

What are te steps to follow for a positive PPD?

A

If the PPD is positive, proceed as follows:

  1. A chest x-ray should be performed to make sure occult active disease has not been detected.
  2. If the chest x-ray is abnormal, sputum staining for tuberculosis is performed.
  3. If this is positive, then full-dose, 4-drug therapy is used.

Isoniazid alone is used for 9 months to treat a positive PPD. This reduces the 10 percent lifetime risk of developing tuberculosis to 1 percent. Once a PPD is positive, the test should never be repeated.

26
Q

What other screening tests can be performed in place of PPD?

A

Interferon gamma release assay (IGRA) (Quantiferon) is an in-vitro blood test that is used for the detection of latent tuberculosis. The indication for an IGRA is the same as for a PPD. The main difference is that the IGRA is more specific than a PPD. There are no false positives on an IGRA with previous BCG infection.

Bacille-Calmette Guerin (BCG) administration in the past has no effect or influence on these recommendations for treatment of latent TB. It does not matter if a patient has had BCG in the past; the patient must still take isoniazid if the PPD is positive. If BCG is an answer choice, it is always wrong according to current guidelines.

IGRAs have a 90 percent sensitivity for previous TB exposure. A positive test is treated with INH alone. A positive IGRA does not mean active infection. As with a PPD, a positive IGRA confers only a 10 percent lifetime risk of TB.

27
Q

Diagnosis: Decreased TLC, Decreased RV, Decreased VC, Normal FEV1, Normal FEV1/FVC ratio, Normal DLCO

A

Extra-parenchymal (extra-thoracic) restriction

  • Kyphosis
  • Obesity
28
Q

Diagnosis: Increased TLC, Increased RV, Decreased FEV1, Decreased FVC, Decreased FEV1/FVC ratio, Decreased DLCO

A

COPD

29
Q

Diagnosis: Normal or Increased TLC, Normal or Increased RV, Decreased FEV1, Decreased FVC, Normal or Decreased FEV1/FVC ratio, Normal or Increased DLCO

A

Asthma

30
Q

Diagnosis: Decreased TLC, Decreased RV, Decreased FEV1, Decreased FVC, Normal or Increased FEV1/FVC ratio, Decreased DLCO

A

Fibrotic (or Interstitial Lung) Disease

31
Q

List the minimum that should be done for all patients with shortness of breath (SOB)

A

Oxygen

Continuous oximeter

Chest X-ray

Arterial blood gas (ABG)

32
Q

Causes of low DLCO

A

Emphesema

Pneumonectomy

Interstitial lung disease

pulmonary embolism

Pulmonary HTN

33
Q

Arterial blood gases measurements

A

pH: 7.35 to 7.45

PCO2: 33-45mmHg

PO2: 75-105mmHg

34
Q

Which is the only form of interstitial lung disease that responds to steroid and why?

A

Berryliosis, because it is a granulomatous disease

35
Q

List the diagnostic tests in ILD and explain the findings in each test

A

CXR: interstitial fibrosis

High-resolution CT scan: more detail of interstitial fibrosis

Lung biopsy

PFT

36
Q

What is BOOP?

A

Bronchiolitis obliterans organizing pneumonia

37
Q

What is another name for bronciolitis obliterans organizing pneumonia (BOOP)?

A

Cryptogenic organizing pneumonia (COP)

38
Q

Compare BOOP/COP and ILD

A
  • Fever, myalgias, malaise (clubbing uncommon) present in BOOP; No fever, no myalgias in ILD
  • Symptoms presents over days to weeks in BOOP; Symptoms present over six months or more in ILD
  • Patchy infiltrates in BOOP; Interstitial infiltrates in ILD
  • Steroids effective in BOOP; ILD rarely responds to steroids
39
Q

The two most common lung cancers

A

Adenocarcinoma

Squamous cell carcinoma

40
Q

Centrally located lung carcinomas

A

Squamous cell ca

Small cell ca

41
Q

What lung ca is associated with Eaton-Lambert syndrome, syndrome of inappropriate antidiurectic hormone and other paraneoplastic syndromes

A

Small cell ca

42
Q

Type of lung ca most commonly associated with venocaval obstruction syndrome

A

Small cell ca

43
Q

Peripherally located lung cancers

A

Large cell carcinoma

Adenocarcinoma

44
Q

Lung ca associated with cavitation

A

Large cell ca

45
Q

Lung ca associated with pleural effusion with high hyaluronidase levels

A

Adenocarcinoma

46
Q

Most common initial presentation of cystic fibrosis

A

Meconium ileus

47
Q

Other clinical features of cystic fibrosis

A

Failure to thrive

Rectal prolapse

Persistent cough

May also present with

  • Infertility
  • Allergic bronchopulmonary aspergillosis
48
Q

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.

49
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.

50
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.

51
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.

52
Q

Antibiotics to Rx cystic fibrosis

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.

53
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

54
Q

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

A

>50 years

Lesions >2cm

Smoker

Irregular contours

No calcification

55
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

56
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

57
Q

The diagnosis of allergic bronchopulmonary aspergillosis (ABPA) is based on clinical, radiographic, and immunologic criteria. List them

A
  • A history of asthma
  • immediate skin test reactivity to Aspergillus antigen
  • Precipitating serum antibodies to Aspergillus fumigatus
  • Serum total IgE concentration of greater than 1000 ng/mL
  • Peripheral blood eosinophilia greater than 500 per cubic millimeter
  • Lung infiltrates, usually involving the upper lobes
  • Central bronchiectasis

N/B: If the skin prick test is negative, the diagnosis of ABPA is extremely unlikely

(UW)

Pulmonology USMLE Step 3 (5 decks)

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