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  #1  
Old 10-29-2011
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Lungs Five Pulmonology Questions - Part 2

(1) A 25-year-old accountant with a history of severe asthma is brought to the hospital from her office because of severe respiratory distress. A coworker reports that the patient had a cold on the day of the exacerbation and had inadvertently inhaled chemical fumes from a nearby office that is under renovation. The accountant was unable to breathe and was brought emergently to the emergency department. Her respiratory rate is 44/min and oxygen saturation is 97% on room air. She is unable to speak a full sentence and is markedly diaphoretic. She is using accessory muscles of respiration and there are suprasternal retractions. Pulmonary examination shows bilateral wheezes that are less than expected given her clinical condition. She is given two successive albuterol nebulizer treatments and started on intravenous corticosteroids. An arterial blood gas after two treatments shows:

pH--7.39mm Hg
pCO2--42mm Hg
PO2--78mm Hg


After treatment, she is now able to speak a full sentence. Her respiratory rate is 30/min. Which of the following is the most appropriate next step in management?
A. Administer epinephrine
B. Administer a saline bolus
C. Administer sedation
D. Continue albuterol treatments
E. Consider elective intubation



(2)A 25-year-old patient with Hodgkin disease who has recently completed chemotherapy is sent to the emergency department from the oncology clinic. The oncology resident wished to have him admitted for neutropenic fever. He has had approximately 3 days of fever with temperatures of approximately 38.0 C (100.4 F), and he has recently developed a dry cough with occasional small amounts of hemoptysis and pleuritic chest pain. At this time, he has a temperature of 38.3 C (101.0 F), blood pressure of 110/71 mm Hg, pulse of 112/min, and respirations of 28/min. His oxygenation saturation is 94% on room air. Pulmonary examination reveals diffuse, coarse inspiratory crackles. In the emergency department, the patient is evaluated for a pulmonary embolus with a CT scan with angiography, which did not show evidence of a clot. CT scan and chest radiograph, however, show upper lobe nodular lesions and diffuse infiltrates. Additionally, the radiologist reports that a “halo sign” is present, an area of infiltrate surrounded by a crescent of air. Laboratory studies at this time reveal an absolute neutrophil count of 108 cells/mm3. The patient is admitted and presumptive treatment is begun for pneumonia. The patient is started on broad-spectrum antibiotics and granulocyte colony stimulating factor. Cultures are sent for bacterial and fungal growth. By day three the patient has not improved. He continues to spike fevers and has a worsening cough. The pulmonary medicine service performs a flexible fiberoptic bronchoscopy with bronchoalveolar lavage and biopsy. Histopathologic examination of the tissue and lavage fluid reveals narrow, septated hyphae with acute angle branching suggestive of aspergillosis. Fungal cultures obtained at admission also grow a similar organism. At this time, which of the following is the most appropriate therapy?
A. Amphotericin B
B. Caspofungin
C. Itraconazole
D. Prednisone
E. Surgery


(3)
A 58-year-old man comes to the urgent care clinic for a prescription refill. He uses a variety of metered dose inhalers, including both a short- and long-acting beta agonist, an atropine inhaler, and a steroid inhaler. He is currently on a steroid taper, after having an elevated aspergillus-specific IgE level. While going over his medications, the patient begins to hack and cough, producing a small amount of purulent, blood-tinged sputum. Upon questioning, he states that he has had this cough for years, and that he attributes it to his 60-pack-year tobacco history. Occasionally, his daily sputum production becomes more purulent, and he is treated with antibiotics. He also reports numerous episodes of dyspnea, hemoptysis, and pleurisy-type chest pain over the years. Physical exam reveals diffuse crackles and rhonchi over both hemithoraces. A chest radiograph is ordered to further define the extent of this patient’s disease. Which of the following are findings on chest radiograph that are consistent with his disease?
A. Bilateral areas of opacification with air-bronchograms and fluffy infiltrates
B. Hyperlucent lung fields with flattened diaphragms and reduced vasculature
C. Increased peritracheal stripe, splaying of the tracheal bifurcation
D. Parallel linear opacities and mucus-filled bronchi or small abscesses, branched tubular structures extending from the hilus
E. Vascular redistribution, small linear markings towards the periphery of the lung fields, blunting of both costophrenic angles





(4)
A 24-year-old woman is involved in a severe automobile accident. Three of the car’s occupants die at the scene of the accident. She is the only survivor. None of the car’s occupants were wearing seat belts. She arrived at the emergency department already intubated by the emergency medical technicians and with a 16-gauge intravenous line on her right arm, through which Ringer’s lactate is being infused. She is in a coma, with fixed, dilated pupils. Her blood pressure on admission is 90/65 mm Hg, with a pulse of 110/min. She has obvious multiple closed fractures of both upper extremities and both lower extremities, but the quick physical examination performed in the emergency department reveals no pelvic fracture and no abdominal distention. No breath sounds are heard over the right chest. Chest x-ray shows diffuse opacity of the right pleural space, suggestive of hemothorax. Sonogram of the abdomen is negative for blood. A right chest tube is inserted, and 800 ml of blood is recovered immediately. Within the next 2 minutes, another 1,200 ml of blood is drained out of the chest, and her blood pressure drops to 40/20 mm Hg. Which of the following is the most appropriate next step in management?
A. Arteriographic embolization of bleeding sites
B. Cardiopulmonary bypass in preparation for aortic repair
C. Emergency right thoracotomy
D. Pericardial window
E. Transfusion until blood pressure is stable, and reassess the situation


(5)
A 29-year-old man comes to the emergency department because of the acute onset of dyspnea and pleuritic chest pain for the last 2 hours. He has a known history of Factor V Leiden deficiency that runs in his family. His condition was discovered 4 months prior, when he suffered a pulmonary embolus and was placed on warfarin. Aside from this condition and its complications, his past medical history is unremarkable. Currently his vital signs are: temperature 37.0 C (98.6 F), blood pressure 150/95 mm Hg, pulse 112/min, respirations 30/min, and oxygen saturation 97%. Chest examination reveals some diffuse crackles at the right base, but is otherwise unremarkable. A CT-angiogram shows two small filling defects in the right lower lobe pulmonary vasculature. STAT coagulation laboratory studies reveal an INR of 3.2 and an aPPT of 28 seconds. In addition to starting heparin, which of the following is an appropriate management for this patient?
A. Add aminocaproic acid
B. Begin thrombolytic therapy
C. Increase the dose of warfarin
D. Send him for a thrombectomy
E. Surgically place an inferior vena cava filter
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  #2  
Old 10-29-2011
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1.e
2.a
3.d
4.b
5.e
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b
c
d
b
e
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  #4  
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anymore replies or shall i post the answers????
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  #5  
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Arrow answer 1

The correct answer is D. The patient is having an acute exacerbation of asthma and is apparently compensating for the increased resistance and work of breathing as seen by the blood gas. However, blood gas values can be misleading and should always be correlated with the patient’s current clinical condition. Because the patient’s condition is improving, there is a role for continuing the treatment that she responded to, particularly the beta-adrenergic agonist albuterol.

Epinephrine (choice A) can be used in the treatment of severe bronchospasm. This patient, however, is improving on less aggressive therapies. The risks of administering epinephrine at this time (hypertension, cardiac arrhythmias) do not outweigh its potential benefits in this patient and should be avoided.

Administering a saline bolus (choice B) is not therapeutic treatment for this patient. Intravenous access should be secured; if the patient were to decompensate, medications could be administered for resuscitation. However, fluids would not be a priority in this patient unless she was profoundly hypotensive; therapy should be directed to relieving bronchospasm.

Sedation (choice C) is contraindicated in this patient now because the patient, with the combined effects of increased work of breathing and pharmacologically mediated bronchiolar relaxation, has been able to maintain oxygenation and ventilation. As the patient continues to improve, her anxiety will most likely decrease as work of breathing decreases and the subjective feeling of dyspnea decreases.

Elective intubation (choice E) is not warranted at this time because clinically the patient is improving and has been able to maintain adequate oxygenation and ventilation. Intubation and mechanical ventilation may expose the patient to the risks of ventilation, including ventilation-induced trauma.
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Arrow answer 2

The correct answer is A. This patient has invasive aspergillosis. There are four broad categories of Aspergillus infection, most of which require a different treatment: (1) allergic bronchopulmonary aspergillosis (ABPA), (2) aspergilloma, (3) Aspergillus colonization, and (4) invasive aspergillosis that may or may not be disseminated. Invasive aspergillosis requires treatment with amphotericin B or voraconazole.

If the patient is refractory to the previously mentioned treatments, caspofungin (choice B) or combination antifungal therapies are tried.

Once the patient is improving, itraconazole (choice C) is often used, as it is less toxic than amphotericin. The initial agent, however, should still be a stronger antifungal.

Prednisone (choice D) is used to treat ABPA, often in conjunction with itraconazole, whereas surgery (choice E) is the treatment of choice for an aspergilloma.
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Arrow answer 3

The correct answer is D. This patient has bronchiectasis, either from years of smoking or from allergic bronchopulmonary aspergillosis, or both. Daily sputum production, with frequent hemoptysis, is classic for bronchiectasis. Chest radiograph findings consistent with bronchiectasis include tramline shadows, which are parallel linear opacities due to thickened walls of nondilated bronchi. Ring shadows are due to mucus-filled bronchi or small abscesses seen en face next to pulmonary blood vessels. Gloved finger shadows are due to intrabronchial exudates with bronchial wall thickening. These appear as branched tubular structures that extend from the hilus.

Bilateral opacification and air-bronchograms (choice A) are seen in consolidative parenchymal disease, namely pneumonia. The air-bronchograms are due to radiodense consolidation surrounding an air-filled bronchus.

Hyperlucent lung fields with flattened diaphragms (choice B) are seen in conditions with significant air trapping. This patient has more of a bronchitic pattern of lung disease than emphysemic and would not be expected to have entirely clear lung fields.

The peritracheal stripe is the thin line forming the boundary of the tracheal lucency on chest radiograph. It is often thickened when mediastinal lymphadenopathy is present. The tracheal bifurcation, or carina, may be splayed with atrial hypertrophy or lymphadenopathy. A condition with increased peritracheal stripe and splaying of the tracheal bifurcation (choice C) would be any disease with significant mediastinal lymphadenopathy.

Vascular redistribution, Kerley B lines, and blunting of the costophrenic angles (choice E) are radiographic findings consistent with heart failure. Increased filling pressures and volume overload results in vascular redistribution towards the apices. Resulting septal edema manifests as Kerley B lines, which are small linear markings toward the periphery of the lung fields. Effusions of varying size are common, which often first manifest as blunting of the costophrenic angles
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Arrow answer 4

The correct answer is C. The massive amount of blood recovered from the chest tube constitutes clear-cut indication for surgical intervention to find and control the site or sites of bleeding. Usually the culprit that accounts for a large hemothorax is a lacerated intercostal vessel, but in this case the injury is probably in a major vein where the tamponade effect of the closed chest kept bleeding to a minimum until the chest tube was inserted.

Arteriographic embolization (choice A) works in many areas of trauma, but it is not indicated here. The bleeding is too massive and control is needed immediately.

We have no evidence that there is an aortic rupture, but if that were the case, the location is usually at the junction of the arch and the descending, where clamping can be done without cardiopulmonary bypass. If bypass were required, it would be instituted after the surgical exploration has ascertained that it is needed. One does not begin with bypass before exploration, as suggested in choice B.

A pericardial window (choice D) can be lifesaving when there is pericardial tamponade. The presentation in that case would be shock, with distended head and neck veins and minimal drainage of blood from the chest tube.

In hemorrhagic shock the first order of business is to stop the bleeding, provided one knows the location and is in a place where necessary surgery can be done. That is the situation here. Once open vessels are clamped, the vascular space is filled. In the face of massive, ongoing blood loss, it is useless to keep pouring blood and hoping for the best, as suggested in choice E.
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Arrow answer 5

The correct answer is E. Patients who suffer pulmonary emboli while on warfarin are candidates for a Greenfield filter. A Greenfield filter placed in the inferior vena cava can help prevent recurrent emboli, though the filter itself increases the risk for a deep vein thrombosis.

Aminocaproic acid (choice A) inhibits plasminogen activators, interfering with fibrinolysis. It is a procoagulant and is contraindicated.

Thrombolytic therapy (choice B) is controversial in the management of submassive pulmonary embolus. Most deaths from pulmonary embolus, however, are caused by recurrent emboli, not the original embolus. The best strategy, particularly for a patient with a low clot load, is to focus on preventing future emboli.

An increased dose of warfarin (choice C) is inappropriate in this patient. He is already adequately anticoagulated and has already clotted despite warfarin.

Thrombectomy (choice D) is indicated for massive pulmonary emboli when all else has failed. This patient does not need a thrombectomy, given that he has two small subsegmental lesions.
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these were the answers given.....any doubts can be discussed
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can u just tell us the source of ur questions?
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I have a question...in #5
"STAT coagulation laboratory studies reveal an INR of 3.2 and an aPPT of 28 seconds. In addition to starting heparin, which of the following is an appropriate management for this patient?"

I dont see why we should start heparin...his INR is 3.2, so the best next step if the filter (as you said before)...but I don't see the benefits of adding heparin... thoughts?
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Old 11-14-2011
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Quote:
Originally Posted by kundra View Post
can u just tell us the source of ur questions?
Yes, I second this as well - these are nicely written and helpful.
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