Usmle Ck - Pulmonology

Front 1

therapeutic level of warfarin? what do you do if warfarin is not therapeutic and pt with DVT?

Back 1

- 2-3
- unfractionated heparin; mech: heparin stabilizes but does not lyse the clot

Front 2

pt with hemodynamically signficiant PE?

Back 2

- thrombolytics! not routinely used for pts with DVT

Front 3

when do you put in IVC filter?

Back 3

- c/i to anticoag
- still getting DVT even though anticoag is at therapeutic level

Front 4

how long to anticoag first time DVT?

Back 4

- 6 months

Front 5

normal ABG pH/pCO2/pO2/bicarb

Back 5

7.35-7.45/33-45/75-105/22-28

Front 6

pt w/ long hx of smoking, had sx or URI (mild fever, cough) 1 wk ago now with SOB, ABG showing mild respiratory distress?

Back 6

- COPD exacerbation that is often precipitated by URI

Front 7

what ABG do you see in COPD exacerbation?
- ABG in CHF?
- ABG in PE?

Back 7

- resp acidosis, hypoxia, hypercapnia
- resp alkalosis, widened A-a gradient
- same as CHF

Front 8

sx of patient presenting with CHF?

Back 8

- exertional dyspnea, orthopnea, chronic nonproductive cough
- gallops on cardiac auscultation, peripheral edema, other signs of fluid overload

Front 9

first line treatment for asthma exacerbation?

Back 9

- short acting beta-2 agonist, anticholinergic, IV steroids
- CS take several hours to decrease inflammation, no role in acute exacerbation
- intubate if pt's ABG shows CO2 retention and metal status changes

Front 10

mechanism of ipratropium? role in acute asthma exacerbation?

Back 10

- anticholinergic agenet, reverses vagally mediated, but no allergen-induced bronchospasm
- some benefit in adjunctive meds in mo tosevere exacerbations if given early

Front 11

how to calculate anion gap?

Back 11

Na-Cl-HCO3
- normal value: 8-15

Front 12

algorithm for acid/base disturbance

Back 12

low pH
-- high CO2 = resp acidosis
-- low CO2 = met acidosis

high pH
-- high CO2 = met alk
-- low CO2 = resp alk

Front 13

pt with recurrent bacterial infx?

Back 13

- immunodeficiency involving humoral immunity
- ddx: deficiency of IgA, IgG
- IgG common in females and associated with recurrent sinopulmonary, GI infx, food allergies
- IgA associated with increased risk malignancy
- dx: quantitative measurement serum immunoglobulin

Front 14

what is obesity hypoventilation syndrome?

Back 14

- pt with sleep apnea only have transient hypoxia and hypercarbia that resolves once awake
- pts with sleep apnea and obesity hypoventilation do not have normal ventilation at day and so have chronic respiratory failure
- results in cor pulmonale, high erythrocytosis, hypoxia, chronic hypercapnia and resp acidosis

Front 15

how do the kidneys compensate for met acidosis?

Back 15

- increases bicarb retention, which in response decreased chloride reabsorption

Front 16

pt with cough, mucopurulent sputum and hemoptysis? mechanism? causes?

Back 16

- bronchiectasis, see dilated bronchioles on CXR; do CT scan!
- abnormally dilated bronchial tree ==> impaired clearance of secretions ==> airflow obstruction
- ddx: CF (inherited), Tb or recurrent bacteria PNA (acquired)

Front 17

pt with seizure and acidosis, is it 2/2 hypoventilation or lactic acid?

Back 17

if CO2 is high, then it's resp, if HCO3 (bicarb) is low then it's lactic acidosis

Front 18

why is PE associated with resp alkalosis?

Back 18

pt is hyperventilating to overcome hypoxia and V/Q mismatch

Front 19

what metabolic disturbance would renal failure pts have?

Back 19

- renal failure causes met acidosis 2/2 inadequate excretion of met-produced acids (phosphates, sulfates)
- if chronic it's compensated by mild resp alkalosis
- ABG: low pCO2 and low bicarb level

Front 20

ABG in person vomiting?

Back 20

- met alkalosis 2/2 gastric acid loss
- high pH and elevated HCO3

Front 21

normal PCWP? causes of increased PCWP?

Back 21

2-15
- LV failure, MV disease

Front 22

pt with sudden tachypnea, tachy, fever,deyspnea with PCWP <18 vs PCWP >18?

Back 22

- < 18 is ARDS
- >18 is cardiogenic pulmonary edema

Front 23

ARDS etiology, pathophys, workup, tx??

Back 23

- etiology: in setting of sepsis, PNA, aspiration, toxic ingestions, trauma, burns, hx of EtOH
- pathophys: release of inflammatory mediators ==> alveolar damage ==> increased alveolar capillary permeability ==> leakage of proteinaceous fluid into alveoli ==> tachypnea, tachycardia, fever, dyspnea
- workup: ABG shows hypoxia, CXR shows bilateral alveolar infiltrates, incresed A-a gradient 2/2 shunting PCWP to ddx cardiogenic pulm edema shows PCWP < 18 (v. important to do)
- tx: mechanical ventilation

Front 24

causes of decreased lung compliance? increased lung complicance?

Back 24

- fluid/edema in lung or fibrosis of lung
- emphysema

Front 25

causes of left ventricular end diastolic pressure?

Back 25

CHF 2/2 HTN or hypertrophic cardiomyopathy

Front 26

causes of pulmonary arterial HTN?

Back 26

- hypoxic vasoconstrition, destruction of lung parenchyma

Front 27

causes of hypoxemia with normal A-a gradient? elevated A-a gradient?

Back 27

- hypovewntilation, decreased FiO2
- ARDS

Front 28

causes of hypoxia 2/2 alveolar hypoventilation?

Back 28

- obstructive lung disease, obesity hypoventilation

Front 29

hypoxia 2/2 increased A-a gradient?

Back 29

- ARDS, PCP (PNA secondary to alveolar and interstital inflammation causes areas of V/Q mismatch

Front 30

antibiotic for anerobic infx?
- gram neg infection?

Back 30

- clindamycin
- amp and gent or cipro

Front 31

pt with COPD and clubbing?
- ddx for clubbing?

Back 31

- pt has malignancy b/c COPD is not associated with clubbing
- pulm HTN, hypoexmia 2/2 congenital heart disease, lung abscess, bronchiectasis, CF, ILD, sarcoid

Front 32

pt w/ hx hodgkin's lymphoma tx with chemo/radiation, now 20 yrs later with lung mass?

Back 32

- secondary malignancy
- 3% chance of malignancy s/p radiation and chemo

Front 33

pt with kidney dz (RBC casts), sinusitis/oral ulcers and CXR w/ nodular densities?

Back 33

- pt has kidney dz, upper URI and lower URI = wegener's
- kidney dz is 2/2 RPGN
- test: cANCA, + in 90%, definitive tx is biopsy
- tx: CS, cytotoxic agents

Front 34

primary TB vs reactive TB?

Back 34

- primary occurs as lower lobe infiltrate
- reative occurs as apical infiltrate

Front 35

greatest clinical utility of ESR?

Back 35

dx temporal arteritis and polymyalgia rheumatica

Front 36

ipratropium inhaler?

Back 36

anticholinergic, more effective in COPD than asthma

Front 37

tx of exercise induced asthma?

Back 37

short acting beta 2 agonist 20 min prior exercise

Front 38

pt with swelling of head and neck, dyspnea, engorged chest veins? next step?

Back 38

- SVC syndrome 2/2 small cellca or NHL
- next step CXR

Front 39

Pleural effusions pathophys
1. pleural membrane and capillary permeability
2. capillary hydrostatic pressure
3. increased permeabilty of hemidiaphragm
4. increase amylase
5. low glucose

Back 39

1. increased pleural membrane and capillary permeability 2/2 inflammation
2. increased capillary hydrostatic pressure 2/2 transudative pleural effusion
3. increased permeability of hemidiaphragm (transudative) = hepatic hydrothorax 2/2 cirrhosis
4. increased amylase: esoph rupture/ pancreatitis
5. low glucose (30-50) = malignancy, lupus, esoph rupture, TB; 2/2 increased leukocytes

Front 40

light's criteria

Back 40

pleural effusion is exudative if 1 or more:
1. ratio pleural to serum protein > 0.5
2. ratio of pleural to serum LDH > 0.6
3. pleural LDH > 2/3 upper normal limit

Front 41

pt w/ URI, GI sx, sputum has increased neutraphils, G stain is neg? associated w/? tx?

Back 41

- legionella, G- rods that don't stain well
- associated with water supplies, cruise ships
- tx w/ macrolide or levo

Front 42

CXR PCP? CD4?

Back 42

- ground glass
- CD4 <200

Front 43

Dx of sarcoid?

Back 43

- CXR shows perihilar lymphadenopathyt ==> do medistainal bronchoscopy

Front 44

** pt with nasal blockage and wheezing... which med? mechanism?

Back 44

- ASA sensitivity syndrome = pseudo allergic syndrome, causing nasal polyp blockage and bronchoconstriction
- aspirin inhibits arachidonate to COX and so arachidone makes increased 5-lipoxygenase which makes increased leukotriene (imbalanced with PGE) ==> bronchoconstriction and polyps

Front 45

mechanism of asthma?

Back 45

IgE mediated, immune complex dz

Front 46

pt taking theophylline, cipro, erythromycine... what toxicity?

Back 46

- increased theophylline in blood
- toxicity: CNS (HA, insomnia), GI (N/V), cardiac toxicity (arrhythmia, ectopic beats)
- 2/2 epinephrine release

Front 47

SE Beta agonist?

Back 47

arrhythmia, nervousness, tremor
- no GI sx

Front 48

PEX, hx suggestive of DVT... next step? tx?

Back 48

- dopplers
- if low prob then just do D-dimer
- tx: heparin and warfarin, ASA has no role

Front 49

dysmorphic RBC and RBC casts + pulm infiltrates/hemoptysis? pathophys? dx?

Back 49

- goodpasture
- Ab to type IV collagen in glomerular and alveolar BM
- system sx are UNcommon
- dx renal biopsy

Front 50

what is a parapneumonic effusion?

Back 50

effusion 2/2 PNA

Front 51

indications for chest tube placement in effusion? what are not indiciations?

Back 51

- if signs of empyema: pH < 7.2 or glucose <60, WBC > 10,000 WITH high PMNs or WBC >100,000
- but note increased WBC may indicated TB, lymphoma and not infection of pleural space
- exudative pleural effusion is not indication for chest tube

Front 52

pt with anterior uveitis? ddx?

Back 52

- sarcoid: will see infiltrates on CXR
- ankylosing spondylitis: will have back pain, resp sx 2/2 costovertebral joint inflammation causing restrictive chest wall expansion

Front 53

pt with abnormal bleeding after normal vaginal delivery now with resp complaints? workup?

Back 53

- abnormal bleeding after NSVD = gestational trophoblastic disease
- can either be choriocarcinoma or gestations trophoblastic neoplasm
- lung dz = metastasis whcih is chorio; GTN is locally invasive
- workup: betaHCG

Front 54

pt w/ PE and hemodynamically unstable?

Back 54

- fibrinolytics
- embolectomy if c/i to fibrinolytics e.g. post op pt with bleeding risk

Front 55

pt with dry cough, rhinnorhea, skin rash? tx?

Back 55

- allergic rhinitis causing PND causing cough
- tx: antihis

Front 56

mechanism of cough 2/2 ACE-I?

Back 56

- ACE-I causes decreased degradation of bradykinin and substance P ==> buildup causes cough

Front 57

how to ddx asthma from COPD (i.e. emphysema)?

Back 57

- FEV1 measurement w/ and w/out bronchodilator
- if 15% improvement means constriction was reversible and it's 2/2 asthma
- in COPD see low DLCO and CT findings
- NOTE: asthma and COPD are v. similar pathophys and sx

Front 58

settings of mechanical ventilation?

Back 58

Tidal volume = 6ml/kg of body weight
FiO2 ~40% (appropriately low to avoid O2 toxicity)
can decrease resp rate if pt has signs of hyperventilation via ABG

Front 59

pt with productive cough, fever, night sweats AND skin involvement, lytic bone lesions?

Back 59

- blastomycosis if from Mississippi and Ohio river basin esp Wisconsin
- ddx TB and histo, but hese don't have bone and skin lesions
- if from southwest, coccidiodomycosis

Front 60

pt with sx of low grade fever, headache, sore throat cough x 1 wk, skin lesions, CXR show interstital infiltrates in LLL?

Back 60

- mycoplasma PNA, sx of indolent course (1 wk sx), extrapulm sx (headache, cough, sore throat)
- of all the atypical PNA, skin rash is most typical of mycoplasma

Front 61

pt with hx of asbestos exposure now with mass in lung periphery... which type of cancer?

Back 61

- MCC malignancy in asbestosis is bronchogenic carcinoma, greater than mesothelioma

Front 62

pt with recurrent PNA in same area? When do you do CT vs bronchoscopy?

Back 62

- suggests bronchial obstruction (bronchiectasis, foreign body, bronchial stenosis, bronchogenic carcinoma)
- always do CT first when suspect cancer to help locate mass and then bronchoscopy

Front 63

indications for O2 therapy in COPD?

Back 63

PaO2 =< 55, SaO2 =< 88%, hematocrit > 55%, evidence of cor pulmonale

Front 64

pt given 6L of fluid preop; post op, CXR shows bilateral fluffy infiltrates, PCWP is 8mmHg, ddx?

Back 64

- pulmonary edema from cardiogenic or non-cardiogenic causes
- if PCWP < 18, then noncardiogenic, so ARDS
- if elevated PCWP, then could be iatrogenic fluid overload, L systolic dysfunction

Front 65

pt on chemo now presents with diffuse interstial infiltrates, fever, dry cough, SOB?

Back 65

PCP
- note: characteristic chest xray is diffuse interstitial infiltrates beginning in perihilar region

Front 66

sx of cor pulmonale? causes? sx?

Back 66

right heart failure 2/2 pulmonary disease
- elevated JVP, hepatomegaly, ascites, lower extremity edema w/out evidence of pulmonary congestion, chronic cough!, right sided S3, ventricular heave
- MCC COPD; others: pneumoconiosis, pulmonary fibrosis, hyphoscoliosis, primary pulm HTN, repeated PEs

Front 67

pt with solitary nodule that hasn't grown in >2yrs?

Back 67

essentially rules out malignancy

Front 68

chronic progressive dyspnea, nonproductive cough, digital clubbing? A-a gradient? CXR? PaCO2?

Back 68

idiopathicpulm fibrosis
- A-a gradient is increased because diffusing capacity is progressively reduced
- CXR: pulm vascular congestion in hilum, honeycomb pattern
- PaCO@ is usually low until end stage disease

Front 69

CXR showing left main stem bronchus pushed up? sx?

Back 69

- mitral stenosis (rheumatic fever) causing enlarged left atrium that pushes up on left main stem bronchus
- persistent cough 2/2 irritation on left main stem and phrenic nerve; loud S1, opening snap and diastolic murmur; afib on EKG

Front 70

breath sounds that are louder and more prominent in expiratory component?

Back 70

bronchial breath sounds = consolidation

Front 71

pt with hoarseness?

Back 71

compresssion of recurrent laryngeal nerve 2/2 enlarged right ventricle 2/2 pulm HTN

Front 72

How does PCP cause hypoxia?

Back 72

- alveolar and interstitial inflammation ==> V/Q mismatch ==> A-a o2 gradient

Front 73

when to use bronchoalveolar lavage?

Back 73

suspected malignancy and opportunistic infection (PCP)

Front 74

encapsulated gram negative bacillus

Back 74

klebsiella
- seen in alcoholics, upper lobe

Front 75

pt s/p albuterol treatment has muscle weakness?

Back 75

- hypokalemia

Front 76

pt with pulm infections, celiac disease or IBD?

Back 76

selective IgA deficiency

Front 77

pt with recurrent skin infections?

Back 77

- 2/2 staph aureus 2/2 primary phagocytic defects

Front 78

pt with recurrent infx by virus, fungi, mycobacteria?

Back 78

- defective cell-mediated immunity

Front 79

MCC lobar PNA? tx of outpt vs inpt CAP?

Back 79

pneumococcus; others Hemophilus, moraxella
- outpt: azithromycin or doxy never ampillcin 2/2 resistance
- inpt: quinolone e.g. levo or moxifloxacin

Front 80

pt with progressive cough and yellowish sputum now w/ blood? vitals normal, no other sig hx

Back 80

viral bronchitis, ususally + wheezes, no fever
- if fever then PNA

Front 81

calcified nodes in lung, mediatstinum, spleen or liver?

Back 81

histoplasmosis,
- MCC fungal infx in USA
- no vacitary lesions

Front 82

destruction of nasal cartilage? sx? tx? ddx?

Back 82

- wegener's 2/2 granulomatous inflammation; also see cutaneous manifestations: subQ nodules, palpable purpura, pyoderma gangrenosum (leg ulcer)
- tx: cytotoxic agents
- ddx: leprosy has destruction of nasal cartilage

Front 83

massive hemoptysis?

Back 83

bronchiectasis

Front 84

risk most indicative of TB infx?

Back 84

- foreign born > health care worker, prison, etc

Front 85

CT/CXR with wedge-shaped areas?

Back 85

- hampton's hump = PE

Front 86

URI associated with hyponatremia, mildly elevated LFTs?

Back 86

legionella

Front 87

organisms in PNA in COPD vs teens vs recent influenza?

Back 87

1. F. flu, moraxella
2. mycoplasma
3. staph aureus

Front 88

pt with ARDS tx?

Back 88

increase PEEP (normal =5) increase up to 15
- risk of barotrauma

Front 89

source of PE?

Back 89

90% proximal (iliac, femoral, popliteal) > lower extremities (calf)

Front 90

pt with opacification and mediastinal shifting towards opacificatio? workup?

Back 90

atelectasis 2/2 foeign object, mucus plugging (hx COPD), tumor
- do bronchoscopy to fix obstruction

Front 91

tx of empyema w/ thick rim, localized complex, and chest tube can't tx?

Back 91

surgery

Front 92

PFTs of ILD?

Back 92

-restrictive pattern, decreased volumes, normal or increased FEV1/FVC, decreased DLCO and compliance

Front 93

PCWP vs pulm HTN?

Back 93

PCWP = left atrial pressure = cardiac origin
- pulm HTN = increased atrial pressure e.g. scarred lung parenchyma impedes blood flow in lung

Front 94

muscarinic antagonists?

Back 94

used to tx bronchitis; i.e. anticholinergic
- e.g. ipratropium

Front 95

alpha-adrenergic blocker?

Back 95

tx BPH, HTN

Front 96

alpha 2 adrenergic blocker?

Back 96

HTN, sedating
e.g. clonidine, methyldopa, dexmedetomide

Front 97

purulent sputum specimen?

Back 97

25 PMN, < 10 epithelial cells per low power fields

Front 98

sx of mycoplasma PNA?

Back 98

fever, dry couhg, bilateral perihilar infiltrates on CXR

Front 99

pt with COPD, O2 is bad even on 4L, next step?

Back 99

not intubation, try non-invasive positive pressure ventilation (NIPPV)
- resp distress w/ pH <7.35, PaCO2 >45, RR> 25, if pt not crashing

Front 100

what is bad about increased O2 in pt with chronic COPD?

Back 100

PCO2 is elevated at baseline so doesn't stimulate resp center. Only drive comes from hypoxia, thus if give O2 then worses
- NIPPV gives O2 and washes out CO2

Front 101

scleroderma increases risk of what type of cancer?

Back 101

bronchogenic ca

Front 102

pt with pleural effusion 2/2 decreased plasma oncotic pressure?

Back 102

liver failure

Front 103

pt with clubbing, sudden onset joint arthropathy in chronic smoker?

Back 103

hypertrophic osteoarthropathy affecting wrists, handjoints
- associated with lung ca so do CXR

Front 104

INR goal for pt with prosthetic heart valve? afib?

Back 104

2.5-3.5
- 2-3

Front 105

right heart cath values?

Back 105

right atrium 4-6, pulm arterial pressure <25/15, PCWP 6-12

Front 106

pt with acute artery pressure 43/21 in shock?

Back 106

increased pressure 2/2 left heart dz, COPD or PE
- if normal PCWP then most likely PE and pt in shock

Front 107

right heart cath value in
- hypovolemic shock
- MI
- aortic dissection
- septic shock?

Back 107

- decreased PCWP, CO, increased PVR
- MI w/ 40% left ventricle ==> cardiogenic shock 2/2 left heart failure: increased PCWP, PVR, decreased CO
- a dissection ==> pericardial tamponade: increased PCWP, PVR, decreased CO
-septic shock: decreased PCWP, pulm arterial pressure, right atrial pressure

Front 108

what causes increased A-a gradient?

Back 108

any process that impairs gas exchange: ILD, PE

Front 109

what part of lung is destroyed in COPD?

Back 109

alveolar capillary membrane (site of respiratory gas exchange)

Front 110

pt with anterior mediastinal mass + increased BHG and AFP

Back 110

germ cell tumor (not teratoma which has no tumor markers)
- increased BHG = seminomatous and nonseminomatous
- AFP = nonseminomatous

Front 111

thymoma associated with?

Back 111

myasthenia gravis and pemphigus

Front 112

heart complication from PE?

Back 112

obstructs flow to lungs from right ventricle ==> right ventricular dilation

Front 113

relative indication for thromboyltics in PE?

Back 113

right ventricular strain, hemodynamic instability

Front 114

assymetric hypertrophy of right ventricular septum?

Back 114

hypertrophic obstructive cardiomyopathy

Front 115

mechanical ventilation: what control PO2 vs PCO2?

Back 115

PO2: FiO2, PEEP (measure of oxygenation
- pCO2: meassure of ventilation: RR, TV