Gmditt Step 2 Day 6 Pulmonary

Front 1

Which class of antihypertensive is contraindicated in pts with advanced renal failure?

Back 1

K+ sparing diuretics
if hyperkalemia - ACEI/ ARBs contraindicated

Front 2

What heart defect is assoc with Chr 22q11 deletion?

Back 2

Truncus arteriosus
Tetrology of fallot

Front 3

What heart defect is assoc with Down Syndrome

Back 3

Endocardial cushion defects (ASD, VSD, abnormal connection btw all 4 chambers)

Front 4

What heart defect is assoc with Congenital rubella?

Back 4

PDA
Pulmonary Artery Stenosis

Front 5

What heart defect is assoc with Turner's Syndrome?

Back 5

Coarctation of aorta

Front 6

What heart defect is assoc with Marfan's Syndrome?

Back 6

Aortic insufficiency

Front 7

What is the next step once a brain tumor has been identified on CT or MRI of the head?

Back 7

(Step up pg 187)
need to realize most common source of tumor in the brain in adults is metastasis, so you need to look for the source of cancer:
full body CT scan
bone scan - mets may have gone to bones as well

Front 8

antidote to acetominophen?

Back 8

n-acetylcysteine

Front 9

antidote to lead?

Back 9

Penicillamine
EDTA
Dimercaprol
Succimer

Front 10

antidote to Cyanide?

Back 10

Thiosulfate
Hydroxycobalamin
Nitrates

Front 11

antidote to Methemoglobin

Back 11

Methylene blue
Vit C

Front 12

What are the indications for surgical parathyroidectomy?

Back 12

- symptomatic
- serum Ca++ conc >1.0 above the upper limit of normal
- Creatinine clearance reduced by 30%
- bone mineral density T-score < -2.5 at any site
- younger than 50 yrs of age

Front 13

What are the diagnostic features of a peritonsillar abscess?

Back 13

- Infxn btw the tonsil & pharyngeal constrictors by Strep pyogenes, staph aureus and/or Bacteroides
- severe sore throat, fever, muffled "hot potato" voice
- classic diagnostic feature is obvious abscess on the tonsil or deflection of the uvula to the opposite site
- other signs and symptoms include trismus ("lockjaw") and drooling

Front 14

What is the tx for peritonsillar abscess?

Back 14

- needle aspiration or I&D
- Pain meds + ABX:
Augmentin 875mg PO BID x10days or
Clindamycin 300mg or 450mg PO q6hrs x10days

Front 15

What is a normal range for the A-a gradient?

Back 15

5-15mmHg

Front 16

Deviated uvula - trouble opening mouth - muffled "hot potatoe" voice

Dx?

Back 16

Peritonsillar abscess

Front 17

What is a helpful symptom to differentiate a common cold from the flu?

Back 17

myalgias (muscle aches) are common in flu but not in colds

Front 18

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

Back 18

Rhinosinusitis symptoms lasting seven or more days and any of the following:
- purulent nasal discharge
- maxillary tooth or facial pain (esp unilateral)
- unilateral maxillary sinus tenderness
- worsening symptoms after initial improvement

Radiologic tests are of little value b/c they cannot distinguish acute viral sinusitis from acute bacterial sinusitis, but CT of the sinuses can rule out sinusitis if another etiology of the symptoms is being considered

Front 19

What is the treatment for ACUTE bacterial sinusitis?

Back 19

- Observation and symptom relief alone in otherwise healthy pts with mild pain and temp <101F
---nasal saline irrigation
---analgesics
---topical decongestant (ie Afrin) or systemic decongestant (ie Sudafed)

- Antibiotics:
--- First line: Amoxicillin 1g TID x10-14days >Augmentin 875 BID x10-14days
--- Second line: Cephalosporins (omnicef 300mg BID x10days) > Fluoroquinolones (Levaquin 750mg qd x5days, or moxifloxacin 400mg qd x5days) or Bactrium > Macrolides (ZIthromax 500mg qd x3days)

+/- Intranasal glucocorticoids - may reduce inflammation and symptoms, but studies lacking

Front 20

What is the treatment for CHRONIC (>3mos of symptoms) bacterial sinusitis?

Back 20

Combined therapy:
- Oral steroids (ie Prednisone 20mg BID x5days -- then qd x5days)
- Oral Antibiotics for 3-6wks (Augmentin or clindamycin)
- Intranasal saline irrigation
- Intranasal steroids indefinitely
- if underlying allergies -- antihistamines, antileukotrienes (ie Singulair) and/or allergen immunotherapy
- if nasal polyps refractory to steroids -- surgical debulking
- if allergic fungal sinusitis -- sinus surgery -- prolonged course of steroids

Front 21

What are the potential complications of sinusitis?

Back 21

meningitis
abscess
orbital infection
osteomyelitis

Front 22

What is the classic presentation of allergic fungal rhinosinusitis? How is the diagnosis made?

Back 22

- chronic rhinosinusitis
- in this disase the sinuses are opacified with thick "alelrgic mucin" that is colonized with fungus (not to be confused with invasive fungal disease)
- the diagnosis is made at the time of surgery when the "allergic mucin" is identified

Front 23

What antibiotics would you use to treat pneumonia in a NEWBORN?
What are the most common bugs in this age group you are trying to kill?

Back 23

Ampicillin & Gentamicin
+/- Vancomycin (if MRSA is a concern)
(use Erythromycin for Chlamydia)

Bugs: GBS > Gram negs (E coli)
Listeria
Chlamydia trachomatis

Front 24

What antibiotics would you use to treat pneumonia in a 1-4mo?
What are the most common bugs in this age group you are trying to kill?

Back 24

Macrolides (azithromycin, erythromycin, clarithromycin)
+/- cefotaxime

RSV, Chlamydia trachomatis, Parainfluenza, Bordatella, Strep pneumo, Staph aureus

Front 25

What antibiotics would you use to treat pneumonia in a 4mo-4yo?
What are the most common bugs in this age group you are trying to kill?

Back 25

Amoxicillin or Ampicillin (oral)

RSV or other virus, Strep pneumo, H flu, mycoplasma, staph aureus

Front 26

What antibiotics would you use to treat pneumonia in a 5-15yo?
What are the most common bugs in this age group you are trying to kill?

Back 26

1) Amoxicillin + clarithromycin (or erythromycin)
2) Azithromycin
3) Amoxicillin + doxycycline

Strep pneumo > Mycoplasma, C. pneumonia, other viruses (rhino, influenza, adenovirus, coronavirus)

Front 27

What are the indications for the pneumococcal vaccination in adults?

Back 27

- 65 yrs or older
- serious long-term health problem such as heart disease, sickle cell disease, alcoholism, leaks of CSF, lung disease (not including asthma), diabetes or liver cirrhosis
- resistance to infxn is lowered due to Hodgkin's disease, multiple myeloma, cancer treatment with Xrays or drugs; treatment with longterm steroids; bone marrow or organ transplant; kidney failure; HIV/AIDS, lymphoma/ leukemia or other cancers, nephrotic syndrome, damaged spleen or no spleen
- Cigarette smokers btw the age of 19-64

Front 28

What antibiotics can be used in the treatment of Pseudomonas pneumonia?

Back 28

An antipseudomonal beta-lactam (piperacillin-tazobactam (zosyn) cefepime, imipenem, meropenem, aztreonam) must be added to one of the following for at least 2 weeks for adequate coverage:
- Antipseudomonal quinolone (ciprofloxacin, or levofloxacin 750mg)
- Aminoglycoside (tobramycin, gentamicin, or amikacin) + azithromycin
- Aminoglycoside (tobramycin, gentamicin, or amikacin) + antipseudomonal quinolone

Front 29

A surgical pt has had a NG tube in place for 2wks due to gastroparesis. He has had a persistent fever and elevated WBC ct w/o an identified source. UA, cultures, and CXRs are negative and the wound is healing well w/o signs of infection. He has no abdominal pain or symptoms to indicate intra-abdominal catastrophe. What study might reveal the source of this fever?

Back 29

CT of head and face (to show sinusitis)

Front 30

What are the classical findings in atypical pneumonia?

Back 30

diffuse interstitial infiltrates

Front 31

What organism is associated with atypical pneumonia in young adults?

Back 31

mycoplasma pneumonia

Front 32

What organism is associated with atypical pneumonia in the elderly and very young?

Back 32

chlamydia pneumonia

Front 33

What organism is most common pneumonia in children (infant to 5yrs old)

Back 33

RSV

Front 34

What organism is the most common cause of pneumonia in neonates?

Back 34

Group B Strep (GBS)

Front 35

A hospital has multiple admissions of elderly pts presenting with atypical pneumonia. All were present at the grand reopening of an old bingo establishment that has an indoor waterfall. what is the likely causal organism?

Back 35

Legionella

Front 36

What is the treatment for atypical pneumonia?

Back 36

Macrolide (erythromycin, azithromycin, clarithromycin)

Front 37

What is the typical time frame after which acute bacterial sinusitis is the cause of purulent nasal discharge?

Back 37

more than 7 days

Front 38

Whats the dx?
CXR shows diffuse, bilateral, interstitial infiltrates
in an AIDs pt with CD4 ct < 200
What other lab value would you expect?

Back 38

Dx: PCP pneumonia
Lab: LDH level usually >220 (and a rising LDH despite appropriate treatment portends a poor prognosis)

Front 39

What is the tx for for PCP?

Back 39

21 days of antibiotics - Choices include:
TMP-SMX (Bactrim) - IV or PO
Pentamidine (Nebupent) - IV
Primaquine (PO) + Clindamycin (IV or PO)

If moderate-severe disease (PaO2 <70mmHg, or A-a gradient >35):
- hospitalize + prednisone 40mg PO BIDx5days then 40mg qd x5days then 20mg PO qd x11 days

Front 40

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

Back 40

- interstitial pneumonia
- PCP pneumonia
- Pulmonary edema
- Pulmonary Hemorrhage
- Hypersensitivity pneumonitis

Front 41

mcc of pneumonia in immunocompromised

Back 41

PCP

Front 42

common causative agent for pneumonia in alcoholics

Back 42

klebsiella

Front 43

can cause an interstitial pneumonia in bird handlers

Back 43

chlamydia ptisacci

Front 44

often the cause of pneumonia in a pt with h/o exposure to bats or bird droppings

Back 44

histoplasma

Front 45

often the cause of pneumonia in a pt who has recently visited south carolina, new mexico, or west texas

Back 45

cocciodiodes

Front 46

pneumonia assoc with "currant jelly" sputum

Back 46

klebsiella

Front 47

infectious agent causing Q fever

Back 47

Coxiella burnetti

Front 48

pneumonia acquired from air conditioners

Back 48

Legionella

Front 49

Mcc of pneumonia in children 1yo or younger

Back 49

RSV

Front 50

mcc of pneumonia in the neonate (Birth-28days)

Back 50

GBS & E. coli

Front 51

mcc of pneumonia in children and young adults (including college students, military recruits, and prison inmates)

Back 51

mycoplasma pneumonia

Front 52

common cause of pneumonia in pts with other heatlh problems

Back 52

Klebsiella

Front 53

Mcc of viral pneumonia

Back 53

RSV & influenza

Front 54

Causes a woolsorter's disease (a life-threatening pneumonia)

Back 54

Bacillus anthracis

Front 55

Common bacterial cause of COPD exacerbation

Back 55

H. influenza

Front 56

Common pneumonia in venilator pts and those with cystic fibrosis (CF)

Back 56

Pseudomonas

Front 57

Pontiac fever (similar to the flu)

Back 57

Legionella

Front 58

Which bug causes pneumonia and gram stain shows:
Gram + cocci in clusters

Back 58

staph aureus

Front 59

Which bug causes pneumonia and gram stain shows:
Gram + cocci in pairs

Back 59

streptococcus pneumonia

Front 60

Which bug causes pneumonia and gram stain shows:
gram neg rods in 80yr olds

Back 60

E coli

Front 61

Which bug causes pneumonia and gram stain shows:
gram + cocci in neonate

Back 61

GBS

Front 62

Which bug causes pneumonia and gram stain shows:
Gram neg rods in neonate

Back 62

E. coli

Front 63

How is the dx of active TB made?

Back 63

TB organisms seen in any of the following is sufficient to make the dx:
- sputum acid-fast stain - if seen in any of the 3 samples ideally obtained qd over 3 days in early AM
- Sputum culture for TB (takes 1-8 wks depending on the media used)
- Bronchoscopy with bronchoaveolar lavage (BAL) or biopsy

Front 64

- bilateral pulmonary infiltrates on imaging consistent with pulmonary edema
- acute onset of respiratory distress
- no evidence of cardiac origin
- PaO2/ FiO2 <200mmHg
Dx?

Back 64

Acute Respiratory Distress Syndrome (ARDS)

Front 65

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

Back 65

(1) treat underlying disease & provide supportive care in the ICU
(2) mechanical ventilation with low tidal volumes (to minimize injury) and adequate PEEP (to recruit collapsed alveoli)
- Conservative fluid management to reduce pulmonary edema - Goal CVP 4-6 H2) (Furosemide and albumin may also be helpful to prevent pulmonary edema)
- Prone positioning improves oxygenation but does not improve survival
- Minimize oxygen consumption by preventing fever (anti-pyretics), minimizing anxiety and pain (sedative and analgesics) and limiting respiratory muscle use (paralytics) particularly in cases of asynchrony of the ventilator and pt's efforts
- transfuse blood only if Hgb drops below 7 g/dL as transfusion may increase risk of death in ARDS pts

Front 66

A friend tells you that he was hospitalized for fungal pneumonia after a trip to the deserts of New Mexico. What medication did he most likely receive in the hospital to treat his pneumonia?

Back 66

Amophotericin B (for coccidiomycosis)

Front 67

What is the treatment for histoplasmosis & bastomycis?

Back 67

Itraconazole

Front 68

In what situations is an induration of 5mm during a PPD screening considered a positive test?

Back 68

HIV
close contacts with TB
CXR signs of TB

Front 69

In what situations is an induration of 10mm during a PPD screening considered a positive test?

Back 69

Homeless
immigrants from endemic areas
IV drug users
chronically ill
health workers
recently incarcerated

Front 70

In what situations is an induration of 15mm during a PPD screening considered a positive test?

Back 70

Low risk populations

Front 71

Why is pyridoxine (vit B6) given to pts on RIPE therapy?

Back 71

to prevent or attenuate the peripheral neuropathy caused by isonizid

Front 72

How might someone that received the BCG vaccine have a negative PPD test?

Back 72

they could have had the BCG vaccine before 1 yr of age or if 10 yrs have passed since they received the vaccination

Front 73

You notice someone's PPD test converts from negative to positive, could this be a result of the BCG vaccine?

Back 73

yes, if the vaccine was given LESS THAN 1 MONTH ago

(takes 1 month after you get the BCG vaccine for a positive PPD test, and will have a positive test up to about 10 yrs post-vaccination)

Front 74

What is the PaO2:FiO2 ratio in ARDS?

Back 74

normal = 300-500 mmHg
ARDS = <200mmHg during mechanical ventilation
gas exchange deficit: <300

Front 75

Which method of O2 delivery can be used to give the patient the most O2 without putting them on a ventilator?

Back 75

non-rebreather mask can give up to 95% FiO2

Front 76

In a pt with pulmonary edema, how can pulmonary wedge pressure (PCWP) distinguish ARDS from cardiogenic shock?

Back 76

if PCWP <12 = noncardiogenic pulmonary edema (usually ARDS)

If PWCP >18 = cardiogenic edema (heart failure)

(note: Swan-Ganz catheters are not proven to improve outcomes in ARDS)

Front 77

What are the diagnostic characteristics of Acute Respiratory Distress Syndrome (ARDS)?

Back 77

- acute onset respiratory distress
- no evidence of cardiac origin
- PaO2/FiO2 <200mmHg
- bilateral pulmonary infiltrates on imaging consistent with pulmonary edema

Front 78

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

Back 78

Interstitial pneumonia
PCP pneumonia
Pulmonary edema or ARDS
Pulmonary Hemorrhage
Hypersensitivity Pneumonitis

Front 79

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

Back 79

normal = 5-15 mmHg
High A-a gradient: PE, pulmonary edema or ARDS, Right to Left shunt

Front 80

What is the empiric treatment for pneumonia in a 2mo old? In a 2yr old?

Back 80

2 month old: macrolide (erythromycin, clarithromycin, azithromycin)

2 yr old: amoxicillin or ampicillin

Front 81

How is asthma managed using different symptom based categories?
(draw the dreaded chart!!)

Back 81

Front 82

How is COPD managed based on stage of the disease?

Back 82

Front 83

What are the possible etiologies for bronchiectasis?

Back 83

Unknown etiology in 50% of pts
Cystic fibrosis
Immunodeficiency
Dyskinetic cilia: Kartagener’s syndrome (dextrocardia, sinusitis, bronchiectasis), Aut Dom polycystic kidney dz
Pulmonary infections (TB, fungal, or lung abscess)
Obstruction (ie foreign body aspiration, tumor, lymph nodes)
Other etiologies: Young’s syndrome, foreign body aspiration, rheumatoid arthritis, Sjogren’s Syndrome, allergic bronchopulmonary aspergillosis, cigarette smoking

Front 84

What does an asthma pt who has asthma attacks about 4x/week need for her medication regimen?

Back 84

Dx: mild persistent asthma
Tx: Albuterol + low dose steroid
+/- Singulair (Montelukast)
+/- Cromolyn

Front 85

What is the most effective tx for COPD?

Back 85

Stop smoking!

Front 86

At what pt do pts with COPD qualify for home O2?

Back 86

Pulse oximetry < 88%

Front 87

What treatment is proven to ↓ M&M in COPD pt?

Back 87

Supplemental Oxygen

Front 88

What are the requirements to diagnose chronic bronchitis?

Back 88

Productive cough >3mos over 2 yrs

Front 89

The mc form of emphysema has what kind of distribution?

Back 89

Centrilobar

Front 90

What is the hallmark sign of COPD?

Back 90

↓ FEV1: FVC ratio

Front 91

How is interstitial fibrosis diagnosed?

Back 91

CXR possible findings → normal in 10%, reticular pattern, nodular pattern, or honeycomb lung (poor prognosis)
High resolution CT scan – greater diagnostic accuracy than plain films
Serum markers including SP-A, SP-B, MCP-1, KL-6
Pulmonary function testing (PFTs) reveal restrictive lung disease with ↓ TLC, FRC, and RV
Lung biopsy is required to make the definitive diagnosis & determine the stage of disease

Front 92

Which lung cancers are more common in smokers, and where are they found?

Back 92

Small cell & squamous cell → Found centrally

Front 93

A 60yo smoker presents with the c/o paresthesias and pain in the left upper extremity. On exam he has left eyelid drooping and miosis, which he says are new. What is the name of the syndrome? What is the disease?

Back 93

Dx: Pancoast Syndrome, due to lung tumor

Front 94

How might a pt w/ superior vena cava syndrome present? Tx?

Back 94

S/S: head swelling/ plethora, headache, vision changes, AMS
Tx: Steroids & endovascular stent

Front 95

HYQ: What is the initial tx for small cell lung cancer?

Back 95

Chemotherapy

Front 96

What is the classic symptom of laryngeal cancer?

Back 96

Hoarseness that worsens over time

Front 97

Wegener’s granulomatosis & Goodpasture’s syndrome can have similar presentations with hemoptysis, dyspnea & hematuria. What are some key differences to help distinguish the two?

Back 97

Front 98

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

Back 98

Smoker
> 45yrs
New/progressive lesion
No calcifications
Irregular calcifications
> 2cm
Irregular margins

Front 99

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

Back 99

Compare to previous xray

Front 100

Which type of lung cancer is a/w the following syndrome?
Elevated ACTH → glucocorticoid excess → Cushing’s Syndrome

Back 100

Small Cell

Front 101

Which type of lung cancer is a/w the following syndrome?
Elevated PTH related peptide → hypercalcemia

Back 101

Squamous Cell

Front 102

Which type of lung cancer is a/w the following syndrome?
Elevated ADH → SIADH → hyponatremia

Back 102

Small Cell

Front 103

Which type of lung cancer is a/w the following syndrome?
Antibodies to presynaptic Ca2+ Channels → Lambert-Eaton Syndrome

Back 103

Small cell

Front 104

HYQ: What is the initial tx of a localized non-small cell lung ca?

Back 104

Surgical resection

Front 105

What are the classic radiological findings in idiopathic pulmonary fibrosis?

Back 105

Reticular / honeycomb pattern on CXR

Front 106

What is the tx for idiopathic pulmonary fibrosis?

Back 106

Steroids, azathioprine or cyclophosphamide, Nacetylcysteine

Front 107

Which type of pneumonoconiosis matches the following?
Progressive fibrosis

Back 107

Silicosis &
Coal Workers disease

Front 108

Which type of pneumonoconiosis matches the following?
↑ risk of TB

Back 108

Silicosis

Front 109

Which type of pneumonoconiosis matches the following?
a/w working with electronics → ↑ cancer risk

Back 109

Berylliosis

Front 110

Which type of pneumonoconiosis matches the following?
Malignant mesothelioma & bronchogenic carcinoma

Back 110

Abestosis

Front 111

Pt with chronic sinusitis + hemoptysis + hematuria → tx?

Back 111

Dx: Wegener’s Granulomatosis
Tx: steroids & cyclophosphamide

Front 112

Pt with anti-glomerular basement membrane Abs → tx?

Back 112

Dx: Goodpasture’s Syndrome
Tx: Plamapheresis, steroids, possibly immunosuppressants

Front 113

A smoker has rapid onset JVD, facial swelling, and altered mental status → tx?

Back 113

Dx: Superior vena cava syndrome
Tx: steroids, endovascular stent

Front 114

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

Back 114

Dx: COPD
TX: inhaled steroids, long acting bronchodilatory, PRN short acting bronchodilator, risk factor reduction, Flu & pneumococcal vaccine

Front 115

What studies are helpful in dx of pulmonary embolism (PE)?

Back 115

Front 116

Vasodilators used in Pulmonary Hypertension:

Back 116

Prostanoids – epoprostenol, treprostinil, iloprost
Endothelin receptor antagonists – bosentan, ambrisentan
Cyclic GMP phosphodiesterase inhibitors: sildenafil (Viagra)
CCB – nifedipine (Procardia)

Front 117

What imaging studies are most helpful in diagnosing a PE?

Back 117

Spiral CT with IV contrast
V/Q Perfusion Scan
Pulmonary Angiography

Front 118

What is a classic sign of PE on CXR?

Back 118

Hamptom’s Hump

Front 119

What is the next step in the management of a pt that you suspect has pulmonary HTN b/c of his symptoms of JVD< loud S2, dyspnea, and fatigue?

Back 119

Echocardiogram

Front 120

What is the primary drug category used to tx pulmonary HTN?

Back 120

Vasodilators: Prostanoids, endothelin receptor antagonists, GMP phophodiesterase inhibitors, Dihydropyridine CCBs

Front 121

A lung cancer pt is re-admitted to the hospital for dyspnea. He is found to have re-accumulation of his pleural effusion. What do you expect the pleural-to-serum protein & LDH ratios from the thoracentesis to be? What do you expect the pleural fluid protein content to be?

Back 121

Exudate (malignancy) → high protein, high LDH
Pleur: Ser protein > 0.5
Pleur: Ser LDH > 0.6
Pleural fluid protein > 3g/dL

Front 122

• A trauma pt involved in MVC has a R-sided fluid collection evident on CXR. An emergent chest tube is places and thick pink fluid evacuates. What is the pink fluid? What structure is likely damaged in this pt?

Back 122

What is it: Chylohemothorax (pink = mixture of blood & lymph, chyle in lymphatic fluid = white)
Thoracic duct is damaged

Front 123

What study can help you determine whether pleural effusion is loculated or free-flowing in the thorax?

Back 123

Upright CXR, Lateral decubitus CXR
If you see that fluid mass moves → free flowing

Front 124

What are the CXR findings of a pneumothorax?

Back 124

Front 125

What are the components of rapid sequence intubation?

Back 125

Front 126

What anatomic locations are options for immediate needle decompression of a tension pneumothorax (PTX)?

Back 126

Midclavicular line – 2nd or 3rd ICS
Midaxillary line – 4th or 5th ICS

Front 127

How is a small pneumothorax treated?

Back 127

Supplemental O2 & observation

Front 128

What are important symptoms in tension pneumothorax?

Back 128

Dyspnea, tachycardia, unilateral ↓ in breath sounds
↑ resonance to percussion, tracheal deviation

Front 129

How do you treat a large hemothorax, chylothorax, pneumothorax (>15%) or pleural effusion?

Back 129

Place a chest tube

Front 130

An obese middle-aged man comes to your clinic with the complaint of fatigue. He reports that he falls asleep in the middle of conversations with his wife and children. What condition does he likely have, and what options are available to help him?

Back 130

Dx: obstructive sleep apnea
Tx: weight loss, CPAP, Jaw positioning devices, surgery of upper airway

Front 131

A pt is intubated & a color change end tidal CO2 indicates that CO2 is indeed coming out with expirations. However, only the right lung sounds are audible. What is the problem?

Back 131

Intubation of right mainstem bronchus

Front 132

A tall, thin, young male develops an abrupt onset of SOB and R-sided chest pain. What CXR findings would indicate a pneumothorax int his pt?

Back 132

Lung retraction
Mediastinal shift from the affected side

Front 133

What are the classic signs & symptoms of Croup?

Back 133

Front 134

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

Back 134

Front 135

What are the characteristic features of epiglottits?

Back 135

Front 136

What is the treatment for epiglottitis?

Back 136

Front 137

What is the classic presentation of RSV bronchiolitis?

Back 137

Starts with 1-3 days of mild URI symptoms: rhinorrhea, mild cough, and mild fever +/- otitits media
Cough with prlonged expiration, expiratory wheezing, crackles, and hyperresonance on percussion
Possible respiratory distress with nasal flaring, tachypnea, retractions, grunting
Possible apnea in infants (indication for mech ventilation)
Complete resolution usually takes one month

Front 138

What is the treatment for RSV bronchiolitis?

Back 138

Front 139

How is the lecithin/sphingomyelin (L:S) ratio used in determining fetal lung maturity?

Back 139

Front 140

What CXR characteristics distinguish neonatal respiratory distress syndrome from transient tachypnea of the newborn?

Back 140

RDS – low lung volumes, diffuse ground glass appearance with air bronchograms
TTN – ↑ lung volumes with flattening of the diaphragms, prominent vascular markings from the hilum (sunburst pattern) fluid streaking in interlobular fissures, +/- pleural effusions

Front 141

What is the treatment for neonatal respiratory distress syndrome?

Back 141

Surfactant administration (from porcine or bovine source)
Continuous positive airway pressure (CPAP) or intubation and mechanical ventilation
CPAP is preferred in larger babies (>1500g) or if active, breathing spontaneously, and not in resp failure
Mechanical ventilation if respiratory failure

Front 142

How is cystic fibrosis diagnosed?

Back 142

Sweat chloride test: sweat chloride conc > 60mEq/L on 2 or more occasions
Performed by a lab familiar with the test
Considered the gold standard for dx of CF
Genetic testing for CFTR gene mutations: identifies about 90% of cases
Nasal transepithelial chloride secretion: measures abnormalities in ion transport across the nasal epithelium

Front 143

What are the general strategies for managing the GI component of cystic fibrosis?

Back 143

Pancreatic enzyme replacement during meals
Fat soluble vitamin replacement

Front 144

What is the most common cause of Croup?

Back 144

Parainfluenza virus

Front 145

Croup can be diagnosed by remembering the “4 S’s” :

Back 145

Seal-bark cough
Stridor
Subglottic narrowing
Steeple sign on xray

Front 146

What radiologic sign do you look for with epiglottis?

Back 146

Thumb print sign

Front 147

What organism is responsible for epiglottitis?

Back 147

Haemophilus Influenza type B

Front 148

What is extremely important to remember before examining a child suspected of having epiglottits?

Back 148

Make sure you are in a setting in which you are capable of intubating rapidly

Front 149

What is a typical presentation of bronchiolitis?

Back 149

< 2yrs old
tachypneic, rhinorrhea, nasal congestion, fever, costal retractions, grunting, +/- nasal flaring

Front 150

When is maternal administration of corticosteroids indicated in the case of preterm delivery?

Back 150

Give before the initiation of labor
Always give if < 34wks gestation
Lecithin: sphingomyeline ratio < 2.0
Phosphatidylglycerol is absent

Front 151

What tests are available to confirm the dx of cystic fibrosis?

Back 151

Sweat chloride test > 60 mEq
Genetic testing for CFTR gene
Nasal transepithelial chloride secretion test

Front 152

HYQ: What substances should be avoided in pts with obstructive sleep apnea?

Back 152

Sedatives at bedtime – Benzos, alcohol, antihistamines

Front 153

HYW: Shortly after birth a child has stridor, wheezing, and SOB despite medical therapies. What is likely to be causing this pt’s symptoms?

Back 153

Vascular ring

Front 154

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

Back 154

β-2 agonists, DNAse 1, hypertonic saline, chest physiotherapy, liberal PRN antibiotics

Front 155

What is the treatment for epiglottitis?

Back 155

Minimize anxiety, IV antibiotics, intubation

Front 156

What is the treatment for Croup?

Back 156

O2, steroids, racemic epinephrine

Front 157

What is the treatment for RSV bronchiolitis?

Back 157

O2, albuterol or racemic epinephrine

Front 158

HYQ: Trauma pt in respiratory distress → CXR shows pleural effusion → what is the next step in the management of this pt?

Back 158

Dx: assume hemothorax
Tx: place a chest tube

Front 159

What might cause a transudative pleural effusion?

Back 159

CHF, cirrhosis, nephrotic syndrome

Front 160

What size pneumothorax requires chest tube placement?

Back 160

Pneumothorax > 15%

Front 161

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

Back 161

Lidocaine

Front 162

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

Back 162

S1Q3T3 (wide S in lead I, Large Q & inverted T in lead III)

Front 163

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

Back 163

Low lung volumes
Diffuse ground glass appearance
Air bronchograms

Front 164

What is the typical CXR appearance of newborn with transient tachypnea?

Back 164

see above