Cram The Pance - S1E34 50 High Yield Pulmonology Questions

Episode Date: August 17, 2021

**Update Question 8:Uptodate: "While in the past V/Q scan was the preferred mode for imaging patients with suspected PE (during pregnancy), we now use CTPA as the primary imaging modality. This preference is based upon the practical rationale that CTPA is more readily available than V/Q scanning, may provide an alternate diagnosis in 12 to 13% of cases, is associated with lower doses of radiation than in the past and has better interobserver agreement for radiologists than nuclear scans."50 High Yield Pulmonology Questions ►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!) --- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right, so let's do 50 high yield pulmonology questions. If you haven't done one of these before, I go through the NCCA blueprint for the pants, and I pick out a few questions from each topic. So it's just a really good, well-rounded review. Good way to cram before an exam or before the pants if pulmonology is a weaker area of yours. And I just always thank you so much for all the really nice comments you guys have been leaving the new subscriptions. And if you haven't checked out the YouTube channel, please do its cram the pants on YouTube. And that's some really good visuals to go along with these questions.

Let's get started with question number one. A 45-year-old African-American female presents to the office today for a persistent, non-productive cough. She has had for the last five months. On exam, you note violaceous plaques on her nose and cheeks. Bilateral hylar lymphadenopathy is visualized on chest x-ray. The first-line medication for the likely diagnosis in this patient is, and that's going to be oral corticosteroids. This patient has sarcoidosis. It's evident by the fact that she has lupus pernial, which is pathanomotifer sarcoidosis.

That was those phylicious plaques in the nose and the cheeks. She has bilateral hylar lipedanopathy. And she fits the demographic. She's an African-American female, which is most common in. So those signs all point to sarcoidosis. A way to remember that. A mnemonic that I came up with is ACE levels super high because the ACE levels are very high in sarcoidosis. So you remember ACE level super high.

It's A-C-E. L for levels, S for super-H-for-high, and all those letters correspond to a certain thing you need to know about sarcoidosis. Ace stands for African-American, three or four times more. common in this race. C stands for cough. Dry cough is very common. The poem complaints. E stands for aerothema no dosum, another common dermatologic finding. L stands for lupus pernium, which we saw in this vignette, pathonymonic for sarcoidosis. S stands for steroids, which is first-line treatment, then the H stands for hylar lymphadenopathy, bilateral hylar lymphadenopathy. Question two, which tuberculosis medication can cause reddish-orange secretions, like in the tears and

urine. So that is going to be refampin. And the way that I used to remember that is the medications for tuberculosis, which is ripe, refampin, isonized, pyrazinamide, and Athambutal, the only one that starts with an R is raphampin. So I just always remembered red or reddish orange secretions like we see in refampin. The other ones I used to remember isonized. I remembered isonum instead of isonized because you have peripheral neuropathy. Athambutal, it's the only one that starts with an E. So I used to think of the eye complaints like optic neuritis. And then pyrazinamine, I have this long. description if you go to the tuberculosis podcast or the YouTube channel you can check it out relating to a pyramid I won't bore you with that now question three what

antibiotics are commonly used in the treatment of community acquired pneumonia in an outpatient setting so which antibiotics are you going to use in a community acquired pneumonia in the outpatient setting and that would be macrolides like azithromycin amoxicillin doxycycline and then plus or minus fluoroquinolones remember you only use fluoroquinolones in patients with comorbidities or risk factors for drug-resistant pathogens Question four, a homeless patient presents to the ER with a productive cough, foul-smelling sputum, and admits to blacking out two nights ago due to excessive alcohol use.

On physical exam, you know, decreased breath sounds and dullness to percussion in the right lower lung field. Which antibiotics should be considered in this patient for the likely diagnosis? So there's going to be two antibiotics. It's going to be moxacusiline clavulonate, which is also known as augmented, or ampicillin-sobactam. Well, depending on the severity, because remember, ampacillin-sobactam is going to be given intravenously and then amoxicillin clavulani is going to be given oral so depending on how you're going to treat them inpatient or outpatient so this is a classic presentation for aspiration pneumonia he has foul-smelling sputum which honestly you could stop right there and probably get there

right in a vignette that's a key for aspiration pneumonia so anytime you see a patient also with reduced consciousness like in this patient which obviously in his case was due to alcohol use you have to consider aspiration and he likely vomited and aspirated in addition on physical exam we had those decreased sounds and dull this percussion in the right lower lung this is the most common area for aspiration pneumonia to be present just due to the angle of the right main stem bronchus and leading to this consolidation which is the physical exam findings we found in this patient so remember moxiciclobulinate or ampicillin solbactin for aspiration pneumonia question five what medications are used in patients with idiopathic pulmonary fibrosis to slow progression of the disease

which meds are you going to use to slow the progression of the disease that's going to be two meds it's going to be pure phenadone and it's had a nib. So there's no medications that are going to cure idiopathic pulmonary fibrosis. These are the only two meds that have shown any type of, you know, slowing of the progression of the disease. They're the only two that have helped it all. They're really the only meds you should know for this outside of maybe steroids for an acute exacerbation. Question six, tuberculosis of the vertebrae is known as tuberculosis of the vertebrae is known as potts disease. So it's tuberculosis spondylitis. It's potts disease. It most commonly affects the lower thoracic and upper lumbar region. I used to remember this because it works better with the visual I have

on the YouTube channel. But if you stack up pots, they kind of look like vertebrae. So I just always have this visual of pots stacked on top of each other. They look like vertebrae. So that just used to help me make the connection that TB of the spine is known as pot's disease. Question seven, which type of lung cancer is considered the most aggressive and has the lowest, five-year survival rate. So which lung cancer is the most aggressive has the lowest five-year survival rate? That would be small cell lung cancer. It's the most aggressive form of lung cancer. About two-thirds of patients have evidence of distant metastases presentation, and it only has about a seven percent five-year survival rate. Question eight, a 32-year-old female in her third

trimester of pregnancy presents to the office complaining of shortness of breath, chest pain that worsens with deep inspiration. On exam, her respirations are rapid and shallow. Her vitals reveal a pulse of 122. She admits for the last four days she has mostly been on bed rest due to difficulty ambulating in her late stage of pregnancy and due to some pain she has had in her left lower extremity. What is the most appropriate diagnostic test to use in this patient to confirm the likely diagnosis? This patient you would do a VQ scan.

So what's the most likely diagnosis? It's going to be a P.E., a pulmonary ambulance. So she's been immobile for four days. She has unilateral lower leg pain, likely from a DVT, and she's experiencing pleuritic chest pain, dyspnea. On exam, she's tachypnic, tachycardic. These are all very classic findings in pulmonary embolism. So your first thought may have been CT, because that's normally the test of choice for diagnosis.

But don't forget, she's pregnant. Even though she's in the third trimester, you could kind of argue it, we still have to consider the risk of radiation. So in pregnant patients or anybody else where they mentioned a contraindication to a CT, VQ scan is going to be your diagnostic test of choice because of the lower dose of radiation and a VQ scan compared to a CT. Question nine, a patient who is called. currently living with his brother, who has active tuberculosis, would have a positive PPD at what size of end duration. So that is going to be five millimeters or greater. This is considered a high-risk patient because they're living in close proximity with someone that has active TB. And then other

high-risk patients that are in this category that are positive at five millimeters greater are going to be your HIV patients, your immunocupress. So other patients that are like on chemo, chronic steroid use, organ transplantation. Question 10, a patient with the history of tuberculosis. As a chest x-ray performed that displays diffuse small nodular lesions spread throughout the lungs Which type of tuberculosis does this patient likely have? So this is something known as milliary tuberculosis. So the classic appearance in miliary disease is these small infiltrates Distributed fairly uniformly throughout the lung. It was originally called millary at TB because of the appearance on the nodules on chest x-ray Looked like they're called millet seeds of these little tiny seeds. It looked like they were spread throughout the lungs and

Now the name also implies all forms of progressive, widely disseminated TB. Question 11. What is the most common bacterial cause of community acquired pneumonia? You got to know this one. That would be Streptococcus pneumonia. At this time, Streptneummo, it's still the most commonly detected bacterial cause of cap of community acquired pneumonia. Its incidence is decreasing, though, mainly due to the pneumococcal vaccine, but it's still the most common bacterial cause. Question 12, define chronic bronchitis, looking for the clinical manifestations, the time frame.

So that's going to be a productive cough for at least three months a year for two consecutive years. This is, of course, in a patient with the absence of other causes of chronic cough, like they've been excluded like bronchiactistics, etc. So remember, productive cough, at least three months a year for two consecutive years. Question 13, a six-year-old boy presents to the ER complaining of a sore throat that has gotten worse over the last. last few days. In addition, he's at trouble swallowing and a fever. On exam, he is drooling and leaning forward while sitting on his father's lap and refuses to lay down on the exam table. When speaking to you, his voice sounds muffled and he is invisible distress. What is the first and most important step in management of this patient? So that answer is always going to be maintaining the airway.

It's always going to be the right answer for first line management of someone with acute epiglottitis, which this patient clearly has. They have the triad of the three Ds, which is drool. grueling dysphasia and distress. Combined with the preferred tripodting position, he's in on his father's lap to help him breathe better, the muffled voice, sometimes you'll hear that as a hot potato voice. And the first step in these patients, it's always to maintain their airway, because at any time their airway can collapse, and this can be fatal. So that means avoidance of anything that's going to agitate them.

You don't want to use a tongue depressor to visualize the pharynx. They may need bag valve mask ventilation. You may need to call anesthesia to assist securing the airway. And then when you do intubation, it's best performed in the OR. Question 14, a 17-year-old male presents at the office today with pharyngitis, non-productive cough, and an earache. On chest x-ray, Apache infiltrate is visualized. He has no past medical history and is not taking any medications. What is the likely organism causing this patient's symptoms?

So that is going to be mycoplasma pneumonia. So we have an infiltrate on x-ray. Why are we suspecting mycoplasma? So mycoplasma pneumonia is the most common cause of walking pneumonia. And we have a classic description in this vignette. So we have a young otherwise healthy patient. That's the first check for mycoplasma. We have a young healthy patient here.

Next, we have extra pulmonary symptoms, which is very important. It's common in mycoplasma. So yes, pharyngitis, earache. And then finally, we have the description of the infiltrate. So atypical organisms like micoplasma pneumonia have a patchy or hazy appearance on chest x-ray. And that's compared to your typical organisms like strepneumo that have this more clearly defined low bar infiltrate in most cases. So all of those factors lead us to the organism of mycoplasma pneumonia.

Question 15. Patient with sarcoidosis presents with erythema, nodosum, bilateral hylar lymphadenopathy, and polyarthriogias with fever. This syndrome is known as, that is going to be Lofgren syndrome. So Lofgren syndrome, it's a very specific finding in patients with sarcoidosis, so much so that accompanied by the right clinical manifestations, that you don't even need a biopsy to confirm the diagnosis. Question 16.

What treatment option is most effective in patients with small cell carcinoma, small cell lung carcinoma? So that is going to be chemotherapy. So small cell lung cancer is very responsive to chemo, plus or minus radiation, and surgery is rarely, if ever used. It's just not effective. But remember, small cell is very responsive to chemo. That's your number one treatment option for small cell lung cancer is going to be chemotherapy.

The way that I used to remember, this, among other things, that are important for small cell lung cancer. Small cell lung cancer, SCLC, stands for smoking because cigarette smoking has a strong association with small cell and squamous cell, the biggest association with those two. The C stands for central because the mask is often located in the central part of the airway in small cell lung cancer. L stands for Lambert Eton syndrome, because peroneoplastic syndrome is like Lambert Eton syndrome are very common in small cell lung cancer, the most common in small cell. And then finally, the C stands for chemo like we went over here because it's extremely responsive.

That's your best treatment option for small cell lung cancer. Question 17, a combination of asthma, nasal polyps with chronic rhinocinucitis, and sensitivity to aspirin is known as. That's going to be Sampter's triad. Question 18. A soft tissue lateral cervical radiograph would display what classic finding in a patient with acute epiglottitis. So that is going to be something known as the thumbprint or thumb sign.

And it's from an enlarged epiglottis protruding from the the anterior wall of the hypofarynx. And on imaging, it basically just looks like the tip of a thumb poking out. It's not a really great diagnostic test. Most of the time, it's not really something you're going to use in real life. But it makes for a very good and easy exam question. So you should be aware of it. Question 19, which type of lung cancer is most commonly seen in non-smokers? So what type of lung cancer is most commonly seen in non-smokers?

That's going to be adenalcarsin. So adenal carcinoma, most common type of lung cancer seen among non-smokers. And per the CDC, it's about 50 to 60% of lung cancers found in people who have never smoked our adenal carcinomas. Question 20. Patient presents with a cavitory lesion and a proximal bronchus visualized on imaging. Labs show an elevation in serum calcium levels. What type of lung malignancy does this patient likely have?

So this is going to likely be a squamous cell carcinoma. So how do we know it's squamous cell long carcinoma? Not another type of malignancy. You have to remember your four Cs of squamous cell long carcinoma. And the way that I used to remember that, with squamous cell, squamous is spelled with a cue, but I remember it spelled with a C instead of that cue to help me remember there's four Cs that are important in squamous cell long carcinoma. So first, the mass is centrally located, with which this mass we stated it was in the proximal bronchus

and not the periphery of the lung. So centrally located, that's our first clue. Second, we mentioned that it was a cavitary lesion located in the proximal bronco. Remember, that's your second C. The third C, we mentioned that this patient has hypercalcemia. So calcium elevation, that's your third C. And then the fourth C that we didn't mention would be cigarette smoking, because remember, again, squamous and small cell, strongest association with cigarette smoking.

So that's the four Csies of squamous cell lung cancer. Question 21, a six-month-old old boy presents with a harsh, Barking cough. On exam, you note inspiratory strider at rest marked intercostal retractions and cyanosis. He is diagnosed with laryngotrakeitis, also known as croup, and he started on nebulized epinephrine to relieve his symptoms. What other therapy should be considered in this patient for relief of his respiratory symptoms in addition to the nebulized epinephrine? So that is going to definitely be dexamethosome. So moderate to severe croup, as this patient has, evident by the inspiratory strider at rest, marked retraction, cyanosis. You want to treat with a combination of

of both nebulized epinephrine and dexamethazone. In addition to your supportive care, so your humidified air, oxygen, antipyratics. So glucocorticoids like dexamethyzone, they're really your best treatment option in croup, and they're effective in all levels of severity with croup. So if they ask you a croup question and dexamethazone is on there, it's likely going to be the right answer. Question 22, a patient with co-workers pneumoconiosis would likely have nodules in what part of the lungs. So that's going to be the upper lobes of the lung. So pneumoconiosis and other, so certain types of pneumoconiosis have pulmonary nodules or plaques that have a predilection for a certain part of the lung. And it's going to be the way that I remembered it, the mnemonic

that I came over there, it's going to be opposite of the height they do their work at. So let me explain this. So let's say asbestosis. Asbestosis patients, this type of pneumoconiosis. These patients work with roofing tiles insulation and attics old buildings up high they normally have their plural plaques in the lower lobes silicosis another type of pneumoconiosis they work with rocks granite slate slate deep down in the earth so deep down their nodules are low normally located in the upper lobes and then in this patient co-worker pneumoconiosis they work deep down in coal mines down in the earth they normally have their nodules up high in the upper part of the lobes so it's opposite of where they do their work at that's where they have the predilection for the certain part

of the lungs. So remember that. Wherever they're doing their work, if it's high up, the nodules will be down low. If they're doing work down low, the nodules are going to be high up. Question 23, a 42-year-old male presents to the office complaining of fever, cough, and diarrhea for the past week. He has no past medical history and works as a plumber. His lab show elevated hepatic transaminases as well as hyponatremia. What diagnosis should be suspected in this patient? So you should be suspecting Legionella. So as soon as you see diarrhea combined with a cough, right away you should be thinking of Legionella. That's your first red flag, but obviously other things can cause this. But in the vignette, we also see he works as a plumber. Remember, Legionella is often caused by

contaminated water sources. So we're working with plumbing systems, showerheads, sink faucets. They're all things this patient is going to have occupational exposure to. So that's your second red flag. And then finally we see those lab findings, those hyponatremia, elevated liver enzymes. They're both potential findings in Legionella. Of course, to confirm this diagnosis, we do PCR testing, but this presentation is more than an other. in a vignette to diagnose Legionella. Question 24, musin or gland formation visualized on histology is suspicious for which type of pulmonary neoplasm. So that is going to be an adenal carcinoma. So this type of cancer arises from the bronchial mucosal glands. So if they mention

histologic findings with mucin production or gland formation, you should be thinking of adenal carcinoma. Question 25, a 16-year-old male with the history of asthma presents to the office due to worsening of his asthma over the past year. The only medication he currently uses for asthma is albuterol PRN. He currently has symptoms three to four times per week and is woken up four times per month with wheezing and a dry cough, which medication is recommended for this patient in addition to his albuteral inhaler. So that is going to be an inhaled corticosteroid, a low dose. It doesn't matter which guidelines you're looking at, the NAEPP 2020 guidelines or the newer gina guidelines. They both recommend at stage two, you add inhale corticosteroid. Of course,

genoa recommends the genital guidelines also have an option of doing an ICS combined with promoterol. But just remember if they ask you like a level two inhale corticosteroid is normally going to be the treatment they're looking for. Question 26. A 62-year-old woman presents to the office complaining of a chronic productive cough that contains thick sputum and at times she notes it has even been tinged with blood. A CT of a chest is ordered and reveals dilated bronchye and thickening of the airway.

The CT also reveals that the bronchiales appear abnormal. normally larger than the adjacent pulmonary artery. No appreciable mass is visualized on CT. What is the likely diagnosis in this patient? So that is going to be bronchiectocyst. So how do we know that? First, she has a persistent, productive cough with hemoptosis, all classic clinical manifestations and rockyectasis. That's not enough, of course, to make the diagnosis. Next, we see her CT findings. They display thickened and dilated bronchiales. And also mentioned is what's known as the Signette ring sign, which is when the airway diameter, the bronchiales, are larger than the adjacent vessel diameter of the pulmonary arteries.

So it's a classic finding of bronchiectocyst. And then finally, we have to roll out our differentials, but they mentioned the, there's no weight loss, and the CT did not show a pulmonary mass, so we can get rid of that potential for malignancy, which leads us with the most likely diagnosis, which is going to be bronchiectesis. Question 27, a 14-month-old female presents accompanied by her mother. The mother states the child has had sudden, severe coughing episodes that often end in the child vomiting. She also describes a noise that the child makes after each coughing spell that almost sounds like the child is having trouble catching her breath. The mother states that the child is

not up to date on her immunizations. If antibiotics were initiated in this child for the likely diagnosis, which antibiotic class is preferred. So that is going to be macrolides, a zithromycin. So the child in this vignette has severe paroxysmal coughing fits, post-tus of emisysis, which is that. And the noise she makes after the coughing spells, the mother described, it's a classic inspirer. respiratory whooping sound. Plus, she's not up to date on her vaccination. So very classic presentation for pertussis, aka whooping cough. And if antibiotics are initiated, often supportive measures are going to be enough. But if you do use antibiotics, macrolides are going to be your antibiotic class of choice. So sittermicin, chlorithromycin, erythromycin. Question 28, what is the

most common cause of acute bronchialitis? So that is going to be a respiratory synchial virus, RSV. It's the most common cause of broncholitis. And most of the time, when they do actually see what pathogens are found, it's only the sole pathogen found in broncholitis. And then, of course, the second most common cause is going to be rhinovirus. Question 29, patients with secondary or reactivation tuberculosis will most commonly have localization of cavitory lesions in which region of the lungs. So that's going to be the apices, the upper lobes. So reactivation TB is typically going to involve the posterior segment of the apices and the upper lobe.

in about 80 to 90% of patients. Question 30. A four-year-old boy presents to the office with his mother. The mother describes a harsh barking cough. He's at for the past week that gets worse when he is agitated. She also states he has a low-grade fever and is hoarse when he speaks. An AP cervical spine x-rays performed that displays subglotic narrowing of the airway. This sign is known as, that's going to be the steeple sign.

So subglotic narrowing of the airway is known as the steeple sign in patients with lorangeotracheitis. a.k.a. Krupp. This child has this evident by the seal-like or barking cough, which is worse with agitation, the low gray fever, hoarseness. This test, again, it's not often performed. Krupp is very much a clinical diagnosis. And the steeple sign, like a lot of the other imaging findings we've gone over for these types of things, just doesn't have a very high test sensitivity. But again, these types of things they do like to ask on vignettes, so I would be familiar with it. Question 31. What is the first line medication used for treatment and prophylaxis for pneumocystis pneumonia, which is also known as PCP pneumonia. So that is going to be trimptoprim so sulfomethoxazole, which is also known as back trim. The way that I used to remember that. Remember this is PCP pneumonia. So I used to remember PCP stands for your posterior is coarse and prickly. You need your back trimmed. So your posterior is coarse and prickly. Got like hair all over your back. You need your back trim. your back trim, so that's your going to be your trimetoprimmed, sulfomethox's hall.

Question 32, a 24-year-old male presents to the emergency department complaining of right-sided chest pain and shortness of breath that began two days ago. He states that the symptoms started when he was at home watching TV and came on suddenly. Initially thought this may have just been a muscle strain but is not improved over the next of the last couple days and he's starting to get worried. On exam, he is tall and thin and sculptatory findings reveal breath sounds that are diminished in the right hemisthorax compared to the left. Describe what would likely be heard on percussion of the right side of the thorax in this patient. So what you're likely going to hear is hyper resonance to percussion. So this patient has a pneumothorax, specifically a primary spontaneous pneumothorax. So this is all evident by the fact

that he fits the criteria. He's young, thin, and tall, and he's a male. The second key is the fact that there was no precipitating trauma or event to cause the pneumothorax. You have diminished breath sounds on the right side, sudden dyspnea and chest pain. So a pretty clear presentation. So why do we have hyperresonance to percussion? Well, anytime you have air trapping like in an anumothorax when you have air trapped in the plural space, you're going to hear hyper resonant notes to percussion. It's true in any disease that causes excess air to be trapped. So whether it's COPD, asthma, the way you always remember it. And I know I've talked about this another podcast. You puff out your cheek and you tap on it that's hyper resonant because all the air that's trapped in your cheek. So the same in all

the air trapping conditions. And it's the exact opposite when you have fluid in a cavity or a consolidation. So like plural effusion or pneumonia, they're going to have dullness and percussion the opposite. Question 33, a 66-year-old male presents to the office with history of a non-productive cough. He works for a construction company that restores and renovates old buildings. On chest x-ray, an ill-defined cardiac border is seen and bilateral plural plaques are noted in the lower lobes. What diagnosis should be suspected in this patient? So that's going to be asbestosis. So you have pleural plaques in the lower lobes.

Remember what we talked about earlier with the pneumoconiosis opposite of where they work. He works up high, renovating old buildings. So his pulmonary findings are down low in the lower lobes. In addition, we mentioned the ill-defined cardiac border. This is something seen in asbestosis, which is known as the shaggy heart sign. They're all common imaging findings in asbestosis. Finally, we mentioned that he works in the construction business repairing and renovating old buildings, which is one of the risk factors for exposure to asbestos.

And then he has that nonproductive cough, which is nonspe specific, but it's seen in asbestosis. Question 34, what is the most common cause of lorinco-trakeitis, also known as croup? I ask you a lot of croup questions. The most common cause is going to be para-influenza virus type 1. The way that I used to remember that is croup is most commonly caused by para-influenza virus. I'm sure you've heard of paratroopers. They're like the people in the armed forces that jump out of the airplane with the parachute. So they're known as paratroopers.

but I used to remember it as paracruppers. So para, para influenza virus type one, cruppers, croup. I used to have that association in my head and I never forgot that. Question 35, an 11-month-old boy presents to the office today. Mother states that the child has frequent bowel movements per day, and the stools often appear loose and appear shiny. She also notes over the last year the child has had multiple lung infections and has been on a number of antibiotics, but the infections seem to keep coming back.

On exam, the child is below the fifth percentile in both height and weight. What is the test of choice to make the diagnosis in this patient? So that is going to be the sweat chloride test. So this child clearly has cystic fibrosis, the frequent bowel movements, the looser shiny stools, which is from malabsorption, so diarrhea and steataria, which is those greasy stools, which the mother described is shiny, plus the recurrent upper respiratory infections, below average growth rate. So in these patients, the sweat chloride test remains the primary and really the best way to diagnose cystic fibrosis.

Question 36. What medication class should never be used as monotherapy in treating long-term asthma? So what medication class should never be used as monotherapy in long-term asthma? That's going to be your labas, your long-acting beta-2 agonists. So that's for motorol, so meterole. They must always be used in combination with an inhaled corticosteroid. When you use them as monotherapy long-term, you increase the frequency. of treatment failures. It's also associated with an increased risk of asthma-related death.

So remember, really, the only wrong answer in asthma treatment is going to be a lava by itself. Always have to combine it with an inhale corticosteroid. Question 37. Patient with pertussis is experiencing the characteristic severe paroxysmal coughing fits combined with inspiratory whooping after the coughing fit. Which of the three phases or stages are they currently in? the cuterol, the paroxysmal, or the convalescent phase. So they have the characteristic inspiratory whooping, the paroxysmal coughing fits.

They are going to be in the paroxysmal phase. So you have three phases with pertussis, the cuterol phase, which is generally where they have the upper respiratory symptoms, the carise and mild cough. This is also when the transmission is highest, it's most infectious at this point. And then they have when the symptoms really kick in and we have our classic presentation. And that's the one we're all familiar with. the paroxysmal stage. So the inspiratory whoop, the coughing fits, post-dustive emesis, et cetera.

And then it concludes with the convalescent stage, which is where the cough slowly subsides over weeks to months. Question 38. The majority of malignant lung nodules are found in what region of the lungs. So that is going to be the upper lobe. So malignant nodules can be found in any lobe of the lung, but those that are located in the upper lobe have a much higher probability of being malignant. About two-thirds of all malignant nodules are found in the upper lobes of the lung.

lungs. Question 39. Which type of emphysema is most commonly seen in patients with alpha-1 antitripsin deficiency? So that is going to be panacinar, which is also known as diffuse. So panacinar or diffuse emphysema is where you have destruction in all parts of the asenus. It's most commonly seen in patients with alpha-1 antitrips and deficiency. Then you also have the other type, which is known as central lobular, and it's destruction of the central and proximal part of the Asenus. It's more commonly seen in emphysema patients who are smokers. The way that I used to remember that, central lobular is seen in smokers. Central lobular starts with the C, so I used to remember cigarettes. And then panacinar, which is commonly seen in alpha 1 antitripsin deficiency.

I used to remember panacin. I used to remember a pan, cooking a steak in the pan, and you're putting A1 sauce in it. So alpha 1 antitripsin, A1 sauce on the steak that's in the pan, panasin. That's how I used to remember it. Question 40. And hemo dimend, I'm sorry. sorry, in a hemodynamicly stable patient, got it the third time, with pulmonary embolism, what treatment option would be indicated if anticoagulation is contraindicated? So they're hemodynamicly stable. I don't know why I try to say that again. They have a PE.

What treatment option would be indicated if anticoagulation is contraindicated? So that's when you're going to use something known as an IVC filter. So an IVC filter, it's a small filter you place in the inferior vina Kava, so that if this patient gets another DVT, gets dislodged, it's never going to reach the pulmonary vascular. It's going to get stuck in this little filter in the IVC. So who do you use these in? Well, they have to be stable. And then the IVC filter should be considered in patients that have either contraindications to anticoagulation. So maybe they have a hemorrhagic stroke or recent surgery. Second reason is if they have recurrent emboli despite already being adequately anticoagulated or the third reason you would use

an IVC filter is high-risk patients. So patients that have either an underlying. cardiopulmonary disease like rife ventricular dysfunction where if they had another PE it would be fatal so the three reasons again is one they can't take anticoagulation two anticoagulation doesn't work for them or three they're going to die if they get another PE that's when you use your IVC filter question 41 horner syndrome which is classically seen in a superior sulcus also known as a pancostomor is a triad of what three clinical manifestations so that is going to be toosis myosis and anhydrosis remember toosis is drooping of the myosis constriction of the pupil and in hydrosis is a lack of sweat we see these in superior sulcus tumors which is a tumor commonly seen in non small cell lung cancer

it's a type of tumor that's located near the apices of the lung which leads to this neurologic symptom but Horner syndrome can actually be produced by a mass anywhere along that sympathetic pathway that supplies the head the eyes and the neck question 42 a 47 year old male presents to the office today complaining of shortness of breath and chest pain Chester X-ray and ECG are ordered. The chest x-ray reveals a shallow wedge-shaped opacity in the periphery of the lung. And the ECG displays deep S-wave in lead one, prominent Q-wave in lead three, and T-wave inversion in lead three.

That should throw off all these little signals in your head. What diagnosis should be suspected in this patient? So that's going to be a pulmonary embolism. So chest pain, dyspnea, there's a lot of differentials. But the key is those diagnostic tests that we did. So on ECG, we have what's known as the S-1-Q-1-Q-1. 3-t3. It's not the most specific or sensitive indication on PE, but if you see it in the right clinical context, like in the spignette, PE should definitely be on your list of differential.

So S-1Q-Q-3-T-3, it's a prominent S-wave in lead-1, Q-wave in lead-3, and then an inverted T-wave in lead-3. And then on chest x-ray, we have what's known as the Hamptons hump. So it's a wedge or hump-shaped opacity in the periphery of the lung, which is due to the infarction caused by that pulmonary ambuli. Question 43, a 42-year-old female. was brought into the ER by fire rescue after a near drowning incident at a local beach. She is admitted and on the second day she becomes unstable. And on exam, you notice she is tachypnic, tachycardic, and diffuse crackles are auscultated bilaterally. Chest X-ray displays diffuse pulmonary infiltrates bilaterally that spare the cost of pharaenic angles.

Plural effusion, cardiomegaly, and pulmonary venous congestion are all absent on imaging. What diagnosis should be suspected in this patient? So you should be suspecting acute respiratory distress syndrome, also known as ARDS. So when you see a patient that had some sort of trauma infection, severe trauma or infection, like near drowning, sepsis, shock, other critically ill patients. And then they mention a chest x-ray that has these diffuse pulmonary infiltrates, or also known as air bronchograms, is another finding. But then they purposely mentioned there's no findings to indicate CHF,

so it spares the claustrophrenic angles, no cardiomagalli, no pleural fusion. this is acute respiratory distress syndrome. Definitely on a vignette, that'll be the correct answer. Question 44, a patient that shows a decrease in FV-1 FEC ratio less than 0.70, likely has an obstructive or restrictive disease of the airway. So decrease in the FV-1 FEC ratio, that is going to be an obstructive lung disease, like an asthma or COPD. The way that I used to remember that is obstructive.

I used to remember the O stands for O. the ratio, so keeps it down. And then I used to remember that restrictive diseases, like idiopathic pulmonary fibrosis, the R stands for remains the same or raises the ratio, because restrictive diseases, your FV1 FEC ratio is either going to remain the same or raise. It's either going to go up or stay the same. Question 45. Compensatory hyperventilation with a deep and labored breathing pattern, often in response

to severe metabolic acidosis like DCA, is known as, that is going to be Cousman. all respiration. So it's the body's way of attempting to blow off excess CO2 to correct the metabolic acidosis in the body. Question 46, a 39-year-old male presents to the office complaining of pleuritic chest pain. He is recovering from an upper respiratory infection he had three weeks prior. He has no past medical, no past medical history and is not taking any medications. On exam, you note point chest wall tenderness around the upper sternocastal joints. There's no edema, arithema or other abnormalities noted on the chest wall. ECG chest x-ray and labs are all normal. What was the most appropriate treatment option for this patient? So that's going to be supportive

measures like ensigns. So this is costocondritis. You have a young male with pleuritic chest pain. He had a recent upper respiratory infection. He has no past medical history, normal diagnostic testings, reproducible pain on exam. Those all likely indicate costocondritis, which you just treat supportively mostly with insets. Question 40. a four-year-old boy presents to the emergency room after his mother noted a sudden onset of cough dyspnea and whee's foreign body is visualized via rigid broncoscopy what part of the airway is the foreign body most likely located so that is going to be the right main bronchus so foreign bodies will most commonly be located in the right main bronchus and children because it has a more vertical orientation and a larger diameter compared to the left main bronchus question 48 a 44 year old male presents to the er with a productive cough and fever he has had over the last two weeks. Chest x-ray is ordered, which displays an infiltrate in the right lower lobe. On exam, his blood pressure is 98 over 56, pulses 97, and respiratory rate is 32.

Community acquired pneumonia is diagnosed, and it is decided that he will be started on antibiotics. Can this patient be treated as an outpatient, or should he be admitted? So this patient should be admitted. He should be treated as an inpatient. So how do we know that? We use curb 65. Curb 65, again, remember, stands for confusion, urea over 7 millimoles, respiratory rate over 30 or higher, blood pressure, systolic under 90 or diastolic 60 or less, and then age of 65 or higher. So you have 0 to 1 points.

They can be treated as outpatient. You have somebody with two points. They should be admitted to the hospital, and then a score of three or higher should be assessed for ICU care. So each one of those is a point. And remember, we said his diastolic blood pressure was 50. 56 and his respiratory rate was 32. So he gets two points for that. Remember, diastolic should be 60 or under to get a point. Didn't matter that his systolic didn't fit the criteria. You only need one of those and that his respiratory weight was 32. Respiratory rate of 30 or higher gets another point. He doesn't fit any other criteria. Doesn't fit the criteria for the age. Didn't mention any confusion, any altered mental status and we didn't mention the blood urea nitrogen. So we obviously can't give that point for that. So he gets two points. He should be admitted to the hospital and treated as an inpatient.

Question 49. A pulmonary nodule is a small, well-defined lesion, completely surrounded by pulmonary parankuma, less than or equal to how many millimeters. So that would be less than than or equal to 30 millimeters. Any larger than this, it's no longer considered a pulmonary nodule, but is now considered a pulmonary mass. All right. Last question. 50. A 58-year-old male presents to the office complaining of persistent diarrhea. He's also noticed episodes of facial flushing, wheezing, and palpitations with no known precipitated. factors. A tumor is localized on CT and follow-up bronchoscopy identifies a well-differentiated centrally located tumor in the main stem bronchus. The syndrome of symptoms this patient is experiencing is known as. That's going to be carcinoid syndrome. So this is a classic presentation in a patient with a carcinoid tumor, which is a rare neuroendocrine tumor and it secretes serotonin, histamine, histamine, chastomines, and it leads to the symptoms we see here in this patient, which is known as

carcinoid syndrome. So the skin flushing, wheezing diarrhea palpitations patient in this vignette had all of those and he had a bronchial carcinoid tumor which is the second most common area for a carcinoid tumor the first would be the GI tract it's the first most common area to see carcinoid tumor all right so that was it 50 high yield pulmonology questions I hope it was helpful as always thank you so much you guys are super supportive and I just appreciate all the really nice things you say and it's just been really nice making these for you because you guys are just really nice and leave really nice comments I do appreciate it and I'm so happy to hear

that it is helping you so please let me know if it's if there's anything you suggest any things you like me to do in the future or if you you know just want to leave me a comment please do and thank you so much as always and good luck on your pants your panery your EORs and good luck in PA school