Pulm Uw Step 2

Front 1

Increased loudness when whispering "99" on auscultation

Back 1

whispered pectoriloquy

Front 2

smoking hx, productive cough, SOB
PE: emphysema

Back 2

COPD (chronic obstructive pulmonary disesae)

Front 3

Emphysema - 3 characteristics

Back 3

1. "pink puffer"
2. Dyspnea
3. Pursed lips
-terminal airway destrution and dilation 2ndary to smoking or alpha 1 antitrypsin deficiency

Front 4

CXR: emphysematous changes in B/L lower lobes

Back 4

Alpha 1 antitrypsin deficiency

Front 5

Alpha 1 antitrypsin deficiency. Centrilobular or panlobular

Back 5

Panlobular

Front 6

Tx for tension pneumothorax

Back 6

Needle thoracstomy

Front 7

Tension pneumothorax
2 signs

Back 7

1. Markedly decreased breath sounds
2. Hypotension
(increased jugular venous pressure)

Front 8

Cardiac Tamponade (4 signs)

Back 8

1. Hypotension
2. Distended neck veins
3. Pulsus paradoxsus
4. Muffled heart sounds

Front 9

Define Pulsus Paradoxsus

Back 9

Fall in BP >10 mmHg systolic during inspiration

Front 10

Endotracheal intubation
Decreased/absent breath sound
Tx?

Back 10

Reposition Endotracheal tube

Front 11

Wegener's granulomatosis (other name)

Back 11

Granulomatosis with polyangiitis

Front 12

Triad of Wegener's

Back 12

1. Systemic vasculitis (skin manifestation)
2. Upper and lower airway granulomatous inflammation (nose bleed)
3. glomerulonephritis (hematuria with some proteinuria)

Front 13

Male or female
Age 40 onset
Upper respiratory tract Most common presentation-epistaxis

Back 13

Wegener's granulomatosis
-think Pulm-renal

Front 14

Epistaxis
Cutaneous - painful subcut nodules, palpable purpura,

Back 14

Lab test; C-ANCA; elevated CRP
(Wegener's)
-Antibodies against proteinase-3

Front 15

RBC casts, proteinuria, sterile pyuria

Back 15

Glomerulonephritis

Front 16

Wegener's Granulomatosis tx

Back 16

Cyclophosphamide (cyotoxic agent)

Or

High dose corticosteroids

Front 17

Pneumonia (cough) + GI symptoms (loose stools, abd pain)

Back 17

Legionella pneumoniae (associated cooling towers and water supply) - intracellular Gram neg
Lab: hyponatremia
Dx: urine antigen testing/culture on charcoal agar
Tx: Azithormycin / levofloxacin

Front 18

Pneumonia + lab: hyponatremia

-note key gram stain finding

-place/location (2 places)

Back 18

Legionella pneumoniae

-Stains poorly because intracellular Gram neg rod

-cruise ship and hotel water supplies

Front 19

Lab test for Legionella (3 options)

Back 19

Urine Legionella antigen test
Sputum staining with direct fluorescent Ab
Culture

Front 20

Top 3 bugs for COPD related pneumonia

Back 20

1. H. influenzae
2. Moraxella catarrhalis
3. S. pneumoniae

Front 21

Severe renal insufficiency =eGFR

Back 21

<30 ml/min/1.73 m2

Front 22

Anticoagulants CANNOT use with severe renal insufficiency

Back 22

1. low molecular weight heparin (enoxaparin)
2. Fondaparinux (injection factor Xa inhibitor)
3. Rivaroxaban (oral factor Xa inhibitor)

Front 23

3 Complications of high PEEP

Back 23

1. Alveolar damage
2. Tension pneumothorax
3. hypotension

Front 24

Classic Pulmonary Embolism findings (name 5)

Back 24

1. sudden onset Shortness of breath
2. Pleuritic chest pain
3. hypoxia
4. tachypnea
5. Tachycardia

Front 25

Sign of poor respiratory drive (4)

Back 25

1. Decreased breath sounds
2. Absent wheezing
3. Decreased mental status
4. marked hypoxia with cyanosis
Suggested by normal or elevated PaCO2

Front 26

Tx Mild to Mod asthma

Back 26

1. Inhaled short acting beta agonist
2. O2

Front 27

Tx Mod to severe asthma

Back 27

1. Short acting beta agonist
2. Ipratropium nebulizer
3. systemic corticosteroids (beclomethasone, prednisone)

Front 28

What is Ipratropium nebulizer

Back 28

Muscarinic antagonist - competitively blocks muscarinic receptors, prevents bronchoconstriction

Front 29

When to intubate?
acute asthma attack based on PCO2 and PO2

Back 29

PCO2 >50 mmHg
or
PO2 <50 mmHg

Front 30

Narrow therapeutic toxic index drug for asthma (name 2 organ systems affected

Back 30

Theophylline (type of drug: methylxanthines)
-cardiotoxicity
-neurotoxicity

Front 31

Mild-to moderate Asthma: FEV1 or PEF

Back 31

>40%

Front 32

Moderate to severe Asthma

Back 32

<40%

Front 33

Two types of pleural effusions

Back 33

1. Transudates - imbalance between hydrostatic and oncotic pressure, move fluid from capillaries into visceral pleura and pleural space
2. Exudate - pleural and lung inflammation; increased capillary and pleural membrane permeability

Front 34

Define Exduative effusion - which criteria?

Back 34

Light criteria (at least one)
Pleural fluid:
1. protein/serum protein ratio >0.5
2. lactate dehydrogenase (LDH)/serum LDH ratio >0.6
3. LDH >2/3 of upper limit of normal for LDH

Front 35

Pleural glucose <30 mg/dL suggests

Back 35

1. empyema (reduced glucose due to high metabolic activity of leukocytes and/or bacteria)
2. rheumatic effusion

Front 36

Tx: Acute COPD

Back 36

1. inhaled/nebulized bronchodilators (albuterol)
2. Systemic steroids (methylprednisolone)
3. O2
4. anticholinergics (ipatropium, tiotropium)

Front 37

Dyspnea, weakness, fatigue - early
chest pain, hemoptysis, syncope or hoarseness - middle
Right ventricular failure, JVD, tender hepatomegaly, ascities, edema

Back 37

Pulmonary Hypertension

Front 38

Pulmonary HTN - CXR (2 findings)

Back 38

1. Enlargement of Pulmonary arteries with rapid tapering of distal vessels (pruning)
2. Enlargement of right ventricle

Front 39

Definition of Pulm HTN:
mean pulmonary arterial pressure

Back 39

Defines Pulm HTN
@ rest >25 mmHg
with exercise 30 mmHg

Front 40

1. A-a gradient defined.
2. What is normal A-a gradient
3. What happens to A-a gradient with age.

Back 40

1. Estimates the degree of alveolar oxygen transfer to blood
2. <15
3. Increases with age

Front 41

P A O2 =

Back 41

FiO2 x [Patm - PH20]) - (PaCO2 / R)
= 0.21 x [760-47] - (PaCO2/ 0.8)

Front 42

A-a gradient

Back 42

PA O2 - PaO2

Front 43

3 situation A-a gradient elevated

Back 43

1. Interstitial dz
2. V/Q mismatch (pulm edema)
3. Shunt (intracardiac shunt, ARDS severe)

Front 44

Which high A-a gradient does not correct with supplemental O2?

Back 44

Intracardiac shunt

Front 45

Lung consolidation PE (2 signs)

Back 45

1. Bronchial breath sounds - louder and have more prominent expiratory component
2. Egophony - sounds like "a" when pt says "e"

Front 46

Glucocorticoid effect on leukocytosis

Back 46

1. Increased neutrophil count increasing bone marrow release, moblize marginated neutrophil pool (nml 54-62%)
2. Decreased eosinophils (nml 1-3%) and lymphocytes (nml 25-33%)

Front 47

Four categories of Asthma

Back 47

1. Intermittent
2. Mild persistent
3. Moderate Persistent
4. Severe persistent

Front 48

Mild intermittent asthma
a. days per week
b. nights/month
c. FEV1

Back 48

1. <equal 2 days/wk
2. <equal 2 nights/ month
3. >equal 80% FEV1

Front 49

Mild Persistent asthma
a. days per week
b. nights/ month
c. FEV1

Back 49

1. >2 days/week but not daily
2. >2 nights/month
3. > equal 80% FEV1

Front 50

Moderate persistent Asthma
a. days/week
b. nights/month
c. FEV1

Back 50

1. daily asthma symptoms
2. weekly night time awakening/month
3. 60-80% FEV1

Front 51

Tx Asthma
1. Mild intermittent
2. Mild persistent
3. Mod persistent
4. Severe persistent

Back 51

1. PRN short acting bronchodilator
2. Daily low does inhaled corticosteroid/ PRN bronchodilator
3. Low to med dose inhaled corticosteroid/ Long acting inhaled B2 agonist (salmeterol)
4. High dose inhaled corticosteroid/ long acting inhaled B2 agonist/ possible PO corticosteroid/Possible PRN bronchodilator

Front 52

Mild intermittent asthma tx

Back 52

PRN short acting bronchodilator

Front 53

Mild persistent asthma tx

Back 53

Daily low does inhaled corticosteroid/ PRN bronchodilator

Front 54

Mod persistent asthma tx

Back 54

Low to med dose inhaled corticosteroid/ Long acting inhaled B2 agonist (salmeterol)

Front 55

Severe persistent asthma tx

Back 55

High dose inhaled corticosteroid/ long acting inhaled B2 agonist/ possible PO corticosteroid/Possible PRN bronchodilator

Front 56

4 risk factors/symptoms for GERD

Back 56

1. Obesity
2. Supine position soon after large meal
3. Laryngitis
4. change in voice quality
(others heartburn, regurgitation, dysphagia, chest pain

Front 57

Mechanism GERD exacerbates asthma

Back 57

1. Increased vagal tone
2. Heightened brochial reactivity
3. Microaspiration of gastric contents into upper airway
Tx: elevate head of bed, dietary changes, weight loss; PPI inhibitors (esomeprazole)

Front 58

Ace inhibitors SE and mechanism

Back 58

Accumulation of kinins, substance P, prostaglandin, thromboxane

- cough within several weeks of ACE inhibitor

Front 59

Pulmonary embolism (2 most common symptoms)

Back 59

1. acute onset shortness of breath
2. Pleuritic chest pain
(other tachypnea (70), tachycardia (30), low grade fever (15)
Widened A-a oxygen gradient; hypoxemia; respiratory alkalosis

Front 60

CHF - blood gas findings

Back 60

hypoxia, hypocapnia, respiratory alkalosis
Mechanism: CHF exacerbation cause tachypnea as left ventricular dysfunciton alllow fluid to pool in the lungs, causing a pleural effusion and hypoxemia due to reduced ventilation. Tachypnea causes hypocapnia and respiratory alkalosis.

Front 61

CHF findings on PE

Back 61

Fluid overload (peripheral edema/ JVD)
S3 and S4 gallops
Cardiomegaly
Bibasilar crackles

Front 62

COPD - PE lung exam & ABG findings (2)

Back 62

Widespread bilateral wheezes
ABG: respiratory acidosis & hypoxia

Front 63

Hx:
Chronic productive cough
Mucopurulent sputum
Hemoptysis

How Dx?

How dx?

Back 63

Bronchiectasis

Dx: High-reslution chest Ct-show bronchial dilation, lack of airway tapering, bronchial wall thickening on CT scan

Front 64

Two chronic cough etiologies.

How do differentiate between two.

Back 64

1. Brochiectasis (larger volume sputum >100ml/day)
2. Chronic bronchitis (nonpurulent expectorance)

Front 65

COPD - baseline O2 and CO2

Back 65

1. chronic hypoxia
2. chronic hypercapnia

Front 66

Hypoxia physio review pulm mechanism
1. what happens to pulm vasculature
2. what happens to CO2 affinity

Back 66

Hypoxia causes pulmonary vasoconstriction
-blood directed to better ventilated or perfused areas
-Deoxyhemoglobin has HIGHER CO2 affinity, increasing CO2 excretion for exhalation

Front 67

3 effects of acute hypercapnia

Back 67

1. Decreased level of conscoiusness
2. Decreased seizure threshold
3. Decreased myocardial contractility

Front 68

Key problem with excess O2 on COPD

Back 68

O2 can blunt hypoxic respiratory drive!!!

Front 69

Tx: Cough with foul-smelling sputum s/p upper GI or airway instrumentation

Back 69

suspect anaerobic lung infeciton
Tx: Clindamycin

Front 70

Tx Pneumocystis Pneumonia

Back 70

Trimethoprim-Sulfamethoxazole (TMP-SMX)

Front 71

Tx Aspiration Pneumonia

Back 71

Clindamycin

Front 72

HIV + upper lobe infiltrate with cavity

Back 72

Reactivation tuberculosis

-Lung apices, O2 tenion highest in area

Front 73

HIV associated with lowest CD4 counts (3)

Back 73

1. kaposi sarcoma (Human herpes virus -8)
2. large B-cell lymphoma
3. Pneumocystis pneumonia (diffuse granular opacities)

Front 74

Ghon complex

Back 74

Tubercle and associated lymphadenopathy
tubercle - accumulation of macrophages, neutorphils and proliferation of bacilli

Front 75

Ventilation equals?

Back 75

Ventilation = tidal volume x respiratory rate

Front 76

Hyperventilation occurs by (a)

Hypoventilation occurs by (b)

Back 76

(a)
1. Increased tidal volume
2. Increased respiratory rate
(b)
Decreased tidal volume or decreased resp rate

Front 77

Hyperventialtion
CO2? increase or loss
Respiratory acidosis or alkalosis?

Back 77

CO2 loss

Respiratory alkalosis

Front 78

Hypoventilation

CO2 increase or loss

Respiratory acidosis or alkalosis?

Back 78

CO2 increase (retention)

Respiratory acidosis

Front 79

Normal PaCO2

Back 79

40 mmHG PaCO2

Front 80

Respiratory alkalosis compensation is?

Back 80

Renal compensation - serum bicarbonate level reduced

thus urine bicarbonate increased
Increased H+ in serum

Front 81

Increased Serum Aldosterone increases loss of what two electrolytes?

When does this occur?

Back 81

H+ loss and K+ loss

"contraction alkalosis" - intracellular volume contraction - increased aldosterone restores intravascular volume but increased urine proton loss

Front 82

Malignancy

pro or anti thrombotic state?

Back 82

prothrombotic state!

Front 83

Signs of Pulmonary Embolism (5 signs)

Back 83

1. Acute dyspnea
2. Chest pain
3. Tachycardia
4. Hypoxia
5. Clear lungs

Front 84

Morbid obesity
2 pulmonary issues

Back 84

1. Obstructive sleep apnea
2. Obesity hypoventilation syndrome

Front 85

Sleep apnea: Pathophysiology

Tx?

Back 85

transient hypoxia and hypercarbia, resolves with wakefulness

Tx: Weight loss, avoid sedatives/alcohol, avoid supine posture during sleep

Front 86

Obesity hypoventilation syndrome

Back 86

DO NOT resume normal ventilation, develop chronic respiratory failure -

Front 87

Obesity hypoventilation syndrome
consequences

Back 87

Pulmonary hypertension with cor pulmonale
-secondary erythrocytosis, hypoxia, chronic hypercapnia, respiratory acidosis

(key compensation: kidney increase bicarb and decrease Cl reabsorption)

Front 88

If kidney increased bicarb retention, what is not reabsorbed?

Back 88

Chloride

Front 89

Peak airway pressure =

Back 89

Airway resistance + Plateau pressure

Plateau pressure = Elastic pressure and Positive end-expiratory pressure (PEEP)

Front 90

Elastic pressure

Back 90

Elastic pressuure = lung's elastance x volume of gas delivered

Elastic pressure = tidal volume/ compliance

Compliance decrease - fibrosis

Front 91

Increased peak pressure

Back 91

increased airway resistance - bronchospasm, mucus plug, endotrachila tube obstruction

Front 92

Elevation of peak and plateau pressures

Back 92

mean decreased pulm compliance
e.g. pulm edema, atelectasis, pneumonia, right mainstem intubation

Front 93

New or worsening respiratory symptoms within one week of known clinical insult
-respiratory distress
PE: diffuse crackles
severe hypoxemia
Imaging: B/l alveolar infiltrates (white all over)

Back 93

Acute Respiratory Distress Syndrome (ARDS)

Front 94

How to measure ARDS severity?

Back 94

PaO2/ FiO2 ratio (PF) <equal 300 mmHg with PEEP >equal 5 mm cm H20

Front 95

Severity of Hypoxemia in ARDS categorized into 3

Back 95

1. Mild: PF 200-300 mm Hg
2. Moderate : PF 100-200 mm Hg
3. Severe: PF <equal 100 mm Hg

Front 96

What is ARDS?

Back 96

Inflammatory condition due to infections (sepsis, pneunomia), trauma (fractures, pulm contusions), or other (massive transfusion, pancreatitis).

-Lung injury leas to release of proteins, inflam cytokines and neutrophils into alveolar space. Then leakage of bloody and proteinaceous fluid into alvoeli, collapse and damage.

Front 97

Results of ARDS

Back 97

1. Impaired gas exchange
2. Decreased lung compliance (stiff lungs)
3. Increased Pulm arterial pressure (Pulm HTN)

Front 98

Guidelines for mechanical ventilation in ARDS?

Back 98

1. Low tidal volume ventilation (6-8 ml/kg)
2. Inspiratory plateau airway pressure <equal 30cm h20
3. Arterial oxygenaiton tension (PaO2) of 55-80 mmHg
4. High PEEP for mod to severe hypoxemia

Front 99

What is empyema?

Back 99

Infection of pleural space
-commonly after hemothorax,
-rupture of lung abscess, bronchopleural fistula, penetrating trauma, thoracotomy, abscesss, ruptured esophagus

Front 100

Low grade fever and dyspnea
Dx:
Tx:

Back 100

Ct scan
Tx: Surgery (especially with thick peel)

can treat with abx, chest tube and fibrinolytic (streptokinase and urokinase)

Front 101

Most common source of PE (>90%)

specifically name 3 veins

Back 101

Proximal deep leg veins

3 veins: iliac, femoral and popliteal veins

Front 102

Occupations related to asbestosis (4)

Back 102

mining, shipbuilding, insulation, pipe work

-> 20 yrs between asbestos exposure and disease

Front 103

Progressive shortness of breath over months
PE: digital clubbing, bibasilar end-inspiratory crackles

What dz?
Dx CXR: 2 notes

Back 103

Asbestos

CXR:
1. calcified pleural plaques
2. @ lung base - linear opacities and interstitial fibrosis

Front 104

Name two PE of asbestos

Back 104

1. digital clubbing
2. bibasilar end-inspiratory crackles

Front 105

Acute massive pulmonary embolism presents 2

Back 105

1. syncope
2. shock

right atrial pressure >10 mm Hg
Pulmonary artery pressure >40 mm Hg

Front 106

DLCO reflects?

Low DLCO

Back 106

diffusion across alveolar-epithelial membrane

Low DLCO indicates impaired diffusion; Dx of Interstitial lung dz

Front 107

Obstructive
FEV1/FVC ?

Back 107

<80%

Front 108

Restrictive Lung Dz
FEV1/FVC ?

Back 108

>80% or Normal