Board Review- Goljan Pulmonary

Front 1

What is the formula for the alveolar-arterial gradient?

Back 1

PAO2 = % O2 (713 mm Hg) + (arterial PCO2/0.8)

Front 2

What does hypoxemia of pulmonary origin do to the A-a gradient?

Back 2

increases

(NOTE: gradient normally increases with age)

Front 3

What is a medically significant value for the A-a gradient?

Back 3

30 mm Hg

(NOTE: ideal gradient value is 5 mm Hg)

Front 4

What are four causes of hypoxemia with an increases A-a gradient?

Back 4

1) Ventilation defect
2) Perfusion defect
3) Diffusion defect
4) Right to left shunt

Front 5

What are three causes of hypoxemia with a normal A-a gradient?

Back 5

1) Depression of respiratory center in the medulla
2) Upper airway obstruction
3) Chest bellows (muscles of respiration) dysfunction

Front 6

What volumes are not directly measured by spirometry?

Back 6

TLC, FRC, RV

Front 7

What is the normal FEV1/FVC?

Back 7

4-5 L

Front 8

How do you calculate RV?

Back 8

FRC - ERV

Front 9

In a flow-volume loop, what is seen in obstructive disease?

Back 9

expiratory curve shifts to the left of the normal curve, increasing both TLC and RV

Front 10

In a flow-volume loop, what is seen in restrictive disease?

Back 10

expiratory curve shifts to the right of the normal curve, decreasing both TLC and RV

Front 11

What is Choanal atresia?

Back 11

bony septum between nose and pharynx; newborn cannot breathe through nose and turns cyanotic when breast-feeding

Front 12

What are the most common type of nasal polyps in adults?

Back 12

IgE-mediated allergic polyps

Front 13

What is the clinical triad association with nasal polyps?

Back 13

aspirin, asthma, nasal polpys

(NOTE: Nasal polyps in child, order sweat test to rule out cystic fibrosis)

Front 14

What is Obstructive sleep apnea (OSA)?

Back 14

excessive snoring with intervals of breath cessation (apnea)

(NOTE: obesity is a very common cause of it)

Front 15

What lab findings are associated with OSA?

Back 15

apnea causes respiratory acidosis and hypoxemia

Front 16

What is a serious complication associated with OSA?

Back 16

pulmonary hypertension leading to right ventricular hypertrophy (AKA cor pulmonale)

Front 17

What is the confirmatory test for OSA?

Back 17

Polysomnography (a sleep study)

Front 18

Where are the common locations for sinus infections in adults and in children?

Back 18

maxillary in adults

ethmoid in children

Front 19

What is the most common cause of sinusitis?

Back 19

Viral upper respiratory infection; reason why antibiotics not recommended

Front 20

What is the most common bacterial pathogen causing sinusitis?

Back 20

Streptococcus pneumoniae

Front 21

What is the most sensitive test for diagnosing sinusitis?

Back 21

CT scan (especially if surgery is recommended)

(NOTE: Gold standard for bacterial culture is sinus aspiration)

Front 22

What is the pathogenesis of sinusitis?

Back 22

Blockage of sinus drainage in nasal cavity

Front 23

What is nasopharyngeal carcinoma associated with?

Back 23

EBV

Front 24

What is the most common cause of laryngeal carcinoma?

Back 24

smoking

(NOTE: HPV virus type 6 and 11 associations)

Front 25

What are common clinical findings with laryngeal carcinoma?

Back 25

persistent hoarseness bc most are on the true vocal cords

(NOTE: majority are squamous cell carcinomas)

Front 26

What are three kinds of atelectasis?

Back 26

1) Resorption
2) Compression
3) Surfactant loss

Front 27

What is the most common cause of a fever 24-36 hr post surgery?

Back 27

Resorption atelectasis bc airway obstruction by thick secretions prevents air from reaching alveoli and mucus plugs form after surgery

Front 28

What are two examples of compression atelectasis?

Back 28

1) tension pneumothorax where air compresses lung

2) pleural effusion

Front 29

What cell type synthesizes surfactant?

Back 29

type II pneumocytes

Front 30

What increases and what decreases surfactant?

Back 30

increases: cortisol and thyroxine

decreases: insulin

Front 31

What causes Respiratory Distress Syndrome in infants?

Back 31

decreased surfactant in lung caused by:

1) Prematurity (b4 28th week)

2) Maternal diabetes (fetal hyperglycemia with increased insulin)

3) Cesarean section (lack of stress induced increase in cortisol from vaginal delivery)

Front 32

How can you induce increased fetal surfactant?

Back 32

maternal intake of glucocorticoids

Front 33

What are some clinical findings with RDS?

Back 33

grunting, tachypnea, intercostal retractions, "ground glass" appearance on chest x-ray

Front 34

What are some complications of RDS?

Back 34

blindness (free radical damage from O2 therapy), bronchopulmonary dysplasia (damage to small airways), hypoglycemia in newborns bc excess insulin in response to fetal hyperglycemia)

Front 35

What is the most common cause of pulmonary edema?

Back 35

Left heart failure

Front 36

What is a form of noncardiogeniic pulmonary edema?

Back 36

Acute respiratory distress syndrome (ARDS)

Front 37

What are some risk factors associated with ARDS?

Back 37

Gram (-) sepsis (40%), gastric aspiration (30%), trauma with shock (20%), hantavirus, heroin, acute pancreatitis, etc

Front 38

What is the pathogenesis of ARDS?

Back 38

acute damage to alveolar capillary walls and epithelial cells

alveolar macrophages release cytokines

Front 39

What do the neutrophils damage in ARDS?

Back 39

type I and II pneumocytes

Front 40

How can you distinguish cardiogenic pulmonary edema vs noncardiogenic pulmonary edema?

Back 40

PA wedge pressure <18 mm Hg

Front 41

What causes the increase in A-a gradient with ARDS?

Back 41

intrapulmonary shunting

diffusion abnormalities (capillary damage causes leakage of protein rich exudate producing hyaline membranes)

Front 42

What is the most common cause of typical community-acquired pneumonia?

Back 42

Streptococcus pneumoniae

Front 43

What is bronchopneumonia?

Back 43

begins as acute bronchitis and spreads locally into the lungs

lung has microabscesses present in areas of consolidation

Front 44

What will you see clinically with typical pneumonia?

Back 44

sings of consolidation (alveolar exudate)

(NOTE: gold standard for diagnosis is chest x-ray)

Front 45

T/F: Positive gram stain is more useful than bacterial culture

Back 45

true

Front 46

What is the most common cause of atypical pneumonia?

Back 46

Mycoplasma pneumoniae

Front 47

Do you see alveolar spaces with exudate in atypical pneumonia?

Back 47

No, free of exudate

You see a patchy interstitial pneumonia and mononuclear infiltrate

Front 48

What is the most common source of infection in nosocomial pneumonia?

Back 48

respirators

Front 49

What is the gram negative pathogen associated with respirator infection?

Back 49

Pseudomonas aeruginosa

Front 50

What is the most common pathogen causing pneumonia in AIDS?

Back 50

Pneumocystis jiroveci

Front 51

What is the acid-fastness of TB stain due to?

Back 51

Mycolic acid

Front 52

What is the TB virulence factor?

Back 52

Cord factor

Front 53

Does PPD test distinguish active from nonactive TB?

Back 53

No

Front 54

Where does primary TB affect?

Back 54

upper part of lower lobes or lower part of upper lobes

Front 55

Where does reactivation TB affect?

Back 55

upper lobe cavitary lesions

Front 56

What are some clinical signs of TB?

Back 56

drenching night sweats, fever, weight loss

Front 57

What is the most common extrapulmonary site in TB?

Back 57

kidney

Front 58

What is TB in the vertebra called?

Back 58

Potts disease

Front 59

What is the most common TB in AIDS?

Back 59

Mycobacterium avium-intacellulare complex

(NOTE: occurs when CD4 counts < 50)

Front 60

What are lung abscesses most often due to?

Back 60

aspiration of oropharyngeal material

(NOTE: risk factors include dental work, alcoholism)

Front 61

What is the most common site for aspiration?

Back 61

Superior segment, right lower lobe

Front 62

What is the most likely source of pulmonary thromboembolism?

Back 62

femoral vein (95%)

Front 63

What protects the lungs from infarction?

Back 63

bronchial arteries

(NOTE: pt with normal bronchial artery flow, only 10% of pulmonary embolus will produce infarction)

Front 64

Where do the bronchial arteries arise from?

Back 64

from aorta and intercostal arteries

Front 65

What is a large embolus occluding the main branches of the pulmonary artery?

Back 65

saddle embolus, which is associated with sudden death

Front 66

What is the diagnosis standard for PE?

Back 66

V/Q scan + d-dimer; also spiral CT

(NOTE: normal ventilation scan, abnormal perfusion scan, increased d-dimers)

Front 67

What is the main cause of secondary pulmonary hypertension (PH)?

Back 67

respiratory acidosis and hypoxemia

(NOTE: chronic respiratory acidosis can be caused by chronic bronchitis or obstructive sleep apnea)

Front 68

What is a common pathological finding of PH?

Back 68

atherosclerosis of main pulmonary arteries

Front 69

What is the most common clinical symptom with PH?

Back 69

exertional dyspnea

Front 70

What is Cor pulmonale?

Back 70

PH + RVH

Front 71

What is clinically seen with Goodpasture's syndrome?

Back 71

hemoptysis followed by renal failure

Front 72

What is the earliest manifestation of interstitial fibrosis leading to restrictive lung disease?

Back 72

alveolitis

(leukocytes release cytokines, which stimulate fibrosis)

Front 73

What do you see in lung compliance and elasticity with restrictive lung disease?

Back 73

decreased compliance

increased elasticity

Front 74

What is the definition of pneumoconioses?

Back 74

inhalation of mineral dust into the lungs leading to interstitial fibrosis

Front 75

Where does a particle size of 1-5 um settle? How about < 0.5 um?

Back 75

1-5 um = bifurcation respiratory bronchioles and alveolar ducts

0.5 um = alveoli

Front 76

What is the source of Coal worker's pneumoconiosis (CWP)?

Back 76

anthracotic pigment (carbon pigment from breathing dirty air of coal mines, large urban centers, tobacco smoke)

Front 77

What are alveolar macrophages with anthracotic pigment called?

Back 77

dust cells

Front 78

What is complicated CWP referred to as?

Back 78

Black lung disease (progressive massive fibrosis)

Front 79

T/F - There is no increased risk for incidence of TB or primary lung cancer with CWP

Back 79

True

Front 80

Caplan syndrome can occur with CWP. What is it?

Back 80

pneumosoniosis and cavitating rheumatoid nodules

Front 81

What is the most common occupational disease in the world?

Back 81

Silicosis

Front 82

What is silicosis?

Back 82

chronic exposure to quartz (crystalline silicone dioxide) often in foundries, sandblasting, working in mines

Front 83

What is the pathogenesis of silicosis?

Back 83

Quartz is higly fibrogenic and activates alveolar macrophages to release cytokines that stimulate fibrogenesis

Front 84

T/F There is no increased risk for developing lung cancer and TB with silicosis

Back 84

False

Front 85

Where do asbestos fibers deposit into?

Back 85

Respiratory bronchiles, alveolar ducts, alveoli

Front 86

What are ferruginous bodies?

Back 86

iron coated asbestos fibers

Front 87

What is the most common asbestos related cancer?

Back 87

Bronchogenic carcinoma

(NOTE: risk further increases in smokers)

Front 88

What is an asbestos-related disease that has no etiologic relationship with smoking and arises from serosa of lung pleura?

Back 88

Malignant mesothelioma

(NOTE: occurs 25-40 years after first exposure)

Front 89

Is there risk for TB in patients with asbestos?

Back 89

No

Front 90

T/F - In patients exposed to the nuclear or aerospace industry, berylliosis does not increase risk for lung cancer.

Back 90

False

Front 91

What is the most common noninfectious granulomatous disease of the lungs?

Back 91

sarcoidosis (accounts for 25% of cases of chronic interstitial lung disease)

Front 92

What is the likely pathogenesis of sarcoidosis?

Back 92

CD4 TH cells interact with unknown antigen, which releases cytokines causing the formation of noncaseating granulomas

(NOTE: skin nodules on pts. will have granulomas on biopsy)

Front 93

What is the most common noninfectios granulomatous disease of the liver?

Back 93

Sarcoidosis

Front 94

What is a nonspecific lab finding in pts with sarcoidosis?

Back 94

increase ACE (60%)

Front 95

What can the hypercalcemia in sarcoidosis be caused by?

Back 95

increased synthesis of 1-alpha hydroxylase in granulomas (hypervitaminosis D)

Front 96

What is the pathogenesis of idiopathic pulmonary fibrosis?

Back 96

repeated cycles of alveolitis trigger unknown

lung has honeycomb appearance

Front 97

What are three Collagen vascular diseases associated with interstitial fibrosis?

Back 97

systemic sclerosis, SLE, RA

Front 98

If you have young female pt with pleural effusion, consider this?

Back 98

SLE (Interstitial lung disease occurs in 50% of patients)

Front 99

What is the antigen causing hypersensitivity pneumonitis in farmers lung?

Back 99

thermophilic actinomyces in moldy hay

(NOTE: Farmer's lung is type III and chronically type IV HYP)

Front 100

What is Silo filler's disease?

Back 100

immediate HYP associated with inhalation of gases (oxides of nitrogen)

Front 101

What is Byssinosis?

Back 101

Contact with cotton, linen, hemp products produces HYP

Workers feel better over weekend bc no exposure, then develop depression on Mondays bc symptoms returns "Monday blues"

Front 102

What drugs are commonly associated with interstitial fibrosis?

Back 102

amiodarone, bleomycin, cyclophoshamide, methotrexate

Front 103

What does emphysema target?

Back 103

respiratory bronchioles, alveolar ducts, alveoli

Front 104

What is the most common cause of emphysema?

Back 104

smoking

Front 105

What happens to compliance and elasticity in emphysema?

Back 105

increased compliance and decreased elasticity

Front 106

What is the pathogenesis of cigarette smoke in emphysema?

Back 106

acts as a chemotactic to neutrophils; releases free radicals and elastases; inactivates AAT and glutathione

Front 107

What does the destruction of the elastic tissue cause in emphysema?

Back 107

loss of radial traction and the small airways collapse

Front 108

Where is the destruction occuring in centriacinar emphysema?

Back 108

distal terminal bronchioles and upper lobe

(most common type in smokers)

Front 109

Where is the destruction occuring in panacinar emphysema?

Back 109

distal terminal bronchiloles and the entire respiratory unit; lower lobe

(most common type in AAT deficiency)

Front 110

What do you see in a serum protein electrophoresis with panacinar emphysema?

Back 110

absent alpha-1 globulin peak

Front 111

What are some things you see on chest x-ray with emphysema?

Back 111

increased AP diameter, vertically oriented heart, depressed diaphragms

Front 112

What do you see with lung volumes and ABG's in emphysema?

Back 112

increased TLC, RV; decreased FEV1/FVC; decreased PCO2 (respiratory alkalosis)

Front 113

What does paraseptal emphysema put you at risk for?

Back 113

spontaneous pneumothorax

Front 114

What is irregular emphysema associated with?

Back 114

scar tissue, does NOT produce obstructive airway disease

Front 115

What is definition of chronic bronchitis?

Back 115

productive cough at least 3 months for 2 consecutive years

(NOTE: smoking is most common cause)

Front 116

What kind of acid/base disturbance is seen in chronic bronchitis?

Back 116

chronic respiratory acidosis and metabolic alkolosis

Front 117

What is a basic definition of asthma?

Back 117

episodic and reversible airway disease

Front 118

What type of hypersensitivity is extrinsic asthma? Intrinsic asthma?

Back 118

Extrinsic is Type 1 HYP

Intrinsic is nonimmune

Front 119

What role do IL-4 and IL-5 play in the pathogenesis of asthma?

Back 119

IL-4 stimulates isotype switching to IgE production
IL-5 stimulates production & activation of eosinophils

Front 120

What do eosinophils release?

Back 120

major basic proteins and cationic protein that damage epithelial cells & airway constriction

Front 121

What are LTC-D-E4?

Back 121

Potent bronchoconstrictors

Front 122

What are curschmann spirals?

Back 122

spiral shaped mucus plugs that are shed in epithelial cells

Front 123

What do crystalline granules in eosinophils coalesce to form?

Back 123

Charcot-Leyden crystals

Front 124

What does someone with bronchial asthma initially present with? (think acid/base)

Back 124

Respiratory alkalosis bc of the increased breathing efforts

(progress to respiratory acidosis if does not improve)

Front 125

What is the definition of bronchiectasis?

Back 125

permanent dilation of the bronchi and bronchioles

Front 126

What is the most common cause of bronchiectasis?

Back 126

cystic fibrosis (CF)

(NOTE: most common fatal hereditary disorder in whites in US)

Front 127

What is clinically seen in patients with broncheictasis?

Back 127

productive cough (sometimes cupfuls of sputum) and hemoptysis

Front 128

What is the genetics of CF?

Back 128

AR and 3 nucleotide deletion on chrom 7 coding for phenylalanine

Front 129

Where is the defective CFTR Cl- degraded in?

Back 129

golgi apparatus due to defectvie protein folding

Front 130

What are some clinical associations with CF?

Back 130

Nasal polyps

respirtory infections (most common cause of death in CF)

malabsorption and type 1 diabetes

infertility, esp in males

meconium ileus and rectal prolapse

Front 131

How can you screen infants for CF?

Back 131

immunoreactive trypsin increased levels at birth

Front 132

What is a diagnositc test for CF?

Back 132

sweat test (>60 in children and >80 in adults)