Pulmonology Review

Which of the following is a common, non-pulmonary sequelae of cystic fibrosis?

male infertility

A 76-year-old man with chronic obstructive pulmonary disease (COPD) presents complaining of 3 weeks of cough and progressive dyspnea on exertion in the setting of a 20 pound weight loss. He is a 60 pack-year smoker, worked as a shipbuilder 30 years ago, and recently traveled to Ohio to visit family. Chest radiograph shows increased bronchovascular markings, reticular parenchymal opacities, and multiple pleural plaques. Labs are unremarkable except for a slight anemia. What is he mostly likely to have and which of the following is the most likely finding on this patient's chest CT?

malignancy CT finding: lower lobe cavitary mass most likely to have bronchogenic carcinoma, more specifically squamous cell carcinoma given his asbestos exposure (from shipbuilding) and smoking history. A CT scan of squamous cell carcinoma would most likely show a lower lobe mass with cavitation.

positive cold agglutinin titer

mycoplasma pneumonia

theophylline side effect

nausea, fast heartbeat, and tremor

Decreased FEV1/FVC ratio

obstructive pattern

dullness to percussion, decreased fremitus

pleural effusion pleural lining is filled = dullness to percussion but not true LUNG consolidation hence decreased fremitus

A 64-year-old man with hypertension, coronary artery disease, and poorly-controlled left ventricular congestive heart failure presents with a 3-day history of insidious chest pain. Pain is made worse when he takes a deep breath in and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, abdominal pain, nausea, vomiting, diarrhea, or peripheral edema. His physical exam reveals a widespread friction rub upon inspiration, absent lung fremitus, and reduced lung sounds over the thoracic cavity. Question What additional physical exam finding would be most likely expected in this patient? Vesicular breath sounds Dullness to percussion Tracheal shift to the affected side Chest wall tenderness

pleural effusion; dullness to percussion

lobar consolidation

pneumococcal pneumonia, CAP

dullness to percussion, increased fremitus

pneumonia consolidation

Asthma CXR findings

typically normal hyperinflation bronchial wall thickening

Pathogens for CAP

unidentified mycoplasma strep pneumonia haemophilus influenza

Pathogens for HAP

unidentified staph aureus pseudomonas aeriginosa

Which of the following physical examination findings would be consistent with a pleural effusion? increased TF positive egophony unilateral lag on chest expansion

unilateral lag on chest expansion

tx for silicosis

usually supportive like o2, smoking cessation exacerbations: prednisone

VATS

video-assisted thoracic surgery used for PNEUMOTHORAX

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

viral pneumonia

Normal FVC

> 80%

Normal FEV1

> 80%

d-dimer test

(+) = bad (=) = good is a global marker of coagulation activation and measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is used for the diagnosis of DVT when the patient has few clinical signs and stratifies patients into a high-risk category for reoccurrence. Useful as an adjunct to noninvasive testing, a negative D-dimer test can exclude a DVT without an ultrasound.

On a shift in the emergency department, several arterial blood gasses are drawn from different patients at approximately the same time. When preparing the tubes for transport to the labs the samples are mixed up. One such sample had the following values: pH 7.3, PCO2 50, HCO3 25. Which of the following patients most likely had this result? 17-year-old with an acute asthma attack 14-year-old with diabetic ketoacidosis

17-year-old with an acute asthma attack

pneumonococcal vaccine

2, 4, 6, 12-15 months: PCV13 or PCV15 (everyone) 19-64 years old: PCV20 or PCV15 with PPSV23 1 year later (certain chronic medical consitions) >65: PCV20 or PCV15 with PPSV23 1 year later (everyone)

An O2 sat of 90% corresponds to a PaO2 of

60 mmHg

Which imaging technique to increased visualization of a pulmonary embolism?

A and lateral chest X-ray views may show blunting of the costophrenic angles in patients who have a pleural effusion once at least 250 mLs of fluid have accumulated. Chest radiographs taken in the lateral decubitus position and chest computed tomography (CT) scans are more sensitive and can identify a pleural effusion with less than 10 mL of accumulated fluid.

Pneumothorax TF and percussion findings

A pneumothorax is characterized by decreased to absent tactile fremitus, but would have a hyperresonant percussion note, not dullness.

A 36 year-old male who is hospitalized because of severe injuries from a motor vehicle accident develops rapid onset of profound dyspnea. Initial chest x-ray shows a normal heart size with diffuse bilateral infiltrates. Follow-up chest x- ray shows confluent bilateral infiltrates that spare the costophrenic angles. What do you suspect they have? Which of the following is the best clinical intervention for this patient?

ARDS, tracheal intubation

A patient is brought to the emergency room with acute onset of dyspnea and tachypnea. He has a long history of alcoholism and was involved in a motor vehicle accident two days ago. He is hypoxic with crackles auscultated bilaterally. Chest radiography reveals diffuse bilateral infiltrates which spare the costophrenic angle and air bronchograms, there was no cardiomegaly or pleural effusion noted. Oxygen saturation is 70%. What does he have and which of the following is the most important initial treatment?

ARDS, tracheal intubation Tracheal intubation with lowest level of PEEP is required to maintain the PaO2 above 60mmHg or SaO2 above 90% in a patient with ARDS. Tracheal intubation is not the same as a tracheostomy

Absolute and relative contraindications to fibrinolytic therapy for DVT and PE

Absolute: prior intracranial hemorrhage, cerebral vascular lesion, malignant intracranial neoplasm, ischemic stroke within 3 months, aortic dissection, active bleeding, close-head trauma or facial trauma within 3 months Relative: Recent invasive procedure, SBP > 200mmHg

A 16-year-old boy presents to the office with a two-week history of runny nose, sore throat, and nasal congestion. He developed a productive cough with yellowish sputum about one week ago that has not improved. He complains of some fatigue but no body aches or malaise. A rapid influenza test is negative. Upon physical exam, he has a fever of 101.0°F, and there are mild diffuse wheezes throughout the lungs posteriorly on auscultation. Which of the following is the most appropriate next step in management? Recommend rest, fluids, and symptomatic treatment with antitussives and cough suppressants Obtain a CXR

Acute bronchitis obtain a CXR because 2 week long symptoms and suspicious for pneumonia

A 28-year-old man with a history of crack cocaine abuse is rushed in to the emergency room. His mother found him in his apartment; he was cyanotic and severely short of breath. No other history is available. Examination reveals a young man in severe respiratory distress with temperature 99.2°F, pulse 102/min, respiration 40/min, BP 165/95 mm Hg, and pulse oximetry of 66%. He was intubated at his apartment by EMS personnel because of lack of improvement of his pulse oximetry on 100% non-rebreathing mask. His chest X-ray shows bilateral alveolar and interstitial infiltrates. The arterial blood gas on the mechanical ventilation (set at a rate of 12 cycles/min, tidal volume 500 mL) shows the following: PAO2/Fi02 ratio = 100 mm Hg, pH 7.52, PCO2 30, PO2 55, and O2 saturation 88%. Question What can be done to improve his oxygenation? Increase tidal volume Increase respiratory rate Add positive end-expiratory pressure Add positive end-inspiratory pressure Perform emergent thoracentesis.

Add positive end-expiratory pressure Acute respiratory distress syndrome (ARDS) is an acute lung injury in which the ratio of PaO2/FIO2 is ≤200 and there are bilateral interstitial infiltrates with no evidence of raised left atrial pressure. Common etiologies are aspiration, sepsis, pancreatitis, toxic inhalation burns, multiple blood transfusions, drugs, and trauma. ARDS is characterized by dyspnea, tachypnea, rales, bilateral infiltrates, marked hypoxemia not corrected by O2 and leukocytosis. Multi-organ failure may also be present. Treatment of ARDS includes identifying and treating the underlying condition and cardiopulmonary support. No pharmacological agents have been shown to be beneficial. Adding positive end-expiratory pressure, not positive end-inspiratory pressure, may improve oxygenation by opening the fluid-filled alveolar units (alveolar recruitment). Other modalities that may improve oxygenation include prone positioning and inverse ratio ventilation. Since he has very high minute ventilation, increasing the tidal volume or respiratory rate would not improve his oxygenation. An emergent thoracentesis would not improve the patient's status.

A 4-year-old male patient accompanied by his mother presents with fever, sore throat, muffled voice, and breathing and swallowing difficulty. The patient is leaning forward with his head and nose tilted upward and forward. He is irritable, with moderate respiratory distress and inspiratory stridor. Pulse 94/min, BP 110/70 mm Hg, temperature 101°F. Direct fiberoptic laryngoscopy shows an edematous larynx. Cultures are taken, and an endotracheal tube is placed. Empiric antibiotics are started with ceftriaxone and vancomycin. The epiglottis cultures reveal Haemophilus influenzae, and acute Haemophilus influenzae epiglottitis is diagnosed. The mother is worried about her 1-year-old child living in the same house and is currently not vaccinated for H. influenzae. Question What prophylactic measure is recommended at this time?

All family members, excluding the patient, should receive prophylactic rifampin. Chemoprophylaxis is to ensure all household members and close contacts have eradicated the bacteria. Eradication decreases the risk of developing invasive disease and prevents the formation of a carrier state, in which a person is not actively sick but has the bacteria and can spread it. Chemoprophylaxis should be instituted as soon as the index case is diagnosed. Rifampin is the drug of choice for all individuals over 1 month old. Chemoprophylaxis is indicated in the index patient to eradicate carrying nasopharyngeal Hib if the patient did not receive at least one dose of ceftriaxone and either is under age 2 or has household members/family members under age 4 who have not received the Hib vaccine age-appropriate doses or are immunocompromised. The patient is 4 years old and has started ceftriaxone treatment, so rifampin is not indicated for the patient.

Which of the following classes of medications is most likely to cause a persistent cough?

Angiotensin converting enzyme inhibitors like Lisinopril

A 69 year-old male presents with complaint of increasing dyspnea over the past 6-8 months. The patient denies cough, chest pain or smoking history. Physical examination reveals inspiratory crackles at the bases and clubbing of the nails. Chest x-ray reveals interstitial fibrosis of the lower lungs, thickened pleura and calcified pleural plaques of the lateral chest wall. Pulmonary function testing shows a restrictive pattern with a decreased diffusing capacity. What information is most likely noted in this patient's history?

Asbestos exposure often presents years later with increasing dyspnea and interstitial fibrosis of the lower lungs, thickened pleura and calcified pleura plaques. They will have a restrictive pattern on PFT.

Interstitial fibrosis and pleural thickening

Asbestosis

Case A 7-year-old boy presents with his mother with a 1-week history of wheezing and dyspnea on any exertion (with productive cough). On physical examination, bilateral rhonchi are heard. After a few days of treatment, spirometry is done on the patient. Total lung capacity (TLC) is 111% on spirometry. re-bronchodilators-> Post-bronchodilators FVC%49 ->63 FEV1%41 ->46 FEV1/FVC49 ->55

Asthma

Asthma TF and percussion findings

Asthma is characterized by decreased tactile fremitus, but would have resonant to hyperresonant percussion, not dullness.

Case A 33-year-old man presents with shortness of breath, wheezing, mild fever, and fatigue. He has had several similar episodes in the past, and each previous episode began after a cold that moved into his chest. Over the past several weeks, he has had a productive cough most mornings. He has no other symptoms or exam findings. He smokes on a social basis. His CXR is normal and most recent pulmonary function tests reveal a reversible airflow limitation. Question What is the most likely diagnosis? Chronic bronchitis Asthmatic bronchitis Bronchiectasis

Asthmatic bronchitis Not chronic bronchitis because PFTs are irreversible Not brochiectasis because CXR is abnormal

Tx for pertussis

Azithromycin (or erythromycin) Isolation until 5 days of therapy Admit if younger than 3 months, apneic, cyanotic, or in respiratory distress treat family with azithromycin or clarithromycin

A 79 year-old female presents with productive cough for 2 days. She has associated fever, chills and shortness of breath. On physical exam, RR 30, BP 90/60, T 101.3. There is no JVD. Lungs reveal crackles at the left lower lobe and decreased breath sounds with dullness to percussion. Heart exam reveals RRR with no S3 or S4. No edema is noted. On chest x-ray the patient has a left sided pleural effusion. Examination of the pleural fluid reveals a decreased glucose and an elevated pleural fluid LDH. Pleural fluid cytology reveals squamous epithelial cells. What is the most likely cause of the patient's effusion?

Bacterial pneumonia is the leading cause of an exudative pleural effusion. Not malignancy

PCP treatment

Bactrim

Low-dose ICS example?

Beclomethasone

An 8-month-old boy presents to the pediatrician in mid-January with 2 days of cough and nasal congestion. His mother reports decreased breastfeeding over the last day and difficulty breathing. The infant's temperature is 38.2°C (100.8°F), heart rate 120/minute, respiratory rate 34/minute, and oxygen saturation 95% on room air. Physical exam is remarkable for intercostal retractions. Question What exam finding would further suggest the suspected diagnosis? Hepatomegaly Heart murmur Bilateral expiratory wheezing Clubbing of the finger

Bilateral expiratory wheezing Bronchiolitis

Southeastern and south central states bordering Mississippi and Ohio River basins

Blastomycosis

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

Broad-spectrum antibiotic Sputum production is extremely variable from patient to patient, but any increase in sputum with a history of COPD reported by a patient must be regarded as potentially infectious and treated promptly.

Upon auscultation of a patient's lungs, there are harsh, hollow breath sounds which have a long inspiratory component in the region of the suprasternal notch. Throughout the periphery of the lung fields, softer breath sounds are heard. What are these breath sounds called?

Bronchial breath sounds Bronchial breath sounds are normally heard near the sternum and vesicular breath sounds are heard over the periphery of the lungs in a healthy, normal patient.

A 15-year-old girl with a history of mild asthma has had worsening episodes of cough, wheezing, and increasing bloody sputum over the past 5 months. She denies weight loss, decreased appetite, lethargy, or travel. She has increased her bronchodilator use, but she had not sought further care. Her mother has noted facial flushing with sweating that sometimes appears when she feels stressed—brief at first but lasting longer now. On exam, her respiratory rate is 32 breaths/min, temperature is 98.6°F, heart rate 84 bpm, BP 114/76 mm Hg, oxygen saturation is 94%. Her throat is clear, RRR without murmur; on auscultation, breath sounds over the left hemithorax are diminished without retractions or wheezes; there are few fine crackles at the base. Right side is clear. Remainder of the exam is normal. Chest X-ray reveals a round area of increased opacification near the right hilar region. CBC shows normal white count and differential. Question What diagnosis would most easily explain the patient's symptoms? Pulmonary embolism Bacterial pneumonia Bronchial carcinoid tumor Pulmonary hemosiderosis Vascular malformation

Bronchial carcinoid tumor facial flushing, bloody sputum, CXR finding all suggestive of this Bronchial carcinoid tumors are the most common primary malignant lung tumor in children. They tend to arise in the perihilar region. Carcinoid tumors are rare neuroendocrine tumors occurring most often in the GI tract. They can be associated with systemic symptoms due to the release of a variety of hormones. One of these hormones, serotonin, is thought to cause carcinoid syndrome, which consists of episodic flushing, wheezing, and diarrhea. Patients can present with recurrent pneumonia, cough, hemoptysis, wheezing, asthma, or chest pain. Resection is the preferred treatment for localized tumors; survival rates, when localized, are >90%.

A 5 year-old male presents with a history of recurrent episodes of acute bronchitis, characterized by fever and productive cough. He has no known significant past medical history. His pulmonary examination reveals crackles in the bilateral lower lobes. The remainder of his physical examination is normal. Chest x-ray demonstrates platelike atelectasis and dilated, thickened airways in the middle and lower lungs. Which of the following is the most likely diagnosis?

Bronchiectasis

A 3 month-old male presents with a hoarse cough and thick purulent rhinorrhea for the past 2 days. The mother noted that yesterday he appeared to get worse and seemed to have increasing problems breathing and trouble feeding. Examination reveals a temperature of 100.2 degrees F and respiratory rate of 80/minute with nasal flaring and retractions. Lung examination reveals a prolonged expiratory phase with inspiratory rales. He is tachycardic. Pulse oximetry reveals oxygen saturation of 89%. Chest x-ray reveals hyperinflation with diffuse interstitial infiltrates. What does he most likely have?

Bronchiolitis

crackles on chest auscultation

CAP

An elderly patient with poorly-controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, and rales at the left base. Pulse oximetry is 90%. What does he have? Which of the following is the next appropriate step in the management of this patient?

CAP risk factors for increased morbidity and mortality include advanced age, alcoholism, comorbid medical conditions, altered mental status, respiratory rate greater than 30 breaths/min, hypotension, and a BUN greater than 30. Need to admit to the hospital

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

COPD smoking cessation and home o2 lung transplantation is definitive

You are seeing 62 year-old African American male for health maintenance. He is a former cigarette smoker with a 40 pack-year history. He quit smoking 10 years ago. He denies cough, hemoptysis, shortness of breath, chest pain, weight loss, or night sweats. What method of screening for lung cancer is appropriate in this patient?

CT 2021 USPSTF recommends annual CT for: smokers 50-80 years 20 pack-year smoking history currently smoke quit within last 15 years

A solitary pulmonary nodule is found on a pre-employment screening chest x-ray in a 34 year-old nonsmoking male. There are no old chest x-rays to compare. Which of the following is the most appropriate next step in the evaluation?

CT scan In the absence of old x-rays in a nonsmoking individual less than 35 years old, CT scan of the chest is the next step in the evaluation of a solitary pulmonary nodule. If older than 35, needle biopsy of lesion is indicated

how to distinguish between tb latent and active infection? preferred screening for latent tb patients who received BCG vaccination?

CXR interferon gamma release assay

Which of the following treatment regimens is the most appropriate for a patient with chronic obstructive pulmonary disease with frequent day-to-day symptoms but no history of acute exacerbations?

Category B of COPD SABA prn (bronchodilator) LABA/LAMA QD no ICS - would use for patients with acute exacerbations in category D

A 50-year-old man presents with a 4-day history of increasing exertional dyspnea. He has had a chronic cough for the past 3 years and attributes it to cigarette smoking. The cough had been productive of watery sputum, but it has changed to a yellowish color over the past week. He has no known allergies and reports no family history of asthma. On general appearance, he is wheezing. His temperature is 101°F, P 105/min, BP 136/86 mm Hg, and RR 30/min. Respiratory system examination reveals decreased chest wall excursion. Auscultation reveals a prolonged expiratory phase with crepitations and generalized rhonchi. Chest X-ray reveals irregular bronchovascular markings. Laboratory results reveal Hb 15 g/dL, WBC 12,000/uL, and platelets 300 x 109/L. Question What do you suspect and what group of pathogens is most commonly associated with acute exacerbation of the patient's most likely diagnosis? Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis Legionella pneumophila, Streptococcus pneumoniae, Haemophilus influenzae

Chronic bronchitis Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis

Arizona, New Mexico, central CA, western Texas

Coccidiomycosis

Consolidation TF and percussion findings

Consolidation from pneumonia is characterized by dullness to percussion, but would have an increased, not decreased, tactile fremitus.

A 69-year-old man presents with dyspnea on exertion (climbing stairs and walking short distances) that has slowly progressed over the last year. He has fatigue, palpitations, intermittent retrosternal chest pain, lower extremity swelling, dizziness, and "feeling faint." Associated symptoms occur upon exertion. He denies fever, chills, weight changes, cough, abdominal pain, early satiety, nausea, vomiting, diarrhea, changes in urine color/odor, flank pain, hematuria, or dysuria. No cigarette, alcohol, or drug use. Cardiac exam shows increased pulmonic component of the second heart sound (P2), wide inspiratory splitting of S2 over the cardiac apex, right-sided S3 and S4 gallops, left parasternal lift, loud diastolic murmur increasing with inspiration and diminishing with Valsalva maneuver, prominent "A" waves in jugular venous pulsations, and increased JVD. Enlarged liver with hepatojugular reflux, peripheral edema, and ascites. EKG reveals peaked P waves, rightward axis deviation, and prominent R waves in the early V leads. What is the most likely diagnosis?

Cor pulmonale

A 64-year-old man presents with a 3-day history of insidious chest pain. He has a past medical history of hypertension, coronary artery disease, and poorly controlled left ventricular congestive heart failure due to medication noncompliance. Pain is made worse when he takes a deep breath and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and peripheral edema. He denies any relation of pain to position, activity, or food intake and is able to perform his normal daily activities. His physical exam reveals no respiratory distress, cyanosis, or accessory muscle usage. There are bibasilar thoracic friction rubs upon inspiration, an absence of lung fremitus, dullness to percussion, and reduced lung sounds. A chest X-ray is performed. Refer to the image. Question What health maintenance approach should be recommended at this time? Explaining the necessity of an emergent and repeated thoracentesis Counseling regarding compliance with heart failure medications No need to reevaluate onset of shortness of breath in this patient's chronic condition

Counseling regarding compliance with heart failure medications This patient's underlying condition is a transudative pleural effusion, most likely due to poorly controlled congestive heart failure. Transudative effusions are usually managed by treating the underlying medical disorder. Observation of pleural effusion is reasonable when benign etiologies are likely, as in the setting of overt congestive heart failure, viral pleurisy, or recent thoracic or abdominal surgery. Thoracentesis should be performed for new and unexplained pleural effusions when sufficient fluid is present to allow a safe procedure. Patients with poor performance status (Karnofsky score <70) and a life expectancy of less than 3 months can be treated with repeated outpatient thoracentesis as needed to palliate symptoms.

A 3-year-old girl presents with a 2-day history of a sore throat and fever. This morning, she was hoarse and seemed to be having more difficulty breathing. On exam, she appears to be in distress and has an oral temperature of 100.0°F. Tympanic membranes are pink but not bulging. Nares are patent without rhinorrhea. She has a barking cough, stridor at rest, and nasal flaring. Question What do you suspect and What treatment is most appropriate in the care of this child? Answer Choices1 Admit patient, start specific antiviral therapy and hydration. Discharge patient home on a broad-spectrum antibiotic for 14 days. Discharge patient home after administering parainfluenza vaccine. Discharge home and advise parents to use cool mist vaporizer. Start humidified oxygen, nebulized racemic epinephrine, and single-dose IM dexamethasone.

Croup Start humidified oxygen, nebulized racemic epinephrine, and single-dose IM dexamethasone bc strider @ rest

A 67-year-old woman presents with shortness of breath and chest pain. She admits to getting home yesterday from a 2-day car ride after visiting her grandchildren. Her heart rate is 110 beats/minute and respirations are 22 breaths/minute. Blood pressure is 125/85 mm Hg. Her oxygen saturation is 99% on room air and temperature is 98.9°F. With additional information provided, her Wells' Criteria Score is calculated to be 4.5. What is the most appropriate initial diagnostic test? D-dimer Echocardiogram CT chest without contrast ECG CT chest pulmonary angiography

D-dimer Wells' Criteria are used to calculate the probability of a pulmonary embolism. In this patient, tachycardia with pulse >100 bpm (1.5 points) with no other diagnosis better explaining the patient's symptoms (3 points) gives a score of 4.5 points. Other components of Wells' Criteria include clinical symptoms of DVT (3 points), immobilization for ≥3 days or recent surgery in the last 4 weeks (1.5 points), history of previous DVT or PE (1.5 points), hemoptysis (1 point) or malignancy (1 point). A score of 4.5 indicates an intermediate or moderate risk of pulmonary embolism, so the correct test for a non-pregnant adult would be a D-dimer. Echocardiogram is used in hemodynamically unstable patients to assess for new right ventricular strain. If a CT were indicated, it would be a CT chest pulmonary angiography. CT chest pulmonary angiography would be indicated if the patient was considered high-suspicion of PE according to a Wells' Criteria score ≥6 or with hemodynamic instability (hypotension with systolic blood pressure of ≤90 mmHg or evidence of shock). ECG is non-specific in patients with suspected PE and is therefore nondiagnostic. The most common finding on ECG in PE patients is tachycardia or non-specific ST/T wave changes.

Which of the following chest x-ray abnormalities would most likely be seen in a patient with hypersensitivity pneumonitis?

Diffuse nodular densities

A 4-year-old boy accompanied by his mother presents with fever, sore throat, muffled voice, and breathing and swallowing difficulty. The child is leaning forward with his head and nose tilted upward and forward. He is irritable, with moderate respiratory distress and inspiratory stridor. Pulse is 94/min, BP is 110/70 mm Hg, temperature is 101°F. Question What is the next step to confirm the diagnosis? Direct fiberoptic laryngoscopy in operating room Indirect laryngoscopy Lateral neck radiograph

Direct fiberoptic laryngoscopy in operating room This patient has symptoms of acute epiglottitis, a medical emergency that can be diagnosed clinically. The main goal of management includes prompt diagnosis and treatment before airway obstruction. Given this patient's high probability of epiglottitis and evidence of upper airway obstruction (respiratory distress and inspiratory stridor), protecting the airway should be done before any diagnostic testing. The next step to confirm the diagnosis is direct fiber-optic laryngoscopy performed in a controlled environment (usually the operation theater) to visualize and culture the edematous larynx and to secure the airway through placement of an endotracheal tube. Lateral neck radiograph usually reveals an enlarged edematous epiglottis (thumbprint sign). Radiographs can be used for diagnosis in stable patients or patients with low suspicion for epiglottitis as a rule-out test. This patient has moderate respiratory distress and inspiratory stridor, so radiographs are not the best option; securing the airway is pertinent.

Bronchiolitis risk factors

Down syndrome, those with significant asthma, those with chronic pulmonary disease, the immunocompromised, and the institutionalized. Infants at increased risk for bronchiolitis with respiratory syncytial virus include those born before 36 weeks gestation, those with cardiopulmonary disease, those with older siblings, and those exposed to secondhand smoke.

A 64 year-old female with a 50 pack year smoking history, presents with worsening dyspnea on exertion, a persistent cough, and increasing oxygen requirement from 2 to 3 liters. She denies any cardiac history. What disease is suspected?What is the most likely chest x-ray finding in this patient?

Emphysema hyperinflation with bullae

A 22-year-old woman at 24 weeks gestation presents with a 3-day history of a nonproductive cough and fever. She states she has been battling an upper respiratory infection that does not seem to go away. Initially, she thought that she had a cold, but the symptoms persisted. She was told by her obstetrician that she has the flu and to drink plenty of fluids and get some rest. Vital signs reveal temperature 101.2°F, blood pressure 120/80 mm Hg, heart rate 110/bpm, and respiratory rate 22 breaths/min. On physical examination, she appears ill; lungs exhibit wheezing. Question What would be an appropriate treatment for this patient? Doxycycline Ciprofloxacin Erythromycin Amoxicillin Penicillin

Erythromycin Doxy and Cipro are contraindicated Amoxicillin and PCN don't help Mycoplasma pneumonia infection

Exudative pleural effusion

Exudates are caused by a increased permeability of pleural surfaces or decreased lymphatic flow. The most common cause of exudative pleural effusion is infection (bacterial pneumonia, tuberculosis) and malignancy (second most common).

A 2 year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and appears non- toxic with a respiratory rate of 42 breaths per minute. What do you suspect and what is the next step in the evaluation of this patient?

Foreign body aspiration CXR

LABA examples

Formoterol Salmeterol

A 68-year-old African American woman with past medical history of obstructive sleep apnea, hypertension, and COPD presents with chronic progressive dyspnea. The dyspnea initially occurred upon exertion, now noted at rest for the past 8 months. She is maintained on home oxygen for COPD. There is associated fatigue, substernal exertional chest pain, and 2 episodes of exertional syncope. She denies other symptoms. Physical exam reveals oxygen saturation of 90%, left parasternal lift, narrow splitting of the second heart sound, accentuation of the pulmonary component of the second heart sound, an early systolic ejection click, and an S4 gallop. No murmurs are identifiable. +1 pitting edema bilaterally to the lower extremities to the mid-calf level. EKG shows right axis deviation and incomplete right bundle branch block. Chest x-ray shows right ventricular enlargement with prominent right pulmonary artery. Question What treatment is most beneficial in the symptomatic management of this patient?

Furosemide This patient's presentation is most consistent with cor pulmonale. Chronic obstructive pulmonary disorder is the most common cause of secondary cor pulmonale while primary pulmonary hypertension is idiopathic. The electrocardiogram demonstrates evidence of right heart strain with right axis deviation and incomplete right bundle branch block. The chest x-ray indicates cardiac enlargement, with a prominence of the pulmonary artery, right atrium, and right ventricle. Furosemide and other diuretics are used to manage chronic cor pulmonale, especially in providing symptomatic improvement in fluid overloaded patients.

Is long-term regular exercise training good or bad in cystic fibrosis?

Good

Respiratory alkalosis

Hyperventilation

wedge shaped opacity in CXR

Hamptons Hump seen in PE

Which of the following types of pleural effusion result from increased production of fluid due to underlying inflammatory conditions?

Increased production of fluid due to inflammatory or malignant processes results in an exudative pleural effusion.

Central and midwestern states along Ohio and Mississippi river

Histoplasmosis

Respiratory acidosis

Hypoventilation

A 24 year-old male presents in respiratory distress and appears quite ill. A Gram stain and culture of the sputum reveals gram-positive cocci in clumps and a chest x-ray reveals multiple patchy infiltrates with some cavitations. Which of the following is most likely to also be found in his medical history?

IV drug abuse This patient has pneumonia caused by Staphylococcus aureus which is commonly associated with a history of intravenous drug use, influenza epidemics and the hospital setting.

A 36-year-old woman presents with an acute asthma exacerbation. You have started oxygen, administered inhaled albuterol and ipratropium, administered 60 mg of IV methylprednisolone, and started a continuous albuterol nebulizer treatment. She still has significant wheezing and dyspnea. What is the most appropriate next therapy?

IV magnesium sulfate

A 64-year-old man presents with progressive dyspnea, fatigue, chronic dry cough, and exercise intolerance. His symptoms have worsened over the past year. Pulmonary function testing reveals an FEV1/FVC ratio >0.7, decreased total lung capacity, and decreased residual volume. Question What is the most likely diagnosis? Chronic obstructive pulmonary disease Pulmonary embolism Idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis

After administration of the bronchodilator in an asthmatic patient, which of the following spirometry results would suggest reversibility?

Increase FEV1 FVC does NOT change

What physical exam findings are consistent with consolidation?

Increased TF and egophony

Case A 27-year-old male accident victim with a head injury is admitted to the ICU and kept on mechanical ventilatory support. On the seventh day after admission, he is clinically diagnosed with pneumonia. Blood samples and lower respiratory secretions are submitted to the laboratory for culture; empiric antimicrobial therapy is started. Question What is the most likely etiologic agent of pneumonia in this patient?

Klebisella pneumonia due to mechanical ventilator pseudomonas is also common in ventilators

A 33 year-old HIV-positive woman develops an 8mm area of induration following the administration of a purified protein derivative (PPD) test. Her chest radiograph shows no evidence of active tuberculosis (TB) infection. What stage does she have and which of the following is the most appropriate clinical intervention?

Latent +PPD No active sx No CXR findings Rifampin and Isoniazid (+B6)

Which of the following is a major contraindication to curative surgical resection of a lung tumor?

Liver metastases Distant metastases, except for solitary brain and adrenal metastases are an absolute contraindication for pulmonary resection. Other absolute contraindications include MI within past 3 months, SVC syndrome due to metastatic tumor, bilateral endobronchial tumor, contralateral lymph node metastases and malignant pleural effusion.

A 40-year-old man with chronic alcoholism presents with a cough that produces of large amounts of fetid sputum. He developed the cough about 4 weeks ago, and it has gradually worsened over time. The sputum is now foul-smelling and copious. He has had high intermittent pyrexia for 4 days. His vitals are: T 102°F, PR 98\min, RR 24\min, BP 140\80 mm Hg. HEENT exam shows poor dentition with multiple missing teeth, mild erythema to the nasal muscosa with clear drainage. RRR without a murmur. On lung auscultation, there is pleural rub and diminished air entry on the right side. The chest X-ray shows a large, irregularly shaped, dense opacity on the right side with a fluid level. Question What do you suspect and How should this patient's diagnosis be regarded? Only anaerobic organisms are responsible for this condition Aspiration is the most common cause. Sputum culture is the best investigation. CT has no role as an investigation in this condition. Treatment is with antibiotics for 3 days.

Lung abscess Aspiration is the most common cause This patient displays symptoms of a lung abscess, the result of a microbial infection causing cavities containing necrotic pulmonary tissue to develop in the lung. Aspiration of oropharyngeal material is the most common cause. It is always secondary and is due to an infection reaching the lungs from elsewhere. Predisposing factors include alcohol abuse, periodontal disease, seizures, and dysphagia.

A 6 year-old boy is brought to the pediatric clinic by his mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing. What stage of asthma does he have?

Mild persistent asthma

A 22 year-old female with a history of asthma presents with complaints of increasing "asthma" attacks. The patient states she has been well controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals > 85% predicted value. What stage of asthma control is she in? and which of the following is the most appropriate intervention at this time?

Mild persistent asthma In addition to SABA, start an anti inflammatory agent, ICS, like beclomethasone or formeterol

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

Nebulized racemic epinephrine This patient most likely has laryngotracheobronchitis (viral croup). Treatment with nebulized racemic epinephrine and glucocorticosteroids (dexamethasone) is indicated for patients with stridor at rest.

Does lobar pneumonia cause tracheal deviation?

No

mesothelioma CT findings

Nodular mass spreading along pleural surfaces

Tx of hyaline membrane disease (neonatal respiratory distress syndrome)

O2, intubation, CPAP, surfactant

Tx for carcinoid syndrome

Octreotide

A 62 year-old female is admitted to a nursing home during an outbreak of influenza. In review of her records, you note that she did not receive the flu vaccine this year. Which of the following is the most appropriate drug of choice for influenza prophylaxis in this patient?

Oseltamicir (Tamiflu) or Zanamivir (Relenza)

Which of the following pathophysiological processes is associated with chronic bronchitis?

Overproduction and hypersecretion of mucus Chronic bronchitis results from the enlargement of mucous glands and goblet cell hypertrophy in the large airways.

A 70-year-old man with chronic obstructive pulmonary disease presents to the office concerned about getting sick this winter. He states that a friend of his "suffered severely" from the flu and was admitted to the ICU for a couple of weeks. The patient is up to date on his childhood vaccinations, and he was vaccinated with influenza vaccine 1 year ago but has not received pneumococcal vaccination in the past. Which of the following immunizations should be administered today to reduce his risk for infections and exacerbations?

PCV20

A 43-year-old woman presents to her primary care physician with complaints of mild shortness of breath and right-sided chest pain for three days. She reports that lately she has had a nagging nonproductive cough and low-grade fevers. On examination, her vital signs are: temperature 99.1 deg F (37.3 deg C), blood pressure is 115/70 mmHg, pulse is 91/min, respirations are 17/min, and oxygen saturation 97% on room air. She is well-appearing, with normal work of breathing, and no leg swelling. She is otherwise healthy, with no prior medical or surgical history, currently taking no medications. You have a low suspicion for the most concerning diagnosis and would like to exclude it with a very sensitive though non-specific test. What do you think she has and which of the following should you order?

PE, d-dimer

A 63-year-old female with a known diagnosis of metastatic breast cancer presents to the emergency department after decompensating while at the chemotherapy suite. On arrival, vitals are pulse 124 bpm, blood pressure 92/64 mmHg, temperature 98.5 F, respiration 24/min and shallow. The patient is diaphoretic and disoriented, but able to complain about excruciating chest pain. Labs are drawn, and the patient is quickly worked up with an EKG (seen here) and helical CT (seen here). The patient is started on a heparin drip. What disease and which of the following results confers a poor prognosis for the patient?

PE, elevated troponin This patient presents in sudden distress with evidence of a pulmonary embolism (PE). Elevated cardiac enzymes such as troponin confer poor prognosis in patients with PEs. PE are morbid, and potentially fatal complications of hypercoagulable states. This patient's ongoing malignancy places her at increased risk of thrombosis and PE. Significant PEs can result in right sided cardiac strain, which can be seen with electrocardiographic and ultrasonographic studies. Risk stratification models for patients with PEs have been developed. Elevated cardiac markers, cor pulmonale, cardiogenic shock, as well as ongoing malignancy all confer poor prognostic trajectories for patients.

A 58-year-old woman with a past medical history of hypertension, hyperlipidemia, breast cancer, hip fractures, and coronary artery disease is being evaluated for acute-onset severe left-sided pleuritic chest pain over the course of the last 2 hours. The pain is associated with feelings of anxiety, hemoptysis, shortness of breath, and nausea. She "feels warm" but denies chills, palpitations, wheezing, edema, vomiting, abdominal pain, abnormal bowel habits, or dietary intolerances. She admits to a 30 pack-year smoking history but denies drug or alcohol use. Upon physical exam, she is found to be febrile, hypotensive, tachycardic, tachypneic, diaphoretic, and in acute painful distress. There are perioral cyanosis and a pleural friction rub to the left lung fields; the remainder of the exam is normal. Question What do you suspect What is the most appropriate therapeutic intervention for this patient at this time?

PE; heparin

Treatment for all stages of croup?

PO Dexamethasone

Pancoast syndrome?

Pancoast syndrome involves a lung malignancy in the superior sulcus. These tumors can cause nerve impingement that leads to arm or shoulder pain and hand muscle atrophy. They can also disrupt the sympathetic nerve chain, which innervates the eye, leading to ptosis, miosis, and anhidrosis of the ipsilateral side (Horner syndrome). Most lung malignancies in the superior sulcus are non-small cell carcinomas

Croup MCC

Parainfluenza virus

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

Pertussis Prophylaxis: Macrolide prophylaxis Typically treatment is supportive but can use abx if necessary

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

Pertussis (whooping cough) Macrolide tx

On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause?

Pleural effusion

A 52-year-old woman who lives a non-sedentary lifestyle presents with a 5-day history of low-grade fever, flu-like syndrome, sore throat, and malaise. She has to catch her breath because of pain on inspiration and when coughing. She has no known past medical or surgical history; she is not on any medication, and she has no pertinent family history. She denies any medication use, including over-the-counter medicines. On physical examination, her vitals are: temperature 100.6°F, pulse 86/min, BP 133/75 mm Hg, and RR 20 cycles/min. She has shallow breathing, resonant percussion notes, fair air entry with vesicular breath sounds, and friction rub. Her blood gas on room air is as follows: pH 7.36 PCO2 44 mm Hg PO2 100 mm Hg HCO3 26 mEq\L O2 saturation 99.8% Her chest X-ray (CXR) and D-dimer assay are normal. Question What does she have and what is the most appropriate management for this patient? Albuterol Heparin NSAIDs Oseltamivir Furosemide

Pleuritis without effusion, NSAIDs Pleuritis is inflammation of the pleura, which may occur with or without effusion and is characterized by a sharp pain worsened by cough and inspiration. The pain may radiate to the shoulder if the diaphragmatic pleura is affected, and pressure around the area of inflammation may produce pain. Friction rub is heard on auscultation. The pleuritic chest pain causes shallow rapid breaths. The presentation with flu-like illness, malaise, absence of history of collagen vascular disease, and CXR findings makes the most likely etiology viral in this case. Pleuritis is treated with NSAIDs in cases of pleurisy due to viral etiology. Other examples of etiologic agents are rheumatoid arthritis, systemic lupus erythematosus, radiation, pneumonia, acute pulmonary embolism, and pneumothorax. Albuterol is utilized in reactive airway disease and chronic obstructive pulmonary disease.

A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. What disease is this?

Pneumonia, likely bacterial

A pediatric patient who originally presented to the emergency department for acute asthma exacerbation is being discharged. The patient was initially treated with albuterol without improvement and was later administered dexamethasone intravenously. The patient later had resolution of initial symptoms, and vital signs normalized. What is the most appropriate pharmacotherapy to prescribe upon discharge? Montelukast Prednisone

Prednisone Montelukast (C) is a leukotriene receptor antagonist that may be prescribed as part of a long-term asthma regimen but is not as effective in studies when compared to glucocorticoids for acute exacerbations.

Which of the following is a common presenting clinical manifestation of a patient with interstitial lung disease?

Progessive SOB on exertion interstitial lung disease is progressive scarring of lung tissue ex. Pneumoconiosis, pulmonary fibrosis, pneumonia, sarcoidosis

A 30-year-old previously healthy woman with no significant past medical history presents to your office with gradually worsening shortness of breath of one year's duration. The patient reports worsening dyspnea on exertion, fatigue, shortness of breath, and occasional exertional chest pain. On exam, the patient is noted to have an increased intensity of the P2 heart sound. Chest radiograph is seen here. What disease and what diagnostic test is most likely to lead to a diagnosis?

Pulmonary HTN, Echocardiogram

A 50-year-old male presents to the emergency department with sharp epigastric pain of 7 hours duration. The pain was sudden in onset and radiates to the back. The patient has a history of chronic alcoholism. He does not take any medications. The patient is admitted to the hospital and given 1 liter of normal saline. Several hours later, the patient appears markedly short of breath. Temperature is 36.9 degrees Celsius, blood pressure is 130/75 mmHg, pulse is 110/min, and respiratory rate is 33/min. Physical examination is notable for labored breathing and crackles at both lung bases. Chest X-ray is shown here. Which of the following would help confirm a diagnosis of Acute Respiratory Distress Syndrome (ARDS) PaO2 < 60 mmHg Pulmonary capillary wedge pressure (PCWP) < 18 mmHg

Pulmonary capillary wedge pressure (PCWP) < 18 mmHg This patient has acute pancreatitis, and later experiences symptoms of respiratory failure consistent with ARDS. A PCWP < 18 mmHg would provide additional clinical evidence that the respiratory failure was secondary to ARDS and not hydrostatic edema. ARDS is a dreaded complication of acute pancreatitis. ARDS presents with progressive hypoxemia not responsive to supplemental oxygen and other signs and symptoms similar to cardiogenic pulmonary edema. PCWP is useful in differentiating ARDS from pulmonary edema and is > 18 mmHg in fluid overloaded states, though they can co-exist, and recent changes to the diagnostic criteria for ARDS no longer require a PCWP < 18 mmHg. Hypoxemia (PaO2 < 60 mmHg) is present in both pulmonary edema and ARDS and may also be a feature of pancreatitis; it is thus less specific for ARDS than PCWP.

Hemoptysis, tachypnea, unilateral lower extremity edema

Pulmonary embolism

Cavitary lesions, involving upper lobes

Pulmonary tuberculosis

Cystic fibrosis diagnosis?

Quantitative Pilocarpine Iontophoresis Sweat Test (levels 60 mmol/L or greater on 2 occasions after pilocarpine) OR DNA analysis

Bronchiolitis MCC

RSV

A 20-year-old patient presents to the clinic with a chronic cough and loss of appetite. The patient immigrated to the United States four years ago from Nicaragua. Chest X-ray reveals three small cavitary lesions in the apex of the left lung. Purified protein derivative testing is positive, and sputum is positive for acid-fast bacillus. There is no regional lymph node involvement and no evidence of disseminated disease. Which of the following pathologies is most likely?

Reactivation of latent tuberculosis

Spirometry findings for restrictive pulmonary diseases

Reduced FVC, TLD, DLCO

Bronchiolitis MCC

Respiratory syncytial virus (RSV)

An immunocompromised patient presents with signs and symptoms consistent with Legionella pneumophila who has not responded to initial antibiotic therapy with a macrolide. Which of the following should be added?

Rifampin

LAMA examples

tiotropium

A 55-year-old man presents with a COPD exacerbation managed with a ventilator. The patient's blood pressure drops and the ventilator alarm goes off. The only medication being administered is amlodipine via nasogastric tube. This patient is afebrile. On examination, there is a middle-aged orally-intubated man with temperature 99.4°F, pulse 145/min, and BP 62/34 mm Hg; he breathes above the ventilator at a rate of 36 cycles/min. His breathing is shallow, and there are diminished breath sounds in the right hemithorax. Question What does he have? What is the most appropriate next step?

Right tension pneumothorax in a patient with COPD who is on a ventilator; perform needle thoractomy, chest tube placement. Features supportive of this diagnosis are hypotension, tachycardia, tachypnea, shallow breathing, and decreased breath sounds in the right hemithorax. Management of this condition is emergent thoracentesis through insertion of a large-bore needle into the second intercostal space. Chest tube placement is indicated for definitive treatment.

Which of the following mechanisms leads to a primary pneumothorax? Penetrating or blunt trauma forces Underlying lung cancer Pressure of air in the pleural space exceeds room air pressure Rupture of subpleural apical blebs due to high negative intrapleural pressures

Rupture of subpleural apical blebs due to high negative intrapleural pressures

bilateral hilar adenopathy

Sarcoidosis

A 36-year-old African American woman presents with a nonproductive cough, malaise, mild fever, and mild dyspnea. She also indicates that she has some lesions around her nose. Upon physical exam, you note red-brown dermal papules around her nares. A chest X-ray demonstrates a right hilar mass. A pulmonologist is consulted and performs a biopsy during bronchoscopy. The report reveals that the mass is a non-caseating granuloma. Question What do you suspect and What initial therapy should be prescribed?

Sarcoidosis red-brown dermal papules around her nares = lupus pernio Corticosteroids for symptomatic treatment

Tx for pneumocystis

trimethoprim-sulfamethoxazole (Bactrim)

sputum smear positive for acid-fast bacilli

tuberculosis

eggshell calcifiations of hilar lymph nodes

Silicosis

Obesity hypoventilation syndrome

Similar to OSA but pulse oximetry under 94% in room air during the day

What PE finding is common in foreign aspirated body?

Stridor (inspiratory wheezing)

A 6-week-old male infant presents with a 4-day history of cough and nasal congestion. He occasionally has a bluish tint around his lips while sleeping. No history of fever. Older siblings have upper respiratory infections. Appetite has been decreased due to the copious nasal secretions, but he has a normal urine output. He was delivered at 34 weeks. He had mild respiratory distress syndrome—2 days on a ventilator in the NICU. He went home in 10 days and has done well since. No immunizations. Physical exam reveals mild respiratory distress, respirations 52/min, with slight intercostal retractions. Temperature is 100.2°F, HR 130/min. Perioral duskiness is seen. Oxygen saturation at room air is 83%. HEENT exam otherwise normal. Chest exam shows coarse rhonchi, expiratory wheezes. Heart rate and rhythm regular. No murmurs appreciated. Abdomen is soft and non-tender. Neurological is intact. Chest X-ray shows mild hyperexpansion, no consolidation. Nasal swab for respiratory syncytial virus is positive. He is admitted to the hospital. In addition to supportive therapy, what is the most appropriate treatment?

Supplemental oxygen

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

Supportive care with oxygen

A 3-year-old Caucasian girl presents with her parents for followup after her third episode of pneumonia this year. Her parents report she has been acting more like herself and appears to be feeling better. On exam, she is afebrile and breathing comfortably. She has moderate crackles in the lower right lung base. Past medical history is significant for a few episodes of pneumonia each winter since birth. She has always been small for her age, but her mother says she has a healthy appetite. Her parents and brother are of medium stature. She takes no medication other than the antibiotic that was prescribed 5 days ago. Question What test should be ordered next? Sweat chloride test DNA analysis Pulmonary function tests Abdominal ultrasound CT of the chest

Sweat chloride test Recurrent pneumonia with failure to thrive is a red flag for cystic fibrosis. The gold standard for diagnosis is a sweat chloride test, which uses pilocarpine iontophoresis for chemical analysis of sweat collection. Positive results should be confirmed, and a negative result should be repeated if there is still a suspicion of cystic fibrosis.

A recent Haitian immigrant presents to the clinic for an employment physical examination before starting work at a local hospital. The patient has a history of receiving bacilli Calmette-Guerin (BCG) vaccination. Screening for tuberculosis for this employee should include which of the following tests? Sputum induction PPD skin test Chest x-ray No screening needed TB blood test (IGRA)

TB blood test (IGRA) TB screening is recommended for all healthcare personnel, including a symptom evaluation and test (IGRA or TST) for those without documented prior TB disease or LTBI. TB blood tests (IGRAs) are preferred for most non-United States-born patients who received (or may have received) BCG vaccination. IGRAs, unlike the TB skin test, are not affected by prior BCG vaccination and are not expected to give a false-positive result in people who have received BCG. The TST is an acceptable alternative to IGRA, especially in situations where IGRA is not available or is too costly (even though it is less specific than the IGRA). In this case > 10mm would be positive and will require a follow-up CXR.

Emphysema PFT results

TLV, RV increase DLCO, FEV1, FVC decrease

A 1-month-old premature male infant with bronchopulmonary dysplasia (BPD) remains intubated and monitored in the NICU. He has been doing relatively well and is being gradually weaned from the respirator. Suddenly, his O2 saturations and heart rate plummet, and he becomes very dusky. On quick exam, there are decreased breath sounds on the right with an asymmetric chest rise. Question What is the most likely explanation for his sudden respiratory and clinical change? Inadequate tidal volume Large leak around the tracheal tube Displacement of the tracheal tube Tension pneumothorax Disconnected oxygen supply

Tension pneumothorax Air trappings can occur in patients with lower airway diseases such as BPD and may result in tension pneumothorax. Since the tracheal tube tends to enter the straighter right main bronchus, a tension pneumothorax most frequently occurs on the right side. This presents as a marked sudden deterioration in oxygenation, marked bradycardia, and central cyanosis. Breath sounds and chest rise will be decreased on the affected side due to increased pressure impeding air entry.

Case A 5-month-old infant presents in the winter months with wheezing, rapid respirations (>45 breaths/min), and chest retractions. The patient has a 2-day history of rhinorrhea and low-grade fever. Breath sounds are normal, and there is no cyanosis. Question What does she have and What test can confirm the most likely diagnosis?

The clinical presentation, time of year, and age of the child strongly suggest bronchiolitis caused by respiratory syncytial virus. This is usually diagnosed clinically, but immunofluorescence of nasal secretion (or nasalpharyngeal wash/swab) can be used for definitive testing and can lead to rapid viral identification.

Which of the following findings confirm the adequacy of a sputum specimen for Gram stain and culture?

The presence of increased polymorphonuclear leukocytes and the absence of squamous epithelial cells are the criteria utilized to evaluate the adequacy of a sputum sample. increased WBC = site of infection no squamous epithelial cells which are found in saliva in the mouth

A 40-year-old man with no significant past medical history presents with a 2-day history of alternating fever and rigors, diaphoresis, fatigue, and a productive cough. He admits to mucoid sputum of moderate quantities. He denies a history of smoking, alcohol use, recent travel, or sick contacts. He further denies chest pain, palpitations, hemoptysis, rashes, abdominal pain, nausea, vomiting, or diarrhea. On physical exam, he is found to be tachypneic and was observed to be intermittently coughing. The pulmonary exam was notable for bronchial breath sounds over the right anterior fourth, fifth, and sixth intercostal spaces. A chest radiograph revealed a right middle lobe consolidation. Question What additional physical exam finding would be consistent with this patient's most likely diagnosis? Decreased tactile fremitus Decreased whispered pectoriloquy Dullness to percussion

This patient is most likely presenting with community-acquired pneumonia (CAP). Most patients with CAP experience an acute or subacute onset of fever, cough with or without sputum production, and dyspnea. Other common symptoms include sweats, chills, rigors, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia, headache, and abdominal pain. Common physical findings include fever or hypothermia, tachypnea, tachycardia, and arterial oxygen desaturation. Patients may appear acutely ill. Chest examination often reveals inspiratory crackles and bronchial breath sounds. Dullness to percussion may be observed if lobar consolidation or a parapneumonic pleural effusion is present. Increased tactile fremitus, bronchophony, egophony, and whispered pectoriloquy occur over consolidated lung tissue.

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

This patient most likely has tuberculosis. A chest x-ray finding of cavitary lesions involving the upper lobes would support this suspected diagnosis.

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

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

transudative pleural effusion

Transudates are due to an either elevated capillary pressure in visceral or parenteral pleura or decreased plasma oncotic pressures in the chest. most common cause of transudative pleural effusion is congestive heart failure.

Transudate PE pathophysiology

Transudates result from increased hydrostatic or decreased oncotic pressures across normal capillaries.

Tension pneumothorax sx and treatment

Traumatic injury Examination reveals moderate respiratory distress with absence of breath sounds and hyperresonance to percussion on the left, with tracheal deviation to the right(contralateral side) Increasing SOB and pleuritic pain of sudden onset Aspiration by needle into left 2nd ICS stat

A 68-year-old non-smoking man presents to your pulmonology practice for long-standing dyspnea and non-productive cough. The patient has had the cough and progressively worsening dyspnea for about 1.5 years with no current exacerbation. He denies fevers, chills, night sweats, and any other symptoms. He denies unusual travel, hobbies, or occupational exposures. He does, however, endorse relatively frequent reflux symptoms. The rest of his review of systems is negative. He has had a workup through his family practice and was then sent to the cardiologist, who ruled out cardiovascular causes of his dyspnea. He has been given trials of various antibiotics, inhalers, and steroids, all without improvement in symptoms, despite good compliance. He currently takes no medications. Physical exam is significant for fine inspiratory bibasilar crackles and clubbing in the fingers. An occasional dry cough is noted. What intervention is most likely to prevent complications in this patient? Inhaled beta agonist Inhaled corticosteroid Treatment of gastroesophageal reflux disease Avoidance of supplemental oxygen

Treatment of gastroesophageal reflux disease This patient likely has idiopathic pulmonary fibrosis (IPF). IPF is a chronic progressive restrictive pulmonary disease of the lung parenchyma. IPF presents with exertional dyspnea and non-productive cough, as well as the imaging characteristics described for this patient. Treatment is complex. Overall, medications play a minor role in this relatively rare disease, but treatment of gastroesophageal reflux disease (GERD) is likely to prevent complications in this patient. There is a high incidence of GERD in patients with IPF, even in patients who are asymptomatic. GERD can contribute to microaspirations and the development of pneumonia. Treatment with acid-lowering therapies is likely to lower complications and may help prevent the progression of disease.

A post-op patient has signs and symptoms highly suggestive of a pulmonary embolism. The results of the CT scan of the lung is nondiagnostic. What is the most appropriate next step in the evaluation? VQ scan US of legs

US of legs Ventilation perfusion scans are performed prior to the CT scan of the chest and would not likely add additional information to this clinical scenario.

A 37-year-old male patient presents on a cold winter day with a 10-day history of acute onset of productive cough with a moderate amount of yellow sputum. There is associated fever, shortness of breath, and malaise. Past medical history is unremarkable. He denies recent travel, sick contacts, occupational exposure, and any history of smoking or alcohol use. He denies arthralgias, chills, wheezing, abdominal pain, nausea, vomiting, diarrhea, edema, or rashes. Physical exam is remarkable for fever, tachypnea, reduced fremitus, dullness to percussion, and basilar crackles in the right lower lung field. Question What additional presentation is most likely in this patient? Hemoptysis, tachypnea, unilateral lower extremity edema Unilateral sharp inspiratory chest pain and thoracic friction rub

Unilateral sharp inspiratory chest pain and thoracic friction rub This patient's most likely diagnosis is pleural effusion, a complication of bacterial pneumonia. An exudative effusion is most likely. Common findings of pleural effusion include unilateral, sharp, or knife-like chest pain provoked by breathing, coughing, or movements of the trunk. Physical exam findings include dullness to percussion, a deviated trachea away from the side in large effusions, decreased-to-absent breath sounds, a pleural friction rub, and reduced tactile fremitus. Hemoptysis, tachypnea, and unilateral lower extremity edema should raise suspicion of a pulmonary embolus.

Treatment of MRSA pneumonia

Vancomycin or Linezolid

pulmonary embolism rule out strategy?

Wells criteria are the criteria used to assess the risk of a pulmonary embolism clinically. Patients with a low probability of a pulmonary embolism according to the Wells criteria should be assessed with the pulmonary embolism rule-out criteria (PERC). Patients with an intermediate probability of a pulmonary embolism should have a D-dimer performed. Patients with a high probability of a pulmonary embolism should have a computed tomographic pulmonary angiography (CTPA) performed.

aspirin-exacerbated respiratory disease

a chronic sinusitis characterized by nasal polyposis, non-allergic induced asthma, and aspirin sensitivity. The condition is sometimes called aspirin triad or Samter's triad. It commonly starts in the 20s. Clinical symptoms of aspirin-sensitive patients are characterized by mucosal inflammation and rhinitis, severe asthma precipitated by aspirin ingestion, and aggressive bilateral nasal polyposis. The rhinitis is persistent and difficult to manage, and the rhinorrhea is thin and non-purulent (non-allergic rhinitis with eosinophilia syndrome). Asthma usually appears an average of 2 years after rhinitis, followed by the intolerance to aspirin and the co-occurrence of nasal polyps. Severe acute asthma attack can occur within a few minutes and up to 3 hours after ingestion of aspirin. Aspirin challenge can be used to confirm a diagnosis of aspirin sensitivity in these patients.

cough for 5+ days

acute bronchitis

URI x 2 days, productive cough for 5 days dx? tx?

acute bronchitis guaifenesin. no abx bc viral

peripherally located lung cancers

adenocarcinoma large cell carcinoma bronchial carcinoid tumor

A 26 year-old man is stung by a bee, and shortly thereafter, a wheal develops at the site of the sting. He soon feels flushed and develops hives, rhinorrhea, and tightness in the chest. He is seen in the urgent care center. Immediate therapy should be to administer oral albuterol administer subcutaneous epinephrine transfer to local ED

administer subcutaneous epinephrine albuterol would be delivered via aerosol want to treat systemic (anaphylatic) reactions before sending to ED

SABA examples

albuterol levalbuterol

airway hyperreactivity

asthma

pleural effusion CXR findings

blunting of the costophrenic angle

Platelike atelectasis and dilated and thickened airways, sometimes described as tram lines or ring-like, are common radiographic findings

bronchiectasis

anti muscarinic MOA

bronchodlation

a patient with horner's syndrome and a chest X-ray shows a rounded opacity in the right lung field. what is the CXR finding caused by?

bronchogenic carcinoma tumor mass extending to the sympathetic chain

CURB-65

cap CURB-65 uses five parameters to estimate a 30-day mortality score of patients diagnosed with community-acquired pneumonia: confusion, uremia ( > 19 mg/dL or > 7 mmol/L), respiratory rate ( ≥ 30), blood pressure (< 90 mm Hg systolic or ≤ 60 mm Hg diastolic), and age ≥ 65 years. Each of these parameters is assigned a score of 1 for a possible total of 5. A patient with a score of 0 or 1 (30-day mortality rate of 1.5%) is treated outpatient using a macrolide or doxycycline. A fluoroquinolone should be used for immunocompromised patients or patients recently treated with antibiotics. A patient with a score of 2 has a mortality rate of 9.2% and should be admitted for antibiotic therapy or for observation. A patient with a score of ≥ 3 has a mortality rate of 22% and should be admitted for IV antibiotic therapy Scores of 4 and 5 = consideration for ICU admission

beta 2 agonists MOA

causes relaxation of bronchial smooth muscle (bronchodilation)

What is the most common radiographic presentation of lung abscess?

cavitation

Treatment for klebsiella pneumonia

cefotaxime, third generation cephalosporin

Pts with CAP that require hospitalization are treated with?

ceftriaxine + azithromycin extended-spectrum beta-lactam antibiotic, such as ceftriaxone, with a macrolide, such as azithromycin

which types of lung cancers are more likely to affect phrenic nerve?

centrally located ones like squamous cell CA

Epithelial hyperplasia

chronic bronchitis

Which of the following is a classic clinical finding of interstitial lung disease? Chronic nonproductive cough pleuritic chest pain

chronic nonproductive cough Pleuritic chest pain (C) is chest pain that is exacerbated by deep inhalation. Pleuritic chest pain may be seen with costochondritis, rib fractures, acute pericarditis, pneumothoraces, pneumonia, and pulmonary embolisms. While it may occur with interstitial lung disease, pleuritic chest pain is not one of the classic findings.

You are performing a physical examination on a patient with longstanding COPD. Significant findings include wheezing respirations, cyanosis, and distended neck veins; a left parasternal lift and a tender liver are both noted on palpation. Question What is most likely causing the patient's symptoms?

cor pulmonale

substernal lift, prominent epigastric lift

cor pulmonale

Meconium ileus

cystic fibrosis

sweat chloride test

cystic fibrosis

Light's criteria

distinguish transudates from exudates. According to Light's criteria, need at least one to be an EXUDATE pleural fluid protein to serum protein ratio greater than 0.5 pleural fluid lactate dehydrogenase (LDH) to serum lactate dehydrogenase ratio greater than 0.6 pleural fluid lactate dehydrogenase greater than two-thirds the upper limit of the laboratory's normal serum lactate dehydrogenase range

influenza transmission

droplet nuclei, suspend in air longer

cor pulmonale sx

dyspnea, lethargy, fatigue, syncope, presyncope, exertional chest pain, palpable pulmonic component of the second heart sound, widely split S2, elevated jugular venous pressure, lower extremity edema, and right axis deviation on electrocardiography

pulmonarty HTN diagnostic study?

echocardiogram If there is not a clear justification for the pulmonary hypertension on echocardiogram, then further testing, such as pulmonary function testing, ventilation-perfusion scanning, and overnight oximetry, should be performed. Right heart catheterization (definitive diagnosis) is indicated in patients who still are not found to have a clear explanation of the pulmonary hypertension.

alpha-1 antitrypsin deficiency

emphysema of someone who doesn't smoke and is <40 years old

Case A 3-year-old boy presents with a 4-hour history of respiratory distress, dysphagia, and fever. On examination, temperature is 104.3°F, pulse 150, and respirations 32 and shallow. Marked inspiratory stridor with an open-mouth appearance and sialorrhea is present. What do you suspect and what is second line treatment?

epiglottitis abx: ceftriaxone secure airway first

Tx of legionella

floroquinolones & macrolides (Dr-K erythromycin)

Sarcoidosis CXR finding?

granulomatous inflammation

reminder to check marked questions on exammaster

hi

A 72-year-old man is evaluated at his bedside following hospital admission for a 1-year history of progressive dyspnea, nonproductive cough, weight loss, low-grade fevers, fatigue, and myalgias. Past medical history is remarkable for atrial fibrillation (for which he takes amiodarone), hypercholesterolemia, and recurrent urinary tract infections. He is currently on nitrofurantoin on a chronic prophylactic basis. He denies cigarette use. He denies chills, fatigue, rhinitis, otalgia, chest pain, wheezing, hemoptysis, syncope, abdominal pain, rashes, peripheral edema, diaphoresis, arthralgias, vomiting, and urinary complaints. A bedside echocardiogram and electrocardiograms are unremarkable for abnormalities. A chest x-ray reveals peripheral reticular opacities at the lung bases and a generalized honeycombing pattern. Question What disease do you suspect?

idiopathic pulmonary fibrosis (IPF).

granulomatous nodule

inflammatory process like histoplasmosis

SAMA examples

ipratropium bromide

RSV, rhinovirus, SARS transmission

large particle aerosols, fall to ground

What are some indications for hospitalization in a patient who has acute bronchiolitis?

less than 2 months of age moderate tachypnea with feeding difficulties

foul smelling

lung abscess or foreign body

A 78-year-old woman with a previous history of left-sided stroke and dysphagia presents to the clinic complaining of weeks of productive cough, fever, malodorous sputum, and weight loss. Chest X-ray reveals a solitary pulmonary infiltrate in the right lower lung with a central cavitation and a visible air-fluid level. Which of the following represents the most likely diagnosis? and Tx?

lung abscess; abx therapy. NO surgical resection

most common lung neoplasm in children

lung carcinoid tumor excess secretion of serotonin

When is home oxygen therapy indicated for COPD patients?

oxygen saturation < or equal to 88% pO2 < or equal to 55 mm Hg taken at rest breathing room air

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? chest XR sputum gram stain peak flow ventilation-perfusion scan (V/Q scan)

peak flow not VQ because that is for pulmonary embolism

paroxysms of cough

pertussis (whooping cough)

A 5-year-old female patient has paroxysms of cough that increase in severity and duration. Some coughing episodes are followed by a high-pitched inspiratory noise, and vomiting has occurred after paroxysms. Question What do you suspect and What laboratory test could lead to the earliest confirmation of the likely diagnosis? PCR assay and antigen detection Chest X-ray Culture

pertussis, PCR assay and antigen detection PCR assay and antigen detection are increasingly used to assist in diagnosing pertussis. Advantages include greater sensitivity, more rapidly available results, and use later in the disease course or after antimicrobial therapy because the tests do not rely on the isolation of viable organisms. The infection can be directly confirmed by culture for Bordetella pertussis, but it takes several days, and there is a high rate of false-negative results. Chest x-ray is not required in this patient because the diagnosis of pertussis is mostly clinical.

Blunting of costophrenic angles on CXR

pleural effusion

Unilateral sharp inspiratory chest pain and thoracic friction rub

pleural effusion

On physical exam, the patient is in mild respiratory distress. He has a slightly elevated heart rate and respiratory rate. He is normotensive. His trachea appears deviated to the left. On pulmonary exam, breath sounds are diminished on the right. Hyperresonance is noted on percussion of the right chest compared to the left. Other than tachycardia, his cardiovascular exam is normal.

pneumothorax

hyperresonance to percussion, decreased fremitus

pneumothorax air

sarcoidosis tx

prednisone

3 stages of TB?

primary, latent, reactivation

A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals tachycardia. Which of the following is the most likely diagnosis?

pulmonary embolism

vq scan

pulmonary embolism

Patients with long-term exposure to silica, coal dust, and asbestos may develop which of the following as complications?

pulmonary fibrosis, scarring of the lung

common cause of death in cystic fibrosis

pulmonary infection terminal chronic respiratory failure associated with cor pulmonale

Kussmaul breathing is characterized by

rapid, deep, labored breathing

Air bronchograms

respiratory distress syndrome

cor pulmonale definitive dx

right heart catherization can also be dx by echo with doppler with pulmonary artery pressure >20mmHg

Cor pulmonale pathophysiology and causes

right ventricular hypertrophy and heart failure due to chronic lung disease or chronic hypoxemia Most common chronic cause: COPD Most common acute cause: PE all leading to pulmonary HTN

A 32 year-old African American female presents with complaints of a gradual worsening of exertional dyspnea associated with a mild dry cough. She has tried various cough preparations on her own without any significant relief. Her examination is essentially unremarkable. A chest x-ray reveals the presence of bilateral hilar adenopathy. Which of the following is the most likely diagnosis? silicosis sarcoidosis

sarcoidosis

middle aged AA female

sarcoidosis

A 62-year-old African American woman presents with a persistent cough and shortness of breath. Bronchoscopy is performed and the report includes the following description: "2 x 2 cm non-necrotizing granuloma in the left upper lung field and a 1 x 1 cm non-necrotizing granuloma in the right middle lung field." Question What is the most likely diagnosis?

sarcoidosis Sarcoidosis is a systemic disorder characterized by non-necrotizing granulomatous inflammation with varying degrees of concomitant fibrosis

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

severe respiratory arrest with impaired mental status endotracheal intubation and mechanical ventilation

honeycombing

significant interstitial lung disease such as idiopathic pulmonary fibrosis

foundry workers

silicosis

Which forms of lung cancer is associated with the poorest prognosis?

small cell

when is a low-dose CT imaging for lung CA screening indicated?

smokers 50-80 years w/ 20 pack-year smoking history currently smoke OR quit within last 15 years otherwise, recommended screening for ANY smoker is 40-75 years old

pleural line on chest x-ray (CXR)

spontaneous primary pneumothorax

centrally located lung cancers

squamous cell small cell

pneumoconiosis tx

supportive

tx for idiopathic pulmonary fibrosis

symptomatic, no cure

PE common symptoms

tachypnea

A 50-year-old man presents to the emergency department with a cough and fever. Chest X-ray is obtained to rule-out pneumonia and is negative for any acute findings. However, a 15-millimeter solitary pulmonary nodule is identified incidentally. Which of the following is the next best step in the management of this patient? Chest CT with or without intravenous contrast

without IV contrast contrast is used to see vasculature (pulmonary embolism) and fluid collections (abscess)

Positive egophony means

you hear an "a" instead of an "e", and there is consolidation

Normal FEV1/FVC

≥ 70%