Internal Medicine EOR: Pulmonary (2026) (Smarty PANCE)

What is Asthma?

A chronic inflammatory airway disease marked by reversible airflow obstruction, bronchial hyperresponsiveness, and recurrent episodes of wheezing, cough, chest tightness, and dyspnea.

What are the classic symptoms of asthma?

Episodic wheezing, dyspnea, chest tightness, and cough that worsen at night/early morning or with triggers (exercise, allergens, cold air, URIs).

What is the gold standard diagnostic test for asthma?

Spirometry showing obstruction (decreased FEV1/FVC) with reversibility — FEV1 increase ≥12% and ≥200 mL after bronchodilator.

What is the first-line rescue medication for acute asthma symptoms?

Short-acting beta-2 agonist (SABA), e.g., albuterol.

What is the preferred long-term controller therapy for persistent asthma?

Inhaled corticosteroids (ICS), often combined with a LABA for moderate-to-severe disease.

What findings indicate a severe/life-threatening asthma exacerbation?

Silent chest (no air movement), inability to speak in full sentences, accessory muscle use, altered mental status, and SpO2

What ABG finding is a red flag in an asthma exacerbation?

A normal or rising PaCO2 — patients hyperventilate early (low CO2), so a "normalizing" CO2 signals impending respiratory failure.

What is Chronic Bronchitis?

A form of COPD defined clinically by a productive cough for at least 3 months in 2 consecutive years due to chronic airway inflammation and mucus hypersecretion.

What is the classic clinical phenotype of chronic bronchitis?

The "blue bloater" — cyanotic, overweight, productive cough, hypoxemia, hypercapnia, and signs of right heart failure (cor pulmonale).

What is the diagnostic spirometry finding in COPD?

Post-bronchodilator FEV1/FVC

What is the single most important intervention to slow COPD progression?

Smoking cessation.

What two interventions reduce mortality in COPD?

Smoking cessation and long-term supplemental oxygen in chronically hypoxemic patients.

What are first-line maintenance bronchodilators in COPD?

Long-acting muscarinic antagonists (LAMA) and/or long-acting beta-agonists (LABA).

What is Emphysema?

A form of COPD characterized by permanent destruction and enlargement of the alveoli distal to the terminal bronchioles, with loss of elastic recoil and air trapping.

What is the classic clinical phenotype of emphysema?

The "pink puffer" — thin, barrel-chested, pursed-lip breathing, tachypneic, with minimal cough and relatively preserved oxygenation until late disease.

What inherited deficiency causes early-onset emphysema in nonsmokers?

Alpha-1 antitrypsin deficiency (suspect in patients

What CXR findings suggest emphysema?

Hyperinflation, flattened diaphragms, increased AP diameter, and bullae.

What PFT finding is characteristic of emphysema?

Decreased DLCO (diffusing capacity) from alveolar destruction.

What is Bronchiectasis?

Permanent, abnormal dilation of the bronchi caused by chronic inflammation and recurrent infection that destroys airway walls.

What is the hallmark symptom of bronchiectasis?

Chronic cough producing large volumes of purulent, often foul-smelling sputum with recurrent respiratory infections.

What is the imaging test of choice for bronchiectasis?

High-resolution CT (HRCT) showing dilated airways with "tram-track" lines and the "signet ring" sign.

What conditions are commonly associated with bronchiectasis?

Cystic fibrosis, prior severe infection (TB, pertussis), allergic bronchopulmonary aspergillosis, and immunodeficiency.

What organism is frequently isolated in chronic bronchiectasis?

Pseudomonas aeruginosa (also Haemophilus influenzae).

What is Idiopathic Pulmonary Fibrosis (IPF)?

A chronic, progressive interstitial lung disease of unknown cause characterized by parenchymal fibrosis in a usual interstitial pneumonia (UIP) pattern.

What is the typical presentation of IPF?

Progressive exertional dyspnea and nonproductive cough in an older adult, with bibasilar "Velcro" inspiratory crackles and digital clubbing.

What is the characteristic HRCT finding in IPF?

Subpleural, basal-predominant reticular opacities with honeycombing and traction bronchiectasis (UIP pattern).

What medications slow IPF progression?

Antifibrotics — pirfenidone and nintedanib.

What is the definitive treatment for advanced IPF?

Lung transplantation.

What is Sarcoidosis?

A multisystem granulomatous disease of unknown cause defined by noncaseating granulomas, most commonly affecting the lungs and intrathoracic lymph nodes.

What is the classic CXR finding in sarcoidosis?

Bilateral hilar lymphadenopathy.

What demographic is most commonly affected by sarcoidosis?

Young-to-middle-aged adults, with higher incidence in African Americans and women.

What is the histologic hallmark of sarcoidosis?

Noncaseating granulomas.

What lab abnormalities are associated with sarcoidosis?

Hypercalcemia, elevated ACE level, and elevated ESR.

What is Löfgren syndrome?

An acute sarcoidosis presentation with the triad of erythema nodosum, bilateral hilar lymphadenopathy, and arthralgias/fever — usually self-limited with good prognosis.

What is first-line treatment for symptomatic sarcoidosis?

Systemic corticosteroids.

What is Pneumoconiosis?

A group of restrictive interstitial lung diseases caused by chronic inhalation of inorganic (mineral) dusts, leading to lung fibrosis.

What exposure causes asbestosis and what are its key complications?

Asbestos (shipbuilding, insulation, construction); associated with pleural plaques, bronchogenic carcinoma, and malignant mesothelioma.

What exposure causes silicosis and what infection risk does it carry?

Silica (mining, sandblasting, quarrying); increases tuberculosis risk, with classic "eggshell" calcification of hilar nodes.

What is coal worker's pneumoconiosis ("black lung")?

Lung disease from coal dust inhalation causing upper-lobe nodular opacities; Caplan syndrome = pneumoconiosis plus rheumatoid arthritis.

What exposure causes berylliosis?

Beryllium (aerospace, electronics, ceramics) — produces noncaseating granulomas that mimic sarcoidosis.

What is Hypersensitivity Pneumonitis?

An immune-mediated interstitial lung disease caused by inhalation of organic antigens, producing inflammation of the alveoli and small airways.

What are classic causes of hypersensitivity pneumonitis?

Farmer's lung (moldy hay/thermophilic actinomycetes) and bird fancier's lung (avian proteins).

How does acute hypersensitivity pneumonitis present?

Fever, cough, dyspnea, and malaise occurring 4–8 hours after antigen exposure and resolving away from exposure.

What is the cornerstone of treatment for hypersensitivity pneumonitis?

Antigen avoidance; corticosteroids for severe or chronic cases.

What is Acute Bronchitis?

A self-limited inflammation of the large airways (bronchi), usually following a viral upper respiratory infection.

What is the hallmark symptom of acute bronchitis?

Cough lasting up to 1–3 weeks, often initially dry then productive, without signs of pneumonia.

What is the most common cause of acute bronchitis?

Viruses (influenza, rhinovirus, adenovirus, RSV).

What is the appropriate treatment for acute bronchitis?

Supportive care (fluids, antitussives, analgesics); antibiotics are NOT indicated for typical viral acute bronchitis.

What finding should prompt consideration of pneumonia over bronchitis?

Abnormal vital signs (fever, tachycardia, tachypnea) or focal lung findings/consolidation warranting a chest x-ray.

What is Acute Epiglottitis?

A rapidly progressive, life-threatening inflammation of the epiglottis and supraglottic structures that can obstruct the airway.

What is the classic presentation of epiglottitis?

The "3 D's" — Drooling, Dysphagia, Distress — with rapid-onset fever, muffled "hot potato" voice, and tripod positioning.

What organism historically caused epiglottitis and how has this changed?

Historically Haemophilus influenzae type B (Hib); now less common due to Hib vaccination, with more cases from Streptococcus and Staphylococcus species.

What is the classic lateral neck x-ray finding in epiglottitis?

The "thumbprint sign" (swollen epiglottis).

What is the priority management of epiglottitis?

Secure the airway first (controlled intubation in a prepared setting), avoid agitating the patient, then give IV antibiotics (ceftriaxone) — do NOT examine the throat with a tongue depressor.

What is Empyema?

A collection of pus within the pleural space, most often a complication of bacterial pneumonia.

What pleural fluid findings indicate empyema?

Exudative fluid with pH

What is the treatment of empyema?

IV antibiotics plus drainage via chest tube (tube thoracostomy); may require intrapleural fibrinolytics or surgical decortication (VATS).

What is a parapneumonic effusion?

A pleural effusion adjacent to pneumonia; uncomplicated effusions resolve with antibiotics, while complicated effusions require drainage and can progress to empyema.

What is Influenza?

An acute, contagious respiratory illness caused by influenza viruses (types A and B).

What is the classic presentation of influenza?

Abrupt onset of fever, myalgias, headache, malaise, nonproductive cough, and sore throat.

What antiviral treats influenza and when is it most effective?

Oseltamivir (neuraminidase inhibitor), most effective when started within 48 hours of symptom onset.

What is the most common complication of influenza?

Pneumonia — including secondary bacterial pneumonia (often Streptococcus pneumoniae or Staphylococcus aureus).

What is the best prevention for influenza?

Annual influenza vaccination.

What is Bacterial Pneumonia?

An infection of the lung parenchyma caused by bacteria, producing alveolar inflammation and consolidation.

What is the most common cause of community-acquired pneumonia?

Streptococcus pneumoniae.

What is the classic presentation of bacterial pneumonia?

Acute fever, productive cough with purulent sputum, pleuritic chest pain, dyspnea, and focal consolidation (crackles, egophony, dullness to percussion).

What imaging confirms pneumonia and what is the typical finding?

Chest x-ray showing lobar consolidation or infiltrate.

What tool assesses CAP severity and disposition?

CURB-65 — Confusion, Urea/BUN >19, Respiratory rate ≥30, Blood pressure

What is typical outpatient treatment for CAP?

Amoxicillin, doxycycline, or a macrolide for healthy patients; a respiratory fluoroquinolone or beta-lactam plus macrolide for those with comorbidities.

What is Viral Pneumonia?

An infection of the lung parenchyma caused by viruses, typically producing diffuse interstitial inflammation.

What are common causes of viral pneumonia?

Influenza, RSV, SARS-CoV-2, adenovirus, and parainfluenza.

How does viral pneumonia typically differ from bacterial pneumonia on imaging?

Viral pneumonia shows bilateral, diffuse interstitial infiltrates rather than focal lobar consolidation.

What is the general treatment for viral pneumonia?

Supportive care, with antivirals (e.g., oseltamivir for influenza) when indicated.

What is Fungal Pneumonia?

Lung infection caused by inhalation of fungal spores, often endemic to specific geographic regions.

What fungus causes pneumonia in the Ohio/Mississippi River valleys and is linked to bird/bat droppings?

Histoplasma capsulatum (histoplasmosis).

What fungus causes "Valley fever" in the southwestern US?

Coccidioides immitis (coccidioidomycosis).

What fungus found in the Pacific Northwest/Great Lakes can cause both skin and lung disease?

Blastomyces dermatitidis (blastomycosis).

What is the treatment for fungal pneumonia?

Amphotericin B for severe disease; azoles (itraconazole, fluconazole) for mild-to-moderate disease.

What is HIV-Related Pneumonia?

Pneumonia occurring in patients with HIV/AIDS, including opportunistic infections whose risk correlates with the CD4 count.

What is the most common opportunistic pneumonia in AIDS and at what CD4 count?

Pneumocystis jirovecii pneumonia (PCP), typically when CD4

What is the classic presentation and imaging of PCP?

Subacute dyspnea, nonproductive cough, fever, and hypoxia with diffuse bilateral interstitial ("ground-glass") infiltrates and elevated LDH.

What is the treatment for PCP?

Trimethoprim-sulfamethoxazole (TMP-SMX); add corticosteroids if PaO2

At what CD4 count is PCP prophylaxis started, and with what agent?

CD4

What is Tuberculosis (TB)?

A chronic granulomatous infection caused by Mycobacterium tuberculosis, primarily affecting the lungs.

What are the classic symptoms of active pulmonary TB?

Chronic cough, hemoptysis, night sweats, weight loss, fever, and fatigue.

What is the difference between latent and active TB?

Latent TB: positive PPD/IGRA, asymptomatic, normal CXR, noninfectious; Active TB: symptomatic, abnormal CXR, infectious.

What is the classic CXR finding in reactivation TB?

Upper-lobe cavitary lesions (Ghon complex/calcified nodes seen in primary TB).

What is the standard treatment regimen for active TB?

RIPE — Rifampin, Isoniazid, Pyrazinamide, Ethambutol (typically 2 months, then rifampin plus isoniazid for 4 more months).

What is the treatment for latent TB?

Isoniazid with pyridoxine (B6) for 9 months, or shorter rifampin-based regimens.

What is a Carcinoid Tumor?

A neuroendocrine tumor that can arise in the bronchus and is capable of secreting vasoactive substances such as serotonin.

How do bronchial carcinoid tumors typically present?

Cough, recurrent pneumonia, hemoptysis, or wheezing from airway obstruction, often in younger patients and nonsmokers.

What is carcinoid syndrome?

Flushing, diarrhea, wheezing, and right-sided heart valve disease from serotonin secretion (more common with metastatic or GI primary tumors).

What lab test helps diagnose carcinoid syndrome?

Elevated 24-hour urinary 5-HIAA (a serotonin metabolite).

What is the primary treatment of a localized carcinoid tumor?

Surgical resection.

What is a Pulmonary Nodule?

A discrete, rounded opacity ≤3 cm in diameter surrounded by lung parenchyma (a "coin lesion").

What features suggest a benign pulmonary nodule?

Small size (

What features suggest a malignant pulmonary nodule?

Large size, spiculated/irregular borders, upper-lobe location, older age, smoking history, and interval growth.

How is a low-risk pulmonary nodule generally managed?

Serial CT surveillance to assess for growth (per Fleischner Society guidelines).

What is the value of comparing with prior imaging?

Stability for ≥2 years strongly suggests a benign lesion, while documented growth raises concern for malignancy.

What is Lung Cancer?

A malignant neoplasm of the lung, broadly divided into non-small cell (NSCLC) and small cell (SCLC) types; it is the leading cause of cancer death.