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Pulmonary Board Review

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Transmitted Voice Sounds in Pneumonia. Egophany (ee to ay) Whispered Pectoriloquy (ninety nine) ... Cryptogenic organizing pneumonia. Pulmoanry Langerhans cell ... – PowerPoint PPT presentation

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Title: Pulmonary Board Review


1
Pulmonary Board Review
  • Kathryn Robinett
  • 6/8/07

2
Item 6 Question
  • A 25 yo man is evaluated because of a 3 month
    history of episodic dyspnea at rest. The
    episodes occur approximately 3x/month. He had
    asthma as a child, which resolved.
  • His temp 36.5, HR 85 RR 14 BP 125/75 and the
    only abnormality on PE is bilateral wheezing w/o
    crackles. CXR is normal.
  • Spirometry shows a FEV1 78 and FVC 93. He
    has 17 improvement in FEV1 after bronchodilators

3
Asthma Severity and Treatment
4
Item 6 Answer
  • Which of the following is the most appropriate
    treatment regimen for this patient.
  • A. Albuterol
  • B. Albuterol long acting Beta agonist
  • C. A long acting Beta agonist
  • D. Albuterol and a low-dose inhaled
    corticosteroid.

5
Question VII-5
  • A patient is admitted to the intesive care unit
    with sudden-onset shortness of breath and chest
    pain followed by PEA arrest. After resucitation,
    the pt is dependent on vasopressors. The pt is
    undergoing tx for metastatic breast cancer. She
    complained to her husband 3 days earlier that her
    left leg was slightly more swollen than her
    right. Current meds include lasix, tamoxien,
    pantoprazole and diazepam. PE is notable for
    cool extremities, tachycardia, elevated JVP and a
    right ventricular heave. Lungs are clear.

6
Answer VII-5
  • Which of the following is indicated for this
    patient now.
  • Fondaparinux
  • Intra-aortic balloon pump
  • IV tPA
  • Enoxaparin SQ
  • None of the Above

7
Question VII-6
  • The patient survives and is ready for discharge
    from the hospital. Which of the following meds
    should be discontinued.
  • Diazepam
  • Furosemide
  • Pantoprazole
  • Tamoxifen
  • None of the Above

8
A 72 yo male w/ long hx of tobacco use is seen in
the clinic for 3 weeks of progressive dyspnea on
exertion. He has had a mild nonproductive cough
and anorexia but denies fevers, chills or
sweats. On physical exam, he has normal vitals
and nml oxygen sat on RA. JVP is nml, and
cardiac exam shows decreased heart sounds but no
other abnormality. The trachea is midline and
there is no associate lymphadenopathy. On
pulmonary exam, the pt has dullness over the
left lower lung field, decreased tactile
fremitus, decreased breath sounds and no voice
transmission.
9
Causes of Dullness to Percussion
  • Lobar pneumonia
  • Pleural Effusion
  • Atelectasis
  • Hemothrorax
  • Empyema
  • Tumor

10
Tactile Fremitus Increased Decreased
  • Lobar pneumonia
  • Atelectasis
  • Aveolar hemorrage
  • COPD
  • Pleural effusion
  • Pneumothorax
  • Tumor w/ chest wall involvement
  • Thick chest wall
  • Obstructed bronhcus

11
Transmitted Voice Sounds in Pneumonia
  • Egophany (ee to ay)
  • Whispered Pectoriloquy (ninety nine)
  • Bronchophony (spoken words louder and clearer)

12
A 72 yo male w/ long hx of tobacco use is seen in
the clinic for 3 weeks of progressive dyspnea on
exertion. He has had a mild nonproductive cough
and anorexia but denies fevers, chills or
sweats. On physical exam, he has normal vitals
and nml oxygen sat on RA. JVP is nml, and
cardiac exam shows decreased heart sounds but no
other abnormality. The trachea is midline and
there is no associate lymphadenopathy. On
pulmonary exam, the pt has dullness over the
left lower lung field, decreased tactile
fremitus, decreased breath sounds and no voice
transmission. The right lung is normal After
obtaining CXR, appropriate initial management at
this point would include which of the following
13
Choices
  • A. IV Antibiotics
  • B. Thoracentesis
  • C. Bronchoscopy
  • D. Deep Suctioning
  • E. Bronchodilator Therapy

14
Question VI-17
  • A 23 yo hospital worker is evaluated for a known
    contact w/ a pt w/ active tuberculosis. One year
    ago his intermediate strength PPD had 3mm of
    induration now it has 13 mm of induration at
    48hrs. He has no significant past medical
    history and is on no mediations.

15
When is a PPD positive?
  • Close Contacts w/ Pt w/ Active TB
  • 5mm
  • Recent Conversion
  • 10mm increase in 2yrs
  • General Public
  • 15mm
  • CXR c/w prior TB
  • 5mm
  • High-risk populations
  • 10mm
  • HIV or Immunocompromised
  • 5mm

16
Question VI-17
  • A 23 yo hospital worker is evaluated for a known
    contact w/ a pt w/ active tuberculosis. One year
    ago his intermediate strength PPD had 3mm of
    induration now it has 13 mm of induration at
    48hrs. He has no significant past medical
    history and is on no mediations.

17
Answer VI-17
  • Subsequent management should include
  • CXR
  • Isoniazid 300 mg Qday x 3 months
  • Measurement of baseline liver function
  • Measurement of liver function test every 3 months
  • Repeated intermediate-strength PPD testing in 2
    weeks

18
Question VI-30
  • 65 yo man w/ bronchiectasis presents to ED w/
    hemoptysis. He reports increased cough and
    sputum production over the last week with
    low-grade fevers. There is often blood streaking
    his sputum, but in the last day he has noted that
    he is coughing up tablespoons of clotted blood
    approximately 1 cup total over 24hrs. Physical
    exam shows normal vital signs. The pt is mildly
    dyspneic and has diffuse expiratory wheezing.
    CSR, besides showing bronchiectasis is normal.

19
Answer VI-30
  • What is the most likely etiology of the
    hemoptysis?
  • Aveolar hemorrhage
  • Aspergillus colonization
  • Bronchial artery erosion
  • Endobronchial neoplasia
  • Necrotizing gram-negative infection

20
QA VI-31
  • What is the most appropriate immediate treatment
    for this hemoptysis?
  • Bronchoscopy
  • Bronchial artery embolization
  • Chest CT
  • Lung transplantation
  • Surgical resection

21
Question VI-51
  • A 56 yo man presents to his PMD for eval of
    progressive dyspnea and fatigue. The man states
    that he has felt that he cannot do as much
    activity as he once could but attributes that to
    aging. He thinks he first noticed feeling DOE 1
    yr ago. At that time the pt could no longer
    carry his golf bag and started to use a golf cart
    on the course. The pt now reports that he cannot
    play golf b/c of SOB. The dyspnea is now to the
    point he feels breathless after 2 flights of
    stairs. No PMHx. Tobacco abuse x 30 yrs and
    quit 10 years ago.

22
Question VI-51 cont
  • He takes no meds. He denies fevers, chills or
    weight loss. On physical exam the pt appears his
    stated age and does not get dyspneic during
    conversation. Resting oxygen saturation is 94
    on RA. It declines to 82 w/ walking. The
    pulmonary exam is remarkable for normal expansion
    and percussion. On inspiration, fine, dry
    crackles are heard bilaterally at the bases. The
    patient has clubbing. No edema or cyanosis is
    present .

23
Clinical Presentation of ILD
  • Dyspnea
  • Restrictive PFTs
  • Diffuse disease on CXR
  • A-a gradient
  • There are over 100 disorders and the name is a
    misnomer because there is often bronchial and
    aveolar involvement

24
Trigger Words in ILD
  • Hypersensitivity Pneumonitis moldy hay, grain,
    pet birds recurrent fleeting infiltrates on CXR
  • Byssinosis inh cotton, flax or hemp Monday
    chest tightness
  • Silicosis yrs of exposure to glassmaking,
    sandblasting, brick hilar eggshell
    calcification Incr. Suseptibility to TB (yearly
    PPD)
  • Berylliosis - 2yr exposure electronics, alloys,
    manhattan project hilarlymphadenopathy
    beryllium lymphocyte transormation CAN BE
    TREATED w/ steroids!

25
COP (BOOP) vs. IPF
26
Answer VI-51
  • What is the best test for definitively making the
    diagnosis in this patient?
  • Pulmonary function testing
  • High-resolution CT
  • Bronchoscopy w/ transbronchial biopsy
  • Surgical lung biopsy
  • Ventilation-perfusion scan

27
QA VI-52
  • A diagnosis of IPF is made. What do you tell the
    pt about the treatment and prognosis?
  • His survival and quality of live will be improved
    w/ use of prednisone and cyclophosphamide.
  • His 5 yr survival is less than 10
  • Single-lung transplantation should be considered
    if he continues to exhibit clinical deterioration
    while on medical therapy
  • Interferon gamma has been shown to improve
    survival in all pts w/ this disease
  • Glucocorticoids alone are the best therapy

28
QA VI-50
  • Which of the following interstitial lung diseases
    is not associated with smoking.
  • Desquamative interstitial pneumonitis
  • Respiratory bronchiolitis interstitial lung
    disease
  • Idiopathic pulmonary fibrosis
  • Cryptogenic organizing pneumonia
  • Pulmoanry Langerhans cell histoiocytosis

29
Explaination VI-50
  • COP (previously BOOP) is often an idiopathic
    syndrome that presents in the fifth to sixth
    decade of life w/ DOE, cough, fevers, malaise and
    weight loss. The cause in most instances is
    unknown. Responds well to steroid therapy, which
    induces clinical recovery in 2/3 of patients.

30
Question VI-10
  • A 45 yo male is evaluated in the clinic for
    asthma. His symptoms began 2 yrs ago and are
    characterized by an episodic cough and wheezing
    the responded initially to inhaled
    bronchodilators and inhaled corticosteroids but
    now require nearly constant prednisone tapers.
    He notes that the symptoms are worst on the
    weekdays but cannot pinpoint specific triggers.
    His medications are albuterol, fluticasone and
    prednisone 10mg. The pt has no habits and works
    as a textile worker. Physical exam is notable
    for mild diffuse polyphonic espiratory wheezing
    but no other abnormality.

31
Question VI-10
  • Which of the following is the most appropriate
    next step?
  • Exercise physiology testing
  • Measurement of FEV1 before and after work
  • Methacholine challenge testing
  • Skin testing for allergies
  • Sputum culture or Aspergillus fumigatus

32
Question VI-76
  • A 63 yo male w/ a long history of cigarette
    smoking comes to see you for a 4 month history of
    progressive SOB and DOE. The symptoms have een
    indolent w/ no recent worsening. He denies
    fever, chest pain or hemoptysis. He has a daily
    cough of 3-6 tablespoons of yellow phlegm. The
    patient says he has not seen a physician for over
    10 years. Physical exam shows normal vitals, a
    prolonged expiratory phase, scattered rhonchi,
    elevated JVP and moderate pedal edema. Hct 49

33
Answer VI-76
  • Which of the following therapies is most likely
    to prolong his survival?
  • Atenolol
  • Enalapril
  • Oxygen
  • Prednisone
  • Theophylline

34
Question VI-8182
  • A 35 yo male seeks medical attention for
    breathlessness on exertion. He has never smoked
    cigarettes and has not been coughing. One
    sibling died of respiratory failure at 40 years
    of age. His 3 children are healthy. Physical
    exam reveals the pt to be tachypneic as he
    exhales through pursed lips. His chest is
    tympanitic to percussion and breath sounds are
    poorly heard. CXR shows flattened diaphragms
    with peripheral attenuation of bronchovascular
    markings that is most noticeable in the lung
    bases.

35
Answers VI-81
  • Expected results of PFTs in this patient would
    include
  • Increased lung elastic recoil
  • Increased total lung capacity
  • Reduced functional residual capacity
  • Increased vital capacity
  • Increased diffusing capacity

36
Answers VI-82
  • Which of the following would be the most
    reasonable next step in the assesment of this
    patient.
  • Measurement of serum alpha 1 antitrypsin activity
  • Measurement of sweat chloride concentration
  • High Resolution CT scan
  • Exercise stress test
  • Echocardiogram
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