Clin Med: Pulm

Steps to dealing with a pulmonary nodule

1. Incidental finding on CXR 2. Send for CT 3. If malignant potential (Ill-defined, lobular or spiculated), will need biopsy 4. If not suspicious < 1 cm it should be monitored at 3 mo, 6 mo, and then yearly for 2 yr

Long-term oxygen therapy is recommended for patients with a partial pressure of oxygen in arterial blood < ______ mm Hg or oxygen saturation <______%

55, 90

PPD are considered positive when?

> 5mm if high risk (immunocompromised) > 10 mm if some risk >15mm if no risk

Which of the following causes of pneumonia is most likely to be complicated by diarrhea? A. Legionella B. Chlamydophila C. Mycoplasma D. Pneumococcal

A

Which of the following physical examination findings would be consistent with a pneumothorax? A. Hyperresonance to percussion B. Increased tactile fremitus C. Egophony

A

A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient? A. spoken "ee" heard as "ay" B hyperresonant percussion note C wheezes over the involved area D vesicular breath sounds over involved area

A (patient most likely has a bacterial pneumonia with consolidation, which would produce egophony)

dx of TB

AFB stain

A 4-month-old infant is brought to the clinic by his mother with complaints of a cough for the past 3 weeks. Initially, symptoms included running nose, sneezing and an irritating cough. Over the past week the cough has changed to persistent staccato, paroxysmal forceful coughs ending with a loud inspiration. WBC is 20,0000/mcl with 72% lymphocytes. Which of the following is the drug of choice for managing this patient?

Azithromycin (patient has pertussis)

A 27 year-old woman presents with one week of worsening productive cough, dyspnea, fever and malaise. Which of the following physical examination findings would support the diagnosis of lobar pneumonia? A. Decreased tactile fremitus B. Egophony C. Hyperresonance to percussion D. Wheeze

B

A 33 year-old HIV-positive woman develops an 8mm area of induration following the administration of a purified protein derivative (PPD) test. Her chest radiograph shows no evidence of active tuberculosis (TB) infection. Which of the following is the most appropriate clinical intervention? A. Four-drug regimen for 4 months B. Isoniazid with Rifampin C. Observation only D. Repeat PPD and chest radiograph in 3 months

B (patient has latent TB)

Which of the following physical examination findings would be consistent with a consolidation? A. Hyperresonance to percussion B. Increased tactile fremitus C. Egophony

B, C

A 30 year-old male presents with sudden onset of chills, fever, chest pain and a cough productive of greenish-brown sputum. On examination his temperature is 102 degrees F. He appears acutely ill and his respirations are shallow. Chest x-ray demonstrates left lower lobe consolidation. Which of the following findings would most likely be present on examination of his left lower lung? A. Hyperresonance B. Vesicular breath sounds C. Increased tactile fremitus D. Wheezing

C

Which of the following conditions will produce a transudative pleural effusion? A. Kaposi's sarcoma B. Pneumonia C. Cirrhosis D. Mesothelioma

C

Which of the following physical exam findings is consistent with moderate emphysema? A. Increased tactile fremitus B. Dullness to percussion C. Distant heart sounds D. Deviated trachea

C. Distant heart sounds (due to hyperinflation of the lungs.)

MC causes of transudative pleural effusions

CHF, cirrhosis, hypoproteinemic states

A 56 year-old female with a 35 pack year smoking history presents to the clinic with shortness of breath and cough. On examination, she is thin with no recent weight loss. She appears uncomfortable, breath sounds are diminished without adventitious sounds. Pulmonary function tests show a marked increase in total lung capacity (TLC) and a decreased FEV1. What is the most likely diagnosis for this patient?

COPD

Airflow limitation that is irreversible or only partially reversible with bronchodilator is the characteristic physiologic feature of

COPD

A 62 year-old homeless patient presents complaining of fever, weight loss, anorexia, night sweats and a chronic cough that recently became productive of purulent sputum that is blood streaked. On physical examination, the patient appears chronically ill and malnourished. What chest x-ray findings supports your suspected diagnosis?

Cavitary lesions involving the upper lobes

A 45 year-old male presents with complaints of a chronic cough productive of mucopurulent sputum. The cough has been present for the past 3 years, but he attributed it to a "smoker's cough". He has been coughing up a lot of sputum lasting all winter long for the past 2 years. He denies any hemoptysis, weight loss or chest pain. Physical examination reveals a moderately obese male in no acute respiratory distress. Lung fields reveal presence of scattered rhonchi and wheezes. There is 1+ peripheral edema. What is the most likely diagnosis?

Chronic bronchitis

On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause? A. asthma B. consolidation C. pneumothorax D. pleural effusion

D

a 24-year-old with increasing cough for 3 weeks. The cough comes and goes sometimes lasting for 10 minutes and causing gasping inhalations.

pertussis

severe paroxysmal cough followed by an inspiratory high-pitched whoop

pertussis

A 73-year-old obese female with a 20 pack year smoking history presents complaining of chronic productive cough. She states that it has been occurring over the past 3 years more frequently November through February. What pulmonary function test values would you expect to find decreased?

FEV1/FVC

A 55 year-old man with a history of chronic bronchitis presents with two days of increased dyspnea and cough with worsening purulent sputum production. He is currently using inhaled albuterol as needed. In addition to systemic corticosteroids, what pharmacologic agent is warranted at this time for treatment of this patient?

Empiric antibiotic treatment (indicated in the treatment of acute exacerbations of COPD if there are sputum changes suggestive of bacterial infection, such as increased quantity and purulence.)

pneumonia seen in patients with underlying pulmonary disease like COPD

H. flu

A 67 year-old man presents complaining of gradually worsening fatigue and shortness of breath. He is a previous smoker with an 80 pack-year smoking history. He denies chest pain, night sweats, or hemoptysis. On physical examination, you note a very thin male who appears older than his stated age. Lung and heart sounds are barely audible to auscultation. What intervention is likely to alter the disease course (Reduce mortality)?

Home oxygen therapy (has been shown to prolong life in patients with COPD and alter the natural history of the disease.)

NSCLC that commonly causes hemoptysis and is more likely in smokers

squamous cell carcinoma

characterized by muscle weakness of the limbs caused by ACTH/ADH

Lambert-Eaton myasthenic syndrome:

2-year-old boy who is brought to you by his father who is concerned about a "barking cough," mild fever, and a hoarse voice. He reports that he had a runny nose last week that has since resolved. Physical exam reveals an inspiratory stridor. CXR shows

steeple sign

A 4-year-old boy is sent home from day care for a severe cough following one week of cold symptoms, including sneezing, conjunctivitis, and nocturnal cough. He presents with paroxysms of cough followed by a deep inspiration, and occasional post-tussive emesis. During severe paroxysms, he exhibits transient cyanosis. What is the most appropriate treatment for exposed contacts at his day care center?

Macrolide prophylaxis (patient has pertussis)

what is more prevalent, NSCLC or SCLC?

NSCLC

The most common pathogen identified in community acquired pneumonia (CAP) is

strep pneumoniae

tx of acute bronchitis

supportive: fluids, antitussives (ONLY in adults), expectorant, bronchodilator

A 60-year-old female with a 30-pack year smoking history complains of new onset shortness of breath. On physical examination, dullness is noted on percussion with diminished breath sounds over her left base. Chest x-ray shows a new left pleural effusion. Which of the following is the next step in the management of this patient?

thoracentesis

screening tools for TB

PPD, IGRAs (designed for latent TB)

An 18-month-old male presents with his parents who report symptoms of a barking cough and intermittent stridor that has worsened over the past 12 hours. They note improvement in symptoms when he was taken outdoors to the cool night air. Which of the following is the most likely organism causing this patient's symptoms

Parainfluenza virus (MC cause of croup)

pneumonia found in patients that are malnurished, HIV CD4 <200, immunosupressed (cancer/chemo), taking high dose steroids,

Pneumocystis (PCP, PJP)

pneumonia most common in patients with cystic fibrosis, ventilators

Pseudomonas Pneumonia

MC cause of pneumonia and bronchiolitis in infants

RSV

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days, but symptoms worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 7 pounds, and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 100.8° F, pulse of 120 beats/minute, blood pressure within normal limits, and respiratory rate of 60 breaths/minute. The infant is well hydrated but appears ill. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical examination. Chest radiographs show patchy atelectasis and hyperinflation of the lungs. The most common cause of this condition is:

RSV (patient has bronchiolitis)

_____ is the most common cause of acute bronchiolitis

Respiratory syncytial virus (RSV)

pneumonia with Salmon colored sputum, lobar, after influenza,

S. aureus pneumonia

A 62 year-old male smoker presents to the clinic with the complaint of a chronic cough, hemoptysis, and weight loss. Chest CT shows a mass obstructing the bronchus with hilar and mediastinal lymph node abnormalities. Bronchoscopy with biopsy is performed. On reviewing pathology results you explain to the patient that his type of lung cancer is prone to early hematogenous spread, is rarely amenable to surgical resection and has a very aggressive course. What type of lung cancer is most likely in this patient?

SCLC

type of lung cancer that is highly aggressive and almost always occurs in smokers.

SCLC

A 61-year-old male presents to your office with the chief complaint of "coughing up blood and weakness" for the past 3 weeks. He reports at least five to six episodes every 2 to 3 days of coughing of bright red blood, approximately one to two tablespoons each time. The patient denies any chest pain, fevers, chills, or recent travel. He has mild dyspnea at baseline. He has recently developed lower extremity muscle cramps and he has difficulty rising from a chair. Past medical history is significant for COPD diagnosed 5 years ago and HTN. He has a 40-pack-year smoking history and currently smokes 1 pack per day. Examination is notable for end-expiratory wheezing and a prolonged expiratory phase on lung auscultation. He has 3/5 hip flexion and decreased deep tendon reflexes bilaterally in lower extremities. Laboratory tests are normal including electrolytes. CXR reveals typical changes seen in COPD (flattened diaphragms, hyperinflation) and a perihilar mass. What is the most likely diagnosis?

SCLC (mass located in the central/proximal airways and the weakness suggestive of Lambert-Eaton syndrome)

differences in tx for SCLC vs NSCLC

SCLC: can NOT be treated with surgery, treat with chemo and radition (limited) or chemo that may follow with radiation (extensive) NSCLC: tx depends on stage Stage 1-2 surgery stage: 4 chemo

Lung cancer associated condition: ADH is produced by tumor cells, resulting in hyponatremia. What type of lung cancer is it associated with?

SIADH. SCLC

tumor pushes on a specific structure causing prominent neck and chest veins, facial plethora what type of lung cancer is this condition related to?

SVC syndrome, SCLC

Management of COPD Exacerbations

Short acting bronchodilators Antibiotics (macrolide/tetracycline) Oral Steroids

tx of bronchiolitis

Supportive: antipyretics, oxygen, fluids, ventilation if severe Palivizumab prophylaxis (once per month during RSV season)

Upper cavitary lesion on CXR sputum specimens positive for acid-fast bacilli

TB

a 78-year-old man with a 3-month history of weight loss, fever, fatigue, night sweats, and cough. He is a former smoker. A recent HIV test was negative. A CT scan of the chest reveals a 3 cm lesion in the upper lobe of the left lung and calcification around the left lung hilus. A sputum smear was positive for acid-fast organisms.

TB

A 75 year-old man with a long history of COPD presents with acute onset of worsening dyspnea, increased productive cough, and marked agitation. While in the emergency department he becomes lethargic and obtunded. His ABG's reveal a PaO2 40 mmHg, PaCO2 65 mmHg, and arterial pH 7.25. Which of the following is the most appropriate management at this point?

This patient is in severe respiratory arrest with markedly impaired mental status; endotracheal intubation and mechanical ventilation is required.

A patient with severe COPD presents to the Emergency Department with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen at 2 liters per minute, and an IV is started. After one hour of treatment, his arterial blood gas now reveals a pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. What is the most appropriate next step in his treatment?

This person has increasing respiratory failure as indicated by the raising PaCO2 levels. Intubation is required at this time.

primary nodule that has not enlarged in ≥ 2 yr suggests

a benign etiology

cough which persists for MORE THAN 5 DAYS, low grade fever, often follows URI

acute bronchitis

subtypes of NSCLC

adenocarcinoma (MC), squamous cell carcinoma, large cell carcinoma and carcinoid tumor

A 60 year-old patient with COPD characteristic of emphysema presents with a cough and increased sputum production. The following information is noted: Temperature 100°F (37.8°C); Respiratory rate 20/min; Heart rate 88 beats/min; pH 7.44; PaO2 75 mmHg; PaCO2 40 mmHg; O2 saturation 92%. Physical examination is remarkable for increased AP diameter, diminished breath sounds without wheezes, rhonchi, or other signs of respiratory distress. What would be an appropriate treatment for this patient?

antibiotic (increase in sputum with a history of COPD reported by a patient must be regarded as potentially infectious and treated promptly)

A 47 year-old HIV positive female presents with a complaint of a nonproductive cough. She is febrile, tachypneic and tachycardic. Lung exam reveals bilateral rales. Chest x-ray shows diffuse interstitial infiltrates. What is the recommended treatment in this patient?

bactrium (pt has pneumocytis)

What is a common symptom associated with laryngotracheobronchitis ?

barking cough

what will you see on a CXR of a patient with a pleural effusion?

blunting of costophrenic angle

CXR: hyperinflation, alectactais and peribronchial thickening, tree in bud pattern

bronchiolitis

infant presents with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C (101.4 F), and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Flaring of the alae nasi, use of accessory muscles, and subcostal and intercostal retractions are noted. Expiratory wheezes are present.

bronchiolitis

fluid in pleural space due to lower osmotic pressure or increased hydrostatic pressure

transudative effusion

A tumor arising from neuroendocrine cells → leading to excess secretion of serotonin. The syndrome includes flushing, diarrhea, dermatitis, and mental status changes

carcinoid tumor

A 42 year-old male is brought to the emergency department with a stab wound to his right lateral chest wall. On physical examination, the patient is stable with decreased breath sounds on the right with dullness to percussion. An upright chest x-ray reveals the presence of a moderate pleural effusion. Subsequent diagnostic thoracentesis contains bloody aspirate. What is the next most appropriate intervention?

chest tube (patient has hemothorax)

An elderly nursing home resident is admitted with methicillin-resistant Staphylococcus aureus pneumonia. What is the most appropriate treatment to initiate?

vanco

acute bronchitis is typically viral or bacterial?

viral

A 56 year-old male with a 40 pack-year smoking history presents complaining of progressive shortness of breath. Spirometry reveals an FEV1 of 2 L (40% of predicted), an FVC of 4 L (80% of predicted) and an FEV1/FVC of 50%. These findings are most consistent with

chronic bronchitis

Chest radiographs demonstrate increased interstitial markings, particularly at the bases and thickening of the bronchial walls. elevated HGB, peripheral edema.

chronic bronchitis

Mucous gland enlargement and goblet cell hyperplasia is associated with

chronic bronchitis

dyspnea, chronic cough that is productive of phlegm, 40 pack-years of smoking, wheezes/rales on PE

chronic bronchitis

dx of acute bronchitis

clinical if pneumonia suspected --> cxr

CXR shows subepiglottic narrowing of the trachea

croup (this sign on cxr is aka steeple sign)

A 22 month-old male infant presents with one day of barking cough preceded by three days of cold symptoms. On physical examination, his axillary temperature is 100.4°F and he has no stridor at rest. Inspiratory stridor is evident when he becomes agitated during the examination. There are no signs of respiratory distress or cyanosis. Which of the following is the most appropriate treatment for this patient?

dexamethasone (Nebulized racemic epinephrine is only indicated in cases of moderate to severe rest stridor, respiratory distress, or hypoxia.)

A 24 year-old male presents complaining of a 9 month history of increasing shortness of breath, dyspnea on exertion, and a cough productive of white sputum, mostly in the mornings. He denies orthopnea, PND, peripheral edema, fever, chills, night sweats, recent changes in weight, palpitations, chest pain, food intolerances, or other complaints. Patient has a history of recurrent lung infections. He states that his father had chronic pulmonary problems and died at age 42 from unknown lung disease. The patient denies smoking, alcohol or illicit drug use. On physical examination, the respiratory rate is 22 per minute, pulse of 98 bpm, temperature of 98.7 degrees. Pulmonary exam reveals end-expiratory wheezes bilaterally and hyperresonance to percussion. His cardiac exam is normal. Chest x- ray shows decreased lung markings. ECG is normal. Pulmonary function tests show an FEV1 63% of expected and residual capacity is 123% of expected. What is the most likely diagnosis?

emphysema

CXR reveals loss of lung markings, hyperinflation, increased anterior-posterior diameter PFTs show a decreased FEV1 / FVC ratio + increased TLC

emphysema

On physical exam, you note a thin, barrel-chested man with decreased heart and breath sounds, pursed-lip breathing, end-expiratory wheezing, and scattered rhonchi. Chest X-ray reveals a flattened diaphragm, hyperinflation and a small, thin appearing heart. PFTs show a decreased FEV1 / FVC ratio.

emphysema

enlarged air spaces secondary to alveolar destruction

emphysema

Isolated left-sided pleural effusion is likely transudative or exudative?

exudative (transudative more common B/L, if its unilateral more commonly right side)

fluid in pleural space due to breakdown inflammation and increase capillary permeability

exudative pleural effusion

MC causes of exudative pleural effusions

infection, malignancy, inflammation

5-year-old with sudden onset of fever, chills, malaise, sore throat, headache, and coryza. The child is also complaining of myalgia, especially in her back and legs. On physical exam, the patient appears lethargic, has a temperature of 102.5 F, and palpable cervical lymph nodes. Breath sounds are distant with faint end-expiratory wheezes.

influenza

what vaccines are recommended for patients with COPD

influenza and pneumococcal vaccines

pneumonia due to Alcohol abuse, aspiration

klebsiella pneumonia

What physical examination findings are consistent with a diagnosis of lobar pneumonia?

late inspiratory crackles, dullness to percussion, increased tactile fremitus

evaluation of pleural effusion

lateral decubitus CXR CT pleural fluid analysis thoracentesis to determine transudative or exudative

pneumonia caused by Air conditioning/aerosolized water, low NA+ (hyponatremia), GI symptoms (diarrhea) and high fever

legionella pneumonia

A 15 year-old male presents with a 1 week history of hacking non-productive cough, low grade fever, malaise and myalgias. Examination is unremarkable except for a few scattered rhonchi and rales upon auscultation of the chest. The chest x-ray reveals interstitial infiltrates and a cold agglutinin titer was negative. What is the most likely diagnosis?

viral pneumonia (interstitial consolidation seen on CXR, negative cold agglutinin suggests its not mycoplasma)

A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is

mycoplasma pneumonia

pneumonia: Young people living in dorms, (+) cold agglutinins, bullous myringitis, "walking pneumonia", low fever

mycoplasma pneumonia

dx of pertussis

nasopharyngeal swab, PCR

A 2 year-old presents to the emergency department in acute respiratory distress. The parents relate a history of a recent upper respiratory illness that was followed by a sudden onset of barking cough during the night, but this morning they noted increased difficulty breathing. The child is noted to have stridor at rest, but has no evidence of cyanosis. What is the most appropriate initial intervention?

nebulized racemic epinephrine and glucocorticosteroids (This patient most likely has croup, these meds are indicated for patients with stridor at rest.)

A 57-year-old man is being evaluated for shortness of breath. The following spirometric data are obtained: VC 4.90 L (predicted), 5.15 L (observed) 105% predicted FRC 3.99 L (predicted), 4.37 L (observed) 110% predicted RV 2.47 L (predicted), 3.17 L (observed) 128% predicted FEV1 3.50 L (predicted), 2.35 L (observed) 67% predicted. These findings are consistent with what type of disease?

obstructive lung disease (typically show normal or increased total lung capacity, decreased vital capacity, prolonged FEV1, and increased residual volume.)

An 85-year-old nursing home resident presents with abrupt onset of cough, sore throat, headache, myalgias, and malaise. On examination the patient's temperature is 102 degrees F; the rest of the exam is unremarkable. Nasal smear is positive for Influenza B. Which of the following is the treatment of choice in this patient?

oseltamivir

A previously healthy 8-month-old boy is hospitalized for acute bronchiolitis. He has no known significant past medical or family history. On admission, he exhibits nasal flaring and retractions with a respiratory rate of 68, axillary temperature of 102.0 degrees F and O2 saturation of 86%. Which of the following medications is indicated? A. Prednisolone B. Oxygen C. Ceftriaxone (Rocephin) D. Palivizumab

oxygen

58-year-old female who returns to the hospital with chest pain and difficulty breathing several weeks after being discharged following a myocardial infarction requiring immediate cardiac catheterization. She has been coughing up frothy sputum for the past three days. The patient complains of a sharp pain that worsens during inspiration. Physical exam reveals decreased tactile fremitus, dullness to percussion and diminished breath sounds on the left side

pleural effusion

pneumonia with High fever, productive cough with Rust colored sputum

pneumococcal pneumonia

dx of influenza

rapid antigen test viral culture, PCR (gold standard)

In patients with COPD, what has been shown to decrease rate of malignancy and cardiovascular disease and improve survival?

smoking cessation