clin med pulm #3 exam #9

brooklyns quizlet

restrictive lung disease volumes

- FEV1 and FVC are low

- FEV1/FVC ratio is normal but can be low

- VC and TLC are low

idiopathic pulmonary fibrosis patho

- chronic progressive ILD of unknown etiology

- inflammation and fibrosis of lung parenchyma

- no specific pathognomonic or pathologic findings

- chronic, nonmalignant, noninfectious disease of lower resp tract

- assoc with hx of smoking, increases with age

most common interstitial lung disease of unknown etiology

idiopathic pulmonary fibrosis

idiopathic pulmonary fibrosis signs and symptoms

- onset insidious and progressive over mos to yrs

- progressive exertional dyspnea

- diffuse, fine, end inspiratory crackles at bases

- end expiratory crackles that do not shift with coughing

- clubbing of fingernails

- no wheezing or hemoptysis

idiopathic pulmonary fibrosis diagnosis

- CXR: basal predominant reticular opacities in lower lungs (honeycombing) or ground glass. might be normal

- PFT: restrictive pattern. decrease lung volume with normal to high ratio

- bx: honeycombing. helps exclude other causes

- HRCT: preferred choice. shows honeycombing, ground glass opacification, patchy diffuse fibrosis

idiopathic pulmonary fibrosis treatment

- refer to pulmonologist

- no effective medical management

- oxygen

- pulm rehab

- antifibrotic therapy: nintedanib, pirfenidone

- lung transplant

which of the following is a common presenting clinical manifestation of a patient with interstitial lung disease

progressive dyspnea on exertion

3 multiple choice options

A 74-year-old male with a history of coronary artery disease and atrial fibrillation presents to the clinic for follow-up of his shortness of breath. Patient's medications include amiodarone (Cordarone) and metoprolol (Lopressor). His chest x-ray reveals patchy ground-glass infiltrates. Which of the following is the most likely diagnosis?

pulmonary fibrosis

3 multiple choice options

pneumoconiosis patho

- occupational fibrotic pulmonary disease

- from inhalation of dust, chemical, gases, environmental pollutants

- major diseases: asbestosis, black lung (anthracosis), berylliosis, brown lung, silicosis

- can lead to pulmonary HTN

asbestosis

- slow, progressive, diffuse pulmonary fibrosis

- result of inhalation of asbestos fibers

- seen 15 to 20 yrs after lengthy exposure

- risk: destruction, repair, or renovation of old buildings; insulation, ship building

asbestosis signs/symptoms

- asymptomatic initially

- dyspnea on exertion

- dry cough

- fatigue

- bibasilar crackles

- clubbing

asbestosis diagnosis

- CXR: pleural plaques in lower lobes, honeycombing, shaggy heart sign (indistinct heart border)

- CT: more sensitive than x ray

- PFT: restrictive pattern. normal or high ratio. decreased lung volumes

- bx: definitive, may show linear asbestos bodies

asbestosis treatment

- smoking cessation

- oxygen

- bronchodilators

- corticosteroids

- lung transplant

asbestosis complications

- bronchogenic carcinoma MC

- malignant mesothelioma of pleura most specific

anthracosis

- occupational fibrotic pulmonary disease from chronic inhalation and deposition of coal dust particles

- usually over >20 yrs after inhalation

- symptoms: dyspnea, cough, fine crackles

- treatment: supportive

caplan syndrome

coal worker pneumoconiosis and rheumatoid arthritis

anthracosis diagnosis

- CXR: small nodules in upper lung with hyperinflation of lower lobes in an obstructive pattern

- CT: more sensitive

- PFT: restrictive, obstructive pattern

- lung bx: dark, black lungs

silicosis

- occupational pulm disease caused by inhalation of silicon dioxide

- greatly increases risk for TB and infxns

- seen in coal mining, quarry work with granite slate or quartz, pottery makers, sandblasting

silicosis signs/symptoms

- dyspnea

- cough with sputum

- weight loss

- fatigue

- chronic: often asymptomatic, dyspnea w/exertion, nonproductive cough, crackles

silicosis diagnosis

- CXR: multiple small (<10mm) round opacities in upper lobes; EGGSHELL calcifications of hilar and mediastinal nodes

- CT: more sensitive

- PFT: restrictive, obstructive, or normal

silicosis treatment

- removal from exposure

- oxygen

- bronchodilators

- corticosteroids for acute symptoms

- pulm rehab

- should have TB skin test and CXR to rule out TB

pneumoconiosis treatment

- avoid exposures

- oxygen

- pulm rehab

- smoking cessation

- vaccinations: pneumococcal, flu, COVID

- lung transplant as last resort

A patient presents with a history of progressive worsening of dyspnea over the past several years. He gives a history of having worked as a ship builder for over 50 years. He denies any alcohol or tobacco use. On examination you note clubbing and inspiratory crackles.

Which of the following chest x-ray findings support your

suspected diagnosis?

interstitial fibrosis and pleural thickening

3 multiple choice options

which of the following is an independent risk factor for development of a mesothelioma

asbestos exposure

3 multiple choice options

A patient presents with respiratory complaints. Chest

x-ray reveals calcification of the hilar nodes with an

eggshell pattern.

Which of the following occupations is most consistent

with these chest x-ray findings?

sandblasters

3 multiple choice options

patients with long term exposure to silica, coal dust, and asbestos may develop which of the following as complications

pulmonary fibrosis

3 multiple choice options

A 69 year-old male presents with complaint of increasing dyspnea over the past 6-8 months. The patient denies cough, chest pain or

smoking history. Physical examination reveals inspiratory crackles at the bases and clubbing of the nails. Chest x-ray reveals interstitial fibrosis of the lower lungs, thickened pleura and calcified pleural

plaques of the lateral chest wall. Pulmonary function testing shows a restrictive pattern with a decreased diffusing capacity.

What information is most likely noted in this patient's history?

asbestos exposure

3 multiple choice options

most common population affected by sarcoidosis

african american females 20 to 40 yo

sarcoidosis patho

- variety of antigens or self antigens trigger exaggerated T cell and macrophage response immune activation

- formation of responding cells into noncaseating granuloma

- triggers: bacteria, mold/mildew, pesticides, tobacco

sarcoidosis signs/symptoms

- 50% asymptomatic, found on imaging

- pulm: dry cough, dyspnea with insidious onset, chest pain, rales

- lymphadenopathy, intrathoracic LAD

- skin: erythema nodosum on shins, lupus pernio on nasal rim, maculopapular rash MC, parotid gland enlargement

- arthralgias, fever, malaise, weight loss

- blurry vision

- cranial nerve palsies, diabetes insipidus

- cardiac: cardiomyopathy, arrhythmias, heart blockers

- hypercalcemia

sarcoidosis associated diseases

- loefgren's syndrome: triad of erythema nodosum, bilateral hilar LAD, and polyarthralgia with fever

- heerfordt syndrome: parotitis, uveitis, chronic fever, facial nerve palsy

- blau syndrome: child <4 yo, arthritis, rash, uveitis

- all usually self limiting, treat with NSAIDs or treat sarcoidosis

sarcoidosis "GRUELING disease" pneumonic

- granulomas (noncaseating)

- arthritis

- uveitis

- erythema nodosum

- lymphadenopathy

- interstitial fibrosis

- negative TB test

- gammaglobulinemia

- vit D deficiency

sarcoidosis diagnosis

- CXR: best initial test. shows bilateral hilar lymphadenopathy and interstitial lung disease

- bx: non caseating granulomas is diagnostic

- labs: ACE levels 4x normal, hypercalcemia, hypercalciuria

- PFT: restrictive pattern

sarcoidosis treatment

- asymptomatic: observation. spontaneous remission in 2 to 4 yrs

- NSAIDs for MSK sx and erythema nodosum

- oral corticosteroids 1st line

- immunosuppressives such as methotrexate

sarcoidosis staging

- stage 1: BHL, no symptoms or mild pulm sx

- stage II: BHL and ILD, mod pulm sx

- stage III: ILD only

- stage IV: fibrosis

A 35-year-old African-American female presents with dyspnea worsening over the last 2 months. She also complains of cough, generalized fatigue,

and intermittent low-grade fevers. She does not smoke. Chest x-ray shows hilar adenopathy and small bilateral pleural effusions. Spirometry is

consistent with a restrictive pattern.

Of the following, which is the most likely diagnosis?

sarcoidosis

3 multiple choice options

which of the following is not commonly associated with sarcoidosis

hypothyroidism

3 multiple choice options

which of the following is not found as part of sarcoidosis

myocardial infarction

3 multiple choice options

which of the following is true about ACE levels in sarcoidosis

ACE levels often correlate with disease severity in sarcoidosis

3 multiple choice options

the patient is found to only have pulmonary sarcoidosis with some mild systemic symptoms

which of the following is the best initial choice for management

observation

3 multiple choice options

A 52-year-old man is seen for fevers and weight loss. A chest

radiograph shows mediastinal lymphadenopathy. Laboratory

findings show hypercalcemia, elevated alkaline phosphatase,

and an elevated level of ACE. The most likely diagnosis is:

sarcoidosis

3 multiple choice options

obstructive lung disease PFT

- decreased FEV1/FVC ratio

- decreased FEV1

- lung capacities normal

most common chronic childhood disease

asthma

asthma patho

- reversible, often intermittent, obstructive disease of small airway

- chronic inflammation leads to airway hyperreactivity and bronchoconstriction

- IgE binds to mast cells initiating an inflammatory response

asthma classifications

- T2 low phenotypes: nonallergic asthma, asthma with persistent airflow limitation, asthma with obesity

- T2 high phenotypes: allergic asthma (MC), late onset T2 high asthma, aspirin/NSAID assoc

precipitants of asthma

- nonspecific: URI, rhinosinusitis, postnasal drip, aspiration, GERD, stress, weather changes

- exposure to products of combustion

- air pollution

- medications: ASA, NSAIDs, tartrazine dyes

- occupational

- catamenial: during menstrual cycle

- exercise induced

- cough variant: cough instead of wheezing as predominant sx

asthma risk factors

- boys before puberty

- girls after puberty

- smoking

- environmental exposure

- early viral infections

- perinatal: premature, poor nutrition, no breast feeding

- obesity

- low socioeconomic status

- fam hx

- samters triad

- atopy (strongest)

- atopic triad

samters triad

- asthma

- chronic rhinosinusitis with nasal polyps

- sensitivity to ASA and or NSAIDs

atopic triad

- asthma

- atopic dermatitis

- allergic rhinitis

intrinsic asthma triggers

- nonallergic

- anxiety, stress

- exercise

- cold air

- dry air

- hyperventilation

- viral infections

extrinsic asthma triggers

- allergic

- animal dander

- pollen

- mold

- dust mites

- cockroaches

- smoke

- air pollution

- associated with high IgE

asthma signs/symptoms

- classic triad: dyspnea, intermittent wheezing, cough (esp PM)

- maybe chest tightness and fatigue

- prolonged expiration with wheezing

- hyperresonance to percussion

- decreased breath sounds

- tachycardia

- tachypnea

- accessory muscle use

- pursed lips

severe asthma and status asthmaticus symptoms

- inability to speak in full sentences

- tripod positioning

- silent chest

- AMS

- pulsus paradoxus

- PEFR <40% predicted

asthma diagnosis

- PFT: most useful. shows low FEV1, ratio, and high lung volumes

- bronchoprovocation: methacholine has over 20% decreased in FEV1, bronchodilator increase FEV1 by 12%

- children 5 and under: recurrent acute wheezing episode OR 1 acute wheezing episodes, no likely alt for symptoms, timely clinical response or signs to asthma meds

acute asthma exacerbation diagnosis

- PEFR: best and most objective way to assess exacerbation severity, pt response to treatment

- pulse ox

- ABG if resp alkalosis susp

- CXR: usually normal

acute asthma exacerbation treatment

- oxygen

- nebulized SABA for quick relief of symptoms

- ipratropium bromide

- inhaled corticosteroids is mainstay: fluticasone, budesonide, beclomethasone

- LABAs can help control symptoms but should not be used as sole therapy

- leukotriene modifiers for allergic rhinitis, ASA induced asthma

- mast cell modifiers for long term maintenance

- remove offending agents, education

GINA assessment of asthma

- over past 4 weeks has patient has:

- daytime symptoms more than twice a week

- any night wakening due to asthma

- SABA reliever for symptoms more than twice a wk

- any activity limitation due to asthma

- well controlled: none of these

- partly controlled: 1 to 2

- uncontrolled: 3 to 4

intermittent asthma

- symptoms <2 days/week

- no interference with daily activities

- nighttime symptoms <2 times/month

- use of rescue medication <2 days/wk

- PFT: FEV1 >80% predicted, FEV1/FVC normal

mild persistent asthma

- symptoms >2 days wk but not daily

- minor limitation

- nighttime symptoms 3 to 4 times a mo

- rescue med use >2 days week but not daily or more than once a day

- PFT: FEV1 >80% predicted, FEV1/FVC normal

moderate persistent asthma

- daily symptoms

- some limitation in daily activity

- nighttime symptoms >1 time a week but not nightly

- use of rescue meds daily

- PFT: FEV1 >60% but <80% of predicted, FEV1/FVC ratio reduced 5%

severe persistent asthma

- continual symptoms

- extremely limited physical activities

- nighttime symptoms often 7 times/wk

- rescue meds several times a day

- PFT: FEV1 <60% of predicted, FEV1/FVC reduced >5%

vaccinations needed in asthma patients

- pneumococcal

- flu

- COVID

A 20-year-old woman with no significant past medical history presents with a 2-month history of episodic shortness of breath. These symptoms began

with an upper respiratory tract infection. She has fits of coughing and trouble catching her breath with exertion. She states that her breath "sounds

like whistles" at times. She tried a friend's albuterol inhaler and an over-the-counter epinephrine inhaler with

some improvement and wonders if she has asthma. On examination, she is

breathing comfortably at 16 times per minute and her oxygen saturation is 96% on room air. Her lungs are clear to auscultation, and the remainder of her examination is unremarkable. You want to better categorize this patient's

disease.

which of the following tests is most appropriate to order now

spirometry

3 multiple choice options

if this patient has mild asthma, which of the following pulmonary function test results would you expect to find

FEV1/FVC ratio <0.7

3 multiple choice options

Your patient's office spirometry shows the following:

- Normal FVC

- FEV1 82% predicted

- FEV1/FVC 0.68

These findings are most consistent with which of the following?

obstructive lung disease

3 multiple choice options

Six months after you discuss her findings and prescribe inhaled beta-agonist therapy, she returns with complaints of continued wheezing and difficulty breathing. Her symptoms are brought on by cold weather and exercise and she uses her inhaler two times per week or less. She woke up two nights over the last 6 months with shortness of breath and coughing. Her albuterol still works for these

symptoms, but she finds them bothersome and asks, "Why haven't I gotten over this?"

how would you categorize this patient's respiratory state

intermittent asthma

3 multiple choice options

Six months after you discuss her findings and prescribe inhaled beta-agonist therapy, she returns with complaints of continued wheezing and difficulty breathing. Her symptoms are brought on by cold weather and exercise and she uses her inhaler two times per week or less. She woke up two nights over the last 6 months with shortness of breath and coughing. Her albuterol still works for these

symptoms, but she finds them bothersome and asks, "Why haven't I gotten over this?"

which of the following is most appropriate for this patient given that she has intermittent asthma?

continue albuterol as needed

3 multiple choice options

Your patient goes on to develop more frequent recurrent symptoms, such

that she is using her albuterol inhaler more than three times per week, although her nighttime symptoms are rare.

Which medication is the most appropriate next step in treating this patient's asthma?

inhaled triamcinolone

3 multiple choice options

Your patient goes on to develop more frequent recurrent symptoms, such

that she is using her albuterol inhaler more than three times per week, although her nighttime symptoms are rare.

Which medication is the most appropriate next step in treating this patient's asthma?

which of the following is the most likely reason for this patient's acute exacerbation of asthma

sensitivity to aspirin

3 multiple choice options

After a brief hospitalization, your patient recovers nicely. Prior to this incident involving aspirin, she had been free of exacerbations for about a month.

In addition to a short course of oral steroids, which of the following medication

regimens do you prescribe for this patient with aspirin sensitive asthma at

discharge?

inhaled triamcinolone, oral montelukast, and inhaled albuterol as a rescue

3 multiple choice options

which of the following medications, when used alone as maintenance therapy in persistent asthma, is associated with an increased risk of asthma related mortality

inhaled salmeterol

3 multiple choice options

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes exercise routine due to

increasing dyspnea. She denies any cough, fever, recent

surgeries or use of oral contraceptives. On examination, you note the presence of prolonged

expiration and diffuse wheezing. The remainder of the exam is unremarkable.

Which of the following is the most appropriate initial diagnostic evaluation

prior to initiation of treatment?

peak flow

3 multiple choice options

a 17 year old male who is trying out for the track team notes excessive coughing with chest tightness when running. which of the following is the most appropriate preventative agent for this patient

albuterol inhaler

3 multiple choice options

A 22 year-old female with a history of asthma presents with

complaints of increasing "asthma" attacks. The patient states she has been well controlled on albuterol inhaler until one month ago. Since

that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three

episodes in the past month. Spirometry reveals > 85% predicted value.

Which of the following is the most appropriate intervention at this

time?

beclomethasone inhaler

3 multiple choice options

a 3 year old girl is diagnosed with atopic dermatitis. which of the following disorders is this child at risk for in the future

asthma

3 multiple choice options

a 25 year old male with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. he is on a SABA inhaled prn. he is presently using his SABA on a daily basis. which of the following is the most appropriate addition to this patient's regimen

inhaled corticosteroid

which of the following is the most effective way for patients with persistent asthma to monitor the severity of their symptoms

monitor peak flow

3 multiple choice options

which of the following is the major pathogenetic mechanism that causes asthma

airway inflammation

3 multiple choice options

A patient presents with occasional wheezing and chest tightness that occurs approximately once a week and at night only about once a month. Peak expiratory flow is

85% of predicted. Which of the following is the most appropriate initial treatment?

albuterol inhaler

3 multiple choice options

You are evaluating a patient whom you suspect has

asthma. You perform spirometry before and after

administration of an inhaled short-acting bronchodilator. After administration of the

bronchodilator, which of the following spirometry results would suggest reversibility?

increase in FEV1

3 multiple choice options

A 14 year-old male presents to the ED experiencing a severe

asthma attack. His respiratory effort is shallow and he is using

accessory muscles to breathe. Auscultation of his chest reveals no audible wheezing. Vital signs include BP 90/60 mmHg, P 160 bpm, RR 52. An arterial blood gas (ABG) is ordered. Normal ABG values at

your institution are pH 7.35-7.45, CO2 35-45, pO2 80-95.

Which of the following ABG findings suggests the poorest prognosis?

pH = 7.27, pCO2 = 46, pO2 = 56

3 multiple choice options

A 6 year-old boy is brought to the pediatric clinic by his

mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing.

Which of the following would be the most appropriate treatment for this patient?

low dose inhaled corticosteroid

3 multiple choice options

what is the mechanism of action of salmeterol in the treatment of asthma

relaxing of bronchial smooth muscle

3 multiple choice options

COPD patho

- inflammation of airways leads to thickening of airway walls

- increased mucus production

- damage to alveoli and alveolar ducts

- leads to enlargement of air spaces/ emphysema and potential air trapping

- progressive, NOT fully reversible airflow obstruction

- loss of elastic recoil, increased airway resistance

COPD risk factors

- smoking/ exposure: 90%

- occupational or environmental exposures

- AAT deficiency in pts <40

COPD chronic bronchitis patho

- chronic inflammation and airway destruction

- increased mucus production secondary to inflammation

- mucosal edema and mucous hypersecretion

- more resistance causes airflow obstruction (dysfunctional cilia)

COPD chronic bronchitis signs/symptoms

- crackles (rales)

- rhonchi

- wheezing

- cor pulmonale: enlarged liver, JVD, peripheral edema

- cyanosis and obesity (blue bloaters)

- 3 cardinal symptoms: chronic cough, sputum production, dyspnea

COPD chronic bronchitis diagnosis

- productive cough at least 3 months a year for 2 years

- CXR: increased interstitial marking mostly at bases, diaphragms NOT flattened

- PFT: gold standard, shows obstructive pattern. low FEV1, ratio. high volumes due to hyperinflation

- labs: high Hgb, Hct, CO2. low O2. resp acidosis

- lung bx postmortem by increased Reid index

- ECG: cor pulmonale, MAT

COPD chronic bronchitis treatment

- smoking cessation most effective

- combo of SABA or LABA and SAMA or LAMA and inhaled glucocorticoids

- long term O2 therapy for those with resting sat <89%

- vaccinate for flu, pneumococcal, COVID

COPD chronic bronchitis exacerbation treatment

- systemic corticosteroids such as prednisone 40 mg PO qd x 5d

- antibiotics tailored to likelihood or specific pathogens

- antiviral therapy if flu suspected

which of the following pathophysiological processes is associated with chronic bronchitis

mucous gland enlargement and goblet cell hyperplasia

3 multiple choice options

a 65 year old with COPD having received their first PPSV23 vaccination at age 63 should be revaccinated with PPSV23 in

5 years

3 multiple choice options

A patient with severe COPD presents to the Emergency Department with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen at 2 liters per minute, and an IV is started. After

one hour of treatment, his arterial blood gas now reveals a pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg.

Which of the following is the most appropriate next step in his treatment?

intubate the patient

3 multiple choice options

COPD emphysema patho

- chronic inflammation, decreased protective enzymes, and increase damaging enzymes cause alveolar capillary and wall destruction

- loss of elastic recoil and airway collapse makes expiration an active process and increased compliance leads to airway obstruction

- permanent enlargement of terminal airspaces

centrilobar emphysema

- associated with smoking and dust exposure

- mainly occuring in proximal respiratory bronchioles, leaving normal distal alveolar ducts and sacs

panacinar emphysema

- diffuse or localized

- associated with AAT deficiency

- uniform dilation of air space from bronchioles to alveoli, resulting in evenly distributed emphysematous changes in secondary lobules

alpha-1 antitrypsin deficiency

- genetic disorder that causes panacinar emphysema, hepatomegaly, and cirrhosis

- dx: CXR show bullous changes at lung bases, CT scan, PFTs, liver bx

- tx: IV pooled AAT, lung transplant

paraseptal emphysema

- assoc with fibrosis, may coexist with other types

- usually asymptomatic, considered to be a cause of PTX in young adults

- enlarged airspace at periphery of acini, MC along dorsal surface of upper lung

COPD emphysema signs/symptoms

- dyspnea is hallmark

- chronic cough with or w/o sputum

- hyperinflation

- decreased breath sounds

- barrel chest

- hyperresonance to percussion

- wheezing

- cachectic and non cyanotic (pink puffers)

- severe: pursed lip expiration, semi tripod positioning

COPD emphysema CXR findings

- decreased vascular markings

- hyperinflation

- flattened hemidiaphragm

- increased AP diameter

- widened rib spaces

- bullae

- narrow heart shadow