Dit - Pulmonary

Front 1

What are the diagnostic features of acute bacterial sinusitis that distinguish it from the common cold?

Back 1

Rhinosinusitis symptoms lasting 7+ days and:
- purulent nasal discharge
- maxillary tooth or facial pain
- unilateral maxillary sinus tenderness
- worsening symptoms after initial improvement

Front 2

What is the treatment for chronic bacterial sinusitis (> 3 months of symptoms)?

Back 2

Combined therapy:
- Oral steroids
- Oral antibiotics (3-6 weeks of Augmentin or clindamycin)
- Intranasal saline irrigation
- Intranasal steroids indefinitely
- If underlying allergies: antihistamines, antileukotrienes, and/or allergen immunotherapy
- If nasal polyps refractory to steroids: surgical debulking
- If allergic fungal sinusitis: sinus surgery -> prolonged steroids

Front 3

What are the potential complications of sinusitis?

Back 3

Meningitis
Abscess formation
Orbital infection
Osteomyelitis

Front 4

What are the most common causes of pneumonia in newborns?
What is the empiric treatment?

Back 4

GBS > Gram negative coliforms (i.e. E. coli), Listeria, Chlamydia trachomatis

Ampicillin + Gentamycin
+/- Vancomycin (if MRSA is a concern)
Use Erythromycin for Chlamydia

Front 5

What are the most common causes of pneumonia in infants aged 1-4 months?
What is the empiric treatment?

Back 5

RSV, Chlamydia trachomatis, Parainfluenza, Bordetella, Strep pneumo, Staph. aureus

Macrolide (Erythromycin or Azithromycin) +/- cefotaxime

Front 6

What are the most common causes of pneumonia in infants aged 4 months - 4 years?
What is the empiric treatment?

Back 6

RSV or other virus, Strep pneumo, H. flu, Mycoplasma, Staph aureus

Amoxicillin or Ampicillin

Front 7

What are the most common causes of pneumonia in infants aged 5-15 years?
What is the empiric treatment?

Back 7

Strep pneumo > Mycoplasma, C. pneumoniae, other viruses

1) Amoxicillin + Clarithromycin (or Erythromycin)
2) Azithromycin
3) Amoxicillin + Doxycycline

Front 8

What are the indications for pneumococcal vaccination in adults?

Back 8

- 65 years old or older
- serious long-term health problem (Heart disease, sickle cell, alcoholism, lung disease, DM, cirrhosis)
- Resistance to infection is lowered due to Hodgkin's, multiple myeloma, cancer treatment, long-term steroid use, bone marrow or organ transplant, HIV/AIDS, lymphoma or other cancers, nephrotic syndrome, spleen pathology
- Alaskan native or certain Native American groups

Front 9

What X-ray and lab findings would lead you to highly suspect PCP pneumonia as a cause of respiratory distress?

Back 9

- CXR: diffuse, bilateral, interstitial infiltrates (most common finding)
- CD4 usually < 200
- LDH level usually > 220 (and a rising LDH despite appropriate treatment portends a poor prognosis)

Front 10

What is the treatment for PCP?

Back 10

21 days of antibiotics
- TMP-SMX
- Pentamidine
- Trimetrexate + leucovorin
- Primaquine + Clindamycin

If moderate-severe disease (PaO2 < 70 mmHg, or A-a > 35) -> Hospitalize + Prednisone

Front 11

What is the differential diagnosis for ground-glass opacities (diffuse hazy infiltrate) of the lung on CXR?

Back 11

PCP
Interstitial pneumonia
Pulmonary edema
Pulmonary hemorrhage
Hypersensitivity pneumonitis

Front 12

What infectious agent fits the following description?
- Common cause of pneumonia in immunocompromised patients
- Most common cause of atypical/walking pneumonia
- Common causative agent for pneumonia in alcoholics
- Can cause an interstitial pneumonia in bird handlers
- Often the cause of pneumonia in a pt with a history of exposure to bats and bat droppings
- Often the cause of pneumonia in a patient who has recently visited Southern California, New Mexico, or West Texas

Back 12

Common cause of pneumonia in immunocompromised patients
- PCP

Most common cause of atypical/walking pneumonia
- Mycoplasma pneumoniea

Common causative agent for pneumonia in alcoholics
- Klebsiella

Can cause an interstitial pneumonia in bird handlers
- Chlamydia psittaci

Often the cause of pneumonia in a pt with a history of exposure to bats and bat droppings
- Histoplasma capsulatum

Often the cause of pneumonia in a patient who has recently visited Southern California, New Mexico, or West Texas
- Coccidioides

Front 13

What infectious agents fits the following description?
- Pneumonia associated with "currant jelly" sputum
- Q fever
- A/w pneumonia acquired from air conditioners
- Most common cause of pneumonia in children 1 year old or younger
- Most common cause of pneumonia in the neonate (B-28d)
- Most common cause of pneumonia in children and young adults (including college students, military recruits, and prison inmates)

Back 13

Pneumonia associated with "currant jelly" sputum
- Klebsiella

Q fever
- Coxiella burnettsi

A/w pneumonia acquired from air conditioners
- Legionella

Most common cause of pneumonia in children 1 year old or younger
- RSV

Most common cause of pneumonia in the neonate (B-28d)
- GBS

Most common cause of pneumonia in children and young adults (including college students, military recruits, and prison inmates)
- Mycoplasma

Front 14

Which infectious agent fits the following description?
- Common cause of pneumonia in pts with other health problems
- Most common cause of viral pneumonia
- Causes a wool-sorter's disease (a life-threatening pneumonia)
- Common bacterial cause of COPD exacerbation
- Common pneumonia in ventilator pts and those with cystic fibrosis
- Pontiac fever

Back 14

Common cause of pneumonia in pts with other health problems
- Klebsiella

Most common cause of viral pneumonia
- RSV

Causes a wool-sorter's disease (a life-threatening pneumonia)
- Bacillus anthracis

Common bacterial cause of COPD exacerbation
- Hemophilus influenza

Common pneumonia in ventilator pts and those with cystic fibrosis
- Pseudomonas

Pontiac fever
- Legionella

Front 15

What infectious agent is the cause of pneumonia based on the following lab test?
- Gram + cocci in clusters
- Gram + cocci in pairs
- Gram - rods in 80 y/o
- Gram + cocci in neonates
- Gram - rods in neonates

Back 15

Gram + cocci in clusters
- Staphylococcus

Gram + cocci in pairs
- Streptococcus

Gram - rods in 80 y/o
- E. coli

Gram + cocci in neonates
- GBS

Gram - rods in neonates
- E. coli

Front 16

How is the diagnosis of active TB made?

Back 16

TB organisms seen in any of the following is sufficient for a diagnosis:
- Sputum acid fast stain - if seen in any of 3 samples obtained over 3 days in early AM
- Sputum culture for TB (takes 1-8 weeks)
- Bronchoscopy with bronchoalveolar lavage or biopsy

Front 17

What treatments are available when managing a patient with Acute Respiratory Distress Syndrome (ARDS)?

Back 17

- Treat underlying disease
- Supportive care in ICU
- Mechanical ventilation with low tidal volumes and adequate PEEP
- Conservative fluid management to reduce pulmonary edema. Goal CVP 4-6 H20.
- Prone positioning
- Minimize oxygen consumption: prevent fever, minimize anxiety and pain, limit respiratory muscle use (paralytics)
- Transfuse blood only if Hb < 7 g/dL (transfusion increases risk of death)

Front 18

In a patient with pulmonary edema, how can pulmonary capillary wedge pressure (PCWP) distinguish a diagnosis of ARDS from cardiogenic edema?

Back 18

Normal range: 2-15 mmHg
ARDS has normal PCWP, cardiogenic edema has elevated PCWP.

Front 19

What are the diagnostic characteristics of ARDS?

Back 19

- PCWP < 18 mmHg
- Bilateral pulmonary infiltrates consistent with pulmonary edema

- PaO2/FiO2 < 200 mmHg
- No evidence of cardiac origin

Front 20

What is the differential diagnosis of ground-glass infiltrates on CXR?

Back 20

PCP
Pulmonary edema (ie. ARDS)
Interstitial pneumonia
Pulmonary hemorrhage
Hypersensitivity pneumonitis (methotrexate)

Front 21

What is considered a positive TB skin test in an immunocompromised patient?

Back 21

5 mm = positive for immunocompromised
10 mm = positive for those are risk for exposure
15 mm = always positive

Front 22

What is a normal A-a gradient? What causes a high A-a gradient?

Back 22

Normal A-a gradient = 5-15 mmHg

High A-a gradient:
PE
Pulmonary Edema (ARDS)
Right-to-left shunt
High inspired oxygen content

Front 23

What are the signs of peritonsillar abscess?

Back 23

- Uvula deviation away from abscess
- Difficulty opening mouth
- Muffled "hot potato" voice

Front 24

What is the empiric treatment for pneumonia in a 2 month-old? In a 2-year old?

Back 24

2 month old:
Macrolide (Erythromycin)

2 year old:
Ampicillin or Amoxicillin

Front 25

What is the treatment for atypical pneumonia?

Back 25

Macrolide (Erythromycin or Azithromycin)

Front 26

What is the next step in the work-up of a patient with a solitary pulmonary nodule?

Back 26

Compare with prior X-rays
If no prior X-rays, CT scan

Front 27

What is the clinical definition of chronic bronchitis?

Back 27

Cough and sputum production for at least 3 months, for 2 years.

Front 28

At what point do patients with chronic COPD qualify for home O2?

Back 28

O2 Sat ≤ 88%
Pulmonary Hypertension
Peripheral edema
Polycythemia

Front 29

What type of lung cancer is associated with the following paraneoplastic syndrome?

- Elevated ACTH -> Glucocorticoid excess -> Cushing syndrome

- Elevated PTH related peptide -> Hypercalcemia

- Elevated ADH -> SIADH -> Hyponatremia

- Antibodies to presynaptic Ca channels -> Lambert-Eaton syndrome

Back 29

Elevated ACTH -> Glucocorticoid excess -> Cushing syndrome
- Small cell

Elevated PTH related peptide -> Hypercalcemia
- Squamous cell

Elevated ADH -> SIADH -> Hyponatremia
- Small cell

Antibodies to presynaptic Ca channels -> Lambert-Eaton syndrome
- Small cell

Front 30

What is the initial treatment for small cell lung cancer?

Back 30

Start with chemotherapy

Front 31

What is the initial treatment of a localized non-small cell lung cancer?

Back 31

Surgical resection

Front 32

What findings make a solitary pulmonary nodule more likely to be malignant?

Back 32

Smoker
Age > 45
New or progressing lesion
No calcifications or irregular calcifications
> 2cm or irregular margins

Front 33

What defines mild persistent asthma? What is the outpatient management for this asthma severity?

Back 33

Mild persistent asthma:
Symptoms occur > 2 times/week (daytime), nocturnal awakening > every 2 weeks

Albuterol + Inhaled low dose steroid
Possible Cromolyn or montelukast added to regimen

Front 34

What are the classical radiological findings in idiopathic pulmonary fibrosis?

Back 34

Ground-glass appearance
Honey-comb appearance

Front 35

What is the treatment for idiopathic pulmonary fibrosis?

Back 35

Steroids + Azathioprine (or Cyclophosphamide) + N-acetylcysteine
Lung transplant

Front 36

Which type of pneumoconiosis matches the following description?

- Progressive fibrosis
- Increased risk of TB
- A/w working with electronics -> increased cancer risk
- Malignant mesothelioma and bronchogenic carcinoma

Back 36

Progressive fibrosis
- Silicosis, Coal worker's

Increased risk of TB
- Silicosis

A/w working with electronics -> increased cancer risk
- Berylliosis

Malignant mesothelioma and bronchogenic carcinoma
- Asbestosis

Front 37

A patient chronically has an FEV1 of 40%. What medications are used in the daily management?

Back 37

This is stage 3 COPD

Long acting and short acting bronchodilators + inhaled corticosteroids + risk factor reduction + annual influenza vaccine

Front 38

Patient with chronic sinusitis + hemoptysis + hematuria. What is the treatment?

Back 38

Wegener's granulomatosis

Cytotoxic therapy (e.g. cyclophosphamide), corticosteroids

Front 39

Patient with anti-glomerular basement membrane antibodies. What is the treatment?

Back 39

Goodpasture's syndrome

Plasmapharesis to remove auto-antibodies; corticosteroids and immunosuppressive agents

Front 40

A smoker has rapid onset JVD, facial swelling, and altered mental status. What is the treatment?

Back 40

Superior Vena Cava syndrome

High dose steroids
Endovascular stenting

Front 41

What is the treatment for obstructive sleep apnea?

Back 41

- Weight loss if overweight or obese
- Avoidance of alcohol and other CNS depressants or sedatives
- Continuous positive air-way pressure (CPAP) at night - first line
- Oral appliance to protrude the mandible forward or prevent posterior tongue displacement
- Modafinil for excessive daytime sleepiness
- Surgical options: Tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty (UPPP), genioglossus advancement, maxillary-mandibular advancement

Front 42

What is the treatment for croup? What are the indications for hospitalization?

Back 42

ER Treatment
- Humidified oxygen mask
- Racemic epinephrine
- Dexamethasone, prednisone

Admission criteria: Hypoxia/cyanosis, respiratory distress, toxic appearance, depressed mentation, progressive stridor or stridor at rest, no improvement 5 hours after steroids

Home treatment: cool mist humidifier (esp. at night), however no proven benefit

Front 43

What is the treatment for RSV bronchiolitis?

Back 43

- Supportive care such as O2 and IV fluids as needed
- Albuterol nebulizers or racemic epinephrine
- Steroids are NOT effective in bronchiolitis
- Ribavirin use in children is controversial, generally not used
- Hospitalize if: toxic appearing, poor feeding, dehydration, respiratory distress, apnea, hypoxemia (<95%)

Front 44

What chest x-ray characteristics distinguish neonatal respiratory distress syndrome from transient tachypnea of the newborn?

Back 44

RDS: low lung volumes, diffuse ground-glass appearance with air-bronchogram

TTN: increased lung volumes with flattening of the diaphragms, prominent vascular markings from the hilum (sunburst pattern), fluid streaking in interlobular fissures, +/- pleural effusions.

Front 45

What is the treatment for neonatal respiratory distress syndrome?

Back 45

- Surfactant administration (from porcine or bovine sources)
- CPAP or intubation and mechanical ventilation

Front 46

How is cystic fibrosis diagnosed?

Back 46

- Sweat chloride test: sweat chloride concentration > 60 mEq/L on two or more occasions

- Genetic testing for CFTR gene mutations (identifies 90% of CF cases)

- Nasal transepithelial chloride secretion

Front 47

What are the general strategies for treating the pulmonary component of cystic fibrosis?

Back 47

- Beta-2 agonist
- DNase I to decrease sputum viscosity
- Hypertonic saline for chronic cough
- Physiotherapy (aerobic exercise) for increased mucus clearance
- Azithromycin used liberally when lung function decreases in order to slow the decline in lung function and treat any Pseudomonas aeruginosa infections

Front 48

What substances should be avoided in patients with obstructive sleep apnea?

Back 48

Sedatives: benzos, alcohol, anti-histamines

Front 49

Shortly after birth a child has stridor, wheezing, and shortness of breath despite medical therapies. What is likely to be causing this patient's symptoms?

Back 49

Vascular ring compromising the upper airway and trachea

Front 50

What are the general strategies for treating the pulmonary component of cystic fibrosis?

Back 50

- Beta-2 agonists
- DNase I
- Hypertonic saline
- Physiotherapy
- Azithromycin

Front 51

What sweat test finding is diagnostic of cystic fibrosis?

Back 51

Sweat chloride concentration > 60

Front 52

What is the treatment for epiglottitis?

Back 52

Minimize anxiety
Antibiotics
Intubation

Front 53

What is the treatment for croup?

Back 53

O2
Steroids
Racemic epinephrine

Front 54

Trauma patient in respiratory distress -> CXR shows pleural effusion -> What is the next step in the management of this patient?

Back 54

Hemothorax

Place chest tube

Front 55

What might cause a transudate pleural effusion?

Back 55

CHF, Cirrhosis, nephrotic syndrome

Front 56

What size pneumothorax requires a chest tube placement?

Back 56

Larger than 15%

Front 57

What medication is used prior to intubation in head injury patients?

Back 57

Lidocaine

Front 58

What Xray finding is indicative of croup? What xray finding is indicative of epiglottitis?

Back 58

Croup: Steeple sign

Epiglottitis: Thumb sign

Front 59

What is the treatment for RSV bronchiolitis?

Back 59

Oxygen
Albuterol or epinephrine

Front 60

What lecithin/sphingomyelin ratio indicates fetal lung maturity?

Back 60

> 2.0

Front 61

What is the classic (but rare) EKG finding in pulmonary embolism?

Back 61

S1Q3T3

Wide S in lead 1
Large Q and inverted T in lead 3

Front 62

What is the typical CXR appearance of newborn respiratory distress syndrome?

Back 62

Low lung volumes
Diffuse ground-glass appearance with air-bronchograms