1
Q
Time stamps
A. Chronic dyspnea
B. Acute cough
C. Subacute cough
D. Chronic cough
A
A. Chronic dyspnea- >1 month
B. Acute cough- <3 weeks
C. Subacute cough- 3-8 weeks
D. Chronic cough- >8 weeks
2
Q
Define massive or life-threatening hemoptysis
A
> 400 mL of blood in 24 h or >150 mL at one time
3
Q
Risk factors for MRSA and P aeruginosa
A
prior isolation particularly from the respiratory tract during the preceding year, and/ or hospitalization and treatment with an antibiotic in the previous 90 days
4
Q
Stages of pneumonia
Initial stage is edema with a proteinaceous exudate and often bacteria in the alveoli
A
Exudative
5
Q
Stages of pneumonia
Erythrocytes in the intraalveolar exudate give this stage its name
A
Red hepatization
6
Q
Stages of pneumonia
The neutrophil is the predominant cell, fibrin deposition is abundant, and bacteria have disappeared. This phase corresponds with the successful containment of the infection and improvement in gas exchange
A
Gray hepatization
7
Q
Stages of pneumonia
the macrophage reappears as the dominant cell in the alveolar space and the debris of neutrophils, and bacteria and fibrin have been cleared, as has the inflammatory response
A
Resolution phase
8
Q
This pattern is most common in nosocomial pneumonias
Vs bacterial CAP
A
Bronchopneumonia pattern- nosocomial
Lobar pattern- bacterial
9
Q
Typical bacterial pathogens in CAP
A
S. pneumoniae
Haemophilus influenzae
S. aureus
Klebsiella pneumoniae
P. aeruginosa
10
Q
Atypical bacterial pathogens in CAP
A
Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species as well as respiratory viruses such as influenza virus, adenoviruses, human metapneumoviruses, respiratory syncytial virus, and coronaviruses
11
Q
Pneumonia
They are intrinsically resistant to all Betalactams and require treatment with a macrolide, a fluoroquinolone, or a tetracycline
A
Atypicals
12
Q
Risk factors for this pathogen infection include diabetes, hematologic malignancy, cancer, severe renal disease, HIV infection, smoking, male gender, and a recent hotel stay or trip on a cruise ship
A
Legionella
13
Q
A 68-year-old man presents with cough, fever, and dyspnea. Chest X-ray shows a right lower lobe pneumonia. On evaluation:
• He is disoriented to time
• Blood pressure: 88/56 mmHg
• Respiratory rate: 32 breaths/min
• BUN: 24 mg/dL
Question:
1. What is his CURB-65 score?
2. What is the recommended site of care?
A
CURB-65:
• Confusion → +1
• Urea (BUN >7 mmol/L) → +1
• Respiratory rate ≥30 → +1
• Blood pressure (SBP <90 or DBP ≤60) → +1
• Age ≥65 years → +1
👉 Total score: 5
Interpretation / Disposition:
• Score 0–1: Outpatient
• Score 2: Inpatient (ward)
• Score ≥3: Severe pneumonia → ICU admission
14
Q
Macrolide resistance in S pneumoniae resulting in high level resistance is caused by?
Low level resistance?
A
ermB gene mutation
mef gene
15
Q
CA-MRSA isolates tend to be less resistant than the older hospital-acquired strains and are often susceptible to what antibiotics?
A
trimethoprim-sulfamethoxazole
clindamycin
tetracycline
in addition to vancomycin and linezolid
16
Q
the most important distinction is that CA-MRSA strains also carry _____
A
genes for superantigens such as enterotoxins B and C and Panton-Valentine leukocidin
17
Q
Treatment for CAP LR
Without comorbids
A
Harrisons:
Amoxicillin 1g + macrolide/doxycycline
OR
Monotherapy with macrolide/doxycycline
CPG 2020:
Amoxicillin 1g TID
OR
Clarithromycin 500mg BID
OR
Azithromycin 500mg OD
18
Q
Treatment for CAP LR
With comorbids
A
Harrisons:
Coamoxyclav/cephalosporin + macrolide/doxycycline
OR
Monotherapy respiratory Fluoroquinolones
CPG 2020:
Coamoxyclav/cephalosporin
+/-
macrolide/doxycycline
19
Q
Treatment for CAP MR
A
Ampicillin-sulbactam 1.5–3 g every 6 h
OR
Cefotaxime 1–2 g every 8 h
OR
Ceftriaxone 1–2 g daily
+
Macrolide
20
Q
Treatment CAP HR
A
1st line:
Ampicillin-sulbactam 1.5–3 g IV every 6 h
OR
Cefotaxime 1–2 g IV every 8 h
OR
Ceftriaxone 1–2 g IV daily
PLUS
Macrolide
Azithromycin 500 mg PO/IV daily
OR
Erythromycin 500 mg PO every 6 hours
OR
Clarithromycin 500 mg PO twice daily
Alternative:
Non-pseudomonal Beta-lactam antibiotic
PLUS
Respiratory fluoroquinolone*
Levofloxacin 750 mg PO/IV daily
OR
Moxifloxacin 400 mg PO/IV daily
* given as 1 hour IV infusion
21
Q
What strategy can you do to prevent VAP in a patient with altered lower respiratory defenses?
A. Hand washing, especially with alcoholbased hand rub
B. Short course of prophylactic antibiotics for comatose patients
C. selective decontamination of digestive tract with nonabsorbable antibiotics
D. Tight glycemic control
A
D. Tight glycemic control
22
Q
the highest hazard ratio for development of VAP?
A
First 5 days
23
Q
What is the threshold of growth necessary for diagnosis of pneumonia in a endotracheal aspirate?
A
Endotracheal aspirate (proximal)- diagnostic threshold is 10^6 cfu/mL
Protected specimen brush (distal)- threshold of 10^3 cfu/mL
24
Q
Factors indicating the likely need for a procedure more invasive than a thoracentesis (in increasing order of importance) include the following:
A
LPG GPus
- Loculated pleural fluid
- Pleural fluid pH <7.20 3. Pleural fluid glucose <3.3 mmol/L (<60 mg/dL) 4. Positive Gram stain or culture of the pleural fluid 5. Presence of gross pus in the pleural space
25
In patients with heart failure, a diagnostic thoracentesis should be performed if the effusions are
not bilateral and comparable in size, if the patient is febrile, or if the patient has pleuritic chest pain to verify that the patient has a transudative effusion
26
patient is clinically thought to have a condition producing a transudative effusion, the difference between the protein levels in the serum and the pleural fluid should be measured
What gradient is exudative category ignored?
>31 g/L (3.1 g/dl)
27
If the pleural fluid initial cytologic examination is negative, what is the best next procedure if malignancy is strongly suspected
thoracoscopy
28
Phase in ARDS
first 7 days of illness, condensed plasma proteins aggregate in the air spaces with cellular debris and dysfunctional pulmonary surfactant to form hyaline membrane whorls
Exudative
29
Phase in ARDS
Day 7-21, The first signs of resolution are often evident in this phase, with the initiation of lung repair, the organization of alveolar exudates, and a shift from neutrophil- to lymphocyte-predominant pulmonary infiltrates
Proliferative
30
Phase of ARDS
alveolar edema and inflammatory exudates of earlier phases convert to extensive alveolarduct and interstitial fibrosis. Marked disruption of acinar architecture leads to emphysema-like changes, with large bullae
Fibrotic
31
HRCT in subacute hypersensitivity pneumonitis
ground-glass airspace opacities are characteristic, as is the presence of centrilobular nodules
32
HP Lung biopsy
As is the case with BAL, histologic specimens are not absolutely necessary to establish the diagnosis of HP, but they can be useful in the correct clinical context. A common histologic feature in HP is _____
presence of noncaseating granulomas in the vicinity of small airways
vs Sarcoidosis (well defined granulomas)
33
Treatment in HP
Acute
Subacute
Mainstay is allergen avoidance
Acute- self limiting; no pharmacologic therapy
Subacute- glucocorticoid (Prednisone 0.5-1 mg/kg IBW)
34
What
-most often affects males between age 20 and 40 with no history of asthma
-presence of >25% eosinophilia on BAL fluid
-not associated with peripheral eosinophilia upon presentation
-HRCT is always abnormal with bilateral random patchy ground-glass or reticular opacities and small pleural effusions in as many as two-thirds of patients
-vs other causes of acute lung injury, absence of organ dysfunction or multisystem organ failure other than respiratory failure
-high degree of corticosteroid responsiveness and the excellent prognosis
Acute eosinophilic pneumonia
35
What?
-female nonsmokers with a mean age of 45
-do not usually develop the acute respiratory failure and significant hypoxemia appreciated in acute eosinophilic pneumonia
-chest x-ray with migratory bilateral peripheral or pleural-based opacities
Chronic Eosinophilic Pneumonia
36
What?
-characterized by eosinophilic vasculitis that may involve multiple organ systems including the lungs, heart, skin, GI tract, and nervous system
-primary distinguishing feature is presence of eosinophilic vasculitis in the setting of asthma and involvement of multiple end organs
-Systemic eosinophilia is the hallmark laboratory finding (eosinophilia >10%)
-CXR consist of bilateral, nonsegmental, patchy infiltrates that often migrate and may be interstitial or alveolar in appearance
-The most common CT findings include bilateral ground-glass opacity and airspace consolidation that is predominantly subpleural
EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA)
37
What
-persistent eosinophilia >1500 eosinophils/:L in association with end organ damage or dysfunction, in the absence of secondary causes of eosinophilia
-typically not associated with ANCA
-poor response to corticosteroids
Hypereosinophilic Syndromes (HES)
38
What
-eosinophilic pulmonary disorder that occurs in response to allergic sensitization to antigens from Aspergillus species fungi.
-The predominant clinical presentation is an asthmatic phenotype, often accompanied by cough with production of brownish plugs of mucus.
-well described as a complication of cystic fibrosis
-characterized by prominent peripheral eosinophilia and elevated circulating levels of IgE (often >1000 IU/ml)
-Central bronchiectasis is described as a classic finding on chest imaging
-Tx: systemic glucocorticoids and antifungal Itraconazole and Voriconazole)
ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA)
39
Infectious causes of Pulmonary eosinophilia
-Löffler Syndrome
-Heavy parasite burden
-ASH Löffler (ascaris, schistosomiasis, hookworm)
-Strongyloidiasis
40
chest radiographic hallmark of asbestosis
Irregular or linear opacities that usually are first noted in the lower lung fields
41
characteristic HRCT pattern of silicosis
Crazy-paving
Calcification of hilar nodes may occur in as many as 20% of cases and produces a characteristic “eggshell” pattern
42
Why are patients with silicosis at greater risk of acquiring lung infections that involve these cells as a primary defense (Mycobacterium tuberculosis, atypical mycobacteria, and fungi?
Alveolar macrophage dysfunction
another potential clinical complication of silicosis is autoimmune connective tissue disorders such as rheumatoid arthritis and scleroderma
43
combination of pneumoconiotic nodules and seropositive rheumatoid arthritis
Caplan syndrome (coal)
44
more commonly associated with a chronic granulomatous inflammatory disease that is similar to sarcoidosis (nodules along septal lines)
-presence of noncaseating granulomas or monocytic infiltration in lung tissue establishes the diagnosis with beryllium-specific CD4+ T cells
Chronic Beryllium Disease
45
-Workers occupationally exposed to cotton dust (but also to flax, hemp, or jute dust) in the production of yarns for textiles and rope making
-characterized clinically as occasional (early-stage) and then regular (late-stage) chest tightness toward the end of the first day of the workweek (“Monday chest tightness”)
Cotton dust (Byssinosis)
46
results from acute exposure to fumes containing zinc oxide, typically from welding of galvanized steel
Metal fume fever
47
Fluoropolymers such as Teflon, which at normal temperatures produce no reaction, become volatilized upon heating. The inhaled agents cause a characteristic syndrome of fever, chills, malaise, and occasionally mild wheezing, leading to the diagnosis of
Polymer fume fever
48
workers exposed to diacetyl, which is used to provide “butter” flavor in the manufacture of microwave popcorn and other foods, have developed ______
Bronchiolitis obliterans
49
Etiology for bronchiectasis depending on lung involvement
Upper
Middle
Lower
Central
Upper- CF, post radiation
Middle- NTM (MAC)
Lower- aspiration, end stage FLD, immunodeficiency
Central- ABPA, Mounier-Kuhn, Williams-Campbell syndrome
50
refers to bronchiectatic changes in a localized area of the lung and can be a consequence of obstruction of the airway
Focal bronchiectasis
51
characterized by widespread bronchiectatic changes throughout the lung and often arises from an underlying systemic or infectious disease process
Diffuse bronchiectasis
52
diagnosis usually is based on presentation with a persistent chronic cough and sputum production accompanied by consistent radiographic features. Chest radiographs lack sensitivity, the presence of “tram tracks” indicating dilated airways is consistent with this pathology. Chest CT is more specific and is the imaging modality of choice for confirming the diagnosis. CT findings include airway dilation (detected as parallel “tram tracks” or as the “signet-ring sign”—a cross-sectional area of the airway with a diameter at least 1.5 times that of the adjacent vessel), lack of bronchial tapering (including the presence of tubular structures within 1 cm from the pleural surface), bronchial wall thickening in dilated airways, inspissated secretions (e.g., the “tree-in-bud” pattern), or cysts emanating from the bronchial wall (especially pronounced in cystic bronchiectasis
Bronchiectasis
53
diagnostic criteria for true clinical infection with NTM should be considered in patients with symptoms and radiographic findings of lung disease who have
at least two sputum samples positive on culture;
at least one bronchoalveolar lavage (BAL) fluid sample positive on culture;
a biopsy sample displaying histopathologic features of NTM infection (e.g., granuloma or a positive stain for acid-fast bacilli) along with one positive sputum culture; or a pleural fluid sample (or a sample from another sterile extrapulmonary site) positive on culture
54
Many CTD-associated ILDs are more common among women, with the exception of _________, which is more common among men
RA-associated ILD
55
Chest pain is rare in most of the ILDs with the exception of ________ where chest discomfort is not uncommon
sarcoidosis
56
ILD dx and tx
-Chest CT findings include subpleural reticulation with a posterior basal predominance usually including more advanced fibrotic features, such as honeycombing and traction bronchiectasis (UIP)
-Diagnostic VATS biopsy findings include subpleural reticulation associated with honeycomb changes and fibroblast foci
Dx: Idiopathic Pulmonary Fibrosis
Tx: antifibrotic therapy (pirfenidone and nintedanib) can slow decline of lung function in IPF patients). immunosuppression, which had been commonly prescribed to many IPF patients, has now been demonstrated (in some cases) to be associated with increased morbidity and mortality
57
Important criteria indicating a patient may be ready for extubation include the following:
* underlying disease process has improved
* patient is awake and largely off sedative medications
* Fio2 ≤0.5
* PEEP <8 cmH2O
* SaO2 >88%
* stable hemodynamics
* manageable respiratory secretions with adequate cough
58
SBT for 30-120 minutes is considered succcessful if:
* comfortable
* RR <35
* SaO2 >90%
* SBP 90-180 mmHg
* HR change <20% or <140bpm
59
**Stages of pneumonia**
What is the predominant cell type
1. Congestion
2. Red Hepatization
3. Gray Hepatization
4. Resolution
1. Congestion- proteinaceous exudate; bacteria in alveoli
2. Red Hepatization- erythrocytes
3. Gray Hepatization- Neutrophil; successful containment of infection; improvement in gas exchange
4. Resolution- macrophage
60
Sputum sample deemed acceptable for culture
>25 neutrophils and <10 squamous epithelial cells per low power field
61
A 70-year-old female consulted for cough, febrile episodes, and dyspnea. The patient was seen awake, alert, and coherent, with vital signs: BP 110/70 HR 105 RR 28 02st 96%. Chest radiograph showed infiltrates on the L lung "base, rest of work-up:
Hemoglobin 120 mg/dL Hematocrit 0.40 WBC 13.5 Neutrophils 90 Lymphocytes Monocytes 2 Eosinophils 2 Basophils 1 Platelet count 300, Sodium 135 Potassium 4.0 Urea 6 mmol/L Creatinine 76 umol/L. Given the following parameters, and based on the CURB-65 criteria, where should the patient be managed?
A. Outpatient department
B. Hospital/Ward
C. Intensive care unit
D. No further management required
A. Outpatient department
CURB 65 score: 1
The CURB-65 criteria is a frequently used tool to assess the risk of adverse outcomes and severity of illness. It includes 5 variables:
• C: Confusion
• U: Urea >7mmol/L
• R: Respiratory rate >/= 30/min
• B: Blood pressure <90mmHg Systolic, <60mmHg Diastolic
• 65: Age of >/= 65 years
Score:
0: Outpatient
1-2: Hospitalization (except if the only factor is age)
3: ICU
62
A vagrant (!!) 35-year-old male was brought to the emergency room for cough, dyspnea and decreasing oral intake. Vital signs: BP 120/80 Heart rate 90 Respiratory rate 18 02saturation 95%. He denies any history of smoking, alcohol use, illicit drug use. Work-
up done: Hemoglobin 130mg/dL WBC 10.0 Neutrophils 80 Lymphocytes 10 Monocytes 4 Eosinophils 3 Basophils 3 Platelet count 400, Sodium 140 Potassium 3.5 Urea 5 mmol/L Creatinine 60 umol/L. Given the following data, where should the patient be managed?
A. Outpatient
B. Hospital/Ward
C. Intensive care unit
D. No further management required
B. Hospital/Ward
Hospitalization is necessary if
* unable to maintain oral intake
* compliance is an issue due to mental condition or living situation
* O2 sat <92%
63
A 55/M consulted for productive cough, dyspnea, fatigue, and febrile episodes for 5 days. The patient was awake, alert and coherent, with the following vital signs: blood pressure 90/60, heart rate 110 bpm, respiratory rate 28 breaths/minute, O2 saturation 88%, temperature 38 degrees Celsius.
Results of the work-up done below.
CBC: Hgb 110 mg/dL, Hct 0.35, WBC 3.9 (Neu 95%, Lym 5%, Mon 0, Eos 0, Bas 0), PC 250
CHEM: BUN 6 mg/dL, Crea 100 umol/L, Na 140, K 3.6
ABG on 40% FiO2: pH 7.37, Pa02 100, pCO2 28, HC03 22
Chest Xray: Multilobar infiltrates
Where should the patient be managed?
A. Outpatient
B. Hospital/Ward
C. Intensive care unit
D. No further management
C. Intensive care unit
* Neither PSI nor CURB-65 is accurate in determining the need for ICU admission. ICU admission is indicated in the following scenarios:
* Patients with septic shock requiring vasopressors
* Acute respiratory failure requiring intubation and mechanical ventilation
* Patients with three of the nine minor criteria listed in the Criteria for Severe Community-Acquired Pneumonia
* When applied to this scenario, the patient presents with the following: leukopenia <4000cells/uL, Pa02/Fi02 ratio of 250, and Multilobar infiltrates on chest radiograph. This fulfills 3 of the nine minor criteria for Severe Community-Acquired Pneumonia, thus ICU admission is indicated.
64
A patient was brought to the emergency room unconscious with blood pressure < 70/50 heart rate 130, respiratory rate 32, O2saturation 85%. Initial management with intubation, mechanical ventilation, fluid resuscitation was done, Ceftriaxone and Azithromycin were started for community acquired pneumonia.
Review of the patient's medical records found: #1 A sputum culture result with growth of / ESBL-producing Klebsiella pneumoniae 11 months prior to the present admission, #2 A sputum culture with growth if MRSA 15 months prior to the present admission.
Given the information above, what is the appropriate course of action?
A. No change in management needed
B. Continue ceftriaxone and azithromycin, and ADD vancomycin 15mg/kg IV every 12 hours
C. Discontinue ceftriaxone, and START Cefepime 2g IV every 8 hours, continue azithromycin
D. Discontinue cetriaxone, and START ertapenem 1g IV every 24 hours, continue azithromycin
D. Discontinue cetriaxone, and START ertapenem 1g IV every 24 hours, continue azithromycin
65
In which of the following patients who test positive for influenza would antiviral treatment be indicated?
A. 25-year-old female pregnant at 8 months AOG admitted for CAP-HR
B. 35-year-old female asthmatic diagnosed with CAP-MR
C. 50-year-old female diagnosed with CAD admitted for CAP-MR
D. 55-year-old male diabetic with last Hbalc 6.0%, with chronic CVD infarct admitted for CAP-HR
Antiviral therapy is recommended IN ADDITION to antibacterial therapy among patients with **high-risk CAP** and **any** of the risk factors:
• Age >/= 60
• Pregnant
• Asthmatic
• Unstable comorbid conditions:
• Uncontrolled diabetes mellitus
• Active malignancies
• Neurologic disease in evolution
• Congestive heart failure class II-IV
• Unstable coronary artery disease
• Renal failure on dialytic
• Uncompensated COPD
• Decompensated liver disease
66
As soon as the diagnosis of community acquired pneumonia is established, regardless of risk, treatment should be initiated within how many hours?
A. 3
B. 4
C. 6
D. 12
B. 4 hours
As soon as the diagnosis is established, treatment of community acquired pneumonia, regardless of risk should be initiated within **4 hours**. The majority of the studies reviewed for the purpose of creating the CPG found that administering antibiotic therapy within the first 4 hours of admission was beneficial in reducing mortality, however, results were inconsistent in terms of length of stay and readmission. Evidence comparing antibiotic therapy within 8 hours and past 8 hours of diagnosis had heterogenous results.
67
For patients with community acquired pneumonia, when are fever and leukocytosis expected to resolve assuming appropriate treatment is instituted?
A. 12-24 hours
B. 2-4 days
C. 5-7 days
D. 8-12 days
B. 2-4 days
68
Which of the following vaccines produce T-cell-dependent antigens, thus resulting in long-term immunologic memory?
A. PPSV 13
B. PCV 13
C. PPSV 23
D. PCV 23
B. PCV 13
69
What is the recommended minimum interval/timing to request post-treatment chest x-rays for patients treated for community acquired pneumonia but have persistent symptoms?
A. 2-4 weeks
B. 6-8 weeks
C. 8-10 weeks
D. 12-14 weeks
B. 6-8 weeks
70
Which of the following factors is **not** critical in the pathogenesis of ventilator associated-pneumonia?
A. Aspiration of pathogenic organisms from the oropharynx into the lower respiratory tract
B. Colonization of the oropharynx with pathogenic microorganisms
C. Compromise of normal host defense mechanisms
D. Endothelial injury resulting in the release of cytokines, chemokines and catecholamines which selectively promote the growth of certain bacteria
D. Endothelial injury resulting in the release of cytokines, chemokines and catecholamines which selectively promote the growth of certain bacteria
VAP pathogenesis:
* Aspiration
* Colonization
* Compromise
71
Which of the following prevention strategies for ventilator associated pneumonia have been demonstrated to be effective in at least 1 randomized controlled trial?
A. Avoidance of prophylactic agents that raise gastric pH
B. Daily awakening from sedation
C. Post-pyloric enteral feeding with orally placed feeding tube
D. Selective decontamination of digestive tract with nonabsorbable antibiotics
B. Daily awakening from sedation → VAP bundle
72
Which of the following factors have the largest contribution to the oropharyngeal colonization with pathogenic bacteria observed in patients with VAP?
A. Antibiotic selection pressure
B. Cross-infection from other infected /colonized patients
C. Malnutrition
D. Severe systemic illness
A. Antibiotic selection pressure
Antibiotic exposure poses the greatest risk
73
Which of the following clinical parameters of HAP and VAP may be used to identify pneumonia earlier than other findings, and may also be used to monitoring improvement with therapy?
A. Chest radiographs
B. Fever
C. Leukocytosis
D. Oxygenation
D. Oxygenation
74
The incidence or probability of encountering the following organisms are lower in ventilator associated pneumonia than community acquired pneumonia except for which organism?
A. Chlamydia pneumoniae
B. Influenza virus
C. Legionella species
D. Mycoplasma pneumoniae
C. Legionella species
The major difference from CAP is the variety of causative organisms, with markedly lower incidence of atypical pathogens in VAP, except for Legionella, which can be a nosocomial pathogen, especially with local epidemics due to breakdowns in the treatment of potable water.
75
A 65 year-old-male is intubated and admitted to the ICU for a myocardial infarction. The patient has no history of prior antibiotic therapy nor contact with the healthcare system. On the 5th day of admission, the patient presented with increasing yellow tracheal secretions, increasing oxygen requirements, and febrile episodes, but has
remained hemodynamically stable throughout the admission. Work-up showed a new infiltrate on chest radiograph, and leukocytosis on complete blood count. Labs show no evidence of renal or hepatic impairment. Cultures were obtained, and a decision was made to start antibiotic treatment. What is an acceptable empiric antibiotic regimen for this patient?
A. Monotherapy: cefepime
B. Combination therapy: ceftazidime + amikacin
C. Combination therapy: meropenem + amikacin
D. Combination therapy: meropenem + amikacin + linezolid
A. Monotherapy: cefepime
No MDR risk
76
Assuming a patient diagnosed with ventilator associated pneumonia was started on appropriate antibiotics, improvement in what parameter is usually observed and when would improvement usually be evident from time of
initiation of antimicrobial treatment?
A. Blood pressure, 24-48 hrs
B. Chest radiograph, 72-96 hrs
C. Heart rate, 24-48 hrs
D. Oxygenation, 48-72 hrs
D. Oxygenation, 48-72 hrs
Clinical improvement is usually evident within 48-72 hours with initiation of appropriate antimicrobial treatment, and is usually observed with an improvement in oxygenation. Chest radiograph findings often worsen initially during treatment, and are less helpful than clinical criteria as an indicator of response to therapy.
77
Which of the following tests confirms the presence of M. tuberculosis
A. Sputum acid fast bacilli
B. Tuberculin skin test (TST)
C. Xpert MTB/RIF
D. Sputum TB culture e
B. Tuberculin skin test (TST)
TB infection is defined as persistent immune response to TB antigen without exhibiting signs/symptoms of TB. Two tests
currently exist for identification of individuals with TB infection: **the TST and IGRA**, both of which measure host immunological response to TB antigens.
78
Which of the following monitoring tools will allow early detection of treatment failure during TB treatment?
A. Xpert MTB/RIF
B. Sputum AFB microscopy
C. Sputum TB culture
D. Nucleic acid amplification test
C. Sputum TB culture
AFB smear conversion may lag behind culture conversion a s a result of the expectoration and microscopic visualization of dead bacilli.
Sputum TB cultures should be examined monthly until cultures become negative to allow early detection of treatment failure.
79
Treatment dose of Pyridoxine (B6) for peripheral neuropathy in TB patients on isoniazid?
Prevention dose?
Give pyridoxine (Vit B6) 50-100 mg daily for treatment;
it can also be given 10 mg daily for prevention
80
A newly diagnosed HIV patient with no signs/symptoms of active TB has a tuberculin reaction size of 5 mm. What TB preventive treatment is recommended?
A. Isoniazid for 6 months
B. Rifampin alone for 3 months
C. Isoniazid plus rifampin for 6 months
D. Isoniazid pus rifapentine for 4 months
A. Isoniazid x 6 months
• B- should be 4 months
• C- should be 3 months
• D- should be 3 months
81
Which test confirms excessive variability in lung function among patients suspected to have asthma?
A. Increase in FEV1 >12% of (AND) >200 mL 15 minutes after giving salbutamol
B. Increase in FEV1 by 12% and > 200 mL from baseline 2 week after ICS-containing treatment.
C. Average diurnal PEF variability>20%
D. Fall in FEV1 >10% and >200 mL from baseline after an exercise challenge test
D. Fall in FEV1 >10% and >200 mL from baseline after an exercise challenge test
82
Which test documents expiratory airflow limitation among patients with suspected asthma?
A. FEV1 <80%
B. FEV1 <70%
C. FEV/FVC <80%
D. FEV1/FVC <70%
D. FEV1/FVC <70%
83
A 40-year-old asthmatic was started on budesonide-formoterol metered dose inhaler 2 puffs BID. On follow-up, she has daytime symptoms /once/week, no nighttime waking, no limitation of activities but she has as needed SABA use 1x/week. What is her level of asthma control?
A. Well controlled
B. Partly controlled
C. Uncontrolled
D. Severely uncontrolled
A. Well controlled
84
Amy, a 27-year-old asthmatic has symptoms less than 4-5 days/week. What is the preferred treatment regimen?
A. Take ICS whenever SABA is taken
B. Low-dose maintenance ICS-formoterol + as needed SABA
C. Low dose maintenance ICS-Formoterol + as needed ICS/formoterol as reliever (Single maintenance and reliever therapy)
D. As needed low dose ICS-formoterol
D. As needed low dose ICS-formoterol
85
Jose is a known asthmatic who has respiratory symptoms more than twice per month but less than 4-5 days per week. He is unable to buy ICS-formoterol. What is the alternative treatment regimen?
A. Take ICS whenever SABA is used
B. Start low dose maintenance ICS
C. Low dose maintenance ICS plus as needed SABA
D. Low dose ICS-LABA
C. Low dose maintenance ICS plus as needed SABA
86
When is the best time to step down asthma treatment?
A. After achieving good symptom control for 2-4 weeks
B. After achieving good symptom control for 4-8 weeks
C. After achieving good symptom control for 8-12 weeks
D. Stepping down treatment in asthma is not recommended
C. After achieving good symptom control for 8-12 weeks
Once good asthma control has been achieved and maintained for 2- 3 months and lung function has reached a plateau, treatment can often be successfully reduced, without loss of asthma control.
87
Vaccinations for COPD
Influenza
Pneumococcal vaccine
- 1 dose of PCV 20 OR
- PCV15 followed by PPSV23 after 1 year
RSV for individuals over 60 and/or with chronic heart or lung disease
Pertussis (dTap/dTPa)
Shingles for over 50 years
Covid
88
Aside from cigarette smoking, which among the following is a risk factor to develop COPD?
A. Obesity
B. Personal history of atopy
C. Exposure to ionizing radiation
D. History of childhood pneumonia
D. History of childhood pneumonia
A. Obesity - ASTHMA
B. Personal history of atopy - ASTHMA
C. Exposure to ionizing radiation - Lung Cancer
D. History of childhood pneumonia
**Risk factors for COPD include:**
• cigarette smoking
• cigar and pipe smoking
• childhood asthma
• history of childhood respiratory infections
• occupational exposure (coal, silica, fumes)
• ambient air pollution (especially biomass combustion)
89
COPD patient has 2 exacerbations while on LAMA+LABA inhaler. CBC shows absolute eosinophil count of 320. Chest CT scan shows emphysematous changes in the mid to lower lobe. Recent spirometry revealed FEV1 of 45%
After shifting to budesonide/ glycopyrronium/ formoterol 160/9/4.8 mcg 2 puffs BID, he follows up still complaining of 2 exacerbation episodes requiring admission within the past 6 months. What will be the next best step?
A. Add Roflumilast 500 mcg OD
B. Add Azithromycin 500 mg 3x weekly
C. Shift the current MDI inhaler to a dry powder LABA+LAMA+/CS inhaler
D. Start a 5-7 day course of oral prednisone
A. Add Roflumilast 500 mcg OD
90
Patient KEG is a 40 year old male with a 30 pack year smoking history diagnosed with COPD 1 year ago. He is on maintenance glycopyrronium/indacaterol 110/50 mcg 1 puff OD. He confides that he still occasionally smokes 2-3 sticks a week. CBC shows absolute eosinophil count of 320. Chest CT scan shows emphysematous changes in the mid to lower lobe. Recent spirometry revealed FEV1 of 45%. He reports no dyspnea but verbalized that he was admitted in the hospital twice this year for an exacerbation. He has good inhaler technique and is compliant with meds.
what additional intervention can you provide that will have a mortality benefit?
A. Add on biologics: benralizumab
B. Pneumococcal and flu vaccination
C. Referral to thoracic surgeon for a lung volume reduction surgery
D. Enroll patient in a smoking cessation program and institute pharmacotherapy
D. Enroll patient in a smoking cessation program and institute pharmacotherapy
**THREE interventions with mortality benefit:**
- smoking cessation
- long term oxygen supplementation
- lung volume reduction surgery (for upper lobe emphysema only)
91
Which among the following patients is a candidate/s for long term supplemental oxygen therapy?
A. Patient who has 02 saturations of 90% at rest but drops to 85% on physical activity
B. Patient who has 02 saturations of 89% both at rest and physical activity
C. Patient who has 02 saturations of 89% at rest and with signs of cor pulmonale
D. Al of the above patients should have a trial of long term supplemental oxygen
C. Patient who has 02 saturations of 89% at rest and with signs of cor pulmonale
Supplemental 02 is the only pharmacologic therapy demonstrated to unequivocally decrease mortality in patients with COPD
• For patients with resting hypoxemia (resting 02 saturation ≤ 88% in any patient or ≤ 89% with *signs of pulmonary arterial hypertension, right heart failure or erythrocytosis*, the use of O2 has been demonstrated to have a significant impact on mortality.
92
Equitable accessibility of medications is a concern for underserved areas. If a long acting bronchodilator is not available in the area, what is the alternative drug regimen recommended by the Philippine CPG for COPD Management 2023?
A. Lagundi
B. Mucolytic
C. Methylxanthines
D. Short acting bronchodilators via MDI or nebulization
C. Methylxanthines
Among stable COPD patients in the primary care setting, it is recommend to use oral methylanthines versus no treatment if inhaled long-acting bronchodilator is not available (which is still the first line)
93
What is the best initial imaging in a patient suspected to have pleural effusion?
A. Chest Xray postero-anterior view
B. Chest Xray lateral decubitus view
C. Chest Ultrasound
D. Chest CT scan with contrast
C. Chest Ultrasound
Chest ultrasound has replaced the lateral decubitus x-ray in the evaluation of suspected pleural effusions and as a guide to thoracentesis. Once effusion is confirmed, an effort to identify the cause should be made by fluid analysis and further imaging if warranted.
94
Tuberculous pleural effusion primarily occurs a s a result of what phenomenon?
A. Direct pleural invasion of tuberculous bacilli causing caseation necrosis to the pleural space
B. Delayed type hypersensitivity reaction to tuberculous proteins in the pleural space
C. Lymphatic blockage by the TB bacilli resulting to poor pleural fluid drainage
D. Rupture of cavitation with spillage to the pleural space
B. Delayed type hypersensitivity reaction to tuberculous proteins in the pleural space
95
A patient with bronchiectasis was admitted for another bout of pneumonia. Pleural effusion was noted at the left lung this time around, with thoracentesis draining 600 mL of serous fluid. Which of the following results from the pleural fluid analysis would warrant a surgical referral?
A. Gram negative bacilli seen on Pleural fluid
B. Loculated pleural effusion noted on chest UTZ
C. Pleural fluid pH of 7.1
D. Pleural fluid glucose of 40 mg/dL
A. Gram negative bacilli seen on Pleural fluid
LPG GP
Loculated
pH <7.2-
Glucose <60 mg/dl (3.3 mmol/L)
Gram stain or culture positive
Pus in pleural space
96
A patient who underwent diagnostic thoracentesis for parapneumonic pleural effusion developed iatrogenic hemothorax, prompting for a chest tube to be inserted. On monitoring, there was increase in bloody output from initial level of 250 mL to 360 mL in 2 hours. What should be done next?
A. Schedule for emergency thoracotomy
B. Apprise patient for VATS (Video assisted thoracoscopic surgery)
C. Refer to interventional radiology for angiographic embolization
D. Observe further and maintain negative pressure suction from the tube, with supportive transfusion
D. Observe further and maintain negative pressure suction from the tube, with supportive transfusion
If the pleural hemorrhage exceeds 200 mL/h, consideration should be given to angiographic coil embolization, thoracoscopy, or thoracotomy.
97
More pleural effusions
Thoracentesis reveals milky fluid. What triglyceride level is suggestive of chylothorax?
Grossly bloody effusion. What pleural fluid hematocrit suggests hemothorax?
triglyceride level that exceeds 1.2 mmol/L (110 mg/dL)
Pleural fluid hematocrit >50% that of peripheral blood
98
Which of the following would be the expected result of the pleural effusion analysis of a patient with effusion secondary to myxedema coma?
A. Pleural fluid LDH: 160 U/L (Serum LDH: 300 U/L; Normal range: 140-280 U/L)
B. Pleural fluid total protein: 17 g/dL (Serum total protein: 20 g/dL; Normal range: 15-20 g/dL)
C. Pleural fluid LDH: 190 U/L (Serum LDH: 380 U/L; Normal range: 140-280 U/L)
D. Pleural fluid total protein: 13 g/dL (Serum total protein: 16 g/dL; Normal range: 15-20 g/dL)
A. Pleural fluid LDH: 160 U/L (Serum LDH: 300 U/L; Normal range: 140-280 U/L)
Transudative
99
A 32-year-old male patient with no known comorbid was admitted for progressive dyspnea and pleural effusion. Previous admission yielded unremarkable pleural fluid analysis and cytology results hence patient was empirically treated for PTB and is currently on the 4th month of treatment. For the current admission, a drainable pleural effusion at the right with a suspicious mediastinal widening and nodular pleural thickening on chest radiograph. What is the next best step in managing patient?
A. Repeat therapeutic thoracentesis, chest CT scan, then monitor for recurrence
B. Pigtail catheter insertion with as needed drainage for symptomatic relief
C. Tube thoracostomy with instillation of sclerosing agent
D. Thoracoscopy with pleural biopsy and abrasion
D. Thoracoscopy with pleural biopsy and abrasion
If entertaining pleural malignancy, Thoracoscopy is the best next procedure and an alternative to thoracoscopy is CT- or ultrasound-guided needle biopsy of pleural thickening or nodules.
100
Which pleural fluid qualitative study is most consistent with effusion commonly occurring within the 1st week of CABG?
A. Clear yellow, slightly turbid; RBC 5400/mm3 WBC 990/mm3 (Neutrophil 10%, Lymphocyte 90%, Monocytes 0%, Eosinophil 0%)
B. Dark yellow, slightly turbid; RBC 300/uL WBC 1000/ul (Neutrophil 60%, Lymphocyte 30%, Monocyte 10%, Eosinophil 0%)
C. Amber red, turbid; RBC 5000/uL WBC 1500/uL (Neutrophil 20%, Lymphocyte 30%, Monocyte 10%, Eosinophil 40%)
D. Dark red, turbid; RBC 7000/uL WBC 900/uL (Neutrophil 20%, Lymphocyte 30%, Monocyte 40%, Eosinophil 10%)
C. Amber red, turbid; RBC 5000/uL WBC 1500/uL (Neutrophil 20%, Lymphocyte 30%, Monocyte 10%, Eosinophil 40%)
Pleural effusions commonly occur after CABG and those that develop during the first weeks are usually left-sided and bloody, with large numbers of *eosinophils*. These respond to one or two therapeutic thoracenteses.
• On the other hand, effusions after the first weeks are typically left-sided and clear-yellow, with predominantly small lymphocytes (option a), and they tend to recur.
101
A 40 year old male developed retrosternal chest pain, dysphagia, dyspnea, and fever after he had recurrent vomiting from an alcoholic binge drinking session. On workup, there was note of mediastinal emphysema and drainable left sided pleural effusion. Which specific test should also be added to the routine pleural fluid analysis to confirm the likely etiology?
A. Pleural fluid adenosine deaminase
B. Pleural fluid amylase
C. Pleural fluid NTproBNP
D. Pleural fluid triglyceride
B. Pleural fluid amylase
Measurement of pleural fluid amylase is helpful in cases wherein esophageal rupture or pancreatic disease is strongly suspected. In this case the patient went on a drinking spree and subsequently had
recurrent vomiting which may lead to esophageal rupture, as his symptoms also indicate
102
A patient admitted in the ICU for severe pneumonia was referred for sudden-onset chest pain, tachycardia and desaturations despite previously being stable. On interview, the chest pain is described as sharp, and precipitated by inspiration. An arterial blood gas was taken demonstrating an increased A-a gradient. Which of the following pathophysiologic abnormalities would not be observed in this condition?
A. Alveolar hypoventilation
B. Increased anatomic dead space
C. Increased physiologic dead space
D. Increased pulmonary vascular resistance
A. Alveolar hypoventilation (hyperventilation)
103
Which of the following is not a hallmark sign/symptom of massive Pulmonary Embolism?
A. Dyspnea
B. Hypotension
C. Tachycardia
D. Syncope
C. Tachycardia
Dyspnea, syncope, hypotension and cyanosis are hallmarks of massive PE.
104
A patient was referred for shortness of breath. The patient was initially admitted for community acquired pneumonia 5 days prior to the referral and was managed with antibiotics. On physical examination, breath sounds are clear, with distinct heart sounds white blood on auscultation. Patients records show decreasing white blood cell count, and procalcitonin trends. D-dimer was elevated, and an ECG was requested as part of the initial evaluation. Which of the following ECG findings would be most likely observed in this patient?
A. Sinus tachycardia
B. S wave in lead I, Q wave in lead Ill and an inverted T wave in lead Ill
C. A and B
D. T-wave inversion in leads V1-V4
D. T-wave inversion in leads V1-V4
RV strain and ischemia cause the most common abnormality - T- wave inversion in leads V1-V4.
105
A patient was brought to the emergency room for decrease in sensorium. On review of the patient's medical records, it was discovered that the patient was being treated for recurrent venous thromboembolism and had been started on Warfarin but was lost to follow-up. A plain cranial computed tomography scan found an intracerebral hemorrhage, and the patient's INR was measured at a value of 10.0. A decision for reversal of the anticoagulation was made. Which of the following would be appropriate in this scenario?
A. Andexanet
B. Protamine sulfate
C. Prothrombin complex concentrate
D. Vitamin K
C. Prothrombin complex concentrate - for MAJOR bleeding from Warfarin
A. Andexanet - Apixaban/Rivaroxaban
B. Protamine sulfate - Heparin or LMWH
D. Vitamin K - for minor bleeding caused by Warfarin
106
A patient was admitted for tumor debulking surgery for ovarian cancer. Post-operatively, the patient was started on enoxaparin as DVT prophylaxis. Given the presence of active malignancy and recent cancer surgery, a decision
was made to give extended-duration VTE prophylaxis on hospital discharge.
Which of the following medications would be most appropriate?
A. Dabigatran
B. Fondaparinux
C. Rivaroxaban
D. Unfractionated Heparin
C. Rivaroxaban - only FDA approved for post-discharge prophylaxis
107
M.J., a 60 year-old miner sought consult for a 5 month-history of progressive dyspnea, dry cough, calcified pleural plaques on chest x-ray, and bilateral subpleural reticulations on chest CT scan. What is the most common cancer associated with M.J.'s condition?
A. Mesothelioma
B. Laryngeal cancer
C. Ovarian cancer
D. Lung cancer
D. Lung cancer
Asbestosis
108
A 59 year-old male who works as a stonecutter in a granite quarry for 30 years presented with a 6 month-history of nonproductive cough, exertional dyspnea, and apical nodular opacities with "eggshell" calcifications on his hilar nodes. What disease is he at risk to develop?
A. Byssinosis
B. Coal worker's pneumoconiosis
C. Mesothelioma
D. Scleroderma
D. Scleroderma (secondary to silicosis)
This is a case of silicosis. Silica has immunoadjuvant properties. A potential clinical complication of silicosis is autoimmune connective tissue diseases such as rheumatoid arthritis and scleroderma.
109
A 55-year-old sandblaster of 20 years shows variably sized, poorly
defined nodules predominating in the upper lobes. He is at risk for acquiring
which of the following infections?
A. Hepatitis B virus
B. Human immunodeficiency virus
C. Mycobacterium tuberculosis
D. Pseudomonas aeruginosa
C. M tuberculosis
This is silicosis. Silica causes alveolar macrophage dysfunction. Patients with silicosis are at greater risk for acquiring lung infections that involve these cells as primary defense (TB, atypical mycobacteria, and fungi)
110
A 30-year-old textile production manager complains of chest tightness, dry cough, exertional dyspnea and a significant drop in FEV1 during the workweek which improves during the weekends. What risk factor is associated with this condition?
A. Cotton dust exposure
B. Grain dust exposure
C. Moldy hay exposure
D. Silica exposure
A. Cotton dust exposure
Workers occupationally exposed to cotton dust (but also to flax, hemp, or jute dust) in the production of yarns for textiles and rope making are at risk for at risk for an asthma-like syndrome known as byssinosis.
111
All of the following are known risk factors for Obstructive Sleep Apnea EXCEPT?
A. Male sex
B. Old age
C. Hypothyroidism
D. Diabetes mellitus
D. DM
The major risk factors for OSA are **obesity, male sex, and older age**.
Additional risk factors include:
• mandibular retrognathia and micrognathia
• positive family history of OSA
• sedentary lifestyle
• genetic syndromes that reduce upper airway patency (e.g., Down syndrome, Treacher-Collins syndrome)
• adenotonsillar hypertrophy menopause and various endocrine syndromes (e.g., acromegaly, hypothyroidism).
112
A 55 year old obese male was diagnosed with severe OSA during a sleep study and was prescribed an auto-titrating CPAP machine on full face mask at initial pressure of 18 cmH2O. After 2 days on CPAP, he reports "difficulty exhaling" What measure can be done to address his concern?
A. Shift to bilevel airway pressure
B. Administer antacids
C. Provide heated humidification
D. Promote habituation: practice breathing on CPAP while awake
A. Shift to bilevel airway pressure
113
What is the most important risk factor for respiratory bronchiolitis related ILD (RB-ILD) and desquamative interstitial pneumonia (DIP)?
A. Age
B. Atopy
C. Occupational exposure
D. Smoking history
D. Smoking history
114
What is the most common pulmonary function test finding for most ILD?
A. Reduced FEV1 to FVC ratio
B. Reduced total lung capacity (TLC) and forced vital capacity (FVC)
C. Reduced diffusing capacity of the lung for carbon monoxide (DLCO)
D. Absence of reversibility in post bronchodilator study
B. Reduced total lung capacity (TLC) and forced vital capacity (FVC)
RESTRICTIVE LUNG DISEASE
115
What is the classic imaging pattern in Idiopathic Pulmonary Fibrosis? TX?
Usual interstitial pneumonia (UIP)
Anti fibrotic (Pirfenidone, Nintedanib)
116
RS, a 4 0 year old male came to the ED with a 3 day history of flu like symptoms: cough, low grade fever and myalgia. He has dyspnea on exertion, with mild respiratory distress and peripheral 02 saturation of 88% on room air. He is a non-smoker. Initial infectious workup for bacterial pneumonia, respiratory viruses were negative.
CXR showed patchy peripheral consolidations.
HRCT was performed showing subpleural consolidation and a reversed halo sign
What is your primary working impression?
A. Sarcoidosis
B. Idiopathic pulmonary fibrosis
C. Acute interstitial pneumonia (Hamman rich syndrome)
D. Cryptogenic organizing pneumonia
D. Cryptogenic organizing pneumonia
Cryptogenic organizing pneumonia (COP) typically involves patients in their 50-60s and often presents as a subacute flu-like illness, with cough, dyspnea, fever, and fatigue. Inspiratory rales are often present on examination, and most patients are noted to have restrictive lung deficits on pulmonary function testing with hypoxemia. COP is commonly mistaken for pneumonia.
• The most common imaging findings include **patchy, sometimes migratory, subpleural consolidative opacities often with associated ground-glass opacities**. Peribronchiolar or perilobar opacities can be present, and sometimes a rim of subpleural sparing **(often referred to as a reversed halo or atoll sign)** can be seen, which can aid in the diagnosis.
117
What is the most common imaging pattern of ILD in patients with rheumatoid arthritis?
A. Usual interstitial pneumonia pattern (UIP)
B. Non-specific interstitial pneumonia pattern (NSIP)
C. Desquamative interstitial pneumonia (DIP)
D. Lymphocytic interstitial pneumonia (LIP)
A. Usual interstitial pneumonia pattern (UIP)
IPF and RA: UIP
Other CTDs: NSIP
118
Infection with which organism is associated with worst prognosis in patients with bronchiectasis?
A. Haemophilus influenzae
B. Pseudomonas aeruginosa
C. Mycobacterium avium complex
D. Bordetella pertussis
B. Pseudomonas aeruginosa
119
Which among the following is a dependent variable not controlled by the physician during assist control-volume control mode (AC-VC)?
A. PEEP
B. Tidal volume
C. Plateau pressure
D. Inspiratory flow rate
C. Plateau pressure
AC VC: dependent pressures (Ppeak, Pplat)
AC PC: dependent volume (Vt)
120
A 52 year old female patient on long term NGT feeding due to chronic CVD infarct has 3-week history of intermittent low grade fever, night sweats, cough with brownish foul-smelling sputum. Physical exam showed poor dentition, diminished gag reflex, and cavernous breath sound at the right lower lung. Which if the following is the best imaging in the evaluation of the patient?
A. Chest X-ray PA and lateral view
B. Chest CT scan
C. Chest ultrasound
D. Bronchoscopy
B. Chest CT scan
Chest CT scan is the imaging of choice as it permits better definition and may provide earlier evidence of cavitation than chest Xray.
121
64-year-old male and a heavy alcoholic drinker was brought to the ER due to chest pain, fever, and cough with purulent foul-smelling sputum which started 2 weeks prior. No known comorbids. CXR showed a cavity with air fluid level at right middle lung field and confirmed by chest CT to be a 5cm abscess. No masses or foreign body seen. Which of the following in the patient portends a poor prognosis?
A. Age of the patient
B. Duration of the symptoms
C. Patient having primary rather than secondary abscess
D. Size of the abscess
A. Age of patient
The following are poor prognostic factors in lung abscess:
• Secondary abscess (75% mortality rate in some cases as opposed to 2% in primary abscess)
• Presence of aerobic bacteria
• Sepsis at presentation
• Age >60 years
• Abscess size >6 cm
• Symptom duration of >8 weeks
122
**Hypersensitivity pneumonitis**
What antigen?
Grain, moldy hay
Sugarcane
Mushroom
Wheat (Miller’s lung)
Barley (Malt worker’s lung)
Tobacco
Grapes
Grain, moldy hay: *Thermophilic actinomycetes*
Sugarcane: *Thermophilic actinomycetes*
Mushroom: *Thermophilic actinomycetes*
Wheat (Miller’s lung): *Thermophilic actinomycetes*
Barley (Malt worker’s lung): *Aspergillus*
Tobacco: *Aspergillus*
Grapes: *Botrytis cinerea*
123
Which of the following may be a helpful intervention in a patient with chronic hyperventilation?
A. Encourage yawning during episodes of rapid breathing
B. Periodic intentional sigh breathing exercises
C. Avoid conversations about triggering factors such as anxiety/fears
D. Beta blockers for palpitations
D. Beta blockers for palpitations
124
Upon returning for follow-up after an asthma exacerbation, a patient mentions that her symptoms have been well-controlled over the last 4 weeks with good adherence to medications and no adverse events. Which among the following will be part of therapy goals in her succeeding visits?
a. No more than 2 exacerbations per year
b. Reliever use of ≤2 times a week (except before exercise)
c. Reduction of nighttime awakenings to ≤2 times/week
d. Ability to do activities up to 80% of capacity
b. Reliever use of ≤2 times a week (except before exercise)
A. 2 exacerbation/year
C. Nighttime awakenings <2x/month
D. Normal daily activities
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