Pulmonology/Allergy/ENT

Kelly CoveyEric Robinette

1. A 32yo AA woman c/o mild fevers, fatigue X1 mo. No sig PMH. T 38.1, BP 115/70, P 75, R 18. Nontender, mobile, cervical and axillary lymphadenopathy noted. Fine crackles B/L. CXR: hilar adenopathy, diffuse interstitial infiltrates. Lymph node biopsy: noncaseating granulomas. Appropriate treatment?

A)AllopurinolB)ACE inhibitorC)CyclosporineD)GlucocorticoidsE) Isoniazid

Sarcoidosis• Peak age: 20-40• More common in AA females• Restrictive lung disease• Noncaseating granulomas: lungs, heart, skin, etc.• Typical CXR appearance-B/L hilar LAD, interstitial infiltrates• ACE levels may be high, but ACE inhibitors have no benefit• Erythema nodosum, Bell’s palsy.• May be asymptomatic & found via CXR.

• Tx: Steroids, usually prednisone

1. A 32yo AA woman c/o mild fevers, fatigue X1 mo. No sig PMH. T 38.1, BP 115/70, P 75, R 18. Nontender, mobile, cervical and axillary lymphadenopathy noted. Fine crackles B/L. CXR: hilar adenopathy, diffuse interstitial infiltrates. Lymph node biopsy: noncaseating granulomas. Appropriate treatment?

A)AllopurinolB)ACE inhibitorC)CyclosporineD)GlucocorticoidsE) Isoniazid

2. 56 yo woman with 60-pack-year smoking hx c/o fatigue, dyspnea with minimal exertion, & productive cough each morning. Which is most likely finding in this pt?

A)Normal diffusing capacity of lung for carbon monoxideB) Decreased residual volumeC) Normal to slightly increased forced expiratory volume in

first second (FEV1)D)Decreased forced expiratory volume in first

second/forced vital capacity (FEV1/FVC)E) Decreased forced vital capacity (FVC)

COPD• Air trapping in lungs, leads to hyperinflation.• Hallmark is decreased FEV1/FVC ratio• CXR: hyperinflated lungs, flat diaphragms• Air can’t get out of lungs vs. restrictive lung dz: air can’t

get into lungs.• Can also be caused by alpha-1-antitrypsin deficiency (will

be young pt with insignificant smoking hx, +/- cirrhosis)• Tx: Only treatments proven to reduce mortality:

• Quit smoking• Supplemental oxygen used continuously

– Other treatments: inhaled tiotropium, albuterol, oral prednisone, antibiotics in exacerbations.

2. 56 yo woman with 60-pack-year smoking hx c/o fatigue, dyspnea with minimal exertion, & productive cough each morning. Which is most likely finding in this pt?

A)Normal diffusing capacity of lung for carbon monoxideB) Decreased residual volumeC) Normal to slightly increased forced expiratory volume in

first second (FEV1)D)Decreased forced expiratory volume in first

second/forced vital capacity (FEV1/FVC)E) Decreased forced vital capacity (FVC)

Restrictive Vs. Obstructive

• Poor breathing mechanics-extrapulm.– Poor muscular effort-

polio, myasthenia gravis– Poor structural apparatus-

scoliosis, obesity

• Interstitial Lung Dz– ARDS, sarcoid, drug

toxicity (chemo), pulmonary fibrosis, neonatal resp distress

• Chronic bronchitis• Emphysema• Asthma• Bronchiectasis (think

CF)

3. 55yo homeless, alcoholic man who has recently been binge drinking c/o 2 wks of fever, malaise, productive cough & pain on deep inspiration. 60-pack-yr hx. CXR: infiltrate of superior portion of rt lower lobe with a cavity containing an air fluid level. A biopsy is likely to show:

A)Acid-fast bacilli and caseating granulomasB) Anaplastic squamous cells with numerous mitotic

figuresC) Fibrosis and needle-like ferruginous bodiesD)Gram-positive diplococci in chainsE) Mixture of anaerobic organisms

3. 55yo homeless, alcoholic man who has recently been binge drinking c/o 2 wks of fever, malaise, productive cough & pain on deep inspiration. 60-pack-yr hx. CXR: infiltrate of superior portion of rt lower lobe with a cavity containing an air fluid level. A biopsy is likely to show:

A)Acid-fast bacilli and caseating granulomasB) Anaplastic squamous cells with numerous mitotic

figuresC) Fibrosis and needle-like ferruginous bodiesD)Gram-positive diplococci in chainsE) Mixture of anaerobic organisms

4. 37 yo florist comes to employee health for a routine eval. Healthy without complaints. Five units of tuberculin protein (PPD) is injected intradermally. He returns to clinic 48-72 hrs later. Which of the following would be a positive rxn in this pt?

A) 5mm erythema and 5 mm indurationB) 10 mm erythema and 5 mm indurationC) 15 mm of erythema and 5 mm indurationD)15 mm of erythema and 15 mm indurationE) 20 mm of erythema and 10 mm induration

Mantoux Test (PPD)

• Degree of erythema not important• 5 mm induration positive for:– Pts at high risk: immunocompromised pts, household

contacts of TB pts, CXR consistent with.• 10 mm induration positive for:– Pts at elevated risk: healthcare workers

• 15 mm induration positive for:– Pt at low risk: general population.

• False positive: BCG vaccine

4. 37 yo florist comes to employee health for a routine eval. Healthy without complaints. Five units of tuberculin protein (PPD) is injected intradermally. He returns to clinic 48-72 hrs later. Which of the following would be a positive rxn in this pt?

A) 5mm erythema and 5 mm indurationB) 10 mm erythema and 5 mm indurationC) 15 mm of erythema and 5 mm indurationD)15 mm of erythema and 15 mm indurationE) 20 mm of erythema and 10 mm induration

TB• Mycobacterium tuberculosis• Caseating granulomas• Presents with cough, fever, hemoptysis, night sweats, wt

loss• Primary TB

– Hilar LAD, Ghon focus (usually lower lobes) Ghon complex• Secondary TB (Reactivation)

– Cavity lesions in upper lobes• Tx: Active: isoniazid, rifampin, pyrazinamide• Tx: Latent (pos PPD, no sympts): isoniazid• Pyridoxine (vit B6) added to prevent peripheral neuropathy

5. 38 yo woman c/o SOB that started suddenly on the morning of presentation. Otherwise healthy. Takes oral contraceptives, 10-pack-yr smoking hx. Appears anxious. Resp 30, P 110, BP 120/80, stable. Most appropriate initial step?

A) AspirinB) CoumadinC) HeparinD)IV fluidE) Streptokinase

Pulmonary Embolus• Risk factors: smoking, OCPs, immobility, recent surgery,

factor V leiden, pregnancy, malignancy• Tachypnea, tachycardia, pain on respiration • Sudden onset• Massive PE’s can cause shock-BP would be unstable• EKG: can show afib, or S1Q3T3 (S wave in lead I, Q wave in

lead III, inverted T wave in lead III)• Elevated d-dimer, Abnl V/Q scan, Abnl CT, CXR usually

normal• Usually from DVTsInitial tx: Anticoagulation with heparin

• Coumadin takes several days to become effective.• IVF and streptokinase if pt hemodynamically unstable

5. 38 yo woman c/o SOB that started suddenly on the morning of presentation. Otherwise healthy. Takes oral contraceptives, 10-pack-yr smoking hx. Appears anxious. Resp 30, P 110, BP 120/80, stable. Most appropriate initial step?

A) AspirinB) CoumadinC) HeparinD)IV fluidE) Streptokinase

6. 45 yo alcoholic man admitted with acute pancreatitis. Req’d large volumes IVF, but was improving at 24 hrs and stable. On 4th hospital day pt develops rapidly progressive resp distress, with labored breathing and tachypnea. T 37, P 100, R 24, BP 128/75. Intercostal retractions and crackles are noted on chest exam.

Hct 42%, Leukocytes 9800/mm3, Glucose 110, BUN 20, AST 98, ALT 60, Amylase 280, ABG: pH 7.32, PaO2 52, PaCO2 51.

CXR: diffuse B/L infiltrates, air bronchograms, normal cardiac silhouette, minimal pleural effusions. Dx?

A) Acute bilateral bronchopneumoniaB) Adult respiratory distress syndrome (ARDS)C) Cardiogenic pulmonary edemaD)Exacerbation of acute pancreatitisE) Pulmonary embolism

A) Acute bilateral bronchopneumoniaB) Adult respiratory distress syndrome (ARDS)C) Cardiogenic pulmonary edemaD)Exacerbation of acute pancreatitisE) Pulmonary embolism

ARDS• Causes: trauma, sepsis, shock, gastric aspiration,

uremia, acute pancreatitis, amniotic fluid embolism.

• Diffuse alveolar damage increased alveolar capillary permeability leakage into alveoli formation of intra-alveolar hyaline membrane

• Acute respiratory failure unresponsive to oxygen• Tx: treat underlying condition, mechanical

ventilation with PEEP.

7. 49 yo man with acute pancreatitis develops severe SOB 15 minutes after undergoing placement of a catheter in his subclavian vein. BP 100/60, P 124, R 50. Cyanotic, obvious distress, distended neck veins, trachea deviates to left. Breath sounds diminished on right side of chest. Next step?

A) CXRB) Removal of catheterC) Endotracheal intubationD)Needle thoracostomy in second right intercostal spaceE) Tube thoracostomy in the left fifth intercostal space

Pneumothorax•Punctured pt’s lung apex with catheter•Hypotension, tachycardia, tachypnea, cyanosis, distended neck veins, diminished breath sounds, tracheal deviation•Tx: needle thoracostomy at second right intercostal space followed by chest tube insertion at right fifth intercostal space

7. 49 yo man with acute pancreatitis develops severe SOB 15 minutes after undergoing placement of a catheter in his subclavian vein. BP 100/60, P 124, R 50. Cyanotic, obvious distress, distended neck veins, trachea deviates to left. Breath sounds diminished on right side of chest. Next step?

A) CXRB) Removal of catheterC) Endotracheal intubationD)Needle thoracostomy in second right intercostal spaceE) Tube thoracostomy in the left fifth intercostal space

8. 55 yo man with hx of alcoholism presents with fever and cough productive of mucopurulent sputum for 2 days. T 39, BP 120/75, P 110, R 26. Chest exam: rales and decreased breath sounds in left lower lung field. CXR: infiltrate in lower left lobe. Most likely pathogen?

A) Influenza virusB) Klebsiella pneumoniaeC) Legionella pneumophilaD)Mycoplasma pneumoniaeE) Pneumocystis cariniiF) Staph aureus

8. 55 yo man with hx of alcoholism presents with fever and cough productive of mucopurulent sputum for 2 days. T 39, BP 120/75, P 110, R 26. Chest exam: rales and decreased breath sounds in left lower lung field. CXR: infiltrate in lower left lobe. Most likely pathogen?

A) Influenza virusB) Klebsiella pneumoniaeC) Legionella pneumophilaD)Mycoplasma pneumoniaeE) Pneumocystis cariniiF) Staph aureus

9. 48 yo man with extensive smoking hx presents to ER with c/o difficulty breathing for 2 days. T 38.3, BP 120/70, P 103. Dullness to percussion and decreased breath sounds over right lower lung. CXR: significant right pleural effusion. Diagnostic thoracentesis shows:

Pleural fluid: pH 7.18, Glucose 40, Protein 3.8, LDH 220 Serum: protein 7.0, LDH 320. Likely etiology of effusion?

A) Exudate of infectious etiologyB) Exudate of malignant etiologyC) Transudate of infectious etiologyD)Transudate of noninfectious etiology

Light’s Criteria

• Exudate if 1+ criteria met– Pleural protein : serum protein >0.5– Pleural LDH : serum LDH >0.6– Pleural LDH >2/3 upper limits of normal for serum• Different labs have different ULN, use whatever value

given on exam

Transudate vs Exudate

• protein content• CHF• Nephrotic syndrome• Hepatic cirrhosis• Spec grav <1.012

• protein content• Cloudy• Malignancy• Pneumonia• Collagen vascular

disease• Spec grav >1.020• Must be drained!

9. 48 yo man with extensive smoking hx presents to ER with c/o difficulty breathing for 2 days. T 38.3, BP 120/70, P 103. Dullness to percussion and decreased breath sounds over right lower lung. CXR: significant right pleural effusion. Diagnostic thoracentesis shows:

Pleural fluid: pH 7.18, Glucose 40, Protein 3.8, LDH 220 Serum: protein 7.0, LDH 320. Likely etiology of effusion?

A) Exudate of infectious etiologyB) Exudate of malignant etiologyC) Transudate of infectious etiologyD)Transudate of noninfectious etiology

10. 55 yo pt presents with chronic cough. Pt has gained weight recently with the development of a “buffalo hump” and Cushingoid features. A CXR demonstrates a mass involving the central area of the chest. Bronchoscopy is performed and a biopsy taken. Which is most likely diagnosis?

A) AdenocarcinomaB) Bronchioloalveolar carcinomaC) Large cell carcinomaD)Small cell carcinomaE) Squamous cell carcinoma

10. 55 yo pt presents with chronic cough. Pt has gained weight recently with the development of a “buffalo hump” and Cushingoid features. A CXR demonstrates a mass involving the central area of the chest. Bronchoscopy is performed and a biopsy taken. Which is most likely diagnosis?

A) AdenocarcinomaB) Bronchioloalveolar carcinomaC) Large cell carcinomaD)Small cell carcinomaE) Squamous cell carcinoma

• Lung CA– Leading cause of cancer death.– Presents with cough, hemoptysis, bronchial

obstruction, wheezing, lesion on CXR.– Mets to brain, bone, liver– Complications: SVC syndrome, pancoast tumor,

horner’s syndrome, paraneoplastic syndromes, effusions

11. A medical consultant for a managed care organization receives a call from a hospital administrator who is concerned about the health care dollars spent on patients with lung CA over the past 5 years. The administrator wants to reduce the expenditures for treatment by implementing a screening test for lung CA. What should the consultant advise the administrator?

A) Annual CXR after age 50B) Annual CXR after age 40 for all smokersC) Annual physical exam with PFTsD)Annual questionnaire to look for high risk behaviorE) No effective screening program is available

11. A medical consultant for a managed care organization receives a call from a hospital administrator who is concerned about the health care dollars spent on patients with lung CA over the past 5 years. The administrator wants to reduce the expenditures for treatment by implementing a screening test for lung CA. What should the consultant advise the administrator?

A) Annual CXR after age 50B) Annual CXR after age 40 for all smokersC) Annual physical exam with PFTsD)Annual questionnaire to look for high risk behaviorE) No effective screening program is available

12. 62 yo man with extensive smoking hx presents with drooping right eyelid. Pt denies HA or weight loss. C/o occasionally productive cough but otherwise is in good health. Exam: right ptosis, small right pupil. EOMI. Visual acuity normal. Right side of face appears warm and dry. Next most appropriate diagnostic step?

A)CXRB) Lab testing for syphilisC) MRI of headD)Opthalmologic referralE) Tonometric measurement

12. 62 yo man with extensive smoking hx presents with drooping right eyelid. Pt denies HA or weight loss. C/o occasionally productive cough but otherwise is in good health. Exam: right ptosis, small right pupil. EOMI. Visual acuity normal. Right side of face appears warm and dry. Next most appropriate diagnostic step?

A)CXRB) Lab testing for syphilisC) MRI of headD)Opthalmologic referralE) Tonometric measurement

Pancoast Tumor

• Carcinoma in apex of lung• Affects cervical sympathetic plexus– Causes Horner’s syndrome• Ptosis, miosis, anhydrosis.

13. Elderly Asian man comes to ER because of rapid onset of severe pain and blurred vision in right eye. Also reports seeing halos around lights. Eye is red, pupil is fixed and dilated. Only med is imipramine for depression. Which diagnostic procedure should be performed at this time?

A)Direct ophthalmoscopyB) MRI of headC) Slit-lamp examD)TonometryE) Visual field assessment

13. Elderly Asian man comes to ER because of rapid onset of severe pain and blurred vision in right eye. Also reports seeing halos around lights. Eye is red, pupil is fixed and dilated. Only med is imipramine for depression. Which diagnostic procedure should be performed at this time?

A)Direct ophthalmoscopyB) MRI of headC) Slit-lamp examD)TonometryE) Visual field assessment

Narrow-angle Glaucoma

• Red eye, extreme pain, blurred vision with halos around lights.

• Impaired flow of aqueous humor inc’d intraocular pressure

• Tonometry to diagnose, although eye is often hard on palpation

• Emergency• Immediate treatment to lower intraocular pressure

– acetazolamide or osmotic diuretics (glycerol, mannitol)

• Less common than open angle which is “silent” and painless

14. 40 yo man presents with 5 episodes of severe vertigo with N/V over the past 6 months. Episodes begin with a sense of fullness in his right ear, often with tinnitus and a sense of hearing loss in the right ear. Each episode lasts hrs to days and then resolves. Otoscopic exam of right ear is normal. Dx?

A)Benign paroxysmal positional vertigoB) Herpes zoster oticusC) Meniere diseaseD)Purulent labyrinthitisE) Vestibular neuronitis

14. 40 yo man presents with 5 episodes of severe vertigo with N/V over the past 6 months. Episodes begin with a sense of fullness in his right ear, often with tinnitus and a sense of hearing loss in the right ear. Each episode lasts hrs to days and then resolves. Otoscopic exam of right ear is normal. Dx?

A)Benign paroxysmal positional vertigoB) Herpes zoster oticusC) Meniere diseaseD)Purulent labyrinthitisE) Vestibular neuronitis

15. A term neonate is healthy at birth and receives routine perinatal care. Infant is discharged from hospital on day 3. Ten days after delivery, infant develops severe erythema and edema in both eyelids with associated watery discharge that soon becomes copious and mucopurulent, with presence of pseudomembranes. Which condition is this infant most at risk for?

A)Corneal ulcerationB) EncephalitisC) PneumoniaD)SepsisE) Silver toxicity

15. A term neonate is healthy at birth and receives routine perinatal care. Infant is discharged from hospital on day 3. Ten days after delivery, infant develops severe erythema and edema in both eyelids with associated watery discharge that soon becomes copious and mucopurulent, with presence of pseudomembranes. Which condition is this infant most at risk for?

A)Corneal ulcerationB) EncephalitisC) PneumoniaD)SepsisE) Silver toxicity

16. 7 yo boy brought to doc due to persistent nasal obstruction for 6 months. No personal or family hx of allergic disorders. Nasal fossae exam reveals B/L ethmoidal polyps. Most appropriate next step in diagnosis?

A)Cutaneous allergen testingB) Excisional biopsyC) Nasal provocation testingD)Pilocarpine iontophoresis sweat testE) Radioallergosorbent test (RAST)

Nasal Polyps

• Not neoplasms• Hyperplastic response of mucosa to chronic

inflammation• Allergic rhinitis/sinusitis is most common

underlying condition…BUT think of cystic fibrosis in children

• Also consider aspirin allergy: triad of nasal polyps, asthma, & sinusitis

16. 7 yo boy brought to doc due to persistent nasal obstruction for 6 months. No personal or family hx of allergic disorders. Nasal fossae exam reveals B/L ethmoidal polyps. Most appropriate next step in diagnosis?

A)Cutaneous allergen testingB) Excisional biopsyC) Nasal provocation testingD)Pilocarpine iontophoresis sweat testE) Radioallergosorbent test (RAST)

Cystic Fibrosis• Autosomal recessive defect in CFTR gene on

Chromosome 7, usually deletion of Phe 508.• Defective chloride channel leads to secretion of

abnormally thick mucous that plugs the lungs, pancreas, and liver

• Recurrent pulmonary infections (esp. Pseudomonas and S. aureus)

• Chronic bronchitis, bronchiectasis, pancreatic insufficiency, meconium ileus in newborns, nasal polyps.

• Tx: N-acetylcysteine—loosens mucous plugs.

17. 10yo girl has recurrent attacks of wheezing and dyspnea. Attacks occur mostly at home or soon after exercise when outdoors. Exacerbations are noted in spring. Severity of symptoms is mild. PFTs show peak expiratory flow and FEV1 are reduced during an attack but are normal otherwise. CBC shows 8% eosinophils. Allergy testing shows pt allergic to variety of allergens: dust mites, animal dander, pollens. Most effective step in management?

A)Avoid exerciseB) Avoid respiratory irritantsC) Use air cleaners at homeD)Administration of multiple-drug regimensE) Immunotherapy against identified allergens

17. 10yo girl has recurrent attacks of wheezing and dyspnea. Attacks occur mostly at home or soon after exercise when outdoors. Exacerbations are noted in spring. Severity of symptoms is mild. PFTs show peak expiratory flow and FEV1 are reduced during an attack but are normal otherwise. CBC shows 8% eosinophils. Allergy testing shows pt allergic to variety of allergens: dust mites, animal dander, pollens. Most effective step in management?

A)Avoid exerciseB) Avoid respiratory irritantsC) Use air cleaners at homeD)Administration of multiple-drug regimensE) Immunotherapy against identified allergens

18. 12 yo girl has mild case of PNA. Treated with IM injection of penicillin. 15 mins later, develops extreme itchiness & wheals scattered over her chest and extremities. Pt begins to wheeze and c/o difficulty breathing. Lips and face remain rosy. Which is the following is the most appropriate first step in management?

A)Epinephrine injectionB) IV corticosteriodsC) IntubationD)Oral corticosteroidsE) No specific therapy is needed

18. 12 yo girl has mild case of PNA. Treated with IM injection of penicillin. 15 mins later, develops extreme itchiness & wheals scattered over her chest and extremities. Pt begins to wheeze and c/o difficulty breathing. Lips and face remain rosy. Which is the following is the most appropriate first step in management?

A)Epinephrine injectionB) IV corticosteriodsC) IntubationD)Oral corticosteroidsE) No specific therapy is needed

Type I HypersensitivityAnaphylaxis

• Itchiness and wheals result from changes in small cutaneous vessels that favor shift of fluid out of the vascular space.

• SOB and wheeze are due to edema and bronchoconstriction of upper airways.

• Free antigen cross-links IgE on presensitized mast cells, triggering release of vasoactive amines (histamine).

Type II Hypersensitivity

• Antibody mediated– IgM, IgG bind to antigen on enemy cell, leading to

lysis by complement or phagocytosis.• Hemolytic anemia, pernicious anemia, ITP,

erythroblastosis fetalis, rheumatic fever, bullous pemphigoid, pemphigus vulgaris, Graves’ disease, myasthenia gravis.

Type III Hypersensitivity

• Immune complex– Antigen-antibody complex activates complement, which

attracts neutrophils, which release lysosomal enzymes• Serum sickness-usually caused by drugs.– Fever, urticaria, arthralgias, proteinuria, LAD 5-10 days

after antigen exposure.– 5 days to produce the antibodies to the antigens-then

complex forms, gets deposited and leads to damage.• Arthus rxn-intradermal injection of antigen attracts

antibodies, form complex in skin.– Edema, necrosis.

Type IV Hypersensitivity

• Delayed T-cell mediated• Sensitized T cells encounter antigen and

release lymphokines leading to macrophage activation

• PPD test• Contact dermatitis – poison ivy• Transplant rejections