Pulm Qs

A 20-year-old woman comes to the office for her routine checkup. She has a past history of asthma and presently is being treated with albuterol MDI on prn basis. She states she uses the inhaler at least once a day for wheezing. She admits to awakening from sleep 3-4 times per week for cough/wheeze. Past History: Hospitalized 1-2 times/year; emergency department visits ~ 6 times/year; 2 prior ICU admits at ages 6 and 8. Previously treated with inhaled steroids for 4-6 weeks around the time of hospital discharge (noticed no benefit). Requires oral steroid bursts every 6-8 weeks for 3-5 days. PE: Essentially normal Office spirometry: FVC 88%, FEV1 59%, FEF25-75 48% Based on the guidelines, how would this patient be classified? a) Mild persistent b) Moderate persistent c) Severe persistent d) Mild intermittent

Answer C. Severe persistent Explanation This is straight from the NHLBI-asthma guidelines. Severe persistent asthma is defined as: continual symptoms, frequent exacerbations, frequent nighttime asthma symptoms, physical activities limited by asthma symptoms, FEV1 or PEF ≤ 60% predicted, and/or PEF variability > 30%. Based on this definition, she has daily use of inhaled bronchodilators and FEV1 less than 60%. Classification is based on the worst symptoms in any category. A patient of yours is concerned about bioterrorism agents and asks if he should be worried about a "severe pneumonia" diagnosed in one of his colleagues.

Which of the following organisms can be spread from person to person in respiratory droplets from a person with pneumonia and is useful as a bioterrorist agent because of this characteristic? a)Neisseria meningitidis b) Clostridium botulinum c) Arcanobacterium haemolyticum d) Bacillus anthracis e) Yersinia pestis

Answer E. Yersinia pestis Explanation Yersinia pestis is the only agent listed that can cause a necrotizing pneumonia that is infectious by spread of coughing or sneezing respiratory droplets. Pneumonia due to anthrax (from Bacillus anthracis) is not contagious. Botulism does not cause pneumonia. Neisseria meningitidis is not a potential bioterrorism agent, and Arcanobacterium haemolyticum just causes sore throats in adolescents and young adults.

Which of the following is the treatment for acute methemoglobinemia? a) Carbon monoxide and methylene blue b) 100% oxygen and methylene blue c) Carbon dioxide and methylene blue d) Sodium pentathlon e) Ascorbic acid

Topic Pulmonary Medicine Answer B. 100% oxygen and methylene blue Explanation Most commonly this is seen with use of "poppers." Giving the methylene blue causes rapid reduction of methemoglobin back to hemoglobin. Ascorbic acid is useful for chronic hereditary methemoglobinemia. Note that the other agents would kill the patient.

A 54-year-old male with moderate COPD presents to the emergency department with a 4-day history of progressive shortness of breath. He is noted to be lethargic and in respiratory distress with accessory muscle use and a respiratory rate of 36. He has poor air movement without any wheezing. The patient is intubated and placed on mechanical ventilator support with the following settings: Mode: Assist control ventilator rate (set): 14 Patient spontaneous rate: 22 Tidal volume: 450 mL F i O 2 : 100% PEEP: 5 cm An arterial blood gas is obtained: pH: 7.22 pCO 2 : 64 P a O 2 : 240 HCO 3 : 22 Which of the following would help improve the pH? a) Decrease the F i O 2 to 50%. b) Deeper sedation to decrease respiratory rate to 14. c) Increase the tidal volume to 500 mL. d) Increase the set rate on the ventilator to 22 breaths per minute. e) Start continuous infusion of bicarbonate mixed in dextrose 5%.

Pulmonary Medicine Answer C. Increase the tidal volume to 500 mL. Explanation This patient has acute hypercarbic respiratory failure with respiratory acidosis, which necessitated mechanical ventilatory support. In order to increase the pH, the respiratory acidosis must be improved. This is accomplished by increasing the overall minute ventilation (MV). MV is the product of the respiratory rate and the tidal volume. The patient is already breathing at a rate of 22. Increasing the rate on the ventilator is unlikely to have any overall change in the minute ventilation, but increasing the tidal volume while maintaining the same respiratory rate will increase the MV. The patient is indeed hyperoxygenated and should have the F i O 2 reduced to avoid oxygen toxicity, but this will do little to improve the respiratory acidosis. Deeper sedation may actually reduce the respiratory rate and thus the MV, causing a reduction in the pH. Bicarbonate infusion has no role in a respiratory acidosis but may be used in cases of severe metabolic acidosis.

A 25-year-old complains of "shortness of breath" that began at a social gathering. He complains of paresthesias of his hands and feet and developed left-sided pleuritic chest pain. PMH: Major depression On exam he is tachypneic. ABG: pH 7.47, pCO 2 32, pO 2 92 Which of the following is the most likely diagnosis? a) Anaphylactoid reaction b) Asthma exacerbation c) Panic attack d) Hypersensitivity pneumonitis e) Pulmonary embolism

Pulmonary Medicine Answer C. Panic attack Explanation This healthy patient develops sudden dyspnea associated with paresthesias suggesting a respiratory alkalosis. He is not hypoxic, however. The best way to determine whether severe disease, such as a pulmonary embolism, is occurring in the alveolar-capillary unit is to calculate the A-a gradient. Recall this calculation: P A O 2 - P a O 2 , when P A O 2 = 150 - (PCO 2 x 1.25) Normal = 5-20 mmHg Therefore, in this case: P A O 2 = 150 - (32 x 1.25) = 150 - 40 = 110 A-a gradient = 110 - 92 = 18 = NORMAL! This normal gradient indicates no problem at the alveolar-capillary unit (such as asthma or pulmonary embolism). The most likely explanation is supratentorial hyperventilation. Anaphylaxis has a very pronounced clinical presentation that is not described in this case.

Three dishwashers started working at 8:30 a.m. By 1:00 p.m., 11 workers were involved in washing the dishes since there was a huge banquet the previous night, leaving lots of dirty dishes. The dishwashing procedures consisted of: Pre-rinsing the dirty dishes by hand in a water tank. Washing the pre-rinsed dishes in the automatic dishwasher. Draining the washed dishes and placing them in cupboards. Starting around 2:00 p.m., workers began complaining of such symptoms as headaches and dizziness. By 2:30 p.m., all workers showed the same symptoms. Two seriously affected workers were taken to a local hospital by ambulance; the other 9 workers were also eventually taken to the hospital for treatment. One of the workers arriving in the emergency department is a 54-year-old woman whose last memory was washing asparagus off a plate. The next thing she remembers was riding in the ambulance. PAST MEDICAL HISTORY: Peptic ulcer disease, fibromyalgia MEDICATIONS: Unknown anxiolytic, estrogen FAMILY HISTORY: Unknown SOCIAL HISTORY: Divorced; lives with her boyfriend in a trailer park; smokes 3 ppd; drinks a 6-pack of beer daily ROS: Positives: Headache; dizziness; weakness; nausea; difficulty concentrating; dyspnea; visual changes PHYSICAL EXAMINATION: BP 126/91, HR 86, RR 30, T 98.8° F MS: Oriented to name only; speech without dysarthria; 2/3 recall at 5 minutes General: Erythema to face and trunk HEENT: PERRLA, EOMI, Throat clear Neck: No masses Heart: RRR without murmurs Lungs: CTA Abdomen: +BS, soft, nontender Neuro: CN grossly intact; reflexes equal and symmetrical Motor: Full strength throughout with normal muscle tone and bulk Sensory: Unremarkable ABG: 7.41/30/370 with O2 Sat 98% on 100% FiO2; carboxyhemoglobin level is 26% Which of the following is the most likely diagnosis based on the epidemiology of multiple people being ill and this woman's ABG results? a) Allergic reaction to dishwasher detergent b) Meningococcemia c) Influenza A outbreak d) Carbon monoxide poisoning e) Asthma

Pulmonary Medicine Answer D. Carbon monoxide poisoning Explanation All of the workers were diagnosed as suffering from carbon monoxide poisoning. CO has been called the silent killer and is the cause of approximately 5,000 deaths annually, with 2 to 5 times that number requiring treatment. Even with treatment, the devastating sequelae that can accompany CO poisoning can be life-changing. These include chorea, rigidity, dementia, myoclonus, impaired sensory function, seizures, and gait dysfunction. There can also be permanent cardiac damage due to the hypoxia involved in the poisoning process. CO is an odorless, colorless, and tasteless gas that results from incomplete combustion of fuels (i.e., coal, wood, gasoline). Once inhaled, it binds quickly and tightly to the hemoglobin (Hgb) and crowds out the oxygen; studies have shown CO can bind 200 times stronger than oxygen. Since the Hgb can no longer carry the oxygen, the patient becomes hypoxemic and anoxic. Also, the CO binds with myoglobin in the muscles and interferes with cellular metabolism, causing metabolic acidosis. Normal carboxyhemoglobin (HbCO) levels are 0-3% for nonsmokers and 3-8% for smokers. A level of 10-20% causes headaches, nausea, vomiting, and dyspnea. A level of 30-40% causes severe headaches, syncope, and tachyarrhythmias. Levels greater than 40% cause Cheyne-Stokes respiration or respiratory failure, seizures, unconsciousness, permanent brain damage, cardiac arrest, and even death. Because of the vagueness of the symptoms and their similarity to flu-like symptoms (nausea, vomiting, dizziness, headache, etc.), CO poisoning is often misdiagnosed. Also, even if HbCO is present, it cannot be diagnosed with a simple pulse oximetry device—because the displayed saturation level equals the sum of the oxyhemoglobin and carboxyhemoglobin. So if you suspect a patient has CO poisoning, what should you do? First and foremost, the patient needs high-flow, high-concentration O2, preferably a non-rebreather mask at 15 liters per minute, as well as a large bore IV. Prepare for blood draws (ABG, CBC, electrolytes, CPK, lactate, and carboxyhemoglobin). A urine sample is also useful to rule out rhabdomyolysis (cardiac muscle breakdown secondary to the myoglobin damage from CO). Other treatment modalities may include a CXR, cardiac monitoring, and possibly mannitol to help decrease the cerebral edema accompanying the CO poisoning. Finally, probably the most effective treatment is transfer of the patient to a hyperbaric oxygen unit (HBO). This is clearly indicated when the patient is very symptomatic and/or the HbCO is 25% or greater.

Which of the following values is consistent with emphysema? a) %TLC %DLCO Low Normal b) %TLC %DLCO Normal Normal c) %TLC %DLCO Low High d) %TLC %DLCO Low Low e) %TLC %DLCO High Low

Pulmonary Medicine Answer E. %TLC %DLCO High Low Explanation The high TLC and disproportionately low DLCO is classic for emphysema. The other values are not consistent with emphysema.

A 67-year-old man with a 100-pack-year history of smoking (2 ppd for 50 years) is essentially dragged in by his wife, who says that he has withered away to nothing and has been acting very confused lately. He says he is fine but keeps calling you his grandchild. You don't get much more information out of him. PAST MEDICAL HISTORY: Prostatectomy 5 years ago HTN for 20 years on an ACE inhibitor SOCIAL HISTORY: Retired used car salesman Lives with his wife of 50 years Doesn't drink FAMILY HISTORY: Father died at age 75 of lung cancer Mother died at age 74 of lung cancer Brother died at age 74 of lung cancer Sister died at age 74 of lung cancer REVIEW OF SYSTEMS: No fever or chills Has had night sweats on occasion 30-lb weight loss in last 6 months No appetite Coughed up blood once last week (about a teaspoon, according to wife) PHYSICAL EXAMINATION: Oriented only to person, place; thinks the year is 1978 BP 110/70, P 92, RR 14, Temp 99° F, Ht 6'1", Wt 170 HEENT: PERRLA, EOMI TMs clear Throat clear Neck: Supple, no masses Heart: RRR with II/VI systolic murmur (heard for 10 years now) Lungs: Coarse scattered crackles; no focal findings Abdomen: Bowel sounds present; no hepatosplenomegaly Extremities: No cyanosis, clubbing, or edema LABORATORY: CXR: Central/hilar mass with area of cavitation Calcium: 11.5 mg/dL Based on your findings, which of the following types of lung cancer does this man most likely have? a) Bronchoalveolar carcinoma b) Adenocarcinoma c) Small cell d) Large cell e) Squamous cell carcinoma

Pulmonary Medicine Answer E. Squamous cell carcinoma Explanation Squamous cell more commonly involves the central/hilar area with local extension, and it is the most likely cancer to cavitate. Also, it is most commonly associated with hypercalcemia (large cell is next). Adenocarcinoma and large cell are usually peripheral. Bronchoalveolar carcinoma is just a subtype of adenocarcinoma. Squamous and small cell are usually central (remember the S-S sounds like Sentral). With small cell, cavitation never occurs. So if you put together central lesions, this leaves squamous and small cell; then put in cavitation and that leaves only squamous. Plus, for an added bonus, squamous is the one most commonly to have hypercalcemia.

A 30-year-old female with asthma presents to your office for routine followup. She is currently using her albuterol inhaler 2-3 times/week and is waking from sleep about once/week needing a treatment. She is not on any long-term therapy. She has never been hospitalized and usually does well using albuterol until she gets a cold, at which time she has moderate to severe exacerbations. On physical examination today she is stable with no wheezes. Her peak flow is in the green zone. How would you change her daily therapy? a) Add daily inhaled corticosteroids. b) Do not change anything. c) Add inhaled steroids only during a cold. d) Continue current regimen but give oral steroids every time she gets a cold. e) Change the albuterol to a long-acting beta-agonist.

Topic Pulmonary Medicine Answer A. Add daily inhaled corticosteroids. Explanation This patient has mild persistent asthma and therefore requires a long-term control medication. Inhaled glucocorticoids are now considered the first-line agent and cornerstone therapy for mild persistent asthma. They are safe when used at the appropriate doses. There is a delayed onset of action, and therefore they must be given daily. The goal will be to limit major exacerbations and the need for oral steroids.

A 58-year-old woman has had pain and tenderness of the long bones of the lower extremities, knees, and ankles for 2 months. She has smoked 1 pack of cigarettes daily for 30 years. She has had rheumatoid arthritis for 15 years. Examination of the lower extremities shows tenderness to palpation of the femur and tibia bilaterally and slight warmth and tenderness of the knees and ankles. X-ray films show periosteal new bone formation of the femurs. Her symptoms are most likely a complication of which of the following? a) Adenocarcinoma of the lung b) Osteoporosis c) Rheumatoid arthritis d) Small cell lung cancer e) Squamous cell carcinoma

Topic Pulmonary Medicine Answer A. Adenocarcinoma of the lung Explanation Hypertrophic pulmonary osteoarthropathy (HPOA) consists of clubbing, painful periosteal hypertrophy of long bones, and symmetrical arthralgia of the large joints. The features can appear separately or in combination. Radiographs of the long bones show thickening and hypertrophy of the periosteum. HPOA occurs most commonly as a paraneoplastic syndrome associated with adenocarcinoma of the lung. Resection of the primary tumor may relieve the symptoms of HPOA. RA doesn't present with long-bone pain. Osteoporosis is asymptomatic unless a fracture develops. HPOA is not associated with squamous cell carcinoma and is not typically associated with small cell lung cancer.

A 50-year-old man with a history of pneumonia diagnosed 2 days ago presents for follow-up. He was seen as an outpatient and sent home on oral levofloxacin. He says he took 1 pill and it made his stomach hurt, so he stopped the medication. He said he meant to call and let you know, but he was too busy and thought he would get better without the medicine. Now he complains of right-sided chest pain that is pleuritic in character. He says it really hurts to take a deep breath. PAST MEDICAL HISTORY: Essentially negative; few office visits for sildenafil prescriptions SOCIAL HISTORY: Works as an attorney; prosecutes medical malpractice cases Lives alone FAMILY HISTORY: Mother alive and healthy Father died at age 70 of myocardial infarction Brother 49, healthy, mechanic REVIEW OF SYSTEMS: Fever has been persistent and unremitting since early this morning Chills prominent Sputum production has increased markedly since yesterday Chest pain as described above Minor sore throat Generalized body aches and pains No arthritis No vision changes No rash PHYSICAL EXAMINATION: BP 120/70, P 90, RR 20 (splinting), Temp 103.5° F HEENT: PERRLA, EOMI TMs clear Throat clear Neck: Supple; no masses Heart: RRR without murmurs, rubs, or gallops Lungs: Upper lung fields clear Left lower lung has scattered crackles Right lower lung has the following localized findings: absent breath sounds, dullness to percussion, vocal fremitus is absent Abdomen: Bowel sounds are present; no hepatosplenomegaly Extremities: No cyanosis, clubbing, or edema Skin: No rashes noted now LABORATORY: WBC: 15,000 cells/mm3 with 80% polys and 10% bands Hemoglobin/Hematocrit: 15.5 mg/dL; 52% Platelets: 350,000 CXR: Marked consolidation of the right LL with pleural effusion noted bilaterally; right much greater than left Pleural fluid: WBC 70,000 with 90% polys pH 7.02 Gram stain: Few lancet-shaped gram-positive diplococci Based on your findings, which of the following is the most appropriate next step? a) Admit to the hospital, place a chest tube, and start intravenous ceftriaxone and azithromycin. b) Admit to the hospital, start intravenous ceftriaxone plus azithromycin, and observe on therapy 24 hours before placing a chest tube. c) Give IM shot of ceftriaxone and oral azithromycin; observe in waiting room and discharge home if doing better in 4 hours. d) Admit to the hospital, start intravenous ceftriaxone plus azithromycin; get pulmonary consult to decide if he needs a chest tube. e) Admit to the hospital, place a chest tube, and start intravenous vancomycin and gentamicin (for synergy).

Topic Pulmonary Medicine Answer A. Admit to the hospital, place a chest tube, and start intravenous ceftriaxone and azithromycin. Explanation He began with a community-acquired pneumonia and now has an empyema by definition: He has organisms seen on Gram stain of his pleural fluid! The organism is likely pneumococcus. Because he has an empyema, you must place the chest tube as soon as possible; he will not get better without drainage of the pus. Intravenous antibiotics alone will not work. Waiting 24 hours or consulting a pulmonologist will not change the basic fact that he needs "drano"! If you chose to send this patient home, you get 20 lashes with a wet noodle. Remember: Organisms on Gram stain of pleural fluid = needs chest tube. Finally, the choice of vancomycin and gentamicin for synergy is not correct. This choice would be useful if you thought he had community-acquired MRSA, for which he has no risk factors and his Gram stain is not consistent (you would expect gram-positive cocci in clusters for Staphylococcus).

An otherwise healthy 50-year-old woman presents after being discharged from the hospital with a recent diagnosis of lung cancer with a 2-cm isolated tumor. She was found to have squamous cell carcinoma, stage 1A (T1, N0, M0). She is here to find out what further therapy is indicated. Which of the following is the next therapy for her? a) After surgical resection, no further therapy is indicated. b) After surgical resection, radiation therapy is indicated. c) After surgical resection, chemotherapy and radiation therapy are indicated. d) After surgical resection, chemotherapy is indicated. e) After surgical resection, follow-up resection is indicated.

Topic Pulmonary Medicine Answer A. After surgical resection, no further therapy is indicated. Explanation She has a very localized lesion to the lung and a small tumor < 3 cm. She does not have any nodal involvement and has no metastases. Also, she has a non-small cell type of cancer, so surgical resection should be sufficient. She does not need further therapy at this point, and studies have shown that adjuvant chemotherapy for this stage is actually deleterious. If her tumor was > 3 cm and she was Stage 1B (no nodes, no metastases), some trials have indicated that adjuvant chemotherapy may be useful and could be considered because of the size of the tumor.

A 25-year-old woman with past history of mild persistent asthma presents with exacerbation of asthma. This is the fourth exacerbation in 3 months. Prior to 3 months ago, she had been well controlled with last exacerbation being at age 6. On presentation today, she had increased cough productive of brown sputum (described as plugs) and wheezing. With each exacerbation, a CXR was obtained showing infiltrates in different areas, usually upper lobes. Lab evaluation showed elevated peripheral blood eosinophil count. Which of the following is her most likely etiology? a) Allergic bronchopulmonary aspergillosis b) Aspiration pneumonia c) GE reflux d) Chronic sinusitis

Topic Pulmonary Medicine Answer A. Allergic bronchopulmonary aspergillosis Explanation This is an allergic reaction (not invasive infection) to Aspergillus with Type I and Type III reactions. It is usually associated with very high IgE (> 1,000). As in the case above, suspect this in asthmatics with fleeting infiltrates (usually upper lobes), eosinophilia, clinical worsening of asthma, and cough productive of brown plugs. CXR shows "fleeting infiltrates." Treat with corticosteroids and itraconazole.

A 27-year-old complains of "chest pain" and fever. He is diagnosed with pneumonia and treated with levofloxacin as an outpatient 10 days ago. At the time he had rust-colored sputum with lancet-shaped, gram-positive diplococci. Initially he improved, but now on day 4 after starting therapy, he has developed new fever and right-sided, pleuritic chest pain. A CT scan of the chest is done, and the results are presented here: What is the most appropriate next step in management? a) Attempt tube thoracostomy with CT guidance with possible need for more invasive therapy depending on response. b) Send acid-fast smears and cultures of sputum and place a TB skin test. c) Schedule a CT-pulmonary angiogram. d) Begin prednisone 60 mg daily with 10-day wean. e) Add oral amoxicillin-clavulanic acid for anaerobe coverage.

Topic Pulmonary Medicine Answer A. Attempt tube thoracostomy with CT guidance with possible need for more invasive therapy depending on response. Explanation The CT scan shows pleural effusion with multiple loculations. The only effective therapy for this is adequate drainage. Commonly this can be attempted by CT or ultrasound guided tube thoracostomy, which can be done with multiple tubes if multiple loculations are present. If this fails, then more invasive therapy such as video-assisted thoracoscopic surgery (VATS) with debridement may be necessary. Antibiotic therapy alone would be recommended if this was an uncomplicated pleural effusion (free flowing without loculations, pleural fluid pH > 7.2, and negative Gram stain on the pleural fluid). Adding anaerobic coverage is an excellent idea, but oral penicillins are not going to achieve adequate tissue levels for this level of severe disease. Tuberculosis is not very likely in the face of a bacterial infection without risk factors. This is an infection and not a pulmonary embolism, so CT-pulmonary angiogram is not indicated. Prednisone is not going to do anything to treat the infection. For an uncomplicated pleural effusion with a single loculation, antibiotics alone may be effective.

A surgical colleague calls you one afternoon asking if you could see him in your office. You know him to be a healthy 50-year-old male who likes to play tennis and golf. When he arrives at the office, you notice that he appears thinner and less tan than usual. He is carrying a large manila envelope that you see contains x-rays. He reports that he has had a dry, nagging cough for the past 4 weeks. He self-medicated himself with a quinolone antibiotic that he had at the office and after 2 weeks, he switched to azithromycin. He grew concerned when he developed low-grade fever, the cough became productive of clear phlegm, and he noticed that he was winded early in a set of tennis. He had a chest x-ray at the hospital today and decided to bring it to you to look at. On physical exam you find no abnormalities, and his lungs are clear to auscultation. You walk him to the lab where a CBC is done, and you find a mild elevation in the WBC count. His chest x-ray shows diffuse bibasilar parenchymal fibrotic pattern and patchy airspace densities in the right lower lobe. Which of the following is the most likely diagnosis? a) Loeffler syndrome b) Cryptogenic organizing pneumonia (COP) c) Allergic bronchopulmonary aspergillosis d) Hypersensitivity pneumonitis e) Idiopathic pulmonary fibrosis

Topic Pulmonary Medicine Answer B. Cryptogenic organizing pneumonia (COP) Explanation While histologic confirmation is warranted, this is a classic presentation of COP. The flu-like illness that has not responded to antibiotics is a favorite of the ABIM. Histologic confirmation is needed because the patient will need a prolonged course (6-12 months) of corticosteroids and possible additional immunosuppressive agents. ABPA is unlikely because there is no prior history of asthma. Loeffler's is a self-limiting, benign eosinophilic pneumonia that is asymptomatic. IPF or other interstitial lung diseases are in the differential, but the time course is a little short and we have no occupational, environmental, or medication history. Hypersensitivity pneumonitis is not suggested by the history, and frequently the patient would appear more ill and have basilar rales on auscultation.

A 56-year-old male is brought to your office because his wife complains of his constant snoring. She reports that he seems to stop breathing sometimes at night. He does report unrefreshed sleep, headaches upon awakening, and takes a nap nearly every day in his office after lunch. You suspect obstructive sleep apnea and order a polysomnogram. The report indicates that the patient has an AHI (apnea/hypopnea index) of 18 events/hour associated with oxygen desaturations as low as 79%. Which of the following is true about obstructive sleep apnea (OSA)? a) CPAP (continuous positive airway pressure) can be effective in eliminating all respiratory related events due to OSA. b) Patients with treated OSA have a higher incidence of hypertension. c) Treatment with CPAP has not been shown to reduce subsequent cardiovascular events in patients with coronary artery disease. d) Neck circumference < 16 inches is a risk factor for OSA. e) Nocturnal oxygen alone has been shown to be an effective therapy.

Topic Pulmonary Medicine Answer A. CPAP (continuous positive airway pressure) can be effective in eliminating all respiratory related events due to OSA. Explanation Obstructive Sleep Apnea (OSA) is diagnosed via polysomnography. Apneas are complete cessation of airflow during sleep, and hypopneas are a reduction in flow during sleep. The total of apneas plus hypopneas is divided by the total sleep time to provide the AHI (apnea/hypopnea index). Mild OSA is present with an AHI of 5-15 events/hour, moderate at 15-35, and severe OSA at > 35 events/hour. OSA has been shown to be associated with a higher risk of hypertension, coronary artery disease, and stroke. OSA treated with CPAP has been shown to reduce incidence of hypertension and future cardiovascular events. CPAP therapy for OSA is the treatment of choice and has been shown to reduce the incidence of hypertension and reduce cardiovascular mortality in patients with coronary artery disease. Risk factors for developing OSA include elevated BMI, increased neck circumference (> 17"), male gender, post-menopausal women, and advancing age. CPAP treats OSA by causing a splinting open of the upper airways to provide adequate flow. Oxygen alone doesn't provide the same benefit and is not an appropriate solo therapy for OSA.

A 56-year-old man is brought to the emergency department 2 hours after the onset of severe shortness of breath that began during a social gathering. He thinks perfume from a guest triggered his shortness of breath. PMH: Major depressive disorder, hypertension, tobacco abuse (1½ ppd cigarettes x 30 years) ROS: Stable early a.m. cough x 5 years and shortness of breath with exertion of 1 flight of stairs. Meds: HCTZ 25 mg qd, zoloft 50mg qd PE: Moderate distress with RR 32, BP 138/86, afebrile Normal PE except for tachypnea ABG: pH 7.47, pCO 2 32 mmHg, pO 2 85 mmHg CXR: blunting at right costophrenic angle Which of the following is the most appropriate next step in patient care? a) CTA Albuterol and ipratropium inhalation by metered-dose inhaler with a spacer plus oral prednisone 60 mg. b) Change sertraline to paroxetine and recommend follow-up with his primary care provider in 72 hours. c) Albuterol inhalation by metered-dose inhaler with a spacer. d) Intramuscular injection of epinephrine for anaphylactoid reaction.

Topic Pulmonary Medicine Answer A. CTA Explanation If you did this question sequentially, you can see that I changed this question slightly from the first time you saw it (if you didn't do this sequentially, then never mind and forget that I said this ☺). I made the patient a little older and gave him a smoking history as a risk factor for occult malignancy. These two changes make his risk for DVT and PE much higher than in the first setting, where the patient was young and healthy. Immediately, your differential diagnosis should include PE at the top of the list because of these changes in epidemiology. On first inspection of the blood gas, you can appreciate the respiratory alkalosis. This is more supportive evidence of a PE, but you could consider that he's hyperventilating because of a panic attack. If you calculate the A-a gradient, you'll see that even though a PO 2 of 85 doesn't look so bad, the gradient is abnormal: P A O 2 = 150 - (PCO 2 x 1.25) = 150 - (32 x 1.25) = 110 A-a gradient = 110 - 85 = 25 (normal 5-20), elevated! Something's going on at the alveolar-capillary unit. Of the choices listed, the only appropriate next step to evaluate for a pulmonary embolism is to perform a CTA, which is now considered first-line imaging in patients in whom you suspect PE. He does not have anaphylaxis, so epinephrine is inappropriate. He does not have asthma or COPD, so inhalation medications are a waste of time. Changing his antidepressant might be appropriate if this were a true panic attack, but the abnormal A-a gradient mandates a workup for pulmonary embolism.

A 19-year-old male presents to the local college infirmary with complaints of fever, cough, and chest pain. A review of his chart indicates the patient was seen for sore throat approximately 2 weeks prior to onset of current illness. Which of the following is his most likely diagnosis? a) Chlamydophila (formerly known as Chlamydia) pneumoniae b) Streptococcus pyogenes c) Klebsiella pneumoniae d) Legionella

Topic Pulmonary Medicine Answer A. Chlamydophila (formerly known as Chlamydia) pneumoniae Explanation This is the TWAR pathogen. These patients present with fever, malaise, headache, sore throat, and nonproductive cough. The sore throat is commonly seen 2-3 weeks prior to onset of pneumonia. Treatment is with a macrolide or doxycycline. Streptococcus pyogenes presents with acute onset of fever, chills, chest pain, and dyspnea similar to pneumococcus. Klebsiella in children typically occurs in those with underlying immunosuppression or prolonged endotracheal intubation. With Legionella, expect to hear symptoms involving the gastrointestinal tract such as vomiting, diarrhea and abdominal pain, neurologic manifestations, high fever, and possibly hyponatremia on lab evaluation.

A 45-year-old man presents with a history of stable asthma on the following regimen of medications for 20 years: Cromolyn sodium, theophylline, and inhaled steroids. He is doing well; however, last weekend he developed a sore throat and a cough. He went to a local doctor and was prescribed an unknown antibiotic, which he has continued to take. You are concerned that he was put on an antibiotic for a viral infection. Meanwhile, the patient throws up and says he has been really nauseated for 2 days and hasn't been able to keep anything down. Physical exam findings are within normal limits except that his mucous membranes are a little dry. His vital signs are normal and he does not have any signs of dehydration at this point. Which of the following antibiotics could be causing his troubles? a) Ciprofloxacin b) Amoxicillin c) Cefixime d) Sulfamethoxazole

Topic Pulmonary Medicine Answer A. Ciprofloxacin Explanation The problem is that he is on theophylline and adding ciprofloxacin has caused his theophylline clearance to decrease, thus resulting in increased serum levels of theophylline. The result of increased theophylline levels in the toxic range usually begins with nausea and vomiting. The other antibiotics listed do not induce changes in theophylline clearance.

For which of the following is a 5 mm PPD considered significant? a) Close contact with a documented case b) Health-care workers c) IV drug abusers d) Homeless persons e) Prisoners

Topic Pulmonary Medicine Answer A. Close contact with a documented case Explanation Note that health-care workers, IV drug abusers, prisoners, and homeless persons are considered positive at 10 mm. Outside of close contact with a documented case, for 5 mm to be considered positive, you have to have HIV or other major cell-mediated dysfunction, fibrotic changes on CXR consistent with prior TB, an organ transplant, or be significantly immunosuppressed (generally considered so if taking the equivalent of 15 mg/day or more of prednisone for at least 1 month).

An 18-year-old man presents for evaluation and relates that he has a herd of cattle. About 3 weeks ago, he was helping a cow deliver, and he had to assist the cow by manually removing the calf and the placenta. The cow was not ill before the delivery. He reports that he became ill about 2 days ago with a high fever, night sweats, and cough. He has noted that he also has a left upper quadrant tenderness in his belly. PAST MEDICAL HISTORY: Negative; healthy farm boy SOCIAL HISTORY: Lives with his mother, a widow Has 3 cats, 2 dogs, and a pet iguana Chews tobacco Doesn't drink alcohol FAMILY HISTORY: Dad died at the age of 35 in a bull-riding accident Mother healthy, 40 Has 2 younger sisters REVIEW OF SYSTEMS: Complains of joint aches and pains with the fever Headache Weakness PHYSICAL EXAMINATION: BP 110/80, P 110, RR 20, Temp 103° F, Ht 6' 1", Wt 210 lbs Well-developed, very muscular man in some distress HEENT: PERRLA, EOMI TMs clear Throat: mild erythema Neck: Supple, no meningismus Heart: RRR without murmurs, rubs, or gallops Lungs: Coarse breath sounds with defined crackles at the right base Abdomen: Bowel sounds present; liver edge palpated 5 cm below right costal margin; spleen tip palpated 4 cm below left costal margin Extremities: No cyanosis, clubbing, or edema Skin: No rashes LABORATORY: WBC: 18,000 with 75% polys, 20% bands Hgb: 16.0 mg/dL Platelets: 150,000 Electrolytes: Normal AST: 100 ALT: 120 CXR: Right lower lobe pneumonia Which of the following is the likely etiology of his pneumonia? a) Coxiella burnetii b) Streptococcus pneumoniae c) Yersinia pestis d) Staphylococcus aureus e) Francisella tularensis

Topic Pulmonary Medicine Answer A. Coxiella burnetii Explanation In this case, the fact that he worked with animal placentas should make you think about Coxiella burnetii. Remember, if you see some type of animal "placenta" or birthing event, consider Coxiella burnetii. Recent literature reported outbreaks with cats—so be suspicious if Tabby is around delivering kittens and people are getting pneumonia. The other clue that this might be Coxiella is the marked hepatosplenomegaly. This is one of those "pneumonia with splenomegaly" organisms.

A 33-year-old woman presents with facial pain and nasal congestion. She reports she had the onset of sore throat and rhinorrhea 5 days ago. Over the past 48 hours she has had facial pressure over the maxillary sinus and yellow nasal discharge. On exam, T 99.2° F, P 90, BP 110/70; nose: swollen turbinates; neck: no adenopathy; chest: clear Which of the following treatments would you recommend? a) Decongestants/nasal irrigation b)Decongestants/nasal irrigation + Metronidazole c) Decongestants/nasal irrigation + Amoxicillin d) Decongestants/nasal irrigation + TMP/Sulfa e) Decongestants/nasal irrigation + Amoxicillin-clavulanate

Topic Pulmonary Medicine Answer A. Decongestants/nasal irrigation Explanation This patient presents with a 5-day history of rhinorrhea, sore throat, and facial pain. She is afebrile with swollen nasal turbinates on exam. Her symptom complex is most consistent with the common cold. The CDC campaign to limit antibiotic use advises to wait 7-10 days before considering treatment with antibiotics for "sinusitis" for facial pain/persistent congestion. The yellow discharge does not increase the likelihood of a bacterial infection. The best treatment would be to begin saline nasal irrigation and topical decongestants for several days without antibiotic treatment.

You are asked to evaluate a patient due to their shortness of breath. He is 74 years old with a history of coronary artery disease with CABG eight years prior. He reports exertional dyspnea, difficulty breathing when lying flat, and increased lower extremity edema. A chest radiograph is done and reveals a moderately sized, right-sided pleural effusion. On your examination, he had diminished breath sounds along the lower right portion of the right lung with dullness to percussion along the lower right back. A thoracentesis is performed and 900 mL of clear, straw-colored fluid is removed. Pleural Fluid: Serum: Protein: 1.9 Protein: 4.2 LDH: 120 LDH 315 pH: 7.30 WBC: 200; RBC: 0 Gram stain: no organisms Two days later a CXR is repeated, and the effusion is still present, although slightly smaller. The patient is comfortable and not in any distress. What should be done next? a) Echocardiogram b) Placement of a large bore chest tube c) Repeat thoracentesis d) Placement of a small bore chest tube e) Cardiac catheterization

Topic Pulmonary Medicine Answer A. Echocardiogram Explanation This patient has a moderately sized pleural effusion that you can determine is transudative in nature because it does not meet the criteria of an exudative effusion according to Light's criteria. These criteria are: Pleural fluid protein/serum protein ratio greater than 0.5 Pleural fluid LDH/serum LDH ratio greater than 0.6 Pleural fluid LDH greater than 2/3 the upper limits of normal of the serum LDH The most common etiologies for a transudative effusion are congestive heart failure, hepatic hydrothorax from cirrhosis, nephrotic syndrome, and severe hypoalbuminemia. This patient has a history of coronary artery disease and other stigmata to suggest congestive heart failure, including orthopnea and edema. In addition, pleural effusions in CHF are typically bilateral and symmetric or right-sided if unilateral. Since this is a transudative effusion, the underlying cause should be sought, and an echocardiogram would be the next most reasonable step to gauge cardiac and valvular function. Proceeding with cardiac catheterization would be premature at this point, as there is not enough evidence to suggest ischemia as an etiology. Repeat drainage, either by chest tube or thoracentesis, would likely result in reaccumulation because the underlying cause has not been clarified. This would not be recommended at present, especially if the patient is stable and comfortable.

A 52-year-old man presents to your office with a 2-month history of exertional dyspnea and nonproductive cough. There is no history of wheezing or prior asthma. He has a 10-pack-year smoking history but quit 10 years ago. There is no history of chest pain, and he has a copy of an ECG done for a recent insurance physical that was normal. He works in an office with no known occupational exposure, and he is on no prescription medications. On exam, he is a well-developed male in no apparent distress. He has no adenopathy. The cardiovascular exam is normal. On examination of the chest, you note late inspiratory crackles at the bases. He has no clubbing, cyanosis, or edema. LABORATORY: Hematocrit 45%; hemoglobin 15 g/dL CXR—PA and Lateral: Normal ABG: pH 7.45; pCO2 36 mmHg; pO2 70 on room air Office spirometry: Reduced FVC, reduced FEV1, but FEV1/FVC normal Which of the following should be the next step in this patient's workup? a) High-resolution CT of the chest b) Pulmonary function tests at a PFT lab, which would include a determination of his total lung capacity (TLC) and diffusing capacity (DLCO) c) Open lung biopsy d) Transbronchial biopsy

Topic Pulmonary Medicine Answer A. High-resolution CT of the chest Explanation Nearly 10% of patients presenting with interstitial lung disease (ILD) will have a normal CXR. High-resolution chest CT is the test of choice to evaluate for the presence of an interstitial lung disease. HRCT will be helpful diagnostically in assessing the distribution of the disease as well as providing guidance for a possible lung biopsy. In addition, HRCT may provide a clue to the staging of the disease (ground-glass appearing airspace disease suggests an active cellular component vs. burnt out fibrosis). This case is a little different from a similar case you saw elsewhere; here, the CXR is normal and thus you would want more information/data (HRCT) before proceeding directly to bronchoalveolar lavage and/or transbronchial biopsy. Full PFTs would merely provide confirmation of what you already suspect: This patient has an interstitial lung disease with probably restricted lung volumes and a reduced diffusing capacity. Flexible bronchoscopy with transbronchial biopsy could be entertained if we felt a strong suspicion for sarcoid or an infectious etiology. The yield on transbronchial biopsy is very good for these etiologies. However, in order to provide an adequate tissue sample for examination in most ILDs, an open lung biopsy (traditional or thorascopic) is required—but again, we would wait on the HRCT first.

A 45-year-old female presents to the Emergency Department with a 7-day history of progressive shortness of breath. She was seen earlier this week by her primary care provider, who ordered a chest radiograph. This revealed a hazy area of infiltration in her right lower lobe, and he started a quinolone antibiotic. Upon presentation to the ED 4 days later, she was noted to be in severe respiratory distress with a respiratory rate of 45, HR of 130, and oxygen saturations of 78% on 4 L oxygen. She was promptly intubated and placed on mechanical ventilation. Chest radiograph revealed bilateral alveolar infiltrates throughout the entire lung fields. Her BNP level was normal, and an echocardiogram revealed normal LV function and moderately elevated pulmonary artery pressures. Currently she is on FiO2 of 100%. Her ABG reveals a PaO2 of 90 mmHg. Blood cultures grew Streptococcus pneumoniae. She has now been admitted to the intensive care unit. Which of the following interventions has been shown to reduce mortality in patients with this disease process? a) Initiation of mechanical ventilation with tidal volumes set at 4-6 mL/kg of ideal body weight b) Initiation of mechanical ventilation with tidal volumes set at 8-10 mL/kg of actual body weight c) Use of prone positioning d) Use of continuous narcotic infusion to improve ventilator synchrony e) Use of pulmonary artery catheter to measure pressures to guide further management

Topic Pulmonary Medicine Answer A. Initiation of mechanical ventilation with tidal volumes set at 4-6 mL/kg of ideal body weight Explanation This patient presents with pneumonia with development of ARDS (Acute Respiratory Distress Syndrome). She has a P/f (PaO2 divided by fraction of inspired oxygen) ratio of 90, with ratios ≤ 350 consistent with acute lung injury and ≤ 250 consistent with ARDS. Furthermore, she has bilateral infiltrates, and her echocardiogram doesn't reveal any evidence of left heart disease to implicate cardiogenic pulmonary edema. The ARDSNET study group compared groups to lower versus higher tidal volume groups, with a significant reduction in mortality in the patients with tidal volumes set at 4-6 mL/kg of ideal body weight. Prone positioning has only been shown to temporarily improve oxygenation. The use of sedatives and narcotics are most often required to allow for patient comfort and synchrony but have not been shown to affect mortality. Pulmonary artery catheters have been specifically studied in patients with ARDS, with no overall outcome improvement in those patients that had these invasive devices placed.

A 68-year-old man with a history of smoking for 50 years presents to the emergency department with acute onset of shortness of breath and right-sided chest pain, which is sharp and worse with inspiration. His wife says he has had a chronic daily cough for 30 years, but today it was worse—and then he developed this acute shortness of breath. PAST MEDICAL HISTORY: Negative for hospitalizations Hypertension for 30 years, on various agents in the past Diabetes insipidus diagnosed 5 years ago SOCIAL HISTORY: Former police officer, retired 6 years Lives with wife of 50 years Also lives with his 45-year-old unemployed son, which causes a lot of tension in the household according to the patient's wife You diagnose a pneumothorax in the emergency department. His CXR also shows a "honeycomb appearance" with interstitial changes and small cystic spaces in the upper lung fields. Putting together the pneumothorax with his CXR results, diabetes insipidus, and smoking history, which of the following are you most likely to find at lung biopsy? a) Langerhans cells b) Plasma cells c) Fungal elements d) Acid-fast bacilli e) Chylous material

Topic Pulmonary Medicine Answer A. Langerhans cells Explanation This patient most likely has eosinophilic granuloma. Langerhans cells are the predominant cell form. It occurs in smokers and men much more often than in women. About 10% of patients will present with pneumothorax. The diabetes insipidus is seen when the granuloma involve the posterior pituitary. Treatment is to stop smoking. If he had lytic bone lesions (particularly skull), diabetes insipidus, and exophthalmus, then he would have Hand-Schüller-Christian syndrome.

A 45-year-old non-smoker presents with dyspnea on exertion for 2 months. He has bibasilar crackles and has restrictive disease on pulmonary function testing. He is sent for transbronchial biopsy. On further questioning, you learn he works with beryllium. Which of the following would help differentiate between sarcoid and berylliosis? a) Lymphocyte transformation test (LTT) on BAL lymphocytes and/or blood b) CD4 to CD8 ratios c) Kveim skin test d) Non-caseating granulomas on biopsy e) ACE level

Topic Pulmonary Medicine Answer A. Lymphocyte transformation test (LTT) on BAL lymphocytes and/or blood Explanation These 2 diagnoses are very similar, and the only test listed that will differentiate between the two is this one, also called the beryllium lymphocyte proliferation test. A positive LTT indicates berylliosis. The Kveim test is no longer used. ACE levels are non-specific. CD4 to CD8 ratios are also non-specific. Both sarcoid and berylliosis present with non-caseating granulomas.

A 35-year-old female presents to the emergency department with complaints of shortness of breath for 3 days. She has had a dry cough, fever, and chills. Her symptoms of shortness of breath have progressed very rapidly such that she cannot walk from room to room without difficulty. She has no significant past medical history and works as a waitress in a diner. She is a nonsmoker and denies any illicit drug use. On presentation, she is in marked respiratory distress. P: 125, BP: 90/45, Oxygen sats: 79% room air, T: 39.4° C, RR: 38 She has marked accessory muscle use. Lung exam reveals diffuse bilateral crackles and coarse rhonchi. She has a tachycardic rhythm and no peripheral edema. CXR reveals bilateral alveolar infiltrates without cardiomegaly or pleural effusions. Echocardiogram reveals normal LVEF, mild TR, and moderate elevation of pulmonary artery systolic pressures. Her WBC is elevated to 18,000. Her renal function is normal. Blood cultures are now growing Streptococcus pneumoniae . The patient is intubated and placed on mechanical ventilation. Her initial ABG on 100% FiO2 is: pH: 7.29, pCO2: 58, pO2: 74, HCO3: 21. Which of the following is associated with a reduction in mortality in this condition? a) Mechanical ventilation with tidal volumes set at 6-8 mL/kg of ideal body weight b) Use of nitric oxide during ventilation c) Use of neuromuscular blockade during ventilation d) Placement of the patient in the prone position e) Initiation of high-dose corticosteroids

Topic Pulmonary Medicine Answer A. Mechanical ventilation with tidal volumes set at 6-8 mL/kg of ideal body weight Explanation This patient presents with hypoxemic respiratory failure associated with bilateral alveolar infiltrates, high FiO2 requirement, and no evidence of congestive heart failure. This is most consistent with the acute respiratory distress syndrome (ARDS). The leading differential diagnosis for ARDS is congestive heart failure, but her echocardiogram is not supportive of significant cardiac dysfunction. The most common etiologies for ARDS are sepsis, pneumonia, aspiration, and transfusion-related acute lung injury. ARDS requires support by mechanical ventilation in a great majority of patients. Studies have shown a reduction in mortality when lung protective strategies are used (6-8 mL/kg) as compared to traditional strategies (10-12 mL/kg). Unfortunately, all other interventions for ARDS have not shown a mortality benefit. The use of neuromuscular blockade may be beneficial in the first 24 hours of ARDS to improve oxygenation. Prone positioning, which involves placing the patient on their front, has also been shown to improve oxygenation for brief periods of time. Use of high-dose steroids have not been shown to be beneficial in ARDS, although medium-dose steroids may help with lung injury scores if started early in the course of ARDS. Nitric oxide is a selective pulmonary vasodilator that will temporarily improve oxygenation. However, studies have not revealed any benefit and, in fact, may be harmful in patients with ARDS.

An obese 60-year-old man with diabetes mellitus complains that lately he will fall asleep during the middle of conversations and that he spends half his day asleep in front of the television set. His favorite show, he says, is the "Andy Griffith Show," and he has all of the episodes taped. He tries to talk about the show, but he falls asleep mid-sentence. His wife says this happens all the time. You send him for formal sleep testing, and he is found to have moderate obstructive sleep apnea-hypopnea (OSAH). Besides weight loss and avoidance of alcohol and sedatives, which of the following have been proven to be effective in treatment of OSAH? a) Nasal continuous positive airway pressure (CPAP) b) Watching "Leave It to Beaver" instead of "Andy Griffith" reruns c) Sleeping supine d) Using hypnotics to induce sleep at night e) Sleeping under a fan

Topic Pulmonary Medicine Answer A. Nasal continuous positive airway pressure (CPAP) Explanation The continuous pressure "splints" the nasopharynx open at night. Unfortunately, it is uncomfortable for many patients. Sleeping supine and using hypnotics actually would worsen obstructive sleep apnea-hypopnea (OSAH). Sleeping under a fan would not have any effect. The type of television show shouldn't affect this either—although I know of no scientific study to prove this wrong.

Which of the following is not considered an indication to place a patient on treatment for latent tuberculosis infection (assume all CXRs are normal)? a) PPD reading at 72 hours of 7 mm in an asthmatic patient on 5 mg/day of prednisone b) PPD reading at 72 hours of 11 mm in a diabetic c) PPD reading at 48 hours of 6 mm in a patient who lives with a person who has active tuberculosis d) PPD reading at 48 hours of 16 mm in a healthy 20-year-old e) PPD reading at 72 hours of 11 mm in a prisoner

Topic Pulmonary Medicine Answer A. PPD reading at 72 hours of 7 mm in an asthmatic patient on 5 mg/day of prednisone Explanation According to the guidelines, the cut-off is 10 mm for this patient. All of the other patients require treatment; generally, you would use INH for 9 months in each of these other patients. If this patient had been on 15 mg or more of daily prednisone, then they would have met the criteria for therapy.

Which of the following is most consistent with an effusion due to rheumatoid arthritis? a) Pleural fluid glucose < 30 mg/dL b) Pleural fluid glucose > 80 mg/dL c) Pleural fluid pH < 7.0 d) Pleural fluid white cell count of 15,000 e) Pleural fluid triglyceride > 115 mg/dL

Topic Pulmonary Medicine Answer A. Pleural fluid glucose < 30 mg/dL Explanation Low glucose values with normal protein and WBC counts are classic for rheumatoid arthritis pleural effusions. Pleural effusions with large numbers of WBCs or a low pH are consistent with severe bacterial infection or empyema. High triglycerides in a pleural effusion are consistent with a chylous effusion.

A 42-year-old man presents to your office complaining of cough, wheezing, and shortness of breath that has been progressive for the past 3 months. PMH is negative, and he takes no medications. He works in private practice as an attorney and has been in a monogamous marriage for 17 years. He drinks 1 glass of wine nightly and denies the use of tobacco or drugs. PE: Normal vital signs Normal exam except for diffuse fine crackles auscultated in the lung bases CXR: Diffuse interstitial infiltrates Which of the following is the most appropriate next step in patient care? a) Schedule a high-resolution CT scan of the chest. b) Prescribe albuterol by MDI. c) Begin prednisone 60 mg daily. d) Refer to the pulmonologist for bronchoscopy. e) Order a sweat test.

Topic Pulmonary Medicine Answer A. Schedule a high-resolution CT scan of the chest. Explanation This clinical scenario describes an otherwise healthy man in his 40s who develops dyspnea. Radiograph clarifies his disease as interstitial. History and physical exam give you no further clues as to etiology. The question specifically queries whether you know that biopsies are no longer used in the diagnosis of interstitial lung disease except to exclude cancer and infections. High-resolution CT scans are the procedure of choice to evaluate possible interstitial lung disease because trained radiologists can often supply a diagnosis simply by evaluating a pattern. Sweat tests are useful to diagnose cystic fibrosis, which is not an interstitial lung disease. Treatment with a beta-agonist or prednisone should not be initiated until a diagnosis is made.

Which of the following interstitial lung diseases has upper lobe predominance? a) Silicosis b) Asbestosis c) Lymphangitic carcinomatosis d) Rheumatoid fibrosis Pulmonary infiltrates related to scleroderma

Topic Pulmonary Medicine Answer A. Silicosis Explanation Silicosis has an upper lobe predominance. The other choices more commonly occur in the lower lobes. Other upper lobe predominant diseases include ankylosing spondylitis and eosinophilic granuloma.

A 65-year-old man presents to his physician's office with a 9-month history of dyspnea on exertion associated with a mild cough. He has daily sputum expectoration, most pronounced in the morning. He has a past medical history notable for coronary artery disease for which he is on aspirin, simvastatin, and atenolol. He is a 50 pack-year smoker and works in an office-based setting. On physical exam, he has no evidence of resting or exertional hypoxemia. His breath sounds are moderately-to-severely diminished without any adventitial sounds. Pulmonary function tests reveal: forced expiratory volume in 1 second (FEV1) is 1.5 L (60% of predicted), forced vital capacity (FVC) is 2.3 L, and the FEV1/FVC ratio is 0.65. TLC is 5.25 L (125% predicted) and DLCO is 25 mmHg (56% predicted). Which of the following will be most effective for improving this patient's long-term survival? a) Smoking cessation b) Oxygen therapy c) Pulmonary rehabilitation d) Inhaled tiotropium e) Inhaled corticosteroids combined with long-acting beta-agonists

Topic Pulmonary Medicine Answer A. Smoking cessation Explanation Smoking is the single most preventable cause of lung disease, which accelerates the rate of lung function decline as compared to non-smokers. For those patients who are successful with smoking cessation, lung function decline as defined by FEV1 will approach the same rate as non-smokers after approximately one year. FEV1 severity is an independent predictor of mortality in patients with COPD, hence, smoking cessation is the best answer. Pharmacologic therapies have been shown to improve dyspnea scores, quality of life, and reduce exacerbations. However, they have not consistently shown an improvement in lung function or mortality. Pulmonary rehabilitation has been shown to have similar favorable outcomes as medications as well as improved exercise tolerance and skeletal muscle strength. Finally, oxygen has been shown to improve mortality in those patients who demonstrate resting, exertional, or nocturnal hypoxemia. This patient does not manifest any of these.

A 29-year-old woman is admitted to the hospital with a 1-week history of nonproductive cough, shortness of breath, and dyspnea on exertion. She is only able to walk a room's length before she needs to rest. Further symptoms include fever and chills. She has a known history of HIV disease and previous CD4+ cell count was 10 cells/µL ten months ago. She has otherwise been noncompliant with follow-up visits and has not been on any treatment for her HIV disease. On examination, the patient is in mild respiratory distress. Vital signs: T: 39.2° C, BP: 121/62, HR: 127, RR: 25, Pulse ox saturation: 88% on room air. She has a white exudate throughout the posterior oropharynx as well as on her tongue. Cardiovascular examination reveals tachycardia with regular rate and rhythm and no murmurs. Lung examination reveals diffuse crackles with poor air movement throughout. Labs reveal a normal WBC count and basic metabolic panel. Lactate dehydrogenase (LDH) is elevated by three times the normal range. Her P a O 2 is 60. Chest x-ray is below. Bronchoscopy with BAL is performed, and the results are pending. What is the best step in management for this patient? a) TMP/SMX and prednisone b) Vancomycin Amphotericin B c) Isoniazid, ethambutol, rifampin, and pyrazinamide d) Trimethoprim/sulfamethoxazole (TMP/SMX)

Topic Pulmonary Medicine Answer A. TMP/SMX and prednisone Explanation Based on the clinical presentation and findings on chest radiograph, this patient has P. jiroveci (formerly known as P. carinii ) pneumonia (PJP). Clinically, patients with HIV and PJP have a gradual onset of symptoms characterized by fever, cough, and progressive dyspnea. Other symptoms may include fatigue, chills, chest pain, and weight loss. Patients with PJP also tend to have diffusion abnormalities and hypoxemia, resulting in lower arterial oxygen saturations. The most common radiographic findings are diffuse bilateral alveolar or interstitial infiltrates. Occasionally findings will include pneumothorax, lobar or segmental infiltrates, cysts, nodules, or pleural effusions. PJP is an opportunistic infection in patients with AIDS when CD+ cell counts drop below 200 cells/µL. Additionally, LDH levels often are elevated but are nonspecific. TMP/SMX remains the initial drug of choice for treatment of PJP. Consensus guidelines recommend that HIV-infected patients with hypoxia be treated with adjunctive corticosteroids. Although the patient has signs suggestive of oral thrush, this is likely related to Candida , and amphotericin would not be indicated to treat this. Furthermore, fungal infections tend to be more nodular or cavitary in nature than the current patient. Although HIV-infected patients are at risk for Mycobacterium tuberculosis , for which four drug therapies would be indicated, this patient does not present with symptoms consistent with tuberculosis both radiographically and clinically. On the Board exam they will frequently give you scenarios in which a patient will present with shortness of breath and you have to discern the etiology. Some of their favorites include high-risk procedures/conditions for pulmonary embolism.

A 45-year-old woman who was diagnosed with influenza A last week presents today with a much worse cough and return of her fever. She was feeling better near the end of the week, but now, in the last 24 hours, has become acutely ill again. She says that she has pain in her left lower chest when she takes a deep breath. Before this influenza diagnosis, she has been healthy. PAST MEDICAL HISTORY: Negative Took amantadine for 5 days; finished 3 days ago SOCIAL HISTORY: Works as a bartender in local pub Doesn't drink; Doesn't smoke but exposed to second-hand all night long, 5 days a week FAMILY HISTORY: Noncontributory REVIEW OF SYSTEMS: Fevers to 103° F Chills Sore throat now resolved Body achiness is severe again PHYSICAL EXAMINATION: BP 110/70, P 80, RR 24, Temp 102° F Ill-appearing woman in moderate distress HEENT: PERRLA, EOMI TMs clear Throat slightly hyperemic Neck: Supple, no masses Heart: RRR without murmurs, rubs, or gallops Lungs: Diffuse crackles fairly localized to the left base Abdomen: Bowel sounds present; no hepatosplenomegaly Extremities: No cyanosis, clubbing, or edema LABORATORY: Pending Besides Streptococcus pneumoniae, which of the following organisms should you also consider in this patient? a) Staphylococcus aureus b) Haemophilus influenzae c) Mycoplasma pneumoniae d) Staphylococcus epidermidis e) Streptococcus pyogenes

Topic Pulmonary Medicine Answer A. Staphylococcus aureus Explanation She recently had influenza, a classic setting where staphylococcal pneumonia will occur. Streptococcus pneumoniae is still very common in these patients also. Influenza virus is known to both increase respiratory colonization by S. aureus and impair ciliary function (and therefore clearance of staphylococci). Influenza does not predispose a patient to any of the other answer options nearly as much as to S. aureus.

You are seeing a 50-year-old nurse who works at a local hospital. He has had annual tuberculin skin testing for 30 years. His last PPD a year ago was 7 mm. Today, he presents at 72 hours for reading of his PPD placed earlier in the week. He is healthy and denies any health problems, particularly no fevers, sweats, or weight loss. This is an employee health check, and therefore no physical exam or other information is obtainable. LABORATORY: PPD at 72 hours: 17 mm CXR: Normal Based on the data presented, which of the following is the most appropriate next step? a) Start INH 300 mg daily for 9 months. b) Repeat PPD in 2 weeks; if still positive then start therapy. c) No treatment because he is older than 35 years old. d) 4-drug therapy because he is high-risk by being in a hospital environment. e) Start INH 300 mg daily for 12 months.

Topic Pulmonary Medicine Answer A. Start INH 300 mg daily for 9 months. Explanation This nurse is a recent converter. He has had a 10-mm increase in 1 year's time. By definition, he should receive prophylaxis. His CXR is normal, and he has no signs or symptoms of tuberculosis; therefore, he does not need to be treated for active tuberculosis. 12 months of INH is no longer recommended for anyone, including HIV-infected patients! It is not reasonable to repeat the PPD in 2 weeks; he has a positive result, and it will not change with repeated testing.

A 70-year-old man with a history of working in a brickyard for 50 years presents for evaluation at his granddaughter's request. He has been retired for 10 years. He is still active and plays bingo at the local church every day. He usually wins about once a week. Members of his bingo group are around his age, and recently one of his contemporaries at the bingo hall was diagnosed with tuberculosis. Your patient has been healthy and has no complaints. He denies weight loss, cough, fevers, or night sweats. PAST MEDICAL HISTORY: Prostatic hypertrophy diagnosed 5 years ago; doing well currently HTN for 40 years MEDICATIONS: Propranolol 20 mg q day ECASA q day SOCIAL HISTORY: Widowed for 20 years Lives alone; still drives without difficulty Volunteers at local nursing home on occasion Never smoked; Doesn't drink alcohol FAMILY HISTORY: Mother died at age 80 of "old age" Father died at age 75 of stroke Brother alive, 68, healthy except HTN Sister died at age 50 of stroke REVIEW OF SYSTEMS: No sore throat No vision changes No chest pains No headaches Minor arthritis-type pain in knees in the early morning; better with movement GU symptoms much improved; no difficulty initiating urine stream PHYSICAL EXAMINATION: BP 130/69, P 66, RR 15, Temp 98.8° F Ht 6' 1", 190 lbs HEENT: PERRLA, EOMI TMs clear Throat clear Neck: Supple, no masses Heart: RRR without murmurs, rubs, or gallops Lungs: Coarse breath sounds but clear Abdomen: Bowel sounds present in all 4 quadrants, no hepatosplenomegaly, nontender Extremities: No cyanosis, clubbing, or edema GU: Normal male genitalia, no masses LABORATORY: CXR: Small nodules located in upper lobes; calcified hilar lymph nodes with "hilar eggshell calcification" PPD: 20 mm at 72 hours 3 induced sputum samples for AFB: All negative smears and cultures Based on these findings, which of the following is the most appropriate next step? a) Start INH prophylaxis. b) Initiate workup for asbestos-related disease process. c) Ignore +PPD in this 70-year-old man. Sputum tests are negative; therefore, it is unlikely he needs prophylaxis. d) Initiate 4-drug therapy for tuberculosis. e) Start treatment for silicosis.

Topic Pulmonary Medicine Answer A. Start INH prophylaxis. Explanation This patient has silicosis based on his history of working in a brickyard and the classic CXR findings of small nodules in the upper lobes that are calcified and the "hilar eggshell calcifications." There is no specific treatment for uncomplicated silicosis. The problem with silicosis, however, is that alveolar macrophages are made ineffective by the ingestion of silica; therefore, patients with silicosis are at increased risk of tuberculosis. Therefore, anytime a patient with known silicosis has a positive PPD, no matter what age or duration, he should be "prophylaxed" with INH. He has no evidence of active disease, and therefore treatment with 4-drug therapy is not indicated. Asbestosis more commonly involves the lower lobes, and his presentation does not warrant a big workup for this disease.

A 68-year-old woman is admitted to a nursing home, and one year later she develops a cough. Workup is implemented and she has a positive PPD. A CXR is done and shows a left apical infiltrate, and sputums are positive for acid-fast organisms. She is placed in immediate respiratory isolation. Which of the following do you recommend for your patient? a) Start INH, rifampin, PZA, and ethambutol. b) Further TB workup is necessary to determine what should be done. c) Start INH and rifampin. d) Await sensitivities to begin therapy. e) Start INH only.

Topic Pulmonary Medicine Answer A. Start INH, rifampin, PZA, and ethambutol. Explanation She has active tuberculosis and must receive 4-drug therapy. With CXR and positive sputum she does not need further workup. You will begin 4-drug therapy and await sensitivities. If the Mycobacterium tuberculosis is sensitive, then you can place her on 2-drug therapy.

A 25-year-old female presents to your office for initial evaluation of her asthma. She reports she was diagnosed with asthma 3 years ago. Her symptoms include daily cough that is nonproductive and seems to be worse at night. She has occasional wheezing and some dyspnea on exertion when exercising. She has been prescribed a short-acting beta-agonist that she uses 4-5 times daily with relief that lasts about 30-60 minutes. She has no other significant past medical history. Her sister also has asthma. She denies any smoking history. She has 2 dogs at home and has never had allergy testing. She has no symptoms of reflux. Which of the following is the next best step in management for this patient? a) Start a low-dose inhaled corticosteroid. b) Start a long-acting beta-agonist. c) Start once-daily oral leukotriene receptor antagonist. d) Continue current treatment regimen with short-acting beta-agonist. e) Start a proton pump inhibitor every night.

Topic Pulmonary Medicine Answer A. Start a low-dose inhaled corticosteroid. Explanation This patient has asthma that would be categorized as moderate persistent asthma, given the frequency of her symptoms, and needs further titration of her care. All patients with any category of persistent asthma should be started on maintenance therapy with the foundation of an inhaled corticosteroid. In this case, this is the best answer. Additional therapies, such as leukotriene receptor antagonists, should be added sequentially if adequate controls of symptoms are not achieved with an inhaled corticosteroid alone. A long-acting beta-agonist has been associated with a higher risk of death in patients with asthma, particularly if not administered along with an inhaled steroid. They should not be prescribed alone in patients with asthma. She has no symptoms consistent with GERD. Studies have shown that asthma control is not improved with the addition of proton pump inhibitors in those without specific reflux symptoms.

A 25-year-old asthmatic patient has a history of frequent exacerbations. On CXR, she frequently has lung infiltrates that migrate and do not seem to respond to antibiotic therapy. She is usually afebrile during these episodes, but it really sets off her asthma and she has a significant exacerbation. Usually, she has to be admitted to the hospital and placed on systemic steroids, with aggressive pulmonary management. PAST MEDICAL HISTORY: Asthma since early childhood; has never required mechanical ventilation Has 1 child, age 2; no problems during pregnancy MEDICATIONS: Albuterol prn Cromolyn sodium daily Zafirlukast daily SOCIAL HISTORY: A 3rd year medical student (considering a career in Radiology) Married and lives with husband and 2-year-old son FAMILY HISTORY: Mother 50 and healthy Father 50 and has hypertension No siblings REVIEW OF SYSTEMS: Occasional headache Stressed by 3rd year rotations PHYSICAL EXAMINATION: Well-developed, well-nourished woman in moderate respiratory distress BP 110/60, P 90, RR 30, Temp 98° F HEENT: PERRLA, EOMI TMs clear Throat clear Neck: Supple; no masses Heart: RRR without murmurs, rubs, or gallops Lungs: Scattered wheezes especially in upper lung fields Poor airway movement Few scattered crackles Abdomen: Bowel sounds present; no hepatosplenomegaly Extremities: No cyanosis, clubbing, or edema Skin: No rashes LABORATORY: WBC: 10,000 with 50% polys, 20% lymphs, 30% eosinophils Hgb: 13.5 mg/dL Platelets: 340,000 CXR: Scattered infiltrates throughout all lung fields Sputum: Normal flora on bacterial stain KOH is shown in this image: Branching yeasts Based on your findings, which of the following is the best treatment for her condition? a) Systemic corticosteroids and itraconazole b) Amphotericin B 1 mg/kg IV q day c) Fluconazole 200 mg bid x 1 day then once daily thereafter d) Itraconazole 200 mg bid x 3 days, then daily thereafter e) Amphotericin gargles with 5 mg in a 200 cc suspension

Topic Pulmonary Medicine Answer A. Systemic corticosteroids and itraconazole Explanation The key here is that she has allergic bronchopulmonary aspergillosis (ABPA). The standard therapy used to be steroids alone; however, recent data have shown that adding itraconazole to the steroid therapy is beneficial. If you see something fungal that is branching, it is likely Aspergillus, especially if there is "right-angle" or 90-degree branching. Amphotericin IV or as a gargle is inappropriate in this instance, and fluconazole has limited activity against Aspergillus.

An 18-year-old man comes to your office for follow-up examination. He has a known history of asthma since age 12. His PEF is 400 L/min (80% of personal best). He currently takes fluticasone 110 µg 2 puffs twice daily and uses an albuterol inhaler 3-4 times daily. He is compliant with his medications, but he still wakes up at night 3-4 times a week with coughing that is relieved with his albuterol inhaler. Which of the following is the best management option for this patient? a) No change in treatment and reassurance. b) Add a long-acting β-agonist such as salmeterol or formoterol to his fluticasone therapy. c) Prescribe prednisone 40 mg daily for 7 days. d) Start therapy with omalizumab. e) Prescribe azithromycin 500 mg daily for seven days.

Topic Pulmonary Medicine Answer B. Add a long-acting β-agonist such as salmeterol or formoterol to his fluticasone therapy. Explanation This patient has moderate, persistent asthma. Furthermore, the presence of nightly cough and frequent use of his rescue inhaler both support poorly controlled asthma. His maintenance regime should be augmented. Increasing the dose of his inhaled corticosteroid or adding a long-acting β-agonist are both acceptable treatment options. Systemic steroids such as prednisone are usually reserved for patients with acute exacerbations of asthma symptoms and PEFs below 50% of predicted. There is no evidence of an infection such as bacterial bronchitis, so the addition of azithromycin would not be helpful. Omalizumab, a monoclonal anti-IgE antibody, is currently the only approved anti-IgE therapy licensed in the United States for the prophylaxis of asthma exacerbations and control of symptoms in moderate to severe allergic asthma in patients ≥ 12 years of age. It is given as an add-on therapy to ICS in moderate to severe allergic asthma and has been shown to significantly reduce asthma exacerbations and allows doses of ICS to be reduced. It should be considered for those patients with poorly controlled disease despite the use of high-dose inhaled steroids and long-acting beta-agonists. This patient currently is only on a medium dose ICS.

A 40-year-old nurse presents with a PPD of 15 mm. A CXR reveals a cavitary lesion. Initial sputum reveals acid-fast organisms with cultures pending. She works and lives in rural Iowa where resistant tuberculosis has not been documented. Which of the following do you recommend for her? a) Because the risk of resistance is low, INH and RIF only are sufficient therapy. b) Begin 4-drug therapy with INH, RIF, PZA, and ethambutol. c) Begin 5-drug therapy with INH, RIF, PZA, ethambutol, and streptomycin. d) Do not start therapy until the cultures return with sensitivities. e) INH alone is sufficient therapy.

Topic Pulmonary Medicine Answer B. Begin 4-drug therapy with INH, RIF, PZA, and ethambutol. Explanation She has active tuberculosis and must be treated. In almost all areas of the U.S., 4-drug therapy is recommended for 2 months, followed by 2-drug therapy (INH, RIF) to finish 6 months of therapy. Much depends on the sensitivities as to whether more drugs are needed, but without a history of resistant organisms in the community, there is no need to add a 5th drug. INH alone is only used for treatment of latent tuberculosis, not active pulmonary disease. INH and RIF as initial therapy is incorrect based on current guidelines, which recommend 4-drug therapy for all until sensitivities return, even in areas of the U.S. with low risk of resistance to INH or RIF. You are presented a patient with asthma exacerbation. He is on beta-blocker medications after a recent myocardial infarction.

A 29-year-old female is 32-weeks pregnant with her first gestation. She presents to the emergency department with a 2-day history of acute shortness of breath and left-sided chest pain. She describes the pain as sharp, located in the mid axilla along the 6 th to 8 th rib location. She denies any recent trauma. She further denies any fevers, chills, syncope, cough, or sputum production. Her legs are swollen and have been progressively increasing in size over the last 4 weeks of her pregnancy, but they are equal in size and without erythema. Upon presentation her vitals: T: 99.1° F, P: 125 RR: 24 BP: 100/45 O 2 Sats: 92% on room air. She is without any respiratory distress. Her exam is notable for a regular tachycardia and a gravid uterus appropriate for stage of gestation. Lungs are clear to auscultation. She has 1+ lower extremity edema without any asymmetry. There is no sign of fetal distress. Chest radiograph is without any abnormalities, and EKG reveals a sinus tachycardia. Lower extremity venous Doppler ultrasound reveals an acute deep venous thrombosis in the left common femoral vein. Which of the following is the next best step in treatment? a) Stat C-section for emergent delivery. b) Begin unfractionated heparin by continuous infusion according to weight. c) Initiate aspirin therapy. d) Obtain a ventilation-perfusion scan. e) Initiate therapy with low molecular weight heparin at 1 mg/kg SQ q12 with concomitant warfarin therapy.

Topic Pulmonary Medicine Answer B. Begin unfractionated heparin by continuous infusion according to weight. Explanation This patient has developed a venous thrombolic event (VTE) related to her pregnancy. At the minimum, she has a deep venous thrombosis, and her signs and symptoms also suggest a pulmonary embolus. She will require treatment for her VTE with either unfractionated heparin or low-molecular-weight heparin. Although further imaging to exclude a pulmonary embolus would be helpful, this should not delay the initiation of anticoagulation therapy. Furthermore, the best study to evaluate for pulmonary embolus is chest CT angiogram, even in the setting of pregnancy. Aspirin therapy alone is not adequate treatment for VTE. Warfarin is contraindicated in pregnant patients due to its significant teratogenic properties. There are no signs of fetal distress, and the fetus is not yet at term; so emergent C-section would not be indicated.

A 50-year-old school teacher presents with concerns about asbestos exposure. He has been in a school that has recently been closed because of concerns of asbestos. Which of the following manifestations of asbestos-induced lung disease has the shortest latency period of occurrence? a) Diffuse pleural effusions b) Benign asbestos pleural effusions c) Asbestosis d) Localized pleural effusions e) Mesothelioma

Topic Pulmonary Medicine Answer B. Benign asbestos pleural effusions Explanation These appear to be immune mediated in character and have a relatively short latency period of 5-10 years. The other choices require much longer to show up, sometimes 20-30 years or more.

A 45-year-old man presents to your office with a 2-month history of exertional dyspnea and nonproductive cough. There is no history of wheezing or prior asthma. He smoked in his early 20s but now limits himself to an occasional cigar. There is no history of chest pain, and he has a copy of an ECG done for a recent insurance physical that was normal. He works in an office with no known occupational exposure, and he is on no prescription medications. On exam, he is a well-developed male in no apparent distress. He has no adenopathy. The cardiovascular exam is normal. On examination of the chest, you note late inspiratory crackles at the bases. He has no clubbing, cyanosis, or edema. LABORATORY STUDIES: Hematocrit 45%; hemoglobin 15 g/dL CXR-PA and lateral: Increased interstitial markings at the bases ABG: pH 7.45, pCO2 36 mmHg, pO2 70 mmHg on room air You send him for full PFT testing, and this is consistent with restrictive lung disease. Various serologic markers are sent for systemic disease and are negative. Which of the following is the appropriate next step in this patient's workup? a) Ventilation-perfusion scan. b) Bronchoalveolar lavage and/or transbronchial lung biopsy. c) CT angiography of the lung. d) Open-lung biopsy and resection of diseased lung. e) Follow serial pulmonary function tests at a PFT lab, which would include a determination of his total lung capacity (TLC) and diffusing capacity (DLCO).

Topic Pulmonary Medicine Answer B. Bronchoalveolar lavage and/or transbronchial lung biopsy. Explanation This patient has an interstitial lung disease with restricted lung volumes and a reduced diffusing capacity; and it may worsen without definitive diagnosis and treatment. Serial PFTs would merely provide confirmation of what you already suspect. You need to know which ILD the patient has and how to stage it in terms of activity to decide on treatment options. Some would begin with bronchoalveolar lavage with transbronchial lung biopsy in the right clinical scenario. If this is negative, then a high-resolution CT could be performed, or some would just proceed to a HRCT and the definitive open lung biopsy. The yield on transbronchial biopsy is very good for some etiologies (particularly sarcoid or infectious etiologies). However, in order to provide an adequate tissue sample for examination, an open-lung biopsy (traditional or thorascopic) is often required. This is not consistent with pulmonary embolism, and V/Q scanning or CT angiography are not indicated. Open-lung biopsy certainly could be considered, but you would not resect all of the areas of "diseased lung" without a known diagnosis or reason.

A 42-year-old woman with a history of end-stage renal disease on hemodialysis presents to the emergency department with fever of 103° F, shaking chills, hypotension 70/50, tachypneic, and tachycardic. Her dialysis graft site is erythematous, warm to the touch, and has purulent drainage at a prior access site. A diagnosis of septic shock is made, and the patient is given intravenous antibiotics, IV fluids, and arrangements are made to transfer the patient to the ICU with a vascular surgery consult to remove the hemodialysis graft. The intensivist meets the patient in the emergency department and immediately places a Swan-Ganz catheter out of concern of volume overloading this patient with end-stage renal disease and now a non-functioning dialysis catheter. The initial hemodynamic profile for this patient would most resemble which of the following? a) Cardiac Output L/min: Low; Systemic Vascular Resistance dynes-sec/cm5: High; Wedge Pressure mmHg: Normal/Low b) Cardiac Output L/min: High; Systemic Vascular Resistance dynes-sec/cm5: Low; Wedge Pressure mmHg: Low c) Cardiac output L/min: Low; Systemic Vascular Resistance dynes-sec/cm5: High; Wedge Pressure mmHg: Low d) Cardiac Output L/min: Low; Systemic Vascular Resistance dynes-sec/cm5: High; Wedge Pressure mmHg: High

Topic Pulmonary Medicine Answer B. Cardiac Output L/min: High; Systemic Vascular Resistance dynes-sec/cm5: Low; Wedge Pressure mmHg: Low Explanation Utilizing a Swan-Ganz catheter to generate a hemodynamic profile of shock, such as in this case, is a reasonable question for the exam. They may even throw in more data such as pulmonary artery pressure, mixed venous oxygen saturation, and even left ventricular stroke volume to foul you up. Stick to the parameters above and you should be able to narrow down the answer sufficiently. Remember: The hallmark of early, "warm" sepsis is a hyperdynamic heart (increased cardiac output) coupled with a very low systemic vascular resistance. Typically the patient in early septic shock is volume depleted and "third spacing" a considerable amount of the fluids given for resuscitation due to the low systemic vascular resistance. In all the other options listed, the systemic vascular resistance is high because it is the only thing holding the blood pressure together! Volume depletion due to hypovolemic shock (whether hemorrhagic or intravascular) is characterized by a low wedge pressure, a reduced cardiac output, and a high SVR. Cardiogenic shock is defined by a low cardiac output, high-filling pressures (think CHF), and a high SVR. Obstructive shock is typified by a massive PE or a tension pneumothorax. There is reduced cardiac filling, reduced cardiac output, and a high SVR. In pericardial tamponade, the filling pressures will be normal as a reduced volume is acted on by a decreased compliance of the ventricular wall.

A 36-year-old woman has had increasing dyspnea for 8 years. She has no cough or increased sputum production. No smoking history. On physical exam, there is hyperresonance to percussion in the bases. A chest radiograph reveals increased lung volumes with flattening of the diaphragmatic leaves bilaterally. Which of the following laboratory findings is she most likely to have? a) Elevated serum iron stores b) Decreased alpha-1-antitrypsin c) Increased sweat chloride d) Decreased ceruloplasmin e) Positive methacholine challenge test

Topic Pulmonary Medicine Answer B. Decreased alpha-1-antitrypsin Explanation The illness script is consistent with obstructive pulmonary disease, specifically emphysema: dyspnea with hyperresonance in the bases and objective evidence of increased lung volumes and diaphragm flattening on radiograph. The most likely cause of emphysema in a young woman this age with no history of tobacco smoking is alpha-1-antitrypsin deficiency. The methacholine challenge test is used to diagnose patients with suspected asthma who have normal pulmonary function studies. This case does not describe asthma, because asthmatic symptoms are reversible, and this clinical presentation is one of chronic obstruction. Elevated serum iron stores are seen in hemochromatosis that does not directly affect the lungs. Decreased ceruloplasmin levels are associated with Wilson disease and have also been observed in research studies evaluating cigarette smokers and neonates with hyaline membrane disease. The sweat chloride test is used to diagnose cystic fibrosis that presents differently.

A 32-year-old female presents to your office complaining of wheezing for 2 weeks. At her last appointment 6 weeks ago, she was noted to have intentionally lost weight through an exercise program, and she requested to be taken off two of her medications, cimetidine and acyclovir. She was in a good state of health until developing cold symptoms two weeks ago, and since then, she has wheezed daily. She denies tobacco, drugs, or alcohol. She has not had any fever. The cold symptoms have since resolved. PMH: Asthma since childhood, previously stable x 5 years on her current regimen GERD Genital herpes Meds: theophylline, cimetidine (discontinued), acyclovir (discontinued), beclomethasone high-dose bid, salmeterol bid, montelukast qd, albuterol PRN At her last appointment, her theophylline level was 17 mg/dL (therapeutic range: 10-20 mg/dL) Which of the following is the most likely cause of her persistent wheezing? a) Antagonistic drug interaction between theophylline and montelukast b) Decreased serum theophylline concentration c) Undiagnosed Bordetella pertussis d) Tachyphylaxis to salmeterol e) Underlying interstitial lung disease

Topic Pulmonary Medicine Answer B. Decreased serum theophylline concentration Explanation This patient has severe asthma that is controlled on multiple modalities of therapy until such time as some of her ancillary meds are discontinued. Recall that both cimetidine and acyclovir increase theophylline levels; therefore, when the drugs are discontinued, the theophylline is metabolized faster, and levels in the serum decrease. The lower level may have precipitated an asthma attack, especially after the patient developed an upper respiratory infection. Tachyphylaxis to salmeterol does not occur, nor is there an antagonistic drug interaction between theophylline and montelukast. B. pertussis presents as a chronic cough lasting for weeks in adults after an initial upper respiratory presentation. Undiagnosed pertussis could be a factor here, but it is not the most likely explanation for her new wheezing. An undiagnosed interstitial lung process is also less likely given the recent changes in her medications and the resulting change in her theophylline levels.

A 35-year-old woman presents complaining of dyspnea with exertion since delivering her baby 6 months earlier. She is a nonsmoker. Her recent pregnancy and delivery were uncomplicated. She owns a parakeet. Her family history is significant for Factor V Leiden gene mutation and venous thromboembolic events in several family members. PE: Afebrile, BP 122/76, HR 82, RR 12, BMI 31 Well-nourished female in no respiratory distress Distant breath sounds and trace edema in both feet and otherwise normal exam ECG: Nonspecific T-wave changes, leads V4-V6 CXR: Normal ABG: pH 7.45, pCO 2 48, pO 2 76 D-dimer: Normal range Which of the following is the most likely diagnosis? a) Acute pulmonary embolism b) Dyspnea due to obesity c) Amniotic fluid embolus d) Hypersensitivity pneumonitis e) Primary pulmonary hypertension

Topic Pulmonary Medicine Answer B. Dyspnea due to obesity Explanation The patient in this case has two epidemiologic risk factors for pulmonary embolism (recent pregnancy, which can exacerbate an inherited thrombophilia and a familial Factor V Leiden mutation). You would be correct to worry that her dyspnea is related to a pulmonary embolism. But look at her BMI: It's 31. This is very important because sometimes the Boards will sneak obese patients by you by showing you only their BMI and not stating that they are "obese." Her blood gas is normal, as is her D-dimer. Her calculated A-a gradient is 14 mmHg (normal). 150 - (48 x 1.25) = 90 90 - 76 = 14 So all is well at her alveolar-capillary unit. The combination of her obesity, normal A-a gradient, and normal D-dimer suggests an alternative cause for her dyspnea. She has no physical exam findings to support primary pulmonary hypertension. A normal A-a gradient and a stable patient help to exclude an amniotic fluid embolus (and most amniotic fluid emboli occur during pregnancy or shortly after delivery). Hypersensitivity pneumonitis is associated with recurrent symptomatic pneumonias—conspicuously absent from her history, in spite of her bird ownership. (Don't select hypersensitivity pneumonitis just because she owns a bird! You need to carefully examine the situation to make sure that diagnosis fits.) Obesity is the only option that is supported by the clinical data.

A 55-year-old woman presents to your office for evaluation of dyspnea. She has no cough or chest pain and complains of shortness of breath with exertion only. No nocturnal symptoms. She has occasional episodes of near syncope but no palpitations. Chest radiograph doesn't reveal any abnormalities. Pulmonary function tests are ordered. Actual Predicted % FVC (L) 4.88 122 FEV1 (L) 3.09 126 FEV1/FVC .63 82 TLC (L) 6.17 107 RV (L) 1.41 81 DLCO 12 50 Based on her DLCO result, which of the following is unlikely? a) Pulmonary embolus b) Erythrocytosis c) Anemia d) Pulmonary arterial hypertension e) Emphysema

Topic Pulmonary Medicine Answer B. Erythrocytosis Explanation The diffusion capacity of carbon monoxide measures the ability of the lung to transfer and exchange gas. During testing, the patient fully exhales then inhales a gas mixture with CO. After a 10 s breath hold, rapid exhalation is done and the amount of gas is analyzed to determine the amount transferred. Disruption of the alveolar-capillary surface reduces the DLCO, which occurs in emphysema, interstitial inflammation and fibrosis, edema, and infections. In addition, reduced capillary lung volumes as occurs in pulmonary hypertension and pulmonary embolism also decrease the DLCO. Due to decreased hemoglobin, the DLCO will be low if not corrected for anemia. Elevation in hemoglobin will increase the carrying capacity of oxygen and carbon monoxide, thus increasing gas exchange and increasing the DLCO.

A 35-year-old Caucasian male with chronic lung disease of unknown etiology at this point presents for follow-up care. He has had episodes of sinusitis, bronchiectasis, and pancreatic insufficiency for at least 30 years. He has had recurrent pneumonias over the last 10 years. Usually, his pneumonias are associated with pseudomonal infections. PAST MEDICAL HISTORY: As above FAMILY HISTORY: Older brother with similar complaints Mother healthy Father healthy, of Scandinavian ancestry patient has 2 sons, both healthy SOCIAL HISTORY: Works as a used car salesman Doesn't smoke Doesn't drink REVIEW OF SYSTEMS: Frequent colds Frequent sinus infections Frequent bloody noses because of increased blowing of nose Chronic cough PHYSICAL EXAMINATION: BP 120/70, RR 18, Temp 98.5° F, P 90 HEENT: Nasal polyps; PERRLA, EOMI Throat: Normal tonsils Neck: Supple, no masses Heart: RRR without murmurs, rubs, or gallops Lungs: Coarse breath sounds; occasional expiratory wheeze anteriorly and posteriorly Abdomen: No HSM, nontender Extremities: Clubbing present, no cyanosis GU: Normal male genitalia; no masses Based on the history and physical exam, which of the following does not support the diagnosis of cystic fibrosis? a) Clubbing b) Family history c) Nasal polyps d) Recurrent sinusitis e) Recurrent pneumonias

Topic Pulmonary Medicine Answer B. Family history Explanation It would be exceedingly unusual for a male patient with cystic fibrosis (CF) to have children. The rest of the findings are consistent with CF. Remember that this gene is encoded on chromosome 7. It causes a defect in sodium and chloride transport channels in lungs particularly, but also in other organs.

A 75-year-old Caucasian male with recent fracture of his right femur 3 hours ago presents by ambulance and is seen by an orthopedist, who places him in a cast and admits him for observation. Three hours later, you are called by the doctor because his patient is now short of breath and confused. He thinks the patient might have pneumonia because he is breathing fast. He is consulting you for antibiotic choices. You tell him you will take over the care for the respiratory disorder. On evaluation, you find a disheveled elderly man lying in the bed in traction. He is having some difficulty breathing. He has supplemental oxygen with a 40% FiO2 facemask that is keeping his pulse oximetry at 95%. He is unable to answer any questions due to his dyspnea, and he is also quite confused. Eventually, he says the year is 1960 and that you are his 5th grade school teacher. PHYSICAL EXAMINATION: BP 130/70, P 99,Temp 99° F, RR 24 HEENT: PERRLA, EOMI; conjunctival petechiae TMs clear Throat clear Neck: Supple, no masses; petechiae on neck Heart: RRR without murmurs, rubs, or gallops Lungs: Coarse breath sounds; few basilar scattered crackles Abdomen: Bowel sounds present; no hepatosplenomegaly Extremities: No cyanosis, clubbing, some edema on the fractured leg at the ankle; exam of fractured extremity limited but neuro-vasculature looks to be grossly intact LABORATORY: Pending Based on the history and physical findings, which of the following is the most likely diagnosis? a) Cerebrovascular accident b) Fat embolism c) Drug toxicity d) Hospital psychosis e) Aspiration pneumonia

Topic Pulmonary Medicine Answer B. Fat embolism Explanation Based on the findings of dyspnea, confusion, and petechiae (particularly neck, conjunctiva, and axilla [not described in this patient]), you can make the diagnosis of fat emboli in the setting of a recent large bone fracture. Fat emboli can also occur after aggressive CPR and with sickle cell bone occlusive crisis. The other answer options do not cause this combination of findings. Treatment is supportive; unless the patient has secondary ARDS, steroids have not proven of benefit. We don't give you a lot of lab values here, and you shouldn't need them at this point. Again, the triad of dyspnea, confusion, and petechiae in the setting of recent fracture ... think of fat embolism!

A 72-year-old male who is a nursing home resident is brought to the emergency department due to fever to 39.1° C. Upon presentation, he is noted to have a heart rate of 125 and a blood pressure of 75/42. Urinalysis reveals many WBCs, and many bacteria and cultures are drawn. He appears to be in moderate distress and has moderate diffuse abdominal pain. He is fairly lethargic and barely arouses to verbal or painful stimuli. Initial labs drawn reveal a lactate level of 4.2, WBC of 23.5, and Hgb of 10.4. Which of the following would not be indicated in the treatment of this patient? a) Early initiation of empiric antibiotics Initiation of drotrecogin alfa (activated) by continuous IV infusion for 96 hours b) Admission to the intensive care unit c) Delivery of crystalloid fluid to target a central venous pressure of 8-12 mmHg d) Placement of a central venous catheter

Topic Pulmonary Medicine Answer B. Initiation of drotrecogin alfa (activated) by continuous IV infusion for 96 hours Explanation This is an example of a patient with septic shock with evidence of hypotension and organ hypoperfusion with an elevated lactate level. Early initiation of treatment is important with clear evidence of benefit for certain interventions. The early initiation of targeted empiric antibiotics has been shown to improve mortality. Maintenance of organ perfusion is vital to prevent end organ ischemia and failure. Placement of a central venous catheter can assist with the delivery of intravenous fluids, antibiotics, blood products, and vasopressors if indicated. Furthermore, estimates of intravascular filling pressures can be obtained from properly placed central venous catheters. Early goal-directed therapy in severe sepsis has been a protocol that has shown mortality benefit. This includes initial crystalloid infusion for goal CVP to 8-12 mmHg. If the patient remains hypotensive despite this, then vasopressors should be initiated. Admission to an intensive care unit would be appropriate given the evidence of septic shock. Drotrecogin alfa is a recombinant form of human activated protein C that has antithrombotic, antiinflammatory, and profibrinolytic properties. Initial studies suggested that there was some mortality benefit in patients with very severe sepsis. However, subsequent studies have not shown efficacy in the setting of the sepsis syndrome and the manufacturer has now withdrawn this medication from the market.

Which of the following agents would be useful in an acute exacerbation to improve bronchodilation quickly? a) Albuterol b) Ipratropium c) Epinephrine d) Cromolyn sodium e) Prednisone

Topic Pulmonary Medicine Answer B. Ipratropium Explanation Ipratropium is the only agent that will bronchodilate effectively in the face of chronic beta-blockade. Cromolyn sodium does not work acutely. Epinephrine and albuterol would have their effects blunted by the beta-blockade. Prednisone would also not be helpful acutely.

A 38-year-old man presents with an acute asthma attack. He has been feeling bad for a few days. This morning he awakened and could not breathe. When you see him in the emergency department, he is anxious and cannot talk because of his discomfort. You realize that you have to act quickly and note in his chart that he has had to be ventilated 3 times in the past for severe asthma exacerbations. PAST MEDICAL HISTORY: As above Most recent hospitalization was 1 year ago at another hospital Has been on an inhaled medium-dose steroid, an inhaled long-acting beta2-agonist, and zafirlukast SOCIAL HISTORY: Works as a puppet maker Lives with his friend FAMILY HISTORY: Mother with severe asthma Father with coronary artery disease REVIEW OF SYSTEMS: Deferred for the moment—he is about to crash! PHYSICAL EXAMINATION: BP 150/95, RR 40 with shallow breaths and marked accessory muscle use, P 120 HEENT: Cyanotic around his lips Heart: RRR without murmurs, rubs, or gallops Lungs: Faint squeaks is all you hear Abdomen: Benign LABORATORY: ABG: pH 7.06 pCO2 90 PaO2 55 Oxygen saturation 84% On 100% FiO2 You realize that you are not going to be able to ventilate him effectively without putting him on mechanical ventilation. Which of the following ventilator settings are appropriate for a severely ill asthmatic patient? a) Low rate, high tidal volume, high flows b) Low rate, small tidal volume, high flows c) Low rate, high tidal volume, low flows d) High rate, small tidal volume, high flows e) High rate, high tidal volume, low flows

Topic Pulmonary Medicine Answer B. Low rate, small tidal volume, high flows Explanation When ventilating an asthmatic patient, the idea of "permissive hypercapnia" is important to remember. Focus on getting the oxygen saturation up and don't worry as much about the pCO2. Each of the factors (low rate, small tidal volume, high flows) addresses the need for a prolonged expiratory phase. High flow on the inspiration allows for less time devoted to inspiration and more time to expiration. So, based on the idea of "permissive hypercapnia," it makes sense to have a lower rate and smaller tidal volume.

An 81-year-old female has severe emphysema with severe dyspnea on exertion. She is on 4 L oxygen continuously. She has difficulty with performing her activities of daily living (ADLs). She uses an inhaled long-acting anticholinergic, an inhaled long-acting beta-agonist/inhaled steroid combination, and oral theophylline. She has been to pulmonary rehabilitation. She asks your opinion about surgical options for her COPD. Which of the following is true? Lung volume reduction surgery has been shown to increase mortality in all patients who undergo the procedure. Lung volume reduction surgery improves outcomes in patients with predominantly upper-lobe disease and very low exercise capacity. This patient should be considered for lung transplantation. Lung volume reduction surgery has been shown to decrease mortality in all patients who undergo the procedure.

Topic Pulmonary Medicine Answer B. Lung volume reduction surgery improves outcomes in patients with predominantly upper-lobe disease and very low exercise capacity. Explanation Surgical options are available for patients with emphysema. However, outcomes are variable and depend on the patient's underlying condition. Transplantation is available for emphysema; however, most centers set the age limit at < 75 years of age, and this patient is unlikely to be eligible. Lung volume reduction surgery (LVRS) involves removal of diseased portions of emphysematous lungs, particularly large bullous regions. In a large multicenter randomized controlled trial, overall 90-day mortality was increased for those who underwent surgery as compared to those who did not. However, subset analysis did reveal improved functional outcomes and survival in those patients with predominantly upper-lobe disease and very low exercise capacity. At present, LVRS is only recommended for this patient population with emphysema.

A 65-year-old male comes to the emergency department with increasing respiratory distress over the past 2 days. He is a smoker and has known COPD, for which he has been hospitalized twice in the past year for exacerbations. The patient appears cyanotic, is in moderate distress utilizing accessory musculature, and is perched forward sitting on the stretcher. He is alert and reports feeling "better" since getting to the emergency department. Lung sounds are quite diminished in all lung fields, and an ABG on room air shows pH 7.30, pCO2 63 mmHg, and a pO2 of 44 mmHg. The respiratory therapist is awaiting your orders. Your orders for initial oxygen therapy should be which of the following? a) O2 100% by non-rebreather face mask with continuous pulse oximetry. b) Nasal oxygen, 1-2 L/min with follow-up ABG in 20 minutes. Increase oxygen flow based on the ABG to a pO2 of 55-60 mmHg. c) Institute BiPAP therapy because patient is already showing signs of inspiratory fatigue and respiratory acidosis. d) Nasal oxygen initially, 3-4 L/min with pulse oximetry to achieve a saturation of 92% or greater. e) Withhold oxygen therapy at this time since patient is stable and you do not want to induce further respiratory acidosis. f) Intubate the patient and place on mechanical ventilation with an initial FiO2 of 100%.

Topic Pulmonary Medicine Answer B. Nasal oxygen, 1-2 L/min with follow-up ABG in 20 minutes. Increase oxygen flow based on the ABG to a pO2 of 55-60 mmHg. Explanation Imperative treatment is to provide this patient with supplemental oxygen to achieve a hemoglobin saturation of 88-90%. This is to prevent further hypoxemia, which can cause cardiac arrhythmias and acute cor pulmonale. Oxygen supplementation may result in worsening respiratory acidosis. (HINT: not through reduction in respiratory drive—COPD patients are just like the rest of us in that our chemiotaxic centers for the control of ventilation are CO2 sensitive, not O2 driven!) Worsening respiratory acidosis can be detected only by ABGs, not pulse oximetry. If providing supplemental FiO2 to achieve an oxygen saturation of 88-90% results in severe respiratory acidosis, then positive pressure ventilation via noninvasive methods or conventional ventilation must be considered.

A 51-year-old female presents in an outpatient clinic with a new onset of a rash on her back and chest. This rash began about 2-3 months ago. Initially, she thought it was some form of fungal infection or allergic reaction and applied a 1% hydrocortisone cream without much benefit. The rash was not particularly itchy. At the same time, she had begun to develop some pain in her shoulders and hips but no early morning stiffness and no swelling of the joints of her fingers or toes. At age 16, she had presented with unexplained painful nodules on her lower extremities, but the cause of this was never fully understood and she has never had any recurrence. During her second normal pregnancy, she developed a weakness of one side of her face and was told that she had a Bell's palsy. Her facial expression returned to normal fairly soon after the birth of her child. Her internist had been concerned because he had found mild elevations of her calcium levels 3 years ago and again 6 months ago, but these have normalized on their own. There was no particular explanation found for this at that time. On examination, she was well appearing. Height was 5' 7", weight was 136, BP was 127/76, and pulse was 72. Cardiac and respiratory exams were benign. The abdomen was without hepatosplenomegaly. Musculoskeletal exam revealed no joint synovitis. Neurological exam was normal without any proximal myopathy. Cutaneous exam revealed several circumscribed, somewhat elevated, 2 x 2 coin-sized lesions on her chest and back. Her dermatologist suggested a biopsy. Which of the following is the most likely pathological finding that could be obtained from the skin biopsy of one of these coin lesions? a) Panniculitis b) Non-caseating granulomatous inflammatory changes c) Interface dermatitis d) Eosinophilic fasciitis

Topic Pulmonary Medicine Answer B. Non-caseating granulomatous inflammatory changes Explanation She has multi-organ involvement to suggest the diagnosis of sarcoidosis. The initial lesions on her legs were probably those of erythema nodosum. A biopsy would have found a probable panniculitis at that time. Hypercalcemia, facial nerve palsy, and cutaneous involvement are, again, typical. ACE levels may be elevated, but not always. A chest x-ray would probably be appropriate as part of her workup. Non-caseating granulomas are charactertistic of sarcoidosis.

A 42-year-old female complains of exertional dyspnea for about 2 years that seems to be gradually progressing. She now has difficulty doing simple household chores without dyspnea. She has no associated cough, sputum, fever, chills, or wheezing. She has occasional episodes of feeling lightheaded with exercise but no palpitations. She has no significant past medical history and takes no medications except for a multivitamin. She is a lifelong nonsmoker. Physical exam reveals normal vitals except a resting oxygen saturation of 89%. Lungs are without abnormal sounds. Cardiovascular exam reveals a 2/6 holosystolic murmur at the left midsternal border, an RV impulse at the left sternal border, and A2 and P2 sounds that are equal in intensity. Pulmonary function tests only reveal a reduced DLCO, which is 45% predicted. Chest radiograph is normal. Echocardiogram reveals normal left ventricular function but is notable for right atrial and ventricular dilatation, 3+ tricuspid regurgitation, and an estimated pulmonary artery systolic pressure of 84 mmHg. Right heart catheterization is performed, which estimated the mean pulmonary artery pressure to be elevated at 55 mmHg. Pulmonary capillary wedge pressure is normal. Chest angiogram is without pulmonary embolus. Serologic testing for connective tissue disease is all negative. Which of the following is not currently used for treatment in patients with this clinical entity? a) Subcutaneous prostacyclin therapy b) Oral cyclophosphamide daily c) Oral endothelin receptor antagonist d) Oxygen therapy e) Warfarin

Topic Pulmonary Medicine Answer B. Oral cyclophosphamide daily Explanation The patient in this scenario has a diagnosis of pulmonary arterial hypertension (PAH). Based on the information given, this is likely idiopathic primary pulmonary hypertension. Her exam findings are quite typical, and the echocardiogram is also indicative. Right heart catheterization, however, is the gold standard for making the diagnosis and assessing the degree of severity. Multiple studies have shown survival benefits in patients with PAH given warfarin. Oxygen improves exercise capacity and symptoms in patients with hypoxemia. Specific medications for PAH include calcium channel blockers (in patients with a positive vasodilator challenge), oral endothelin receptor antagonists, phosphodiesterase inhibitors, and prostacyclin analogues. This final category has been administered in inhaled, subcutaneous, and intravenous formulations. Cyclophosphamide has not been evaluated nor is it approved for use in PAH. Note that "not" questions will not usually appear on Boards; however, we occasionally use them for teaching purposes because essentially in 1 question we have provided you with 4 correct answers that you could be asked on the Boards about the treatment of PAH.

A 60-year-old male patient is found to have a 4 cm lung mass in his right upper lobe on CXR. CT scan confirms that it is suspicious for malignancy, but there are no other lesions or significant adenopathy. Bullous lung disease is noted in the apices, particularly on the right. A fine needle aspiration of the mass reveals non-small cell carcinoma. A thoracic surgery consult is requested, but the surgeon refers him back to you for pre-op clearance. The patient has a history of asthma and admits to at least a 30 pack/year history smoking, though he has cut back to "a few a day." He reports that he uses his beta-agonist inhaler only once or twice a week because it only makes him cough. On physical exam, he is well appearing except for a limp in his right leg. His respiratory rate is 16/minute. Examination of the chest is normal with only a few scattered end-expiratory wheezes. The remainder of the physical examination is unremarkable. Pulmonary function tests (with bronchodilators held prior to testing) reveal an obstructive pattern with FEV1 of 1.6 liters. There is minimal response to bronchodilators in the lab. ABG on room air show pH 7.41, PaCO2 38, and PaO2 of 87. In addition to initiating a smoking-cessation program, which of the following do you recommend? a) Refer him for a pulmonary consultation. b) Order a quantitative ventilation scan. c) Refer him to an oncologist for non-surgical treatment of his tumor. d) Start inhaled steroids and repeat PFT in 4 months.

Topic Pulmonary Medicine Answer B. Order a quantitative ventilation scan. Explanation The only cure for lung cancer is a surgical resection. As such, we strive to make any patient a surgical candidate. This patient's pre-op PFTs show an FEV1 less than 2.0 liters—the traditional cutoff for surgical candidates. Smoking cessation, inhaled steroids, and further intervention from a pulmonologist may improve his FEV1, but at the risk of delaying the curative procedure. Therefore, since there are asymmetrical bullae on the CT scan, it is likely that the ventilation scan will show less ventilation to the right lung, and a quantitative assessment would allow even a right pneumonectomy.

A 50-year-old male patient is brought to your office at his wife's insistence. You have seen him in the past for borderline hypertension, but when you last saw him 2 years ago, he was on no medications. His wife has insisted that he come today because she says that he is always sleeping. She adds that he fell asleep parking the new car in the driveway and crashed through the garage wall. She states that his snoring has gotten so bad that she has moved to another bedroom. The patient admits to being even sleepier during the daytime, though he thinks that he gets a good night's sleep. He knows he snores, but it doesn't bother him. He admits to waking up tired and often with morning headaches. He is concerned about his performance at work, where he sometimes operates heavy equipment. He denies that he is depressed and states that he doesn't use drugs or alcohol. On physical exam, you note that he has gained 20 lbs since his visit 2 years ago and that he now weighs 230 lbs. He is 5' 8". Blood pressure on repeated measurement is 170/105. On examination of his throat, you notice for the first time his large uvula. Cardiopulmonary as well as neurological exams are within normal limits. Which of the following would you recommend? a) Recommend an initial trial of acetazolamide and theophylline before more invasive testing is performed. b) Order polysomnography with trial of nasal continuous positive airway pressure (CPAP). c) Ear, nose, and throat consultation for uvulopalatopharyngoplasty. d) Order polysomnography. e) Advise weight loss, exercise regimen, and follow-up visit in 1 month.

Topic Pulmonary Medicine Answer B. Order polysomnography with trial of nasal continuous positive airway pressure (CPAP). Explanation The probability of this patient having serious obstructive sleep apnea is high. Therefore, a "split-study" polysomnography should be ordered such that the technician performing the study can analyze the results during the first part of the study and institute a trial of nasal CPAP if the preliminary result is unequivocally positive for serious obstructive sleep apnea (greater than 15 significant apnea/hypopnea events per hour). In this way, a patient can be started on nocturnal nasal CPAP as soon as possible. While weight loss, alcohol avoidance, and exercise are important instructions, it is unlikely that these measures alone will work in the short term in this patient. Uvulopalatopharyngoplasty is an alternative treatment for obstructive sleep apnea, but the results to date are inferior to CPAP. Theophylline and acetazolamide have not been shown in clinical trials to be beneficial.

A 16-year-old male presents to your office with complaints of wheezing on exertion. He has recently started cross-country track and notes wheezing at the height of his exercise that often remains for several hours after activity. He has tried his friend's asthma inhaler but can't tell if it helps. He denies smoking. PMH: Good health except for prolonged ICU stay for Guillain-Barré syndrome at age 12. Normal physical exam. Which of the following is the most appropriate course of action? a) Prescribe cromolyn sodium as prophylaxis for exercise-induced asthma. b) Perform PFTs with a flow-volume loop. c) Perform fluoroscopy of the diaphragm to document residual paralysis. d) Prescribe a short-acting beta-agonist before starting exercise.

Topic Pulmonary Medicine Answer B. Perform PFTs with a flow-volume loop. Explanation This young patient has an illness script consistent with asthma: reversible airway obstruction during exercise. The first step in diagnosis of asthma is to document reversibility of the obstruction with pulmonary function studies. Some form of pulmonary function testing should always be your first step in diagnosing asthma. The methacholine challenge is used to diagnose asthma in asymptomatic patients with normal spirometry but is not 100% sensitive; therefore, usually most recommend exercising the patient and then seeing if they have a fall in FEV 1 (this was not one of the choices here but would be a good alternative in someone with classic symptoms of EIB—which his symptoms are not classic). He could have exercise-induced bronchospasm (EIB), but he complains of wheezing that begins during exercise and is prolonged. EIB usually is associated with bronchodilation during exercise and bronchoconstriction after, such that patients complain of post-exercise coughing and/or wheezing. Usually, EIB symptoms will resolve within 15-60 minutes. He could have an upper airway fixed obstruction or some form of diaphragm paralysis as a result of Guillain-Barré, but most cases of Guillain-Barré recover completely. And this patient functions very well until the peak of exercise, suggesting his diaphragm and upper airways function normally. A flow-volume loop will also provide additional information regarding the upper airway that would help diagnose vocal cord dysfunction, benign adenomas, or fixed airway obstructions as alternate causes of wheezing. Patients who wheeze daily with exertion may have true asthma, not EIB, and they benefit from long-term control therapy as opposed to simply pre-exercise medications.

A 17-year-old woman presents to your office with fever for 3 days up to 105° F, complaints of severe sore throat, refusal to swallow, and is speaking with a "hot potato" voice. On exam, her oropharynx is erythematous with exudates, and the uvula is displaced laterally. Which of the following is the most likely etiology? a) Retropharyngeal abscess b) Peritonsillar abscess c) Epiglottitis d) Acute pharyngitis

Topic Pulmonary Medicine Answer B. Peritonsillar abscess Explanation Peritonsillar abscess usually occur in older children, adolescents, and young adults. It is almost always due to either group A strep or anaerobes. Patients present with high fever, severe throat pain, trismus, "hot potato" voice, and deviation of the uvula laterally away from the abscess. Treatment is with penicillin and incision and drainage. Retropharyngeal abscess usually occurs in infants and children < 5 years old. Symptoms are sore throat, neck stiffness, fever, dysphagia, and stridor. It can be difficult to see the swelling. The epiglottis is the flap that closes off the trachea when swallowing. Epiglottitis is a soft tissue infection of this flap. Patients have swelling, dysphagia, drooling, and are at risk for pharyngeal obstruction with life-threatening respiratory compromise. Physical examination my need to be done in the operating room.

A 52-year-old smoker presents for follow-up. He has stable dyspnea on exertion, but he notes new lower extremity edema. PMH: CHD, HTN, COPD PE: O2 sat 89% JVD, trace pedal edema Barrel-shaped chest Distant heart sounds, loud P2 Left sternal holosystolic murmur Wheezes Which of the following is the most appropriate next step in patient care? a) Increase the beclomethasone dose. b) Prescribe oxygen for continuous use. c) Prescribe oxygen for use during ambulation. d) Order dobutamine stress test with nuclear images. e) Change metoprolol to an ACE inhibitor.

Topic Pulmonary Medicine Answer B. Prescribe oxygen for continuous use. Explanation This smoking patient has COPD (FEV1/FVC < 0.70) with chronic hypoxia (oxygen saturation 89%) leading to pulmonary hypertension with cor pulmonale (split S2 with loud P2 component and murmur of tricuspid regurgitation, pedal edema). Continuous oxygen therapy in patients with COPD and hypoxemia improves survival. Review the indications for continuous oxygen prescription: Resting PaO2 ≤ 55 or O2 sat ≤ 88% PaO2 ≤ 59 mmHg or O2 sat ≤ 89% if cor pulmonale or erythrocytosis (Hct > 55%) The presence of cor pulmonale in this patient makes him eligible for continuous oxygen therapy. You need to memorize these oxygen parameters. Because his symptoms are stable, except for the new lower-extremity edema, change in his inhaled steroid dose is not warranted. Changing his beta-blocker to an ACE inhibitor will not change the edema. The development of pulmonary hypertension and cor pulmonale is expected from his degree of lung obstruction, so the clinical presentation should be attributed to his long-standing COPD. He has no new symptoms to suggest further cardiac decompensation, so repeating his stress test is not the correct answer.

A 35-year-old woman who had a stillbirth at 25-weeks gestation approximately 2 weeks previously presents with increasing dyspnea for 6 days, which has progressed to the point that she cannot perform daily activities without resting. Walking to the kitchen from her den causes severe dyspnea. She has no history of orthopnea or paroxysmal nocturnal dyspnea, chest pain, cough, or hemoptysis. She has no history of swelling or pain over her calves, and she has not had a history of bleeding disorder or thromboembolism. She has had 3 full-term normal vaginal deliveries 18 years, 6 years, and 3 years previously. PAST MEDICAL HISTORY: As above; otherwise negative SOCIAL HISTORY: Vice-President of Marketing for major computer company Lives with husband and 3 children Has never smoked Drank glass of wine/week before was pregnant; none during pregnancy REVIEW OF SYSTEMS: No fever No chills No productive cough 10-lb. weight loss after delivery PHYSICAL EXAMINATION: BP 130/90 mmHg, Pulse 125/min, RR 24/min, Temp 99.1° F HEENT: PERRLA, EOMI TMs clear Throat clear Neck: Supple; no masses Right jugular venous pressure was not raised Wave pattern showed prominent Y collapse Heart: Point of maximal impulse: 5th intercostal space in the midclavicular line with a parasternal heave S1 was loud; S2 with normal splitting with a loud pulmonary component S3 was present Holosystolic murmur over left lower sternal border; increasing with inspiration Lungs: Scattered rhonchi Abdomen: Bowel sounds present; no masses; no hepatosplenomegaly, nontender Extremities: No cyanosis, clubbing, or edema LABORATORY: ECG: Right axis deviation, an S-wave in Lead I, and a Q-wave and inverted T-wave in lead III (S1, Q3, T3). T-wave inversion in leads V2 and V3, and S wave persistence in leads V5 and V6. CXR: Normal CBC: WBC 7100/mm3; hemoglobin 11.5 gm/dL; platelets 375,000 ESR: 15 mm in 1 hour Glucose: 90 mg/dL BUN: 30 mg/dL Creatinine: 0.8 mg/dL Echocardiogram: Dilatation of the right ventricle and right atrium; moderate valvular insufficiency noted. Based on your findings, which of the following is the most likely diagnosis? a) Myocardial infarction b) Pulmonary embolism c) Sepsis d) Bacterial pneumonia e) Bacterial endocarditis

Topic Pulmonary Medicine Answer B. Pulmonary embolism Explanation There is an increased risk of thromboembolic disease during pregnancy with possible contributing factors including: Decreased vasomotor tone due to increased prostaglandins Venous compression by the gravid uterus Hypercoagulability due to increased levels of coagulation factors I, II, VIII, IX, and X Decreased plasma fibrinolytic activity This patient had her onset of pulmonary embolism approximately 1 week ago. Thrombolytic therapy is as effective if started in 6-14 days as compared to within 5 days of pulmonary embolism. Her ECG is classic. The S1, Q3, T3 pattern is what is classically described but usually not seen. Echocardiogram is consistent with PE. With treatment and resolution, her tricuspid regurgitation disappeared. Her right ventricle also returned to normal size as did her pulmonary artery systolic pressure.

A 50-year-old African-American woman with a history of hypertension and obesity presents with a 4-month history of worsening shortness of breath. She had been able to walk up a flight of stairs without any difficulty about 3 months ago. Now she complains of shortness of breath while walking around her home. Also, at night she has a new onset of orthopnea. She denies other symptoms at this point. PAST MEDICAL HISTORY: Hypertension for 10 years, treated with HCTZ 25 mg daily Delivered 5 healthy children in her 20s; no problems during pregnancies SOCIAL HISTORY: Works in a day care with 30 preschool children Says her job is very stressful but less stressful than her previous job, which was as a housemother for a fraternity house Never smoked Never drank alcohol No pets Widowed; lives alone FAMILY HISTORY: Father, 80; recent MI 1 year ago Mother, 79; recent admission to nursing home for Alzheimer's Sister, 55; healthy but obese Brother, 53; hypertension, on medication Sister, 48; with SLE REVIEW OF SYSTEMS: No headaches No chest pain No cough No fever No sweats No rashes No joint complaints PHYSICAL EXAMINATION: BP 120/85, P 90, RR 16, Temp 98.8° F Ht 5'2", Wt 260 lbs HEENT: PERRLA, EOMI, discs sharp Throat clear Neck: Supple, no masses Heart: RRR without murmurs, rubs, or gallops; loud pulmonic second sound Lungs: Clear to auscultation Extremities: Bilateral 2+ pitting edema; no cyanosis or clubbing noted Skin: No rashes Rectal: Heme-negative LABORATORY: Pulse oximetry on room air was 93% at rest; with walking dropped to 87% CXR: Echocardiogram: Ejection fraction of 80% and pulmonary hypertension with a PA systolic pressure of 61 mmHg. Right ventricular size and function were normal. Pulmonary function tests: FEV1 of 0.9 L (43% predicted) and an FVC of 1.6 L (59% predicted). High-resolution CT scan showed diffuse pulmonary nodules and hilar enlargement. Three sputum samples for acid-fast bacilli were negative. She underwent bronchoscopy with transbronchial biopsy for evaluation of her pulmonary nodules. The bronchoscope showed hyperemia with nodular irregularities and distal concentric narrowing in the main, segmental, and proximal subsegmental bronchi. The transbronchial biopsy is shown in the image below. Special stains for fungi and acid-fast bacilli were negative. Which of the following is the most likely diagnosis? a) Bacterial pneumonia b) Pulmonary sarcoidosis c) Asbestosis d) Tuberculosis e) Granulomatosis with polyangiitis (Wegener's)

Topic Pulmonary Medicine Answer B. Pulmonary sarcoidosis Explanation Her chest radiograph shows a diffuse miliary pattern, which is suspicious for tuberculous or metastatic carcinoma. Her biopsy shows 2 small, non-necrotizing granulomas. The differential diagnosis includes mainly infectious granulomatous disease, hypersensitivity pneumonia, and sarcoidosis. Granulomas may also be seen with aspiration pneumonia, in chronic beryllium disease, or exposure to titanium or aluminum dusts, as a response to certain drugs, and rarely with granulomatosis with polyangiitis (Wegener's), lymphocytic interstitial pneumonia, or eosinophilic pneumonia. Tuberculosis has been effectively ruled out at this point, and bacterial pneumonia does not fit this clinical picture or any of the results. Asbestosis would cause parenchymal fibrosis and involves lower lobes. The bronchoscopy findings are inconsistent with asbestosis. Granulomatosis with polyangiitis (Wegener's) is on the differential as mentioned above, but we have no evidence of renal disease, and it is much rarer than sarcoidosis in the African-American population.

On a routine x-ray film of the chest, a 62-year-old man has a solitary pulmonary nodule. He has smoked one pack of cigarettes daily for 40 years and has had early-morning cough and expectoration for 5 years. The lesion is 2.4 cm in diameter, peripheral, and contains no calcium deposits on chest CT. PMH is significant for rheumatoid arthritis for 10 years. Physical examination confirms bilateral metacarpal involvement with bilateral ulnar deviation of the digits. He has rheumatoid nodules over the extensor surface of his right forearm. Laboratory tests show a rheumatoid factor of 1:1280. His tuberculosis skin test was positive 2 years ago, and he completed 9 months of isoniazid. The patient feels well, except for his morning cough. Which of the following is the most appropriate management? a) Obtain sputum for mycobacterial culture and acid-fast smear. b) Refer for biopsy or surgical removal of the nodule. c) Repeat a low-dose helical CT scan in 3 months. d) Advise the patient to stop smoking; perform no additional studies. e) Start etanercept.

Topic Pulmonary Medicine Answer B. Refer for biopsy or surgical removal of the nodule. Explanation Although this patient has rheumatoid arthritis, a disease that is associated with the development of necrobiotic rheumatoid nodules in the lung, the burden of the correct diagnosis lies with the physician. The lesion cannot be assumed to be benign. Because patients with rheumatoid arthritis who smoke tobacco can develop lung carcinoma, tissue must be obtained and examined. Recognize also that the patient has all of the concerning features: advanced age, smoking history, no calcium deposition, and a larger-sized nodule. His previous positive TB skin test and treatment should not dissuade you from working up his solitary pulmonary nodule. This kind of question will be straightforward. The ABIM won't ask you about handling tiny nodules in low-risk patients, because different centers have different reasonable approaches. But the Boards may ask you to recognize the high-risk patient who definitely requires tissue resection.

Which of the following is associated with lower lobe interstitial infiltrates? a) Silicosis b) Rheumatoid fibrosis c) Ankylosing spondylitis d) Eosinophilic granuloma e) Pneumocystis jiroveci pneumonia in patients on inhaled pentamidine therapy

Topic Pulmonary Medicine Answer B. Rheumatoid fibrosis Explanation Rheumatoid fibrosis, asbestosis, and other pulmonary manifestations of connective tissue diseases, such as SLE, present with interstitial infiltrates of the lower lobes. The other conditions present with upper lobe disease.

A 32-year-old female complains of cough for 1 year duration. She also has exertional dyspnea as well as a purplish-colored rash that recurs intermittently across her cheeks and shins. Chest radiograph reveals bilateral hilar lymphadenopathy. She has no significant past medical history, no significant family history, and currently works in a supermarket. She denies smoking, alcohol, or drug use except for occasional marijuana. Mediastinoscopy is done to assess the enlarged lymph nodes. Biopsy indicates "the presence of well-formed non-caseating granulomas." Bacterial, AFB, and fungal cultures are all negative. Which of the following disorders is the most likely diagnosis? a) Lymphoma b) Sarcoidosis c) Tuberculosis d) Histoplasmosis e) Berylliosis

Topic Pulmonary Medicine Answer B. Sarcoidosis Explanation Sarcoidosis is a non-infectious multisystem disease of unknown cause, commonly affecting young and middle-age adults. The most common radiographic presentation is bilateral symmetrical hilar lymphadenopathy, although lung parenchymal changes are also quite common. Other extrapulmonary symptoms are often seen and can affect nearly every organ system. Generally occurs in the middle-age group, more common in women, and more common in African-Americans in the United States. The typical biopsy will reveal non-caseating granulomas as seen also in berylliosis, but no exposure history provided. Formation of granulomas is also seen in fungal and mycobacterial diseases, such as tuberculosis and histoplasmosis, but these tend to be caseating and associated with positive cultures. Although berylliosis and lymphoma can both present with lymphadenopathy, pathology characteristics are not those of granulomatous disease.

A 24-year-old male who lives in southwestern Ohio comes to the emergency department complaining of a rash on his legs. He reports that these "red bumps" erupted about 1 week ago, and they are becoming more painful. He has no significant past medical history and is a nonsmoker. He has no recent exposures to any new dusts, chemicals, detergents, etc. He also denies any new medications. He did eat shrimp about 10 days ago but does this often and has never had any reactions. He has never been allergy tested, but he has never had any food-related reactions. His rash appears below: On a previous emergency department visit, he had a chest radiograph done for cough about 2 months prior, which is also below: What is the most likely diagnosis? a) Berylliosis b) Sarcoidosis c) Histoplasmosis d) Poison ivy e) Allergic reaction to shellfish

Topic Pulmonary Medicine Answer B. Sarcoidosis Explanation This patient has classic features of Löfgren syndrome, which includes erythema nodosum and bilateral symmetrical hilar lymphadenopathy. Sarcoidosis is a noninfectious multisystem disease of unknown cause, commonly affecting young and middle-aged adults with pulmonary symptoms or findings being most common, specifically bilateral symmetrical hilar lymphadenopathy and pulmonary infiltrates. It can also cause skin lesions, eye lesions, and affect other organs including the liver, spleen, lymph nodes, heart, and central nervous system. The other diagnoses listed do not have the same constellation of skin and lung findings and thus are incorrect.

A 74-year-old woman with a 100-pack-year history of smoking (2 ppd for 50 years) is essentially dragged in by her husband, who says that she has withered away to nothing and has been acting very confused lately. She says she is fine but keeps calling you her grandchild. You don't get much more information out of her. PAST MEDICAL HISTORY: Hysterectomy 24 years ago HTN for 20 years; on an ACE inhibitor SOCIAL HISTORY: Retired used car salesperson Lives with her husband of 50 years Doesn't drink FAMILY HISTORY: Father died at age 75 of lung cancer Mother died at age 74 of lung cancer Brother died at age 74 of lung cancer Sister died at age 74 of lung cancer Brother recently diagnosed with lung cancer REVIEW OF SYSTEMS: No fever or chills Has had night sweats on occasion 30-lb weight loss in last 6 months No appetite Coughed up blood once last week (about a teaspoon, according to husband) PHYSICAL EXAMINATION: Oriented only to person, place; thinks the year is 1965 BP 110/70, P 92, RR 14, Temp 99° F, Ht 5' 2", Wt 140 HEENT: PERRLA, EOMI TMs clear Throat clear Neck: Supple, no masses Heart: RRR with II/VI systolic murmur (heard for 10 years now) Lungs: Coarse scattered crackles; no focal finding Abdomen: Bowel sounds present; no hepatosplenomegaly Extremities: No cyanosis, clubbing, or edema LABORATORY: CXR: Central mass seen in right hilum; no cavitation noted Serum sodium: 120 mg/dL Urine sodium: 60 mg/dL (normal should be less than 10 mg/dL with this serum sodium) Based on your findings, which of the following types of lung cancer does this woman most likely have? a) Adenocarcinoma b) Small cell carcinoma c) Large cell carcinoma d) Bronchoalveolar carcinoma e) Squamous cell carcinoma

Topic Pulmonary Medicine Answer B. Small cell carcinoma Explanation Let's put this together. It is central, which means it is either Small Cell or Squamous Cell (Remember S-S-Sentral). Now you presume from the information that the patient has SIADH, which generally is associated with small cell. Therefore, put together central carcinoma with SIADH and you get small cell as the answer. Adenocarcinoma, large cell, and bronchoalveolar (a type of adenocarcinoma) are usually peripheral.

A 23-year-old female has a history of asthma since age 16. She reports symptoms of dry cough and exertional dyspnea. Her cough is worse at night but also worsens with cold air. She has symptoms almost every night. She has an inhaler of albuterol that she uses nightly and as needed for increased shortness of breath. She denies smoking, has no pets, and currently is a full-time student. She has not noticed any seasonal variation or any worsening with different environments. She denies symptoms of reflux. What is the next best step in management? a) Refer for allergy testing. b) Start treatment with a medium dose inhaled corticosteroid along with albuterol as needed. c) Start treatment with a long-acting beta-agonist along with albuterol as needed. d) Initiate treatment with a proton pump inhibitor nightly.

Topic Pulmonary Medicine Answer B. Start treatment with a medium dose inhaled corticosteroid along with albuterol as needed. Explanation This patient with a history of chronic asthma has symptoms consistent with uncontrolled asthma. Her chronic dry cough, exertional dyspnea, and nocturnal cough are common symptoms found in asthma. Additionally, increased symptoms with certain exposures such as cold air, perfumes, smoke, dusts, pets and pet dander, and other allergens suggest a history of bronchial hyperresponsiveness. This patient has almost daily symptoms consistent with moderate persistent asthma. Based on NHLBI guidelines for asthma management, first-line treatment for persistent asthma of any severity is an inhaled steroid (ICS). As the severity increases, then the dosage of the ICS may be increased with other therapies added on. For those with moderate severity asthma, long acting beta-agonists may be added to low dose ICS for maintenance. However, long acting beta-agonists (LABAs) should not be used in asthma without the concomitant use of ICSs. In fact, some studies have suggested potential for harm in patients who received LABAs alone. Allergy testing might be helpful for those patients with uncontrolled asthma despite adequate maintenance therapy. Additionally, patients may report worsening of symptoms with certain exposures in different locations, and allergy testing might help the patient with allergen avoidance. In this patient, however, no history of worsening with exposures nor adequate maintenance therapy was given. Gastroesophageal reflux disease (GERD) may be a cause for worsening asthma symptoms. However, studies have shown that treatment of asymptomatic GERD does not improve symptoms. This patient did not endorse symptoms of GERD, and, thus, a proton pump inhibitor is unlikely to be helpful.

A 52-year-old female was evaluated for a lung mass three months ago. This was biopsied via bronchoscopy, and pathology was consistent with lung adenocarcinoma. After further evaluation, she was determined to have Stage IIIB lung carcinoma. She has completed her first cycle of combined chemotherapy and radiation therapy. Today, she complains of a one-week history of right lower extremity edema and pain, as well as a sudden onset of left-sided pleuritic chest pain associated with shortness of breath. Her vitals are as follows: HR 120 bpm, RR 24, oxygen saturations 92% RA, blood pressure 125/80. Duplex ultrasonography of the right leg reveals an occlusive thrombus of the right common femoral vein. Serum creatinine level is 2.3. Which of the following is the next appropriate action? Start LMWH treatment. Start unfractionated heparin treatment. Obtain chest CT angiogram. Start infusion of thrombolytic agent. Obtain V/Q scan.

Topic Pulmonary Medicine Answer B. Start unfractionated heparin treatment. Explanation This patient has clear evidence of venous thromboembolic (VTE) disease with a DVT and high clinical probability of a pulmonary embolism. Also, this patient is at substantial continued risk for VTE because of her malignancy. Initiate anticoagulation immediately before any further testing is done. Unfractionated and LMW heparins have been shown to decrease the risk of PE compared to warfarin and are recommended. Unfractionated heparin does not rely on normal renal clearance and is appropriate, but LMW heparins are renally cleared and could accumulate unpredictably in this patient with decreased renal function. Further studies, such as a chest CT angiogram and V/Q scan are not needed in this case as diagnosis has been made. Also, with impaired renal function, the contrast associated with a chest CTA would be a relative contraindication for ordering this test. This patient has relatively stable hemodynamics with only mild hypoxemia. Thrombolytics are not appropriate for this patient.

A 29-year-old female is 32 weeks pregnant with her first pregnancy. She has a history of mild intermittent asthma for which she uses an albuterol inhaler occasionally. She presents to your office with a 5-day history of increased dyspnea associated with dry cough and some intermittent wheezing. She denies any reflux symptoms, fever, nasal drainage, or recent sick contacts. On exam, she is slightly tachypneic with a respiratory rate of 20; the remainder of the vital signs are normal. Lung exam reveals mild expiratory wheezing with slightly prolonged expiratory phase. Which of the following is true regarding asthma in pregnancy? a) Budesonide is the only inhaled steroid with a Class X rating in regard to safety in pregnancy. b) The management principles for asthma are the same in pregnant and non-pregnant patients. c) Approximately 80% of patients with asthma will have symptoms that worsen with pregnancy. d) Oral corticosteroids would be contraindicated in patients with asthma exacerbation and pregnancy. e) Controlled asthma during pregnancy is associated with a higher risk of preeclampsia.

Topic Pulmonary Medicine Answer B. The management principles for asthma are the same in pregnant and non-pregnant patients. Explanation Worsening of asthma during pregnancy is very common, but 80% do not worsen. A simple rule is that 1/3 of patients will have asthma that gets worse, 1/3 that gets better, and 1/3 where symptoms remain stable. In patients with uncontrolled asthma, the management principles are the same in both pregnant and non-pregnant patients. It is important to manage asthma aggressively as uncontrolled asthma is associated with a higher risk of preterm delivery, low birth weight, and complications such as preeclampsia. Inhaled steroids would be the mainstay of treatment for persistent asthma. Although budesonide is the only agent in this class with a Class B safety rating, it is considered safe to use other inhaled steroids, particularly if a patient is already controlled on one prior to pregnancy. Oral corticosteroids may be required for severe asthma exacerbations. While they carry side effects, such as hyperglycemia, they should be used if the clinical situation warrants it as the risk to the fetus is high with severe asthma exacerbations.

A 26-year-old female is admitted to the ICU after an emergency exploratory laparotomy for a ruptured ectopic pregnancy. She received 16 units of packed cells in the OR, and a Swan-Ganz catheter was placed by anesthesia because they heard rales and were concerned about volume overload. On admission, she is in shock with a blood pressure of 70/30 and a hemoglobin of 5.0 g/dL. She is on mechanical ventilation in CMV mode with FiO2 60%, PEEP 10 cm, rate 20, and tidal volume 700 cc. Two additional units of packed cells were given on arrival to the ICU; the blood pressure came up to 100/60, and the heart rate is 120/minute. Post-transfusion labs reveal a hemoglobin of 7.0 g/dL, and the Swan-Ganz readings show a cardiac output of 10 L/min, pulmonary arterial "wedge" pressure of 12 mmHg, and a systemic vascular resistance of 600 dyne-sec-cm-5 (low!). The arterial blood gas now is pO2 85 mmHg, pCO2 44 mmHg, and pH of 7.26. Which of the following therapies is the most appropriate next step in continuing the resuscitation of this patient? a) Start dopamine at 10 µg/kg/min to increase the systemic vascular resistance. b) Transfuse 2 units packed red blood cells. c) Increase FiO2 to 70%. d) Increase the rate of the ventilator to increase the minute ventilation and lower the pCO2. e) Start dobutamine at 10 µg/kg/min to increase the cardiac output.

Topic Pulmonary Medicine Answer B. Transfuse 2 units packed red blood cells. Explanation This patient is still only partially resuscitated with evidence for both hemorrhagic shock and the hyperdynamic phase of SIRS (systemic inflammatory response syndrome). Most important is the continued acidosis, which is predominantly a metabolic acidosis and presumably a lactic acidosis indicating inadequate tissue perfusion. The best way to continue the resuscitation is to improve oxygen delivery (DO2) to the tissues and monitor the ABG and lactate level to assess improvement. Oxygen delivery is determined by cardiac output, hemoglobin, and oxygen saturation. In this case, the CO2 is already high, and the oxygen saturation with a pO2 of 85 is at least 90%. Increasing the pO2 will not provide much more hemoglobin saturation. Therefore, the best way to improve oxygen delivery is to increase the hemoglobin through additional packed red cell transfusions. Increasing the minute ventilation to compensate for the metabolic acidosis will only mask the problem. Dobutamine will reduce the systemic vascular resistance even more, resulting in further hypotension. Dopamine will increase the blood pressure and cause further tachycardia with no improvement in oxygen delivery to the tissues.

A 62-year-old male presents to your office for follow-up. He has a history of COPD but has had no recent testing. He complains of chronic dyspnea on exertion walking on flat ground after 50 feet as well as shortness of breath with stairs. He has not previously been intubated and was hospitalized twice in the last six months for respiratory issues. His only respiratory-related medication included albuterol q6h as needed for dyspnea. He is an active smoker with a 50-pack-year history of smoking. Pulmonary Function Tests were performed: FEV 1 : 1.5L (49% predicted) FVC: 3.0L (64% predicted) FEV 1 /FVC: 50% Oximetry Testing: Resting, Room Air: > 95% Exercise, Room Air: > 93% Overnight, Room Air: > 91% Based on current evidence, which of the following would not be beneficial for this patient? a) Pulmonary rehabilitation b)Use of oxygen at 2 LPM daily with rest and exertion c) Annual influenza vaccine d) Daily use of an inhaled corticosteroid e) Smoking cessation

Topic Pulmonary Medicine Answer B. Use of oxygen at 2 LPM daily with rest and exertion Explanation The patient described has obstructive disease based on his PFTs. Based on his FEV 1 , his COPD disease severity would be categorized as severe. Multiple interventions have proven to be beneficial for these patients, with endpoints including improvements in survival, decreased number of exacerbations, reduced hospitalizations, and improved quality of life. Smoking cessation has been shown to significantly reduce the decline of lung function in a previous smoker. Although lung function will not substantially improve, the rate of decline can approximate that of a nonsmoker after one year of smoking cessation. Pulmonary rehabilitation has been shown to reduce hospitalizations, increase exercise endurance, and improve quality of life. It should be considered in all patients with symptomatic COPD. Inhaled corticosteroids have been shown to reduce the number of exacerbations in those patients with COPD with an FEV 1 < 50% predicted. The influenza vaccine should be considered in all patients with COPD regardless of severity. It has been shown to lead to a 52% reduction in hospitalizations for all episodes of influenza and pneumonia and a 70% reduction in deaths from all causes. Oxygen is the only modality proven to improve the long-term mortality in those patients with COPD who meet certain qualifications. The criteria to start continuous oxygen (ideally 24 hrs but 15 hrs minimum) include: Resting P a O 2 < 55, O 2 Sat < 88%, P a O 2 < 59 with evidence of cor pulmonale or erythrocytosis. The patient in this scenario does not meet these criteria based on oximetry testing, and thus the use of oxygen has not been shown to be beneficial in this population.

A 67-year-old male presents with complaints of shortness of breath. It has been occurring for years, but he has noticed it more over the last 6 months. He complains of exertional dyspnea not associated with any chest pain but does have some occasional dry cough. He smokes 1 pack per day and has been doing so since age 31. His only other significant past medical history includes hypertension and diabetes. His examination reveals a normal cardiac exam with distant breath sounds on lung auscultation without any adventitial sounds. Chest radiograph reveals mild hyperexpansion and mild cardiomegaly without any other major abnormalities. He is sent for pulmonary function tests: Actual: Predicted: FVC: 2.2 L 51% FEV1: 0.98 L 31% FEV1/FVC: 44% TLC: 7.51 L 125% DLCO: 9.03 mL/min/mmHg 25% The pattern seen on pulmonary function testing is most consistent with which of the following? a) Moderate obstructive airways disease without hyperinflation b) Very severe obstructive airways disease with hyperinflation c) Mixed restrictive and obstructive pattern d) Isolated reduction in diffusion capacity related to pulmonary vascular disease e) Moderate restrictive disease

Topic Pulmonary Medicine Answer B. Very severe obstructive airways disease with hyperinflation Explanation The patient has a reduction in the ratio of the forced expiratory volume of 1 second (FEV1 ) to the forced vital capacity (FVC). A ratio less than 70% is consistent with obstructive disease. The severity of obstruction is characterized by the FEV1 percent predicted. An FEV1 of: FEV1 > or equal to 80% predicted—mild obstruction FEV1 50-80% predicted—moderate obstruction FEV1 30-50% predicted—severe obstruction FEV1 < 30% predicted—very severe obstruction Increases in the total lung capacity (TLC) greater than 120% predicted are consistent with hyperinflation. TLC < 80% would be consistent with a restrictive disease pattern that this patient does not have. Clearly, there is more than just an isolated diffusion abnormality, but causes of an isolated DLCO include pulmonary vascular disease and anemia.

Which of the following is most important in distinguishing between ventilatory failure and a gas exchange defect in a patient with breathing difficulties? a) Pulse oximetry b) PaCO2 c) A-a gradient d) PaO2 levels e) Serum pH

Topic Pulmonary Medicine Answer C. A-a gradient Explanation Inadequate oxygen levels leading to hypoxia can occur from: 1) Defects in moving oxygen-containing air from the environment to the alveoli (hypoventilation) 2) Difficulties exchanging oxygen across the alveolar membranes 3) Compromises in circulating adequate oxygen-saturated blood cells to the tissues Ventilatory deficiencies and abnormal alveolar exchange both lead to a diminished PaO2 with an elevated PaCO2. Oxygen saturation by pulse oximetry measurement will be low and and serum pH will be low. Comparison of the oxygen in the alveoli and the oxygen in the arterial blood (the A-a gradient) can help differentiate an alveolar gas exchange problem from a ventilatory defect.

A 72-year-old male comes in for follow-up evaluation. He has a known history of emphysema. He complains of persistent shortness of breath with exertion, which he says is getting worse. He can only walk about half a block on flat ground prior to getting dyspneic. He is significantly impaired with steps. He smoked 1 pack per day for 45 years and still smokes about 1/2 pack per day. He denies any exertional chest pain, palpitations, or lower extremity edema. His current medications include tiotropium bromide q day, salmeterol/fluticasone combination discus bid, and albuterol MDI qid. On exam: P 100; RR 28; oxygen saturation on RA 89%; BP 110/65 Wt: 52 kg (decreased by 3 kg since last visit) Lungs: severely diminished breath sounds bilaterally, prolonged exhalation, no wheezing His PFTs are as follows: FVC: 2.05 L (65% predicted) FEV1: 0.87 (35% predicted) FEV1/FVC: 55% TLC: 4.12 L (125% predicted) DLCO: 11.2 (45% predicted) Which of the following should be offered to this patient next? a) Smoking cessation program. b) Oxygen determination with rest, exercise, and nocturnally. c) All of the choices are correct. d) Referral to pulmonary rehabilitation. e) Influenza vaccine annually.

Topic Pulmonary Medicine Answer C. All of the choices are correct. Explanation This patient has COPD and most likely emphysema, which would be categorized as severe based on his FEV1. He also has significant exertional dyspnea as well as signs of hyperinflation on PFTs and muscle wasting, which is a component of advanced emphysema. He is already being treated with the conventional medications for COPD including long-acting beta-agonists and anticholinergics. In addition, inhaled steroids are indicated for those with moderate-to-severe COPD. All patients with COPD, regardless of severity, should be offered the influenza vaccine annually. This patient appears to have resting room air hypoxemia, which likely worsens with exertion. Oxygen has been the only specific therapy that has been shown to decrease mortality in patients with COPD, particularly if testing reveals desaturations below certain thresholds and the patient uses it for greater than 14 hours/day. Pulmonary rehabilitation has been proven to increase exercise capacity, decrease hospital admissions, and decrease dyspnea scores. It should be considered in all patients with moderate COPD or worse. All patients should be counseled regarding smoking cessation, especially those with impaired lung function. If a patient does quit smoking, the rate of decline of lung function can approximate the rate of decline for a nonsmoker after 1 year of smoking cessation.

A 74-year-old male with a known history of COPD presents to the emergency department cyanotic and in severe respiratory distress. He is a thin man weighing 70 kg. An arterial blood gas indicates severe respiratory acidosis and hypoxemia on room air (pH 7.00; pCO2 120 mmHg; and pO2 40 mmHg). He is intubated immediately and placed on mechanical ventilation in the assist/control mode at the following settings: Rate: 25/min Tidal volume: 1,000 cc Peak inspiratory flow rate: 50 L/min When you arrive in the emergency department to see your patient, you note that his blood pressure is 60/30 and his heart rate is 140/min. His pulse is thready, his neck veins are full, and his trachea is midline. There are equal breath sounds bilaterally. There are many alarm lights going off on the ventilator. You yell for someone to page Respiratory Therapy, disconnect the patient from the ventilator for a few minutes, and watch his blood pressure and heart rate improve. The respiratory therapist arrives. Which of the following orders do you give the respiratory therapist for mechanical ventilation? a) Assist/control mode, rate 28/min, tidal volume 600 cc, peak flow 40 L/min b) Assist/control mode, rate 18/min, tidal volume 1,000 cc, peak flow 60 L/min c) Assist/control mode, rate 12/min, tidal volume 700 cc, peak flow 80 L/min d) T-bar with 80% oxygen on blow by

Topic Pulmonary Medicine Answer C. Assist/control mode, rate 12/min, tidal volume 700 cc, peak flow 80 L/min Explanation We all recognize that the hemodynamic demise in this patient was from dynamic hyperinflation and the creation of auto-PEEP. Just think of air trapping and breath "stacking." This patient's underlying problem is expiratory airflow obstruction. So, what did the emergency department doctor do? In an effort to immediately reverse the acute hypercapnic respiratory failure, he hyperventilated the patient and provided a large tidal volume at a low peak flow rate. (Peak flow determines how fast the gas is delivered for each breath—a higher peak flow results in the breath being delivered quickly [short inspiratory time], allowing for a longer expiratory phase.) This patient could not possibly have had enough time to empty his lungs with each breath. Ultimately, he builds up such a large pressure in his chest (auto-PEEP) that blood flow return is compromised and hypotension ensues. In removing the patient from mechanical ventilation, you allowed the trapped gas to be released and hemodynamic stability returned. While it is tempting to leave the patient on a T-bar without any positive pressure, be assured that he will quickly tire and have a respiratory arrest. Therefore, you return the patient to mechanical ventilation (assist/control mode is as good as any) with the understanding that you want a tidal volume of 5-10 mL/kg, a high peak flow rate, and a lower respiratory rate (8-14). Even without sophisticated monitoring, you should be able to see that you are not trapping air by auscultating the lungs through a few respiratory cycles and see that the patient has finished his expiration phase before the next breath by the ventilator is delivered. Recognize that this method of ventilating the patient may not fully correct his respiratory acidosis. That's OK; a moderate amount of respiratory acidosis is well tolerated (permissive hypercapnia), so aim to get a pH > 7.20 as your initial goal and let the bronchodilators, steroids, etc., start to work.

You are presented a patient with respiratory problems. Her PFT patterns are as follows: Reduced expiratory flows Increased total lung capacity Reduced vital capacity Mild increase in DLCO Significant response to bronchodilator Based on the above results, which of the following diagnoses is most likely? a) Sarcoidosis b) Interstitial lung disease c) Asthma d) COPD e) Emphysema

Topic Pulmonary Medicine Answer C. Asthma Explanation Note the clues here: 1) significant response to bronchodilator; few of the diagnoses will significantly improve with this. Emphysema will not respond to bronchodilators; COPD may have a little improvement but not marked; interstitial lung disease and sarcoid will not be affected. 2) For the DLCO, only asthma has a potential to have a mild increase in DLCO; all the rest will be normal or reduced. Just about all will have reduced expiratory flows except for interstitial lung disease, which can have reduced flows but commonly will have slightly increased values to normal. Total lung capacity and vital capacity are not much help, since asthma will have similar patterns as compared to COPD and emphysema for these 2 values. Hyperinflation is common in both asthma and emphysema. So, key elements to look for to differentiate: Asthma will have mild increase in DLCO and respond to bronchodilators. COPD will have a normal or reduced DLCO and normal to slight increase in total lung capacity. Emphysema will have decreased DLCO with increased total lung capacity (hyperinflation). Finally, interstitial lung diseases will have reduced DLCO with total lung capacity reduction as well

Your receptionist asks you to see her 17-year-old daughter. The daughter has had a fever and cough for 2 days and is not better with over-the-counter medications. Her cough has become productive in the past day, and last night she coughed most of the night. Her fevers have ranged up to 101.5° F. She feels bad and complains of generalized body aches. PAST MEDICAL HISTORY: Negative SOCIAL HISTORY: Lives with her mother and 2 brothers, ages 12 and 10 Attends high school and makes As and Bs, except a D in Art Denies smoking or drinking FAMILY HISTORY: Mother 40 Father 42, healthy 2 brothers, healthy REVIEW OF SYSTEMS: Essentially negative PHYSICAL EXAMINATION: BP 100/60, P 90, Temp 100° F, RR 14 HEENT: PERRLA, EOMI, wears glasses TMs clear Throat clear; non-erythematous Neck: Supple no masses Heart: RRR with ejection click; no murmurs, rubs, or gallops Lungs: Coarse crackles heard at the left base Abdomen: Bowel sounds present; no hepatosplenomegaly Extremities: No cyanosis, clubbing, or edema Skin: No rashes LABORATORY: CXR: Left lower lobe infiltrate Based on your findings, which of the following is the best antibiotic choice for her? a) Amoxicillin-clavulanate 850 mg PO bid for 10 days b) Cefuroxime 250 mg PO bid for 10 days c) Azithromycin 250 mg two tabs PO today, then 1 tab PO q day x 4 days d) Amoxicillin 500 mg tid for 10 days e) Levofloxacin 500mg q day for 10 days

Topic Pulmonary Medicine Answer C. Azithromycin 250 mg two tabs PO today, then 1 tab PO q day x 4 days Explanation This patient could have Streptococcus pneumoniae, Mycoplasma pneumoniae, or Chlamydophila pneumoniae. Azithromycin and levofloxacin are the only agents listed that are effective against all 3 organisms. The problem is that she is 17. You must be cautious when giving a quinolone to a patient under the age of 18 except in special circumstances (anthrax, cystic fibrosis patients, etc.) for skeletal maturity concerns. The beta-lactam antibiotics listed are great for pneumococcus but won't get the atypicals. In a young patient with uncomplicated pneumonia, look for a macrolide or doxycycline as an acceptable choice.

A 40-year-old female comes to your office complaining of increased dyspnea and coughing accompanied by fever and night sweats. She is well known to you and has had stable asthma for the past 10 years, with good control achieved with her inhaled corticosteroid and occasional use of her beta-2 agonist inhaler. This is her third visit to your office in the past 2 months for "exacerbation of her asthma." CBC indicates a mildly elevated WBC count with 15% eosinophils. Which of the following would a chest x-ray most likely reveal? a) Right upper lobe cavity b) Segmental atelectasis c) Bilateral peripheral infiltrates d) No infiltrates

Topic Pulmonary Medicine Answer C. Bilateral peripheral infiltrates Explanation This presentation of a 40-year-old woman with a history of fever, night sweats, asthma exacerbation, and new eosinophilia is classic for chronic eosinophilic pneumonia. The CXR is classically referred to as the "photographic negative" of pulmonary edema. ABPA would be suggested by a history of coughing brownish sputum and the subsequent mucous plugging that can lead to segmental atelectasis on chest x-ray. There is always a possibility of pulmonary tuberculosis (right upper lobe cavity), but the eosinophilia would not be a hallmark.

What is the most likely fungal lung disease in a patient from Arkansas or Missouri with a draining leg lesion? a) Aspergillosis b) Histoplasmosis c) Blastomycosis d) Streptococcus pneumoniae e) Coccidioidomycosis

Topic Pulmonary Medicine Answer C. Blastomycosis Explanation Blastomycosis would present with lung and skin/bone lesions in Arkansas/Missouri. Note that histoplasmosis is very common also but does not have the draining skin lesions. Aspergillosis would be seen in immunocompromised and does not present with draining skin lesions. Coccidioidomycosis is seen in the desert Southwest but can have bony lesions that might drain.

A 60-year-old man has had a cough with production of sputum for the past month. He is afebrile with decreased breath sounds at the right lung base. A chest radiograph reveals an area of consolidation in the right lower lobe with air bronchograms. He is given antibiotic therapy; but when he is seen 2 months later, the chest radiograph is unchanged, and his cough continues. Sputum is clear but has a "salty" taste. Which of the following is the most likely diagnosis? Lipoid pneumonia from aspiration Obstructive pneumonia from squamous cell carcinoma Bronchoalveolar cell carcinoma Unresolved Mycoplasma pneumoniae Tuberculosis

Topic Pulmonary Medicine Answer C. Bronchoalveolar cell carcinoma Explanation This case details a patient with a clear pulmonary malignancy. But you are given additional information: sputum with a "salty taste." You are asked to associate this information with bronchoalveolar cell carcinoma, a subtype of adenocarcinoma that is often accompanied by bronchorrhea and a salty taste. The other choices are not associated with a classic salty taste. This is a straightforward recall question, and on occasion, the Boards will throw you a few of these.

A 52-year-old female initially complained of cough and fever. She was seen in the emergency department and was noted to have significant respiratory distress. Her O2 sat was 84% on 100% non-rebreather mask. Due to continued respiratory distress, the patient was intubated and placed on mechanical ventilation. Her initial ABG post-intubation is: pH 7.28, PaO2 59, PaCO2 54, O2 sat 89%, FiO2 100%. Mechanical ventilator settings: AC mode; rate 20; FiO2 100%; tidal volume 550; PEEP 8 Vitals: T 39.1° C (102.38° F); P 120; BP 100/44; RR 24 Her CXR reveals diffuse bilateral infiltrates. Echocardiogram reveals an estimated LVEF of 55% without any significant valvular abnormalities. Which of the following has been shown to improve mortality in those with this condition? a) Placement of a right heart catheter to assess cardiac parameters b) Initiation of systemic corticosteroids after 5 days of ventilatory support c) Maintenance of tidal volumes at 6 mL/kg of ideal body weight d) Use of nitric oxide e) Maintenance of tidal volumes at 12 mL/kg/hour

Topic Pulmonary Medicine Answer C. Maintenance of tidal volumes at 6 mL/kg of ideal body weight Explanation This patient has pneumonia, which has progressed to acute respiratory distress syndrome (ARDS). The clinical definition for ARDS includes: Acute onset of diffuse bilateral infiltrates PaO2 ratio < 200 (< 300 for acute lung injury [ALI]) No evidence of cardiogenic pulmonary edema Mechanical ventilatory support is almost always necessary for patients with ARDS. This inflammatory condition has been extensively studied, and outcomes continue to improve. However, the only proven intervention to reduce mortality is a lung protective strategy. Ventilatory support with a goal tidal volume (TV) of 6 mL/kg of ideal body weight and limitation of plateau pressures < 30 cm (protective group) was compared to those with goal TV of 12 mL/kg with no limit to plateau pressures (traditional group). Those in the protective group had a significant reduction in mortality. Associated with a lung-protective strategy was worsening ventilation, but this permissive hypercapnia still resulted in better outcomes. The use of the right heart catheter in the ICU has diminished significantly. Many studies have shown that use of these catheters and the information they provide does not lead to better outcomes, including conditions such as ARDS. Nitric oxide is a specific pulmonary vasodilator that is delivered by inhalation gas. It has been shown to improve oxygenation temporarily. However, no mortality benefit has ever been shown, and it may, in fact, be associated with worse outcomes. Systemic steroids have not improved mortality but may improve lung injury scores if initiated early in the course of ARDS

A 60-year-old woman who has been on mechanical ventilation for 1 week due to ARDS from a pneumococcal pneumonia is slowly being weaned. Clinically, she is doing well and you are pleased with her progress. MEDICATIONS: Day 8 of ceftriaxone PHYSICAL EXAMINATION: HEENT: Pupils responsive and equal Mild thrush of her oral mucosa Neck: Supple, no masses Heart: RRR without murmurs, rubs, or gallops Lungs: Still with basilar crackles right greater than left Abdomen: Positive bowel sounds, tolerating tube feeds well; no masses Extremities: No cyanosis, clubbing, or edema LABORATORY: CBC shows a mild increase in WBC to 11,000 from 9,500 yesterday with 80% lymphs Tracheal aspirate culture from 2 days ago returns today and shows Pseudomonas aeruginosa sensitive only to amikacin, piperacillin/tazobactam, and ceftazidime AST 25 ALT 26 Bilirubin 0.2 mg/dL Creatinine 0.5 mg/dL BUN 10 mg/dL CXR: Slow improvement from admission; no new infiltrates Based on clinical evaluation and laboratory results, which of the following is the most appropriate next step? a) Switch antibiotic coverage to piperacillin/tazobactam alone. b) Add amikacin to ceftriaxone. c) Continue current therapy. d) Switch antibiotics to piperacillin/tazobactam + amikacin. e) Perform bronchoscopy and then start piperacillin/tazobactam + amikacin.

Topic Pulmonary Medicine Answer C. Continue current therapy. Explanation Clinically she is doing well. You are weaning her off the vent; her physical examination is stable; her laboratory is stable (never base antibiotic therapy on a minor bump in WBC). The sputum results are not unusual for a patient in the Intensive Care Unit; they will frequently become colonized with gram-negative organisms—particularly Pseudomonas. Never change therapy based on just a tracheal aspirate; you must have some other change in exam or laboratory that is significant for you to consider treating the organism found on a tracheal aspirate.

A 21-year-old woman is brought to your office, accompanied by her parents, after a "near syncope" event at home while they were carrying the daughter's trunk of dirty laundry into the house on her arrival from college. The daughter admits to feeling lightheaded while carrying the laundry and says that she is often short of breath climbing the 2 flights of stairs to her dormitory room. Upon further questioning, she admits to substernal chest pain accompanying her exertional dyspnea, but states that it isn't important because "I'm too young to have a heart attack." She denies fever, cough, hemoptysis, wheezing, orthopnea, or ankle swelling. She is on no medications and denies smoking or illicit drugs. She is sexually active but has never used oral contraceptives. On physical exam, she is afebrile with a heart rate of 90 and a blood pressure of 110/60. She is of average build and in no apparent distress. Neurological exam is normal. Her lungs are clear on auscultation. Her cardiovascular exam is remarkable for a parasternal heave and an increase in the intensity of P2. You perform a chest x-ray, which is normal, and an ECG, which reveals normal sinus rhythm with right axis deviation. CBC and basic chemistries are normal. Pregnancy test is negative. Which of the following is the most appropriate procedure for further evaluation of this patient? a) Pulmonary function tests b) Exercise stress test c) Echocardiogram d) V/Q scan e) Right heart catheterization

Topic Pulmonary Medicine Answer C. Echocardiogram Explanation Look for the young woman with exertional dyspnea, chest pain, and has physical exam findings consistent with right heart strain. The next step in the workup is an echocardiogram to document the existence of pulmonary hypertension and exclude significant mitral stenosis. After echocardiographic documentation of pulmonary hypertension, the workup would proceed in the absence of any discernible parenchymal lung disease to V/Q scan to look for thromboembolic disease. A pulmonary angiogram would be helpful in evaluating any perfusion defects seen on V/Q. The role of right heart catheterization is further down the road when you are considering vasodilator therapy in the patient with primary pulmonary hypertension. We do not suspect cardiac ischemia. Pulmonary function tests (particularly diffusion capacity) are helpful in assessing severity in documented cases of pulmonary hypertension, but have little use in the initial workup of the patient unless you suspect secondary pulmonary hypertension from underlying COPD.

You are seeing a 29-year-old with documented tuberculosis. He is currently on INH, rifampin, PZA, and ethambutol. He comes in because he has noted that he cannot see colors as well. He is an interior decorator and noted that last week he tried to put two shades of teal together, and he was embarrassed when he realized what he had done. PAST MEDICAL HISTORY: Essentially negative Tuberculosis exposure was from his mother, who works in a nursing home SOCIAL HISTORY: Smokes 1 ppd for 10 years Drinks alcohol at night; quit when started on his anti-TB meds Lives with his mother Not sexually active FAMILY HISTORY: Mother 55, with cavitary TB diagnosed 4 months ago Father died 10 years ago of massive stroke; age 60 REVIEW OF SYSTEMS: Besides the vision changes, no other problems PHYSICAL EXAMINATION: Essentially normal Snellen office chart shows 20/30 vision in both eyes Referral to ophthalmologist for extensive eye examination reveals loss of color discrimination. Which of the following is the most likely etiology for his change in vision? a) Rifampin toxicity b) Combination of ethambutol and INH toxicity c) Ethambutol toxicity d) INH toxicity e) Tuberculous involvement of the retina

Topic Pulmonary Medicine Answer C. Ethambutol toxicity Explanation Ethambutol is generally not hepatotoxic, but will cause problems with visual acuity, particularly color perceptions. The other agents are not associated with this problem.

A 28-year-old male smoker presents to the emergency department with complaints of a swollen and painful left leg. He states he was in good health until 1 week ago when he began to notice a dull pain in his leg. Since then, he has experienced swelling and redness. He denies trauma to the leg. Doppler ultrasound reveals a left popliteal thrombosis. Which of the following is the most likely cause of his DVT? a) Antithrombin III deficiency b) Homocysteinemia c) Factor V Leiden gene mutation (activated protein C resistance) d) Protein S deficiency e) Occult malignancy

Topic Pulmonary Medicine Answer C. Factor V Leiden gene mutation (activated protein C resistance) Explanation This question asks about basic epidemiology: What is the most common cause of venous thromboembolism in a young man aged 28 years? Even though he is a smoker, he is too young to have a common malignancy. The remaining choices are inherited causes of a hypercoagulable state. Factor V Leiden mutation is the most common cause (40-50% of cases) of inherited thrombophilia followed by deficiencies of protein C, S, and antithrombin III, and the prothrombin gene mutation. Aberrant homocysteine levels are now believed to be a marker of clotting, not a cause of it.

A 30-year-old male with history of asthma comes to the emergency department complaining that he "can't breathe." He is diaphoretic, 140/90, HR 128, RR 30. On physical exam the following is noted: He has an "Inspiratory Fall in Blood Pressure." He is leaning forward using his accessory muscles. Hyperresonance and diffuse wheezes are found on chest exam. ABG on room air: pH 7.39 pCO 2 45 mmHg pO 2 60 mmHg Which of the following is the most appropriate next step in management? a) Antibiotic therapy b) Magnesium sulfate IV c) Intubation and mechanical ventilation d) Noninvasive mask ventilation e) 40% F i O 2 by face mask

Topic Pulmonary Medicine Answer C. Intubation and mechanical ventilation Explanation This patient presents with a clinical history of asthma and the signs of status asthmaticus. The arterial blood gas does not show the expected respiratory alkalosis characteristic of early asthmatic exacerbations. Instead, the normal blood gas indicates that the patient is tiring and will need ventilatory support. Noninvasive positive pressure ventilation (NPPV) has been used in the treatment of status asthmaticus, but its use is not yet standard of care due to a lack of prospective studies. In addition, a tiring patient may ultimately cease respirations, and NPPV offers nothing to assist these patients if respiratory arrest develops. Intubation and careful mechanical ventilation are recommended.

A 72-year-old male with a history of coronary artery disease and systolic cardiomyopathy presents with a 2-week history of progressive shortness of breath associated with a dry cough. He also complains of 2+ lower extremity edema. On lung exam, there are decreased breath sounds throughout the lower 2/3 of his right lung with dullness to percussion. Chest x-ray reveals a moderate pleural effusion. The patient undergoes bedside thoracentesis with the removal of 800 mL of clear, straw-colored fluid. Studies sent: Pleural fluid: Protein 1.3 LDH: 130 Culture: No growth Serum: Protein 4.2 LDH: 290 This improves the patient's symptoms, but a repeat chest x-ray four days later reveals recurrent pleural fluid. What should be done next for this patient? a) Repeat thoracentesis b) Thoracic surgery consult for pleurodesis c) More aggressive treatment for congestive heart failure with diuretics d) Placement of large bore chest tube for continued drainage

Topic Pulmonary Medicine Answer C. More aggressive treatment for congestive heart failure with diuretics Explanation This patient has an effusion most likely related to congestive heart failure. Based on Light's criteria, this patient has a transudative effusion. Light's criteria for an exudative effusion are: Pleural fluid protein/serum protein ratio greater than 0.5 Pleural fluid LDH/serum LDH ratio greater than 0.6 Pleural fluid LDH greater than 2/3 the upper limits of normal of the serum LDH If all negative, then classified as a transudate The most common etiology of a transudative effusion is congestive heart failure. CHF-related pleural effusions are: 65% bilateral, 25% right unilateral, and 10% left unilateral. Other causes of transudative effusions include hepatic hydrothorax, nephrotic syndrome, and hypoalbuminemia. The most effective treatment for this patient is more aggressive management of his congestive heart failure that may include diuretics. Placement of a chest tube or repeat thoracentesis will unlikely be beneficial because pleural fluid will continue to re-accumulate without correction of the underlying cause. Pleurodesis involves evacuation of the pleural space and instillation of a sclerosing agent such as talc or doxycycline. In the setting of pleural effusions due to CHF, this treatment is not very effective and would not be indicated.

A 40-year-old female patient comes to your office with complaints of a "flu-like" illness that began 4 days ago. She has just returned from Ohio, where she remembers there was a flu going around the neighborhood. While in Ohio, she helped her parents and neighbors shovel out an old barn that had been used as a bird roost. Which of the following would you recommend? a) Empiric trial of amphotericin B b) Cultures for Histoplasma capsulatum c) No testing or therapy d) Acute and convalescent serologic testing and treatment with amphotericin B e) A histoplasmin skin test

Topic Pulmonary Medicine Answer C. No testing or therapy Explanation This patient has acute histoplasmosis from the neighborhood barn-cleaning party. The neighborhood outbreak is not uncommon when there is land cleared or bulldozed. The key is that histoplasmosis is usually a self-limited disease for which we do not consider treatment unless there is evidence for progression to more disseminated disease. Some would consider treatment if symptoms persist more than 4 weeks, but before then treatment is not indicated by current guidelines. Treatment for mild disease that has persisted longer than 4 weeks would be with itraconazole, not amphotericin B, which is reserved for severe or disseminated disease. Accurate diagnosis relies on the history of exposure. Histoplasmin skin tests are useless, because many people will test positive after exposure without having the disease. Cultures are not very sensitive and may take weeks to grow. A positive culture from sputum or tissue is diagnostic, however. Serologic testing has variable sensitivity but would be the best test to diagnose her definitively; however, amphotericin B is not indicated.

A 65-year-old male insulation worker has a chest radiograph that shows bilateral pleural plaques along the lateral chest walls. He was exposed to asbestos intermittently during his occupational pursuits. He is asymptomatic, and his physical exam is unremarkable. He does not smoke. What is the most appropriate next step in patient care? a) CT scan of the chest to determine if plaques contain calcium b) Pulmonary function tests to determine if plaques are causing restriction c) Observation and reassurance d) Tuberculin skin test with standard strength PPD e) Bronchoscopy with biopsy to check for pulmonary fibrosis

Topic Pulmonary Medicine Answer C. Observation and reassurance Explanation Pleural plaques indicate significant exposure to asbestos. Their presence does not cause impairment in pulmonary function. The presence or absence of calcium in the plaques has no clinical significance. Bronchoscopy with biopsy is not indicated in this otherwise asymptomatic patient with an otherwise normal chest radiograph. Tuberculin skin test with standard-strength PPD is imperative in the patient with silicosis, but the risk of active tuberculosis disease is not known to be increased in asbestos exposure. Reassurance that the plaques are benign and continued observation of the patient (yearly chest radiographs) are appropriate since he still has potential for developing bronchogenic cancer of the airways in the future.

A 65-year-old male presents to the emergency department with acute shortness of breath. He complains of pain in his right chest that is worse with deep inspiration. He also reports some lightheadedness but no syncope. These symptoms started to occur 2 hours prior to presentation and awoke him from sleep. He does report that he recently returned from an overseas airplane trip that lasted 6 hours. He denies any lower extremity edema. On exam: P 125; BP 130/45; T 37.1° C (98.78° F); RR 24; Oxygen sat 88% on room air He is in mild distress without accessory muscle use. His lungs are clear to auscultation. Cardiac exam reveals tachycardia with regular rhythm, no murmurs. The remainder of his exam is unremarkable. ECG reveals sinus tachycardia with right bundle-branch block. A CXR is read as: "No significant cardiopulmonary process." Which of the following should be done next? a) Start empiric antibiotics for pneumonia. b) Discharge home with NSAIDs with follow-up with primary care physician in 1 week. c) Obtain chest CT angiogram. d) Start low-dose aspirin orally. e) Start PO warfarin at 10 mg daily.

Topic Pulmonary Medicine Answer C. Obtain chest CT angiogram. Explanation This patient has had recent immobilization with prolonged air travel, sudden onset of shortness of breath and pleuritic chest pain, and now tachycardia and hypoxemia. These are classic signs and symptoms of a pulmonary embolus, and this should be explored further. Chest CT angiogram is considered the gold standard for diagnosis of pulmonary emboli if there is no contraindication to obtaining the study. When there is a high clinical suspicion for pulmonary emboli, early administration of anticoagulants should be considered without delay. However, treatment should be started with intravenous unfractionated heparin or low-molecular-weight heparins. Although warfarin is used for maintenance treatment for venous thromboembolic disease, there is a delay before an appropriate level of anticoagulation is achieved. Although coronary ischemia certainly must be considered, the ECG does not reveal any ischemic changes. Therefore, aspirin would not be the next best step. The CXR does not have any evidence of pneumonia, so starting antibiotics wouldn't be indicated. Discharge home without further investigation would be inappropriate given this patient's presentation.

Yesterday a 20-year-old male presented with adult respiratory distress syndrome due to shock, and he required mechanical ventilation and positive end-expiratory pressure (PEEP). His condition gradually improves. Which of the following would not be a criterion for cessation of mechanical ventilation? a) Tidal volume 4 to 5 b) mL/kg c) FiO2 35% d) PEEP of 10 cm H2O e) Vital capacity greater than 15 mL/kg

Topic Pulmonary Medicine Answer C. PEEP of 10 cm H2O Explanation PEEP should be less than 5 cm H2O before discontinuation of mechanical ventilation and extubation can be considered. Vital capacity should be greater than 10 to 15 mL/kg. Tidal volume of 4 to 5 mL/kg is acceptable for removal from the ventilator. FiO2 should be less than 40% before discontinuation of mechanical ventilation. P(A-a) O2 at an FiO2 of 100%, less than 350 mmHg would also indicate increased probability of successful weaning off the ventilator and extubation.

You are seeing a 70-year-old man with severe COPD for follow-up. He quit smoking about 5 years ago, but his health has continued to deteriorate. He is at the point now where he cannot ambulate in his home without getting severely short of breath. He wants to know if there is anything else that he can do to improve his health status. You explain to him that supplemental oxygen may be beneficial to him, but you will have to do some laboratory studies to demonstrate to Medicare that they should pay for this. He agrees to the testing. PAST MEDICAL HISTORY: History of coronary artery disease; status-post 4 vessel CABG 5 years ago History of gout History of MI in 1992 Multiple hospitalizations for COPD exacerbations—about once a year on average in the last 10 years Morbid obesity SOCIAL HISTORY: Lives with his new wife of 2 years, Bambi, a 28-year-old dancer Drinks 2 glasses of red wine every night Quit smoking 5 years ago; before that, he smoked 2 packs/day for 50+ years FAMILY HISTORY: No change from the last 20 H&Ps you've done; documented well for the chart REVIEW OF SYSTEMS: Occasional headache Occasional sore throat Dyspnea on exertion at 5 feet Stable exertional chest pain; usually relieved with one nitroglycerin or rest Cough: productive cough every morning of every day; no change in character or frequency No nausea or vomiting Increased difficulty initiating his urine stream PHYSICAL EXAMINATION: BP 126/67, HR 86, RR 28, Temp 97.9° F MS: Oriented x 3 General: Obese man in no distress at rest; but when you saw him walk in from the waiting room he was markedly distressed. HEENT: Left cataract Throat clear; dentures Neck: No masses, no bruits Heart: RRR without murmurs, rubs, or gallops Lungs: Chronic crackles throughout; no change from previous examinations; prolonged expiratory phase noted as usual Abdomen: +BS, soft, nontender Neuro: CN grossly intact; reflexes equal and symmetrical Motor: Full strength throughout with normal muscle tone and bulk Sensory: Unremarkable LABORATORY: ABG: 7.5 PCO2 = 50; PaO2 = 50; Oxygen saturation 85% Based on your findings, which of the following should you recommend? a) Supplemental oxygen is not indicated based on his laboratory values. b) Supplemental oxygen is not indicated based on his physical examination. c) Supplemental oxygen should be worn 24 hours a day by this patient. d) Supplemental oxygen worn intermittently would be better than continuous oxygen therapy because of the concern that his respiratory drive will be too suppressed on continuous oxygen therapy. e) Supplemental oxygen may be indicated, but you need more information.

Topic Pulmonary Medicine Answer C. Supplemental oxygen should be worn 24 hours a day by this patient. Explanation Only objective data from an arterial blood gas is acceptable to Medicare for supplemental oxygen. History and physical examination will not help get this funded. He needs to meet one of the following criteria: Resting PaO2 ≤ 55 mmHg, or O2 saturation ≤ 88%, or PaO2 ≤ 59 mmHg (O2 sat ≤ 89%) with evidence of cor pulmonale Evidence of cor pulmonale in these considerations is: Clinical evidence of right heart failure Pulmonale on ECG (P wave height > 2.5 mm in II, III, and AVF) Hct > 56 (due to polycythemia from chronic hypoxia 2° cor pulmonale) You can tell him that being on supplemental oxygen is likely to improve his symptoms and there is a possibility that, in several months, he may not need the oxygen anymore. Medicare guidelines require you to bring him back between 61 and 90 days and retest him. Note that the use of supplemental oxygen does not depress the respiratory drive and cause an elevated CO2. This is due to several factors, including an easing of pulmonary vasoconstriction, which leads to perfusion of previously underperfused spaces and possibly due to ventilation of previous dead space.

Spirometry and peak flow measurement are 2 methods for evaluating airway status in pulmonary patients. When considering the data available from these two modalities, the value obtained with a peak flow meter corresponds most directly to which spirometric equivalent? a) Total lung capacity (TLC) b) Forced vital capacity (FVC) c) The first few milliseconds of airflow d) Forced expiratory volume in 1 second (FEV1)

Topic Pulmonary Medicine Answer C. The first few milliseconds of airflow Explanation Spirometry is a useful tool to evaluate pulmonary and airway function. Peak flow meters are used primarily in the management of asthma symptoms. Values obtained from peak flow meters correspond to the first few milliseconds of airflow. In the absence of chronic lung changes, this value indirectly relates to FEV1. This relationship does not hold up well for patients with COPD. Peak flow monitors are therefore practically useful only in the management of reactive airway disease.

An 80-year-old male is admitted to the hospital with dyspnea and a large right-sided pleural effusion. He is afebrile, complains of a cough that is productive of whitish-clear sputum and reports about a 10-lb. weight loss over the previous 6 months. He denies fever, chills, night sweats, hemoptysis, or chest pain. He has a 50-pack/year history of smoking but quit recently as a 50th anniversary present for his wife. He worked as an accountant and worked in the Brooklyn Naval Yard in World War II but denies any asbestos exposure. On physical exam he is noted to be afebrile, without adenopathy or skin lesions. Breath sounds are diminished at the right side, and he has dullness to percussion posteriorly to the inferior border of the scapula. There is no clubbing, cyanosis, or edema; his nails and fingertips on his right hand are discolored from nicotine. CBC: WBC count of 5,000 with 50% neutrophils, 3% bands, 24% lymphs, 17% monocytes, and 6% eosinophils Serum chemistries indicate: Glucose 84 mg/dL; protein 7.8 g/dL; LDH 162 U/L Review of the chest x-rays (PA, lateral, decubitus) shows a large, free-flowing effusion with no discernible underlying lung or mediastinal pathology. Sputum Gram stain has a few WBCs, no organisms Sputum cytology: Negative for malignant cells You perform a right-sided thoracentesis and remove almost 1 liter of dark, straw-colored fluid. Pleural fluid is sent for routine studies: Cell count: RBCs 8100μL WBC 3600/μL Differential: 88% lymphocytes 1% neutrophils 11% monocytes Fluid Chemistries: Glucose 45 mg/dL Protein 5.9 mg/dL LDH 332 U/L Cytology: Negative Which of the following is the most likely etiology of this patient's pleural effusion? a) Lymphoma b) Bronchogenic carcinoma c) Tuberculosis d) Malignant mesothelioma e) Parapneumonic effusion

Topic Pulmonary Medicine Answer C. Tuberculosis Explanation This effusion is clearly exudative, hemorrhagic, and with a lymphocytic predominance. There were no mesothelial cells noted. Tuberculosis pleuritis is common in elderly patients and should be a leading consideration in this case. Confirmation via fluid AFB stain and culture and/or pleural biopsy with culture should be performed. The absence of parenchymal or nodal disease leads us away from suspecting parapneumonic, lymphoma, or bronchogenic carcinoma. The negative pleural cytology rules out malignant mesothelioma. On the Board examination, a series of pleural effusions are presented to you.

A 30-year-old male is brought to the emergency department after being found unresponsive at home with a syringe in his arm. The patient is unresponsive, blood pressure is 120/60, and pulse is 100. His pupils are very small and unreactive. He appears cyanotic, and his respiratory rate is 8/minute. Arterial blood gas on room air shows a pH 7.22, PCO2 of 72 and a PO2 of 50. Which of the following is responsible for this patient's hypoxemia? a) Alveolar hypoventilation plus low V/Q b) Low V/Q ratio c) Venous blood was sampled, not arterial d) Alveolar hypoventilation alone e) Alveolar hypoventilation plus right-to-left shunt

Topic Pulmonary Medicine Answer D. Alveolar hypoventilation alone Explanation The differential diagnosis of arterial hypoxemia includes all of the choices plus decreased diffusion and high altitude (low FiO2). While this patient is at risk for aspiration pneumonia, pulmonary edema, and other underlying pulmonary pathology, a quick calculation of the A-a gradient on room air reveals a normal A-a gradient. (150 - (50 + 72/0.8) = A-a gradient of 10. The A-a gradient is increased in all causes of hypoxemia except hypoventilation and high altitude. We were not given any information that this patient was found on the summit of a 10,000 foot mountain; therefore, alveolar hypoventilation due to the presumed narcotic injection is the physiological mechanism for hypoxemia in this patient.

A 65-year-old male with poor general health status was evaluated in your office for progressive complaints of shortness of breath and decreasing exercise tolerance. As part of the workup, pulmonary function testing was ordered. The results of the testing revealed a significant decrease in the total lung capacity, functional reserve capacity, and the residual volume. The carbon monoxide diffusional capacity was found to be normal. Which of the following diagnoses would be most consistent with these findings? a) Eosinophilic pneumonia b) Silica pneumoconiosis c) Procainamide-induced pneumonitis d) Ankylosing spondylitis e) Pulmonary sarcoidosis

Topic Pulmonary Medicine Answer D. Ankylosing spondylitis Explanation Decreases in the total lung capacity, functional reserve capacity, and the residual volume are consistent with restrictive lung disease. This group of disorders occurs with both parenchymal processes and with conditions that cause limitations in chest wall mobility. A normal carbon monoxide diffusion test suggests a functional parenchyma and implicates chest wall mobility as the cause of the compromise. Of the choices provided, silica pneumoconiosis, drug (procainamide) induced pneumonitis, sarcoidosis, and eosinophilic pneumonia lead to parenchymal damage and restrictive changes. Kyphoscoliosis is the most common reason for restrictive lung disease arising from chest wall limitations, but several rheumatologic processes can also interfere. Ankylosing spondylitis can lead to both parenchymal and mobility limitations, but is the choice most likely to exhibit a normal diffusional capacity.

A 15-year-old who hunts ducks regularly in northern Louisiana and southern Arkansas. She comes to you with a 2-month history of cough and recent development of hemoptysis. On talking to her, you discover that she has lost 8 pounds in the last month. Past Medical History: Negative Social History: Lives in with her mother and stepfather Denies use of alcohol No illicit drug use Family History: Father died at age 45 of lung cancer Grandmother died at age 46 of lung cancer Physical Examination: BP 100/70, P 95, Temp 100° F, RR 25, Weight 110 lbs. HEENT: PERRLA, EOMI, TMs: Clear, Throat: Clear Neck: Supple Heart: RRR without murmurs, rubs, or gallops Lungs: Scattered crackles in the bases Abdomen: No hepatosplenomegaly Extremities: Draining pustular lesion noted on her left arm; she reports that it has been there for 1 month; puts "poultice" on it and it gets better, then it gets worse again. CXR: Possible mass noted at left base Laboratory: Gram stain of left arm lesion's fluid: Mixed bacterial flora KOH of left arm lesion's fluid: Small budding yeasts Acid-fast smear of left arm lesion's fluid: No organisms seen Based on your findings, which of the following is the most likely diagnosis? a) Histoplasmosis b) Lung carcinoma c) Coccidioidomycosis d)Blastomycosis e) Tuberculosis

Topic Pulmonary Medicine Answer D. Blastomycosis Explanation The combination of lung mass, draining cutaneous lesion, and the finding of budding yeast should point you toward either blastomycosis or coccidioidomycosis. Geography will narrow this down to blastomycosis, which occurs in the southeast and central U.S. bordering the Ohio and Mississippi River basins. Coccidioidomycosis occurs in the southwest states from west Texas to California. Histoplasmosis will not usually cause skin lesions as are seen with blastomycosis or coccidioidomycosis. Treatment would generally be with oral itraconazole for about 6 months. If she was severely ill, you would use amphotericin B.

Your next patient is an 18-year-old woman who is HIV-infected. Her most recent CD4 count was 10. She is moving to your area from Iowa. She says she had a TB skin test 2 years ago and some other skin tests, all of which were read as 0 mm. She remembers that the doctor there told her to tell people the number was "0 millimeters" and not "negative." PAST MEDICAL HISTORY: She has not required hospitalization in 3 years; at that time, she was hospitalized for Pneumocystis pneumonia, which was when she was diagnosed with HIV and found to have AIDS. MEDICATIONS: Trizivir one PO bid, which she has been on for 3 months (she is now adherent, though she says in the past she had not been) Bactrim DS one PO M, W, F Azithromycin q week SOCIAL HISTORY: Lives with her boyfriend, a welder She works as a waitress at the local IHOP Smokes 3 packs/day cigarettes Doesn't drink FAMILY HISTORY: Unknown; ran away from home at age 13 REVIEW OF SYSTEMS: Occasional night sweats Low-grade fevers every 3-5 days Sore throat on occasion Cough daily; especially in the morning Loose stools daily; normal for her is 4-5 bowel movements daily; no blood Vomiting on occasion No rash Decreased appetite PHYSICAL EXAMINATION: Fairly well-appearing woman in no distress BP 110/70, P 90, RR 14, Temp 99° F, Ht 5' 5", Wt 110 HEENT: PERRLA, EOMI TMs clear Throat clear Neck: Supple; no masses Heart: RRR with no murmurs, rubs, or gallops Lungs: Scattered rhonchi at bases; cleared with cough Abdomen: Bowel sounds present; liver span 10 cm; no spleen palpated Extremities: No cyanosis, clubbing, or edema Skin: Facial acne; no other rashes LABORATORY: WBC: 2,400 with 70% lymphs, 20% neutrophils Hgb: 12.5 mg/dL; MCV 105 Platelets: 450,000 Electrolytes: Normal Albumin: 3.4 mg/dL AST: 30 U/L ALT: 25 U/L Total bilirubin: 0.4 mg/dL Viral load: < 50 copies/mL CD4: 50 She is due for her tuberculosis screening; which of the following do you recommend? a) PPD containing 5 TU of tuberculin with 2 controls (mumps and Candida) b) PPD containing 250 TU of tuberculin without controls 2-step boosted PPD with 5 TU of tuberculin (place one today and repeat in 2 weeks) c) PPD containing 5 TU of tuberculin without controls d) PPD containing 250 TU of tuberculin with 2 controls (mumps and Candida)

Topic Pulmonary Medicine Answer D. PPD containing 5 TU of tuberculin without controls Explanation The use of "control" testing is no longer recommended by the American Thoracic Society or the CDC for any patient routinely. Therefore, the use of controls should be discouraged. Even though she is severely immunocompromised, a standard PPD is still appropriate. Never, ever pick the 250 TU on a test. There is no reason to use it, so you can effectively mark out those answers when you see them listed on a test! The 2-step (or boosted) PPD has no place in routine practice; it is generally reserved for people who are repeatedly tested, such as health care workers.

A 26-year-old woman presents with complaints of shortness of breath. She states that she first noticed the shortness of breath about 5 months ago. It mainly occurs when she is exercising, and she is unable to jog anymore because of shortness of breath. Recently she has been awakened at night with shortness of breath and has the feeling that she can't catch her breath. She has not had any fever, cough, or sputum production. She denies orthopnea. Her physical examination is significant for the following: Heart: RRR without murmurs, rubs, or gallops Lungs: Clear to auscultation Abdomen: Benign Extremities: No edema, clubbing, or cyanosis CXR is normal. Office spirometry is normal for age. ABG on room air: pH 7.40, PaCO2, 42 mmHg, and PaO2 of 93 mmHg Which of the following diagnostic tests would you perform next? a) Flow-volume loop b) High-resolution CT of the chest c) Echocardiography d) Bronchoprovocation (methacholine challenge test) e) Full pulmonary function tests with diffusing capacity determination

Topic Pulmonary Medicine Answer D. Bronchoprovocation (methacholine challenge test) Explanation She has a normal cardiac examination as well as a normal pulmonary examination. The most likely etiology of dyspnea under the age of 40 years is asthma, especially if it is episodic. It is not unusual for office spirometry to be normal between episodes. The best test is the methacholine bronchoprovocation test, which will reveal hyperreactive airways—the key to diagnosing asthma. The echo would be good if pulmonary hypertension was suspected with a right parasternal heave and an accentuated 2nd heart sound. Interstitial lung disease would be more likely in an older patient, and the high resolution CT scan would be useful then. If stridor was present, the flow-volume loop could be helpful for upper airway obstruction. The normal ABG would make the diffusing capacity determination essentially unhelpful.

An 18-year-old college freshman developed a sore throat approximately 8 days ago that was cultured and did not grow Streptococcus pyogenes. However, her throat culture did grow Staphylococcus aureus. She presents today with complaint of fever and cough that began last night. She also describes hoarseness since she has had her sore throat symptoms. The sore throat symptoms resolved after 3 days without specific antimicrobial therapy. PAST MEDICAL HISTORY: Attention deficit disorder diagnosed at age 8; on no medication since 4 years ago SOCIAL HISTORY: Recently moved here for college Doesn't smoke or drink alcohol Not sexually active Has a pet parrot back home FAMILY HISTORY: Mother 40, healthy Father 42, in prison for securities fraud Sister 15, pregnant REVIEW OF SYSTEMS: Negative for other symptoms; no rash, no joint manifestations PHYSICAL EXAMINATION: BP 110/70, P 88, Temp 100° F, RR 18 Ill-appearing woman in no acute distress HEENT: PERRLA, EOMI, wears contact lenses TMs clear Throat: slightly erythematous; no exudates Neck: Supple, no meningismus Heart: RRR without murmurs, rubs, or gallops Lungs: Coarse breath sounds with crackles heard on the left base Abdomen: Bowel sounds present in all 4 quadrants, nontender; no hepatosplenomegaly Extremities: No cyanosis, clubbing, or edema LABORATORY: CXR: Left lower lobe infiltrate Besides Streptococcus pneumoniae, which of the following is a likely etiology for her pneumonia? a) Chlamydia trachomatis b) Staphylococcus aureus c) Chlamydophila psittaci d) Chlamydophila pneumoniae e) Haemophilus influenzae type b

Topic Pulmonary Medicine Answer D. Chlamydophila pneumoniae Explanation With the history of prior sore throat and now a febrile illness with documented pneumonia by chest x-ray, Chlamydophila pneumoniae is the most likely. The parrot is a red herring here because she had no signs of C. psittaci infection—look for a pneumonia with an extensive interstitial pattern that appears to be much worse than the physical exam would indicate. C. trachomatis, remember, causes genitourinary and eye disease. S. aureus would be seen after an influenza-like illness or if she were immunocompromised, and she would be much sicker. Don't be thrown by the positive throat culture for this organism—it can be found frequently in asymptomatic people. H. influenzae should not cause pneumonia in her age group.

A 40-year-old female comes to your office complaining of increased dyspnea and coughing brownish sputum. She is well known to you, and has had stable asthma for the past 5 years with good control achieved with her inhaled corticosteroid and occasional use of her beta2-agonist inhaler. This is her third visit to your office in the past 2 months for exacerbation of her asthma. At this visit you do a chest x-ray, which shows patchy pulmonary infiltrates, and blood work that indicates a mildly elevated WBC count with eosinophilia on the differential. Which of the following is not consistent with a diagnosis of allergic bronchopulmonary aspergillosis (ABPA)? a) Marked elevation in serum IgE level b) Sputum culture positive for Aspergillus fumigatus c) Immediate skin test reaction (Type I, wheal and flare) to Aspergillus fumigatus d) Delayed (Type IV, cell mediated) skin test reaction to Aspergillus fumigatus e) Expectoration of brown mucous plugs and airway casts

Topic Pulmonary Medicine Answer D. Delayed (Type IV, cell mediated) skin test reaction to Aspergillus fumigatus Explanation All of the other choices are considered minor or major criteria for the diagnosis of ABPA, except that there is no Type IV, cell-mediated skin reaction. There are Type I and Type III (erythema and induration) skin test reactions. ABPA should be a consideration in any asthmatic who clinically worsens with repeated attacks despite adherence to therapy.

A 29-year-old woman has an x-ray film of the chest that shows bilateral prominent pulmonary arteries without pulmonary congestion. She has fatigue and chest discomfort with exertion. Physical examination shows a large a wave in the jugular pulse, clear lung fields, a systolic lift along the left sternal border, and a split S2 audible at the left sternal border and apex, with a loud second component. No cardiac murmur is present. Which of the following tests is most likely to provide the correct diagnosis? a) Pulmonary function with flow-volume loops b) Bronchoscopy with bronchoalveolar lavage c) CT angiogram with PE protocol d) Echocardiogram e) High-resolution CT of the chest

Topic Pulmonary Medicine Answer D. Echocardiogram Explanation This patient has symptoms of pulmonary hypertension. Primary pulmonary hypertension (PPH) is a rare disease of unknown cause. Secondary pulmonary hypertension is the result of other types of lung or heart disease. Recent advances in the treatment of PPH make identification and recognition imperative. When PPH is suspected, an echocardiogram should be done. This test will provide a rough estimate of resting pulmonary artery pressures. Mean pulmonary artery pressures greater than 20 mmHg at rest or 30 mmHg during exercise establishes a diagnosis of pulmonary hypertension. The diagnosis of PPH requires the absence of coexisting pulmonary or cardiac disease, and the echocardiogram helps determine if cardiac disease is present. Once PPH is suggested, perform right-heart catheterization to determine the response to vasodilators and plan appropriate long-term therapy.

A 65-year-old man presents with fever, chills, cough, and dyspnea for 3 days duration. This is associated with right-sided pleuritic chest pain as well as fatigue and mild nausea. His past medical history is only notable for hypertension for which he takes a thiazide diuretic. He has a 15-pack-year history of smoking but quit 10 years ago. On physical exam, his vitals are: T 102.4° F, RR 24, BP 100/45, O2 sat 92%. Lung exam reveals dullness to percussion with diminished breath sounds from mid-right lung to base. The remainder of the exam is not pertinent. PA/Lat and decubitus chest radiograph films reveal a free flowing moderate-size pleural effusion. Thoracentesis is performed using ultrasound guidance and sent for multiple studies. Which of the following findings on pleural fluid studies would necessitate complete pleural fluid drainage with tube thoracostomy? a) Pleural pH of 7.42 b) White blood cell count of 5,000 c) LDH level of 100 d) Growth of Streptococcus pneumoniae e) Pleural fluid protein/serum protein ratio less than 0.5

Topic Pulmonary Medicine Answer D. Growth of Streptococcus pneumoniae Explanation Pleural fluid with growth of organisms is consistent with a diagnosis of empyema. In this case, the pleural space should be evacuated to prevent complications related to an infection. Other reasons to consider tube thoracostomy or a similar procedure to allow complete evacuation of a pleural effusion include: gross pus, low pH (< 7.25), low glucose, and high LDH > 1,000. Based on Light's criteria, a low LDH and low pleural fluid to serum protein ratio are consistent with transudative pleural effusions. An elevated WBC is typically seen with most exudative effusions. However, empyema and complicated parapneumonic effusions, for which drainage is usually required, typically have WBC elevations > 50,000.

A 70-year-old man with COPD has had worsening shortness of breath for the last 6 months. He cannot move from his chair to his refrigerator without stopping several times along the way to catch his breath. A resting ABG is obtained and reveals the following: pH: 7.46 PCO2: 50 PaO2: 50 HCO3: 32 O2 sat: 84% Based on his history and laboratory results, what do you recommend? a) He should be placed on oxygen therapy during the daytime. b) He should be placed on oxygen therapy when he has exertion. c) He should not be placed on oxygen therapy except for episodes of shortness of breath. d) He should be placed on oxygen therapy 24 hours/day. e) He cannot be placed on oxygen therapy because his ventilatory drive will be impaired.

Topic Pulmonary Medicine Answer D. He should be placed on oxygen therapy 24 hours/day. Explanation He qualifies for 24-hour continuous oxygen therapy because his PaO2 is less than 55. Continuous (not intermittent or exertional) oxygen therapy is the only thing shown to prolong survival in these patients. There is a common misconception that chronic CO2 retainers have an impaired ventilatory drive that is O2 regulated rather than CO2 regulated. This led practitioners to withhold supplemental O2 out of concern that giving the patient a high PaO2 would depress the respiratory drive and cause increased CO2 retention. This is not true. Oxygen should be given to achieve a 90% O2 saturation.

A 30-year-old non-smoker presents with worsening shortness of breath. A CXR is done and shows emphysematous bullae in the bases consistent with early-onset COPD. Which of the following is a likely etiology for his condition? a) Eosinophilic granuloma b) Sarcoidosis AIDS c)Homozygous α1-antitrypsin deficiency d) Berylliosis

Topic Pulmonary Medicine Answer D. Homozygous α1-antitrypsin deficiency Explanation Think of this in a non-smoker who presents at a young age with COPD and has changes on CXR consistent with that diagnosis (as we see here with emphysematous bullae). IV therapy is available but controversial in efficacy. If the emphysema is severe, then lung transplant is indicated. The other diseases mentioned would not be common in a person this age, except for AIDS, which would not cause emphysematous bullae.

A 45-year-old female presents to your office complaining of fever and shortness of breath. This is the 4 th Monday in the past 2 months that she has come to see you for this complaint. She began to wheeze and cough this morning, and as the day progressed, she developed fever to 101.5° F and shortness of breath. She bought a parakeet in the last few months. Meds: HCTZ and lovastatin PE: T 101.7° F, RR 22, HR 89, BP 136/82. Mild respiratory distress. No jugular venous distention. Lungs show symmetric expansion, normal resonance, diffuse wheezing, and inspiratory crackles audible at the bases. Remaining exam is normal. CXR: Diffuse alveolar filling pattern and variable interstitial streaks. For which of the following is this patient at risk if the correct diagnosis is missed today? a) Diffuse alveolar hemorrhage b) Sudden cardiac death c) Lymphoma Interstitial fibrosis d) Obstructive lung disease

Topic Pulmonary Medicine Answer D. Interstitial fibrosis Explanation This question gives you the historical information you need to diagnose the patient with hypersensitivity pneumonitis. The patient is a generally healthy woman who episodically develops acute wheezing and dyspnea with fever. The new bird could certainly be a cause of hypersensitivity pneumonitis due to a reaction to avian proteins. The PE directs your attention to the bases of her lungs, and the radiograph shows classic interstitial abnormalities. The question queries whether you know that fibrosis is a long-term consequence of recurrent hypersensitivity pneumonitis. Her physical exam is not concerning for lymphoma, nor does the clinical history suggest that diagnosis. Sudden cardiac death is a concern in patients with pulmonary hypertension and structural heart disease, but this patient has no indication of either on physical exam. Diffuse alveolar hemorrhage is a complication of the pulmonary-renal vasculitides, especially Goodpasture syndrome; but the clinical presentation here does not match that of a vasculitis.

A 45-year-old woman with lymphoma has been neutropenic for 10 days and develops nodules in her lungs on CXR. Initially she is treated with broad-spectrum antibiotics. Amphotericin B is added on day 7, which is also the day the nodules are seen on CXR. She has been having continued fevers and now is developing respiratory distress. A biopsy of her lung is shown in this figure: It is a methenamine silver stain. The histopathology shows numerous extracellular yeasts within an alveolar space. The yeasts show a narrow based budding and are of different sizes. A different stain would accentuate the capsule of this organism. Based on your findings at lung biopsy, which of the following studies should you order next? a) Lumbar puncture b) Ultrasound of her liver c) Upper endoscopy d) Nothing; continue treatment with amphotericin B e) MRI of the mandible Topic

Topic Pulmonary Medicine Answer D. Nothing; continue treatment with amphotericin B Explanation She has cryptococcal lung disease, and there is a high risk of dissemination to the central nervous system with this organism. The patient is neutropenic and developing respiratory failure. Treatment would be to cover for disseminated disease including cryptococcal meningitis.So at this juncture, a lumbar puncture is not needed. You aren't really going to have to differentiate, say, a Histoplasma from a Cryptococcus, but you will need to know the more common organisms that an immunocompromised person gets. A person with lymphoma, like this patient, is at increased risk for cryptococcal infection, Coccidioides infection, and Aspergillus infection. If we had said she was from the San Joaquin Valley—then it is a no-brainer, right? Aspergillus, remember, is branching. If they show you Cryptococcus, they will likely show it to you with the nice capsule that you remember from 2nd year medical school microbiology.

A 67-year-old man with Type 2 diabetes mellitus, obesity, and hypertension is admitted for elective colonoscopy for chronic iron deficient anemia. He undergoes a prepped colonoscopy and receives midazolam 1 mg and fentanyl 25 µg. His eyelids close, and he does not respond to voice. Within a few minutes, the nurse reports that the patient's pulse oximetry reading is falling. He is making an effort to breathe, but there are paradoxical movements of the chest and abdomen. Vital signs, including temperature and blood pressure, remain stable. The patient is suctioned, but scant material is recovered. Chest radiograph does not reveal acute infiltrates. What is the most likely cause of this patient's response to conscious sedation? a) Aspiration pneumonitis b) Decreased respiratory drive due to sedation c) Hemorrhagic shock d) Obstructive sleep apnea (OSA) e) Sepsis

Topic Pulmonary Medicine Answer D. Obstructive sleep apnea (OSA) Explanation When providing conscious sedation, providers should be cognizant of the possibility of OSA syndrome. The prevalence of OSA in patients presenting for surgery has been estimated at 1-9%; although, it may be more common but undiagnosed in certain populations. Usual medications for conscious sedation include benzodiazepines (e.g., midazolam), which act as amnestics and anxiolytics, and opiates (e.g., fentanyl), which provide pain relief. These medications not only suppress respiratory drive centrally but also lower the tone of pharyngeal structures. This change in tone may provoke obstructive apneas or hypopneas. While central hypoventilation, or central apnea, is characterized by a decreased central effort to breathe, the hallmark of obstructive apnea is obstruction at the palatal-glossopharyngeal level. Often, the apneas can be mixed. Falling oximetry, continued effort to breathe, and paradoxical movements of the chest and abdomen suggest obstruction of upper airway muscles, most consistent with OSA. In the absence of fever or hypotension, hemorrhagic shock or sepsis syndrome is unlikely. There is no history of aspiration given lack of secretions and normal chest radiograph.

A 75-year-old male is admitted to the hospital with an exacerbation of COPD. He is treated with oxygen, antibiotics, and bronchodilators. On the 4th day, he is feeling better and he wants to go home. A pulse oximetry on room air today reveals a saturation of 89%, which was confirmed by a simultaneous ABG on room air, which demonstrated a PaO2 of 58 and a saturation of 89%. With ambulation, the oxygen saturation falls to 86%, and the patient becomes dyspneic. His Hct on admission was elevated to 52%. You request a referral from Social Services for home oxygen for your patient, and you are told that "he doesn't qualify but he could pay for it himself." Your patient, and his family, are quite distressed to learn that they will have to pay for the oxygen out of their own pockets. You are determined to see if you can get your patient qualified for home oxygen. Which of the following is the best plan of action? a) Secretly tell your patient to ambulate and repeat the ABG. b) Take up a collection for your patient. c) Resubmit the application on the basis of his erythrocytosis. d) Order an ECG and echocardiogram to evaluate for cor pulmonale.

Topic Pulmonary Medicine Answer D. Order an ECG and echocardiogram to evaluate for cor pulmonale. Explanation For insurance to cover this man's home oxygen, you would need to demonstrate evidence of cor pulmonale in addition to his blood gas results. His Hct does not qualify him on the basis of erythrocytosis. Only objective data from an arterial blood gas is acceptable to Medicare for supplemental oxygen. History and physical examination will not help get this funded. He needs to meet one of the following criteria: Resting PaO2 ≤ 55 mmHg, or O2 saturation ≤ 88%, or PaO2 ≤ 59 mmHg (O2 sat ≤ 89%) with evidence of cor pulmonale Evidence of cor pulmonale in these considerations is: Clinical evidence of right heart failure Pulmonale on ECG (P wave height > 2.5 mm in II, III, and AVF) Hct > 56 (due to polycythemia from chronic hypoxia 2° cor pulmonale) You can tell him that being on supplemental oxygen is likely to improve his symptoms and there is a possibility that, in several months, he may not need the oxygen anymore. Medicare guidelines require you to bring him back between 61 and 90 days and retest him. Note that the use of supplemental oxygen does not depress the respiratory drive and cause an elevated CO2. This is due to several factors, including an easing of pulmonary vasoconstriction, which leads to perfusion of previously underperfused spaces and possibly due to ventilation of previous dead space.

A 32-year-old female comes to your office to establish primary care. Her past medical history is only notable for asthma, diagnosed as a teenager. She reports symptoms nearly daily that can range from dry cough, worse at night, and exertional dyspnea. She denies any symptoms consistent with reflux disease but does endorse occasional chest tightness and burning, particularly when she tries to jog outside in the morning. She smokes 1/2 ppd and has been doing so for 11 years. She denies any pets. Family history is notable for a brother with asthma. Her medications include theophylline, salmeterol inhaler once daily, and albuterol nebulizer three times a day. Which of the following regarding asthma is true? a) A negative methacholine challenge test does not rule out the diagnosis of asthma. b) Proton pump inhibitors are helpful in asthma control if a patient has asymptomatic GERD. c) Inhaled corticosteroids should be considered only in patients with persistent asthma who have severe nocturnal symptoms. d) Patients may have pulmonary function tests that are normal. e) Prior to exercise or during periods of acute shortness of breath, long-acting beta-agonists should be used.

Topic Pulmonary Medicine Answer D. Patients may have pulmonary function tests that are normal. Explanation Based on NHLBI guidelines for the management of asthma, all patients with asthma that is categorized as persistent should be considered for maintenance therapy. First line medications are inhaled corticosteroids with the dose recommendations based on the degree of severity. Short-acting beta-agonists may be helpful for exercise-induced asthma and may be used as rescue inhalers in periods of acute shortness of breath. Long-acting beta-agonists (LABAs), such as salmeterol or formoterol, should not be used for these purposes. In fact, LABAs have been shown in some studies to be associated with a higher risk of death, particularly if not used in conjunction with inhaled steroids. Furthermore, treatment with LABAs without concomitant use of inhaled steroids is not advised. Although treatment of symptomatic GERD may help control asthma symptoms, multiple studies have shown that treatment of asymptomatic GERD did not alter the course of asthma in terms of symptoms, exacerbations, or dyspnea scores. Asthma is characterized as episodic airflow obstruction that is fully or partially reversible. Therefore, patients may not manifest any objective signs of obstruction when pulmonary function testing is performed, but this doesn't exclude the diagnosis of asthma. Methacholine challenge testing evaluates the tendency of airways to cause bronchoconstriction in response to antigens such as methacholine. The patient inhales escalating doses of methacholine, and the dose that causes a 20% reduction in FEV1 is graphed. If there is not a reduction of the FEV1 by at least 20%, then the test is negative, which essentially rules out asthma.

A 32-year-old man presents with pleural effusion and cough. He was released from prison 4 months ago and has been living on the streets of Miami for the past 2 months. You are highly suspicious of tuberculosis. His sputum smear x 3 is negative for AFB. Which of the following is more likely to be diagnostic for tuberculosis? a) Acid-fast smear of pleural fluid b) CT scan of the chest c) Repeat sputums d) Pleural biopsy e) ACE levels

Topic Pulmonary Medicine Answer D. Pleural biopsy Explanation Pleural biopsy will have the highest yield of the tests listed. Repeating sputums is also a good idea, and it may be that they were just poor specimens. Pleural effusion acid-fast smears are rarely positive. CT of the chest is not going to give you any diagnostic information, and ACE levels are of no use.

A 54-year-old male who resides in Ohio presents with a 6-month history of recurrent cough that is nonproductive. He reports that the cough is persistent and worse during the day and seems to improve during the night. It has been persistent, but it seemed to improve when he took a vacation to Florida 2 months ago and recurred on his return. He denies any sputum, wheezing, reflux symptoms, chest pain, edema, orthopnea, paroxysmal nocturnal dyspnea, or palpitations. He does endorse mild dyspnea on exertion, as well as occasional fevers without chills. He has no recent sick contacts or travel exposure. He denies any smoking or illicit drug use. He began working for a mushroom farm 9 months ago. Prior to that, he worked on various construction jobs and was told that there was some asbestos material exposure, but he is not sure how much. Chest radiograph is ordered and reveals patchy infiltrates in the right upper lobe and left lingula region, without any effusions or masses. Which of the following is the next best step in management for this patient? a) Initiation of corticosteroids at 1 mg/kg daily. b) Bronchoscopy with transbronchial biopsy. c) Start empiric treatment with oral fluoroquinolone. d) Prolonged duration away from his work environment. e) Transthoracic echocardiogram.

Topic Pulmonary Medicine Answer D. Prolonged duration away from his work environment. Explanation This patient has signs and symptoms most consistent with hypersensitivity pneumonitis that is most likely related to his exposure to toxins from working with mushrooms. Hypersensitivity pneumonitis (HP) is an immune-mediated reaction to an antigen that can result in acute, subacute, and chronic forms of HP. The acute form often presents with cough, fever, dyspnea, and fleeting infiltrates. A history of recurrent "pneumonias" and a temporal relation to an organic trigger is often elicited. In this patient, the temporal history of symptoms after starting work in a mushroom farm associated with improvement when away from work is very consistent with subacute HP, aka mushroom farmer's lung. Antigen avoidance is the mainstay of treatment. For those who have severe symptoms without improvement with antigen avoidance, corticosteroids may be effective. Bronchoscopy is not indicated because the tissue obtained from transbronchial biopsy is often not sufficient to make an adequate diagnosis. There are no signs of congestive heart failure or other cardiovascular issues, so echocardiogram is not indicated at present. The current presentation is not consistent with acute bacterial pneumonia, so antibiotics would not be an appropriate first choice.

An asthmatic presents in respiratory distress. He requires mechanical ventilation. Which of the following parameters is best for an asthmatic? A) Rate Tidal Volume Flows High High High b) Rate Tidal Volume Flows High Low Low c) Rate Tidal Volume Flows Low High Low d) Rate Tidal Volume Flows Low Low High e) Rate Tidal Volume Flows Low High High

Topic Pulmonary Medicine Answer D. Rate Tidal Volume Flows Low Low High Explanation These patients need a prolonged expiratory phase.

A 45-year-old man with interstitial pulmonary fibrosis (IPF) returns to your office for routine follow-up after receiving his diagnosis 2 months prior. He continues on prednisone and cyclophosphamide and says, "I feel great!" He states he is certain he will be one of the few who does well with this diagnosis because he has had a "dramatic response." Physical exam is unchanged. Repeat HRCT shows persistent ground-glass opacities. Which of the following is associated with physiologic improvement of IPF after treatment? a) Development of diabetes secondary to steroid use b) Subjective improvement in dyspnea c) Improvement in lung pathology d) Reduction of the A-a gradient with exercise e) Improvement of the ground glass on HRCT

Topic Pulmonary Medicine Answer D. Reduction of the A-a gradient with exercise Explanation Recall that all patients who are treated with steroids usually feel better, including those with IPF. Objective improvement in IPF is made by observing the A-a gradient with exercise. A reduction in the gradient after the prescription of steroids or other immune modulators suggests a true response to treatment. Even so, evidence is lacking on whether response to treatment translates to a better outcome. The other answer choices do not indicate a response to treatment.

A 59-year-old man is seen in follow-up. He was initially evaluated for cavitating pulmonary nodules. He has a history of severe, deforming rheumatoid arthritis for 20 years that has required surgical interventions. In the past he has been on azathioprine, sulfasalazine, hydroxychloroquine, and methotrexate. None has been effective recently. He has been taking prednisone (varies from 5 mg to 20 mg a day) for many years. Four months ago, etanercept was begun, and his arthritic pain resolved almost completely. However, over the past 7-8 months he has developed a progressively worsening cough. It has been productive on occasion, but he denies any blood or blood-tinged sputum. Over the last 2 months, he has had increasing shortness of breath with exertion, to the point that he now cannot walk a block without being short of breath. PAST MEDICAL HISTORY: Diabetes mellitus, adult onset at age 40; probably associated with steroids Positive PPD 30 years ago and he took INH for 1 year SOCIAL HISTORY: Worked as a locksmith for 20 years before having to retire for disability Stopped smoking cigarettes 30 years ago; previously smoked 1 pack/day for 10 years Doesn't drink alcohol FAMILY HISTORY: Doesn't know; he was adopted REVIEW OF SYSTEMS: No fever No chills No sweats No chest pain No weight loss No change in vision No appetite changes PHYSICAL EXAMINATION: BP 130/82, P 69, RR 17, T 99° F, appears comfortable at rest HEENT: PERRLA, EOMI, developing cataract in left eye TMs clear Throat clear Neck: Supple, no masses Heart: RRR without murmurs, rubs, or gallops Lungs: Diffuse crackles at left base; no wheezes Abdomen: Bowel sounds present; no hepatosplenomegaly; no masses Extremities: Chronic, symmetric, deforming polyarthritis with moderate synovitis of metacarpophalangeal joints Joints were cool and without effusions Skin was without evidence of vasculitis or nodules LABORATORY: Sputum: Negative for acid-fast bacilli x 3 Liver functions: AST 30 U/L; ALT 28 U/L; total bilirubin 0.2 mg/dL; alkaline phosphatase 200 U/L; GGT 20 U/L; albumin 3.5 mg/dL Renal function: BUN 10 mg/dL; creatinine 0.5 mg/dL Urinalysis: Normal for age Pulmonary function testing: Predicted Actual % Predicted FVC (L) 3.8 1.9 50 FEV1 (L) 2.6 1.5 58 FEV1/FVC (%) 70 80 114 DLCO mL/min/mmHg 26.02 8.63 33 Which of the following do the pulmonary function findings indicate? a) Severe obstructive lung disease, with no restrictive defect and marked decrease in diffusing capacity b) Severe obstructive disease with mild restrictive defect and normal diffusing capacity c) Restrictive ventilatory defect and normal diffusing capacity d) Restrictive ventilatory defect and marked decrease in diffusing capacity e) Restrictive ventilatory defect only

Topic Pulmonary Medicine Answer D. Restrictive ventilatory defect and marked decrease in diffusing capacity Explanation Note that FVC and FEV1 are reduced in parallel—this suggests a restrictive ventilatory defect. The marked decrease in diffusing capacity suggests loss of capillary surface area, which may be seen in pulmonary fibrosis, emphysema, or pulmonary vascular disease.

A 60-year-old woman with lung cancer presents with new onset of anisocoria. Her right pupil is much smaller and rounder than her left pupil. You dim the lights in the examination room and note that the left pupil has dilated much more. On examination, her right pupil responds briskly to light. She has mild ptosis on the right and anhidrosis on the right as well. Her right pupil constricts with pilocarpine administration, and dilates with atropine. However, when you apply 4% cocaine, it minimally dilates. Where is her likely abnormality located? a) Left occipital lobe b) Left optic nerve c) Left sympathetic chain d) Right sympathetic chain e) Right optic nerve

Topic Pulmonary Medicine Answer D. Right sympathetic chain Explanation The symptoms are consistent with sympathetic denervation of her right eye—the "Horner" pupil. Most commonly, a pulmonary neoplasm of the superior sulcus will produce this lesion. Usually it is associated with ipsilateral ptosis and anhidrosis. Pupillary light responses should be normal, as should the response to agents that dilate and constrict the pupil. However, since the sympathetic chain is not working, cocaine cannot cause local release of sympathomimetic substances and is a poor dilator.

What do "egg-shell" calcifications make you think of? a) Blastomycosis b) Sarcoidosis c) Histoplasmosis d) Silicosis e) Asbestosis

Topic Pulmonary Medicine Answer D. Silicosis Explanation These usually are hilar in location. None of the other choices have "egg-shaped" calcifications associated with them.

A 65-year-old man presents to his physician's office with a 6-month history of wheezing, dyspnea on exertion, and daily sputum production. He is a 50-pack-year smoker but is otherwise healthy. Examination shows markedly decreased breath sounds with mild wheezing at the end of expiration. Spirometry is performed: FVC is 2.3 L. FEV1 is 1.5 L (60% of predicted). The FEV1 /FVC ratio is 65%. Which of the following interventions will be most effective for improving this patient's long-term survival? a) Inhaled corticosteroids b) Inhaled ipratropium c) Long-term oral corticosteroids d) Smoking cessation

Topic Pulmonary Medicine Answer D. Smoking cessation Explanation Smoking cessation is the single most effective and cost-effective intervention for slowing the progression of COPD. After 1 year of smoking cessation, the rate of decline of lung function can approximate the rate of decline of a nonsmoker. Counseling patients to stop smoking, even if only a brief encounter, can be an effective intervention. Additionally, it has been shown that multimodality efforts toward smoking cessation, including counseling, ongoing support, nicotine replacement, and pharmacology are more effective in combination than individually. Inhaled corticosteroids and ipratropium may reduce hospitalization rates in patients with moderate-to-severe COPD, but they failed to slow the rate of decline of FEV1 in large randomized controlled trials. It is unlikely that either of these medications has a positive impact on long-term survival in stable COPD patients. Oral corticosteroids do not benefit most patients with COPD and can cause severe adverse effects. To date, no pharmacologic intervention for COPD has been shown to reduce mortality.

A 60-year-old man with COPD on chronic bronchodilator therapy and theophylline visits a local "doc-in-the-box" and receives a prescription for an antibiotic for "bronchitis." He begins his medication but 3 days later returns to you with nausea, vomiting, and tremulousness. Which of the following is the likely explanation for his new symptoms? a) He stopped taking his theophylline. b) The antibiotic he was given was amoxicillin. c) The antibiotic he was given was cefazolin. d) The antibiotic he was given was ciprofloxacin. e) The antibiotic he was given was gatifloxacin.

Topic Pulmonary Medicine Answer D. The antibiotic he was given was ciprofloxacin. Explanation Ciprofloxacin when given to a patient on theophylline can raise the theophylline levels into the toxic range. Therefore, never use both drugs in combination. Gatifloxacin and the newer quinolones do not have this effect. Amoxicillin and cefazolin would not cause this problem. Stopping the theophylline would not cause him to have nausea, vomiting, and tremulousness. Other drugs that increase theophylline levels include cimetidine, erythromycin, propranolol, and tetracycline.

A 57-year-old man with a history of obesity and hypertension presents to the emergency department complaining of dizziness, weakness, and dyspnea on exertion. This has been occurring for one day but continues to escalate. He denies chest pain or calf tenderness. He recently traveled overseas on a 6-hour flight and returned seven days prior to presentation. Physical examination reveals: HR: 105, BP: 132/76, RR: 22, 87% oxygen saturations on room air. Chest radiograph is unremarkable, and the ECG reveals sinus tachycardia. Chest CT angiogram demonstrates a saddle pulmonary embolus in the main pulmonary arterial trunk. Transthoracic echocardiogram reveals evidence of acute right heart strain, with moderate reduction in the right ventricular systolic function. There is also tricuspid regurgitation with pulmonary hypertension. Computed tomography of the head is normal and reveals no cause for dizziness. He has no known contraindications to anticoagulation. How should the echocardiographic findings of right ventricular strain alter management of this patient? a) The patient is at increased risk for recurrent PE and should receive LMWH rather than warfarin. b) The patient is at increased risk for shock or death from PE and should receive thrombolytic therapy. c) The patient is at increased risk for ongoing embolization and should receive a vena caval interruption device. d) The patient is at increased risk for shock or death from PE and should receive more intensive monitoring.

Topic Pulmonary Medicine Answer D. The patient is at increased risk for shock or death from PE and should receive more intensive monitoring. Explanation Most patients with pulmonary embolus will have a normal echocardiogram. When evidence of right ventricular strain is present on echocardiogram, this is associated with an increased risk of death from PE. Even if patients are hemodynamically stable when the echocardiogram reveals right ventricular compromise, 10% of such patients will develop shock, and 5-10% will die in the hospital. Given the risk for clinical worsening, these patients should be closely monitored in high levels of care such as in an intensive care unit. Although some physicians advocate more aggressive treatment for such patients, such as thrombolysis or venal caval filter, these have not been proven to improve mortality. There is some evidence to suggest that those patients who present with RV strain have a higher risk for recurrent VTE; different regimens have not been thoroughly studied to show a difference in recurrence between warfarin and LMWH. The exception is for the patient population with solid tumor malignancy.

If prophylaxis is not given, which of the following patients is considered at highest risk for pulmonary embolism? a) A 35-year-old woman undergoing hysterectomy b) A 30-year-old man undergoing tonsillectomy c) A 90-year-old man undergoing cataract surgery d) A 50-year-old woman undergoing hysterectomy e) A 50-year-old man undergoing knee replacement

Topic Pulmonary Medicine Answer E. A 50-year-old man undergoing knee replacement Explanation Knee replacement surgery has the highest risk—approaching 70% if prophylaxis is not given. This is closely followed by hip replacement surgery. Other very high-risk surgeries include extensive pelvic/abdominal surgery for cancer. Moderate-risk include patients undergoing any other surgery who are older than 40. CHF and those with pneumonias also are at moderate risk. Lower-risk procedures include all immobilized patients and patients under age 40 undergoing thoracic, gynecologic, or abdominal surgery. Cataract surgery has very low risk. So, on the Boards, look out for the person who is having or has had a knee or hip replacement and who presents with shortness of breath!

A 26-year-old female with asthma presents to your office for routine follow-up. She was diagnosed with asthma at age 16 and required ICU admission once at age 17. She has never been on a ventilator. She is adherent to her asthma regimen. Review of systems is positive for daily wheezing, requiring inhaled bronchodilators, and nocturnal coughing 3x/week that wake her from sleep. Meds: Beclomethasone 80 mcg bid Albuterol MDI prn PE: Normal vital signs No jugular venous distention Lungs with symmetric expansion, resonant to percussion, clear to auscultation Which of the following is the most appropriate next step in patient care? a) Add ipratropium bromide bid. b) Add montelukast daily. c) Add theophylline. d) Increase beclomethasone to 320 mcg bid. e) Add salmeterol bid.

Topic Pulmonary Medicine Answer E. Add salmeterol bid. Explanation This is a common question on Board exams requiring you to determine whether a patient's asthma is controlled. Because the patient is on long-standing asthma medications, you will assess her level of "control" (remember that "severity" assessments are made at initial presentation in patients not yet prescribed long-term control medications). First determine the treatment "step" the patient is receiving now: low-dose ICS +prn SABA (Step 2 treatment). Next, determine how well the Step 2 treatment is controlling her asthma. From the asthma guidelines, note that daily symptoms indicate "very poorly controlled" disease, and nocturnal symptoms 3x/week indicate "not well-controlled" disease. Therefore, assign her the most severe classification of "very poorly controlled." Next determine how to manage a patient whose asthma is very poorly controlled. The recommendation is to consider a short course of systemic steroids, and step up her treatment regimen 1-2 steps. Increasing this patient's regimen by 1-2 steps would include adding either a LABA and/or increasing her inhaled steroids to medium-dose. Of the choices listed, adding salmeterol (a LABA) is the only correct answer. Theophylline and montelukast additions to low-dose ICS are only alternatives to the preferred Step 3 treatment, and alternative options should not take precedence over the preferred Step 3 recommendation. 360 mcg of beclomethasone is the highest available dose of this medication and would be considered Step 5 treatment. A LABA should be added prior to increasing an ICS to the highest dose. Ipratropium is not used in the outpatient control of persistent asthma. Certainly, you should consider whether this patient needs a dose of oral corticosteroids. You could make this assessment by performing a post-bronchodilator FEV 1 measurement. However, prescribing corticosteroids is not a choice in the list of answers.

You are presented with an HIV-infected patient with possible tuberculosis versus atypical mycobacterium lung infection. Which of the following would make you lean more toward tuberculosis as an etiology? a) HIV for 20 years. b) CD4 of 20. c) Taking trimethoprim/sulfamethoxazole for prophylaxis. d) Acid fast smears of the sputum are negative. e) CD4 of 450.

Topic Pulmonary Medicine Answer E. CD4 of 450. Explanation Having a CD4 count that high would go very much against MAI/MAC as an etiology. Tuberculosis would be much more likely. None of the other factors by themselves would help differentiate tuberculosis from MAI/MAC.

You are seeing a 46-year-old man who was raised in rural Mississippi. On a routine CXR (done by another physician), a 5-mm nodule was found in his left upper lobe. The nodule has some calcifications in it. He does not smoke. He has never had a CXR before. PAST MEDICAL HISTORY: Negative SOCIAL HISTORY: Teaches 9th grade Art at the local high school Lives alone Quit smoking 20 years ago FAMILY HISTORY: Mother 72; MI 2 years ago; doing well now Father 66; MI 1 year ago; doing well Brother 42; healthy REVIEW OF SYSTEMS: No weight loss No night sweats No fever No chills No cough No rashes No travel history PHYSICAL EXAMINATION: BP 120/70, P 90, RR 13, T 98.6° F HEENT: PERRLA, EOMI TMs clear Throat clear Neck: Supple Heart: RRR without murmurs, rubs, or gallops Lungs: Clear to auscultation Abdomen: Bowel sounds present; no hepatosplenomegaly Extremities: No cyanosis, clubbing, or edema Skin: No masses or rashes LABORATORY: CXR: 5-mm calcified nodule seen in mid-left upper lung field Which of the following should you do next to work up this nodule? a) Repeat CXR in 1 month. b) Place PPD. c) No further workup is needed. d) V/Q scan. e) CT of chest to evaluate the nodule.

Topic Pulmonary Medicine Answer E. CT of chest to evaluate the nodule. Explanation Calcified nodules are usually benign; however, increasing evidence has shown that almost all nodules need an initial CT scan. Then if things look OK, serial CT scans to follow up. Even though this patient is low-risk and this is likely old histoplasmosis, it warrants workup. This has been a change in thinking with the goal being not to miss any resectable lung cancers. For this patient, if the 5-mm nodule appears to be consistent with a benign lesion, repeat CT would be done in 6 to 12 months; if this shows no change, then it would be safe to stop surveillance. If changed, resection is warranted. Of note is that if he had a "popcorn" calcified pattern, this likely would be a hamartoma, but you would still check a CT scan and follow as indicated to be sure. Solitary nodules without calcifications are also watched with serial CT scans. If the patient is higher-risk (smoker, family history, etc.), these scans may be repeated in 3 months if the initial scan appears non-cancerous. Many would just proceed with excision, particularly if there are suspicions of malignancy.

A 27-year-old young woman came to the Emergency Department complaining of pleuritic chest pain of several hours duration. She was not a smoker but gave a history of using birth control pills. Her chest x-ray and physical exam were normal except for splinting with deep inspirations. Arterial blood gas showed pH 7.45, PaCO2 31 mmHg, HCO3 21 mEq/L, PaO2 83 mmHg (breathing ambient air; PB 747 mmHg). What should be the next step in management? a) Discharge with pain medication. b) Consider SSRI for panic attacks. c) Start PO fluoroquinolone for treatment of pneumonia. d) Start bicarbonate infusion. e) Diagnostic imaging to exclude pulmonary embolus.

Topic Pulmonary Medicine Answer E. Diagnostic imaging to exclude pulmonary embolus. Explanation This young woman's PaO2 often is judged "normal," and so an abnormality in oxygen transfer may be missed. The calculated PaO2 is 108.25mmHg. Her P(A-a)O2 was elevated at 25 mmHg (108 minus 83), indicating a state of V-Q imbalance, and therefore some parenchymal lung disease or abnormality. With her history of using oral contraceptives and symptoms, consideration for the diagnosis of pulmonary embolism must be made. Hence, risk stratification and imaging, such as chest CTA or V/Q scan, should be ordered. Discharge with a pain medication or treatment with an SSRI for panic attacks would not be indicated given the elevated A-a gradient and may miss an important diagnosis. Bicarbonate infusion has a limited role in the setting of metabolic acidosis. Furthermore, this patient has a normal pH, so infusion of bicarbonate likely will not be beneficial and may in fact be harmful. There is no evidence of pneumonia on chest radiograph, so antibiotics for this specific indication would not be appropriate.

A 25-year-old pregnant woman presents at 22 weeks for evaluation with dyspnea and pleuritic type chest pain. She says that she has had progressive left leg swelling for the past 6 days. A room air ABG is obtained and shows: pH 7.48, PaCO2 23, PaO2 80. What is the best diagnostic test to do at this point? a) Pulmonary angiography b) D-dimer c) V/Q scan d) Bilateral venography e) Duplex ultrasonography

Topic Pulmonary Medicine Answer E. Duplex ultrasonography Explanation She is pregnant, she has all the symptoms of DVT, right? The duplex ultrasound is the best test from the list. It won't require an invasive test like V/Q, but note—a V/Q is safe during pregnancy if needed. If V/Q results were indeterminate, an additional study would still be needed for diagnosis. The other radiologic tests are not safe in pregnancy. The D-dimer test would not be helpful—if it is positive, you still have to do some study to evaluate the leg; if it is negative, you can't ignore the swollen leg. The D-dimer is useful in a low-probability setting to rule out disease; it is not helpful in a high probability setting, especially in the face of a likely DVT.

A 30-year-old woman comes to your office complaining of shortness of breath. She states that she first noticed the shortness of breath 6 months ago. She is fine at rest but cannot go jogging any longer due to shortness of breath, and she is awakened at night once or twice a week with a feeling that she can't catch her breath. She denies fever, cough, sputum production, orthopnea, or chest pain. On exam, she is a well-appearing female in no apparent distress. The cardiovascular exam is normal, and auscultation of the lungs is normal. There is no leg edema, clubbing, or cyanosis. You perform routine blood work that indicates a normal CBC and chemistries. A chest x-ray is normal, and spirometry done in the office is normal. An arterial blood gas on room air shows pH 7.41, pCO2 40 mmHg, and pO2 of 90 mmHg. Which of the following diagnostic tests would you perform next? a) Full pulmonary function tests with diffusing capacity determination b) Flow-volume loop c) High-resolution CT (HRCT) of the chest d) Echocardiography e) Exercise challenge test

Topic Pulmonary Medicine Answer E. Exercise challenge test Explanation With a normal cardiovascular and pulmonary exam, the most likely cause of the episodic dyspnea in this patient under 40 years of age is exercise-induced bronchospasm (EIB). Because this bronchospasm is episodic and a reversible airways obstruction, spirometry performed while the patient is asymptomatic may well be normal. An exercise challenge test is the most direct way to establish a diagnosis of EIB. This usually involves 6 to 8 minutes of ergometer or treadmill exercise, sufficient to raise the heart rate to 85% of the predicted maximum. A test is generally considered positive if the FEV1 falls by 10% or more, although a fall of 15% is more diagnostic. Alternatively, surrogate tests to assess bronchial hyperresponsiveness (e.g., cold air hyperventilation, methacholine or histamine inhalation challenge) may be performed in specialized laboratories but do not always correlate with the presence of EIB. If the patient had rales on the exam and was older, the possibility of an interstitial lung disease would have to be entertained, and an HRCT of the chest would be indicated. Remember: 10% of patients with interstitial lung disease will have a normal chest x-ray at the time of presentation. If the patient gave a history of chest pain or syncope with exertion and physical exam revealed a right parasternal heave and an accentuated P2, then the diagnosis of pulmonary hypertension by echocardiography would be warranted. If an upper airway obstruction was suggested by the history or the patient was found to have stridor, a flow-volume loop would be a good screening test for upper airway obstruction. A normal ABG with a normal A-a gradient would make a diffusing capacity limitation unlikely.

A 40-year-old woman with sarcoidosis that is under fairly good control comes in today for a routine checkup and is noted to have a BP of 150/95. In reviewing her file, you note that the last time she came in she also had an elevated BP, and you had recommended dietary changes as well as weight loss. She has attempted these but evidently will require a pharmacologic agent to control her hypertension. Her current routine laboratory studies are normal. Which of the following is the best agent for her to use? a) Thiazide diuretic b) Loop diuretic c) Atenolol d) Calcium channel blocker e) Fosinopril

Topic Pulmonary Medicine Answer E. Fosinopril Explanation Think about it—what is frequently elevated in sarcoid patients? ACE-levels! So, if they have hypertension, the first drug to try is an ACE-inhibitor.

What is eosinophilic granulomatosis in association with lytic bone lesions, diabetes insipidus, and exophthalmus called? a) Maple-syrup lung disease b) Treacher-Collins syndrome c) Löffler syndrome d) Hannaman-Cross syndrome e) Hand-Schüller-Christian syndrome

Topic Pulmonary Medicine Answer E. Hand-Schüller-Christian syndrome Explanation Just something stupid to memorize. Actually look for it on the Boards. They are likely to give you the lytic bone lesions, diabetes insipidus, and exophthalmus and ask you what you would look for on lung biopsy—eosinophilic granulomatosis. Treacher-Collins syndrome is associated with malar hypoplasia and a cleft in the zygoma. Loeffler's syndrome is associated with pulmonary infiltrates and peripheral eosinophilia usually due to Ascaris or other worm migrating through the lung. Maple-syrup lung disease and Hannaman-Cross syndrome do not exist.

A 62-year-old male presents with a 3-year history of dyspnea on exertion. He has a chronic dry cough without any specific triggers. He is a lifelong nonsmoker and spent most of his working life in a chemical plant dealing with petroleum. His oxygen saturation at rest is 93% but decreases to 86% with exertion after 3 minutes. He has digital clubbing but no cyanosis or edema. His lung exam reveals dry, coarse inspiratory crackles without wheezing. A chest CT is performed. It reveals bibasilar fibrosis with traction bronchiectasis and subpleural blebs without any ground glass abnormalities. The patient is sent for surgical lung biopsy, and the pathology is read as "UIP pattern with fibroblastic foci, temporal heterogeneity, honeycombing appearance, and minimal inflammation." What is the most likely diagnosis? a) Asbestosis b) Acute respiratory distress syndrome c) Sarcoidosis d) Emphysema e) Idiopathic pulmonary fibrosis

Topic Pulmonary Medicine Answer E. Idiopathic pulmonary fibrosis Explanation Idiopathic pulmonary fibrosis (IPF) is a diagnosis of exclusion with histopathologic findings of usual interstitial pneumonitis (UIP). Heterogenous changes are noted on biopsy ranging in stages from early with inflammation to late with severe fibrosis. Patients generally present in middle age with dry cough and progressive dyspnea. Biopsy will confirm the diagnosis of UIP or exclude other diagnosis. However, in the absence of any evidence to support an alternative diagnosis (serologic tests, drug/toxin/occupational exposure, other history), and then radiographic evidence on chest CT, this may be adequate to make a diagnosis without surgical lung biopsy. Characteristic radiographic findings include bibasilar reticular opacities, minimal ground glass opacities, honeycombing, and traction bronchiectasis. Sarcoidosis can present with areas of fibrosis along with areas of inflammation, but biopsy typically will reveal non-caseating granulomas. Acute respiratory distress syndrome is a rapid onset disorder that leads to respiratory failure. This patient's history is more insidious in onset, so it is inconsistent. Emphysema will not have the chest CT findings or physical exam findings of crackles. A biopsy would reveal emphysematous areas of lungs with destroyed alveolar walls. Asbestosis does cause pulmonary fibrosis with similar radiographic and pathologic findings of IPF. However, there is no history to suggest asbestos exposure, so asbestosis would be unlikely.

A 30-year-old female comes to your office with complaints of dyspnea, cough, and wheezing for the past 4 months. She reports that initially the symptoms were related only to exercise, which forced her to stop her aerobic workouts. Now she has daily symptoms even at rest and awakens several nights a week with wheezing. She is a nonsmoker. She denies any particular environmental factors and had no respiratory problems until now. On exam, she has a very mild end-expiratory wheeze. Office spirometry reveals a reduced FEV1 and FEV1/FVC at 70% predicted. Which of the following is the best initial treatment plan? a) Inhaled beta2-agonist, every 4-6 hours b) Inhaled cromolyn, 4 times a day c) Low-dose inhaled corticosteroid alone d) Sustained release theophylline, twice a day e) Inhaled corticosteroid plus long-acting beta-agonist

Topic Pulmonary Medicine Answer E. Inhaled corticosteroid plus long-acting beta-agonist Explanation This patient has asthma that would be characterized as moderate-persistent by the National Asthma Education and Prevention Program Guidelines. As such, she should be on daily medication with an inhaled corticosteroid and a long-acting inhaled beta-agonist; alternatively, you could prescribe medium doses of an inhaled corticosteroid alone. The emphasis on utilizing antiinflammatory therapies (inhaled corticosteroids) was a major focus on the NAEPP guidelines for any asthma patient characterized as mild-persistent or greater. This was to overcome the over-reliance on symptomatic relief with beta2-agonist inhalers and the rising number of asthma deaths (most clutching their beta-agonist inhalers and on no steroids!). A beta2-agonist inhaler must be available for symptomatic relief with the understanding that more frequent use of the beta-agonist inhaler indicates a need for stepped-up antiinflammatory therapy (higher-dose inhaled steroids, PO prednisone). Sustained release theophylline may help with nocturnal symptoms but has no antiinflammatory action. Inhaled cromolyn alone can take weeks to start working and is best used in atopic asthma in children.

A usually healthy 38-year-old woman comes to you because of a 3-day history of pain and swelling of her right leg. She has smoked 1 pack of cigarettes daily for 20 years. Her only medication is oral contraceptives. Her pulse is 78 bpm and regular. Her right calf is edematous and tender. The peripheral arterial pulses are present and normal in upstroke. Venous duplex ultrasonography shows that the superficial and deep femoral veins are not compressible. Which of the following is the most appropriate next step in management? a) V/Q scan b) Insertion of an inferior vena cava (IVC) filter c) Observation d) Thrombolytic therapy e) Low-molecular-weight heparin therapy

Topic Pulmonary Medicine Answer E. Low-molecular-weight heparin therapy Explanation This patient has symptomatic calf thrombosis with propagation of the clot across the popliteal fossa into the deep circulation. Treatment goals should be aimed at stabilizing the clot, preventing it from becoming larger, and preventing new clots from forming in other vessels. Some form of heparin followed by the oral administration of warfarin remains the mainstay of treatment. Subcutaneously administered low-molecular-weight (LMW) heparin and unfractionated heparin are equally effective. Heparin may be discontinued after the warfarin has maintained the INR in a therapeutic range, between 2 and 3, for 48 hours. The duration of warfarin therapy depends on the individual patient and is usually continued for at least 3 months. Alternatively, LMW heparin may be continued for the full duration of treatment and is preferred therapy in the pregnant female and in patients with cancer. Observation is incorrect because the DVT is causing symptoms. A V/Q scan is unnecessary because 1) she has no symptoms of a pulmonary embolism, and 2) even if a PE is present, management will be the same. The patient doesn't meet criteria for an IVC filter. Thrombolytics are used only in unstable patients.

A 33-year-old woman in your clinic has a chest CT (see below). She has mild, worsening airflow limitation on serial spirometry. She has increasing exertional dyspnea that is now significantly limiting her activity. She had a small, spontaneous pneumothorax last year that resolved without intervention. Alpha-1 antitrypsin levels were normal when checked at that time. She has never smoked, but her spouse does smoke. The most likely diagnosis is which of the following? a) Advanced emphysema from secondhand smoke b) Idiopathic pulmonary fibrosis Asthma c) Alpha-1-antitrypsin deficiency with advanced emphysema d) Lymphangioleiomyomatosis (LAM)

Topic Pulmonary Medicine Answer E. Lymphangioleiomyomatosis (LAM) Explanation This woman has sporadic lymphangioleiomyomatosis (LAM), a rare cystic lung disease caused by abnormal proliferation of smooth muscle cells that affects premenopausal women (average age 35) almost exclusively. Progressive exertional dyspnea with worsening airflow limitation, recurrent pneumothoraces, and chylous pleural effusions are the common clinical manifestations. 30-50% of women with sporadic LAM also have renal angiomyolipomas that are usually clinically silent. Tuberous sclerosis complex-associated LAM, another form of the condition, includes tumors in the brain, skin, and other organs, causing seizures and intellectual delay. The diagnosis of LAM can be made by high-resolution CT without biopsy in classic cases; lung biopsy (positive for the HMB-45 immunohistochemistry assay) may be required in others. LAM's major mimics on HRCT are pulmonary Langerhans cell histiocytoma and emphysema. In a trial, enrolling 89 women, those randomized to sirolimus had stable or improved lung function (FEV 1 and DLCO) and improved respiratory symptoms over 12 months of treatment, compared to those taking placebo. After stopping the drug, though, decline in lung function resumed. In an observational series, 12 women with chylous effusions due to LAM, who were treated with sirolimus, had marked improvement or resolution of their effusions. Lung transplantation is an important treatment option for severe cases of LAM. Early referral to a transplant center for those with severe disease seems prudent. Alpha-1-antitrypsin deficiency is a genetic disorder and not acquired—so it is ruled out by a previously normal Alpha-1-antitrypsin level. Idiopathic pulmonary fibrosis has a honeycombing and denser fibrotic changes on CT.

A 60-year-old male is sent to you by his orthopedist for pre-op clearance prior to elective hip arthroplasty. The patient has a history of asthma and is a nonsmoker, though admits to smoking 1 pack a day when he was in his 20s. He is on a steroid inhaler twice a day and reports that he uses his beta-agonist inhaler only once or twice a week. On physical exam, he is well appearing except for a limp in his right leg. His respiratory rate is 16/minute. Examination of the chest is normal with only a few scattered end-expiratory wheezes. The remainder of the physical examination is unremarkable. A peak flow done in the office is 90% of his predicted value. Which of the following is/are the most appropriate step(s) to take prior to your clearing the patient for surgery? a) You refuse to clear him for any elective surgery. b) Spirometry and arterial blood gasses with a carboxyhemoglobin level. c) Spirometry before surgery. d) Pulmonary consultation. e) No pulmonary function tests prior to surgery.

Topic Pulmonary Medicine Answer E. No pulmonary function tests prior to surgery. Explanation Preoperative PFTs and blood gasses are recommended for patients with underlying lung disease who are to undergo operative procedures that are in proximity to the diaphragm. An FEV1 less than 1 liter and arterial blood gases revealing hypoxemia and/or respiratory acidosis would place the patient at a higher risk for postoperative pulmonary complications (prolonged mechanical ventilation, pneumonia, atelectasis). This patient requires no further testing because his asthma is stable and the procedure is not in proximity to the diaphragm.

A 30-year-old health care worker was recently found to have a PPD of 12 mm on his routine screen. He is about to be started on INH therapy of 300 mg daily for 9 months. He is otherwise healthy and has no complaints. His CXR was normal. PAST MEDICAL HISTORY: Negative; except for gonorrhea at age 18 SOCIAL HISTORY: Lives with mother in a motel Drinks on occasion; 2 beers at most on a weekend FAMILY HISTORY: Mother 60, healthy; runs the motel Father died at age 30; murdered at the motel No siblings REVIEW OF SYSTEMS: Negative Denies fever, chills, sore throat Occasionally hears voices—knows they are not real PHYSICAL EXAMINATION: BP 110/70, P 55, RR 14, Temp 98.5° F Well-developed, well-nourished man in no distress HEENT: PERRLA, EOMI TMs clear Throat clear Neck: Supple, no masses Heart: RRR with S4 gallop (runs marathons) Lungs: Scattered rhonchi; cleared with cough Abdomen: No masses; no hepatosplenomegaly; nontender Extremities: No cyanosis, clubbing, or edema You are about to start him on INH. Of the following options, when should you check screening laboratory (AST, ALT, and bilirubin)? a) Today, then q month for 3 months; none after that unless has problems b) Today, then q month for 3 months, then every other month until completes therapy c) Today, then q month until therapy complete d) Today, then in 1 week, then q month until finishes therapy e) None needed unless clinical symptoms/problems develop

Topic Pulmonary Medicine Answer E. None needed unless clinical symptoms/problems develop Explanation He is a healthy person without evidence of liver disorder. If he had evidence during the initial evaluation to suggest a liver disorder, then you would draw baseline serum alanine aminotransferase (ALT) and bilirubin. Baseline testing is also indicated for patients with HIV infection treated with HAART, pregnant women, women in the immediate postpartum period (within 3 months of delivery), persons with a history of chronic liver disease (hepatitis B or C, alcoholic hepatitis, or cirrhosis), persons who use alcohol regularly, and persons at risk for chronic liver disease. Baseline testing is no longer absolutely indicated in older persons (> 35 years old), although some experts recommend that baseline and scheduled ALT testing be done in those older than 35 years. For patients with chronic conditions on medications that could cause problems, testing may be warranted. After baseline testing, individuals may be followed every 2-4 weeks depending on the severity of their clinical condition or if baseline laboratory is abnormal. All patients regardless of age or health status require clinical monitoring! This includes educating patients about signs and symptoms that might indicate a problem with the medication. These include any of the following: unexplained anorexia, nausea, vomiting, dark urine, icterus, rash, persistent paresthesias of the hand and feet, persistent fatigue, weakness or fever lasting 3 or more days, abdominal tenderness (especially right upper quadrant discomfort), easy bruising or bleeding, and arthralgia. Clinical monitoring begins at the first visit and should be done monthly.

A 45-year-old hospital orderly complains of progressive shortness of breath with ambulation for 2 weeks. Over the past week, he has also developed a nonproductive cough that is worse at night. He is otherwise healthy and does not smoke or use drugs. Lung exam: Symmetric excursions, decreased resonance to percussion, and reduced tactile fremitus at the left base CXR: Left pleural effusion TB skin test: 13 mm Induced sputum shows no acid-fast organisms Sputum NAA is pending. Thoracentesis: pH 7.20 Glucose 67 mg/dL LDH 1,162 IU/L Protein 6.5 g/dL Cells 133 cells/mm3 (30% neutrophils, 60% lymphocytes) Acid-fast smears show no organisms. Which of the following is the most appropriate next step in patient care? a) Intravenous ceftriaxone. b) No treatment and follow-up repeat CXR in 6 weeks. c) Oral prednisone. d) MRI of the chest with thin cuts through the diaphragm. e) Start isoniazid, rifampin, pyrazinamide, and ethambutol.

Topic Pulmonary Medicine Answer E. Start isoniazid, rifampin, pyrazinamide, and ethambutol. Explanation This question tests your knowledge of pleural tuberculosis. The case includes a health care worker with a TB skin test of 12 mm, which is positive (10 mm is the cut-off for a negative test in health care workers). Therefore, at minimum, this man has latent tuberculosis. Next, you must consider how the pleural effusion relates to his positive TB skin test. You are asked to recall that tuberculosis can variably present, and one manifestation is isolated disease of the pleural space. The pleural fluid has a slightly low glucose, lymphocyte predominance, and a pleural fluid LDH value of > 2/3 the normal value of serum (qualifying the fluid as an exudate); hence, the pleural fluid is highly suggestive of tuberculosis. The fact that the acid-fast smears do not show organisms does not exclude tuberculosis and is a rather common occurrence. This patient with a positive TB skin test and a pleural effusion consistent with tuberculosis should be evaluated next according to his risk for true tuberculosis. If he is truly at high risk for TB, he should be treated while undergoing further testing and awaiting cultures. If he is determined to be low risk, he can be observed. This patient would be high risk because he is a health care worker. Therefore, the correct answer is to start 4-drug therapy against tuberculosis. Further workup should include a repeat thoracentesis with multiple samples submitted for AFB smears and cultures and a pleural fluid ADA level. If the ADA level cannot be performed, a pleural biopsy is needed to send tissue for pathology and mycobacterial culture. Ceftriaxone is ineffective against tuberculosis. Prednisone is used in tuberculosis only in cases of CNS disease and TB pericarditis.

A 55-year-old male mail carrier is referred to your office from the hospital emergency department. He had been seen there after a fall on the ice, which left him with right-side pain. In the emergency department, he had a chest x-ray done to look for rib fractures. No rib fractures were found, but a 4-mm smooth, well-demarcated peripheral lesion was seen in the left lower lobe. He is a non-smoker and reports to be in good health. He denies any occupational exposures and enjoys the long walks while delivering the mail. His father is alive with hypertension; his mother died of breast cancer. He had a prior chest x-ray 1 year ago for a "rule-out" pneumonia office visit. Which of the following is the most appropriate next step? a) Thoracic surgery. b) Transthoracic needle biopsy. c) Bronchoscopy. d) Order sputums for AFB and fungus. e) Obtain prior chest x-rays for comparison.

Topic Pulmonary Medicine Answer E. Obtain prior chest x-rays for comparison. Explanation When a lung lesion is first identified in a patient, it is imperative to determine whether the lesion is, in fact, new or old. If the lesion is old, you want to evaluate the stability of the lesion (no appreciable growth over 2 years.) Therefore, the first step is to obtain any old films. If there are no prior films, the next step is a high-resolution CT scan of the chest to evaluate the presence of disease. Or, if the old films are suspicious for growth, the CT scan is also indicated. Generally, in most cases your next step after looking at old plain films is to proceed with a high-resolution CT scan. If abnormalities are demonstrated, then bronchoscopy is indicated (if the lesion is amenable) to look for endobronchial involvement and rule out an infectious etiology for the lesion. If bronchoscopy is not helpful, there is some controversy as to whether it is best to perform transthoracic needle biopsy or just go to surgical removal of the lesion. The decision involves whether your patient would tolerate a thoracotomy and whether a non-diagnostic transthoracic needle biopsy (atypia, inflammatory Schmutz) would just mandate a thoracotomy anyway.

A 43-year-old female is referred to your office for an abnormal chest CT. About 3 weeks ago, she had RUQ abdominal pain and underwent an abdominal CT. She was diagnosed with cholecystitis and underwent a laparoscopic cholecystectomy. An incidental finding of an oval-shaped right lower lobe lung nodule was noted. It is characterized as calcified and about 3 x 4 mm in size. A chest CT was then performed that confirmed these findings without any other abnormalities. The patient has a PMH notable for hypertension for which she takes an ACE inhibitor. She is a lifelong nonsmoker and works in an office environment. There is no family history of malignancy. What would you recommend for this patient? a) Referral to a thoracic surgeon for surgical resection of the nodule. b) Obtain a PET scan. c) CT guided biopsy of nodule. d) Repeat chest CT scan every 6 months for a total of 2 years to ensure stability. e) Reassurance with no further follow-up.

Topic Pulmonary Medicine Answer E. Reassurance with no further follow-up. Explanation This patient has the incidental finding of a very small lung nodule. She has no clear risk factors for malignancy, including age < 50, nonsmoker, and no personal or family history of malignancy. Furthermore, the nodule is calcified, which strongly suggests chronicity and a very low likelihood of malignancy. Finally, this nodule is very small. Current guidelines would support optional follow-up for a nodule < 4 mm in a low-risk patient. None of the options of an intervention to either remove or diagnose the nodule would be appropriate. A PET scan would only be indicated for nodules > 8 mm in size in those with moderate-to-high risk factors for malignancy. Repeat chest CT scan in 12 months could be considered for patient reassurance but more frequent surveillance would not be appropriate.

A 65-year-old man presents with progressive dyspnea on exertion associated with a dry cough. This has been occurring for over two years. He has a 25 pack-year history of smoking. Occupational history includes over 30 years working in a factory that manufactured glass bowls and vases, as well as 2 years working in an auto body shop doing brake repair jobs. His chest radiograph is described as: "bilateral apical regions of parenchymal fibrosis with coalescent areas of consolidation." Previous testing indicates an FEV1/FVC ratio of 80%, FEV1 that is 1.5 L (56% predicted), and a TLC of 3.50 L (50% predicted). Which of the following occupational causes of interstitial lung disease is associated with a higher risk of tuberculosis? a) Berylliosis b) Byssinosis c) Coal worker's pneumoconiosis d) Asbestosis e) Silicosis

Topic Pulmonary Medicine Answer E. Silicosis Explanation Silicosis is an occupational lung disease characterized by restrictive lung function. Occupational exposures include any exposure to silica dust, which can occur in mining, stone cutting, quarrying, road and building construction, glass manufacturing, and sand blasting. Typically, patients will have biapical distribution of parenchymal lung disease but often will have areas of "eggshell calcification" of hilar lymph nodes. Silicosis is associated with a higher risk of contracting tuberculosis and developing lung cancer as well as strong association with scleroderma and rheumatoid arthritis. Coal worker's pneumoconiosis will have similar radiographic and PFTS findings to silicosis. Eggshell calcification is not associated with this, and there is no increased risk of TB or cancer. Berylliosis is seen in patients with exposure to electronics, nuclear material, or ceramics. Radiographically, it presents with bilateral hilar lymphadenopathy, similar to the appearance of sarcoidosis. Asbestos exposure does carry an increased risk of developing lung cancer, but this association is not seen for tuberculosis. Byssinosis is related to exposure to impurities in cotton, flax, and hemp dusts. It often develops after >10 years of exposure and is associated with a temporal relationship to exposures. For example, patients may complain of difficulty of breathing on the first day of the workweek. It is associated with a gram-negative exotoxin but not tuberculosis.

A 50-year-old man was placed on mechanical ventilation yesterday due to a pulmonary embolism that resulted in respiratory failure. It appears he now has developed ARDS. You have managed his ventilator settings adequately and have told the family that he will likely require prolonged mechanical ventilation before he starts to improve. He appears to be stable at 24 hours out. PAST MEDICAL HISTORY: Negative SOCIAL HISTORY: Negative FAMILY HISTORY: Negative REVIEW OF SYSTEMS: Negative (this is a rather boring case for a change) PHYSICAL EXAMINATION: HEENT: PERRLA, EOMI TMs clear Intubated Neck: No masses Heart: RRR with no murmurs, rubs, or gallops Lungs: Coarse BS without other focal findings Abdomen: Bowel sounds present; no hepatosplenomegaly Extremities: No cyanosis, clubbing, or edema Knowing that he will be on the ventilator for a prolonged period of time, which of the following would be an appropriate nutritional intervention? a) Continue NPO status another 24 hours. b) Start parenteral TPN feeds. c) Start peripheral TPN feeds. d) Continue NPO status until you are assured he is stable. e) Start enteral feeding.

Topic Pulmonary Medicine Answer E. Start enteral feeding. Explanation Enteral feeds are preferred over TPN because enteral feeds will maintain the intestinal epithelium and its natural defenses against bacteria. There is no reason to make this patient NPO. Pulmonary ventilation, alveolar gas exchange, or a combination of these 2 elements can affect respiratory compromise

A 40-year-old distance runner presents with a new diagnosis of lymphoma. She has been doing well but presents with new-onset pleural effusion. A pleural tap is done and shows white-appearing exudative fluid. Which of the following is causing the fluid to be white? a) The WBC of the fluid is > 1,000, and there are clumped WBCs causing the whitish color. b) The rheumatoid factor of the fluid is high, and the RF causes a whitish color. c) The triglyceride level of the fluid is < 50 mg/dL, and cholesterol causes the whitish color. d) The calcium level of the fluid is > 10 mg/dL, and there are calcium globules causing the whitish color. e) The triglyceride level of the fluid is > 115 mg/dL, and there are chylomicrons causing the whitish color

Topic Pulmonary Medicine Answer E. The triglyceride level of the fluid is > 115 mg/dL, and there are chylomicrons causing the whitish color. Explanation She has a chylous effusion that is associated with leakage of thoracic duct lymph. It is most commonly seen in trauma, lymphoma, mediastinal cancer/fibrosis, and lymphangioleiomyomatosis. Pseudochylous effusions are associated with chronic inflammatory processes such as tuberculosis or rheumatoid arthritis lung disease and have a triglyceride level < 50 mg/dL but an elevated cholesterol level of > 250. In this patient, the white effusion is due to chylomicrons with elevated triglycerides.

A 60-year-old man presents to your office for routine yearly follow-up. He has mild hypertension for which he takes lisinopril. He is otherwise healthy. He denies cough or shortness of breath. He used to smoke 1 ppd of cigarettes for 20 years but quit 6 years ago. He works in a manufacturing plant, and as part of the yearly physical, he underwent Pulmonary Function Tests. The results are as follows: FEV1/FVC 65%, FEV1 2.4 L (82% predicted). There was no bronchodilator response. A chest radiograph was read as "unremarkable." Which one of the following recommendations would be most appropriate for this patient? a) Start nocturnal oxygen. b) Start long-acting anti-cholinergic agent once daily. c) Start long-acting beta-agonist twice daily. d) Initiate pulmonary rehab program. e) Vaccinate for influenza annually.

Topic Pulmonary Medicine Answer E. Vaccinate for influenza annually. Explanation This case scenario outlines a patient with asymptomatic fixed airflow obstruction with a significant smoking history, most consistent with a diagnosis of chronic obstructive pulmonary disease (COPD). Based on his spirometry, he has GOLD Criteria Stage I COPD. Guidelines would recommend yearly influenza vaccination, short-acting bronchodilator as needed, and routine spirometric follow-up annually. Long-acting beta-agonists and anti-cholinergics are considered for patients with symptoms and Stage II or more severe COPD. They have been shown to improve symptoms and reduce the number of exacerbations in this patient population. Pulmonary rehabilitation should also be considered in this same group and has been shown to improve exercise capacity, decrease hospitalizations, and enhance quality of life. This scenario doesn't provide data regarding oxygen testing, so this therapy would not be initiated based on the available information. However, oxygen therapy has been shown to increase survival in those patients with documented oxygen desaturations if used for > 15 hours/day.