Pulmonary/CC Board Review

Transcript Pulmonary/CC Board Review

Pulmonary/CC Board Review

A 25-year-old woman is evaluated for recurrent episodes of acute dyspnea associated with rapid breathing, tightness in her chest and throat, voice changes, and inspiratory difficulty. When she has these episodes she feels that she “can’t get enough air.” The symptoms typically start and resolve abruptly, and treatment with albuterol provides only minimal relief. On physical examination, her vital signs are normal. Lungs are clear. Spirometry shows an FEV 1 80%. of 2.8 L (88% of predicted) and FEV 1 /FVC ratio of Which of the following is the most appropriate next diagnostic step?

Chest radiography CT scan of the neck Flow volume loops Thyroid function tests

Vocal Cord Dysfunction

A 35-year-old man is evaluated for episodic wheezing, dyspnea, and cough. Two months ago he had an acute episode of cough, dyspnea, wheezing, and chest tightness within minutes of inhaling high concentrations of ammonia solution after an accidental spill at work. In the emergency department, the chest radiograph was normal, and he received inhaled bronchodilators and a brief course of oral corticosteroids. The patient does not have a history of asthma or allergies and is otherwise healthy and takes no medications. The physical examination is normal. Spirometry shows an FEV 1 of 90% of predicted; FEV 1 /FVC ratio is 82%. Which of the following is the most appropriate next test in this patient’s evaluation?

1. Bronchoscopy with biopsy 2. Inhalation challenge with chlorine 3. Methacholine challenge test 4. Spirometry before and after work

Asthma- Diagnosis

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Spiromery shows low FEV1/FVC ratio and reversibility 12% of greater improvement in FEV1 after administration of bronchodilators Next step bronchial challenge test

A 27-year-old man is evaluated for a 6-month history of cough, which is worse at night and after exposure to cold air. Often his cough is brought on by taking a deep breath or by laughter. He does not have postnasal drip, wheezing, or heartburn. He has a strong family history of allergies. Physical examination, chest radiograph, and spirometry are normal. He receives no benefit from a 3-month trial of gastric acid suppression therapy, intranasal corticosteroids, and an antihistamine-decongestant combination. Which of the following would likely provide the diagnosis of this patient’s chronic cough?

24-Hour esophageal pH monitoring Bronchoscopy CT scan of the chest CT scan of the sinuses Trial of inhaled albuterol

0% 1 0% 2 0% 3 0% 4 0% 5

Occupational Asthma Reactive Airways Dysfunction Syndrome Virus-Induced Asthma Cough-Variant Asthma GERD and Asthma ABPA Exercise-Induced Bronchospasm Aspirin-Sensitive Asthma Vocal Cord Dysfunction

A 28-year-old man is evaluated for a 6-month history of episodic dyspnea, cough, and wheezing. As a child, he had asthma and allergies, but he has been asymptomatic since his early teenage years. His recent symptoms started after an upper respiratory tract infection, and they are often triggered by exercise or exposure to cold air. He is also awakened with asthma symptoms 5 or 6 nights a month. He is otherwise healthy and takes no medications.

On physical examination, vital signs are normal. There is scattered wheezing in both lung fields. Chest radiograph is normal. Spirometry shows an FEV 70% of predicted with a 15% improvement after inhaled albuterol. 1 of Which of the following is the most appropriate therapy for this patient?

Azithromycin Inhaled Albuterol as needed Inhaled low-dose corticosteroids plus inhaled albuterol as needed Long-acting B-agonist

0% 0% 0% 0% 2 3 4 0% 5

Components of Severity Impairment Symptoms Nighttime awakenings ≤2 ×/month SABA use for symptom control (not prevention of EIB) ≤2 days/week Interference with normal activity Lung function Intermittent ≤2 days/week None Normal FEV 1 between exacerbations FEV 1 >80% of predicted FEV 1 /FVC normal Persistent Mild > 2 days/week 3-4 ×/month >2 days/week but not more than 1 ×/d Minor limitation FEV 1 >80% of predicted FEV 1 /FVC normal Moderate Daily >1 ×/week but not nightly Daily Some limitation FEV 1 >60% but <80% of predicted FEV 1 /FVC reduced 5% Severe Throughout the day Often 7 ×/week Several times a day Extremely limited FEV 1 <60% of predicted FEV 1 /FVC reduced >5% Risk Exacerbations (consider frequency and severity) b,c Recommended step for initiating treatment (see Figure 4 for treatment steps) d 0-2/year Step 1 Step 2 >2/year Step 3; consider short courses of systemic corticosteroids Step 4 or 5; consider short courses of systemic corticosteroids

A 70-year-old woman is evaluated for a 6-month history of fatigue, an unintentional weight loss of 4.4 kg (10 lb), an increase in chronic cough with sputum production, and a decrease in exercise capacity. The patient has a 40-pack-year history of cigarette smoking but stopped smoking 10 years ago when chronic obstructive pulmonary disease was diagnosed. She has no other symptoms and specifically denies abdominal pain, nausea, vomiting, diarrhea, or change in her bowel habits. Her medications are albuterol as needed, an inhaled corticosteroid, and salmeterol. She has been on stable dosages of these drugs for 18 months. Age- and sex-appropriate cancer screening tests done 6 months ago were normal. On physical examination, the temperature is 37.5 °C (99.5 °F), the blood pressure is 128/76 mm Hg, the pulse rate is 94/min and regular, the respiration rate is 16/min, and the BMI is 20. Heart sounds are distant, and breath sounds are diminished bilaterally. There are no abdominal masses or organomegaly and no peripheral edema.

Labs: Hg: 15, Alb: 3.0, Cr: 0.8, TSH: 2.0

Spirometry shows an FEV 1 of 40% of predicted and an FEV 1 /FVC ratio of 45%. Chest radiograph shows hyperinflation. Which of the following is the most likely reason for this patient’s weight loss?

Breast Cancer Cervical Cancer Colon Cancer Chronic Obstructive Pulmonary Disease

1 0% 0% 2 0% 3 0% 4

A 50-year-old man is evaluated for a 1-year history of cough productive of mucoid sputum. He has not had fever or lost weight during that time. The patient has smoked one pack of cigarettes a day for 20 years. He has no history of allergic disease or gastroesophageal reflux disease. On physical examination, the temperature is 37.0 °C (98.6 °F), the blood pressure is 124/76 mm Hg, the pulse rate is 78/min and regular, and the respiration rate is 15/min; BMI is 25. The lungs are clear, and the chest radiograph is normal. Spirometry shows an FEV 1 of 85% of predicted and an FEV 1 /FVC ratio of 75%; there is no change in results after administration of a bronchodilator. Which of the following is the most likely diagnosis?

1. Asthma 2. At risk of chronic obstructive pulmonary disease (COPD) 3. Mild (GOLD stage I) COPD 4. Moderate (GOLD stage II) COPD

1 0% 0% 2 0% 3 0% 4

All in patient with FEV1/FVC < 70%

COPD

Table 8

At risk -- GOLD 1 GOLD 2 Mild Moderate GOLD 3 Severe GOLD 4 Very Severe Normal Spirometry Chronic Symptoms FEV1/FVC <70% FEV >80% of predicted FEV1/FVC <70% 50%

A 55-year-old man with a 7-year history of severe chronic obstructive pulmonary disease is evaluated after being discharged from the hospital following an acute exacerbation; he has had three exacerbations over the previous 18 months. He is a long-term smoker who stopped smoking 1 year ago. He adheres to therapy with albuterol as needed and inhaled salmeterol and tiotropium and has demonstrated proper inhaler technique. On physical examination, vital signs are normal. Breath sounds are decreased bilaterally; there is no edema or cyanosis. Oxygen saturation after exertion is 92% on ambient air. Spirometry shows an FEV 1 of 32% of predicted and an FEV 1 /FVC ratio of 40%. Chest radiograph done in the hospital 3 weeks ago showed no active disease. Which of the following should be added to this patient’s therapeutic regimen?

1. An inhaled corticosteroid 2. Ipratropium 3. N-acetylcysteine 4. Oral Prednisone

1 0% 0% 2 0% 3 0% 4

Level of Airflow Obstruction

FEV1 60-80% of predicted (THINK GOLD 1 or 2) FEV1< 60% of predicted (THINK GOLD 3) FEV1< 50% of predicted (THINK GOLD 3 and 4)

Recommended Therapy

Inhaled bronchodilator therapy (short acting anticholinergic or short acting B2 agonist) Daily monotherapy with an Inhaled bronchodilator therapy (long acting anticholinergic or long acting B2 agonist) Consider combination inhaled therapy (long acting anticholinergic, long acting B2 agonist, or cortisteroid) Consider adding pulmonary rehabilitation

A 64-year-old woman is evaluated for a 6-week history of dyspnea, dry cough, fever, chills, night sweats, and fatigue, which have not responded to treatment with azithromycin and levofloxacin; she has lost 2.2 kg (5 lb) during that time. The patient had a thorough examination 6 months ago while she was asymptomatic that included routine laboratory studies, age- and sex-appropriate cancer screening, and a chest radiograph; all results were normal. The patient has never smoked, has had no known environmental exposures, and has not traveled recently or been exposed to anyone with a similar illness. Her only medications are aspirin and a multivitamin. On physical examination, temperature is 37.8 °C (100.0 °F); other vital signs are normal. Cardiac examination is normal. There are scattered crackles in the mid-lung zones with associated rare expiratory wheezes. There is no digital clubbing. Musculoskeletal and skin examinations are normal. Chest radiograph is shown Which of the following is the most likely diagnosis?

. Cryptogenic organizing pneumonia Idiopathic pulmonary fibrosis Lyphocyti interstitial pneumonia Nonspecific interstitial pneumonia

1 0% 0% 2 0% 3 0% 4

55 year old F with fever, dyspnea, malaise for 2 weeks…

Cryptogenic Organizing Pneumonia

• • • • • • • • History: Insidious onset (weeks to 1-2 months), often failed outpatient treatment for viral pneumonitis or bacterial pneumonia Epidemiology: M=F, Age=middle aged HPI: Cough, fever , dyspnea, malaise, and myalgias PE: Rales Imaging: bronchial thickening, some interstitial findings patchy bilateral alveolar infiltrates, MIGRATES Histology: organizing pneumonia, bronchiolitis and chronic alveolitis (open lung bx preferred, often adequate with TBB) Associations: Penicillamines and RA Treatment: Good prognosis, responds to steroids. Slow taper to avoid exacerbations

55 year old male presents with 6 months dyspnea, cough…

Usual Interstitial pneumonia

Idiopathic Pulmonary Fibrosis (IPF)

• • • • • • • • • History: VERY slow onset, at least 6 months Epidemiology: M=F, average age = 55 HPI: dyspnea, poor exercise tolerance, cough, NO FEVER PE: no extrapulmonary manifestations, CLUBBING usually seen, coarse, dry crackles at lung bases Imaging: CT “ground glass” early, “honeycombing “late, CXR interstitial Histology: Usual Interstitial Pneumonia (UIP) Associations: smoking exacerbates, ~ 10% low titers of ANA or RF, no associations with infections, drugs, chemicals Treatment: steroids +/- cyclophosphamide or azathiprine (20-30% improve), Single-lung transplant in late cases Response: A-a gradient response to exercise.

45 year old F, h/o IVDA, with dyspnea and cough over last 2-3 months…

Nonspecific Interstitial Pneumonitis (NSIP)

• • • • • • • • History: subacute presentation 2-3 months coughing, dyspnea PE: bibasilar crackles, stimata of CTD Imaging: basilar or mid-lung reticular changes, (spares subpleural region) rarely with honeycombing, pattern of ground-glass opacification in the mid- and lower-lung zones Diagnosis: requires open lung biopsy (difficult to differentiate fro IPF) Histo: lymphoplasmacytic interstitial infiltration in a uniform pattern, accompanied by chronic fibrosis (NSIP) Associations: HIV, CTD, HSP, drug induced lung disease Treatment: steroids +/- cytotoxic meds Prognosis: better that IPF, but still grim when fibrosis on bx

38 year old F presents with acute onset shortness of breath…

Lymphangioleiomyomatosis

• • • • • • • Epidemiology: Premenopausal women Pathophys: Immature smooth muscle proliferation in lymph, vasc, and alveolar wall/perbronchial structures  cysts and constriction in these structures HPI: often presents with pneumothorax PE: hamartomas, ash leaf spots, adenoma sebaceum Imaging: honeycombing diffusely throughout the lung (in contrast to upper lung in Langerhans) Associations: Pneumothorax , chylous pleural effusions (TG >110 +/- chlomicrons, common with Tuberous Sclerosis or multiple hamartomas (Cowden’s Syndrome) Treatment: Oophorectomy with progestin treatment, lung transplant (may recur)

32 year M, smoker, presents with gradual worsening of shortness of breath/cough…

Pulmonary Langerhans Cell Histocytosis

• • • • • • • • • History: 10% present with pneumothorax, 50% will have PTX sometime during illness Epidemiology: M>F, smokers, majority <40 y/o PFTs: OBSTRUCTIVE Imaging: interstitial changes and small cystic spaces in upper lung fields , honeycomb, Histology: Langerhans cells Associations: smoking Treatment: stop smoking, steroids generally do not help . Occasional spontaneous resolution Hand-Schuller Christian syndrome: lytic bone lesions, diabetes insipidius, exophthalmus Smoking related ILDs: Pulm Langerhans, Resp Bronchiolitis, DSIP

60 year old F with h/o asthma presents with 3 months insidious cough,

ESR: 82

wheezing, night sweats, low grade fevers…

BAL: high percentage eosinophils

Eosinophilic Pneumonias

• Acute, benign eosinophilic pneumonia: Loefflers syndrome, minimal resp symptoms. MIGRATORY infiltrates. Peripheral eosinophilia. Rule out drugs and parasites.

• Acute eosinophilic pneumonia: acute, febile, hypoxemic resp failure resembling ARDS. Steroids and vent support.

• Chronic Eosinophilic pneumonia: most common in U.S. Middle aged women. Subacute. CXR edema bilateral, very peripheral infiltrates, photographic negative of pulm , High ESR. Steroids. Relapse common.

55 year old f presents with joint pain, Rash & fevers…

Sarcoidosis

• • • • • • • Lofgren’s sndrome: Erythema nodosum (good prognosis) , polyarthralgias, hilar LAD, and fever Multisystem disease Imaging: bilateral hilar and/or mediastinal adenopathy (disappears as dz progresses), +/- parenchymal infiltrates Histo: noncaseating granuloma BAL: increased lymphs, helper/supressor ratio of > 4:1 (opposite of HSP) Associations: ACE level, hypercalcemia, hypergammaglobulinemia Treatment: 75 % recover without treatment, steroids for severe cases I 0 II III IV

Stage Radiographic Pattern

Normal Hilar lymphadenopathy with normal parenchyma Hilar lymphadenopathy with abnormal parenchyma No lymphadenopathy with abnormal lung parenchyma Parenchymal chagnes with fibrosis and architectural distortion

Histology

UIP

Clinical Diagnosis

IPF/ Cryptogenic fibrosing alveolitis CTD associated lung disease Radiation NSIP Organizing Pneumonia Respiratory Bronchiolitis Diffuse Alveolar Damage NSIP (CTD, HIV, Drugs) Cryptogenic Organizing Pneumonia Respiratory Bronchiolitis ILD -DSIP Lymphoid Interstitial pneumonia Lymphoid Interstitial pneumonia Acute Interstitial Pneumonia

A 30-year-old medical resident is evaluated for cough, right-sided chest pain, and fever of 21 days’ duration. He has no significant medical history or family history, and he takes no medications. Hemoglobin is 14 g/dL (140 g/L), and the leukocyte count is 8000/µL (8 × 10 9 /L). Chest radiograph shows a right pleural effusion occupying approximately 50% of the hemithorax without other abnormalities. Thoracentesis yields turbid, yellow fluid, and analysis shows: RBC Count: 500 uL, Nucleated Cell count: 3500 with 20% neutrophils, 60%lymphocytes, 10% macrophages, 4%mesothelial cell, and 6% eosinophils Total Protein: 4.2, LDH: 240, pH: 7.35, Glucose: 68 Serum total protein is 7.0 g/dL and serum lactate dehydrogrenase is 100U/L. Gram stain shows no organism and culture is pending. Which of the following is the most appropriate next step in management?

1. Chest CT scan 2. Flexible bronchoscopy

0% 0% 0% 0%

3. Pleural biopsy

1 2 3 4

4. Repeat chest radiograph after a 5-day course of azithromycin

A 70-year-old man is evaluated in the emergency department for a 2-day history of dyspnea with exertion, orthopnea, and paroxysmal nocturnal dyspnea. He has ischemic heart disease with left ventricular dysfunction and had coronary artery bypass graft surgery 6 weeks ago. His medications include aspirin, nitroglycerin, metoprolol, lisinopril, and furosemide. On physical examination, the patient is sitting upright and breathing with difficulty; the temperature is 37 °C (98.6 °F), the blood pressure is 150/85 mm Hg, the pulse rate is 105/min and regular, and the respiration rate is 28/min. Oxygen saturation is 89% on ambient air. There are fine crackles at the lung bases bilaterally, and breath sounds are diminished at the right base. There is a regular tachycardia and an S 3 at the apex. There is no jugular venous distention or peripheral edema. Hemoglobin is 12.5 g/dL (125 g/L), and the leukocyte count is 10,500/µL (10.5 × 10 9 /L). Chest radiograph shows cardiomegaly and small bilateral pleural effusions, greater on the right than the left. Thoracentesis is performed, and pleural fluid analysis shows: Nucleated Cell Count: 450/UL with 3% neutrophils, 70% lymphocytes, 10% macrophages, 15% mesothelial cells, and 2% eosinophils Pleural Fluid to serum total protein ratio: 0.54, Plerual fluid to upper limits of normal serum LDH ration: 0.52, Glucose: 80, Total Protein: 3.7, pH: 7.45, Albumin: 1.5, Cholestrol 35, The serum pleural fluid albumin gradient is 1.7.

Which is the most likely diagnosis?

Heart Failure Parapneumonic Effusion Post-cardiac injury syndrome Pulmonary embolism

1 0% 0% 2 0% 3 0% 4

Pleural Fluid Pearls

• • • • • • • WBC>1000 (exduate), >10,000 (parapneumonic effusion); >100,000 (pus/empyema) Eosinophils>10% (pneumothorax, drug reaction, parasites, fungus, asbestos) Lymphocytes>50% (TB, or cancer) Glucose ~80 (TB); ~60 (cancer or empyema); <30 (RA) Amylase (pancreatic fistula, esophageal rupture, local malignancy) pH<7.0 (loculated effusion/empyema), <7.2 (PLACE CHEST TUBE), < 7.3 (with malignancy, suggests high tumor burder) TG>115= chylous; <50= pseudochylous

A 64-year-old woman who resides in a nursing home and has a history of end-stage kidney disease for which she receives hemodialysis presents with fever, copious sputum production, and hypoxemia. Chest radiograph shows a right-sided infiltrate. She is intubated and started on vancomycin, levofloxacin, and piperacillin-tazobactam for treatment of diffuse right-sided pneumonia. On day 3 in the hospital, she has been afebrile for 48 hours, and her secretions are scant and white. On physical examination, the temperature is 36.9 °C (98.5 °F), pulse rate is 88/min, respiration rate is 14/min, and blood pressure is 140/86 mm Hg; oxygen saturation is 96% on FiO 2 0.4. There are diffuse right-sided inspiratory crackles. Leukocyte count is 9600/µL (9.6 × 10 9 /L) (20,400/µL [20.4 × 10 9 /L] on admission). Admission sputum culture is now growing methicillin-resistant Staphylococcus aureus; blood cultures are negative. Chest radiograph shows slight improvement in the right sided infiltrate compared with admission. Which of the following is the most appropriate antibiotic therapy at this time?

Complete an 8-day course of all three antibiotics Complete an 8-day course of vancomycin and discontinue the other antibiotics Complete a 14-day course of all three antibiotics Discontinue all antibiotics

1 0% 2 0% 3 0% 4 0% 5

A 30-year-old woman develops bilateral pulmonary infiltrates and hypoxemia 48 hours after undergoing repair of multiple long-bone fractures. Her initial arterial blood gases are pH 7.48, PCO 2 30 mm Hg, and PO 2 45 mm Hg on 100% oxygen by nonrebreather mask. The patient is intubated and placed on mechanical ventilation. The temperature is 38.3 °C (101.0 °F), the pulse rate is 100/min, the respiration rate is 28/min, and the blood pressure is 120/60 mm Hg. The patient weighs 60 kg (132.3 lb). Oxygen saturation is 83%. She is sedated, hemodynamically normal, and not using accessory muscles to breathe. There are bilateral inspiratory crackles. The ventilator settings are as follows: volume control mode, respiration rate 26/min, tidal volume 360 mL, positive end-expiratory pressure (PEEP) 5 cm H 2 O, FiO 2 pH 7.45, PCO 2 33 mm Hg, and PO 2 50 mm Hg. 0.8. Arterial blood gases are Which of the following is the most appropriate next step in the management of this patient?

Increase FiO 2 to 1.0

Increase PEEP to 10 cm H 2 O Increase respiration rate to 32/min Increase tidal volume to 700 mL Start vecuronium infusion

0% 1 0% 2 0% 3 0% 4 0% 5

ALI/ARDS

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ALI

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PaO2/FiO2< 300

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Bilateral infiltrates

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PCWP <18mg Hg ARDS

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PaO2/FiO2<200

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Bilateral infiltrates

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Pulmonary/CC Board Review

Transcript Pulmonary/CC Board Review