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Pulmonary Board Review 2006

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Pulmonary Board Review 2006 Wissam Abouzgheib Thaddeus Bartter A 36 year-old woman presents to your office after coughing up 5 to 10 ml of bright red blood the ... – PowerPoint PPT presentation

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Title: Pulmonary Board Review 2006


1
Pulmonary Board Review 2006
  • Wissam Abouzgheib
  • Thaddeus Bartter

2
  • A 36 year-old woman presents to your office after
    coughing up 5 to 10 ml of bright red blood the
    previous day. Three days earlier she noted the
    onset of coryza and frequent nonproductive cough.
    She denies fever, chest pain, and dyspnea.The
    rest of ROS is negative Denies previous history
    of hemoptysis. She smoked 1 pack /day for 5
    years.
  • Physical exam was normal
  • Labs were Nl
  • UA No erythrocytes, 40 WBC, 4
    bacteria, No proteins, No casts
  • CXRay Nl
  • The most appropriate diagnostic plan at this time
    is
  • -fiberoptic Bronchoscopy
  • -HRCT of chest
  • -serum ANCA and antiGBM antibody
  • -Repeat CXRay at 3 and 6 month

3
  • A 36 year-old woman presents to your office after
    coughing up 5 to 10 ml of bright red blood the
    previous day. Three days earlier she noted the
    onset of coryza and frequent nonproductive cough.
    She denies fever, chest pain, and dyspnea.The
    rest of ROS is negative Denies previous history
    of hemoptysis. She smoked 1 pack /day for 5
    years.
  • Physical exam was normal
  • Labs were Nl
  • UA No erythrocytes, 40 WBC, 4
    bacteria, No proteins, No casts
  • CXRay Nl
  • The most appropriate diagnostic plan at this time
    is
  • -fiberoptic Bronchoscopy
  • -HRCT of chest
  • -serum ANCA and antiGBM antibody
  • -Repeat CXRay at 3 and 6 month

4
Key Points
  • Most common causes of hemoptysis in smoker and
    non smoker is acute viral bronchitis
  • Bacterial infection in HIV
  • Even small amounts should be investigated
  • History and examination are important in
    diagnosis
  • Initial test CXRay , lead the rest
  • Bronchoscopy if gt40 pack-year, gt40 years age, gt30
    cc of blood daily or recurrent
  • CT scan if bronchoscopy CI
  • Massive hemoptysis (gt200 ml / 24 hrs)
  • The cause of death is asphyxiation, not
    exsanguination
  • protect airway, adequate o2
  • bronchial artery embolisation especially
    if bronchiectasis

5
What is causing hemoptysis in this 60 year old
with severe emphysema?
6
What is causing hemoptysis in this 40 year old
with h/o chronic cough and bronchorrhea?
7
For each patient select the most likely flow
volume loop
  • 1 A 34 year old woman with dyspnea at rest
    and hoarseness after being intubated for 20 days
    for aspiration pneumonia .
  • 2 A 70 year old woman who smoked 2 packs of
    cigarettes daily for 50 years and who had severe
    exertional dyspnea and diminished intensity of
    breath sounds on auscultation .
  • 3 A 30 year old female with goiter .

8
Intra thoracic
Extra-thoracic
9
AIPF B COPD C
Pneumonectomy smoker
10
AIPF B COPD C
Pneumonectomy smoker
11
AIPF B COPD C
Pneumonectomy smoker
12
AIPF B COPD C
Pneumonectomy smoker
13
AIPF B COPD C
Pneumonectomy smoker
14
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15
Empyema
  • Chest tube is indicated
  • Purulent effusion
  • pH lt 7.00
  • Glucose lt 40
  • LDH gt 1,000
  • Positive gram stain

16
  • Analysis of Pleural Effusion without Phlebotomy
  • An Exudate Possesses Any One of the Following
    Characteristics
  • Pleural fluid LDH gt 45 of serum upper limit of
    normal, or Pleural fluid cholesterol gt 45 mg/dL,
    or Pleural fluid protein gt 2.9 g/dL

Light Criteria An Exudate Possesses Any One of
theFollowing Characteristics Pleural fluid
proteintoserum protein ratio ³ 0.5, or Pleural
fluid LDHtoserum LDH ratio³ 0.6, or Total
pleural fluid LDH level greater than two-thirds
the upper limit of normal for serum LDH
17
A 41-year-old man with a long history of asthma
has increased wheezing over the past 2 months. He
was treated for pneumonia while on vacation a
month ago and still requires prednisone, 7.5
mg/d. His FEV l despite prednisone therapy, has
fallen 9 over the past 2 months. He notices that
his cough is more productive, and at times, forms
"casts" of his airways. He has increased sinus
complaints. His peripheral blood eosinophil
percentage is 11. His CT scan is shown What is
your diagnosis?
18
  • A-Hypersensitivity pneumonitis
  • B-Chronic eosinophilic pneumonia
  • C-Allergic bronchopulmonary aspergillosis
  • D-Eosinophilic granuloma
  • E-Lymphagioleiomyomatosis

19
  • A-Hypersensitivity pneumonitis
  • B-Chronic eosinophilic pneumonia
  • C-Allergic bronchopulmonary aspergillosis
  • D-Eosinophilic granuloma
  • E-Lymphagioleiomyomatosis

20
The Major Diagnostic Features of ABPA include
  • History of asthma
  • Immediate skin test reactivity to aspergillus
    antigens
  • Precipitating serum antibodies to A. Fumigatus
  • Serum total IgE concentration greater than 1000
    ng/ml
  • Peripheral blood eosinophilia gt 500/mm3
  • Lung infiltrates
  • Proximal bronchiectasis
  • Elevated serum specific IgG and IgA to A.
    Fumigatus

21
A
  • A 28 yo HIV women with SOB, Pao2 of 62 and LDH
    of 1000
  • Most common Bacteria involved in pulmonary
    superinfection after influenza infection
  • Most common organism that infects the lungs of
    patient with PAP

B
C
22
  • A 28 year-old male smoker has had dyspnea on
    exertion for 6 months. Physical examination is
    unremarkable. PFTs demonstrate a mixed
    obstructive and restrictive ventilatory defect.
    BAL performed

23
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24
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25
Pulmonary Langerhans cell histiocytosis
26
Pulmonary Langerhans cell histiocytosis-Eosinophil
ic Granuloma
  • Young adults 20-40 years old
  • Equal gender, Caucasian predominance
  • Symptoms non productive cough, dyspnea, chest
    pain
  • Physical exam unremarkable
  • Recurrent PTX, arteriopathy, Hemoptysis, DI,
    cystic bone lesions
  • Radiographic ill defined nodules,
    reticulonodular infiltrates, upper zone cysts,
    costophrenic angle sparing
  • PFTs Normal flow or restrictive with reduced
    DLCO

27
Pulmonary Langerhans cell histiocytosis-Eosinophil
ic Granuloma
  • Diagnosis BAL, TBbiopsy
  • Treatment
  • Smoking cessation
  • Steroids and cytotoxic limited value

28
  • A 34-year-old woman has progressive dysp- nea
    and severe airflow obstruction (FEV1 34 of
    predicted). One year ago, she had an episode of
    hemoptysis.
  • What is your diagnosis?

29
Lymphangioleiomyomatosis
  • Women of childbearing age
  • Caucasians
  • Recurrent pneumothorax
  • Chylous effusion
  • Hemoptysis
  • PFTs obstruction

30
Lymphangioleiomyomatosis
  • Radiographic normal, interstitiel opacities,
    honeycomb changes, hyperinflation
  • TBbiopsy, VATS components of smooth muscle
  • Treatment hormonal manipulation, oopherectomy,
    progesterone therapy, Lung transplantation

31
  • A 70-year-old male former smoker has had
    progressive dyspnea and a nonproductive cough for
    18 to 24 months. Physical examination reveals
    bibasilar crackles and clubbing.

32
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33
  • Diagnosis?

34
IPF - UIP
  • Sporadic case, 5th or 6th decade
  • Men/women 2/1
  • Progressive dyspnea and non productive cough
  • PFTs restrictive pattern with reduced DLCO

35
IPF - UIP
  • Peripheral or subpleural
  • Bibasilar reticulonodular opacities
  • Architectural distortion with traction
    bronchiectasis
  • Honey combing
  • In the right clinical setting, radiographic
    findings may be sufficient

36
  • A 68 year old retired automative mechanic who
    sandblasted radiators for 20 years. He has
    dyspnea on exertion and a chronic cough. He has
    restrictive lung volumes and abnormal gaz exchange

37
Silicosis
  • Inhilation of silica
  • Mining, Tunneling, Quarrying, Foundry,
    Sandblasting, Ceramics, Stone work
  • Complications
  • Progressive Massive Fibrosis
  • Tuberculosis superinfection
  • ? Increase lung cancer risk
  • RA may increase the risk
  • Radiographic predominance in the upper lobes
  • Clinical diagnosis, open lung biopsy

38
  • A 48 year-old bird fancier with 3 weeks of
    dyspnea, cough, and fever.

39
  • Diagnosis?

40
Hypersensitivity pneumonitis
  • Symptoms start 4-6 hours after exposure
  • Fever, chills, sweats, dry cough and dyspnea
  • No wheezing
  • Resolves in 18-24 hours and recur on re-exposure
  • Radiographic Upper or mid lobes, with diffuse
    micronodular and ground glass attenuation

41
Hypersensitivity pneumonitis
  • Diagnosis
  • Exposure history, clinical and radiological
    findings
  • Result of removal of the patient from the
    suspected etiologic exposure.
  • Treatment
  • Reduction of antigenic burden
  • Protective devices
  • Corticosteroids

42
  • A 48 year-old metal machinist who has night
    sweats, chronic cough, and shortness of breath.
    Transbronchial lung biopsy specimen shows
    noncaseating granulomas and patchy interstitial
    fibrosis

43
Berylliosis
  • Ceramic worker, beryllium processors, and some
    aerospace worker
  • Beryllium lymphocyte transformation test
  • Mimic sarcoidosis clinical, radiographic, and
    pathology

44
  • A 70 year-old retired construction worker, a
    current smoker with dyspnea on exertion. He has
    bibasilar crackles on respiratory examination.

45
Asbestos
  • Interval between exposure and bronchogenic
    carcinoma 15 to 35 years,
  • malignant mesothelioma 30 to 40 years
  • Pleural plaque is the most common related
    disorder
  • Asbestos exposure alone increase the risk of lung
    cancer minimally
  • Asbestos and smoking acts synergistically

46
  • A 32 year-old woman presents with a 1-week
    history of painful, tender lumps overlying the
    pretibial regions, a low-grade fever, and
    polyarthritis primarily involving her ankles. A
    BAL performed is AFB stain negative.

47
Choose the correct statement
  • Cutaneous involvement occurs in 80 of the cases
  • Cutaneous sarcoidosis is associated with a good
    prognosis
  • EN is associated with a good prognosis
  • EN occurs in 30 of the cases with lorgrens
    syndrome

48
Correct statement
  • Cutaneous involvement occurs in 80 of the cases
  • Cutaneous sarcoidosis is associated with a good
    prognosis
  • EN is associated with a good prognosis
  • EN occurs in 30 of the cases with lofgrens
    syndrome

49
  • A 62 year-old woman presents to the ER with
    cough, dyspnea, and low-grade fever. She is
    nonsmoker and had been healthy until 5 weeks ago,
    when she developed a viral syndrome associated
    with a paroxysmal cough.
  • PE reveals inspiratory crackles in the left lower
    lobe. WBC13,000 differential is nl, c7 is nl.
    ESR elevated Sputum gram stain and AFB are
    negative.

50
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51
What is your Diagnosis?
  • Chronic Aspiration
  • Hypersensitivity pneumonitis
  • Non Specific interstitiel pneumonia
  • Crypotgenic organinzing pneumnia
  • Sarcoidosis

52
What is your Diagnosis?
  • Chronic Aspiration
  • Hypersensitivity pneumonitis
  • Non Specific interstitiel pneumonia
  • Crypotgenic organinzing pneumonia
  • Sarcoidosis

53
Cryptogenic organizing pneumonia or Boop
  • 5th or 6th decade, menwomen
  • Symptomatic for less than 2 months
  • Persitent non productive cough, dyspnea on
    exertion, weight loss, crackles
  • Leucocytosis, with elevated ESR
  • Radiographic diffuse, bilat alveolar opacities,
    peripheral, migratory or recurrent.
  • Diagnosis open lung biopsy
  • Treatment steroids for 4 to 8 weeks

54
Distinguishing
Obliterative Bronchiolitis from Bronchiolitis
Obliterans
with Organizing Pneumonia (BOOP)
Manifestations
BOOP
Obliterative Branchiolitis. Focal alveolar
infiltrates
Typical
No Airways obstruction (on pulmonary
No (except function
testing)
in smokers)
Yes Intraluminal polypoid masses within
Typical
No bronchioles Organizing
pneumonia Typical- Response to corticosteroids

Excellent
Rare Prognosis
Excellent
Poor
55
  • A 30 year-old man presents with hemoptysis,
    dyspnea, and generalised weakness. He has no
    sinus or upper airway symptoms. PE reveals pallor
    and bibasilar crackles.
  • Hemoglobin 7.8 , creatinine 3, microscopic
    hematuria and hypoxemia.

56
Most likely Diagnosis?
  • Goodpastures syndrome

57
How would you treat this patient
  • Steroids
  • Plasmapheresis
  • Steroids and Plasmapheresis
  • Cyclophosphamide
  • Steroids plasmapheresiscyclophosphamide

58
How would you treat this patient
  • Steroids
  • Plasmapheresis
  • Steroids and Plasmapheresis
  • Cyclophosphamide
  • Steroids plasmapheresiscyclophosphamide

59
A 34-year-old female medical technician is
referred to you with a diagnosis of asthma.
Despite initial Therapy with inhaled
corticosteroids and beta-agonists. she remains
symptomatic with cough and wheeze. The FEV1 is 78
of predicted and improves 13 after
albuterol. The most important next step in the
management of lis patient is A) Increase the
corticosteroid dosage B) Perform a methacholine
challenge C) Perform an inspiratory limb of a
flow-volume loop D) Add theophylline E) Add a
leukotriene receptor antagonist
60
A 34-year-old female medical technician is
referred to you with a diagnosis of asthma.
Despite initial Therapy with inhaled
corticosteroids and beta-agonists. she remains
symptomatic with cough and wheeze. The FEV1 is 78
of predicted and improves 13 after
albuterol. The most important next step in the
management of lis patient is A) Increase the
corticosteroid dosage B) Perform a methacholine
challenge C) Perform an inspiratory limb of a
flow-volume loop D) Add theophylline E) Add a
leukotriene receptor antagonist
61
  • All that wheezes is not asthma
  • Not all asthmatic wheeze
  • Drug-induced bronchospasm
  • Vocal cord dysfunction
  • GERD
  • Provocation inhalation challenge is used to
    detect latent asthma

62
  • A 64-year-old man, a 38-pack-year smoker,
    presents with recent onset of pain in both knees
    and shins. Examination reveals clubbing,
    gynecomastia, tenderness of both shins, and mild
    expiratory slowing of lung sounds.

63
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64
Most likely diagnosis
  • RA with pulmonary involvement
  • IPF
  • Cryptogenic organizing pneumonia
  • Hypertrophic osteoarthropathy
  • Acromegaly

65
Most likely diagnosis
  • RA with pulmonary involvement
  • IPF
  • Cryptogenic organizing pneumonia
  • Hypertrophic osteoarthropathy
  • Acromegaly

66
Hypertrophic Pulmonary Osteoarthropathy
  • Common Causes
  • adenocarcinoma and large cell carcinoma of
    the lung
  • idiopathic
  • Radiographs of long bones
  • Thickened and raised periostom
  • Therapy
  • Resection of the tumor
  • Somatostatin analog
  • Ipsilateral vagotomy

67
  • A 65-year-old woman, a 100-pack-year smoker,
    develops progressive weakness.The serum potassium
    level is 2.3

68
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69
Paraneoplastic syndrome
  • Caused mostly by primary tumor
  • Does not indicate metastatic spread

70
Match
  • SIADH
  • ACTH production
  • HPO
  • Myasthenic syndrome
  • 5. Hypercalcemia
  • 6. Cerebellar ataxia
  • Small cell carcinoma
  • Squamous cell

71
  • 19 y.o man presented to ER with SOB and chest
    tightness. Thin, Tall Guy. Current smoker, works
    in Wawa store in Camden
  • Test?

72
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73
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74
20 PTX
75
First episode, What is the correct answer
regarding best management of this patient?
  • A. Observation with oxygen supplementation, rate
    of re-absorption 5/ day, rate of recurrence
    similar to general population
  • B. Video-assisted thoracoscopy for pleurodesis
    and bullae wedge resection
  • C. Tube thoracostomy with talc pleurodesis
  • D. Tube thoracostomy with doxycycline pleurodesis
    once air leak resolves
  • E. Admit him, Tube thoracostomy without
    pleurodesis till air leak resolves

76
First episode, What is the correct answer
regarding best management of this patient?
  • A. Observation with oxygen supplementation, rate
    of re-absorption 5/ day, rate of recurrence
    similar to general population
  • B. Video-assisted thoracoscopy for pleurodesis
    and bullae wedge resection
  • C. Tube thoracostomy with talc pleurodesis
  • D. Tube thoracostomy with doxycycline pleurodesis
    once air leak resolves
  • E. Admit him, Tube thoracostomy without
    pleurodesis till air leak resolves

77
While preparing for chest tube insertion, he
informs you that hes planning to be a flight
attendant
  • A. Observation with oxygen supplementation, rate
    of re-absorption 5/ day, rate of recurrence
    similar to general population
  • B. Video-assisted thoracoscopy for pleurodesis
    and bullae wedge resection
  • C. Tube thoracostomy with talc pleurodesis
  • D. Tube thoracostomy with doxycycline pleurodesis
    once air leak resolves
  • E. Admit him, Tube thoracostomy without
    pleurodesis till air leak resolves

78
While preparing for chest tube insertion, he
informs you that hes planning to be a flight
attendant
  • A. Observation with oxygen supplementation, rate
    of re-absorption 5/ day, rate of recurrence
    similar to general population
  • B. Video-assisted thoracoscopy for pleurodesis
    and bullae wedge resection
  • C. Tube thoracostomy with talc pleurodesis
  • D. Tube thoracostomy with doxycycline pleurodesis
    once air leak resolves
  • E. Admit him, Tube thoracostomy without
    pleurodesis till air leak resolves

79
  • A 59-year-old man is evaluated for snoring,
    abnormal motor behavior during sleep, daytime
    somnolence, systemic hypertension, and morning
    headaches.

80
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81
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82
His polysomnography study is shown
83
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84
" For each numbered hemodynamic profile, select
the most likely etiology of shock. SBP
RAP PAP
PAOP C1 (mm Hg)
(mm Hg) (mm Hg) (mm Hg)
(L/min/m2) 1 90/68 18
36/24 22
1.8 2 90/46 5
22/8 6
4.7 3 88/40
20 22/16
7 2.2 4 84/60
3 18/6
5 1.8 5 90/68
18 32/18
17 1.8 a. Severe
hemorrhage b. Pneumococcal sepsis c.
Anterolateral myocardial infarction d. Cardiac
tamponade e. Right ventricular myocardial
infarction
85
  • A 24 -year-old woman develops sepsis and ARDS
    postpartum. She has been stable with mechanical
    ventilation . The ventilator setting are
    Fio20.6 TV800ml RR24/min PEEP10 cm H2O
  • You are consulted by the nurse because the
    patient is suddenly anxious and agitated.
  • Measurements during controlled breaths
  • Peak airway pressure 55 cm H2O
    (baseline35)
  • Plateau airway pressure 50 cm H2O
    (baseline 30)
  • Tidal Volume 720 ml (baseline 768 ml)
  • What is the most important next step in the
    management of this patient
  • Sedation with midazolam and observation of
    patient
  • Stat portable chest radiography
  • Endotracheal suctioning and reassessment of
    patient
  • Stat electrocardiogram
  • Increase the ventilatory rate to 28/min and
    rassessment in 30 minutes

86
  • A 24 -year-old woman develops sepsis and ARDS
    postpartum. She has been stable with mechanical
    ventilation . The ventilator setting are
    Fio20.6 TV800ml RR24/min PEEP10 cm H2O
  • You are consulted by the nurse because the
    patient is suddenly anxious and agitated.
  • Measurements during controlled breaths
  • Peak airway pressure 55 cm H2O
    (baseline35)
  • Plateau airway pressure 50 cm H2O
    (baseline 30)
  • Tidal Volume 720 ml (baseline 768 ml)
  • What is the most important next step in the
    management of this patient
  • Sedation with midazolam and observation of
    patient
  • Stat portable chest radiography
  • Endotracheal suctioning and reassessment of
    patient
  • Stat electrocardiogram
  • Increase the ventilatory rate to 28/min and
    rassessment in 30 minutes

87
Ppeak Resistance x Elastance Pplateau
Elastance Ppeak - Pplateau Airflow
Resistance
88
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89
  • A 68-year-old man, a 56-pack-year smoker,
    undergoes bronchoscopy under topical anesthesia
    for evaluation of streak hemoptysis. One hour
    after he notices bluish discoloration of his
    finger and lips. He has minimal dyspnea and his
    vitals are normal.
  • ABGs Pao2 86 Paco2 46 PH 7.38 Sao2 56
  • A. Polycythemia from copd
  • B. Methemoglobinemia
  • C.Right to left anatomical shunt
  • D.shock

90
  • A 68-year-old man, a 56-pack-year smoker,
    undergoes bronchoscopy under topical anesthesia
    for evaluation of streak hemoptysis. One hour
    after he notices bluish discoloration of his
    finger and lips. He has minimal dyspnea and his
    vitals are normal.
  • ABGs Pao2 86 Paco2 46 PH 7.38 Sao2 56
  • A. Polycythemia from copd
  • B. Methemoglobinemia
  • C.Right to left anatomical shunt
  • D.shock

91
Pearls
  • Sore throat
  • Amoxicillin
  • Rash
  • Infectious mononucleiosis

92
Pearls
  • Recurrent sinusitis
  • Non responsive to adequate therapy
  • Check Immunoglobulins

93
Pearls
  • When you suspect tuberculous pleural effusions,
    all pleural fluid workup is non diagnostic, next
  • Pleural Biopsy

94
Pearls
  • Tuberculosis prophylaxis in an area with less
    than 4 resistance to INH
  • INH for 9 months

95
Pearls
  • Two simple maneuvers to decrease auto peep
  • Decrease TV or RR

96
Pearls
  • Vocal cord dysfunction
  • Gold standard test
  • Fiberoptic laryngoscopy

97
Pearls
  • Mild obstructive lung disease
  • Colon Cancer
  • Next step before OR
  • Nothing ! Let him go

98
  • GOOD LUCK !
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