ROSH Pulmonology UPDATED ACTUAL Questions and CORREC
Answers
1. Sarcoidosis Systemic disease with unknown etiology, can affect all organ systems
Sx: cough, dyspnea, fever, fatigue, skin lesions, arthralgias
PE: lupus pernio (chronic, violaceous, raised plaques and nodules commonly
found on the cheeks, nose, and around the eyes) is pathognomonic for
sarcoidosis
Labs: hypercalcemia, hypercalciuria, elevated serum ACE
CXR: bilateral hilar adenopathy, possible reticulonodular opacities in upper
lung fields
Biopsy: noncaseating granulomas
Tx: spontaneous remission may occur, oral glucocorticoids
Comments: Löfgren syndrome: fever, erythema nodosum, hilar adenopathy,
migratory polyarthralgia
2. Chronic Obstructive Main subtypes: chronic bronchitis, emphysema
Pulmonary Disease Hypoxemic patients should be given supplemental oxygen with SpO2 goal of
(COPD) 88-92%
Management options include bronchodilators, anticholinergics, steroids,
supplemental oxygen, noninvasive ventilation, smoking cessation, vaccina-
tions, and antibiotics for severe disease, infection present, or those requiring
ventilation
3. What are the Answer: An increase in the FEV1 of more than 12% and greater than 200 mL.
spirometry criteria
for the airways to be
considered respon-
sive to bronchodila-
tors?
4. Influenza Patient presents with sudden onset of fever, headache, cough, myalgia, sore
throat, fatigue
Diagnosis is made clinically, can be confirmed with reverse transcription
polymerase chain reaction (RT-PCR) or viral culture
, Treatment is mainly supportive or oseltamivir for patients at increased risk for
severe disease
Start oseltamivir as early as possible, after 48 hours it may not confer any
benefit
Most common cause of viral pneumonia in adults
New vaccine needed yearly
Monitor patients for postinfluenza pneumonia
5. Chronic Bronchitis Chronic productive cough for at least 3 months in at least 2 successive years
PE: decreased breath sounds, increased resonance upon percussion of the
lung fields
Diagnosis: FEV1/FVC ratio < 0.7 postbronchodilator
Tx: smoking cessation, lifestyle changes with pulmonary rehabilitation, in-
haled bronchodilators, inhaled steroids
6. What genetic dis- Alpha-1-antitrypsin deficiency.
ease is known to
cause chronic ob-
structive pulmonary
disease in younger
patients or patients
who do not smoke
cigarettes?
7. What condition is Sarcoidosis.
characterized by
granuloma forma-
tion in various parts
of the body, most
commonly the lungs
and lymph nodes?
8.
, Asthma in Adults Asthma: airway inflammation + bronchial hyperresponsiveness + reversible
and Adolescents airflow obstruction
NAEPP Classifications:Intermittent Symptoms d2days/weekd2 nighttime
awakenings/monthFEV1 > 80% of predictedMild persistentSymptoms >
2 days/week but < daily> 3-4 nighttime awakenings/monthFEV1 e80%
of predictedModerate persistent Symptoms daily> 1 nighttime awaken-
ing/week but not nightlyFEV1 60-80% of predictedSevere persistent Symp-
toms throughout the dayNightly awakenings commonFEV1 < 60% of predict-
ed
Management depends on factors such as asthma classification, level of con-
trol, and patient factors (such as age)
Treatment options may include SABAs, ICS, combination ICS-formoterol,
LAMAs, and LTRAs
Step-up or step-down therapy based on asthma control
9. A 73-year-old Pseudomonas aeruginosa
woman is in the - empiric antibiotics should be started as soon as possible to cover
hospital with ex- gram-negative rods (Escherichia coli, Klebsiella pneumoniae, Enterobacter
acerbation of her spp, Pseudomonas aeruginosa, Acinetobacter spp). If the patient has signs
systolic heart fail- of sepsis or septic shock, then antibiotics need to be initiated within one
ure. 72 hours af- hour. Antibiotic choice is best made with the resistance patterns known
ter admission, she for the specific facility in which the patient is hospitalized to minimize the
begins to devel- risk of secondary infection such as enterocolitis. Risk factors for multidrug
op a productive resistance should be identified, including IV antibiotics in the past 90 days,
cough and short- structural lung disease, septic shock, and ventilatory assistance. Resistance
ness of breath. You patterns for the specific facility should be reviewed in these cases, and a
diagnose her with two-drug regimen should be initiated. In patients without these risk factors,
pneumonia and or- common empiric regimens include piperacillin-tazobactam 4.5 g IV every
der sputum cul- six hours, cefepime 2 g IV every eight hours, or levofloxacin 750 IV daily.
tures. When choos- However, fluoroquinolones have inferior activity against gram-negative bacilli
ing an antibiotic reg- compared to piperacillin-tazobactam and cefepime. If there are risk factors for
imen, which bacte-
, ria do you need to methicillin-resistant Staphylococcus aureus (MRSA), then a second antibiotic
ensure is covered should be added to cover for both P. aeruginosa and MRSA.
until cultures are re-
turned?
10. Cheyne-Stokes Res- Apnea, followed by increasing respiratory frequency and increased tidal vol-
pirations ume, which is then followed by decreasing frequency and decreased tidal
volume until the next period of apnea
Seen in cardiac disease, acid-base disorders, neurological disorders
Poor prognostic sign
Central sleep apnea syndrome
Manage the comorbid conditions and treat underlying causes
11. When examin- Cheyne-Stokes respiration
ing a comatose
87-year-old man,
you note his breath-
ing steadily increas-
es in depth and
frequency until it
reaches a peak, then
decreases in depth
and frequency un-
til he has an apne-
ic episode. This pat-
tern continues dur-
ing your evaluation.
What is the classi-
fication of this pat-
tern of breathing?
12.
Answers
1. Sarcoidosis Systemic disease with unknown etiology, can affect all organ systems
Sx: cough, dyspnea, fever, fatigue, skin lesions, arthralgias
PE: lupus pernio (chronic, violaceous, raised plaques and nodules commonly
found on the cheeks, nose, and around the eyes) is pathognomonic for
sarcoidosis
Labs: hypercalcemia, hypercalciuria, elevated serum ACE
CXR: bilateral hilar adenopathy, possible reticulonodular opacities in upper
lung fields
Biopsy: noncaseating granulomas
Tx: spontaneous remission may occur, oral glucocorticoids
Comments: Löfgren syndrome: fever, erythema nodosum, hilar adenopathy,
migratory polyarthralgia
2. Chronic Obstructive Main subtypes: chronic bronchitis, emphysema
Pulmonary Disease Hypoxemic patients should be given supplemental oxygen with SpO2 goal of
(COPD) 88-92%
Management options include bronchodilators, anticholinergics, steroids,
supplemental oxygen, noninvasive ventilation, smoking cessation, vaccina-
tions, and antibiotics for severe disease, infection present, or those requiring
ventilation
3. What are the Answer: An increase in the FEV1 of more than 12% and greater than 200 mL.
spirometry criteria
for the airways to be
considered respon-
sive to bronchodila-
tors?
4. Influenza Patient presents with sudden onset of fever, headache, cough, myalgia, sore
throat, fatigue
Diagnosis is made clinically, can be confirmed with reverse transcription
polymerase chain reaction (RT-PCR) or viral culture
, Treatment is mainly supportive or oseltamivir for patients at increased risk for
severe disease
Start oseltamivir as early as possible, after 48 hours it may not confer any
benefit
Most common cause of viral pneumonia in adults
New vaccine needed yearly
Monitor patients for postinfluenza pneumonia
5. Chronic Bronchitis Chronic productive cough for at least 3 months in at least 2 successive years
PE: decreased breath sounds, increased resonance upon percussion of the
lung fields
Diagnosis: FEV1/FVC ratio < 0.7 postbronchodilator
Tx: smoking cessation, lifestyle changes with pulmonary rehabilitation, in-
haled bronchodilators, inhaled steroids
6. What genetic dis- Alpha-1-antitrypsin deficiency.
ease is known to
cause chronic ob-
structive pulmonary
disease in younger
patients or patients
who do not smoke
cigarettes?
7. What condition is Sarcoidosis.
characterized by
granuloma forma-
tion in various parts
of the body, most
commonly the lungs
and lymph nodes?
8.
, Asthma in Adults Asthma: airway inflammation + bronchial hyperresponsiveness + reversible
and Adolescents airflow obstruction
NAEPP Classifications:Intermittent Symptoms d2days/weekd2 nighttime
awakenings/monthFEV1 > 80% of predictedMild persistentSymptoms >
2 days/week but < daily> 3-4 nighttime awakenings/monthFEV1 e80%
of predictedModerate persistent Symptoms daily> 1 nighttime awaken-
ing/week but not nightlyFEV1 60-80% of predictedSevere persistent Symp-
toms throughout the dayNightly awakenings commonFEV1 < 60% of predict-
ed
Management depends on factors such as asthma classification, level of con-
trol, and patient factors (such as age)
Treatment options may include SABAs, ICS, combination ICS-formoterol,
LAMAs, and LTRAs
Step-up or step-down therapy based on asthma control
9. A 73-year-old Pseudomonas aeruginosa
woman is in the - empiric antibiotics should be started as soon as possible to cover
hospital with ex- gram-negative rods (Escherichia coli, Klebsiella pneumoniae, Enterobacter
acerbation of her spp, Pseudomonas aeruginosa, Acinetobacter spp). If the patient has signs
systolic heart fail- of sepsis or septic shock, then antibiotics need to be initiated within one
ure. 72 hours af- hour. Antibiotic choice is best made with the resistance patterns known
ter admission, she for the specific facility in which the patient is hospitalized to minimize the
begins to devel- risk of secondary infection such as enterocolitis. Risk factors for multidrug
op a productive resistance should be identified, including IV antibiotics in the past 90 days,
cough and short- structural lung disease, septic shock, and ventilatory assistance. Resistance
ness of breath. You patterns for the specific facility should be reviewed in these cases, and a
diagnose her with two-drug regimen should be initiated. In patients without these risk factors,
pneumonia and or- common empiric regimens include piperacillin-tazobactam 4.5 g IV every
der sputum cul- six hours, cefepime 2 g IV every eight hours, or levofloxacin 750 IV daily.
tures. When choos- However, fluoroquinolones have inferior activity against gram-negative bacilli
ing an antibiotic reg- compared to piperacillin-tazobactam and cefepime. If there are risk factors for
imen, which bacte-
, ria do you need to methicillin-resistant Staphylococcus aureus (MRSA), then a second antibiotic
ensure is covered should be added to cover for both P. aeruginosa and MRSA.
until cultures are re-
turned?
10. Cheyne-Stokes Res- Apnea, followed by increasing respiratory frequency and increased tidal vol-
pirations ume, which is then followed by decreasing frequency and decreased tidal
volume until the next period of apnea
Seen in cardiac disease, acid-base disorders, neurological disorders
Poor prognostic sign
Central sleep apnea syndrome
Manage the comorbid conditions and treat underlying causes
11. When examin- Cheyne-Stokes respiration
ing a comatose
87-year-old man,
you note his breath-
ing steadily increas-
es in depth and
frequency until it
reaches a peak, then
decreases in depth
and frequency un-
til he has an apne-
ic episode. This pat-
tern continues dur-
ing your evaluation.
What is the classi-
fication of this pat-
tern of breathing?
12.
