Pulmonary

Question 1

What are two possible explanations for shortness of breath in the hospital 3 days after a femur fracture?

Answer 1

1. Fat embolism

2. Acute respiratory distress syndrome (ARDS)

Question 2

What is the etiology of ARDS?

Answer 2

lung damage is triggered by NEUTROPHILS that release cytokines. Cytokines produce a variety of compounds that damage the alveolar epithelium.

Vascular damage = leakage of protein rich exudate, hyaline membrane formation = decreased CO2 excretion

Question 3

What are chest xray findings of typical community acquired pneumonia by klebsiella?

Answer 3

Lobar cavitation

Question 4

What is the most common cause of croup in a young child?

Answer 4

Parainfluenza type 1

Question 5

What is the most common cause of typical pneumonia in HIV patients?

Answer 5

Strep Pneumo

Question 6

What is the use of Oxymetazoline? what are adverse fx to be aware of when using?

Answer 6

topical decongestant applied directly to nasal passage

–if used more than 3 days, pt will experience rebound congestion (because of alpha receptor down-regulation)

Question 7

What are two uses of N-acetylcysteine?

Answer 7

1. acetaminophen overdose

2. mucolytic agent - classically used w cystic fibrosis

Question 8

How is Asthma diagnosed?

what drug, what receptor?

Answer 8

Methacholine challenge test

–muscarinic (M3) receptor - causes bronchospasm

Question 9

What is the most common HISTOLOGIC type of lung cancer? what are histologic signs?

Answer 9

Adenocarcinoma - neoplastic, invading glands filled with MUCIN (magenta colored material inside glands)

-lesions are usually peripherally located

Question 10

How do you distinguish Transudative from exudative pleural fluid?

Answer 10

Light’s criteria: pleural fluid (PF) has to meet 2/3 criteria to be EFFUSION:

1. PF protein: serum protein > 0.5
2. PF LDH: serum LDH > 0.6
3. PF LD 2/3 upper limit of normal serum LDH

Question 11

identify type of malignancy and explain symptoms:
60 year old who smokes (30 packyear hx)
weightloss. CT shows hilar mass. elevated calcium levels

Answer 11

Squamous cell lung cancer

• -a/w smokers, central lesion
• -PTHrP production = hypercalcemia

Question 12

identify type of malignancy:
50 year old nonsmoker presents with worsening shortness of breath. CXR shows peripheral nonnecrotic lesions

what other type can present similarly (how do you tell them apart)

Answer 12

Adenocarcinoma of lung

• -a/w nonsmokers
• -peripheral lesion

other peripheral is large cell
–Large cell with have NECROSIS

Question 13

What is the function of pulmonary surfactant?

Answer 13

DECREASE alveolar surface tension

• decrease lung recoil
• increase lung compliance

Question 14

What are adverse effects of therapeutic O2 for neonatal respiratory distress syndrome?

Answer 14

RIB

Retinopathy of prematurity
Intraventricular hemorrhage
Bronchopulmonary dysplasia

Question 15

What type of cells are found

1. until the end of bronchi
2. until the beginning of terminal bronchioles
3. until the end of terminal bronchioles

what segment is this called?

Answer 15

Conducting zone - nose, pharynx, larynx, trachea, bronchi, bronchioles, terminal bronchioles (anatomic dead space)

1. cartilage, goblet cells
2. Pseudostratified ciliated columnar cells - transition to cuboidal cells at the beginning of terminal bronchioles
3. Airway smooth muscles extend to end of terminal bronchioles

Question 16

What levels do what structures perforate the diaphragm?

Answer 16

I ate ten eggs at 12

T8 - Vena Cava
T10 - Oesophagus
T12 - aortic hiatus, thoracic duct, azygos vein

Question 17

Cold winter morning, 6 month baby presents to ED for coughing, fever of 100F, respiratory distress. CXR shows hyperinflated lungs.
RR: 66/min with wheezing

what is most likely diagnosis?

Answer 17

Respiratory Syncytial Virus infection
–common cause of cough, fever, resp distress in infants during winter months

—case is NOT pneumonia b/c of CXR findings.

Question 18

How can you tell if a pulmnoary thrombus was formed before or after death?

Answer 18

before death:

Lines of Zahn = interdigitating areas of pink (platelets, fibrin) and red (RBCs)

Question 19

What is the light microscopy finding of lung tissue in small cell lung cancer?

Answer 19

Small round blue cells

Question 20

several elderly patients present with difficulty breathing, high fever, intermittent diarrhea. All pts recently shopped at same grocery store where fresh veggies are stored under mist machines. Cant obtain sputum samples. What is the pathogen and what should be obtained for testing?

Answer 20

Legionnaires disease - Legionella pneumophila
(mild flu-like syndrome w fever, resp sx and diarrhea)
–found in elderly, alcoholics, smokers,

L. pneumophila antigens can be detect in URINE SAMPLES
+ sputum culture on Buffered Charcoal Yeast extract agar

Question 21

85 year old presents with dyspnea. hemoptysis. Pulm fxn tests shows decreased FEV1, decreased FVC, normal FEV1/FVC ratio. social hx includes 20 pack year hx of cigarette smoking. alcohol use. Served in navy then retired to work in a tractor assembly plant.

What is dz? what is the histological appearance?

Answer 21

Asbestos related lung disease

• -decreased FEV1, FVC
• -normal FEV1/FVC ratio

Gold-grown fusiform, beaded rods that consist of fibers which are coated with iron containing proteinaceous material

Question 22

40 year old alcoholic presents with fever, dyspnea, and productive cough. normal PaO2. Tender nodule in 4th intercostal space on right. Sputum sample is Pinkish in color, contains gram-positive organisms. CXR shows right middle lobe consolidation. Which is the most likely pathgen?

Answer 22

Staphylococcus aureus

• one of the most common organism that can cause pneumonia in ALCOHOLICS.
• SALMON-colored SPUTUM

Question 23

What is the most common pathogen that causes pneumonia that requires hospitalization in pts with chronic bronchitis.

Answer 23

Moraxella catarrhalis

Question 24

4 month old infant is brough to ED in january with respiratory distress. Sx began as runny nose and cough prior night. Now he is breathing heavily with audible wheezing. Breathing with accessory muscles. What is dx and what is most likely pathogen?

Answer 24

Bronchiolitis - acute inflammation of the small airways in children <2 years.

• -Most common cause = RSV in late fall, winter months
• deted by directed fluorescent antibody testing or culture

Question 25

Pt presents with adenocarcinoma of the stomach with metastasis to the left supraclavicular lymph node (Virchow's Node) - this can cause regional lymphatic vessel obstruction which can impede the drainage of what?

Answer 25

obstruction of the thoracic duct. --drains bilateral lower extremities, pelvis, abdomen, left pleural cavity, upper lobe of left lung, left upper extremity, left head and neck.

Question 26

What parts of the lung are drained the right lymphatic duct drain? thoracic duct?

Answer 26

Right lymphatic duct: Upper, middle, lower lobes of Right lung Lower lobe of left lung Thoracic duct: upper lobe of left lung, left pleural cavity

Question 27

What electrolyte imbalance is observed in Legionnaires disease? what type of organism is the pathogen?

Answer 27

Hyponatremia Legionella pneumophila = facultative intracellular --infect alveolar macrophages

Question 28

7 year old male seen in rural Guatemala clinic. complains of dry cough, dyspnea, chest pain, febrile. CXR - several rounded infiltrates scattered throughout the lung fields bilatearlly. Sputum analysis reveals Charcot-Leyden crystals and eosinophils. Large round eggs are seen in stool sample, several larvae are seen in respiratory secretions, denies prurities in lower extremities. What is the pathogen?

Answer 28

Ascaris lumbricoids - eggs are ingested via fecal oral route -larvae migrate through lungs Strongyloides stercorali - also can cause pulmonary sx but NOT a/w Charcot-Leyden crystals

Question 29

How do you distinguish Mesothelioma from a Carcinoma of the lung?

Answer 29

Mesothelioma - -a/w asbestosis - -Psammoma bodies seen on histology - -**CYTOKERATIN + CALRETININ (negative in carcinoma) --smoking is not a risk factor

Question 30

9 year old w history of asthma presents with worsening of ocugh. dry cough which is worse at night and wakes him up. Needs to use his inhaler everyday. What is the first line treatment to prevent his sx from recurring

Answer 30

pt has progressed from mild intermittet asthma to persistent asthma (daily albuterol use + new nighttime cough) --First line tx for mild persistent asthma = start inhaled steroid (BECLOMETHASONE)

Question 31

pt who works at local sheep/goat farm presents with nonproductive cough, chills, malaise, fever that waxes and wane over the past 6 months. PMH: unknown valvular heart disease. febrile, mild hepatomegaly CXR shows non-cavitary unilateral infiltrate. What is dz? how is it most commonly contracted? what is pt at higher risk for?

Answer 31

Q fever - Coxiella burnetii --chronic form most commonly in pts that are pregnant, immunocompromised, underlying valvular disease --chronic form: multiplies in macrophages = higher risk for Endocarditis (from immune complexes, autoabs) -most commonly from cattle, goats, sheep placenta

Question 32

How are squamous cell carcinomas distinguished histologically?

Answer 32

cells with eosinophilic cytoplasm and keratin pearls intracellular desmosomes = "intracellular bridges"

Question 33

Which type of lung carcinoma is this: Sheets of round to polyonal cells with prominent nucleoli and abundant pale staining cytoplasm -malignant epithelial neoplasm lacking glandular or squamous differentiation by light microscopy what can this carcinoma secrete?

Answer 33

Large cell Carcinoma can secrete B-hCG

Question 34

Pt presents with a knife wound in his side. absent breath sounds on right, right side of thoacoabdominal diaphragm in an inhaled position relative to the left. What would be seen on CXR?

Answer 34

pt has a tension pneumothorax - commonly from penetrating trauma to lungs ----acts as one-way valve CXR: tracheal deviation to the left - from build up of intrathoracic pressure on the right side

Question 35

Pt presents with acute dyspnea. PMH of asthma. pulse-ox 84%. Physical exam = decreased breath sounds. labored respiration with subcostal retractions, extensive rales and wheezing throughout every lung field. Labs shows eosinophilia. Recent right arm pain with numbness and paresthesias. What is the dz and what are serum findings?

Answer 35

Churg-Strauss (allergic granulomatous angiitis) - dx criteria: 1. asthma 2. eosinophilia > 10% 3. Sinusitis 4. Pulmonary infiltrates 5. vasculitis 6. Polyneuropathy -p-ANCA

Question 36

What is the paraneoplastic syndromes a/w Small cell Lung cancer? what are histological markers?

Answer 36

ADH + ACTHsecretion Positive for: Chromogranin A Neuron-specific enolase

Question 37

previously healthy 21 yr old college student presents with malaise, headache, and muscle pain for past 5 days. febrile, nonproductive cough and sore throat. CXR: extensive diffuse infiltrates. lab findings show elevated WBCs w high percentage of PMN cells. what is the pathogen? what is the drug of choice? what else would be seen in serum?

Answer 37

Mycoplasma pneumoniae - atypical pneumonia, - note imaging = diffuse infiltrates/patchy consolidation - -dx = imaging + hx of living in close quarters (college student or military) Tx: Macrolides (Erythromycin, Azithromycin) - for atypical pnemonia serum: Cold agglutinins = IgM Abs to Ags on RBC membranes (anti-erythrocyte Abs)

Question 38

What structure is located behind the angle of Louis? what spine level is this? What is this location used for in the emergency department?

Answer 38

Carina bifurcation of lung at T4 used to identify second rib for needle decompression for tension pneumothorax at second intercostal space

Question 39

pt presents with chronic cough. moved from central america when he was a child. sputum sample is negative on culture and gram stain. Microscopic KOH pprep shows multiple budding yeasts concentrically projecting from the larger yeast what is pathogen?

Answer 39

Paracoccidioides basiliensis

Question 40

Pt w PMH of IBS presents with progressive recurrent episodes of wheezing and difficulty breathing. admites to occasional periods of diarrhea, flushing of the neck, and dizziness. What is the dz and what are additional findings?

Answer 40

Carcinoid syndrome from metastatic neuroendocrine tumor --systolic murmur of the LLSB frm Carcinoid heart disease - plaque like deposits of fibrous tissue on endocardium Carcinoid tumors are most common carcinoma of the appendix and can present as appendicitis - most carcinoid tumors are slow growing = misdiagnosed as IBS

Question 41

A patient with panacinar emphysema has associated liver disease? what is the mechanism of injury?

Answer 41

Alpha-1 antitrypsin cirrhosis is caused by the accumulation of an insoluble (A1AT) mutant protein within hepatocytes

Question 42

Which sinus is most commonly affected in sinusitis?

Answer 42

Maxillary

Question 43

What is the major health risk for the fetus related to gestational diabetes?

Answer 43

lack of surfactant and massive intrapulmonary shunting = atelectasis surfactant synthesis is decreased at high insulin levels

Question 44

What will appear on lung biopsy of asbestosis?

Answer 44

Bx will show Ferruginous bodies = | Stain positive with Prussian blue