Clin Med II - Exam 9 (Pulm 3)

allybrown271

Patient will present as → a 5-year-old boy

who is brought to the emergency

department by his parents for a

cough and shortness of breath. He has a

past medical history of eczema and

seasonal rhinitis. On physical exam, you

note a young boy in respiratory distress

taking deep slow breaths to try and catch

his breath. He has diminished breath

sounds in all lung fields with prolonged,

expiratory wheezes. What is the most likely diagnosis?

Asthma

T/F: Asthma is reversible

True

1 multiple choice option

What is the most common chronic childhood disease?

Asthma

What population has the highest death rates from asthma?

African Americans ages 15-24

What are the three major patho components of asthma?

-airway hyperreactivity

-bronchoconstriction/obstruction

-inflammation

What immunoglobulin is associated with the inflammation seen in patients with asthma?

IgE

What is Samter's Triad?

1. asthma

2. nasal polyps/chronic rhinosinusitis

3. ASA/NSAID allergy/sensitivity

What is the strongest risk factor for asthma?

Atopy

The risk for developing asthma is greater for boys (before/after) puberty.

Before

The risk for developing asthma is greater for girls (before/after) puberty.

After

What is the Atopic Triad?

atopic dermatitis (eczema), allergic rhinitis, asthma

What is atopy?

genetic tendency to develop allergic reactions (such as allergic rhinitis or asthma) and produce elevated levels of IgE upon exposure to an antigen

What cardiac medicine should be avoided in patients with asthma?

beta blockers

What is the classic triad of symptoms in asthma patients?

dyspnea, wheezing, cough

What is the primary finding seen on physical exam in patients with asthma?

Prolonged expiration with wheezing

What are some SERIOUS signs of severe asthma?

silent chest, altered mental status, pulsus paradoxus

What is pulsus paradoxus?

inspiratory blood pressure decreases >10 mmHg (usually increases)

What is bronchoprovocation?

Patient inhales methacholine (or histamine) to induce airway hyperreactivity. AKA methacholine challenge

If you have an asthmatic patient that is showing signs of respiratory acidosis, what does this mean?

Impending complete respiratory failure (ACT FAST! - This is really bad)

What acid-base disturbance do we expect to see in asthma exacerbation patients?

respiratory alkalosis

How do we treat an asthma exacerbation?

Oxygen

Nebulized SABA

Ipratropium bromide

Oral steroids

What is the preferred treatment for controlling asthma in patients over 12?

low dose ICS -formoterol as a reliever

What is the mainstay treatment for maintenance of asthma (taken daily)? What are some specific examples?

Inhaled Corticosteroids (ICS)

-budesonide

-fluticasone

What can be done to reduce the risk of candidiasis when taking ICS?

Use of a spacer or rinsing mouth after inhalation

T/F: LABAs can be used as a monotherapy for asthma maintenance

False

1 multiple choice option

When might you add a LABA to a patient's asthma regimen?

only if persistent asthma is not controlled with ICS alone

What are some side effects we need to warn our patients of when putting them on an anticholinergic?

thirst, blurred vision, dry mouth, urinary retention, dysphagia, acute glaucoma, BPH

What type of med is Ipratropium bromide?

anticholinergic

What type of med is albuterol?

SABA (inhaled bronchodilator)

What are some side effects that might be seen in SABAs such as albuterol?

B-1 cross reaction, tachycardia/arrhythmias, muscle tremors, CNS stimulation, mild hypokalemia (warn patients they may feel anxious)

Why should SABAs not be used as a first-line monotherapy for asthma?

associated with increased airway hyperresponsiveness and reduced bronchodilator effect (can make asthma worse in the long run)

When are mast cell modifiers such as cromolyn or nedocromil helpful?

patients with acute responses to cold air, exercise, or sulfites

What is important to remember in smoking patients when prescribing theophylline?

Will need increased dose

What side effects should patients be made aware of when taking theophylline?

toxicity causes arrhythmia and seizures

What are the three main goals in asthma management?

prevent future exacerbations, decrease nocturnal awakenings, maintain pulmonary function

What is desensitization therapy?

"allergy shots"

What medicine can precipitate an acute asthma attack and should be avoided/used with caution in asthma patients?

NSAIDs/ aspirin

If a patient has mild asthma, which of the following pulmonary function test results would you expect to find?

A) Forced vital capacity (FVC) 50% of predicted

B) Forced expiratory volume in 1 second (FEV1) 100% of predicted

C) FEV1/FVC ratio <0.7

D) Total lung capacity (TLC) 50% of predicted

E) FEV1/TLC <0.7

C

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?

A) Normal spirometry

B) Obstructive lung disease

C) End-stage emphysema

D) Interstitial fibrosis

E) Obesity-hypoventilation syndrome

B?

Which of the following is most appropriate for a patient given that she has intermittent asthma?

A) Add theophylline

B) Add montelukast

C) Continue albuterol as needed

D) Schedule albuterol every 4 hours

E) Prednisone 5 mg daily

C

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

A) Inhaled fluticasone

B) Inhaled salmeterol

C) Oral zafirlukast

D) Oral prednisone

B

T/F: COPD is reversible

False

1 multiple choice option

What is the most common risk factor for COPD?

cigarette smoking/exposure

What genetic component can lead to the development of COPD and should be considered if COPD is seen in a patient younger than 40?

Alpha-1 antitrypsin deficiency

Patient will present as → a 60-year-old female with shortness of breath of recent onset. She has a six-year history of cough and rhonchi and is on oxygen at home. Physical exam reveals a respiratory rate of 32, slightly labored breathing, and a temperature of 98.9F. Her SpO2 is 90% while receiving oxygen via nasal cannula at 2 Lpm. What is the diagnosis?

COPD - chronic bronchitis (blue bloater)

What are the three essentials of Dx for COPD-chronic bronchitis?

-productive cough

-at least 3 months of the year

-2 consecutive years

What are the three cardinal symptoms seen in patients with COPD-chronic bronchitis?

-chronic cough

-sputum production

-dyspnea

Are diaphragms flattened in chronic bronchitis or emphysema?

Emphysema

1 multiple choice option

What is the gold standard for diagnosing COPD- chronic bronchitis?

PFT

What is the most effective therapy for COPD?

Smoking cessation

Patient will present as → a 35-year-old female who was found to have a small (2.5 cm) pulmonary lesion on chest radiograph found incidentally after a screening exam for a positive PPD at work. The patient has no significant past medical history and is asymptomatic. What is the most likely diagnosis?

Benign Pulmonary Nodules (AKA coin lesions)

If a benign pulmonary nodule is larger than 3 cm, what is it called?

A mass

What is another name for benign pulmonary nodule?

coin lesion

What is the most common type of benign pulmonary nodule and what is this often caused by?

infectious granulomas from old or active TB

T/F: most patients with benign pulmonary nodules are asymptomatic.

True

1 multiple choice option

Is a mass in the upper or lower lung more worrisome?

Upper

1 multiple choice option

What should you be thinking if you see a spiculated lesion?

Cancer

What is the first most important step in imaging evaluation of pulmonary nodules?

Review old images

If you find a small nodule (<1cm), what do we do?

Monitor; if no change in two years, it is likely benign

If a nodule has a rapid doubling time, what is the most likely cancer?

squamous cell carcinoma

If a nodule has a slow doubling time, what is the most likely cancer?

Adenocarcinoma

What is a PET scan and what does it measure?

Positron emission tomography - detects increase in glucose metabolism within malignant lesions

What is the only way to definitively diagnose cancer?

Biopsy

A solitary pulmonary nodule is found on a pre-employment screening chest x-ray in a 34-year-old nonsmoking male. There are no old chest x-rays to compare. Which of the following is the most appropriate next step in the evaluation?

A) CT scan of the chest

B) Needle biopsy of the lesion

C) Positron emission tomography of the chest

D) Fiberoptic bronchoscopy

A

A 42 year-old male smoker presents for further evaluation of a 4 cm solitary pulmonary nodule discovered on a recent chest x-ray. Which of the following diagnostic tests is indicated next?

A) Bone scan

B) Thoracotomy

C) Mediastinoscopy

D) CT scan of chest

D

A 40 year-old male nonsmoker in good health undergoes a routine chest x-ray for an insurance physical. Results show an isolated, well-defined, coin lesion 1 cm in size. Which of the following is the next step in the evaluation of this problem?

A) Review old radiographs

B) Order chest CT

C) Schedule lung biopsy

D) Prepare for surgical lung resection

A

A 60 yo male presents for a cough. His sxs began with a cold 2 weeks ago, & the other sxs have improved, but cough has persisted. He has mild production of white sputum with no hemoptysis. The pt denies fevers, night sweats, chills, & weight loss. He's had no chest pain or dyspnea. He smokes one pack per day, works in construction, & doesn't t have a regular doctor. He says, "I haven't seen a doctor in over 30 years." On PE, you find a fit-appearing male in no acute distress. His vitals are normal. Lung sounds are diminished bilaterally. While breathing ambient air, the patient's oxygen sat is 94%. You obtain a CXR, find& a nodule in the right lower lobe. Your next step is to:

A) Prescribe a 5-day course of azithromycin

B) Refer the pt to a pulmonologist

C) Order a high-resolution CT scan of the chest

D) Have the pt return to you in 3 mos to repeat a CXR

E) Reassure the pt and have him return as needed

C

Which of the following is NOT considered a benign pattern of calcification on CT scan?

A) Diffuse, homogeneous calcification

B) Central calcification

C) Laminar calcification

D) Spiculated, irregular calcification

E) "Popcorn" calcification

D

All of the following are useful to help assess the risk of cancer in a patient with a solitary pulmonary nodule (SPN) EXCEPT:

A) Smoking status

B) Age

C) Diameter of the nodule

D) Gender

D

Your patient wants to quit smoking for good, and he thinks that he will need some assistance. You recommend nicotine replacement products and bupropion, but your patient claims to have had an allergic reaction to bupropion. Fortunately, you know of an effective alternative. To assist with tobacco cessation, you prescribe which of the following?

A) Varenicline

B) Fluoxetine

C) Olanzapine

D) Metoprolol

E) Clonidine

A

As you are walking out of your patient's room, your patient says, "Hey Doc, my brother smokes too, is there a test you can do to make sure he doesn't have lung cancer?" You respond:

A) "Sure, I'll put in an order for him to get an outpatient chest x-ray"

B) "Tell him to make an appointment and we will discuss the risks/benefits of low-dose CT scan"

C) "Here have him expectorate in this cup, and I'll send his sputum for cytology"

D) "Nah, we don't recommend lung cancer screening at this time"

E) "Yes. We just need a Ouija board and a magic 8-ball"

B

Patient will present as → a 65-year-old woman with a 40 pack-year history of smoking presents with a 7kg weight loss over the last 3 months and recent onset of streaks of blood in the sputum. PE reveals a thin, afebrile woman with clubbing of the fingers, an increased anteroposterior diameter, scattered and coarse rhonchi and wheezes over both lung fields, and distant heart sounds. What is the likely diagnosis?

Malignant Lung Cancer

Which of the following is a major contraindication to curative surgical resection of a lung tumor?

A) Liver metastases

B) Vagus nerve involvement

C) Non-malignant pleural effusion

D) Chest wall invasion of the tumor

A

A patient taking bleomycin (Blenoxane) should be monitored for which of the following side effects?

A) Optic neuritis

B) Hyperuricemia

C) Encephalopathy

D) Pulmonary fibrosis

D

Which of the following forms of lung cancer is associated with the poorest prognosis?

A) squamous cell

B) adenocarcinoma

C) large cell

D) small cell

D

What will be seen in the sputum of patients with malignant lung cancer?

small clusters of hyperchromatic pleomorphic cells

What is the most common cancer worldwide?

Lung cancer

What is the number one risk factor for lung cancer?

smoking

A 60 year year old patient comes in for an annual check-up. His history reveals that he just stopped smoking 4 months ago. What is the appropriate next step?

Order an annual low dose CT scan

What is the most common presenting complaint in patients with lung cancer?

new cough or change in chronic cough

What is the most common type of non-small cell lung cancer?

Adenocarcinoma

2 multiple choice options

What treatment is CRUCIAL for patients with small cell cancer?

Chemotherapy

What is the most common primary lung cancer in women, men, and non-smokers?

Adenocarcinoma of the lung

Where does adenocarcinoma of the lung arise from?

bronchial mucosal glands

What type of lung cancer is most commonly seen in smokers?

Squamous cell lung carcinoma

Where does squamous cell carcinoma of the lung arise from?

proximal portions of tracheobronchial epithelium to central location

What is CCCP associated with squamous cell lung cancer?

-Centrally located

-Cavitary lesions

-hyperCalemia

-Pancoast syndrome

T/F: Large cell lung cancer is usually peripherally located

True

1 multiple choice option

What type of lung cancer is AGGRESIVE and associated with early mets?

Small cell carcinoma

What type of lung cancer has the poorest prognosis?

Small cell carcinoma

Can small cell lung cancer be treated with surgery?

No

1 multiple choice option

What is the most common risk factor for the development of mesothelioma?

Chronic asbestos exposure

What is commonly seen on CXR in patients with mesothelioma?

Unilateral pleural thickening and effusion

What is the definitive treatment for mesothelioma?

None

3 multiple choice options

Where are the three cancers that metastasize to the lungs most often?

Breast, colon, liver

What is first line treatment of metastatic lung cancer?

treat primary cancer

A 62 year-old male presents with a right hilar mass. Needle-biopsy of the mass reveals the presence of small-cell carcinoma and a bone scan reveals the presence of scattered hot spots throughout the skeleton. Which of the following is the most appropriate treatment?

A) Lobectomy

B) Pneumonectomy

C) Thoracic radiation therapy

D) Combination chemotherapy

D

Which histologic type of lung cancer is typically centrally located?

A) Adenocarcinoma

B) Bronchoalveolar

C) Large cell

D) Squamous cell

D

A 62 year-old male smoker presents to the clinic with the complaint of a chronic cough, hemoptysis, and weight loss. Chest CT shows a mass obstructing the bronchus with hilar and mediastinal lymph node abnormalities. Bronchoscopy with biopsy is performed. On reviewing pathology results you explain to the patient that his type of lung cancer is prone to early hematogenous spread, is rarely amenable to surgical resection and has a very aggressive course. What type of lung cancer is most likely in this patient?

A) Squamous cell

B) Small cell

C) Large cell

D) Adenocarcinoma

B

A 61 YO male presents with the chief complaint of "coughing up blood & weakness" for the past 3 wks. He reports 5-6 episodes every 2-3 days of coughing of bright red blood, approximately 1-2 tbps each time. Pt denies chest pain, fevers, chills, or recent travel. He has mild dyspnea at baseline. He has recently developed lower extremity muscle cramps & has difficulty rising from a chair. PMHx is significant for COPD diagnosed 5 yrs ago & HTN. He has a 40-pk-yr smoking Hx & currently smokes 1 pk/day. Exam is notable for end-expiratory wheezing & a prolonged expiratory phase on lung auscultation. He has 3/5 hip flexion & decreased deep tendon reflexes bilaterally in lower extremities. Lab tests are normal. CXR reveals typical changes seen in COPD (flattened diaphragms, hyperinflation) & a perihilar mass. What is the dx?

A) Bronchial carcinoid

B) Large cell carcinoma

C) Squamous cell carcinoma

D) Small cell carcinoma

D