Usmle Step 2: Respiratory Qbank

Front 1

Immediately after intubation, breath sounds on the left side are markedly decreased. Explain what happened.

Back 1

An endotracheal tube is placed into the lung during intubation. If pushed too far, the tube may preferentially head towards the right mainstem bronchus (it's at a less acute angle than the left). Thus, you lose breath sounds on the opposite side. Goal is to withdraw tube so that it sits at the carina.

Front 2

When would you use a chest tube?

Back 2

if pt has a pneumothorax, hemothorax, empyema, or malignant effusing requiring drainage.

Front 3

Risk factors for recurrent aspiration PNA?

Back 3

1) altered consciousness: seizures, alcoholism, drug overdose, and CVA, etc

2) Dysphagia: esophageal refulux, diverticula, obstruction, etc.

3) Neurological disorder: advanced dementia, Parkinsonism, myasthenia

4) Sedation to procedures, such as bronchoscopy, intubation, endoscopy, etc

Front 4

Pt with asthma-like sx that occur only at night and not during the day - what's a common dx?

Back 4

GERD! adopt anti-GERD lifestyle modifications and receive a trial of PPI

Nighttime GERD is especially likely in people who eat dinner late in the evening and go straight to bed bc recumben position favors reflux.

Subsequent aspiration of gastric contents during slep is very inrritating to the upper and lower airways, and can cause sore throat, cough, horaseness, and wheezing. (can also cause paroxysmal nocturnal coughing)

Front 5

Asbestos exposure leads to what diseases?

Associated with which jobs?

Back 5

Increases risk of malignancy (bronchogenic carcinoma and mesothelioma), pulmonary fibrosis, and pleural plaques --> most likely malignancy is bronchogenic carcinoma

mining, shipbuilding, insulation, or pipe work

Typical presentation?

Hint 5

- dyspnea w/o cough or sputum
- bibasilar end-inspiratory crackles and clubbing (40-50%)
- CXR reveals interstitial abnormalities of the lower lung fields c/w pulm fibrosis
- pleural plaques (50%) on CXR

Front 6

Cor pulmonale: pathophys and associated clinical findings

Back 6

R sided heart failure most commonly due to pulm disease (ie COPD)

Signs include: elevated JVD, right sided S3, right ventricular heave, hepatomegaly, ascites, and dependent edema

other causes of R sided HF

Hint 6

pneumoconiosis, pulm fibrossis, kyphoscoliosis, primary pulm HTN, and repeated episodes of PE

Front 7

Classical features of cardiac tamponade

Back 7

elevated JVD, hypotension, distant heart sounds, and pulsus parodoxus

Front 8

GERD - induced asthma

more common in what setting?

Back 8

present in up to 75% of asthma patients, and may be the PRIMARY trigger in many.

more common in: adult onset asthma and sx that are worse after meals, exercise or laying down.

Trial of PPI can be both diagnostic and therapeutic.

Front 9

Asthma medication indications:

Fluticasone
Albuterol
Theophylline
Inhaled steroids

Back 9

Fluticasone: inhaled glucocorticoid persistent asthma (sx more than twice weekly). prevents inflammation and bronchial hyperresponsiveness

Albuterol: beta agonist casing bronchodilation. Used during acute asthma exacerbations for immediate relief

Theophylline: methylxanthine phosphodiesterase inhibitor that causes bronchodilation. Use limited by side effect profile

Inhaled steroids

Front 10

How does pulmonary edema affect A-a gradient and compliance

Back 10

increases A-a gradient due to V/Q mismatch, and excess fluid reduces lung compliance by preventing some alveoli from fully expanding. Supplemental O2 usually corrects the hypoxemia, V/Q mismatch, and A-a gradient.

Front 11

COPD exacerbation: what do you do when they're de-satting?

Back 11

noninvasive positive pressure ventilation (NIPPV)

should be tried ebefore intubation and mechanical ventilation in COPD pts with CO2 retention

When would you consider intubation/mechanical ventilation instead?

Hint 11

septis, hypotension, or dysrhythymic patients present a contraindication to NIPPV

Front 12

Why does increasing O2 in someone with COPD worsen the situation of their exacerbation?

Back 12

Their only drive to increase the respiratory rate is hypoxia because PCO2 is elevated at baseline and no longer stimulates the respiratory center as in normal individuals.

Thus, increasing O2 will reduce respiratory drive

Front 13

When is BAL useful?

Back 13

evaluation of suspected malignancy and opportunistic infxn. BAL is greater than 90% sensitive and specific for PCP.

side: sputum induction with hypertonic saline is the first line method of dx bc it is minimally invasive. Though highly specific, only 50% sensitive.

Front 14

Distinguishing factors of PNA due to Legionella

Back 14

prominent GI sx (ab pain + loose stools), hyponatremia, LFT abnormalities

tx?

Hint 14

fluoroquinolone or macrolide

Front 15

mitral stenosis findings?

occurs commonly in what setting?

Back 15

Enlarged LA

Persistent cough (due to irritation of the left main stem and phrenic nerve by enlarged LA)

Elevation of the left mainstem bronchus

ECG reveals AFibb and/or LA enlargement when NSR is present

Front 16

Findings in acute pericarditis

Back 16

CP sharp and pleuritic
low grade fever and palpitations
ECG: diffuse ST segment elevations
CXR: enlarged cardiac silhoutte
ECHO: presence of effusion

Front 17

Sarcoidosis findings

Back 17

systemic granulomatous dz that may be asymptomatic or may present with cough, fever, wt loss, anorexia, and fatigue

CXR: enlarged mediastinum (bilateral hilar adenopathy)
CT scan: adenopathy

Blood work: elevated calcium and ACE levels

Front 18

Pleural effusion: distinguishing btw exudative or transudative process

Back 18

Light's criteria - exudative if...
- fluid protein/serum protein ratio greater than 0.5
- fluid LDH/serum LDH greater than 0.6
- pleural fluid LDH greater than 2/3 upper limits of nl serum LDH

makes sense --> allows protein and LDH to pass into pleural fluid

Transudate vs exudate

Hint 18

transudate: increased hydrostatic or decreased oncotic pressure

exudate: increased capillary permeability (infxn, autoimmune dz, neoplasm)

Front 19

New clubbing in pt with COPD

Back 19

often indicates dvt of lung cancer

- finger clubbing is NOT a feature of simple COPD

mechanism: thickienign of nail bed that causes a decrease in the angle between the nail bed and the nail fold.

What other dz results in clubbing?

Hint 19

pulm HTN and hypoxemia due to congenital heart dz OFTEN

Other conditions: lung abscesses, bronchiectasis, CF, interstitial lung dz and sarcoidosis

Front 20

COPD findings

Back 20

elevated PaCO2
increased production of purulent sputum
diffuse rhonchi and wheezing
sx appear gradually rather than acutely (as in the case of PNA or pneumothorax)

Front 21

CHF findings

Back 21

transudation of pleural fluid --> characterized by dullness to percussion and decreased breath sounds over effusion

takes a very large and/or bilateral pleural effusion to cause SOB --> slower to evolve

Front 22

Secondary pneumothorax in COPD patients - what do you expect on CT scan

Back 22

catastrophic worsening of respiratory sx and usually due to DILATED alveolar blebs that rupture air into the pleural space

2-14 pic

Front 23

SVC syndrome and workup

Back 23

SOB, venous congestion, swelling of head, neck and arms.

Malignancy most common cause of obstruction (ie lung cancer, non-Hodgkin's lymphoma) - 60%

Front 24

Unexplained unilateral arm swelling - workup and possible dx

Back 24

May be DVT --> evaulate with Doppler U/S

Front 25

Criteria for ARDS dx?

2-16 pic

Back 25

- acute onset of respiratory distress in the setting of a predisposing condition (sepsis, PNA, etc)
- PaO2/FiO2 ratio < 200
- bilateral infiltrates on CXR
- nl PCWP (less than 18mmHg)

What suggests cardiogenic pulmonary edema?

Hint 25

PCWP > 18 mmHg suggests cardiogenic pulmonary edema

Front 26

CF can affect which organs? What is the mechanism?

Back 26

- Respiratory tract, sinuses, pancreas, intestines, and reproductive systems

- secondary to abnormally thickened secretions

- recurrent bronchiectasis and pulmonary infections are commonly seen in the lungs. Decreased exocrine function of the pancreas leading to fat malabsorption is also often present

Front 27

restrictive lung dz -> FEV1/FVC ratio, and VC. DLCO

Back 27

nl or increased FEV1/FVC ratio with a low VC seen in restrictive lung dz. DLCO is decreased with interstitial lung dz. Neuromuscular disorders are not a/w decreased DLCO.

pic 2-18

Front 28

Most common inherited disorder causing hypercoagulability and predisposition to thromboses?

Back 28

Factor V Leiden

Due to mutation, Factor V becomes resistant to inactivation by protein C, an important counterbalance factor in hemostatic cascade.

side: prevalence as high as 5% in population.

Front 29

PE classic presentation, including CT findings

Back 29

sudden onset pleuritic CP
SOB and cough
hemoptysis

CT: wedge-shaped infarction virtually pathognomonic for PE

Front 30

Explain this CT:

2-20 pic (filling defect)

Back 30

Pulmonary artery filling defect visible on contrast-enhanced CT scan

Front 31

indicators of severe asthma attack

Back 31

nl to increased Pco2 values, speech difficulty, diaphoresis, altered sensorium, cyanosis, and silent lungs

Front 32

common complication of bronchiectasis

Back 32

hemoptysis

(no a/w ptx, pe, malignancy)

Front 33

tactile fremitus

Back 33

palpable vibration felt on chest

sounds travel faster in solids (consolidation) than in an aerated lung, resulting in increased fremitus in PNA.

presence of fluid or air outside the lung interrupts the transmission of sound, resulting in decreased fremitus in pleural effusion and PTX.

Front 34

aspirin sensitivity syndrome

Back 34

believed to be a PSEUDO-ALLERGIC reaction, resulting from aspirin-induced prostaglandin/leukotriene misbalance in susceptible individuals.

tx includes avoidance of NSAIDs and the use of leukotrient receptor antagonists (drug of choice)

EXTREMELY HIGH YIELD!

Front 35

qID 3048

Back 35

answer

Front 36

impaired consciousness, advanced dementia, and other neuro disorders are predisposed to aspiration PNA due to what mechanism?

Back 36

impaired epiglottic function!

Front 37

drug effect causing neutrophilia

Back 37

glucocorticoids (such as those used in asthma) cause neutrophilia by increasing the bone marrow release and mobilizing the marginated neutrophil pool. Eosinophil and lymphocytes are decreased.

Front 38

mobile cavitary mass in lung p/w intermittent hemoptysis

Back 38

aspergilloma

Front 39

obesity hypoventilation syndrome

Back 39

long-term consequence of severe obesity and untreated OSA. causes chronic hypercapnic/hypoxic respiratory failure, secondary erythrocytosis, pulmonary HTN, and cor pulmonale

characterized by underventilation of lungs during all hours!, leading to a chronically elevated PaCO2 and reduced PaO2. Nl ABG may point to OSA instead.

Front 40

kidney compensation in respiratory alkalosis (such as in the case of mechanical ventilation)

Back 40

preferentially excretes bicarb in the urine resulting in alkalinized urine

Front 41

Wegener's

Back 41

aka granulomatosis with polyangiitis defined clinically as the triad of systemic vasculitis, upper and lower airway granulomatous inflammation, and glomerulonephritis

nasal cartilage destruction and vasculitic cutaneous lesions (tender nodules, palpable purpura, ulceration) are common external manifestations

Front 42

45yo 2d bilateral hand pain most severe in wrists. PE revealing bilateral wrist tenderness, thickening of the distal fingers, and convex nail beds.

Back 42

description consistent with nail clubbing -> get CXR to r/o CA!

Front 43

solitary pulmonary nodule mgmt

Back 43

defined as lesion < 3cm that is within and completely surrounded by pulmonary parenchyma

lesions with high malignancy: surgical excision

low risk: monitored with serial CT scans

intermediate risk: further imaging and excision depending on imaging findings

Front 44

Lab test more useful in determining the need for chest tube placement in parapneumonic effusion

Back 44

pleural fluid pH

when less than 7.2, the probability is very high that this fluid needs to be drained.

glucose of less than 60 in pleural fluid is also an indication for tube thoracostomy.

Front 45

lung consolidation PE findings

Back 45

bronchial breath sounds, dullness to percussion, increased fremitus, bronchophony, egophony, and whispered pectoriloquy on PE.

Bronchial breath sounds have a a full expiratory phase

Front 46

sarcoidosis

Back 46

systemic granulomatous dz of unknown etiology that affects multiple organ systems including thel ungs, skin, eyes, liver, kidney and/or heart.

pulmonary sarcoidosis characterized by interstitial inflammation that can progress to fibrosis.

CXR: bilateral hilar lymphadenopathy and diffuse interstitial infiltrates.

1/4 will develop uveitis, which is self-limited in some cases but could progress to blindness in others

Front 47

complications of ventilation with a high PEEP

Back 47

alveolar damage, tension PTX, and hTN.

Front 48

flow volume loops: fixed airway obstruction

Back 48

look up qid 4630

decresae airflow rate during inspiration, active expiration, and passive expiration

Front 49

empyema: characteristics of fluid

Back 49

low glucose concentration due to high metabolic activity of leukocytes and bacteria within pleural fluid

Light criteria?

Hint 49

pleural fluid protein/serum protein ratio > 0.5

fluid LDH/serum LDH > 0.6

fluid LDH > 2/3 upper limit of normal for serum LDH

Front 50

CT scan showing complex loculated effusion with thick surrounding peel. chest tube reveals little drainage and pt still with low grade fever. next step in mgmt?

Back 50

surgery! probably clotted blood with fibrinous peel

Front 51

choriocarcinoma

Back 51

metastatic form of gestational trophoblastic dz. may ocurr after molar pregnancy or nl gestation, and the lungs are the most frequent site of metastatic spread.

suspect chorio in any postpartum woman with pulmonary sx and multiple nodules on cxr.

elevated beta HCG helps confirm dx!!!

Front 52

criteria for initiating home O2 therapy in COPD pts:

Back 52

1) PaO2 < 55mmHg or SaO2 < 88%
2) pts with cor pulmonale, e/o pulmonary HTN or hct > 55%
3) resting awake PaO2 > 60 with SaO2 > 90% if they become hypoxic during exercise or sleep (nocturnal hypoxia)

Front 53

OSA risk for what conditions?

Back 53

HTN, heart dz, cor pulonale, and acidents

Front 54

most common adverse effect of inhaled corticosteroid therapy

Back 54

oral candidiasis

Front 55

qid 4713

Back 55

ventilation

Front 56

obesity hypoventilation syndrome

Back 56

defined by severe obesity (greater than 150% of ideal body weight) and alveolar hypoventilation during wakefullness

abg will demonstrate hypercapnia, hypoxemia and respiratory acidosis as a consequence of decreased lung compliance. weight loss, ventilator support, O2 therapy, and progestins (a respiratory stimulant) are all potential therapies for these pts

Front 57

drugs of first choice for inpatient treatment of CAP?

Back 57

levofloxacin or moxifloxacin

(cipro does not have good streptococcal coverage and also does not cover atypical organisms)

for outpt therapy?

Hint 57

either azithro or doxy

Front 58

pancoast syndrome

Back 58

apical lung tumor that can cause compression of the sympathetic trunk (horner syndrome), the brachial plexus (pancoast syndrome), the right recurrent laryngeal nerve (hoarse voice) and the SVC (SVC syndrome)

specifically, pancoast syndrome is characterized by shoulder pain radiating into the arm in an ulnar distribution and is caused by tumor invasion of the eighth cervical and first thoracic nerves

Front 59

systemic blastomycosis

Back 59

may cause characteristic ulcerated skin lesions and lytic bone lesions

found most often in the vicinity of the great lakes, mississippi river, and ohio river basins (wisconsin with highest infection rate)

Front 60

ph of pleural fluid

Back 60

nl 7.6

transudative fluid usually with 7.4-7.55

exudate usually 7.3-7.45

Front 61

elevated A-a gradient

Back 61

any process that results in impaired gas exchange. possible etiologies: interstitial dz and processes that result in V/Q mismatching, such as PE

Front 62

atypical PNA

Back 62

more indolent course and higher incidence of extrapulmonary manifestations than pyogenic PNA. CXR may be out of proportion to findings on PE.

Erythema multiforme!!! is a characteristic extrapulmonary manifestation of mycoplasma pneumoniae!!!, the most common cause of atypical PNA.

Front 63

goal of PaO2 in ARDS

Back 63

goal is to maintain paO2 above 60. Levelsof FiO2 should be kept below 50-60% if possible to prevent oxygen toxicity

Front 64

tx of Legionella

Back 64

sx of legionairre's dz include: cough, fever > 39, GI sx, and confusion.

dx confirmed by urine antigen testing or cx on charcoal agar

tx with azithro or levofloxacin

Front 65

anticoagulation in severe renal insufficiency

Back 65

don't use lovenox!! (LMWH, or fondaparinux or rivaroxaban

USE UNFRACTIONATED HEPARIN!!!

Front 66

physical exam findings a/w consolidation

Back 66

dullness to percussion, bronchial breath sounds (assuming patent airways) which are louder and have a more prominent expiratory component, and egophony (increased sound transmission over the consolidated lung region) -> if letter E sounds like A with a nasal or bleating quality, it is called egophony and suggests consolidation

Front 67

secondary malignancy in hodgkin lymphoma

Back 67

common due to chemo and radiation therapy.

most common secondary solid tumor malignancies are lung (especially in smokers), breast, thryoid, bone, and GI (colorectal, esophageal, gastric tumors)

Front 68

Friedlander's pneumoniae (klebsiella

Back 68

most frequently affets upper lobe and produces CURRANT JELLY LIKE SPUTUM with tissue necrosis adn early abscess formation and a fulminant course.

one of the most common organisms responsible for PNA in alcoholics. it is encapsulated gnb and grows as mucoid colonies

Front 69

theophylline toxicity

Back 69

can manifest as CNS stimulation (HA, insomnia, seizures), GI disturbances (N/V), and cardiac toxicity (arrhythmia).

inhibition of the cytochrome oxidase system by other meds, diet or underlying dz can alter its narrow therapeutic window

Front 70

CHF ABG findings

Back 70

tachypnea as LV dysfunction causes fluid to pool in the lungs, causing a pleural effusion and hypoxemis due to reduced ventilation.

tachypnea causes HYPOCAPNIA and RESPIRATORY ALKALOSIS

exam typically shows signs of fluid overload, S3 and S4 gallops, cardiomegaly, and bibasilar crackles in the lungs

Front 71

patients with COPD treated with high flow O2

Back 71

if treated with O2 -> risk for developing worsening hypercapnia and CO2 narcosis.

d/t combination of reduced alveolar ventilation, increased dead space ventilation causing ventilation-perfusion mismatch, and decreased hemoglobin affinity for CO2

goal oxyhemoglobin saturation in these pts is 90-94%!!! (not >95%)

Front 72

mass in mediastinum

Back 72

anterior: thymoma
middle: bronchogenic
posterior: neurogenic (neuroblastoma)

Front 73

high doses of beta 2 agonists for acute asthma exacerbation -> pt develops difficulty lifting arms over head an dmild hand tremors. next step?

Back 73

measure serum electrolytes, specifically for hypokalemia

may present with muscle weakness, arrhythmias and EKG abnormalities.

other common side effects include tremor, palpitations, and HA

Front 74

increased physiologic shunting in the setting of acute PNA

Back 74

see 4770

this is what happens when you lie pt on side where consolidation is occurring -> there is increased shunting that occurs when you lie person on dependent side, which further decreases amount of blood that reaches the less affected side

Front 75

Light's criteria

Back 75

exudative if one are met:
1) pleural fluid protein/serum protein ratio > 0.5
2) pleural fluid LDH/serum LDH ratio > 0.6
3) Pleural fluid LDH > 2/3 of the upper limit of nl for serum LDH

when things are exudative, think of how an inflammatory process opens up the vasculature so that the protein and LDH are closer to 1

Front 76

hypersensitivity pneumonitis mgmt

Back 76

chronic exposure may cause weight loss, clubbing, and honeycombing of the lung.

cornerstone of HP mgmt is avoidance of hte responsible antigen

in exacerbations, use oral prednisone

Front 77

undiagnosed pleural effusion. next step?

Back 77

best evaluated with thoracentesis, except in pts with clear-cut e/o CHF

Front 78

exudative pleural effusions

Back 78

exudative: infection, malignancy, PE, connective tissue dz, and iatrogenic causes

Front 79

COPD features

Back 79

increased TLC, FRC, and RV leading to hyperinflation and diaphragmatic flattening

Flattening of the diaphragm increases the work of breathing (because of increased residual volume - area of lung that is not being exchanged with the outside air)

Front 80

acute bronchitis can have blood-tinged sputum!

Back 80

4566 (no need to review)