Transcript Pulmonary/CC Board Review

Pulmonary/CC Board Review
A 25-year-old woman is evaluated for recurrent episodes of acute dyspnea
associated with rapid breathing, tightness in her chest and throat, voice
changes, and inspiratory difficulty. When she has these episodes she feels
that she “can’t get enough air.” The symptoms typically start and resolve
abruptly, and treatment with albuterol provides only minimal relief.
On physical examination, her vital signs are normal. Lungs are clear.
Spirometry shows an FEV1 of 2.8 L (88% of predicted) and FEV1/FVC ratio of
80%.
Which of the following is the most appropriate next diagnostic step?
1.
2.
3.
4.
Chest radiography
CT scan of the neck
Flow volume loops
Thyroid function tests
Vocal Cord Dysfunction
A 35-year-old man is evaluated for episodic wheezing, dyspnea, and cough.
Two months ago he had an acute episode of cough, dyspnea, wheezing, and
chest tightness within minutes of inhaling high concentrations of ammonia
solution after an accidental spill at work. In the emergency department, the
chest radiograph was normal, and he received inhaled bronchodilators and a
brief course of oral corticosteroids. The patient does not have a history of
asthma or allergies and is otherwise healthy and takes no medications.
The physical examination is normal. Spirometry shows an FEV1 of 90% of
predicted; FEV1/FVC ratio is 82%.
Which of the following is the most appropriate next test in this patient’s
evaluation?
1.
2.
3.
4.
Bronchoscopy with biopsy
Inhalation challenge with chlorine
Methacholine challenge test
Spirometry before and after work
Asthma- Diagnosis
• Spiromery shows low
FEV1/FVC ratio and
reversibility 12% of
greater improvement
in FEV1 after
administration of
bronchodilators
• Next step bronchial
challenge test
A 27-year-old man is evaluated for a 6-month history of cough, which is worse
at night and after exposure to cold air. Often his cough is brought on by taking
a deep breath or by laughter. He does not have postnasal drip, wheezing, or
heartburn. He has a strong family history of allergies.
Physical examination, chest radiograph, and spirometry are normal. He
receives no benefit from a 3-month trial of gastric acid suppression therapy,
intranasal corticosteroids, and an antihistamine-decongestant combination.
Which of the following would likely provide the diagnosis of this patient’s
chronic cough?
1.
2.
3.
4.
5.
24-Hour esophageal pH monitoring
Bronchoscopy
CT scan of the chest
0%
CT scan of the sinuses
Trial of inhaled albuterol
1
0%
0%
2
3
0%
0%
4
5
Occupational Asthma
Reactive Airways Dysfunction Syndrome
Virus-Induced Asthma
Cough-Variant Asthma
GERD and Asthma
ABPA
Exercise-Induced Bronchospasm
Aspirin-Sensitive Asthma
Vocal Cord Dysfunction
A 28-year-old man is evaluated for a 6-month history of episodic dyspnea,
cough, and wheezing. As a child, he had asthma and allergies, but he has
been asymptomatic since his early teenage years. His recent symptoms
started after an upper respiratory tract infection, and they are often triggered
by exercise or exposure to cold air. He is also awakened with asthma
symptoms 5 or 6 nights a month. He is otherwise healthy and takes no
medications.
On physical examination, vital signs are normal. There is scattered wheezing
in both lung fields. Chest radiograph is normal. Spirometry shows an FEV1 of
70% of predicted with a 15% improvement after inhaled albuterol.
Which of the following is the most appropriate therapy for this patient?
1.
2.
3.
4.
5.
Azithromycin
Inhaled Albuterol as needed
Inhaled low-dose corticosteroids plus inhaled albuterol as needed
0%
0%
0%
0%
Long-acting B-agonist
Long-acting B- agonist plus inhaled albuterol
as2 needed3
1
4
0%
5
Components of
Severity
Impairment
Symptoms
Intermittent
Persistent
Mild
Moderate
Severe
≤2 days/week
> 2 days/week
Daily
Throughout the day
Nighttime awakenings ≤2 ×/month
SABA use for
≤2 days/week
symptom control (not
prevention of EIB)
3-4 ×/month
>1 ×/week but not
nightly
>2 days/week but not Daily
more than 1 ×/d
Often 7 ×/week
Minor limitation
Extremely limited
Interference with
normal activity
None
Lung function
Normal FEV1 between FEV1 >80% of
exacerbations FEV1
predicted FEV1/FVC
>80% of predicted
normal
FEV1/FVC normal
Risk
Exacerbations
0-2/year
(consider frequency
and severity)b,c
Recommended step
Step 1
for initiating
treatment (see Figure
4 for treatment
steps)d
Some limitation
Several times a day
FEV1 >60% but <80% FEV1 <60% of
of predicted FEV1/FVC predicted FEV1/FVC
reduced 5%
reduced >5%
>2/year
Step 2
Step 3; consider short Step 4 or 5; consider
courses of systemic
short courses of
corticosteroids
systemic
corticosteroids
A 70-year-old woman is evaluated for a 6-month history of fatigue, an unintentional
weight loss of 4.4 kg (10 lb), an increase in chronic cough with sputum production, and
a decrease in exercise capacity. The patient has a 40-pack-year history of cigarette
smoking but stopped smoking 10 years ago when chronic obstructive pulmonary
disease was diagnosed. She has no other symptoms and specifically denies abdominal
pain, nausea, vomiting, diarrhea, or change in her bowel habits. Her medications are
albuterol as needed, an inhaled corticosteroid, and salmeterol. She has been on stable
dosages of these drugs for 18 months. Age- and sex-appropriate cancer screening tests
done 6 months ago were normal.
On physical examination, the temperature is 37.5 °C (99.5 °F), the blood pressure is
128/76 mm Hg, the pulse rate is 94/min and regular, the respiration rate is 16/min,
and the BMI is 20. Heart sounds are distant, and breath sounds are diminished
bilaterally. There are no abdominal masses or organomegaly and no peripheral edema.
Labs: Hg: 15, Alb: 3.0, Cr: 0.8, TSH: 2.0
Spirometry shows an FEV1 of 40% of predicted and an FEV1/FVC ratio of 45%. Chest
radiograph shows hyperinflation.
Which of the following is the most likely reason for this patient’s weight loss?
1.
2.
3.
4.
Breast Cancer
Cervical Cancer
0%
Colon Cancer
Chronic Obstructive Pulmonary Disease1
0%
2
0%
3
0%
4
A 50-year-old man is evaluated for a 1-year history of cough productive of
mucoid sputum. He has not had fever or lost weight during that time. The
patient has smoked one pack of cigarettes a day for 20 years. He has no
history of allergic disease or gastroesophageal reflux disease.
On physical examination, the temperature is 37.0 °C (98.6 °F), the blood
pressure is 124/76 mm Hg, the pulse rate is 78/min and regular, and the
respiration rate is 15/min; BMI is 25. The lungs are clear, and the chest
radiograph is normal. Spirometry shows an FEV1 of 85% of predicted and an
FEV1/FVC ratio of 75%; there is no change in results after administration of a
bronchodilator.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
Asthma
At risk of chronic obstructive pulmonary disease (COPD)
Mild (GOLD stage I) COPD
0%
0%
0%
0%
Moderate (GOLD stage II) COPD 1
2
3
4
COPD
All in patient with FEV1/FVC < 70%
Table 8
At risk
---
Normal Spirometry
Chronic Symptoms
GOLD 1
Mild
FEV1/FVC <70%
FEV >80% of predicted
GOLD 2
Moderate
FEV1/FVC <70%
50%<FEV1<80% of
predicted
GOLD 3
Severe
FEV1/FVC<70%
30% < FEV1< 50% of
predicted
GOLD 4
Very Severe
FEV1/FVC <70%
FEV1< 30% of predicted
A 55-year-old man with a 7-year history of severe chronic obstructive
pulmonary disease is evaluated after being discharged from the hospital
following an acute exacerbation; he has had three exacerbations over the
previous 18 months. He is a long-term smoker who stopped smoking 1 year
ago. He adheres to therapy with albuterol as needed and inhaled salmeterol
and tiotropium and has demonstrated proper inhaler technique.
On physical examination, vital signs are normal. Breath sounds are decreased
bilaterally; there is no edema or cyanosis. Oxygen saturation after exertion is
92% on ambient air. Spirometry shows an FEV1 of 32% of predicted and an
FEV1/FVC ratio of 40%. Chest radiograph done in the hospital 3 weeks ago
showed no active disease.
Which of the following should be added to this patient’s therapeutic
regimen?
1.
2.
3.
4.
An inhaled corticosteroid
Ipratropium
N-acetylcysteine
Oral Prednisone
0%
1
0%
2
0%
3
0%
4
Level of Airflow Obstruction
Recommended Therapy
FEV1 60-80% of predicted
(THINK GOLD 1 or 2)
Inhaled bronchodilator therapy (short
acting anticholinergic or short acting B2
agonist)
FEV1< 60% of predicted
(THINK GOLD 3)
Daily monotherapy with an Inhaled
bronchodilator therapy (long acting
anticholinergic or long acting B2 agonist)
Consider combination inhaled therapy
(long acting anticholinergic, long acting B2
agonist, or cortisteroid)
FEV1< 50% of predicted
(THINK GOLD 3 and 4)
Consider adding pulmonary rehabilitation
A 64-year-old woman is evaluated for a 6-week history
of dyspnea, dry cough, fever, chills, night sweats, and
fatigue, which have not responded to treatment with
azithromycin and levofloxacin; she has lost 2.2 kg (5 lb)
during that time. The patient had a thorough
examination 6 months ago while she was
asymptomatic that included routine laboratory studies,
age- and sex-appropriate cancer screening, and a chest
radiograph; all results were normal. The patient has
never smoked, has had no known environmental
exposures, and has not traveled recently or been
exposed to anyone with a similar illness. Her only
medications are aspirin and a multivitamin.
On physical examination, temperature is 37.8 °C (100.0
°F); other vital signs are normal. Cardiac examination is
normal. There are scattered crackles in the mid-lung
zones with associated rare expiratory wheezes. There
is no digital clubbing. Musculoskeletal and skin
examinations are normal. Chest radiograph is shown .
Which of the following is the most likely diagnosis?
1. Cryptogenic organizing pneumonia
0%
2. Idiopathic pulmonary fibrosis
3. Lyphocyti interstitial pneumonia
1
4. Nonspecific interstitial pneumonia
0%
2
0%
3
0%
4
55 year old F with fever, dyspnea,
malaise for 2 weeks…
Cryptogenic Organizing Pneumonia
• History: Insidious onset (weeks to 1-2 months), often failed
outpatient treatment for viral pneumonitis or bacterial
pneumonia
• Epidemiology: M=F, Age=middle aged
• HPI: Cough, fever, dyspnea, malaise, and myalgias
• PE: Rales
• Imaging: bronchial thickening, some interstitial findings
patchy bilateral alveolar infiltrates, MIGRATES
• Histology: organizing pneumonia, bronchiolitis and chronic
alveolitis (open lung bx preferred, often adequate with TBB)
• Associations: Penicillamines and RA
• Treatment: Good prognosis, responds to steroids. Slow taper
to avoid exacerbations
55 year old male presents with 6
months dyspnea, cough…
Usual
Interstitial
pneumonia
Idiopathic Pulmonary Fibrosis (IPF)
•
•
•
•
•
•
•
•
•
History: VERY slow onset, at least 6 months
Epidemiology: M=F, average age = 55
HPI: dyspnea, poor exercise tolerance, cough, NO FEVER
PE: no extrapulmonary manifestations, CLUBBING usually seen, coarse, dry
crackles at lung bases
Imaging: CT “ground glass” early, “honeycombing “late, CXR interstitial
Histology: Usual Interstitial Pneumonia (UIP)
Associations: smoking exacerbates, ~ 10% low titers of ANA or RF, no
associations with infections, drugs, chemicals
Treatment: steroids +/- cyclophosphamide or azathiprine (20-30%
improve), Single-lung transplant in late cases
Response: A-a gradient response to exercise.
45 year old F, h/o IVDA, with
dyspnea and cough over last 2-3
months…
Nonspecific Interstitial Pneumonitis
(NSIP)
• History: subacute presentation 2-3 months coughing, dyspnea
• PE: bibasilar crackles, stimata of CTD
• Imaging: basilar or mid-lung reticular changes, (spares subpleural region)
rarely with honeycombing, pattern of ground-glass opacification in the
mid- and lower-lung zones
• Diagnosis: requires open lung biopsy (difficult to differentiate fro IPF)
• Histo: lymphoplasmacytic interstitial infiltration in a uniform pattern,
accompanied by chronic fibrosis (NSIP)
• Associations: HIV, CTD, HSP, drug induced lung disease
• Treatment: steroids +/- cytotoxic meds
• Prognosis: better that IPF, but still grim when fibrosis on bx
38 year old F presents with acute
onset shortness of breath…
Lymphangioleiomyomatosis
• Epidemiology: Premenopausal women
• Pathophys: Immature smooth muscle proliferation in lymph,
vasc, and alveolar wall/perbronchial structures cysts and
constriction in these structures
• HPI: often presents with pneumothorax
• PE: hamartomas, ash leaf spots, adenoma sebaceum
• Imaging: honeycombing diffusely throughout the lung (in
contrast to upper lung in Langerhans)
• Associations: Pneumothorax, chylous pleural effusions (TG >110
+/- chlomicrons, common with Tuberous Sclerosis or multiple
hamartomas (Cowden’s Syndrome)
• Treatment: Oophorectomy with progestin treatment, lung
transplant (may recur)
32 year M, smoker, presents with
gradual worsening of shortness of
breath/cough…
Pulmonary Langerhans Cell
Histocytosis
• History: 10% present with pneumothorax, 50% will have PTX sometime
during illness
• Epidemiology: M>F, smokers, majority <40 y/o
• PFTs: OBSTRUCTIVE
• Imaging: interstitial changes and small cystic spaces in upper lung fields,
honeycomb,
• Histology: Langerhans cells
• Associations: smoking
• Treatment: stop smoking, steroids generally do not help. Occasional
spontaneous resolution
• Hand-Schuller Christian syndrome: lytic bone lesions, diabetes insipidius,
exophthalmus
• Smoking related ILDs: Pulm Langerhans, Resp Bronchiolitis, DSIP
60 year old F with h/o asthma presents
with 3 months insidious cough,
wheezing, night sweats, low grade
fevers…
ESR: 82
BAL: high percentage
eosinophils
Eosinophilic Pneumonias
• Acute, benign eosinophilic pneumonia: Loefflers syndrome,
minimal resp symptoms. MIGRATORY infiltrates. Peripheral
eosinophilia. Rule out drugs and parasites.
• Acute eosinophilic pneumonia: acute, febile, hypoxemic
resp failure resembling ARDS. Steroids and vent support.
• Chronic Eosinophilic pneumonia: most common in U.S.
Middle aged women. Subacute. CXR bilateral, very
peripheral infiltrates, photographic negative of pulm
edema, High ESR. Steroids. Relapse common.
55 year old f presents with joint pain,
Rash & fevers…
Sarcoidosis
• Lofgren’s sndrome: Erythema nodosum
(good prognosis), polyarthralgias, hilar
LAD, and fever
• Multisystem disease
• Imaging: bilateral hilar and/or mediastinal
adenopathy (disappears as dz
progresses), +/- parenchymal infiltrates
• Histo: noncaseating granuloma
• BAL: increased lymphs, helper/supressor
ratio of > 4:1 (opposite of HSP)
• Associations: ACE level, hypercalcemia,
hypergammaglobulinemia
• Treatment: 75 % recover without
treatment, steroids for severe cases
Stage
Radiographic
Pattern
0
Normal
I
Hilar
lymphadenopathy
with normal
parenchyma
II
Hilar
lymphadenopathy
with abnormal
parenchyma
III
No
lymphadenopathy
with abnormal lung
parenchyma
IV
Parenchymal
chagnes with
fibrosis and
architectural
distortion
Histology
Clinical Diagnosis
UIP
IPF/ Cryptogenic fibrosing
alveolitis
CTD associated lung disease
Radiation
NSIP
NSIP (CTD, HIV, Drugs)
Organizing Pneumonia
Cryptogenic Organizing
Pneumonia
Respiratory Bronchiolitis
Respiratory Bronchiolitis ILD -DSIP
Lymphoid Interstitial pneumonia
Lymphoid Interstitial pneumonia
Diffuse Alveolar Damage
Acute Interstitial Pneumonia
A 30-year-old medical resident is evaluated for cough, right-sided chest pain,
and fever of 21 days’ duration. He has no significant medical history or family
history, and he takes no medications.
Hemoglobin is 14 g/dL (140 g/L), and the leukocyte count is 8000/µL (8 ×
109/L). Chest radiograph shows a right pleural effusion occupying
approximately 50% of the hemithorax without other abnormalities.
Thoracentesis yields turbid, yellow fluid, and analysis shows:
RBC Count: 500 uL, Nucleated Cell count: 3500 with 20% neutrophils,
60%lymphocytes, 10% macrophages, 4%mesothelial cell, and 6% eosinophils
Total Protein: 4.2, LDH: 240, pH: 7.35, Glucose: 68
Serum total protein is 7.0 g/dL and serum lactate dehydrogrenase is 100U/L.
Gram stain shows no organism and culture is pending.
Which of the following is the most appropriate next step in management?
1.
2.
3.
4.
Chest CT scan
Flexible bronchoscopy
0%
0%
0%
0%
Pleural biopsy
1
2
3
4
Repeat chest radiograph after a 5-day course of azithromycin
A 70-year-old man is evaluated in the emergency department for a 2-day history of dyspnea with
exertion, orthopnea, and paroxysmal nocturnal dyspnea. He has ischemic heart disease with left
ventricular dysfunction and had coronary artery bypass graft surgery 6 weeks ago. His
medications include aspirin, nitroglycerin, metoprolol, lisinopril, and furosemide.
On physical examination, the patient is sitting upright and breathing with difficulty; the
temperature is 37 °C (98.6 °F), the blood pressure is 150/85 mm Hg, the pulse rate is 105/min and
regular, and the respiration rate is 28/min. Oxygen saturation is 89% on ambient air. There are
fine crackles at the lung bases bilaterally, and breath sounds are diminished at the right base.
There is a regular tachycardia and an S3 at the apex. There is no jugular venous distention or
peripheral edema. Hemoglobin is 12.5 g/dL (125 g/L), and the leukocyte count is 10,500/µL (10.5
× 109/L). Chest radiograph shows cardiomegaly and small bilateral pleural effusions, greater on
the right than the left. Thoracentesis is performed, and pleural fluid analysis shows:
Nucleated Cell Count: 450/UL with 3% neutrophils, 70% lymphocytes, 10% macrophages, 15%
mesothelial cells, and 2% eosinophils
Pleural Fluid to serum total protein ratio: 0.54, Plerual fluid to upper limits of normal serum LDH
ration: 0.52, Glucose: 80, Total Protein: 3.7, pH: 7.45, Albumin: 1.5, Cholestrol 35, The serumpleural fluid albumin gradient is 1.7.
Which is the most likely diagnosis?
1.
2.
3.
4.
Heart Failure
Parapneumonic Effusion
Post-cardiac injury syndrome
Pulmonary embolism
0%
1
0%
2
0%
3
0%
4
Pleural Fluid Pearls
• WBC>1000 (exduate), >10,000 (parapneumonic effusion);
>100,000 (pus/empyema)
• Eosinophils>10% (pneumothorax, drug reaction, parasites,
fungus, asbestos)
• Lymphocytes>50% (TB, or cancer)
• Glucose ~80 (TB); ~60 (cancer or empyema); <30 (RA)
• Amylase (pancreatic fistula, esophageal rupture, local
malignancy)
• pH<7.0 (loculated effusion/empyema), <7.2 (PLACE CHEST
TUBE), < 7.3 (with malignancy, suggests high tumor burder)
• TG>115= chylous; <50= pseudochylous
A 64-year-old woman who resides in a nursing home and has a history of end-stage
kidney disease for which she receives hemodialysis presents with fever, copious
sputum production, and hypoxemia. Chest radiograph shows a right-sided infiltrate.
She is intubated and started on vancomycin, levofloxacin, and piperacillin-tazobactam
for treatment of diffuse right-sided pneumonia.
On day 3 in the hospital, she has been afebrile for 48 hours, and her secretions are
scant and white. On physical examination, the temperature is 36.9 °C (98.5 °F), pulse
rate is 88/min, respiration rate is 14/min, and blood pressure is 140/86 mm Hg;
oxygen saturation is 96% on FiO2 0.4. There are diffuse right-sided inspiratory crackles.
Leukocyte count is 9600/µL (9.6 × 109/L) (20,400/µL [20.4 × 109/L] on admission).
Admission sputum culture is now growing methicillin-resistant Staphylococcus aureus;
blood cultures are negative. Chest radiograph shows slight improvement in the rightsided infiltrate compared with admission.
Which of the following is the most appropriate antibiotic therapy at this time?
1.
2.
3.
4.
5.
Complete an 8-day course of all three antibiotics
Complete an 8-day course of vancomycin and discontinue the other antibiotics
Complete a 14-day course of all three antibiotics
Complete a 14-day course of vancomycin and
the
antibiotics
0% discontinue
0%
0%other 0%
0%
Discontinue all antibiotics
1
2
3
4
5
A 30-year-old woman develops bilateral pulmonary infiltrates and hypoxemia
48 hours after undergoing repair of multiple long-bone fractures. Her initial
arterial blood gases are pH 7.48, PCO2 30 mm Hg, and PO2 45 mm Hg on 100%
oxygen by nonrebreather mask. The patient is intubated and placed on
mechanical ventilation.
The temperature is 38.3 °C (101.0 °F), the pulse rate is 100/min, the
respiration rate is 28/min, and the blood pressure is 120/60 mm Hg. The
patient weighs 60 kg (132.3 lb). Oxygen saturation is 83%. She is sedated,
hemodynamically normal, and not using accessory muscles to breathe. There
are bilateral inspiratory crackles. The ventilator settings are as follows:
volume control mode, respiration rate 26/min, tidal volume 360 mL, positive
end-expiratory pressure (PEEP) 5 cm H2O, FiO2 0.8. Arterial blood gases are
pH 7.45, PCO2 33 mm Hg, and PO2 50 mm Hg.
Which of the following is the most appropriate next step in the management
of this patient?
1.
2.
3.
4.
5.
Increase FiO2 to 1.0
Increase PEEP to 10 cm H2O
Increase respiration rate to 32/min
Increase tidal volume to 700 mL
Start vecuronium infusion
0%
1
0%
0%
2
3
0%
0%
4
5
ALI/ARDS
• ALI
– PaO2/FiO2< 300
– Bilateral infiltrates
– PCWP <18mg Hg
• ARDS
– PaO2/FiO2<200
– Bilateral infiltrates
– PCWP < 18 mg Hg
ARDS