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Old 10-28-2011
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Lungs 5 Pulmonology Questions - Part 1

(1) You are called by the emergency-room physician to evaluate a 62-year-old man who complains of “coughing up blood.” Three weeks before presentation, the patient first developed small amounts of maroon-tinged blood in his sputum. At baseline, he has a chronic cough that was typically yellow-tinged until this recent presentation. During the past 3 weeks, his blood-tinged sputum has not changed in amount, frequency, or color. He denies any shortness of breath or light-headedness. He does report a 15-pound unintentional weight loss over the past 4 weeks, as well as increasing fatigue. The patient has a history of chronic obstructive pulmonary disease, hypertension, non–insulin-dependent diabetes, and gout. He is a former smoker with a 30-pack-year history, quitting 3 years ago, and has no past history of hemoptysis. He is currently being treated with colchicine, metformin, lisinopril, and a baby aspirin. His vital signs are: blood pressure 142/73 mm Hg, pulse 74/min, respirations 14/min, temperature 37 C (98.6 F), and oxygen saturation on ambient air of 95%. Physical examination reveals crackles at the right lower lung base with no associated egophony or increased tactile fremitus. Chest x-ray demonstrates a poorly circumscribed nodule in the right lower lobe. Which of the following is the most appropriate next step in caring for this patient?
A. Consult interventional radiology to perform bronchial artery embolization
B. Consult the pulmonary service for fiberoptic bronchoscopy
C. Determine if the airway is secure and maintain appropriate oxygen saturation
D. Obtain a CT of the thorax to better characterize the site of bleeding
E. Place a nasogastric tube to determine if the bleeding site is of gastrointestinal or pulmonary origin









(2)
A 50-year-old man with a history of alcohol abuse is brought to the hospital complaining of fever, dizziness, and a cough. He denies any other medical history. He has a cough productive of brownish sputum. The patient denies any other medical symptoms. He is not taking any medications and has a sulfa allergy. In the emergency department, the patient seems very lethargic. His blood pressure is 100/70 mm Hg and his pulse is 100/min. Examination reveals crackles in the left upper lobe. Heart examination is regular rate and rhythm. Chest x-ray reveals an infiltrate in the left upper lobe. Which of the following is appropriate pharmacologic management?
A. Ceftriaxone and azithromycin
B. Clindamycin
C. Erythromycin and levofloxacin
D. Trimethoprim-sulfamethoxazole
E. Vancomycin



(3) A 22-year-old man with a 2-year history of asthma comes to see you because of worsening respiratory function. He states that he has seen a couple of doctors and tried a couple of inhalers, but has not had much success in controlling his asthma exacerbations. He has had two episodes of pneumonia in the last 2 years and often suffers from episodes of coughing and wheezing. These episodes are associated with blood-tinged, greenish sputum, fever, malaise, and expectoration of brownish mucous plugs. Past medical history and review of symptoms are otherwise unremarkable. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 120/72 mm Hg, pulse 68/min, and respirations 28/min. Examination reveals an ill appearing man in moderate distress. Respiratory examination reveals rare inspiratory crackles in the left lung base and coarse breath sounds in both upper lung lobes. The rest of the examination is normal. A chest radiograph reveals a small amount of parenchymal infiltrates in the upper lobes, some plate-like atelectasis at the left lung base, and some branched, tubular radiodensities that the radiologist describes as “gloved finger” shadows. A skin test reveals hypersensitivity to Aspergillus. Serum IgE levels are sent and come back as 1,500 ng/mL (normal is less than 1,000 ng/mL). Which of the following is the most appropriate therapy?
A. Amphotericin B
B. Caspofungin
C. Fluconazole
D. Prednisone
E. Surgery

(4)
A 33-year-old woman with no significant past medical history is brought to the emergency department with acute onset of severe shortness of breath. She reports that right-sided calf pain developed after a long plane trip home from Australia, and that several hours after the onset of this calf pain she became acutely short of breath. History is difficult to obtain because of the patient’s extreme shortness of breath, but her companion reports that she has had no recent surgeries or history of bleeding. Her temperature is 37.8 C (100.0 F), systolic blood pressure is 70 mm Hg, pulse is 140/min, and respirations are 34/min. Physical examination reveals a woman in severe respiratory distress. She is using accessory respiratory muscles. Her heart is rapid and regular, her lungs are clear, and her abdomen is benign. Her right calf is swollen and tender. Ventilation perfusion scan is high probability. Arterial blood gases show:

pH-7.48
pCO2-20mm Hg
PaO2-48mm Hg on 6L Oxygen


Which of the following is the most appropriate management?
A. Embolectomy
B. Low molecular-weight heparin
C. Thrombolysis
D. Unfractionated heparin
E. Warfarin alone


(5)
A 42-year-old man with a long history of emphysema comes to the clinic complaining of
worsening pulmonary symptoms. Over the past few months he has developed a productive cough, dyspnea, fatigue, and night sweats. In addition to these pulmonary concerns, he suffers from diffuse arthralgias and intermittent sharp chest pain, as well as red, painful “lumps” on his legs. Lung examination reveals decreased breath sounds and diffuse crackles over both apices. Cardiac examination is remarkable for a friction rub, while examination of the skin reveals lesions consistent with erythema nodosum. A CT scan of the thorax reveals cavitation and fibrotic stranding of both lung apices. Given the concern for tuberculosis, the patient is placed in isolation. Over the following days, three sputum samples are examined for acid-fast bacilli, all of which are unrevealing. Further, a PPD skin test is read as negative. A sputum stain, however, reveals multiple yeast forms, replicating by narrow-based budding. Which of the following studies is likely to quickly identify this patient’s primary disease?
A. Coccidioidomycosis serologies
B. Fungal blood cultures
C. HIV antibody screening
D. India ink stain of sputum
E. Urine histoplasma antigen
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Old 10-29-2011
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seems like all the forum gurus r bsy in prep....n questions would be a waste now..,..
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Quote:
Originally Posted by sonu.agarwall View Post
seems like all the forum gurus r bsy in prep....n questions would be a waste now..,..
no dear i am trying to solve them just hold on..........
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Old 10-29-2011
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1.e
2.b
3.d.
4.b
5.a
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Old 10-29-2011
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Hi dear seems no1 is interested in questions but count me in i have posted my answers....but not sure abt them..
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Old 10-29-2011
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1.d
2.a
3.c
4.d
5.d

Akua
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1-b, 2-a, 3-d, 4-d, 5-c
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I'm Predictable In The Unpredictable Future !
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Arrow answer 1

The correct answer is C. All patients presenting with hemoptysis require further evaluation. The first step in the management of a patient presenting with hemoptysis is to determine if the airway is secure and to maintain adequate oxygenation. This step is part of establishing “ABC”—or airway, breathing, and circulation—in every patient. Massive hemoptysis is invariably defined as hemoptysis exceeding 100 to 600 mL of blood over a 24 hour period. Patients presenting with massive hemoptysis should be evaluated to determine whether intubation is required to secure the airway. If active hemoptysis occurs and the patient needs to be intubated for airway protection, fiberoptic intubation should be considered for direct visualization. Most patients with massive hemoptysis die not from exsanguination but rather from asphyxiation. This is the reason why the airway should be assessed before any of the other answer choices are performed.

Bronchial artery embolization (choice A) should be considered, especially in cases of massive hemoptysis from bronchiectasis, but after securing the airway.

Fiberoptic bronchoscopy (choice B) should be considered in patients to evaluate hemoptysis, particularly in patients with a normal chest x-ray, and risk factors for lung cancer such as advanced age, tobacco use, and persistence of hemoptysis. The primary role of bronchoscopy is to evaluate whether an endobronchial tumor lesion is present, and to refer the patient for surgical resection, chemotherapy, and/or radiation therapy at an early stage.
Chest CT (choice D) can be used to further evaluate hemoptysis, particularly if the patient had a contraindication to bronchoscopy. Chest CT should be strongly considered in patients with a normal chest x-ray and normal bronchoscopy. Fiberoptic bronchoscopy has been evaluated to be more cost effective when compared with chest CT.

A nasogastric tube (choice E) should be placed if the source of bleeding is not clear, with respect to whether it is gastrointestinal or pulmonary in origin. However, in this case the history is clearly consistent with a pulmonary source. A positive Gastroccult does not rule out a pulmonary source since this may represent swallowed sputum.
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Default answer 2

The correct answer is A. A beta-lactam (i.e. ceftriaxone) and a macrolide (i.e. azithromycin) or a fluoroquinolone alone is the appropriate treatment for community-acquired pneumonia in a patient with a modifying factor (alcohol abuse).

Clindamycin (choice B) would be more appropriate in the treatment of aspiration pneumonia or a lung abscess.

Erythromycin and levofloxacin (choice C) is inappropriate because fluoroquinolones can be used alone in community-acquired pneumonia and therefore the combination is unnecessary.


The patient has a sulfa allergy. Furthermore, trimethoprim-sulfamethoxazole (choice D) is not routinely indicated to treat community-acquired pneumonia.

Vancomycin (choice E) is not routinely indicated in treating adults with community-acquired pneumonia unless the patient also has suspected bacterial meningitis.
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Arrow answer 3

The correct answer is D. This patient has allergic bronchopulmonary aspergillosis (ABPA), a hypersensitivity reaction in asthmatic patients that occurs when bronchi become colonized by Aspergillus. Difficult to control asthma exacerbations, expectoration of brownish mucous plugs, and radiographic findings of bronchiectasis are a common presentation of the condition. Skin testing and measurement of serum IgE combined with this presentation and a history of asthma are adequate for diagnosis. The treatment of choice is steroids to reduce hypersensitivity. Itraconazole has been found a useful adjunct in patients with frequent exacerbations or in those patients requiring high-dose steroids.

Amphotericin B (choice A) and caspofungin (choice B) are highly toxic antifungal agents used to treat invasive aspergillosis, a distinct presentation of Aspergillus infection Caspofungin is approved for infections that do not respond to amphotericin B or vorconazole, a highly potent azole antifungal.

Fluconazole (choice C) is an antifungal with relatively weak activity against Aspergillus. Its primary use is for Candidal infections.

Surgery (choice E) is the treatment of choice for an Aspergilloma, or fungal ball. Aspergillus sometimes colonizes a large cystic area of the lung, such as that left by tuberculosis, sarcoid, carcinoma, or silicosis.
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Default answer 4

The correct answer is C. This patient has a pulmonary embolism and is hemodynamically unstable. Therefore, she requires a thrombolytic agent to attempt to dissolve the blood clot. The contraindications to thrombolyisis include recent surgery or recent bleeding. Other contraindications to thrombolysis include uncontrolled blood pressure, or age. Because this patient does not have any contraindications, thrombolysis is the most appropriate management. If a contraindication to thrombolysis were present, surgical embolectomy (choice A) would be required Both low molecular-weight heparin (choice B) and unfractionated heparin (choice D) are appropriate choices for patients with acute DVT or pulmonary embolism if they are hemodynamically stable. Because this patient is not stable, simple anticoagulation is not aggressive enough medical management.

Warfarin alone (choice E) would not be appropriate for this patient. Warfarin would take between 48 and 72 hours to reach a therapeutic level, which would leave our patient unprotected during this time
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Arrow answer 5

The correct answer is E. Pulmonary histoplasmosis can often mimic a tuberculosis infection, and is most likely to occur in patients with underlying lung disease. Associated findings that can provide clues to the diagnosis include erythema nodosum, polyarthritis, and pericarditis, caused by a systemic immune response to histoplasma. A urinary histoplasma antigen is a quick and sensitive way to diagnose the disease, particularly when compared with fungal culture (choice B), which can take 4 to 6 weeks. Further, the infection can be limited to the lungs and have negative blood cultures.
Coccidioidomycosis (choice A) may form thin-walled pulmonary cavities and may cause a systemic inflammatory response. The yeast form is typically described as spherules within a sphere (like a gumball machine).

HIV (choice C) can predispose a patient to a variety of fungal infections. However, there is no evidence that this patient has HIV.

India ink (choice D) can be used to diagnose cryptococcus, particularly cryptococcal meningitis. It will not help detect histoplasmosis.
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any doubts n discussions in answers can b done now
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