Pulmo Ques Packet 2

What is the Tx for Extensive stage SCLC?

- Chemo - Pallative radiation

What is the Tx for Limited stage small cell lung cancer?

- Chemo - concomitant contamination - Prophylactic cranial irradiation

What are the NORMAL ABG values for: 1. pH 2. PCO2 3. PO2 4. HCO3 5. Base Excess 6. SaO2

1. 7.4 2. 40 mmHg 3. 90 mmHg 4. 24 mmol/L 5. -2 through +2 6. >95%

A pulmonary function test, like spirometry, is helpful in diagnosing: 1. Chronic bronchitis 2. Lung Cancer 3. Pneumonia 4. TB

1. Chronic Bronchitis

If the trachea is deviated to the UNAFFECTED side what 2 things could be the problem?

1. Plueral effusion 2. massive normal pnuemonthorax

Bob, a 69 yo, has COPD. Her O2 sat is less than 89%. He is going to start oxygen therapy to relieve her symptoms. Her penis also hurt but as you are a pulmonologist you can't help him with his ovary problem. Ok - seriously - this COPD'r needs O2 therapy at home. How many hours a day will he need to be on it to have it be effective?

18 hours a day NO LESS. If he doesn't do it for 18 hrs then its essentially the same as not using it.

In which condition would you assess vesicular breath sounds, moderate vocal resonance and localized crackles with sibiliant (hissing) wheezing? 1. Bronchiectasis 2. Acute Bronchitis 3. Emphysema 4 Asthma

2. Acute Bronchitis 1. Bronchiectasis has very coarse crackles 3. Emphysema has NO crackles 4. Asthma is wheezing with NO crackles

Unexplained nocturnal cough in an OLD person can be explained by: 1. allergies 2. CHF 3. virus 4. post nasal drip

2. CHF causes unexplained nocturnal cough in the elderly because when they lie down the venous return to the heart is increased so it gets more congested. GERD is a close second... so you have old person coughing at night think CHF or GERD!

Which of the following is not a risk factor for lung cancer? 1. Exposure to asbestos or uranium 2. smoking 3. chronic pneumonia 4. Exposure to radon gas

3. Chronic pneumonia

Unexplained nocturnal cough in an YOUNG person can be explained by: 1. allergies 2. CHF 3. virus 4. post nasal drip

4. Post nasal drip!

Inner city kids with asthma have to worry about what bug?

Roaches (EWEWEWEWEWE)

What are the Main Differences between Asthma and COPD?

*ASTHMA: * 1. Reversible 2. Eosinophil driven 3. Allergic reaction/hypersensitivity 4. Bronchodialtors/Steroids make it better - Roids kill the eosinophils *COPD:* 1. Irreversible 2. Neutrophil driven 3. Reaction to noxious particle you put in your lungs (smoke) 4. No cure, slow progressing

A young kid presents to the ER with marked Stridor, drooling and dyspnea. You do a CXR and see a thumb sign - what is your Dx? Should you look in this kids throat?

1. Acute epiglottitis 2. NO!!! No tongue depressor it could kill him

The inspiratory rate equals the expiratory rate in what normal breath sound? 1. Bronchial 2. Bronchiovesicular 3. Vesicular 4. Tracheal

1. Bronchial

You are examining a pt in your office. While auscultating the chest you ask the pt. to say "99". It comes through the stethescope as a much louder "99". What is this technique called? When does the change in sound mean?

1. Bronchophony 2. The area where the 99 was louder is an area of consolidation.

A 4-year-old female is brought in by her parents due to an increased nightly cough and low grade temperature. The x-ray shows a Steeple Sign. Which of the following is your diagnoses? 1. Croup 2. Epiglottitis 3. FB aspiration 4. Peritonsillar Abcsess

1. Croup, also known as laryngotracheobronchitis - is associated with upper tracheal narrowing and edema, which is visible on an anteroposterior soft tissue neck x-ray. This is termed the "steeple sign." Epiglottitis is associated with a thickened epiglottis on a lateral soft-tissue neck x-ray, termed the "thumb" sign. Foreign body aspiration and tracheal carcinoma may have x-ray findings based on the location, size, and components present. Peritonsillitis is best visualized on physical exam. If assessing for a potential peritonsillar abscess, a contrasted CT is recommended.

You are examining a pt in your office. While auscultating the chest you ask the pt. to say "eeee". It comes through the stethescope as "aaa". What is this technique called? When does the change in sound mean?

1. Egophony 2. You use it to determine if the lungs have pnuemonia. If the "eee" changes to "aaa" as in this case the pt may have pnuemonia.

Which of the following upper respiratory tract infections occurs most often in kids 2-5? 1. Epiglottis 2. Peritonsillar abscess 3. Croup (laryngotracheobronchitis) 4. Bacterial tracheitis

1. Epiglottitis (Personally I would have said croup but apparently that is not the answer so DON"T pick that one)

What are the 3 most common causes of SOB?

1. MI (with Chest Pain) 2. PE (with dyspnea) 3. Aortic dissection

What is the difference btwn a primary and secondary Pneumothorax?

1. Primary is usu in a young, healthy person with no underlying lung disease 2. Secondary is usu due to an underlying disease

Marvin is a 34 yo asthmatic. He uses his short acting beta agonist several times a day. His attacks have severely impacted his daily activities. He is frequently woken up at night by his asthma. 1. Which Category of Asthma is he in? 2. How would you Tx it?

1. Severe Persistant 2. SABA, LABA, High Dose Inhaled Steroids and maybe a Leukotriene receptor agonist (-lukast)

What are some alternatives to cigarettes you can offer your pt's in order to get them off their nicotine addiction?

1. The patch (they will have crazy dreams) 2. The gum (not so yummy) 3. Nasal spray - really good for quick fix (think snorting cigs) 4. A tomacco fruit

You are examining a pt in your office. While auscultating the chest you ask the pt. to whisper "123". You know you should not hear anything through the stethescope but in the lower R lobe you hear "123". What is this technique called? When does the change in sound mean?

1. Whispered Pectoriloquy 2. The lower R lobe has consolidation

When teaching your pt about the nicotine gum what instructions should you give (and "read the damn directions" is apparently NOT a choice): 1. Chew it like regular gum 2. Spit it out after 30 mins of chewing 3. Drink coffee with the foul tasting gum cause it'll help the nicotine get absorbed 4. Chew 6-9 pieces daily to prevent withdrawal

2. Spit it out after 30 mins -its not regular gum fool! 1. Chew it like regular gum - Its not regular gum fool! 3. Drink coffee with the foul tasting gum cause it'll help the nicotine get absorbed - um really? 4. Chew 6-9 pieces daily to prevent withdrawal - the package says you should chew AT LEAST 9 pieces a day in the first 5-7 weeks to avoid withdrawal.

Of the 50 or so million idiots that smoke each year, about 34% try to quit. How many of that 34% actually manage to kick the habit for good?

2.5%

Intermittent episodes of airway obstruction caused by bronchospasm, excessive bronchial secretions and edema of the bronchial mucosa are characteristic of: 1. Atelectasis 2. Acute Bronchitis 3. Asthma 4. Emphysema

3. *Asthma* - The bronchospasm is caused by the hyerreactivity of the bronchus to allergens, the muscous secretion and edema are part of the inflammatory response. ***remember - asthma is eosinophil mediated response

Chronic cough in kids is frequently caused by everything BUT: 1. Sinusitis 2. Allergic rhinitis 3. cystic fibrosis 4. enlarged adenoids

3. Cystic Fibrosis - this cough takes years to develop. It is very rare in children.

Which of the following diseases will NOT cause a 2ndary pneumothorax? 1. COPD 2. Lung Abscess 3. Marfans 4. Cystic Fibrosis

3. Marfan's will not cause a pneumothorax.

A patient presents with mild dyspnea, increased cough, and rhinorrhea. On physical exam, you auscultate low-pitched, sonorous, and adventitious sounds over the bilateral upper lung fields, which are suggestive of secretions. Which of the following terms is defined by these findings? 1. Rales 2. vesicular 3. Rhonchi 4. Crackles 5. Wheeze

3. Rhonchi - are defined as low-pitched, often harsh breath sounds, with increased secretions and inflammation. Rhonchi due to secretions may improve with coughing. Crackles, also known as rales, are due to an increase of fluid shifting from the intravascular space into the alveoli, and are often described as brief, nonmusical sounds with popping. Wheezes, which are high-pitched, musical sounds, are due to the narrowing of the airway related to mucosal edema, secretions, and bronchospasm. Vesicular breath sounds are normal lung sounds found over the periphery.

Which of the following about Smoking and weight is true? 1. Smokers weigh 10-20 lbs less than nonsmokers 2. Upon quitting 85% of smokers gain weight. 3. Smokers gain weight after they smoke cause the eat a ton more in order to ignore the fact that they want a butt. 4. Men gain more than women when they quit.

3. Smokers gain weight after they smoke cause the eat a ton more in order to ignore the fact that they want a butt. Now the NOT TRUE stuff: 1. Smokers weigh 10-20 lbs less than nonsmokers - they actually weigh 5-7 lbs less 2. Upon quitting 85% of smokers gain weight. - Only about 50% of ex-smokers gain weight. 4. WOMEN gain more because that is just the way life always is... men get to eat and eat and stay skinny but us girls, we eat and get fat, have babies and get fat and apparently do something good for ourselves like stop smoking and get fat!

Which of the following are indications for you to bronchoscope someone? 1. Evaluation of indeterminant lung lesions 2. Staging of cancer 3. Widen a stenosed trachea 4. Determine inhalation injuries

3. Widen a stenosed trachea - this is a surgical correction Bronchoscopy is used to look not fix.

At smoker presents with chest pain and dyspnea. I wish to god they had anything else wrong with them but since this is a pulmn test I suppose these have to be the symptoms... anyway they have SOB, chest pain, etc etc. You conduct your exam and note hyperresonance on percussion. What do you think is going on with them? 1. pneumonia 2. Pleural effusion 3. Lung tumor 4. Emphysema

4. Emphysema - there is extra air trapped in the lungs so you get hyperresonance. The other 3 will sound dull upon percussion

A 23 yo women presents at your office with new onset asthma. You start her on albuterol and a long acting beta agonist. Which of the following is not one of your goals in treating her asthma? 1. Get her back to her normal activity level. 2. Allow her to sleep w/o S/S. 3. No school/work absences from asthma 4. Eventually get her off the meds

4. Eventually get her off the meds... Asthma treatment is surpressive therapy - the goal is to restore and maintian the patient's NORMAL life without interference from S/S of asthma. This means the asthmatic will prob be on meds for the rest of their lives.

In order for you to Dx a person with asthma the pt must do all of the following EXCEPT: 1. demonstrate episodic S/S of airflow obstruction 2. Show airflow obstruction is @least partially reversible. 3. R/O other diseases in ur DDX 4. Improve 3% after a trial of Proventil.

4. Improve 3% after a trial of Proventil. Proventil is a bronchodilator and the asthma pt MUST show an improvement but it has to be *@least a 12% improvement*

Which of the following statements are true regarding lung TB? 1. Manifestations are usu confined to the lungs. 2. Dyspnea is usu present in early stages 3. Crackles and bronchial breath sounds are usu present in ALL phases of the disease. 4. Night sweats are often noted as a manifestation of the fever.

4. Night sweats are often noted as a manifestation of the fever. - Big S/S for secondary TB 1. Manifestations are usu confined to the lungs. - TB is a systemic disease so manifestations in many places. 2. Dyspnea is usu present in early stages - Nope this doesn't happen til later. 3. Crackles and bronchial breath sounds are usu present in ALL phases of the disease. - These don't appear til your pretty much dead.

Which of the following organisms will NOT cause an infectious exacerbation of COPD? 1. Strep.Pneumonia 2. Hib 3. Branhamella catarrhalis 4. Pneumococcus coli

4. Pneumococcus coli - this bug attacks in the abdomen 1. Strep.Pneumonia - causes pneumonia DUH! 2. Hib - causes pneumonia 3. Branhamella catarrhalis - Aka MORAXELLA -nonmotile, Gram-negative, aerobic, oxidase-positive diplococcus that can cause infections of the respiratory system, middle ear, eye, central nervous system and joints of humans - so yeah its gonna annoy the crap out of COPD.

What percent of pack a day (or more) smokers have a cough?

40-60% (I hate percents!)

Assuming no contraindications, which of the following class of medications is considered the preferred long-term control therapy for persistent asthma? A. inhaled corticosteroids B. leukotriene antagonists C. long-acting B2 agonists D. methylxanthines E. muscarinic antagonists

A. Corticosteriods... they kill eosinophils Inhaled corticosteroids (eg, beclomethasone, fluticasone, triamcinolone, etc) are the preferred long-term control therapy for persistent asthma in all patients because of their potency and consistent effectiveness. Low- to medium-dose inhaled corticosteroids offer several advantages over other medications, including the ability to reduce bronchial hyper-responsiveness, improve overall lung function, and reduce severe exacerbations that often lead to emergency department visits and hospitalizations.

A 67-year-old female presents for a follow-up visit for chronic obstruction pulmonary disease (COPD). Her most recent FEV1 is <80% predicted. Her room air oxygen saturation is 94%. She is currently managed on a short acting beta-agonist as needed, and has recently been on a taper-dosed corticosteroid for an exacerbation. Which of the following is the most appropriate next step of management for this patient? A. Increase the dosage of the short acting beta-agonist B. Add an anticholinergic, such as tiotropium C. Begin oral theophylline D. Begin chronic oxygen therapyE. Begin daily oral corticosteroids

B. Add anticholinergic - Management of COPD patients focuses on improving symptoms and decreasing the severity of exacerbations. The initial management should focus on smoking cessation in all patients that smoke. Medications may be utilized to allow bronchodilation, but must be used appropriately, to avoid side effects and potential harm. Anticholinergic agents have been shown to improve symptoms, FEV1, and reduce exacerbations, with less side effects than high dose beta-agonists. Long-acting beta-agonists have been shown to have similar benefits, with caution being needed when using these agents in certain populations. Corticosteroids, both inhaled and systemic, have been shown to have a vital role in COPD exacerbations, but benefits regarding mortality or limiting lung function decline have not been shown, with these agents not being considered a vital part of long-term COPD management. Oral theophylline, which provides bronchodilation and anti-inflammatory properties, is a fourth-line COPD agent, based upon its narrow therapeutic index and potential for adverse side effects. Oxygen therapy has been shown to improve the progression of COPD in patients with resting hypoxemia, defined by most as a resting O2 saturation <88% or <90% with other comorbid findings.

A 70 year old retired coal miner comes to your office. He has trouble expanding his lungs and taking a deep breath. He has a chronic cough. CXR shows some anthracosis. What does this man have?

Coal miners pneumociosis

Which of the following is a tumor of bronchial origin that is known to grow rapidly and have diffuse metastases at the time of diagnosis? A. Adenocarcinoma B. Carcinoid C. Large cell D. Small cell E. Squamous cell

D. Small Cell -Small cell lung cancer is a fast-growing, rapidly spreading form of lung cancer. Although the cells are small, they grow very quickly, metastasize to many parts of the body, and form large tumors. At the time of diagnosis, tumor spread is presumed. The growth and spread is considered much faster than that of non-small cell lung cancers. Staging is also different, utilizing a two-stage system based on the extent of spread.

What is the limited stage of Small Cell Lung Cancer?

Defined as tumor involvement of one lung, the mediastinum and ipsilateral and/or contralateral supraclavicular lymoh nodes. OR disease that can be encompassed in a single radiotherapy port.

What is Extensive stage SCLC?

Defined as tumor that has spread beyond one lung, the mediastinum and ipsilateral and/or contralateral supraclavicular lymoh nodes. Common distant sites of mets are adrenal glands, bone, liver, marrow and brain.

Increased rigidity of the lung tissue, Increased airway resistance or enhanced ventilation during exercise can all be a cause of:

Dyspnea

The volume that can be maximally exhaled after a passive exhalation

Expiratory reserve volume (1500 cc)

Volume that has been exhaled at the end of the first second of forced expiration

FEV1

the determination of the vital capacity from a maximally forced expiratory effort

Forced vital capacity (FVC)

Name the horizontal groove in the rib cage at the level of the diaphragm, extending from the sternum to the midaxillary line, that is mostly seen in kids, esp those with rickets?

Harrison's Groove - - Prominence of this area is a sign of respiratory distress - In a pt that is tachypneic it means IMPENDING FAILURE

A young kid presents to the ER with marked Stridor. Where in the respiratory tract is his issue?

In the Upper Airway (Above the vocal cords) - Wheezing means the problem is in the lower airway (below the cords)

the maximal volume that can be inhaled from the end-inspiratory level

Inspiratory reserve volume (1500 cc)

What should be your first thought with an adult that presents with asthma for the first time?

It's probably work related

A pt presents with SOB, a productive cough, fever and chills. You conduct your physical exam and notice that there is increased tactile fremitus over her lower right lobe. What is your diagnosis?

Lobar Pnuemonia - Pnuemonia is the only thing that increases tactile fremitus.

Marge, age 36, blue gal from Springfield presents to your ER looking for Dr. Hibbert but she finds you. She complains of acute onset of dyspnea. Her pertinent positives are chest pain, faintness, tachypnea, peripheral cyanosis, hypotension, crackles and a slight wheeze. She has been on OCP for the last 15 years and smokes an occasional cigarette. Whatcha thinkin Marge has? And how will Homie survive without her?

Marge has got herself a little Pulmonary Emboli, but you give her some TPA and it clears right up. She's home in time to give Homer his nightly Duff.

One of your asthma pt. has symptoms more than 2 times a week but never more than once a day. They also wake up about 2 nights a month with symptoms. Their FEV1 is 80% of expected. What is the severity of their asthma?

Mild persistant

An asthmatic presents with daily symptoms. She wakes up about 1 night a week. You give her a lung capactiy test and her PEF is at about 70% of expected. What stage of asthma is she in?

Moderate persistant

Meg, a 45 yo asthmatic has been diagnosed with step 1 (intermittent mild) asthma. What long term control therapy are you going to prescribe her?

NONE SON! Intermittent mild people get an albuterol rescue inhaler and nothing else. Have you not been reading the words I've been spewing?? :)

Would you hear stridor in atelectasis?

NOPE - that is a lower airway problem - stridor is an upper airway problem

At what time of day is a cough from postnasal drip most prevalent?

Night time bitches!! And that is what it is... Bed time for me...

A pt of yours is in the hospital. He has an indwelling catheter, increased severity in his underlying illness and is on broad spectrum antibiotics (don't ask me which ones because this school refuses to give me a damn class in antibiotics). All the above factors make your pt predisposed to get what kind of pneumonia?

Nosocomial - Hospital Aquired pnuemonia ***DO NOT confuse this with community aquired which is pneumonia in people who have not recently been in the hospital or another health care facility (nursing home, rehabilitation facility).

Old people have trouble coughing. They are old and feeble. Which of the following changes in their geriatric lungs account for this: 1. Decrease in VC 2. Less elasticity 3. Increase in RV 4. All of the above (and don't pick me because you think - oh it must be all of the above... think about your answer!)

Ok so it was all of the above. - Old people have less elastic lungs and have a much harder tine getting air in and out.

How would you treat Streptococcus Pneumoniae?

Penicillin

A drunk stubles into your ER hacking up a lung. He has been at a shelter for the last few days but they kicked him out because he thought sobriety was optional. You take a CXR and Dx him with pneumonia. What is the most common community aquired pneumonia in alcoholics?

Pneumococcus Klebsiella

What is the most common cause of chronic cough in kids?

Postinfection cough (Surprisingly not postnasal drip or asthma)

Which organism is the most common cause of nosocomial pneumonia?

Pseudomonas aeruginosa - this little bastard will NOT leave

The amount of gas left in the lung after exhaling all that is physically possible is called:

Residual Volume (1500cc)

Some dumb teenager heard they could hallucinate if they took a bottle of aspirin, and rather than googling it he decided just to give it a shot. So he takes like 250 aspirin and presents to your ER. Now assuming he is still alive, what early acid-base disturbance might you notice?

Respiratory Alkalosis Why? Well Because phase 1 of the toxicity is characterized by hyperventilation resulting from direct respiratory center stimulation, leading to respiratory alkalosis and compensatory alkaluria. Potassium and sodium bicarbonate are excreted in the urine.

A pt. presents to the ER with difficulty breathing. He has COPD from years of smoking. You draw an ABG and the results are as follows: pH: 7.3 PaO2: 57 PaCO2: 54 Ox Sat: 84% What is his acid-base status?

Respiratory acidosis In this case the 02 is very low and the CO2 is very high. His body seems to be having trouble blowing off the CO2. Mike Weber taught us that PCO2 abnormality is respiratory in nature and he is acidotic because increased CO2 means increased acid. His Ph has not dropped yet because his kidneys are compensating.

A 32 yo white female comes to your office with complaints of hemoptysis, chest pain and shortness of breath. On CXR you see potato nodes. Microscopy of her sputum shows schaumann bodies and Asteroid bodies. You have r/o the usual pulmonary suspects. What might this young, white female have?

Sarcodosis (Which according to our path test is a hypersentivity to a unknow antigen and we know as UNKNOWN ETIOLOGY)

I occur in healthy, young people with no pre-existing lung disease. I prefer men who are tall and thin. I am an accumulation of air in the normally airless pleural space. I can be caused by a popped bleb (a common side effect of smoking the ganja). What am I?

Spontaneous pneumothorax PS - I do NOT happen in Marfan's

What bacteria is the M/C cause of exacerbation in chronic bronchitis?

Strep. Pnuemoniae (who else?)

What is the most common community aquired bacterial pnuemonia?

Streptococcus Pneumoniae

You are an asthmatic. Yup, can't breathe. And a female... boys you now have boobs... Oops you didn't listen to Malka's contraception lecture and now you are preggo! Congrats btw. How is the pregnancy going to affect your asthma?

Symptoms in 1/3 of preggos improve Symptoms in 1/3 remain unchanged Symptoms in 1/4 get worse.... This is a stupid question!

A fat, hypertensive, alcoholic, smoker walks into your office with SOB and chest pain. You diagnose him with a PE. Which of the following things about him did not increase his risk for PE? 1. fat 2. HTN 3. ETOH 4. Smoking

The fact that he drinks like a fish did not contribute to his risk of a PE. His fat, hypertensive smoking put him in the HIGH risk category tho... so any blood thinning achieved by drinking a liter of gin a day was lost.

What's one of the main differences between the patch and either the gum or the spray?

The patch provides continuous nicotine where the gum/spray only provides it for a limited time.

that volume of air moved into or out of the lungs during quiet breathing

Tidal Volume (500cc)

The sum of vital capacity and Residual volume is:

Total Lung Capacity (5L)

the volume equal to TLC − Reserve volume

Vital capacity

Which is NOT a principle trigger for an asthma attack: 1. allergens 2. weather changes 3. infection 4. psychological factors

Weather Changes are not a principle trigger 0 they can contribute but they are not "front line" triggers.

What is Bronchoscopy?

an examination by means of a bronchoscope.

What is a bronchovesicular breath sound?

are heard in the posterior chest between the scapulae and in the center part of the anterior chest. Bronchovesicular sounds are softer than bronchial sounds, but have a *tubular quality*. *Bronchovesicular sounds are about equal during inspiration* *and expiration*; differences in pitch and intensity are often more easily detected during expiration.

What are Bronchial Breath Sounds?

bronchial breath sounds over the trachea has a higher pitch, louder, inspiration and expiration are equal and there is a pause between inspiration and expiration.

What is a tracheal breath sound?

heard over the trachea. These sounds are harsh and sound like air is being blown through a pipe.

What are the Vesicular Breathe Sounds?

is heard over the thorax, lower pitched and softer than bronchial breathing. *Expiration is shorter and there is no* *pause between inspiration and expiration*. The intensity of breath sound is higher in bases in erect position and dependent lung in decubitus position.